Implementation, access and use of integrative and complementary practices in the unified health system: a literature review

Ruela, Ludmila de Oliveira; Moura, Caroline de Castro; Gradim, Clícia Valim Côrtes; Stefanello, Juliana; Iunes, Denise Hollanda; Prado, Rogério Ramos do

doi:10.1590/1413-812320182411.06132018

Abstract

In Brazil, the Integrative and Complementary Practices (ICP) achieved greater visibility after the establishment of the National Integrative and Complementary Practices Policy (NICPP) in 2006. However, there are still gaps in the general setting of these practices. Thus, this study aimed to analyze the implementation, access and use of ICPs in the Brazilian Unified Health System (SUS) after the establishment of this policy. We performed an integrative literature review, guided by the question: “What is the current setting of implementation, access and use of ICPs within the SUS?”, in the Virtual Health Library (BVS), the U.S. National Library of Medicine and in the Web of Science, with descriptors “Sistema Único de Saúde” / “Unified Health System” AND “Terapias Complementares” / “Complementary Therapies”. The analysis of papers gave rise to four categories for discussion: “The ICP approach in the SUS: main practices used”; “Access to ICPs: Primary Health Care as a gateway”; “Current implementation scenario of ICPs: the preparation of health services and professionals for to implement ICPs”; “Main advances in the use of ICPs and future challenges”. We have observed that ICPs are bashfully offered and that data available are scarce, despite the positive impacts on users and services that have embraced their use.

Key words
Unified Health System; Complementary therapies

Introduction

Since the 1990s, the use of Integrative and Complementary Practices (ICPs) has increased in global proportions¹1 Frass M, Strassl RP, Friehs H, Müllner M, Kundi M, Kaye AD. Use and acceptance of Complementary and Alternative Medicine among the general population and medical personnel: A Systematic Review. Ochsner J 2012; 12(1):45-56.. Its growth and visibility occurred mainly with incentive from the World Health Organization (WHO) in 2002, through the elaboration of a normative document to its member countries, which aims to develop and regulate such practices in health services, as well as increase access, rational use and evaluation of the efficacy and safety of such techniques from scientific studies²2 World Health Organization (WHO). WHO Traditional Medicine Strategy 2002 - 2005. Geneva: WHO; 2002..

In this setting, in 2006, through Ordinance Nº 971/2006, the Ministry of Health published the National Integrative and Complementary Practices Policy (NICPP) in the Unified Health System (SUS), with the aim of ensuring integrality in health services³3 Brasil. Ministério da Saúde (MS). Política Nacional de Práticas Integrativas e Complementares no SUS. Brasília: MS; 2006.. From then on, the provision and incentive to use ICPs, such as herbal medicine, homeopathy, acupuncture, among others, was legitimized in the SUS, increasing the use of these practices⁴4 Brasil. Ministério da Saúde (MS). Revista Brasileira Saúde da Família. Práticas Integrativas e Complementares em Saúde: uma realidade no SUS. Brasília: MS; 2008..

It is worth emphasizing that the implantation of the NICPP was of a political, technical, economic, social and cultural nature since it established national guidelines for the use of ICPs based on experiences and practices already adopted in the health services, which obtained satisfactory results³3 Brasil. Ministério da Saúde (MS). Política Nacional de Práticas Integrativas e Complementares no SUS. Brasília: MS; 2006..This fact further facilitated the dissemination of these practices in different parts of the country.

In this context, Brazil has emerged as one of the 69 WHO Member States with specific policies and strategies for the use of ICPs⁵5 World Health Organization (WHO). WHO traditional medicine strategy: 2014-2023. Geneva: WHO; 2013.. After the NICPP was established, 30% of Brazilian municipalities adopted their regulations for the use of these therapies, which indicates significant growth in healthcare practices, and PHC is one of the primary environments for their application⁴4 Brasil. Ministério da Saúde (MS). Revista Brasileira Saúde da Família. Práticas Integrativas e Complementares em Saúde: uma realidade no SUS. Brasília: MS; 2008..

Therefore, it is imperative to analyze the current setting of the provision of these treatments in the country, as well as access to them and their use in public health services. Thus, this study aimed to analyze the implementation, access and use of ICPs in the SUS through a review of the national literature published after the implementation of the NICPP.

Methods

This is an integrative review of the literature, based on the steps proposed by Whittemore and Knafl⁶6 Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005; 52(5):546-553., with the following guiding question: “What is the current setting of implementation, access and use of Integrative and Complementary Practices within the Unified Health System?”

We searched the Latin American & Caribbean Health Sciences Literature (Lilacs), Nursing Database (BDENF), HomeoIndex and the Spanish Bibliographic Index of Health Sciences (IBECS) via the Virtual Health Library (BVS); in the Medical Literature Analysis and Retrieval System Online (Medline) via the US National Library of Medicine (PubMed) and the Web of Science, by two independent researchers, with standardized descriptors extracted from the Health Sciences Descriptors (DeCS) and the Boolean operator AND, which resulted in the combination “Sistema Único de Saúde’ / “Unified Health System” AND “Terapias Complementares”/ “Complementary Therapies”.

Papers published in the 2006-2017 period, in Portuguese, English and Spanish languages, with abstract available in the database, and which were conducted in a national setting were the inclusion criteria. Studies that did not respond to the guiding question were excluded.

Firstly, papers were selected by two independent researchers, who read the title and abstract, according to the guiding question and the eligibility criteria. After the selection, they were read in full and, for data collection and evaluation, a tool elaborated by researchers adapted from Ursi⁷7 Ursi ES. Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura [dissertação]. Ribeirão Preto: Universidade de São Paulo; 2005. was applied. This tool consisted of the following items: title of paper; authors and year of publication; objective (s) of the study; methodological characteristics; level of health care (primary, secondary and tertiary) where the study was conducted; results; and conclusions.

Figure 1 shows the flowchart of the selection of papers.

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Figure 1
Flowchart of the selection of papers.

Results

Chart 1 shows the main information extracted from the selected papers.

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Chart 1
Papers included in the analysis of the integrative review. Minas Gerais, 2017.

Concerning the type of ICP used, 23.52% of the studies addressed herbal medicine⁸8 Ceolin T, Heck RM, Pereira DB, Martins AR, Coimbra VCC, Silveira DSS. A inserção das terapias complementares no sistema único de saúde visando o cuidado integral na assistência. Enferm. glob. 2009; 16:1-10.

9 Santos RL, Guimaraes GP, Nobre MSC, Portela AS. Análise sobre a fitoterapia como prática integrativa no Sistema Único de Saúde. Rev. Bras. Pl. Med. 2011; 13(4):486-491.

10 Oliveira SGD, Moura FRR, Demarco FF, Nascente PS, Del Pino FAB, Lund RG. An ethnomedicinal survey on phytotherapy with professionals and patients from Basic Care Units in the Brazilian Unified Health System. J Ethnopharmacol 2012; 140(2):428-437.^-¹¹11 Fontenele RP, Sousa DMP, Carvalho ALM, Oliveira FA. Fitoterapia na Atenção Básica: olhares dos gestores e profissionais da Estratégia Saúde da Família de Teresina (PI), Brasil. Cien Saude Colet 2013; 18(8):2385-2394., 17.64% homeopathy¹²12 Monteiro DA, Iriart JAB. Homeopatia no Sistema Único de Saúde: representações dos usuários sobre o tratamento homeopático. Cad Saude Publica 2007 ago; 23(8):1903-1912.

