ABSTRACT:

Introduction:

Well-planned and executed pharmaceutical services (PS) are important for proper treatment of the population’s health needs, thus enabling the access to essential drugs and promoting their rational use.

Objective:

To assess the situation of PS in the city of Uruguaiana (State of Rio Grande do Sul), Brazil.

Methods:

This cross-sectional study was applied to 650 interviews between June and September of 2013 in 11 Basic Health Units (UBS) and in the Main Pharmacy of the city. The indicators of prescription, of patient’s care, and of service, were assessed according to the recommendations of the World Health Organization (WHO).The Instrument of Self-Assessment for Pharmaceutical Services Planning (IAPAF) from the Brazilian Department of Health was used to assess the management and planning capacity of the PS, which was then applied in the Main Pharmacy and in the medicine stockroom.

Results:

The number of drugs per prescription varied from 1 to 10 (mean = 1.7). The percentages of prescribed drugs by generic name, and included in the City List of Essential Drugs (REMUME) were, respectively, 75.5 and 67.7%; antibiotics were prescribed in 9.7% of the medical appointments. The average time of medical appointment was 6 minutes; 51.4% of the users obtained their prescription; only 18.9% of the patients completely understood their prescriptions. Of the 24 items analyzed in the IAPAF, 12 were found in stage 1 (worst rating), 12 in stage 2, and none in stage 3 (ideal situation).

Conclusion:

Results seem to show the lack of PS in Uruguaiana with regard to planning, management, and patient’s care. The absence of effective management may result in waste and incorrect use of drugs.

Keywords:
Pharmaceutical services; Drug prescriptions; Indicators of health services; Health services; Health management; Delivery of health care

INTRODUCTION

The Brazilian Unified Health System (SUS, acronym in Portuguese) is responsible for the elaboration and performance of actions regarding integral therapeutic care, including pharmaceutical services (PS)¹1. Brasil. Casa Civil. Lei nº. 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providencias. Brasília: Diário Oficial da União; 1990.. They are characterized as a group of actions focused on the promotion, protection and recovery of health²2. Marin N, Luiza VL, Osorio-de-Castro CGS, Machado-dos-Santos S (Orgs.). Assistência farmacêutica para gerentes municipais. Rio de Janeiro: OPAS/OMS; 2003., in which drugs are their essential input³3. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Resolução - CNS nº 338, de 06 de maio de 2004. Portaria de aprovação da Política Nacional de Assistência Farmacêutica. Brasília: Ministério da Saúde; 2004., and their good functioning is a determining factor for healthcare solubility and good results of full care indicators²2. Marin N, Luiza VL, Osorio-de-Castro CGS, Machado-dos-Santos S (Orgs.). Assistência farmacêutica para gerentes municipais. Rio de Janeiro: OPAS/OMS; 2003..

With the aim of promoting and improving the use of drugs, the World Health Organization (WHO) proposed in 1993, a selection of indicators to analyze health services in a quantitative and standardized manner with regard to the use of drugs in basic care, thus creating a group of indicators of prescription, of patient’s care and of health services⁴4. Organizacíon Mundial de la Salud (OMS). Como investigar el uso de medicamentos en los servicios de salud: indicadores seleccionados del uso de medicamentos. Ginebra: OMS; 1993..

By means of these indicators, studies carried out in the cities of Esperança (PB)⁵5. Portela AS, Silva PCD, Simões MOS, Medeiros ACD, Montenegro Neto AN. Indicadores de prescrição e de cuidado ao paciente na atenção básica do município de Esperança, Paraíba, 2007. Epidemiol Serv Saúde 2012; 21(2): 341-50. and Ribeirão Preto (SP)⁶6. Santos V, Nitrini SMOO. Indicadores do uso de medicamentos prescritos e de assistência ao paciente de serviços de saúde. Rev Saúde Pública 2004; 38(6): 819-26. have concluded that the PS provided to the patient are not adequate in all the assessed indicators.

