Abstract

This paper aims to analyze the process of medicine dispensation in prisons. A qualitative study was conducted in seven penitentiaries in Paraíba with 13 health professionals and 43 people deprived of liberty using essential/strategic medicines from February to August 2016. The results were categorized from the perspective of Bardin’s content analysis. Three categories emerged: medicine storage location in the prison system, delivery process in the prison system, and health-related responsibilities with pharmaceutical care. We can conclude that the lack of pharmacies, the legal non-compliance regarding the availability of skilled professionals with technical competencies to perform the dispensation, focusing on the quality/safety standards and relevance of the use and storage guidelines associated with the lack of clarity in the definition of health responsibilities of managers from a government authority, are factors that compromise the policy since they increase the investment, but do not ensure pharmaceutical care in the prison system.

Key words:
Pharmaceutical Services; Prisons; Good Dispensation Practices

Introduction

To ensure therapeutic care, incorporation of health technology within the SUS¹1 Brasil. Lei nº 12.401, de 28 de abril de 2011. Altera a lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a assistência terapêutica e a incorporação de tecnologia em saúde no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União; 2011. and people’s access to medicines, with the necessary safety, efficacy, and quality, and promote rational use, the Ministry of Health (MoH) approved the National Medicines Policy (PNM) (Ordinance No. 3,916/1998)²2 Brasil. Ministério da Saúde (MS). Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Política Nacional de Medicamentos. Brasília: MS; 2001. and the National Pharmaceutical Care Policy (PNAF) (Resolution No. 338/2004)³3 Brasil. Resolução nº 338, de 6 de maio de 2004. Dispõe sobre a aprovação da Política Nacional de Assistência Farmacêutica. Diário Oficial da União; 2004.. The documents consider that Pharmaceutical Care (PC) involves a set of actions and services that aim to ensure comprehensive therapeutic care and the promotion, protection, and recovery of health in public and private establishments that perform pharmaceutical activities, where drugs are an essential supply⁴4 Brasil. Lei nº 13.021, de 8 de agosto de 2014. Dispõe sobre o exercício e a fiscalização das atividades farmacêuticas. Diário Oficial da União; 2014..

However, PC is not limited to the methods of supplying medicines. It has a systemic and multidisciplinary professional nature, which implies promoting the necessary articulation of the several procedures to ensure the supply of medicines per the criteria of need, quality, quantity, risk, and cost-benefit, respecting the stages of conservation, control of quality, safety and therapeutic efficacy of medicines, monitoring, and evaluation of use, obtaining and disseminating information on medicines and continuing education of health professionals, patients, and the community toward the rational use of medicines in health care²2 Brasil. Ministério da Saúde (MS). Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Política Nacional de Medicamentos. Brasília: MS; 2001.^,55 Silva Júnior EB, Nunes LMN. Avaliação da Assistência Farmacêutica na atenção primária no município de Petrolina (PE). ABCS Health Sci 2012; 37(2):65-69.. Therefore, the selection, programming, acquisition, storage/distribution, quality control/use, prescription, and dispensing activities are part of an effective PC³3 Brasil. Resolução nº 338, de 6 de maio de 2004. Dispõe sobre a aprovação da Política Nacional de Assistência Farmacêutica. Diário Oficial da União; 2004..

Since 1973, the term dispensing has been legally defined in Brazil as the supply of medicines to consumers in compliance with a medical prescription or not. It has often been understood simply as the delivery of medicines, compliance with legal norms, or mere bureaucracy. However, the PNM, the PNAF, and the recent enactment of Law No. 13,021⁶6 Brasil. Lei nº 13.021, de 8 de agosto de 2014. Dispõe sobre o exercício e a fiscalização das atividades farmacêuticas. Diário Oficial da União 2014; 11 ago. approach the goal of a simple supply of medicines to promote the rational use of medicines⁷7 Leite SN, Bernardo NLMC, Álvares J, Guerra Junior AA, Costa EA, Acurcio FA, Guibu IA, Costa KS, Karnikowski MGO, Soeiro OM, Soares L. Serviço de dispensação de medicamentos na atenção básica no SUS. Rev Saude Publica 2017; 51(Supl. 2):11s..

