Storage and disposal of expired medicines in home pharmacies: emerging public health problems / Armazenamento e descarte dos medicamentos vencidos em farmácias caseiras: problemas emergentes para a saúde pública

ABSTRACT Objective To characterize storage and disposal practices associated with expired medicines in home pharmacies of Primary Care users. Methods Cross-sectional study based on data collected from 423 users of 15 Primary Care units located in a Brazilian city, between August 2014 and July 2016. Data were collected via face-to-face interviews. Categorical (demographic and socioeconomic characteristics) and continuous variables were expressed as proportions and means and standard deviations, respectively . Storage behaviors and disposal practices associated with unused and expired medicines were described as frequencies. Results Most (83%) interviewees were female and approximately 70% had completed high school. The kitchen was the most common medicine storage place (58.6%). Approximately 75% of participants reported inappropriate medicine disposal practices. Conclusion This study revealed high rates of inappropriate medicine disposal practices with direct impacts on pharmacological treatment and the environment. Continuing education of healthcare professionals and the general public is required to raise awareness about proper medicine use and disposal.

RESUMO Objetivo Caracterizar o armazenamento e o descarte de medicamentos vencidos contidos em farmácias caseiras de usuários da Atenção Primária à Saúde. Métodos Estudo transversal, realizado com 423 usuários de 15 unidades de saúde da Atenção Primária em um município brasileiro. Os dados foram coletados de agosto de 2014 a julho de 2016, por meio de entrevistas face a face. As características demográficas e socioeconômicas foram descritas por meio de proporções para as variáveis categóricas. As formas de armazenamento e o descarte de medicamentos vencidos ou não vencidos foram descritos em forma de frequência. Resultados Dentre os entrevistados, 83% eram do sexo feminino e aproximadamente 70% possuíam Ensino Médio completo. A cozinha foi o local mais citado para armazenamento de medicamentos (58,6%). Cerca de 75% dos participantes relataram descartar os medicamentos de forma incorreta. Conclusão O estudo evidenciou que grande proporção dos entrevistados possui hábitos incorretos de descarte, que, por sua vez, impactam diretamente no tratamento medicamentoso e na natureza. Assim, é necessária a educação continuada dos profissionais de saúde e da população, a fim de conscientizar a população sobre a correta utilização e o descarte de medicamentos.

Cost analysis of a medication dispensing service in community pharmacy in Brazil

This study was aimed to calculate in detail the costs of a medication dispensing service in community pharmacy in Brazil. Descriptive and retrospective analysis with a cost analysis based on mixed costing; absorption costing and time-driven activity based-costing, considering year 2018 and both public and private health system perspectives within a one-year time horizon to estimates costs related to implement and to deploy the service, costs per patient and costs per activity of process (US$ 1 = R$ 3.8310 in October, 2018). Total costs of dispensing service ranged from US$ 24,451.61 to US$ 37,914.48. Costs per patient ranged from US$ 2.43 to US$ 3.77. Costs per activity of the process ranged from US$ 0.39 in pharmacotherapy assessment to US$ 2.46 in pharmaceutical interview. This provides evidence to deploy and implement a structured medication dispensing service in community pharmacy in Brazil with a view to optimize the usage of medicines.

Brazilian generics market change after Farmácia Popular program

ABSTRACT OBJECTIVE To evaluate trends in the use of generic and non-generic medicines to treat hypertension and diabetes under the Farmácia Popular Program (FP) and its impact on generic medicines sales volume and market share in the Brazilian pharmaceutical market. METHODS This longitudinal, retrospective study used interrupted time series design to analyze changes in monthly sales volume and proportion of medicines sales (market share) for oral antidiabetic and antihypertensive medicines for generic versus non-generic products. Analyses were conducted in a combined dataset that aggregate monthly sales volumes from the Farmácia Popular program and from the QuintilesIMS™ (IQVIA) national market sales data from January 2007 to December 2012. The Farmácia Popular program phases analyzed included: a) 2009 reductions in medicines reference prices (AFP-II) and b) 2011 implementation of free medicines program for hypertension and diabetes, the Saúde não tem preço (SNTP - Health has no price). RESULTS Patterns of use for FP-covered antidiabetic and antihypertensive medicines were similar to their use in the market in general. After one year of the decreases in government subsidies in April 2010, market share of antidiabetic and antihypertensive medicines experienced relative declines of -54.5% and -59.9%, respectively. However, when FP-covered medicines were made free to patients, overall market volume for antidiabetic and antihypertensive generics increased dramatically, with 242.6% and 277.0% relative increases by February 2012, as well as non-generics with relative increase of 209.7% and 279% for antidiabetic and antihypertensive medicines, respectively. CONCLUSIONS Ministry of Health policies on the amount of patient cost sharing and on the choice of medicines on coverage lists have substantial impacts on overall generic sales volume in retail pharmacies.

