Abstract

The integration of Integrative and Complementary Practices into public health systems has been the subject of national and international debate. In Brazil, the National Policy on Integrative and Complementary Practices guides the integration of acupuncture into the Unified Health System (UHS). This article explored the availability and/or accessibility of acupuncture in the UHS in 26 municipalities in the XIII Health Region of the State of São Paulo between 2001 and 2011, based on the analysis of Municipal Health Plans, Annual Management Reports and complementary data obtained from Information Systems. The data was analyzed using a framework for policy analysis based on: context, process, content and actors. Results show that the legislative framework provides a favorable environment; however public funding for these activities is particularly limited. Only government actors participated in the decision-making processes; the plans and reports contained inconsistencies both in structure and in the references made to acupuncture; the process showed that the policy helped to describe the organization of the provision of acupuncture services. The study concludes that the integration of acupuncture and use of health management and planning tools is limited in the 26 municipalities and that this precludes monitoring and maintains these practices on the periphery of the system.

Key words
Acupuncture; Unified Health System; Health policy; Document analysis

Introduction

The integration of Integrative and Complementary Practices such as traditional Chinese medicine and acupuncture into public health systems is the subject of national and international debate. In Brazil, the integration of these forms of treatment into the Unified Health System (Sistema Único de Saúde – SUS) is guided by the National Policy for Integrative and Complementary Practices (Política Nacional de Práticas Integrativas e Complementares - PNPIC)¹1. Souza EFAA, Luz MT. Análise crítica das diretrizes de pesquisa em medicina chinesa. Hist Cienc Saude 2011; 18(1):155–174.^–66. Otani MAP, Barros NF. A Medicina Integrativa e a construção de um novo modelo na saúde. Cien Saude Colet 2011; 16(3):1801–1811.. However, the availability and/or accessibility of acupuncture on the public health system remains limited due to a number of factors: lack of public funding for acupuncture; participation in this debate is largely restricted to government actors; lack of reference to acupuncture in key municipal health care management tools.

The World Health Organization (WHO) has developed a number of strategies to promote the integration of Chinese medicine and acupuncture⁷7. Luz MT. VI Seminário do projeto Racionalidades Médicas: estudo comparativo das medicinas ocidental contemporânea, homeopática, tradicional chinesa e ayurvédica em programas públicos de saúde. Rio de Janeiro: Instituto de Medicina Social da Universidade Estadual do Rio de Janeiro; 1996. [Série Estudos em Saúde Coletiva, n. 140].^–99. Luz MT, Camargo Júnior KR. A comparative study of medical rationatilies. Curare Journal of Ethnomedicine 1997; 12: 47–58. and other “nonconventional” therapies into national health systems⁴4. World Health Organization (WHO). Tradicional Medicine Strategy 2014–2023. Geneva: WHO; 2013.^,1010. Organización Mundial de la Salud (OMS). Informe de la Conferencia Internacional sobre Atención Primaria de Salud Alma-Ata. Genebra: OMS; 1978.. An important political and technical landmark in this context was the publication of the document “WHO Traditional Medicine Strategy 2014–2023”.

Apart from providing for access to traditional Chinese medicine, acupuncture, homeopathic medicine, phytotherapy and hydrotherapy on the SUS, the PNPIC, published under the Ministerial Order Nº 971 of May 2006, encourages states and municipalities to develop Integrative and Complementary Practices policies²2. Brasil. Ministério da Saúde (MS). Política Nacional de Práticas Integrativas e Complementares no SUS: atitude de ampliação de acesso. Brasília: MS; 2008. (Série B. Textos Básicos de Saúde)^,1111. Brasil. Ministério da Saúde (MS). Portaria nº 971, de 3 de maio de 2006. Aprova a Política Nacional de Práticas Integrativas e Complementares (PNPIC) no Sistema Único de Saúde. Diário Oficial da União 2006; 4 maio. and, as a result, 22 of the Brazil's 27 states provide traditional Chinese medicine and acupuncture services through the public health system¹²12. Brasil. Ministério da Saúde (MS). Relatório de Gestão 2006/2010. Brasília, DF, 2011. Anexo 03 [acessado 2011 jun 27]. Disponível em: http://189.28.128.100/dab/docs/geral/anexo3_relgestao.pdf
http://189.28.128.100/dab/docs/geral/ane... .