Thus, dispensing medicines is one of the steps for rational consumption, and it must be accompanied by relevant information for proper use⁸8 World Health Organization (WHO). The rational use of drugs, report of the conference of experts (Nairobi nov. 1985). Genebra: WHO; 1987.. Adopting the National List of Essential Medicines is recommended as a strategy (RENAME) to streamline this step⁹9 Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos em Saúde. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Relação Nacional de Medicamentos Essenciais: RENAME 2020. Brasília: MS; 2020.. It should be noted that the national legal apparatus has guaranteed health care for all Brazilians since the 1980s, including people deprived of liberty (PDL), textually assuring them of medical, pharmaceutical, and dental care¹⁰10 Brasil. Lei nº 7.210, de 11 de julho de 1984. Institui a Lei de Execução Penal. Diário Oficial da União; 1984..

For this reason, the Brazilian government implemented the National Health Plan for the Penitentiary System (PNSSP)¹¹11 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Plano Nacional de Saúde no Sistema Penitenciário. Brasília: MS; 2005.. With the successful experience of implementing teams, the National Comprehensive Health Care Policy for People Deprived of Liberty in the Prison System (PNAISP) was established in 2014. It aimed to promote access to the health care network, providing humane and qualified comprehensive care¹²12 Brasil. Portaria Interministerial nº 1, de 2 de janeiro de 2014. Institui a Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional (PNAISP) no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2014..

Moreover, it is essential to note that some international standards provide principles for treating PDLs. The Nelson Mandela Rules make it clear that “all prisoners must be treated with respect, because of their inherent human worth and dignity”¹³13 Conselho Nacional de Justiça (CNJ). Regras de Mandela: regras mínimas das Nações Unidas para o tratamento de presos. Brasília: CNJ; 2016.. The Bangkok Rules emphasize that prisons require qualified health professionals to care for inmates¹⁴14 Conselho Nacional de Justiça (CNJ). Regras de Bangkok: regras das Nações Unidas para o tratamento de mulheres presas e medidas não privativas de liberdade para mulheres infratoras. Brasília, CNJ; 2016..

Access to and availability of medicines for the population are essential indicators of the effectiveness and equity of health systems. The availability of medicines must meet epidemiological needs in an integrated and guided way to ensure the correct and adequate use of pharmaceutical products¹⁵15 Brasil. Conselho Nacional de Secretarias Municipais de Saúde (CONASEMS). Instrumento de Referência dos Serviços Farmacêuticos na Atenção Básica. Brasília: CONASEMS; 2020.. In this sense, this research aimed to analyze the dispensing essential and strategic medicines of continuous use in prison units from the perspective of health professionals and PDLs.

Methods

This exploratory, qualitative, and descriptive study was conducted in seven prisons in the state of Paraíba from February to August 2016. The following inclusion criteria were adopted to select the prison units: having a health unit in its physical structure, with a team of professionals per the PNAISP and a prison population of fewer than 800 inmates, for safety and feasibility reasons.

During the initial visits to the prison units, we observed and recorded in the field diary¹⁶16 Bogdan R, Biklen S. Investigação qualitativa em educação. Porto Alegre: Porto Editora; 1994. the routine of the services and the physical structure of the pharmacy/medicine storage and dispensing place.

Health professionals and people deprived of liberty (PDL) were interviewed in subsequent visits. We adopted purposeful sampling, and our sample included professionals from the health teams and PDLs, using the following inclusion criteria: for doctors and nurses, we adopted the criterion of working for at least six months in the unit, and for PDLs, being men or women sentenced to a closed regime who had been using essential and strategic medicines for at least three months. Thus, 13 health professionals and 43 PDLs were interviewed.

We conducted individual, semi-structured, audio-recorded interviews scheduled per the participants’ convenience and the service’s routine to collect data, which had a mean duration of 21 minutes. The sample closure¹⁷17 Fontanella BJB, Ricas J, Turato ER. Amostragem por saturação em pesquisas qualitativas em saúde. Cad Saude Publica 2008; 24(1):17-27. for health professionals occurred by exhaustion (in which all available individuals are included) and for the other research participants by theoretical saturation (interrupted capture of the collected data because the information no longer contributes to improving the intended theoretical reflection).