Some Brazilian studies assessed PS by means of other methodologies⁵5. Portela AS, Silva PCD, Simões MOS, Medeiros ACD, Montenegro Neto AN. Indicadores de prescrição e de cuidado ao paciente na atenção básica do município de Esperança, Paraíba, 2007. Epidemiol Serv Saúde 2012; 21(2): 341-50.^,66. Santos V, Nitrini SMOO. Indicadores do uso de medicamentos prescritos e de assistência ao paciente de serviços de saúde. Rev Saúde Pública 2004; 38(6): 819-26.^,77. Arrais PSD, Barreto ML, Coelho HLL. Aspectos dos processos de prescrição e dispensação de medicamentos na percepção do paciente: estudo de base populacional em Fortaleza, Ceará, Brasil. Cad Saúde Pública 2007; 23(4): 927-37.^,88. Souza LS, Porto JG, Lyra Júnior DP. Avaliação da estrutura e dos processos de organização e gestão da assistência farmacêutica em município do estado de Sergipe. Rev Ciênc Farm Básica Apl 2011; 32(3): 403-10.^,99. De Bernardi CLB, Bieberbach EW, Thomé HI. Avaliação da assistência farmacêutica básica nos municípios de abrangência da 17ª Coordenadoria Regional de Saúde do Rio Grande do Sul. Saude Soc 2006; 15(1): 73-83.. This is the case of a study carried out in Fortaleza (CE), Brazil, which used its own instrument by making questions related to the practice of prescription and dispensation, and it found low quality in medical and pharmaceutical services⁷7. Arrais PSD, Barreto ML, Coelho HLL. Aspectos dos processos de prescrição e dispensação de medicamentos na percepção do paciente: estudo de base populacional em Fortaleza, Ceará, Brasil. Cad Saúde Pública 2007; 23(4): 927-37.. An assessment of PS was carried out in Rio Grande do Sul using as instrument the assessment indicators of basic PS, which were developed by the State Bureau of Health. The study approached indicators of structure, process, and results, and found problems regarding human, material, and financial resources in most cities. On the other hand, most of them presented proper organization of drug supplies⁹9. De Bernardi CLB, Bieberbach EW, Thomé HI. Avaliação da assistência farmacêutica básica nos municípios de abrangência da 17ª Coordenadoria Regional de Saúde do Rio Grande do Sul. Saude Soc 2006; 15(1): 73-83..

In 2006, the Department of Pharmaceutical Services and Strategic Supplies (DAF) from the Brazilian Department of Health (MS) developed the Instrument of Self-Assessment for Pharmaceutical Services Planning (IAPAF)¹⁰10. Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Planejar é preciso: uma proposta de método para aplicação à assistência farmacêutica. Brasília: Editora do Ministério da Saúde; 2006., which is composed of 24 items that cover the entire cycle of PS, from selection to pharmacosurveillance, in order to assess the managerial and planning capacity of the PS. The advantage of its use is the support to elaborate a work plan through the identification of the current stage of development, and definition of goals to develop technical and managerial capacity of PS¹⁰10. Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Planejar é preciso: uma proposta de método para aplicação à assistência farmacêutica. Brasília: Editora do Ministério da Saúde; 2006..

A study using an instrument developed by the researchers, based on the IAPAF, was carried out in a city of Sergipe State, where, in the main stockroom, the capacity of management, selection, scheduling, acquisition, storage/distribution, and transportation of drugs and pharmaceutical supplies was verified. On the other hand, the indicators of prescription and dispensation were assessed in Basic Health Units (UBS), and Psychosocial Care Centers (CAPS), and the stages of storage, distribution, and transportation presented the best results, while prescription was the most critical stage of the process⁸8. Souza LS, Porto JG, Lyra Júnior DP. Avaliação da estrutura e dos processos de organização e gestão da assistência farmacêutica em município do estado de Sergipe. Rev Ciênc Farm Básica Apl 2011; 32(3): 403-10..

Owing to the small amount of studies that assessed PS in Brazil and in order to stimulate managers from other cities to perform the assessment in their cities and to improve their local PS, acknowledging the existence of these instruments and their results, this study aimed at assessing PS in the city of Uruguaiana (RS) using the indicators recommended by the WHO and the instrument proposed by the MS (IAPAF).

METHODS

This is a cross-sectional study carried out from June to September 2013 in Uruguaiana (RS, Brazil) - a city with approximately 126 thousand residents. The city had full management of health actions, but it did not have PS in its organizational chart.

The basic care network of the city was composed of 19 UBS, 5 of them were located in the rural area; 2 CAPS; 1 polyclinic of medical and dentistry specialties, and 1 polyclinic for children. Five UBS from the rural area and three from the urban area were not included because they did not have medical services. When users from the rural area needed medical care, the City Hall provided transportation from there to the urban area.

