Abstract

Comprehensive access to health is a global issue. One-third of the population does not have regular access to essential medicines. People Deprived of Liberty (PDL) are one of those people in a situation of unequal access. Given the uniqueness of the penitentiary system, this research aimed to identify the determining factors in the access to medicines made available by the Brazilian Unified Health System (SUS) for the PDLs in Pará, Brazil. The applied, exploratory, qualitative research was conducted from August 2019 to February 2020 using the APOTECA framework. The APOTECA framework analysis revealed that technical, political, and administrative factors are the main hurdles to guaranteeing equal access to medicines made available by the SUS for the PDLs in Pará. The deprivation of liberty, social vulnerability, and other factors inherent to the prison reality hinder the implementation of PDLs’ right to health, and several challenges must be overcome to secure equal access to medicines.

Key words:
Penitentiary System; Prison Health; People Deprived of Liberty; Pharmaceutical Care; Medicines

Introduction

The right to health for every Brazilian citizen was defined by the 1988 Brazilian Constitution as a duty of the State, guaranteed through political, social, and economic measures to reduce the risk of diseases and disorders, and the universal and equal access to actions and services for their health promotion, protection, and recovery through concerted action between the three federative levels - Federal Government, states, and municipalities - through the Brazilian Unified System of Health (SUS)¹1 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out..

With doctrinal and administrative principles established from Article 198 of the Brazilian Constitution and the Organic Health Law, the SUS represents a set of health actions and services that promote quality of life for the entire Brazilian population, guaranteeing people’s access to equitable, comprehensive health care²2 Brasil. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 20 set..

Comprehensive health care includes ensuring access to medicines. Access to medicines available in the SUS occurs differently, depending on the medicine and the governmental sphere responsible for the respective stage of the pharmaceutical care cycle. Furthermore, we should note the difficulty of including the PDLs in the SUS, even with the constitutional assurance and specific legislation that guarantee full access to health without exclusions and stigmas.

PDLs’ right to health was secured in Brazil by the Criminal Enforcement Law in 1984 and the 1988 Federal Constitution. However, both were insufficient to include this population in the SUS¹1 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out.^,33 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 7.210, de 11 de julho de 1984. Institui a Lei de Execução Penal. Diário Oficial da União 1984; 13 jul..

A significant boost to ensure the principles of universality, equity, comprehensiveness, and care resolution stemmed from the institutionalization of the National Penitentiary System Health Plan in 2003 and the National Comprehensive Health Care Policy for People Deprived of Liberty in the Prison System (PNAISP) in 2014, which aim to guarantee access and comprehensive care, considering the inherent heterogeneity of the penitentiary system, and establishing that prison units are gateways and points of care for the Health Care Network⁴4 Brasil. Ministério da Saúde (MS). Gabinete do Ministro. Portaria Interministerial nº 1.777, de 9 de setembro de 2003. Aprova o Plano Nacional de Saúde no Sistema Penitenciário, destinado a prover a atenção integral à saúde da população prisional confinada em unidades masculinas e femininas, bem como nas psiquiátricas. Diário Oficial da União; 2003.^,55 Brasil. Portaria Interministerial nº 1, de 2 de janeiro de 2014. Institui a Política Nacional de Atenção Integrada de Saúde das Pessoas Privadas de Liberdade no Sistema Prisional no âmbito do Sistema Único de Saúde. Diário Oficial da União 2014; 2 jan..

In general, the health of PDLs in the Brazilian penitentiary system is troubling due to the prevalence of diseases resulting from confinement and the reductionist, fragmented, and limited view of care offered in correctional facilities⁶6 Brasil. Resolução do Conselho Nacional de Saúde nº 338, de 6 de maio de 2004. Aprova a Política Nacional de Assistência Farmacêutica. Diário Oficial da União 2004, 6 maio..

Access to health is a global issue, and it is estimated that one-third of the population does not have regular access to essential medicines⁷7 Leite SN. Gestão da assistência farmacêutica. Florianópolis: UFSC; 2016., and the prison population is one with more critical inequitable access⁸8 Assis MMA, Jesus WLA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cien Saude Colet 2012; 17(11):2865-2875..