A national study on the use of opioid analgesics in dentistry

Abstract The aim of this study was to assess the frequency of opioid analgesics prescribed by Brazilian dentists, potential regional differences and their association with socioeconomic and health-related factors. Data for all opioid prescriptions by dentists was obtained from the 2012 database of the National Controlled Substances Management System, regulated by the Brazilian Health Surveillance Agency. The number of defined daily doses (DDD) and DDDs per 1,000 inhabitants per day for each Brazilian state were calculated as the primary outcomes. DDDs were compared by regions and Brazilian states. Spearman's rho correlation coefficient was used to determine the influence of the states' characteristics, such as the Human Development Index; poverty; education; number of dentists per 100,000 inhabitants; visit to the dentist; dental care plan; good or very good oral health; number of pharmaceutical establishments per 100,000/inhabitants; and ability to get all prescribed medications. Data analysis was performed using IBM SPSS Statistics 25.0. A total of 141,161 prescriptions for opioids analgesics by 36,929 dentists were recorded, corresponding to 658,855 doses of opioids dispensed in 2012. The most commonly dispensed opioids were codeine associated with paracetamol (83.2%; n = 117,493). The national DDDs per 1,000 inhabitants per day was 0.0093 (range: 0.0002-0.0216). DDD per 1,000 inhabitants per day was positively associated to visits to dentists (rs = 0.630; P < 0.001) and inversely associated to poverty (rs = -0.624; p = 0.001). There are significant differences in opioid prescriptions in dentistry among the Brazilian states. These differences may be associated with non-clinical factors.

Evaluation of community pharmacists' involvement in public health activities in Nigeria

The aims of the study were to identify the types, determine the extent of community pharmacists' involvement, and evaluate the factors influencing their participation in public health activities in Nigeria. The study was a cross-sectional survey of randomly selected 130 registered community pharmacies. Pretested questionnaire was the instrument for data collection. Descriptive and inferential statistics were used to analyse data. Response rate was 94.9%. The study identified 31 types of public health activities which community pharmacists participated in. Their extent of involvement was highest in patient counseling (4.93 ± 0.25), personal hygiene (4.90 ± 0.37), maintenance of normal blood pressure (4.88 ± 0.32), and techniques for using vagina pessaries (4.85 ± 0.38). Lowest areas of involvement were elimination of smokeless tobacco use (2.27 ± 1.56), use of seat belts when driving (2.03 ± 1.46), and the need to live in a safe neighborhood (1.42 ± 0.53). Inadequate training (96%), lack of pharmacists' time (94.6%), inadequate personnel (92.3%), lack of patients' time (88.5%), lack of profit (85.4%), inadequate space in the pharmacy (82.3%) and inadequate patients' information (69.9%) significantly influenced their participation. The study concluded that community pharmacists would participate more in public health activities if the identified barriers are reduced.

Analysis of analgesic, antipyretic, and nonsteroidal anti-inflammatory drug use in pediatric prescriptions / Análise do uso de analgésicos, antipiréticos e anti-inflamatórios não esteroides em prescrição pediátrica

ABSTRACT OBJECTIVE: Data on clinical practice in pediatrics on the use of analgesic, antipyretic, and nonsteroidal anti-inflammatory drugs considering the best available evidence and regulatory-agency approved use are uncertain. This study aimed to determine the frequency of prescription of these drugs according to the best scientific evidence and use approved by regulatory agencies. METHODS: This was a cross-sectional study of 150 pediatric prescriptions containing analgesic, antipyretic, and nonsteroidal anti-inflammatory drugs, followed by interview with caregivers at 18 locations (nine private drugstores and nine Basic Health Units of the Brazilian Unified Health System). The assessed outcomes included recommended use or use with no contraindication, indications with benefit evidence, and health surveillance agency-approved use. Data were analyzed in electronic databases and the variables were summarized by simple frequency. RESULTS: A total of 164 analgesic, antipyretic, and nonsteroidal anti-inflammatory drugs were prescribed to 150 children aged 1-4 years (38.6%). Dipyrone was included in 82 (54.6%) and ibuprofen in 40 (26.6%) prescriptions. Non-recommended uses were identified in 15% of prescriptions and contraindicated uses were observed in 13.3%. Nimesulide (1.5%) is still prescribed to children younger than 12 years. The dose was incorrect in 74.3% of prescriptions containing dipyrone. Of the 211 reported clinical indications, 56 (26.5%) had no evidence of benefit according to the best available scientific evidence and 66 (31.3%) had indications not approved by the regulatory agencies. CONCLUSION: There are significant discrepancies between clinical practice and recommended use of analgesic, antipyretic, and nonsteroidal anti-inflammatory drugs in pediatrics.

RESUMO OBJETIVO: Dados sobre a prática clínica em pediatria no uso de analgésicos, antipiréticos e anti-inflamatórios não esteroides considerando a melhor evidência disponível e o uso aprovado por agências reguladoras são incertos. Este estudo tem como objetivo verificar a frequência de prescrição de tais medicamentos segundo a melhor evidência científica e o uso aprovado por agências reguladoras. MÉTODO: Estudo transversal de 150 prescrições pediátricas, contendo analgésicos, antipiréticos e anti-inflamatórios não esteroides, seguido de entrevista aos cuidadores, em 18 locais (nove drogarias privadas e nove unidades de saúde do SUS). Os desfechos avaliados incluíram uso recomendado ou sem contraindicação, indicações com evidência de benefício e o uso autorizado por agências de vigilância sanitária. Os dados foram analisados em banco eletrônico e as variáveis sumarizadas por frequência simples. RESULTADOS: Foram prescritos 164 analgésicos, antipiréticos e anti-inflamatórios não esteroides para as 150 crianças entre um e quatro anos (38,6%). Dipirona constou em 82 (54,6%) e ibuprofeno em 40 (26,6%). Usos não recomendados foram encontrados em 15% das receitas e usos contraindicados em 13,3%. Nimesulida (1,5%) ainda é usada em crianças com menos de 12 anos. Em 74,3% das prescrições contendo dipirona a dose estava incorreta. Das 211 indicações clínicas referidas, 56 (26,5%) não tinham evidências de benefício segundo a melhor prova científica disponível e 66 (31,3%) eram indicações não aprovadas em agências de vigilância sanitária. CONCLUSÃO: Existem importantes discrepâncias entre prática clínica e recomendações de uso de analgésicos, antipiréticos e anti-inflamatórios não esteroides em pediatria.

