Introduction

The popular consumption of medicinal plants and their derivatives as therapeutic practice for health has been recorded since the beginning of civilization, being technique of integral care in the field of popular medicines and ancestral knowledge.¹ The allopathic medicine has been highlighting in the pharmaceutical market, however, the application of medicinal plants and phytotherapeutic medicines is still widely used by the population, mainly due to the effects caused by synthetic medicines, demonstrating better adherence to the consumption of natural products, as well as the Integrative and Complementary Practices (ICPS), with holistic approaches applied to the concepts of health and well-being.²

The phytotherapy is the treatment characterized by the use of medicinal plants in their different pharmaceutical forms, without using isolated active substances, even with vegetable origin.³ In this way, the phytotherapy encompasses the medicinal plants and phytotherapeutic medicines.

Medicinal plants are plant species, whether or not cultivated, used for therapeutic purposes. The plants can be fresh, when collected at the time of their use, or dried, which have been preceded by drying and stabilization, both equating to plant drugs.³Phytotherapeutic medicines are obtained exclusively from active raw materials of plants, whose efficacy and safety are validated. The drugs that include, in their composition, active substances isolated or associated with plant extracts are not considered phytotherapeutic.⁴

In Brazil, the legitimacy and institutionalization of ICPS of health care began in the 1980's, after the creation of the Unified Health System (UHS).⁴ In 2002, the World Health Organization (WHO) formulated a guideline to encourage the inclusion of non-conventional care practices in the organization of official health care systems, facing the evidence of their significant increased use by the population.⁵

This guideline of the WHO came to add to what was already a claim in Brazil. In the VIII National Health Conference, in 1986, the introduction of alternative practices for assistance in the context of health services was considered, enabling the user to the democratic access to choose the preferred therapy.⁶ At the same time, health professionals and managers involved with the Brazilian Sanitary Reform advocated that the medicinal and phytotherapeutic plants could be accessible therapies, rescuing the popular knowledge and strengthening the natural therapies, with less risk of side effects.⁷

National meetings were happening to exchange experiences about Phytotherapy in the UHS, and, in 1999, during the National Symposium of Medicinal plants, in Águas de Lindóia, São Paulo, was founded the National Association of Phytotherapy in Public Services, which worked for the strengthening of phytotherapeutic programs and in defense of the institutionalization of the National Policy of Medicinal and Phytotherapeutic Plants.⁸

The Management of Pharmaceutical Assistance of the Science, Technology and Inputs Department, of the Ministry of Health (MoH), initiated the process of institutionalization in 2000, which constituted a Working Group composed of UHS professionals, who coordinated programs of Phytotherapy and researchers for the elaboration of the National Policy of Medicinal and Phytotherapeutic Plants.⁷ In 2001 and 2003 were conducted national seminars aiming to validate the proposal of the Policy.⁷

The forwarding of this claim became part of the discussions of the MoH, especially in 2003, when a work team was nominated, which, in 2004, carried out a diagnosis along with municipalities, observing the different therapeutic practices. This study was directed to 5,560 municipalities, obtaining return from 4,052 municipal managers, and of these, 72% (2,917 municipalities) used ICPS in Basic Care and 30% had law or institutional act certifying the use of ICPS, predominantly municipalities in southern and southeastern regions.⁹

After completing the works, was instituted the National Policy of Integrative and Complementary Practice (PNPIC) in the UHS, by Decree GM/MS n. 971 of 3 May 2006, which mainly covered the areas of Phytotherapy and Medicinal Plants, Thermalism, Anthroposophy, Homeopathy and Traditional Chinese Medicine (TCM) Acupuncture.¹⁰ On 22 June 2006, by means of the Presidential Decree n. 5,813, was approved the National Policy of Medicinal Plants and Phytotherapeutic Medicines.⁹

The ICPS policy was presented with the goals to incorporate, implement, structure and strengthen those practices in the UHS; to contribute to increase the resolvability of the system and the expansion of access to ICPS, particularly of homeopathic and phytotherapeutic medicines; to promote the rationalization of health actions; to stimulate the actions relating to the social control/participation; to develop strategies for qualification of personnel; to disseminate knowledge and information on ICPS for health professionals, managers and users of the UHS and to encourage intersectoral actions, researches, the actions of monitoring and evaluation, as well as national and international cooperation in the framework of integrative and complementary therapies.⁹