Access to medicines is knowingly a guiding line of public policies in pharmaceutical care in the SUS, and medicines are one of the primary therapeutic interventions, directly impacting the resolution of health actions⁹9 Brasil. Conselho Nacional de Secretários de Saúde. Assistência Farmacêutica no SUS. Brasília: CONASS; 2011., where the lack of medication can aggravate diseases, elevating expenses with secondary and tertiary care¹⁰10 Paniz VMV, Fassa AG, Facchini LA, Bertoldi AD, Piccini RX, Tomasi E, Thumé E, Silveira DS, Siqueira FV, Rodrigues MA. Acesso a medicamentos e uso contínuo em adultos e idosos nas regiões Sul e Nordeste. Cad Saude Publica 2008; 24(2):267-280..

Access to medicines is fundamental in assuring the constitutional right to health. In this context, pharmaceutical care is understood as a cross-sectional policy that encompasses a set of actions geared to promote, protect, and recover individual and collective health based on access and rational use of medicines. However, the process for obtaining medicines from the SUS commonly involves the need to access different programs in different spheres (municipal, state, or federal) per the National List of Essential Medicines (RENAME)¹¹11 Brasil. Relação Nacional de Medicamentos Essenciais RENAME 2020 [Internet]. [acessado 2021 jan 21]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/assistencia-farmaceutica-no-sus/rename.
https://www.gov.br/saude/pt-br/assuntos/... , which contains the medicines available in the SUS, to meet the priority health needs of the Brazilian population and the responsibility of the federative entity for the respective acquisition and distribution⁶6 Brasil. Resolução do Conselho Nacional de Saúde nº 338, de 6 de maio de 2004. Aprova a Política Nacional de Assistência Farmacêutica. Diário Oficial da União 2004, 6 maio..

While being a State’s responsibility, contributing to the health promotion of PDLs is a mission and a challenge for health professionals and citizens who believe in a fair society without being excluded. Given the uniqueness of the penitentiary system, this research was conducted to identify the determining factors in the access to medicines made available by the SUS for the PDLs of Pará to promote equitable and comprehensive access to drug therapy treatment and, consequently, improve pharmaceutical care within the penitentiary system.

Methods

This applied, exploratory, qualitative research was conducted from August 2019 to February 2020, using the APOTECA framework to identify determining factors and generate insights about strategies to overcome barriers and promote facilitators¹²12 Onozato T. Fatores que influenciam a implementação de serviços clínicos farmacêuticos em hospitais: identificação e análise pelo framework Apoteca [tese]. Aracaju: Universidade Federal de Sergipe; 2018.^,1313 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan - a web and mobile app for systematic reviews. Syst Rev 2016; 5:210..

The APOTECA framework proposes the Attitudinal, Political, Technical, and Administrative factors, whose initials coincidentally formed the acronym Apoteca, very close to the Latin word apothēca, which gave rise to the English word apothecary and with some variations, currently means pharmacy in German, Dutch, Slavic, Scandinavian, and other languages. Political, technical, and administrative factors are fundamental and independent but interconnected by attitudinal factors¹²12 Onozato T. Fatores que influenciam a implementação de serviços clínicos farmacêuticos em hospitais: identificação e análise pelo framework Apoteca [tese]. Aracaju: Universidade Federal de Sergipe; 2018.^,1313 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan - a web and mobile app for systematic reviews. Syst Rev 2016; 5:210..

Gerhardt and Silveira¹⁴14 Gerhardt TE, Silveira DT. Métodos de Pesquisa. Porto Alegre: UFRGS; 2009. record that the exploratory study provides greater proximity to the investigated object to make it more explicit through the bibliographic survey and interviews that may contribute to a greater understanding of the problem. Sampieri et al.¹⁵15 Sampieri RH, Collado CF, Lucio MPB. Metodologia de pesquisa. 5ª ed. Porto Alegre: Penso; 2013. affirm that qualitative research provides a more concrete analysis of the social world per what is observed.

The study was developed within the Pará State Public Health Secretariat (SESPA) and Pará State Penitentiary Administration Secretariat (SEAP). The instruments used for data collection (qualitative approach) were formatted from the theoretical framework, prepared, and standardized in May 2019, covering aspects related to organizational structure, SUS regulatory frameworks, concepts related to pharmaceutical care in the prison system, Pará prison system setting, funding medicines made available by the SUS, the logistical cycle of care in the prison system and access to medicines within the prison system, and they are specific to each category of survey informants.

They consisted of open-ended and closed- ended questions, answered in writing and without the researcher’s interference or influence, applied through an interview directed to the research informants (https://doi.org/10.48331/scielodata.DTYP7X)¹⁶16 Costa APAM, Soler O, Queiroz LMD. Replication Data for: Assistência farmacêutica prisional paraense: fatores determinantes ao acesso aos medicamentos e ao direito à saúde [Internet]. Disponível em: https://doi.org/10.48331/scielodata.DTYP7X, SciELO Data, V1; 2022.
https://doi.org/10.48331/scielodata.DTYP... .

