ABSTRACT:

Objective:

To estimate the prevalence of use of oral medications for the treatment of diabetes, as well as the distribution of sources for obtaining according to sociodemographic variables, in the Brazilian states’ capitals and in the Federal District, and their evolution from 2012 to 2018.

Methods:

Cross-sectional and population-based study with individuals aged ≥ 20 years who reported a medical diagnosis of diabetes, interviewed through Vigitel from 2012 to 2018. We estimated the prevalence of use and the distribution of sources for obtaining according to sociodemographic variables (95%CI). We checked differences among proportions using the Pearson’s χ² test (Rao-Scott), with a significance level of 5%.

Results:

There was an increase in the prevalence of use of oral medications for the treatment of diabetes from 77.4 to 85.2% between 2012 and 2018, and a decrease in obtaining in the Health Unit Pharmacies of the Unified Health System (SUS), while there was an increase in obtaining in Popular Pharmacies.

Conclusions:

In Brazil, SUS remained the main source for obtaining oral antidiabetic drugs, financing more than 70% of them in the country, considering the Health Unit Pharmacies and Popular Pharmacies, thereby showing the importance of public Pharmaceutical Policies in guaranteeing the access to medications by the Brazilian population, as well as in reducing inequities in the country. Nevertheless, the migration of obtaining by users from SUS Health Units to Popular Pharmacies suggests the weakening the responsibility of Primary Health Care in the provision oral antidiabetic drugs, thereby undermining the bond and the longitudinal care.

Keywords:
Drug utilization; Diabetes mellitus; Behavioral risk factor surveillance system; Unified Health System; Cross-sectional studies

INTRODUCTION

The global prevalence of diabetes, which was 4.6% in 2000, reached 9.3% in 2019, representing 463 million people, and could reach up to 700 million in 2045. According to the International Diabetes Federation (IDF), three in every four (79%) people with diabetes live in developing countries, and 63% of the total are of economically active age (up to 60 years old)¹1. International Diabetes Federation. IDF Diabetes Atlas. 9ª ed. Bruxelas: International Diabetes Federation; 2019..

Brazil is the fifth country in the world in number of adults with diabetes¹1. International Diabetes Federation. IDF Diabetes Atlas. 9ª ed. Bruxelas: International Diabetes Federation; 2019.. Data from the Risk and Protection Factors Surveillance System for Chronic Diseases by Telephone Survey (Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico - Vigitel) in 2018 show that the prevalence of self-reported diabetes in the population over 18 years of age was 7.7%, showing an increase in relation to 2011, which was 5.6%²2. 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. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis; 2019..

Diabetes can cause many health complications, with high morbidity and mortality, increasing costs for individuals and health systems due to amputations, early retirements, loss of work functions in the productive age group, absenteeism from work and hospital medical costs, as well as the risks of premature death (from 30 to 69 years of age)³3. Brasil. Caderno 36 da Atenção básica - Estratégias para o cuidado da pessoa com doença crônica: Diabetes Mellitus. Brasília: Ministério da Saúde; 2013.^,44. Secretaria do Estado da Saúde de São Paulo. Manual de Orientação Clínica: Diabetes Mellitus. São Paulo: Secretaria do Estado da Saúde de São Paulo; 2011.^,55. IDF. IDF Diabetes Atlas. Country report 2017 & 2045 [Internet]. 8ª ed. IDF; 2018 [acessado em 4 jun. 2020]. Disponível em: Disponível em: https://idf.org/e-library/epidemiology-research/diabetes-atlas/134-idf-diabetes-atlas-8th-edition.html
https://idf.org/e-library/epidemiology-r... ^,66. Salomé GM, Blanes L, Ferreira LM. Capacidade funcional dos pacientes com diabetes mellitus e pé ulcerado. ACTA Paul Enferm 2009; 22(4): 412-6. https://doi.org/10.1590/S0103-21002009000400010
https://doi.org/https://doi.org/10.1590/... , in addition to being among the main causes of death in adults worldwide, before diseases such as acquired immunodeficiency syndrome (AIDS), tuberculosis, and malaria⁵5. IDF. IDF Diabetes Atlas. Country report 2017 & 2045 [Internet]. 8ª ed. IDF; 2018 [acessado em 4 jun. 2020]. Disponível em: Disponível em: https://idf.org/e-library/epidemiology-research/diabetes-atlas/134-idf-diabetes-atlas-8th-edition.html
https://idf.org/e-library/epidemiology-r... .

