Abstract

This article aims to analyze the development of pharmaceutical services in the context of the primary health care (PHC) in the period 2008- 2014, focusing on selection, procurement and financing of medicines. A retrospective study was undertaken, using as data sources administrative documents of Rio de Janeiro Municipality Health Secretariat (SMS-RJ) as well as secondary database. We found a growth of numbers medicines offered for PHC of 57 items in 2008 to 222 in 2014. Actual spending on drugs paid by the city has grown 38% in the period, with a reversal from 2010, of the proportion of PHC related to tertiary care drugs, reaching 2.4 times in 2014, the year that public spending on medicines per capita of PHC was 9% greater than the value agreed between the three federal levels. It can be concluded that there have been important changes in pharmaceutical services in Rio de Janeiro Municipality in the period following the reform of PHC held in this territory, with increasing the conditions for therapeutic coverage and increased drug funding. The growth of per capita public spending on medicines above the agreed value raises the need to strengthen the rationalization of management measures.

Pharmaceutical services; Drugs; Health expenditures; Healthcare financing; Primary Health Care

Introduction

The political and administrative decentralization of the SUS (Single Health System), involving individual management at each area of government, was planned in Brazil, with specific emphasis at municipal level. This was because it became essential to expand municipal management liability and capacity¹1. Brasil, Governo Federal. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 20 set.. The aim was that this policy, with its newly acquired universality, would increase the access of the population to therapeutic aid, includingpharmaceutical aid²2. Dourado DA, Elias PEM. Regionalização e dinâmica política do federalismo sanitário brasileiro. Rev Saude Publica 2011; 45(1):204-211.

3. Bodstein R. Atenção básica na agenda da saúde. Cien Saude Colet 2002; 7(3):401-412.

4. Brasil. Presidência da República. Lei nº 12401, de 28 de abril de 2011. Altera a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a assistência terapêutica e a incorporação de tecnologia em saúde no âmbito do Sistema Único de Saúde – SUS. Diário Oficial da União 2011; 29 abr.^-55. Brasil. Decreto nº 7508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde - SUS, o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União 2011; 29 jun..

Brazil’s Política Nacional de Medicamentos (National Medications Policy, hereinafter referred to asPNM) was enacted in1998. Its aim was to ensure the safety, effectiveness, and quality of medications, to promote their rational use, and assure the population of access to essential medications⁶6. Vieira FS, Zucchi P. Distorções causadas pelas ações judiciais à política de medicamentos no Brasil. Rev Saude Publica 2007; 41(2):214-222..

Among thenew PNM guidelines, we highlight, as being of particular interest to this article, the “reorientation ofpharmaceutical aid”. This is based on delegating managementto the municipalities by improving and upgrading the distribution system in the public sector and to develop systems for reducing product prices⁷7. Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria nº 3916, de 30 de outubro de 1998. Aprova a Política Nacional de Medicamentos. Diário Oficial da União 1998; 31 out.. The objective here is to provide primary aid agenda guidance to, and exact the responsibility of, local management authorities.

Although the enactment of the PNMwas a national primary aid achievement, there remained a significant imbalance in the actual municipal level implementation of this and other healthcare policies.Subsequent regulatory attempts sought to fill this gap by stressing the importance of primary aid in resolving healthcare actions, access to medications as a right under the National Healthcare Policy⁸8. Brasil. Conselho Nacional de Saúde. Resolução nº 338, de 6 de maio de 2004. Aprova a Política Nacional de Assistência Farmacêutica. Diário Oficial da União 2004; 7 maio., balancing primary aid financing via the SUS¹1. Brasil, Governo Federal. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 20 set.,explaining the mechanisms of integral pharmaceutical aid, and the role of essential medications⁴4. Brasil. Presidência da República. Lei nº 12401, de 28 de abril de 2011. Altera a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a assistência terapêutica e a incorporação de tecnologia em saúde no âmbito do Sistema Único de Saúde – SUS. Diário Oficial da União 2011; 29 abr.^,55. Brasil. Decreto nº 7508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde - SUS, o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União 2011; 29 jun..

Primary aidhas introduced an interconnected and interdependent activity package⁷7. Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria nº 3916, de 30 de outubro de 1998. Aprova a Política Nacional de Medicamentos. Diário Oficial da União 1998; 31 out.^,88. Brasil. Conselho Nacional de Saúde. Resolução nº 338, de 6 de maio de 2004. Aprova a Política Nacional de Assistência Farmacêutica. Diário Oficial da União 2004; 7 maio., where the selection, programming, storage, distribution, expiration, dispensing, and use of medications occurs under the auspices of the healthcare system⁹9. Pereira NC, Luiza VL, Cruz MM. Serviços farmacêuticos na atenção primária no município do Rio de Janeiro: um estudo de avaliabilidade. Saúde Debate 2015; 39(105):451-468..

