ABSTRACT

The pharmacist play a vital role in PHC. However, studies addressing how pharmacists influence the health care network are still scarce. We aim to verify to what extent the inclusion of pharmacists in PHC Units (UBS) in the country is associated with the expanded structural aspects of pharmacies and drug availability in Brazil. This cross-sectional, retrospective, and analytical study employed secondary data from cycles 2 (2014) and 3 (2017) of the external evaluation of the Improvement of Access and Quality of Primary Care Program (PMAQ-AB) and the National Register of Health Facilities (CNES) databases. The results showed an essential centralization in drug dispensing over PMAQ-AB cycles 2 and 3. In contrast, we identified an improvement in the structural aspects of the UBS pharmaceutical services and an increase in the mean drug availability and the total UBS with drug availability ≥ 80%. Such advances were even more significant in the presence of registered pharmacists at the UBS. We conclude by stating that the presence of pharmacists in the PHC of the Unified Health System (SUS) enhances drug availability and provides better structural conditions for PHC pharmacy services.

KEYWORDS
Primary Health Care; Pharmaceutical services; Health evaluation; Practice patterns, pharmacists’

Introduction

Primary Health Care (PHC) is the user’s main gateway to the Unified Health System (SUS)¹1 Campos RTO, Ferrer AL, Gama CAP, et al. Avaliação da qualidade do acesso na atenção primária de uma grande cidade brasileira na perspectiva dos usuários. Saúde debate. [acesso em 2019 nov 12]; 38(esp):252-264. Disponível em: https://www.scielo.br/j/sdeb/a/JC63pCCBWxw8kfdrKTqfsgH/abstract/?lang=pt.
https://www.scielo.br/j/sdeb/a/JC63pCCBW... . It plays a vital role as a care coordinator and organizer of actions and services available in the health care network²2 Brasil. Ministério da Saúde. Portaria no 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 Set 2017..

PHC has had the Family Health Strategy (ESF) since 1994, initially a Program, as the primary method for its expansion, qualification, and consolidation³3 Escorel S, Giovanella L, Mendonça MHM, et al. O Programa de Saúde da Família e a construção de um novo modelo para a atenção básica no Brasil. Rev. Panam. Salud Pública. 2007 [acesso em 2019 nov 12]; (21):164-176. Disponível em: https://iris.paho.org/handle/10665.2/9334.
https://iris.paho.org/handle/10665.2/933... , ⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... . The Family Health Support Centers (NASF) were established to support the incorporation of the ESF into the network and the territorialization and regionalization process. The NASFs started, among other initiatives, to include pharmacists among professionals who can compose such a team⁵5 Brasil. Ministério da Saúde. Portaria n° 154, de 24 de janeiro de 2008. Cria os Núcleos de Apoio à Saúde da Família – NASF. Diário Oficial da União. 25 Jan 2008. to expand care comprehensiveness.

Pharmacists play a vital role in management and care in PHC. Regarding management, they can organize Pharmaceutical Care (PC) actions, promote the rational use of medicines, ensure the availability, quality, and conservation of medicines, and conduct stock control. In care, this activity is related to overseeing drug therapy, evaluating the prescription, advising the patient and his family, and disseminating information about medicines and health⁶6 Barberato LC, Scherer MDA, Lacourt RMC. O farmacêutico na atenção primária no Brasil: uma inserção em construção. Ciênc. Saúde Colet. 2018 [acesso em 2019 nov 12]; (24):3717-3726. Disponível em: https://www.cienciaesaudecoletiva.com.br/artigos/o-farmaceuti-co-na-atencao-primaria-no-brasil-uma-insercao-em--construcao/16679?id=16679#:~:text=H%C3%A1%20predom%C3%ADnio%20do%20isolamento%20do,e%20normativas%20no%20cen%C3%A1rio%20nacional.
https://www.cienciaesaudecoletiva.com.br... . However, pharmacists’ actions are still drug-centered and not user-oriented⁷7 Araújo PS, Costa EA, Guerra Junior AA, et al. Pharmaceutical care in Brazil’s primary health care. Rev. Saúde Pública. 2017 [acesso em 2020 set 24]; 51(supl2):6s. Disponível em: https://www.revistas.usp.br/rsp/article/view/139748.
https://www.revistas.usp.br/rsp/article/... .

Brazilian legislation determines the obligation of pharmacists to be technically responsible in all health establishments (pharmacies and drugstores) where drugs are dispensed⁸8 Brasil. Lei nº 13.021, de 08 de agosto de 2014. Dispõe sobre o exercício e a fiscalização das atividades farmacêuticas. Diário Oficial da União – Edição Extra. 11 Ago 2014., with a few exceptions applicable to particular situations, for example, dispensaries and mobile units⁹9 Brasil. Lei nº 5991, de 17 de dezembro de 1973. Dispõe sobre o Controle Sanitário do Comércio de Drogas, Medicamentos, Insumos Farmacêuticos e Correlatos, e dá outras Providências. Diário Oficial da União. 19 Dez 1973.. However, a study by Carvalho et al.¹⁰10 Carvalho MN, Álvares J, Costa KS, et al. Workforce in the pharmaceutical services of the primary health care of SUS, Brazil. Rev. Saúde Pública. 2017 [acesso em 2019 nov 12]; 51(supl2):16s. Disponível em: https://www.revistas.usp.br/rsp/article/view/139750.
https://www.revistas.usp.br/rsp/article/... points out that the workforce operating in drug dispensing units in SUS primary care services was predominantly staffed with nursing technicians or assistants, followed by pharmacists.

