Abstract

This research aimed to understand health secretaries’ perception of the concept of health, describe the experiences of these secretaries before challenges related to the management of Integrative and Complementary Health Practices (PICS), and identify if the Regional Interagency Committee (CIR) has discussed these practices. This is a qualitative and exploratory study conducted with 22 health secretaries in municipalities of Bahia from May to November 2018. The interviews were collected with a semi-structured script and recorded, transcribed, and analyzed by thematic content analysis. According to the health secretaries, some of the obstacles to PICS supply in the Brazilian National Health System (SUS) services are the lack of material resources, trained professionals, and a physical structure. All secretaries affirmed that PICS were not discussed at CIR meetings. The participation of the population, health teams, and managers in the committees is essential to hold discussions and strengthen the PICS as a powerful resource for comprehensive health care.

Keywords:
Complementary Therapies; Health Management; Comprehensive Health Care

Introduction

Integrative and Complementary Health Practices (PICS) are part of the field of healthcare that encompasses medical rationalities and integrative and complementary therapeutic health practices (Losso; Freitas, 2017LOSSO, L. N.; FREITAS, S. F. T. Avaliação do grau da implantação das práticas integrativas e complementares na Atenção Básica em Santa Catarina, Brasil. Saúde em Debate, Rio de Janeiro, v. 41, n. spe3, p. 171-187, 2017. DOI: 10.1590/0103-11042017S313
https://doi.org/10.1590/0103-11042017S31... ).

Regarding the history of the nomenclature of PICS, the World Health Organization (WHO) named such health resources as complementary and traditional medicine since they gather knowledge and practices based on theories, beliefs, and experiences of different cultures, including Indigenous culture (WHO, 2013WHO - WORLD HEALTH ORGANIZATION. WHO traditional medicine strategy: 2014-2023. Genebra, 2013. Disponível em: Disponível em: https://www.who.int/medicines/publications/traditional/trm _strategy14_23/en/ . Acesso em: 8 out. 2021.
https://www.who.int/medicines/publicatio... ). WHO also characterizes them as complementary for including health care practices from different countries not fully integrated into the dominant health system.

In Brazil, the health tools that encompass comprehensive care are called Integrative and Complementary Health Practices. According to Otani and Barros (2011OTANI, M. A. P.; BARROS, N. F. A Medicina Integrativa e a construção de um novo modelo na saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 3, p. 1801-1811, 2011. DOI: 10.1590/S1413-81232011000300016
https://doi.org/10.1590/S1413-8123201100... ), this definition aims to cover several aspects, including the integration of alternative and complementary medicine with conventional medicine and the combination of old healing systems with modern biomedicine.

Despite the several definitions for health tools and resources not limited to the purely biomedical view, Melchart (2018MELCHART, D. From Complementary to Integrative Medicine and Health: Do We Need a Change in Nomenclature? Complementary Medicine Research, Basiléia, v. 25, p. 76-78, 2018. DOI: 10.1159/000488623
https://doi.org/10.1159/000488623... ) emphasizes that the nomenclature of PICS brings closer conventional and complementary approaches, seeking to value the broader concepts of health promotion and disease prevention.

A transformation in health actions requires the involvement of social, institutional, and professional actors to democratize management and expand healthcare (Santos; Tesser, 2012SANTOS, M. C.; TESSER, C. D. Um método para a implantação e promoção de acesso às Práticas Integrativas e Complementares na Atenção Primária à Saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 17, n. 11, p. 3011-3024, 2012. DOI: 10.1590/S1413-81232012001100018
https://doi.org/10.1590/S1413-8123201200... ). In Brazil, the National Policy of Integrative and Complementary Health Practices (PNPIC) is an example of the intense participation of actors and of the importance and mobility of management. The PNPIC regulated the PICS in Brazil in 2006, establishing essential objectives for health managers and healthcare professionals, including the institutionalization of these practices at the municipal and state levels considering the competencies of each federated entity (MS, 2015aMS - MINISTÉRIO DA SAÚDE. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Manual instrutivo do PMAQ para as equipes de Atenção Básica (Saúde da Família, Saúde Bucal e Equipes Parametrizadas) e Nasf. 2. ed. Brasília, 2015a.).