Although evaluations carried out by the Health Ministry¹³13. Brasil. Ministério da Saúde (MS). Relatório de Gestão 2006/2010. Brasília: MS; 2011. suggest that a number of advances have been made towards integrating Integrative and Complementary Practices into the SUS, gaps still exist in monitoring and evaluation and the development and/or adaptation of specific legislation directed at the delivery of these services through the SUS. It is important to note that national research into Integrative and Complementary Practices concentrates mainly on the use of these treatments by the population. Few studies explore the availability and/or accessibility of Integrative and Complementary Practices in local health care systems, which is a major challenge currently facing the SUS¹³13. Brasil. Ministério da Saúde (MS). Relatório de Gestão 2006/2010. Brasília: MS; 2011.^–1818. Álvarez C, Luz S. El uso de medicina alternativa y medicina tradicional en Medellín, 2005. Revista de La Facultad Nacional de Salud Publica 2007; 25(2):100–109.. The aim of this article is therefore to analyze the process of locally integrating acupuncture into the public health system in the 26 municipalities that make up the XIII Health Region (Departamento Regional de Saúde XIII - DRS XIII) in the State of São Paulo.

Methods

The method used comprised document analysis based on a quanti-qualitative approach¹⁹19. Minayo MCS. Pesquisa social: teoria, método e criatividade. 27ª ed. Rio de Janeiro: Vozes; 2008. of key documents produced in the 26 municipalities belonging to the DRS XIII during the period 2001 to 2011, to enable the analysis of the integration of acupuncture before and after the publication of the Ministerial Order Nº 971/2006.

The document analysis drew on the following health care management tools: Municipal Health Plans (Plano Municipal de Saúde - PMS) and Annual Management Reports (Relatório Anual de Gestão - RAG), obtained directly from the DRS XIII and/or the websites of the relevant Municipal Health Departments, and the Management Report Support System (Sistema de Apoio ao Relatório de Gestão – SARGSUS), respectively. Complementary data was also obtained from the Information System of the Department of Information and Information Technology of the Unified Health System (Sistema de Informação do Departamento de Informação e Informática do Sistema Único de Saúde – DATASUS), the National Registry of Health Facilities (Cadastro Nacional dos Estabelecimentos de Saúde – CNES) and Outpatient Information System (Sistema de Informação Ambulatorial do SUS – SIA/SUS).

PMSs and RAGs are the basic instruments of the SUS's health planning system. PMSs guide the management of the SUS at every level and the annual organization of actions and health services, while the RAG is a monitoring instrument used for measuring health care management performance, to evaluate the use of resources, present results and guide any necessary modifications to the plan²⁰20. Brasil. Ministério da Saúde (MS). Lei nº 8.142, de 28 de dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde—SUS e sobre as transferências intergovernamentais de recursos financeiros na área de saúde e dá outras providencias. Diário Oficial da União 1990; 29 dez.^,2121. Brasil. Ministério da Saúde (MS). Portaria nº 3.085, de 1 de dezembro de 2006. Regula o Sistema de Planejamento do SUS. Diário Oficial da União 2006; 2 dez..

Printed copies of the PMSs were made available by the DRS XIII Results Monitoring and Evaluation Unit (Núcleo de Avaliação e Monitoramento de Resultados do DRS XIII) of the Center for Health Planning and Evaluation (Centro de Planejamento e Avaliação em Saúde). However, it was not possible to obtain printed copies of all PMSs for the study period and it was therefore necessary to contact the Municipal Health Departments by telephone or access their website in an attempt to obtain digital copies of the plans.

To obtain the RAGs, the State of São Paulo section of the SARGSUS²²22. Sistema de Apoio ao Relatório de Gestão. SARGSUS. SGEP—Secretaria de Gestão Estratégica e Participativa. [acessado 2013 ago 12]. Disponível em: http://aplicacao.saude.gov.br/sargsus/login%21carregaRelatorioExterno.action?codUf=35&codTpRel=01
http://aplicacao.saude.gov.br/sargsus/lo... was searched between 10 and 21 December 2012 using the following variables: type (municipal), municipality (the 26 municipalities belonging to the DRS XIII), and year (2007 to 2011). The search yielded the following findings: RAGs examined and approved by the Health Council, but not available in digital form; or RAGs available for download in pdf format. The websites of the Municipal Health Departments were also consulted in an attempt to find RAGs produced in the period prior to 2007.

