Is the Pharmacy Door Our Limit? Challenges in the Professional Identity of Pharmacist in Primary Health CareAbstract
Pharmacists have been undergoing changes in their professional identity (PI), understood as the skills, knowledge, values, behaviors, and attitudes necessary for their role in the world of work. This article aimed to analyze the elements of pharmaceutical PI in Primary Health Care (PHC). The study is an exploratory, qualitative study using semi-structured interviews. The event was attended by pharmacists working in PHC, the Regional Pharmacy Council, and universities. Thematic content analysis of the interviews was used based on three categories: “professional and training path,” “PI considering PHC attributes,” and “performance in PHC in the face of professional and health regulation.” Those working in the PHC exhibited a significant level of education and an average of seven years of experience. The analysis of the interviews points to the emergence of a “new identity,” more aware and confident in their role in care and assistance, albeit constructed through the confrontation of challenges in labor relations, a technocratic teaching approach, little recognition from peers, and the obstacles of professional regulation. Changes in public policy were identified to ensure that pharmacists play an integral role as part of the healthcare team.
Keywords:
Social Identification; Pharmacists; Pharmaceutical Care; Primary Health Care; Public Health.
Resumo
O farmacêutico vem passando por alterações em sua identidade profissional (IP), compreendida pelas habilidades, conhecimentos, valores, comportamentos e atitudes necessárias para seu papel no mundo do trabalho. Esse artigo tem por objetivo analisar elementos da IP farmacêutica na Atenção Primária à Saúde (APS). Trata-se de um estudo exploratório, qualitativo, com entrevista semiestruturada. Participaram farmacêuticos que atuam na APS, no Conselho Regional de Farmácia e em universidades. Utilizou-se análise de conteúdo temática das entrevistas a partir de três categorias: “percurso profissional e formativo”, “IP considerando os atributos da APS” e “atuação na APS frente à regulação profissional e sanitária”. Observou-se elevada escolaridade e tempo médio de sete anos de atuação para aqueles da APS. A análise das entrevistas aponta para o surgimento de uma “nova identidade”, mais consciente e segura de seu papel no cuidado e na assistência, ainda que construída com o enfrentamento dos desafios nas relações de trabalho, ensino tecnicista, pouco reconhecimento pelos pares e com os obstáculos da regulação profissional. Foi possível explicitar mudanças nas políticas públicas para a garantia da atuação do farmacêutico como parte integrante da equipe de saúde.
Palavras-chave:
Formação da Identidade Profissional; Farmacêuticos; Assistência Farmacêutica; Atenção Primária à; Saúde; Saúde Pública.
Introduction
Pharmacists are professionals with a wide range of career opportunities; one such area is social pharmacy, which encompasses public health initiatives and activities. In this field, there has been a growing role for pharmacists as healthcare professionals in Primary Health Care (PHC), with a new patient-centered model of practice and activities aligned with the essential attributes of PHC within the Unified Health System (SUS) (Barberato, Scherer, & Lacourt, 2019; Destro et al., 2021).
This expansion of the profession’s activities in primary health care is partly due to the adoption of the new National Curriculum Guidelines (DCN-Diretrizes Curriculares Nacionais) established by the Ministry of Education (MEC) in 2017 and the establishment of a new training profile for pharmacists, based on three core areas of training: Health Care, Health Technology and Innovation, and Health Management. It advocates that pharmacists be health professionals qualified to provide health care, make decisions, and interact with other professionals and the public, while promoting the early and progressive involvement of students in the SUS (Brazil, 2017). The new DCN also emphasizes the importance of incorporating reflections on the health-disease process in the context of the user, the family, and the community into the training curriculum for pharmacists (Osorio-de-Castro et al., 2020).
Despite the expansion of their scope of practice, there are significant considerations regarding the process of integrating pharmacists’ activities into primary health care and their recognition as professionals within a multidisciplinary health care team (Barberato, Scherer, & Lacourt, 2019; Dóczy et al., 2023). This recognition, which stems from social relationships in the workplace, entails the concept of professional identity (PI) (Dubar, 2005).
