Abstract

This study aimed to describe and characterize the pharmaceutical services provided in Brazil’s Unified Health System (SUS) from the point of view of the healthcare networks that are organized by region in the QualiSUS-Rede Project. This was a cross-sectional study, with data collected from December 2013 to July 2015, in public health establishments that carried out delivery or warehousing of medications (n = 4,938), in 465 municipalites, and the Federal District, in 43‘Health Regions’. The results show the existence of at least one management service supporting the health network, and warehousing of medications in all the regions (> 90%). It also showed the availability of at least one healthcare service, in healthcare locations, by pharmaceutical professionals is irregular between the Regions, being highest in the Southeastern Region (74.3%), and lowest in the Northeastern Region (43.3%). The results underpine the need for effective structuring of pharmaceutical assistance in the SUS networks, overcoming the current restrictive vision of its activities, which gives value almost exclusively to the logistical component of support to the network, to the detriment of the clinical component. It is also important to expand, and improve the quality of, the population’s access to medical drugs, and improve the quality of the healthcare offered to users of the system.

Health systems; Regionalization; Pharmaceutical services

Introduction

The challenge of combating fragmentation, and providing continuous health services in a fair and wide-ranging manner, continues to be a major imperative for the majority of the countries of the Americas¹1. Organización Panamericana de la Salud (OPAS), Organización Mundial de la Salud (OMS). Redes Integradas de Servicios de Salud Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Washington: OPAS; 2008..

This challenge is more complicated in a country such as Brazil which, as well as its continental scale and very long frontier, lives with what is referred to as the “triple burden”. This situation obliges managers to seek care solutions giving special attention to the simultaneous growth of the external causes and of chronic diseases, principally because of the significant aging of the population, while parasitic and infectious diseases, and malnutrition, typical of underdevelopment countries, continue to require attention and care²2. Mendes EV. O controle social e a participação democrática nos conselhos municipais de saúde da Ride-DF [Internet]. 2012 [cited 2016 Jun 27]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/cuidado_condicoes_atencao_primaria_saude.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... .

In this context, the regionalization of Brazil’s Unified Healthcare System (Sistema Único de Saúde, or SUS) is the major orienting axis of development of this system for the coming decades. It is the result of coordinated action by the three federal entities involved in the implementation of constitution of Health Regions, in which regional healthcare networks are organized³3. Lavras CCC. Descentralização, regionalização e estruturação de redes regionais de atenção à saúde no SUS. In: Nelson Ibañez, Paulo Eduardo Mangeon Elias, Paulo Henrique D’Ângelo Seixas, editors. Política e gestão pública em saúde [Internet]. São Paulo: Hucitec; 2011 [cited 2016 Jun 27]. p. 285-316. (Saúde em debate; vol. 212). Available from: http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=LILACS&lang=p&nextAction=lnk&exprSearch=605172&indexSearch=ID
http://bases.bireme.br/cgi-bin/wxislind.... .

In Brazil, the Federal Government, the States and the municipalities are defined as territories by political-administrative division. They are thus constituted into territories in which health practices are organized. However, from the point of view of organization of healthcare networks, it is necessary to configure other territories, that correspond to the Health Regions. These are understood as being a geographical area that holds a population with singular epidemiological and social characteristics and its own healthcare needs, and also with health resources already existing within it to serve that population³3. Lavras CCC. Descentralização, regionalização e estruturação de redes regionais de atenção à saúde no SUS. In: Nelson Ibañez, Paulo Eduardo Mangeon Elias, Paulo Henrique D’Ângelo Seixas, editors. Política e gestão pública em saúde [Internet]. São Paulo: Hucitec; 2011 [cited 2016 Jun 27]. p. 285-316. (Saúde em debate; vol. 212). Available from: http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=LILACS&lang=p&nextAction=lnk&exprSearch=605172&indexSearch=ID
http://bases.bireme.br/cgi-bin/wxislind.... ,⁴4. Brasil. Presidência da República. 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..