In 2017, the PNPIC was extended through the inclusion of 14 new practices, from the publication of the decree GM 849/2017.¹¹ In the following year, in 2018, the PNPIC was again extended, from the publication of the decree GM 702/2018, including 10 new practices.¹²

For the ICPS policy to happen, it is essential to register health establishments, because it provides knowledge for the manager of the existing health care network and its potential, aiming to assist in health planning at all levels of government. In this sense, the MoH established the the National Record of Health Establishments (NRHE) with the goal of providing information on infrastructure and operation conditions of services.¹³

The NRHE aims to support the operationalization of Health Information Systems, which are essential for an effective and efficient management of the UHS. The information system assists in health planning, at all levels of government; provides information on infrastructure, type of care provided, specialized services, beds and health professionals present in health institutions. In addition, it provides knowledge for the manager of the reality of the existing healthcare network, its potential and ability, as well as greater visibility to the social control to be exercised by the population.¹³

This article has as research question: what are the health establishments accredited in the UHS using medicinal plants and phytotherapeutic medicines as ICPS registered in the NRHE? In this way, the objective is to analyze the health establishments accredited in the Unified Health System and in the National Record of Health Establishments that use medicinal plants and phytotherapeutic medicines as Integrative and Complementary Practices.

Method

This is a survey that uses procedures of the documentary analysis, which enables elaborating and clarifying the issue/problem in line with the researcher's objective. A document is an important tool for understanding the social context, concepts and favoring on observation of the past, in addition to providing for the visualization of the process of maturation or evolution of individuals, groups, concepts, knowledge, behaviors, attitudes, and practices.¹⁴

In the first step of the documentary analysis, relevant documents were located and their credibility were evaluated; thus, were located establishments that offer ICPS, whether UHS or not, outpatient clinics or hospitals using the site http://cnes.datasus.gov.br/, laws, decrees and resolutions relating to Brazilian ICPS,^9,11-12 held during May 2018. The documents were selected according to the criteria: relevance of content to the study objective and reliability, since they are official MoH documents. The documents relating to establishments that offer the ICPS, resolutions, laws and decrees are public documents that can be searched through documentary analysis.¹⁴

Thus, with these documents, a preliminary documentary analysis was performed, according to the five guidelines: context analysis, authors, authenticity and reliability of the text, the nature of the text, key concepts and internal logic of the text.¹² With regard to the ICPS context, the legitimacy and institutionalization of these healthcare practices began in the 1980's, after the creation of the UHS,⁴ subsequently ratified in 2006 and added, in 2017 and 2018, other ICPS, and, currently, 39 ICPS are described and recognized in Brazil.^9,11-12 Regarding the authenticity and reliability of the analyzed material, the documents are records in the NRHE of ICPS, laws, decrees and resolutions, i.e., they are reliable and authentic documents, analyzed in their entirety. The record has information of healthcare establishments registered in the national sphere through the consultation field of integrative and complementary practices, code 134, which allows for choosing the state, the municipality, the type of service, the specialized service, the classification of the service and the type of care (outpatient clinic or hospital and UHS or non-UHS), resolutions, laws and decrees that conceptualize the 39 ICPS, their applicability, policies of inclusion in health and/or private health systems.

The last step was the analysis of documents regarding their internal logic, using the documentary consistent content.¹⁴ The content analysis is a set of techniques of analysis of verbal and non-verbal communication that seeks, by means of systematic and objective procedures, to describe the content of messages to obtain qualitative, or not, indicators, which allow for the inference of knowledge regarding conditions of production/reception of these messages. It is considered one of the content analysis techniques, whose operability is distinguished in three stages: pre-analysis, exploration of the material, treatment of results, inference and interpretations.¹⁵

It is important to highlight that this research is exempt from the Informed Consent Form (ICF) due to its documentary character. Therefore, since the documents analyzed in this study were extracted from official sites, the issues relating to ethical aspects were respected, considering that the exposed information translate the meaning of the data found.

Results

The data obtained in the present study showed that, of the 5,570 Brazilian municipalities,¹⁶126 feature some service that uses phytotherapy as an integrative and complementary practice. In the search, there was no search option separately from medicinal plants and phytotherapeutic medicines. There are vocabulary distortions in relation to the term, because, in 2006, the PNPIC⁹ brought phytotherapy not covering the medicinal plants, which goes against the national record that has only the record of phytotherapy, which correctly contains the medicinal plants and phytotherapeutic medicines.