Complementary data was also obtained from the DATASUS website²³23. Departamento de Informática do Sistema Único de Saúde—DATASUS. Informações de Saúde (TABNET) – Assistência à Saúde. [acessado 2013 ago 12]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=0202
http://www2.datasus.gov.br/DATASUS/index... ^,2424. Departamento de Informática do Sistema Único de Saúde - DATASUS. Informações de Saúde (TABNET) - Rede Assistencial. [acessado 2013 ago 12]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=0204&id=6906
http://www2.datasus.gov.br/DATASUS/index... , which shows municipalities with some kind of record (registered services, doctor's appointments and procedures) related to acupuncture. The search for information on acupuncture in the municipalities belonging to the DRS XIII available for the period 2001 to 2007 was carried out by selecting the option ‘health information (TABNET)’, followed by the options ‘health care’, ‘outpatient services between 1994 and 2007’ and ‘State of São Paulo’. Data was collected using the following variables: Health Region/Municipality (line), year/processing (column) quantity presented (content), period available (January 2001 to December 2007), Health Region (Ribeirão Preto); Proced. after 10/99: 0701234 – acupuncture medical appointment.

The search for information available for the period 2008 a 2011 was carried out by selecting the option ‘health information (TABNET)’, followed by the options ‘care network’, ‘CNES-facilities’, ‘service/classification – up to 2008’, and ‘State of São Paulo’. Data was collected using the following variables: Health Region/Municipality (line), year/month (column), quantity (content), periods available (all), Health Region (Ribeirão Preto), type of service provider (public) and service classification (acupuncture). This search was then repeated using the option ‘service/classification – from March 2008’ for the variable ‘periods available’ (March 2008 to December 2011).

The inclusion criterion used for the above searches was the appearance of the terms “acupuncture” and/or “traditional medicine”, “practices”, “complementary”, “alternative”, “integrative”, “natural” and “nonconventional” individually or together.

The above documents reveal the degree of political commitment shown by the health manager and his/her management team to Integrative and Complementary Practices, while policy analysis reveals the content of policy ²⁵25. Mattos RA, Baptista TWF. Caminhos para análise das políticas de saúde, 2011. [acessado 2011 set 9]. Disponível em: http://www.ims.uerj.br/ccaps/wp-content/uploads/2011/10/LivroCompleto-versao-online.pdf
http://www.ims.uerj.br/ccaps/wp-content/... . Documentary research therefore facilitates knowledge acquisition and is one of the most widely used methods for obtaining the necessary data to develop a greater insight into the research problem²⁶26. Barros AJP, Lehfel NAS. Fundamentos da Metodologia: um guia para a iniciação científica. São Paulo: Mc Graw-Hill; 1986..

The PMSs and RAGs were analyzed using a framework for policy analysis developed by Araújo and Maciel²⁷27. Araújo JLJ, Maciel RF. Developing an operational framework for policy analysis. Rev Bras Saude Matern Infantil 2001; 1(3):203–221. based on four categories: context, process, content and actors. The study was approved by the Ethics Committee of the School of Nursing of the University of São Paulo.

Results

The search process resulted in a total of 32 PMSs, which is equivalent to 41% of an estimated 78 plans developed in the 26 municipalities belonging to the DRS XIII during the period 2001 to 2011, meaning that 46 PMSs, or 59% of the estimated total, were not found. Five of the 32 plans (15.6%) mentioned the term “acupuncture”, while 27 (84.4%) made no mention of this type of treatment. Figure 1 shows these results by municipality. It is important to highlight that only one municipality (M18) mentioned acupuncture in all the PMSs produced during the period; however, none of these plans mentioned funding for this type of treatment.

Figure 2 shows the RAGs found and those that mentioned acupuncture guidelines and/or actions by municipality. A total of 45 RAGs were found for the 26 municipalities, which is equivalent to 15.7% of the total expected number of 241. Acupuncture was mentioned in seven of the RAGs produced by municipality M18 between 2005 and 2011 and in one RAG produced by municipality M16 in 2011. It is important to note that only the RAG produced by municipality M18 in 2010 mentions funding and that the amount is mentioned is zero.

