Popular Pharmacy – which, for what and for whom?

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By FRANCISCO JUNIOR*

The great challenge that lies ahead is to place pharmaceutical assistance in the path of the conceptual dictates of the SUS, assuring the population, without distinction, universal, comprehensive and qualified access to medication

Brief context of pharmaceutical care in Brazil

Throughout its structuring and implementation process, the Unified Health System (SUS) has faced one of its biggest and main bottlenecks in pharmaceutical assistance. At the root of this gigantic difficulty, is the fact that medicine has historically been considered a commodity like any other – therefore, it can be dispensed by anyone, and be administered and consumed without any technical or sanitary care – and that pharmaceutical establishments are seen and treated as mere commercial establishments like any other.

In recent years, a deepening of the mercantilist culture of pharmaceutical care has been observed, with the creation of large chains of “stores” selling more and more “articles” and items with no relation to the drug. The search to sell and profit as much as possible is unbridled, regardless of the needs and clinical condition of the user/client, contributing to the strengthening of this mistaken culture of the indiscriminate and irresponsible use of what should be seen and treated as a necessary good for the health of the population.

 

Lula government and the program “Popular Pharmacy in Brazil”

It was under this reality that the Lula government, in its first version, introduced the Popular Pharmacy Program of Brazil (PFPB) to the country, through the 5.090 Decree 2004. We perceived at that moment a unique opportunity for the State to assume the task and responsibility of opposing a culture that was profoundly harmful to the health of the people and, politically and economically, to the country.

During the long debate held at the Plenary Session of the National Health Council, we defended that the PFPB, popularly known only as “Popular Pharmacy”, could be developed based on partnerships with the municipalities, so that a network of pharmaceutical establishments could be structured in the basic care in all municipalities in the country as effective health establishments, with a team of professionals trained to carry out pharmaceutical care in a qualified and resolute manner under the command of the pharmaceutical professional.

The municipalities, with all the capillarity that they contain and allow, would then have in their own network, pharmaceutical establishments that would not only become a reference for the population in terms of pharmaceutical assistance policy, but would also be a fundamental counterpoint to the private commercial network of medications that you would naturally feel pressured to do something similar.

Without any change in the legal framework and without any interference that could be seen as undue in the right to free initiative, the Brazilian State would be making history and transforming the social and health profile of the population's health.

 

The waste of a historic opportunity

Unfortunately and regrettably, the Program took the worst, most wasteful and unsustainable path, with the bulk of its funding being directed to the private network, with “Aqui tem Farmácia Popular” in 2006, while the so-called own network rapidly agonized, until it was definitively extinguished in 2017. In 2016 there were already 35 thousand accredited pharmacies.

Medicines for hypertension, diabetes and asthma at no additional cost, for dyslipidemia, high cholesterol, rhinitis, Parkinson's, osteoporosis and glaucoma with up to 90% discount on the market price and contraceptives and geriatric diapers through the co-payment system, had important impacts on the profile socioepidemiology of the Brazilian population.

 

The impacts and their limits

According to studies by the Federal University of Bahia, published in 2017, between 2006 and 2015 the rate of hospitalization for diabetes fell by 13% and hospitalizations for hypertension decreased by 23% across the country. Between 2011 and 2015, deaths from diabetes-related complications dropped by 8,23%. The drop in mortality in the Northeastern states was five times higher than the national average (Ministério da Saúde, 2023).

These are numbers and facts that unquestionably show the impacts of “Popular Pharmacy” on people's lives. After all, it was the concrete possibility that a significant portion of the Brazilian population, the most humble and excluded, had to access medicines that in normal circumstances were beyond their reach. For a significant range of people who until then were excluded, partially or completely, from access to medicine, it is obvious and understandable that the results obtained point to the importance of the change brought about by the Program.

It is here that we believe that a debate on the conception of the SUS and the State is of the utmost importance, which should always guide the themes and proposals to be implemented as a public policy by the Brazilian State. It is natural that in a reality characterized by increasing demands in all areas, any proposal that somehow guarantees an increase in access will have positive results. The question is to know the political and economic price to be paid by the SUS, what are the repercussions on its structure and its ability to function in accordance with the constitutionally defined principles.