The development of professional identity is reinforced through professional socialization-the process by which one acquires the skills, knowledge, values, behaviors, and attitudes necessary to fulfill one’s role in the workplace-and is further supported by daily practices, professional knowledge, and workplace relationships throughout one’s professional career (Vozniak, Mesquita, Batista, 2016).
Claude Dubar (2012) highlighted the importance of social interaction and subjectivity in the processes of professional formation. This approach allows for an analysis of the pharmacist’s work, with a particular focus on their career, professional trajectory, and the relationships that shape it. According to Dubar, the constituent elements of this analysis encompass both academic and professional training as well as experiences in different socialization settings.
In this way, the research can delve deeper into the practical representations and professional knowledge that emerge from these experiences, understanding how they relate directly to the contexts of education, work, and career. Using a qualitative approach, the contemporary framework proposed by this author enables an investigation of the pharmacist’s transition onto new paths, reshaping their career in public health practice.
Works dedicated to pharmaceutical PI are scarce. However, other health professions have studies with this focus, such as nursing, dentistry, and psychology. Focusing on nursing, the study by Alves et al. (2021) reveals that PI is influenced by a lack of understanding of work processes, with the mechanical incorporation of practices into daily routines, hindering the development of a strong sense of PI.
Thus, this article analyzes these elements of PI from the perspective of pharmacists, including their academic and professional training, experiences, expectations, limitations, and challenges regarding their practice within the context of PHC in the SUS.
Methods
This study is the result of an exploratory, qualitative research project conducted with pharmacists who have worked for at least one year in primary health care (PHC), faculty members teaching the Public Health course in undergraduate pharmacy programs at universities in Rio de Janeiro, or representatives of the Regional Pharmacy Council of Rio de Janeiro (CRF RJ). Recruitment was conducted via invitations on social media and the WhatsApp® app within networks of potential participants, followed by individual contact with those who expressed interest. Professionals working in management, psychosocial care centers, hospitals, and CRF-RJ inspectors were not included.
Nine pharmacists, coded as E01 through E09, participated in the study. They were interviewed between September 2021 and April 2022, after providing informed consent. However, one participant withdrew consent after the interview and was not included in the study.
The individual semi-structured interviews conducted remotely were recorded, manually transcribed, and reviewed and allowed the participants to describe their personal and professional trajectories, as well as their expectations regarding the profession. To characterize the interviewees, questions were asked about sex, age, duration, and location of education and degree (stricto and lato sensu). The interview guide was structured around the following themes: career path, education and professional practice, activities performed on the job, challenges at work, and information regarding guidelines, public policies, protocols, and regulations that govern the training and practice of pharmacists.
The study employed thematic content analysis (Bardin, 2011) to organize and process the interview data. The interviews underwent a pre-analysis process, followed by a thorough exploration of the material. While one pair of researchers searched for elements in the statements to create analytical categories, another pair classified the material based on a pre-established theoretical framework. The use of these two work processes aimed to identify, code, and validate the categories and subcategories, which were established at the end of the process by consensus (Bardin, 2011). No software was used to process the interviews. The theoretical framework for the categorization was based on the following themes: the perspective of socialization with the PI configured within social and work relationships (Dubar, 2005) and the attributes of PHC (Starfield, 2002). Thus, three categories were constructed for the analysis of the study: “the pharmacist’s professional and educational trajectory,” “the pharmacist’s professional identity considering the attributes of PHC,” and “the pharmacist’s role in PHC in light of professional and health regulations.” Table 1 presents the categories and their subcategories, along with the guiding concepts for each.
The study was registered with CAAE under numbers 50225121.4.3001.5279 and 50225121.4.0000.5240 and approved by the Research Ethics Committee of the National School of Public Health Sérgio Arouca and the MHS-RJ, pursuant do opinions nº under opinions nº. 4.980.567 and nº 5.064.118, respectively.
