Characterization of the selection of medicines for the Brazilian primary health care

Karnikowski, Margô Gomes de Oliveira; Galato, Dayani; Meiners, Micheline Marie Milward de Azevedo; Silva, Emília Vitória da; Gerlack, Letícia Farias; Bós, Ângelo José Gonçalves; Leite, Silvana Nair; Álvares, Juliana; Guibu, Ione Aquemi; Soeiro, Orlando Mario; Costa, Karen Sarmento; Costa, Ediná Alves; Guerra Junior, Augusto Afonso; Acurcio, Francisco de Assis

doi:10.11606/S1518-8787.2017051007065

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Original Articles • Rev. Saúde Pública 51 (suppl 2) • 2017 • https://doi.org/10.11606/S1518-8787.2017051007065 linkcopy

Characterization of the selection of medicines for the Brazilian primary health care

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE To characterize the process of selection of medicines for primary health care in the Brazilian regions.

METHODS This article is 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), a cross-sectional study that consisted of an information gathering in a sample of cities in the five regions of Brazil. The data used were collected by interviews with those responsible for pharmaceutical services (PS) (n = 506), professionals responsible for the dispensing of medicines (n = 1,139), and physicians (n = 1,558). To evaluate the difference between ratios, we adopted the Chi-square test for complex samples. The differences between the averages were analyzed in generalized linear models with F-test with Bonferroni correction for multiple comparisons. The analyses considered significant had p≤0.05.

RESULTS The professionals responsible for pharmaceutical services reported non-existence of a formally constituted Pharmacy and Therapeutics Committee (PTC) (12.5%). They claimed to have an updated (80.4%) list of Essential Medicines (85.3%) and being active participants of this process (88.2%). However, in the perception of respondents, the list only partially (70.1%) meets the health demands. Of the interviewed professionals responsible for the dispensing of medicines, only 16.6% were pharmacists; even so, 47.8% reported to know the procedures to change the list. From the perspective of most of these professionals (70.9%), the list meets the health demands of the city. Among physicians, only 27.2% reported to know the procedures to change the list, but 76.5% would have some claim to change it. Most of them reported to base their claims in clinical experiences (80.0%). For 13.0% of them, the list meets the health demands.

CONCLUSIONS As this is the first national survey of characterization of the process of selection of medicines within primary health care, it brings unpublished data for the assessment of policies related to medicines in Brazil.

Drugs, Essential, classification; Pharmacy and Therapeutics Committee; Pharmaceutical Services; National Policy of Pharmaceutical Assistance; Primary Health Care; Health Services Research; Unified Health System

