Results obtained from the focus group

Twenty (20) pharmacists participated in this stage of the study. The average age was 35 years old, 45% of participants graduated between 5 and 10 years ago and 25% less than 5 years ago. Concerning the time working in the SUS, 35% have worked in the SUS for a period between 5 and 10 years and 50% for less than 5 years. Therefore, the sample is heterogeneous, as there is a mixture of new and more experienced pharmacists.

After analyzing the focus group data, two central themes emerged.

Pharmaceutical services go beyond the medicine

• • “Do we pay attention to health promotion? Providing the patient with medication that will cure or treat him is useless if they have no guidance, we are there between the medicines and the patient as we provide them this information.” (SIC)

• • “Both in inventory management and guidance on how to use medications properly, or how to get the medication through the SUS, we promote access, regardless of the procedure stage.” (SIC)

• • “The access to health, medications, and treatment, to name a few, is promoting health. The health promotion she [another participant] just mentioned here, from the orientation, you can control the inventory of this medication so you are able to provide the medication for that patient, and thereby to promote health.” (SIC) From these direct quotations, the pharmacists demonstrate the breadth of their services and the possibilities of reorienting their work towards people’s care, being the professionals responsible for ensuring access to and adequate use of medicines.

In 2006, the WHO already defined pharmaceutical services as a set of actions in the health system that aim to ensure comprehensive and continuous attention to the population’s health needs, both individual and collective, with medicines as one of the elements to be employed (WHO, 2006). In Brazil, the change in focus of the pharmacist’s work processes from medicines-centered to people’s health care has a direct relationship with the development of the SUS.

The participants understood that the pharmacist could reconstruct the notion of health care as restricted to the use of medicines, which is closest to the PHC guidelines:

• • “the interesting part for them is to obtain the medication, the patient is very focused on the medicines and we, as pharmacists, have to take the focus off the medication.” (SIC)

• • “When you question the services, the services should be way beyond just the medicine, in my view, you know? The moment the patient has any complaints, any situation that goes beyond the medication, I think we as health professionals can contribute.” (SIC)

Stimulated by the society that consume them, medicines became a mixture of consumer goods and therapeutic instruments, and these factors were decisive for the pharmacist to take distance from individual care (Angonesi and Sevalho, Reference Angonesi and Sevalho2010; Pereira and Freitas, Reference Pereira and Freitas2008).

Taking advance of this scenario, participants have an expanded understanding of their services, such as guidance to help people, from guidelines on how to access medicines to therapeutic monitoring, or just inventory management, as illustrated in the transcripts:

• • “From promoting access to this orientation to an effective follow up and also the inventory management part, because one thing leads to another.” (SIC)

When asked about their services goals, pharmacists were able to state that their services are performed with a focus on people rather than on medicines and made the following statements:

• • “for people, but patients are very attached to medicine.” “For both.” (SIC)

The resignification of pharmaceutical services in this area can be described by the concept of social constructionism, which investigates the way social phenomena are produced and challenge conventional ideas, demystifying the status quo (current state of affairs) of phenomena as it comprises, they are created through historical processes and social interactions (Giddens and Sutton, Reference Giddens and Sutton2016). Thus, pharmaceutical services built in conjunction with other services provided in PHC challenge the normativity that a pharmacist is not a health professional who is able to take care of people.

The contributions of the pharmacist to a multidisciplinary team work in PHC

• • “We can take care of the patient dealing not only with medication but also with any other problem that may happen, rather than just being there. I think [a pharmacy] has a broader and more strategic view than most health services.” (SIC)

Many activities could be developed by the pharmacist in the multidisciplinary teams in PHC, which is an area of important investment by health systems.

Internationally, there is a discussion related to the advances of the participation of pharmacists in PHC teams (Dolovich et al., Reference Dolovich, Pottie, Kaczorowski, Farrel, Austin, Rodriguez, Gaebel and Sellors2008), as well as the health results for chronic diseases with a better use of medicines, which are possible due to pharmacist interventions (Tan et al., Reference Tan, Stewart, Elliott and George2014).