Results and Discussion
Characteristics of the survey participants
The average age of the respondents was 43.3 years, ranging from 31 to 54 years. The sample consisted of five men and three women. Five participants graduated from private institutions, while the others attended public universities. The average time elapsed since graduation was 16.9 years, spanning between 10 and 27 years.
Almost all (7 out of 8) reported having completed a stricto sensu and/or lato sensu graduate program. In terms of fields, two professionals completed a multiprofessional residency; six specialized in clinical and hospital pharmacy, two in public health, and one in pharmaceutical care management. Four completed the “Update on Pharmaceutical Services in Primary Health Care” program, an 80-hour professional qualification program offered by ENSP/Fiocruz in partnership with the Rio de Janeiro Municipal Health Secretariat (SMS-RJ), and two participated in the distance learning extension course “Pharmacists in Primary Health Care: Working in a Network,” offered by the Federal University of Rio Grande do Sul, with a course load of 360 hours. The importance of these latter programs in creating a sense of belonging and consolidating PI in the field of PHC was highlighted.
From this perspective, in line with Dubar (2005), it is worth noting that the research participants’ experiences reflect characteristics that shape representations of the pharmaceutical profession, demonstrating that professional identity is (re)constructed through relationships in the fields of work, employment, and education.
Seven respondents had experience working in PHC, five of whom were still employed there, having spent at least three years in their current position, ranging from four to 11 years (mean = 7 years).
The pharmacist’s professional and educational background
For most respondents, their professional careers began in the retail sector, at a drugstore or pharmacy. This reality is highlighted by Silva et al. (2019), who found that approximately 53% of job openings are in drugstores. A report on the profile of pharmacists in Brazil by the Federal Council of Pharmacy (CFF), based on 2014 data, showed that 52% of pharmacists work in private pharmacies and drugstores (Serafin, 2015).
Brazilian health regulations, dating back to Law No. 5,991/73, require the presence of a responsible technician in pharmacies and drugstores, but are vague regarding the mandatory technical responsibility of the pharmacist (Brazil, 1973). Forty years later, Law No. 13,021/2014 reinforced this requirement and specified that only pharmacists may assume this professional role. This measure aims to ensure the quality of services provided and compliance with technical standards, with the pharmacist being the professional qualified to guarantee pharmaceutical care (PC) and perform pharmaceutical activities related to promotion and guidance (Brazil, 2014).
When analyzing the average training duration, the interviewees highlighted a gap between theoretical knowledge acquisition and its effective application in a professional context. The 2017 DCN promoted a renewal in the future professionals’ training, making it flexible and adapted to the demands of society. However, studies point to discussions regarding barriers to entry and weaknesses, marked in part by the technical model, which ultimately distances professionals from their promotion and care activities (Dóczy et al., 2023).
[...] A drugstore means health, but we know that what really matters in a drugstore is the business relationship. It is awful to work in a drugstore; the work environment is very uncomfortable (E07).
[...] I can say that when we graduate, we start seeking employment. It does not matter where, especially because when I graduated, I was already married and had a family. So, basically, your goal is to make money (E06).
While the role of pharmacists in drugstores represents a significant advancement, it also underscores the tension between technical expertise and commercial demands. Furthermore, in this context, it is marked by challenges intertwined with historical, social, and economic factors that impact their practice and social perception (Mattos et al., 2022).
In light of the concrete situations experienced, it becomes clear that the social subject, embedded in professional, economic, and family contexts, demonstrates that PI is the provisional synthesis of certain conflicts between what individuals want to be and what society and the market expect or impose upon them (Dubar, 2012). In other words, the constraints and opportunities imposed by the labor market and the social structure influence the trajectories and representations that individuals form of themselves and their profession.
While some are seeking to advance professional practice and implement pharmaceutical care in drugstores (Melo, Filho, & Oliveira, 2023), others have shifted their focus to PHC and to understanding their attitudes toward patient care.