The PICS policy is regulated in some municipalities and states of Brazil, including the municipality of Vitória (ES), from the involvement of social and institutional actors (Sacramento, 2017SACRAMENTO, H. T. Vitória (ES): experiência exitosa em Práticas Integrativas e Complementares (PICs). Journal of Management and Primary Health Care, Uberlândia, v. 8, n. 2, p. 333-342, 2017. DOI: 10.14295/jmphc.v8i2.556
https://doi.org/10.14295/jmphc.v8i2.556... ), and Recife (PE), by a higher court and management leaders (Santos et al., 2011SANTOS, F. A. S. et al. Política de práticas integrativas em Recife: análise da participação dos atores. Revista de Saúde Pública, São Paulo, v. 45, n. 6, p. 1154-1159, 2011. DOI: 10.1590/S0034-89102011000600018
https://doi.org/10.1590/S0034-8910201100... ). The state of Bahia has also recorded regulated PICS policies from a broad social mobilization (Bahia, 2019BAHIA. Resolução CIB-BA nº 113, de 19 de junho de 2019. Aprova a Política Estadual de Práticas Integrativas e Complementares em Saúde na Bahia. Diário Oficial do Estado da Bahia, n. 22.685, 20 jun. 2019. Disponível em: Disponível em: http://www5.saude.ba.gov.br/portalcib/images/arquivos/Resolucoes/2019/RES_CIB_113_2019.pdf . Acesso em: 08 out. 2021.
http://www5.saude.ba.gov.br/portalcib/im... ).

All of the PNPIC document addresses health services managers, stimulating responsible and continued involvement with workers and users in the different implementations of health policies. The Policy also establishes the institutional responsibilities of federal, state, and municipal managers. Municipal management responsibilities include establishing management tools and indicators to monitor and assess the impact of policy introduction/implementation, elaborating technical standards to insert the PNPIC in the municipal health network, and presenting and obtaining approval for a proposal to include the PNPIC in the Municipal Health Council (MS, 2015bMS - MINISTÉRIO DA SAÚDE. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Práticas Integrativas e Complementares no SUS. 2. ed. Brasília, 2015b.).

The PNPIC was regulated 13 years ago but its consolidation still faces obstacles, including the lack of financial investment for PICS implementation and the absence of clinical studies in the area - reinforcing the need for expanding knowledge on these practices and their potentialities among managers, professionals, and users (Contatore et al., 2015CONTATORE, O. A. et al. Uso, cuidado e política das práticas integrativas e complementares na Atenção Primária à Saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 20, n. 10, p. 3263-3273, 2015. DOI: 10.1590/1413-812320152010.00312015
https://doi.org/10.1590/1413-81232015201... ).

Moreover, the policy requires intersectoral articulation and social movements that can strengthen PICS in collective boards, health councils, and organizations and services as well as support from institutions and managers. Among the spaces that can strengthen and favor the debates on these practices are the Regional Interagency Committees (CIRs), bodies of agreement and consensual articulation between federative entities which define the rules of shared management of the Brazilian National Health System (SUS) (Brasil, 2011BRASIL. Decreto nº 7.508, de 28 de junho de 2011. Regulamenta a Lei nº 8080, de 19 de setembro de 1990, para dispor sobre a organização do SUS, o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Brasília, DF, Diário Oficial da União, 19 set. 2011. Disponível em: <Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2011/decreto/d7508.htm#:~:text=DECRETO%20N%C2%BA%207.508%2C%20DE%2028,interfederativa%2C%20e%20d%C3%A1%20outras%20provid%C3%AAncias >. Acesso em: 8 out. 2021.
http://www.planalto.gov.br/ccivil_03/_at... ).

Considering that CIRs are spaces of potential for debating actions related to public policies in health and organizing regional healthcare management, these committees become essential in the discussion and articulation of PICS implementation in the numerous services of the Healthcare Network (RAS) of SUS.

This study seeks to understand health secretaries’ perceptions of the concept of health, to describe the experiences of this group when faced with challenges related to PICS management, and to identify if these experiences have been discussed in the different management committees.

Methods

This is a descriptive exploratory research of qualitative approach. Twenty-two health secretaries from the Jequié health region participated in the study. The Southern Regional Center for Health (NRS-Sul) includes 26 municipalities and is coordinated by the municipality of Jequié, the Regional Director Center which offers technical advice and institutional support for this microregion.

The municipality of Jequié is located in the Southwestern region of Bahia, 364 km from the city capital Salvador and between the forest area and the caatinga, with a warm and semi-arid climate. Its territorial unit area is 2,969.039 km², with an estimated population of 156,277 people.¹1BRAZILIAN INSTITUTE OF GEOGRAPHY AND STATISTICS - IBGE. Brasil / Bahia / Jequié. Panorama. Available in: <https://cidades.ibge.gov.br/brasil/ba/jequie/panorama>. Access on: 8 Oct. 2021.

For this research, primary data collected from interviews with health secretaries were used. The researchers elaborated a semi-structured interview script with questions related to the research objectives as a data collection instrument.

A researcher interviewed the 22 secretaries individually and only once between May and November 2018. Fifteen interviews were conducted before the start of CIR meetings in Jequié, with an average duration of 15 minutes each. The other seven interviews occurred after visits to the municipalities, inside the Health Secretariats, and had an average duration of 25 minutes each.

Qualitative data obtained from the interviews were fully transcribed and analyzed according to the Thematic Content Analysis Technique (BARDIN, 2011BARDIN, L. Análise de Conteúdo. Lisboa: Edições 70, 2011.), which allowed codifying, classifying, and categorizing data after a thorough reading of the material, considering the study’s objectives and theoretical basis.