Given the critical role of pharmacists in PHC and the low availability of studies¹¹11 Melo DO, Castro LLC. A contribuição do farmacêutico para a promoção do acesso e uso racional de medicamentos essenciais no SUS. Ciênc. Saúde Colet. 2017 [acesso em 2019 nov 12]; (22):235-244. Disponível em: http://www.cienciaesaudecoletiva.com.br/artigos/a-contribuicao-do-farmaceutico-para-a-pro-mocao-do-acesso-e-uso-racional-de-medicamentos--essenciais-no-sus/15351.
http://www.cienciaesaudecoletiva.com.br/... that identify how many pharmacies in PHC Units (UBS) have pharmacists in Brazil and how these professionals influence PC actions, it is relevant to analyze the distribution of these professionals in the country. In other words, we should verify whether the decentralized services in PC have been following PHC territorialization to ensure comprehensiveness, a fundamental principle of the SUS.

This study aims to verify from national secondary databases to what extent the inclusion of pharmacists in Brazilian UBS is associated with the expanded structural aspects of pharmacies and drug availability.

Material and methods

This cross-sectional, retrospective, and analytical study used secondary data from the second (2014) and third (2017) cycles of the external evaluation of the National Program for Improving Access and Quality of Primary Care (PMAQ-AB) and registration of professionals in the database of the National Registry of Health Establishments (CNES).

The variables used were selected according to the equivalence between the questions in Modules I or Electronic in the second and third cycles of the PMAQ-AB, given that both questions and answer options were changed from one cycle to another. For compatibility, detailed in Peixoto, Campos, and Luiza¹²12 Peixoto RT. Influência do Farmacêutico nos Serviços de Farmácia da Atenção Primária à Saúde no Brasil: análise comparativa entre ciclos do PMAQ-AB (2014-2017). Rio de Janeiro: Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca; 2021., other pre-existing questions were used in the same module (I) or between modules (I and Electronic). Municipality characterization data (Municipal Human Development Index – MHDI and population data) were obtained from the Brazilian Institute of Geography and Statistics (IBGE)¹³13 Instituto Brasileiro de Geografia e Estatística. Panorama das cidades. [acesso em 2021 abr 1]. Disponível em: https://cidades.ibge.gov.br/brasil/panorama.
https://cidades.ibge.gov.br/brasil/panor... .

The variable exposure, presence, or absence of the pharmacist registered at the UBS was adopted according to the professional’s registration data at the CNES (December/2014 and December/2017) due to the low response rate of this variable in the PMAQ-AB (approximately 30%). Validation was performed between CNES and PMAQ-AB (second cycle – pharmacist dispenses) about the presence of the pharmacist, where we found 80% agreement¹²12 Peixoto RT. Influência do Farmacêutico nos Serviços de Farmácia da Atenção Primária à Saúde no Brasil: análise comparativa entre ciclos do PMAQ-AB (2014-2017). Rio de Janeiro: Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca; 2021..

The characteristics of the municipalities and UBS (population size and MHDI) were the explanatory (stratification) variables. The following analysis variables were considered:

1. PC-related aspects: dispensing of medicines in general at the UBS and, if applicable, dispensing psychotropic drugs; the health unit’s structural and ambiance characteristics (shown in box 1);

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   Box 1
   Equivalent variables selected in the 2nd and 3rd cycles of the PMAQ-AB, 2014 and 2017

2. Drug availability: a) mean percentage of available drugs (continuous variable) and b) drug availability ≥80% and total drug availability in the pharmacological group (32 drugs divided into nine groups) in sufficient quantity (binary variables). The selection of variables related to drug availability was based on the logical model developed by Mendes et al.⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
   https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... .

The following methodological criteria were used for these variables:

1. The availability of medicines was only analyzed for UBS that reported dispensing medicines at the unit;

2. The drug was considered available when sufficient quantity in the unit was indicated; that is, according to the procedure defined by the PMAQ-AB, the drug was considered available when at least one unit was available in the UBS, identified by the field researcher’s direct observation;

3. As for psychotropics, availability was evaluated only for municipalities with no centralized dispensing of these drugs and when at least one drug from this group was available in sufficient quantity;

   1. The term centralization will be used throughout the paper as a synonym for concentrating health actions and services. In particular, when referring to PHC pharmacy services. The opposite is true when we refer to the decentralization of services.

4. The drugs included in this analysis were those available in both cycles, without the issue being submitted to a draw in the second cycle. A previous definition by specialists⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
   https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... of essential drugs included in the Basic Component of Pharmaceutical Care (CBAF) in the National List of Essential Medicines (RENAME) and distributed into nine pharmacological groups was also considered;

5. Mean availability was calculated considering that this value would be equal to 100% when the 32 drugs selected in this study were available in the unit in sufficient quantity;

6. From the variable (‘e’) above, the cut-off point of 80% was drawn, where UBS with the availability of <80% of drugs in sufficient quantity and ≥80%¹⁴14 World Health Organization. WHO Medicines Strategy 2008-2013. [acesso em 2020 dez 7]. Disponível em: https://www.who.int/medicines/publications/Medicines_Strategy_draft08-13.pdf.
   https://www.who.int/medicines/publicatio... were grouped;

7. Availability by pharmacological group was considered total when all drugs in the group were available in sufficient quantity.