The SUS financing mechanisms, a crucial aspect for enabling action have gradually been improved and have directly impacted primary aid activities and management. Furthermore, as a result of the Federal Government’s proposed investment in primary healthcare services as a key service network, the level of importance ofassistênciafarmacêuticabásica(basic pharmaceutical aid, hereinafter referred to as AFAB)was significantly raised in management’s agenda.

Since 1999, when AFABcommenced, resources rose by 391% — fromR$2,00 to the current R$9,82 per person per annum¹⁰10. Silva RM, Caetano R. Gastos da Secretaria Municipal de Saúde do Rio de Janeiro, Brasil, com medicamentos: uma análise do período 2002-2011. Cad Saude Publica 2014; 30(6):1207-1218.. TheMinistério de Saúde(Ministry of Health, hereinafter referred to asMS)has created a number of support aids focusing on medication planning, selecting, and purchasing actions, to upgrade technical quality, be thisin a management or aid context¹¹11. Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Diretrizes para estruturação de farmácias no âmbito do Sistema Único de Saúde. Brasília: MS; 2009..

The aim of medication selection is to define, based on scientific evidence, the range of medicationsto which the Government can commit and on which it should offer guidance from production planning through to assuring the availability of the respective products. This is an integral part of technical and aid actions, since it is the basis for classifying the correct use of such medications.¹²12. Marin N, Luiza VL, Osorio-de-Castro CGS, Machado-dos-Santos S. Assistência Farmacêutica para gerentes municipais. Rio de Janeiro: OPAS, OMS; 2003.

These technical and aid actionsinvolve the creation of logistical and administrative management stages¹²12. Marin N, Luiza VL, Osorio-de-Castro CGS, Machado-dos-Santos S. Assistência Farmacêutica para gerentes municipais. Rio de Janeiro: OPAS, OMS; 2003..

Purchasing includes procedures whereby the acquisition process of the medications, duly defined during the selection stage, occursin the volumes and within the deadlines established by the program. This also covers quality and a regular supply system.In public administration, purchasing is also subject to specific criteriadefined by the law, aimed at ensuring financial justification; fair competition for suppliers, and procedural integrity and transparency¹³13. Bevilacqua G, Farias MR, Blatt CR. Aquisição de medicamentos genéricos em município de médio porte. Rev Saude Publica 2011; 45(3):583-589..

There are still a number of challenges to be met before the AFAB is implemented at local level¹⁴14. Brasil. Conselho Nacional de Secretários de Saúde (CONASS). Assistência farmacêutica no SUS. Brasília: CONASS; 2011.

15. Mendes LV, Campos MR, Chaves GC, Silva RM, Freitas PS, Costa KS, Luiza VL. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde Em Debate 2014; 38(n. esp.):109-123.^-1616. Vieira FS. Qualificação dos serviços farmacêuticos no Brasil: Aspectos inconclusos da agenda do Sistema Único de Saúde. Rev Panam Salud Publica 2008; 24(2):91-100.. These relate to the various policies in place and also to the considerable progress made by Brazilian municipalities in providing access to medication¹⁴14. Brasil. Conselho Nacional de Secretários de Saúde (CONASS). Assistência farmacêutica no SUS. Brasília: CONASS; 2011.. Also, primary aid related management actions have caused considerable concern for the administrators, managers, and professionals in this area due, not only to the total financial resources involved, but also to the scope of the actions and services required. The implementation of a number of measures has not always led to successful results due to the possible flaws in the methods and tools, administrative and financial problems, and limited management and operating capacity⁹9. Pereira NC, Luiza VL, Cruz MM. Serviços farmacêuticos na atenção primária no município do Rio de Janeiro: um estudo de avaliabilidade. Saúde Debate 2015; 39(105):451-468.^,1515. Mendes LV, Campos MR, Chaves GC, Silva RM, Freitas PS, Costa KS, Luiza VL. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde Em Debate 2014; 38(n. esp.):109-123..

In 2009, theSMS-RJbegana technical and management primary health care reform. An example of this new policy is the expanded coverage offered by the Estratégia de Saúde da Família (Family Health Strategy, hereinafter referred to as ESF) at 3.5% in 2008, the lowest rate among Brazilian capital cities which had increased to close to 40% by 2013¹⁷17. Brasil. Ministério da Saúde. Evolução do credenciamento e implantação da estratégia Saúde da Família 2012. [acessado 2015 set 15]. Disponível em: http://dab.saude.gov.br/historico_cobertura_sf.php.
http://dab.saude.gov.br/historico_cobert... . The proposed model is based on a multi-professional team, where healthcare is viewed in its widest context. Pharmaceutical services play a vital role in healthcare service results, since the guarantee access to, and appropriate use of, quality medicine as in the case of management sustainability, thanks to its potential for contributing to cost rationalization.

The aim of this article is to analyze how pharmaceutical aidhas developed in the Rio de Janeiro municipality’s healthcare performance, from 2008 through 2014, with particular attention to the financing, selection, and purchase of medications.