Access to medicines for chronic diseases in Brazil: a multidimensional approach / Acesso a medicamentos para doenças crônicas no Brasil: uma abordagem multidimensional

ABSTRACT OBJECTIVE To analyze the access to medicines to treat non-communicable diseases in Brazil according to socioeconomic, demographic, and health-related factors, from a multidimensional perspective. METHODS Analysis of data from the National Survey on Access, Use and Promotion of Rational Use of Medicines (PNAUM), household survey, sampling plan by conglomerates with representativeness of the Brazilian population and large areas of the country, according to sex and age domains. Data collected in 2013–2014 with sample of adults (≥ 20 years) who reported having non-communicable diseases and medical indication for use of medicines (n = 12,725). We assessed the prevalence of access to medicines for self-reported non-communicable diseases, considering four dimensions: availability, geographic accessibility, acceptability, and affordability. We applied Pearson’s Chi-square test to assess the statistical significance of the differences between strata, considering the level of significance of 5%. We found prevalence of 94.3%, 5.2%, and 0.5% for full, partial, and null access, respectively. Higher prevalence was observed among seniors in the South compared to the Northeast; for those who reported having one non-communicable disease compared to those who reported having two or more; for those who needed one medicine compared to those who needed three or more; and for those who self-assessed their health as good or very good. Geographic accessibility was similar in the Unified Health System and in the private pharmacies (72.0%). Total availability of medicines was 45.2% in the Unified Health System, 67.4% in the Popular Pharmacy Program, and 88.5% in private pharmacies. Acceptability was 92.5% in the Unified Health System, 97.8% in the Popular Pharmacy Program, and 98.7% in private pharmacies. As to affordability, 2.6% of the individuals failed to take the medicines they should in the 30-day period prior to the interview due to financial difficulty. Prevalence of full access to medicines for non-communicable diseases in Brazil is high and presents significant differences for age group, region of the country, number of non-communicable diseases, and for medicines prescribed and self-assessment of health. The major barriers to access to medicines were identified in the dimensions analyzed.

RESUMO OBJETIVO Analisar o acesso a medicamentos para tratar doenças crônicas não transmissíveis no Brasil segundo fatores socioeconômicos, demográficos e de saúde, sob perspectiva multidimensional. MÉTODOS Análise de dados da Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM), inquérito domiciliar, plano amostral por conglomerados com representatividade da população brasileira e grandes regiões do País, segundo domínios de sexo e idade. Dados coletados em 2013-2014 com amostra constituída por adultos (≥ 20 anos) que referiram ter doenças crônicas não transmissíveis e indicação médica para usar medicamentos (n = 12.725). Avaliou-se a prevalência de acesso aos medicamentos para doenças crônicas não transmissíveis autorreferidas, considerando quatro dimensões: disponibilidade, acessibilidade geográfica, aceitabilidade e capacidade aquisitiva. Aplicou-se teste Qui-quadrado de Pearson para avaliar a significância estatística das diferenças entre os estratos, considerando o nível de significância de 5%. RESULTADOS Foram encontradas prevalências de 94,3%, 5,2% e 0,5% para acesso total, parcial e nulo, respectivamente. Maiores prevalências ocorreram entre os idosos, na região Sul comparada à região Nordeste; naqueles que referiram ter uma doença crônica não transmissível comparados aos que referiram ter duas ou mais; naqueles que precisavam de um medicamento comparados aos que precisavam de três ou mais; e naqueles que autoavaliaram sua saúde como boa ou muito boa. A acessibilidade geográfica foi semelhante no Sistema Único de Saúde e nas farmácias privadas (72,0%). A disponibilidade total de medicamentos foi de 45,2% no Sistema Único de Saúde, 67,4% no Programa Farmácia Popular e 88,5% nas farmácias privadas. A aceitabilidade foi de 92,5% no Sistema Único de Saúde, 97,8% no Programa Farmácia Popular e 98,7% nas farmácias privadas. Quanto à capacidade aquisitiva, 2,6% dos indivíduos não tomou os medicamentos que deveria nos 30 dias anteriores à entrevista devido à dificuldade financeira. CONCLUSÕES A prevalência do acesso total aos medicamentos para doenças crônicas não transmissíveis no Brasil é alta e apresenta diferenças significativas por faixa etária, região do País, número de doenças crônicas não transmissíveis e de medicamentos prescritos e autoavaliação da saúde. Foram identificadas as principais barreiras ao acesso a medicamentos nas dimensões analisadas.

