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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.24 no.11 Rio de Janeiro Nov. 2019  Epub Oct 28, 2019

https://doi.org/10.1590/1413-812320182411.06132018 

REVIEW

Implementation, access and use of integrative and complementary practices in the unified health system: a literature review

Ludmila de Oliveira Ruela1 
http://orcid.org/0000-0001-9071-539X

Caroline de Castro Moura2 
http://orcid.org/0000-0003-1224-7177

Clícia Valim Côrtes Gradim3 
http://orcid.org/0000-0002-1852-2646

Juliana Stefanello1 
http://orcid.org/0000-0003-3926-0144

Denise Hollanda Iunes3 
http://orcid.org/0000-0003-1396-9980

Rogério Ramos do Prado4 
http://orcid.org/0000-0003-2767-3283

1Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Av. dos Bandeirantes 3900, Monte Alegre. 14040-902 Ribeirão Preto, SP, Brasil. ludmilaoliveira@usp.br

2Escola de Enfermagem, Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil.

3Escola de Enfermagem, Universidade Federal de Alfenas. Alfenas, MG, Brasil.

4Diretoria de Extensão e Assuntos Comunitários, Universidade José do Rosário Vellano. Alfenas, MG, Brasil.


Abstract

In Brazil, the Integrative and Complementary Practices (ICP) achieved greater visibility after the establishment of the National Integrative and Complementary Practices Policy (NICPP) in 2006. However, there are still gaps in the general setting of these practices. Thus, this study aimed to analyze the implementation, access and use of ICPs in the Brazilian Unified Health System (SUS) after the establishment of this policy. We performed an integrative literature review, guided by the question: “What is the current setting of implementation, access and use of ICPs within the SUS?”, in the Virtual Health Library (BVS), the U.S. National Library of Medicine and in the Web of Science, with descriptors “Sistema Único de Saúde” / “Unified Health System” AND “Terapias Complementares” / “Complementary Therapies”. The analysis of papers gave rise to four categories for discussion: “The ICP approach in the SUS: main practices used”; “Access to ICPs: Primary Health Care as a gateway”; “Current implementation scenario of ICPs: the preparation of health services and professionals for to implement ICPs”; “Main advances in the use of ICPs and future challenges”. We have observed that ICPs are bashfully offered and that data available are scarce, despite the positive impacts on users and services that have embraced their use.

Key words Unified Health System; Complementary therapies

Resumo

No Brasil, as Práticas Integrativas e Complementares (PIC) tiveram maior visibilidade após a criação da Política Nacional de Práticas Integrativas e Complementares, em 2006. Contudo, ainda existem lacunas sobre o cenário geral dessas práticas. O objetivo deste estudo foi analisar a implementação, o acesso e o uso das PIC no Sistema Único de Saúde (SUS) após a implantação da política. Foi realizada uma revisão integrativa da literatura, guiada pela questão: “Qual o atual cenário de implementação, acesso e utilização das PIC no âmbito do SUS?”, na Biblioteca Virtual em Saúde, na US National Library of Medicine e na Web of Science, com os descritores “Sistema Único de Saúde”/“Unified Health System” AND “Terapias complementares”/“Complementary Therapies”. Da análise dos artigos, emergiram quatro categorias de discussão: “A abordagem das PIC no SUS: principais práticas usadas”; “O acesso às PIC: a Atenção Básica à Saúde como porta de entrada”; “Atual cenário de implementação das PIC: o preparo dos serviços e dos profissionais da saúde para a realização das PIC”; “Principais avanços no uso das PIC e desafios futuros”. Observa-se que as PIC são oferecidas de forma tímida e os dados disponíveis são escassos, apesar dos reflexos positivos para os usuários e para os serviços que aderiram à sua utilização.

Palavras-chave Sistema Único de Saúde; Terapias complementares

Introduction

Since the 1990s, the use of Integrative and Complementary Practices (ICPs) has increased in global proportions1. Its growth and visibility occurred mainly with incentive from the World Health Organization (WHO) in 2002, through the elaboration of a normative document to its member countries, which aims to develop and regulate such practices in health services, as well as increase access, rational use and evaluation of the efficacy and safety of such techniques from scientific studies2.