13 Salles SAC, Schraiber LB. Gestores do SUS: apoio e resistências à Homeopatia. Cad Saude Publica 2009; 25(1):195-202.^-¹⁴14 Galhardi WMP, Barros NF, Leite-Mor 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., 5.90% acupuncture¹⁵15 Silva EDC, Tesser CD. Experiência de pacientes com acupuntura no Sistema Único de Saúde em diferentes ambientes de cuidado e (des)medicalização social. Cad Saude Publica 2013; 29(11):2186-2196. and 52,94% of the studies have evaluated ICPs in general¹⁶16 Fontanella F, Speck FP, Piovezan AP, Kulkamp IC. Conhecimento, acesso e aceitação das práticas integrativas e complementares em saúde por uma comunidade usuária do Sistema Único de Saúde na cidade de Tubarão/SC. ACM 2007; 36(2):69-74.

17 Tesser CD, Barros NF. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Rev Saude Publica 2008; 42(5):914-920.

18 Andrade JT, Costa LFA. Medicina Complementar no SUS: práticas integrativas sob a luz da Antropologia médica. Saude Soc 2010; 19(3):497-508.

19 Marques LAM, Vale FVVR, Nogueira VAS, Mialhe FL, Silva LC. Atenção farmacêutica e práticas integrativas e complementares no SUS: conhecimento e aceitação por parte da população sãojoanense. Physis. 2011; 21(2):663-674.

20 Nagai SC, Queiroz MS. Medicina complementar e alternativa na rede básica de serviços de saúde: uma aproximação qualitativa. Cien Saude Colet 2011; 16(3):1793-1800.

21 Thiago SCS, Tesser CD. Percepção de médicos e enfermeiros da Estratégia de Saúde da Família sobre terapias complementares. Rev Saude Publica 2011; 45(2):249-257.

22 Ischkanian PC, Pelicioni MCF. Desafios das práticas integrativas e complementares no SUS visando a promoção da saúde. Rev Brasileira de Crescimento Desenvolvimento Humano. 2012; 22(2):233-238.

23 Lima KMSV, Silva KL, Tesser CD. Práticas integrativas e complementares e relação com promoção da saúde: experiência de um serviço municipal de saúde. Interface (Botucatu) 2014; 18(49):261-272.^-²⁴24 Sousa IMC, Tesser CD. Medicina Tradicional e Complementar no Brasil: inserção no Sistema Único de Saúde e integração com a atenção primária. Cad Saude Publica 2017; 33(1):e00150215..

Regarding the level of care where practice was performed, 52.94% occurred at the primary care level⁸8 Ceolin T, Heck RM, Pereira DB, Martins AR, Coimbra VCC, Silveira DSS. A inserção das terapias complementares no sistema único de saúde visando o cuidado integral na assistência. Enferm. glob. 2009; 16:1-10.^,¹⁰10 Oliveira SGD, Moura FRR, Demarco FF, Nascente PS, Del Pino FAB, Lund RG. An ethnomedicinal survey on phytotherapy with professionals and patients from Basic Care Units in the Brazilian Unified Health System. J Ethnopharmacol 2012; 140(2):428-437.

11 Fontenele RP, Sousa DMP, Carvalho ALM, Oliveira FA. Fitoterapia na Atenção Básica: olhares dos gestores e profissionais da Estratégia Saúde da Família de Teresina (PI), Brasil. Cien Saude Colet 2013; 18(8):2385-2394.^-¹²12 Monteiro DA, Iriart JAB. Homeopatia no Sistema Único de Saúde: representações dos usuários sobre o tratamento homeopático. Cad Saude Publica 2007 ago; 23(8):1903-1912.^,¹⁶16 Fontanella F, Speck FP, Piovezan AP, Kulkamp IC. Conhecimento, acesso e aceitação das práticas integrativas e complementares em saúde por uma comunidade usuária do Sistema Único de Saúde na cidade de Tubarão/SC. ACM 2007; 36(2):69-74.^,¹⁹19 Marques LAM, Vale FVVR, Nogueira VAS, Mialhe FL, Silva LC. Atenção farmacêutica e práticas integrativas e complementares no SUS: conhecimento e aceitação por parte da população sãojoanense. Physis. 2011; 21(2):663-674.

20 Nagai SC, Queiroz MS. Medicina complementar e alternativa na rede básica de serviços de saúde: uma aproximação qualitativa. Cien Saude Colet 2011; 16(3):1793-1800.^-²¹21 Thiago SCS, Tesser CD. Percepção de médicos e enfermeiros da Estratégia de Saúde da Família sobre terapias complementares. Rev Saude Publica 2011; 45(2):249-257.^,²⁴24 Sousa IMC, Tesser CD. Medicina Tradicional e Complementar no Brasil: inserção no Sistema Único de Saúde e integração com a atenção primária. Cad Saude Publica 2017; 33(1):e00150215. and 17.65% at the primary/secondary level¹⁵15 Silva EDC, Tesser CD. Experiência de pacientes com acupuntura no Sistema Único de Saúde em diferentes ambientes de cuidado e (des)medicalização social. Cad Saude Publica 2013; 29(11):2186-2196.^,²²22 Ischkanian PC, Pelicioni MCF. Desafios das práticas integrativas e complementares no SUS visando a promoção da saúde. Rev Brasileira de Crescimento Desenvolvimento Humano. 2012; 22(2):233-238.^,²³23 Lima KMSV, Silva KL, Tesser CD. Práticas integrativas e complementares e relação com promoção da saúde: experiência de um serviço municipal de saúde. Interface (Botucatu) 2014; 18(49):261-272.. Other authors (29.41%) addressed practice in the general SUS scenario⁹9 Santos RL, Guimaraes GP, Nobre MSC, Portela AS. Análise sobre a fitoterapia como prática integrativa no Sistema Único de Saúde. Rev. Bras. Pl. Med. 2011; 13(4):486-491.^,¹³13 Salles SAC, Schraiber LB. Gestores do SUS: apoio e resistências à Homeopatia. Cad Saude Publica 2009; 25(1):195-202.^,¹⁴14 Galhardi WMP, Barros NF, Leite-Mor 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.^,¹⁷17 Tesser CD, Barros NF. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Rev Saude Publica 2008; 42(5):914-920.^,¹⁸18 Andrade JT, Costa LFA. Medicina Complementar no SUS: práticas integrativas sob a luz da Antropologia médica. Saude Soc 2010; 19(3):497-508.. It was also identified that all the analyzed papers showed level IV of evidence. Also, the main topics covered were the main ICPs adopted in the SUS, access to these practices, and preparedness of health services and professionals for their implementation and use. The categories of discussion were elaborated from these themes.