Uni, bi, and multivariate tests were performed at a 5% significance level using the SPSS V.22.0 program. Student t-test was applied for the mean difference of continuous variables (e.g., drug availability) and the Chi-square test and odds ratios (crude OR) for categorical variables (e.g., infrastructure – with refrigerator Yes/No) for both cycles (2014/2017) and pharmacist presence per the CNES (Yes/No), with a significance level of 5%.

Multivariate logistic regression was also performed with the outcome of the presence of pharmacists (Yes/No), evaluating the adjusted odds ratios (ORadj) regarding the structural aspects of care and availability of medicines by pharmacological group > 80%.

The study was exempted from ethical review by the Research Ethics Committee as this is public domain secondary data.

Results

Approximately 62.0% of the 38,812 UBS in Brazil registered in the first cycle of the PMAQ-AB (2012) adhered to the second cycle (2014) and 78.2% to the third cycle (2017). Regarding PC-related aspects, the proportion of UBS with medication dispensing fell from 78.1% to 66.8% in the second and third cycles. The downward trend in the third cycle against the second cycle was also observed for UBS with dispensing of psychotropic drugs and for the storage and proper packaging of drugs, respectively 16.1% and 67.6% in the second cycle and 13.1% and 56.9% in the third cycle. In contrast, improvement was observed for a UBS with a refrigerator for pharmacy and a UBS with a storage room for medicines, respectively 24.0% and 42.8% in the second cycle and 32.3% and 50.8 % in the third cycle. The indicator ‘Does the pharmacist dispense medications at the unit?’ was found only in the second cycle, hindering comparison. As for the presence of the pharmacist at the UBS, according to CNES data, the same proportion was found between the two cycles (table 1).

The mean MHDI was stable among the different population strata, with a mean of 0.7 in the country. However, the UBS indicator/10,000 inhabitants, with a mean of 2.0, showed significant variation by population size, decreasing linearly from 4.8 for municipalities with up to 10,000 inhabitants to 0.6 for municipalities with more than 500,000 inhabitants (table 2).

In both cycles, the percentage of UBS that dispensed medications varied positively with size, from 68.8% to 90.1% in 2014; and from 61.3% to 84.7% in 2017, from the smallest to the largest. Still, regarding drug dispensing, specifically for psychotropics, the highest rates in the second cycle were found at both size extremes (up to 10,000 inhabitants – 33.7%; and greater than 500,000 inhabitants – 38.2%).

In the third cycle, we observed a significant decline in the percentage of UBS with psychotropic drugs in municipalities with up to 10,000 inhabitants (from 33.7% to 6.3%) and a growth in those with more than 500,000 inhabitants (from 38.2% to 57.2%), assuming the same profile of internal distribution among the population sizes identified in the dispensing of other types of medication (linear gradient) (table 2).

The proportion of UBS with drug availability ≥ 80% was also higher in the two extremes of population size (≤ 10,000 and > 500,000 inhabitants) in both cycles. Around 10% increase was observed in the proportion of units with drug availability > 80% (ranging from approximately 20.6% to 29.6%) between cycles. The total availability of critical drugs increased by 9.2% between the two cycles (from 60.0% to 69.2%). The total availability of psychotropics decreased from 84.5% (2014) to 49.9% (2017) (table 2).

Regarding the presence of pharmacists at the UBS, no significant variation was identified between the years, with a Brazilian mean of 14.4% in 2014 and 14.7% in 2017. When observing such distribution among population strata, a low percentage of UBS (about 7%) with pharmacists is identified in the central strata (20,000-100,000 inhabitants), which increases (ranging from 28.4 to 32.2%) as they approach the two extremes (up to 10,000 and more than 500,000 inhabitants), in both cycles.

When stratifying the total availability of drugs by pharmacological group and population size (table 3), anti-infectives were identified as the drugs with the lowest availability, both in the second and third cycles (2.6 and 2.9%, respectively). This availability was even lower in 2014 in the UBS of municipalities with 50,000 to 100,000 inhabitants (1.4%). In the second cycle, the highest availability was observed for psychotropics (84.5%), followed by analgesics/antipyretics (66.6%) and antianemics (61.5%). Analgesics and antipyretics (81.7%), followed by anti-anemics (74.2%) and cardiological (62.3%), had the highest availability (table 3) in the third cycle.

Regarding drugs for the treatment of Noncommunicable Diseases and Disorders (DANT), antihypertensive, antidiabetic, and cardiological drugs showed a significantly higher availability between cycles (ranging from 41.5%, 30.8%, and 49.3% to 60.8%, 43.8%, and 62.3%, respectively) (table 3).

We identified a substantial variation in the availability of antiasthmatics, contraceptives, and antidiabetics in the second cycle, by population size, repeated in the third cycle, except for contraceptives, which become equally distributed among different population sizes (table 3).