In the Health Regions, regional healthcare networks are organized based on complementarities and exchanges, and agreed in a participative manner between managers of municipalities and States. The modelling of these regional networks of healthcare in the SUS presents a group of challenges which need to be overcome for an integrated system to be consolidated that ensures the access and the healthcare quality offered. For this, there is a need for cooperation and a spirit of solidarity between states and municipalities and between municipalities of each Health Region⁵5. Lavras C. Atenção primária à saúde e a organização de redes regionais de atenção à saúde no Brasil. Saúde Soc. 2011; 20(4):867-874..

In 2010, guidelines were agreed in Brazil for structuring of the Healthcare Network (Rede de Atenção à Saúde, or RAS), which were defined as a strategy for overcoming the fragmentation of healthcare and management in the Health Regions. They seek to optimize the political and institutional functioning of the SUS, aiming to ensure that the user gets the group of services that s/he needs, with effectiveness and efficiency⁶6. Brasil. Ministério da Saúde (MS). Portaria no 4.279, de 30 de dezembro de 2010. Aprova as Diretrizes para a Organização da Rede de Atenção à Saúde do SUS, e dá outras providências. Diário Oficial da União 2010; 30 dez..

The Healthcare Networks can be understood as organizing arrangements of functional health units, either as care points or as diagnosis and therapy points, where procedures are carried out with different technological densities and which, when integrated through the logistics and management systems, seek to ensure integral healthcare in a given territory²2. Mendes EV. O controle social e a participação democrática nos conselhos municipais de saúde da Ride-DF [Internet]. 2012 [cited 2016 Jun 27]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/cuidado_condicoes_atencao_primaria_saude.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . One of the fragilities that Rodrigues et al.⁷7. Rodrigues LBB, Silva PCS, Peruhype RC, Palha PF, Popolin MP, Crispim JA, Pinto IC, Monroe AA, Arcêncio RA. A atenção primária a saúde na coordenação das redes de atenção: uma revisão integrativa. Cien Saude Colet 2014; 19(2):343-352.encountered, in an integrative review was lack of knowledge, on the part of primary healthcare professionals, of the various healthcare points.

Pharmaceutical policies are one of the cross-sectional, strategic types of public policy for the process of structuring and organization of the RAS, and with it strengthening of primary healthcare.

Pharmaceutical services involve technical and management activities such as a Healthcare Support System, but above all activities of healthcare itself, and they should express commitment to direct support for the user and obtaining of health results. Effective structuring of the pharmaceutical services in the RAS is a fundamental need, not only for widening and improving the population’s access to medical drugs, but also for improving the healthcare offered directly to users of the system²2. Mendes EV. O controle social e a participação democrática nos conselhos municipais de saúde da Ride-DF [Internet]. 2012 [cited 2016 Jun 27]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/cuidado_condicoes_atencao_primaria_saude.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ,⁸8. Organización Panamericana de la Salud (OPS), Organización Mundial de la Salud (OMS). Servicios farmacéuticos basados en la atención primaria de salud. Documento de posición de la OPS/OMS. Washington: OPS; 2013. (La Renovación de la Atención Primaria de Salud en las Américas).. This type of action has been and is being defended in Brazil by significant actors such as the Health Ministry⁹9. Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Serviços farmacêuticos na atenção básica à saúde. Brasília: MS; 2014. (Cuidado farmacêutico na atenção básica)., and the Federal Pharmacies Council¹⁰10. Conselho Federal de Farmácia, Conselho Regional de Farmácia do Paraná. A assistência farmacêutica no SUS. Brasília: Conselho Federal de Farmácia; 2009..

This group of activities, articulated in the multi-professional and inter-sectorial actions, is also essential for ensuring access to quality medical drugs, and promotion of their appropriate use⁸8. Organización Panamericana de la Salud (OPS), Organización Mundial de la Salud (OMS). Servicios farmacéuticos basados en la atención primaria de salud. Documento de posición de la OPS/OMS. Washington: OPS; 2013. (La Renovación de la Atención Primaria de Salud en las Américas).. A systematic review¹¹11. Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Bond CM, Bero L. Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev [Internet]. 2010 [cited 2016 Jun 27];7(7). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000336.pub2/pdf/
http://onlinelibrary.wiley.com/doi/10.10... found that the majority of the studies included pointed to the importance of the action of pharmaceutical professionals in the management of therapy, in advising the patient and in training of health professionals in the improvement of the process of care and achievement of clinical results.