Method

This is a longitudinal and retrospective study, based on secondary data, sourced viaboth free and internal accessto the Rio de Janeiro municipal administration authorities.It seeks to define the technical and administrative organization of local pharmaceutical aid, from 2008 through 2014. In other words, we included the year prior to the municipal primary aid reform.Besides being based on access availability and feasibility, the choice of aspects and data analyzed was also guided by sensitivity, within the scope of the AFAB, to the changes that occurred during this research period.

The SMS-RJ is responsible for formulating and carrying out municipal healthcare policies. It is composed of five sub-secretariats, two of which specifically involved with the aid network. Among other duties, the Subsecretaria de Atenção Hospitalar, Urgência e Emergência (Hospital, Urgencies, and Emergencies Sub-Secretariat, hereinafter referred to as SUBHUE) is responsible for a wide range of own hospitals of varying levels of treatment complexities. The Subsecretaria de Atenção Primária, Vigilância e Promoção de Saúde (Primary Aid, Vigilance, and Healthcare Promotion Sub-Secretariat, hereinafter referred to as SUBPAV) organizes theprimary aid, with its basic healthcare units (family clinics, polyclinics, healthcare centers). It is currently undergoing a major expansion process aimed at increasing ESFcoverage, via contracting the Organizações Sociais (Social Organizations, hereinafter referred to as OS). Healthcare organization is decentralized and distributed over ten health districts known as Planning Areas. These areas have an organizational structure known as Coordenação de Áreas de Planejamento (Coordination of Planning Areas, hereinafter referred to as CAP), which manages promotion and healthcare aid actions at primary aid level, in areas of coverage formed into groupings of zones, created on a territorial basis¹⁸18. Rio de Janeiro. Secretaria Municipal de Saúde. Plano Municipal de Saúde do Rio de Janeiro 2010-2013. [acessado 2015 set 15]. Disponível em: http://www.rio.rj.gov.br/dlstatic/10112/3700816/4130215/PLANOMUNICIPALDESAUDE20102013.pdf
http://www.rio.rj.gov.br/dlstatic/10112/... .

Despite not yet being formally listed in the municipal organization chart, SMS-RJ has a technical advisory area which provides assessoria no nível central (central level advisory services, hereinafter referred to as NAF-RJ), responsible for pharmaceutical aid policy, organization, and distribution of actions at the various healthcare attention levels. Primary aid management for the Municipality of Rio de Janeiro is hierarchical and decentralized within the CAP, which has regional units dedicated to Pharmaceutical Aid (NAF-regional) activities, and share specific central and local management responsibilities¹⁹19. Rio de Janeiro. Secretaria Municipal de Saúde e Defesa Civil. Manual de Instruções, Diretrizes e Procedimentos Operacionais da Assistência Farmacêutica 2011. [acessado 2015 set 15]. Disponível em: http://subpav.org/download/assfarm/assfarm_Diretrizes_AF_na_SMSDC_SUBPAV.pdf
http://subpav.org/download/assfarm/assfa... .

Medication selection data was obtained via the versions of the Rio de Janeiro Relação Municipal de Medicamentos (Municipal Medications List, hereinafter referred to as REMUME_RIO) freely available in copies of the Diário Oficial do Município (Official Municipal Daily Paper), available in the SUBPAV website²⁰20. Rio de Janeiro. Secretaria Municipal de Saúde. Relação Municipal de Medicamentos Essenciais (REMUME-Rio) 2013. [acessado 2015 set 12]. Disponível em: http://subpav.org/download/assfarm/REMUME-RIO%202013.pdf
http://subpav.org/download/assfarm/REMUM... .

The range of medications specifically available for SMS-RJ primary aid from 2008 through 2014was based on electronic spreadsheet medication requests. These were used as a parameter for supplying the basic units, with January as the reference month, and involve the possibility of inclusion or exclusion of given items throughout each year. The medications were classified under pharmacological groups, as per the anatomical therapeutic chemical (ATC) system, according to the most recent issue of REMUME_RIO, in 2013²⁰20. Rio de Janeiro. Secretaria Municipal de Saúde. Relação Municipal de Medicamentos Essenciais (REMUME-Rio) 2013. [acessado 2015 set 12]. Disponível em: http://subpav.org/download/assfarm/REMUME-RIO%202013.pdf
http://subpav.org/download/assfarm/REMUM... .

Pharmaceutical aid financing data on medication purchase expenses were obtained from the Sistema de Informação sobre Orçamentos Públicos em Saúde (Public Healthcare Budget Information System, hereinafter referred to as SIOPS), using the methodology applied by Vieira & Zucchi²¹21. Vieira FS, Zucchi P. Financiamento da assistência farmacêutica no sistema único de saúde. Saude Soc 2013; 22(1):73-84..