Avaliação do conhecimento sobre níveis tensionais e cronicidade da hipertensão: estudo com usuários de uma Farmácia Básica no Sul do Brasil / Evaluation of knowledge on blood pressure levels and chronicity of hypertension among users of a public pharmacy in Southern Brazil / Evaluación de los conocimientos acerca de los niveles de presión y de la cronicidad de la hipertensión arterial: estudio con usuarios de una Farmacia Comunitaria en el Sul de Brasil

Objetivou-se avaliar o conhecimento sobre hipertensão arterial sistêmica (HAS) e fatores associados, por meio de estudo transversal com adultos usuários de medicamentos anti-hipertensivos adquiridos na Farmácia Básica de São Francisco de Paula, Rio Grande do Sul, Brasil. Avaliou-se o conhecimento sobre os limites de normalidade para a pressão arterial sistólica e diastólica e sobre a condição crônica da HAS. Utilizou-se regressão multinomial para conhecimento (satisfatório/moderado/insatisfatório) e considerou-se como satisfatório o conhecimento sobre dois ou mais aspectos avaliados. Dos 635 usuários, portadores de HAS, 27,7% apresentaram conhecimento satisfatório e 47,2% conheciam apenas a cronicidade da HAS. Após ajuste, sexo feminino, maior escolaridade, não morar só, comportamento saudável e maior tempo de diagnóstico associaram-se ao conhecimento satisfatório sobre a HAS. Considerando a importância da autonomia do portador no monitoramento dos níveis tensionais e da continuidade do tratamento no controle da pressão arterial, encontrou-se baixa prevalência de conhecimento satisfatório.

The aim of this study was to evaluate patients' knowledge on hypertension and associated factors through a cross-sectional study of adults using antihypertensive medication dispensed by the São Francisco de Paula Public Pharmacy in Rio Grande do Sul State, Brazil. The study evaluated knowledge on the normal limits for systolic and diastolic blood pressure and chronicity of hypertension. Multinomial regression was used to measure knowledge (satisfactory/moderate/unsatisfactory); satisfactory was defined as correct knowledge on two or more items. Of the 635 users with hypertension, 27.7% showed satisfactory knowledge, while 47.2% were only aware of the chronic nature of hypertension. After adjustment, female gender, more education, not living alone, healthy lifestyle, and greater time since diagnosis were associated with satisfactory knowledge on hypertension. Considering the importance of patient autonomy in monitoring blood pressure and continuous treatment to control hypertension, the study showed a low prevalence of satisfactory knowledge.

Este estudio objetivó evaluar el conocimiento sobre la hipertensión arterial (HTA) y los factores asociados. Estudio transversal con usuários de fármacos antihipertensivos que obtuvieron sus medicamentos en una farmacia comunitaria de São Francisco de Paula, Rio Grande do Sul, Brasil. Se evaluó los conocimientos acerca de los niveles de presión arterial sistólica y diastólica y de la condición crónica de la HTA. Se utilizó la regresión multinomial para evaluar el conocimiento (insuficiente/parcialmente suficiente/ suficiente), considerado conocimiento suficiente cuando el usuario sabía dos o más de los aspectos evaluados. De los 635 usuários, 27,7% tenían un conocimiento suficiente y sólo 47,2% conocían la cronicidad de la HTA. El sexo femenino, la educación superior, no vivir solo, el comportamiento saludable y el tiempo de diagnóstico se asociaron con el conocimiento suficiente. Considerando la importancia de la autonomía del usuário en el monitoreo de la presión arterial y la adesión al tratamiento en el control de la HTA, se ha encontrado una baja prevalencia de conocimiento suficiente.

Usefulness of pharmacy dispensing records in the evaluation of adherence to antiretroviral therapy in Brazilian children and adolescents

INTRODUCTION: Adherence, which is crucial to the success of antiretroviral therapy (HAART), is currently a major challenge in the care of children and adolescents living with HIV/AIDS. OBJECTIVE: To evaluate the prevalence of nonadherence to HAART using complementary instruments in a cohort of children and adolescents with HIV/AIDS followed in a reference service in Campinas, Brazil. METHODS: The level of adherence of 108 patients and caregivers was evaluated by an adapted standardized questionnaire and pharmacy dispensing records (PDR). Non-adherence was defined as a drug intake lower than 95% (on 24-hour or seven-day questionnaires), or as an interval of 38 days or more for pharmacy refills. The association between adherence and clinical, immunological, virological, and psychosocial characteristics was assessed by multivariate analysis. RESULTS: Non-adherence prevalence varied from 11.1% (non-adherent in three instruments), 15.8% (24-hour self-report), 27.8% (seven-day self-report), 45.4% (PDR), and 56.3% (at least one of the outcomes). 24-hour and seven-day self-reports, when compared to PDR, showed low sensitivity (29% and 43%, respectively) but high specificity (95% and 85%, respectively). In multivariate analysis, medication intolerance, difficulty of administration by caregiver, HAART intake by the patient, lower socioeconomical class, lack of virological control, missed appointments in the past six months, and lack of religious practice by caregiver were significantly associated with non-adherence. CONCLUSION: A high prevalence of HAART non-adherence was observed in the study population, and PDR was the most sensitive of the tested instruments. The instruments employed were complementary in the identification of non-adherence.