In this setting, in 2006, through Ordinance Nº 971/2006, the Ministry of Health published the National Integrative and Complementary Practices Policy (NICPP) in the Unified Health System (SUS), with the aim of ensuring integrality in health services3. From then on, the provision and incentive to use ICPs, such as herbal medicine, homeopathy, acupuncture, among others, was legitimized in the SUS, increasing the use of these practices4.

It is worth emphasizing that the implantation of the NICPP was of a political, technical, economic, social and cultural nature since it established national guidelines for the use of ICPs based on experiences and practices already adopted in the health services, which obtained satisfactory results3.This fact further facilitated the dissemination of these practices in different parts of the country.

In this context, Brazil has emerged as one of the 69 WHO Member States with specific policies and strategies for the use of ICPs5. After the NICPP was established, 30% of Brazilian municipalities adopted their regulations for the use of these therapies, which indicates significant growth in healthcare practices, and PHC is one of the primary environments for their application4.

Therefore, it is imperative to analyze the current setting of the provision of these treatments in the country, as well as access to them and their use in public health services. Thus, this study aimed to analyze the implementation, access and use of ICPs in the SUS through a review of the national literature published after the implementation of the NICPP.

Methods

This is an integrative review of the literature, based on the steps proposed by Whittemore and Knafl6, with the following guiding question: “What is the current setting of implementation, access and use of Integrative and Complementary Practices within the Unified Health System?”

We searched the Latin American & Caribbean Health Sciences Literature (Lilacs), Nursing Database (BDENF), HomeoIndex and the Spanish Bibliographic Index of Health Sciences (IBECS) via the Virtual Health Library (BVS); in the Medical Literature Analysis and Retrieval System Online (Medline) via the US National Library of Medicine (PubMed) and the Web of Science, by two independent researchers, with standardized descriptors extracted from the Health Sciences Descriptors (DeCS) and the Boolean operator AND, which resulted in the combination “Sistema Único de Saúde’ / “Unified Health System” AND “Terapias Complementares”/ “Complementary Therapies”.

Papers published in the 2006-2017 period, in Portuguese, English and Spanish languages, with abstract available in the database, and which were conducted in a national setting were the inclusion criteria. Studies that did not respond to the guiding question were excluded.

Firstly, papers were selected by two independent researchers, who read the title and abstract, according to the guiding question and the eligibility criteria. After the selection, they were read in full and, for data collection and evaluation, a tool elaborated by researchers adapted from Ursi7 was applied. This tool consisted of the following items: title of paper; authors and year of publication; objective (s) of the study; methodological characteristics; level of health care (primary, secondary and tertiary) where the study was conducted; results; and conclusions.

Figure 1 shows the flowchart of the selection of papers.

Source: Authors.

Figure 1 Flowchart of the selection of papers. 

Results

Chart 1 shows the main information extracted from the selected papers.

Chart 1 Papers included in the analysis of the integrative review. Minas Gerais, 2017. 