The method applied for searching in SIOPS²²22. Brasil. Ministério da Saúde (MS). Sistema de Informação sobre Orçamentos Públicos em Saúde (SIOPS). [acessado 2015 set 26]. Disponível em: http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/siops
http://portalsaude.saude.gov.br/index.ph... was as follows: Data advised>Municipalities>Consultation of one or more accounting codes, by economic classification, for a municipality, per year or by historic series. The parameters applied to obtain the data for all the years assessed were: “Municipality: Rio de Janeiro”; “Type: Expense”; “File: Direct administrative expense - Healthcare”; “Stage: Concluded”; “Stage: Ongoing”; “Classification: all codes whose title included the phrase “os códigos cujo título continha a palavra medicamentos” (“all codes whose title included the word ‘medications’”). In this last case, it should be noted that the decision was taken to only utilize code “3.3.3.90.30.09.00 - medications” since this covered the expenses incurred in all the years examined. The rare exceptions where expenses in more than one code for the same year were identified, the amounts had been duplicated.

Not only does the public sector purchase cycleinvolve a bid procedure, but so also do other stages of these expenses; these are the budgeting, settlement, and payment stages²³23. Fenili RR. Gestão de Materiais. Brasília: ENAP; 2015.. The first of these requires a prior budget to be drawn up to settle the undertaking, which is processed when management receives the object of the budget, followed by the issue of the formal instruction for payment of the materials supplied²⁴24. Brasil. Portal da Transparência do Governo Federal. [acessado 2015 set 15]. Disponível em: http://www.portaldatransparencia.gov.br/glossario/
http://www.portaldatransparencia.gov.br/... .

Different strategies were required to estimate the amounts involved in the purchases of medication for primary aid use, since the SIOPSreports do notspecify the location where the medications expenditures occurred (whether this relates to a basic network or a hospital). Incoming medications expenditures purchased by the SMS-RJ hospital network were analyzed, using the Sistema de Gestão de Materiais (Materials Management System, hereinafter referred to as SIGMA), which controls all goods purchased and stored in the Rio de Janeiro municipal units²⁵25. Rio de Janeiro. Manual de Operação do SIGMA 2008. [acessado 2015 set 15]. Disponível em: http://www.rio.rj.gov.br/dlstatic/10112/317751/DLFE-190811.pdf/Manual_Sigma_Gestao_Estoques_17102008.pdf
http://www.rio.rj.gov.br/dlstatic/10112/... . Subsequently, the settled amounts from SIOPSwere deducted from hospital purchase expenses, thereby enabling a proxy primary aid medication expense account.

These two medication purchase expense components were fed into an Excel© software database, which is also utilized for analysis purposes, involving the calculation of simple, median, and percentage distribution frequencies.

Average municipal expense estimates per inhabitant and per primary aid visits were calculated.The per capita expense calculations were based on the division of SMS-RJexpenses by the primary aidpurchases of the inhabitants estimated by the InstitutoBrasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics, hereinafter referred to as the IBGE).The average expense per visit was also calculated based on the ratio between the expenses incurred on medication purchases at the primary aidto the group of medication visits recorded by the municipal Sistema de InformaçãoAmbulatorial(Outpatient Attendance Information System, hereinafter referred to as SIASUS) which has the potential for generating medication expiration dates.

The scope of the period assessed required price level restatements of the respective amounts via the Índice de Preços ao Consumidor Amplo (Consumer Price Index – Amplified, hereinafter referred to as IPCA), obtained directly from the Instituto de PesquisaEconômicaAplicada (Institute of Applied Economic Research, hereinafter referred to as IPEA)²⁶26. Instituto de Pesquisa Econômica Aplicada (IPEA) - Ipeadata Macroeconômico. [acessado 2015 set 10]. Disponível em: http://www.ipeadata.gov.br
http://www.ipeadata.gov.br... thereby enabling their comparison with December 2014.

The study complied with the requirements of CNS (National Health Council) Resolution No. 466/2012, from which it obtained authorization to access administrative data not available in free access databases.

Results

The third edition of the REMUME-Rio listing, preceded by the 2004 and 2008 versions²⁰20. Rio de Janeiro. Secretaria Municipal de Saúde. Relação Municipal de Medicamentos Essenciais (REMUME-Rio) 2013. [acessado 2015 set 12]. Disponível em: http://subpav.org/download/assfarm/REMUME-RIO%202013.pdf
http://subpav.org/download/assfarm/REMUM... has been issued and, as in the case of the previous versions, was formalized by an SMS-RJResolution.It contains 386 active principles (except for medical, immunobiological, and sanitation products), totaling 676 specialized pharmaceutical items, distributed over 14 anatomical groups (Anatomical Therapeutic Chemical Code, hereinafter referred to as ATC). The covering document does not specify the formal multidisciplinary commission responsible for defining the range, but was the result of the work of NAF-RJ performed jointly with the managements of care lines of the Superintendência da AtençãoPrimária à Saúde (Primary Healthcare Superintendency) which is part of SUBPAV, and by an analysis of SUBHUE technical assessments. It explains the joint work with Relação Nacional de Medicamentos Essenciais (National Listing of Essential Medicines, hereinafter referred to as RENAME) achieved for 90% of the items²⁰20. Rio de Janeiro. Secretaria Municipal de Saúde. Relação Municipal de Medicamentos Essenciais (REMUME-Rio) 2013. [acessado 2015 set 12]. Disponível em: http://subpav.org/download/assfarm/REMUME-RIO%202013.pdf
http://subpav.org/download/assfarm/REMUM... .

