Implementation, access and use of integrative and
complementa-ry practices in the unified health system: a literature review
Abstract In Brazil, the Integrative and Com-plementary Practices (ICP) achieved greater vi-sibility after the establishment of the National Integrative and Complementary Practices Policy (NICPP) in 2006. However, there are still gaps in the general setting of these practices. Thus, this study aimed to analyze the implementation, ac-cess and use of ICPs in the Brazilian Unified He-alth System (SUS) after the establishment of this policy. We performed an integrative literature re-view, guided by the question: “What is the current setting of implementation, access and use of ICPs within the SUS?”, in the Virtual Health Library (BVS), the U.S. National Library of Medicine and in the Web of Science, with descriptors “Sistema Único de Saúde” / “Unified Health System” AND “Terapias Complementares” / “Complementary Therapies”. The analysis of papers gave rise to four categories for discussion: “The ICP approach in the SUS: main practices used”; “Access to ICPs: Primary Health Care as a gateway”; “Current im-plementation scenario of ICPs: the preparation of health services and professionals for to implement ICPs”; “Main advances in the use of ICPs and future challenges”. We have observed that ICPs are bashfully offered and that data available are scarce, despite the positive impacts on users and services that have embraced their use.
Key words Unified Health System, Complemen-tary therapies
Ludmila de Oliveira Ruela (http://orcid.org/0000-0001-9071-539X) 1 Caroline de Castro Moura (http://orcid.org/0000-0003-1224-7177) 2 Clícia Valim Côrtes Gradim (http://orcid.org/0000-0002-1852-2646) 3 Juliana Stefanello (https://orcid.org/0000-0003-3926-0144) 1
Denise Hollanda Iunes (http://orcid.org/0000-0003-1396-9980) 3 Rogério Ramos do Prado (https://orcid.org/0000-0003-2767-3283) 4
1 Escola de Enfermagem
de Ribeirão Preto, Universidade de São Paulo. Av. dos Bandeirantes 3900, Monte Alegre. 14040-902 Ribeirão Preto SP Brasil. [email protected]
2 Escola de Enfermagem,
Universidade Federal de Minas Gerais. Belo Horizonte MG Brasil. 3 Escola de Enfermagem, Universidade Federal de Alfenas. Alfenas MG Brasil.
4 Diretoria de Extensão e
Assuntos Comunitários, Universidade José do Rosário Vellano. Alfenas MG Brasil.
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Introduction
Since the 1990s, the use of Integrative and Com-plementary Practices (ICPs) has increased in global proportions1. Its growth and visibility
occurred mainly with incentive from the World Health Organization (WHO) in 2002, through the elaboration of a normative document to its member countries, which aims to develop and regulate such practices in health services, as well as increase access, rational use and evaluation of the efficacy and safety of such techniques from scientific studies2.
In this setting, in 2006, through Ordinance Nº 971/2006, the Ministry of Health published the National Integrative and Complementary Practices Policy (NICPP) in the Unified Health System (SUS), with the aim of ensuring integral-ity in health services3. From then on, the
provi-sion and incentive to use ICPs, such as herbal medicine, homeopathy, acupuncture, among others, was legitimized in the SUS, increasing the use of these practices4.
It is worth emphasizing that the implanta-tion of the NICPP was of a political, technical, economic, social and cultural nature since it es-tablished national guidelines for the use of ICPs based on experiences and practices already ad-opted in the health services, which obtained sat-isfactory results3.This fact further facilitated the
dissemination of these practices in different parts of the country.
In this context, Brazil has emerged as one of the 69 WHO Member States with specific poli-cies and strategies for the use of ICPs5. After the
NICPP was established, 30% of Brazilian mu-nicipalities adopted their regulations for the use of these therapies, which indicates significant growth in healthcare practices, and PHC is one of the primary environments for their application4.
Therefore, it is imperative to analyze the cur-rent setting of the provision of these treatments in the country, as well as access to them and their use in public health services. Thus, this study aimed to analyze the implementation, access and use of ICPs in the SUS through a review of the national literature published after the implemen-tation of the NICPP.
Methods
This is an integrative review of the literature, based on the steps proposed by Whittemore and Knafl6, with the following guiding question:
“What is the current setting of implementation, access and use of Integrative and Complementa-ry Practices within the Unified Health System?”
We searched the Latin American & Caribbean Health Sciences Literature (Lilacs), Nursing Da-tabase (BDENF), HomeoIndex and the Spanish Bibliographic Index of Health Sciences (IBECS) via the Virtual Health Library (BVS); in the Med-ical Literature Analysis and Retrieval System Online (Medline) via the US National Library of Medicine (PubMed) and the Web of Science, by two independent researchers, with standardized descriptors extracted from the Health Sciences Descriptors (DeCS) and the Boolean operator AND, which resulted in the combination “Siste-ma Único de Saúde’ / “Unified Health System” AND “Terapias Complementares”/ “Comple-mentary Therapies”.
Papers published in the 2006-2017 period, in Portuguese, English and Spanish languages, with abstract available in the database, and which were conducted in a national setting were the inclu-sion criteria. Studies that did not respond to the guiding question were excluded.
