The results of this article revealed the complexity involved in a PPS system. A Municipal PPS is characterized as an open system and interrelates with the municipal management and the municipal health systems as described in Fig. 1. Within the sociotechnical approach, these larger systems represent the environment of the municipal PPS.
The used index shows sustainability as the balanced development of the social, cultural, environmental, economic, and political dimensions. Despite the political weaknesses, the studied municipality showed good economic development. Its health indicators have a high average level. Social participation was the only indicator that was below average . We can better understand some aspects of the sociotechnical nature of PPS in this context in which it did not please stakeholders.
The aim of the organizational structure is identified as the central element of the model. The other system components interrelate with its scope. For municipal managers, health professionals, and users the lack of medicines was the main frustration. The central aim of the Municipal Health Plan and PPS was the same. It was “to have medicine available from the Municipal List of Medicines in the dispensing centers”. This aim exposes a conceptual reduction. Ensuring access to medicines is making them available. A broader perspective comes from WHO: availability is a dimension of access to medicines. So are affordability, acceptability, and rational use of medicines [41, 42]. In Brazil, access is the purpose of PPS and involves its many dimensions . It is more complex than the mere availability of medicines.
Medicine availability is a key part ofthePPS architecture. This dimension can suffer many constraints. We need supply-side strategies to ensure medicine availability and help expand access to medicines in health care systems . But when a PPS system chooses medicine availability as a central goal, its commitment is narrowed down to delivering medicines. Barreto and Guimarães, and Rover and Leite discussed the constraintsof this approach for PPS development in public health systems [8, 6].
We identify weaknesses in the PPS management component generated. Lack of central coordination, pharmaceutical services with more than a manager, and a fragmented organization prevented integrated planning with other sectors (Fig. 2). At the health secretariat, there were no human resources available to plan the actions that involved the services. PPS issues were discussed and decisions were made with no integration of the directorates (PHC, specialized services, or warehouse). In 76% of Brazilian municipalities PPS coordination is nominated in the health department organization chart .
PPS has a management logic based on an input distribution model. The environment refers only to technical elements of the system: infrastructure, technical process, and technology. The social components of workforce and culture are not mentioned in the Municipal Health Plan. But, the organizations' reality is based on social components. People are essential sociotechnical elements, as well as the components affecting them . The architecture of municipal PPS should not ignore general and organizational culture.
We did not find working groups organized in the municipal PPS. The working group is considered the elementary construction of the sociotechnical structure. Self-regulation, semi-autonomy, and specific functions but with interrelated tasks are working group features. What connects the groups is to achieve a common goal. This increases the capacity to meet the demands of the internal and external environments .
The organizational culture established was the culture of isolation: “each one does their own”. People working in the health system did not know each other in a municipality system with only 130,000 inhabitants. There were no shared symbols or collective rituals. The ideology was based on the care logic of contribution. The national pharmaceutical policy advocates PPS with a comprehensive approach to the health-disease process [8, 9, 10, 11].
The distribution and dispensing centers' infrastructure is the indicator that showed the best result. The result is better than those observed in other municipalities in the state . But, the infrastructure does not seem to be enough to provide articulated pharmaceutical services. This component is connected to the PPS aim, restricted to distributing medicines.
The processes of the municipal PPS emphasized medicine supply. We highlight the regulation of technical processes for making medicines available. It involved prescription, acquisition, inventory control, and dispensing. Even with technical components in focus, pharmacists did not take part in planning or executing scheduling and purchasing services. In most municipalities in the state, this process involves the pharmacist. This reality impacts on availability, reasonableness of costs, and sustainability of access. In view of the volume of financial resources allocated, this aspect is fundamental . Processes that need intersectionality and participation, such as a Pharmacy and Therapeutics Committee and participatory planning, have not been carried out either.
In the technology component, PPS management at PHC did not meet the needs of prescribers or patients. The problems involved both the diversity of medication available and their recurrent scarcity. Here the key factors are: the formal constitution of the Pharmacy and Therapeutics Committee; and the consumption of 10% of the budget bu the “non-selected medicines' program”. In both situation, there were no defined access criteria. These factors are like those found in the studies by Hoepfner and Gerlack[45, 10].
We can understand the weaknesses of the municipal PPS by looking at some results obtained by the system. The resource used for the PPS (R$ 38.90 / inhabitant) is higher than the national or state average (R$ 20.00) . Even with a high cost, the observed effects show professionals' and users' dissatisfaction as well as a waste of medicines. What works in one configuration may not work elsewhere. We must adapt improvements to the local context and check. The sociotechnical systems approach is capable of answering to local specificities. It also helps to produce incremental results and contributes to building flexible organizational structures [17, 30]. Understanding the municipal PPS as a sociotechnical system contributed to developing an intervention project. For Carayon et al. (2011), such understanding has the ability to transfer and put in place new knowledge and methods to impact the entire health system .
The results presented here suggest that the municipal PPS is a complex system, like the one Appelbaum found . In a sociotechnical intervention, there are many strengths. They should be used within a strategic plan for organizational development instead of as an isolated approach. Policymakers and managers should target their support to systemic solutions, rather than contributing to proliferate fragmented efforts.
Some limitations of this study need to be highlighted. One difficulty is collecting data from different and poorly systematized sources. The lack of good electronic systems and transparency of public data weaken the ability to study this field. The scarcity of references to sociotechnical systems applied to PPS required the adaptation of study instruments, such as the management capacity assessment protocol, besides using references from administration and sociology.