To identify whether public organizations that adopt the competency-based management model consider the collective component of competencies in their management practices. The academic literature highlights the potential of collective competencies to achieve organizational objectives, but there is a mismatch between the theoretical perspective and people management practices, which was confirmed throughout the study. The field research was carried out in three federal public organizations. Evidence was collected from documentary analysis and semi-structured interviews with ten employees from the respective Personnel Management areas.
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The Brazilian constitution guarantees the right to health, including access to medicines. Under FPP, a selected list of medicines is subsidized by the government and provided in public and private pharmacies. The aim of this study is to describe the historical stages of the FPP and to identify associated changes in the geographical accessibility of medicines through the FPP over time.
It was performed documentary review and an ecological study assessing program coverage in terms of number of facilities and a FPP Pharmacy Facilities Density PFD index at national and regional levels from to , using the FPP database.
We used geographic information system mapping to depict a pharmaceutical facilities density PFD index at the municipality level on thematic maps. In the public sector, the program started in ; by , there was a sharp increase in the numbers of participating pharmacies, stabilizing in In the private sector, the program started in ; by the PFD ratio had increased substantially and it continued to grow through There was an increase in FPP coverage in most regions between , when the private pharmacy component started, and , but participating pharmacies remain unequally distributed across geographical regions.
Specifically, the wealthy areas in the South and Southeast have higher coverage, with lower coverage mostly in the North and Northeast, relatively poorer areas with greater need for access to medicines, health care, and other basic services such as potable water and sanitization.
There has been a substantial increase in the number of pharmacies participating in the FPP over time. This has led to greater program coverage and has potentially improved access to FPP medicines in the country. Nevertheless, disparities in pharmacy coverage remain among the regions.
The online version of this article doi Equitable access to health care and medicines is a challenge worldwide. The World Health Organization WHO considers equitable access to safe and affordable medicines as vital to achieving the highest possible standard of health for all [ 1 ].
In the Latin America and Caribbean LAC region, health expenditures are estimated to account for more than one-third of all household expenditures [ 2 ], of which a large proportion is dedicated to medicines. The high prices of medicines and the need for high out-of-pocket payments by patients represent important barriers in their access [ 3 ]. A government subsidy system is one method to expand access to medicines in a sustainable way.
In Brazil, total expenditures on health services accounted for 5. The majority of these deaths, were attributed to cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases [ 6 ]. NCDs are also the leading causes of premature death and illness throughout the Americas [ 7 ].
About Control of NCDs continues to be one of top health priorities in Brazil, addressed through a set of integrated policies [ 8 ]. Access to and appropriate use of medicines are crucial for controlling NCDs, especially hypertension and diabetes, contributing to improved health outcomes and quality of life.
Governments or third-party payers subsidize medicines when they pay a percentage of the cost, with patients responsible for the remained. One important question that arises regarding the effect of medicine subsidies is whether subsidies increase overall access to medicines for all population segments. Currently, there are few studies conducted in LMIC that attempt to address this critical question.
Most existing studies have weak designs and limited analytic scope. Lack of knowledge about the effectiveness of subsidy policies in low and middle-income countries LMICs presents a barrier to [ 10 ].
The National Health System consists of a tax-funded public sector, where care is offered free of charge to the entire population, and a private sector, comprising diverse prepayment mechanisms such as health insurance and out-of-pocket financing.
Private sector health facilities and practitioners also provide health services under contracts with the government [ 12 ]. Before , medicines in Brazil were obtained through two pathways, either free in public health care facilities or paid out-of-pocket in the private sector retail pharmacies. The lower reported prevalence of hypertension and diabetes may be attributed in part to lower diagnostic capacity.
Economic, health structure and health indicators, Brazil and regions, to Marked geographic inequalities in access to health services and health outcomes are also present; while the prevalence of morbidity is inversely proportional to household income per capita and thus higher in the North and Northeast, the rate of health services use in those regions is lower [ 15 ].
This paper was developed under a broader study denominated Impact of consecutive subsidies policies on access to and use of medicines in Brazil ISAUM-Br Project [ 16 , 17 ]. Understanding the geographic impacts of these changes in Brazilian medicines subsidy policy will increase knowledge about whether large government subsidies for specific categories of medications can reduce disparities in access.
It was performed a documentary review of the FPP from to and an ecological study that assessed coverage in terms of the number of participating facilities and a Pharmacy Facilities Density PFD index at national and regional levels, using data from the FPP and the Ministry of Health.
The documentary review intended to describe the FPP and its stages of implementation according to official regulations, including technical changes in the program. In order to identify changes in geographical coverage of the FPP program over time, three indicators were used: number of facilities; percentage of municipalities covered i. These measures were applied separately for public and private pharmacies. A growth index was calculated summarizing the percentage change over time, considering as baseline year for comparison, since the number of facilities in on the different stratum are zero.
When facilities did not exist in a specific population stratum in , we used as the base year. Additionally, geographic information system mapping was used [ 18 ] to allow visualization of the PFD ratio at municipality level on thematic maps for the years and Complete results of the documents search in Additional file 1. In , the government expanded the program to the private retail pharmacies; in the medicines list Additional file 2 was expanded and some administrative requirements changed; and in , medicines for diabetes and hypertension started to be fully subsidized.
The medicines list covered also changed over time, becoming broader and covering more diseases. These modalities are described below. After changes on administrative procedures and on medicines covered.
Free of Charge medicines for Hypertension and Diabetes. This policy specified a list of medicines to be subsided by the government and supplied in public pharmacies and it was especially aimed at low income people covered by private health care insurance, since in Brazil, few private insurance programs include outpatient medicines as a benefit [ 19 ]. Considering the size of Brazil, the total number of pharmacies was low, especially in the north and northeast regions.
