ABSTRACT:

Objective:

The prevalence of hypertension in Brazil and worldwide has been increasing in recent decades, and drug therapy is one of the strategies used to control this condition. The objective of this study was to estimate the prevalence of use and identify the sources for obtaining antihypertensive drugs in Brazil, according to sociodemographic variables, comparing three periods: 2011, 2014 and 2017.

Methods:

Data from individuals aged ≥20 years who reported a medical diagnosis of hypertension, interviewed by Vigitel in 2011, 2014 and 2017 were used. Frequency and prevalence of drug use in addition to the sources for obtaining medication were estimated by sociodemographic variables, with 95% confidence intervals. The differences between proportions were verified by Pearson’s chi-square test (Rao-Scott), with a significance level of 5%.

Results:

The prevalence of antihypertensive drug use remained stable (80%). Regarding the sources for obtaining these medicines, there was variation in the period, indicating a decrease in usage through the Brazilian Unified Health System (SUS) (44.2% in 2011; 30.5% in 2017). This decrease was accompanied with increase in PFPB (16.1% in 2011; 29.9% in 2017). The prevalence of other sources for obtaining medicine (private pharmacies/drugstores) showed stability in the period.

Conclusions:

The prevalence of medication use remained high and there was a change in the pattern of use according to sources, demonstrating migration between SUS pharmacies to the PFPB, and suggesting a reduction in the availability of medicines from public pharmacies universally, and for free.

Keywords:
Drug Utilization; Health Services Accessibility; Hypertension; Behavioral Risk Factor Surveillance System

INTRODUCTION

Chronic non-communicable diseases (NCDs) were responsible for 71% of a total of 57 million deaths worldwide in 2016¹1. Brasil. Vigitel Brasil 2018: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados br. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis; 2019. 132 p.^,22. World Health Organization. World Health Statistics - Monitoring Health for the SGD’s, Sustainable Development Goals. Genebra: World Health Organization; 2018. 100 p. . Data from 2014 indicate that approximately 75% of deaths from NCDs occur in low- and middle-income countries, and 40% of them are considered premature deaths (before the age of 70)³3. World Health Organization. Global status report on noncommunicable diseases 2014. Genebra: WHO Library Cataloguing-in-Publication Data; 2014. 302 p.. Arterial hypertension is the main risk factor for cardiovascular diseases and has an important impact on NCD mortality⁴4. Malta DC, Gonçalves RPF, Machado IE, Freitas MMF, Azeredo C, Szwarcwald CL. Prevalência da hipertensão arterial segundo diferentes critérios diagnósticos, Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2018; 21(Supl. 1): e180021. http://dx.doi.org/10.1590/1980-549720180021.supl.1
https://doi.org/http://dx.doi.org/10.159... . In Brazil, in 2016, more than 975 thousand deaths were attributed to NCDs, which represents 74% of the total deaths that year, 28% due to cardiovascular diseases⁵5. World Health Organization. Noncommunicable diseases country profiles 2018 [Internet]. Genebra: World Health Organization ; 2018 [acessado em 6 dez. 2019]. Disponível em: Disponível em: https://www.who.int/nmh/countries/2018/bra_en.pdf?ua=1
https://www.who.int/nmh/countries/2018/b... .

The global prevalence of arterial hypertension in adults (≥ 18 years old) was around 22% in 2014, ranging from 30% in the African continent to 18% in the Americas³3. World Health Organization. Global status report on noncommunicable diseases 2014. Genebra: WHO Library Cataloguing-in-Publication Data; 2014. 302 p.. According to data from the National Health Survey (Pesquisa Nacional de Saúde - PNS) of 2013, the prevalence of hypertension reported by the adult Brazilian population was 21.4%⁶6. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Jr. JB. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013 Use of medication for treatment of noncommunicable chronic diseases in Brazil: results from the National Health Survey, 20. Epidemiol Serv Saúde 2015; 24(2): 315-23. http://dx.doi.org/10.5123/S1679-49742015000200014
https://doi.org/http://dx.doi.org/10.512... , results similar to those obtained by the Vigitel survey, which pointed to a prevalence of 22.7% in 2011, and reaching 24.3% in 2017. This study considered 27 cities⁷7. Brasil. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde; 2018. 130 p.^,88. Brasil. Vigitel Brasil 2011: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Secretaria de Gestão Estratégica e Participativa; 2012. 134 p.^,99. Brasil. Vigitel Brasil 2014: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde ; 2015. 154 p. and indicated, therefore, that approximately one in four adults in Brazil is hypertensive.