It is interesting to observe that, in both cycles, both for the general mean and all pharmacological groups, availability was higher with the presence of a registered pharmacist in the unit. The mean availability of crucial medicines ranged from 60.0% to 69.2% between the second and third cycles, reaching 69.7% and 77.9%, respectively, with the presence of a registered pharmacist at the UBS. In the second cycle, the difference reached almost 24% for antidiabetics (30.8%, the general mean, and 54.6%, the mean with the presence of a registered pharmacist – OR: 3.4), about 17% in the contraceptive and antiasthmatic group (from 38.5% and 25.5%, it reached 55.7% and 42.4% in the presence of the registered pharmacist, respectively – OR: 2.3 and OR: 2.6). In the third cycle, the psychotropic medication group stands out, reaching 73.7% with the presence of a registered pharmacist at the UBS (about 24% higher than the general group mean; OR: 4.5). Additionally, in 2017, the antidiabetic and antiasthmatic groups stand out – they hiked from 43.8% and 21.1% to 61.9% and 40.8% (OR: 2.4 and 3.4, respectively) with the presence of a registered pharmacist at the UBS (table 3 and table 4).

Considering those with a registered pharmacist, 92.7% of the units in the second cycle had a medication dispensing area – with no significant variation in the third cycle (92.1%). Regarding the units that had medicines stored and conditioned properly and a storage room for medicines, we observed an increase from 84.6% to 92.8% and from 69.3% to 84.1%, respectively, between cycles.

The likelihood (p≥ 0.05) of medication availability being > 80% was 4.57 times in 2014 when there was a pharmacist at the units (ORadj=1.79) and 3.79 in 2017 (ORadj=1.86). A similar effect was observed for the other indicators, where the presence of pharmacists was associated, for example, with the existence of a computer (OR^adj= 4.07, in 2014; OR^adj=5.03, in 2017) and a refrigerator in the pharmacy (ORadj=2.60 – in 2014; ORadj=2.71 – in 2017) (table 4). However, the association between the presence of pharmacists at the UBS and the adequate storage and packaging of medicines in the two cycles was not statistically significant (α=0.05) when the multivariate logistic regression was performed.

Discussion

In general terms, we noted a trend towards centralizing drug dispensing throughout the second and third cycles, especially psychotropics. On the other hand, we observed an improvement in the structural profile of UBS pharmacy services and an increase both in the mean availability of medicines and the total of UBS, with the availability of medicines ≥80%. These advances were even more significant in the presence of registered pharmacists at the UBS.

The centralized drug dispensing observed in the third cycle was even more pronounced than in previous cycles, both in the second cycle, addressed in this work, and the first cycle, in which 24.7% of the UBS were not dispensing drugs⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... , which brings a substantial potential impact on users if it is not accompanied by strategies that guarantee geographic accessibility and PC interaction with other PHC health actions. The patient’s access to comprehensive care as recommended by PHC¹⁵15 Leite SN, Bernardo NLM C, Álvares J, et al. Medicine dispensing service in primary health care of SUS. Rev. Saúde Pública. 2017 [acesso em 2020 nov 16]; 51(supl2):11s. Disponível em: https://www.revistas.usp.br/rsp/article/view/139757.
https://www.revistas.usp.br/rsp/article/... will be impaired without such care.

Several factors can lead to concentrating drug dispensing in one or more specific health units or even in an isolated location (own building). Regulatory aspects and the low perception of managers regarding the role of pharmacists in the proper drug management and the user care process can be significant limiting factors to realizing the decentralization of pharmacy and drug dispensing services.

On the other hand, we should consider that, in some contexts, centralization may indeed be linked to the adequacy of the service and rational management of medicines and supplies (and of the PC itself), with an improved physical structure for storage, drug dispensing⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... , and assurance of drug availability and qualified professionals. This is the case, for example, of the Rede Farmácia de Minas (RFM) Program, where the concentration of dispensing was applied, achieving organizational advantages¹⁶16 Faleiros DR, Silva GD. Gestão Racional da Assistência Farmacêutica: Farmácia de Minas. In: Assistência Farmacêutica: Gestão e prática para profissionais da saúde. Rio de Janeiro: Editora Fiocruz; 2014..

The RFM Program was implemented in 2008 in the public pharmacy network in Minas Gerais. Besides centralizing the offer, it focused on concentrating investments to structure the units, training pharmaceutical professionals, streamlining its computerized PA management, securing continuous and regular drug supply, and promoting rational use¹⁶16 Faleiros DR, Silva GD. Gestão Racional da Assistência Farmacêutica: Farmácia de Minas. In: Assistência Farmacêutica: Gestão e prática para profissionais da saúde. Rio de Janeiro: Editora Fiocruz; 2014., ¹⁷17 Pereira VOM, Acurcio FA, Guerra Júnior AA, et al. Perfil de utilização de medicamentos por indivíduos com hipertensão arterial e diabetes mellitus em municípios da Rede Farmácia de Minas. Cad. Saúde Pública. 2012 [acesso em 2020 nov 16]; 28:1546-1558. Disponível em: https://www.scielo.br/j/csp/a/rRH-h6dm4ydk8d5hpqXqRmmg/abstract/?lang=pt.
https://www.scielo.br/j/csp/a/rRH-h6dm4y... .