Perfil de utilização de medicamentos por indivíduos com hipertensão arterial e diabetes mellitus em municípios da Rede Farmácia de Minas / Use of medicines by individuals with hypertension and diabetes in municipalities covered by the Pharmacy Network in Minas Gerais State, Brazil

Este trabalho descreve o perfil de utilização de medicamentos de indivíduos com hipertensão e/ou diabetes, que adquirem esses produtos por meio de uma rede pública de farmácias, com ênfase nas diferenças entre sexos. No primeiro bimestre de 2010 foram entrevistados indivíduos hipertensos e/ou diabéticos, em metade dos 64 municípios então participantes da Rede Farmácia de Minas. Os 4.777 entrevistados tinham em média 60,9 anos, fato que pode ter contribuído para a elevada média de medicamentos utilizados (4,0 entre as mulheres e 3,5 entre os homens). Os medicamentos mais frequentes foram os que atuam no sistema cardiovascular (56,3%), trato alimentar e metabólico (14,9%), sistema nervoso (13,8%) e estão de acordo com o perfil epidemiológico dos entrevistados. As mulheres, juntamente com os mais idosos destacaram-se no que diz respeito à utilização de um maior número de medicamentos. Os resultados deste estudo mostraram elevados gastos com medicamentos pelos entrevistados e sugerem o delineamento de ações educativas voltadas para o uso racional de medicamentos, entre esses indivíduos.

This article analyzes the use of medicines by individuals with hypertension and/or diabetes mellitus who received their medication through a public network of pharmacies, with a particular emphasis on gender differences. During the first two months of 2010, individuals with hypertension and/or diabetes were interviewed in half of the 64 municipalities (counties) participating in the Minas Gerais Pharmacy Network. Mean age of the 4,777 interviewees was 60.9 years, which may have contributed to the high mean number of medicines used (4.0 among women and 3.5 among men). The most frequently used drugs were those acting on the cardiovascular system (56.3%), alimentary tract and metabolism (14.9%), and nervous system (13.8%), consistent with the sample's epidemiological profile. Women and more elderly individuals tended to use more medicines. The findings show high expenditures on medicines by the interviewees and suggest the design of educational activities targeting rational use of medication.

Capacidade aquisitiva e disponibilidade de medicamentos para doenças crônicas no setor público / Affordability and availability of drugs for treatment of chronic diseases in the public health care system

OBJETIVO: Avaliar a capacidade aquisitiva do trabalhador para pagar medicamentos utilizados no tratamento de doenças crônicas e a disponibilidade desses medicamentos na forma de referência, similar ou genérica para fornecimento gratuito no setor público. MÉTODOS: Utilizou-se metodologia preconizada pela Organização Mundial da Saúde (OMS) e Health Action International (HAI) para coleta padronizada de informações sobre preços de venda no setor privado e disponibilidade no setor público de medicamentos em seis cidades do Rio Grande do Sul, Brasil. A coleta de dados ocorreu de novembro de 2008 a janeiro de 2009. A capacidade aquisitiva foi estimada como o número de dias do salário que um trabalhador com rendimento de 1 salário mínimo nacional necessita trabalhar para adquirir, em uma farmácia privada, a quantidade necessária de medicamento para 1 mês de tratamento. A disponibilidade foi avaliada verificando-se a presença dos medicamentos nas farmácias do setor público. RESULTADOS: A pesquisa incluiu 22 estabelecimentos públicos e 30 farmácias privadas. Dos 21 medicamentos utilizados no tratamento de sete doenças crônicas, apenas nove eram disponibilizados gratuitamente nos seis municípios pesquisados. O percentual médio da disponibilidade variou de 83,3 por cento (São Leopoldo) a 97,6 por cento (Caxias do Sul). A capacidade aquisitiva variou de 0,4 a 10,5 dias de salário para medicamentos de referência; de 0,2 a 8,4 dias de salário para medicamentos similares; e de 0,3 a 3,8 dias de salário para medicamentos genéricos. CONCLUSÕES: A disponibilidade geral dos medicamentos pesquisados foi superior aos 80 por cento recomendados pela OMS; porém, alguns tratamentos não estavam disponíveis, ou apresentaram uma disponibilidade limitada no setor público. A capacidade aquisitiva dos trabalhadores nos municípios estudados indicou um comprometimento de dias do salário que pode afetar a continuidade dos tratamentos com medicamentos para doenças crônicas.

OBJECTIVE: To assess the affordability by workers of drugs used for treatment of chronic diseases, as well as the availability of the reference, similar, or generic forms of these drugs in the public health care system. METHODS: We employed the methodology recommended by the World Health Organization (WHO) and Health Action International (HAI) for the standardized collection of information on selling prices in the private sector and availability in the public health care system of drugs in six cities in the state of Rio Grande do Sul, Brazil. Data were collected from November 2008 to January 2009. Affordability was estimated as the number of salary days required for a worker receiving the national minimum wage to buy, in a private pharmacy, the amount of medication required for one month of treatment. Availability was assessed by the presence of these drugs in public health care system facilities. RESULTS: Twenty-two public facilities and 30 private pharmacies were studied. Of 21 drugs used for the treatment of seven chronic disorders, only nine were available free of charge in the six cities. Mean availability ranged from 83.3 percent (São Leopoldo) to 97.6 percent (Caxias do Sul). Affordability ranged from 0.4 to 10.5 salary days for reference drugs, 0.2 to 8.4 salary days for similar drugs, and 0.3 to 3.8 salary days for generic drugs. CONCLUSIONS: The overall availability of the drugs surveyed was higher than the 80 percent recommended by WHO. However, some treatments were not available, or had limited availability in the public system. Concerning affordability, the number of salary days required to buy these drugs may affect the continuation of drug treatments for chronic diseases.