The updated version of the REMUME-Rio 2013 is not accessible on the SMS-RJ website²⁷27. Rio de Janeiro. Secretaria Municipal de Saúde. [acessado 2015 ago 22]. Disponível em: http://www.rio.rj.gov.br/web/sms
http://www.rio.rj.gov.br/web/sms... (searches attempted on a number of different occasions in August 2015), for municipal access, although it is available on the SUBPAV website, although proof of registration is required, which complicates general user access. This website includes a form to be filled out for professionals to request REMUME updates. An electronic mechanism was also introduced, via the web, for consulting REMUME_RIO medication monographs that coincide with the 2010 National Therapeutic Form²⁸28. Rio de Janeiro. Secretaria Municipal de Saúde. Subsecretaria de Atenção Primária, Vigilância e Promoção da Saúde (SUBPAV). [acessado 2015 ago 26]. Disponível em: http://subpav.org/index.php
http://subpav.org/index.php... .

Based on theREMUMEand, in accordance with current ministerial Basic Pharmaceutical Aid Component²⁹29. Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria MS/GM nº 1555, de 30 de julho de 2013. Dispõe sobre as normas de financiamento e de execução do Componente Básico da Assistência Farmacêutica no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2013; 31 jul. financing regulations, the lists available for the various levels of aid, are coordinated by NAF-RJ jointly with the management departments of the healthcare lines.

The range of specialized pharmaceutical items available for primary aidpurposes increased from 57 in 2008 to 222 in 2014.The greatest increments occurred in 2011, 2012, and 2009, when 75, 46, and 45 specialized pharmaceutical items, respectively, were added. 2011 saw a major review in the range of mental health medications and antibioticsavailable to theprimary aid sector. In 2012, among a number of other medications (Chart 1), the range of phytotherapics and of anti-Parkinson’s medications available was increased. 2009 was a reorganization year for municipal primary aid in the municipality, which explains the first major increase in medication availability.

This venture included the decision to fill the pharmaceutical requirements of all primary aid branches. Based on the decision to decentralize the treatments of certain treatable diseases with Strategic Primary Aid Component Medications (tuberculosis and Hansen’s disease) for the entire primary aid network, as in the case of non-contagious diseases, such as asthma, these medications also became available at all branches.This range includes products that, as in the case of mental health treatment medication, that, under federal law, require special controls³⁰30. Brasil. Ministério da Saúde. Secretaria Nacional de Vigilância Sanitária. Portaria nº 344, de 12 de maio de 1998. Aprova o Regulamento Técnico sobre substâncias e medicamentos sujeitos a controle especial. Diário Oficial da União 1998; 31 dez.. This process is likely to lead to conflict, since, frequently, pharmacists decline to accept technical liability before the Regional Pharmaceutical Council, an essential prerequisite for storing and selling prescription-only medications.

The products list is sent to the pharmacists responsible for primary aid who handle different aid points as structured in the electronic medications order spreadsheet, made available via the Regional CAP Pharmaceutical Aid Nucleus (NAF-regional), which regularly communicates any update to the range where upon a new spreadsheet becomes available.This spreadsheet contains only the medications purchased by the SMS-RJ, whereas, the Strategic Primary Aid Component Medications are requested in controlled forms required by the MS, in compliance with the specific requirements of each program.

Throughout the entire assessment period, all programming responsibilities were in the hands of NAF-RJ and were issued annually, based on the budget for the subsequent year. Whenever a new item is added, the corresponding programming process is carried out by NAF jointly with epidemiological healthcare professionals, based on the total estimated cases to be treated over a given period of time, in accordance with standard dosage of the most commonly used dosage in line with technical references.

Financial resources are covered by the amount agreed within the Basic Primary Aid Component, which can increase via municipal treasury coverage to more than the minimal installment established in ministry-issued regulations.

After this programming has received SUBPAV approval, the purchasing by price registration, operated on an electronic bidding process, is ordered. The specifications are pre-established in the Municipal Administration Secretariat products catalogue, the medications group where of is coordinated by NAF-RJ. The latter is also responsible for issuing the technical appraisal, with due regard for compliance with specifications, the validity of the respective medication registration, and certification of good manufacturing practices by production line of the Agência Nacional de Vigilância Sanitária (National Sanitation Authorities).

A real increase in financingwas noted in the amounts allocated to municipal medication purchases. This applied to both the amount budgeted (24%) and the amount spent (38%) from 2008 through 2014 (Graphic 1), where the greatest increase, of 37% was recorded for 2011against 2010. Average settlement of the amounts budgeted within the same year was 82% (SV = 5%) with no clear trend over the years.

Primary aid medication expenses increased by 128% over the period under assessment, against a 29% reduction in hospital medication expenses.This represented 76% in relation to expenses incurred on pharmaceutical productsused in hospitals in 2008,and increased to 244% in 2014 (Table 1).