Discussion

The ICPs’ approach in the SUS: main practices

Initially, the NICPP only included five ICPs in its guidelines to be employed in the SUS in order to promote the recovery, maintenance and prevention of users’ health, besides the cure of some diseases, and they are: Traditional Chinese Medicine/Acupuncture; Homeopathy; Medicinal Plants/Herbal Medicine; Thermalism/Cryotherapy; and Anthroposophical Medicine²⁵25 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Portaria nº 145, de 11 de janeiro de 2017. Altera procedimentos na Tabela de Procedimentos, Medicamentos, Órteses, Próteses e Materiais Especiais do SUS para atendimento na Atenção Básica. Diário Oficial da União 2017; 13 jan.. However, in recognizing the increasing use of other practices based on traditional knowledge by the population in general, the MoH included, between 2017 and 2018, new therapeutic resources in the NICPP, through Ordinances No. 849/2017²⁶26 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Portaria nº 849, de 27 de março de 2017. Inclui a Arteterapia, Ayurveda, Biodança, Dança Circular, Meditação, Musicoterapia, Neturopatia, Osteopatia, Quiropraxia, Reflexologia, Reiki, Shantala, Terapia Comunitária Integrativa e Yoga à Política Nacional de Práticas Integrativas e Complementares. Diário Oficial da União 2017; 28 mar. and No. 702/2018²⁷27 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Portaria nº 702, de 21 de março de 2018. Altera a Portaria de Consolidação nº 2/GM/MS, de 28 de setembro de 2017, para incluir novas práticas na Política Nacional de Práticas Integrativas e Complementares - PNPIC. Diário Oficial da União 2018; 22 mar.. With these measures, the SUS currently provides 29 of these practices.

Given the ICPs options fostered by the policy, the results of this study show that many of these were not addressed by the authors or were merely cited without further elaboration. Therefore, studies that analyzed several practices in the same research prevailed, such as: acupuncture, homeopathy, herbal medicine, among others, analyzing their implantation and organization and the knowledge of users and professionals about ICPs¹⁶16 Fontanella F, Speck FP, Piovezan AP, Kulkamp IC. Conhecimento, acesso e aceitação das práticas integrativas e complementares em saúde por uma comunidade usuária do Sistema Único de Saúde na cidade de Tubarão/SC. ACM 2007; 36(2):69-74.^,¹⁹19 Marques LAM, Vale FVVR, Nogueira VAS, Mialhe FL, Silva LC. Atenção farmacêutica e práticas integrativas e complementares no SUS: conhecimento e aceitação por parte da população sãojoanense. Physis. 2011; 21(2):663-674.^,²⁰20 Nagai SC, Queiroz MS. Medicina complementar e alternativa na rede básica de serviços de saúde: uma aproximação qualitativa. Cien Saude Colet 2011; 16(3):1793-1800.^,²²22 Ischkanian PC, Pelicioni MCF. Desafios das práticas integrativas e complementares no SUS visando a promoção da saúde. Rev Brasileira de Crescimento Desenvolvimento Humano. 2012; 22(2):233-238.

23 Lima KMSV, Silva KL, Tesser CD. Práticas integrativas e complementares e relação com promoção da saúde: experiência de um serviço municipal de saúde. Interface (Botucatu) 2014; 18(49):261-272.^-²⁴24 Sousa IMC, Tesser CD. Medicina Tradicional e Complementar no Brasil: inserção no Sistema Único de Saúde e integração com a atenção primária. Cad Saude Publica 2017; 33(1):e00150215.; as well as those studies that pointed out a general context of therapies in the SUS, without specifying the practices used¹⁷17 Tesser CD, Barros NF. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Rev Saude Publica 2008; 42(5):914-920.^,¹⁸18 Andrade JT, Costa LFA. Medicina Complementar no SUS: práticas integrativas sob a luz da Antropologia médica. Saude Soc 2010; 19(3):497-508.^,²¹21 Thiago SCS, Tesser CD. Percepção de médicos e enfermeiros da Estratégia de Saúde da Família sobre terapias complementares. Rev Saude Publica 2011; 45(2):249-257.. Thus, it was possible to observe the lack of studies that investigated the use of some practices, such as Thermalism/Crenotherapy and Anthroposophical Medicine, pointing out a gap for their use in the SUS. However, this may be a reflection of the low supply of such therapies in services, which precludes the discussion of these practices in the studies analyzed.

Among the studies that addressed specifically practices, we highlight the use of herbal medicine⁸8 Ceolin T, Heck RM, Pereira DB, Martins AR, Coimbra VCC, Silveira DSS. A inserção das terapias complementares no sistema único de saúde visando o cuidado integral na assistência. Enferm. glob. 2009; 16:1-10.

9 Santos RL, Guimaraes GP, Nobre MSC, Portela AS. Análise sobre a fitoterapia como prática integrativa no Sistema Único de Saúde. Rev. Bras. Pl. Med. 2011; 13(4):486-491.

10 Oliveira SGD, Moura FRR, Demarco FF, Nascente PS, Del Pino FAB, Lund RG. An ethnomedicinal survey on phytotherapy with professionals and patients from Basic Care Units in the Brazilian Unified Health System. J Ethnopharmacol 2012; 140(2):428-437.^-¹¹11 Fontenele RP, Sousa DMP, Carvalho ALM, Oliveira FA. Fitoterapia na Atenção Básica: olhares dos gestores e profissionais da Estratégia Saúde da Família de Teresina (PI), Brasil. Cien Saude Colet 2013; 18(8):2385-2394. and homeopathy¹²12 Monteiro DA, Iriart JAB. Homeopatia no Sistema Único de Saúde: representações dos usuários sobre o tratamento homeopático. Cad Saude Publica 2007 ago; 23(8):1903-1912.

13 Salles SAC, Schraiber LB. Gestores do SUS: apoio e resistências à Homeopatia. Cad Saude Publica 2009; 25(1):195-202.^-¹⁴14 Galhardi WMP, Barros NF, Leite-Mor 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.. Acupuncture was investigated in isolation by Silva and Tesser¹⁵15 Silva EDC, Tesser CD. Experiência de pacientes com acupuntura no Sistema Único de Saúde em diferentes ambientes de cuidado e (des)medicalização social. Cad Saude Publica 2013; 29(11):2186-2196.. However, both homeopathy and acupuncture, even in the studies that analyzed several practices together, emerged as those with higher adherence by users and greater provision of services¹⁵15 Silva EDC, Tesser CD. Experiência de pacientes com acupuntura no Sistema Único de Saúde em diferentes ambientes de cuidado e (des)medicalização social. Cad Saude Publica 2013; 29(11):2186-2196.^,²¹21 Thiago SCS, Tesser CD. Percepção de médicos e enfermeiros da Estratégia de Saúde da Família sobre terapias complementares. Rev Saude Publica 2011; 45(2):249-257.^,²²22 Ischkanian PC, Pelicioni MCF. Desafios das práticas integrativas e complementares no SUS visando a promoção da saúde. Rev Brasileira de Crescimento Desenvolvimento Humano. 2012; 22(2):233-238.. This is in line with data presented by the MoH in 2008, which show keen interest on the part of the government and the population in these therapies when compared to the others²⁸28 Brasil. Ministério da Saúde (MS). Práticas Integrativas e Complementares no SUS:ampliação do acesso. Brasília: MS; 2009. [Informes da Atenção Básica Nº 53]..