Some themes emerged from the analysis of these transcriptions, including: concept of health; definition of Integrative and Complementary Practices; knowledge of the National Policy of Integrative and Complementary Practices; academic background in PICS; PICS supply in the municipal health services; PICS and challenges related to management for PICS implementation in SUS services; discussion on PICS in management committees; and secretaries’ perceptions about CIR. Final themes were later listed for elaborating this article, including: a) understanding of health in the expanded logic; b) experiences of health secretaries with challenges related to the management of Integrative and Complementary Practices; c) National Program for Improving Access and Quality of Primary Care as a strategy for assessing and monitoring Integrative and Complementary Practices; d) Regional Interagency Committee as a committee to strengthen management.

The research was approved by the Human Research Ethics Committee of the Universidade Estadual do Sudoeste da Bahia (UESB) according to opinion no. 2.627.055/2018. Participants were interviewed after signing an informed consent form which guaranteed anonymity. The interviewees were identified by the letter “I” (interviewee) followed by their corresponding number in the order of the interviews.

Results and discussion

Of the 22 participants, 16 were women and six were men. Regarding age group, 12 participants were 30 to 40 years old, seven were 41 to 50 years old, two were 51 to 60 years old, and only one participant was 18 to 29 years old. Regarding schooling, 12 participants had a higher education degree in nursing, five had a higher education degree in administration, one in social services, one in pharmacy, and another a bachelor’s degree in law. Of the other two secretaries, one had a high school degree and the other had incomplete higher education and was studying history. No participant reported having a Master’s or Doctorate degree. Fifteen participants had been working as a secretary from 1 year to 1 year and 8 months and six had been working for 11 months or less. Only one secretary had been in office for over two years, indicating a high staff turnover since the management of the latest mayor’s mandate had begun 24 months earlier.

Presented below are the main themes identified during the reading and transcription of the material, which explores the PICS related to aspects of health management. The interviewees’ citations were highlighted in italics.

Understanding health in the expanded logic

Overcoming the hegemony of the biomedical model, which focuses on disease, for a care model focused on health expansion and comprehensiveness is a challenge for the consolidation of SUS (Fertonani et al., 2015FERTONANI, H. P. et al. Modelo assistencial em saúde: conceitos e desafios para a atenção básica brasileira. Ciência & Saúde Coletiva, Rio de Janeiro, v. 20, n. 6, p. 1869-1878, 2015. DOI: 10.1590/1413-81232015206.13272014
https://doi.org/10.1590/1413-81232015206... ). Fertonani et al. (2015FERTONANI, H. P. et al. Modelo assistencial em saúde: conceitos e desafios para a atenção básica brasileira. Ciência & Saúde Coletiva, Rio de Janeiro, v. 20, n. 6, p. 1869-1878, 2015. DOI: 10.1590/1413-81232015206.13272014
https://doi.org/10.1590/1413-81232015206... ) reported that managers, control bodies, health professionals and health teams, and users must understand and assimilate the political and theoretical perspectives of care models.

Healthcare has had different models throughout history, developed according to the context and cultural and material bases of each period (Otani; Barros, 2011OTANI, M. A. P.; BARROS, N. F. A Medicina Integrativa e a construção de um novo modelo na saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 3, p. 1801-1811, 2011. DOI: 10.1590/S1413-81232011000300016
https://doi.org/10.1590/S1413-8123201100... ). According to Otani and Barros (2011OTANI, M. A. P.; BARROS, N. F. A Medicina Integrativa e a construção de um novo modelo na saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 3, p. 1801-1811, 2011. DOI: 10.1590/S1413-81232011000300016
https://doi.org/10.1590/S1413-8123201100... ), the biomedical Cartesian healthcare model has prevailed in Western medicine despite the increasing number of people seeking other healthcare resources. Biomedicine has contributed to the treatment of numerous diseases, and its technical and scientific advances over time and in relation to the increase in life expectancy are undeniable (Guimarães et al., 2020GUIMARÃES, M. B. et al. As práticas integrativas e complementares no campo da saúde: para uma descolonização dos saberes e práticas. Saúde e Sociedade, São Paulo, v. 29, n. 1, p. e190297, 2020. DOI: 10.1590/S0104-12902020190297
https://doi.org/10.1590/S0104-1290202019... ).