Firstly, papers were selected by two indepen-dent researchers, who read the title and abstract, according to the guiding question and the eligi-bility criteria. After the selection, they were read in full and, for data collection and evaluation, a tool elaborated by researchers adapted from Ursi7
was applied. This tool consisted of the following items: title of paper; authors and year of publi-cation; objective (s) of the study; methodologi-cal characteristics; level of health care (primary, secondary and tertiary) where the study was con-ducted; results; and conclusions.
Figure 1 shows the flowchart of the selection of papers.
aúd e C ole tiv a, 24(11):4239-4250, 2019 results
Chart 1 shows the main information extracted from the selected papers.
Concerning the type of ICP used, 23.52% of the studies addressed herbal medicine8-11,
17.64% homeopathy12-14, 5.90% acupuncture15
and 52,94% of the studies have evaluated ICPs in general16-24.
Regarding the level of care where practice was performed, 52.94% occurred at the primary care level8,10-12,16,19-21,24 and 17.65% at the
prima-ry/secondary level15,22,23. Other authors (29.41%)
addressed practice in the general SUS
scenar-Figure 1. Flowchart of the selection of papers. Source: Authors.
Studies identified by searching in databases (n=108) - LILACS via BVS = 48 - BDENF via BVS = 09 - HomeoIndex via BVS = 06
IBECS via BVS = 01 - Medline via PubMed = 31
- Web of Science = 13
Duplicated papers (n=16) - Web of Science/PubMed = 06 - BIREME/PubMed/ Web of Science = 07
- Within own database (BVS) = 03 Papers excluded after reading titles and abstracts because
they did not meet the inclusion criteria and did not respond to the guiding question (n = 66)
Eligible papers for full-text reading (n=26)
Papers excluded (n= 09)
Papers included (n= 17) - MEDLINE via PubMed = 09
- Web of Science = 03 - LILACS via BVS = 05 Id ent ificat io n So rt ing Elig ib ilit y Inc lusio n
R ue la L C har t 1. P ap er s inc lud ed in the anal ysis o f the int eg rat iv e r ev ie w . M inas Ge rais, 2017. A u tho rs (y ear s) Stud y ap pr oac h Stud y o b je ct iv e M ain r es ults C onc lusio n Fo ntane lla et al. (2007) 16 Quant itat iv e To e val uat e the kno w le dg e, a cc ess and a cc ep tanc e re lat ed t o ICP s o f a SUS use r c omm unit y o f the Sou th B razilian r eg io n. M ost ICP s w er e not kno w n b y the p opulat io n. T he use o f the rapies w ithou t e xp er t f ol lo w-up was fr eq ue nt, w hic h, to ge the r w ith the lo w a cc ess o f the c omm unit y, sho w s the la ck o f p ro fessio nals q ualifie d f or this car e. T he re is e vid enc e o f lo w kno w le dg e and ac cess t o ICP s, d espit e p opulat io n’ s int er est and a cc ep tanc e. A lso , the use o f the rapies oc cur s w ithou t the c ons ultat io n o f sp ecializ ed pr of essio nals. M ont eir o and I riar t (2007) 12 C ase st ud y U nd er
stand the mot
iv at io ns o f use rs t o lo ok fo r ho me opath y, ho w the y p or tr ay and e xplain the a ct io n o f me dicat io ns and ho me opathic tr eat me nts. T he p rimar y mot iv at io n f or se eking ho me opath y was the fail ur e o f al lo pathic t reat me nt. T he holist ic p er sp ec ti ve, the use o f nat ur al me dicines, lo ng c ons ultat io n t ime and ac ti ve list ening w er e b roug ht as fa vo rab le diff er ent ial char ac te rist ics w he n c ompar ed t o al lo pathic t reat me nt. T he p ot ent ial o f the c ont rib u tio n o f the rap eu tic alt er nat iv es s uc h as ho me opath y in the pub lic health se rv ic e is p oo rl y e xplo re d. Tesse r and B ar ros (2008) 17 R efle ct iv e anal ysis To anal yz e p ot ent ialit
ies and difficult
ies o f pr ac tic es and A lt er nat iv e and C omple me ntar y M edicines (A CM) fr om c linical-inst it u tio nal exp er ie nc es and sp ecializ ed lit er at ur e T he SUS p ro vid es A CM. T he re ar e c ommo n fa vo rab le manif estat io ns o f p olicies o f the ci vil so cie ty and use rs ’ re pr ese ntat iv es r eg ar ding the p ro visio n o f A CM b y the SUS. A CM has limit ed “d eme dicalizing ” p ot ent ial. T he p olit ical-e pist emolo gical he ge mo ny o f bioscie nc
e and the cur
re nt health mar ke t dispu te, w hose t end ency is t o t ransf or m an y kno w le dg e or p ra ct ic e o f the health-disease p ro cess int o co mmo dit ies o r p ro ce dur es t o b e c ons ume d m ust be o bse rv ed. C eolin e t al. (2009) 8 R efle ct iv e anal ysis
To discuss the use o