Authors (years) Study approach Study objective Main results Conclusion
Fontanella et al. (2007)16 Quantitative To evaluate the knowledge, access and acceptance related to ICPs of a SUS user community of the South Brazilian region. Most ICPs were not known by the population. The use of therapies without expert follow-up was frequent, which, together with the low access of the community, shows the lack of professionals qualified for this care. There is evidence of low knowledge and access to ICPs, despite population's interest and acceptance. Also, the use of therapies occurs without the consultation of specialized professionals.
Monteiro and Iriart (2007)12 Case study Understand the motivations of users to look for homeopathy, how they portray and explain the action of medications and homeopathic treatments. The primary motivation for seeking homeopathy was the failure of allopathic treatment. The holistic perspective, the use of natural medicines, long consultation time and active listening were brought as favorable differential characteristics when compared to allopathic treatment. The potential of the contribution of therapeutic alternatives such as homeopathy in the public health service is poorly explored.
Tesser and Barros (2008)17 Reflective analysis To analyze potentialities and difficulties of practices and Alternative and Complementary Medicines (ACM) from clinical-institutional experiences and specialized literature The SUS provides ACM. There are common favorable manifestations of policies of the civil society and users' representatives regarding the provision of ACM by the SUS. ACM has limited "demedicalizing" potential. The political-epistemological hegemony of bioscience and the current health market dispute, whose tendency is to transform any knowledge or practice of the health-disease process into commodities or procedures to be consumed must be observed.
Ceolin et al. (2009)8 Reflective analysis To discuss the use of complementary therapies in Brazil, aiming at the comprehensive care of the individual and the introduction of the nurse practitioner in these practices. The use of medicinal plants has increased to meet the needs of users. Nurses must expand their knowledge and gain space for the use of complementary therapies. The biomedical model is flawed in the comprehensive care to the user. Thus, it has sought other treatments. Medicinal plants bridge this gap.
Salles and Schraiber (2009)13 Reflective analysis To investigate the characteristics of the relationship currently established between Homeopathy and Biomedicine, according to the point of view of non-homeopathic physicians. The support of managers to the presence of Homeopathy in the SUS is related to the perception of social demand, to the protection of the right of choice of users and to the fact that it is a medical practice that revives the humanist realm of medicine. The notion of Homeopathy as a "mild medicine" predominates, which could slowly promote improved symptoms. There is a lack of service structure for acute care cases. The training of homeopaths is flawed since the specialization courses do not provide training to attend severe cases.
Andrade and Costa (2010)18 Reflective analysis To consider the aspects of the institutionalization of ICPs, to reflect on the paradigmatic foundations of their therapeutic action and to analyze the comprehensive and complex character of its application, with specific anthropological views in the dialogue. The public health system carries to its core other traditional knowledge and rationalities, which come to live with the conventional logic and services of biomedicine. It is necessary to study the concept of integrality further, as well as to face the practical challenges of implementing the ICPs.
Marques et al. (2011)19 Qualitative To investigate the knowledge and acceptance of integrative and complementary therapies and pharmaceutical care by users of SUS PHC facilities 100% of participants did not know what integrative and complementary therapies were all about. Doctors' knowledge about acupuncture and homeopathy is almost non-existent. Most of the respondents would accept the use of the therapies if they were offered by the health facility, in addition to finding the pharmacist's attention more critical. There is little dissemination, and few social programs seek to show the benefits of such therapies.
Nagai and Queiroz (2011)20 Qualitative To focus the implementation of complementary and alternative practices with the purpose of evaluating the conditions of their occurrence from the social representations of the professionals who participate in this process. Four reasons were found for the success of the inclusion of ICPs: the willingness of the clientele; the health vision of hygienist doctors; extensive support from non-medical health professionals; and the perspective of alternative and complementary medicines that are in line with the SUS proposal. Despite the success in implementing these practices in the primary network, the planning of these actions is insufficient and the vision is simplified, which turns alternative rationalities into mere techniques that follow the same mechanistic principles of allopathic medicine and the same reified understanding of the disease.
Santos et al. (2011)9 Qualitative To do a bibliographical survey, on the subjects like the importance of the herbal medicine; how it is being used; its benefits to the Public Health System; training of professionals in this area and programs and laws for implementation in the SUS. The government has shown interest in the development of policies for health care procedures that are effective, comprehensive, humanized and less dependent on the pharmaceutical industry. Brazilian municipalities have carried out the implementation of Herbal medicine Programs in primary care. Studies on herbal medicine are still scarce in Brazil, and research is needed in this area to expand the knowledge of health professionals and students, helping and strengthening the safety and efficacy bases for the implementation of herbal medicine practices in the SUS.