The primary objective of the treatment of arterial hypertension is to reduce cardiovascular morbidity and mortality. As such, the proposed treatments should not only reduce blood pressure, but also reduce fatal and non-fatal cardiovascular events and, if possible, the mortality rate¹⁰10. Sociedade Brasileira de Cardiologia, Sociedade Brasileira de Hipertensão, Sociedade Brasileira de Nefrologia. VI Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2010; 95(1 Supl. 1). 51 p.. Appropriate management of hypertension is vital to alleviate possible disabilities and loss of quality of life. Additionally, it decreases health system costs, thus having an important socioeconomic impact⁴4. Malta DC, Gonçalves RPF, Machado IE, Freitas MMF, Azeredo C, Szwarcwald CL. Prevalência da hipertensão arterial segundo diferentes critérios diagnósticos, Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2018; 21(Supl. 1): e180021. http://dx.doi.org/10.1590/1980-549720180021.supl.1
https://doi.org/http://dx.doi.org/10.159... ^,1111. Malachias MV, Souza WK, Plavnik FL, Rodrigues CI, Brandão AA, Neves MF, et al. 7a Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol [Internet] 2016 [acessado em 21 set. 2019]. 103 p. Disponível em: Disponível em: http://publicacoes.cardiol.br/2014/diretrizes/2016/05_HIPERTENSAO_ARTERIAL.pdf
http://publicacoes.cardiol.br/2014/diret... ^,1212. Stopa SR, Cesar CLG, Segri NJ, Alves MCGP, Barros MB de A, Goldbaum M. Prevalência da hipertensão arterial, do diabetes mellitus e da adesão às medidas comportamentais no Município de São Paulo, Brasil, 2003-2015. Cad Saúde Pública 2018; 34(10): e00198717. http://dx.doi.org/10.1590/0102-311x00198717
https://doi.org/http://dx.doi.org/10.159... . Therefore, a therapeutic approach includes measures without the use of antihypertensive drugs in order to reduce blood pressure, protect target organs and prevent cardiovascular and renal outcomes⁵5. World Health Organization. Noncommunicable diseases country profiles 2018 [Internet]. Genebra: World Health Organization ; 2018 [acessado em 6 dez. 2019]. Disponível em: Disponível em: https://www.who.int/nmh/countries/2018/bra_en.pdf?ua=1
https://www.who.int/nmh/countries/2018/b... ^,1111. Malachias MV, Souza WK, Plavnik FL, Rodrigues CI, Brandão AA, Neves MF, et al. 7a Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol [Internet] 2016 [acessado em 21 set. 2019]. 103 p. Disponível em: Disponível em: http://publicacoes.cardiol.br/2014/diretrizes/2016/05_HIPERTENSAO_ARTERIAL.pdf
http://publicacoes.cardiol.br/2014/diret... .

Based on the definition of health as a constitutional right, comprehensive therapeutic assistance, including free access to medicine is a universal guarantee of the Brazilian government¹³13. Brasil. Constituição da República Federativa do Brasil. Brasília: Secretaria de Documentação; 1988. 533 p.^,1414. Brasil. Lei nº 8.080 de 19 de setembro de 1990. Brasília; 1990.. Since 1998, the advancement of pharmaceutical assistance policies that ensure the population’s access to medicine has become part of health priority agendas.¹⁵15. Oliveira LCF, Assis MMA, Barboni AR. Assistência Farmacêutica no Sistema Único de Saúde: da Política Nacional de Medicamentos à Atenção Básica à Saúde. Ciên Saude Colet 2010; 15(Supl. 3): 3561-7. http://dx.doi.org/10.1590/S1413-81232010000900031
https://doi.org/http://dx.doi.org/10.159... ^,1616. Brasil. Política Nacional de Medicamentos. Brasília: Ministério da Saúde, Secretaria de Políticas de Saúde, Departamento de Atenção Básica; 2001. 40 p.^,1717. Brasil. Resolução nº 338, de 6 de maio 2004. Política Nacional de Assistência Farmacêutica. Brasil: Ministério da Saúde, Conselho Nacional de Saúde; 2004. p. 2. Among them include the promotion and expansion of free access through the SUS, which then motivated the creation of the Farmácia Popular do Brasil Program (PFPB). The PFPB initially only dealt with its own system, but then it started working in partnership with private pharmacies, inaugurating the co-payment system in the country in 2006, through the “Aqui Tem Farmácia Popular” (ATFP). The PFPB, instituted by Decree No. 5,090/2004, was created due to the need to promote universal access to medicine, and to reduce the impact of these expenses on families’ budgets¹⁸18. Tavares NUL, Luiza VL, Oliveira M, Costa KS, Mengue SS, Arrais PSD, et al. Acesso gratuito a medicamentos para tratamento de doenças crônicas no Brasil. Rev Saúde Pública 2016; 50(Supl. 2): 7s. http://dx.doi.org/10.1590/S1518-8787.2016050006118
https://doi.org/http://dx.doi.org/10.159... ^,1919. Alencar T de OS, Araújo PS, Costa EA, Barros RD, Lima YOR, Paim JS. Programa Farmácia Popular do Brasil: uma análise política de sua origem, seus desdobramentos e inflexões. Saúde Debate 2018; 42(N. Esp. 2): 159-72. http://dx.doi.org/10.1590/0103-11042018s211
https://doi.org/http://dx.doi.org/10.159... ^,2121. Mattos L, Silva R, Chaves G, Luiza VL. Assistência farmacêutica na atenção básica e Programa Farmácia Popular: a visão de gestores de esferas subnacionais do Sistema Único de Saúde. Saúde Soc 2019; 28(1): 287-98. http://dx.doi.org/10.1590/s0104-12902019170442
https://doi.org/http://dx.doi.org/10.159... ^,2222. Cavalcanti de Almeida AT, Batista de Sá E, Vieira FS, Benevides RP de S E. Impacto do Programa Farmácia Popular do Brasil sobre a saúde de pacientes crônicos. Rev Saúde Pública 2019; 53. http://dx.doi.org/10.11606/s1518-8787.2019053000733
https://doi.org/http://dx.doi.org/10.116... . Since 2011, it has been providing free antihypertensive drugs in both types of health system. The sources for obtaining anti-hypertensive drugs in Brazil can be subdivided into private pharmacies and/or drugstores, where individuals pay in full; public pharmacies, primarily those in the public health units, whose financing comes from three institutions (Federal, State and Municipal) and through PFPB.

