1. Introduction
Access to medicines is an essential component to achieve universal health coverage [
1]. However, access to medicines and their rational use are persistent global concerns. These issues have a significant impact on the health system’s quality and, consequently, on health [
2]. The expansion of access to medicines was listed as one of the ten most prominent problems that demand attention from the World Health Organization [
3]. It is necessary to address this issue from a health system perspective, considering the complex relationships between medicines and health financing, human resources, health information, and the broader issue of access to health services and interventions [
1,
4].
In Brazil, access to medicines is a responsibility defined by public policy. The National Pharmaceutical Policy defines services and responsibilities at all levels of governance of the unified health system (Sistema Único de Saúde—SUS) to guarantee access to medicines and pharmaceutical services.
With the decentralization of the Brazilian health system, the federal government is responsible for the general policies and guidance strategies. The 5560 municipalities, for their part, undertake a series of responsibilities that demand the mobilization of knowledge and technical, managerial, and political skills relative to medicines and services delivery [
5]. Citizens have the constitutional right to access medicines, and about 47% of the population access essential medicines. Such access is ensured by a network of widely distributed public healthcare centers [
6,
7].
In about 90% of municipalities’ health departments, pharmacists manage the selection, planning, purchase, and distribution of medicines [
8]. More than 30,000 pharmacists work in public healthcare and are employed by the SUS. This number grew by 75% from 2008 to 2013 [
9]. However, there are still failures in the organization of pharmaceutical services and management. In Brazil, some studies have suggested that the currently available pharmaceutical workforce’s professional skills do not correspond with the expected profile for work in SUS, mainly related to management and leadership skills [
10,
11].
Health systems governance and management are currently critical concerns in many countries [
12]. In fact, not only pharmacists but a significant number of healthcare managers do not hold formal management qualifications. In many healthcare professional degrees, there is little, or no management training integrated into the curriculum. This may be extremely problematic, given that clinical and managerial competencies are vastly different [
13].
“Organization and management” competencies are one of the four fields of professional competencies that pharmacists need, according to FIP [
14]. They are related to the management of teams, supply chains, services, budgets, and procurements. Communication, leadership, and interprofessional collaboration also belong to the set of competencies for pharmacists. Nevertheless, the literature mostly focuses on leadership training and competencies of physicians, nurses, and public health specialists [
15].
The Ministry of Health (MoH) identified the need for training pharmacists, in charge of the pharmaceutical policy and development of services in the municipalities, in the management of health systems (focused on pharmaceutical-related issues). The MoH requested one public university to develop a national course to address the need for management training. The Pharmaceutical Services and Access to Medicines Management Course (PSAMM) was the most important continuing education (CE) initiative for pharmacists ever developed in Brazil. It was funded by the MoH as part of the activities of the Brazilian Unified Health System Open University (UNA-SUS, a consortium of universities created by the MoH to meet the training and education needs of the SUS). The course was offered to pharmacists working in the public health system, using e-learning as the main approach [
16].
It is essential to broadly assess the CE initiatives and their impact on healthcare organizations [
17,
18], including several methods and points of view. An extensive analysis of the development and implementation of the PSAMM showed that it was affected by internal elements such as its didactic project and support infrastructure and also by external elements such as the sociopolitical scenario in the health system and support from the health services heads [
16]. This study aimed to analyze the impacts of a management training course, perceived by pharmacists, in the context of the Brazilian health system.
3. Results
3.1. Students’ Sociodemographic, Educational, and Professional Characteristics
The profile of students who completed the course is shown in
Table 3.
Most students are women (77%) and are between 25 and 39 years old (68%). More than 60% had already completed some postgraduate studies before taking the course, predominantly specialization courses, and 55.4% reported having no previous experience with the use of distance education in continuing education. A total of 75.2% point out flaws in their undergraduate courses for not focusing on SUS.
The Southeast region has the highest concentration of students who completed the course (36.7%), followed by the Northeast region (26.3%). Among the students, working at the municipal level (76.3%) and being hired through public examinations (73.5%) predominate. Most students had one job (51.1%), but 10.4% had three or more job contracts. This is related to the fact that 38.6% work more than 40 h a week.
