We present a short situational overview of the presence of Traditional, Complementary, and Integrative Medicine (TCIM) in Brazilian Primary Health Care (PHC) and the training and research in this area in Brazil. Databases, legislation, regulations and government reports were analyzed. In 2017-2018, 29 TCIM modalities were institutionalized in the Unified Health System (SUS). According to official data, they expanded and were offered by 20% of the PHC teams in 2016, in 56% of the municipalities. Almost 80% of TCIM occur in PHC, being more common: body practices, medicinal plants, acupuncture, and homeopathy. There is little national training and practice regulation in TCIM. Most MTCI practitioners are conventional PHC practitioners who learn and offer MTCI on their own initiative. They play an important role in the expansion of TCMI in PHC. The insertion of the theme in education is incipient and there are researches in the area, but few publications. TCIM institutionalization strategies in PHC involve federal stimulus to municipalities, through competent professionals, permanent education in service, and governmental action for their insertion in the professional training.

Keywords: complementary therapies, primary health care, staff development, health policy, Brazil

SUS, brazilian unified health system; TCIM, traditional, complementary, and integrative medicine; PHC, primary health care; PNPIC, brazilian national policy of integrative and complementary practices; PMAQ, brazilian national program for access and quality improvement of Primary Care; MS, brazilian ministry of health; CNPq, national council for scientific and technological development of brazil; BIREME, latin american and caribbean center on health sciences information

The Brazilian Unified Health System (SUS) is one of the largest public health systems in the world. It covers most outpatient care and hospitalizations in the country that currently is home to more than 200million people.¹

Traditional, Complementary, and Integrative Medicine (TCIM) experiences in the SUS have been in place since the 1980s. However, in 2006, with the enactment of the National Policy of Integrative and Complementary Practices (PNPIC), they gained visibility and growth, especially in Primary Health Care (PHC).² Currently, the PNPIC includes 29 types of care.^3,4 however, without a budget or an inductive budget from the Federal Government. The municipalities fund this offer mainly through professionals from the Family Health teams (consisting of general practitioners and nurses), the primary PHC modality in Brazil.⁵ This paper aims to provide a short situational overview of the presence of TCIM in the SUS and the training and research in this area in Brazil.

The study was documented by reports from the Ministry of Health (MS), Brazilian government database (Tabnet DataSUS), and results from the National Program for Access and Quality Improvement of Primary Care (PMAQ), in which data recorded in 2016 and 2017 was analyzed. We adopted a literature review on TCIM in Brazil as it allowed an outline of their incorporation into the Brazilian PHC. The analysis built on two analytical categories, namely, institutional presence and expansion of TCIM in PHC, training, and research in TCIM in Brazil and PHC.

Institutional presence and TCIM expansion in the PHC

The PNPIC2 was enacted in 2006, and included Traditional Chinese Medicine/Acupuncture, Homeopathy, Herbal Medicine Therapy, Anthroposophic Medicine and Thermalism-Crenotherapy, with emphasis on PHC. Later, in 20173 and 20184, it officialized 25 other practices: art therapy, Ayurveda, biodance, circular dance, meditation, music therapy, naturopathy, osteopathy, chiropractic, reflexotherapy, Reiki, shantala, integrative community therapy, yoga, apitherapy, aromatherapy, bioenergetics, family constellation, hand-laying therapy, ozone therapy and flower therapy.