Providing adequate drug treatment for NCDs, including hypertension, in order to reduce early mortality from these diseases, is one of the objectives for sustainable development defined by the World Health Organization (WHO). It is supposed to be achieved by 2030²2. World Health Organization. World Health Statistics - Monitoring Health for the SGD’s, Sustainable Development Goals. Genebra: World Health Organization; 2018. 100 p.. Reports of anti-hypertensive drug use among hypertensive patients in Brazilian capital cities in 2013 was 81.4%⁶6. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Jr. JB. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013 Use of medication for treatment of noncommunicable chronic diseases in Brazil: results from the National Health Survey, 20. Epidemiol Serv Saúde 2015; 24(2): 315-23. http://dx.doi.org/10.5123/S1679-49742015000200014
https://doi.org/http://dx.doi.org/10.512... , indicating that a large portion of individuals with this condition have been accessing the various networks in the country to obtain these drugs. In 2011, the Ministry of Health prepared a Strategic Action Plan for tackling NCDs (2011-2022), which provides the expansion of access to free medicines for hypertension and diabetes, among other measures²³23. Brasil. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise de Situação de Saúde; 2011. 160 p.. In order to verify the effectiveness of these actions, it is necessary to monitor indicators, such as the use of medicines and where they are obtained, in order to identify the availability of free access to such medicines.

Vigitel is part of the Ministry of Health’s surveillance system for NCD risk factors and in 2011, it incorporated issues related to the use of medicines. The year 2017 was the last year in which the supply of anti-hypertensive drugs occurred free of charge in the establishments of the PFPB. As such, the objective of the present study was to estimate the prevalence of use and to identify the sources of obtaining anti-hypertensive drugs in Brazil, according to sociodemographic variables, comparing three periods: 2011, 2014 and 2017.

METHODS

This was a cross-sectional population-based study that used data from Vigitel for the years 2011, 2014 and 2017. This telephone survey has been carried out annually, since 2006, to monitor the frequency and distribution of risk and protective factors for NCDs in adults (age ≥ 18 years) living in all capital cities of the 26 Brazilian states and in the Federal District, in homes with at least one fixed telephone line⁷7. Brasil. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde; 2018. 130 p.^,88. Brasil. Vigitel Brasil 2011: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Secretaria de Gestão Estratégica e Participativa; 2012. 134 p.^,99. Brasil. Vigitel Brasil 2014: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde ; 2015. 154 p..