The results were categorized from the perspective of content analysis¹⁸18 Bardin L. Análise de Conteúdo. Lisboa: Edições 70; 2014.. The analysis units were identified after a free-floating reading of the interviews. They were grouped per content similarity. Subsequently, the statements were broken down and grouped into three categories: medicine storage in the penitentiary system, medicine dispensing in the penitentiary system, and health responsibilities to ensure pharmaceutical care.

The State University of Paraíba Research Ethics Committee approved the research under CAAE nº 20476213.4.0000.5187. Study participants signed the Informed Consent order to protect the confidentiality of the research participants and the prison institutions, the interviews were identified sequentially per the cities (α, β, γ, δ, ε, ζ, η), with inmates (1, 2, ...) and professionals (A, B, ...), and the domain was exclusive to the researchers.

Results

Characterization of the participants

Fourteen professionals were interviewed: six doctors, seven nurses, and a representative of the Penitentiary Health Coordination of Paraíba. We also interviewed 43 participants deprived of liberty using essential or strategic medicines, of which 35 (81.4%) were men and 8 (18.6%) were women. Regarding age group, prisoners were classified as follows: 1 (2.3%) under 19, 4 (9.3%) 20-29 years, 19 (44.2%) 30-39 years, 9 (20.9%) 40-49 years, 8 (18.6%) 50-59 years, and 2 (4.6%) aged 60 or over.

When investigated the pathologies, 21 (48.8%) had hypertension, 3 (7%) had diabetes, 8 (18.6%) were hypertensive and diabetic, 5 (11.6%) had a TB diagnosis, 1 (2.3%) had leprosy, 1 (2.3%) had leprosy and diabetes, and 4 (9.3%) were HIV-positive.

Regarding the professionals responsible for prescribing drugs, 39 medical records (90.7%) showed they were doctors, 03 (7%) nurses, and 01 (2.3%) medical record did not mention who made the initial prescription.

Three categories emerged after analyzing the results: medication storage location in the penitentiary system, medication dispensing process in the penitentiary system, and healthcare responsibilities to ensure PC.

Discussion

Storage of medicines in the penitentiary system

The 1988 Federal Constitution provides in its art. 5, XLIX that “prisoners are assured respect for physical and moral integrity”, showing the need to respect human rights within penitentiaries, such as the number of prisoners inside cells, as the conglomerate in a small space will generate severe health and behavioral issues, removing fundamental rights¹⁹19 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out..

The Inter-American Commission on Human Rights (IACHR) highlights the poor situation of health services in Brazilian prisons, underscoring the lack of necessary medicines and equipment and warning that overcrowding, lack of hygiene, and inadequate ventilation are severe threats to the health of inmates²⁰20 Comissão Interamericana de Direitos Humanos (CIDH). Situação dos direitos humanos no Brasil. Aprovado pela Comissão Interamericana de Direitos Humanos em 12 de fevereiro de 2021 [Internet]. Organização dos Estados Americanos; 2021 [acessado 2022 jan 21]. Disponível em: http://www.oas.org/pt/cidh/relatorios/pdfs/Brasil2021-pt.pdf.
http://www.oas.org/pt/cidh/relatorios/pd... .

After on-site observation, we found that in penitentiaries α, γ, δ, ε, and ζ had no physical structure housing the pharmacy. This unavailability was attested in the service professionals’ statements, as seen below:

In this way, medicines are not organized by alphabetical order and class, nor is their validity verified. Medicines arriving at the units are only placed at the intended location and distributed on-demand.

Units β and η are equipped with a place for storing medications. However, they are not authorized by the Regional Pharmacy Council or the Health Permit issued by the Municipal Health Surveillance to ensure compliance with the technical and health requirements that cover the operation of the medicine dispensing establishment²¹21 Brasil. Secretaria de Ciência, Tecnologia e Insumos Estratégicos (SCTIE). Departamento de Assistência Farmacêutica e Insumos Estratégicos. Diretrizes para estruturação de farmácias no âmbito do Sistema Único de Saúde. Brasília: SCTIE; 2009..

