Access and rational use of medicines in the prison system in Paraíba

Objective: This article aims to evaluate the access and rational use of essential and strategic medicine in the prison population in Paraiba prison system. Method: Qualitative study, carried out with 13 health professionals and 43 prisoners, between February and August of 2016 in seven penitentiary units of the state of Paraiba. Results: Some interviews pointed out that the prisons have ensured the medications, others, however, have stated the constant lack of these supplies and that depend on the family to guarantee access. It has been found that those who are routinely discharged do not have the professional prescriptions and that dose monitoring is not a practice. Medications are cared for by the subjects and although storage is careful, they are kept in the cells in places with poor ventilation. Final considerations: In this way, it has been verified that, although policies guarantee the access and rational use of medicines in penitentiaries, there are cases of lack of them, besides the lack of adequate prescription, supervision of the doses taken, correct storage and follow-up to guarantee the continuity of the treatment. Implications for practice: It is perceived the need of the management to program professional capacities aimed at care in the prison system, besides identifying the gaps related to access and rational use of medicines, allowing their restructuring.


INTRODUCTION
The national health policy when recognizing the pharmaceutical assistance (AF) as a priority instituted the National Medicines Policy (PNM) and the National Pharmaceutical Care Policy (PNAF) with the objective to promote the rational use and the people access to medicines considered essential, 1 emphasizing the articulation among the spheres of government 2,3 in the financing provided for in the Health Pact 4 and the adoption of the National Relation of Essential Medicines (RENAME), for the standardization and uniformity of the prescription and the supplies for pharmacies in the assistance network. 5 According to PNM the access should ensure the supply of medicines to the population through adequate prescription and dispensation and the promotion of rational use 6 that includes administration of the appropriate medicine for the clinical situation. 7 However, the unhealthy in the penitentiaries scenario, the prevalence of hazards to health, the population´s difficulty in accessing medicines and the frequent undue use compromise the due assistance. However, the health in the prison scope was guaranteed with the publication of the Law on Penal Execution (LEP) no. 7.210/84 which states that "the health care of the prisoner and of the internee of preventive and curative nature, shall include medical, pharmaceutical and dental assistance". 8 In this sense, recognizing the need for the inclusion of the Brazil´s prison population in the SUS healthcare network 9 was approved the National Health Plan for the Prison System (PNSSP).
In order to consolidate the commitment of the State with the healthcare of the prisoners, in 2014 the National Policy for Integral Health Care of Persons Deprived of Liberty in the Prison System (PNAISP) with the intention to promote access of this population group to Health Care Network and ensure the financing and implementation of the basic component of AF within the prison scope. 10 Facing the reflections, there is the need for continuous evaluation of the pharmaceutical policies in Brazil, including in the penitentiary system, which has precarious structural aspects and adverse sanitary conditions, beyond the cells overcrowding, which transform the prisons into an environment favorable to proliferation and spread of infection-contagious, such as tuberculosis (TB), leprosy (HAN), DST/HIV, hepatitis, systemic arterial hypertension (HAS) and diabetes (DIA). 11 In this way, considering the national scenario, the implementation of these policies, the urgent need for medicines, as well as the government´s legal and social commitment with AF, the objective of this study was to evaluate the access and the rational use of essential and strategic medicines of the population deprived of liberty.