In the years considered, the Vigitel system established a minimum sample size of approximately 2,000 individuals in 2011 and 2017, and 1,500 individuals in 2014, in each city. It estimated with a 95% confidence coefficient and a maximum error of three percentage points of frequency of any risk factor in the adult population (≥ 18 years). Particularly in 2017, samples of about 1,500 individuals were accepted in locations with fixed telephone coverage below 40% of households, and the absolute number of households with a telephone number below 50 thousand. Thus, maximum errors of about four percentage points were expected for specific estimates according to sex, assuming similar proportions of men and women in the sample⁷7. Brasil. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde; 2018. 130 p.^,88. Brasil. Vigitel Brasil 2011: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Secretaria de Gestão Estratégica e Participativa; 2012. 134 p.^,99. Brasil. Vigitel Brasil 2014: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde ; 2015. 154 p.^,2424. World Health Organization. Global status report on noncommunicable diseases 2010 [Internet]. Genebra: World Health Organization ; 2011 [acessado em 21 set. 2019]. Disponível em: Disponível em: http://www.who.int/about/licensing/copyright_form/en/index.html
http://www.who.int/about/licensing/copyr... .

The survey for those years was carried out through probabilistic sampling in three stages: the first consisted of the systematic random selection of 5,000 telephone numbers in each city, divided into replicates or subsamples of 200 numbers each, reproducing the same proportion of numbers per city region or telephone prefix (stratification by postal code (CEP), which were based on the electronic registration of fixed residential lines from the telephone companies that cover the cities studied). The second stage, carried out concurrently with the interviews, included the identification of residential and active lines, which were considered eligible for the system. The third stage included randomly selecting an adult resident, among all of the adults (≥ 18 years old) living in the household, to answer the interview questions⁷7. Brasil. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde; 2018. 130 p.^,88. Brasil. Vigitel Brasil 2011: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Secretaria de Gestão Estratégica e Participativa; 2012. 134 p.^,99. Brasil. Vigitel Brasil 2014: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde ; 2015. 154 p..

In the present study, individuals aged 20 years or older, who reported a medical diagnosis of arterial hypertension in 2011 (n = 15,027), 2014 (n = 12,905) and 2017 (n = 18,614) were considered.

The following question was used to ask whether they took drugs to treat blood pressure: “Are you currently taking any medications to control high blood pressure?” Among those who reported the use of antihypertensive drugs, they questioned where they got them: “Where do you get the medication to control high blood pressure?”, which were categorized into: SUS Health Unit (HU), PFPB and Other Sources - Private Pharmacy/Drugstores (OS).

The sociodemographic variables considered were: region of residence (Center west, Northeast, North, Southeast, South); sex (male, female); age (20-39 years, 40-59 years, 60 years or more); marital status (no spouse, spouse); race/color (white, black/ brown/ other); education (from 0 to 4 years of study, from 5 to 8 years of study, from 9 to 11 years of study, 12 or more years of study) and having a private health plan (yes, no).

The estimates were weighted for the population of each city. Final weights were assigned to each individual in order to match the estimated sociodemographic composition for the adult population with a telephone in the Vigitel sample, to the sociodemographic composition estimated for the total adult population of the same city. The post-stratification weight was calculated using the rake⁷7. Brasil. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde; 2018. 130 p.^,88. Brasil. Vigitel Brasil 2011: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Secretaria de Gestão Estratégica e Participativa; 2012. 134 p.^,99. Brasil. Vigitel Brasil 2014: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde ; 2015. 154 p.^,2525. Brasil. Ponderação pelo método rake [Internet]. Brasília: Ministério da Saúde; 2014 [acessado em 21 set. 2019]. 2 p. Disponível em: Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2014/setembro/29/Nota-----pondera----o-Rake.pdf
https://portalarquivos2.saude.gov.br/ima... method and the analyzes were performed using the Stata 14.0 software, considering the sample design of the research.

The prevalence of medication use was estimated among adults who reported a medical diagnosis of arterial hypertension, according to sociodemographic variables. For those who reported taking medications, distributions were verified according to the where they obtained them. Comparisons between proportions were performed using Pearson’s χ² test (Rao-Scott), with a 5% significance level.

Individuals were informed about the research objectives at the time of being contacted by telephone and free and informed consent was replaced by verbal consent. Vigitel was approved by the National Human Research Ethics Commission (processes nº 13.081/2008 and 355.590/2013). The project in which the present study was carried out was exempt from the Unicamp Research Ethics Committee (Ofício CEP/PRP/Nº 149/2019).

RESULTS

The prevalence of medication use for the treatment of hypertension was high in the three years observed (79.6, 79 and 80%, respectively) (Table 1). As for the where individuals obtained medication, there were changes in the period, verified by the decrease in procurement through the HU (44.2%, in 2011, to 30.5%, in 2017) and by the increase in procurement through the PFPB (16.1% in 2011 to 29.9% in 2017); procurement from other sources showed stability in the period (Figure 1).

