Over time, Primary Health Care (PHC) has acquired different meanings for different people, at specific times and places, which poses important challenges for its understanding. It is necessary to be clear about the time, the social actors involved, the culture and the purposes of the health system on the basis of which PHC is sought to be defined¹.

In the last century, important elements influenced the conception of PHC; the first reference to a hierarchical health system, with “primary health centers” as the gateway for users and integrated with other specialized and hospital care levels, dates back to the 1920s². In conceptual terms, it was from the Conference on Primary Health Care (CPHC), held in 1978 in Alma-Ata, Kazakhstan, that a definition for PHC was sought¹.

As a result of this conference, the Declaration of Alma-Ata emerged, considering PHC as essential health care based on practical, scientifically proven and socially acceptable technology and methods, made universally accessible to individuals and families in the community by means acceptable to them and at a cost that both the community and the country can afford at every stage of their development [...].

Despite the conceptual differences, in the Declaration of Alma-Ata PHC was interpreted as a central strategy for organizing the health system, which was intended to be more equitable, appropriate, and effective to respond to the health needs presented by the population using health services. Considering the several interpretations, PHC has also been understood as a set of activities associated with health promotion, prevention and recovery practices, which may or may not be restricted to the field of health; a level of assistance connected with the other levels that make up the health service system; and as a guiding principle of the actions developed at any time of the care offered by the health system³.

In this perspective, from the academy Primary Care is understood as crucial in the training of future health professionals, since through involvement with it students can perceive the need for health promotion, monitoring of pregnant women and children, the expression of individual problems in the collective dimension, the longitudinal follow-up of patients with chronic diseases, group care, teamwork, the need for intersectoral actions, the perception of a field of complexity that involves suffering that is difficult to dimension, social determination of illness, and other aspects that are little explored in other points of the care networks, given the very characteristics of hospital work and of teaching focused on diseases⁴.

This study aimed at analyzing essence and significance of Primary Health Care from an academic perspective within the field of Nursing, specifically within two Higher Education Institutions in Brazil and Colombia.

# Study design

This is a qualitative study with an exploratory approach, carried out at the State University of Feira de Santana (Universidade Estadual de Feira de Santana, UEFS) in the state of Bahia, Brazil, and at the Pedagogical and Technological University of Colombia (Universidad Pedagógica y Tecnológica de Colombia, UPTC) in Boyacá, Colombia.

# Recruitment of the participants

There were 36 participants in this study: 19 from UEFS and 17 from UPTC; such sampling was defined by progressive inclusion guided by the field findings, confronting them with the theories that demarcate the study object⁵ and by the saturation criterion considering repetitions of the data collected⁶. Thus, the participants were organized in four groups, considering the subsequent inclusion criteria for each one: Group I, managers (2), represented by the coordinator and vice-coordinator of the Nursing Collegiate both possessing a minimum of six (6) months of managerial experience; Group II, teachers (22) having a minimum of six (6) months of experience specifically in curricular components related to theory, practice, and internship in Basic/Primary Health Care settings; Group III, Nursing students (8) from the latter semesters (7th to 10th), who have previously taken academic courses that include the Primary Health Care (PHC) component within the curriculum matrix; Group IV comprises key informants (4) consisting of individuals who have actively participated in the implementation and/or the development of the respective courses, including those involved in curricular modifications. Participants who chose not to participate voluntarily in the research and, consequently, did not sign the informed consent form were excluded.

# Data collection

Data collection was carried out through semi-structured interviews carried out between April 2019 and June 2020. In this context, the interviews were administered by a researcher with a master’s degree in Public Health and a doctorate in Collective Health. The researcher has experience in Research, Family and Community Nursing, Primary Health Care and Social Projects, as well as in disciplinary and interdisciplinary research. The participants were informed about the objectives of the research and other relevant aspects.

