National Pharmaceutical Care Policy and COVID-19: analysis of the pandemic response in the state of São Paulo

Abstract

The National Pharmaceutical Care Policy (Política Nacional de Assistência Farmacêutica - PNAF) is defined by the National Health Council as essential to the realization of the constitutional right to health. It is a cross-cutting and intersectoral policy that coordinates state and municipal managers at different levels of care in the Unified Health System (SUS). The objective was to identify and analyze the aspects of Pharmaceutical Care (PC) in the fight against COVID-19 in the state of São Paulo from the perspective of local and regional SUS managers, based on the PNAF. This is a mixed-method, multiple-case study with structured quantitative questionnaires and semi-structured qualitative interviews. Responses were obtained from 255 municipal managers (39.5%), representing 29,039,968 inhabitants (65.4% of the state population), and 14 regional health directors (82% of the Health Regions). This study identifies and analyzes ‘What are the contributions of the PNAF to addressing the COVID-19 pandemic in the state of São Paulo?’ The results revealed: joint action by federal entities, decentralization of PC, access to and rational use of medicines, irrational use of medicines from the COVID kit, tensions between managers, prescribers, pharmaceutical professionals and users, and supply difficulties.

Key words:
Pharmaceutical Policy; COVID-19; Unified Health System; Health Policy; Pharmaceutical Services

Resumo

A Política Nacional de Assistência Farmacêutica (PNAF) é definida pelo Conselho Nacional de Saúde como fundamental para a concretização do direito constitucional à saúde. É uma política transversal e intersetorial, que atua articulando gestores estaduais e municipais nos diferentes níveis de atenção do Sistema Único de Saúde (SUS). O objetivo foi identificar e analisar os aspectos da Assistência Farmacêutica (AF) no enfrentamento da COVID-19 no estado de São Paulo na visão dos gestores locais e regionais do SUS, a partir da PNAF. É um estudo de método misto, de múltiplos casos, com questionários estruturados quantitativos e entrevistas qualitativas semiestruturadas. Obteve-se respostas de 255 gestores municipais (39,5%) representando 29.039.968 habitantes (65,4% da população), e 14 diretores regionais de saúde (82% dos DRS). O estudo identifica e analisa ‘Quais as contribuições da PNAF no enfrentamento da pandemia de COVID-19 no estado de São Paulo?’ Nos resultados, observou-se: atuação conjunta dos entes federados, descentralização de ações da AF, acesso e uso racional de medicamentos, uso irracional de medicamentos do kit COVID, tensões entre gestores, prescritores, profissionais da AF e usuários, e dificuldades no abastecimento.

Palavras-chave:
Política Nacional de Assistência Farmacêutica; COVID-19; SUS; Política de Saúde; Assistência Farmacêutica

Resumen

La Política Nacional de Asistencia Farmacéutica (PNAF) es definida por el Consejo Nacional de Salud como fundamental para la realización del derecho constitucional a la salud. És una política transversal e intersectorial que coordina a los gestores estatales y municipales en los diferentes niveles de atención del Sistema Único de Salud (SUS). El objetivo fue identificar y analizar los aspectos de la Asistencia Farmacéutica (AF) en la lucha contra la COVID-19 en el estado de São Paulo desde la perspectiva de los gestores locales y regionales del SUS, con base en la PNAF. Se realizó un estudio de casos múltiples, de método mixto, con cuestionarios cuantitativos estructurados y entrevistas cualitativas semiestructuradas. Respuestas de 255 gestores municipales (39,5%; 29.039.968 hab., 65,4% pob.) y 14 directores regionales de salud (82% DRS) fueron obtenidas. El estudio identifica y analisa ‘¿Cuáles son las contribuciones de la PNAF en la lucha contra la pandemia de COVID-19 en el estado de São Paulo?’ Los resultados revelaron: acción conjunta federativa, AF descentralizada, acceso/uso racional e irracional de medicinas (kit COVID), tensiones (gestores, prescriptores, farmacéuticos, usuarios) y problemas de suministro.

Palabras clave:
Política Nacional de Asistencia Farmacéutica; COVID-19; Sistema Único de Salud; Política de Salud; Servicios Farmacéuticos

Introduction

The Unified Health System (SUS) in Brazil, for over three decades, has, through a specific set of policies, been guaranteeing advances in the health care of the Brazilian population¹. An essential and strategic component for its strengthening is the National Pharmaceutical Care Policy (Política Nacional de Assistência Farmacêutica - PNAF), which, throughout its twenty years, has contributed to the recognition of the right to health².