A single medical rationality, however, cannot answer all questions and include complete therapeutic resources for illness. The association of diverse knowledge and practices has greater potential for success in disease resolution (Barros et al., 2020BARROS, L. C. N. et al. Práticas Integrativas e Complementares na Atenção Primária à Saúde: Percepções dos Gestores dos Serviços. Escola Anna Nery, Rio de Janeiro, v. 24, n. 2, p. e20190081, 2020. DOI: 10.1590/2177-9465-EAN-2019-0081
https://doi.org/10.1590/2177-9465-EAN-20... ). Moreover, the restrictive perspective of biomedicine could not solve many problems of the health-disease process faced by the population (such as diffuse suffering, violence, and illness chronicity) (Guimarães et al., 2020GUIMARÃES, M. B. et al. As práticas integrativas e complementares no campo da saúde: para uma descolonização dos saberes e práticas. Saúde e Sociedade, São Paulo, v. 29, n. 1, p. e190297, 2020. DOI: 10.1590/S0104-12902020190297
https://doi.org/10.1590/S0104-1290202019... ).

In this sense, the knowledge and logic of care that underlie the various PICS in health can overcome Cartesian positivism, valuing other dimensions in healthcare - such as emotion, intuition, and sensitivity - to provide an integral and expanded look for people in the process of illness (Guimarães et al., 2020GUIMARÃES, M. B. et al. As práticas integrativas e complementares no campo da saúde: para uma descolonização dos saberes e práticas. Saúde e Sociedade, São Paulo, v. 29, n. 1, p. e190297, 2020. DOI: 10.1590/S0104-12902020190297
https://doi.org/10.1590/S0104-1290202019... ).

The managers in this research showed a consensus on their understanding of health, particularly the expanded concept of health which exceeds the purely biomedical view by referring to biological, mental, social, and spiritual aspects:

One of the basis of the use of several PICS as a healthcare resource is comprehensive care, which defends comprehension according to the physical, mental, social, and spiritual dimensions, helping individuals gain autonomy and responsibility in the health-disease process (Cruz; Sampaio, 2016CRUZ, P. L. B., SAMPAIO S. F. As práticas terapêuticas não convencionais nos serviços de saúde: revisão integrativa. Revista de APS, Juiz de Fora, v. 19, n. 3, p. 483-494, 2016.). Cruz and Sampaio (2016CRUZ, P. L. B., SAMPAIO S. F. As práticas terapêuticas não convencionais nos serviços de saúde: revisão integrativa. Revista de APS, Juiz de Fora, v. 19, n. 3, p. 483-494, 2016.) indicate that the official medical system cannot deal with all the sufferings of the population, showing that the inclusion of new paradigms and tools in health - including PICS - can expand their actions, allowing the development of new strategies for care.

Managers presented a superficial understanding of the term PICS and of complementing such resources with tools or techniques already used in health services.

When discussing the concept of health, the secretaries seemed concerned about meeting the principles of comprehensive care, which can be achieved by articulating various levels of care:

The PNPIC also seeks using PICS for disease prevention and health recovery with effective and safe technologies and for promotion of primary healthcare, focused on continued, humanized care, and valuing a welcoming listening and strengthening the therapeutic bond (MS, 2015bMS - MINISTÉRIO DA SAÚDE. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Práticas Integrativas e Complementares no SUS. 2. ed. Brasília, 2015b.).

The idea of health promotion involves not only the absence of disease but also the strengthening of individual and collective capacities in dealing with multiple health constraints - thus addressing people’s living conditions such as schooling, housing, income, work, food, environment, access to goods, essential services, and leisure, among other social determinants of health (Buss et al., 2020BUSS, P. M. et al. Promoção da saúde e qualidade de vida: uma perspectiva histórica ao longo dos últimos 40 anos (1980-2020). Ciência & Saúde Coletiva, Rio de Janeiro, v. 25, n. 12, p. 4723-4735, 2020. DOI: 10.1590/1413-812320202512.15902020
https://doi.org/10.1590/1413-81232020251... ). Processes of change thus gain strength, enhancing individuals’ construction of autonomy and protagonism.

To ensure healthcare according to the principle of comprehensive care, management should articulate the levels of care from the perspective of health promotion, prevention of injuries and risks, and rehabilitation, as advocated by SUS. When discussing the concept of health, the secretaries included in this research were concerned with ensuring that the population is assisted in all levels of care.

Experiences of health secretaries before challenges related to the management of Integrative and Complementary Practices

The main challenges experienced by the secretaries regarding PICS management were the need for professional training for applying integrative practices and the lack of material resources. The secretaries also reported the situation experienced by municipalities with the financial aspect, one of the main difficulties for health planning and management:

Regarding the financial difficulty experienced by the municipalities, in 2016, the Proposed Amendment to Constitution No. 241 (Ipea, 2018IPEA - INSTITUTO DE PESQUISA ECONÔMICA APLICADA. Políticas Sociais: acompanhamento e análise, 2018. Disponível em: Disponível em: http://repositorio.ipea.gov.br/bitstream/11058/9625/1/BPS_25_2018.pdf . Acesso em: 8 out. 2021.
http://repositorio.ipea.gov.br/bitstream... ) greatly changed the federal financing of SUS due to a New Fiscal Regime aiming to establish a ceiling for primary expenditures, including health. This caused potential losses of resources to SUS due to the decoupling of health expenditure from the revenue and its freezing in real terms.

