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2537DOI: 10.1590/1413-81232023289.15342022ENREVIEWWhat contributes to Primary Health Care effectiveness? Integrative literature review, 2010-2020Abstract Primary Health Care (PHC) intends to rearrange services to make it more effective. Nevertheless, effectiveness in PHC is quite a challenge. This study reviews several articles re-garding the effectiveness improvements in PHC between 2010 and 2020. Ninety out of 8,369 ar-ticles found in PubMed and the Virtual Health Library databases search were selected for the-matic analysis using the Atlas.ti® 9.0 software. There were four categories identified: strategies for monitoring and evaluating health services, organizational arrangements, models and te-chnologies applied to PHC. Studies concerning the sensitive conditions indicators were pre-dominant. Institutional assessment programs, PHC as a structuring policy, appropriate work-force, measures to increase access and digital technologies showed positive effects. However, payment for performance is still controversial. The expressive number of Brazilian publications reveals the broad diffusion of PHC in the coun-try and the concern on its performance. These findings reassure well-known aspects, but it also points to the need for a logical model to better define what is intended as effectiveness within primary health care as well as clarify the poly-semy that surrounds the concept. We also sug-gest substituting the term “resolvability”, com-monly used in Brazil, for “effectiveness”.Key words Primary Health Care, EffectivenessAna Cláudia Cardozo Chaves (https://orcid.org/0000-0003-3711-3829) 1Magda Duarte dos Anjos Scherer (https://orcid.org/0000-0002-1465-7949) 1Eleonor Minho Conill (https://orcid.org/0000-0003-4395-0594) 21 Universidade de Brasília. Campus Universitário Darcy Ribeiro. 70910-900 Brasília DF Brasil. anaccardozo@hotmail.com2 Universidade Federal de Santa Catarina. Florianópolis SC Brasil. 2538Chaves ACC et al.IntroductionHealthcare systems are a historical, economic, political and cultural setting. Although health-care services are only part of these systems, their performance embase practices and public policies analyses1,2.Primary Health Care (PHC) intends to rear-range services to make it more effective3. Prac-tices guided by PHC are expected to meet most of community needs enabling timely access to continued and high-quality health, with the right technologies to avoid unnecessary interven-tions4,5.However, in many countries, PHC is differ-ent from that with disparities between what in-dividuals and communities need and the quality of services, with standardized services for a small part of the population6-8. In Brazil, even though there is a universal health system with PHC as a structural policy8, we found selective practices and fragmented care9,10.Nevertheless, effectiveness in PHC is quite a challenge. In Brazil, the National Primary Health Care Policy (Política Nacional de Atenção Básica - PNAB)8 established it as a goal and the National Health Plan 2020-2023 considered it an strategic objective “to promote the expansion of PHC ser-vices in a integrated and planned manner” to be achieved by the performance of 20 indicators11.Effectiveness is a complex political commit-ment because it depends on several demograph-ic, epidemiological and sociocultural variables which determine health conditions. There is a wide range of needs often in adverse sociopolitical contexts which challenges the services capacities. Moreover there is a conceptual and orthograph-ic polysemy around effectiveness ranging from a health policy goal to an evaluation tool12. This study presents an overview of the literature con-tributions about PHC effectiveness because map-ping the problem is the first step towards facing it.MethodologyThis study used the integrative review13 method and the PRISMA14 methodology. It started with the guiding question: “what theoretical-method-ological contributions are presented in scientific literature to improve PHC effectiveness?” The criteria for inclusion and exclusion, the keywords and databases for search were defined. The study included original articles from indexed journals in English, Spanish and Portuguese, published between February 2010 and February 2020, with the search words in the title and/or abstract. Re-view studies were excluded as well as guidelines, meetings presentations, courses, speeches and management reports.The key words came from the Descriptors in Health Sciences (DeCS) and the Medical Subject Headings (MeSH), complemented by the Boolean operators “OR” and “AND”. Due to the absence of a term to translate the exact Portuguese concept of “resolvability” for the international literature in evaluation, we used effectiveness with the follow key words: “resolubilidade”; effectiveness OR ef-fectividad OR efetividade; primary health care OR atención primaria de salud OR atenção primária à saúde. PHC related terms such as general prac-titioner (Europe, North America), community/lo-cal/rural health (Asia, Africa) and atenção básica - AB (Brazil) were considered.The research was done from February 1st to 4th, 2020 at PubMed® and the Virtual Health Library (BVS, in Portuguese), that includes LI-LACS, MEDLINE, BDENF and IBECS databases. Three reviewers performed the screening of 8,369 studies. The inclusion/exclusion criteria, remov-al of duplicates, reading of titles and abstracts reduced the number of studies to 1,679. From those, 191 studies were removed because their fo-cus was cost-effectiveness and 1,375 clinical effec-tiveness, which did not allow inferences regarding the PHC practices and policies in general. After a complete reading of the remaining 113 articles, 23 were excluded leaving a total of 90 selected ar-ticles (Figure 1) classified by title, author, year, da-tabase, journal and place of origin of the study for thematic analysis by the Atlas.ti® software, version 9.0 (Figure 2).To establish the analytical categories, it was considered that models are reality simplifica-tions or idealizations to explain or systematize a phenomenon hypothetically or paradigmati-cally16. Monitoring and evaluation strategies are activities for follow-up and information analysis regarding services effects for decision-making17. Technologies transform a given object in the context of a labor process18. Organizational ar-rangements are ways to promote changes in the services and establish levels of care to help the supply management19.ResultsThere were studies published in all of the years analyzed, especially 2018 and 2012 (18 e 14 ar-2539Ciência & Saúde Coletiva, 28(9):2537-2551, 2023Figure 