Access to medicines: relations with the institutionalization of pharmaceutical services

Barros, Rafael Damasceno de; Costa, Ediná Alves; Santos, Djanilson Barbosa dos; Souza, Gisélia Santana; Álvares, Juliana; Guerra Junior, Augusto Afonso; Acurcio, Francisco de Assis; Guibu, Ione Aquemi; Costa, Karen Sarmento; Karnikowski, Margô Gomes de Oliveira; Soeiro, Orlando Mario; Leite, Silvana Nair

doi:10.11606/S1518-8787.2017051007138

person Rafael Damasceno de Barros

schoolInstituto de Saúde Coletiva. Universidade Federal da Bahia. Salvador, BA, Brasil

person Ediná Alves Costa

schoolInstituto de Saúde Coletiva. Universidade Federal da Bahia. Salvador, BA, Brasil

person Djanilson Barbosa dos Santos

schoolCentro de Ciências da Saúde. Universidade Federal do Recôncavo da Bahia. Santo Antônio de Jesus, BA, Brasil

person Gisélia Santana Souza

schoolFaculdade de Farmácia. Universidade Federal da Bahia. Salvador, BA, Brasil

person Juliana Álvares

schoolDepartamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

person Augusto Afonso Guerra Junior

schoolDepartamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

person Francisco de Assis Acurcio

schoolDepartamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

person Ione Aquemi Guibu

schoolDepartamento de Saúde Coletiva. Faculdade de Ciências Médicas. Santa Casa de São Paulo. São Paulo, SP, Brasil

person Karen Sarmento Costa

school Núcleo de Estudos de Políticas Públicas. Universidade Estadual de Campinas. Campinas, SP, BrasilschoolPrograma de Pós-Graduação em Saúde Coletiva. Departamento de Saúde Coletiva. Faculdade de Medicina. Universidade Estadual de Campinas. Campinas, SP, Brasilschool Programa de Pós-Graduação em Epidemiologia. Faculdade de Medicina. Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brasil

person Margô Gomes de Oliveira Karnikowski

schoolFaculdade de Ceilândia. Universidade de Brasília. Brasília, DF, Brasil

person Orlando Mario Soeiro

schoolFaculdade de Ciências Farmacêuticas. Pontifícia Universidade Católica de Campinas. Campinas, SP, Brasil

person Silvana Nair Leite

schoolDepartamento de Ciências Farmacêuticas. Universidade Federal de Santa Catarina. Florianópolis, SC, Brasil

Correspondence: Rafael Damasceno de Barros. Instituto de Saúde Coletiva - Universidade Federal da Bahia. Rua Basílio da Gama, s/n - Canela. 40.110-040 Salvador, BA, Brasil. Email:
rafael.barros@ufba.br

Authors’ Contribution: Conception, analysis, and interpretation of results; critical review of content: RDB, EAC, DBS, GSS, JA, AAG Jr., FAA, IAG, KSC, MGOK, OMS, SNL. All authors claim to be responsible for all aspects of the study, ensuring its accuracy and completeness.

Conflict of Interests: KSC declares conflict of interest for being former director of the Brazilian Ministry of Health, the research funding institution. The other authors declare no conflict of interest.

Instituto de Saúde Coletiva. Universidade Federal da Bahia. Salvador, BA, Brasil

Centro de Ciências da Saúde. Universidade Federal do Recôncavo da Bahia. Santo Antônio de Jesus, BA, Brasil

Faculdade de Farmácia. Universidade Federal da Bahia. Salvador, BA, Brasil

Departamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil

Departamento de Saúde Coletiva. Faculdade de Ciências Médicas. Santa Casa de São Paulo. São Paulo, SP, Brasil

Núcleo de Estudos de Políticas Públicas. Universidade Estadual de Campinas. Campinas, SP, Brasil

Programa de Pós-Graduação em Saúde Coletiva. Departamento de Saúde Coletiva. Faculdade de Medicina. Universidade Estadual de Campinas. Campinas, SP, Brasil

Programa de Pós-Graduação em Epidemiologia. Faculdade de Medicina. Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brasil

Faculdade de Ceilândia. Universidade de Brasília. Brasília, DF, Brasil

Faculdade de Ciências Farmacêuticas. Pontifícia Universidade Católica de Campinas. Campinas, SP, Brasil

Departamento de Ciências Farmacêuticas. Universidade Federal de Santa Catarina. Florianópolis, SC, Brasil