The list was expanded in an adverse political context, without a public discussion about the relevance and the potential effectiveness of the incorporated practices, which led to opposite and favorable reactions in different corporate associations.⁶

In 2016, before the expansion of PNPIC, TCIMs were found in 9,470 health facilities distributed in 3,097 (56%) municipalities in the country, with a higher concentration in the capitals, especially in the South and Northeast. PHC accounted for about 78% of the provision of these services in the SUS, while 16.7% were in specialized care and 3.4% in hospital and high-complexity care.⁷

The same establishment could offer more than one TCIM modality, such as homeopathy and acupuncture, for example, registered by the MS as TCIM services. An offer of 3.09 TCIM services per 100,000 inhabitants was recorded between January and September 2017, which, while signaling growth, remains insignificant for the size of the SUS and Brazil.⁸

Data from the Ministry of Health indicated that the most offered TCIMs were bodily practices found in 53% of the municipalities with TCIM services; acupuncture, in 20% of them, and herbal medicine therapy in only 6% of them8. The PHC-specific PMAQ data reported that in 2016, bodily practices were offered by 16.6% of the teams with TCIM services; medicinal plants / herbal medicine, by 14.9%; acupuncture, by 12.7%; community and integrative therapy, by 10.7%; and auricoacupuncture, by 7.3% of them.⁹

Research on TCIMs in Brazilian PHC reports that the perception of conventional professionals who practice TCIM (most of the supply) and service users is favorable to its provision in the SUS, with satisfaction regarding the use and effectiveness of these practices. However, when all the PHC professionals were surveyed, the result showed that the vast majority does not practice TCIM, is relatively unaware of them, and is interested in learning about them.^10–14

TCIM training in Brazil is insufficient and diffuse, with limited supply and quality. It is concentrated in private educational institutions, especially in lato sensu postgraduate courses, or in open courses lectured by (non-official) practitioners. In general, training tends to reproduce models of action appropriate to private practice, which does not meet the needs of the SUS and PHC. The inclusion of TCIM in undergraduate health is incipient and modest, far from the experience of other countries¹⁵ and is found in 21% of medical schools¹⁶ and 26.1% of nursing courses,¹⁷ mainly through optional disciplines.¹⁸

The MS offers some informative distance learning TCIM courses, most of them introductory, and two training courses: Auriculotherapy¹⁹ (semi-classroom) and Integrative Community Therapy (group-driving technique created in Brazil, aimed at sharing experiences, mental distress and community self-help)²⁰ (classroom), with about 4,000 PHC professionals trained in each of these practices. Some municipal health departments of large cities offer training courses to their professionals, especially a multi-professional residency in TCIM in the city of São Paulo.²¹

TCIM research has grown in Brazil in recent decades but is still scarce. Between 2002 and 2014, about 1% of the investment was raised from the Health Research System²² mainly in the biomedical field, with 59 research groups linked to the TCIM, registered in the Directory of the National Council for Scientific and Technological Development (CNPq), and distributed in different areas, such as biophysics, sociology, veterinary medicine, agronomy, among others, with higher concentration in the area of public health.⁶

Despite the increased fundraising and the diverse research groups, national scientific production is still negligible. Only 3% of 7,243 TCIM scientific publications in the Latin American and Caribbean Center on Health Sciences Information (BIREME) database between 2006 and 20166, and 12% of open access publications in the Virtual Health Library and PubMed/MEDLINE between 2002 and 2011, in a review of the most commonly used TCIM in Brazilian PHC, contextualized in this care environment.²³

TCIM has the potential to attenuate the hegemony of drug therapy in overly medicalizing PHC clinical care, and is a rich source of interpretative and therapeutic resources that can diversify the approaches to problems brought by PHC users. Its expansion in Brazil depends on investments in in-service training, especially for PHC professionals, and the incorporation of the teaching of these practices into health professional training. In research, it deserves studies on effectiveness, and of its establishment as knowledge and technique, as well as to advance in the dialogue between systems and different care practices.

None.

We declare no conflicts of interest.