METHODS
Qualitative study, carried out between the months of February and August 2016 in seven penitentiaries of the state of Paraíba that fitted the following inclusion criteria: having in the physical structure a health unit, with professionals team according to PNAISP and prison population less than 800 prisoners.
Duly authorized, a survey in all medical records of prisoners of the penitentiaries included was carried out to verify the individuals who had prescription of essential (HAS/DIA) and strategic medicines (TB/HAN/HIV). These medical records were selected to compose the research, being identified: age, sex, medicines prescribed, professional responsible for the prescription and date of diagnosis and beginning of treatment. After this step, interviews with six doctors and seven nurses who worked in the prison health team for at least six months, besides the coordinator of state´s penitentiary health were scheduled. Then, interviews with the subjects deprived of liberty identified in the medical records selection, men and/or women, who carried out penalty in closed regime and used essential (HAS/DIA) and/or strategic medicines (TB/HAN/HIV) were scheduled, being excluded those who used medicines for less than three months.
As a tool for data collection a semi-structured interview was carried out, being made in an individual way and audiotaped on health care offices of the own penitentiaries, composed of questions relating to access, rational use and dispensation of medicines. In each prison unit the interviews were interrupted according to sampling by saturation, when the data obtained began to present repetition, 12 being 5 prisoners of the penitentiary α, 9 of the β, 8 of the γ, 7 of the δ, 3 of the ε, 6 of the ζ and 5 of the η, totaling 43 interviewees.
As to the data analysis, a descriptive analysis was carried out for the interviewees´ profile with relative and absolute values, and the content analysis, methodological proposal of Bardin was used for the semi-structured interview, 13 being carried out in three phases: pre-analysis, exploration of material and results processing. After analyses, two thematic categories became clear to orient the interpretations: path of AF in penitentiaries and rational use of medicines.
The participants in the study signed the Free Informed Consent Form (TCLE), and to ensure the secrecy and anonymity, the penitentiaries, the prisoners and the professionals were identified, respectively, by letters of the Greek alphabet (α, β, γ, δ, ε, ζ, η), cardinal numbers (1, 2, 3, 4.

Profile of the interviewees
Fourteen professionals were interviewed, from which one representative of the Coordination of Penitentiary Health of the State of Paraíba, six doctors and seven nurses. Besides these, 43 subjects deprived of liberty using essential and/or strategic medicines, of whom 35 (81.4%) men and 08 (18.6%) women. Of the total prisoners 1 (2.3%) is less than 19 years old, 04 (9.3%) are in the 20-29 years age group, 19 (44.2%) are 30-39 years old, 09 (20.9%) are 40-49 years old, 08 (18.6%) are 50-59 years old and 02 (4. 6%) are 60 years or over.
During the collect of information in the medical records it was found that 15 (34.9%) prisoners stated that were diagnosed before deprivation of liberty and 28 (65.1%) after they entered the prison system.
In 39 medical records (90.7%), the doctors were the professionals responsible for the prescription of the medicines, in 03 (7%) the nurses and in 01 (2.3%) it was not recorded in the medical record who carried out the initial prescription. With regard to the record of abandonment and/or recurrence, only 03 (7%) medical records contained these information and referred to two participants with tuberculosis and one with systemic arterial hypertension, under the allegation that they have left the penitentiary for a period of time after having served their sentence, but that returned after reoccurring.
In the analysis of the results of the investigation the following categories emerged: ways of AF in the penitentiaries and the rational use of medicines.

Ways of AF in the penitentiaries
According to the PNM the access occurs by appropriate prescription and dispensation, with safety, efficacy and quality guarantee of the medicines necessary for the promotion of the rational use. 6 Studies point out that the access to AF does not constitute a peculiar problem only in the Brazilian scope. In different countries the medicines availability, mainly those considered essential, is needy, this fact may be related to the inexistence of universal social protection systems in health and to the low acquisitive capacity of the governments and populations of these countries. 14 In this sense, when asked about the way of acquisition of medicines, considering that the situation of deprivation imposed by the prison environment have repercussions in different ways, 15 the prisoners reported: I get the medicines right here on the unit. Every month they call us, the evaluation is done and the nurse deliver the tablets. Sometimes delay, but i comes. (γ-17) Here, the attendance is more difficult than the medicine. I receive everything here from the prison. My family even says that here is easier than out there. (ζ-33) It is noticed from the comments that the participants have access to the medicines for HAS, DIA, HAN, TB and HIV in the own penitentiary system. The reality contrast to the world scenario, since the World Health Organization (OMS) estimates that one-third of the population does not have regular access to essential medicines, being, therefore, a world public health problem. 16 Consequently, in the units studied, the guarantee of supply of medicines occurs in a continuous way, regular and timely, and has as reference the RENAME and the PNSSP recommendation. 9 It is likely that the observance in the medicines prescription that are on the RENAME roll, as provided for in Decree No 7.508/2011, as aspect that favor the access to medicines in the penitentiary units of the state, enabling availability. After all, the lists serve as a basis for the prescriptions of the health professionals, who must standardize their clinical practice and, for the commitment by the public to providing and distributing the substances that compose the relation. 17 The acquisition of these medicines is recommended from therapeutic protocols defined by the MS, in order to standardize the prevalent treatment of the grievances, through records of patients according to the pathology. 5 In addition to the access, the prisoners ensure that continuous treatments are guaranteed: From the start I´ve never let to receive the medicine that I need. Here, when they carry out the attendance and find diseases that concern such as high pressure, tuberculosis, AIDS, no one is left without treatment. (β-6)