Defined by the National Health Council (Conselho Nacional de Saúde - CNS) as an integral part of the National Health Policy, the PNAF “involves a set of actions aimed at promoting, protecting, and restoring health, and guarantees the principles of universality, comprehensiveness, and equity”².

Even with historical underfunding¹, the collective construction of SUS has provided its growth, complexity, and robustness, making it a reference for a universal health system. In this context, the PNAF strengthens the system at different levels of care, connecting state and municipal managers in an intersectoral manner².

The contributions of the PNAF to the Brazilian health system are undeniable³. However, a large part of the users, workers, and managers of SUS do not fully know its role in health policies⁴, nor its transformative potential as a cross-cutting policy that contributes to the Pharmaceutical Care (PC) that SUS requires⁵, through the promotion of the Rational Use of Medicines (RUM)⁶, the structuring of the health-industrial complex⁷, access to medicines for chronic problems and for situations of individual and collective crises⁸; that is, in guaranteeing the right to full access to health⁹. An article by Leite et al.¹⁰ at the 16^th National Health Conference highlights that the PNAF is a public policy instituted by social control, through the Health Council. Moreover, more recently, there has been a significant growth in scientific production on the issue of PC throughout Brazil¹¹.

Worldwide, PC policies are presented in different models. The World Health Organization (WHO) advocates the advancement of PC in countries through a set of recommendations. One of its initiatives is the constant updating of the List of Essential Medicines as a guiding document¹². One study conducted by the International Pharmaceutical Federation reports on pharmaceutical manufacturing trends in 17 countries through a case study synthesis. Countries with national health systems, such as Canada, Portugal, and Spain, are in the continuous process of incorporating pharmaceutical manufacturing into their health systems¹³.

In a comparison of the PNAF with policies from other countries, significant differences can be found. The English National Health Service (NHS), which is from a high-income country, has the “Drug Tarrif”, which is equivalent to the National List of Essential Medicines (RENAME) of SUS. The Drug Tariff contains 3.9-fold more medicines than RENAME (3,620 compared to RENAME, 921 - comparing the 2020 Drug Tariff and RENAME 2020)¹⁴. However, the medicines in the Drug Tariff are partially paid for by users, while those in RENAME are provided free of charge.

Furthermore, in the NHS, PC is part of Primary Health Care (PHC) through “primary care trusts”¹⁵. Another comparison is that of PC in Mozambique, a low-income country, where there is a lack of effective policies for PC and obstacles to its sustainability¹⁶. In Cuba, the integration of PC with public health stands out through pharmacovigilance and pharmacoeconomic activities¹⁷.

Between 2019 and 2023, the world experienced a major global health problem, the COVID-19 pandemic. Across all continents, countries mobilized resources and efforts to address this event¹⁸. Brazil, thanks to SUS, has a universal health system that includes, among other attributes, Family Health as part of its policies¹⁹. During the pandemic, the intersectoral nature of the PNAF gained prominence through social participation, for example, through the Integra project²⁰.

The first confirmed case of COVID-19 in Brazil was in the state of São Paulo²¹ and from the arrival of the pandemic in February 2020 until April 2024, the state registered 6,851,049 cases and 183,150 deaths²². The case fatality rate in the state (2.7) was higher than the world average (0.9) and the national average (1.8)²².

São Paulo is the state with the largest population in the country, 44,411,238 inhabitants; the highest Human Development Index (HDI) - 0.806 - with 645 municipalities; and the largest urbanized area in the country (8,614.62 km²)²³. For the management of the system, the state is divided into 63 health regions and 17 macro-regions, spaces for intergovernmental agreements and the operational organization of SUS. The São Paulo State Health Department (SES-SP) has an administrative structure, also divided into 17 Regional Health Departments (RHDs), under the responsibility of its Health Region’s Coordination, which coordinates the activities of SES-SP at the regional level²⁴. However, the territory of the 17 macro-regions of health does not always coincide with the territories of operation of the 17 RHDs.

To understand the contributions of PC, anchored in the guidelines of the PNAF, the study starts from the question: What are the contributions of the PNAF when confronted with the COVID-19 pandemic in the state of São Paulo?

This article aims to identify and analyze the aspects related to PC in facing COVID-19 in the state of São Paulo from the perspective of municipal and regional health managers, using the PNAF guidelines as an analytical framework².