Medication purchases are carried out by Direct SMS-RJ Administration under aprice registration systemthat dating back to the nineteen-nineties. In 2007, face bidding on the price registration system began. In 2010, this was replaced by an electronic bidding system. For nearly ten years, different purchasing systems have been in place; one for stocking basic units and another for the hospital network. The first, operated and centralized in the SMS-RJ, handles deliveries to the central inventories warehouse to simplify controls and the investment of funds at the AFAB, and has a specific budget title (Work Program). The other system also operates under the auspices of the central SMS-RJ, and controls decentralized deliveries by outsourced suppliers to hospitals that manage and calculate their own budgets³¹31. Rio de Janeiro. Tribunal de Contas do Município (TCM-RJ). Auditoria Operacional TCM-RJ/PROMOEX - Estratégia de Saúde da Família. Rio de Janeiro: TCM; 2009..

A check of the increase in per capita medication costs, both of total medical visits and in respect of the total population, shows a significant increase in the latter and a slightly lower increase in the former. This suggests that the effort to increase the financing of medications was proportional to the extended cover of primary aid. This becomes even more marked when we consider the amount agreed for primary aid medications. Up until 2012, municipal medications expenses per doctor’s visit exceeded the agreed amount and the per capita expense was lower. Since then, with theincrease in doctors’ visits, both categories of expenses exceed the agreed amount (Graphic 2).

Discussion

This article examined certain technical and administrative aspects of pharmaceutical aid in primary aid in Rio de Janeiro. It must be re-emphasized that this was a cross-sectional option utilized for the purposes of this study. In no way does it diminish recognition of the technical and clinical importance of the technical and clinical aspects of primary aid, nor that may these have failed to receive important assistance or to show advances in the municipality.

After an analysis of the selection of medication, financing, and storage of such medications in a time-bound cross-section that covered the year before the primary aid reform through to 2014, some major changes occurred. Despite the fact that this analysis did not allow for causality, and even less for directionsism, it was clearly evident that observable alterations in the aspects of analysis of primary aid appear to have accompanied the changes in overall primary aid organization.

As recommended on a national level⁴4. Brasil. Presidência da República. Lei nº 12401, de 28 de abril de 2011. Altera a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a assistência terapêutica e a incorporação de tecnologia em saúde no âmbito do Sistema Único de Saúde – SUS. Diário Oficial da União 2011; 29 abr., REMUME_RIO has considered medications for all levels of care since its earliest days. Similarly, it has sought to clearly define each level for which the respective medication is available.

A positive factor is the municipality’s effort to formulate its range of essential medications, particularly, its commitment to supply each item under the auspices of SUS.A nation-wide representativity study showed that few Brazilian municipalities prepare their essential medication listings and few managers clearly comprehend their usefulness³²32. Magarinos-Torres R, Pepe VLE, Oliveira MA, Osorio-de-Castro CGS. Medicamentos essenciais e processo de seleção em práticas de gestão da Assistência Farmacêutica em estados e municípios brasileiros. Cien Saude Colet 2014; 19(9):3859-3868..

The REMUME in force at the time this article was submitteddid not include a multidisciplinary committee for its preparation. However, it describes primary aid team discussions with the professionals responsible for care giving management. Despite the fact that this process suggests the involvement of multi-professional knowledge mobilization to define the range, the absence of any explanation from the group of individuals involved in the process erodes its commitment and transparency, given the potential risk of a conflict of interests.

A studyof the perception of Brazilian state and municipal leaders shows that, of the minority who define and formalize their essential medications listing, very few clearly disclose their essential medications listings in their websites³³33. Weber D, Bueno CS, Steiger LL, Oliveira KR. Seleção de medicamentos: uma visão do processo em quatro municípios do Rio Grande do Sul - RS. Rev Bras Farm 2010; 91(3):141-148.. In Brazil, if on the one hand, the process is being continuously structured at national level, as a rule, this does not occur at other levels³⁴34. Magarinos-Torres R, Pepe VLE, Osorio-de-Castro CGS. Estruturação da assistência farmacêutica: plano de ação para a seleção de medicamentos essenciais. Cad Saude Coletiva 2013; 21(2):188-196.^,3535. Rio de Janeiro. Secretaria Municipal de Saúde e Defesa Civil. Superintendência de Atenção Primária. Carteira de Serviços: Relação de serviços prestados na Atenção Primária à Saúde. Rio de Janeiro: SMSDC; 2011.. States and municipalities do not, necessarily, need to establish their local lists and can simply use the national list for their guidance. However, given Brazil’s wide diversity, it seems reasonable that this be done, particularly, in the country’s larger municipalities, which harbor a huge diversity of problems, ranging from the services available to the structuring of a healthcare network. On deciding to draw up their own listings, they should strive to ensure the quality and transparency of their methodologies. The success of listing lies in the shared nature of the selection process, a multi-professional team, and representatives with various degrees of familiarity with fields such as clinical pharmacology, pharmacokinetics, and epidemiology. Its success is closely linked to its legitimacy with healthcare professionals, particularly those who can write out prescriptions, and intergroup disclosure³⁴34. Magarinos-Torres R, Pepe VLE, Osorio-de-Castro CGS. Estruturação da assistência farmacêutica: plano de ação para a seleção de medicamentos essenciais. Cad Saude Coletiva 2013; 21(2):188-196..