An increase in the prevalence of use was observed in the Northern Region from 2011 (63.8%) to 2014 (74.6%); in the Northeast, from 76.6% in 2014, to 80.9% in 2017, and in the Center West Region (73.5% in 2011 to 81.7% in 2017). It is important to note that when assessing the differences between the regions, in 2011, the prevalence of use in the North Region was lower than all other regions and, in 2014, it was lower only in relation to the Southeast Region. It was equal to the others in 2017, and there were no statistically significant differences between them (p> 0.05) (Table 1).

Regarding gender, there was an increase in the use of medicines by the male population, between 2011 (67.5%) and 2017 (74.4%). Use remained stable for women. The increase in use also occurred with age, with an emphasis on the age group of 40 to 59 years (76 and 80.7% in 2011 and 2017, respectively). As for skin color/race, there was an increase in the prevalence of use in both subgroups, with a higher percentage of medication use among whites (p<0.05) (Table 1).

Individuals with less education had a higher prevalence of use than the others, around 80% in the three years observed. From 2011 (72.3%) to 2017 (81.4%), there was an increase in the use of antihypertensive drugs by individuals with 5 to 8 years of study and, in the more educated individuals, the prevalence was 65.9% in 2011, reaching 72.3% in 2014. Among those who reported having a private health plan, the prevalence of use increased between 2011 and 2017 (71.7 to 84.6%) (Table 1).

The prevalence of obtaining medication from the HU decreased in all regions in the period observed. In the North and South regions, the decrease was observed from 2014 to 2017. In the Northeast and Center West regions there was a reduction in 2014 and an increase in 2017. The Southeast Region showed an increase in this source in 2014, when compared to 2011, followed by a sharp drop in 2017. The biggest difference was observed in the Center West Region (42.5% in 2011 and 17.3% in 2017). On the other hand, there was an increase in procurement of medicines from the PFPB in the period in all regions, being most evident in the South Region. The prevalence of obtaining medicine from other sources remained stable in the period, with the exception of the South Region, which decreased in 2014, a result that was maintained in 2017 (Table 2).

A similar behavior was observed in the other variables studied in all strata, with a decrease in the prevalence of procurement from the HU, and an increase in procurement from the PFPB, without alteration to other sources, except among more educated people. It is worth noting that these changes were observed between 2014 and 2017. In the period from 2011 to 2014, the only statistically significant variation occurred for individuals who did not have a private health plan, which may indicate a migration from the HU to PFPB during the period (Table 2).

DISCUSSION

The results of this study showed a high prevalence of medication use for the treatment of arterial hypertension in the three years considered. However, they were less than the results found in the PNAUM in 2014²⁶26. Serrate Mengue S, Dâmaso Bertoldi A, Roberto Ramos L, Rocha Farias M, Auxiliadora Oliveira M, Urruth Leão Tavares N, et al. Acesso e uso de medicamentos para hipertensão arterial no Brasil. Rev Saúde Pública 2016; 50(Supl. 2): 8s. http://dx.doi.org/10.1590/S1518-8787.2016050006154
https://doi.org/http://dx.doi.org/10.159... . According to data from the 2013 PNS, the prevalence of arterial hypertension and the use of antihypertensive drugs in the Brazilian adult population was 21.4 and 81.4%, respectively. Lower frequencies of drug treatment or non-use among patients with hypertension and diabetes, may be related to barriers to access and adherence to treatment, in addition to the possibility that some segments of patients reduced their use of drugs and adopting other forms of controlling the diseases, such as changes in habits and lifestyles²⁷27. Costa KS, Francisco PMSB, Malta DC, Barros MBA. Fontes de obtenção de medicamentos para hipertensão e diabetes no Brasil: resultados de inquérito telefônico nas capitais brasileiras e no Distrito Federal, 2011 Sources. Cad Saúde Pública [Internet]. 2016 [acessado em 17 dez. 2019]; 32(2). Disponível em: Disponível em: http://dx.doi.org/10.1590/0102-311X00090014
http://dx.doi.org/10.1590/0102-311X00090... .