1. Methodological process for studies' selection in the integrative review.Source: Diagram adapted from the Prisma model15.Studies selected for reviewn=90 Full reading of 113 studies and exclusion of 23 that were not elegible according to pair assessmentReading of titles and abstracts to select studies that correspond to the study questionn=1,679Studies based on inclusion/exclusion criteria, duplicates excluded n=2,735PubMed® n=2,391 BVS n=5,978Searching using key words defined for the studyPeriod: february 1-4, 2020n=8,369Exclusion of 191 studies that treat cost-effectiveness, using PHC as empirical field, but did not allow general inferencesExclusion of 1,375 studies that threated clínica effectiveness, using PHC as empirical field, but did not allow general inferencesIdentificationScreenningElegibilityInclusionticles, respectively). From the 90 articles select-ed, 50 were from BVS and 40 from PubMed®. Quantitative approaches were predominant (52) followed by qualitative (32) and mixed methods (06).In terms of language, 69 of the studies were in English, 15 in Portuguese and 6 in Spanish. Con-cerning the place of origin, South America had 31 articles, 26 of which were from Brazil. There were 23 from Europe, 19 from North America, 6 from Asia, 4 from Africa, 3 from Oceania, and 4 conducted in more than one country. Chart 1 shows the complete list of references of the se-lected studies, as well as their place of origin.There were four categories identified by the-matic analysis: strategies for PHC quality mon-itoring and services evaluation (34 studies), or-ganizational arrangements (25 studies), models (17 studies) and technologies applied to PHC (14 studies). Chart 2 synthesizes the main content found in these studies.Strategies for PHC quality monitoring and services evaluation The indicator ‘Emergency/hospital admis-sions for PHC Sensitive Conditions’ which ap-peared mostly in Brazilian studies, was indicated as adequate for quality evaluation with certain limitations. Emergency/hospital admissions are inversely proportional to PHC teams availabili-ty (ID 71; 74; 42; 80; 78; 16; 58; 47; 33). Howev-er, that indicator can by itself be insufficient to evaluate PHC and requires additional measures of care effectiveness (ID 10; 60). One alternative would be to choose conditions/diseases based on sensitivity and specificity instead of frequency, considering geographic and sociodemographic 2540Chaves ACC et al.Figure 2. Network of categories and codes.Source: Authors, using the Atlas.ti® software, version 9.0.characteristics, model of care, labor processes and management at the health centers (ID 06).Brazil and Argentina applied the Primary Care Assessment Tool (PCATool) (ID 32; 64) to evaluate ‘PHC attributes’ as a standard quality measure. South Africa applied a combination of the Nominal Group Technique (NGT) and the PCATool (ID 67) for the same purpose. In 11 countries, the Commonwealth Fund Interna-tional Health Policy Survey (CFIHPS) was used to analyze care coordination (ID 54). An estab-lished relationship with a primary care physician was significantly associated with better care coor-dination, whereas being chronically ill or young-er was associated with poorer care coordination.“Institutional Assessment Programs” con-tribute to improve effectiveness. Fifty six indi-cators of The Swiss Primary Health Care Active Monitoring Program in Switzerland (ID 56) show a decrease in mortality. In England, 20 in-dicators from the pay-for-performance program of the Public Health Impact create an effective-ness score for PHC (ID 29). The European Prac-tice Assessment in Switzerland (ID 43) points to ímprovements in quality and safety, information and finances. In Germany (ID 09), the same tool points to improvements only in quality and safe-ty. The Estratégia de Evaluación Reformulada para Latinoamérica (Reformulated Evaluation Strategy for Latin America) was appropriate to evaluate performance in all of the subsystems in Argentina (ID 05). The Change Process Ca-pability Questionnaire Strategies Score from the USA revealed heterogeneity of quality im-provement strategies applied to PHC centers, making it difficult to standardize the perfor-mance evaluation (ID 72). In Brazil, the Health Services Performance Assessment Methodology (PROADESS, in Portuguese) found heteroge-neity in effectiveness, access, efficiency and ap-propriateness subdimensions, with considerable improvements in geographic areas with PHC (ID 17). The Agreements for PHC and for Healthcare led, in general, to improvements in process and results indicators (ID 20). The National Program for Access and Quality in Primary Care (PMAQ-AB, in Portuguese) found better results in first contact and comprehensiveness attributes, and worse in longitudinal care and coordination (ID 73). There were improvements in teamwork and data management, regardless of limitations due to overload and the large amount of data to be collected. There also were difficulties to share re-sults throughout the teams (ID 82). Performance effectiveness does not guarantee outputs and out-comes (ID 59).Organizational arrangements“Multidisciplinary teams” with expanded roles, new protagonists and new competencies have proven to be useful (ID 63), especially in 2541Ciência & Saúde Coletiva, 28(9):2537-2551, 2023Chart 1. Studies selected for review.ID Study Place of origin1 Báscolo, 201030 Argentina2 Perron et al., 201031 Switzerland3 Vieira-da-Silva et al., 201032 Brazil4 Miller et al., 201033 USA5 Yavich et al., 201034 Argentina6 Nedel et al., 201135 Brazil7 Sohrabi and Albalushi, 201136 Iran8 Wilson, 201137 United Kingdom9 Szecsenyi et al., 201138 Germany10 Rehem et al., 201239 Brazil11 Baratieri et al., 201240 Brazil12 Grills et al., 201241 India13 Albalushi et al., 201242 Oman14 Ortiz and Wan, 201243 USA15 Alkmim et al., 201244 Brazil16 Oliveira et al., 201745 Brazil17 Viacava et al., 201246 Brazil18 Greaves et al., 201247 England19 Mold et al., 201248 USA20 Lima et al., 201249 Brazil21 Campo, 201250 Chile22 Sanabria and Orta, 201251 Venezuela23 Dookie and Singh, 201252 South Africa24 Kirschner et al., 201253 The Netherlands25 Lavoie et al., 201354 Canada26 Liddy et al., 201355 Canada27 Hinchcliff et al., 201356 Australia28 Keely et al., 201357 Canada29 Ashworth et al., 201358 England30 Heard et al., 201359 Bangladesh31 Kirschner et al., 201360 The Netherlands32 Chomatas et al., 201361 Brazil33 Zhao et al., 201362 Australia34 Violán et al., 201363 Spain35 Porter et al., 201364 USA36 Maini et al., 201465 D. Republic of Congo37 Costa et al., 201466 Brazil38 Roots and Macdonald, 201467 Canada39 Rao and Pilot, 201468 United Kingdom and The