All units with medical services were included in the study, i.e. 11 UBS and 1 polyclinic of specialties. All the places had drug dispensation services, but a pharmacist only did it in the polyclinic of specialties, where the Main Pharmacy was located.

Indicators of prescription, of patient’s care and of health services proposed by the WHO⁴4. Organizacíon Mundial de la Salud (OMS). Como investigar el uso de medicamentos en los servicios de salud: indicadores seleccionados del uso de medicamentos. Ginebra: OMS; 1993. were assessed, and the IAPAF proposed by the MS¹⁰10. Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Planejar é preciso: uma proposta de método para aplicação à assistência farmacêutica. Brasília: Editora do Ministério da Saúde; 2006. was used.

The PS assessments with the indicators proposed by the WHO must have a minimum sample of 600 observations⁴4. Organizacíon Mundial de la Salud (OMS). Como investigar el uso de medicamentos en los servicios de salud: indicadores seleccionados del uso de medicamentos. Ginebra: OMS; 1993.. Six hundred and fifty interviews were conducted. This sample enabled the estimation of the indicators with acceptable error margin of 3.5 percentage points, and a 95% level of confidence.

The interviewers approached the first 5 patients older than 18 years, who were standing on the waiting line for service, and they included only those who accepted taking part in the study after signature of the Free Informed Consent. In cases of refusal, the next user in the waiting line was approached.

Each user provided the following information:

After the conclusion of interviews, all prescriptions were analyzed using the City List of Essential Drugs (REMUME) and the Dictionary of Pharmaceutical Specialties, with the aim of verifying if the drugs were prescribed according to the Brazilian Common Denomination (DCB) and if antibiotics and injectable drugs were also prescribed.

The analyzed indicators of prescription were:

The analyzed indicators of service were:

The patient’s answer was compared with the prescription. When the patient answered the five questions mentioned above correctly, it was considered as comprehension of the prescription (total knowledge of the prescription). When the prescription was not complete and the patient did not know how to answer due to lack of such item on it, we considered it as a lack of comprehension of the prescription.

The indicators of health services were assessed in the Main Pharmacy and UBS, where interviews and observations were performed. In addition, the availability of REMUME and the main drugs chosen based on the epidemiological profile of the city (captopril 25 mg; enalapril 10 mg and 20 mg; hydrochlorothiazide 25 mg; furosemide 40 mg; metformin 850 mg; glibenclamide 5 mg; ibuprofen 600 mg and 50 mg/mL; paracetamol 750 mg and 200 mg/mL; levothyroxine 25 mg and 50 mg; neomycin + bacitracin cream; and oral rehydration salts) were also verified.

IAPAF was applied to pharmacists in charge of the Main Pharmacy and of the drug stockroom. IAPAF classifies the items comprising the PS cycle in three stages, in which the first stage corresponds to the one with the lowest capacity, and the third approaches what the MS and WHO proposes as ideal regarding capacity of planning and management of PS¹⁰10. Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Planejar é preciso: uma proposta de método para aplicação à assistência farmacêutica. Brasília: Editora do Ministério da Saúde; 2006..

Data were typed twice in EpiDATA 3.1, and data consistency analyses and statistics were performed in the statistical program STATA 12.0 (Stata Corp, College Station, USA). Student’s t test and analysis of variance (ANOVA) were used to compare the average time of medical appointment to each category of the studied variables, considering a 5% level of significance.

The Research Ethics Committee of Universidade Federal de Pelotas (No.314.838) and the City Bureau of Health of Uruguaiana (RS) approved the project.

RESULTS

Five interviews were done per day in each place; therefore, there were 50 interviews in each one of the 11 UBS (550) and 100 in the polyclinic of specialties in alternate shifts, according to the service provided in each health unit. Among the 650 interviewed patients, 413 (63.5%) received drug prescriptions and the others received requests for exams or were submitted to specialized doctors. The sample characteristics are described in Table 1; however, the most prevalent subjects were urban area residents, women, subjects aged 41-70 years, with 5-8 years of schooling, white skinned, and family income between 1 and 2 minimum wages.