In penitentiary β, the place for the pharmacy has a window without a grid or screen, allowing the direct incidence of sunlight and the entry of birds and other animals that can contaminate the place and invalidate the use of medicines. On the other hand, even with a specific place to store medications and with a physical structure very close to the recommended standards, penitentiary η did not have the proper organization, as highlighted in the following statements:

Inadequacies in terms of physical space are found not only in penitentiary units. A study conducted in the state of Espírito Santo observed that there are also difficulties and non-compliance in the services of the SUS network¹⁷17 Fontanella BJB, Ricas J, Turato ER. Amostragem por saturação em pesquisas qualitativas em saúde. Cad Saude Publica 2008; 24(1):17-27.^,2222 Fernandes BD, Freitas RR, Melchiors AC. Avaliação dos serviços farmacêuticos: indicadores de estrutura e processo em farmácias comunitárias. Rev Bras Pesqui Saude 2015; 17(1):31-37.. This disorganization can compromise the quality of medicines, causing services to spend resources to provide them. Prisoners receive medicines with compromised pharmacological properties²¹21 Brasil. Secretaria de Ciência, Tecnologia e Insumos Estratégicos (SCTIE). Departamento de Assistência Farmacêutica e Insumos Estratégicos. Diretrizes para estruturação de farmácias no âmbito do Sistema Único de Saúde. Brasília: SCTIE; 2009.; consequently, health needs are not met, with unresolved issues.

The Bangkok Rules state that penitentiary establishments must “have facilities, material and pharmaceutical products that enable sick prisoners to be provided with adequate care and treatment” and that professionals must have sufficient professional training to meet the needs of this population¹⁴14 Conselho Nacional de Justiça (CNJ). Regras de Bangkok: regras das Nações Unidas para o tratamento de mulheres presas e medidas não privativas de liberdade para mulheres infratoras. Brasília, CNJ; 2016.^,2323 United Nations Office on Drugs and Crime (UNODC). Compendium of United Nations standards and norms in crime prevention and criminal justice. New York: UN; 2016..

The environment intended for the storage of medicines must meet the technical standards of current legislation and the manufacturer’s specifications, preserving their identity, integrity, quality, safety, efficacy, and traceability, with the necessary conservation to keep the quality of medicines²¹21 Brasil. Secretaria de Ciência, Tecnologia e Insumos Estratégicos (SCTIE). Departamento de Assistência Farmacêutica e Insumos Estratégicos. Diretrizes para estruturação de farmácias no âmbito do Sistema Único de Saúde. Brasília: SCTIE; 2009.. Also, Law No. 13,021 of August 8, 2014, conditions the operation of pharmacies to competent authority’s authorization/licensing, the presence of a pharmacist, and the observance of a convenient location, considering the health aspect⁴4 Brasil. Lei nº 13.021, de 8 de agosto de 2014. Dispõe sobre o exercício e a fiscalização das atividades farmacêuticas. Diário Oficial da União; 2014..

We could not ascertain a routine of cleaning the environment in penitentiaries with pharmacies. Furthermore, the internal and external areas of pharmacies are not in good physical and structural conditions to allow hygiene, thus posing risks to users and employees, as can be seen in the following statements:

The structures of existing pharmacies do not promote adequate pharmaceutical care and compromise efforts to implement policies. Thus, guaranteeing adequate structure and consequent expansion of the population’s access to medicines, fundamental for the organization of services by state and municipal managers to secure an efficient operation, should be highlighted as challenges for proper PC⁵5 Silva Júnior EB, Nunes LMN. Avaliação da Assistência Farmacêutica na atenção primária no município de Petrolina (PE). ABCS Health Sci 2012; 37(2):65-69..