Methods

To carry out the study, the following were investigated: the experiences of municipal managers in São Paulo in the acquisition of equipment, supplies, and medicines during the COVID-19 pandemic; the use (receipt, distribution, and dispensing) of specific medicines: hydroxychloroquine, chloroquine, and ivermectin, called the “COVID kit”; the interruption of the activity of dispensing medicines in PHC; and the experiences of regional health directors regarding the availability of medicines from the covid kit and medicines for orotracheal intubation during the fight against the pandemic.

This is a mixed-methods (qualitative-quantitative) multiple-case study^25,26, developed by researchers affiliated with Brazilian and Portuguese public universities, in partnership with SES-SP and the Council of Municipal Health Secretaries of the State of São Paulo (Conselho dos Secretários Municipais de Saúde do Estado de São Paulo - Cosems-SP).

For its implementation, two questionnaires were used, intended for the municipal health secretaries of the 645 municipalities in São Paulo and the 17 regional health directors of the RHD in the state of São Paulo, both similar, with adaptations for the two groups. The questions addressed various topics concerning the pandemic and, for this article, three closed questions were used for municipal managers and one closed question for regional managers.

The choice of the 4 questions for this study aimed to explore PC actions, using the following strategic axes of the PNAF as a reference: the regulation and monitoring of the market for strategic inputs and products for health, including medicines; the promotion of the rational use of medicines; the use of RENAME; the qualification of PC services; and the decentralization of actions².

To increase respondent participation, the chosen platform was Google Forms, which provided access to the Informed Consent Form and the possibility of responding via a link generated by the platform.

The first questionnaire was applied as a pilot test in November 2021 to the municipal health secretaries who make up the Executive Board of Cosems-SP; and the second, during the same period, to a representative of the SES-SP coordination. After the tests, the questionnaires underwent a consolidation that included minor textual adjustments to facilitate their understanding, and the grouping of some response categories in order to reduce the completion time.

Subsequently, both questionnaires were made available through an invitation sent by email. The first questionnaire was made available to municipal health secretaries by Cosems-SP, with a data collection period from 11/24/2021 to 02/01/2022. The second questionnaire was made available to regional health directors by the AB coordination of SES-SP, with a data collection period from 11/24/2021 to 03/07/2022.

The results were exported to Microsoft Excel 2019 software for descriptive statistical analysis. Subsequently, the results were discussed in a virtual research seminar with the research group, in which the exclusion criterion was applied for municipalities and RHDs that responded in duplicate, thus considering the last response sent by the managers.

After the quantitative analysis, semi-structured interviews were conducted with municipal and regional managers, the latter linked to the RHD and the regional health surveillance centers, from two macro-regions selected by indication of the representatives of Cosems-SP and SES-SP, one from a metropolitan region and the other from the interior of the state. The municipal managers interviewed were from municipalities of different population sizes, with managers from small municipalities (up to 20,000 inhabitants), medium-sized municipalities (between 20,000 and 100,000 inhabitants), large municipalities (between 100,000 and 500,000 inhabitants), and extra-large municipalities (over 500,000 inhabitants) being interviewed in each macro-region. The interviews were recorded, transcribed, coded, and analyzed by categories, as recommended by content analysis²⁷, using Atlas.ti software version 24.

The analysis of the empirical material²⁸ was produced from four axes, which had been previously defined and which formulated the structure for the approach to the theme: 1 - acquisition of supplies, equipment, and medicines in the municipalities during the pandemic; 2 - use of specific medicines from the covid kit during the pandemic in the municipalities; 3 - interruption of the activity of dispensing medicines in the PC of Primary Health Care (PHC) during the pandemic in the municipalities; 4 - availability of medicines from the COVID kit and medicines for orotracheal intubation by the state management.

In the analysis of the field interviews - carried out in situ in the two regions - each interview received a code and each theme addressed a subcode in the interviews. The semantic excerpts of the coded text within the four axes analyzed in this article are presented in the context of the discussion of the results, using the PNAF guidelines as a reference.

This study was approved by the Research Ethics Committee of the Federal University of São Paulo, logged under protocol number 45679521.6.0000.5505, and was funded by the São Paulo Research Foundation - PPSUS-2020.