Dimension	Variable	Users (n)	Access % (95CI%)			p*

			Full	Partial	Null
Formal PS structures in the SSM	Pharmaceutical services are included in the Municipal Health Plan					0.324
	Yes	4,361	60.6 (58.6–62.6)	35.3 (33.3–37.3)	4.1 (3.3–5.0)
	No	268	54.2 (46.8–61.4)	43.2 (36.1–50.6)	2.6 (0.9–6.9)
	Existence of Pharmacy and Therapeutics Committee					0.102
	Yes	2,268	57.5 (54.3–60.6)	39.4 (36.3–42.6)	3.1 (2.2–4.4)
	In the implementation phase	483	66.1 (60.2–71.6)	30.5 (25.3–36.2)	3.4 (1.7–6.7)
	No	1,993	61.0 (58.4–63.5)	34.6 (32.2–37.1)	4.5 (3.5–5.7)
	Existence of Standardized Medicines List					0.878
	Yes	4,468	60.1 (58.1–62.1)	35.7 (33.8–37.7)	4.1 (3.4–5.1)
	No	316	61.8 (55.1–68.1)	34.6 (28.5–41.1)	3.7 (1.8–7.5)
	Existence of an exclusive Permanent Commission for the purchase of medicines					0.012
	Yes	1,666	64.0 (61.0–67.0)	32.7 (29.8–35.7)	3.3 (2.4–4.6)
	No	3,042	58.1 (55.6–60.6)	37.7 (35.2–40.2)	4.2 (3.3–5.4)

Financing	Expenses with the structuring of PS					0.417
	Yes	2,484	59.2 (56.4–61.9)	36.8 (34.2–39.6)	3.9 (3.0–5.2)
	No	1,969	61.5 (58.6–64.3)	35.3 (32.5–38.2)	3.2 (2.3–4.4)
	Coordination of PS has autonomy in the management of financial resources					0.004
	Yes, completely	924	60.8 (56.9–64.5)	36.5 (32.9–40.3)	2.7 (1.7–4.2)
	Yes, partially	2,324	60.8 (57.9–63.6)	35.3 (32.6–38.2)	3.9 (2.9–5.3)
	No	1,445	56.9 (53.3–60.4)	36.9 (33.5–40.5)	6.2 (4.6–8.3)

Management tools	Existence of computerized system for PS management					< 0.001
	Yes	3,722	62.7 (60.5–64.8)	34.2 (32.2–36.4)	3.1 (2.4–3.9)
	No	1,093	52.8 (48.7–56.8)	40.3 (36.4–44.4)	6.9 (5.0–9.3)
	Existence of protocol for the storage of medicines					< 0.001
	Yes	3,449	64.3 (62.0–66.5)	32.6 (30.4–34.9)	3.1 (2.4–4.0)
	No	1,202	51.1 (47.5–54.8)	43.1 (39.5–46.8)	5.8 (4.2–7.9)
	Existence of protocol for the dispensing of medicines					< 0.001
	Yes	3,268	64.8 (62.4–67.1)	32.0 (29.7–34.3)	3.2 (2.5–4.2)
	No	1,418	52.3 (49.0–55.5)	42.4 (39.2–45.4)	5.3 (4.0–7.1)
	Existence of protocol for the delivery of medicines					< 0.001
	Yes	3,027	61.9 (59.5–64.3)	35.0 (32.7–37.4)	3.1 (2.4–4.0)
	No	1,591	54.6 (51.1–58.0)	39.1 (35.8–42.5)	6.3 (4.7–8.4)
	Existence of control of entry and exit of medicines from the warehouse					0.951
	Yes	4,625	60.5 (58.5–62.4)	35.6 (33.7–37.5)	3.9 (3.2–4.8)
	No	190	60.3 (51.7–68.3)	36.2 (28.5–44–8)	3.4 (1.3–8.4)
	Existence of some type of training or qualification of the PS professionals					< 0.001
	Yes	872	73.0 (69.0–76.7)	25.6 (22.0–29.5)	1.4 (0.8–2.7)
	No	2,951	56.4 (54.0–58.9)	38.5 (36.1–41.0)	5.0 (4.0–6.3)

Participation and social control	Existence of mechanisms for receiving criticism by users about PS					0.051
	Yes	1,938	62.6 (59.6–65.5)	32.3 (29.6–35.2)	5.1 (3.8–6.8)
	No	1,971	58.3 (55.2–61.3)	38.1 (35.1–41.1)	3.6 (2.7–4.9)
	Participation of the RPS in the Municipal Health Council					0.007
	Always or repeatedly	1,138	65.6 (62.0–69.1)	31.8 (28.4–35.3)	2.6 (1.6–4.1)
	Sometimes or rarely	921	59.5 (55.0–63.9)	36.9 (32.7–41.4)	3.6 (2.3–5.5)
	Never	1,493	59.2 (56.0–62.4)	35.8 (32.7–38.9)	5.0 (3.7–6.7)