Drug dispensing process in the penitentiary system

Among the technical-assistance steps to ensure pharmaceutical care, dispensing consists of the pharmacist’s service, in compliance with a prescription by a qualified professional, which involves the analysis of the legal/technical aspects of the prescription, the implementation of interventions, the delivery of medicines to the patient or guardian, with guidelines on the proper and safe use and conservation/disposal, to ensure patient safety, access, and adequate use⁸8 World Health Organization (WHO). The rational use of drugs, report of the conference of experts (Nairobi nov. 1985). Genebra: WHO; 1987., besides providing adequate guidance and education regarding medication use and care and the promotion of adherence toward the best therapeutic results and risk reduction⁷7 Leite SN, Bernardo NLMC, Álvares J, Guerra Junior AA, Costa EA, Acurcio FA, Guibu IA, Costa KS, Karnikowski MGO, Soeiro OM, Soares L. Serviço de dispensação de medicamentos na atenção básica no SUS. Rev Saude Publica 2017; 51(Supl. 2):11s..

The World Health Organization emphasizes that the needs of each prisoner must be considered to carry out an effective drug treatment, providing continuous and individualized medication for the appropriate period and dose, which reduces the risk of complications and hospitalizations and improves well-being²⁴24 World Health Organization (WHO). Regional Office for Europe, United Nations Office on Drugs and Crime (UNODC). Prisons and health. Copenhagen: WHO; 2014..

In the setting of the researched penitentiaries, the delivery of medication varies with the professionals of each penitentiary and the convict’s disease and behavior. However, we failed to classify the delivery as a dispensation in each since it did not fulfill the minimum necessary aspects.

Medication delivery occurred in the medical/nursing office without safeguarding the inmate’s privacy in all the penitentiaries studied. Moreover, the medical prescription is not retained in the medical records, or it is not recorded correctly:

The dispensing process should generally involve evaluating the prescription, correlating the prescribed drugs with the patient’s health conditions and characteristics, and considering factors that would interfere with the treatment outcome and patient safety²⁵25 Conselho Federal de Farmácia (CFF). Serviços farmacêuticos diretamente destinados ao paciente, à família e à comunidade: contextualização e arcabouço conceitual. Brasília: CFF; 2016..

The international literature has pointed out the central role of health technology assessment (HTA) in the access to medicines and its potential beyond the delivery of the medicine and the purpose of allocating resources in situations of scarcity²⁶26 Ventura M. O direito ao acesso a medicamento e a avaliação e incorporação tecnológica no SUS: uma questão de saúde global e de direitos humanos. São Paulo: Universidade de São Paulo; 2021..

In this sense, when asked about the regularity of this delivery, inmates of some penitentiaries stated that they receive the medicines monthly, depending on the stock, regardless of the clinical condition or routine evaluation:

Having only one monthly meeting with the convict compromises the communication and dialogue. It prevents the professional from identifying the patient’s level of knowledge and experience with the treatment.

The lack of structure of pharmacies identified in the study also prevents the realization of fractionation in the delivery of medicines. The delta penitentiary is the only one that delivers the medicines more fractionally, as can be seen in the statements:

This fractionated delivery is essential for the success of the dispensing process. The pharmacist must ask the user questions about the drug use process and correct any irregularities, such as those related to the indication, dosage, treatment time, and expected results, besides possible adverse reactions, drug, and food interactions, drug storage, and monitoring when necessary²¹21 Brasil. Secretaria de Ciência, Tecnologia e Insumos Estratégicos (SCTIE). Departamento de Assistência Farmacêutica e Insumos Estratégicos. Diretrizes para estruturação de farmácias no âmbito do Sistema Único de Saúde. Brasília: SCTIE; 2009..

We should mention that the number of people deprived of liberty in some units can be a factor that hinders daily and individualized follow-up, depending on the number of health professionals and prison officers to meet the demand. However, the occupation of cells above the established number of spaces violates human rights, which is cruel, inhuman, or degrading treatment and infringes the constitutional guarantee of human dignity, endangering the physical, moral, and psychological integrity of individuals and hampering access to elementary material resources for life²⁷27 Organização dos Estados Americanos (OEA). Direitos das Pessoas Privadas de Liberdade [Internet]. 2006 [acessado 2022 jan 21]. Disponível em: https://www.oas.org/pt/cidh/ppl/default.asp.
https://www.oas.org/pt/cidh/ppl/default.... ^,2828 Brasil. Decreto nº 678, de 6 de novembro de 1992. Promulga a Convenção Americana sobre Direitos Humanos (Pacto de São José da Costa Rica), de 22 de novembro de 1969. Diário Oficial da União; 1992..