Results and discussion

Sample characterization

Of the 645 municipalities, 340 responses were obtained from municipal managers. After applying the criteria for eliminating duplicates, 255 responses were considered valid, which corresponds to 39.5% of the municipalities in São Paulo, with two-thirds answered by municipal health secretaries and one-third by their advisors. The 255 municipalities correspond to a population of 29,039,968 inhabitants, which is equivalent to 65.4% of the population of the state of São Paulo. Of the 17 RHDs, 14 regional managers (82% of the RHDs) responded to the questionnaire.

Table 1 presents the frequency and percentage of responding municipalities, grouped by RHD. Figure 1 illustrates the distribution of responding municipalities according to population size. Graph 1 shows the number of responding RHDs and classifies participants as either RHD directors or appointed advisors.

Table 1
Frequency and percentage in relation to the responding municipalities, grouped by RHD (Regional Health Department) (n=255).

RHD	Frequency of responding municipalities (n)	Percentage (%)	Accumulated (%)
1	20	7.84	7.84
2	13	5.10	12.94
3	9	3.53	16.47
4	7	2.75	19.22
5	8	3.14	22.35
6	35	13.73	36.08
7	12	4.71	40.78
8	8	3.14	43.92
9	28	10.98	54.90
10	9	3.53	58.43
11	15	5.88	64.31
12	7	2.75	67.06
13	14	5.49	72.55
14	5	1.96	74.51
15	37	14.51	89.02
16	13	5.10	94.12
17	15	5.88	100.00
Total	255	100.00

• Source: Authors.

Graph 1
RHD participants, classified as responded to by the regional health director or by an appointed advisor (n = 17).

Figure 1
Distribution and population size of the responding municipalities in the State of São Paulo (n = 255).

Acquisition of equipment, supplies, and medicines by municipalities

During the pandemic, there was a significant increase in demand for equipment, supplies, and medicines; this phenomenon occurred in both Brazil and worldwide²⁹. In the State of São Paulo, this study investigated the challenges faced by managers in the procurement process. The results are shown in Graph 2 and in excerpts from the interviews. Only 3.9% (n=10) of the municipal managers reported that there were no difficulties in procurement. Among the difficulties mentioned, the lack of products on the market (90.5%) and abusive prices (85.1%) stand out, as illustrated by the following excerpts.

Graph 2
Difficulties faced by municipal managers in acquiring equipment/supplies and medicines (n = 255).

And like I said [...] the issue, for example, of the overpricing of, uh, of PPE, even basic medications [...]. Municipal Manager (1:28 ¶ 201).

Second wave... and there were no medications, for intubation, there were no anesthetics, there were no PPEs, everything you found was absurd... Municipal Manager (2:24 ¶ 150).

In market logic, the value of input, medicine, or service tends to increase when there is greater demand and less supply. Moreover, with greater demand, scarcity arises, and during the pandemic, this was no different, even at the global level³⁰.

As a global response to this phenomenon, the WHO, in partnership with the World Economic Forum, created a collaborative network called “The Pandemic Supply Chain Network” with the objective of assessing the risks and enabling the supply of inputs and medicines necessary to confront the pandemic³¹. In Brazil, those responsible for the health system at the federal level did not act with the same caution³², thus making the challenges for municipal and state managers even greater in the acquisition of inputs and medicines that, when not exhausted, presented a very significant overpricing in relation to what they cost before the pandemic³³.

The constitutional right to PC has been historically debated by society, and by establishing the PNAF, the CNS defined guidelines for legitimate access to PC². Over its two decades, many challenges have been faced, including through processes of the judicialization of health³⁴, which largely deal with access to medicines and health supplies. In addition, administrative and legal obstacles in public administration have also been characterized as a challenge to access to the components of PC²¹, being pointed out by 44.7% (n=114) of municipal managers. Catanheide et al.³⁵ showed, through a systematic review of the judicialization of health processes in Brazil, that the phenomenon is directly related to access to medicines and the implementation of the PNAF guidelines. Furthermore, according to Floriano et al.³⁶, Brazil is the country with the most studies on the judicialization of medicines. The following statement by the municipal manager presents the difficulties.

...we had to reinvent ourselves, there was no way to make direct purchases...of equipment...of probes... We bought the first masks ourselves, with our own money [...] it was a very difficult phase...there was a shortage of medicine. Municipal Manager (10:32 ¶ 311).

During the pandemic, society mobilized in response to the scarcity of medicines and essential supplies to guarantee the lives of those affected by COVID-19. The PNAF presents item XII as a strategic axis, as defined in its second article, the ‘establishment of adequate mechanisms for the regulation and monitoring of the market for strategic health supplies and products, including medicines’², that is, what was already advocated as a national policy became dramatically evident in the face of the health emergency.