Here, in no way, do we dismiss attempts to disclose this listing to primary aid professionals nor the facilitated possibility of electronic consultation of the therapeutic form. But, the more systematic disclosure of the REMUME_RIO, including access by the community, as well as by non-primary aid professionals would seem to represent improvement opportunities that should be introduced.

The increase in quality availability of primary aid items, with the inclusion, not only of new presentations of existing medications, but also coverage of new setbacks has converged with the decision to expand the services portfolio³⁵35. Rio de Janeiro. Secretaria Municipal de Saúde e Defesa Civil. Superintendência de Atenção Primária. Carteira de Serviços: Relação de serviços prestados na Atenção Primária à Saúde. Rio de Janeiro: SMSDC; 2011. and the primary aid assumption of care previously in the hands of reference units or, even, at secondary aid level attention. It also introduced the need to increase the inclusion of pharmaceutical professionals in these units’ teams, thereby enabling the services offered by such professionals. This is an important change, given the evidence that efficient technical management of medication logistics procedures, allied to the involvement of these healthcare professionals, contributes to promoting the appropriate utilization of medications thereby assuring improvements in primary aid services³⁶36. Correr CJ, Otuki MF, Soler O. Assistência farmacêutica integrada ao processo de cuidado em saúde: gestão clínica do medicamento. Rev Pan-Amaz Saude 2011; 2(3):41-49..

The SMS-RJ has a successful purchasing record; so much so that its experience was related in 1999, in the final report issued by the Parliamentary Medication Enquiry Commission, highlighting its success in obtaining substantial price discounts by applying its purchasing power³⁷37. Brasil. Ministério da Saúde. Departamento de Atenção Básica. Histórico de Cobertura da Saúde da Família. [acessado 2015 set 12]. Disponível em: http://dab.saude.gov.br/portaldab/historico_cobertura_sf.php
http://dab.saude.gov.br/portaldab/histor... . A more recent comparative study of purchasing expenses, from 2000 through 2012, involving thirteen medications for treating hypertension, diabetes, asthma, and rhinitis, showed that SMS-RJ tem has obtained lower prices than the Rio de Janeiro State Secretariat and, in a number of cases, similar or lower prices than those researched in the Banco de Preços em Saúde (Healthcare Price Bank)³⁸38. Brasil. Câmara dos Deputados. Relatório da CPI – Medicamentos. Comissão Parlamentar de Inquérito destinada a investigar os reajustes de preços e a falsificação de medicamentos, materiais hospitalares e insumos de laboratórios. Brasília: Câmara dos Deputados; 2000..

Among other reasons, the problems encountered by the public sector in settling supply expenses, among other reasons, are usually linked to deliveries by suppliers close to the end of the financial year, or to circumstances where deliveries are not fully performed in accordance with contractually agreed specifications and agreements. This occasionally results in delivery failures within that financial year³⁹39. Zaire C, Silva RMM, Hasenclever L. Aquisições no âmbito do Sistema Único de Saúde no Rio de Janeiro: o caso dos programas de atenção básica. Cad Desenvolv Flum 2013; (3):62-85..

Specialized literature describes an expansion of medications financing throughout Brazilian national territory. Vieira and Zucchi²¹21. Vieira FS, Zucchi P. Financiamento da assistência farmacêutica no sistema único de saúde. Saude Soc 2013; 22(1):73-84. reported a 314% increase in federal transfers to municipalities for medication purchases from 2005 through 2009, at an average of 53% per annum. Using as their source, registered transfers of funds from the MS to the Fundo Nacional de Saúde (National Healthcare Fund), Silva and Caetano⁴⁰40. Conselho Nacional de Secretarias Estaduais de Saúde. Apresentação das dificuldades enfrentadas pelas Secretarias Estaduais de Saúde na aquisição de medicamentos 2014. [acessado 2015 set 21]. Disponível em: http://www.conass.org.br
http://www.conass.org.br... noted an increase of only 27% from 2008 through 2014 in federal transfers to municipalities for financing the Basic Primary Aid Component.

Also, in their study for this same period, Vieira and Zucchi²¹21. Vieira FS, Zucchi P. Financiamento da assistência farmacêutica no sistema único de saúde. Saude Soc 2013; 22(1):73-84. identified a significantly lower average increase in the allocation of municipal treasuries’ own funds, of approximately 22.7%.