Moreover, individual pharmaceutical care ensures treatment adherence and positively impacts clinical outcomes. In practice, the medication can be delivered without a health professional, but it will only be delivered with the effective collaboration of prison security officers:

Another relevant characteristic of medication delivery is related to the person responsible for distributing the medication and the place where it is carried out, done several times in several places by different professionals:

Only two of the seven prisons in this study had a professional responsible for the health unit’s pharmacy, and they were not pharmacists. In the other units, as highlighted in the statements, the medicines are delivered by several people without a pre-established protocol. Furthermore, we also observed that this delivery is often carried out at the entrance grid of the pavilions without any specific and individualized guidance. Also, identifying whether inmates know how to read to understand the recommendation for use has yet to be observed, although leaflets or prescriptions do not accompany the drugs.

Several authors report that approximately 50% of prescription drugs are prescribed, dispensed, or applied inappropriately without a pharmacist²⁹29 Mainardes NM, Sousa SF, Xavier MP. Análise do perfil das prescrições médicas e da dispensação farmacêutica em uma farmácia escola do município de Gurupi-TO. Rev Amaz 2014; 2(1):19-27.

30 Bueno D, Guzatto P. Análise de prescrições medicamentosas dispensadas na farmácia de uma unidade básica de saúde de Porto Alegre RS. Rev HCPA 2007; 27(3):20-26.

31 Angonesi D. Dispensação Farmacêutica: uma análise de diferentes conceitos e modelos. Cien Saude Colet 2008; 13(Supl.):629-640.^-3232 Portela AS, Simões MOS, Fook SML, Montenegro Neto NA, Silva PCD. Prescrição médica: orientações adequadas para o uso de medicamentos? Cien Saude Colet 2010; 15(3):3523-3528. in Brazil. Medicine dispensing is a private attribution of the pharmacist²⁵25 Conselho Federal de Farmácia (CFF). Serviços farmacêuticos diretamente destinados ao paciente, à família e à comunidade: contextualização e arcabouço conceitual. Brasília: CFF; 2016.^,3333 Brasil. Decreto nº 85.878, de 7 de abril de 1981. Estabelece normas para execução da Lei nº 3.820, de 11 de novembro de 1960, sobre o exercício da profissão de farmacêutico, e dá outras providências. Diário Oficial da União; 1981.. It cannot be delegated to others, as pharmacists can provide adequate guidance on the correct and safe use, evaluate and interpret the prescription, and guide users on the correct preservation and disposal, considering therapeutic aspects, contraindications and interactions, and technical and legal aspects²⁵25 Conselho Federal de Farmácia (CFF). Serviços farmacêuticos diretamente destinados ao paciente, à família e à comunidade: contextualização e arcabouço conceitual. Brasília: CFF; 2016..

When asked about the professional responsible for delivering the medication and guiding its use, inmates and professionals reported:

We identified a few cases in which the professional responsible for the pharmacy is the one guiding the treatment. The recommendations indicate that the pharmacist, when available, should take special care in providing information and ensure that the user understands the entire process of using the medication¹⁷17 Fontanella BJB, Ricas J, Turato ER. Amostragem por saturação em pesquisas qualitativas em saúde. Cad Saude Publica 2008; 24(1):17-27..

Health responsibilities to ensure pharmaceutical care

Recognizing the legal and ethical duty and recommendations described in international human rights documents, the new Sustainable Development Goals (SDGs) to be achieved by 2030 aim to provide access to medicines, ensuring that all human beings can reach their potential in dignity and equality in a healthy environment³⁴34 Fernandes DA. Direito a saúde e a dignidade da pessoa humana: acesso a medicamentos e a visão das farmacêuticas. Rev Interdisc Direito 2021; 19(1):92-112.. This access is an indispensable part of the right to health under the resolution of the United Nations Commission on Human Rights³⁵35 Hogerzeil HV, Samson M, Casanovas JV, Rahmani-Ocora L. Is access to essential medicines as part of the fulfilment of the right to health enforceable through the courts? Lancet 2006; 368(9532):305-311.. Therefore, presumably, the reflections raised here are grounded on the theoretical recognition of the principle of human dignity as a primary value of the Brazilian State²⁸28 Brasil. Decreto nº 678, de 6 de novembro de 1992. Promulga a Convenção Americana sobre Direitos Humanos (Pacto de São José da Costa Rica), de 22 de novembro de 1969. Diário Oficial da União; 1992..