The majority considered the workplace structure to be inadequate (64%) and considered the quality of Internet access at work to be good (51.6%). However, 35.3% consider access to be precarious or state they do not have access to the Internet.
The variables age group, gender, distribution of students by region, type and government level of employment refer to the 2500 students who completed the course. The educational level variables, perceived level of previous training focused on SUS, the number of work contracts, weekly workload, quality of Internet access in the workplace, the structure of the workplace, and previous use of distance education refers to 1500 students in class B.
3.2. Evaluation of the Infrastructure, Contents, and Teaching Methods
In total, 966 questionnaires of 1500 administered were considered valid, 44 (4.5%) in the North Region, 364 (37.8%) in the Northeast Region, 122 (12.6%) in the Midwest Region, 309 (32.0%) in the Southeast Region, and 127 (13.1%) in the South Region. The results are presented in
Table 4.
Students from all regions rated the course very positively. The operative plan (an in-1500 service hands-on activity that was mandatory for all the students) and the tutoring in small groups of students (the same tutor following the group throughout the course) stood out as the most useful and important resources for learning. In all the country regions, the rate was high, but for the operative plan and the tutoring, there were significant differences in rates between regions.
The results of the assessment of infrastructure, contents, and teaching methods from the perspective of PSAMM Course students in focus groups and interviews are presented in
Table 5. There are 2215 min of audio recordings.
The themes identified among the categories of analysis highlight important motivators to attend the course, as well as constraints that made it difficult to complete it, including characteristics of the course, but also of the workplaces and the environment. The themes that emerged in the category “configuration of the course to overcome the barriers encountered” describe the course’s characteristics that contributed in a crucial way so that students could complete the course.
3.3. Perceived Impacts of the PSAMM Course on the Students’ Behaviors and on Management Practices in Health Services
The closed questionnaire results are presented in
Table 6, with 966 responses considered valid (the same as item 3.2).
Students from all regions assessed that the course provided behavioral changes for them and positive changes in management practices in their workplaces. There was a significant difference between the regions and an average disagreement of 5.4% about the conditions to develop leadership in their workplace.
The results of the evaluation of the impacts of the course from the perspectives of PSAMM Course’s students obtained in the focus groups and in the interviews are presented in
Table 7.
4. Discussion
The evaluation of the course from the perspective of the students brings insights on strategic issues for the offer of continuing education (CE) for health professionals who are responsible for the practical implementation of an important public policy in the country.
Although the evaluation of the course was generally positive, students described some difficulties in attending it. The profile of students presents the same characteristics of the professional category in the country [
32,
33] and helps to understand the constraints found. The perceived precarity in public health contents during the undergraduate course and the rates of students who have already taken some kind of specialization or post-graduation courses to demonstrate some capacity, as well as motivation, to seek training and professional improvement. Regarding the opportunity to change professional behavior, considering the CE as a key element of this process,
Table 3 and
Table 5 bring essential elements that indicate substantial limitations for students related to workload and workplaces with no or precarious Internet access and support for CE.
Even though e-learning has provided a very important opportunity for these professionals to be able to access CE while staying in their own cities, access to good quality Internet (and sometimes also electricity) is still a challenge in remote regions [
34]; as described, for instance, by students from the Amazon region. It is worth highlighting that CE attendance barriers for pharmacists worldwide are lack of time [
35], cost, workplace, personal factors, and significant constraints related to geographical access [
36].
In addition to the country’s structural difficulties, students also realized that there is a low incentive for education on the part of health institutions for pharmacists, which constrains opportunities for behavioral changes. This finding is corroborated by data found in the literature, which suggests that training for skills development, such as leadership, focuses mainly on doctors, nurses, and public health specialists [
15].
In this sense, the pharmacists’ path in the search for better training goes through obstacles. As shown in the students’ profile, several pharmacists face a high workload, with two or three jobs as a barrier to the search for professional development. Data available in the literature [
15] suggest that health professionals do not have protected time for professional training, which requires the use of resources such as distance learning. As a result, students take this responsibility individually; professional development invades their personal lives, which results in work overload.