While mechanisms of action of acupuncture²⁹29 Kawakita K, Okada K. Acupuncture therapy: mechanism of action, efficacy, and safety: a potential intervention for psychogenic disorders? Biopsychosoc Med 2014; 8(1):4.^,³⁰30 Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008; 85(4):355-375. and homeopathy³¹31 Carpenter JS, Neal JG. Other complementary and alternative medicine modalities: acupuncture, magnets, reflexology, and homeopathy. Am J Med 2005; 118(12B):109S-117S.^,³²32 Cucherat M, Haugh MC, Gooch M, Boissel JP. Evidence of clinical efcacy of homeopathy. A meta-analysis of clinical trials. Eur J Clin Pharmacol. 2000; 56(1):27-33. are still not entirely clear and sometimes inconclusive, their benefits have been demonstrated in different studies for different diseases³³33 Iunes DH, Chaves ECL, Moura CC, Côrrea B, Carvalho LC, Silva AM, Carvalho EC. Role of Auriculotherapy in the treatment of temporomandibular disorders with anxiety in university students. Evid Based Complement Alternat Med 2015; 2015:430143.

34 Kurebayashi LFS, Gnatta JR, Borges TP, Belisse G, Coca S, Minami A, Souza TM, Silva MJP. Aplicabilidade da auriculoterapia com agulhas ou sementes para diminuição de estresse em profissionais de enfermagem. Rev Esc Enferm USP 2012; 46(1):89-95.

35 Macías-Cortés EC, Llanes-González L, Aguilar-Faisal L, Asbun-Bojalil J. Individualized Homeopathic Treatment and Fluoxetine for Moderate to Severe Depression in Peri- and Postmenopausal Women (HOMDEP-MENOP Study): A Randomized, Double-Dummy, Double-Blind, Placebo-Controlled Trial. PLoS One 2015; 10(3):e0118440.^-³⁶36 Toca-Villegas J, Esmer-Sánchez D, García-Narváez J, Sánchez-Aguilar M, Hernández-Sierra JF. Eficacia de la auriculoterapia modificada como tratamento para el control del dolor post operatorio em pacientes intervenidos mediante colecistectomía laparoscópica. Cirurgia y Cirujanos (English Edition) 2017; 85(3):220-224.. As a result, adherence to these treatments is increasingly progressive, so that 80% of the 129 WHO member countries already recognize acupuncture as a health treatment⁵5 World Health Organization (WHO). WHO traditional medicine strategy: 2014-2023. Geneva: WHO; 2013., and homeopathy is one of the most indicated ICPs in European countries, as in France³⁷37 Rossignol M, Bégaud B, Avouac B, Lert F, Rouillon F, Bénichou J, Massol J, Duru G, Magnier AM, Guillemot D, Grimaldi-Bensouda L, Abenhaim L. Who seeks primary care for musculoskeletal disorders (MSDs) with physicians prescribing homeopathic and other complementary medicine? Results from the EPI3-LASER survey in France. BMC Musculoskelet Disord 2011; 12:21..

In general, ICPs can be seen as an essential healthcare strategy, especially considering the person as a whole, differing from the biomedical model²³23 Lima KMSV, Silva KL, Tesser CD. Práticas integrativas e complementares e relação com promoção da saúde: experiência de um serviço municipal de saúde. Interface (Botucatu) 2014; 18(49):261-272.. Demand for ICPs is mostly due to complicated reasons, ranging from factors such as low profile of adverse effects, to the natural consequence of incentive towards inside-out healing, search for complementation of allopathic treatment, reception and active listening performed during the consultation, as well as compatibility of such practices with values, beliefs and philosophy of health and life of the user¹⁷17 Tesser CD, Barros NF. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Rev Saude Publica 2008; 42(5):914-920.^,³⁸38 Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998; 279(19):1548-1553.. Also, they may be perceived as a potential drug consumption reducer¹⁵15 Silva EDC, Tesser CD. Experiência de pacientes com acupuntura no Sistema Único de Saúde em diferentes ambientes de cuidado e (des)medicalização social. Cad Saude Publica 2013; 29(11):2186-2196..

Tesser³⁹39 Tesser CD. Práticas complementares, racionalidades médicas e promoção da saúde: contribuições poucos exploradas. Cad Saude Publica 2009; 25(8)1732-1742. also points out that the reasons that lead users to seek such treatments may be associated with critical socioeconomic factors. In developing countries, local culture, easy access to alternative practices, the high cost of conventional medicine, and the limited availability of biomedical resources facilitate the search for complementary medicine. However, in rich countries, dissatisfaction with the biomedical model and the benefits of ICPs are the factors that foster this demand.

Access to ICPs: Primary Health Care (PHC) as a gateway

Since PHC should be the user’s first contact and gateway to the healthcare network, according to the National Primary Healthcare Policy (PNAB)⁴⁰40 Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Básica. Brasília: MS; 2012., it is possible to infer that this level of care is a privileged locus for the implementation of ICPs in the Brazilian public health system. In fact, data from the MoH indicate that ICPs are mostly provided in PHC services⁴¹41 Brasil. Ministério da Saúde (MS). Política Nacional de Práticas Integrativas e Complementares. Informe - maio de 2017 [Internet]. 2017 Maio [acessado 2018 Mar 06]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/Informe_Maio_2017.pdf
http://189.28.128.100/dab/docs/portaldab... .

A recent study⁴²42 Faqueti A, Tesser CD. Utilização de Medicinas Alternativas e Complementares na atenção primária à saúde de Florianópolis/SC: percepção de usuários. Cien Saude Colet 2016; 23(8):2621-2630. conducted in Florianópolis indicated that PHC professionals usually encouraged ICP use during the consultation with the patient and started treatment as soon as possible, often during the consultation itself. Thus, treatment with ICPs can be in some cases the initial approach, where conventional therapy is the second option, if necessary, or complementing the ICPs approach. Also, the availability of ICPs in PHC services may promote increased dialogue between practitioners and users about which therapy to use, namely, conventional therapy or ICPs, and this may have a positive effect on this contact⁴²42 Faqueti A, Tesser CD. Utilização de Medicinas Alternativas e Complementares na atenção primária à saúde de Florianópolis/SC: percepção de usuários. Cien Saude Colet 2016; 23(8):2621-2630..

In this study, some authors point to secondary care services¹⁵15 Silva EDC, Tesser CD. Experiência de pacientes com acupuntura no Sistema Único de Saúde em diferentes ambientes de cuidado e (des)medicalização social. Cad Saude Publica 2013; 29(11):2186-2196.^,²²22 Ischkanian PC, Pelicioni MCF. Desafios das práticas integrativas e complementares no SUS visando a promoção da saúde. Rev Brasileira de Crescimento Desenvolvimento Humano. 2012; 22(2):233-238.^,²³23 Lima KMSV, Silva KL, Tesser CD. Práticas integrativas e complementares e relação com promoção da saúde: experiência de um serviço municipal de saúde. Interface (Botucatu) 2014; 18(49):261-272. as access to ICPs. However, in order to achieve these sites as a field of care and provision of complementary treatments, it is necessary to approach professionals at both the primary and secondary levels so that they can be consolidated as a network of comprehensive care and universal access, taking into account the principles and foundations of each of the practices²³23 Lima KMSV, Silva KL, Tesser CD. Práticas integrativas e complementares e relação com promoção da saúde: experiência de um serviço municipal de saúde. Interface (Botucatu) 2014; 18(49):261-272..

