Availability of essential medicines in primary health care of the Brazilian Unified Health System

Nascimento, Renata Cristina Rezende Macedo do; Álvares, Juliana; Guerra Junior, Augusto Afonso; Gomes, Isabel Cristina; Costa, Ediná Alves; Leite, Silvana Nair; Costa, Karen Sarmento; Soeiro, Orlando Mario; Guibu, Ione Aquemi; Karnikowski, Margô Gomes de Oliveira; Acurcio, Francisco de Assis

doi:10.11606/S1518-8787.2017051007062

Acessibilidade / Reportar erro

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Original Articles • Rev. Saúde Pública 51 (suppl 2) • 2017 • https://doi.org/10.11606/S1518-8787.2017051007062 copy

Availability of essential medicines in primary health care of the Brazilian Unified Health System

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To characterize the availability of tracer medicines in pharmaceutical services in primary health care of the Brazilian Unified Health System (SUS).

METHODS

This is a cross-sectional and evaluative study, part of the Pesquisa Nacional Sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos – Serviços, 2015 (PNAUM – National Survey on Access, Use and Promotion of Rational Use of Medicines – Services, 2015). To analyze the availability of medicines, we verified 50 items selected from the Relação Nacional de Medicamentos Essenciais (Rename – National List of Essential Medicines) of 2012. Observation scripts were applied to medicine dispensing services in the primary health care. Interviews were carried out with patients, health care professionals, and public managers, using semi-structured questionnaires. The availability index was presented as the percentage of health units where the medicines were available. For statistical analysis, absolute, relative, and mean frequencies were presented (with 95% confidence intervals). The comparison of groups was carried out by Pearson Chi-square tests or variance analysis, when needed.

RESULTS

One thousand, one hundred, and seventy-five observation scripts were filled in a national representative sample composed by 273 cities. Statistically significant differences were observed regarding the type of unit, infrastructure, and presence of a pharmacist between regions of Brazil. The average availability of tracer medicines in primary health care was 52.9%, with differences between regions and sampling strata. This index increased to 62.5% when phytotherapic medicines were excluded. We found limited availability of medicines for treatment of chronic and epidemiological diseases, such as tuberculosis and congenital syphilis.

CONCLUSIONS

The low availability of essential medicines purchased centrally by the Brazilian Ministry of Health indicates deficiencies in supply chain management. The different views on the availability of tracer medicines in SUS confirm the general availability verified in this study. Among patients, about 60% said they obtain medicines in SUS units, data consistent with the lack of medicines reported by medicine dispensers and in line with physicians’ evaluations.

Drugs, Essential, supply & distribution; Pharmaceutical Services; Primary Health Care; Health Services Research; Unified Health System