Organizing the health needs of municipalities is therefore a challenge for managers since this sector is underfunded, creating territorial imbalances. A study conducted with managers of small municipalities that assessed RAS also showed complaints regarding insufficient consultations, procedures, and examinations for the population (Medeiros; Gerhardt, 2015MEDEIROS, C. R. G.; GERHARDT, T. E. Avaliação da Rede de Atenção à Saúde de pequenos municípios na ótica das equipes gestoras. Saúde em Debate, Rio de Janeiro, v. 39, n. spe, p. 160-170, 2015. DOI: 10.5935/0103-1104.2015S005201
https://doi.org/10.5935/0103-1104.2015S0... ).

Of the 22 municipalities in NRS-Sul, 15 offer PICS in the numerous services of the SUS Healthcare Network. The financial issue was one of the most cited obstacles to the provision of these resources:

The Health Secretaries of São Paulo also complained about the financial issue in PICS supply, considering that the implementation of these practices is impaired since the PNPIC does not ensure sufficient resources (Galhardi; Barros; Leite-Mor, 2013GALHARDI, W. M. P.; BARROS, N. F.; LEITE-MOR, A. C. M. B. O conhecimento de gestores municipais de saúde sobre a Política Nacional de Prática Integrativa e Complementar e sua influência para a oferta de homeopatia no Sistema Único de Saúde local. Ciência & Saúde Coletiva, Rio de Janeiro, v. 18, n. 1, p. 213-220, 2013. DOI: 10.1590/S1413-81232013000100022
https://doi.org/10.1590/S1413-8123201300... ). The theme of financing “is obscure in the Policy because values, responsibilities, and flows for resources in the three spheres of government were not determined”, which may hinder “the introduction/implementation of PICS” (Galhardi; Barros; Leite-Mor, 2013GALHARDI, W. M. P.; BARROS, N. F.; LEITE-MOR, A. C. M. B. O conhecimento de gestores municipais de saúde sobre a Política Nacional de Prática Integrativa e Complementar e sua influência para a oferta de homeopatia no Sistema Único de Saúde local. Ciência & Saúde Coletiva, Rio de Janeiro, v. 18, n. 1, p. 213-220, 2013. DOI: 10.1590/S1413-81232013000100022
https://doi.org/10.1590/S1413-8123201300... , p. 218). Though the PNPIC was published a decade ago, its effective implementation and supply within SUS is still underfunded (Sousa et al., 2017SOUSA, L. A. et al. Acupuntura no Sistema Único de Saúde - uma análise nos diferentes instrumentos de gestão. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, n. 1, p. 301-310, 2017. DOI: 10.1590/1413-81232017221.10342015
https://doi.org/10.1590/1413-81232017221... ).

Regarding the implementation of complementary practices in SUS, the Ministry of Health (MH) developed a manual for the elaboration of an integrated planning according to the situational diagnosis of each territory, aiming to identify the traditional knowledge of the communities and map the PICS already offered in the region (MS, 2018MS - MINISTÉRIO DA SAÚDE. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Manual de implantação de serviços de práticas integrativas e complementares no SUS. Brasília, 2018.). In the municipality of Vitória (ES), the Municipal Policy of PICS was regulated based on the involvement of social and institutional actors and on the guarantee of strengthened social participation in the Municipal Health Council, systematic promotion of popular health education, and courses on health promoters (Sacramento, 2017SACRAMENTO, H. T. Vitória (ES): experiência exitosa em Práticas Integrativas e Complementares (PICs). Journal of Management and Primary Health Care, Uberlândia, v. 8, n. 2, p. 333-342, 2017. DOI: 10.14295/jmphc.v8i2.556
https://doi.org/10.14295/jmphc.v8i2.556... ).

The three spheres of SUS management are responsible for financing public health actions and services. From Ordinance No. 3,992/2017, new rules were instituted on the financial transfer of the National Health Fund, conducted in the fund-by-fund modality to the States, the Federal District, and the Municipalities. According to this ordinance, health expenses are defined in two blocks: Costing of Public Health Actions and Services and Investment in the Public Health Services Network. The resources included in each funding block may be increased by specific resources as long as the Tripartite Interagency Committee (CIT) approves them (Brasil, 2017BRASIL. Ministério da Saúde. Portaria nº 3.992, de 28 de dezembro de 2017. Altera a Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017, para dispor sobre o financiamento e a transferência dos recursos federais para as ações e os serviços públicos de saúde do Sistema Único de Saúde. Diário Oficial da União, Brasília, DF, 28 dez. 2017. Disponível em: <Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt3992_28_12_2017.html >. Acesso em: 8 out. 2021.
https://bvsms.saude.gov.br/bvs/saudelegi... ).