Among complications, 35% of people with diabetes develop some degree of diabetic retinopathy, 44% of chronic kidney disease, and peripheral neuropathy ranges from 16 to 66% in these individuals, with amputation 20 times more common among people with diabetes than in the overall population⁵5. IDF. IDF Diabetes Atlas. Country report 2017 & 2045 [Internet]. 8ª ed. IDF; 2018 [acessado em 4 jun. 2020]. Disponível em: Disponível em: https://idf.org/e-library/epidemiology-research/diabetes-atlas/134-idf-diabetes-atlas-8th-edition.html
https://idf.org/e-library/epidemiology-r... .

The control of glycemic levels is essential for the treatment of diabetes mellitus. With it, patients remain asymptomatic and prevent acute and chronic complications, promoting quality of life and reducing mortality³3. Brasil. Caderno 36 da Atenção básica - Estratégias para o cuidado da pessoa com doença crônica: Diabetes Mellitus. Brasília: Ministério da Saúde; 2013.^,44. Secretaria do Estado da Saúde de São Paulo. Manual de Orientação Clínica: Diabetes Mellitus. São Paulo: Secretaria do Estado da Saúde de São Paulo; 2011.^,77. World Health Organization. Global report on diabetes. Genebra: World Health Organization; 2016.. In most people with diabetes, this control can be achieved with the use of medications, in addition to changes in lifestyle, such as the adoption of a balanced diet and the practice of regular physical activity³3. Brasil. Caderno 36 da Atenção básica - Estratégias para o cuidado da pessoa com doença crônica: Diabetes Mellitus. Brasília: Ministério da Saúde; 2013.^,77. World Health Organization. Global report on diabetes. Genebra: World Health Organization; 2016.. Therefore, expanding access to medicines, as part of comprehensive care for people with diabetes, is an important therapeutic strategy⁸8. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Júnior JB da. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2015; 24(2): 315-23. https://doi.org/10.5123/S1679-49742015000200014
https://doi.org/https://doi.org/10.5123/... .

According to the Family Budget Survey (Pesquisa de Orçamentos Familiares - POF), spending on medicines represented 37% of family health expenditures in the 1990s and 42.9% in 2009, with a major impact on family expenses⁹9. Vieira FS. Evolução do gasto com medicamentos do sistema único de saúde no período de 2010 a 2016. Texto para Discussão - Instituto de Pesquisa Econômica Aplicada [Internet]. Brasil: Ipea; 2018 [acessado em 4 jun. 2020]. Disponível em: Disponível em: http://www.ipea.gov.br/portal/images/stories/PDFs/TDs/180117_td_2356.pdf
http://www.ipea.gov.br/portal/images/sto... . In order to expand free access to medicines in Brazil, it was observed, especially, until 2016, an increase in the contribution of public resources in this area, especially federal ones¹⁰10. 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. https://doi.org/10.1590/S1518-8787.2016050006118
https://doi.org/https://doi.org/10.1590/... .

Data from the Institute of Applied Economic Research (Instituto de Pesquisa Econômica Aplicada - IPEA) showed that the Ministry of Health’s spending on basic, strategic, and specialized components of pharmaceutical assistance increased from R$ 9.7 to 12.8 billion from 2010 to 2016. In the same period, the spending on the Programa Farmácia Popular do Brasil - PFPB) increased by 580%, which corresponded to more than 6 billion reais in 2016. Total spending on medicines by the Ministry and by the state and municipal health departments, including the PFPB, passed from 14.4 billion in 2010 to 20 billion in 2015⁹9. Vieira FS. Evolução do gasto com medicamentos do sistema único de saúde no período de 2010 a 2016. Texto para Discussão - Instituto de Pesquisa Econômica Aplicada [Internet]. Brasil: Ipea; 2018 [acessado em 4 jun. 2020]. Disponível em: Disponível em: http://www.ipea.gov.br/portal/images/stories/PDFs/TDs/180117_td_2356.pdf
http://www.ipea.gov.br/portal/images/sto... , which was also measured in population-based surveys, such as the 2014 National Survey on Access, Use and Promotion of Rational Use of Medicines in Brazil (Pesquisa Nacional sobre o Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil - PNAUM): 98% of diabetics obtained full access to their medications, of these, 70.7% obtained it free of charge¹¹11. Meiners MMM de A, Tavares NUL, Guimarães LSP, Bertoldi AD, Pizzol T da SD, Luiza VL, et al. Acesso e adesão a medicamentos entre pessoas com diabetes no Brasil: Evidências da PNAUM. Rev Bras Epidemiol 2017; 20(3): 445-59. https://doi.org/10.1590/1980-5497201700030008
https://doi.org/https://doi.org/10.1590/... .