Variable	North		Northeast		Midwest		Southeast		South		Brazil

	n ^a	% (IC95%)	n ^a	% (IC95%)	n ^a	% (IC95%)	n ^a	% (IC95%)	n ^a	% (IC95%)	n ^a	% (IC95%)
Type of unit ^b
Center/basic health unit	179	68.8 (62.3–74.6)	181	72.9 (63.9–80.3)	53	25.4 (16.2–37.5)	124	42.0 (29.7–55.5)	171	64.5 (52.1–75.1)	708	58.8 (53–64.3)
Health Center	24	8.7 (5.7–13.1)	56	13.9 (9.8–19.4)	88	28.4 (18.7–40.6)	49	15.4 (10.4–22.4)	40	12.4 (7.6–19.7)	257	14.6 (12–17.6)
Pharmacy in an independent building	37	15.5 (11.2–20.9)	6	4.1 (1.0–15.3)	20	37.4 (20.2–58.5)	22	17.8 (10.4–28.8)	31	16.8 (7.9–32.4)	116	13.4 (9.6–18.3)
Mixed unit	8	3.3 (1.6–6.5)	11	4.3 (1.7–10.5)	16	7.5 (3.1–16.8)	31	20.3 (9.9–37.3)	7	5.7 (1.9–15.7)	73	9.6 (5.7–15.8)
Other	11	3.8 (2.0–7.1)	5	4.8 (1.6–13.5)	1	1.3 (0.2–9.0)	3	4.4 (0.8–20.5)	1	0.6 (0.1–4.0)	21	3.7 (1.6–8.2)
Unit has a responsible pharmacist ^b	78	26.8 (21.9–32.2)	52	18.5 (11.7–28.1)	95	66.9 (55.6–76.6)	176	72.0 (57.3–83.1)	105	44.8 (34.5–55.6)	506	43.0 (37.8–48.4)
Equipment and furnishings of the storage area ^b
Exclusive refrigerator for medicines	97	37.2 (31.0–43.8)	97	21.3 (16.1–27.6)	112	50.7 (36.6–64.7)	180	76.0 (65.9–83.9)	164	56.8 (46.7–66.4)	650	47.2 (42.0–52.5)
Air conditioner	163	59.0 (52.4–65.4)	92	21.3 (14.8–29.5)	103	72.7 (61.6–81.6)	101	46.0 (33.1–59.4)	76	37.1 (26.7–48.8)	535	37.7 (32.4–43.2)
Locker cabinet ^c	99	38.2 (32.0–44.7)	66	22.6 (15.9–31.1)	80	65.1 (50.7–77.3)	154	63.4 (49.6–75.3)	103	48.9 (38.5–59.5)	502	43.4 (38.0–49.0)

Medicine	Availability % (95%CI)