f c omple me ntar y the rapies in B razil, aiming at the c omp re he nsi ve car e o f the indi vid
ual and the int
ro duc tio n o f the n ur se pr ac tit io ne r in these p ra ct ic es. T he use o f me
dicinal plants has incr
ease d t o me et the ne eds o f use rs. N ur ses m ust e xpand the ir kno w le dg e and gain spa ce f or the use o f c omple me ntar y the rapies. T he b io me dical mo de l is fla w ed in the co mp re he nsi ve car e t o the use r. T hus, it has soug ht othe r t reat me nts. M edicinal plants b ridg e this g ap . Sal les and Sc hr aib er (2009) 13 R efle ct iv e anal ysis To in vest ig at e the c har ac te rist ics o f the re lat io nship cur re ntl y estab lishe d b etw ee n H ome opath y and B io me dicine, a cc or ding t o the p oint o f v ie w o f no n-ho me opathic p hy sicians. T he s up po rt o f manag er s t o the p rese nc e o f H ome opath y in the SUS is r elat ed t o the p er ce pt io n o f so cial d emand, to the p rot ec tio n o f the r ig ht o f c ho ic e o f use rs and t o the fa ct that it is a me dical p ra ct ic e that r ev iv es the h umanist realm o f me dicine. T he not io n o f H ome opath y as a “mild me dicine ” pr ed ominat es, w hic h c ould slo w ly p ro mot e imp ro ve d sy mp to ms. T he re is a la ck o f se rv ic e st ruc tur e f or a cu te car e cases. T he t raining o f ho me opaths is fla w ed sinc e the sp ecializat io n cour ses d o not p ro vid e t raining t o att end se ve re cases. it c ont in ues
aúd e C ole tiv a, 24(11):4239-4250, 2019 C har t 1. P ap er s inc lud ed in the anal ysis o f the int eg rat iv e r ev ie w . M inas Ge rais, 2017. A u tho rs (y ear s) Stud y ap pr oac h Stud y o b je ct iv e M ain r es ults C onc lusio n Fo ntane lla et al. (2007) 16 Quant itat iv e To e val uat e the kno w le dg e, a cc ess and a cc ep tanc e re lat ed t o ICP s o f a SUS use r c omm unit y o f the Sou th B razilian r eg io n. M ost ICP s w er e not kno w n b y the p opulat io n. T he use o f the rapies w ithou t e xp er t f ol lo w-up was fr eq ue nt, w hic h, to ge the r w ith the lo w a cc ess o f the c omm unit y, sho w s the la ck o f p ro fessio nals q ualifie d f or this car e. T he re is e vid enc e o f lo w kno w le dg e and ac cess t o ICP s, d espit e p opulat io n’ s int er est and a cc ep tanc e. A lso , the use o f the rapies oc cur s w ithou t the c ons ultat io n o f sp ecializ ed pr of essio nals. M ont eir o and I riar t (2007) 12 C ase st ud y U nd er
stand the mot
iv at io ns o f use rs t o lo ok fo r ho me opath y, ho w the y p or tr ay and e xplain the a ct io n o f me dicat io ns and ho me opathic tr eat me nts. T he p rimar y mot iv at io n f or se eking ho me opath y was the fail ur e o f al lo pathic t reat me nt. T he holist ic p er sp ec ti ve, the use o f nat ur al me dicines, lo ng c ons ultat io n t ime and ac ti ve list ening w er e b roug ht as fa vo rab le diff er ent ial char ac te rist ics w he n c ompar ed t o al lo pathic t reat me nt. T he p ot ent ial o f the c ont rib u tio n o f the rap eu tic alt er nat iv es s uc h as ho me opath y in the pub lic health se rv ic e is p oo rl y e xplo re d. Tesse r and B ar ros (2008) 17 R efle ct iv e anal ysis To anal yz e p ot ent ialit
ies and difficult
ies o f pr ac tic es and A lt er nat iv e and C omple me ntar y M edicines (A CM) fr om c linical-inst it u tio nal exp er ie nc es and sp ecializ ed lit er at ur e T he SUS p ro vid es A CM. T he re ar e c ommo n fa vo rab le manif estat io ns o f p olicies o f the ci vil so cie ty and use rs ’ re pr ese ntat iv es r eg ar ding the p ro visio n o f A CM b y the SUS. A CM has limit ed “d eme dicalizing ” p ot ent ial. T he p olit ical-e pist emolo gical he ge mo ny o f bioscie nc
e and the cur
re nt health mar ke t dispu te, w hose t end ency is t o t ransf or m an y kno w le dg e or p ra ct ic e o f the health-disease p ro cess int o co mmo dit ies o r p ro ce dur es t o b e c ons ume d m ust be o bse rv ed. C eolin e t al. (2009) 8 R efle ct iv e anal ysis
To discuss the use o
f c omple me ntar y the rapies in B razil, aiming at the c omp re he nsi ve car e o f the indi vid
ual and the int
ro duc tio n o f the n ur se pr ac tit io ne r in these p ra ct ic es. T he use o f me
dicinal plants has incr