Among patients who received a drug prescription (n = 413), the number of prescription varied between 1 and 10, in which 1,132 was the total amount of prescribed drugs. The WHO indicators of prescription and of service presented in Table 2 were calculated based on the number of patients that had a prescription, and on the number of prescribed drugs.

The analysis of average time of medical appointment duration was stratified based on socioeconomic and demographic characteristics of the sample, and a statistically significant difference was found only for the residence area. The mean time of medical appointment was higher for patients from the urban area than for those from the rural area (p = 0.003) (Table 3).

With regard to knowledge of prescribed drugs, only 78 (18.9%) patients completely knew about the prescription, 267 (64.7%) were completely unaware, and 68 (16.5%) knew something about the questioned items. Figure 1 presents reasons for unawareness reported for each drug. The pieces of information that patients showed to have more difficulty in understanding were the number of doses taken per day (for 80.1% of the drugs) and reason for using the drug (78.1%).

The average time of medical appointment was higher for users who completely knew about the prescription if compared with those that were unaware of some item in it (7.6 minutes, 95%CI 6.7 - 8.5 versus 6.1 minutes, 95%CI 5.8 - 6.5, p = 0.001) (data are not shown in the tables).

The percentages of medical appointments with drug prescription (one or more), based on age, were 59.1% for 18-59 years old, 72.4% for 60-79 years old, and 81.3% for the elderly aged 80 years or more. Thus, it shows a tendency of growth with age increase (p < 0.001) (data are not shown in the tables).

With regard to indicators of health services, REMUME was available in all UBS and in the polyclinic of specialties, and none of the health services had the 15 main studied drugs available.

In the assessment of management and planning capacity of PS, 12 of the 24 items analyzed through IAPAF were in stage 1 (worst assessment) and 12 in stage 2. No items were classified as stage 3 (ideal situation). In the stage of drug selection, it was seen that elaboration, use, and disclosure of REMUME are in level 2 and scheduling and acquisition of drugs are found in level 1. In terms of storage, correct storage of drugs is in level 1. All indicators of drug prescription are in level 1, which is in agreement with the results obtained in previous indicators, especially regarding selection, because both are closely associated. In the UBS, dispensation is carried out without the supervision of a pharmacist, and there are no standardized operational procedures for dispensation. In terms of human resources, training, and capacitation are the worst indicators. Details of this assessment are found in Table 4.

DISCUSSION

Results indicate a lack in planning and in organizing the different stages of the PS cycle in the studied city, which varies from failures in the selection to drug prescription. It is worth noting the fact that most of the medical appointments of this study generated drug prescription, and one third of the prescribed drugs were not in the REMUME. About two thirds of the interviewed subjects did not understand any aspect of the prescription, and the average time of medical appointment was of only six minutes.

The fact that most medical appointments of this study generated a drug prescription makes us believe that, even today, search for these services is still much more curative than preventive. After the analysis of the prescription indicators, the average number of prescribed drugs (1.7) did not correspond to polymedication¹²12. Fulton MM, Allen RE. Polypharmacy in the elderly: a literature review. J Am Acad Nurse Pract 2005; 17(4): 123-32., but it was similar to what was seen in other studies carried out in Brasília (2.3)¹³13. Naves Jde O, Silver LD. Evaluation of pharmaceutical assistance in public primary care in Brasília, Brazil. Rev Saúde Pública 2005; 39(2): 223-30. and Belo Horizonte (2.4)¹⁴14. Acurcio FA, Perini E, Magalhães SM, Terceiro LG, Vieira Filho JM, Coutinho KE, et al. Analysis of medical prescriptions dispensed at health centers in Belo Horizonte, Minas Gerais, Brazil. Cad Saúde Pública 2004; 20(1): 72-9.. However, the result of this study concerns the prescription of the medical appointment assessed in the day of its performance and does not consider other drugs that the patient had used.

Users aged 80 or more years received more prescriptions of a drug. This result is found due to the greater number of years of an elderly living with chronic health problems, which results in higher consumption of drugs¹⁵15. Loyola Filho AI, Uchoa E, Firmo JOA, Lima-Costa MF. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53..