In addition to that, in order to complement the field research, the documentary analysis technique was used and were selected fifteen (15) documents related to reports from the World Health Organization, the Pan American Health Organization, the National Primary Care Policy, Nursing Protocols in Primary Care to Health, Political Pedagogical Project of Nursing Courses, laws and resolutions, allowing us to carry out triangulation during data analysis with the combination of different methodologies to research the same phenomenon⁷.

# Data analysis

In delving into the data, Content Analysis method has been implemented considering its distinct emphasis on a category-based approach. This approach involves identifying key categories within the text that encapsulate the core meaning. The qualitative content analysis procedure employed is intricately tied to the research questions, and showcasing a deliberate and systematic approach as suggested by Mayring (2019)⁷. The Content Analysis method was used, systematically facilitating the description of messages and attitudes linked to the context of the utterance, as well as inferences about the data collected⁸, and were approached the three moments: first, data organization, organizing the empirical materials, when the ipsi literis transcriptions of the recorded interviews of the recorded interviews were made and a general reading of the material was carried out, which allowed us to have an initial approximation to the nuclei of meanings contained, particularly in the interviewees' speeches, considering each group of participants. The second moment, data classification, with floating reading, allowed us to apprehend the relevance structures and the nuclei of meanings of the interviews and documents.

In this perspective, the following guiding questions were posed in the interview: What is Primary Health Care? What is the role of nursing in Primary Health Care? What is the importance of the referral and counter-referral process in Primary Health Care? How is continuity of health care guaranteed to the population? Thus, two categories with subcategories emerged: Category 1: Senses and meanings of Primary/Basic Health Care: Academic views on Nursing/Health; and Category 2: Sustainability of the health system in Primary Health Care: Enabling access and coverage in the health services from the first care levels; as well as four subcategories: 1) Primary Health Care: The starting point to ensure health care for people, families and communities; 2) Primary/Basic Primary Health Care: A possibility for Nursing/Health care; 3) Referral and counter-referral process: Strengthening care in the Health Care Networks; and 4) Investment in Primary Health Care: Ensuring continuity of the health care provided to the population.

Finally, at the third moment, final data analysis, was carried out the actual data analysis with deepening of the empirical data, with a view to carrying out the triangulation with these different sources of empirical data collected, also supported by the theoretical framework.

# Ethical considerations

Research based on the 1975 Helsinki Declaration, which describes the ethical principles for research with human subjects, has been considered to minimize risks. In this research, due to its approach with human beings, were complied with the norms proposed in Resolution No. 466 of the National Health Council dated December 12^th, 2012⁹, whose preliminary provisions bring together, from the perspective of the individual and the collectives, four basic principles considered important in Bioethics, such as autonomy, non-maleficence, beneficence, justice and equality, among others, aiming to ensure the rights and duties that refer to the scientific community, the study participants and the State. In addition to that, the project was submitted for appraisal by the Research Ethics Committee of the State University of Feira de Santana (Comitê de Ética em Pesquisa – Universidade Estadual de Feira de Santana, CEP – UEFS), and approved under Opinion No.: 3,194,308. Consequently, it was only after due authorization that was initiated the research. When were started data collection, each participant read and signed the Free and Informed Consent Form (FICF), containing the necessary information to ensure that the subjects voluntarily expresses their intention to participate in the research, after having understood the information they were given about the study objectives, benefits, inconveniences, possible risks and alternatives, as well as their rights and responsibilities.

It is emphasized that while discussing the research results, the empirical data analyzed are identified at the end of each fragment of the speeches by each group to which the study participants belong, accompanied by a number that represents the ascending order of each interview, exemplified as follows: Manager, (Int. M13); Teacher, (Int. Te5); Student, (Int. St); Key informant (Int. KI18).

The group of managers integrates knowledge areas in Health Surveillance, comprising the curricular unit called “Adults' and Older Adults' Health Nursing (UEFS/Brazil) and Pediatric Nursing, working in the curricular unit called “Children's Nursing; Adolescents' Nursing” (UPTC/Colombia). In relation to the training of the teachers, all of them have a graduate course in areas such as Public Health, Collective Health, Nursing, Women's Health, Health Policies, Family Health, Primary Health Care; three (3) at the specialization level; 16 (sixteen) with a Master's degree and three (3) with a PhD. Regarding the knowledge area, the UEFS teachers belonged to the following areas: Health Surveillance (5), Public Management Nursing (4), Women's Health Nursing I (2), Adults' Health Nursing (1), and 10 teachers from UPTC/Colombia belong to the Disciplinary and Deepening area.

