Strategies and challenges for integrating PHC with other health system levels: Experiences of major urban centers in Brazil

Integrating PHC services into the healthcare system and coordinating care are not new issues. However, epidemiological changes towards a prevalence of chronic diseases and the acknowledged fragmentation in health service supply continue to challenge consolidation of Brazil’s Unified Health System (SUS) and guaranteed comprehensive care.
This study analyzes strategies and instruments for integrating PHC into the healthcare system in four large urban centers in Brazil.
This research involved case studies, using quantitative and qualitative methodology and conducted on the basis of semi-structured interviews of municipal government health managers, and transverse studies, applying questionnaires to PHC health practitioners and user families.
Strategies developed by the municipalities to ensure integration between PHC and other system levels included: IT-based regulatory systems for health center scheduling of specialized procedures, clinical priority setting, waiting list monitoring, local regulatory commissions in health centers, distribution of specialized care services by health district, regulatory centers for beds and admissions, referrals and counter-referrals among health centers and emergency units, discussion forums between PHC and specialized care, introduction of clinical protocols, lines of care and electronic patient records.
In spite of local measures to integrate PHC into the service system certain challenges remain, such as the difficulty of effecting decentralized regulation from local health clinics, low fees paid by the public system for specialized procedures, difficulty of guaranteeing counter-referral, lack of a federal specialized care policy, presence of various health service providers at the municipal and state levels, and a lack of communication among general practitioners and specialists.