Although the use of ICPs in secondary and tertiary care environments is more restricted, there is an albeit bashful tendency for their use at these levels, since 1,708 Brazilian municipalities provide ICPs, 78% in PHC, 18% in secondary care and 4% in tertiary care⁴³43 Brasil. Ministério da Saúde (MS). Departamento de Atenção Básica. Portal da Saúde SUS. Portaria amplia oferta de PICS [Internet]. 2017 Jan [acessado 2017 Jul 09]. Disponível em: http://dab.saude.gov.br/portaldab/noticias.php?conteudo=_&cod=2297
http://dab.saude.gov.br/portaldab/notici... . However, when considering PHC as the level of care with the highest capacity to develop health prevention and recovery actions, the use of ICPs in these services is the most appropriate. Furthermore, such practices do not require sophisticated technological resources, they provide lower risks of side effects when compared to conventional treatments, and demand fewer financial resources, making health care more affordable and of high quality, besides providing satisfactory results²2 World Health Organization (WHO). WHO Traditional Medicine Strategy 2002 - 2005. Geneva: WHO; 2002.^,⁴⁴44 Spadacio C, Castellanos MEP, Barros NF, Alegre SM, Tovey P, Broom A. Medicinas Alternativas e Complementares: uma metassíntese. Cad Saude Publica 2010; 26(1):7-13..

However, the difficult of access to ICPs at the various levels of care, especially in the secondary and tertiary sectors, may be related to the lack of knowledge by professionals about the use of these practices. Also, it is emphasized that many of these workers do not understand the importance or do not have the adequate ability to indicate or apply such practices¹⁶16 Fontanella F, Speck FP, Piovezan AP, Kulkamp IC. Conhecimento, acesso e aceitação das práticas integrativas e complementares em saúde por uma comunidade usuária do Sistema Único de Saúde na cidade de Tubarão/SC. ACM 2007; 36(2):69-74.^,¹⁸18 Andrade JT, Costa LFA. Medicina Complementar no SUS: práticas integrativas sob a luz da Antropologia médica. Saude Soc 2010; 19(3):497-508..

Despite this obstacle, their availability in services is accepted and expected, especially by users¹⁷17 Tesser CD, Barros NF. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Rev Saude Publica 2008; 42(5):914-920.^,¹⁹19 Marques LAM, Vale FVVR, Nogueira VAS, Mialhe FL, Silva LC. Atenção farmacêutica e práticas integrativas e complementares no SUS: conhecimento e aceitação por parte da população sãojoanense. Physis. 2011; 21(2):663-674.. Thus, a movement of Brazilian municipalities to implement the use of ICPs in the last years is observed⁹9 Santos RL, Guimaraes GP, Nobre MSC, Portela AS. Análise sobre a fitoterapia como prática integrativa no Sistema Único de Saúde. Rev. Bras. Pl. Med. 2011; 13(4):486-491.. However, local management should encourage the strengthening and use of these practices and provide conditions for their provision to the population, through dissemination and support, following recommendations of the NICPP¹¹11 Fontenele RP, Sousa DMP, Carvalho ALM, Oliveira FA. Fitoterapia na Atenção Básica: olhares dos gestores e profissionais da Estratégia Saúde da Família de Teresina (PI), Brasil. Cien Saude Colet 2013; 18(8):2385-2394.^,²²22 Ischkanian PC, Pelicioni MCF. Desafios das práticas integrativas e complementares no SUS visando a promoção da saúde. Rev Brasileira de Crescimento Desenvolvimento Humano. 2012; 22(2):233-238..

Current scenario of implementation of ICPs: preparedness of health services and practitioners for ICPs

Human resources are essential for the use of ICPs in the SUS. In this context, vocational training is a significant gap for the successful implementation of the practices¹³13 Salles SAC, Schraiber LB. Gestores do SUS: apoio e resistências à Homeopatia. Cad Saude Publica 2009; 25(1):195-202.^,¹⁶16 Fontanella F, Speck FP, Piovezan AP, Kulkamp IC. Conhecimento, acesso e aceitação das práticas integrativas e complementares em saúde por uma comunidade usuária do Sistema Único de Saúde na cidade de Tubarão/SC. ACM 2007; 36(2):69-74.^,²²22 Ischkanian PC, Pelicioni MCF. Desafios das práticas integrativas e complementares no SUS visando a promoção da saúde. Rev Brasileira de Crescimento Desenvolvimento Humano. 2012; 22(2):233-238.. The lack of knowledge of the NICPP, as well as of therapies addressed in the policy hinders professionals’ and services’ participation in the provision of practices¹³13 Salles SAC, Schraiber LB. Gestores do SUS: apoio e resistências à Homeopatia. Cad Saude Publica 2009; 25(1):195-202.^,¹⁴14 Galhardi WMP, Barros NF, Leite-Mor 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..

In Brazil, in addition to physicians, other health professionals, such as nurses, physiotherapists, pharmacists, among others, are qualified to use various practices fostered by the policy³3 Brasil. Ministério da Saúde (MS). Política Nacional de Práticas Integrativas e Complementares no SUS. Brasília: MS; 2006.. However, the low adherence to specializations in the area of complementary interventions and poor education about the purposes of using ICPs during training prevent more significant improvement of health professionals⁹9 Santos RL, Guimaraes GP, Nobre MSC, Portela AS. Análise sobre a fitoterapia como prática integrativa no Sistema Único de Saúde. Rev. Bras. Pl. Med. 2011; 13(4):486-491., although many show an interest in training and agreement with the use of practices in services²¹21 Thiago SCS, Tesser CD. Percepção de médicos e enfermeiros da Estratégia de Saúde da Família sobre terapias complementares. Rev Saude Publica 2011; 45(2):249-257..

One of the main difficulties pointed out by the managers for the implementation of these therapies is the resistance by some health professionals attributed to scarce scientific evidence and lack of logistical and structural support of the local management¹¹11 Fontenele RP, Sousa DMP, Carvalho ALM, Oliveira FA. Fitoterapia na Atenção Básica: olhares dos gestores e profissionais da Estratégia Saúde da Família de Teresina (PI), Brasil. Cien Saude Colet 2013; 18(8):2385-2394.. This is therefore considered an important problem since the positive attitude of professionals vis-à-vis these practices is relevant to motivate users towards adopting ICPs¹⁵15 Silva EDC, Tesser CD. Experiência de pacientes com acupuntura no Sistema Único de Saúde em diferentes ambientes de cuidado e (des)medicalização social. Cad Saude Publica 2013; 29(11):2186-2196..