“[...] A PHC pharmacist differs from a pharmacist at a drugstore, for example, because we do carry out activities outside the clinic, such as the school health program (E03).”
Although there is diversity in the career paths described, there is a common thread in the professional trajectories of some interviewees, who worked in hospital pharmacy before moving into primary health care. Nevertheless, it is not possible to establish a direct link between the two in terms of practice settings and career paths.
“[...] I have worked in retail, distribution, warehousing, and hospital pharmacies. [...] Since 2011, I have been working in primary care, either as a consultant or on the front lines (E01).”
The professional’s hospital practice is outlined in health regulations regarding the pharmacist’s role in caring for inpatients and outpatients, as a means of adjusting drug therapy, contributing to pharmacoeconomics, and serving as part of a multidisciplinary team. In line with the hospital setting, the clinical pharmacy movement has emerged as a revival of the professional’s role in health promotion (Leal et al., 2022), but it does not fully guarantee its practical implementation across all health services. This role in the hospital setting highlights, based on the results, the need for complementary training in the field. Five of the eight interviewees completed the specialization program in Clinical and Hospital Pharmacy before working in PHC.
The interviewees’ professional trajectories revealed the importance of continuing and specialized education. As noted by Silva and Dalbello-Araujo (2020), the multiprofessional residency program serves as a valuable strategy for professional development, providing a collaborative learning environment that fosters knowledge sharing and practical healthcare activities.
[...] It was the residency, everyone’s focus. Everything I am today started during residency. I even have difficulty saying that I am a pharmacist. My professional journey began during residency. Prior to that, there were just random scenes, things I would rather not do. (E08).
For many professional groups working in primary health care, their career path begins with residency training, a powerful educational strategy for working in family health and reinforcing the significance of health interventions, especially within the context of the Brazilian Unified Health System (SUS) (Flor et al., 2022). This training can be decisive in giving new meaning to the profession, making it more connected to its social role and less commercial. These elements reinforce the need to contextualize this training, starting at the undergraduate level, and strengthening the links between disciplines within the field of public health and beyond.
Another study that analyzed the Hospital Pharmacy Residency as a setting for training continuing health education providers in hospitals found that the majority of participants worked in the public sector (67.8%) and that some of them performed their professional duties in PHC (Salgues, Cardoso, & Silva, 2024). Regardless of a residency program specifically designed for pharmacists working in PHC, the interviewees sought additional training only upon beginning their professional practice in this field.
Although there are various opportunities for practice in public health, the pharmacists interviewed explained that the context of primary health care remains unfamiliar to them, pointing out gaps between theoretical and practical training and the public policies that regulate their practice (Destro et al., 2021; Dóczy et al., 2023).
[...] She invited me to work there. [...] I thought, “What is primary care?” I had no idea how this whole system works or what the SUS means in patients’ lives (E04).
[...] They asked me if I wanted to work at a family clinic. [...] I had no experience, but I gradually gained it and adapted it to my own style (E06).
PI and its relationship with PHC are things that are still taking shape and continue to present challenges. One of these challenges lies in the shift in the training process, which must align with the development of skills and competencies and goes far beyond mere technical knowledge, as noted by Dóczy et al. (2023).
The professional identity of pharmacists in light of perceptions of the attributes of PHC
To work in PHC, pharmacists’ activities suggest management priorities, particularly regarding the operational aspects of medication logistics, as well as clinical management, with a focus on expanding work within multidisciplinary teams and on promotion, prevention, and care activities (Brazil, 2013, 2024; Diel et al., 2019; Peixoto et al., 2022). In this regard, there are tensions between technical-managerial and technical-care issues, as the latter remains a challenge to be fully realized in PHC, where such activities are often sporadic (Barberato et al., 2022; Destro et al., 2021).
Participation in a multidisciplinary team consists of a “form of collective work characterized by the reciprocal relationship between various technical interventions and the interaction of professionals from different fields” (Peduzzi, 2001, p. 103). This partnership is one of the key aspects for the pharmacist, and within it, each healthcare profession contributes knowledge from its own field and learns from others, sharing insights and contributing to the resolution of users’ needs.