Table 1 - Number of States by Brazilian regions that use Phytotherapy as integrative and complementary practice accredited in the Unified Health System. Brazil, 2018

Region ICPS	Phytotherapy	Total
Northeast	8	8
Southeast	4	4
South	3	3
Midwest	3	3
North	3	3
Total	21	21

Source: National Record of Health Establishments. Brazil, 2018

Although medicinal plants are cited in the policy as a type of care, they do not appear in isolation as a therapeutic practice of service in the records of the NRHE. Another relevant aspect to be highlighted is that, in all Brazilian regions, there are municipalities that subscribe phytotherapy in the NRHE, with Northeast as the region of greater implementation (38.11%), followed by the Southeast (19.05%), South (14.28%), Midwest (14.28%) and North (14.28%).

Despite the policy approval in 2006, only 2.26% of Brazilian municipalities made the phytotherapy service official in the UHS. Thus, various questions are possible in relation to the officialization of the phytotherapy service within the ICPS: did the managers implement the action in the care network, but cannot register the service?; Haven't the managers adhered to the phytotherapy service?; Or also, are there incomplete information in the records of the NRHE that do not recognize the municipalities that offer the phytotherapeutic service? These questions become even more relevant when there is only the option of phytotherapy for registration among the PICS, not defragmenting medicinal plants of herbal medicines.

There is no clarification between the registered health services that offer only the medicinal plants or phytotherapeutic medicines, as well as does not distinguish health services that offer the two practices together (medicinal plants and phytotherapeutic medicines). This inappropriate record can generate confusion about the correct term to be used and what the health service is really offering to the population. Currently, there are contradictions in the numbers and lack of data to issue a substantiated point of view that brings arguments to present the reality of deployment of the national phytotherapy in the UHS.

The information in the NRHE in May of 2018 presented 589 phytotherapy services within the ICPS (Table 2).

Table 2- Total number of health services that offered Phytotherapy as integrative and complementary practice. Brazil, 2018

Region ICPS	Phytotherapy	Total
Southeast	324	324
South	151	151
Northeast	97	97
Midwest	10	10
North	7	7
Total	589	589

Source: National Record of Health Establishments. Brazil, 2018

The phytotherapy services are more concentrated in the Southeastern region, followed by the South and Northeast regions.

According to the analyzed data, the 589 registered UHS and non-UHS phytotherapy services are distributed among 126 Brazilian municipalities. Of these, 110 services are in the care network of the UHS (Frame 1), distributed in 563 services that provide assistance in the UHS using the phytotherapy (11 are also hospitals).

Frame 1 – Municípios brasileiros que possuem o serviço de fitoterapia no SUS, cadastrados no CNES. Brasil, 2018