Use of specific drugs from the COVID kit in municipalities

In the absence of specific pharmacological treatment for COVID-19 - the drugs hydroxychloroquine, chloroquine and ivermectin (combined or not with azithromycin) were used in Brazil under the justification of “early treatment”, even in the absence of scientific evidence³⁷. During the pandemic, this set of drugs was popularly called the “COVID kit”.

The view of municipal managers regarding the use (receipt, distribution, and dispensing) of these drugs in the municipalities is presented in Graph 3 and highlighted in the interview excerpts. It should be noted that 58% (n=148) of the municipalities did not make the covid kit available, while 15.2% (n=39) stated that the municipality acquired it with its own resources and dispensed it for early treatment. In the qualitative interviews, some managers declared the existence of the drugs in the covid kit for treatment in their municipality, while others reported not having these drugs in their municipal services, as can be seen in the excerpts below.

Graph 3
Use of chloroquine, hydroxychloroquine and ivermectin (COVID kit) by municipalities in São Paulo during the fight against COVID-19 (n = 255).

We had ivermectin, vitamin D, a lot of things, right? Municipal manager (10:69 ¶ 1072-1074).

Chloroquine? No, I don’t have chloroquine. No, we didn’t have it at the PHC unit. Municipal manager (17:16 ¶ 176-179).

The PNAF has, as one of its strategic axes, as set forth in article two, item XIII, the “promotion of the rational use of medicines, through actions that regulate prescription, dispensing, and consumption”. The rationalizing instrument for this strategy is RENAME, which contains the National Therapeutic Form (Formulário Terapêutico Nacional - FTN)³⁸.

The three medicines in the COVID kit are listed in RENAME, with hydroxychloroquine and chloroquine classified as part of the Specialized Component of the PC, and ivermectin classified as a medicine of the Basic Component of the PC³⁸.

The FTN establishes the clinical guidelines, with recommendations and protocols for the use of the medicines listed in RENAME. According to the FTN, chloroquine is a medicine used in the Clinical Protocol and Therapeutic Guidelines for the treatment of Rheumatoid Arthritis and Systemic Lupus Erythematosus. Hydroxychloroquine is recommended for the treatment of Rheumatoid Arthritis, Dermatomyositis and Polymyositis, and Systemic Lupus Erythematosus³⁸. Ivermectin, on the other hand, is a medication used to treat parasitic infections, such as intestinal strongyloidiasis, onchocerciasis, filariasis, ascariasis, scabies, and pediculosis³⁹. The following excerpt from an interview with one of the municipal managers presents an example of how some municipalities dealt with the use of the COVID kit.

No, that protocol never existed, of using ivermectin to treat a virus [...] between the 1^stwave and the 2^ndwave, the kit no longer existed, they stopped...you could see in the prescription that it was always the same thing...Azithromycin, ivermectin, and so on ... if I were to change something back then, I wouldn’t have let that happen. Municipal Manager (8:26 ¶ 229).

In the present study, the majority of municipalities (58%) did not make these medications available for the treatment of COVID-19. However, five municipal managers (1.9%) received donations and distributed these medications for hospital use in their municipalities; five municipal managers (1.9%) received donations and dispensed these medications to users of municipal health services for early treatment; 21 municipal managers (8.2%) received these medications from the Ministry of Health or SES-SP and distributed them for hospital use; 24 managers (9.4%) acquired these medications with their own municipal resources and distributed them for hospital use; and 39 managers (15.2%) acquired these medications with their own municipal resources and distributed them to users for early treatment. The interviews reveal the learning curve of municipal managers regarding the use of medications from the COVID kit.

Actually, we grew up together, because initially nobody knew anything about COVID....to give you an idea, I was one of the first doctors to have COVID [...] I even took Chloroquine [laughs]. Municipal Manager (10:44 ¶ 556).

The results also show that 10.9% (n=28) of municipal managers were unable to report whether or not medications from the COVID kit were used as treatment in their municipality, as exemplified in the following excerpt.

What’s it called? The covid kit… Chloroquine! I forgot the name, I think Freud could explain it… I can’t guarantee that no doctor in the network used it, it wasn’t our medical practice, right? But it wasn’t the municipal protocol. Municipal Manager (17:15 ¶ 164-175).