“[...] Being part of a multidisciplinary team makes a big difference in our training (E08),” and “Everyone is there to acquire knowledge and strengthen working relationships. [...] Having this bond allows them to see that you are there to contribute, to talk (E01).”
In this regard, integration with the multidisciplinary team requires revisiting the provisions outlined in the guidelines of the Ministry of Health’s (MS) National Primary Care Policy (PNAB). Primary Health Care (PHC) serves as a model for organizing services and a set of strategic actions (including the Family Health Strategy-FHS) that require the involvement of various professionals. Pharmacists are among the professions that can comprise the teams supporting the FHS, such as the former Family Health Support Center (NASF), now called the Multidisciplinary Team (eMulti). This professional works permanently in health units housing FHS teams, eMulti teams, and physically established pharmacies, as well as in other physical spaces that serve as referral points for these teams, ensuring the necessary support to address user needs, providing matrix support, and carrying out other actions.
If, on the one hand, policy recognizes the pharmacist as a component of eMulti, the National Pharmaceutical Care Policy (PNAF), on the other hand, fails to define the scope of practice and the limits of the pharmacist’s role in primary health care. Pharmacists seek to redefine their profession by performing various activities to promote rational use, protect and restore health, and prevent diseases, overcoming technical barriers to provide care (Destro et al., 2021; Dóczy et al., 2023).
In the specific case of Rio de Janeiro, the Municipal Health Secretariat (SMS) has allocated resources to include these professionals in primary health care centers, thereby contributing to the provision of pharmaceutical services and fostering teamwork.
In this way, the service is better organized based on respect, autonomy, and the bond between professionals and users, aiming at a comprehensive and effective approach grounded in multidisciplinary interventions. Furthermore, it fosters a sense of belonging to primary care, which strengthens the role of the professional and direct care for users (Destro et al., 2021; Peixoto et al., 2022).
“Primary care involves a unique relationship with the patient; it is the action of the patient within comprehensive care and of the pharmacist within comprehensive care. It goes far beyond simply dispensing medication. It is a unique form of care (E02).”
The sense of belonging in the workplace is also undermined by the long disorganization process experienced by professionals in their daily practice (Peixoto et al., 2022). This situation undermines the sustainability of the PI. The respondents’ contributions highlight that the presence of the pharmacist goes beyond a mere legal requirement devoid of practical meaning and further emphasize the relevance of promoting their integration as an integral part of the healthcare team, extending beyond the walls of the clinic to engage in multidisciplinary activities, home visits, and community initiatives.
“The role of the pharmacist has always been-how should I put it-a bit of a shadow. [...] They are not included in the minimum staffing requirements for family health care, and funding does not impact whether you can pay staff better or expand the team (E01).”
“[...] Managers and society still need to see pharmacists as healthcare professionals who do more than just delivering prescriptions, you know? (E02)”.
The interviewees acknowledged that their courses fell short in terms of providing the knowledge and methods required for their work, citing, on the one hand, the limited availability of such courses: “About eight years ago, we had many more courses focused on pharmacy. (E06)” and, on the other hand, the challenges of their work routine: “I would like to study more. Occasionally, I cannot keep up with my routine, let alone set aside time to study anything (E04).” However, the course on Pharmaceutical Services in PHC offered in partnership between the SMS-RJ and the Department of Drug Policy and PHC at ENSP/Fiocruz was cited by three interviewees for providing opportunities to develop knowledge in the care sector and in building social relationships, as noted in a study by Dóczy et al. (2023).
Despite the long journey ahead before pharmacists’ roles in PHC can be fully realized, the articulation between the “world of work” and the way work is performed contributes to the construction of professional identity (Dubar, 2012), with pharmacists playing an increasingly significant role regarding the essential attributes of PHC-access, continuity, comprehensiveness, and coordination of care (Starfield, 2002).