With regard to the use of antihypertensive drugs in the various regions of the country, observing the years 2014 and 2017, the increase in prevalence in the North and Northeast regions stands out, reflecting possible improvements in regional inequalities. These two macro-regions, in particular, are less developed socially and economically, however these findings may suggest advances in the organization of the networks that make up the SUS, favoring access to services in basic Health Units (HU), medicines, and diagnoses²⁸28. Costa KS, Zaccolo AV, Leão Tavares N, Arrais PSD, Lucia Luiza V, Oliveira MA, Mengue SS. Avaliação dos usuários sobre as farmácias públicas no Brasil. Ciên Saúde Colet [Internet] 2018 [acessado em 21 set. 2019]. Disponível em: Disponível em: http://www.cienciaesaudecoletiva.com.br/artigos/avaliacao-dos-usuarios-sobre-as-farmacias-publicas-no-brasil/17073?id=17073&id=17073&id=17073
http://www.cienciaesaudecoletiva.com.br/... ^,2929. Bertoldi AD, Pizzol T da SD, Ramos LR, Mengue SS, Luiza VL, Tavares NUL, et al. Sociodemographic profile of medicines users in Brazil: results from the 2014 PNAUM survey Andréa. Rev Saúde Pública 2016; 50(Supl. 2). http://dx.doi.org/10.1590/s1518-8787.2016050006119
https://doi.org/http://dx.doi.org/10.159... ^,3030. Andrade MV, Noronha KVM de S, Menezes R de M, Souza MN, Reis C de B, Martins DR, et al. Desigualdade socioeconômica no acesso aos serviços de saúde no Brasil: um estudo comparativo entre as regiões brasileiras em 1998 e 2008. Econ Apl 2013; 17(4): 622-45. http://dx.doi.org/10.1590/S1413-80502013000400005
https://doi.org/http://dx.doi.org/10.159... ^,3131. Monteiro CN, Lima MG, Szwarcwald CL, Bastos TF, Barros MBA. Use of antihypertensive and antidiabetic medications in Brazil: an analysis of socioeconomic differences. National Health Survey, 2013. Rev Bras Epidemiol 2019; 22(Supl. 2): e190014. https://doi.org/10.1590/1980-549720190014.supl.2
https://doi.org/https://doi.org/10.1590/... .

The percentage of medication use was lower among men, findings that corroborate other national surveys⁶6. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Jr. JB. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013 Use of medication for treatment of noncommunicable chronic diseases in Brazil: results from the National Health Survey, 20. Epidemiol Serv Saúde 2015; 24(2): 315-23. http://dx.doi.org/10.5123/S1679-49742015000200014
https://doi.org/http://dx.doi.org/10.512... ^,2626. Serrate Mengue S, Dâmaso Bertoldi A, Roberto Ramos L, Rocha Farias M, Auxiliadora Oliveira M, Urruth Leão Tavares N, et al. Acesso e uso de medicamentos para hipertensão arterial no Brasil. Rev Saúde Pública 2016; 50(Supl. 2): 8s. http://dx.doi.org/10.1590/S1518-8787.2016050006154
https://doi.org/http://dx.doi.org/10.159... , but there was an increase in 2017 when compared to 2011. Women tend to visit the health care system more frequently. Additionally, they have more accurate perceptions of their symptoms and their own health³²32. Matta SR, Bertoldi AD, Emmerick ICM, Fontanella AT, Costa KS, Luiza VL. Fontes de obtenção de medicamentos por pacientes diagnosticados com doenças crônicas, usuários do Sistema Único de Saúde. Cad Saúde Pública 2018; 34(3). http://dx.doi.org/10.1590/0102-311X00073817
https://doi.org/http://dx.doi.org/10.159... . The prevalence of medication use increased with advancing age, results similar to those observed in previous studies⁶6. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Jr. JB. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013 Use of medication for treatment of noncommunicable chronic diseases in Brazil: results from the National Health Survey, 20. Epidemiol Serv Saúde 2015; 24(2): 315-23. http://dx.doi.org/10.5123/S1679-49742015000200014
https://doi.org/http://dx.doi.org/10.512... ^,2626. Serrate Mengue S, Dâmaso Bertoldi A, Roberto Ramos L, Rocha Farias M, Auxiliadora Oliveira M, Urruth Leão Tavares N, et al. Acesso e uso de medicamentos para hipertensão arterial no Brasil. Rev Saúde Pública 2016; 50(Supl. 2): 8s. http://dx.doi.org/10.1590/S1518-8787.2016050006154
https://doi.org/http://dx.doi.org/10.159... ^,3333. Ferreira RA, Barreto SM, Giatti L. Hipertensão arterial referida e utilização de medicamentos de uso contínuo no Brasil: um estudo de base populacional. Cad Saúde Pública 2014; 30(4): 815-26. http://dx.doi.org/10.1590/0102-311X00160512
https://doi.org/http://dx.doi.org/10.159... , since younger people are prescribed drugs less frequently. In addition, they adhere less to treatment than older individuals²⁶26. Serrate Mengue S, Dâmaso Bertoldi A, Roberto Ramos L, Rocha Farias M, Auxiliadora Oliveira M, Urruth Leão Tavares N, et al. Acesso e uso de medicamentos para hipertensão arterial no Brasil. Rev Saúde Pública 2016; 50(Supl. 2): 8s. http://dx.doi.org/10.1590/S1518-8787.2016050006154
https://doi.org/http://dx.doi.org/10.159... .