However, as to significant advances in Brazil’s pharmaceutical policies, it is recognized that there are still challenges to be faced in relation to the prospect of guaranteeing access to medical drugs and qualification of the pharmaceutical services provided to the population¹²12. 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.,¹³13. 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..

Considering the phase of implantation of the RAS in the country, it becomes opportune to work towards adaptation of the pharmaceutical services in such a way that they can contribute to this strategy with all their potential.

This present study aims to characterize the pharmaceutical services provided in the SUS from the point of view of the Healthcare Networks in the Health Regions included in the QualiSUS-Rede Project.

METHODS

This is an analysis of data from the survey ‘Pharmaceutical Services in the Brazilian Healthcare Networks (RASs): an approach in the QualiSUS-Rede regions’, which was carried out through a partnership established between the Ministry of Health and World Bank. The aim of the study was to identify the situation of the pharmaceutical services, and management and healthcare techniques in the 15 priority Regions of the QualiSUS-Rede Project, in accordance with the guidelines proposed for the functioning of the Regional Healthcare Network (RAS). The QualiSUS-Rede was instituted as a strategy of support for organization of the RAS in Brazil, aiming to contribute to higher quality of care, management in health and management and development of technologies, through the organization of regional and themed Healthcare Networks and improvement of quality of care in general. It comprises five strategy directives, the first of which is ‘Support for Structuring and Quality Improvement of the RAS’¹⁴14. Brasil. Ministério da Saúde (MS). Secretaria Executiva. Diretoria de Programa. Manual Operacional do Projeto de Investimento para a Qualificação do Sistema Único de Saúde. Brasília: MS; 2009. (Serie C: Projetos, Programas e Relatórios)..

The study had a cross-sectional design, with data collected from December 2013 to July 2015 in all the public health establishments that were carrying out local warehousing of medical drugs, in 485 municipalities and the Federal District, in 43 Health Regions (http://sage.saude.gov.br/), which were part of the QualiSUS-Rede Regions in September 2013. The initial selection of the establishments was the National Health Establishments Registry (Cadastro Nacional de Estabelecimentos de Saúde – CNES) (http://cnes.datasus.gov.br/).

Five instruments were used for the collection of data: (1) a questionnaire to the Health Secretary; (2) a questionnaire to the person responsible for Pharmaceutical Services; (3) a questionnaire to the person responsible for the healthcare point and/or the therapeutic support point; (4) a questionnaire for the person responsible for the Pharmaceutical Supply Center; and (5) a questionnaire to the person responsible for the Hospital Pharmacy. The last three of these instruments were accompanied by a ‘script’ of direct observation.

In this article the data from instrument 3 were used – this instrument included structured questions, relating to management, structure and services offered in the establishment. It was applied by an interview of the persons responsible for the pharmacies of the following establishments: Primary Health Units/Health Centers/Health Posts, Psycho-social Care Centers (CAPSs), pharmacies of the prison system, and pharmacies in exclusive buildings (basic medical drugs/“live pharmacy”/Popular Pharmacy/medical drugs of the specialized component).

The following were excluded from the analysis: hospital pharmacies; and the municipal and State pharmaceutical supply centers – because they have different instruments due to their specific characteristics.

The outcomes considered were the pharmaceutical services offered in the health establishments considered to be pertinent to: (1) Healthcare Points (Pontos de Atenção à Saúde, or PASs) – when the establishment and the related sector or area identified had a pharmacist (as a technical responsible and/or assistant), and carried out at least one of the following Clinical Pharmaceutical activities: dispensing; pharmacotherapeutic follow-up; therapeutic guidance; pharmacotherapeutic review and pre/post-treatment drug comparison or drug surveillance activities; (2) Diagnosis and Therapy Support Points (Pontos de Apoio Diagnóstico e Terapêutico, or PADTs) – when the professional of the establishment and related sector or area identified said that they carry out the delivery of the medical drugs in the establishment; (3) the Healthcare Network Support System (Sistema de Apoio a Rede de Atenção à Saúde, or SARAS), when the establishment stated that it in some way participates in at least one of the Technical Management Pharmaceutical Services of support to the network, and also local warehousing of medical drugs (selection/programming/acquisition/distribution). The operational definitions of the variables used in the study are described in Chart 1.