A total of three PMSs and seven RAGs produced by the municipality M18 were analyzed: one PMS for the period 2001 to 2004 (RAGs were not available for this period); one PMS and five RAGs for the period 2005 to 2009; one PMS concerning the period 2010 to 2013; and two RAGs from the period 2010 to 2011.

Acupuncture was referred to in the form of proposals, goals, actions and expected results, as shown by the following extracts: “Develop acupuncture actions […]” (PMS 2001 to 2004); “Develop partnerships to consolidate natural health practices” (PMS 2005 to 2008); “Disseminate the basic principles of Integrative and Complementary Practices” (RAG 2006, RAG 2009); “Consolidate and implement a Department of Health Acupuncture Program, in accordance with the parameters of the Ministerial Order Nº 971 of 3 May 2006 […]” (RAG 2006, RAG 2009); “Expand the Program Coordination team, incorporating a health care professional specialized in the area” (RAG 2011).

A number of government actors were identified in the documents produced by M18: the RAG referred to the “Town Council and the Department of Health”, while the PMSs mentioned the “Town Council, the Municipal Health Secretary, Assistant to the Municipal Health Secretary, the Health Planning Division (responsible for coordinating and preparing the PMS), the technical teams of the departments, divisions and programs of the Municipal Health Department, the Municipal Health Council, representatives from partner education institutions and participants from the integration workshops”.

Figure 3 presents the results of the search of the DATASUS, SIA/SUS and CNES, which showed that six municipalities (23.1%) made some kind of reference to acupuncture between 2001 and 2011.

The analysis of the PMSs and RAGs and complementary data obtained from DATASUS, SIA/ SUS and CNES showed that seven municipalities from the DRS XIII (26.9%) made some kind of reference to acupuncture in at least one of these data sources between 2001 and 2011: M1, M3, M9, M14, M16, M18 and M26 (Chart 1).

Discussion

During the period 2001 to 2011, the macro context, involving the SUS and PNPIC at national level, and the micro context, in terms of local/ municipal acupuncture policy, have been the backdrop of important political, economic and social changes²⁸28. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. O sistema de saúde brasileiro: história, avanços e desafios. Lancet (Série Brasil) [Internet]. 2011; 11–31. [acessado 2011 set 8]. Disponível em: http://download.thelancet.com/flatcontentassets/pdfs/brazil/brazilpor1.pdf
http://download.thelancet.com/flatconten... . During this period a national legal framework was developed to strengthen the structure of the SUS, support and inform health system planning and management, and promote the regionalization, decentralization and municipalization of health services²⁹29. Brasil. Ministério da Saúde (MS). Sistema de Planejamento do SUS (PlanejaSUS):uma construção coletiva trajetória e orientações de operacionalização. Brasília: Organização Pan-Americana da Saúde; 2009.^–3131. Brasil. Ministério da Saúde (MS). Portaria no 2.751, de 11 de novembro de 2009. Dispõe sobre a integração dos prazos e processos de formulação dos instrumentos do Sistema de Planejamento do Sistema Único de Saúde (SUS) e do Pacto pela Saúde. Diário Oficial da União 2009; 12 nov.. However, at the same time, this period was marked by profound funding problems, resulting from the noncompliance with Constitutional Amendment 29 in all three levels of government, leading to chronic underfunding of the public health sector³²32. Carvalho G. Financiamento da saúde pública no Brasil no pós-constitucional de 88. Tempus - Acta de Saude Coletiva 2008; 2(2):39–51..

The PNPIC was created within this context in 2006, the fruit of joint efforts made during various national health conferences and recommendations of the WHO, but without the due allocation of resources. The policy is considered a breakthrough and important landmark for the integration of nonconventional practices into the SUS, and it is widely recognized that it has led to a movement away from the informal sector towards the integration of Integrative and Complementary Practices into the health system³³33. Simoni CD. Processo de institucionalização das RM e PICS: relato de uma experiência de gestão. In: Nascimento MC, Nogueira MI, organizadores. Intercâmbio solidário de saberes em saúde: racionalidades médicas e práticas integrativas e complementares. São Paulo: Hucitec; 2013. p. 206–15..