Considering the complexity of diabetes, its impact on morbidity and mortality, the magnitude of expenditures related to this disease, both by individuals and by the government, as well as the efforts of federated entities, expanding spending on medications, it is important to provide information to verify the effectiveness of such actions and the free access to medicines by the Brazilian population.

In this study, the prevalence of use of oral medication for the treatment of diabetes was estimated, as well as the distribution of obtaining sources according to sociodemographic variables, in the capitals of the Brazilian states and in the Federal District and its evolution in the period from 2012 to 2018. Thus, this research is justified, since this information is unknown and necessary for the evaluation of public policies on pharmaceutical assistance for the treatment of this disease in Brazil.

METHODS

This is a cross-sectional population-based study that used data from Vigitel, implemented in 2006 by the Ministry of Health aiming to monitor the frequency and distribution of the main determinants of chronic non-communicable diseases (NCD) in the capitals of the 26 Brazilian states and in the Federal District²2. 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. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis; 2019..

Survey data from the years 2012 (n = 3,828), 2013 (n = 45,790), 2015 (n = 5,421), 2016 (n = 6,583), 2017 (n = 5,935), and 2018 (n = 5,895) were used. In 2014, questions related to diabetes treatment drugs were not included in the Vigitel system.

Sampling procedures employed by Vigitel aim to obtain, in each of the capitals of the 26 Brazilian states and the Federal District, probabilistic samples of the population of adults (≥ 18 years of age) residing in households that have at least one landline²2. 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. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis; 2019..

The first step of the Vigitel sampling consists of systematic and stratified drawing by zip code of about five thousand telephone lines per city; then, these lines are divided into replicas of 200 lines, each replica reproducing the same proportion of lines per zip code of the original record²2. 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. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis; 2019..

In the second stage of sampling, one of the adults (≥ 18 years of age) living in the household drawn in the previous stage is drawn from the household. This step is performed after the identification, among the drawn lines, of those eligible for the system, that is, effectively residential and active lines²2. 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. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis; 2019.. Post-stratification weights were applied in order to match the sample composition to the population composition of each city, in the same period²2. 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. Brasília: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis; 2019..

In this study, data obtained from questions in the referred morbidity module were used, specifically on the use and sources of diabetes medications, in addition to questions related to the sociodemographic characteristics of individuals, with a cut-out for the population aged 20 years old or older.

The diagnosis of diabetes mellitus was determined by the question: “Has a DOCTOR ever told you that you have diabetes?”, and the use of medications by the question: “Are you currently taking any pills to control diabetes?”.

Obtaining sources were analyzed by the question “How do you get your diabetes medication?” and categorized into: the Unified Health System (Sistema Único de Saúde - SUS) health units - which represent public pharmacies, primarily those in basic units, whose funding is tripartite (federal, state, and municipal) -, PFPB - linked to private establishments with shared participation of paid acquisitions and free of charge drugs for the treatment of diabetes, hypertension and asthma, throughout the Brazilian territory - and other sources (OS; private pharmacy/drugstores) - upon full payment with self-financing.

The survey also includes questions about the use of insulin for the treatment of diabetes, however, in this study, only individuals taking oral medication were involved.

The sociodemographic variables considered were: region of residence (Midwest, Northeast, North, Southeast, South), gender (male, female), age (20 to 39 years, 40 to 59 years, 60 years or more), race/color (white, black/brown/other), education (0 to 4 years of study, 5 to 8 years of study, 9 to 11 years of study, 12 years or more of study) and having private health insurance (yes, no).

The data were analyzed using the Stata program, version 14®, using the set of svy commands, appropriate for the analysis of complex samples, ensuring the necessary sample weighting. The prevalence of use of oral medication for the treatment of diabetes mellitus and the distribution of different sources of medication were estimated, according to sociodemographic variables, with respective 95% confidence intervals (95% CI). Pearson’s χ² test (Rao-Scott) was applied to assess the differences between proportions, and adherence to the normal distribution of point estimates of drug use in the years considered was verified by the Shapiro-Wilk test. All analyses were performed with a 5% significance level.