Furthermore, Leite et al.¹⁵15 Leite SN, Bernardo NLM C, Álvares J, et al. Medicine dispensing service in primary health care of SUS. Rev. Saúde Pública. 2017 [acesso em 2020 nov 16]; 51(supl2):11s. Disponível em: https://www.revistas.usp.br/rsp/article/view/139757.
https://www.revistas.usp.br/rsp/article/... identified a better structural profile, with more significant physical space, extended service hours, and greater availability of professionals, when exclusively for the service in isolated pharmacy models.

Regarding the supply of psychotropic drugs (subject to special control), this centralization was even more pronounced than other drugs. It is worth mentioning the fact that the number of UBS with psychotropics dispensed follows the presence of a registered pharmacist at the unit, according to the population size, which is possibly due to the current regulatory requirements that, besides those regarding the physical area segregated for the storage of these drugs, determine that such items can only be dispensed in units with a pharmacist in charge. Thus, centralization could be related to the pressure for the pharmacist’s presence exerted by the Pharmacy Councils to comply with current regulations.

However, drugs subject to special control were identified in units that did not have a pharmacist, which raises an alert, since this legal requirement aims, among other things, to contain the indiscriminate and abusive use of drugs with a high risk of dependence. It is noteworthy that this aspect could be related to the presence of such drugs in emergency carts, which, even so, is insufficient to justify the discrepancy in the behavior of this indicator among the units studied.

The difficult access to medicines from the user’s perspective was pointed out in a diagnosis conducted by the Regional Council of Pharmacy of Rio de Janeiro (CRF-RJ) and the Municipal Health Secretariats of Rio de Janeiro (Municipal Councils of Health Secretariats of Rio de Janeiro – COSEMS-RJ), due to the centralization of its dispensation because of CRF-RJ fines. On the other hand, from the perspective of municipal management, the difficulty/impediment of new recruitments is evidenced due to the limit imposed by the Fiscal Responsibility Law, thus restricting the possibility of expanding the number of pharmacists in the municipalities¹⁸18 Conselho Regional de Farmácia do Estado do Rio de Janeiro; Conselhos Municipais de Secretarias de Saúde do Rio de Janeiro. Relatório Final dos Seminários Regionais de Assistência Farmacêutica no Sistema Único de Saúde. Rio de Janeiro: CRF-RJ; Cosems--RJ; 2020..

It is worth noting that the pharmacist plays an important role within the PHC in technical-management activities to secure regular supply, adequate packaging, and availability of essential medicines, and clinical activities, focused on the patient, family members, and integration with the multidisciplinary team, to promote the appropriate use of medication, medication adherence, and the prevention of drug-related problems¹⁹19 Federación Internacional Farmacéutica; Organización Mundial de la Salud. Directrices conjuntas FIP/ OMS sobre Buenas Prácticas en Farmacia: Estándares para la calidad de los servicios farmacéuticos. La Haya,Holanda: FIP; 2011., ²⁰20 Organización Panamericana de la Salud. Propuesta de Plan Básico de Educación Farmacéutica y Competencias del Farmacéutico para la Práctica Profesional. Washington, DC: OPS; 2017., ²¹21 Brasil. Ministério da Saúde, Secretaria de Atenção Primária à Saúde, Departamento de Saúde da Família. Gestão do Cuidado Farmacêutico na Atenção Básica. 1. ed. Brasília, DF: Ministério da Saúde; 2019., ²²22 Organización Panamericana de la Salud. Servicios farmacéuticos basados en la atención primaria de salud. Documento de posición de la OPS/OMS. Washington, DC: OPS; 2013.. In this sense, Lima et al.²³23 Lima MG, Álvares J, Guerra Junior AA, et al. Indicators related to the rational use of medicines and its associated factors. Rev. saúde pública. 2017 [acesso em 2020 nov 16]; 51(supl2):23s. Disponível em: https://www.revistas.usp.br/rsp/article/view/139771.
https://www.revistas.usp.br/rsp/article/... pointed out that professionals who dispense drugs were 1.82 times more likely to guide how to use medications in units with a full-time pharmacist.

Nevertheless, we observed a reduced percentage of pharmacists working in PHC in 2014 and 2017 and an unequal distribution by population stratum. Similar results were also found by Carvalho et al.¹⁰10 Carvalho MN, Álvares J, Costa KS, et al. Workforce in the pharmaceutical services of the primary health care of SUS, Brazil. Rev. Saúde Pública. 2017 [acesso em 2019 nov 12]; 51(supl2):16s. Disponível em: https://www.revistas.usp.br/rsp/article/view/139750.
https://www.revistas.usp.br/rsp/article/... when evaluating the workforce in drug dispensing units by region of the country.

In an analysis of the PC in the 30 years of the SUS, Bermudez et al.²⁴24 Bermudez JAZ, Esher A, Osorio-de-Castro CGS, et al. Assistência Farmacêutica nos 30 anos do SUS na perspectiva da integralidade. Ciênc. Saúde Colet. 2018 [acesso em 2019 nov 12]; (23):1937-1949. Disponível em: http://www.cienciaesaudecoletiva.com.br/artigos/assistencia-farmaceutica-nos-30-anos-do-sus--na-perspectiva-da-integralidade/16732.
http://www.cienciaesaudecoletiva.com.br/... highlighted that, even with all the efforts made over the last three decades, there are still critical situations in the scope of PC’s human resources, such as the concentration of pharmacists in the capitals and inadequate structures of pharmacy services and lack of adequate staff.