Another fact that causes a stir is related to increased ICPs in the SUS. However, this was more significant from the application of practices by non-medical professionals⁴⁵45 Sousa IMC, Bodstein RCA, Tesser CD, Santos FAZ, Hortale VA. Práticas integrativas e complementares: oferta produção de atendimentos no SUS e em municípios selecionados. Cad Saude Publica 2012; 28(11):2143-2154., which requires that other team members expand their knowledge about complementary treatments and gain space for the use of such practices⁸8 Ceolin T, Heck RM, Pereira DB, Martins AR, Coimbra VCC, Silveira DSS. A inserção das terapias complementares no sistema único de saúde visando o cuidado integral na assistência. Enferm. glob. 2009; 16:1-10.. Thus, managers should provide support and incentives in the supply of these resources to revive the humanistic realm of health care¹³13 Salles SAC, Schraiber LB. Gestores do SUS: apoio e resistências à Homeopatia. Cad Saude Publica 2009; 25(1):195-202..

In this context, greater knowledge about the policy and ICPs, as well as, for example, encouraging professionals through lifelong learning can be effective strategies for implementing and expanding the implementation of NICPP and improving access to health services within the SUS.

Although there are still few Brazilian studies on continuing education geared to these practices, Santos and Tesser⁴⁶46 Santos MC, Tesser CD. Um método para a implantação e promoção de acesso às Práticas Integrativas e Complementares na Atenção Primária à Saúde. Cien Saude Colet 2012; 17(11):3011-3024. show a method of implementation and promotion of access to ICPs in PHC based on previous experiences, consisting of four sequential stages. The first stage establishes the people responsible, who will spearhead this process (preferably, professionals with expertise in ICPs). In the second stage, a situational analysis will be carried out, in which these professionals, whether active or not, will be mapped and recruited so that, through implementation and access discussions, they conduct a survey on issues that hinder access to ICPs, on the organization of actions, the attendance flow of services and the formalization of activities developed, making a local situational analysis of ICPs. Regulations will be set during the third stage, establishing standards and adaptations for the development of ICPs in line with the current policy (NICPP) and, finally, during the fourth stage, the implementation takes place cyclically and continuously, which will be influenced by the productive capacity of the responsible staff⁴⁶46 Santos MC, Tesser CD. Um método para a implantação e promoção de acesso às Práticas Integrativas e Complementares na Atenção Primária à Saúde. Cien Saude Colet 2012; 17(11):3011-3024..

This model can help managers and professionals strategically expand existing services or implement new services that will facilitate and allow the general population’s access to ICPs. Thus, it is likely that initial investments and continuous training of network professionals will be necessary to meet demand in a qualified and decisive manner. However, over time, there may be lower values and higher service quality in services, since most practices require low operational costs and have fast and satisfactory results.

Significant advances in the use of ICPs and future challenges

Despite the increase in ICPs use in recent years, its therapeutic potential and its contributions to health are still poorly explored in the SUS⁸8 Ceolin T, Heck RM, Pereira DB, Martins AR, Coimbra VCC, Silveira DSS. A inserção das terapias complementares no sistema único de saúde visando o cuidado integral na assistência. Enferm. glob. 2009; 16:1-10.^,⁹9 Santos RL, Guimaraes GP, Nobre MSC, Portela AS. Análise sobre a fitoterapia como prática integrativa no Sistema Único de Saúde. Rev. Bras. Pl. Med. 2011; 13(4):486-491.. Although the MoH has positively evaluated this increase⁴⁷47 Brasil. Ministério da Saúde (MS). Relatório de Gestão 2006/2010 - Práticas Integrativas e Complementares no SUS. Brasília: MS; 2011., there are gaps such as assessments of ICPs in services and better monitoring of the policy’s impact.

Moreover, the preeminence of the current biomedical model coupled with the market trend in health care, which transforms knowledge and practices into commodities, can be a substantial limitation in the expected advances for these practices¹⁷17 Tesser CD, Barros NF. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Rev Saude Publica 2008; 42(5):914-920.. Thus, one challenge is the further analysis of care in a comprehensive care model, surpassing the supremacy of the rationale of biomedicine-based services¹⁸18 Andrade JT, Costa LFA. Medicina Complementar no SUS: práticas integrativas sob a luz da Antropologia médica. Saude Soc 2010; 19(3):497-508..

Other vital challenges are related to the training of and incentive to the health team members, support to non-medical professionals, as well as awareness and understanding of ICPs’ perspectives. These factors are essential for the successful introduction of ICPs into the SUS²⁰20 Nagai SC, Queiroz MS. Medicina complementar e alternativa na rede básica de serviços de saúde: uma aproximação qualitativa. Cien Saude Colet 2011; 16(3):1793-1800. and to ensure the principles of the NICPP, contributing to the promotion of health throughout the care network²²22 Ischkanian PC, Pelicioni MCF. Desafios das práticas integrativas e complementares no SUS visando a promoção da saúde. Rev Brasileira de Crescimento Desenvolvimento Humano. 2012; 22(2):233-238..

Study limitations and suggestions for future studies

The use of only two controlled descriptors (Unified Health System and Complementary Therapies) may have reduced the number of papers evaluated as to the eligibility criteria of the study. Thus, for future studies, we would suggest to include other more specific descriptors, such as, for example, Healthcare levels or Primary Health Care, besides specifying ICPs, especially the most prevalent ones, in the search fields (such as herbal medicine, homeopathy, acupuncture, bodily practices, among others) in order to expand the range of results obtained.

Final considerations

After a decade of policy implementation, we can consider that ICPs are provided incipiently in the SUS and scarce data on specific practices are a limitation to the current scenario of this approach. However, positive reflexes can be observed for users and services that have adhered to their use, although there are still challenges in their implementation, in their access and use and the education of trained professionals.

Thus, new studies with a historical approach to complementary practices are required following the creation of the NICPP and on the impacts on the Brazilian public health, as well as incentives for professional improvement, mainly for PHC workers, as a fundamental tool for the implementation, access and use of ICPs in the SUS.

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¹⁶
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» http://189.28.128.100/dab/docs/portaldab/documentos/Informe_Maio_2017.pdf
⁴²
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⁴³
Brasil. Ministério da Saúde (MS). Departamento de Atenção Básica. Portal da Saúde SUS. Portaria amplia oferta de PICS [Internet]. 2017 Jan [acessado 2017 Jul 09]. Disponível em: http://dab.saude.gov.br/portaldab/noticias.php?conteudo=_&cod=2297
» http://dab.saude.gov.br/portaldab/noticias.php?conteudo=_&cod=2297
⁴⁴
Spadacio C, Castellanos MEP, Barros NF, Alegre SM, Tovey P, Broom A. Medicinas Alternativas e Complementares: uma metassíntese. Cad Saude Publica 2010; 26(1):7-13.
⁴⁵
Sousa IMC, Bodstein RCA, Tesser CD, Santos FAZ, Hortale VA. Práticas integrativas e complementares: oferta produção de atendimentos no SUS e em municípios selecionados. Cad Saude Publica 2012; 28(11):2143-2154.
⁴⁶
Santos MC, Tesser CD. Um método para a implantação e promoção de acesso às Práticas Integrativas e Complementares na Atenção Primária à Saúde. Cien Saude Colet 2012; 17(11):3011-3024.
⁴⁷
Brasil. Ministério da Saúde (MS). Relatório de Gestão 2006/2010 - Práticas Integrativas e Complementares no SUS Brasília: MS; 2011.