The evaluation of the infrastructure, contents, and teaching methods of the PSAMM Course indicates that some characteristics of the course provided opportunities to overcome the constraints found in attending the course and also to sustain the results even three years later (
Table 4,
Table 5 and
Table 7). They highlighted the importance of close tutoring with peer feedback, face-to-face meetings, and hands-on in-service activities to promote learning opportunities. Among the results in
Table 5, it is possible to identify the importance of strategies to bring the course closer to the reality experienced by students and their needs, such as regional centers, contents related to the particularities of each region, and flexibilities related to accessing the platform and completing the proposed activities.
Forums were the teaching methods with the lowest evaluation rates (
Table 4) and were not mentioned by students in the qualitative research years later. Some authors suggest that the distance modality may be more suitable for some students than for others, pointing to the blended method (online and face-to-face) as a better choice [
29,
37,
38]. The results reported here show that the use of e-learning proved to be adequate, considering the particularities already mentioned. However, they point out the importance of face-to-face meetings during the course, suggesting that the blended model, with decentralized centers and regional tutoring, provides better conditions for learning. Even in the North (Amazon) and Northeast regions, where the infrastructure of health services and Internet access are of lower quality, students positively evaluated the characteristics of the course. Such positive characteristics are revealed in their impact on students and services.
Students perceived the impacts of the course at all levels defined by Kirkpatrick: from the satisfaction with the educational intervention to the impacts on their levels of knowledge, going through behavioral changes and the reflexes in the management practices of the services where they work (
Table 6 and
Table 7). It is crucial to highlight that the students noticed positive results when they were still in the last stage of the course and that these results persisted and became clearer after about three years of the course’s completion. This result allows us to conclude that the PSAMM course brought a good and sustained return for the investment made by the Ministry of Health.
In this study, it is possible to find evidence of consolidation of competencies, such as leadership and communication, for example, indicated by the FIP as necessary competencies for the pharmaceutical professional. These are fundamental to overcome the barriers found in the health system and to strengthen the role of the pharmacist in public health. The perception that the course had brought students better conditions to exercise leadership and conduct management tasks at the end of the course was, years later, consolidated into the concrete performance of these important competencies for a health services manager.
The changes reported by students in their behavior are in line with their reports about changes in service management practices, particularly in the use of information-based negotiation, with greater confidence and a broader view of the health system and how to overcome the barriers of hierarchy. The reports reveal the adoption of desirable and important management practices for the sustainability of health services, such as interprofessional collaboration and close relationship with popular local health councils, as well as strategic planning and agreement on actions related to access and rational drug use. These changes result in greater visibility and authority for the pharmaceutical sector within the healthcare system and for the pharmacist.
These impacts, however, happened and were reported at different intensities among the participants in this study. Contextual and policy issues related to local health services constrained the full development of behaviors and practices, as evidenced by the reported difference between the regions of the country in the ability to exercise leadership in their workplace (
Table 7). The development of the operative plan was also constrained in some of the workplaces, particularly in regions North, Northeast and Midwest. Consequently, some students found the operative plan was not useful for them (
Table 4 and
Table 6). Hence, the intensity with which students report the achievements after the course must be weighted considering the context in which they attended the course and work.
As its main limitation, this study has an evaluation based on the perception reported only by pharmacists who completed the course, not including other points of view, such as managers and patients. Even so, the evidence presented here indicates that the provision of CE for pharmacists working in the public health system produces important and positive impacts for them and for health services.
The study also reveals issues that need to be considered when offering CE for health professionals. Students, educational intervention, and the workplace are drivers of the impacts of the CE. The Brazilian Policy for health professionals’ permanent education in the SUS [
28] defines that educational interventions for health professionals must be understood and developed as a health system’s investment: therefore, educational activities must be part of health workers’ work, with the aim of achieving the health system’s benefits. Considering this assumption, the workplace support to develop educational intervention is an essential constituent of the CE strategy.
CE proposals must be attentive to the context of the target audience, proposing flexible strategies that make sense with the students and the local health system’s reality. New investments in continuing education should focus primarily on hands-on educational strategies with activities in the workplace, with compatible theoretical load, using the available resources [
15], and meeting the needs of students; in a way that enables the development of the course at the service location and applying guidelines such as those reported by Ramani et al. [
39] for the planning, implementation, and evaluation of the educational interventions in the local context.