The 38% increase in expenses incurred on medication financing from 2008 through 2014, noted in the municipality of Rio de Janeiro, an average annual increase of 7%, is impressive, especially when compared with the drop of 21% between 2009 and 2010, but which recovered with a 37% increase from 2010 through 2011. If we use SIOPS as a reference, the amount paid out on the purchase of medications as a proportion of total municipal healthcare expenses incurred, in restated amounts, was 2.4%, on average, with fluctuations and an average reduction of 11.5% over the period examined. Another study¹⁰10. Silva RM, Caetano R. Gastos da Secretaria Municipal de Saúde do Rio de Janeiro, Brasil, com medicamentos: uma análise do período 2002-2011. Cad Saude Publica 2014; 30(6):1207-1218. for the same municipality, covering 2002 through 2011, showed a slightly higher average proportion (2.8%), where the expenses incurred on medications remained lower than the increase in total public municipal healthcare expenditures.

We noted an increase in AFAB financing over hospital medication increases, where the inversion of the trend occurred after the year in which the primary aid reform occurred.This ration of primary aid medication in relation to hospital medication was 0.8 in 2008 and increased to 2.4 in 2014. Our findings coincided with those ofSilva and Caetano¹⁰10. Silva RM, Caetano R. Gastos da Secretaria Municipal de Saúde do Rio de Janeiro, Brasil, com medicamentos: uma análise do período 2002-2011. Cad Saude Publica 2014; 30(6):1207-1218., confirming the sustainability of the trend identified. This is important, since the allocation decision clearly reflects management priorities.

We identified an increase in average primary aid medication expenses per capita, in a growth curve behaving in a similar manner to that of the coverage by the ESF team (Graphic 2), where these amounts exceeded, respectively, by R$3,88 and 7.9% in 2008 to R$10,70 and 43.1% in 2014. The result was that the Rio de Janeiro municipality’s expense exceeded the per capita amount agreed as from 2013.

Obviously, the increased ESF coverage was very positive.However, it is equally important to ensure the proportional growth of the support funds in addition to the rationalization achieved in its management. The increase in medication expenses over the primary aid ministerial regulations suggests a financial sustainability risk for the growing ESF coverage scenario, which was still below the 48% target for 2014⁴¹41. Silva RM, Caetano R. Gastos com repasses no financiamento da assistência farmacêutica básica e Programa Aqui Tem Farmácia Popular pelo Ministério da Saúde entre 2006-2014 Anais do 11o Congresso Brasileiro de Saúde Coletiva 2015. [acessado 2015 set 15]. Disponível em: http://www.saudecoletiva.org.br/anais/index_int.php?id_trabalho=4322&ano=&ev=#menuanais
http://www.saudecoletiva.org.br/anais/in... .

Measures for improving medication consumption and use do exist⁴²42. Rio de Janeiro. Secretaria Municipal de Saúde. Plano Municipal de Saúde do Rio de Janeiro 2014-2017. [acessado 2015 set 12]. Disponível em: http://www.rio.rj.gov.br/dlstatic/10112/3700816/4128745/PMS_20142017.pdf
http://www.rio.rj.gov.br/dlstatic/10112/... . The municipality of Rio de Janeiro has already started implementing many of these, as stated by Pereira et al.⁹9. Pereira NC, Luiza VL, Cruz MM. Serviços farmacêuticos na atenção primária no município do Rio de Janeiro: um estudo de avaliabilidade. Saúde Debate 2015; 39(105):451-468.. We highlight the initiative of implementing indicators, among them average expense per prescription filled. However, virtual systems are independently implemented for each OS contracted and units that fully supply information have been included, and this continues in many different ways. As a result, this data cannot be used in the present study for the total period in question.

These measures must be reinforced to enable ESF advances in this territory.

With regard to limtiations, this study was based on secondary data, gathered for management purposes that differed from the aims of the present study. Moreover, the accuracy of this data is beyond the control of the authors. The choice of aspects and of the data utilized was also based on availability. Although a wide range of indicators exists for municipal primary aid, these only relate to the period beginning in 2009. Their implementation tends to be incremental and does not allow for a full view of primary aid at municipal level during the period covered in this article.

This study covered one very large municipality, which restricts any generalization of findings. However, it is reasonable to believe that many of these findings are reflected in other Brazilian scenarios.

The increase in public per capita medication costs reveals the need to reinforce management rationalization measures. This involves requiring authorized access and the appropriate use of these medications by the population, in addition to consideration of the potential insufficiency of the investments in financing the Basic Pharmaceutical Aid Component. We emphasize the need for further in-depth studies on the aspects covered herein. But, these should also include the appropriate group of pharmaceutical technical and support aid. Above all, it is vital to upgrade the development of monitoring indicators enabling familiarity with primary aid results in the context of the end objectives, quality access, and correct use of medications.

In conclusion, there have been major changes in pharmaceutical aid in the municipality of Rio de Janeiro over the period subsequent to primary aid reform carried out in this territory in all the actions assessed. A quality increase occurred in the availability of medications, thereby widening the scope of conditions with coverage and the increase in financing, with an inversion of the ratio of primary care medicine expenses to those incurred by hospitals.

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