Every month she calls for evaluation, deliver the medicine, makes exam and monitor my pressure and diabetes and deliver all medicines of the month. (γ-17)
The nurse gives me the medicine, when it comes close to finish, she calls me, she measure my pressure, then she gives me another chart. (ε-29) I notice 5 days before to any person from the medical team and they provide the medicine. They have the control, even today I´ve received. (η-41) These comments demonstrate satisfaction with the receipt of the medicine. However, some authors analyze that the difficulties of access to health care services and the pacts of silence in the units, the assistance present in the prisons, however much be minimal, it is praised, silencing the complaints and showing gratitude. 15 Whe the participants were asked about the lack of medicines the answers varied, including within the same penitentiary. The only different was the penitentiary delta, where all stated that there is no lack of medicines:

Never missing. (δ-26)
There is sufficient medicines for hypertensives, diabetics and tuberculosis. These do not miss in no way, there are medicines for the 30 days. When there are no more than eight tablets, mainly of TB, I already got it before, in order to not miss, they do not stay without medicines. (δ-F) Medicines' use in the prison system Cardins KKB, Freitas CHSM, Simões MOS, Costa GMC Probably, the success of the activities in this prisional unit unidade prisional is due to the constant updating of the number of subjects deprived of liberty, the adequate information about the basic attention and the identification of all prisoners who make use of medicines. These aspects ensure the regular providing of kits of essential medicines with the quantity established in a proportional way to the prisoners. 9 Thus, the findings of the study corroborate the research developed in the primary healthcare of a city of the interior of the state of Rio Grande do Sul that revealed that the population interviewed emphasized that the interpersonal relations, coupled with the clinical practices and the guarantee of access to medicines according to the legal provision, 18 classify the assistance as adequate.
In the other study units some comments of subjects deprived of liberty are detached with the emphasis that the lack of medicines and/or interruptions in the treatments do not occur:

For me until now it has never been missing. (α-4)
Until now it has never been lacking. (ζ-34) Some professionals have also reported that no interruption in the supply occurs: There are all medicines. Such as atenolol, hydro, captopril, because if it lacks in the instate, the access to the municipality is easy for these medicines, we have never passed tightness with these, neithr TB, nor HIV, it always is well supplied.

(α-A)
For these patologies there is no lack. But for others, it have never arrived. (η-L) However, the regular and constant access to medicines has not been unanimous among all penitentiaries studies, and some prisoners and professionals, when asked about this aspect, stated the lack of medicines.