The independent variables investigated were: Administrative Region (North, Northeast, Southeast, South, and Southeast); number of health regions and pharmaceutical services offered. The proportions were estimated, and Pearson chi-squared tests were applied for evaluation of the statistical significance, considering significance level of 5%. The statistics program SPPS 18.0 was used for the analyses.

The study was approved by the National Ethics Research Committee (Comitê Nacional de Ética em Pesquisa, or Conep). All the interviews were preceded by signature of a Free and Informed Consent Form (TCLE).

RESULTS

It was interviewed the persons responsible for pharmacies in 4,938 establishments that warehoused medical drugs, in 15 regions of the QualiSUS-Rede Project. A great majority (79%) were Health Centers/Health Units/Health Posts, located in 465 municipalities and the Federal District, belonging to 43 Health Regions in the period of the data collection. The percentage of loss was 4.1%, corresponding to 20 municipalities, due to problems in storage of the data.

Figure 1 gives the characterization of the sample in terms of the proportion of Health Regions, municipalities and establishments by Administrative Region. Approximately one-third of the establishments (n = 1,773) and of the municipalities (n = 146) are in the Northeastern Region, and the Southeast was the Region with the highest proportion of health regions (n = 13), with all municipalities included in the study.

The great majority (78.0%) of the establishment had the participation of a pharmacist. The supply of pharmaceutical services by professional was analyzed in these 3,377 health service points. The service with the largest supply in the establishments was therapeutic guidance, individually or in groups (44.5%), followed by dispensing (33.5%), and there was a low level of realization of pharmacotherapeutic follow-up of the patients (7.1%). The services of therapeutic conciliation (pre/post-treatment drug comparison) and pharmacotherapeutic review were not reported in any of the establishments visited. It was notable that it was in the Southeastern Region that we found the largest proportion of establishments with the health services offered at the healthcare points, while the lowest supply was found in the Northeastern Region (Table 1).

Drug surveillance service was reported in a quarter of the establishments (24.2%), taking place in the highest proportion in the establishments of the Southern Region (34.5%), and in the lowest proportion in the establishments of the Northern Region of the country (7.5%).

Although the great majority of the establishments (86.0%) reported delivery of medical drugs by other professionals than the pharmacists (data not presented in a table), only 60% carried out this delivery with therapeutic guidance to the user. This proportion was greatest in the Center-West Region (66.9%) and Northeast (63.9%) and lowest in the Northern Region (36.0%) (Table 2).

As to the establishments that participate in the Pharmaceutical Management services, in the form of the Healthcare Network Support System (SARAS) in the regions, it was noted that the great majority of them reported participation in the programming services (83.8%) and services of selection of medical drugs (79.5%).

Comparing the administrative regions of the country: a greater participation in the selection of medical drugs in the establishments was reported in the Southern Region (88.7%); and of programming in the Southeastern (88.8%) and Southern (88.2%) Regions. There was a low participation in the processes of acquisition and distribution of medical drugs to other health service points in general, with the largest proportion in the Southeastern Region, 22.3% for acquisition and 35.1% for distribution.

Table 3 shows the distribution of the number of health regions, population and proportion of supply of pharmaceutical services in the health establishments in Healthcare Points (PASs), Diagnosis and Therapy Support Points (PADTs) and the Healthcare Network Support System (SARAS), by Administrative Region. The total population of the 43 health regions included in the QualiSUS-Rede Project totals approximately 45 million people who may be benefited by the supply of services of the healthcare network, with a highlight for the 13 Health Regions of the Southeastern Region, with approximately 20 million people.

It was found that there was at least one management service in support of the healthcare network – in addition to the storage of medications – in all the regions (> 90%). Supply of at least one assistance service at the care points was found to be irregular between the Regions: in the greatest proportion in the Southeastern Region (74.3%); and in the lowest proportion in the Northeastern Region (43.3%).

DISCUSSION

This study provided an evaluation which, from the regional point of view was unprecedented, of both management and care pharmaceutical services provided in health establishments connected to the SUS in the regions covered by the QualiSUS-Rede Project. Attention can be drawn to the complexity of the sample, and the population coverage, of more than 45 million inhabitants distributed over 485 municipalities in the Federal District, belonging at the time to 43 health regions and 17 units of the Brazilian Federation of States.