Thiago and Tesser (2011)21 Quantitative To analyze the perception of professionals of the Family Health Strategy (ESF) about integrative and complementary practices. 17 health centers provided integrative and complementary practices; 12.4% of professionals were homeopathy or acupuncture experts. In total, 88.7% of the participants did not know the national guidelines on this subject, although 81.4% agreed with their inclusion in the SUS. Professionals accept ICPS, and this is due to with their prior contact and possibly related to in family medicine and community / family health residency / specialization.
Ischkanian and Pelicioni (2012)22 Qualitative To investigate the knowledge, opinions and social representations of the managers and health professionals about the ICPs in the SUS and to identify the difficulties and challenges in their implementation, use and disclosure in the Health Services. The managers were not prepared for the implementation of the NICPP in the SUS. The biomedical model is prevalent and the provision of supplies used for the application of ICPs has been a problem. The dissemination of ICPs has not been sufficient among professionals and users. The municipality must encourage and create conditions for the provision of ICPs, improving their dissemination and supporting the integration of non-medical professionals with appropriate training. ICPs integration in the SUS can undoubtedly contribute to health promotion.
Oliveira et al. (2012)10 Quantitative Interviewing professionals working in the SUS, as well as patients who use PHC, concerning their experience with ethnomedicine. 91.6% of the participants made use of medicinal plants at least once to treat specific diseases. Of the professionals, 65% used medicinal plants and 10% prescribed herbal medicines to patients. Patients and professionals reported knowing the medicinal plants due to their parents or grandparents. A high proportion of users and professionals made use of medicinal plants and plants. Mallow was the most commonly used. The primary source of knowledge about herbal medicine was from parents or grandparents.
Fontenele et al. (2013)11 Quali-quantitative To understand how managers and professionals at tertiary level in Teresina (PI) see the introduction of herbal medicine in Primary Care in the city, relating these data with knowledge of these professionals about this therapeutic practice, its use and the public policies involved. The strengthening of the herbal medicine in PHC and its incorporation in the routine of the professional practice of the ESF are necessary for the discussion about herbal medicine in the PHC between the actors and the bodies involved, and the qualification of the health professionals. The professionals' knowledge about health practices is relevant for the recognition of the situation, planning and streamlining of the application of health actions, especially those involving herbal medicine and other ICPs because they have specific policies.
Galhardi et al. (2013)14 Quanti-qualitative To analyze the knowledge of the health managers of the municipalities of São Paulo on the Policy and its importance for the implementation of homeopathy in the local health services. Of the 645 municipalities analyzed, 47 provided homeopathy. 42 municipalities were interviewed. 26% knew the NICPP, 31% knew little and 41% were unaware of it. NICPP is unknown to health managers and those who know it use it to divulge the homeopathic medical rationality and justify its indication in the SUS.
Silva and Tesser (2013)15 Qualitative To investigate the experience of SUS acupuncture users in Florianópolis, Santa Catarina, Brazil about their treatment, including their perception of efficacy, reduced medication use, guidelines received, changes in self-care and explanatory models of users, from the viewpoint of medicalization in the mentioned focus. To investigate this experience in different care settings by testing the hypothesis that primary health care may assumingly be an environment more favorable to the rationality of Traditional Chinese Medicine and acupuncture. Acupuncture has poorly contributed to autonomy and demedicalization, except for its effectiveness. The attitude of professionals is essential to stimulate a more active and integral posture. Most patients came to acupuncture in secondary care when other treatments failed. The practice was perceived effectively and favored the reduction of medications. Despite the difficulty of access, it was observed that PHC professionals have greater autonomy to care for patients, and can treat more severe cases for a more extended period.
Lima et al. (2014)23 Qualitative To show and discuss results of a research that analyzed the organization of ICPs developed in a CIP referral service, in the metropolitan region of Belo Horizonte, focusing its relationship with the promotion of health and its insertion in the SUS. Practices can be a useful resource in health promotion, notably by establishing a new understanding of the health-disease process. It is necessary to overcome the challenges of its organization and its expansion to strengthen ICPs in the field of promotion and care in the SUS, such as drawing professionals closer to CIP referral and support services of PHC.
Sousa and Tesser (2017)24 Qualitative To analyze the insertion of traditional and complementary medicine (TCM) in the SUS, with the aim of supporting the discussion about its integration in PHC via ESF. Types of TCM insertion and integration: Type 1 - Integrated; Type 2 - Overlapped; Type 3 - Integrated; Type 4 - No integration. The combination of types 1 and 3 is considered a potential for the expansion of TCM in the SUS, influencing growth and its integration into PHC. The growing presence of the TCM in SUS requires thinking strategies for its expansion, beyond NICPP, considering the previous experiences.