Informed consent was obtained orally at the time of telephone contact with the interviewees. The Vigitel project was approved by the National Commission for Ethics in Research for Human Beings of the Ministry of Health (Conep 355.590, of June 26^th, 2013). The project in which the present study was carried out was exempted from the Research Ethics Committee of Universidade Estadual de Campinas (Unicamp) (CEP/PRP/No. 149/2019).

RESULTS

The prevalence of use of oral medication to treat diabetes in Brazil increased from 77.4% in 2012 to 85.2% in 2018. Among the regions, there was an increase in the South Region, growing from 73.4 to 84.9 % from 2012 to 2018, respectively (Table 1).

As for sociodemographic characteristics, there was an increase in the use of these drugs among men (74.7% in 2012; 87.0% in 2018); in individuals aged 20 to 39 years (33.8% in 2012; 60.7% in 2018); among people who reported black/brown/other skin color (74.0% in 2012; 85.3% in 2018). In relation to education, the increase occurred in the intermediate ranges, from 5 to 8 years of study (77.5% in 2012; 89.5% in 2018) and from 9 to 11 years of study (71.3% in 2012; 83.3% in 2018). There was also an increase in the prevalence of use among people who do not have health insurance, from 74.7 to 84.6% during the study period (Table 1).

With regard to the obtaining sources, there were changes in the period, with a decrease in obtaining oral medication for the treatment of diabetes in pharmacies in SUS health units and an increase in popular pharmacies. The prevalence of obtaining drugs from other sources (private pharmacies) showed stability in the period (Figure 1). Differences in the distributions between the strata for the variables education and private health insurance were evidenced throughout the period observed, with obtaining in pharmacies from SUS units higher in the strata with less education, whereas individuals with higher education and those who reported having health insurance had a higher prevalence of obtaining them in popular and private pharmacies (Table 2).

Obtaining oral antidiabetics in SUS went from 48.7% in 2012 to 40.6% in 2018. This decrease occurred in the Midwest (45.9% in 2012; 33.5% in 2018), the Northeast (40.8% in 2012; 30.0% in 2018), and the South (56.1% in 2012; 40.8% in 2018), and remained stable in other regions. Obtaining drugs in SUS decreased among women, adults between 20 and 59 years old, people of black/brown/other color and among those who had no health insurance. In PFPB units, the acquisition of oral antidiabetic drugs grew, starting from 24.0% in 2012 and reaching 32.8% in 2018. This increase occurred in the Midwest (23.5% in 2012; 35.2% in 2018), Northeast (29.2% in 2012; 38.0% in 2018), and South (24.2% in 2012; 35.8% in 2018) regions. An increase was also observed among women, adults aged 20-59 years, white people, individuals with 5 to 8 years of study and among those without health insurance. Obtaining diabetes medications from other sources increased in individuals with 12 years or more of study, however, this increase was occasional and not observed in the general population, in which obtaining drugs from this source showed stability in the period (Table 2).

Despite the fall, SUS remained the main source for obtaining oral antidiabetics in Brazil, in front of the PFPB and other sources, respectively.

DISCUSSION

The study highlights the increase in the use of oral medication to treat diabetes from 77.4% in 2012 to 85.2% in 2018; similar to those results found by Vigitel in 2011 and by the National Health Survey (Pesquisa Nacional de Saúde - PNS) of 2013 whose prevalence was 78.2 and 80.2%, respectively, including oral medication and insulin⁸8. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Júnior JB da. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2015; 24(2): 315-23. https://doi.org/10.5123/S1679-49742015000200014
https://doi.org/https://doi.org/10.5123/... ^,1212. Malta DC, Iser BPM, Chueiri PS, Stopa SR, Szwarcwald CL, Schmidt MI, et al. Cuidados em saúde entre portadores de diabetes mellitus autorreferido no Brasil, Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015; 18(Supl. 2): 17-32. https://doi.org/10.1590/1980-5497201500060003
https://doi.org/https://doi.org/10.1590/... ^,1313. Costa KS, Francisco PMSB, Malta DC, Barros MBDA. Fontes de obtenção de medicamentos para hipertensão e diabetes no Brasil: Resultados de inquérito telefônico nas capitais brasileiras e no Distrito Federal, 2011. Cad Saúde Pública 2016; 32(2): e00090014. https://doi.org/10.1590/0102-311X00090014
https://doi.org/https://doi.org/10.1590/... .