At a regional level, the DRS XIII is composed of 26 municipalities and has an estimated population of 1.2 million people³⁴34. Instituto Brasileiro de Geografia e Estatística (IBGE). 29 de novembro de 2010. Censo Populacional 2010 (PDF). Arquivado do original em 21 de maio de 2011. [acessado 2010 dez 11]. Disponível em: http://cidades.ibge.gov.br/xtras/perfil.php?codmun=354340. Half of this population lives in municipality M18, which is the administrative center of the health region and regional referral center and therefore plays an important role in the delivery of health services. Considered a “technology hub”, the municipality is ranked thirtieth in terms of GDP³⁴34. Instituto Brasileiro de Geografia e Estatística (IBGE). 29 de novembro de 2010. Censo Populacional 2010 (PDF). Arquivado do original em 21 de maio de 2011. [acessado 2010 dez 11]. Disponível em: http://cidades.ibge.gov.br/xtras/perfil.php?codmun=354340. In recent years it has experienced strong economic growth and social development and the Human Development Index is 0.855³⁵35. Federação das Indústrias do Estado de São Paulo (Fiesp). Índice de Desenvolvimento Humano (IDH). Estado de São Paulo. Ranking municipal de IDH. [acessado 2013 set 6] Disponível em: http://apps.fesp.com.br/regional/DadosSocioEconomicos/RankingIDH.aspx
http://apps.fesp.com.br/regional/DadosSo... , which is the sixth highest in the state.

The micro context reflects and is reflected by the macro context, given the advances in integrating Integrative and Complementary Practices into the SUS both at a local and national level. However, nearly a decade after the policy was created, underfunding and other problems mean that the implementation of the PNPIC remains limited and there is little prospect for a closer integration of Integrative and Complementary Practices into the system.

The lack of PMSs and RAGs in the municipalities belonging to the DRS XIII raises a number of questions: do these tools have the potential to help municipalities plan and manage health services? Why have these tools not been effectively used? How were actions determined? How does decision making take place and which actors are involved in the process? What criteria are used to determine priority actions and resource allocation? How were the commitments to action determined? How is the implementation of health policies monitored and evaluated in these municipalities?

In 2000, the Ministry of Health began to develop a strategy to monitor and evaluate health policies and programs implemented under the SUS, and a number of evaluation tools gradually took shape throughout the following decade²⁹29. Brasil. Ministério da Saúde (MS). Sistema de Planejamento do SUS (PlanejaSUS):uma construção coletiva trajetória e orientações de operacionalização. Brasília: Organização Pan-Americana da Saúde; 2009.^,3030. Brasil. Ministério da Saúde (MS). Portaria no 3.332 de 28 de dezembro de 2006. Aprova orientações gerais relativas aos instrumentos do Sistema de Planejamento do SUS. Diário Oficial da União 2006; 29 dez.^,3636. Brasil. Ministério da Saúde (MS), Instituto de Saúde Coletiva da Universidade Federal da Bahia, Instituto Materno Infantil Prof. Fernando Figueira. Avaliação na Atenção Básica em Saúde: caminhos da institucionalização. Brasília: MS; 2005.. However, evaluation processes are based on an approach which pays little regard to health management practices and tend to be more prescriptive, bureaucratic and punitive than supportive when it comes to planning and management³⁶36. Brasil. Ministério da Saúde (MS), Instituto de Saúde Coletiva da Universidade Federal da Bahia, Instituto Materno Infantil Prof. Fernando Figueira. Avaliação na Atenção Básica em Saúde: caminhos da institucionalização. Brasília: MS; 2005.. It is believed, therefore, that this situation may be one of the factors that explain the significant lack of documents for the period 2001 to 2011. However, it is also important to note that all the PMSs

from the last four-year period and all the RAGs from 2011 were found, which suggests that these evaluation strategies were an important or even determining factor influencing the use of these management tools in the municipalities belonging to the DRS XIII.

Of the documents analyzed by this study, 84.4% made no reference to acupuncture, suggesting that there is a lack of availability of acupuncture in these municipalities. This finding could be explained by a possible underreporting of the availability of acupuncture in the local health care system. Before the creation of the PNPIC, in the absence of specific guidelines, treatments were often not registered by the state and municipal public health systems²2. Brasil. Ministério da Saúde (MS). Política Nacional de Práticas Integrativas e Complementares no SUS: atitude de ampliação de acesso. Brasília: MS; 2008. (Série B. Textos Básicos de Saúde). The PNPIC defines clear guidelines, objectives and responsibilities across all three levels of government, and provides that the municipal health manager should “establish management tools and indicators for monitoring and evaluating the impact of the implementation of the Policy”²2. Brasil. Ministério da Saúde (MS). Política Nacional de Práticas Integrativas e Complementares no SUS: atitude de ampliação de acesso. Brasília: MS; 2008. (Série B. Textos Básicos de Saúde). Not registering services provided at local level would therefore be an infringement of this provision.