As for skin color/race, the use of antihypertensive drugs was higher among whites in the study period. Even with an increase in the prevalence of use in both categories, when comparing 2011 and 2017, the differences remain. This may indicate that the white population has better access when compared to blacks, browns/others. Among the latter group, greater access was observed in the SUS health unit pharmacies, results that are consistent with previous studies that show the attendance, in the HU, of groups with historically less favored socioeconomic insertion in the country. This suggests that equity is being promoted²⁷27. Costa KS, Francisco PMSB, Malta DC, Barros MBA. Fontes de obtenção de medicamentos para hipertensão e diabetes no Brasil: resultados de inquérito telefônico nas capitais brasileiras e no Distrito Federal, 2011 Sources. Cad Saúde Pública [Internet]. 2016 [acessado em 17 dez. 2019]; 32(2). Disponível em: Disponível em: http://dx.doi.org/10.1590/0102-311X00090014
http://dx.doi.org/10.1590/0102-311X00090... .

The prevalence of antihypertensive drug use has increased over the years among users who reported having a private health plan, while use by those who did not remained stable. In 2011, use was greater among those who did not have a plan, a situation that was reversed in 2017. Individuals who adhere to supplementary health, in general, tend to be more educated and have a higher income, which can contribute to them being more careful in accepting the most rigorous treatment³⁴34. Paulucci TD, Velasquez-Melendez G, Bernal RIT, Lana FF, Malta DC. Análise do cuidado dispensado a portadores de hipertensão arterial em Belo Horizonte, segundo inquérito telefônico. Rev Bras Epidemiol 2014; (Supl. PeNSE): 227-40. http://doi.org/10.1590/1809-4503201400050018
https://doi.org/http://doi.org/10.1590/1... .

Considering the sources for obtaining medications, the migration from HU to the PFPB is evident. The first year observed (2011) coincides with the start of free anti-hypertensive drugs through the “Health has no price” “Saúde não tem preço” campaign. Until then, the PFPB was still the least prevalent source of medications among the three evaluated, with percentages much lower than the others. In 2014, it was already growing, but it still remained significantly below the other sources.

According to PNAUM data, in 2014, 16% of hypertensive patients using drugs, obtained them through the PFPB.²⁶26. Serrate Mengue S, Dâmaso Bertoldi A, Roberto Ramos L, Rocha Farias M, Auxiliadora Oliveira M, Urruth Leão Tavares N, et al. Acesso e uso de medicamentos para hipertensão arterial no Brasil. Rev Saúde Pública 2016; 50(Supl. 2): 8s. http://dx.doi.org/10.1590/S1518-8787.2016050006154
https://doi.org/http://dx.doi.org/10.159... Vigitel’s data for the same year, presented in the present study, are slightly higher, which may be explained by the fact that the telephone survey is carried out only in the capital cities, where the presence of pharmacy units affiliated with “Aqui tem Farmácia Popular” tends to be greater when compared to other municipalities. In 2017, the percentage of obtaining medicines via PFPB was equal to obtaining them via HU. This reinforces the importance of the program as one of the main access routes to medicines for the treatment of hypertension in Brazil.

Despite this wide coverage, discussions and reflections regarding disconnect with the public health and pharmaceutical services system, in addition to the monetary amount invested in the program in the face of inconsistencies with its restrictive list of medications that do no align with current guidelines and protocols, are frequent¹⁹19. Alencar T de OS, Araújo PS, Costa EA, Barros RD, Lima YOR, Paim JS. Programa Farmácia Popular do Brasil: uma análise política de sua origem, seus desdobramentos e inflexões. Saúde Debate 2018; 42(N. Esp. 2): 159-72. http://dx.doi.org/10.1590/0103-11042018s211
https://doi.org/http://dx.doi.org/10.159... . Specifically, the ATFP received numerous criticisms due to the significant increase in the amount spent by the Ministry of Health, in contrast to the volume of resources transferred to the municipalities for the purchase of the medicines for the Basic Component of Pharmaceutical Assistance (Componente Básico da Assistência Farmacêutica - CBAF). In 2006, the ratio between the volume of resources invested in the ATFP compared to the CBAF was 0.06, increasing to 2.28 in 2014. In the same period, spending on ATFP evolved, on average, 88% compared to only 2% in on-lending of the CBAF³⁵35. Silva RM da, Caetano R. Gastos com pagamentos no Programa Aqui Tem Farmácia Popular: evolução entre 2006-2014. Physis Rev Saúde Coletiva [Internet]. 2018 [acessado em 15 dez. 2019]; 28(1). Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-73312018000100402&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... .