	North	Northeast	Midwest	Southeast	South	Brazil
Anti-hypertensives	73.5 (68.9–78.2)	85.9 (82.2–89.6)	86.1 (80.5–91.6)	91.8 (88.5–95.1)	84.0 (78.7–89.4)	84.3 (82.2–86.3)
1. Captopril/enalapril ^a	84.1 (78.5–88.4)	84.4 (78.3–89.0)	84.1 (75.9–89.9)	95.4 (91.2–97.6)	83.9 (76.7–89.3)	87.7 (84.8–90.1)
2. Hydrochlorothiazide	72.9 (66.5–78.5)	86.6 (80.1–91.2)	81.7 (73.2–88.0)	86.1 (79.6–90.8)	83.5 (76.1–89.0)	84.5 (81.3–87.3)
3. Atenolol/propranolol/carvedilol/metoprolol ^a	70.7 (64.2–76.4)	66.2 (58.4–73.1)	77.6 (65.1–86.6)	90.9 (85.0–94.7)	79.2 (69.8–86.2)	77.1 (73.1–80.6)
Oral antidiabetics and insulin	66.4 (61.7–71.1)	77.1 (72.9–81.3)	80.5 (72.6–88.4)	91.1 (87.7–94.4)	74.9 (69.0–80.8)	78.0 (75.6–80.4)
4. Metformin ^a	79.2 (73.4–84.0)	86.4 (80.0–90.9)	83.8 (74.8–90.1)	91.8 (84.9–95.7)	74.0 (61.4–83.5)	85.2 (81.4–88.4)
5. Glibenclamide/glicazide	79.2 (73.1–84.2)	85.3 (76.8–91.1)	84.3 (74.3–90.9)	84.6 (76.9–90.0)	72.9 (64.3–80.1)	82.4 (78.5–85.8)
6. NPH human insulin ^a	49.5 (42.9–56.0)	55.5 (47.3–63.4)	65.6 (53.0–76.4)	90.3 (84.5–94.1)	67.8 (57.9–76.3)	68.4 (64.0–72.6)
7. Regular human insulin ^a	45.2 (38.7–51.8)	50.6 (42.4–58.8)	64.9 (52.2–75.9)	84.6 (77.3–89.9)	59.8 (49.8–69.0)	63.1 (58.2–67.7)
Contraceptives/hormones	56.3 (51.2–61.4)	69.5 (63.2–75.7)	81.8 (76.0–87.5)	88.3 (83.8–92.9)	83.1 (78.7–87.5)	75.8 (73.5–78.1)
8. Ethinylestradiol + levonorgestrel ^a	48.6 (42.3–54.9)	63.1 (54.6–70.8)	84.1 (75.6–90.1)	87.0 (80.0–91.8)	86.6 (79.1–91.7)	74.5 (70.1–78.4)
9. Norethindrone + estradiol ^a	53.1 (46.6–59.4)	64.1 (55.7–71.8)	78.6 (66.4–87.2)	82.7 (74.7–88.6)	87.6 (80.8–92.2)	73.8 (69.3–77.8)
10. Norethisteronea	52.0 (45.6–58.4)	65.5 (57.1–73.1)	72.9 (61.6–81.8)	73.8 (58.8–84.8)	82.3 (75.3–87.6)	70.2 (64.7–75.2)
11. Medroxyprogesterone ^a	44.9 (38.7–51.4)	45.1 (37.1–53.3)	61.7 (50.1–72.1)	71.6 (61.1–80.3)	72.1 (63.3–79.5)	58.8 (53.6–63.8)
12. Levonorgestrel	46.3 (40.1–52.7)	54.1 (45.7–62.3)	66.5 (56.3–75.4)	62.5 (46.7–76.1)	62.1 (52.3–70.9)	58.2 (52.2–63.8)
13. Estriol vaginal cream ^a	15.4 (11.5–20.3)	20.0 (14.8–26.4)	38.7 (28.3–50.3)	15.4 (10.9–21.3)	27.9 (20.0–37.4)	20.6 (17.5–24.2)
14. Conjugated Estrogens Vaginal cream	10.2 (7.0–14.4)	17.7 (12.4–24.7)	31.0 (20.0–44.7)	18.3 (12.4–26.2)	20.8 (14.5–28.9)	18.6 (15.3–22.4)
Anti-infectious	62.7 (58.2–67.2)	70.0 (65.4–74.7)	76.7 (70.5–82.8)	83.9 (80.1–87.8)	73.3 (66.7–79.9)	73.3 (70.9–75.7)
15. Fluconazole/itraconazol ^a	69.2 (62.6–75.0)	67.2 (59.3–74.3)	83.2 (76.8–88.0)	88.5 (82.1–92.8)	67.3 (57.8–75.6)	74.9 (70.8–78.7)