The research included the following professional categories as research informants: pharmacists, managers, and health professionals from SESPA and SEAP involved in the pharmaceutical care management and cycle within the Pará prison system. The convenience sample consisted of 25 informants, after adopting the inclusion and exclusion criteria for the research, following their acceptance to participate in the investigation.

The informants were located in Metropolitan Regions I and II. The region encompasses 49.02% of the penal units in Pará, with 10,477 PDLs, representing 62.55% of the Pará prison population.

The questionnaire was not applied inside the correctional units due to the recommended intramural security and strict control at the entrance of the units. Prison health professionals responded to the instrument in the administrative area. The informants’ identity was respected and identified by numbers 1 to 25.

Data were plotted in an Excel® spreadsheet, analyzed by the APOTECA framework, and presented through descriptive statistics and narrative synthesis.

Ethical aspects

SESPA and SEAP authorized the study. The project was submitted to Plataforma Brasil on May 25, 2019, under CAAE No. 14831519.5.0000.0018 and approved on July 29, 2019, with Consubstantiated Opinion No. 3.471.005, under Resolution No. 466 of December 12, 2012, and Resolution No. 510 of April 7, 2016¹⁷17 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Diário Oficial da União 2013; 13 dez.^,1818 Brasil. Conselho Nacional de Saúde. Resolução nº 510, de 7 de abril de 2016. Dispõe sobre as normas aplicáveis a pesquisas em Ciências Humanas e Sociais cujos procedimentos metodológicos envolvam a utilização de dados diretamente obtidos com os participantes ou de informações identificáveis ou que possam acarretar riscos. Diário Oficial da União 2016; 24 maio..

The interviews directed to research informants were held within the standards established by the secretariats, which involves the presentation of the project to research informants, also employing the Informed Consent Term to request participation and present the research justification and objectives to retrieve the data (https://doi.org/10.48331/scielodata.DTYP7X)¹⁶16 Costa APAM, Soler O, Queiroz LMD. Replication Data for: Assistência farmacêutica prisional paraense: fatores determinantes ao acesso aos medicamentos e ao direito à saúde [Internet]. Disponível em: https://doi.org/10.48331/scielodata.DTYP7X, SciELO Data, V1; 2022.
https://doi.org/10.48331/scielodata.DTYP... .

Inclusion criteria: Health professionals and managers with Higher Education involved in access to medicines within the prison system in Pará, Brazil. Exclusion criteria: Professionals on vacation or professional leave of any kind or with administrative impediments.

After explaining the investigation and clarifying the doubts to the participants, we informed them that the research could bring minimal risks regarding possible embarrassment or discomfort and that participants could withdraw at any time. We assured anonymity, confidentiality, and privacy and that the use of data would be for research purposes only. We also clarified that the researchers were committed to respecting all the ethical principles governing the research.

Results and discussion

We identified 25 professionals involved in the management and logistical cycle of pharmaceutical care within the Pará Penitentiary System, with 16 professionals linked to SESPA and 09 to SEAP (Table 1), among which 64% are pharmacists (Table 2).

Pharmaceutical care is regulated through policies, programs, and actions agreed between the different managers of the SUS in an interfederative scope¹⁹19 Costa KS, Francisco PMSB, Barros MBA. Utilização e fontes de obtenção de medicamentos: um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2016; 32(1):e00067814.. Resolution No. 338 of May 6, 2004, defines pharmaceutical care as a “[...] set of actions aimed at the promotion, protection, and recovery of individual and collective health based on access to and the rational use of medicines”⁶6 Brasil. Resolução do Conselho Nacional de Saúde nº 338, de 6 de maio de 2004. Aprova a Política Nacional de Assistência Farmacêutica. Diário Oficial da União 2004, 6 maio..

We should note that 16 (64%) informants are pharmacists. However, only one pharmacist is a SEAP staff, developing the activities inherent to the pharmaceutical care cycle in the prison system of Pará.

The lack of pharmacists in prison units prevents planning correctly with technical information for the qualification of services and care management. Lin et al.²⁰20 Lin CH, Tran NT, Muradian IK, Do NH, Lu QD, Tesema L, Henderson SO. Impact of a Pharmacist-Led Diabetes Clinic in a Correctional Setting. J Pharm Pract 2019; 19:897190019888075. affirm that including pharmacists in the multidisciplinary team is a strategy to reduce medical care gaps and improve the quality of care in correctional settings.