Some participants pointed out that, despite new possibilities, there are still barriers for services to be performed apart from the focus on the medicines. The PHC model provides other options, such as the encouragement of therapeutic groups, home visits, and working with the team:

• • “So, I try to show them [patients] what alternatives they have that may decrease the amount of medicines taken at that moment, right? Because they don´t usually really know.” (SIC)

• • “Together with the doctor or nurse in the discussion of clinical cases, we are there working with the whole team, in a case discussion, pharmacotherapy, and everything else.” (SIC)The role of the pharmacist in the multidisciplinary team can be influenced by external and internal factors. There is a need for pharmacists with proactive attitudes and who demonstrate how they can act for the patient’s care, as shown below:

• • “Because if we don’t understand it, if we don’t have a positive attitude, and demonstrate that we can contribute to the health care, to the patient, nobody will go to a pharmacy, they just think that the pharmacy is for taking their medicines and leave… many teams also think that.” (SIC)

It is important for the pharmacist to develop skills that are applied in the context of teamwork, such as being responsible or co-responsible for the pharmaceutical service, being able to directly perform a procedure or develop a practice, supervise and monitor the performance by another worker, who is properly trained and qualified, or to perform an action together with another professional or health team (Campese, Reference Campese2017).

Finally, when discussing the importance of their services, they say that although they encounter barriers, they know how important their jobs are because, in PHC, the bonding and trust are legitimized when there are home visits, for example, and they are linked to real-life contexts:

• • “At home visits, you can see the patients’ home, where they store [their medicine]. Also, because it is difficult for the patient to return to the pharmacy [after the home visit], I [pharmacist] go to their place.” (SIC)

Some studies have already demonstrated advances in the pharmacist work in PHC. However, there are still challenges related to the incorporation of new activities into their work processes and the consolidation of their identity in the multidisciplinary team (Silva et al., Reference Silva, Mendonça, Oliveira and Chemello2018).

Between 2008 and 2013, the number of pharmacists registered in PHC Centers in Brazil grew 75.0%. Two factors possibly enabled it: the implementation of the Family Health Support Center and the growth of pharmaceutical education and services in the country (Carvalho et al., Reference Carvalho, Álvares, Costa, Guerra, Acurcio, Costa, Guibu, Soeiro, Karnikowski and Leite2017).

In Brazil, supporting the Family Health teams there is the Family Health Support Center (NASF, in Portuguese), which expands the scope of Primary Health Care. The insertion of pharmacists in this multidisciplinary context represents an opportunity to improve the work process and the access to medicines and their rational use (Nakamura and Leite, Reference Nakamura and Leite2016).

Furthermore, Brazil is one of the few countries that has a public pharmaceutical service model in which pharmacists coordinate all activities related to the medicine chain in government spheres, from selection to use (Carvalho et al., Reference Carvalho, Álvares, Costa, Guerra, Acurcio, Costa, Guibu, Soeiro, Karnikowski and Leite2017).

We have a lot of work to do: Results of the online survey

A total of 134 responses (83% of the sample) were obtained, 18 of which were excluded (3 duplicates, 7 pharmacists who had participated in the focus group, and 8 unidentified). In the end, 116 responses to the form were analyzed.

Of the pharmacists included, 83.5% were female, all older than the age of 25, and 40% graduated more than 10 years ago. It is noteworthy that 46.5% of the pharmacists were hired by the Public Health System in São Paulo from 01 to 05 years ago, and the majority (92.2%) worked between 31 and 40 h weekly. Regarding their experience working at the SUS, 47% were hired between 5 and 10 years ago.

Pharmaceutical services performed in Primary Health Care are shown in Table 1. Between 70% and 90% of the pharmacists indicate that they perform 12 services in PHC. Eleven types of services are performed by 60% to 30% of pharmacists and only 3 services are performed by less than 5% of them.