Pharmaceutical services in the SUS network are intended to provide users with qualified access to medicines. Thus, the MoH makes available to the municipalities the National Pharmaceutical Care Management System (HÓRUS), which is a tool for the qualification of the PC management since it allows the definition of flows and responsibilities in the work process, the systematic registration of actions, and the possibility of monitoring in real-time the service by issuing and evaluating reports that allow greater agility, security, and control of the activities described here¹⁸18 Bardin L. Análise de Conteúdo. Lisboa: Edições 70; 2014..

When we interviewed the professionals, we asked them who would be responsible for acquiring and distributing medicines to guarantee PC in prison units. The pharmaceutical management professional reported how medicines are distributed to prisons:

In the absence of the pharmacist in the health teams in the penitentiaries, the responsibility for requesting, receiving, and storing the medicines is most commonly attributed to nursing.

We need help accessing the Integrated Agreed Programming (PPI) of the state and municipalities and verifying whether this agreement is known to all and portrays the responsibilities. The MoH must ensure the regular supply of primary medication kits to all teams composed of the professionals mentioned above. In this sense, each sphere of government has responsibilities regarding the acquisition, distribution, and access of inmates to prescribed treatments¹¹11 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Plano Nacional de Saúde no Sistema Penitenciário. Brasília: MS; 2005..

Notably, some medicines financed by the SUS are the Federal Government’s responsibility and others the State Health Secretariat’s. However, users seek access to medicines in the municipalities, and the municipal management only sometimes has the necessary information to guide the correct organization and distribution³⁶36 Brasil. Conselho Nacional de Secretarias Municipais de Saúde (CONASEMS). Manual do(a) gestor(a) municipal do SUS - diálogos no cotidiano. 2ª ed. Brasília: CONASEMS; 2021..

The PNSSP institutionalized the Penitentiary Pharmacy program in 2003 to provide comprehensive health care for the prison population, contributing to greater control or reducing the most prevalent health problems and incidents. As a result, the kits consist of essential medicines (AH/DIA), with the amount established proportionally to the number of prisoners linked to the health teams registered in the National Registry of Health Facilities (CNES)³⁷37 Brasil. Conselho Nacional de Secretários de Saúde (CONASS). Assistência Farmacêutica no SUS. Brasília: CONASS; 2011..

When asked if they recognize who is responsible for the supply, some prison health professionals confirmed that partnerships are taking place with the municipalities but face difficulties:

However, health teams report difficulty accessing the service network and guaranteeing the necessary medicines. According to professionals, the prison seems to be a geographical excerpt on the municipality’s margins. If it were not for isolated actions by professionals and family members, PC would be relegated to convenience, failing to comply with health responsibilities:

The Bipartite Interagency Committee (CIB) approves the list of essential medicines for the care of prevalent diseases identified in the primary care of each municipality. Thus, each state and its municipalities will have their list of selected medicines, which must contain the minimum list of medicines for agreement in primary care, whether inside or outside prison units. The financing definitions involve the three spheres of SUS management³⁶36 Brasil. Conselho Nacional de Secretarias Municipais de Saúde (CONASEMS). Manual do(a) gestor(a) municipal do SUS - diálogos no cotidiano. 2ª ed. Brasília: CONASEMS; 2021.^,3838 Paniz VMV. Acesso a medicamentos em população assistida por diferentes modelos de atenção básica nas regiões Sul e Nordeste do Brasil [tese]. Pelotas: Universidade Federal de Pelotas; 2009..