16. Miconazole nitrate ^a	62.7 (56.0–68.9)	64.1 (56.1–71.4)	72.4 (63.1–80.1)	83.0 (74.9–88.9)	84.4 (75.2–90.6)	73.7 (69.4–77.6)
17. Ciprofloxacin chloride ^a	51.4 (44.8–57.8)	59.7 (51.6–67.3)	60.7 (49.4–70.9)	82.7 (74.5–88.7)	54.0 (43.8–63.9)	65.3 (60.5–69.7)
18. Nystatin cream ^a	44.0 (37.6–50.6)	54.7 (46.6–62.6)	60.1 (44.2–74.0)	68.0 (57.0–77.3)	53.1 (42.4–63.5)	58.0 (52.7–63.1)
19. Benzathine benzylpenicilin ^a	59.0 (52.5–65.3)	37.2 (29.7–45.4)	49.0 (37.4–60.8)	56.3 (42.0–69.7)	60.7 (50.9–69.7)	49.5 (44.0–55.0)
Analgesics/antipyretics/anti-inflammatory	73.9 (69.2–78.6)	80.6 (75.8–85.5)	85.9 (78.8–93.0)	91.0 (86.3–95.7)	95.3 (92.5–98.0)	85.3 (83.1–87.6)
20. Paracetamol ^a	84.8 (79.4–89.1)	83.4 (77.2–88.2)	87.2 (77.6–93.1)	95.4 (90.5–97.8)	98.9 (95.9–99.7)	90.1 (87.3–92.3)
21. Dipyrone oral solution	86.0 (80.6–90.1)	83.0 (76.9–87.7)	83.3 (73.0–90.2)	86.2 (74.4–93.1)	93.5 (87.3–96.7)	86.0 (82.0–89.3)
22. Ibuprofen ^a	58.8 (52.2–65.1)	57.4 (49.1–65.4)	83.4 (73.7–90.0)	75.3 (58.8–86.8)	94.3 (89.7–96.9)	70.8 (65.1–75.9)
Antiemetics/antisecretory	54.3 (49.5–59.1)	65.3 (59.6–71.0)	76.5 (68.3–84.7)	80.3 (73.1–87.5)	83.2 (75.9–90.4)	71.9 (68.9–74.9)
23. Omeprazol ^a	32.0 (26.3–38.4)	55.1 (46.7–63.1)	54.6 (41.6–66.9)	82.8 (73.8–89.1)	85.9 (76.7–91.9)	66.9 (62.1–71.4)
24. Aluminium hydroxide ^a	64.7 (58.5–70.5)	64.4 (56.0–72.0)	77.5 (69.7–83.8)	44.4 (32.4–57.1)	68.4 (55.7–78.8)	59.7 (53.7–65.5)
25. Ranitidine hydrochloride	59.6 (52.8–66.0)	50.2 (42.0–58.4)	70.0 (59.4–78.8)	61.3 (46.9–74.0)	59.7 (48.1–70.2)	57.1 (51.4–62.7)
Anti-asthmatics	67.4 (62.3–72.5)	78.2 (73.0–83.5)	82.1 (76.0–88.1)	88.8 (84.4–93.2)	83.6 (78.7–88.5)	80.0 (77.7–82.3)
26. Prednisolone sodium phosphate/prednisolone ^a	64.9 (58.3–71.0)	74.6 (65.7–81.7)	83.6 (76.8–88.7)	86.6 (75.6–93.1)	80.5 (66.1–89.9)	79.0 (74.0–83.3)
27. Salbutamol sulphate ^a	61.6 (55.0–67.8)	59.3 (50.9–67.2)	69.2 (55.9–79.9)	81.3 (70.6–88.7)	64.2 (54.8–72.6)	67.7 (62.7–72.3)
28. Ipratropium bromide	57.3 (50.6–63.7)	57.9 (49.8–65.7)	62.1 (50.5–72.5)	60.5 (46.4–73.0)	70.8 (60.9–79.1)	61.1 (55.5–66.4)
Antiparasitic agents	70.3 (65.5–75.1)	84.2 (77.9–90.5)	83.1 (76.5–89.7)	91.2 (87.5–94.8)	85.7 (80.1–91.3)	82.9 (80.4–85.4)
29. Albendazol ^a	87.9 (83.0–91.6)	81.4 (72.4–87.9)	80.7 (67.8–89.2)	92.3 (87.3–95.4)	95.9 (92.4–97.8)	87.7 (83.8–90.7)
30. Metronidazole/teclozan ^a	74.0 (68.1–79.1)	82.4 (73.8–88.6)	77.4 (64.2–86.8)	89.3 (83.4–93.3)	78.1 (69.8–84.7)	82.9 (78.9–86.2)
31. Permethrin ^a	15.5 (11.6–20.4)	46.6 (38.7–54.7)	55.7 (46.1–64.9)	57.5 (43.7–70.2)	80.0 (71.9–86.1)	53.6 (48.1–59.0)