Our findings converged with the previous studies⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... , ²⁵25 Leite SN, Manzini F, Álvares J, et al. Infrastructure of pharmacies of the primary health care in the Brazilian Unified Health System: Analysis of PNAUM – Services data. Rev. saúde pública. 2017 [acesso em 2020 nov 16]; 51(supl2):13s. Disponível em: https://www.revistas.usp.br/rsp/article/view/139755.
https://www.revistas.usp.br/rsp/article/... and showed deficiencies in structural aspects, especially infrastructure, which is a highly troubling fact that directly reflects on the proper storage and, thus, the assurance of the quality, safety, and efficacy of the medicines dispensed. We should highlight that, for example, human insulins, essential drugs in the management of type 1 and type 2 diabetes (insulin-dependent), and that must be available in PHC, are thermolabile and require refrigeration to maintain their pharmaceutical properties²⁵25 Leite SN, Manzini F, Álvares J, et al. Infrastructure of pharmacies of the primary health care in the Brazilian Unified Health System: Analysis of PNAUM – Services data. Rev. saúde pública. 2017 [acesso em 2020 nov 16]; 51(supl2):13s. Disponível em: https://www.revistas.usp.br/rsp/article/view/139755.
https://www.revistas.usp.br/rsp/article/... .

While generally unsatisfactory, the structural aspects were considerably better in units with registered pharmacists, reinforcing the importance of their work in pharmacy services (ORadj ranging from 1.06 to 4.07).

Regarding the mean drug availability, the result found in the second cycle (60%) was similar to that observed in the first cycle (58.5%)⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... and the National Survey on Access, Use and Promotion of Rational Use of Medicines in Brazil (PNAUM) (62.5%)²⁶26 Nascimento RCRM, Álvares J, Guerra Junior AA, et al. Availability of essential medicines in primary health care of the Brazilian Unified Health System. Rev. saúde pública. 2017 [acesso em 2020 nov 16]; 51(supl2):10s. Disponível em: https://www.revistas.usp.br/rsp/article/view/139736.
https://www.revistas.usp.br/rsp/article/... . On the other hand, the third cycle improved significantly against the previous cycles (69.2%), albeit lower than the findings of countries such as Nicaragua (73.7%) and Honduras (79.2%)²⁷27 Emmerick ICM, Luiza VL, Camacho LAB, et al. Access to medicines for acute illness in middle income countries in Central America. Rev. saúde pública. 2013 [acesso em 2020 nov 16]; (47):1069-1079. Disponível em: https://www.scielosp.org/article/rsp/2013.v47n6/1069-1079/en/.
https://www.scielosp.org/article/rsp/201... and the recommended by the WHO in PHC (≥80%)²⁸28 World Health Organization. Global status report on noncommunicable diseases 2014: Attaining the nine global noncommunicable diseases targets; a shared responsibility. Geneva, Switzerland: World Health Organization; 2014..

Although the increase of almost ten percentage points (p.p.) (from 20.6 to 29.6%) in the total of UBS with drug availability ≥ 80% should be highlighted, Brazil still must advance in strategies to achieve this goal. Once again, pharmacists’ positive influence is highlighted since, with these professionals, the number of UBS with drug availability ≥80% hiked from 20.6% to 46.1% in 2014 and from 29.6% to 54.7% in 2017.

The improvements found in the drug groups for DANT and the results of the low availability of anti-infectives are aligned with the data in the PNAUM²⁹29 Brasil. Ministério da Saúde, Secretaria de Ciência, Tecnologia e Insumos Estratégicos. PNAUM - Pesquisa Nacional sobre o Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil. Componente populacional: Resultados. Brasília, DF: MS; 2016.. According to the research, higher proportions of drugs for chronic conditions, such as hypertension and diabetes, were obtainable in the SUS, while drugs for acute events such as infections, pain, and fever were in the group whose priority acquisition was through out-of-pocket payment²⁹29 Brasil. Ministério da Saúde, Secretaria de Ciência, Tecnologia e Insumos Estratégicos. PNAUM - Pesquisa Nacional sobre o Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil. Componente populacional: Resultados. Brasília, DF: MS; 2016.. However, unlike the results of PNAUM²⁹29 Brasil. Ministério da Saúde, Secretaria de Ciência, Tecnologia e Insumos Estratégicos. PNAUM - Pesquisa Nacional sobre o Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil. Componente populacional: Resultados. Brasília, DF: MS; 2016., our study showed high availability of analgesics/antipyretics.

The increased availability of drugs, both in general terms and for drugs intended for DANT, with the improved monitoring of chronic conditions and the advance in ESF coverage, may be associated with declining hospitalizations for PHC-sensitive conditions³⁰30 Pinto LF, Giovanella L, Pinto LF, et al. Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB). Ciênc. Saúde Colet. 2018 [acesso em 2020 nov 16]; (23):1903-1914. Disponível em: http://www.cienciaesaudecoletiva.com.br/artigos/do-programa-a-estrategia-saude-da-familia-expansao-do-acesso-e-reducao-das-internacoes-por--condicoes-sensiveis-a-atencao-basica-icsab/16697.
http://www.cienciaesaudecoletiva.com.br/... .