The FPP, initiated in May involved a public network of facilities such as university hospitals and NGOs that were coordinated by the Oswaldo Cruz Foundation Fiocruz on behalf of the Ministry of Health MoH and developed through partnerships with states and municipalities [ 13 ]. The federal government, through Fiocruz management, is responsible for funding infrastructure and maintenance, including training, employee payment, and purchase of medicines [ 19 ].
The sale price of medicines, which means the price paid by the patients, in these pharmacies is established by the federal government and comprises the medicine value, purchased through open bidding, plus the pharmacy operating costs [ 19 ]. In March , the government expanded this policy to include retail pharmacies in the private sector [ 20 ]. Prices paid by patients varied depending on the relation between the reference price RP established by the MoH for each medicine and its selling price SP.
The AFP Phase I was implemented through partnerships with private retail pharmacies, but with a limited set of the medicines than available in the public sector program [ 21 ]. The minimum requirements for the establishments, which included sanitary authorization of operation, presence of a technically responsible pharmacist, fiscal capability, and infrastructure for a computerized system were requirements for accreditation of the participating private pharmacies [ 21 ].
The expanded list contains medicines for hypertension, diabetes, and contraception [ 23 ]. In , the list was further broadened to include medicines for rhinitis, asthma, Parkinson disease, osteoporosis, glaucoma, and adult diapers [ 24 ].
In the AFP Phase II, reorganization included changes in the methodology for accreditation, changes in the computerized system, and greater accuracy in MoH payment to retail pharmacies [ 22 ].
The number of establishments reached 25, in , covering Advertising of the program is standardized by the government and visual inspection of the retail pharmacy facilities is mandatory [ 25 ]. Display of an easily visible document such as a chart containing the medicines list and corresponding price list is required for pharmacies in the program [ 26 ]. During these successive policies, a physician prescription has always been required for dispensing even for OTC medicines.
It was implemented in both public and private pharmacies that were already enrolled in the FPP or AFP under the previous policies. In June , medicines indicated for asthma treatment were also included [ 27 ]. In the public sector FPP, the largest growth was between the implementation in 27 facilities and facilities , when investment in developing additional public pharmacies stopped.
The private sector AFP has a greater number of pharmacy outlets compared with the public program. This growth was intensified by the SNP policy which made medicines for diabetes and hypertension available free of charge in all regions. By , the AFP program covered Municipalities under 20, inhabitants present a Growth Index of In the public sector, the numbers of participating pharmacies increased after , stabilizing in The Growth Index was around two throughout the period analyzed with small variations among the regions.
In the private sector, the program started in , but in and , there were substantial increases in participation. There has been substantial increase in the number of participating pharmacies, which has enormously improved geographic access to medicines through this program.
Previous government financing models did not include patient copayments, with medicines provided free-of-charge in public health care facilities. Stakeholders in the national policy process have long argued the advantages and disadvantages of introducing patient copayments, in light of other access to medicines initiatives [ 28 ].
Utilization depends on household affordability and type of health care needed; According to PNAD and , there was a reduction in SUS health services utilization associate to an increase of education and income level. In the 1rst quintile of income The poorest segment of the population always use SUS, while wealthier individuals are likely to use the public sector only for hospitalization or other high cost care.
Farmacia Popular Program targets diseases that are sensitive to primary health care as well as low-income patients, but with some ability to pay for medicines. In this sense, it expected that by increasing the Farmacia Popular coverage would increase the access to medicines for non-SUS users [ 31 ].
Unfortunately, there was not information from scientific literature describing the profile of Farmacia Popular users in terms of source of health care after AFP intervention. The increase of Farmacia Popular Program coverage in a relatively short period was only possible through a partnership with the private sector in and with continuous government investments over time on retail pharmacies, which increased the coverage capacity and geographic distribution of the program.
Despite its growth, there must be a stronger consideration of equity in the next stages of FPP expansion, in order to not continue the geographic inequalities observed [ 31 , 32 ]. Although an geographic disparity, with a greater coverage in wealthier geographic regions, it was reducing overtime and this inequality does seem to be so marked as the one reported in South Africa [ 33 ], where two provinces met the 1 per 10 benchmark for community pharmacies.
In addition, the financial sustainability of the program in the private sector should be considered [ 28 ], especially in light of the parallel program in public SUS health facilities, since the related dispensing costs are lower in the public sector and the coverage is higher [ 28 , 34 ].
Participation in large and mid-size municipalities has grown rapidly in the North, although disparities in coverage between regions still exist. Lately, the smaller municipalities have exceeded the larger in terms of participating pharmacies per , inhabitants. It is important to understand the reasons for differential growth and implement programs to stimulate growth in poorly covered municipalities, states, and regions in order to achieve adequate distribution of pharmacies according to population need.
The main limitations of this study include the following aspects. The number of participating pharmacies in a geographic area does not represent the actual number of patients covered, since municipalities with a small population might have a large area, although the two numbers should be correlated.
We have no data on sales volumes by region or municipality size, which might influence decisions by pharmacies to participate in the FPP. The results indicate that the FPP succeeded in increasing geographic coverage. There have been dramatic increases in FPP coverage in most regions between when the private pharmacy component started and , but pharmacies remain unequally distributed across geographical regions.
Specifically, the wealthy areas in the South and Southeast have higher coverage, with lower coverage mostly in the North and Northeast, areas with the most need for access to medicines, health care, and other basic services such as potable water and sanitization. Increases in program growth in small municipalities indicate some reduction in disparities within the regions.
Agencia Estatal Boletín Oficial del Estado
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