The results obtained in this study should be considered as input material to help in perfecting the pharmaceutical services provided within the SUS, in terms of better responding to today’s health needs in the context of the structural and functional challenges of the regional network. It is known that the situation of needs in health is changing, calling for decisions on a group of strategies to achieve integration of the SUS in all its dimensions.

The survey showed greater participation in the services of programming and selection of medications at establishments that took part in the Pharmaceutical Management services in the form of the Healthcare Network Support System (SARAS) in the regions; but there was low participation in the processes of acquisition and distribution of medical drugs to other care points. This could be the result of a trend to centralization of management services, and low participation in the integrated planning of pharmaceutical care – which in turn could cause supply gaps for the healthcare network, with low availability of drugs occurring in Primary Health Units¹³13. 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..

The supply of clinical services provided by the pharmacist was identified, by Region, on the basis of what is specified in the framework of the RASs, grouping the results in accordance with whether the health establishment was classified as a Healthcare Points (PAS) and/or as a Diagnosis and Therapy Support Points (PADT). According to Lavras³3. Lavras CCC. Descentralização, regionalização e estruturação de redes regionais de atenção à saúde no SUS. In: Nelson Ibañez, Paulo Eduardo Mangeon Elias, Paulo Henrique D’Ângelo Seixas, editors. Política e gestão pública em saúde [Internet]. São Paulo: Hucitec; 2011 [cited 2016 Jun 27]. p. 285-316. (Saúde em debate; vol. 212). Available from: http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=LILACS&lang=p&nextAction=lnk&exprSearch=605172&indexSearch=ID
http://bases.bireme.br/cgi-bin/wxislind.... , the PASs that comprise the RAS are functional units, which call for differentiated and specific technological conditions (physical structure, equipment and inputs, profile of the professional staff, specific technical knowledge) and a well-defined field of activity, for supply of a group of health actions. The PADTs are also functional units, but ones that offer support procedures such as: diagnosis by image, pathology and clinical analyses, chart/graphic methods, delivery of drugs, etc.

Provision of pharmaceutical clinical services was shown to be inconsistent across the administrative regions of the country.

The activity of dispensing can be defined as an action carried out by a pharmaceutical professional for the purpose of providing medical drugs and orientation for their rational use, in response to the presentation of a prescription prepared by a professional¹⁵15. Brasil. Ministério da Saude (MS). Portaria MS/GM No 3916, de 30 de outubro de 1998. Aprova a política nacional de medicamentos e define as diretrizes, as prioridades e as responsabilidades da Assistência Farmacêutica para os gestores federal, estadual e municipal do Sistema Único de Saúde – SUS. Diário Oficial da União 1998; 31 out.. A consensus has grown in Brazil of designating as ‘delivery of drugs’ any action that involves the supply of medical drugs directly to user, but does not comply with all the conditions in the above definition, especially that of realization by a pharmaceutical professional¹⁶16. Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Relatório do 1º Seminário Internacional para Implementação da Atenção Farmacêutica no SUS. 24 a 27 de maio de 2006 [Internet]. Brasília: MS; 2009 [cited 2016 Sep 19]. (Projetos, Programas e Relatórios). Available from: http://bvsms.saude.gov.br/bvs/publicacoes/relatorio_seminario_implementacao_atencao_farmaceutica.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . The supply of dispensing services was low in the health regions investigated, even when the pharmacist was present, and, in a great majority of the establishments, what was reported was delivery by other non-pharmaceutical professionals without orientation being given to the user. Gaps in the qualification of pharmacists for activities of dispensing, and the non-understanding of the role of the pharmacist in clinical activities directly by the user by the community and also by other healthcare professionals, provide reasons that are frequently referred to for the delivery of drugs being the responsibility of other professionals, as indicated in a study in Malaysia¹⁷17. Azhar S, Hassali MA, Ibrahim MIM, Ahmad M, Masood I, Shafie AA. The role of pharmacists in developing countries: the current scenario in Pakistan. Hum Resour Health [Internet]. 2009 Dec [cited 2016 Sep 16];7(1). Available from: http://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-7-54
http://human-resources-health.biomedcent... .

It can be highlighted that this result can point to gaps in the organization of the services and qualification of the professionals for carrying out of this service in a manner that is integrated to the health actions in the healthcare network, which should have elements of orientation, and promotion, to the population, of rational use of drugs.