State and municipal health services managers are oriented to schedule the financing of practices in relation to the total amount of funding according to the local Health Plan and to the region’s priorities (MS, 2015bMS - MINISTÉRIO DA SAÚDE. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Práticas Integrativas e Complementares no SUS. 2. ed. Brasília, 2015b.). Only Medicinal Plants and Herbal Medicines PICS have a specific code in SUS to receive financial resources in the Costing block (Brasil, 2017BRASIL. Ministério da Saúde. Portaria nº 3.992, de 28 de dezembro de 2017. Altera a Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017, para dispor sobre o financiamento e a transferência dos recursos federais para as ações e os serviços públicos de saúde do Sistema Único de Saúde. Diário Oficial da União, Brasília, DF, 28 dez. 2017. Disponível em: <Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt3992_28_12_2017.html >. Acesso em: 8 out. 2021.
https://bvsms.saude.gov.br/bvs/saudelegi... ).

One secretary mentioned that, despite the investment in PICS, their implementation is being “more imposed than constructed”.

For an adequate performance of the PICS supply teams and more successful experiences that already occur in several health services of SUS, the PNPIC should be effectively assumed as a State policy rather than a policy focused and isolated (Losso; Freitas, 2017LOSSO, L. N.; FREITAS, S. F. T. Avaliação do grau da implantação das práticas integrativas e complementares na Atenção Básica em Santa Catarina, Brasil. Saúde em Debate, Rio de Janeiro, v. 41, n. spe3, p. 171-187, 2017. DOI: 10.1590/0103-11042017S313
https://doi.org/10.1590/0103-11042017S31... ). Federal management must therefore increase the funding transferred to municipalities for the implementation/supply of PICS.

Since most actions and resources in Brazilian health services still follow the biomedical model, PICS have a small chance of competing against the financial investment in conventional medicine therapeutic procedures, including excessive use of medication. In a study conducted in the municipalities of São Paulo, health managers identified that having to overcome all priorities in municipal health, including the actions of health units and specialties, was an obstacle to implementing homeopathy in RAS services (Galhardi; Barros; Leite-Mor, 2013GALHARDI, W. M. P.; BARROS, N. F.; LEITE-MOR, A. C. M. B. O conhecimento de gestores municipais de saúde sobre a Política Nacional de Prática Integrativa e Complementar e sua influência para a oferta de homeopatia no Sistema Único de Saúde local. Ciência & Saúde Coletiva, Rio de Janeiro, v. 18, n. 1, p. 213-220, 2013. DOI: 10.1590/S1413-81232013000100022
https://doi.org/10.1590/S1413-8123201300... )^. In turn, a health secretary of the NRS-Sul mentioned that PICS were only an improvement in health.

The secretaries mentioned as another obstacle the lack of professional training, indicated by some as due to the lack of support from Federal Management in conducting courses and qualifications on PICS.

In Brazil, training in Traditional and Complementary Medicine for SUS is incipient (MS, 2018MS - MINISTÉRIO DA SAÚDE. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Manual de implantação de serviços de práticas integrativas e complementares no SUS. Brasília, 2018.). Regarding the qualification of professionals in PICS, the Ministry of Health recommends developing activities in Permanent Health Education (EPS) articulated with the EPS coordination of municipal management (MS, 2015bMS - MINISTÉRIO DA SAÚDE. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Práticas Integrativas e Complementares no SUS. 2. ed. Brasília, 2015b.). A federal management initiative to promote the qualification of professionals and managers is to provide online courses regarding various themes, including the Management of Integrative and Complementary Practices.²2MS - MINISTÉRIO DA SAÚDE. Health Care Secretariat. Department of Primary Care. Gestão de Práticas Integrativas e Complementares em Saúde - PICS. Available in: <https://aps.saude.gov.br/ape/pics/cursos>. Access on: 8 Oct. 2021.

Regarding professional training, several authors indicate a gap in the curriculum of universities regarding disciplines that address the theme of PICS (Salles; Homo; Silva, 2014SALLES, L. F.; BEL HOMO, R. F.; SILVA, M. J. P. Situação do ensino das práticas integrativas e complementares nos cursos de graduação em enfermagem, fisioterapia e medicina. Cogitare Enfermagem, Curitiba, v. 19, n. 4, p. 741-746, 2014. DOI: 10.5380/ce.v19i4.35140
https://doi.org/10.5380/ce.v19i4.35140... ). Furthermore, the continued training of professionals may be impaired since the PNPIC does not preview an implementation plan with a specific budget that guarantees these actions (Guimarães et al., 2020GUIMARÃES, M. B. et al. As práticas integrativas e complementares no campo da saúde: para uma descolonização dos saberes e práticas. Saúde e Sociedade, São Paulo, v. 29, n. 1, p. e190297, 2020. DOI: 10.1590/S0104-12902020190297
https://doi.org/10.1590/S0104-1290202019... ).