Publication Dates

Publication in this collection
28 Oct 2019
Date of issue
Nov 2019

History

Received
19 July 2017
Accepted
20 Apr 2018
Published
22 Apr 2018

Este é um artigo publicado em acesso aberto (Open Access) sob a licença Creative Commons Attribution, que permite uso, distribuição e reprodução em qualquer meio, sem restrições desde que o trabalho original seja corretamente citado.

[1] ¹
Frass M, Strassl RP, Friehs H, Müllner M, Kundi M, Kaye AD. Use and acceptance of Complementary and Alternative Medicine among the general population and medical personnel: A Systematic Review. Ochsner J 2012; 12(1):45-56.

[2] ²
World Health Organization (WHO). WHO Traditional Medicine Strategy 2002 - 2005 Geneva: WHO; 2002.

[3] ³
Brasil. Ministério da Saúde (MS). Política Nacional de Práticas Integrativas e Complementares no SUS Brasília: MS; 2006.

[4] ⁴
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Authors (years)	Study approach	Study objective	Main results	Conclusion
Fontanella et al. (2007)¹⁶16 Fontanella F, Speck FP, Piovezan AP, Kulkamp IC. Conhecimento, acesso e aceitação das práticas integrativas e complementares em saúde por uma comunidade usuária do Sistema Único de Saúde na cidade de Tubarão/SC. ACM 2007; 36(2):69-74.	Quantitative	To evaluate the knowledge, access and acceptance related to ICPs of a SUS user community of the South Brazilian region.	Most ICPs were not known by the population. The use of therapies without expert follow-up was frequent, which, together with the low access of the community, shows the lack of professionals qualified for this care.	There is evidence of low knowledge and access to ICPs, despite population's interest and acceptance. Also, the use of therapies occurs without the consultation of specialized professionals.
Monteiro and Iriart (2007)¹²12 Monteiro DA, Iriart JAB. Homeopatia no Sistema Único de Saúde: representações dos usuários sobre o tratamento homeopático. Cad Saude Publica 2007 ago; 23(8):1903-1912.	Case study	Understand the motivations of users to look for homeopathy, how they portray and explain the action of medications and homeopathic treatments.	The primary motivation for seeking homeopathy was the failure of allopathic treatment. The holistic perspective, the use of natural medicines, long consultation time and active listening were brought as favorable differential characteristics when compared to allopathic treatment.	The potential of the contribution of therapeutic alternatives such as homeopathy in the public health service is poorly explored.
Tesser and Barros (2008)¹⁷17 Tesser CD, Barros NF. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Rev Saude Publica 2008; 42(5):914-920.	Reflective analysis	To analyze potentialities and difficulties of practices and Alternative and Complementary Medicines (ACM) from clinical-institutional experiences and specialized literature	The SUS provides ACM. There are common favorable manifestations of policies of the civil society and users' representatives regarding the provision of ACM by the SUS.	ACM has limited "demedicalizing" potential. The political-epistemological hegemony of bioscience and the current health market dispute, whose tendency is to transform any knowledge or practice of the health-disease process into commodities or procedures to be consumed must be observed.
Ceolin et al. (2009)⁸8 Ceolin T, Heck RM, Pereira DB, Martins AR, Coimbra VCC, Silveira DSS. A inserção das terapias complementares no sistema único de saúde visando o cuidado integral na assistência. Enferm. glob. 2009; 16:1-10.	Reflective analysis	To discuss the use of complementary therapies in Brazil, aiming at the comprehensive care of the individual and the introduction of the nurse practitioner in these practices.	The use of medicinal plants has increased to meet the needs of users. Nurses must expand their knowledge and gain space for the use of complementary therapies.	The biomedical model is flawed in the comprehensive care to the user. Thus, it has sought other treatments. Medicinal plants bridge this gap.
Salles and Schraiber (2009)¹³13 Salles SAC, Schraiber LB. Gestores do SUS: apoio e resistências à Homeopatia. Cad Saude Publica 2009; 25(1):195-202.	Reflective analysis	To investigate the characteristics of the relationship currently established between Homeopathy and Biomedicine, according to the point of view of non-homeopathic physicians.	The support of managers to the presence of Homeopathy in the SUS is related to the perception of social demand, to the protection of the right of choice of users and to the fact that it is a medical practice that revives the humanist realm of medicine.	The notion of Homeopathy as a "mild medicine" predominates, which could slowly promote improved symptoms. There is a lack of service structure for acute care cases. The training of homeopaths is flawed since the specialization courses do not provide training to attend severe cases.
Andrade and Costa (2010)¹⁸18 Andrade JT, Costa LFA. Medicina Complementar no SUS: práticas integrativas sob a luz da Antropologia médica. Saude Soc 2010; 19(3):497-508.	Reflective analysis	To consider the aspects of the institutionalization of ICPs, to reflect on the paradigmatic foundations of their therapeutic action and to analyze the comprehensive and complex character of its application, with specific anthropological views in the dialogue.	The public health system carries to its core other traditional knowledge and rationalities, which come to live with the conventional logic and services of biomedicine.	It is necessary to study the concept of integrality further, as well as to face the practical challenges of implementing the ICPs.
Marques et al. (2011)¹⁹19 Marques LAM, Vale FVVR, Nogueira VAS, Mialhe FL, Silva LC. Atenção farmacêutica e práticas integrativas e complementares no SUS: conhecimento e aceitação por parte da população sãojoanense. Physis. 2011; 21(2):663-674.	Qualitative	To investigate the knowledge and acceptance of integrative and complementary therapies and pharmaceutical care by users of SUS PHC facilities	100% of participants did not know what integrative and complementary therapies were all about. Doctors' knowledge about acupuncture and homeopathy is almost non-existent.	Most of the respondents would accept the use of the therapies if they were offered by the health facility, in addition to finding the pharmacist's attention more critical. There is little dissemination, and few social programs seek to show the benefits of such therapies.
Nagai and Queiroz (2011)²⁰20 Nagai SC, Queiroz MS. Medicina complementar e alternativa na rede básica de serviços de saúde: uma aproximação qualitativa. Cien Saude Colet 2011; 16(3):1793-1800.	Qualitative	To focus the implementation of complementary and alternative practices with the purpose of evaluating the conditions of their occurrence from the social representations of the professionals who participate in this process.	Four reasons were found for the success of the inclusion of ICPs: the willingness of the clientele; the health vision of hygienist doctors; extensive support from non-medical health professionals; and the perspective of alternative and complementary medicines that are in line with the SUS proposal.	Despite the success in implementing these practices in the primary network, the planning of these actions is insufficient and the vision is simplified, which turns alternative rationalities into mere techniques that follow the same mechanistic principles of allopathic medicine and the same reified understanding of the disease.