Psychotropics	15.0 (11.0–19.0)	10.6 (4.4–16.9)	41.6 (30.2–53.0)	48.0 (35.0–61.1)	45.7 (35.0–56.4)	32.2 (27.9–36.5)
32. Amitriptyline hydrochloride ^a	17.7 (13.5–22.8)	10.8 (5.9–19.0)	38.4 (27.1–51.1)	49.3 (36.3–62.5)	50.4 (40.2–60.6)	31.5 (26.4–37.1)
33. Carbamazepine ^a	17.4 (13.3–22.5)	12.5 (7.0–21.3)	42.1 (29.9–55.2)	46.0 (33.2–59.4)	47.3 (36.8–580.)	30.8 (25.6–36.6)
34. Fluoxetine ^a	11.2 (8.0–15.4)	8.6 (4.1–17.3)	34.8 (22.2–49.9)	50.3 (37.1–63.4)	48.3 (37.9–58.8)	29.9 (24.8–35.6)
35. Clonazepam ^a	17.9 (13.8–22.9)	8.8 (4.3–17.1)	36.2 (24.2–50.2)	46.1 (33.3–59.4)	34.0 (23.2–46.8)	26.9 (21.9–32.6)
Tuberculostatics	32.5 (27.7–38.2)	10.6 (5.9–15.4)	32.2 (21.3–43.2)	44.7 (31.3–58.1)	9.9 (6.4–13.3)	26.0 (22.2–29.8)
36. Isoniazid 75 mg + rifampicin 150 mg + pyrazinamide 400 mg + ethambutol 275 mg ^a	35.6 (29.7–42.0)	10.2 (6.4–15.9)	31.8 (22.0–43.5)	40.7 (29.3–53.3)	9.4 (6.4–13.4)	22.9 (19.1–27.1)
37. Rifampicin 300 mg ^a	30.4 (24.8–36.7)	9.4 (5.6–15.4)	27.8 (18.1–40.1)	36.7 (24.2–51.4)	7.1 (4.7–10.6)	20.3 (15.6–26.0)
Phytotherapics	9.8 (7.4–12.2)	2.8 (0.7–4.9)	12.4 (0.5–24.3)	13.9 (7.5–20.4)	10.8 (6.0–15.6)	8.8 (6.4–11.0)
38. Guaco ^a	10.6 (8.4–13.4)	2.7 (1.2–5.8)	12.0 (4.2–29.7)	12.7 (8.4–18.9)	11.5 (7.2–17.8)	8.5 (6.6–10.7)
39. Soy isoflavone ^a	1.5 (0.8–3.0)	0.3 (0.1–1.3)	7.4 (1.2–33.6)	10.0 (6.1–15.9)	3.8 (1.7–8.4)	4.4 (3.0–6.4)
40. Unha-de-gato ^a	–	–	–	9.5 (5.8–15.3)	–	3.0 (1.9–4.5)
41. Espinheira-santa ^a	1.2 (0.5–2.6)	0.2 (0.0–1.1)	7.2 (1.2–33.9)	1.8 (0.9–3.6)	2.6 (1.0–6.9)	1.6 (0.8–3.0)
42. Aroeira ^a	–	0.5 (0.2–1.4)	7.2 (1.2–33.9)	1.2 (0.3–4.2)	–	1.0 (0.4–2.6)
43. Cáscara-sagrada ^a	0.2 (0.0–1.4)	0.2 (0.0–1.1)	0.5 (0.1–3.6)	2.9 (0.7–12.0)	–	1.0 (0.3–3.7)
44. Garra-do-diabo ^a	0.2 (0.0–1.2)	–	0.1 (0.0–0.9)	2.0 (1.0–3.8)	1.0 (0.2–3.7)	0.8 (0.5–1.4)
45. Artichoke	2.0 (1.1–3.5)	0.6 (0.3–1.6)	–	1.4 (0.6–3.3)	–	0.8 (0.5–1.4)
Other medicines	70.6 (65.8–75.5)	81.4 (76.3–86.6)	81.3 (75.3–87.3)	92.3 (88.7–95.8)	79.5 (74.4–84.5)	81.0 (78.8–83.2)
46. Oral rehydration salts	88.0 (83.0–91.7)	89.7 (83.5–93.7)	89.5 (82.1–94.1)	95.8 (90.2–98.3)	92.3 (87.2–95.5)	91.9 (89.1–94.0)
47. Ferrous sulfate ^a	69.6 (63.3–75.3)	90.4 (85.1–93.9)	84.8 (75.6–91.0)	94.6 (90.2–97.1)	91.5 (82.9–96.0)	89.9 (87.2–92.0)
48. Dexamethasone cream/ointment ^a	70.0 (63.6–75.8)	69.1 (61.2–76.1)	82.7 (74.5–88.6)	90.7 (82.4–95.3)	86.0 (76.1–92.2)	79.5 (75.3–83.1)
49. Folic acid ^a	65.5 (58.9–71.6)	72.9 (65.2–79.4)	72.4 (58.3–83.2)	81.0 (70.9–88.1)	87.8 (80.3–92.7)	77.3 (72.9–81.1)
50. Nicotine ^a	4.5 (2.4–8.1)	4.4 (2.0–9.3)	34.0 (23.0–46.9)	27.2 (17.8–39.3)	17.0 (8.5–31.1)	15.3 (11.6–19.9)