Another explanation for the lack of availability of acupuncture could be the lack of priority given to acupuncture on the political agenda at municipal level, which means that it is not possible to implement the guidelines of the PNPIC and structure and strengthen services to integrate this type of treatment across all levels of the health system, particularly within primary care²2. Brasil. Ministério da Saúde (MS). Política Nacional de Práticas Integrativas e Complementares no SUS: atitude de ampliação de acesso. Brasília: MS; 2008. (Série B. Textos Básicos de Saúde). This situation helps to maintain the PNPIC and acupuncture, together with the universality of access and comprehensiveness inherent to the policy and related practices, on the periphery of the health system.

Apart from the small number of documents found by the searches, shown in Figures 1 and 2, Chart 1 shows that only seven of the 26 municipalities (26.9%) where documents were found made some kind of reference to acupuncture in at least one of the data sources between 2001 and 2011. Organized planning is essential for the effective development of health actions²¹21. Brasil. Ministério da Saúde (MS). Portaria nº 3.085, de 1 de dezembro de 2006. Regula o Sistema de Planejamento do SUS. Diário Oficial da União 2006; 2 dez.^,2929. Brasil. Ministério da Saúde (MS). Sistema de Planejamento do SUS (PlanejaSUS):uma construção coletiva trajetória e orientações de operacionalização. Brasília: Organização Pan-Americana da Saúde; 2009. and it was therefore expected to find some kind of reference to the availability of acupuncture in the different documents and data sources available for a given municipality. The gaps therefore reveal not only inconsistencies but also information inequalities (Chart 2).

The findings related to the inconsistencies and information inequalities in the references to acupuncture corroborate the results of a study which explored the characteristics of the availability and production of Integrative and Complementary Practices in the SUS between 2000 and 2011 in the municipalities of Campinas, Florianópolis and Recife, carried out by Sousa et al.³⁷37. Sousa IMC, Bodstein RCA, Tesser CD, Santos FAS, Hortale VA. Práticas integrativas e complementares: oferta e produção de atendimento no SUS e em municípios selecionados. Cad Saude Publica 2012; 28(11):2143–2154. using the CNES and SIA. This study observed inconsistencies in the information systems, lack of integration between the systems, underreporting, and gaps between what was registered in the documents and practice.

It is important to highlight that, although a number of gaps have been identified, is essential to recognize the pioneering initiative of municipality M18, which has been implementing the PNPIC since its creation in 2006, already offered acupuncture before the policy came into effect, and has been registering acupuncture actions and guidelines in management tools ever since these activities began. This municipality's health system has a wide range of facilities and each of its specialized units have been offering acupuncture services since 1998. Acupuncture is part of the municipality's Phytotherapy and Homeopathy Program which began in 1992 when the Worker's Party (Partido dos Trabalhadores - PT) gained control of the council for the first time between 1993 and 1996. Acupuncture was integrated into the health system during the 1997/2000 administration controlled by the Brazilian Social Democracy Party (Partido da Social Democracia Brasileira - PSDB). The program had a solid enough foundation to absorb a new form of treatment in the form of acupuncture, but lacked additional funding to strengthen and expand actions.

With respect to the different Integrative and Complementary Practices and acupuncture actions and proposals described in the documents, it is evident that concepts related to planning tools²⁹29. Brasil. Ministério da Saúde (MS). Sistema de Planejamento do SUS (PlanejaSUS):uma construção coletiva trajetória e orientações de operacionalização. Brasília: Organização Pan-Americana da Saúde; 2009., such as goal, objective and indicator, are misused. This misuse of concepts leads to inconsistencies in the structure of the PMSs and RAGs and in the references made to acupuncture, such as descriptions of goals without corresponding actions, and guidelines and/or objectives with zero funding or without an estimate of the resources available, and makes it impossible to annually monitor and compare performance.