As for the key informants from UEFS/Brazil, one of them has a Master's degree in Public Health and the other has a specialization in Teaching Methodology, Research and Nursing Care; at UPTC/Colombia, one is a specialist in Sex Education and the other has a Master's degree in Education with an emphasis on University Teaching. The areas of active knowledge during the respective highlighted performance scopes were Health Surveillance and Women's Health Nursing (UEFS/Brazil) and Disciplinary and Deepening (UPTC/Colombia) (Table 1).

In Group III, according to the curricular matrix of the undergraduate Nursing courses at UEFS/Brazil and UPTC/Colombia, a total of eight (8) students are characterized as follows in the current semesters and curricular unit: one (1) in the fourth semester, Women's and Newborns' Nursing; one (1) in the sixth semester, Adults' Nursing I; three (3) in the eighth semester, Nursing Management in Health Services and Public Health Nursing; and three (3) in the ninth semester, Supervised Internship I and Nursing Internship (Table 2).

The analysis delved into the meanings and meaning of Primary Health Care (PHC), taking into account the ideas extracted from the interviews carried out with representatives of the relevant institutions in their native languages. The exploration began with the subcategory: "Primary Health Care: the starting point to guarantee health care for the individual, family and community." According to managers, the PHC serves as a gateway to the health system, addressing the needs of the population through health promotion and disease prevention actions. For example, one manager highlighted: "[...] Primary Care, which is the gateway to the Unified Health System [...]" (Int. M13). Another manager highlighted the role of PHC in guiding people towards their health needs with a focus on health promotion (Int. M20). Key informants and teachers similarly stressed that PHC is the gateway to the healthcare system, responsible for promotion, protection, recovery, rehabilitation, and dignified death (Int. KI18). The teachers emphasized that PHC must respond to an important part of the population's health problems (Int. Te5), maintaining health, preventing diseases, diagnosing, treating, and rehabilitating patients at all levels of complexity (Int. Te30). The consensus is that PHC is the foundational point to guarantee health care for individuals, families, and communities.

However, UEFS teachers also recognized the perception that PHC is often considered of less importance, despite being the first level of care and people's initial contact with the health service. One teacher expressed: "[...] many times we talk about Basic or Primary Care as something less important, less relevant" (Int. Te5). “[...] it is precisely the first care level made available by the service, offered by the SUS, to the system users [...]” (Int. Te10).

Moving on to the subcategory "Primary Health Care: a possibility for nursing care", the students considered PHC as the user's main access to the health system, with emphasis on health promotion and disease prevention services. Students recognized APS as the gateway, providing essential services based on prevention, treatment, and rehabilitation according to individual needs (Int. St15, St34). The convergence of opinions means that PHC is a significant possibility for nursing care, aligning with the commitment to meet the majority of the population's health needs.

In the category "Sustainability of the health system in Primary Health Care: Enabling access and coverage of health services from the first levels of care", the UEFS professor highlighted the importance of strengthening collaboration between Primary Care and the Assistance Networks. This collaboration aims to facilitate the referral and counter-referral system, improving overall care in the health system (Int. Te4).

Regarding the subcategory "Investment in Primary Care: guaranteeing continuity of care for the health of the population", the UEFS professors highlighted the need to invest in comprehensive care. They emphasized the importance of investing in PHC to guarantee the continuity of health care for the population, stating that the gains from these investments exceed those directed only at the secondary and tertiary prevention levels (Int. Te1, Te12). The claims suggested a prevailing reality in Latin American health systems, where investments tend to be disproportionately directed toward the treatment of chronic diseases at the highest levels of care, potentially diminishing the effectiveness of universal health coverage and quality of life offered by primary care.