ease d t o me et the ne eds o f use rs. N ur ses m ust e xpand the ir kno w le dg e and gain spa ce f or the use o f c omple me ntar y the rapies. T he b io me dical mo de l is fla w ed in the co mp re he nsi ve car e t o the use r. T hus, it has soug ht othe r t reat me nts. M edicinal plants b ridg e this g ap . Sal les and Sc hr aib er (2009) 13 R efle ct iv e anal ysis To in vest ig at e the c har ac te rist ics o f the re lat io nship cur re ntl y estab lishe d b etw ee n H ome opath y and B io me dicine, a cc or ding t o the p oint o f v ie w o f no n-ho me opathic p hy sicians. T he s up po rt o f manag er s t o the p rese nc e o f H ome opath y in the SUS is r elat ed t o the p er ce pt io n o f so cial d emand, to the p rot ec tio n o f the r ig ht o f c ho ic e o f use rs and t o the fa ct that it is a me dical p ra ct ic e that r ev iv es the h umanist realm o f me dicine. T he not io n o f H ome opath y as a “mild me dicine ” pr ed ominat es, w hic h c ould slo w ly p ro mot e imp ro ve d sy mp to ms. T he re is a la ck o f se rv ic e st ruc tur e f or a cu te car e cases. T he t raining o f ho me opaths is fla w ed sinc e the sp ecializat io n cour ses d o not p ro vid e t raining t o att end se ve re cases. A u tho rs (y ear s) Stud y ap pr oac h Stud y o b je ct iv e M ain r es ults C onc lusio n A ndr ad e and C osta (2010) 18 R efle ct iv e anal ysis To c onsid er the asp ec ts o f the inst it u tio nalizat io n of ICP s, to r efle ct o n the par adig mat ic foundat io ns o f the ir the rap eu tic a ct io n and t o anal yz e the c omp re he nsi ve and c omple x c har ac te r of its ap plicat io n, w ith sp ecific anthr op olo gical vie w s in the dialo gue. T he pub lic health sy st em car ries t o its c or e othe r tr adit io nal kno w le dg e and r at io nalit ies, w hic h c ome t o li ve w ith the c on ve nt io nal lo gic and se rv ic es o f b io me dicine. It is ne cessar y t o st ud y the c onc ep t o f int eg ralit y fur the r, as w el l as t o fa ce the p ra ct ical c hal le ng es of imple me nt
ing the ICP
s. M ar ques et al. (2011) 19 Qualitat iv e To in vest ig at e the kno w le dg e and a cc ep tanc e of int eg rat iv e and c omple me ntar y the rapies and p har ma ce u tical car e b y use rs o f SUS P HC fa cilit ies 100% o f par
ticipants did not kno
w w hat int eg rat iv e and c omple me ntar y the rapies w er e al l ab ou t. D oc to rs ’ kno w le dg e ab ou t a cupunc tur e and ho me opath y is almost no n-e xist ent. M ost o f the r esp ond ents w ould a cc ep t the use o f the the rapies if the y w er e o ff er ed b y the health fa cilit y, in a ddit io n t o finding the phar ma cist ’s att ent io n mo re cr it ical. T he re is little disse minat io n, and f ew so cial p ro gr ams se ek to sho w the b enefits o f s uc h the rapies. N ag ai and Que ir oz (2011) 20 Qualitat iv e To f
ocus the imple
me ntat io n o f c omple me ntar y and alt er nat iv e p ra ct ic es w
ith the pur
pose o f ev al uat ing the c ondit io ns o f the ir o ccur re nc e fr om the so cial r ep rese ntat io ns o f the pr of essio nals w ho par ticipat e in this p ro cess. Four r easo ns w er e f ound f or the s uc cess o f the inc lusio n of ICP s: the w illing ness o f the c lie nt ele; the health v isio n of h yg ie nist d oc to rs; e xt ensi ve s up po rt fr om no n-me dical health p ro fessio nals; and the p er sp ec ti ve o f alt er nat iv e and co mple me ntar y me dicines that ar e in line w
ith the SUS
pr op osal. D espit e the s uc cess in imple me nt ing these pr ac tic es in the p rimar y ne tw or k, the planning of these a ct io ns is ins ufficie nt and the v isio n is simplifie d, w hic h t ur ns alt er nat iv e r at io nalit ies int o me re t ec hniq ues that f ol lo w the same me chanist ic p rinciples o f al lo pathic me dicine and the same r eifie d und er standing o f the disease. Sant os e t al. (2011) 9 Qualitat iv e To d o a b ib lio gr ap hical s ur ve y, o n the s ub je cts lik e the imp or tanc e o f the he rbal me dicine; ho w it is b eing use d; its b enefits t o the P ub lic H ealth Sy st em; t raining o f p ro fessio nals in this ar ea and pr og rams and la w s f or imple me ntat io n in the SUS. T he g ov er nme nt has sho w n int er est in the d ev elo pme nt of p olicies f or health car e p ro ce dur es that ar e e ff ec ti ve, co mp re he nsi ve, h umaniz ed and less d ep end ent o n the phar ma ce u tical ind ust ry . B razilian m unicipalit ies ha ve car rie d ou t the imple me ntat io n o f H er bal me dicine P ro gr ams in p rimar y car e. St udies o n he rbal me dicine ar e st ill scar ce in B razil, and r esear ch is ne ed ed in this ar ea t o
expand the kno