Medicamentos para adultos mayores: percepciones y adquisición en farmacias privadas de Morelos, México / Medications for senior citizen: perceptions and acquisition in private pharmacies in Morelos

Objetivo: Analizar las características de adquisición de medicamentos para adultos mayores con y sin receta médica, así como sus percepciones. Material y método: Estudio con diseño cuantitativo/cualitativo, realizado de octubre a noviembre de 2006, mediante muestra probabilística/aleatoria/ estratificada se seleccionaron 52 farmacias privadas del estado de Morelos, México en donde se levantaron datos para un total de 324 adultos mayores que compraron medicamentos para su consumo. Resultados: Del total de la población, el 65 por ciento adquirió los medicamentos sin receta, tres cuartas partes compró polifármacos, los medicamentos más adquiridos fueron analgésicos y antibióticos. El gasto fue 2.4 veces mayor cuando fueron recetados por médicos. Además de los medicamentos adquiridos los ancianos consumen remedios caseros, pero no identifican que pudieran presentar efectos secundarios, confían en los dependientes de farmacia para ser medicados. Conclusiones: Debido al elevado costo de los medicamentos cuando son recetados, que puede orillar a que gran parte de los ancianos prefiera adquirirlos sin receta, aunado al consumo de remedios y al desconocimiento de efectos adversos, los ancianos se vuelven altamente proclives a daños a su salud. Es factible que la automedicación y sus consecuencias puedan evitarse con una eficiente promoción de la salud y una oferta de servicios médicos de calidad, acorde a las necesidades de salud de la población.

Objective: Analyze characteristics medication acquisition in senior citizens, with or without prescriptions, as well as their perceptions. Materials and methods: Qualitative and quantitative study design, carried out in October through November of 2006, through a random, probabilistic, stratified sample. 52 private pharmacies were selected in the state of Morelos, Mexico, for a sample of 324 senior citizens the purchase medications. Results: Of the whole population, 65 percent acquired the medications without a prescription. Three fourths bought homeopathic medications. The medications most commonly bought were analgesics and antibiotics. Prices were 2.4 times higher when they were prescribed by doctors. Apart from medications, they also used folk remedies, but do not express understanding of possible side effects, rather, they trust in pharmacy employees. Conclusions: Due to the high cost of prescribed medications, many senior citizens prefer to acquire them without a prescription. That, along with the use of folk remedies and the lack of knowledge of their possible side effects, makes them vulnerable to adverse health effects. It is possible that self medication and its consequences could be avoided with efficient health promotion and quality health care services that fulfill the needs of the population.

Restricción de la venta de antibióticos en farmacias de Bogotá, Colombia: estudio descriptivo / Restriction of antibiotic sales in pharmacies in Bogotá, Colombia: a descriptive study

Objetivo. Describir el estado de la aplicación de la norma relacionada con la prohibición dela venta de antibióticos sin prescripción médica en farmacias de Bogotá, Colombia. Métodos. Estudio descriptivo transversal, en el cual se utilizó la técnica de simulación de compra en farmacias (droguerías) de Bogotá. La muestra de 263 farmacias se calculó con una precisión de 5% y un factor de corrección de 2% mediante estratificación (farmacias de cadenae independientes) y asignación aleatoria simple en cada estrato. Resultados. Del total de farmacias estudiadas, 80,3% no cumplen la norma que establecela venta de antibióticos con receta. En 20,1% de los casos, el expendedor indagó la edad del paciente o sus síntomas o ambos, con el fin de ofrecer otros medicamentos o para cambiar elantibiótico. En ninguna oportunidad se preguntó por antecedentes personales de alergia a los antibióticos. En los casos en los cuales hubo intención de venta del antibiótico, la presentación genérica fue la más comúnmente ofrecida (81,2%). Algunos expendedores de medicamentos hicieronrecomendaciones inapropiadas. Las localidades con mayor incumplimiento de la norma coinciden con aquellas que tienen altas tasas de necesidades básicas insatisfechas. Conclusiones. A cinco años de adopción de la norma orientada a contrarrestar la ventalibre de antibióticos, su cumplimiento es mínimo y la entrega no se realiza de acuerdo a los parámetros establecidos. El personal de farmacia no suministra la información requerida de acuerdo con sus competencias.