Profile of respondents	North	Northeast	Midwest	Southeast	South	Brazil	p

	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)
Professionals responsible for pharmaceutical services
Sex (n = 506)
Female	64.4 (54.0–73.6)	49.9 (39.0–60.8)	67.3 (57.3–75.9)	63.2 (53.1–72.3)	73.2 (63.7–81.0)	62.0 (56.9–66.9)	0.008
Age (n = 493)
Average in years	34.2 (32.3–36.0)	37.1 (34.8–39.4)	31.8 (30.2–33.3)	35.5 (33.8–37.3)	35.6 (34.2–37.2)	34.8 (34.0–35.6)	0.003
Education level (n = 504)
Higher education degree or more	94.4 (87.2–97.7)	97.5 (90.4–99.4)	92.7 (85.5–96.5)	99.0 (92.9–99.9)	99.0 (93.2–99.9)	97.7 (95.8–98.7)	0.122
Time in the position (n = 505)
Average in months	26.3 (20.1–32.5)	43.0 (32.2–53.7)	31.4 (24.3–38.5)	54.2 (41.8–66.6)	49.5 (40.4–58.6)	40.9 (36.7–45.1)	< 0.001
Academic background (n = 505)
Pharmacist	87.5 (78.8–93.0)	84.7 (75.0–91.1)	88.1 (80.0–93.2)	94.8 (88.0–97.8)	95.0 (88.6–97.9)	90.7 (87.3–93.4)	< 0.001
Professionals responsible for the dispensing of medicines
Sex (n = 1,139)
Female	77.5 (70.6–83.2)	80.9 (72.2–87.3)	68.8 (51.6–82.0)	69.7 (52.8–82.6)	87.4 (81.1–91.9)	77.4 (71.2–82.6)	0.087
Age (n = 1,137)
Average in years	37.9 (36.5–39.3)	37.2 (34.8–39.6)	36.3 (33.6–39.0)	36.7 (36.2–41.2)	37.6 (34.9–40.3)	37.5 (36.5–38.6)	0.785
Education level (n = 1,139)
Up to high school	68.3 (58.3–76.9)	72.7 (61.1–81.8)	27.0 (17.3–39.5)	28.3 (15.6–45.7)	42.2 (26.7–59.3)	50.3 (43.0–57.7)	< 0.001
Time in the position (n = 1,139)*
Average in years	3.8 (3.4–4.3)	3.2 (2.5–3.9)	4.9 (3.4–6.3)	4.5 (3.6–5.4)	6.1 (4.4–7.9)	4.5 (4.0–5.0)	0.102
Academic background (n = 1,139)
Pharmacist	8.9 (6.0–13.1)	2.6 (0.5–11.2)	32.7 (20.0–48.5)	33.4 (22.0–47.1)	13.8 (6.5–26.9)	16.6 (12.4–21.7)	< 0.001
Physicians
Sex (n = 1,585)
Male	53.0 (46.8–59.2)	57.4 (50.1–64.3)	54.2 (46.7–61.4)	57.6 (51.4–63.6)	51.5 (45.2–57.8)	55.8 (52.2–59.2)	0.509
Age (n = 1,531)
Average in years	42.1 (40.6–43.6)	41.7 (39.5–43.9)	39.0 (37.0–41.0)	41.0 (39.4–42.6)	42.6 (40.8–44.4)	41.3 (40.5–42.1)	0.033
Time since graduation (n = 1,578)
Average in years	13.8 (12.5–15.2)	13.2 (11.3–15.0)	11.2 (9.6–12.8)	14.6 (12.8–16.3)	14.9 (13.4–16.4)	13.5 (12.8–14.3)	0.005
Time in the position^* (n = 1,585)
Average in months	27.9 (21.2–34.6)	31.8 (25.6–38.1)	37.8 (30.2–43.3)	48.5 (39.1–47.8)	51.5 (42.2–60.8)	39.3 (35.8–42.8)	< 0.001
Education level
At least one residency	93.8 (89.9–96.2)	86.3 (80.4–90.6)	89.5 (83.8–93.3)	92.2 (88.2–95.0)	94.3 (90.5–96.6)	90.5 (88.0–92.5)	0.009

Indicator of the selection of medicines	North	Northeast	Midwest	Southeast	South	Brazil	p