For the existing obstacles to PICS supply in municipalities, only two of the 22 secretaries interviewed mentioned no difficulty regarding the services, whereas 14 secretaries mentioned existing obstacles to the provision of PICS. Nine interviewees complained about the financial issue, six mentioned difficulty in having trained professionals to apply the practices, and one reported a lack of an adequate physical structure. A survey conducted with 21 primary healthcare (PHC) service managers/coordinators showed similar results regarding the difficulties in the provision of PICS in health services, including the lack of qualified professionals, the lack of basic input, and the lack of or a precarious physical structure (Barros et al., 2020BARROS, L. C. N. et al. Práticas Integrativas e Complementares na Atenção Primária à Saúde: Percepções dos Gestores dos Serviços. Escola Anna Nery, Rio de Janeiro, v. 24, n. 2, p. e20190081, 2020. DOI: 10.1590/2177-9465-EAN-2019-0081
https://doi.org/10.1590/2177-9465-EAN-20... ).

These reports show that the health secretaries included in this research face challenges related to the management of PICS. It is therefore essential developing technical standards to include these practices in the municipal health network, defining budgetary and financial resources for the implementation and supply of integrative practices in SUS services and ensuring the hiring and qualification of professionals to apply such tools for population care.

National Program for Improvement of Access and Quality of Primary Care as a strategy for assessing and monitoring integrative and complementary practices

Some secretaries mentioned the National Program for Access and Quality Improvement in Primary Care (PMAQ) as a strategy for assessing health services and PICS supply.

The PMAQ is a program that aims to evaluate the results of the new health policy and an important model to assess the performance of SUS services, seeking to improve the access and quality of the services and health actions developed by primary healthcare (PHC) teams (Brasil, 2015aMS - MINISTÉRIO DA SAÚDE. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Manual instrutivo do PMAQ para as equipes de Atenção Básica (Saúde da Família, Saúde Bucal e Equipes Parametrizadas) e Nasf. 2. ed. Brasília, 2015a.). The program thus values a horizontal management, in which the manager and all health professionals should perform these health actions, which are influenced by their commitment and engagement (Flores et al., 2018FLORES, G. M. S. et al. Gestão pública no SUS: considerações acerca do PMAQ-AB. Saúde em Debate, Rio de Janeiro, v. 42, n. 116, p. 237-247, 2018. DOI: 10.1590/0103-1104201811619
https://doi.org/10.1590/0103-11042018116... ). A survey conducted with 11 health secretaries of the 28^th Health Region in Southern Brazil identified that some secretaries consider the PMAQ an important tool for evaluating health services, as do some secretaries of the NRS-Sul (Flores et al., 2018FLORES, G. M. S. et al. Gestão pública no SUS: considerações acerca do PMAQ-AB. Saúde em Debate, Rio de Janeiro, v. 42, n. 116, p. 237-247, 2018. DOI: 10.1590/0103-1104201811619
https://doi.org/10.1590/0103-11042018116... ).

PICS are among the activities included in the PMAQ information collection and have been evaluated since the first collection cycle, in 2011. The PMAQ thus allows greater visibility for PICS by recognizing that these practices contribute to the quality of PHC and by monitoring the teams that have initiatives in PICS in the various contexts of Brazil, increasing the diversity of therapeutic choices of healthcare (Losso; Freitas, 2017LOSSO, L. N.; FREITAS, S. F. T. Avaliação do grau da implantação das práticas integrativas e complementares na Atenção Básica em Santa Catarina, Brasil. Saúde em Debate, Rio de Janeiro, v. 41, n. spe3, p. 171-187, 2017. DOI: 10.1590/0103-11042017S313
https://doi.org/10.1590/0103-11042017S31... ).

Although the PMAQ recognizes the importance of PICS for strengthening health actions according to a comprehensive model, in 2015, the Ministry of Health published an instruction manual of the program (Brazil, 2015aMS - MINISTÉRIO DA SAÚDE. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Manual instrutivo do PMAQ para as equipes de Atenção Básica (Saúde da Família, Saúde Bucal e Equipes Parametrizadas) e Nasf. 2. ed. Brasília, 2015a.) for the PHC teams and the Family Health Support Center (NASF) which summarizes the components of the external evaluation for the NASF in three limiting categories. One is the common component and the other the satisfaction of the supported teams regarding the work of the support centers. These two components were created to evaluate all NASF teams. The third item is the singular component, which includes the theme of body practices/physical activity besides PICS; these practices, however, are optional, and teams must decide whether to offer them or not.

Regional Interagency Committee as a management strengthening committee

Three management committees reported that the discussion on PICS occurred in the State Council of Municipal Health Secretaries of Bahia (Cosems/BA) and three stated that it took place at the Municipal Health Conference. They also indicated that the CIR agenda never included PICS. However, two secretaries mentioned that at a Cosems/BA meeting - in which they participated - a circular dance presentation and an explanation regarding PICS were conducted.