Region Service	North	Northeast	Midwest	Southeast	South	Total
Municipalities with Phytotherapy	Manacapuru (AM)	Olivenca (AL)	Planaltina (DF)	Mariana (MG)	Londrina (PR)	110
	Xinguara (PA)	Riachão do Jacuípe (BA)	Guará (DF)	Contagem (MG)	Missal (PR)
	Bannach (PA)	Mulungu (CE)	Recanto das Emas (DF)	São João Del Rei (MG)	Pato Bragado (PR)
		Barbalha (CE)	Samambaia (DF)	Uberlândia (MG)	Bom Jesus do Sul (PR)
		Fortaleza (CE)	Gama (DF)	Capetinga (MG)	Ubiratã (PR)
		Viçosa do Ceará (CE)	Vitória (ES)	Queluzito (MG)	Porto Barreiro (PR)
		Carnaubal (CE)	Colatina (ES)	Betim (MG)	Porto Alegre (RS)
		João Pessoa (PB)	Baixo Guandu (ES)	Uberaba (MG)	Ivoti (RS)
		Picui (PB)	Cuiabá (MT)	Juiz de Fora (MG)	Antônio Prado (RS)
		Casserengue (PB)		Águas Formosas (MG)	Gravataí (RS)
		Princesa Isabel (PB)		Matozinhos (MG)	Vacaria (RS)
		Juripiranga (PB)		Nova Lima (MG)	Nova Petrópolis (RS)
		Água Branca (AL)		Teófilo Otoni (MG)	São Vicente do Sul (RS)
		São Sebastião do Umbuzeiro (PB)		Delfinópolis (MG)	Ijuí (RS)
		Goiana (GO)		Claraval (MG)	Rio Grande (RS)
		Recife (PE)		Varzelândia (MG)	Boa Vista do Cadeado (RS)
		Jurema (PE)		Araguari (MG)	Blumenau (SC)
		Petrolina (PE)		Belo Oriente (MG)	Florianópolis (SC)
		Campo Maior (PI)		Ipatinga (MG)	Balneário Picarras (SC)
		Bom Jesus (PI)		São Sebastião do Paraíso (MG)	Rancho Queimado (SC)
		Natal (RN)		Louveira (SP)	Leoberto Leal (SC)
		Tenente Laurentino Cruz (RN)		Boa Esperança do Sul (SP)	Maravilha (SC)
		Baraúna (RN)		Duque de Caxias (RJ)	Vidal Ramos (SC)
		Olho-D’Agua do Borges (RN)		Cachoeiras de Macacu (RJ)	Imbituba (SC)
		Simão Dias (SE)		Rio de Janeiro (RJ)	Salto Veloso (SC)
		Salgado (SE)		Niterói (RJ)	Mirim Doce (SC)
		Aracaju (SE)		Volta Redonda (RJ)	Tubarão (SC)
				Ubirajara (SP)	Princesa (SC)
				Petrópolis (RJ)	Rio das Antas (SC)
				Itaboraí (RJ)	Ponte Serrada (SC)
				São Paulo (SP)	Alfredo Wagner (SC)
				Registro (SP)	Pomerode (SC)
				Campinas (SP)	Rio Negrinho (SC)
				Santa Branca (SP)	Piratuba (SC)
				Ribeirão Preto (SP)	Presidente Castelo Branco (PR)
				Cajamar (SP)
Total	3	27	9	36	35	110

In relation to the distribution of phytotherapy services registered by Brazilian region, the Southeastern region occupies the first place, with 36 municipalities offering at least a service of phytotherapy, followed by South (35) and Northeast (27) regions. Together, the Midwest and North regions add 12 municipalities.

Discussion

The phytotherapy emphasizes the prevention of illness and health recovery, thinking of the human being in his/her entirety. Although it is an ancient practice, it still possesses a timid growth in the UHS. For an overview of this service, were selected some studies that provide information on the health professionals, managers and users.

In a survey conducted with directors of family health units from different professions (nurses, hospital managers, health managers, dental surgeons, pharmacists, social worker and administrator) in the municipality of São Luís (MA), 81% were unaware of the public policies for the deployment of the phytotherapy and 56% did not know the PNPMF.¹⁷ The majority (94%) believed that the insertion of the phytotherapy as a strategy in primary care would bring benefits to the community by being one more option in the search for health promotion, and could reduce costs with medication.¹⁷

A study conducted with health professionals in primary care with the Family Health Program (FHP) in the city of Juiz de Fora (MG) revealed that the team has an interest in using phytotherapy as ICPS, justified by the lack of incentive for managers, the discontinuity of projects in exchanges of management, the need for training and the lack of knowledge of professionals about the use of alternative therapies, such as major difficulties for the effective implementation of the phytotherapy in the service contexts.¹⁸

A study conducted in the city of Porto Alegre (RS) identified that most health professionals are unaware of any of the policies on ICPS, and those who demonstrated knowledge was due to personal search for information and participation in events. Furthermore, in that study, the professionals reported being encouraged, but there is no organized strategy to offer ICPS.¹⁹A research conducted in the municipality of Crato (CE) showed that the nurses were unanimous in favor of the use of phytotherapy and medicinal plants, because they believe it is a viable and beneficial alternative that helps in daily care, favoring the patient and the health system and the reduction of costs in primary care.²⁰

In Caico (RN), a study conducted with health professionals points out that the low level of knowledge is a factor that generates difficulty for using ICPS. The professionals attribute this fact, mainly, to the absence of such content during graduation in courses in the health area.²¹An investigation mentions that the inclusion of such a practice is possible by means of popular participation, which occurs when there are lectures and workshops of manipulation of phytotherapeutic medicines. The same study cited the easy access as important aspect for their inclusion in the UHS. It brings as difficulties the small number of actions to encourage the planting of plant species in the household environment and the small number of health professionals with sufficient knowledge to prescribe medicinal plants and phytotherapeutic medicines.⁷