w le dg e o f health p ro fessio nals and st ud ents, he lping and st re ngthe ning the saf et y and e ffica cy bases f or the imple me ntat io n of he rbal me dicine p ra ct ic es in the SUS. C har t 1. P ap er s inc lud ed in the anal ysis o f the int eg rat iv e r ev ie w . M inas Ge rais, 2017. it c ont in ues
R ue la L A u tho rs (y ear s) Stud y ap pr oac h Stud y o b je ct iv e M ain r es ults C onc lusio n T hiag o and T esse r (2011) 21 Quant itat iv e To anal yz e the p er ce pt io n o f p ro fessio nals o f the Famil y H ealth St rat eg y (ESF) ab ou t int eg rat iv e and c omple me ntar y p ra ct ic es. 17 health c ent er s p ro vid ed int eg rat iv e and c omple me ntar y pr ac tic es; 12.4% o f p ro fessio nals w er e ho me opath y o r acupunc tur e e xp er ts. I n t otal, 88.7% o f the par ticipants
did not kno
w the nat io nal guid elines o n this s ub je ct, althoug h 81.4% ag re ed w ith the ir inc lusio n in the SUS. P ro fessio nals a cc ep t ICPS, and this is d ue t o w ith the ir p rio r c onta ct and p ossib ly r elat ed t o in famil y me dicine and c omm unit y / famil y health resid ency / sp ecializat io n. Isc hkanian and Pelicio ni (2012) 22 Qualitat iv e To in vest ig at e the kno w le dg e, o pinio ns and so cial re pr ese ntat io ns o f the manag er s and health pr of essio nals ab ou t the ICP
s in the SUS and t
o
id
ent
ify the difficult
ies and c hal le ng es in the ir imple me ntat io n,
use and disc
los ur e in the H ealth Se rv ic es. T he manag er s w er e not p re par ed f or the imple me ntat io n of
the NICPP in the SUS.
T he b io me dical mo de l is p re vale nt and the p ro visio n o f s up plies use d f or the ap plicat io n o f ICP s has b ee n a p ro ble m. T he disse minat io n o f ICP s has not b ee n s ufficie nt amo ng pr of essio
nals and use
rs. T he m unicipalit y m ust e nc our ag e and cr eat e co ndit io ns f or the p ro visio n o f ICP s, imp ro ving the ir disse minat io n and s up po rt ing the int eg rat io n o f no n-me dical p ro fessio nals w ith ap pr op riat e t raining . ICP s int eg rat io n in the SUS can und oub te dl y c ont rib ut e t o health p ro mot io n. O liv eir a e t al. (2012) 10 Quant itat iv e Int er vie w ing p ro fessio nals w or
king in the SUS,
as w el l as pat ie nts w ho use P HC, c onc er ning the ir exp er ie nc e w ith e thno me dicine. 91.6% o f the par ticipants ma de use o f me dicinal plants at least o nc e t o t reat sp ecific diseases. Of the p ro fessio nals, 65% use d me
dicinal plants and 10% p
rescr ib ed he rbal me dicines t o pat ie nts. P at ie nts and p ro fessio nals r ep or te d kno w ing the me dicinal plants d ue t o the ir par ents o r gr andpar ents. A hig h p ro p or tio n o f use rs and p ro fessio nals ma de use o f me
dicinal plants and plants.
M
al
lo
w
was the most c
ommo nl y use d. T he p rimar y sour ce o f kno w le dg e ab ou t he rbal me dicine was fr om par ents o r g randpar ents. Fo nt ene le et al. (2013) 11 Quali- quant itat iv e To und er stand ho w manag er s and p ro fessio nals at te rt iar y le ve l in T er esina (P I) se e the int ro duc tio n of he rbal me dicine in P rimar y C ar e in the cit y, re lat
ing these data w
ith kno w le dg e o f these pr of essio nals ab ou t this the rap eu tic p ra ct ic e, its
use and the pub
lic p olicies in vol ve d. T he st re ngthe ning o f the he rbal me dicine in P HC and its inc or po rat io n in the r ou tine o f the p ro fessio nal p ra ct ic e of the ESF ar e ne cessar y f or the discussio n ab ou t he rbal me dicine in the P HC b etw ee n the a ct or s and the b odies in vol ve d, and the q ualificat io n o f the health p ro fessio nals. T he p ro fessio nals ’ kno w le dg e ab ou t health pr ac tic es is r ele vant f or the r ec og nit io n o f the sit uat io n, planning and st reamlining o f the ap plicat io n o f health a ct io ns, esp ecial ly those in vol ving he rbal me
dicine and othe
r ICP s be cause the y ha ve sp ecific p olicies. Galhar di et al. (2013) 14 Quant i-qualitat iv e To anal yz e the kno w le dg e o
f the health manag
er s of the m unicipalit ies o f São P aulo o n the P olicy
and its imp
or tanc e f or the imple me ntat io n o f ho me opath y in the lo cal health se rv ic es. Of the 645 m unicipalit ies anal yz ed, 47 p ro vid ed ho me opath y. 42 m unicipalit ies w er e int er vie w ed. 26% kne w the NICPP , 31% kne w little and 41% w er e una war e of it. NICPP is unkno w n t o health manag er s and those w ho kno w it use it t o di vulg e the ho me opathic me dical r at io nalit y and j ust