Source: Authors.

Concerning the type of ICP used, 23.52% of the studies addressed herbal medicine8-11, 17.64% homeopathy12-14, 5.90% acupuncture15 and 52,94% of the studies have evaluated ICPs in general16-24.

Regarding the level of care where practice was performed, 52.94% occurred at the primary care level8,10-12,16,19-21,24 and 17.65% at the primary/secondary level15,22,23. Other authors (29.41%) addressed practice in the general SUS scenario9,13,14,17,18. It was also identified that all the analyzed papers showed level IV of evidence. Also, the main topics covered were the main ICPs adopted in the SUS, access to these practices, and preparedness of health services and professionals for their implementation and use. The categories of discussion were elaborated from these themes.

Discussion

The ICPs’ approach in the SUS: main practices

Initially, the NICPP only included five ICPs in its guidelines to be employed in the SUS in order to promote the recovery, maintenance and prevention of users’ health, besides the cure of some diseases, and they are: Traditional Chinese Medicine/Acupuncture; Homeopathy; Medicinal Plants/Herbal Medicine; Thermalism/Cryotherapy; and Anthroposophical Medicine25. However, in recognizing the increasing use of other practices based on traditional knowledge by the population in general, the MoH included, between 2017 and 2018, new therapeutic resources in the NICPP, through Ordinances No. 849/201726 and No. 702/201827. With these measures, the SUS currently provides 29 of these practices.

Given the ICPs options fostered by the policy, the results of this study show that many of these were not addressed by the authors or were merely cited without further elaboration. Therefore, studies that analyzed several practices in the same research prevailed, such as: acupuncture, homeopathy, herbal medicine, among others, analyzing their implantation and organization and the knowledge of users and professionals about ICPs16,19,20,22-24; as well as those studies that pointed out a general context of therapies in the SUS, without specifying the practices used17,18,21. Thus, it was possible to observe the lack of studies that investigated the use of some practices, such as Thermalism/Crenotherapy and Anthroposophical Medicine, pointing out a gap for their use in the SUS. However, this may be a reflection of the low supply of such therapies in services, which precludes the discussion of these practices in the studies analyzed.

Among the studies that addressed specifically practices, we highlight the use of herbal medicine8-11 and homeopathy12-14. Acupuncture was investigated in isolation by Silva and Tesser15. However, both homeopathy and acupuncture, even in the studies that analyzed several practices together, emerged as those with higher adherence by users and greater provision of services15,21,22. This is in line with data presented by the MoH in 2008, which show keen interest on the part of the government and the population in these therapies when compared to the others28.

While mechanisms of action of acupuncture29,30 and homeopathy31,32 are still not entirely clear and sometimes inconclusive, their benefits have been demonstrated in different studies for different diseases33-36. As a result, adherence to these treatments is increasingly progressive, so that 80% of the 129 WHO member countries already recognize acupuncture as a health treatment5, and homeopathy is one of the most indicated ICPs in European countries, as in France37.

In general, ICPs can be seen as an essential healthcare strategy, especially considering the person as a whole, differing from the biomedical model23. Demand for ICPs is mostly due to complicated reasons, ranging from factors such as low profile of adverse effects, to the natural consequence of incentive towards inside-out healing, search for complementation of allopathic treatment, reception and active listening performed during the consultation, as well as compatibility of such practices with values, beliefs and philosophy of health and life of the user17,38. Also, they may be perceived as a potential drug consumption reducer15.