The “access” component within the framework of Pharmaceutical Care (PC) aims to ensure the public’s access to essential medicines and promote their correct and rational use. Lack of access to medicines can lead to the worsening of diseases and, consequently, to patients returning to health care services, as well as potentially increasing costs in secondary and tertiary care.
As pharmaceutical practice in PHC has evolved, medication has shifted away from its primary role and has become more broadly integrated into the healthcare process. It should be noted that, according to the findings of Barberato et al. (2012), pharmacists’ role has been focused on the organization and management of pharmaceutical services, particularly medication logistics, which reveals a gap in the provision of clinical services. According to the author, the management of pharmaceutical care aims to ensure that actions involving the patient and medication use do not end with dispensing. In other words, the goal is to ensure that the entire pharmaceutical care process contributes to comprehensive care, even if the primary focus remains on logistics and organization.
“Pharmacists in primary care play a key role in providing guidance, in programs linked to the health center, and in participating in support groups. [...] We have many activities and much to contribute to issues related to the rational and safe use of medications by the public (E09).”
The pharmacist’s role, from a longitudinal perspective, is realized through work over time, thereby reinforcing the bonds among patients, their families, and the professionals involved. It is a powerful strategy for ensuring the continuity and effectiveness of treatment and contributes to promoting preventive measures and preventing health complications (Santos, Romano, & Engstrom, 2018). In the study by Diel et al. (2019), the pharmacist’s work and that of other health professionals are highlighted in health groups, where they can contribute technical information about medications and provide opportunities for participants to share their experiences, encouraging them to collaborate in seeking strategies for a better quality of life.
“I conduct home visits, participate in the school health program, [...] work in the waiting room, lead a smoking cessation group, and facilitate a healthy lifestyle group (E03).”
Comprehensiveness, as an attribute, refers to the services the healthcare system must provide users so that users receive comprehensive care and coordination of education, promotion, protection, and prevention efforts across the various levels of care. From the perspective of the pharmacist’s practice, comprehensiveness is embedded in the very definition of pharmaceutical care proposed by the PNAF and is intertwined with the other attributes and strategies for treatment adherence, given that the user-centered actions and services developed by pharmacists contribute to treatment continuity and the enhancement of outcomes (Barberato, Scherer, & Lacourt, 2019).
The pharmacist recognizes the significant role they play in building a relationship with patients and in taking a holistic view of them, listening not only to the symptoms of their illness but also to their personal stories, which are often implicit.
“[...] I had two patients with tuberculosis who were homeless, you know? [...] They formed a bond with me because they said I was the only person who had sat down next to them [...] to talk about the treatment of one of them, since he had already abandoned it four times (E01).”
Ensuring comprehensive primary care within the SUS is a complex challenge. The judicialization of the right to health and its broad interpretation often place access to medications at the center of the debate (Vieira, 2017). In this regard, the pharmacist’s participation as a mediator in the daily activities of PHC appears to be a promising yet underutilized opportunity for improving access to medications.
“Today, the biggest problem in municipalities [...] is the litigious nature of drug prescriptions. If pharmacists’ actions were more focused [...] it could reduce the number of disputes (E02).”
The final essential attribute is care coordination-the service’s ability to integrate all the care a patient should receive across various health services and interventions. Among the four fundamental attributes, this is the most prominent, since without it, access can become merely an administrative function, and continuity and comprehensiveness lose importance. From the perspective of the pharmacist’s role in PHC, care goes far beyond dispensing medication. It encompasses understanding and adapting one’s actions to promote comprehensive care, whether through participation in multidisciplinary teams or by utilizing tools for problem-solving, service organization, health promotion, and disease prevention, as well as ensuring access to medications across different levels of care. It means being able to use medication as a tool and look beyond it, understanding its role within the broader context of the patient’s health.
“[...] When we consider medication to be our tool [...] we need to know who this patient is, what underlying conditions they have, and what treatments they have already undergone. [...] All of these factors are also relevant to people’s health, not just the medication (E09).”