It is under this prism that, for example, medical cooperatives – particularly – and all forms of outsourcing the workforce, contracting private services to replace the own network, Social Organizations, OSCIP and similar ones such as EBSERH, Foundations of Private Law, Autonomous Social Services and the so-called Public-Private Partnerships. All of them, obviously, somehow guarantee an increase in actions and assistance, but at a political and financial cost that increasingly suffocates the SUS and makes it unviable in its fundamental principles.

This is how, despite having important impacts on the service of the user population, despite this, “Farmácia Popular” has negative aspects as a result of its conceptual mistakes. Practically nothing has been achieved, for example, in the perspective of the qualification of pharmaceutical care, much less in the transformation of pharmaceutical establishments into effective health services. On the contrary, there was reinforcement of the culture of commodification of access to medicines, which reached levels never seen in the country.

It has become a routine, particularly in small and medium-sized municipalities, the worsening of shortages in public pharmacies, in primary care units, with patients being instructed to seek care in private establishments affiliated to the “Popular Pharmacy”, in a unacceptable process of disengagement from managers, whose consequences have been inestimable damage to the health of the population.

At the same time, accusations of corruption, various types of illegality and the absence of accredited establishments in places with low economic appeal, such as small municipalities and the outskirts of medium-sized municipalities, became frequent – ​​and revealing the essentially marketing nature of “Popular Pharmacy” size, limiting access and contributing to the maintenance of social exclusion for a significant portion of the population.

The conclusion we reached is that yet another important proposal from the perspective of serving the population in not only curative actions, but also the prevention of injuries and health promotion, ended up involved and made unfeasible due to private, market and political interests, from of an incongruous logic and contrary to the principles of SUS, and compromising the financial and political sustainability of Pharmaceutical Assistance by our universal health system, as a right of the drug user population.

 

What to do?

The great challenge ahead of us is to place pharmaceutical assistance in the path of the conceptual dictates of the SUS, assuring the population, without distinction, universal, comprehensive and qualified access to medication. In other words, making pharmaceutical care an indispensable and inseparable requirement from medication as a necessary good for health, fundamental at all levels of care in the quest to guarantee people's full health.

For this, it is crucial that the federal government change the mercantilist, counterproductive, unsustainable and exclusionary logic of “Popular Pharmacy”, renewing the program and reorienting it towards the signing of agreements and partnerships with all municipalities in the country, implementing pharmacies in basic units of health, in a regionalized way, providing all pharmaceutical establishments with teams of professionals trained and qualified to develop pharmaceutical care and other possibilities inherent to the service, so that, in these Basic Health Units (UBS), the population can be welcomed, assisted and oriented in the way recommended by manuals and specialized policies.

Structured and organized in a network, these UBS pharmacies must be integrated with the other health services produced in these units, such as the family health strategy, among others, and must be linked to assigned populations in previously determined areas.

In addition, the new “Popular Pharmacy”, reoriented according to the principles of the SUS and bearing a culture that denies the commercialization of medicines, must have a direct link with the official laboratories that have objective conditions to produce a significant part of the list of medicines to be available across the country. The centralization of the acquisition process, as well as its packaging and distribution, must be guided by databases that provide in real time the reality of each municipality and each service unit, as well as their pharmaceutical demands in tune with the socio-epidemiological profile of each stratum of the referenced population.

This change of direction in “Farmácia Popular” is urgent and has the potential to promote a leap in quality in the access and use of medication in Brazil, decisively contributing to make pharmaceutical establishments effective health establishments and placing pharmaceutical professionals and the medicine, a good necessary for health, and not just any commodity, at the center of the policy of pharmaceutical, qualified and resolute assistance. This reorientation of the PFPB implies the recognition of medication as an inalienable right, absolutely fundamental in complying with the principles of universality and comprehensiveness, as advocated by the SUS.

*Francisco Junior He is a hospital pharmacist for the SUS in Rio Grande do Norte. Former President of the National Health Council (2006-2011).


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