Objective. Describe the implementation status of a regulation prohibiting antibiotic sales without a medical prescription in pharmacies of Bogotá, Colombia. Methods. A cross-sectional descriptive study was conducted using the simulated purchase technique in Bogotá pharmacies (drugstores). The sample of 263 pharmacies was calculated by stratification (chain pharmacies and independent pharmacies) with 5% accuracy and a 2% correction factor. Simple randomization was assigned in eachstratum. Results. Out of the total pharmacies studied, 80.3% did not comply with the regulation established for prescription sales of antibiotics. In 20.1% of the cases, the dispenser asked about the patient’s age, symptoms, or both age and symptoms in order to offer other drugs or change the antibiotic. There were no inquiries about amedical history of allergy to antibiotics. In cases in which there was the intention to sell antibiotics, the generic format was most commonly offered (81.2%). Some drug dispensers made inappropriate recommendations. The locations with the highest levels of noncompliance with the regulation were also those with high rates of unmetbasic needs. Conclusions. Five years after passage of a regulation to halt the unrestricted sales of antibiotics, there is minimal compliance, and dispensing does not conform to the established parameters. Pharmacy personnel do not provide the required information according to their responsibilities.

Consumo comunitario de antimicrobianos en Chile, 2000-2008 / Community antibiotic consumption in Chile, 2000-2008

Background: The Chilean Ministry of Health has implemented regulatory rules for the consumption of anti-biotics since September 1999, with sales restriction limited only with medical prescription. Aim: To analyze the impact of established regulatory measures from 2000 to 2008. Material and Methods: A retrospective analysis of antibiotics sales in pharmacies from 2000 to 2008 was performed. The information was obtained from the International Marketing System (IMS Health), an auditing system of pharmacy sales. The consumption unit used was the Defined Daily Dose per 1000 inhabitants/day (DDD). Results: From 2000 to 2002 the regulatory rules had a great impact, but since 2002 the antibiotic consumption increased, especially amoxicillin, returning to similar levéis observed in 1998. Conclusions: The regulatory measures had an initial impact, but there was not reinforcement in the time and there was no further control. It is necessary to assume a permanent task and support of the authorities of health to edúcate the population about the implications of the inadequate use of antimicrobials and his effect on the microbial ecology.

Introducción: El Ministerio de Salud de Chile reguló el consumo de antimicrobianos en el mes de septiembre de 1999, mediante restricción de venta limitada sólo a venta con receta médica. El objetivo de este estudio es conocer el impacto de las medidas regulatorias entre los años 2000 y 2008. Metodología: Se realizó un análisis retrospectivo de las ventas en farmacias privadas desde el año 2000 al 2008. La información se obtuvo del International Marketing System Health (IMS Health), una empresa internacional encargada de auditar las ventas de farmacias. La unidad de consumo usada fue la DDD/1.000 habitantes-día. Resultados: A partir del año 2000 al 2002, las medidas regulatorias tuvieron un gran impacto; sin embargo, desde el año 2002 el consumo de antimicrobianos aumentó, especialmente amoxicilina, obteniéndose valores similares a los existentes en 1998. Conclusiones: Las medidas regulatorias tuvieron un impacto inicial; sin embargo, no fueron reforzadas ni controladas en el tiempo. Es necesario que las autoridades de salud del país asuman la tarea pennanente de educar a la comunidad acerca del uso inadecuado de antimicrobianos y su efecto sobre la ecología bacteriana.

Políticas de saúde no Brasil nos anos 2000: a agenda federal de prioridades / Health policies in Brazil in the 2000s: the national priority agenda

This article analyzes Brazilian national health priorities from 2003 to 2008 under the Lula Administration. The study included a literature review, document analysis, and interviews with Federal health administrators. Four priorities were identified on the national health agenda: the Family Health Program, Smiling Brazil, Mobile Emergency Services, and the Popular Pharmacy Program. The first is a policy with high institutional density launched by the previous Administration, constituting an example of path dependence. The other three are innovations in areas where there had been weaknesses in Federal government action. The four policy priorities are strategies focused on solving key problems in the Brazilian health system. However, they display important differences in their historical development, political and institutional base, inclusion on the Federal agenda, and implications for the principles of the Unified National Health System. Although incremental changes have been introduced, national health policy has been characterized predominantly by continuity.

O artigo analisa as prioridades da política nacional da saúde no período de 2003 a 2008, correspondente ao Governo Lula. A pesquisa envolveu revisão bibliográfica, análise documental, análise de dados e entrevistas com dirigentes federais. Foram identificadas quatro prioridades na agenda federal da saúde: a Estratégia Saúde da Família, o Brasil Sorridente, os Serviços de Atendimento Móvel de Urgência e o programa Farmácia Popular. A primeira configura uma política de alta densidade institucional, iniciada no governo anterior, constituindo um exemplo de "dependência da trajetória". As demais foram adotadas como marcos de governo e trouxeram inovações em áreas em que havia fragilidades da atuação federal. As quatro políticas prioritárias analisadas se voltam para problemas relevantes do sistema de saúde brasileiro, porém apresentam diferenças quanto à sua trajetória, base de apoio e implicações para os princípios do Sistema Único de Saúde. Apesar de mudanças incrementais, observou-se a predominância de elementos de continuidade na política nacional de saúde no período.