It was seen as a high number of prescriptions by generic name (75.5%), which is similar to what was seen in Brasília (73.2%)¹³13. Naves Jde O, Silver LD. Evaluation of pharmaceutical assistance in public primary care in Brasília, Brazil. Rev Saúde Pública 2005; 39(2): 223-30. and higher than in Ribeirão Preto (30.6%)⁶6. Santos V, Nitrini SMOO. Indicadores do uso de medicamentos prescritos e de assistência ao paciente de serviços de saúde. Rev Saúde Pública 2004; 38(6): 819-26. - both studies used the same method and instrument for this study. This result demonstrated good adhesion from the prescribers to generic denomination, even considering the laws determine that 100% of the SUS prescriptions are done using the generic name¹⁶16. Brasil. Lei Federal nº 9.787, de 10 de fevereiro de 1999. Altera a Lei nº 6.360, de 23 de setembro de 1976, que dispõe sobre a vigilância sanitária, estabelece o medicamento genérico, dispõe sobre a utilização de nomes genéricos em produtos farmacêuticos e dá outras providências. Brasília: Diário Oficial da União; 1999..

The percentage of medical appointments with antibiotic prescription (9.7%) were low if compared with other studies⁶6. Santos V, Nitrini SMOO. Indicadores do uso de medicamentos prescritos e de assistência ao paciente de serviços de saúde. Rev Saúde Pública 2004; 38(6): 819-26.^,1313. Naves Jde O, Silver LD. Evaluation of pharmaceutical assistance in public primary care in Brasília, Brazil. Rev Saúde Pública 2005; 39(2): 223-30.. In Brasília, the percentage of prescribed antibiotics was 26.4%¹³13. Naves Jde O, Silver LD. Evaluation of pharmaceutical assistance in public primary care in Brasília, Brazil. Rev Saúde Pública 2005; 39(2): 223-30. and in Ribeirão Preto, 21.3%⁶6. Santos V, Nitrini SMOO. Indicadores do uso de medicamentos prescritos e de assistência ao paciente de serviços de saúde. Rev Saúde Pública 2004; 38(6): 819-26.. This result stand out because of the time of the year when the study was carried out (from June to September) in a city in Southern Brazil, where great temperatures oscillations are registered, usually around 2-20^oC, thus increasing the probability of infectious respiratory diseases. In Bagé, a city located in the same area of Uruguaiana with similar climate and populations, the percentage of prescribed antibiotics during the month of July in 2005 was of 30.4%¹⁷17. Tavares NU, Bertoldi AD, Muccillo-Baisch AL. Antimicrobial prescription in family health units in Southern Brazil. Cad Saúde Pública 2008; 24(8): 1791-800.. This result may be associated with the availability of antibiotics in the Main Pharmacy, but not in the UBS, because previous studies were carried out before publication and implementation of the Resolution-RDC No. 20¹⁸18. Brasil. Agência Nacional de Vigilância Sanitária (ANVISA). Resolução - RDC nº 20, de 5 de maio de 2011. Dispõe sobre o controle de medicamentos à base de substâncias classificadas como antimicrobianos, de uso sob prescrição, isoladas ou em associação. Brasília: ANVISA; 2011., which determines the dispensation control of antimicrobials. The lowest percentage of antibiotics prescription may also be associated with the practice of rational prescription of antimicrobials.

An important criterion in the promotion of rational use of drugs is the existence of REMUME, which aims at guiding the prescription of safe and effective products based on the epidemiological profile of the city and planning of the City Bureau of Health¹⁹19. Brasil. Ministério da Saúde. Portaria GM Nº 3.916, de 30 de outubro de 1998. Portaria de aprovação da Política Nacional de Medicamentos. Brasília: Diário Oficial da União; 1998..

Low percentage of prescribed drugs based on REMUME (67.7%) was an indication of low adhesion of the prescribers to the list. This result was lower than that found in studies in Ribeirão Preto (83.4%)⁶6. Santos V, Nitrini SMOO. Indicadores do uso de medicamentos prescritos e de assistência ao paciente de serviços de saúde. Rev Saúde Pública 2004; 38(6): 819-26., and in the state of Santa Catarina (91.5%)²⁰20. Souza JM, Vinholes ER, Trauthman SC, Galato D. Avaliação dos indicadores de prescrição e da demanda atendida de medicamentos no Sistema Único de Saúde de um município do Sul do Estado de Santa Catarina. Rev Ciênc Farm Básica Apl 2012; 33(1): 107-13., which also used the WHO instrument⁴4. Organizacíon Mundial de la Salud (OMS). Como investigar el uso de medicamentos en los servicios de salud: indicadores seleccionados del uso de medicamentos. Ginebra: OMS; 1993.. The low adhesion to REMUME may happen due to, among many factors, inexistence of a Commission of Pharmacy and Therapeutics (CFT) in the studied city; of outdated REMUME; of low disclosure of its importance; and the fact that REMUME may not be known by the prescribers, even though it is available in most of the cases due to the lack of sensitivity for the promotion of its use. If REMUME were more disclosed and built in a collaborative manner with the prescribers, its use would probably be larger.