	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)
Existence of a formally constituted PTC (n = 503)	10.7 (6.0–18.3)	9.5 (4.8–18.0)	13.6 (8.2–21.9)	13.3 (7.8–21.7)	15.6 (9.8–23.9)	12.5 (9.5–16.3)	0.628
Existence of standard operating procedures (n = 491)	45.9 (35.6–56.6)	48.8 (37.7–60.0)	51.5 (41.4–61.4)	56.5 (46.5–66.1)	45.9 (36.4–55.7)	50.6 (45.3–55.8)	0.564
Existence of LME (n = 495)	70.6 (60.3–79.1)	90.8 (81.8–95.6)	82.9 (73.7–89.2)	86.9 (78.3–92.4)	82.0 (73.2–88.4)	85.3 (81.4–88.5)	0.077
Periodic update of the LME (n = 419)	82.9 (71.8–90.3)	83.8 (73.3–90.7)	83.1 (73.5–89.7)	81.2 (71.1–88.3)	73.1 (62.6–81.5)	80.4 (75.6–84.5)	0.347
Participation of the respondent in the development of the LME (n = 418)	90.5 (80.3–95.7)	87.0 (76.9–93.1)	84.7 (74.8–91.1)	90.1 (81.3–95.0)	88.0 (79.0–93.4)	88.2 (84.0–91.4)	0.592
Professionals request changes on the LME (n = 438)							0.804
Sometimes	33.8 (23.8–45.4)	30.2 (20.8–41.6)	31.3 (22.2–42.1)	29.2 (20.5–39.8)	33.6 (24.3–44.3)	31.0 (26.1–36.4)
Rarely	23.5 (16.6–36.7)	25.8 (17.0–36.9)	25.8 (17.0–36.9)	24.1 (16.1–34.4)	23.1 (15.4–33.3)	24.1 (19.6–29.3)
Never	33.5 (23.5–45.1)	31.4 (21.9–42.8)	31.4 (21.9–42.8)	35.9 (26.3–46.7)	23.8 (15.8–34.1)	31.1 (26.2–36.5)
LME meets the health demands of the city (n = 426)							0.349
Completely	24.6 (15.6–36.5)	27.2 (18.1–38.7)	29.3 (20.4–40.1)	34.6 (25.1–45.5)	27.8 (19.2–38.2)	29.7 (24.7–35.1)
Partially	75.4 (63.5–84.4)	72.8 (61.3–81.9)	70.7 (59.9–79.6)	65.4 (54.5–74.9)	71.1 (60.5–79.7)	70.1 (64.6–75.0)
Provision of non-standard medicines (n = 506)	48.5 (38.3–58.7)	38.4 (28.4–49.6)	31.2 (22.7–41.0)	39.0 (29.8–49.2)	48.7 (39.1–58.4)	41.1 (36.2–46.3)	0.222
Existence of criteria for provision of non-selected medicines (n = 425)	64.8 (52.7–75.2)	56.1 (44.4–67.1)	72.8 (61.9–81.6)	73.9 (63.3–82.3)	71.1 (60.5–79.7)	67.0 (61.5–72.1)	0.081
Existence of a therapeutic form (n = 495)	21.0 (13.7–30.7)	27.9 (19.0–39.1)	16.2 (10.0–25.1)	23.8 (16.2–33.4)	18.3 (11.9–27.2)	22.9 (18.7–27.7)	0.252
Existence of clinical protocols (n = 487)	22.9 (15.3–32.9)	23.4 (15.2–34.3)	31.8 (23.3–41.8)	32.5 (23.7–42.8)	21.2 (14.2–30.4)	26.4 (22.0–31.3)	0.221

Indicator of the selection of medicines	North	Northeast	Midwest	Southeast	South	Brazil	p

	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)
Existence of LME (n = 1,139)	84.6 (76.3–90.4)	88.7 (78.3–94.5)	92.0 (85.1–95.8)	86.6 (72.9–94.0)	95.7 (90.9–98.0)	89.1 (83.8–92.8)	0.189
The LME is available in the health units for consultation of professionals (n = 1,041)	80.2 (72.6–86.2)	88.6 (75.5–95.1)	90.1 (81.4–95.0)	96.5 (91.7–98.6)	93.1 (84.4–97.1)	91.3 (86.5–94.5)	0.057
The respondent knows the procedures for inclusion or exclusion of medicines in the LME (n = 930)	28.0 (21.3–35.9)	36.9 (27.9–46.9)	49.9 (34.1–65.7)	66.8 (50.9–79.7)	42.2 (27.8–58.1)	47.8 (40.6–55.2)	< 0.001
The respondent has already made a claim for inclusion/exclusion of medicines in the LME (n = 930)	31.0 (23.1–40.3)	42.1 (30.1–55.2)	66.2 (50.2–79.2)	45.7 (28.5–63.9)	44.9 (29.4–61.6)	44.4 (36.3–52.9)	0.528
The LME meets the health demands of the city (n = 930)	57.7 (49.1–65.9)	67.0 (55.1–77.0)	78.7 (64.1–88.4)	73.9 (55.1–86.7)	75.5 (60.5–86.1)	70.9 (63.4–77.3)	0.413

Indicator of the selection of medicines	North	Northeast	Midwest	Southeast	South	Brazil	p