While Primary Health Care (PHC) is promoted as a means to achieve Universal Health Coverage (UHC), how it's interpreted can vary widely. Within the Universal Health Coverage (UHC) agenda, PHC describes a basic set of essential services and medicines that are unique to each country. It represents a sophisticated approach to achieving basic universalism, particularly in developing countries⁸. According to this perspective, the statements by the participants in this study they conceived that PHC is the starting point to ensure health care to people, families and communities.

In addition, the primary healthcare approach aims to improve both the extent and equitable distribution of health and well-being. This is achieved by integrating services at the initial care level and within the realm of public health, while empowering individuals and communities⁹. In contrast to the speeches by the UEFS and UPTC teachers, agree with Cárdenas¹⁰ in that there is a clear synonymous ambiguity in the concept of Primary Health Care, which allows for a conceptual confusion with categories that have a historical epistemological relationship with PHC, derived from the critical-social thought currents. Therefore, stresses the importance of unifying conceptual criteria on PHC on the part of the teachers who are responsible for training students in higher education institutions, as referred Bastable¹¹ Nursing is considered one of the professions in the health area with essential performance for its consolidation, especially for the innovative, creative and versatile potential developed in the health promotion and disease prevention actions and in the care offered, especially in rural and deprived areas.

In the same way, as can notice in the participants' statements, there are convergences on the sense and meaning of BHC represented at the users' gateway to the health service network at the first care level in Brazil and Colombia, in addition to signifying a relevant possibility for Nursing/Health care through health promotion and disease prevention actions, with a commitment to respond to most of the population's health needs. Thus, the sense and meaning of PHC/BHC as the primary level of the health care system makes explicit its conception as the way to organize and make the system's gateway work with resoluteness of these services on the most common health problems, with the objective of minimizing economic costs and satisfying the demands of the population, although restricted to first-level care actions¹².

In this context, the document on Renewing Primary Health Care in the Americas¹³ states that a health system based on Primary Care reinforces that this care needs to be comprehensive, integrated and adequate over time, and aimed at disease prevention and health promotion, as well as ensuring the user's first contact with the system, with families and communities as the basis for planning and action.

Recognising the crucial role played by primary care teams, it is imperative to acknowledge their responsibility in establishing a referral and counter-referral process that is carried out in collaboration with the secondary and tertiary levels of healthcare. This collaborative effort serves as a cornerstone in fortifying the foundational principles and coordination of care within healthcare networks. Likewise, highlights the importance of recognizing the responsibility of Primary Care teams to establish a referral and counter-referral process shared with the secondary and tertiary health care levels, with the purpose of strengthening the principles and care coordination in the Health Care Networks. When taking this premise into account, the National Primary Care Policy¹⁴ mentions that shared responsibility between the health teams and Basic Care teams for specific populations provides for a review of the referral practice based on the reference processes, understood as referring PHC users to a more complex service when they need more specialized care^15,16 and on counter-referral: when this specialized need is solved, the professional directs the user to the unit of origin so that care continuity is carried out¹⁷, expanding it to a process of sharing cases and longitudinal monitoring under the responsibility of the Basic Care teams, acting to strengthen its principles and in the role of coordinating care in the Health Care Networks.

However, based on Paixão et al.¹⁸ the referral and counter-referral system becomes precarious and unfeasible when several negative aspects become present in the routine of PHC and of the network services, such as unnecessary referrals, little resolute medical actions at the primary level, infrequent counter-referral, lack of resources and structures and insufficient investments, among others. In this perspective, emphasize that most health systems are focused on hospital care, offering an immediate solution to the population's health problems through specialized care and technological resources¹⁹.