Also incipient was any reporting of pharmacotherapeutic follow-up of the patients in the Health Regions and there was no reference to the supply of services of pre/post-treatment drug comparison and pharmacotherapeutic review. Evidence has demonstrated the impact of clinical services for the community¹⁸18. Messerli M, Blozik E, Vriends N, Hersberger KE. Impact of a community pharmacist-led medication review on medicines use in patients on polypharmacy - a prospective randomised controlled trial. BMC Health Serv Res [Internet]. 2016 Dec [cited 2016 Sep 19];16(1). Available from: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1384-8
http://bmchealthservres.biomedcentral.co... ,¹⁹19. Sabater-Hernández D, Sabater-Galindo M, Fernandez-Llimos F, Rotta I, Hossain LN, Durks D, Franco-Trigo L, Lopes LA, Correr CJ, Benrimoj SI. A Systematic Review of Evidence-Based Community Pharmacy Services Aimed at the Prevention of Cardiovascular Disease. J Manag Care Spec Pharm 2016; 22(6):699-713.. The purpose of pharmacotherapeutic monitoring/follow-up of users, and pharmacotherapeutic review, is evaluation of the medical drugs used by patients, prescribed and not prescribed, for the purpose of identifying drug interactions, or low levels of adherence to treatment, such as might be compromising the therapeutic results. The therapeutic conciliation (comparison of the drugs prescribed after discharge from hospital with those that were being used by the patient before the hospital admission), including those prescribed by the primary healthcare doctors, aims to propose solutions to the user and to the team for harmonization of the patient’s care plan⁹9. Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Serviços farmacêuticos na atenção básica à saúde. Brasília: MS; 2014. (Cuidado farmacêutico na atenção básica)..

It needs to be highlighted that the clinical activity of the pharmacist should be integrated with the health team for the achievement of optimum results, and inter-professional barriers in the integration of pharmacists into the primary healthcare team need to be overcome, as was pointed out in a study made in England²⁰20. Bradley F, Elvey R, Ashcroft DM, Hassell K, Kendall J, Sibbald B, Noyce P. The challenge of integrating community pharmacists into the primary health care team: a case study of local pharmaceutical services (LPS) pilots and interprofessional collaboration. J Interprof Care 2008; 22(4):387-398.. Integration of the actions of the various professionals is fundamental for guaranteeing maximum effectiveness and minimum risk in therapies. For this, it needs to be integrated coordination of the decisions in pharmacotherapeutic care of users, so as to facilitate care continuity in the care network²¹21. Ramos AC, Guirado EA, Gorostiaga JM, San Juan AM, Tolsa LS. Posicionamiento da Sociedade Española de Farmacéuticos en la Atención Primáia en la Gestión Farmacoterpéutica Integrada [Internet]. 2015 [cited 2016 Sep 19]. Available from: http://www.sefap.org/media/upload/arxius/SEFAP-POSICIONAMIENTO-4.pdf
http://www.sefap.org/media/upload/arxius... .

The Northeast and Center-West regions stood out from the others for a low level of supply of services of dispensing, therapeutic guidance and pharmacotherapeutic follow-up. However, these regions presented the highest proportional supply of the service of diagnostic and therapeutic support. This situation both (i) reflects the shortage of professionals, and also (ii) raises questions on the qualifications of the pharmacists that carry out clinical functions in the establishments, and the process of training of those professionals. It is also in our view related to the distribution of work time/working hours – which has the effect of causing them to give priority to the technical and management activities carried out to support the network.

This reaffirms the need for greater discussion on the importance of a qualified supply of clinical services, able to respond better to users’ health needs, and to overcome issues related only to access and to the quality of the pharmaceutical products made available. This requires action articulated with the process of healthcare able to ensure continuity of care, and also prevention and resolution of problems related to pharmacotherapy¹1. Organización Panamericana de la Salud (OPAS), Organización Mundial de la Salud (OMS). Redes Integradas de Servicios de Salud Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Washington: OPAS; 2008.. Various authors⁸8. Organización Panamericana de la Salud (OPS), Organización Mundial de la Salud (OMS). Servicios farmacéuticos basados en la atención primaria de salud. Documento de posición de la OPS/OMS. Washington: OPS; 2013. (La Renovación de la Atención Primaria de Salud en las Américas).,²³23. Castro MS, Correr CJ. Pharmaceutical care in community pharmacies: practice and research in Brazil. Ann Pharmacother 2007; 41(9):1486-1493.