ify its indicat
io n in the SUS. C har t 1. P ap er s inc lud ed in the anal ysis o f the int eg rat iv e r ev ie w . M inas Ge rais, 2017. it c ont in ues
aúd e C ole tiv a, 24(11):4239-4250, 2019 C har t 1. P ap er s inc lud ed in the anal ysis o f the int eg rat iv e r ev ie w . M inas Ge rais, 2017. A u tho rs (y ear s) Stud y ap pr oac h Stud y o b je ct iv e M ain r es ults C onc lusio n Sil va and Tesse r (2013) 15 Qualitat iv e To in vest ig at e the e xp er ie nc e o f SUS a cupunc tur e use rs in Flo rianóp olis, S anta C atar ina, B razil ab ou t the ir t reat me nt, inc luding the ir p er ce pt io n of e ffica cy , r ed uc ed me dicat io n use, guid elines re ce iv ed, c hang es in se lf-car e and e xplanat or y mo de ls o f use rs, fr om the v ie w po int o f me dicalizat io n in the me nt io ne d f ocus. T o in vest ig at e this e xp er ie nc e in diff er ent car e se tt ing s b y t est ing the h yp othesis that p rimar y health car e ma y ass uming ly b e an e nv ir onme nt mo re fa vo rab le t o the r at io nalit y o f T ra dit io nal C hinese M edicine and a cupunc tur e. A cupunc tur e has p oo rl y c ont rib u te d t o au to no m y and de me dicalizat io n, e xc ep t f or its e ff ec ti ve ness. T he att it ud e of p ro fessio nals is esse nt ial t o st im ulat e a mo re a ct iv e and int eg ral p ost ur e. M ost pat ie nts came t o a cupunc tur e in se co ndar y car e w he n othe r t reat me nts faile d. T he p ra ct ic e was p er ce iv ed e ff ec ti ve ly and fa vo re d the re duc tio n o f me dicat io ns. D espit e the difficult y of a cc ess, it was o bse rv ed that P HC p ro fessio nals ha ve g reat er au to no m y t o car e f or pat ie nts, and can t reat mo re se ve re cases f or a mo re e xt end ed p er io d. Lima e t al. (2014) 23 Qualitat iv e To sho w and discuss r es ults o f a r esear ch that anal yz ed the o rg anizat io n o f ICP s d ev elo p ed in a CIP r ef er ral se rv ic e, in the me tr op olitan r eg io n o f B elo H or iz ont e, fo cusing its r elat io nship w ith the pr omot io n o
f health and its inse
rt io n in the SUS. P ra ct ic es can b e a use ful r esour ce in health p ro mot io n, notab ly b y estab lishing a ne w und er standing o f the health-disease p ro cess. It is ne cessar y t o o ve rc ome the c hal le ng es o f its org anizat io n and its e xpansio n t o st re ngthe n ICP s in the fie ld o f p ro mot io n and car e in the SUS, s uc h as dr aw ing p ro fessio nals c lose r t o CIP re fe rr al and s up p or t se rv ic es o f P HC.
Sousa and Tesse
r (2017) 24 Qualitat iv e To anal yz e the inse rt io n o f t ra dit io nal and co mple me ntar y me dicine ( T CM) in the SUS, w
ith the aim o
f s
up
p
or
ting the discussio
n ab ou t its int eg rat io n in P HC v ia ESF . Ty pes o f T CM inse rt io n and int eg rat io n: T yp e 1 - Int eg rat ed; T yp e 2 - O ve rlap pe d; T yp e 3 - I nt eg rat ed; T yp e 4 - N o int eg rat io n. T he c omb inat io n o f t yp es 1 and 3 is co nsid er ed a p ot ent ial f or the e xpansio n o f T CM in the SUS, influe ncing g ro w
th and its int
eg rat io n int o P HC. T he g ro w ing p rese nc e o f the T CM in SUS re quir es thinking st rat eg ies f or its e xpansio n, be yo nd NICPP , c onsid er ing the p re vious exp er ie nc es. Sour ce: A u tho rs.
R
ue
la L
io9,13,14,17,18. It was also identified that all the
an-alyzed papers showed level IV of evidence. Also, the main topics covered were the main ICPs ad-opted in the SUS, access to these practices, and preparedness of health services and professionals for their implementation and use. The categories of discussion were elaborated from these themes.
Discussion
The ICPs’ approach in the SUS: main practices
Initially, the NICPP only included five ICPs in its guidelines to be employed in the SUS in order to promote the recovery, maintenance and prevention of users’ health, besides the cure of some diseases, and they are: Traditional Chinese Medicine/Acupuncture; Homeopathy; Medicinal Plants/Herbal Medicine; Thermalism/Cryother-apy; and Anthroposophical Medicine25. However,
in recognizing the increasing use of other prac-tices based on traditional knowledge by the pop-ulation in general, the MoH included, between 2017 and 2018, new therapeutic resources in the NICPP, through Ordinances No. 849/201726 and
No. 702/201827. With these measures, the SUS
currently provides 29 of these practices.