Tesser39 also points out that the reasons that lead users to seek such treatments may be associated with critical socioeconomic factors. In developing countries, local culture, easy access to alternative practices, the high cost of conventional medicine, and the limited availability of biomedical resources facilitate the search for complementary medicine. However, in rich countries, dissatisfaction with the biomedical model and the benefits of ICPs are the factors that foster this demand.

Access to ICPs: Primary Health Care (PHC) as a gateway

Since PHC should be the user’s first contact and gateway to the healthcare network, according to the National Primary Healthcare Policy (PNAB)40, it is possible to infer that this level of care is a privileged locus for the implementation of ICPs in the Brazilian public health system. In fact, data from the MoH indicate that ICPs are mostly provided in PHC services41.

A recent study42 conducted in Florianópolis indicated that PHC professionals usually encouraged ICP use during the consultation with the patient and started treatment as soon as possible, often during the consultation itself. Thus, treatment with ICPs can be in some cases the initial approach, where conventional therapy is the second option, if necessary, or complementing the ICPs approach. Also, the availability of ICPs in PHC services may promote increased dialogue between practitioners and users about which therapy to use, namely, conventional therapy or ICPs, and this may have a positive effect on this contact42.

In this study, some authors point to secondary care services15,22,23 as access to ICPs. However, in order to achieve these sites as a field of care and provision of complementary treatments, it is necessary to approach professionals at both the primary and secondary levels so that they can be consolidated as a network of comprehensive care and universal access, taking into account the principles and foundations of each of the practices23.

Although the use of ICPs in secondary and tertiary care environments is more restricted, there is an albeit bashful tendency for their use at these levels, since 1,708 Brazilian municipalities provide ICPs, 78% in PHC, 18% in secondary care and 4% in tertiary care43. However, when considering PHC as the level of care with the highest capacity to develop health prevention and recovery actions, the use of ICPs in these services is the most appropriate. Furthermore, such practices do not require sophisticated technological resources, they provide lower risks of side effects when compared to conventional treatments, and demand fewer financial resources, making health care more affordable and of high quality, besides providing satisfactory results2,44.

However, the difficult of access to ICPs at the various levels of care, especially in the secondary and tertiary sectors, may be related to the lack of knowledge by professionals about the use of these practices. Also, it is emphasized that many of these workers do not understand the importance or do not have the adequate ability to indicate or apply such practices16,18.

Despite this obstacle, their availability in services is accepted and expected, especially by users17,19. Thus, a movement of Brazilian municipalities to implement the use of ICPs in the last years is observed9. However, local management should encourage the strengthening and use of these practices and provide conditions for their provision to the population, through dissemination and support, following recommendations of the NICPP11,22.

Current scenario of implementation of ICPs: preparedness of health services and practitioners for ICPs

Human resources are essential for the use of ICPs in the SUS. In this context, vocational training is a significant gap for the successful implementation of the practices13,16,22. The lack of knowledge of the NICPP, as well as of therapies addressed in the policy hinders professionals’ and services’ participation in the provision of practices13,14.

In Brazil, in addition to physicians, other health professionals, such as nurses, physiotherapists, pharmacists, among others, are qualified to use various practices fostered by the policy3. However, the low adherence to specializations in the area of complementary interventions and poor education about the purposes of using ICPs during training prevent more significant improvement of health professionals9, although many show an interest in training and agreement with the use of practices in services21.

One of the main difficulties pointed out by the managers for the implementation of these therapies is the resistance by some health professionals attributed to scarce scientific evidence and lack of logistical and structural support of the local management11. This is therefore considered an important problem since the positive attitude of professionals vis-à-vis these practices is relevant to motivate users towards adopting ICPs15.

Another fact that causes a stir is related to increased ICPs in the SUS. However, this was more significant from the application of practices by non-medical professionals45, which requires that other team members expand their knowledge about complementary treatments and gain space for the use of such practices8. Thus, managers should provide support and incentives in the supply of these resources to revive the humanistic realm of health care13.