The percentage of prescription of injectable drugs was low (3.7%) compared with that found in studies carried out in Brasília¹³13. Naves Jde O, Silver LD. Evaluation of pharmaceutical assistance in public primary care in Brasília, Brazil. Rev Saúde Pública 2005; 39(2): 223-30. (7.5%), and Ribeirão Preto⁶6. Santos V, Nitrini SMOO. Indicadores do uso de medicamentos prescritos e de assistência ao paciente de serviços de saúde. Rev Saúde Pública 2004; 38(6): 819-26. (8.3%). This result may be explained due to the prescribers’ preference for pharmaceutical forms that are more convenient to the user²⁰20. Souza JM, Vinholes ER, Trauthman SC, Galato D. Avaliação dos indicadores de prescrição e da demanda atendida de medicamentos no Sistema Único de Saúde de um município do Sul do Estado de Santa Catarina. Rev Ciênc Farm Básica Apl 2012; 33(1): 107-13. and because these users come from outpatient services.

With regard to indicators of service, the mean time of medical appointment was only of 6 minutes. Similar to the results found in Esperança (Paraíba) (7.8 minutes)⁵5. Portela AS, Silva PCD, Simões MOS, Medeiros ACD, Montenegro Neto AN. Indicadores de prescrição e de cuidado ao paciente na atenção básica do município de Esperança, Paraíba, 2007. Epidemiol Serv Saúde 2012; 21(2): 341-50., Ribeirão Preto (9.2 minutes)⁶6. Santos V, Nitrini SMOO. Indicadores do uso de medicamentos prescritos e de assistência ao paciente de serviços de saúde. Rev Saúde Pública 2004; 38(6): 819-26. and Brasília (9.4 minutes)¹³13. Naves Jde O, Silver LD. Evaluation of pharmaceutical assistance in public primary care in Brasília, Brazil. Rev Saúde Pública 2005; 39(2): 223-30., this time is below the 15 minutes predicted in Decree 1101 GM/02²¹21. Brasil. Ministério da Saúde. Portaria GM nº 1.101, de 12 de junho de 2002. Estabelece os parâmetros de cobertura assistencial no âmbito do Sistema Único de Saúde - SUS. Brasília: Ministério da Saúde ; 2002., which was current at the moment of the performance of this study. This result may have had an impact on the level of users’ knowledge of prescriptions, since only a small proportion of patients (18.9%) fully understood their content. It is worth noting that all medical appointments were performed in the outpatient manner, and there were no urgency/emergency services. On the other hand, more important than the appointment time is its quality and service coverage. Therefore, since the time of appointment and other parameters of the 2002 decree are considered restrictive, in 2015, after public consultation, a new decree²²22. Brasil. Ministério da Saúde. Portaria nº 1.631, de 1º de outubro de 2015. Aprova critérios e parâmetros para o planejamento e programação de ações e serviços de saúde no âmbito do SUS. Brasília: Ministério da Saúde ; 2015. was published that established criteria and parameters for planning and scheduling health actions and services in the range of SUS. This new decree no longer stipulates a minimum time for medical appointment; however, it establishes standards of coverage based on the population’s profile.

In any case, the low percentage of patients who knew the prescription stand out, since it could be associated directly with the appointment time. If, at delivery, the prescription was explained and the repetition of its content was requested to the patient, it would be possible to identify errors of comprehension and therefore their correction.

The percentage of drugs dispensed in health services analyzed in this study was of 51.4%, whereas Santos and Nitrini study, carried out in 2004⁶6. Santos V, Nitrini SMOO. Indicadores do uso de medicamentos prescritos e de assistência ao paciente de serviços de saúde. Rev Saúde Pública 2004; 38(6): 819-26., in the city of Ribeirão Preto, indicated 60.3%. It is worth noting that 67.7% of the prescribed drugs were part of REMUME, which seems to indicate a lack of supplies and of planning the PS in the city.