The infodemic, characterized as a pandemic of inaccurate and harmful information hindering the fight against the pandemic, has affected the entire world⁴⁰. In Brazil, one expression of the infodemic was the dissemination of incorrect information about the use of the “COVID kit,” which led some SUS managers and a significant number of prescribers in the supplementary network to encourage the use of the covid kit as early treatment for COVID-19. This movement also had the support of the federal government, which disseminated and promoted early treatment⁴¹.

In this scenario, the knowledge and appropriation of the PNAF guidelines by municipal managers acted as a tool that mobilized the Rational Use of Medicines (RUM)⁴. The following excerpt reveals one of the strategies employed by municipal managers to avoid the use of medications from the covid kit in municipal SUS services.

Ah, but they prescribed Chloroquine...that was your doctor in the private practice, right? Because that’s the professional’s autonomy, but in our network, where it was, inside the hospitals, we had a training protocol. Municipal Manager (22:5 ¶ 58).

The use of the COVID kit as a pharmacological treatment triggered scenarios of tension among users, managers, and prescribers. Due to the lack of scientific evidence regarding the use of the covid kit, there was no therapeutic justification for these prescriptions. However, the infodemic phenomenon also affected prescribers, who used these medications as a therapeutic resource⁴².

In view of this, the most appropriate tool for management in combating the infodemic was the concept of RUM described in PNAF², which advocates the use of medications based on scientific evidence, from clinical protocols and therapeutic guidelines³⁸.

Interruption of drug dispensing activity at the PHC Pharmacy

Health services had their activities totally or partially interrupted during the pandemic, either to implement specific actions to confront and combat the virus, or due to the resizing and lack of personnel to compose the workforce^43,44.

PHC, the level of care with the greatest reach within SUS, underwent adaptations and modifications during the pandemic in municipalities to meet the emergency needs presented by the health crisis⁴³. The statement by the municipal manager described below presents a strategy implemented by PHC to guarantee access to medications in PHC during the pandemic.

There was even the issue of dispensing for six months...continuous use, right? We extended the validity of the prescription to up to one year...Because then, the user wouldn’t need to go monthly to pick up the medication...depending on the prescription, 6 months, 3 months... Municipal Manager (17:47 ¶ 548-559).

There are differences in the organizational models of PC among municipalities in all regions of the country, including the state of São Paulo. This study sought to investigate if in fact there was an interruption in the PC activity most recognized by users, professionals, and managers of SUS health services: the dispensing of medications in PHC pharmacies⁶. Of the 255 responding municipalities, 5.4% (n=14) had their medication dispensing activities impaired or completely interrupted during the COVID-19 pandemic. The excerpts from the interviews presented below illustrate PC arrangements for continuity of care in PHC.

In the health units, we continued with the routines during the most difficult times... issues with prescriptions, controlled prescriptions... we extended the prescriptions for continuous use, to avoid the patient having to go to the unit just because of prescription renewals. Municipal Manager (11:6 ¶ 62).

And we increased the time frame for dispensing medication... So, we also evaluated this patient, and then it was a more individual approach by the pharmacist: I’m going to reduce the time... I want them to come to the pharmacy more often to pick up medication. So, the pharmacy didn’t stop. Municipal Manager (28:20 ¶ 170-174).

The low percentage of interruption of municipal PC activities reflects the importance of PC during the pandemic, and this construct is one of the results of the PNAF. PC in SUS is recognized as a collective health tool that guarantees access to medicines and supplies in chronic and crisis scenarios⁴⁵.

In addition to access to supplies and medicines, PC acted as a source of information for the use of medicines and supplies and off-label use during the pandemic⁴⁶, as advocated by the PNAF, as expressed in the following excerpt.

The pharmacy plan is medication protocols. Many medications used were later proven ineffective, so these protocols wouldn’t have even been allowed to happen. Municipal Manager (8:20 ¶ 119-126).

The dispensing of medications, which is part of PC, is permeated by technical and scientific knowledge and requires high professional qualification, and can be compared to such activities as medical and nursing care, as well as many other specific activities of professional health categories, whose actions result in comprehensive health care. However, although it was not interrupted during the pandemic, some interviews reveal that dispensing is often interpreted by managers as “delivery” or “collection” of medication.

This result may express the existence of a reductionist understanding, by a part of society, about PC, about the PNAF, and about its importance for health care.