In this context, greater knowledge about the policy and ICPs, as well as, for example, encouraging professionals through lifelong learning can be effective strategies for implementing and expanding the implementation of NICPP and improving access to health services within the SUS.

Although there are still few Brazilian studies on continuing education geared to these practices, Santos and Tesser46 show a method of implementation and promotion of access to ICPs in PHC based on previous experiences, consisting of four sequential stages. The first stage establishes the people responsible, who will spearhead this process (preferably, professionals with expertise in ICPs). In the second stage, a situational analysis will be carried out, in which these professionals, whether active or not, will be mapped and recruited so that, through implementation and access discussions, they conduct a survey on issues that hinder access to ICPs, on the organization of actions, the attendance flow of services and the formalization of activities developed, making a local situational analysis of ICPs. Regulations will be set during the third stage, establishing standards and adaptations for the development of ICPs in line with the current policy (NICPP) and, finally, during the fourth stage, the implementation takes place cyclically and continuously, which will be influenced by the productive capacity of the responsible staff46.

This model can help managers and professionals strategically expand existing services or implement new services that will facilitate and allow the general population’s access to ICPs. Thus, it is likely that initial investments and continuous training of network professionals will be necessary to meet demand in a qualified and decisive manner. However, over time, there may be lower values and higher service quality in services, since most practices require low operational costs and have fast and satisfactory results.

Significant advances in the use of ICPs and future challenges

Despite the increase in ICPs use in recent years, its therapeutic potential and its contributions to health are still poorly explored in the SUS8,9. Although the MoH has positively evaluated this increase47, there are gaps such as assessments of ICPs in services and better monitoring of the policy’s impact.

Moreover, the preeminence of the current biomedical model coupled with the market trend in health care, which transforms knowledge and practices into commodities, can be a substantial limitation in the expected advances for these practices17. Thus, one challenge is the further analysis of care in a comprehensive care model, surpassing the supremacy of the rationale of biomedicine-based services18.

Other vital challenges are related to the training of and incentive to the health team members, support to non-medical professionals, as well as awareness and understanding of ICPs’ perspectives. These factors are essential for the successful introduction of ICPs into the SUS20 and to ensure the principles of the NICPP, contributing to the promotion of health throughout the care network22.

Study limitations and suggestions for future studies

The use of only two controlled descriptors (Unified Health System and Complementary Therapies) may have reduced the number of papers evaluated as to the eligibility criteria of the study. Thus, for future studies, we would suggest to include other more specific descriptors, such as, for example, Healthcare levels or Primary Health Care, besides specifying ICPs, especially the most prevalent ones, in the search fields (such as herbal medicine, homeopathy, acupuncture, bodily practices, among others) in order to expand the range of results obtained.

Final considerations

After a decade of policy implementation, we can consider that ICPs are provided incipiently in the SUS and scarce data on specific practices are a limitation to the current scenario of this approach. However, positive reflexes can be observed for users and services that have adhered to their use, although there are still challenges in their implementation, in their access and use and the education of trained professionals.

Thus, new studies with a historical approach to complementary practices are required following the creation of the NICPP and on the impacts on the Brazilian public health, as well as incentives for professional improvement, mainly for PHC workers, as a fundamental tool for the implementation, access and use of ICPs in the SUS.

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Received: July 19, 2017; Accepted: April 20, 2018; Published: April 22, 2018

Collaborations

LO Ruela: design, conception, analysis and interpretation of data, writing of the article and relevant critical review of the intellectual content, final approval of the version to be published. CC Moura: data analysis and interpretation, article writing and relevant critical review of the intellectual content, final approval of the version to be published. CVC Gradim, J Stefanello, DH Iunes: data analysis and interpretation, article writing and relevant critical review of intellectual content, final approval of the version to be published. RR Prado: data analysis and interpretation, relevant critical review of intellectual content, final approval of version to be published.

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