1. Ministry of Health. Measles: 9 million 20–29 year olds to be vaccinated throughout Brazil. Brazil: Ministry of Health; 2019.
2. Ministry of Health. Ordinance 971 of 2006. Approves the National Policy of Integrative and Complementary Practices (PNPIC) in the Unified Health System. Brazil: Ministry of Health; 2006.
3. Ministry of Health.  ORDINANCE NO. 849, MARCH 27, 2017. Includes Art Therapy, Ayurveda, Biodanza, Circular Dance, Meditation, Music Therapy, Naturopathy, Osteopathy, Chiropractic, Reflexotherapy, Reiki, Shantala, Integrative Community Therapy and Yoga to the National Policy for Integrative and Complementary Practices. Brazil: Ministry of Health; 2017.
4. Ministry of Health.  ORDINANCE NO. 702, MARCH 21, 2018. Amends Consolidation Ordinance No. 2 / GM / MS of September 28, 2017 to include new practices in the National Policy for Integrative and Complementary Practices – PNPIC. Brazil: Ministry of Health; 2018.
5. Ministry of Health. Family Health Strategy (FHS). Brazil: Ministry of Health.
6. Tesser CD, Sousa IMC, Nascimento MC. Traditional and Complementary Medicine in Primary Health Care in Brazil. Cad Saude Publica. 2017;33(1):e00150215.
7. Ministry of Health. Department of Primary Care. Brazil: PNPIC Expansion. 2017.  
8. Ministry of Health. Tabnet Dasus. Brazil: Ministry of Health.
9. Ministry of Health. Access and Quality Improvement Program–2 Cycle. Brazil: Ministry of Health.
10. Nagai SC, Queiroz MS. Alternative and complementary medicine in the basic health system network in Brazil: a qualitative approach.  Cien Saude Colet. 2011;16(3):1793–1800.
11. Thiago SCS, Tesser CD. Family Health Strategy doctors and nurses' perceptions of complementary therapies. Rev Saúde Pública. 2011;45(2):249–257.
12. Silva ER, Tesser CD. Acupuncture patients' experience in the Brazilian Unified National Health System in different healthcare settings and social (de)medicalization. Cad. Saúde Pública. 2013;29(11):2186–2196.
13. Gontijo MBA, Nunes MF. Integrative and complementary practices: knowledge and professional credibility of the public health service. Trab educ saúde. 2017;15(1):301–320.
14. Faqueti A, Tesser CD. Use of Complementary and Alternative Medicine in primary healthcare in Florianópolis, Santa Catarina, Brazil: user perception. Cien. Saude Colet. 2018;23(8): 2621–2630.
15. Teixeira MZ. World panorama of medical education in unconventional therapies (homeopathy and acupuncture). Rev Homeopatia. (São Paulo) 2017;80(1/2):18–39.
16. Albuquerque LVC. The process of teaching learning in integrative and complementary practices in medical schools in Brazil. Dissertation. Master in Medical Sciences, Health Sciences Center. Brazil: University of Fortaleza. 2017.
17. Salles LF, Homo R, Silva JP. Integrative and additional practices: situation of your teaching in nursing graduation in Brazil. Revista Saúde – UNG–Ser. 2014;8(n3–4):37–44.
18. Nascimento MC, Romano VF, Chazan ACS, et al. Professional education in complementary and alternative medicine: challenges for the public universities. Trab Educ Saúde. 2018;16(2):751–772.
19. Moré AOO, Tesser CD, Min LS. Integrating acupuncture into primary health care: the experience of an educational model implemented within the Brazilian Unified Health System in Florianópolis. Acupunct Med. 2016;34(6):476–481.
20. Barreto AP, Barreto MCR, Barreto DOICHC, et al. The insertion of Community and Integrative Therapy in the Family Health Strategy. Fortaleza, 2011.
21. São Paulo City Hall. Secretaries. Health. Primary Care. Traditional Medicines.
22. Santana V. Analysis of the promotion of SUS to scientific production in integrative and complementary practices in health (2002 to 2014): contributions of the National Science Policy Technology and Innovation in Health. Brazil: University of Brasilia; 2016. 71 p.
23. Contatore OA, Barros NF, Durval MR, et al. Use, care and policy of integrative and complementary practices in Primary Health Care. Science & Public Health. 2015;20(10):3263–3273.