Netherlands40 Piropo and Amaral, 201569 Brazil41 Campbell et al., 201570 England42 Castro et al., 201571 Brazil43 Goetz et al., 201572 Switzerland44 Farias et al., 201573 Brazil45 Ford et al., 201574 England46 Mobula et al., 201575 USA47 Fung et al., 201576 China48 Lemak et al., 201577 USA49 Nouwens et al., 201578 The Netherlands50 Markwick et al., 201579 USAit continues2542Chaves ACC et al.ID Study Place of origin51 Brugués et al., 201680 Spain52 Whittaker et al., 201681 England53 Leite et al., 201682 Brazil54 Penm et al., 201783 Australia, Canada, France, Germany, The Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom and USA55 Hone et al., 201784 Brazil56 Ebert et al., 201785 Switzerland57 Murante et al., 201786 Europe58 Zarlotti et al., 201787 Brazil59 Miclos et al., 201788 Brazil60 Mendonça et al., 201789 Brazil61 Molina et al., 201790 Brazil62 Chang et al., 201791 USA63 Wagner et al., 201792 USA64 Segalini et al., 201793 Argentina65 Wan et al., 201894 USA66 Zhou et al., 201895 China67 Mukiapini et al., 201896 South Africa68 Pandya et al., 201897 United Kingdom69 Lin et al., 201898 USA70 Tintorer et al., 201899 Spain71 Arantes et al., 2018100 Brazil72 Balasubramanian et al., 2018101 USA73 Lima et al., 2018102 Brazil74 Santos et al., 2018103 Brazil75 Hayhoe et al., 2018104 England76 Fariño Cortez et al., 2018105 Spain77 Lima-Toivanen and Pereira, 2018106 Argentina, Brazil, Costa Rica and Dominican Republic78 Wensing et al., 2018107 Germany79 Cole, 2018108 USA80 Abel et al., 2018109 United Kingdom81 Fairall et al., 2018110 South Africa82 Ferreira et al., 2018111 Brazil83 Nabelsi et al., 2019112 Canada84 Navathe et al., 2019113 Hawaii85 Lenzi et al., 2019114 Brazil86 Azogil-López et al., 2019115 Spain87 Ballart and Galais, 2019116 Spain88 Sibbald et al., 2019117 Canada89 Harzheim et al., 2019118 Brazil90 Tasca et al., 2020119 BrazilSource: Authors.Chart 1. Studies selected for review.contexts with shortage of doctors (ID 65). The implication of all professionals optimizes work and frees up others for tasks that only they can perform. Hence, a larger number of doctors at PHC improves results in health (ID 62). In a Bra-zilian study (ID 37), effectivenesswas related to multidisciplinary teams that produce bonds of trust and autonomy at the workplace.Nurses stand out for their effectiveness in managing demands, health education and a com-prehensive range of needs. (ID 51). Their com-munity, organizational and services performance 2543Ciência & Saúde Coletiva, 28(9):2537-2551, 2023Chart 2. Selected studies by thematic categories and subthemes.Thematic categories Themes Subthemes Absolute number PercentageStrategies for PHC quality monitoring and services evaluationGeneral PHC quality assessment (ID 88) 1 1.1%Indicators Emergency/hospital admissions by PHC sensitive conditions (ID 71; ID 74; ID 10; ID 06; ID 42; ID80; ID 78; ID 16; ID 60; ID 58; ID 47; ID 33)12 13.3%PHC Attributes Primary Care Assessment Tool (ID 32; ID 67; ID 64); Care coordination (ID 54); Access (ID 69)5 5.6%Institutional Assessment ProgramsCPCQ (ID 72). SPAM (ID 56). European Practice Assessment (ID 43; ID 09). PMAQ-AB (ID 73; ID 82; ID 59). Estrategia de Evaluación Reformulada para Latinoamérica (ID 05). Pacto pela Atenção Básica/Pacto pela Saúde (ID 20). Public Health Impact (ID 29). PROADESS (ID 17)11 12.2%e-Health e-PHC Assessment Framework (ID 77) 1 1.1%User’s satisfaction User’s satisfaction (ID 07; ID 13; ID 76; ID 19) 4 4.5%Subtotal 34 37.8%Models General PHC in Global Health (ID 39) 1 1.1%Governability (ID 01) 1 1.1%Payment For populational basis (ID 84; ID 57) 2 2.3%For performance (ID 68; ID 24; ID 31) 3 3.3%Fee-for-service (ID 48; ID 79), fee subsidies (ID 36) 3 3.3%Accreditation Accreditation (ID 27; ID 49; ID 08) 3 3.3%Models of Care Care approach centered on: person (ID 35; ID 25); relationship (ID 04)3 3.3%Patient no-show predictive model (ID 85) 1 1.1%Subtotal category 17 18.9%Organizational arrangementsMultidisciplinary teamsTeam set-up/practices (ID 63; ID 65; ID 62; ID 51; ID 38; ID 11; ID 75)7 7.8%Services organizationExtended hours (ID 52; ID 45), Team work (ID 46; ID 37), Distribution of teams/professionals (ID 66; ID 18; ID 23); urgencies (ID 44)8 8.9%Structuring strategiesFamily health (ID 90; ID 53; ID 55; ID 21), Rural Health Clinics (ID 14), More Doctors (ID 61), Adjusted Clinical Groups (ID 34)7 7.8%Management Non-governmental organizations (ID 30); Associative Basis Entities (ID 87); and Networking clusters (ID 12)3 3.3%Subtotal category 25 27.8%Technologies applied to PHCDigital Telehealth and Telemedicine (ID 70; ID 40; ID 15; ID 50; ID 22; ID 89)6 6.7%Virtual Appointments (ID 83; ID 26; ID 28) 3 3.3%Use of telephone for: scheduling appointments and waiting list (ID 03); reference/referral (ID 86); screening (ID 41); and electronic alert (ID 02)4 4.5%Non-digital Support to care: Practical Approach to Care Kit (ID 81)1 1.1%Subtotal category 14 15.5%Total 90 100%Source: Authors.2544Chaves ACC et al.is highlighted, improving access and the use of other levels of care, as well as doctor’s acceptance of nurses’ clinical competence. (ID 38). Longi-tudinal care at nurses’ work was also related to improvements in population’s quality of life and in effectiveness within PHC (ID 11).One study from England (ID 75) suggests that including Community Health Agents on a national scale is recommended/advisable and it can be fastly implemented to help relieve work overload within healthcare services (ID 75). In the USA, teams recognized PHC Community Health Agents effectiveness in solving problems (ID 46).Concerning “Services organization”, extend-ed hours at night and/or weekends reduced the use at other levels of care in the first 12 months (ID 52), with possible benefits for young patients who work full time (ID 45).“Rural Health Clinics” experience in the USA (ID 14) revealed that larger clinics are more effi-cient, suggesting that smaller ones should gather integrated systems or districts (ID 23). In En-gland, the size of PHC units was not decisive for the teams performance and the variance can be explained by population characteristics. Organi-zational arrangements focused on responsibili-ties and not merely on the size of population are recommended (ID 18).The Family Health Strategy in Brazil (ESF, in Portuguese) stands out amongst “Structur-ing strategies”: wide health services supply and comprehensiveness (ID 53), PHC expansion and strong governance were associated with a decrease in preventable mortality (ID 55). It was considered the best strategy for a strong PHC, when associated with policies that reinforce its attributes with innovations in management of care and communication technologies (ID 90). However, poor diagnostic and therapeutic supply are still challenges for effectiveness and user’s sat-isfaction (ID 53).ModelsThe “Models” category grouped frameworks to increase effectiveness, predominating those concerning the influence of payment in PHC quality. Payment for population basis in Hawaii (ID 84) resulted in reduction of appointments demand, with no significant increase in costs. An European study (ID 57) concluded higher PHC responsiveness happens when doctors are paid by capitation than when they only receive fee-for-services or a mixed payment method.