As in the PNS of 2013, this study showed no differences between the macro-regions, with the exception of 2016, when the Midwest Region had lower prevalence than the Northeast. PNAUM data showed great variability in the global prevalence of drug use by Brazilian regions, with less global use of drugs in the North Region and lower prevalence of use of drugs for the treatment of chronic diseases in the North, Northeast, and Midwest¹⁴14. Bertoldi AD, Dal Pizzol TS, Ramos LR, Mengue SS, Luiza VL, Tavares NUL, et al. Perfil sociodemográfico dos usuários de medicamentos no Brasil: resultados da PNAUM 2014. Rev Saúde Pública 2016; 50(2): 5s. https://doi.org/10.1590/s1518-8787.2016050006119
https://doi.org/https://doi.org/10.1590/... .

This information indicates that there was a decrease in regional inequalities in access to medicines for diabetes, but these differences remain for other kinds of drugs⁸8. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Júnior JB da. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2015; 24(2): 315-23. https://doi.org/10.5123/S1679-49742015000200014
https://doi.org/https://doi.org/10.5123/... ^,1414. Bertoldi AD, Dal Pizzol TS, Ramos LR, Mengue SS, Luiza VL, Tavares NUL, et al. Perfil sociodemográfico dos usuários de medicamentos no Brasil: resultados da PNAUM 2014. Rev Saúde Pública 2016; 50(2): 5s. https://doi.org/10.1590/s1518-8787.2016050006119
https://doi.org/https://doi.org/10.1590/... . One factor that may contribute to this result is the possibility of obtaining free oral antidiabetic drugs also from the PFPB, which is not the case with the vast majority of medicines in the Basic Component of Pharmaceutical Care, which can be obtained for free only at SUS health units.

There was an increase in the use of these drugs among men, but without significant differences between genders, in agreement with the 2013 PNS, but differently from PNAUM, in which the use was greater in women. This latest study evaluated the use of drugs to treat chronic diseases in general, and not just diabetes⁸8. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Júnior JB da. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2015; 24(2): 315-23. https://doi.org/10.5123/S1679-49742015000200014
https://doi.org/https://doi.org/10.5123/... ^,1414. Bertoldi AD, Dal Pizzol TS, Ramos LR, Mengue SS, Luiza VL, Tavares NUL, et al. Perfil sociodemográfico dos usuários de medicamentos no Brasil: resultados da PNAUM 2014. Rev Saúde Pública 2016; 50(2): 5s. https://doi.org/10.1590/s1518-8787.2016050006119
https://doi.org/https://doi.org/10.1590/... .

There was an increase in the prevalence of use of oral antidiabetics in the age group of 20 to 39 years, however the prevalences found in this study were lower than those observed in the PNS for the same age group (60.0%)⁸8. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Júnior JB da. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2015; 24(2): 315-23. https://doi.org/10.5123/S1679-49742015000200014
https://doi.org/https://doi.org/10.5123/... . The use of medicines by age group is consistent with the population’s morbidity profile, in which the prevalence increases with age, which is already established in the literature.

The lower use among younger people can be attributed to a lower indication of drug treatment in this group and a greater incentive to non-drug therapies, such as healthy eating, physical activity, reduction of alcohol consumption, and non-consumption of tobacco⁸8. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Júnior JB da. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2015; 24(2): 315-23. https://doi.org/10.5123/S1679-49742015000200014
https://doi.org/https://doi.org/10.5123/... ^,1414. Bertoldi AD, Dal Pizzol TS, Ramos LR, Mengue SS, Luiza VL, Tavares NUL, et al. Perfil sociodemográfico dos usuários de medicamentos no Brasil: resultados da PNAUM 2014. Rev Saúde Pública 2016; 50(2): 5s. https://doi.org/10.1590/s1518-8787.2016050006119
https://doi.org/https://doi.org/10.1590/... . Drug treatments may also vary depending on the type of diabetes. People with type 1 diabetes mellitus (DM1) require daily injections of insulin to maintain appropriate glucose levels¹1. International Diabetes Federation. IDF Diabetes Atlas. 9ª ed. Bruxelas: International Diabetes Federation; 2019.. According to data from the World Health Organization (WHO), the global prevalence of DM1 varies from 5 to 10% of the total¹⁵15. World Health Organization. Classification of diabetes mellitus. Genebra: World Health Organization ; 2019.. In Brazil, it is estimated that there are more than one million people living with DM1, and this condition can develop at any age, although it is more common in children and young people¹⁵15. World Health Organization. Classification of diabetes mellitus. Genebra: World Health Organization ; 2019.^,1616. Instituto de Pesquisa e Apoio ao Desenvolvimento Social. Práticas educativas de autocuidado em DM1. Campinas: Instituto de Pesquisa e Apoio ao Desenvolvimento Social; 2019.. A previous study using data from Vigitel 2011, covering oral medications and insulin, found similar results in the same age groups¹³13. Costa KS, Francisco PMSB, Malta DC, Barros MBDA. Fontes de obtenção de medicamentos para hipertensão e diabetes no Brasil: Resultados de inquérito telefônico nas capitais brasileiras e no Distrito Federal, 2011. Cad Saúde Pública 2016; 32(2): e00090014. https://doi.org/10.1590/0102-311X00090014
https://doi.org/https://doi.org/10.1590/... , confirming that, regardless of the route of administration of the medication (oral or injectable, in the case of insulin), the use of antidiabetic drugs in young adult population is lower than in the population aged 40 years old or older.