24. Mendes EV. O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da estratégia da saúde da família. Brasília: OPAS; 2012.-²⁵25. Vieira FS. Possibilidades de contribuição do farmacêutico para a promoção da saúde. Cien Saude Colet 2007; 12(1):213-220. have agreed on the great challenges involved in the implementation of pharmaceutical services, giving priority to the need for healthcare, from basic healthcare to specialized healthcare, with a focus on people – family and community – replacing the focus on the medical drugs as merchandise.

The majority of the services investigated in this study were in basic healthcare – in which the Pan-American Health Organization⁸8. Organización Panamericana de la Salud (OPS), Organización Mundial de la Salud (OMS). Servicios farmacéuticos basados en la atención primaria de salud. Documento de posición de la OPS/OMS. Washington: OPS; 2013. (La Renovación de la Atención Primaria de Salud en las Américas). argues that the provision of pharmaceutical services is a key element, especially in that it involves for the direct relationship with the user/patient. This activity includes: health promotion, dispensing, pharmacotherapeutic accompaniment/follow-up, drug surveillance, and support for responsible self-medication. The list of services investigated includes some addressed to groups in various situations of vulnerability, such as the pharmacies of the CAPSs, of the prison system or those of the specialized component – situations in which there are users with differentiated care requirements.

Health establishments or posts providing Diagnostic and Therapeutic Support were found to be in the same proportion as those supplying clinical services. However a point that calls attention, and should be emphasized, in relation to the regional organization of the services to be offered and the quality of the service of delivery or supply of drugs to the user, is that the majority of the healthcare posts and/or therapeutic support posts report the delivery being carried out by non-pharmaceutical professionals.

Finally, it should be highlighted that the process of systemic integration which is being pursued in the SUS also calls for integration in the dimensions of both health services and professional practices. In this aspect, there is a need to decide on a group of initiatives directed toward qualification, organization and integration of structures or processes related to these services and to the professional practices that are carried out within them²⁶26. Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Projeto QualiSUS-Rede: Assistência Farmacêutica nas Redes de Atenção à Saúde: um recorte na região. Brasília: MS; 2016..

From this perspective, even though there have been a group of significant advances in pharmaceutical services in the SUS, one must recognize that there are still challenges to be faced in the aspect of guaranteeing quality, accesses, and stimulus for the rational use of medical drugs²⁶26. Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Projeto QualiSUS-Rede: Assistência Farmacêutica nas Redes de Atenção à Saúde: um recorte na região. Brasília: MS; 2016..

The programming of actions and services in the regions, especially for the clinical services, should be thought out, programmed and offered based on the needs of the population actually in the territory, based on the epidemiological and nosological data and profiles and obeying the existing capacity of establishments, such as pharmacies²⁷27. Araújo SQ. A assistência farmacêutica nas redes de atenção à saúde: o planejamento e os serviços no SUS [Internet]. Universidade de Brasília; 2014 [cited 2016 Jul 4]. Available from: http://repositorio.unb.br/handle/10482/17424
http://repositorio.unb.br/handle/10482/1... .

Effective structuring of Pharmaceutical Services in the RASs is a fundamental need, not only for expanding and qualifying the population’s access to drugs, but also to improve the quality of the healthcare directly offered to users of the system. For this, there is a need to overcome a restrictive vision of the activities of pharmaceutical care – which habitually gives value almost exclusively to its logistical component, to the detriment of the clinical pharmaceutical component²⁶26. Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Projeto QualiSUS-Rede: Assistência Farmacêutica nas Redes de Atenção à Saúde: um recorte na região. Brasília: MS; 2016..

Pharmaceutical Services should be understood to mean a group of activities that could be characterized as: Support to the Regional Healthcare Networks (RRAS) – related to supply; Therapeutic Support – delivery of drugs; Pharmaceutical Care – related to education in health; and Pharmaceutical Clinical Practice per se. Among the highlights are the activities of drug surveillance, and those carried out through individual or shared consultations, which are essential in the process of facing the chronic conditions.