	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)
Knowledge of the respondent regarding the procedures for inclusion or exclusion of medicines in the LME (n = 1.254)	25.8 (19.6–33.2)	27.7 (20.8–35.7)	21.2 (23.8–36.6)	29.8 (23.8–36.6)	24.2 (18.8–30.6)	27.2 (23.7–30.9)	0.542
Existence of a claim for inclusion/exclusion of medicines in the LME (n = 282)	80.4 (64.3–90.3)	80.3 (77.9–92.1)	89.5 (75.8–95.9)	67.9 (54.0–79.2)	75.6 (62.3–85.3)	76.5 (69.2–82.5)	0.167
Base for solicitation^a
Scientific article (n = 204)	40.4 (25.1–57.7)	44.0 (27.9–61.5)	52.9 (33.3–71.6)	66.9 (50.0–80.4)	63.2 (46.2–77.5)	54.8 (45.5–63.7)	0.095
Scientific events (n = 203)	34.4 (20.3–51.9)	16.2 (7.1–32.8)	35.6 (19.3–55.9)	35.8 (21.6–53.1)	40.8 (25.5–58.1)	29.0 (21.6–37.7)	0.060
Journals (n = 203)	17.9 (8.3–34.6)	14.4 (5.8–31.6)	36.5 (20.1–56.7)	33.2 (20.3–49.4)	22.8 (12.0–39.0)	23.1 (16.6–31.2)	0.145
Media (television, magazines, radio, internet etc.) (n = 202)	11.8 (4.3–28.5)	6.8 (1.7–23.6)	6.0 (1.5–20.7)	8.4 (2.5–24.6)	6.9 (2.1–20.3)	7.6 (3.9–14.4)	0.933
Visit of representative/propagandist (n = 201)	11.8 (4.3–28.5)	14.0 (5.5–31.4)	10.9 (3.4–29.5)	9.2 (3.2–23.7)	25.7 (13.2–44.0)	14.4 (9.0–22.1)	0.261
Clinical experience (n = 200)	85.4 (70.1–93.6)	82.2 (64.5–92.1)	83.2 (62.6–93.6)	80.7 (64.2–90.6)	71.3 (54.3–83.8)	80.0 (71.7–86.4)	0.546
Existence of LME (n = 1,451)	90.9 (86.1–94.2)	94.8 (90.5–97.3)	92.8 (87.4–96.0)	95.5 (92.0–97.5)	98.1 (95.1–99.3)	95.3 (93.5–96.6)	0.092
Participation in the development of the LME (n = 1,311)	10.9 (7.1–16.5)	13.7 (8.9–20.4)	12.8 (8.6–18.7)	17.4 (12.5–23.8)	16.1 (11.8–21.5)	15.1 (12.5–18.3)	0.523
The LME meets completely the health demands of the city (n = 1,296)	14.2 (9.7–20.2)	12.5 (7.9–19.1)	10.0 (5.9–16.6)	15.2 (10.7–21.2)	10.7 (7.5–15.1)	13.0 (10.5–15.9)	0.223
Knowledge of the existence of the LME (n = 1,381)	93.9 (89.7–96.4)	95.3 (90.7–97.6)	95.3 (90.7–97.7)	95.9 (92.4–97.8)	97.7 (94.5–99.1)	95.9 (94.1–97.1)	0.502
Form of access to the LME: ^b
Available in the medical office (n = 1,303)	72.1 (64.9–78.3)	74.6 (67.3–80.8)	74.3 (66.8–80.6)	81.3 (75.6–85.9)	79.6 (73.8–84.4)	77.6 (74.3–80,6)	0.181
Available on the internet (n = 1,172)	17.7 (12.6–24.3)	11.0 (6.8–17.2)	21.3 (14.9–29.4)	24.7 (19.3–31.0)	22.8 (17.4–29.3)	18.6 (15.9–21.7)	0.001
Available at the pharmacy (n = 1,259)	66.8 (59.4–73.4)	63.3 (55.0–70.9)	74.0 (65.8–0.7)	66.3 (59.0–73.0)	62.9 (56.0–69.4)	65.0 (61.0–68.8)	0.551
Available by the SMS or SES-DF (n = 1,149)	49.2 (41.7–56.7)	51.5 (42.9–60.0)	51.4 (42.5–60.3)	49.8 (41.9–57.7)	53.6 (46.7–60.5)	51.3 (47.1–55.0)	0.898
Availability of TF, Consensus, Guidelines, or Lines of Care in the medical office	51.6 (45.0–58.2)	46.7 (39.3–54.3)	41.8 (34.6–49.3)	54.7 (48.0–61.3)	50.1 (43.6–56.6)	49.9 (46.3–53.6)	0.191
The patient requests a change of medicine:
Always, repeatedly, or sometimes (n = 1,578)	56.8 (50.3–63.0)	63.3 (55.9–70.0)	67.5 (60.7–73.8)	71.4 (65.3–76.8)	68.2 (61.5–74.2)	66.5 (63.0–69.8)	0.065

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[TFN1] ^* Average time in the position on the health unit where the interview was carried out. DNA: does not apply

[TFN2] Source: PNAUM – Services, 2015.