Interesting results can be observed concerning population size. Regarding the mean availability of critical medicines (without herbal medicines), the results of the second cycle-2 were similar to those found by Mendes et al.⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... : greater availability in strata with more than 100,000 and 500,000 inhabitants⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... , which the greater economy of scale can explain due to population size and better efficiency of large centers compared to small municipalities³¹31 Miclos PV, Calvo MCM, Colussi CF. Evaluation of the performance of actions and outcomes in primary health care. Rev. saúde pública. 2017 [acesso em 2020 nov 16]; (510):86. Disponível em: https://www.revistas.usp.br/rsp/article/view/138344.
https://www.revistas.usp.br/rsp/article/... .

However, despite the difficulties expected for small municipalities, due to aspects such as the high turnover of professionals and low tax revenue³¹31 Miclos PV, Calvo MCM, Colussi CF. Evaluation of the performance of actions and outcomes in primary health care. Rev. saúde pública. 2017 [acesso em 2020 nov 16]; (510):86. Disponível em: https://www.revistas.usp.br/rsp/article/view/138344.
https://www.revistas.usp.br/rsp/article/... , the third cycle witnessed a significant improvement in the availability of critical drugs in municipalities with up to 10,000 inhabitants (up from 59.9% in the first cycle to 73.6% in the third cycle). Centralized drug dispensing in these municipalities may have positively influenced the concentration of efforts to ensure their availability. Furthermore, it may also be associated with federal financial incentives aimed at poor or impoverished municipalities with lower demographic densities, such as the National Program for the Qualification of Pharmaceutical Care (QUALIFAR-SUS), established to contribute to the improvement, implementation, and integration of PC activities in health care networks³²32 Costa KS, Tavares NUL, Nascimento Júnior JM, et al. Assistência farmacêutica na atenção primária: a pactuação interfederativa no desenvolvimento das políticas farmacêuticas no Sistema Único de Saúde (SUS). Rev. saúde pública. 2017 [acesso em 2020 nov 16]; (51):2s. Disponível em: http://www.rsp.fsp.usp.br/artigo/assistencia-farmaceutica-na-atencao-primaria-a-pactuacao-interfederativa-no-desenvolvimen-to-das-politicas-farmaceuticas-no-sistema-unico-de--saude-sus/.
http://www.rsp.fsp.usp.br/artigo/assiste... .

The collection capacity of the municipalities and their respective health expenditures may also be reflected in the results found here. Araújo et al.³³33 Araújo CEL, Gonçalves GQ, Machado JA. Os municípios brasileiros e os gastos próprios com saúde: algumas associações. Ciênc. Saúde Colet. 2017 [acesso em 2020 nov 16]; (22):953-963. Disponível em: http://www.cienciaesaudecoletiva.com.br/artigos/os-muni-cipios-brasileiros-e-os-gastos-proprios-com-saude--algumas-associacoes/15858.
http://www.cienciaesaudecoletiva.com.br/... found that municipalities with up to 20,000 inhabitants had higher per capita expenditures for most of the components they studied, including drug expenditure; approaching the median expenditure of municipalities with more than 100,000 inhabitants, which concentrate a more specialized health service network. In line with this, Vieira and Zucchi³⁴34 Vieira FS, Zucchi P. Aplicações diretas para aquisição de medicamentos no Sistema Único de Saúde. Rev. saúde pública. 2011 [acesso em 2020 nov 16]; (45):906-913. Disponível em: https://www.scielo.br/j/rsp/a/ZsmvwSnCFvKr8gDfb44Y5kK/?lang=pt.
https://www.scielo.br/j/rsp/a/ZsmvwSnCFv... also observed an inverse relationship between per capita drug expenditure and the municipality’s population. Among the hypotheses raised, the authors point out that the most plausible would be a different power and purchase scale³⁴34 Vieira FS, Zucchi P. Aplicações diretas para aquisição de medicamentos no Sistema Único de Saúde. Rev. saúde pública. 2011 [acesso em 2020 nov 16]; (45):906-913. Disponível em: https://www.scielo.br/j/rsp/a/ZsmvwSnCFvKr8gDfb44Y5kK/?lang=pt.
https://www.scielo.br/j/rsp/a/ZsmvwSnCFv... .

Regarding the total drug availability by pharmacological group in the second and third cycles, similar to the first cycle⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... in some aspects, there is greater availability of antihypertensive drugs in municipalities with up to 10,000 inhabitants. At the same time, antidiabetics and anti-infectives were more available at the population extremes and lower in the central strata, aligned with the findings of Miclos, Calvo, and Colussi³¹31 Miclos PV, Calvo MCM, Colussi CF. Evaluation of the performance of actions and outcomes in primary health care. Rev. saúde pública. 2017 [acesso em 2020 nov 16]; (510):86. Disponível em: https://www.revistas.usp.br/rsp/article/view/138344.
https://www.revistas.usp.br/rsp/article/... .