Regional differences were observed, with emphasis on the North and Northeast regions, which had lower prevalence of obtaining medicine from the HU in 2011, compared to the other regions. These prevalences were even lower in 2017. The biggest drop, however, was in the Center West. However, when analyzing the PFPB, in 2017, the regional differences were no longer so explicit, which can be justified by the wide spread of establishments linked to the “Aqui tem Farmácia Popular”. It was initially thought of as a complement to access, and then it expanded greatly, accounting for more than 30 thousand establishments with agreements in 2014³⁵35. Silva RM da, Caetano R. Gastos com pagamentos no Programa Aqui Tem Farmácia Popular: evolução entre 2006-2014. Physis Rev Saúde Coletiva [Internet]. 2018 [acessado em 15 dez. 2019]; 28(1). Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-73312018000100402&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... .

It is worth mentioning that approximately 40% of adults living in Brazilian capital cities and the Federal District in the three years considered, reported obtaining their medications from other sources (private pharmacies/drugstores). This reveals that more than a third of Brazilian adults do not obtain their medication free of charge, despite the increase in investments by the federal government to expand access to medicines for the treatment of chronic diseases, such as hypertension, in the period²³23. Brasil. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise de Situação de Saúde; 2011. 160 p.. In Brazil, between 2002 and 2006, public spending on medicines increased 115%, while the gross domestic product (GDP) grew 14.4% and the Ministry of Health budget grew 9.6%.³⁵35. Silva RM da, Caetano R. Gastos com pagamentos no Programa Aqui Tem Farmácia Popular: evolução entre 2006-2014. Physis Rev Saúde Coletiva [Internet]. 2018 [acessado em 15 dez. 2019]; 28(1). Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-73312018000100402&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... Even so, in 2017, the last observed period, obtaining medicines from other sources was the most prevalent.

The decrease in access via the HU may suggest a low supply of drugs in the scope of primary care. Although antihypertensive drugs can be purchased free of charge via PFPB, this program guarantees free access only to medicines for hypertension, diabetes and asthma, while the basic component of the National List of Essential Medicines (Relação Nacional de Medicamentos Essenciais - RENAME) currently has 371 items and aims to cover the needs of priority medicines of the Brazilian population³⁶36. Brasil. Relação Nacional de Medicamentos Essenciais 2020 [Internet]. Brasília: Ministério da Saúde ; 2020 [acessado em 16 dez. 2019]. 217 p. Disponível em: Disponível em: http://portalms.saude.gov.br/assistencia-farmaceutica/medicamentos-rename
http://portalms.saude.gov.br/assistencia... , according to well-defined clinical guidelines and protocols.

Among the limitations of the present study, the restriction of the sample to individuals residing in the capital cities of Brazilian states and in the Federal District, and to those who have landlines must be considered. It limits their representativeness, which, however, is minimized by the use of weighting factors of data through post-stratification. In addition, fixed telephone coverage in the country has been constantly monitored by the Vigitel management team³⁷37. Malta DC, Bernal RIT, Nunes ML, Oliveira MM de, Iser BPM, Andrade SSC de A, et al. Prevalência de fatores de risco e proteção para doenças crônicas não transmissíveis em adultos: estudo transversal, Brasil 2012. Epidemiol Serv Saúde 2014; 23(4): 609-22. http://dx.doi.org/10.5123/S1679-49742014000400003
https://doi.org/http://dx.doi.org/10.512... . Also, the use of self-reported morbidity to the detriment of clinical criteria for diagnosing the disease, may underestimate the prevalence of the disease. Thus, the data presented refer only to cases already diagnosed by a physician, and the self-report is an accurate measure to assess the prevalence of a known diagnosis of the disease³⁸38. Malta DC, Iser BPM, Andrade SSC de A, Moura L de, Oliveira TP, Bernal RIT. Tendência da prevalência do diabetes melito autorreferido em adultos nas capitais brasileiras, 2006 a 2012. Epidemiol Serv Saúde 2014; 23(4): 753-60. http://dx.doi.org/10.5123/S1679-49742014000400017
https://doi.org/http://dx.doi.org/10.512... . In addition, possible information bias may arise regarding the indication of drug treatment for hypertension and the correct identification of the source of how individuals obtain medications.

The prevalence of use of antihypertensive drugs remained stable and the sources for obtaining underwent an inversion over the analyzed period, migrating mostly from the HU to PFPB units, with no statistically significant changes in the prevalence of obtaining medications from other sources. This change highlights the capillarity and the geographical ease of access via PFPB, reaffirming it as one of the main sources of medicines for the treatment of hypertension in Brazil. However, the decrease in access through the Health Units may signal a weakening of the supply of medication in primary care, which can be confirmed by monitoring this information for subsequent years.

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