Consequently, in many countries the emergency services are saturated and exceed their response capacity due to the increased care demand that can be solved in the first and second care level. Therefore, it is believed in the evidence which indicates that resorting to PHC/BHC reduces the number of inadequate hospitalizations. By reviewing what Santos et al.²⁰ have sated, it is confirm that the referral and counter-referral system is a mechanism that consists of strategies that allow the population to ensure access to health services, with the support of territorial entities and public service providers in order to ensure continuity of the health care provided to the population. However, for this process to be successful, coordination between the different care levels and the operational capacity of each level according to the needs is essential, considering that users' entry to the system must always be provided from the first care level.

Regarding the investments in PHC/BHC, it is notice that the statements by the UEFS teachers imply a reality that is evident in most health systems in Latin America, given that most investments are directed at the second and third care levels to address chronic diseases of the population. Therefore, systems based on curative and non-preventive cultures continue to generate increased expenses for countries and reductions in universal health coverage and in the improvement of the quality of life offered in Basic Care²¹.

Therefore, investment initiatives focused on PHC necessarily need to consider adequacy of the health units' physical and technological infrastructure, implementation of mechanisms for appreciation and development programs for their professionals, improvement of the management process in all existing basic health care units, implementation of clinical protocols agreed upon with the other units, and permanent incorporation of devices related to health care management, with a view to favoring integration of the professional practices and ensuring care continuity²².

However, in line with such assertion, it is necessary to reinforce investment, especially regarding the personnel sector in PHC, as it is an important part of the solution in the sense of ensuring sustainability of the health system, improving coverage and health of the population and, consequently, strengthening the economy. Consequently, by investing more in PHC/BHC with responsibility in disease prevention and promotion of healthy habits, in the long term, the health system will be able to avoid costs in relation to preventable diseases²³. However, the reality tells us that the countries continue to prioritize a model centered on hospital care, on high technology and on finding cures for diseases²⁴.

In this context, when formulating policies, investments in infrastructure, health workers, technologies and socio-sanitary strategies are not prioritized for effective work with the community, acting on the social determinants and bringing health closer to the people. PHC/BHC makes it clear that investment in increasing the capacity of the first care level for disease prevention, early diagnosis and detection of risk factors is one of the main pillars of the Declaration of Alma Ata and of the Universal Health Strategy diseases²³. It is for this reason that PHC is not “poor quality services for the poor”, but the best investment possible to achieve health for all.

This research aims to enhance the training process of students in Higher Education Institutions by unifying conceptual criteria in approaching various subjects related to Primary Health Care. The goal is to prioritize actions based on health promotion and disease prevention. Nursing is considered one of the essential health professions in consolidating PHC. The importance of enhancing the training, updating, and qualification processes for teachers in subjects related to Primary Health Care is evident. This should be coherent with the national health policy and the reaffirmation of PHC as an integral health model.

Based on the results of this study, it is important to propose further research that evaluates the updated approach to primary healthcare in relation to the contexts in which students carry out their professional practices and the institutions in which they work.

Regarding the analysis of the sense(s) meaning(s) of Primary Health Care, it is noticed convergences in the participants' academic views, as they considered PHC as the starting point and gateway for the population to enter the health care system at the first care level, both in Brazil and in Colombia. In this context, the PHC scenario enables meeting most of the peoples', families' and communities' needs, through health promotion and disease prevention actions. However, there are still some views which consider PHC as a less important service within the care network. Nevertheless, PHC is conceived as a service at the care level that articulates its actions with the secondary and tertiary levels of the health care networks, through a referral and counter-referral process, which, up to this moment, needs to be strengthened with the support, responsibility and integrated work of Primary Health Care teams. In addition, according to the participants of this study, investments represent a relevant aspect in PHC to ensure continuity of the health care provided to the population. It is believe that appropriate investments in PHC make it possible to extend over time the development of actions to promote healthy habits, with the purpose of preventing onset of pathologies, managing to reduce costs to the health system due to the emergence of preventable diseases. Therefore, it is consider that the PHC scenario represents a relevant possibility for the development of Nursing/Health care activities, allowing, through a set of individual, family and collective health actions that involve promotion, prevention, protection, diagnosis, treatment and rehabilitation, to contribute with the commitment to respond to most of the population's health needs.