In the assessment of managerial and planning capacity of PS through the IAPAF, results show the organizational deficiency of PS in the assessed city. Some results were different to those found in a city of Sergipe⁸8. Souza LS, Porto JG, Lyra Júnior DP. Avaliação da estrutura e dos processos de organização e gestão da assistência farmacêutica em município do estado de Sergipe. Rev Ciênc Farm Básica Apl 2011; 32(3): 403-10., which used only a part of the IAPAF. Among the 14 analyzed items, seven were considered level three, which is ideal. In Uruguaiana, none of the items satisfies what is considered ideal by the MS. However, factors such as assessment and monitoring of actions, education for rational use of drugs, and physical area were in level 1 in both studies; therefore, they were critical factors in PS. Inappropriate storage, for instance, may compromise conservation and safety of drugs.

Since there was no constituted CFT, no use of epidemiological profile for scheduling drugs and pharmaceutical inputs and no agreement with good storage practices, transportation, distribution, and dispensation, the assessed city is similar to cities of Amazonas state, where the PS analysis was carried out with an instrument similar to IAPAF²³23. Moura AC. Análise da organização e estruturação da Assistência Farmacêutica nos municípios do Estado do Amazonas. Rev Tempus Actas Saúde Colet 2010; 4(3): 39-42.. CFT is in charge, among other actions, of the REMUME update, of the adoption of clinical protocols, and of the education for promoting rational use of drugs. Therefore, the results are coherent with the reality, since the city does not have a CFT. After checking the indicators regarding prescription, it was found that all of them are in level 1 and depend on the actions of CFT. Thus, the constitution of this interdisciplinary commission could substantially improve the PS quality in the city.

Other indicators found in level 1 depend directly on the management and on financial resources, such as inadequacy of the physical space; insufficient number of pharmacists to ensure capacitation and trainings; physical and financial scheduling to obtain drugs and proper control of stock. Souza et al.⁷ assessed the structure and the processes of organization and management in a Northeastern Brazilian city, and from their results, they suggested a series of both governmental and educational strategies to enable actions for improvement of PS in the studied city, thus contributing to low waste of drugs and better distribution of resources. Such study shows the need of performing an early diagnosis and sensitivity of managers for implementing these initiatives effectively.

The study limitations included the period of data collection (four months), which prevented to verify the seasonality in the patterns of drug use, which, in general, is variable based on the seasons of the year. Despite the absence of doctors in some UBS, data collection occurred in all places of health services in the range of the Health City Bureau of Uruguaiana, which counted with adult medical assistance during the research study. Since PS are not fully recognized in the organizational chart of the Health Bureau, it also made the use of IAPAF difficult, because many involved actors were not aware of their functions and attributions. Another study limitation is about the manner in which the interviewed subjects were chosen: the choice of the first patients waiting for medical appointment in the service, may have introduced a selection bias, because these users may present health conditions different of others.

Therefore, based on the study data, and to improve the quality of PS, we suggest the constitution of a CFT in the city; the adequacy of physical areas destined to PS (Basic Pharmacy, Special Pharmacy, UBS Pharmacies, Supply Central); the incorporation of human resources compatible with the developed activities and complexities; and the adequacy of the prescribers’ working hours to the number of medical services.

FINAL CONSIDERATIONS

Despite the effort made by the MS to use the IAPAF and PS improvement in Brazil, there is still a lot to be done, because many problems are still compromising the quality of PS. Results show deficiency in planning different stages of PS cycle in the analyzed city. Failures are seen in all stages of planning, management, and patient care, especially in the assessment and monitoring of actions, in the adoption of clinical protocols and in the constitution of CFT. Storage of drugs should follow good practices; stock control seems ineffective; and the pharmacy’s physical area is insufficient according to the current laws. In the UBS, dispensation is carried out without the supervision of a pharmacist, and there are no standardized operational procedures for dispensation.

The average time of medical appointment was much below what the WHO establishes, thus it seems to be directly associated with low comprehension of the medical prescription. A period of medical appointment closer to that standardized by the WHO could bring benefits for the patient’s better comprehension of the prescription, resulting in a rational use of drugs.

References

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