“[...] we gather a lot of information from patients, and when this information is used effectively and organized properly, we can provide coordinated care in collaboration with the multidisciplinary team (E01).”
Importantly, in 2024, the Ministry of Health (MS) released the National Guidelines for Pharmaceutical Care (Brazil, 2024). This initiative treats medication as an integral part of care through a model of professional practice and a set of actions involving services provided by pharmacists in an integrated manner with healthcare teams. The impact of this regulation is not yet known, but it serves as an incentive for implementing pharmaceutical care practices in PHC.
There were commonalities in the reports regarding the service portfolio, a tool used in several cities in Brazil as a strategy to strengthen PHC. In the municipality of Rio de Janeiro, there is a section addressing PC that describes the presentation of a plan for the rational use of medications (Rio de Janeiro, 2021); however, it does not provide details to guide activities or the approach to the possibilities of providing pharmaceutical services in light of the attributes of PHC, which go beyond rational use. One suggestion would be the creation of a pharmaceutical services portfolio as a guiding tool for routine pharmaceutical care activities and to align processes that provide health care to the population, as well as to contribute to efficient resource management.
The Role of Pharmacists in the Context of Professional and Public Health Regulations
Pharmaceutical care within the SUS should ensure access to medicines and medical supplies in accordance with its principles and guidelines, particularly universality, equity, comprehensiveness, regionalization, and prioritization.
CFF Resolution No. 585/13 establishes pharmacists’ clinical responsibilities to promote the rational use of medications and optimize pharmacotherapy (CFF, 2013). Law No. 13,021/14, considered a significant milestone for the profession since its publication, also raises many questions regarding the practice and oversight of pharmaceutical activities. This law elevated the pharmacy to the status of a healthcare facility and assigned a prominent role to the pharmacist in the user’s pharmacotherapy, as it ensured, on the one hand, a set of actions and services such as home pharmaceutical care and, on the other, the presence of the professional throughout business hours (Brazil, 2014). These regulations represent efforts to strengthen clinical and care-related roles of pharmacists in the public and private sectors, with the goal of improving patients’ quality of life.
However, when it comes to the guidelines set forth in the PHC, there is a discrepancy determined by the CFF regarding the mandatory presence of a healthcare professional in the physical space where medications are stored and dispensed, which imposes limits on the practices described by the interviewees and raises questions about oversight.
“[...] One of the complaints I hear when I talk to people is about Resolution No. 13,021/2014 [...]. This law confines the pharmacist to the pharmacy, and our role extends beyond the pharmacy; as public health pharmacists [...] we interact with patients and community groups, and we cannot be confined (E02).”
“The door is our limit” (E06)-a very striking line. It highlights the frustration of being unable to participate in activities held within the healthcare facility itself but outside the pharmacy. “So, how can we participate?” was the question some asked.
“[...] more than 90% of the facilities, because there is a law that says it is mandatory to have a pharmacist, and that is it. But that same law that guarantees the presence of a pharmacist within the clinic does not specify that in primary care, the pharmacist has to do this, that, and the other [...] this becomes a problem (E01).”
“[...] as if the pharmacist were a police officer who has to be at the pharmacy 24 hours a day to prevent a single Dipyrone tablet from going missing [...] so this is a very misguided view of the pharmacist as a healthcare professional (E08).”
The alternative “[...] requires outreach efforts because pharmacists working in primary care may leave the facility or attend meetings, but they must notify the Board and keep a record of this activity at the pharmacy. (E09),” cited by one of the interviewees, does not exempt facilities from inspection and enforcement, which have resulted in fines for public facilities (Peixoto et al., 2022).
Another key aspect of Law No. 13,021/2014 concerns the pharmacist’s role in pharmacotherapy. Given the premise of the previous section regarding the professional’s role regarding the attributes of PHC, it is imperative to highlight the social role played by pharmacists working in PHC, who can shift the focus from the medication to the patient, the patient’s family, and the community.