“Payment for performance”, according to studies from the Netherlands and United King-dom (ID 24; 31), may improve clinical quality, patients’ experience and care organization. But proved not to be cost effective in another study from the United Kingdom (ID 68), which recom-mended a redesign of the program or alternative interventions.Regarding “fee-for-service”, studies from the USA (ID 48; 79) on a model of direct Primary Care concluded that fees improved PHC attri-butes. Lining up payment with cost and per-formance encouraged professionals to provide the best quality care. One program of popula-tion-based subsidies for service fees (“fee subsi-dies”) in the Democratic Republic of Congo (ID 36) proved to increase the use of services in the short term and point to the need to study its sus-tainability, long-term effects and the possibility of removing or reducing fees for vulnerable users.Technologies applied to PHCDigital technologies stood out as means through which to increase effectiveness, especial-ly with “Telehealth and Telemedicine” services. These are tools that provide reliable, updated and easily transferable information to clinical activ-ities. Their value is for educational capacity and for expanding access and quality with reductions in cost. They also prevent unnecessary displace-ments and crowding at the reference centers, re-ducing hospitalization, strengthening integration between services and satisfaction for profession-als and patients (ID 70; 40; 15; 50; 22; 89).“Virtual consultations”, according to data from Canada (ID 83; 26; 28), were efficient in improving access to specialized care, besides be-ing well accepted by professionals and patients. It can reduce waiting time, as well as the use of tele-phone to schedule appointments and to organize waiting lists (ID 03), referrals (ID 86), screening (ID 41), and electronic alerts to diminish patient no-show (ID 02).DiscussionThe main contributionsto improve effectiveness in PHC were: sensitive conditions indicators, in-stitutional assessment programs, focus on PHC as a structuring policy, quantitatively (number of doctors) and qualitatively appropriate workforc-es (multidisciplinary teams, nursing, community health agents), organizational measures to in-2545Ciência & Saúde Coletiva, 28(9):2537-2551, 2023crease centers’ availability and the use of digital technologies.However, it’s important to consider some as-pects concerning the validity of this review. The choice of the keywords and the articles profile may have minimized relevant themes. That was the case of PHC coordination and integration with other levels of the system, in whichaccess to specialized care and the waiting lists are one of the most important hurdles in PHC universal systems20. Although contemplated in the catego-ry ‘digital technologies’ and in the results from PMAQ and CFIHPS, there were few papers about this issue. There is also a lack of informa-tion on PHC reforms in countries such as Portu-gal21, especially concerning incentives to improve performance, which may have been published in reports or books.The option to present the most frequent re-sults in each category was also a relevant aspect, which may have prevented exploring less fre-quent ones, yet equally important themes. That is the case of “user’s satisfaction” in studies from Iran, Oman and Ecuador (ID 07; 13; 76), “ac-creditation” in Australia, the Netherlands and the United Kingdom (ID 27; 49; 08), models geared towards care approach centered on the person and on “the relationship” (ID 35; 25), and non-virtual technologies in “support to care” (ID 81). To minimize such limitations, Charts 1 and 2 enable access to the entire set of analyzed studies.An expressive number of Brazilian studies showed indicators of emergency/hospital admis-sions due to PHC sensitive conditions, calling at-tention to the fact that other factors interfere in its effectiveness. This indicator is recommended for health care network evaluation, since it indicates possible problems concerning access and quality at all levels of care (ID 71; 74; 47). To better eval-uate the PHC performance, a more comprehen-sive framework is needed to integrate questions at the macro level (policies) with the meso (man-agement) and micro-social level (care)20.Besides these conceptual challenges, instru-ments and mechanisms which aim to apply PHC sensitive conditions must be operational and sus-tainable. They should consider data sub-registers and those from private services. Methodological and contextual differences also make compari-sons more difficult. Many countries do not ap-ply a wide concept for effectiveness as a desirable outcome for PHC universal systems, with effec-tiveness measures based on selective services, de-fined by guidelines and financial costs7.Payment for performance approaches have increased in recent decades along with reforms in PHC services22, but their effects must be dis-cussed further. Studies in Brazil (ID 73; 82; 59) and in the Netherlands (ID 68; 24; 31) suggest positive results. However, the experience in the United Kingdom with the Quality and Outcomes Framework proved not to be cost-effective (ID 29; 68) since payment rewards were not in line with health incomes, in this case focusing on mortality rather than PHC attributes. A recent study concerning the Brazilian PMAQ points out the capability to improve access and quality, even so indirect professionals remuneration depended on a complex evaluative model and certification process10.The present study confirms the polysemy of ‘resolvability’, concept embraced in Brazil, asso-ciated with the idea that most of the demands could be solved by PHC without referral to other services4,23. This concept isn’t the same in English (effectiveness or responsiveness), nor in Spanish (modelo resolutivo or capacidad resolutiva). Ef-fectiveness evaluate the level at which services reach the expected results in common practical conditions, or the relationship between its poten-tial and real impact, which is closely related to results and classic PHC attributes (ID17)24,25. Re-sponsiveness is the capacity to respond and the system fundamental objective of anticipating and adapting to existing and future needs for better results in health care. It focuses on individuals’ experiences and on how the health systems meet expectations, concerning: dignity, autonomy, confidentiality, immediate care, facilities quali-ty, access to social support networks and service providers choice26. These concepts are close to the way ‘resolvability’ has been understood in Brazil, all of which related to the evaluation field. Although, a clearer differentiation is needed in order to facilitate an adequate use. “Resolvability” according to Brazil’s common use corresponds to the act of establishing effec-tive solutions for health problems, with beneficial results in individual or collective problems27-29. Implies the possibility of identifying commu-nity needs, which will not necessarily appear as demands. This is where the challenge of this concept lies: identifying outcomes which may be expected in this level of care, taking into account the system’s conditioning factors, as well as the socioeconomic and cultural determinants that influence health in general.2546Chaves ACC et al.Final considerationsThe expressive number of Brazilian publications shows the important diffusion of PHC in this country over the last decade, as well as the con-cern with its performance. The scope reinforces already well-known aspects: a positive induc-tion of institutional evaluation, organizational arrangements to improve institutional capacity and services availability, quantitatively and qual-itatively appropriate workforces, PHC as a struc-turing policy and the use of digital resources. However payment for performance is still con-troversial. Complementary studies are warranted in order to overcome the thematic limitations or the bias of the present study.The polysemy that surrounds the concept “resolv-ability” in Brazil proves the need for greater clar-ity in its application, identifying what is intended as effectiveness within PHC. Therefore, a logical model should be considered, with parameters which contemplate determinants and condition-ing that influence PHC. We also suggest substi-tuting the word “resolvability” as used in Brazil for ‘effectiveness to facilitate an international dia-logue concerning outcomes in evaluation.CollaborationsACC Chaves and MDA Scherer contributed substantially to its conception and design. All authors, ACC Chaves, MDA Scherer and EM Conill, contributed substantially to the analysis and interpretation of data, writing of the article, critical review of the content and approval of the final version to be published.2547Ciência & Saúde Coletiva, 28(9):2537-2551, 2023References1. Viacava F, Almeida C, Caetano R, Fausto M, Macinko J, Martins M, Noronha JC, Novaes HMD, Oliveira ES, Porto SM, Silva LMV, Szwarcwald CL. Uma me-todologia de avaliação do desempenho do sistema de saúde brasileiro. Cien Saude Colet 2004; 9(3):711-724.2. Tyrovolas S, Polychronopoulos E, Tountas Y, Panagio-takos D. The role of health care systems on popula-tions’ health status and longevity: A comprehensive analysis. Health Sci J 2010; 4(3):149-156.3. Giovanella L, Mendonça MHM, Buss PM, Fleury S, Gadelha CAG, Galvão LAC, Santos RF. De Alma-Ata a Astana. Atenção primária à saúde e sistemas universais de saúde: compromisso indissociável e di-reito humano fundamental. Cad Saude Publica 2019; 35(3):e00012219.4. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco/MS; 2002.5. Almeida PF, Fausto MCR, Giovanella L. Fortaleci-mento da atenção primária à saúde: estratégia para potencializar a coordenação dos cuidados. Rev Panam Salud Publica 2011; 29(2):84-95.6. Bitton A, Ratcliffe HL, Veillard JH, Kress DH, Barkley S, Kimball M, Secci F, Wong E, Basu L, Taylor C, Bayona J, Wang H, Lagomarsino G, Hirschhorn LR. Primary Health Care as a Foundation for Strengthe-ning Health Systems in Low- and Middle-Income Countries. J Gen Intern Med 2017; 32(5):566-571.7. Brandão JRM. A atenção primária à saúde no Canadá: realidade e desafios atuais. Cad Saude Publica 2019; 35(J):e00178217.8. Brasil. Portaria de Consolidação nº 2, de 28 de se-tembro de 2017. Política Nacional de Atenção Básica. Anexo XXII. Diário Oficial da União 2017; 28 set.9. ConillEM. Análisis de la problemática de la integra-ción de la APS en el contexto actual: causas que inci-den en la fragmentación de servicios y sus efectos en la cohesión social. Intercambio III 2-1-2007. Rio de Janei-ro: Escola Nacional de Saúde Pública Sergio Arouca/Fiocruz; 2007.10. Facchini L, Tomasi E, Thumé E. Acesso e qualidade na atenção básica brasileira: análise comparativa dos três ciclos da avaliação externa do PMAQ-AB, 2012-2018. São Leopoldo: Oikos; 2021.11. Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde 2020-2023. Brasília: MS; 2020.12. D´Aguiar JMM. O Programa Saúde da Família no Brasil. A resolutividade do PSF no município de Volta Redonda (RJ) [dissertação]. Rio de Janeiro: ENSP-Fio-cruz; 2001.13. Mendes KDS, Silveira RCCP, Galvão CM. Revisão in-tegrativa: método de pesquisa para a incorporação de evidência na saúde e na enfermagem. Texto Context Enferm 2008; 17(4):758-764.14. Page MJ, Mckenzie JE, Bossuyt PM, Boutron I, Ho-ffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J,Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372:n71.FundingThe production of this article received financial support from the Pós-Graduação of Universi-dade de Brasília through Public Notice DPG number 0001/2022.2548Chaves ACC et al.15. Pires DEP, Vandresen L, Machado F, Machado RR, Amadigi FR. Gestão em saúde na atenção primária: o que é tratado na literatura. Texto Contexto Enferm 2019; 28:e20160426. 16. Silva FS, Catelli F. Os modelos na ciência: traços da evolução histórico-epistemológica. Rev Bras Ensino Fis 2019; 41:4.17. Souza MF. Conceitos básicos em monitoramento e ava-liação [aula]. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2013.18. Pereira IB. Dicionário da educação profissional em saúde. 