INTRODUCTION

Primary care (PC) is conceptualized as the provision of unified health services and the access that oversees the sanitary professionals. These professionals are responsible to approach a range of individual health necessities, which has a sustained bond with the patients in a family and community context ¹.

In the current context of the sanitary crisis of the COVID-19 pandemic, is necessary to reassess and resume the contributions of Barbara Starfield. Starfield has demonstrated that a strong PC, requires putting into practice its essential attributes (Accessibility, longitudinal continuity of care, coordination, and integrality) ².

Likewise, it must be considered the primary ideas of the Declaration of Alma-Ata (1978), which are still considered valid. These invoke the necessity of countries to strengthen the PC ³⁾ to guarantee the best sanitary results confirmed in recent studies⁴.

In Perú, Ministerial Resolution 278-2011/MINSA approves the National plan for strengthening the first level of care ⁵, and the recent legislation N° 30885 establishes the creation and operation of Integrated Health-RIS Networks ⁶; in addition, Ministerial Resolution 969-2021/MINSA approves the National plan for the implementation of Integrated Health Networks ⁷. Although these regulations reflect the efforts aimed at strengthening PC, there are still many challenges and pending gaps.

The COVID-19 pandemic highlighted the precariousness of the health systems. Due to its unpredicTable magnitude, and unique characteristics is responsible for the catastrophic consequences in the community and the breakdown of the sanitary system ⁸. In the initial stages, health centers and health job positions were closed, care accessibility and continuity of care were limited, and face-to-face care was drastically reduced. Also, preventive-promotional activities stopped, and only emergency and urgent care were available. Only cases of acute respiratory symptoms were treated at the hospital level ⁹; this reveals the weak implementation of the PC, a fact that could have contributed to the collapse of the sanitary system.

PC centers are in a unique position to manage the health crisis since it has been shown that they can resolve 80% of general morbidity ^2,4; therefore, 80% of COVID-19 cases with mild symptoms and without hospital admission requirements ¹⁰.

In consequence, there is an urgent need to renew the PC by optimizing its essential attributes ¹¹. These should be considered essential in the process of strengthening the PC strategy ¹². In this way, PC evaluation represents a key instrument for the continuous improvement of health quality and allows evidence-based decision-making. Therefore, the study objective was to evaluate the fulfillment of the primary care attributes, according to the external user's perspective in the context of the COVID-19 pandemic in a Peruvian region.

METHOD

RESULTS

A total of 1,064 users participated, mostly female (78.9%); high school education (53.2%); housewife occupation (48.1%): Integrated Health Insurance (70,3%); self-perception of good health (50,7%); Parcona PC center (19,8%); average age was 45 years (Table 1).

Table 1. Distribution of frequencies, percentages, and descriptive statistics of the socio-demographic, and health variables of the study participants. 

Results reveal that only 35,1% of the external users recognized their primary care center as a gateway to the health system, answering that they will go there when they had a health problem in the future, and 24,1% would recommend their doctor or health center to a friend or relative. The items with the most ¨not at all¨ responses were item 2, referring to the visit of health personnel on the same day if they were ill (48,0%); item 3, on immediate telephone attention, if necessary (30,3%), and item 8, referring to the coordination of care (35,2%) (Table 2).

Tabla 2. Frequency distribution of the PCAT-A10 scale items. 

The mean total score of the PCAT-A10 scale was 17,94 (SD 6,15); a low score indicates the poor performance of the PC during the COVID-19 pandemic. Similar results were revealed for the attributes; first contact 8,13 (SD 3,16), continuity 5,94 (SD 2,37), coordination 1,75 (SD 1,12), globality 2,12 (SD 1,31), and cultural competence 2,76 (SD 1,10).

NCAPC was confirmed by 76,6% (CI 95%:74,0-79,1) of the external users, the highest perception of NCAPC was identified by females (76,9%; CI 95%:74,0-79,7), with no education (87,5%; CI 95%:69,3-1,05), and without any type of health insurance (80,3%; CI 95%:74,9-85,6); however, the differences were not significant (p>0,05). In addition, the perception of the NCAPC was higher in traders (84,6%; CI 95%:61,9-1,07), self-perception of poor health (87,5%; CI 95%:75,3-99,6) and regular (87,1%; CI 95%:78,3-85,1) respectively, in adults aged 30-59 years (76,5%; CI 95%:76,5-82,9) and external users of Parcona health center (100%; CI 95%:1,00-1,00), the statistical differences in these groups were significant (p<0,05). (Table 3)

Table 3. Descriptive and bivariate analysis of socio-labor and health variables according to non-compliance with PC attributes in the study sample. 

CI95%: Confidence intervals at 95%.

Due to the significant differences found, an adjustment was made using generalized linear models. Associated with greater perception of NCAPC were student status (APR = 1,17; CI95%: 1,08-1,27), self-perception of regular health (APR = 1,09; CI95%: 1,02-1,16), adult between 30 to 59 years old (APR = 1,16; CI95%: 1,08-1,24), and being users of Subtanjalla (APR = 0,63; CI95%: 0,48-0,82), Parcona (APR = 1,42; CI95%: 1,34-1,49), and Guadalupe (APR = 1,28; CI95%: 1,14-1,43) health centers, respectively. (Table 4)

Table 4. Crude and adjusted regression models to assess the association between socio-labor and health factors, and non-compliance with PC attributes, in the sample of the study. 

CI95%: Confidence Interval at 95%; CPR: Crude prevalence ratio; APR: Adjusted prevalence ratio.