There was also an increase in use by those self-reported black/brown/other color, with schooling up to 11 years of study and among people who do not have health insurance, indicating a possible decrease in inequality in the use of drugs to treat the disease in these groups. There was no difference in the use of medications between having and not having health insurance or between levels of education, suggesting, therefore, that access to oral medications for the treatment of diabetes in this period was equitable in the country, highlighting the importance of public pharmaceutical assistance as a factor in reducing health inequities in Brazil.

The study also points out that populations with low schooling, without health insurance and of black/brown/other color were the largest users of medicines from SUS and PFPB, which was also identified in the PNS 2013⁸8. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Júnior JB da. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2015; 24(2): 315-23. https://doi.org/10.5123/S1679-49742015000200014
https://doi.org/https://doi.org/10.5123/... ^,1212. Malta DC, Iser BPM, Chueiri PS, Stopa SR, Szwarcwald CL, Schmidt MI, et al. Cuidados em saúde entre portadores de diabetes mellitus autorreferido no Brasil, Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015; 18(Supl. 2): 17-32. https://doi.org/10.1590/1980-5497201500060003
https://doi.org/https://doi.org/10.1590/... ^,1717. Stopa SR, Malta DC, Monteiro CN, Landmann C, Szwarcwald, Goldbaum M, et al. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saúde Pública 2017; 51(Supl. 1): 3s. https://doi.org/10.1590/S1518-8787.2017051000074
https://doi.org/https://doi.org/10.1590/... ^,1818. Costa KS, Tavares NUL, Mengue SS, Pereira MA, Malta DC , Silva Júnior JB da. Obtenção de medicamentos para hipertensão e diabetes no Programa Farmácia Popular do Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2016; 25(1): 33-44. https://doi.org/10.5123/s1679-49742016000100004
https://doi.org/https://doi.org/10.5123/... and in other studies¹⁰10. 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. https://doi.org/10.1590/S1518-8787.2016050006118
https://doi.org/https://doi.org/10.1590/... ^,1313. Costa KS, Francisco PMSB, Malta DC, Barros MBDA. Fontes de obtenção de medicamentos para hipertensão e diabetes no Brasil: Resultados de inquérito telefônico nas capitais brasileiras e no Distrito Federal, 2011. Cad Saúde Pública 2016; 32(2): e00090014. https://doi.org/10.1590/0102-311X00090014
https://doi.org/https://doi.org/10.1590/... ^,1919. Boing AC, Bertoldi AD, Boing AF, Bastos JL, Peres KG. Acesso a medicamentos no setor público: análise de usuários do Sistema Único de Saúde no Brasil. Cad Saúde Pública 2013; 29(4): 691-701. https://doi.org/10.1590/S0102-311X2013000400007
https://doi.org/https://doi.org/10.1590/... ^,2020. 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 Saude Pública 2018; 34(3): e00073817. http://doi.org/10.1590/0102-311X00073817
https://doi.org/http://doi.org/10.1590/0... ^,2121. Francisco PMSB, Rodrigues PS, Costa KS, Tavares NUL, Tierling VL, Barros MB de A, et al. Prevalência de diabetes em adultos e idosos, uso de medicamentos e fontes de obtenção: uma análise comparativa de 2012 e 2016. Rev Bras Epidemiol 2019; 22: e190061. https://doi.org/10.1590/1980-549720190061
https://doi.org/https://doi.org/10.1590/... . PNAUM, also carried out in 2013, indicated that 61% of diabetes medications were obtained from the SUS network and 18% from the Popular Pharmacy Program (Programa Farmácia Popular - FP)²²22. Brasil. PNAUM. Componente populacional: resultados. Brasília: Ministério da Saúde ; 2016.. These findings reiterate the role of SUS and primary care in equity of care.