2ª ed. Rio de Janeiro: EPSJV; 2008.19. Freitas MA. Arranjos organizativos da atenção primária nas regiões de saúde de um Departamento Regional de Saúde [dissertação]. Ribeirão Preto: Uni-versidade de São Paulo; 2017.20. Conill EM, Fausto MCR, Giovanella L. Contribuições da análise comparada para um marco abrangente na avaliação de sistemas orientados pela atenção pri-mária na América Latina. Rev Bras Saude Matern In-fant 2010; 10(Supl. 1):15-27.21. Biscaia AR, Heleno LCV. A Reforma dos Cuidados de Saúde Primários em Portugal: portuguesa, moderna e inovadora. Cien Saude Colet 2017; 22(3):701-712.22. Poli Neto P, Faoro NT, Prado Júnior JC, Pisco LAC. Remuneração variável na Atenção Primária à Saúde: relato das experiências de Curitiba e Rio de Janeiro, no Brasil, e de Lisboa, em Portugal. Cien Saude Colet 2016; 21(5):1377-1388.23. Chioro A, Scaff A. Saúde e cidadania: a implantação do Sistema Único de Saúde. Santos: Faculdade de Ciências Médicas de Santos; 1999.24. Donabedian A. The Seven Pillars of Quality. Arch Pa-thol Lab Med 1990; 114:1115-1118.25. Poças KC. Avaliação da Atenção Primária à Saúde no Distrito Federal [tese]. Brasília: Universidade de Bra-sília; 2017.26. Mirzoev T, Kane S. What is health systems respon-siveness? Review of existing knowledge and propo-sed conceptual framework. BMJ Glob Health 2017; 2:e000486.27. Rezende VA. A resolutividade na Atenção Básica: uma revisão de literatura [monografia]. Belo Horizonte: Universidade Federal de Minas Gerais; 2010.28. Oliveira IPRM. Resolubilidade do cuidado oftalmoló-gico em centro de atendimento secundário sob a ótica dos pacientes diabéticos e não diabéticos [dissertação]. Botucatu: Universidade Estadual Paulista Júlio de Mesquita Filho; 2017.29. Degani VC. A resolutividade dos problemas de saúde: opinião de usuários em uma Unidade Básica de Saúde [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2002.30. Báscolo E. Gobernanza de las organizaciones de salud basados en Atención Primaria de Salud. Rev Salud Pu-blica 2010; 12(1):8-27.31. Perron NJ, Dao MD, Kossovsky MP, Miserez V, Chuard C, Calmy A, Gaspoz JM. Reduction of mis-sed appointments at an urban primary care clinic: a randomised controlled study. BMC Fam Pract 2010; 11:79.32. Vieira-da-Silva LM, Chaves SC, Esperidião MA, Lo-pes-Martinho RM. Accessibility to primary healthca-re in the capital city of a northeastern state of Brazil: an evaluation of the results of a programme. J Epide-miol Community Health 2010; 64(12):1100-1105.33. Miller WL, Crabtree BF, Nutting PA, Stange KC, Jaén CR. Primary care practice development: a re-lationship-centered approach. Ann Fam Med 2010; 8(Supl. 1):S68-S79.34. Yavich N, Báscolo EP, Haggerty J. Construyendo un marco de evaluación de la atención primaria de la salud para Latinoamérica. Salud Publica Mex 2010; 52(1):39-45.35. Nedel FB, Facchini LA, Bastos JL, Martín-Mateo M. Conceptual and methodological aspects in the study of hospitalizations for ambulatory care sensitive con-ditions. Cien Saude Colet 2011; 16(Supl. 1):1145-1154.36. Sohrabi MR, Albalushi RM. Clients’ satisfaction with primary health care in Tehran: A cross-sectional stu-dy on Iranian Health Centers. J Res Med Sci 2011; 16(6):756-762.37. Wilson T. Improving primary health care deli-very: still waiting for the magic bullet. CMAJ 2011; 183(18):E1280-E1281.38. Szecsenyi J, Campbell S, Broge B, Laux G, Willms S, Wensing M, Goetz K. Effectiveness of a quali-ty-improvement program in improving mana-gement of primary care practices. CMAJ 2011; 183(18):E1326-E1333.39. Rehem TCMSB, Ciosak SI, Egry EY. Internações por condições sensíveis à atenção primária no hospital geral de uma microrregião de saúde do município de São Paulo, Brasil. Texto Contexto Enferm 2012; 21(3):535-542.40. Baratieri T, Mandu ENT, Marcon SS. Longitudinalida-de no trabalho do enfermeiro: relatos da experiência profissional. Rev Esc Enferm USP 2012; 46(5):1260-1267.41. Grills NJ, Robinson P, Phillip M. Networking between community health programs: a case study outlining the effectiveness, barriers and enablers. BMC Health Serv Res 2012; 12:206.42. Albalushi RM, Sohrabi MR, Kolahi AA. Clients’ satis-faction with primary health care in muscat. Int J Prev Med 2012; 3(10):713-717.43. Ortiz J, Wan TH. Performance of rural health clinics: an examination of efficiency and Medicare beneficiary outcomes. Rural Remote Health 2012; 12:1925.44. Alkmim MB, Figueira RM, Marcolino MS, Cardoso CS, Pena de Abreu M, Cunha LR, et al. Improving pa-tient access to specialized health care: the Telehealth Network of Minas Gerais, Brazil. Bull World Health Organ 2012; 90(5):373-378.45. Oliveira ESBE, Oliveira VB, Caldeira AP. Internações por condições sensíveis à atenção primária em Minas Gerais, entre 1999 e 2007. Rev Baiana de Saude Publi-ca 2017; 41(1):144-157.46. Viacava F, Ugá MAD, Porto S, Laguardia J, Moreira RS. Avaliação de Desempenho de Sistemas de Saú-de: um modelo de análise. Cien Saude Colet 2012; 17(4):921-934.2549Ciência & Saúde Coletiva, 28(9):2537-2551, 202347. Greaves F, Millett C, Pape UJ, Soljak M, Majeed A. Association between primary care organisation po-pulation size and quality of commissioning in En-gland: an observational study. Br J Gen Pract 2012; 62(594):e46-e54.48. Mold JW, Lawler F, Schauf KJ, Aspy CB. Does patient assessment of the quality of the primary care they re-ceive predict subsequent outcomes?: An Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med 2012; 25(4):e1-e12.49. Lima RN, Medeiros Junior ME, Martins JS, Santos EP, Bourget MMM. Desempenho de indicadores nos municípios com alta cobertura da Estratégia Saúde da Família no Estado de São Paulo. Rev Bras Med Fam Comunidade 2012; 7(24):164-170.50. Campo CB. Modelo de saludfamiliar en Chile y mayor resolutividad de la atención primaria de salud: ¿contradictorios o complementarios? Medwave 2012; 12(11):e5571.51. Sanabria T, Orta M. The MANIAPURE Program-Les-sons Learned from a Rural Experience: Two Decades Delivering Primary Healthcare Through Telemedici-ne. Telemed J E Health 2012; 18:544-548.52. Dookie S, Singh S. Primary health services at district level in South Africa: a critique of the primary health care approach. BMC Fam Pract 2012; 13:67.53. Kirschner K, Braspenning J, Jacobs JE, Grol R. Design choices made by target users for a pay-for-performan-ce program in primary care: an action research appro-ach. BMC Fam Pract 2012; 13:25.54. Lavoie JG, Wong ST, Chongo M, Browne AJ, MacLeod MLP, Ulrich C. Group medical visits can deliver on patient-centred care objectives: results from a qualita-tive study. BMC Health Serv Res 2013; 13:155.55. Liddy C, Rowan MS, Afkham A, Maranger J, Keely E. Building access to specialist care through e-consulta-tion. Open Med 2013; 7(1):e1-e8.56. Hinchcliff R, Greenfield D, Westbrook JI, Pawsey M, Mumford V, Braithwaite J. Stakeholder perspectives on implementing accreditation programs: a qualita-tive study of enabling factors. BMC Health Serv Res 2013; 13:437.57. Keely E, Liddy C, Afkham A. Utilization, benefits, and impact of an e-consultation service across diverse spe-cialties and primary care providers. Telemed J E Heal-th 2013; 19(10):733-738.58. Ashworth M, Schofield P, Doran T, Cookson R, Sutton M, Seed PT, Howe A, Fleetcroft R. The Public Health Impact score: a new measure of public health effecti-veness