Santos et al. (2011)⁹9 Santos RL, Guimaraes GP, Nobre MSC, Portela AS. Análise sobre a fitoterapia como prática integrativa no Sistema Único de Saúde. Rev. Bras. Pl. Med. 2011; 13(4):486-491.	Qualitative	To do a bibliographical survey, on the subjects like the importance of the herbal medicine; how it is being used; its benefits to the Public Health System; training of professionals in this area and programs and laws for implementation in the SUS.	The government has shown interest in the development of policies for health care procedures that are effective, comprehensive, humanized and less dependent on the pharmaceutical industry. Brazilian municipalities have carried out the implementation of Herbal medicine Programs in primary care.	Studies on herbal medicine are still scarce in Brazil, and research is needed in this area to expand the knowledge of health professionals and students, helping and strengthening the safety and efficacy bases for the implementation of herbal medicine practices in the SUS.
Thiago and Tesser (2011)²¹21 Thiago SCS, Tesser CD. Percepção de médicos e enfermeiros da Estratégia de Saúde da Família sobre terapias complementares. Rev Saude Publica 2011; 45(2):249-257.	Quantitative	To analyze the perception of professionals of the Family Health Strategy (ESF) about integrative and complementary practices.	17 health centers provided integrative and complementary practices; 12.4% of professionals were homeopathy or acupuncture experts. In total, 88.7% of the participants did not know the national guidelines on this subject, although 81.4% agreed with their inclusion in the SUS.	Professionals accept ICPS, and this is due to with their prior contact and possibly related to in family medicine and community / family health residency / specialization.
Ischkanian and Pelicioni (2012)²²22 Ischkanian PC, Pelicioni MCF. Desafios das práticas integrativas e complementares no SUS visando a promoção da saúde. Rev Brasileira de Crescimento Desenvolvimento Humano. 2012; 22(2):233-238.	Qualitative	To investigate the knowledge, opinions and social representations of the managers and health professionals about the ICPs in the SUS and to identify the difficulties and challenges in their implementation, use and disclosure in the Health Services.	The managers were not prepared for the implementation of the NICPP in the SUS. The biomedical model is prevalent and the provision of supplies used for the application of ICPs has been a problem. The dissemination of ICPs has not been sufficient among professionals and users.	The municipality must encourage and create conditions for the provision of ICPs, improving their dissemination and supporting the integration of non-medical professionals with appropriate training. ICPs integration in the SUS can undoubtedly contribute to health promotion.
Oliveira et al. (2012)¹⁰10 Oliveira SGD, Moura FRR, Demarco FF, Nascente PS, Del Pino FAB, Lund RG. An ethnomedicinal survey on phytotherapy with professionals and patients from Basic Care Units in the Brazilian Unified Health System. J Ethnopharmacol 2012; 140(2):428-437.	Quantitative	Interviewing professionals working in the SUS, as well as patients who use PHC, concerning their experience with ethnomedicine.	91.6% of the participants made use of medicinal plants at least once to treat specific diseases. Of the professionals, 65% used medicinal plants and 10% prescribed herbal medicines to patients. Patients and professionals reported knowing the medicinal plants due to their parents or grandparents.	A high proportion of users and professionals made use of medicinal plants and plants. Mallow was the most commonly used. The primary source of knowledge about herbal medicine was from parents or grandparents.
Fontenele et al. (2013)¹¹11 Fontenele RP, Sousa DMP, Carvalho ALM, Oliveira FA. Fitoterapia na Atenção Básica: olhares dos gestores e profissionais da Estratégia Saúde da Família de Teresina (PI), Brasil. Cien Saude Colet 2013; 18(8):2385-2394.	Quali-quantitative	To understand how managers and professionals at tertiary level in Teresina (PI) see the introduction of herbal medicine in Primary Care in the city, relating these data with knowledge of these professionals about this therapeutic practice, its use and the public policies involved.	The strengthening of the herbal medicine in PHC and its incorporation in the routine of the professional practice of the ESF are necessary for the discussion about herbal medicine in the PHC between the actors and the bodies involved, and the qualification of the health professionals.	The professionals' knowledge about health practices is relevant for the recognition of the situation, planning and streamlining of the application of health actions, especially those involving herbal medicine and other ICPs because they have specific policies.
Galhardi et al. (2013)¹⁴14 Galhardi WMP, Barros NF, Leite-Mor 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.	Quanti-qualitative	To analyze the knowledge of the health managers of the municipalities of São Paulo on the Policy and its importance for the implementation of homeopathy in the local health services.	Of the 645 municipalities analyzed, 47 provided homeopathy. 42 municipalities were interviewed. 26% knew the NICPP, 31% knew little and 41% were unaware of it.	NICPP is unknown to health managers and those who know it use it to divulge the homeopathic medical rationality and justify its indication in the SUS.
Silva and Tesser (2013)¹⁵15 Silva EDC, Tesser CD. Experiência de pacientes com acupuntura no Sistema Único de Saúde em diferentes ambientes de cuidado e (des)medicalização social. Cad Saude Publica 2013; 29(11):2186-2196.	Qualitative	To investigate the experience of SUS acupuncture users in Florianópolis, Santa Catarina, Brazil about their treatment, including their perception of efficacy, reduced medication use, guidelines received, changes in self-care and explanatory models of users, from the viewpoint of medicalization in the mentioned focus. To investigate this experience in different care settings by testing the hypothesis that primary health care may assumingly be an environment more favorable to the rationality of Traditional Chinese Medicine and acupuncture.	Acupuncture has poorly contributed to autonomy and demedicalization, except for its effectiveness. The attitude of professionals is essential to stimulate a more active and integral posture.	Most patients came to acupuncture in secondary care when other treatments failed. The practice was perceived effectively and favored the reduction of medications. Despite the difficulty of access, it was observed that PHC professionals have greater autonomy to care for patients, and can treat more severe cases for a more extended period.
Lima et al. (2014)²³23 Lima KMSV, Silva KL, Tesser CD. Práticas integrativas e complementares e relação com promoção da saúde: experiência de um serviço municipal de saúde. Interface (Botucatu) 2014; 18(49):261-272.	Qualitative	To show and discuss results of a research that analyzed the organization of ICPs developed in a CIP referral service, in the metropolitan region of Belo Horizonte, focusing its relationship with the promotion of health and its insertion in the SUS.	Practices can be a useful resource in health promotion, notably by establishing a new understanding of the health-disease process.	It is necessary to overcome the challenges of its organization and its expansion to strengthen ICPs in the field of promotion and care in the SUS, such as drawing professionals closer to CIP referral and support services of PHC.
Sousa and Tesser (2017)²⁴24 Sousa IMC, Tesser CD. Medicina Tradicional e Complementar no Brasil: inserção no Sistema Único de Saúde e integração com a atenção primária. Cad Saude Publica 2017; 33(1):e00150215.	Qualitative	To analyze the insertion of traditional and complementary medicine (TCM) in the SUS, with the aim of supporting the discussion about its integration in PHC via ESF.	Types of TCM insertion and integration: Type 1 - Integrated; Type 2 - Overlapped; Type 3 - Integrated; Type 4 - No integration. The combination of types 1 and 3 is considered a potential for the expansion of TCM in the SUS, influencing growth and its integration into PHC.	The growing presence of the TCM in SUS requires thinking strategies for its expansion, beyond NICPP, considering the previous experiences.

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