A survey on the perception of doctors and managers on the implementation of ICPS in the UHS in the city of Vitória (ES) found that they value and seek to know and study the Phytotherapy, and wish to attend courses regarding the prescription of phytotherapeutic medicines and treatments. Furthermore, BHC doctors realize significant improvements in patients treated with phytotherapy and advocate the integration of phytotherapy at schools and communities to improve users' quality of life, aiming at autonomy, self-empowerment and protagonism.¹⁰

Facing this scenario, there is a need to motivate managers and health professionals in relation to qualification, offer and complementation of integrative care and phytotherapy in municipal services. The aforementioned literature shows that the service of phytotherapy contributes to the consolidation of the principles and guidelines of the UHS, being a therapy of interest of professionals, managers and users of the system. The selected studies indicate difficulties that need to be overcome for the implementation of this service, such as access issues, lack of knowledge about the PNPIC and how to use it, and lack of government incentive.

There also stands out as necessary to implement this therapy, the broadening of the health concept of managers and professionals, the inclusion of the contents of the ICPS in graduation, the qualification in the area, the assessment of satisfaction of the population with the services, institutional, political and infrastructure support and greater involvement of managers. Moreover, these demands included the need to expand researches with macro and micro focus of this service.

Regarding health professionals legally able to prescribe phytotherapeutic medicines, there stands out the involvement of legal aspects such as the authorization by the professional council, which requires specific training of its professionals for this purpose, and ethical aspects, such as the existence of ability to prescribe, demonstrating adequate knowledge.²²

Through the Nursing Council's (COFEN) Resolution n. 197/1997, which states, in its 1^st Art. To establish and recognize Alternative Therapies as a specialty and/or qualification for the nursing professional and 2^nd Art. To receive the title provided for in the preceding article, the nursing professional must have completed and been approved in course recognized by educational institution or similar entity, with a minimum hourly load of 360 hours. In Resolution n. 577/2018,²³nurses can specialize in various areas, which include the ICPS. They are, hierarchically described, in item 30 of area 1 of the resolution, as: acupuncture, phytotherapy, homeopathy, orthomolecular, flower therapy, foot reflexology, Reiki, yoga, therapeutic touch, music therapy, chromotherapy and hypnosis. In this way, there stands out the nursing practice in phytotherapy and other ICPS.

Conclusion

When analyzing the panorama of health establishments accredited for the use of phytotherapy and medicinal plants as integrative and complementary practice in the UHS, firstly, there was a non-suitability of the correct use of the term phytotherapy, which is sometimes synonymous with medicinal plants, and, at other times, represents different meanings, which can hinder the researches about the theme and the records of the referred health establishments. There is also a disparity in the distribution of these services in municipalities and regions of the country.

Even with the deployment of the National Policy of Integrative and Complementary Therapies in the UHS in 2006, there are few health establishments registered, not allowing the user to access the complementary therapies and treatments, restricting to synthetic medicines.

The impossibility of searching in the NRHE separating medicinal plants from phytotherapy and vice versa, can be considered a limitation of this study. The results of this study can subsidize and encourage managers of states, municipalities and the Ministry of Health in planning, monitoring and evaluation of records and the operation of these services, with a view to strengthening integrative and complementary therapies in the UHS. Health professionals are also responsible for seeking knowledge on ICPS and integrating them into the routine of services, in order to facilitate the access of the population to other forms of therapies, not only the biomedical ones, generating the opportunity to choose the service.

In relation to health professionals, as nurses, the potential of the Council's work is believed to expand the recognition of new integrative and complementary therapies as a specialty and/or qualification for the Nursing professional.

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Corresponding author

Marcio Rossato Badke

E-mail: marciobadke@gmail.com ou lapics@ufsm.br

Institutional Address: Universidade Federal de Santa Maria, Centro de Ciências da Saúde - Prédio 26, Sala 1305; Faixa de Camobi, Km 09 - Campus Universitário Santa Maria/RS

CEP: 97105-900

Contributions of Authorship

Marcio Rossato Badke

- Design and planning of the research project; data gathering or analysis and interpretation; composition and critical review.

Silvana Bastos Cogo