for general practices in England. Br J Gen Pract 2013; 63(609):e291-e299.59. Heard A, Nath DK, Loevinsohn B. Contracting urban primary healthcare services in Bangladesh - effect on use, efficiency, equity and quality of care. Trop Med Int Health 2013; 18(7):861-870.60. Kirschner K, Braspenning J, Akkermans RP, Jacobs JE, Grol R. Assessment of a pay-for-performance pro-gram in primary care designed by target users. Fam Pract 2013; 30(2):161-171.61. Chomatas E, Vigo A, Marty I, Hauser L, Harzheim E. Avaliação da presença e extensão dos atributos da atenção primária em Curitiba. Rev Bras Med Fam Co-munidade 2013; 8(29):294-303.62. Zhao Y, Wright J, Guthridge S, Lawton P. The rela-tionship between number of primary health care visits and hospitalisations: evidence from linked clinic and hospital data for remote Indigenous Australians. BMC Health Serv Res 2013; 13:466.63. Violán C, Plana-Ripoll O, Foguet-Boreu Q, Bolíbar B, Aguado A, Navarro-Artieda R, Velasco-Velasco S, Sicras-Mainar A. Relationship between efficiency and clinical effectiveness indicators in an adjusted model of resource consumption: a cross-sectional study. BMC Health Serv Res 2013; 13:421.64. Porter ME, Pabo EA, Lee TH. Redesigning Primary Care: A Strategic Vision to Improve Value By Orga-nizing Around Patients’ Needs. Health Affairs 2013; 32(3):516-525.65. Maini R, Van Den Bergh R, Van Griensven J, Tayler-S-mith K, Ousley J, Carter D, Mhatre S, Ho L, Zachariah R. Picking up the bill - improving health-care utili-sation in the Democratic Republic of Congo through user fee subsidisation: a before and after study. BMC Health Serv Res 2014; 14:504.66. Costa JP, Jorge MSB, Vasconcelos MGF, De Paula ML, Bezerra IC. Resolubilidade do cuidado na atenção primária: articulação multiprofissional e rede de ser-viços. Saude Debate 2014; 38(103):733-743.67. Roots A, Macdonald M. Outcomes associated with nurse practitioners in collaborative practice with ge-neral practitioners in rural settings in Canada: a mi-xed methods study. Hum Resour Health 2014; 12:69.68. Rao M, Pilot E. The missing link - the role of pri-mary care in global health. Glob Health Action 2014; 7:23693.69. Piropo TGN, Amaral HOS. Telessaúde, contextos e implicações no cenário baiano. Saude Debate 2015; 39(104):279-287.70. Campbell JL, Fletcher E, Britten N, Green C, Holt T, Lattimer V, Richards DA, Richards SH, Salisbury C, Taylor RS, Calitri R, Bowyer V, Chaplin K, Kandiya-li R, Murdoch J, Price L, Roscoe J, Varley A, Warren FC. The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consulta-tion requests in general practice: a cluster randomi-sed controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial). Health Technol Assess 2015; 19(13):1-212, vii-viii.71. Castro ALB, Andrade CLT, Machado CV, Lima LD. Condições socioeconômicas, oferta de médicos e in-ternações por condições sensíveis à atenção primária em grandes municípios do Brasil. Cad Saude Publica 2015; 31(11):2353-2366.72. Goetz K, Hess S, Jossen M, Huber F, Rosemann T, Brodowski M, Künzi B, Szecsenyi J. Does a quality management system improve quality in primary care practices in Switzerland? A longitudinal study. BMJ Open 2015; 5(4):e007443.73. Farias DC, Celino SDM, Peixoto JBS, Barbosa ML, Costa GMC. Acolhimento e Resolubilidade das Ur-gências na Estratégia Saúde da Família. Rev Bras Educ Med 2015; 39(1):79-87.74. Ford JA, Jones AP, Wong G, Steel N. Weekend opening in primary care: analysis of the General Practice Pa-tient Survey. Br J Gen Pract 2015; 65(641):e792-e798.2550Chaves ACC et al.75. Mobula LM, Okoye MT, Boulware LE, Carson KA, Marsteller JA, Cooper LA. Cultural Competence and Perceptions of Community Health Workers’ Effecti-veness for Reducing Health Care Disparities. J Prim Care Community Health 2015; 6(1):10-15.76. Fung CS, Wong CK, Fong DY, Lee A, Lam CLK. Ha-ving a family doctor was associated with lower utili-zation of hospital-based health services. BMC Health Serv Res 2015; 15:42.77. Lemak CH, Nahra TA, Cohen GR, Erb ND, Paustian ML, Share D, Hirth RA. Michigan’s Fee-For-Value Physician Incentive Program Reduces Spending and Improves Quality in Primary Care. Health Aff 2015; 34(4):645-652.78. Nouwens E, Van Lieshout J, Wensing M. Determi-nants of impact of a practice accreditation program in primary care: a qualitative study. BMC Fam Pract 2015; 16:78.79. Markwick L, Mcconnochie K, Wood N. Expanding Telemedicine to Include Primary Care for the Ur-ban Adult. J Health Care Poor Underserved 2015; 26(3):771-776.80. Brugués A, Peris Grao A, Pavón Rodríguez F, Mateo Viladomat E, Gascón Ferret J, Flores Mateo G. Evalua-ción de la gestión enfermera de la demanda en atenci-ón primaria. Aten Primaria 2016; 48(3):159-165.81. Whittaker W, Anselmi L, Kristensen SR, Lau YS, Bai-ley S, Bower P, Checkland K, Elvey R, Rothwell K, Stokes J, Hodgson D. Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis. PLoS Med 2016; 13(9):e1002113.82. Leite RS, Santos APM, Lima CA, Ribeiro CDAL, Brito MFSF. Estratégia Saúde da Família versus centro de saúde: modalidades de serviços na percepção do usu-ário. Cad Saude Colet 2016; 24(3):323-329.83. Penm J, Mackinnon NJ, Strakowski SM, Ying J, Doty MM. Minding the Gap: Factors Associated With Pri-mary Care Coordination of Adults in 11 Countries. Ann Fam Med 2017; 15(2):113-119.84. Hone T, Rasella D, Barreto M, Atun R, Majeed A, Millett C. Large reductions in amenable mortality associated with Brazil’s Primary Care expansion and strong health governance. Health Aff (Millwood) 2017; 36(1):149-158.85. Ebert ST, Pittet V, Cornuz J, Senn N. Development of a monitoring instrument to assess the performance of the Swiss primary care system. BMC Health Serv Res 2017; 17(1):789.86. Murante AM, Seghieri C, Vainieri M, Schäfer WLA. Patient-perceived responsiveness of primary care sys-tems across Europe and the relationship with the heal-th expenditure and remuneration systems of primary care doctors. Soc Sci Med 2017; 186:139-147.87. Zarlotti C, Scudese E, Sena GW, Tonini T, Lopes T, Pestana C. Internações por condiçõessensíveis à aten-ção primária após a implantação da estratégia saúde da família no município de Petrópolis/RJ. R Pesq Cuid Fundam Online 2017; 9(3):811-817.88. Miclos PV, Calvo MCM, Colussi CF. Evaluation of the performance of actions and outcomes in primary he-alth care. Rev Saude Publica 2017; 51:86.89. Mendonça CS, Leotti VB, Dias-da-Costa JS, Har-zheim E. Hospitalizations for primary care sensitive conditions: association with socioeconomic status and quality of family health teams in Belo Horizonte, Brazil. Health Policy and Plan 2017; 32(10):1368-1374.90. Molina J, Tasca R, Suárez J, Kemper ES. More Doctors Programme and the