Given the ICPs options fostered by the pol-icy, the results of this study show that many of these were not addressed by the authors or were merely cited without further elaboration. There-fore, studies that analyzed several practices in the same research prevailed, such as: acupuncture, homeopathy, herbal medicine, among others, an-alyzing their implantation and organization and the knowledge of users and professionals about ICPs16,19,20,22-24; as well as those studies that
point-ed out a general context of therapies in the SUS, without specifying the practices used17,18,21. Thus,
it was possible to observe the lack of studies that investigated the use of some practices, such as Thermalism/Crenotherapy and Anthroposophi-cal Medicine, pointing out a gap for their use in the SUS. However, this may be a reflection of the low supply of such therapies in services, which precludes the discussion of these practices in the studies analyzed.
Among the studies that addressed specifically practices, we highlight the use of herbal medi-cine8-11 and homeopathy12-14. Acupuncture was
investigated in isolation by Silva and Tesser15.
However, both homeopathy and acupuncture, even in the studies that analyzed several practices
together, emerged as those with higher adherence by users and greater provision of services15,21,22.
This is in line with data presented by the MoH in 2008, which show keen interest on the part of the government and the population in these thera-pies when compared to the others28.
While mechanisms of action of acupunc-ture29,30 and homeopathy31,32 are still not entirely
clear and sometimes inconclusive, their benefits have been demonstrated in different studies for different diseases33-36. As a result, adherence to
these treatments is increasingly progressive, so that 80% of the 129 WHO member countries already recognize acupuncture as a health treat-ment5, and homeopathy is one of the most
indi-cated ICPs in European countries, as in France37.
In general, ICPs can be seen as an essential healthcare strategy, especially considering the person as a whole, differing from the biomedical model23. Demand for ICPs is mostly due to
com-plicated reasons, ranging from factors such as low profile of adverse effects, to the natural con-sequence of incentive towards inside-out healing, search for complementation of allopathic treat-ment, reception and active listening performed during the consultation, as well as compatibility of such practices with values, beliefs and philos-ophy of health and life of the user17,38. Also, they
may be perceived as a potential drug consump-tion reducer15.
Tesser39 also points out that the reasons that
lead users to seek such treatments may be asso-ciated with critical socioeconomic factors. In de-veloping countries, local culture, easy access to alternative practices, the high cost of convention-al medicine, and the limited availability of bio-medical resources facilitate the search for com-plementary medicine. However, in rich coun-tries, dissatisfaction with the biomedical model and the benefits of ICPs are the factors that foster this demand.
Access to ICPs: Primary Health Care (PHC) as a gateway
Since PHC should be the user’s first contact and gateway to the healthcare network, accord-ing to the National Primary Healthcare Policy (PNAB)40, it is possible to infer that this level of
care is a privileged locus for the implementation of ICPs in the Brazilian public health system. In fact, data from the MoH indicate that ICPs are mostly provided in PHC services41.
A recent study42 conducted in Florianópolis
encour-aúd e C ole tiv a, 24(11):4239-4250, 2019
aged ICP use during the consultation with the patient and started treatment as soon as possible, often during the consultation itself. Thus, treat-ment with ICPs can be in some cases the initial approach, where conventional therapy is the sec-ond option, if necessary, or complementing the ICPs approach. Also, the availability of ICPs in PHC services may promote increased dialogue between practitioners and users about which therapy to use, namely, conventional therapy or ICPs, and this may have a positive effect on this contact42.
In this study, some authors point to second-ary care services15,22,23 as access to ICPs.
Howev-er, in order to achieve these sites as a field of care and provision of complementary treatments, it is necessary to approach professionals at both the primary and secondary levels so that they can be consolidated as a network of comprehensive care and universal access, taking into account the prin-ciples and foundations of each of the practices23.
Although the use of ICPs in secondary and tertiary care environments is more restricted, there is an albeit bashful tendency for their use at these levels, since 1,708 Brazilian municipal-ities provide ICPs, 78% in PHC, 18% in sec-ondary care and 4% in tertiary care43. However,
when considering PHC as the level of care with the highest capacity to develop health prevention and recovery actions, the use of ICPs in these ser-vices is the most appropriate. Furthermore, such practices do not require sophisticated technolog-ical resources, they provide lower risks of side ef-fects when compared to conventional treatments, and demand fewer financial resources, making health care more affordable and of high quality, besides providing satisfactory results2,44.
However, the difficult of access to ICPs at the various levels of care, especially in the secondary and tertiary sectors, may be related to the lack of knowledge by professionals about the use of these practices. Also, it is emphasized that many of these workers do not understand the impor-tance or do not have the adequate ability to indi-cate or apply such practices16,18.