In the study on “Pharmaceutical care in penitentiary systems: a systematic review”, Costa et al.²¹21 Costa APAM, Queiroz LMD, Soler O. Assistência farmacêutica em sistemas penitenciários: revisão sistemática. Braz J Develop 2020; 6(10):77670-77689. present a synthesis of evidence on the effectiveness and efficiency of pharmaceutical care in penitentiary systems, noting that there is evidence of professional, organizational, governmental, financial, and multifaceted intervention categories regarding clinical outcomes, of access to epidemiological, humanistic and economic services, highlighting that pharmaceutical care in prison systems, conducted through effective and efficient interventions, contribute to the health promotion and disease prevention of a vulnerable population due to the conditions to which they are exposed.

Pharmaceutical care is an integral part of health promotion for this population group, particularly care activities performed at points of care that include pharmaceutical care services offered to the user individually or collectively²¹21 Costa APAM, Queiroz LMD, Soler O. Assistência farmacêutica em sistemas penitenciários: revisão sistemática. Braz J Develop 2020; 6(10):77670-77689.. Pharmaceutical professionals committed to health policies should be included in prison systems to cooperate so that inmates have equitable access to rational drug therapy, safety, and quality of life²¹21 Costa APAM, Queiroz LMD, Soler O. Assistência farmacêutica em sistemas penitenciários: revisão sistemática. Braz J Develop 2020; 6(10):77670-77689..

It is noteworthy that health equity focuses on increasing opportunities, primarily for vulnerable populations, to make them reach their health potential²²22 Corgozinho MM, Oliveira AAS. Equidade em saúde como marco ético da bioética. Saude Soc 2016; 25(2):431-441.. In this sense, although the advances achieved by the SUS in recent years are undeniable and representative, the difficulty in overcoming the intense fragmentation of health actions and services and in including the PDLs fully in the SUS becomes evident.

Regarding the determining factors in access to medicines and the right to health in Pará prison pharmaceutical care, the results related to Attitudinal, Political, Technical, and Administrative factors (Figure 1) are presented below.

The findings show that 57.14% of the informants reported knowing the SESPA organizational chart and 78% of the SEAP. The political factor was analyzed by assessing the relationship within the organization, where all involved provide support in guaranteeing a comprehensive and equitable drug therapy treatment for PDLs.

Martinelli et al.²³23 Martinelli ML, Wanderley MB, Paz RDO. Intersetorialidade: desafio para as políticas públicas. SciELO Perspect Huma [periódico na Internet] 2020; [acessado 2021 jan 21]. Disponível em: https://humanas.blog.scielo.org/blog/2020/05/14/intersetorialidade-desafio-para-as-politicas-publicas.
https://humanas.blog.scielo.org/blog/202... interpret intersectoriality in public policies as a democratic public management strategy that responds to sectorization and fragmentation in the search for a perspective of the whole social issue and the citizens demanding public service. From this perspective, considering the intersectoral and cross-sectional nature of pharmaceutical care and the PNAISP, the articulation between Pará health and justice secretariats in the intersectoral nature of public policies is a challenge to overcome the fragmentation of policies and the potentiation of the proposed interventions and actions⁵5 Brasil. Portaria Interministerial nº 1, de 2 de janeiro de 2014. Institui a Política Nacional de Atenção Integrada de Saúde das Pessoas Privadas de Liberdade no Sistema Prisional no âmbito do Sistema Único de Saúde. Diário Oficial da União 2014; 2 jan.^,2424 Paz RDO. Habitação e Trabalho Social: desafios para a atuação profissional. In: Conselho Regional de Psicologia de São Paulo. Psicologia e moradia: múltiplos olhares sobre a questão habitacional. São Paulo: CRP-SP; 2019. p. 44-48..

As for the technical factors, 68% of the survey informants feel updated on the primary component of pharmaceutical care, 64% on the specialized component of pharmaceutical care, and 60% on the PNAISP, which is directly related to the primary component of pharmaceutical care. Furthermore, 48% feel updated on the Clinical Protocols and Therapeutic Guidelines, which are directly related to the specialized component of pharmaceutical care (Table 3).

A total of 56% feel updated on the strategic component of pharmaceutical care, 64% on the National Drug Policy, and 48% on the Pará State Pharmaceutical Care Policy. Also, 76% feel updated on the RENAME and 68% on the HORUS System. Finally, 48% feel updated on the concepts of the Health Care Network in the prison context (Table 3).