Salazar, Campos, and Luiza³⁵35 Salazar BA, Campos MR, Luiza VL. A Carteira de Serviços de Saúde do Município do Rio de Janeiro e as ações em saúde na Atenção Primária no Brasil. Ciênc. Saúde Colet. 2017 [acesso em 2021 fev 27]; (22):783-796. Disponível em: http://www.cienciaesaudecoletiva.com.br/artigos/a-carteira-de-servicos--de-saude-do-municipio-do-rio-de-janeiro-e-as-acoes-em-saude-na-atencao-primaria-no-brasil/16038.
http://www.cienciaesaudecoletiva.com.br/... point out a high percentage of Family Health teams (eSF) that develop family planning actions (from 88.3% to 96.3%, from the lowest to the highest population strata, respectively). However, our study found that the availability of contraceptives does not accompany this offer of services, which may harm the consolidation of the strategies outlined. We observed an essential improvement in the availability of this group of drugs in the third cycle compared to the second and the first cycle⁴4 Mendes LV, Campos MR, Chaves GC, et al. Disponibilidade de medicamentos nas unidades básicas de saúde e fatores relacionados: uma abordagem transversal. Saúde debate. 2014 [acesso em 2019 nov 12]; 38(esp):109-123. Disponível em: https://www.scielo.br/j/sdeb/a/n4Nwv8hcvy7MLNsXTFDC8hr/abstract/?lang=pt#.
https://www.scielo.br/j/sdeb/a/n4Nwv8hcv... . The study by Mattos et al.³⁶36 Mattos L, Silva R, Chaves G, et al. Assistência farmacêutica na atenção básica e Programa Farmácia Popular: a visão de gestores de esferas subnacionais do Sistema Único de Saúde. Saúde Soc. 2019 [acesso em 2021 fev 27]; (28):287-298. Disponível em: https://www.scielo.br/j/sausoc/a/rFhswFTjTgG694bpSTbw4Gb/?lang=pt.
https://www.scielo.br/j/sausoc/a/rFhswFT... presents the report of a municipal manager who points out the difficulties in supplying contraceptives throughout 2013, corroborating our findings from the second cycle. Knowing that these are medicines acquired by the Ministry of Health, we assume that the improved availability throughout the third cycle may be associated with the improvement in the procurement process by that body.

Final considerations

This study had limitations, mainly because the PMAQ-AB was a voluntary adherence program. Thus, although it reached a broad coverage of municipalities with contracted teams, respectively 93.5% and 95.6% in 2014 and 2017, it did not cover all Brazilian UBS. The number of losses in completing the PMAQ-AB variable related to the number of pharmacists in the unit (box 1) is also worth mentioning, which is why the combination with the CNES was necessary, which also has numerous weaknesses such as the possibility of obsolete data. Other limitations identified were the subjective aspect in the term used for the variable about the availability of drugs in sufficient quantity, where no explicit criterion was found for what would be considered a sufficient quantity; and the draw of lots to assess the availability of some drugs in the second cycle of the PMAQ-AB, thus hindering the analysis of the entire list of drugs and also implying disproportionality between the number of drugs per pharmacological group, especially for the psychotropic group.

The break in the longitudinal aspect of the measurement of which professional dispenses the units’ medicines was also a significant limitation since the variable was identified only in the second cycle of the PMAQ-AB. It is also worth noting that the instrument did not allow differentiating between pharmacies and dispensaries, as there was no legal requirement for the pharmacist for the latter.

On the other hand, the national scope, the possibility of analysis by municipal size, and the combination of several dimensions (availability, service structure, and the pharmacist’s presence) are the strengths of this study.

We managed to bring to the debate the relevance of the pharmacist as a component of the health teams that work in PHC in the SUS by combining data from the PMAQ-AB with those from the CNES. The presence of this professional in the health units enhances the availability of medicines and leads to favorable structural issues of PHC pharmacy services. However, it is still necessary to demonstrate better at the national level the inclusion of pharmacists in the care process and its association with health outcomes.

It is essential to transcend the logic of ensuring the presence of the pharmacist as a mere legal requirement devoid of practical meaning, directing efforts towards health outcomes for individuals, families, and the community. It is essential to promote the inclusion of the pharmacist as an integral part of the health team. It is argued that the pharmacist’s role in PHC transcends the walls of the service, engaging in activities such as matrix support for the team, actions in the community, and home visits²¹21 Brasil. Ministério da Saúde, Secretaria de Atenção Primária à Saúde, Departamento de Saúde da Família. Gestão do Cuidado Farmacêutico na Atenção Básica. 1. ed. Brasília, DF: Ministério da Saúde; 2019.. Such aspects are not covered by the legislation, which provides for actions only in the pharmacy’s physical space. Achieving such advances requires broadening the discussion involving actors such as SUS management bodies, class bodies, and society.

Finally, it is worth emphasizing the critical role of the PMAQ-AB in using several indicators within the PHC. Without a proposed equivalent replacement, the regrettable discontinuity of the program in 2019 interrupted the possibility of future longitudinal analyses with national indicators that addressed management and health care aspects in the PHC.

Acknowledgments

We are grateful to the Stricto Sensu Graduate Program in Public Health at the Sérgio Arouca National School of Public Health (PPG-SP/ ENSP) for supporting the publication and translation of this paper.

References

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