Despite this obstacle, their availability in services is accepted and expected, especially by users17,19. Thus, a movement of Brazilian
munic-ipalities to implement the use of ICPs in the last years is observed9. However, local management
should encourage the strengthening and use of these practices and provide conditions for their provision to the population, through dissemina-tion and support, following recommendadissemina-tions of the NICPP11,22.
Current scenario of implementation of ICPs: preparedness of health services and practitioners for ICPs
Human resources are essential for the use of ICPs in the SUS. In this context, vocation-al training is a significant gap for the successful implementation of the practices13,16,22. The lack of
knowledge of the NICPP, as well as of therapies addressed in the policy hinders professionals’ and services’ participation in the provision of prac-tices13,14.
In Brazil, in addition to physicians, other health professionals, such as nurses, physiother-apists, pharmacists, among others, are qualified to use various practices fostered by the policy3.
However, the low adherence to specializations in the area of complementary interventions and poor education about the purposes of using ICPs during training prevent more significant improvement of health professionals9, although
many show an interest in training and agreement with the use of practices in services21.
One of the main difficulties pointed out by the managers for the implementation of these therapies is the resistance by some health pro-fessionals attributed to scarce scientific evidence and lack of logistical and structural support of the local management11. This is therefore
con-sidered an important problem since the positive attitude of professionals vis-à-vis these practices is relevant to motivate users towards adopting ICPs15.
Another fact that causes a stir is related to in-creased ICPs in the SUS. However, this was more significant from the application of practices by non-medical professionals45, which requires that
other team members expand their knowledge about complementary treatments and gain space for the use of such practices8. Thus, managers
should provide support and incentives in the supply of these resources to revive the humanis-tic realm of health care13.
In this context, greater knowledge about the policy and ICPs, as well as, for example, encour-aging professionals through lifelong learning can be effective strategies for implementing and ex-panding the implementation of NICPP and im-proving access to health services within the SUS. Although there are still few Brazilian studies on continuing education geared to these practic-es, Santos and Tesser46 show a method of
imple-mentation and promotion of access to ICPs in PHC based on previous experiences, consisting of four sequential stages. The first stage
establish-R
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es the people responsible, who will spearhead this process (preferably, professionals with expertise in ICPs). In the second stage, a situational analy-sis will be carried out, in which these profession-als, whether active or not, will be mapped and re-cruited so that, through implementation and ac-cess discussions, they conduct a survey on issues that hinder access to ICPs, on the organization of actions, the attendance flow of services and the formalization of activities developed, making a local situational analysis of ICPs. Regulations will be set during the third stage, establishing standards and adaptations for the development of ICPs in line with the current policy (NICPP) and, finally, during the fourth stage, the imple-mentation takes place cyclically and continuous-ly, which will be influenced by the productive capacity of the responsible staff46.
This model can help managers and profes-sionals strategically expand existing services or implement new services that will facilitate and al-low the general population’s access to ICPs. Thus, it is likely that initial investments and continuous training of network professionals will be neces-sary to meet demand in a qualified and decisive manner. However, over time, there may be lower values and higher service quality in services, since most practices require low operational costs and have fast and satisfactory results.
Significant advances in the use of ICPs and future challenges
Despite the increase in ICPs use in recent years, its therapeutic potential and its contribu-tions to health are still poorly explored in the SUS8,9. Although the MoH has positively
evalu-ated this increase47, there are gaps such as
assess-ments of ICPs in services and better monitoring of the policy’s impact.
Moreover, the preeminence of the current biomedical model coupled with the market trend in health care, which transforms knowledge and practices into commodities, can be a substantial limitation in the expected advances for these practices17. Thus, one challenge is the further
analysis of care in a comprehensive care model,
surpassing the supremacy of the rationale of bio-medicine-based services18.
Other vital challenges are related to the train-ing of and incentive to the health team members, support to non-medical professionals, as well as awareness and understanding of ICPs’ perspec-tives. These factors are essential for the successful introduction of ICPs into the SUS20 and to
en-sure the principles of the NICPP, contributing to the promotion of health throughout the care network22.
Study limitations and suggestions for future studies
The use of only two controlled descriptors (Unified Health System and Complementary
Ther-apies) may have reduced the number of papers
evaluated as to the eligibility criteria of the study. Thus, for future studies, we would suggest to in-clude other more specific descriptors, such as, for example, Healthcare levels or Primary Health
Care, besides specifying ICPs, especially the most
prevalent ones, in the search fields (such as herb-al medicine, homeopathy, acupuncture, bodily practices, among others) in order to expand the range of results obtained.
Final considerations
After a decade of policy implementation, we can consider that ICPs are provided incipiently in the SUS and scarce data on specific practices are a limitation to the current scenario of this approach. However, positive reflexes can be ob-served for users and services that have adhered to their use, although there are still challenges in their implementation, in their access and use and the education of trained professionals.
Thus, new studies with a historical approach to complementary practices are required follow-ing the creation of the NICPP and on the impacts on the Brazilian public health, as well as incen-tives for professional improvement, mainly for PHC workers, as a fundamental tool for the im-plementation, access and use of ICPs in the SUS.
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Article submitted 19/07/2017 Approved 20/04/2018
Final version submitted 22/04/2018
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