Topp et al.²⁵25 Topp SM, Moonga CN, Luo N, Kaingu M, Chileshe C, Magwende G, Heymann SJ, Henostroza G. Exploring the drivers of health and healthcare access in Zambian prisons: a health systems approach. Health Policy Plan 2016; 31(9):1250-1261. record that poor access to the Health Care Network is a significant and complex hindrance among PDLs as it impairs the resolution of health problems of the incarcerated population and discredits the value of health actions (Table 3).

Regarding administrative factors, when asked about the physical structure of the work environment at SESPA, all the pharmacists reported that the furniture is adequate for the services and procedures offered, the environment is cooled correctly, the lighting is adequate, and the computers have quality Internet access (Table 3).

The report of the only pharmacist working at the SEAP and allotted to the Pharmaceutical Supply Center informs that the work environment does not have adequate furniture and infrastructure, there is adequate cooling and lighting, and the environment does not have the recommended safety equipment. Computers have quality Internet access (Table 3).

Prison units are not staffed with a pharmaceutical professional to carry out the technical management of pharmaceutical care and clinical drug management, thus hindering the qualification of services and care management.

According to Lin et al.²⁰20 Lin CH, Tran NT, Muradian IK, Do NH, Lu QD, Tesema L, Henderson SO. Impact of a Pharmacist-Led Diabetes Clinic in a Correctional Setting. J Pharm Pract 2019; 19:897190019888075., including the pharmacist in the multidisciplinary team is a strategy to reduce gaps in medical care and improve the quality of care in correctional settings.

The attitudinal factor is knowingly cross-sectional to politicians, technicians, and administrators. Therefore, it is inferred that the knowledge of these domains identified the factors that facilitate or hinder access to medicines made available by the SUS for PDLs in Pará, Brazil, providing the development of strategies that improve equitable access to the medicines made available by the SUS for the PDLs in the Pará penitentiary system.

Results related to the attitudinal factor, which negatively impacts the guarantee of the right to health for PDLs, were observed in the perception that although all the research informants were involved with pharmaceutical care in the penitentiary system, 20% related that the concepts of essential, strategic and specialized pharmaceutical care components, and 24% stated that the RENAME, National Drug Policy, State Pharmaceutical Care Policy do not apply to their activity (Table 3).

The lack of knowledge about the configuration of access to medicines of the primary, strategic, and specialized components of pharmaceutical care in the prison system is evidenced in all informants linked to the SEAP and in 92.85% of those in the SES-PA. Considering the total number of informants in the research, 76% were unaware of the number of PDLs held in custody in the state (Table 3). These results demonstrate a gap in the inclusion of this population in the health care network and can impact social differences and care considering diversity.

Pharmaceutical care only reaches its fullness and objectives when it links its actions to the other care actions of the health team in a qualified way. Thus, it should be incorporated into health care, focusing on the user and not just on the medication. Pharmaceutical services must be integrated with care practices in the health team, and pharmaceutical care must be part of all existing health policies²⁶26 Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Uso de Medicamentos e Medicalização da Vida: recomendações e estratégias. Brasília: MS; 2018..

We observe that technical and political factors are hurdles to ensuring equal access to medicines made available by the SUS for PDLs in Pará; the administrative factor as a facilitator within the SESPA and as a barrier at SEAP, resulting from the shortage of pharmaceutical professionals and structure in the work environment (Table 4).

Conclusion

Deprivation of liberty, social vulnerability, and other factors inherent to the prison reality hinder the implementation of the right to health of PDLs, and several challenges must be overcome to achieve this to secure equal access to medicines made available by the SUS. The situation of vulnerability suffered by the PDLs is reflected in the management of the SUS. The PNAISP must be strengthened as a policy to promote equity in health and guarantee equity in care and access to health, respecting the right to citizenship.

We recommend including pharmaceutical professionals with skills and abilities to offer pharmaceutical services to PDLs in Pará. We reiterate that this vulnerable population deserves more careful attention to guarantee an equitable and comprehensive drug therapy treatment broadly and harmoniously with the policies already in place.

Finally, it is essential to reflect on the fact that PDLs will return to social life after serving their sentence and that preserving intramural health is essential in extramural resocialization²⁷27 Costa APAM, Soler O, Queiroz LMD. Assistência farmacêutica no sistema penitenciário do estado do Pará: análise sobre o acesso aos medicamentos como parte do direito à saúde. Belém: UFPA; 2021..

Limitations, bias, and difficulties

Sampling limitation. Difficulties in accessing data and information. Potential bias regarding the respondents’ understanding of the technical terms used.

References

Publication Dates

History