Dimension	Variable	Users (n)	Access % (95%CI)			p*

			Full	Partial	Null
Personnel structure	Professional category of the RDM					< 0.001
	Pharmacist	1,282	64.9 (61.5–68.3)	32.3 (29.0–35.6)	2.8 (1.9–4.2)
	Pharmacy assist./tech.	370	67.4 (60.8–73.4)	30.3 (24.5–36.8)	2.3 (1.0–5.1)
	Nurse	474	56.6 (51.0–62.1)	38.9 (33.6–44.5)	4.5 (2.6–7.5)
	Nursing assist /tech.	1,312	61.2 (57.2–64.9)	36.0 (32.3–39.9)	2.8 (1.8–4.3)
	Administrative assist.	387	50.4 (42.5–58.3)	35.8 (28.7–43.5)	13.8 (8.7–21.0)
	Community health agent	112	43.9 (29.9–58.9)	53.2 (38.3–67.6)	2.9 (0.6–13.1)
	Others	487	58.2 (51.9–64.3)	35.2 (29.5–41.4)	6.6 (3.4–5.0)
Management tools	Participation in training or course for PS professionals in the city in the past two years					0.009
	Yes	1,491	65.3 (61.8–68.6)	30.3 (27.1–33.6)	4.5 (3.1–6.4)
	No	2,922	59.1 (56.7–61.6)	36.9 (34.5–39.3)	4.0 (3.1–5.0)
	Existence of computerized system for PS management					< 0.001
	Yes	1,979	65.7 (62.8–68.4)	32.0 (29.3–34.8)	2.4 (1.6–3.4)
	No	2,399	57.8 (55.0–60.6)	36.8 (34.1–39.5)	5.4 (4.3–6.8)
	Existence of a computerized system for PS management networked with health units					< 0.001
	Yes	1,533	70.3 (67.1–73.2)	28.0 (25.1–31.1)	1.7 (1.0–2.8)
	No	418	46.3 (39.9–52.9)	48.2 (41.7–54.7)	5.5 (3.0–9.8)
	Pharmacist participates of the scheduling of medicines in the health unit					0.015
	Yes	2,931	62.8 (60.3–65.3)	32.6 (30.3–35.1)	4.6 (3.6–5.8)
	No	1,387	58.3 (54.9–61.7)	38.3 (34.9–41.7)	3.4 (2.4–4.8)
	Pharmacist participates in the stock control in the health unit					< 0.001
	Yes	3,377	64.2 (61.9–66.5)	32.0 (29.8–34.3)	3.8 (3.0–4.8)
	No	1,018	52.1 (48.2–56.1)	42.8 (38.9–46.7)	5.1 (3.5–7.3)
	Pharmacist participates of the medicines dispensing/delivery in the health unit					< 0.001
	Yes	3,045	63.9 (61.5–66.2)	32.1 (29.9–34.5)	4.0 (3.1–5.1)
	No	1,373	54.7 (51.1–58.2)	40.8 (37.3–44.4)	4.5 (3.2–6.3)
	Existence of an inventory control system (entry and exit) of medicines					< 0.001
	Yes, manual	2,327	57.8 (54.9–60.6)	36.9 (34.2–39.7)	5.3 (4.2–6.8)
	Yes, computerized	1,932	65.7 (62.8–68.4)	31.8 (29.2–34.7)	2.5 (1.7–3.5)
	No	160	60.1 (48.1–71.0)	35.5 (25.1–47.4)	4.5 (1.4–13.4)
	Existence of control of the expiration date of medicines					< 0.001
	Yes, manual	2,902	57.1 (54.5–59.6)	37.8 (35.3–40.3)	5.1 (4.1–6.4)
	Yes, computerized	1,437	69.7 (66.5–72.7)	28.5 (25.5–31.6)	1.8 (1.2–2.8)
	No	80	53.4 (37.9–68.3)	36.7 (23.1–52.9)	9.9 (3.7–23.7)
Pharmaceutical care	Performing a clinical activity					0.638
	Yes	343	67.5 (60.2–74.0)	29.3 (23.1–36.5)	3.2 (1.4–6.8)
	No	939	64.3 (60.4–68.1)	33.0 (29.3–36.8)	2.7 (1.7–4.3)

Variable	Null Access OR	Partial Access OR (95%CI)^*		Full Access OR (95%CI)^*
Participation of the RPS always or repeatedly at the Municipal Health Council	1.0	2.3	(1.0–5.1)	3.3	(1.5–7.3)
Existence of protocol for the delivery of medicines	1.0	3.0	(1.3–6.8)	2.7	(1.2–6.1)
Existence of computerized system for PS management	1.0	4.0	(1.9–8.2)	3.9	(1.9–8.0)
Existence of protocol for the storage of medicines	1.0	1.1	(0.4–2.5)	2.9	(1.2–6.9)

Variable	Null Access OR	Partial Access OR (95%CI)^*		Full Access OR (95%CI)^*
Participation in training or course for PS professionals in the city in the past two years	1.0	1.5	(0.8–2.7)	2.0	(1.1–3.5)
Existence of computerized system for PS management	1.0	2.8	(1.6–4.9)	4.3	(2.4–7.5)

[TFN1] PS: pharmaceutical services; SSM: Municipal Health System; RAF: responsible for pharmaceutical services

[TFN2] * Significant association: p < 0.05

[3] Source: PNAUM – Services, 2015.

Access to medicines: relations with the institutionalization of pharmaceutical services

ABSTRACT