strengthening of Primary Health Care in Brazil: Reflections from the monitoring and evaluation of the More Doctors Cooperation Project. Qual Prim Care 2017; 25(2):50-54.91. Chang CH, O’Malley AJ, Goodman DC. Association between Temporal Changes in Primary Care Work-force and Patient Outcomes. Health Serv Res 2017; 52(2):634-655.92. Wagner EH, Flinter M, Hsu C, Cromp DA, Austin BT, Etz R, Crabtree BF, Ladden MD. Effective team-based primary care: observations from innovative practices. BMC Fam Pract 2017; 18:13.93. Segalini AM, Weisbrot M, Vietto V, Rezzónico M, Peña FV, Kopitowski K, Terrasa SA. Valoración de la atención primaria de la salud en el Centro de Medi-cina Familiar y Comunitaria San Pantaleón desde la perspectiva de los profesionales de la salud: estudio de corte transversal. Rev Hosp Ital B Aires 2017; 37(1):4-9.94. Wan S, Teichmanb PG, Latifa D, Boydc J, Gupta R. Healthcare provider perceptions of the role of inter-professional care in access to and outcomes of pri-mary care in an underserved area. J Interprof Care 2018; 32(2):220-223.95. Zhou Y, Bai G, Lou L. Development of a hexagonal, mesh-based distribution method for community he-alth centres. Geospat Health 2018;13:2.96. Mukiapini S, Bresick G, Sayed A-R, Le Grange C. Ba-seline measures of primary health care team functio-ning and overall primary health care performance at Du Noon Community Health Centre. Afr J Prm Heal-th Care Fam Med 2018; 10(1):a1458.97. Pandya A, Doran T, Zhu J, Walker S, Arntson E, Ryan AM. Modelling the cost-effectiveness of pay-for-per-formance in primary care in the UK. BMC Med 2018; 16:135.98. Lin Y, Wan N, Sheets S, Gong X, Davies A. A multi-modal relative spatial access assessment approach to measure spatial accessibility to primary care provi-ders. Int J Health Geogr 2018; 17:33.99. Tintorer DL, Domínguez JMM, Pujol-Rivera E, Be-neyto SF, Tuduri XM, Saigí-Rubió F. Keys to success of a community of clinical practice in primary care: a qualitative evaluation of the ECOPIH project. BMC Fam Pract 2018; 19(1):56.100. Arantes LJ, Shimizu HE,Merchán-Hamann E. Ambu-latory care sensitive hospitalizations after implemen-tation of the master plan in Minas Gerais. Rev Saude Publica 2018; 52:78.101. Balasubramanian BA, Marino M, Cohen DJ, Ward RL, Preston A, Springer RJ, Lindner SR, Edwards S, McConnell KJ, Crabtree BF, Miller WL, Stange KC, Solberg LI. Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Prac-tices. Ann Fam Med 2018; 16(Supl. 1):S35-S43.2551Ciência & Saúde Coletiva, 28(9):2537-2551, 2023102. Lima JG, Giovanella L, Fausto MCR, Bousquat A, Silva EV. Atributos essenciais da Atenção Primária à Saúde: resultados nacionais do PMAQ-AB. Saude De-bate 2018; 42(n. esp. 1):52-66.103. Santos LPR, Castro ALB, Dutra CGP, Guimarães RM. Internações por condições sensíveis à atenção primá-ria à saúde, 2008-2015: uma análise do impacto da ex-pansão da ESF na cidade do Rio de Janeiro. Cad Saude Colet 2018; 26(2):178-183.104. Hayhoe B, Cowling TE, Pillutla V, Garg P, Majeed A, Harris M. Integrating a nationally scaled workforce of community health workers in primary care: a mo-delling study. J R Soc Med 2018; 111(12):453-461.105. Fariño Cortez JE, Vera Lorenti FE, Cercado Mancero AG, Velasco Donoso AP, Millaico Noriega MJ, Saldar-riaga Jiménez DG. Satisfacción de usuarios y calidad de atención en unidades primarias de Salud de Mila-gro. INSPILIP 2018; 2(2):2-25.106. Lima-Toivanen M, Pereira RM. The contribution of eHealth in closing gaps in primary health care in se-lected countries of Latin America and the Caribbean. Rev Panam Salud Publica 2018; 42:188.107. Wensing M, Kolle PK, Szecsenyi J, Stock C, Laux G. Ef-fects of a program to strengthen general practice care on hospitalisation rates: a comparative observational study. Scand J Prim Health Care 2018; 36(2):109-114.108. Cole ES. Direct Primary Care: Applying Theory to Potential Changes in Delivery and Outcomes. J Am Board Fam Med 2018; 31(4):605-611.109. Abel J, Kingston H, Scally A, Hartnoll J, Hannam G, Thomson-Moore A, Kellehear A. Reducing emergen-cy hospital admissions: a population health complex intervention of an enhanced model of primary care and compassionate communities. Br J Gen Pract 2018; 68(676):e803-e810.110. Fairall L, Cornick R, Bateman E. Empowering frontli-ne providers to deliver universal primary healthcare using the Practical Approach to Care Kit. BMJ 2018; 363:k4451.111. Ferreira LR, Silva Júnior JA, Arrigotti T, Neves VR, Silva RA. Influences of the program for access and quality improvement in work processes in primary care. Rev Esc Enferm USP 2018; 52:e03407.112. Nabelsi V, Lévasque-Chouinard A, Liddy C, Pilon MD. Improving the Referral Process, Timeliness, Ef-fectiveness, and Equity of Access to Specialist Medical Services Through Electronic Consultation: Pilot Stu-dy. JMIR Med Inform 2019; 7(3):e13354.113. Navathe AS, Emanuel EJ, Bond A, Linn K, Caldarella K, Troxel A, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim S, Lee EO, Mugiishi M, Endo KT, Yoshimo-to J, Yuen I, Okamura S, Stollar M, Tom J, Gold M, Volpp KG. Association Between the Implementation of a Population-Based Primary Care Payment System and Achievement on Quality Measures in Hawaii. JAMA 2019; 322(1):57-68.114. Lenzi H, Ben AJ, Stein AT. Development and valida-tion of a patient no-show predictive model at a pri-mary care setting in Southern Brazil. PLoS ONE 2019; 14(4):e0214869.115. Azogil-López LM, Pérez-Lázaro JJ, Ávila-Pecci P, Me-drano-Sánchez EM, Coronado-Vázquez MV. Efecti-vidad de un nuevo modelo de derivación telefónica compartida entre atención primaria y atención hospi-talaria. Aten Primaria 2019; 51(5):278-284.116. Ballart X, Galais C. ¿Gestión pública, privada o por el tercer sector? Diferencias en los resultados en atención primaria de Cataluña. Aten Primaria 2019; 51(10):610-616.117. Sibbald SL, Selkirk K, Cherla A, Misra V. An Oppor-tunity for Quality: The Need for Better Evaluation of Family Health Teams in Ontario. Healthc Q 2019; 21:4.118. Harzheim E, Chueiri PS, Umpierre RN, Gonçalves MR, Siqueira ACS, D’avila OP, Molina Bastos CG, Katz N, Dal Moro RG, Telles LF, Schmitz CAA. Te-lessaúde como eixo organizacional dos sistemas uni-versais de saúde do século XXI. Rev Bras Med Fam Comunidade 2019; 14(41):1881.119. Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim, E. Recomendações para o fortalecimento da atenção primária à saúde no Brasil. Rev Panam Sa-lud Publica 2020; 44:e4.Article submitted 25/09/2022 Approved 11/01/2023Final version submitted 13/01/2023 Chief editors: Romeu Gomes, Antônio Augusto Moura da SilvaThis is an Open Access article distributed under the terms of the Creative Commons Attribution LicenseBYCC