Regarding the discussion on PICS in the CIR, the secretaries answered:

We found no material in the literature that reported on discussions on PICS at CIR meetings. The Committee was therefore important for debating and articulating actions in the various themes of health and levels of care, but not on PICS.

This shows that the agenda of formulators and implementers of public health policies should incorporate the PNPIC to promote debates and deal with the difficulties and complexities in the management of integrative practices, allowing a solidary exchange of health knowledge with the participation of health professionals, users, and different segments of society (Sousa et al., 2017SOUSA, L. A. et al. Acupuntura no Sistema Único de Saúde - uma análise nos diferentes instrumentos de gestão. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, n. 1, p. 301-310, 2017. DOI: 10.1590/1413-81232017221.10342015
https://doi.org/10.1590/1413-81232017221... ).

Other questions asked were related to the secretaries’ impressions of CIR meetings. The answers were similar, and the most cited issues were a place to discuss the difficulties of each municipality, similarities of the existing problems in the municipalities of the region, and space to exchange experiences and receive information:

A study conducted in a CIR in Bahia identified a similar reality to the CIR of Jequié about the importance of these spaces. The authors verified that the health secretaries could discuss the construction of strategies during the meetings in this committee, contributing to a shared definition of measures to solve regional problems which affected everyone (Silveira Filho et al., 2016SILVEIRA FILHO, R. M. et al. Ações da Comissão Intergestores Regional para gestão compartilhada de serviços especializados no Sistema Único de Saúde. Physis, Rio de Janeiro, v. 26, n. 3, p. 853-878, 2016. DOI: 10.1590/S0103-73312016000300008
https://doi.org/10.1590/S0103-7331201600... ).

The secretaries of the CIR of Jequié, however, had criticisms regarding the functioning of the meetings:

The main criticisms were related to the time of the meetings since their onset is always delayed, the lack of attitude of some colleagues, the need for different topics other than just for approval, and the staff turnover.

The interviewees’ criticisms were similar to the notes of a study conducted with secretaries of a health region in Rio Grande do Sul, in which managers mentioned the employee turnover, the attitude of colleagues who do not take the lead during the process, the lack of interest and commitment in meetings, and meeting delays (Medeiros et al., 2017MEDEIROS, C. R. G. et al. Planejamento regional integrado: a governança em região de pequenos municípios. Saúde e Sociedade, São Paulo, v. 26, n. 1, p. 129-140, 2017. DOI: 10.1590/S0104-12902017162817
https://doi.org/10.1590/S0104-1290201716... ).

Another study which discussed the meetings of a CIR composed of 19 municipalities in Bahia identified that plenary sessions were hindered by delays and absences of the effective members, lack of interest of managers in regional debates, and turnover of secretaries and managers graduated in courses not limited to Health, which affected the understanding of relevant topics discussed in the plenum (Santos; Giovanella, 2014SANTOS, A. M.; GIOVANELLA, L. Governança regional: estratégias e disputas para gestão em saúde. Revista de Saúde Pública, São Paulo, v. 48, n. 4, p. 622-631, 2014. DOI: 10.1590/S0034-8910.2014048005045
https://doi.org/10.1590/S0034-8910.20140... ).

The CIR of Jequié also presented a high staff turnover. The excessive alternation of municipal health managers hinders the acquisition of knowledge for decision-making and gives the most experienced managers a greater discussion power, which influences the votes of the agendas and the proposals for actions in the health region (Santos; Giovanella, 2014SANTOS, A. M.; GIOVANELLA, L. Governança regional: estratégias e disputas para gestão em saúde. Revista de Saúde Pública, São Paulo, v. 48, n. 4, p. 622-631, 2014. DOI: 10.1590/S0034-8910.2014048005045
https://doi.org/10.1590/S0034-8910.20140... ).

Final considerations

This article sought to explain the understanding of NRS-Sul managers about the concept of health, where participants reached a consensus regarding the notion of health as an expanded idea and in the logic of comprehensiveness. Furthermore, the article showed that the main obstacles for PICS supply in SUS services in the municipalities of NRS-Sul were the financial issue, the difficulty in having trained professionals to apply these practices, and the lack of a physical structure. These issues are related to the funding transferred by federal administration since the funds for PICS implementation and supply integrate the resources of Primary Health Care, and it is up to the municipal secretary to apply them according to the priorities of each region.

Though the CIR is an important space for discussing and planning the actions of the municipalities of the South, all secretaries stated that PICS were not discussed in CIR meetings. Managers - together with health professionals, institutions, and the population - should thus use the spaces of management committees, including the CIR and Health Conferences and Councils, to hold discussions which can strengthen PICS as a powerful health resource for comprehensive and humanized health care.

This study has limitations. Because of the difficulties of scheduling meetings, the secretaries were interviewed only once and many interviews were conducted at CIR meetings; such situations hindered the collection of information on the theme of the research and on the work process of these professionals.

References

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