DISCUSSION

The study describes the compliance of PC attributes in a sanitary region of Peru during the COVID-19 pandemic. Low scores were found in the sample of the study, which reveals a non-compliance of PC essential attributes. Seven out of ten external users reported that attributes were not complied with in PC centers, this is a fact that highlights the weaknesses of the health care system during the sanitary crisis. Before the context of the collapse of the health care system, similar results were reported in several studies ^{14)(15)(16)(17} since PC has had limited development in Latin America and Africa ¹⁸.

Although the differences were significant in the perception of NCAPC according to occupation, self-perception of health, age group, and PC center; the adjusted model showed that the student condition, self-perception of regular health, adults from 30 to 59 years old, and users from Subtanjalla, Parcona and Guadalupe health centers, inferred a higher probability of perceiving that PC attributes are not fulfilled. Therefore, these findings suggest redefining policies for the State's stewardship to guarantee the achievement of the ¨salud para todos¨ project.

Likewise, seven out of ten users consider that the accessibility attribute is not fulfilled in PC centers as reported in other studies ^14,20. This result reveals that PC centers are not assuming their role as the gateway to the system. This fact could limit the resolution of 80% of general morbidity and promote behaviors aimed at seeking health care in the late stages of the disease. On the other hand, user dissatisfaction has increased in PC centers ²¹; with repercussions on user loyalty and first contact.

In addition, there is a persistence of a fragmented health care system in Peru, where 47% of SIS affiliates use care centers and health posts as a gateway to the system; affiliates of other insurance companies use hospitals or clinics, and those who are not insured use pharmacies and drugstores ²². Although, significant progress has been made to improve the accessibility attribute ^5)(6)(7; there is still a limited investment and low-quality management; which results in an inefficient service that does not respond to the health needs of the population. This generates a crisis in the health sector ²³.

Eight out of ten external users perceive that the continuity attribute is not fulfilled and most of them refer that is likely that they will not be attended to by the same physician; similar results were reported in other studies ^14,15. Although, health quality management ¹⁹ and human capital development ²⁴ are essential elements to guarantee the continuity attribute, some factors such as health personnel rotation, the weakening of the support structures for the Health Quality Management System ^25), and user dissatisfaction ²¹, may have repercussions on non-compliance with the longitudinal continuity of care. Another factor to be considered is the lack of resources in PC ⁽²⁶. Fifty-five percent of the PC centers do not have physicians and operate with other types of professionals and technical assistance ²⁷. However, in recent years, significant progress has been made in the development and human capital (HC) management in Peru. Nevertheless, the allocation of human capital in the first level of care (FLC) continues to be a challenge and an obsolete provisional model persists, which has repercussions on the PC's poor functioning ²⁴. There is an urgent need to formulate and develop a National human resources plan to guarantee adequate coverage of health care workers in PC centers ¹⁹. Having HC capable of responding to the health demands and needs of the population is a sectoral priority.

The care coordination attribute is perceived by nine out of ten external users as not very efficient and timely, its non-compliance evidence the limitation of its implementation. Similar results were found in other studies ^14)(15)(28. There are important initiatives in Peru ²⁹; that need to be strengthened to improve the coordination between the different levels of care. This improvement is made through the effective exchange of information between service providers, facilitating an adequate flow of information for integral patient care ³⁰. It is necessary to implement an adequate information system that allows the coordination of health care at the different levels of the system. A good initiative would be to strengthen the implementation of an integrated information system within the Integrated health services network, increase the local management capacity, and have equiTable and sustainable finance ⁷.

The globality of care attribute is considered as the approach to mental health in the current times of pandemic. According to the perception of almost nine out of ten users, this attribute is not met which is consistent with findings from other studies ^14)(15)(30. Although compliance may be limited by the deficient physician training for the PC, the scarce assignment of a psychologist to PC centers, financial resources, and the overload of care; it is necessary to bet on a strengthened PC, and provide it with the necessary resources, and give the leadership that requires and deserves ³¹. It is considered convenient to redirect the supply of health services and guarantee a range of services at the first care level, in, to solve the most frequent health problems of the population, such as physical and psychological sequelae of COVID-19.

Finally, seven out of ten users report that the cultural competence attribute has not been met, therefore, they would not recommend their physicians or health center to a friend or relative; this finding is consistent with studies that report high levels of dissatisfaction in PC centers, in the current context of the health crisis ²¹. Although the COVID-19 pandemic represents an opportunity to improve PC's attributes, it is essential to have social participation in public management, to position PC at the decision-making Table as a priority, and the role of the university in training, university extension, and research in PC an operative level, and a change in the attitude of basic PC teams.

The limitations of the study include the lack of similar research in the current context of the health crisis, which made it difficult to make comparisons. However, this can be also considered a strength since the study is the first of its kind to address this problem in times of pandemic. A casual relationship was not established; nevertheless, characterizing and comparing the study variable is important because it allows us to identify and address specific needs in the analyzed groups. Therefore, future research is required to search for new explanatory variables associated with NCAPC. On the other hand, the reduced 10-item scale could present limitations to assess the different PC attributes, as does the original extensive version. However, several countries have adopted the PCAT in reduced versions, showing strengths, given its applicability as a short instrument; useful content in the current context, accessibility to services, coordination between levels of care, and mental health care from PC are essential priorities.

FINDINGS

From the population's perspective, PC attributes are unfulfilled. This situation reveals weaknesses in the PC functioning, which could have contributed to the collapse of the health care system during the COVID-19 pandemic. There is an urgent need to renew or strengthen policies aimed to improve PC-based health systems to successfully address current health problems and future pandemic events.