It is known that the clinical handling of these conditions calls for not only continuity of care and integration of multi-professional work, but also a differentiated activity of each professional, which in the case of the pharmacist should concentrate as priority on the co-morbidities; multi-drug patients; and/or those with low acceptance of use of drugs.

We agree with Lavras³3. Lavras CCC. Descentralização, regionalização e estruturação de redes regionais de atenção à saúde no SUS. In: Nelson Ibañez, Paulo Eduardo Mangeon Elias, Paulo Henrique D’Ângelo Seixas, editors. Política e gestão pública em saúde [Internet]. São Paulo: Hucitec; 2011 [cited 2016 Jun 27]. p. 285-316. (Saúde em debate; vol. 212). Available from: http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=LILACS&lang=p&nextAction=lnk&exprSearch=605172&indexSearch=ID
http://bases.bireme.br/cgi-bin/wxislind.... , Mendes et al.¹³13. 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., Mendes²⁴24. Mendes EV. O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da estratégia da saúde da família. Brasília: OPAS; 2012. e Magalhães Júnior et al.²⁸28. Magalhães-Júnior HM, Souto-Júnior JV, Andrade LOM, Brêtas-Júnior N, Santos L. Redes de atenção à saúde: desafios da regionalização no SUS. 2ª ed. Campinas: Saberes Editora; 2013. that this regional organization of the health system and the logic of the RASs needs to attend to the various situations of models, and not only a regionalization linked to containment of the use of services, to avoid costs arising from transfers between the regions²⁹29. Touati N, Roberge D, Denis J-L, Pineault R, Cazale L, Tremblay D. Governance, health policy implementation and the added value of regionalization. Health Policy 2007; 2(3):97-114..

It should be able to overcome the factors that perhaps most interfere in formation and consolidation of the RRAS, which are the fragmentation of services, and the absence, or fragile articulation, between its various healthcare posts in their different levels of activity. Pharmaceutical services, which are also in a fragile state and are normally removed from this process of construction of the healthcare network in the territory, are included in this case.

Thus, proposing the characterization of the activities related to Pharmaceutical Services as inherent to the PASs; to the PADTs; and also as part of the SARAS as a whole, whether or not coexisting in a single establishment, widens the understanding of the different natures of these activities. Attention is drawn to the need to value the activities related to pharmaceutical care so as to better respond to the population’s health needs, inserting them clearly as activities specific to the functional units of the healthcare networks.

Finally, it can be emphasized that the guidelines agreed in 2010 for the RAS⁶6. Brasil. Ministério da Saúde (MS). Portaria no 4.279, de 30 de dezembro de 2010. Aprova as Diretrizes para a Organização da Rede de Atenção à Saúde do SUS, e dá outras providências. Diário Oficial da União 2010; 30 dez. – which describe the pharmaceutical services only as part of the Support System, and as part of the so-called Pharmaceutical Services System, which involves the organization of this service in all its phases: selection, programming, acquisition, storage, distribution, prescription, dispensing and promotion of rational use of drugs – need to be redefined on the basis of this evidence obtained in the QualiSUS-Rede Project.

As a limitation of the study we can highlight that absence, in the questionnaire, of a question that explicitly identifies the process of pre/post-treatment drug comparison and pharmacotherapeutic review as a record of the clinical services for establishment of health could be a limiting factor. The data on these services were captured through open questions, which could have contributed to their low degree of mention by interviewees. It is also possible that lack of knowledge or difference of understanding of the services about which the questions were asked may have influenced the findings.

The results underline the need for effective structuring of Pharmaceutical Services in the RAS, overcoming a restrictive vision of the activities of pharmaceutical service, which almost exclusively gives value to its logistical component to the detriment of its clinical component – to expand and increase the quality of the population’s access to drugs, and increase the quality of healthcare offered to users of the system.

Acknowledgment

We especially thank the statistical support team of the project, Paula Santucci and Victor Kitti Tanaka, and the institutional supporters of the survey Pharmaceutical Services in the Brazilian Healthcare Networks (RASs): a cross-section in the QualiSUS-Rede regions.

The project was financed by the Health Ministry, in partnership with the World Bank.

References

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