Table 1. Pharmaceutical services done in PHC of São Paulo, Brazil, based on the perception of the study participants

Brazilian pharmacists have developed an expertise to check the availability of medicines in the SUS: the access routes, inventory management to meet local needs, meetings with the health team to discuss the availability of medicines, and what is prescribed. All services are still under development.

Other studies show similar situations. There is a large number of pharmacists in community pharmacies, and their workforce has increased in recent years. However, the services they develop still need to be better used (Campbell et al., Reference Campbell, Braund and Morris2017). In Canada, for example, pharmacists perform more than 20 PHC services. All the pharmacists reported, in an exploratory study, that they are engaged in direct patient care, including therapeutic issues, drug overhauls, and post-hospitalization drug reconciliation (Gillespie et al., Reference Gillespie, Dolovich and Dahrouge2017).

Another aspect considered for each pharmaceutical service was the frequency of performance. Table 2 shows the frequency of services that 90% of pharmacists claim to perform.

Table 2. Pharmaceutical services in PHC of São Paulo, Brazil, reported as the most frequent ones

Of all services performed daily, only one has direct interaction with the multidisciplinary team: informing other health care teams about medicine. The other services (Table 2) of the pharmacist’s work routine are specific to the pharmacy.

The work with the pharmacy team (which consists of pharmacy technicians) stands out. In Brazil, the technicians are a fundamental part of the health workforce. The pharmacy workforce in dispensing service at a PHC is made up of 43% of technicians and 33.3% of pharmacists (Carvalho et al., Reference Carvalho, Álvares, Costa, Guerra, Acurcio, Costa, Guibu, Soeiro, Karnikowski and Leite2017).

For each service, the pharmacists indicated that the degree of importance and the average answers (1 – unimportant and 5 – very important) are presented in Table 3. It is possible to observe that pharmacists understand their services as important, not differentiating the types of services as more or less important. This is essential, as pharmacists value their work in PHC and recognize themselves as a crucial part of this process.

Table 3. Degree of importance of the pharmaceutical services in the current context and ideal work process in the PHC, according to the pharmacists’ perception

The pharmaceutical services models in Brazil, not contextualized using the PHC principles, have proved to be fragmented, with divisions of service groups considered clinical x managerial ones, and the ones called middle activities for care and clinical services (Correr et al., Reference Correr, Otuki and Soler2011; Pereira et al., Reference Pereira, Luiza and Cruz2015). In 2000, Storpirtis et al. stated that pharmacists should act in an integrated manner, which would certainly benefit the population and could reduce health spending (Storpirtis et al., Reference Storpirtis, Ribeiro, Marcolongo, Gomes and Reis2000).

The right of access to medicines is ensured by ubiquitous public healthcare centers (Castro et al., Reference Castro, Massuda, Almeida, Menezes-Filho, Andrade, Noronha, Rocha, Macinko, Hone, Tasca, Giovanella, Malik, Werneck, Fachini and Atun2019). Pharmacists are playing an increasing role in PHC centers, fulfilling a growing range of roles and responsibilities, especially for improving access to medicines and their appropriate use (Faraco et al., Reference Faraco, Rover, Farias and Leite2020).

PHC has guidelines that provide opportunities for the pharmacist to act in health care such as assistance during the first contact with the SUS, care coordination, longitudinal care plans, mechanisms to ensure accessibility, as well as patient embracement (Portela, Reference Portela2017).

The study’s limitations were the difficulty of contacting pharmacists at the Centers of the Unified Health System in São Paulo. Professionals find it difficult to participate in research and activities that force them to leave the center, as there are many responsibilities and patients to take care of. More than one focus group could have been created, as there were enough participants. However, at that time, the decision was to keep a larger number of participants in the group, as evasion was expected, which did not happen.