Provision of drugs from the COVID kit and medicines for orotracheal intubation by the Regional Health Departments (RHDs)

In the state of São Paulo, the state government, through inter-managerial bodies, such as the Bipartite Intermanagerial Commission (Comissão Intergestores Bipartite - CIB), made some pharmaceutical supplies available for health actions during the pandemic¹⁹. This study investigated the provision of the covid kit by the RHDs to the municipalities of the state.

Of the regional managers, 35.7% (n=5) stated that the COVID kit was made available to the municipalities as defined by the state government, while 64.2% (n=9) stated that they had not made these medicines available to the municipalities. The following statement from the regional manager describes the receipt of these medications for distribution.

We got I don’t know how many drums…from the army, and how are you supposed to store those drums? And how do you distribute them, what parameters do you use? Well, it’s…any parameter, it was just a parameter [laughs]. Regional Manager (4:1 ¶ 43).

Regarding medications for orotracheal intubation, 78.5% (n=11) of the regional managers made them available to municipalities, as defined by the state management; one manager passed the medicines acquired by the Ministry of Health on to the municipalities, and one manager stated that they had not made any of these medicines available to the municipalities.

The majority of regional managers (64.2%) did not make the medicines from the COVID kit available to the municipalities. In addition to the lack of scientific evidence and the political and media controversy surrounding the use of these medicines⁴⁷, the PNAF presents, as a strategic axis, which is defined in its second article, item VII, as “the use of RENAME, updated periodically, as a rationalizing instrument for actions within the scope of pharmaceutical care”².

Medicines for orotracheal intubation were made available by the vast majority of RHDs (78.5%), following what is recommended in the PNAF, which presents, as a strategic axis, as defined in its second article, items III and IV, the “qualification of existing pharmaceutical care services, in connection with state and municipal managers, at different levels of care” and the “decentralization of actions, with definition of the responsibilities of the different management instances, in a consensual manner and aiming to overcome fragmentation in uncoordinated programs”, respectively².

The use of pulmonary ventilation, through orotracheal intubation, was the therapy recommended and prioritized by the WHO during the pandemic for severe and critical cases⁴⁸. In the first wave of the pandemic, there was little knowledge about adequate health care; and yet the health policies built within SUS, including the PNAF, guaranteed social security and ethical health care⁴⁶. The interviews also revealed solidarity among the teams that performed orotracheal intubation, as reported by a regional manager.

We started together, we evolved, and we evolved very well, because we even got to extubate patients here... we had colleagues who were on ICU shifts, they passed on a lot of knowledge to many colleagues. Regional Manager (10:70 ¶ 1096-1103).

This action reflects the intervention of the state government to guarantee the supply of essential pharmaceutical products for healthcare, with their use in accordance with the protocols, guidelines, and recommendations of the WHO, which prioritized the use of pulmonary ventilation, through orotracheal intubation, for severe and critical cases⁴⁸.

Final considerations

The political and scientifically unfounded use of medication, fueled by political party leaders and part of the medical establishment, in search of a solution for COVID-19, led part of society to the irrational use of medicines⁴⁹. It reached the point of prescribing a fallacious “early treatment” on a large scale⁵⁰. This was countered by PHC guided by PNAF guidelines, which were decisive in making decisions that prevented deaths and ensured safety and life.

During the pandemic, the mobilization of all sectors of society highlighted the importance of PC as a component of public health and as a social right, constitutionally grounded and guided by the PNAF.

It should be noted that the critical situations reported in this study, such as the irrational use of medicines from the COVID kit, the tensions between the actors (managers, prescribers, PC professionals, and users), and the difficulties in supply; cannot be minimized and are characterized as challenges for the performance and expansion of PC.

This study is limited by its restriction to municipalities in the state of São Paulo and to the four axes analyzed in this excerpt, and it therefore does not allow us to express all the benefits produced by the PNAF during its twenty years. However, it does expose the power of a national health policy that is strengthened ‘with’ and ‘for’ SUS.

Acknowledgements

Thanks to Cosems-SP, to SES-SP, and to Fapesp.

References

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• Data availability statement
  The data sources adopted in the research are indicated in the article’s body.

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vania de Matos Fonseca

Data availability

The data sources adopted in the research are indicated in the article’s body.

Publication Dates

• Publication in this collection
  26 Jan 2026
• Date of issue
  Jan 2026

History

• Received
  10 Sept 2024
• Accepted
  28 July 2025
• Published
  30 July 2025