Monitoring adherence to antiretroviral treatment in Brazil: an urgent challenge / Monitoramento da adesão ao tratamento antirretroviral no Brasil: um urgente desafio

The aim of this study was to describe the effect of non-adherence on the main laboratory outcomes, TCD4+ lymphocyte count and viral load, routinely used to monitor patients initiating treatment according to three different approaches to measure adherence to antiretroviral therapy. Among 288 participants, 22.9 percent, 31.9 percent and 74.3 percent were considered non-adherent, according to medical charts, self-report and pharmacy records, respectively. Depending on the adherence measures used, the average gain in TCD4+ lymphocyte count ranged from 142.4 to 195.4 cells/mm3 among adherent patients, and from 58.5 to 99.8 lymphocytes TCD4+/mm3 among those non-adherent. The average reduction on viral load ranged from 4.25 to 4.62 log copies/mL among the adherent patients, and from 1.99 to 4.07 log among those non-adherent. Monitoring antiretroviral adherence should be considered a priority in these public AIDS referral centers in order to identify patients at high risk of developing virologic failure. Early interventions are necessary in order to maintain the initial therapeutic regimens for longer periods.

O objetivo deste estudo foi descrever o efeito da não-adesão nos principais desfechos laboratoriais, contagem de linfócitos TCD4+ e carga viral, rotineiramente utilizados para monitoramento de pacientes iniciando tratamento segundo três diferentes formas de medir adesão à terapia antirretroviral. Entre 288 participantes, 22,9 por cento, 31,9 por cento e 74,3 por cento foram considerados não-aderentes, respectivamente, pelos registros em prontuários médicos, autorrelato e registros de dispensação nas farmácias. Dependendo da medida de adesão utilizada, o ganho médio de linfócitos TCD4+ variou de 142,4 a 195,4 células/mm³ para participantes aderentes, comparados com 58,5 a 99,8 para não-aderentes. A redução média na carga viral variou de 4,25 a 4,62 log cópias/mL entre aderentes, comparados com 1,99 a 4,07 para não-aderentes. O monitoramento da adesão à terapia antirretroviral deve ser uma prioridade nos serviços de referência de AIDS, sendo capaz de identificar pacientes com alto risco de desenvolver falência virológica e permitindo intervenções precoces com possibilidade de preservação de esquemas terapêuticos iniciais.

Measuring medicine prices in Peru: validation of key aspects of WHO/HAI survey methodology / Determinación de los precios de los medicamentos en Perú: validación de aspectos fundamentales del método de encuesta de la OMS/HAI

Objectives: To assess the possibility of bias due to the limited target list and geographic sampling of the World Health Organization (WHO)/Health Action International (HAI) Medicine Prices and Availability survey used in more than 70 rapid sample surveys since 2001. Methods: A survey was conducted in Peru in 2005 using an expanded sample of medicine outlets, including remote areas. Comprehensive data were gathered on medicines in three therapeutic classes to assess the adequacy of WHO/HAI's target medicines list and the focus on only two product versions. WHO/HAI median retail prices were compared with average wholesale prices from global pharmaceutical sales data supplier IMS Health. Results: No significant differences were found in overall availability or prices of target list medicines by retail location. The comprehensive survey of angiotensin-converting enzyme inhibitor, anti-diabetic, and anti-ulcer products revealed that some treatments not on the target list were costlier for patients and more likely to be unavailable, particularly in remote areas. WHO/HAI retail prices and IMS wholesale prices were strongly correlated for higher priced products, and weakly correlated for lower priced products (which had higher estimated retailer markups). Conclusions: The WHO/HAI survey approach strikes an appropriate balance between modest research costs and optimal information for policy. Focusing on commonly used medicines yields sufficient and valid results. Surveyors elsewhere should consider the limits of the survey data as well as any local circumstances, such as scarcity, that may call for extra field efforts.

Objetivos: Evaluar la posibilidad de sesgo debido a la limitación de la lista de referencia y del muestreo geográfico de la encuesta de precios y disponibilidad de medicamentos de la Organización Mundial de la Salud/Health Action International (OMS/HAI) usada en más de 70 muestras de encuestas rápidas desde el 2001. Métodos: En el año 2005, se realizó una encuesta en Perú, con una muestra ampliada de puntos de venta de medicamento, incluso en zonas remotas. Se recogieron datos integrales acerca de los medicamentos de tres clases terapéuticas, con el fin de evaluar la idoneidad de la lista de referencia de medicamentos de la OMS/HAI y el énfasis únicamente en dos versiones del producto. Las medianas de los precios al por menor de la OMS/HAI se compararon con el promedio de precios al por mayor del proveedor de datos mundiales de ventas farmacéuticas IMS Health. Resultados: No se observó ninguna diferencia significativa en la disponibilidad general ni en los precios de los medicamentos de la lista de referencia por localización de venta al por menor. La encuesta integral de los inhibidores de la enzima convertidora de la angiotensina, los antidiabéticos y los productos antiulcerosos reveló que algunos tratamientos que no están en la lista destinataria eran más caros para los pacientes y era más probable que no estuvieran a la venta, sobre todo en las regiones remotas. Los precios al por menor de la OMS/HAI y los precios al por mayor de IMS presentaron una correlación intensa en el caso de los productos de precio más alto, y la correlación fue débil en el caso de los productos de precio más bajo (que tuvieron márgenes de beneficio calculados más altos para el minorista). Conclusiones: El método de la encuesta de la OMS/HAI logra un equilibrio adecuado entre los costos de investigación moderados y la información óptima para la política. El énfasis en los medicamentos de uso frecuente produce unos resultados válidos y suficientes. Los encuestadores de otros...