(γ-D)
It is noticed that when the penitentiary does not provide the medicines, or they stay without taking or depend on other acquisition, which can delay and compromise the treatment continuity. This is a problem that result from the situation of the Brazilian prisional system that has different gaps in the management/organization of the attention to health, which may favor the increase of the incidence and prevalence of diseases characteristics of the social context. 19 The PNM established since its beginnings guidelines, priorities and responsibilities related to the AF for SUS managers in the federal, state and municipal scope, by being the Municipal Health Secretaries responsible for carrying out the guard, the management and the delivery of the medicines and, assignment of the MS to provide, in a gradative way, the quantitative of medicines needed for treating patients registered by the municipalities. 6,18 When the management does not meet the own health responsibility, to ensure the access, some prisoners become family-dependents:

My family buy and leaves here. (α-3)
My wife will pick in the health center, leaves in the management and they give me. (α-5) The participants although make the observation, consider this referral more adequate, since the medicine use is prior to the imprisionment and, indeed declare textually that they prefer to use the medicine prescribed, than replace by generics and similar medicines, delivered by the prison system, due to disbefief in the product: It´s because here there is not the medicine that the doctor prescribed. I feel good with this medicine and I do not want to change, even they explaining that it is equal. (β-38) This aspect seems that it has justified the fact that the penitentiary system does not assume the responsibility for the delivery, however, the law No. 12.401, of 28 April of 2011 establishes taht the prescriptions carried out shall be in accordance with the therapeutic guidelines defined in the clinical protocols for the diseases, that is, the professionals need to use the list of medicines proposed by the RENAME to base their prescriptions, since in them the medicines are provided by the government. 20 In this way, as much as part of the medicines that the prisoners used early the prison is not on the list of the RENAME, it is needed evaluating the therapeutic possibility of replacement Medicines' use in the prison system Cardins KKB, Freitas CHSM, Simões MOS, Costa GMC of these medicines, so that, the system can be responsible for the delivery of the medicines. Some participants, when asked about what could be done when the medicines lack, revealed that stay without taking: I stayed without taking, going bad until I can. For few day, we turn around, but after two days I immediately go to hospital. (ζ- 33) I stayed without the medicine because there was not. (η-41) The prisoners, because they have not family, or because the family reside faraway, or by they have not financial conditions to buy the itens solicitated in the precriptions, stay without taking the medicine. This compromise the treatment continuity and interferes in the effectivity of the therapy, in addition to generate impact on the public policies and for the health system, as higher costs with hospitalizations and/or actions and of high complexity procedures. 7 A study carried out by Santana et al. 21 pointed out that the obstacles for the provision in due course and the frequente lack of medicines for the treatment of diseases ends up compromising the population´s health situation.
In some situations, the own professionals mobilize themselves to providence the medicines:

There have already been cases when we gather and buy, because it is betther than he has an outbreak inside there and worsen the situation for everybody. (α-A)
The prisional environment does not provide favorable conditions for the health promotion, aggravated by the problems in the access and resolutivity of the services, by the incomparable demand with the quantitative and professionals qualification, by the poor physical infrasctructure, with few available equipments and imputs, compromising the universalization and integrality of the actions in the primary attention. Due to this scenario, many professionals end up carrying out more than would be their responsibility, in order to try providing a continuity of the treatment and the well-being of the patient. 22 In addition to the comments already cited, the professional of the coordination, who is the responsible for the delivery of medicines for the penitentiaries in Paraíba, confirmed this unsuficiency of medicines: The number of punished varies considerably and this difficult a constant updating of the relation of the quantity of medicines needed for each unit, making that, many times, do not go enough sufficient medicines for everyone.
Among the likely reasons for the shortage of medicines it is highlighed the overcrawding of prisons and the interchangeability of the prisoners, since the number of subjects deprived of liberty increases and varies so quickly that the administration does not succeed in ensuring all inputs needed, making the healthcare an ardous task and far from being appropriately provided. 19 Regarding the difficulties faced by the penitentiary system to ensure the access to medicines the professionals reported the insufficient quantitative of medicines available through the State Secretariat, the difficulty of understanding the sanitary responsibility by the provision of medicines, as well as the lack of transports for the supply of medicines in regular periods: The greatest difficulty is the insufficient quantity of medicines. When  In a study carried out in the primary attention in the city of Petrolina -PE the lack of medicines was cited by all professionals as one of the main problems in the health units. This aspect, among other reasons, may be caused by an inappropriate selection of medicines according to the epidemiological profile of the region, which is the starting point for ensuring the AF correct cycle according to MS. The adoption of effective and safe criteria for the carrying out of a prior diagnosis of the area of action of these professionals with the description of the most prevalent diseases to ensure the medicines for the users´treatment is essential. 23 Based on the above considerations, it is noticed that the access to the medicines occur by way of the availability and capacity of acquisition of the same, leading to the rational use. In Brazil, data referring to the access to medicines by the population are rare, and the most studies carried out evaluates the access based only on the quantity of medicines prescribed that the patient could receive, or that was provided in the health system used, without a due importance for aspects related to the rational and adequate use of these medicines, 24 as discussed below.