“[...] He is not a medical professional; I am convinced of that. [...] we are professionals who deal with people, cases, situations, and contexts; we know a lot about medications, and we will encounter many medications in these places, in these lives (E08).”
The law has further exacerbated a long-standing problem: the lack of recognition for the profession of pharmacy technician, an integral part of the Pharmacy Service’s staff. The role of the pharmacist in PHC is regulated by the CFF, but that of the technician is not; this has been a longstanding issue, with both supporters and opponents. The pharmacy technician present in the units is often the link between the pharmacist and the user. “[...] I learned a lot from the pharmacy technician there. [...] This is a professional who helps us a lot in our daily pharmacy work when we have one (E04).” To date, there is no legal provision for the registration of pharmacy technicians with the Regional Pharmacy Councils in Brazil, with the main concern being the potential replacement of the pharmacist by the technician.
As noted by Destro et al. (2021) and Barberato et al. (2022), the interviewees reported uncertainty regarding the number of staff working in the Pharmacy Department, which falls short of what is needed, and the lack of a patient-centered space for care; both of these factors were cited as barriers to providing proper care that ensures privacy and well-being.
“I think that if this HR issue were reviewed, in accordance with the management contracts [...], it would begin to change the reality for frontline pharmacists so they can actually work as pharmacists. [...] There is no equity in pharmacy HR. How are we supposed to provide care? [...] No human being can handle this (E02).”
“It would be great and ideal if we had our own space. A separate space where we can see these patients individually, where we can schedule appointments, and where we can provide care just like a nursing consultation (E06).”
Final Considerations
Pharmacists are redefining their role, and their professional identity is undergoing a process of renewal, reconstructing itself within a dynamic space and taking shape through the relational processes that characterize the work environment.
Practice in public health must take place in a dialogical or theoretical-practical manner, in which knowledge is articulated and makes sense in its practical application. Articulating this knowledge through comprehensive actions poses a challenge; however, pharmacists have been developing social competencies and skills to integrate themselves as part of the team.
Although this study did not focus specifically on the representation of PHC attributes in the professional practice of pharmacists, it should be noted that the dimensions presented, along with the organization of pharmaceutical services, contribute to the consolidation and improvement of PHC as a key driver of the reorientation of the healthcare model in Brazil and, in parallel, of the pharmaceutical profession itself.
The reorientation of the care model requires a permanent transformation of how services operate and of professionals’ work processes, demanding that all stakeholders-workers, managers, and users-develop greater capacity for analysis, intervention, and autonomy to establish transformative practices, manage change, and strengthen the links between the design and execution of work. Furthermore, the relevance of training programs linked to continuing education and professional development is evident as an institutional strategy to greatly enhance the development of management and care competencies in PHC through interdisciplinary integration involving SUS workers.
Health and professional regulations are important for guiding pharmacists’ actions within the scope of PHC; however, they need to broaden the understanding of the health-disease process and the countless ways in which these professionals can contribute to the delivery of care. To reaffirm the professional identity (PI) established within PHC, regulatory changes are needed that support the professional, ensure adequate human resources, foster efforts toward recognition by professional categories that share the workplace, and, above all, establish public policies that guarantee our role in PHC.
Therefore, it is important to highlight some limitations of this study, one of which concerns the difficulty of capturing other elements of community pharmacy due to the exclusion of the perspectives of other pharmacists and those from locations outside the city of Rio de Janeiro. In addition, the perspectives of other health professionals could also shed light on new possibilities regarding PI and the subject of this study.
This study is innovative because it highlights aspects of professional trajectories and the challenges encountered in redefining the technical training of pharmacists through practices that connect people, fostering a more humane and collective approach to care.
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Financing:
We declare that this work did not receive any external support or funding and was carried out using the authors’ own resources.
Acknowledgments:
We thank the Coordination for the Improvement of Higher Education Personnel (CAPES) for financial support through the PROEX program, PPG Public Health/ENSP/Fiocruz.
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Edited by
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Editors:
Ivia Maksud, Everton Pereira