A policy can have many - and sometimes contradictory - components, which are organized in a structured manner, and it is often not possible to determine its defining characteristic³⁸38. Sampaio J, Araújo Júnior JL. Análise das políticas públicas: uma proposta metodológica para o estudo no campo da prevenção em Aids. Rev Bras Saude Mater Infant [online] 2006; 6(3):335–346. [acessado 2011 set 8]. Disponível em: http://dx.doi.org/10.1590/S1519-38292006000300010.
http://dx.doi.org/10.1590/S1519-38292006... . However, the inaccurate or inappropriate use of basic concepts reveals contradictions that can weaken and compromise the process of planning and integrating acupuncture services and retard their expansion and the implementation of the PNPIC.

The fact that municipality M18 already offered this treatment before the PNPIC came into effect suggests that it was not the policy that spurred efforts to strengthen and expand services and implement acupuncture actions in this municipality. The lack of documents and amount of documents produced in the DRS XIII without any reference to acupuncture confirms the limited impact of the PNPIC on the provision of Integrative and Complementary Practices in the SUS during the study period. This finding corroborates the results of a study conducted by Galhardi et al.³⁹39. Galhardi WMP, Barros NF, Leitemor ACMB. O conhecimento de gestores municipais de saúde sobre a Política Nacional de Prática Integrativa e Complementar e sua influência para a oferta de homeopatia no Sistema Único de Saúde local. Cien Saude Colet 2013; 18(1):213–220 that assessed the influence of the PNPIC on homeopathic therapy in municipalities that provide homeopathy in different regions of the State of São Paulo. The study found that the policy had little significant influence on the provision of homeopathic services, although health managers did mention that the PNPIC had the potential to serve as support and justification for providing homeopathic services and other Integrative and Complementary Practices on the SUS.

Although PMSs and RAGs should be jointly produced documents, only government actors from the municipalities of the DRS XIII, predominantly municipal councils and Health Departments, participated in their preparation. Furthermore, although the participation of various actors from government institutions was mentioned, it is not clear how they participated and their position with respect to Integrative and Complementary Practices and acupuncture.

It is important to note that the acupuncture actions in these municipalities are pioneering initiatives and highlight an advance in health care provided by the SUS at municipal level. This recognition is essential and constitutes the first step towards strengthening and expanding the provision of Integrative and Complementary Practices and acupuncture by local public health services.

Final considerations

Health planning is essential for the successful implementation of health actions through the SUS. Although management tools are essential to this process, their use by municipalities for the local management of health systems appears to be limited.

The integration of acupuncture into the SUS and the effective implementation of the PNPIC at local level is even more limited. Although the first steps have been taken in some of the country's municipalities, it is necessary to strengthen and expand the availability and/or accessibility of acupuncture and other Integrative and Complementary Practices, so that “the SUS becomes a major source for promoting the expansion other kinds of medical logic and their comprehensiveness”⁴⁰40. Tesser CD, Luz MT. Racionalidades médicas e integralidade. Cien Saude Colet 2008; 13(1):195–206. Souza EFAA, Luz MT. Análise crítica das diretrizes de pesquisa em medicina chinesa. Hist Cienc Saude 2011; 18(1):155–174..

In this respect, this assessment of the integration of acupuncture into the SUS based on specific management tools has generated important inputs to inform and propose strategies to meet existing demands, including the need for municipalities to adopt the different management tools and broaden their political commitment to the integration of Integrative and Complementary Practices into the SUS. By seeking to strengthen the integration of acupuncture and other Integrative and Complementary Practices into the SUS may also serve to strengthen various other health policies and, consequently, the Unified Health System as a whole.

Furthermore, decision makers and health policy makers should give priority to the PNPIC and different actors, including health managers, health professionals, service users and different segments of society, should be mobilized to participate to confront the challenges and complexities of building mutual healthcare knowledge sharing.

Finally, it is important to stress that there is a movement towards greater integration of Integrative and Complementary Practices into the center of the Unified Health System, which is also towards the comprehensiveness of health care systems and universality of access, which aims to ensure the consolidation not only of the National Policy for Integrative and Complementary Practices, but also a set of other emancipatory policies concerning the field of health in Brazil.

Acknowledgments

The authors are grateful to the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – CAPES) for the PhD scholarship granted to LA de Sousa.

References

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