By guaranteeing access to medication as a human right, the State recognizes it as an obligation to be fulfilled, considering the constant assessment of the population’s health needs and, when appropriate and necessary, expanding the list of medications²⁶26 Ventura M. O direito ao acesso a medicamento e a avaliação e incorporação tecnológica no SUS: uma questão de saúde global e de direitos humanos. São Paulo: Universidade de São Paulo; 2021..

In the reality studied, the needs are evaluated, and the professionals stated that they send the map with the medication requests for the proper acquisition promptly. However, there is not always a means of transport to get the medication:

Medicines dispensed within the SUS must be distributed to penitentiary health units under what is established in the CIB. The management is entirely responsible for providing the medication, not professionals, family members, or others³⁹39 Brasil. Coordenadoria de Planejamento de Saúde. Deliberação CIB - 72, de 20 de dezembro de 2013. Aprova as diretrizes para dispensação de medicamentos, no âmbito do Sistema Único de Saúde, no Estado de São Paulo. Diário Oficial do Estado de São Paulo; 2013..

It is also important to highlight that CONASEMS developed a Reference Tool for Pharmaceutical Services in Primary Care (IRSFAB), which aims to have an operative definition of the actions and services offered by the PC in primary care, to support other professionals and improve health outcomes for individuals and the population¹⁵15 Brasil. Conselho Nacional de Secretarias Municipais de Saúde (CONASEMS). Instrumento de Referência dos Serviços Farmacêuticos na Atenção Básica. Brasília: CONASEMS; 2020..

Finally, it is worth noting that the responsibilities are joint and several regarding PC for PDLs in the prison environment, as provided for in Ordinance No. 2,765/14, where the MoH is responsible for financing this Component. However, the implementation of health actions and services is decentralized, with solidarity actions between the States and the Federal District⁴⁰40 Brasil. Portaria nº 2.765, de 12 de dezembro de 2014. Dispõe sobre as normas para financiamento e execução do Componente Básico da Assistência Farmacêutica no âmbito da Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional (PNAISP), e dá outras providências. Diário Oficial da União; 2014.. Thus, the imperative need to consider the principle of the dignity of human beings when discussing the right to health as a fundamental right that must be protected and guide the country’s legal system and public policies.

Final considerations

Most units visited do not have a pharmacy in their physical structure. When they are in place, these facilities must meet the requirements, compromising the PC, as they do not adequately dispense, store, and preserve medicines. Thus, the conception guiding the dispensing process is restricted to delivering the medication by any professional, not prioritizing individual care and humanized care, nor the importance of the role of pharmacists or prescribers to primarily use medicines included in the RENAME.

However, the prison environment has peculiarities that make dispensing drugs even more complicated, such as the substandard infrastructure, the lack of supplies, and the non-availability of pharmaceutical professionals responsible for the PC. Thus, we should emphasize the inefficient and unsafe medication use in prison units since medications are dispensed without adequate guidance and proper monitoring and evaluation of use.

These factors can compromise the expected clinical results with the use of medicines and increase the risks to the health of the prison population, especially if added to the risks associated with the use of medicines stored improperly, without control of environmental conditions and validity.

Concerning health responsibilities, before dispensing medicines, we should highlight that the inter-federal units must prioritize the organization, structuring, management, logistics, and access to PC medicines, emphasizing that there are political obstacles in the State that exceed administrative and technical levels. This fact ends up installing in practice the non-fulfillment of attributions and competencies of each government authority.

Therefore, we should emphasize the importance of Pharmaceutical Services in Primary Care (SFAB) for PC in municipal management, which must be integrated with other health actions and services to adequately respond to people’s health needs, considering from the technical-managing viewpoint, focused on planning, logistics, access to medicines, and from a clinical-assistance perspective to achieve better therapeutic results, arising from the use of drug therapy, seeking to improve people’s quality of life.

In this sense, the study’s limitation is the impossibility of direct access to the integrated agreement for the actual identification of responsibilities.

The findings contribute to research related explicitly to the penitentiary setting to be undertaken at the federal level to assess the dimension of expenditures and PC’s efficiency in prisons, the availability of pharmacies, and the legal compliance of professionals with skill and technical competencies to perform the dispensing and the whole process that this action involves.

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