There was an increase in the obtaining of medicines in popular pharmacies and a decrease in obtaining them in pharmacies at SUS health units, the latter being greater in the strata with less education, among those who reported being black/brown/other skin color, whereas individuals with higher education and who reported having health insurance had a higher prevalence of obtaining them in popular and private pharmacies. These results corroborate those found in 2011 by Vigitel¹³13. Costa KS, Francisco PMSB, Malta DC, Barros MBDA. Fontes de obtenção de medicamentos para hipertensão e diabetes no Brasil: Resultados de inquérito telefônico nas capitais brasileiras e no Distrito Federal, 2011. Cad Saúde Pública 2016; 32(2): e00090014. https://doi.org/10.1590/0102-311X00090014
https://doi.org/https://doi.org/10.1590/... .

Another national study that addressed inequalities in access to medicines showed that obtaining drugs from commercial pharmacies increased along with socioeconomic status, while from SUS, it decreased²³23. Katrein F, Tejada CAO, Restrepo-Méndez MC, Bertoldi AD. Desigualdade no acesso a medicamentos para doenças crônicas em mulheres brasileiras. Cad Saúde Pública 2015; 31(7): 1416-26. https://doi.org/10.1590/0102-311X00083614
https://doi.org/https://doi.org/10.1590/... . Possible difficulties in obtaining drugs in SUS pharmacies, such as finding all the drugs prescribed in the same unit, can also contribute to this scenario.

Secondary data from the National Program for Improving Access and Quality in Primary Care (2014) identified that only 30.2% of basic health units (unidades básicas de saúde - UBS) had total availability of standardized antidiabetics²⁴24. Mendes LV, Campos MR, Chaves GC, Silva RM da, Freitas P da S, Costa KS, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde Debate 2014; 38(Núm. Esp.): 109-23. https://doi.org/10.5935/0103-1104.2014S009
https://doi.org/https://doi.org/10.5935/... . This situation can motivate the strata of better socioeconomic conditions to seek for other sources, either through the PFPB or even paying for the drug treatment in private pharmacies.

PNAUM, when evaluating the use of medications by people with chronic diseases who used SUS, also showed a higher prevalence of obtaining drugs in SUS by those who do not have health insurance; however there were no differences in acquisitions according to skin color/race and education²⁰20. 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 Saude Pública 2018; 34(3): e00073817. http://doi.org/10.1590/0102-311X00073817
https://doi.org/http://doi.org/10.1590/0... .

SUS units remained the main source of oral antidiabetics in Brazil and, considering that SUS funding also covers the drugs from FP, adding both sources, the present study points out that SUS finances over 70% of oral diabetes medicines in the country, showing their strategic importance in supporting the health of the Brazilian population¹³13. Costa KS, Francisco PMSB, Malta DC, Barros MBDA. Fontes de obtenção de medicamentos para hipertensão e diabetes no Brasil: Resultados de inquérito telefônico nas capitais brasileiras e no Distrito Federal, 2011. Cad Saúde Pública 2016; 32(2): e00090014. https://doi.org/10.1590/0102-311X00090014
https://doi.org/https://doi.org/10.1590/... ^,1717. Stopa SR, Malta DC, Monteiro CN, Landmann C, Szwarcwald, Goldbaum M, et al. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saúde Pública 2017; 51(Supl. 1): 3s. https://doi.org/10.1590/S1518-8787.2017051000074
https://doi.org/https://doi.org/10.1590/... ^,1818. Costa KS, Tavares NUL, Mengue SS, Pereira MA, Malta DC , Silva Júnior JB da. Obtenção de medicamentos para hipertensão e diabetes no Programa Farmácia Popular do Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2016; 25(1): 33-44. https://doi.org/10.5123/s1679-49742016000100004
https://doi.org/https://doi.org/10.5123/... ^,2020. 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 Saude Pública 2018; 34(3): e00073817. http://doi.org/10.1590/0102-311X00073817
https://doi.org/http://doi.org/10.1590/0... .