General availability	44.6 (42.8–46.3)	46.3 (44.2–48.4)	55.9 (51.3–60.5)	60.5 (58.3–62.8)	56.8 (54.6–58.9)	52.9 (51.6–54.2)
General availability excluding phytotherapics ^b	52.7 (50.6–54.8)	55.0 (52.5–57.5)	65.7 (60.9–70.5)	71.1 (68.6–73.6)	67.2 (64.6–69.7)	62.5 (60.9–64.0)

	Perceived availability	n ^a	% (IC95%)
Patients	Frequency of acquisition of needed medicines in the past three months ^b
	Always	3,357	59.8 (55.1–64.4)
	Repeatedly	410	7.1 (4.7–10.7)
	Sometimes	1,313	23.1 (20.0–26.5)
	Rarely	421	5.6 (4.6–6.9)
	Never	257	4.3 (3.0–6.1)
	Information received when did not receive the medicine(s) ^b
	Lack in unit	1,043	10.9 (8.7–13.5)
	Referred to another unit of the Brazilian Unified Health System	242	1.8 (1.2–2.8)
	Received instructions to buy the medicine	623	8.3 (6.7–10.1)
	Referred to the Popular Pharmacy Program	278	3.1 (2.4–4.0)
	Others	33	0.3 (0.2–0.4)
	No instructions	6,584	75.6 (72.5–78.5)
Physicians	Availability of medicines in the past three months
	Very good/Good	654	58.8 (54.8–62.7)
	Neither bad/Nor good	437	34.3 (30.6–38.2)
	Bad/Very bad	95	6.9 (5.1–9.3)
	Conduct in situations of lack of medicines in the municipal health system ^b
	Analyses the possibility of replacing the medicine prescription	1,240	77.4 (74.2–80.4)
	Refers to the Popular Pharmacy Program in the city	1,202	75.4 (72.1–78.3)
	Recommends the purchase	1,090	69.3 (66.0–72.5)
	Refers to Aqui tem Farmácia Popular	1,049	66.8 (63.4–70.1)
Medicine dispensers	Lack of medicines in the past three months ^b
	Always	376	27.7 (21.8–34.5)
	Repeatedly	117	10.3 (6.2–16.6)
	Sometimes	412	35.6 (29.3–42.5)
	Rarely	141	16.3 (11.8–2.1)
	Never	91	10.1 (6.0–16.3)

Faculdade de Saúde Pública da Universidade de São Paulo Avenida Dr. Arnaldo, 715, 01246-904 São Paulo SP Brazil, Tel./Fax: +55 11 3061-7985 - São Paulo - SP - Brazil
E-mail: revsp@usp.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Correspondence: Renata Cristina Rezende Macedo do Nascimento. Universidade Federal de Minas Gerais. Av. Presidente Antônio Carlos, 6627, 31270-901 Belo Horizonte, MG, Brasil. E-mail: recmacedo@gmail.com