Rational use of medicines
This category aims to discuss the rational use, by recognizing it as a process that includes since the receipt of the medicine adequate to the clinical need, in the correct dose and schedule, for an appropriate time and at the lowest possible cost, being the responsibility of several social actors. 25 Medicines' use in the prison system Cardins KKB, Freitas CHSM, Simões MOS, Costa GMC Magalhães, Lunet and Silva 7 state, in their study carried out in the city of Porto, Portugal, that few are the data available about indicators of rational use of medicines, such as the related to the prescription, the assistance and the service and, besides, state that there are no information on the knowledge, the practice and the articulation of the multiprofessional healthcare team in health about the rational use.
The current profile of prisoners in Brazil tends to be of young, low socioeconomic and schooling level, coming from urban centers and with difficulty of access to the health services. A study conducted in a penitentiary in Ceará about the monthly family income showed that 56.1% mencionated owning monthly income of up too one minimum wage and 12.3% owned income of, at a maximum of R$ 200.00 (two hundred reais), evidencing disfavorable socioeconomic aspect which may contribute to the difficulty in the access to the medicines and healthcare services. 26 The WHO states that the rational consumption of pharmaceuticals perpasses different steps, and in this category the adequate prescription, the supervision of necessary doses and the storage of medicines will be discussed. 16 The prescription is a written recommendation of the legally habilitated professional, containing orientations for the patient about the use, dose, route and schedule time, and must be followed by oral explanation. 27 Studies shows that many times the prescriptions are carried out in an inadequate way, and there is recommendation of medicines use without providing fundamental information in order to the treatment is successfull. 21 In the investigated penitentiaries, the professionals reported that only the first prescription is carried out in two copes, by being one deliver to the prisoner and the other annexed to the medical record, the others remain only in the medical record:

In one cope. When is the first consult we always leave the prescription with them. (α-A)
The prescriptions for the medicines that have in the unit only are done in one cope. Because it ought to be in more copes once these do not leave here? (η-K) The prisoners confirmed that the medical prescription stays in the medical record, but, differently from the professionals, they did not affirm that they receive the prescription in the first consultation: Only the medicine. The prescription stays her in the chart, here they do not give the prescription. (γ-15) It stays with her here, we do not have how to take it. (ζ-32) The professionals and the management of the prisional units consider unnecessary the deliver in two copes once the deprivation of liberty reduce the participation in the decision making and, that any time it may be required by the user and/or family. The reality contrasts to the described in the research developed by Melo, Silva and Castro 28 in a Basic Health Unit (UBS) of São Paulo which showed that the patients receive the prescription at the time of the consultation.
However, we should consider that the main objective of the prescription in two copes is, by remaining one cope with the prisoner, it should clarify whenever judged necessary the recommendations of the therapeutic scheme, if he forgets or has any difficulty to use the medicines.
Another relevant aspect of the medicines prescription is related to the guidelines provided for the patient for the adequate use of the medicines. The professionals were asked about this conduct: I do not need to guide because it is already of their continous use, they already know basically how to use. It is noticed that some professionals affirm carrying out the orientation, others, however, others believe that the patients already know how to make use of the medicines. However, the technical recommendation 6 is that each time a prescription is carried out, this must be followed by orientations about the way to be used, to reduce the occurrence of injuries, being the responsibility of the health professional. In addition, it is noticed the importance of the pharmacists´actuation at the moment of the dispensation at the moment of the dispensation, to guide the patient and avoid the irrational use of medicines, 21 however, it is emphasized that the health teams of the penitentiaries investigated in this study do not have pharmacists, running against the recommendations of the health policy and of the professional bodies.
In order to comply with the prescription and ensure a correct treatment, the patient must make continous use of the medicines, without forgetting, in the dosage and in the recommended timetables, to keep adequate the actuation in the organism. It is indicated associating the intake of medicines with daily activities such as to take a bath or to brush the teeth. 29 Thus, the prisoners were questioned about the forgetting to take the medicines prescribed: When I forget to take my head starts to hurt, then I remember that it occurred because I did not take, and then, I take. (γ-15)  The fact that a person forget to take the medicine can compromise the treatment, once, each medicine is studied considering the time needed to be absorbed by the organismo, the time of duration of the drug effect and the way how it is eliminated from the body. Therefore, by delaying the drug schedule can reduce the efficiency and even cause side effects. 30 In addition, it should be considered the user´s emotional condition, once this factor can interfere in the treatment continuity and in the response to use. This aspects deserves much attention by the health professionals, since they must be attentive to possible memory gaps, by guiding and monitoring the treatment. 15 Another aspect related to the rational use is the supervision of the doses taken, having as one of its strategies the directly observed treatment (TDO), which envolves the observation by the trained professional of the patient when taking the medicine since the beginning of the treatment until his cure, increasing this way the quality in the coverage of the treatment. 31 When the professionals were asked about the supervision of dosages and the knowledge about the TDO strategy, one of them affirmed not knowing the meaning of the acronym and most interviewees affirmed that the strategy implementation in the penitentiaries do not exist: The medicine for tuberculosis is delivered every day, but it is not supervisioned, nobody stay observing if the person will take, if he has any outcome, but the tablets are delivered every day, then, it is a pseudo supervisioned. They deliver the daily intake, and not the palette. ( The professionals interviewees although are in the prisional scenario, report the same difficulties met in the study carried out in several municipalities of Paraná that showed that health professionals argue about lack of time to carry out the TDO, since the nurses are, generally, overloaded of educative care activities, the doctors are unable to meet all the clinical demand and, community health agents (ACS) not always exist in sufficient/ qualified number to carry out the task. However, even with obstacles, the ACS have been the main performer of the TDO in the Family Health Strategy (ESF), since he emerges from own community in that work, facilitating the link between the community and the service. 32 Many times the professionals are included in the prisional system without having any adequate training and without being familiarized with the context specificities and of the hidden population, since they do not receive any training addressed to persons with deprivation of liberty. It is essential that the professionals receive appropriate training in order to reduce, in an effective way, the health problems in this population, that should begin during their professional training, by being encouraged to know more the prisional context, the incentivados a conhecer melhor o contexto prisional, the most prevailing grievances, the challenges faced and the laws and policies that ensure the assistance to health in the environments deprived of liberty. 33 Finally, the prisoners were asked about the location of storage of the medicines received, being the most reffered the own cell, specifically the location where they sleep, as can be identified in the comments:

I keep it in my bed, in the cell. (α-4) I keep it in a little bag in my bed. (ζ-35)
However, this aspect does not differentiate from the habits of the persons who are not deprived of liberty, since a study carried out in the State of Goiás reported that one of the most frequent locations of medicines storage is the location where the persons use to sleep. 34 It is perceived that the prisoners concern of having an exclusive location for the storage of medicines, free from dust, sun, according to the following reports: The technical literature of the area recommends that the medicines must be kept in well-ventilated locals, dry, safe and protected from direct light. It is highlighted that even in precarious conditions, the prisoners store the medicines correctly, excepting the fact of being in a well-ventilated, since bags, boxes, bottles and even the own cell do not allow a good air circulation. 35 It is evident that failures related to steps of prescription, supervision and/or storage of medicines compromiste the rational use of the same. The effective treatment of the pathology,