In addition to oral medications, SUS offers free medications in the basic health network, including other medications for the treatment of diabetes, such as insulins and also the necessary monitoring supplies (blood glucose and glycosuria tapes). In a complementary way, FP in Brazil started to offer, as of 2011, free medicines for hypertension, diabetes, and asthma in order to expand access and treatment to this group of individuals²⁵25. Silva RM da, Caetano R. Gastos com pagamentos no Programa Aqui Tem Farmácia Popular: evolução entre 2006-2014. Rev Saúde Coletiva 2018; 28(1): e280105. https://doi.org/10.1590/s0103-73312018280105
https://doi.org/https://doi.org/10.1590/... ^,2626. Brasil. Portaria nº 184, de 3 de fevereiro de 2011. Dispõe sobre o Programa Farmácia Popular do Brasil. Diário Oficial da União 2011..

In the national scenario, for the period considered, the important austerity crisis in the country stands out, with approval of Constitutional Amendment No. 95 and reduction of investment in health and social policies in 2016²⁷27. Massuda A, Hone T, Leles FAG, De Castro MC, Atun R. The Brazilian health system at crossroads: Progress, crisis and resilience. BMJ Glob Health 2018; 3(4): e000829. https://doi.org/10.1136%2Fbmjgh-2018-000829
https://doi.org/https://doi.org/10.1136%... ^,2828. Malta DC , Reis AAC dos, Jaime PC, Morais Neto OL de, Silva MMA da, Akerman M. O SUS e a Política Nacional de Promoção da Saúde: perspectiva resultados, avanços e desafios em tempos de crise. Ciên Saúde Colet 2018; 23(6): 1799-809. https://doi.org/10.1590/1413-81232018236.04782018
https://doi.org/https://doi.org/10.1590/... ^,2929. Schramm JM de A, Paes-Sousa R, Mendes LVP. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crise. Rio de Janeiro: Fiocruz; 2018. 40 p.. The study points out that, as of 2015, there was a reduction in access to medicines in SUS pharmacies, with replacement by private pharmacies accredited in FP. This fall was accentuated in the 2016 and, especially, 2017, a possible reflection of the austerity policies and the reduction of resources of the municipalities due to the fall in the federal budget assignment²⁷27. Massuda A, Hone T, Leles FAG, De Castro MC, Atun R. The Brazilian health system at crossroads: Progress, crisis and resilience. BMJ Glob Health 2018; 3(4): e000829. https://doi.org/10.1136%2Fbmjgh-2018-000829
https://doi.org/https://doi.org/10.1136%... .

Among the limitations of the study, it should be considered that the information was referred to; it is possible that the prevalence of diabetes is underestimated by the absence of prior medical diagnosis and, consequently, by the underestimation of the prevalence of medication used by these people. In addition, the use of landlines to draw the sample should be considered, however the use of post-stratification weights can reduce this bias. In addition, the study analyzed only the oral use of medications, not including insulin, which could increase the observed frequencies even further.

It is important to highlight as a strong point of this study the representativeness of the data presented regarding the capitals of all Brazilian states and the Federal District. It is also emphasized that the temporal evaluation carried out allowed for the monitoring of information in the period by means of random samples in repeated surveys. Vigitel is the only national survey carried out on an annual basis. Information on oral antidiabetics was included in the research from 2012, and the present study outlined, for the first time, the panorama of use of these drugs, providing the opportunity for regular and continuous monitoring of the evolution of the use of oral drugs for the treatment of diabetes by the adult Brazilian population and its obtaining sources.

SUS remained the main source for obtaining oral antidiabetics in Brazil, financing more than 70% of oral diabetes medicines in the country, considering the pharmacies of health units and popular pharmacies, showing the importance of public pharmaceutical policies in the access to medicines by the Brazilian population and the reduction of inequities in the country. However, the migration of users from SUS health units to popular pharmacies suggests weakening the responsibility of primary health care in offering oral antidiabetic drugs, weakening the bond and longitudinal care that contribute to more accurate diagnoses and treatments, decrease care costs, and greater patient satisfaction³⁰30. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Q 2005; 83(3): 457-502. https://doi.org/10.1111/j.1468-0009.2005.00409.x
https://doi.org/https://doi.org/10.1111/... ^,3131. Saultz JW, Albedaiwi W. Interpersonal Continuity of Care and Patient Satisfaction: A Critical Review. Ann Med 2004; 2(5): 445-51. https://doi.org/10.1370/afm.91
https://doi.org/https://doi.org/10.1370/... ^,3232. Fan VS, Burman M, McDonell MB, Fihn SD. Continuity of Care and Other Determinants of Patient Satisfaction with Primary Care. J Gen Intern Med 2005; 20(3): 226-33. https://doi.org/10.1111%2Fj.1525-1497.2005.40135.x
https://doi.org/https://doi.org/10.1111%... in primary health care.

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