The right to health in the courts of Brazil: Worsening health inequities?

Health and Human Rights

Volumn 11, Issue 2, 2009, Pages 33-45

  Ferraz, Octavio Luiz Motta ^a  

^a UNIVERSITY OF WARWICK   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

HEALTH CARE; HEALTH POLICY; HEALTH STATUS; HUMAN RIGHTS; MODELING; SOCIAL JUSTICE; SOCIOECONOMIC INDICATOR;

ARTICLE; BRAZIL; HEALTH CARE DISPARITY; HEALTH DISPARITY; HUMAN; HUMAN RIGHTS; LEGAL ASPECT; NATIONAL HEALTH SERVICE; ORGANIZATION AND MANAGEMENT; SOCIAL JUSTICE; SOCIOECONOMICS; EPIDEMIOLOGY; LEGISLATION AND JURISPRUDENCE;

BRAZIL; HEALTH STATUS DISPARITIES; HEALTHCARE DISPARITIES; HUMAN RIGHTS; HUMANS; SOCIAL JUSTICE; SOCIOECONOMIC FACTORS; STATE MEDICINE;

BRAZIL;

EID: 77951675709     PISSN: 10790969     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (65)

1. J. J. Rousseau, Discours sur l'économie politique (1755). Available at http://classiques.uqac.ca/classiques/Rousseau_jj/discours_economie_politique/discours_eco_pol.html.
2. U. Baxi, "The avatars of Indian judicial activism," in S. K. Verma and Kusum (eds), Fifty years of the Supreme Court of India: Its grasp and reach (New Delhi: Oxford University Press, 2000), p. 161.
3. For a good account of the history, successes, and failures of the "sanitary movement" into the mid-1990s, see K. Weyland, "Social movements and the state: The politics of health reform in Brazil," World Development 23/10 (1995), pp. 1699-1712.
4. IK. Weyland, "Social movements and the state: The politics of health reform in Brazil," World Development 23/10 (1995), p. 1703.
5. For the most comprehensive and up-to-date analysis of health inequalities in Brazil, see National Commission on Social Determinants of Health, As causas sociais das iniqüidades em saúde no Brasil: Relatório final da Comissão Nacional sobre Determinantes Sociais da Saúde (CNDSS) (Rio de Janeiro: Brazilian Ministry of Health, 2008), in Portuguese with an Executive Summary and Annex in English (pp. 203-216). Available at http://www.cndss.fiocruz.br/pdf/home/relatorio.pdf.
6. J. Lambert, Os dois Brasis (Brasilia: INEP, 1959).
7. K. Weyland, Democracy without equity: Failures of reform in Brazil (Pittsburgh, PA: University of Pittsburgh Press, 1996).
8. I have dealt in some detail with these issues in O. Ferraz, "Poverty and human rights," Oxford Journal of Legal Studies 28/3 (2008), pp. 585-603.
9. O. Ferraz, "Between usurpation and abdication? The right to health in the courts of Brazil and South Africa," Social Science Research Network (August 20, 2009). Available at http://ssrn.com/abstract=1458299.
10. Three very recent decisions by the president of the STF seem to signal a potential change in the current jurisprudence, but it is too early to tell. For a summary, see "Presidente do STF decide ação sobre fornecimento de remédios com subsídios da audiência pública sobre saúde." Available at http://www.stf.jus.br/portal/cms/verNoticiaDetalhe.asp?idConteudo=113461.
11. See R. G. Parker, J. Galvão, and M. S. Bessa (eds), Saúde, desenvolvimento e política: Respostas frente à AIDS no Brasil (São Paulo: Editora 34, 1999), p. 11.
12. For a brief account of the historical development of right-to-health litigation in Brazil, see Brazilian Ministry of Health, O remédio via justiça: Um estudo sobre o acesso a novos medicamentos e exames em HIV/AIDS no Brasil por meio de Ações Judiciais (Brasilia: Ministry of Health, 2005).
13. Until very recently, the Brazilian system had no binding precedents. Each judge at any level was able to decide freely each new case, even if the STF had already decided thousands of similar cases in a particular way. That had an important effect on the number of cases coming to courts. This changed with the reforms that occurred in late 2006 (brought about by Federal Laws 11.417 and 11.418); the STF is now able to issue "binding principles" (sumulas vinculantes) with erga omnes effect whenever it feels that an issue has been thoroughly analyzed and decided in a certain way several times. No binding principle has been issued on right-to-health litigation to date, although the STF is presently considering this option. Unless otherwise noted, all translations of Brazilian legal terms and documents cited in this paper are by the author.
14. RE 271.286 AgR- RS (2000), Relator Min. Celso de Mello. Translated from the Portuguese at the STF website (http://www.stf.gov.br/), where the original reads: "O direito à saúde - além de qualificar-se como direito fundamental que assiste a todas as pessoas - representa conseqüência constitucional indissociável do direito à vida.... A interpretação da norma programática não pode transformá-la em promessa inconsequente.... Entre proteger a inviolabilidade do direito à vida, que se qualifica como direito subjetivo inalienável assegurado pela própria Constituição da República (art. 5°, caput), ou fazer prevalecer, contra essa prerrogativa fundamental, um interesse financeiro e secundário do Estado, entendo - uma vez configurado esse dilema - que razões de ordem ético-jurídica impõem ao julgador uma só e possível opção: o respeito indeclinável à vida."
15. The phrase "opportunity structure for litigation" is from S. Gloppen, "Litigation as a strategy to hold governments accountable for implementing the right to health," Health and Human Rights: An International Journal 10/2 (2009), pp. 21-36. Available at http://hhrjournal.org/index.php/hhr/article/view/79/164.
16. It is important to note that a minority of judges in the lower courts and courts of appeal of several states still decide against claimants on the basis that the best interpretation of the right to health does not mean unlimited access to medical treatment, but rather a right to equal access to health benefits the state is able to provide within limited resources. This explains why (as mentioned later in the text) the rate of success in right-to-health litigation is not 100%.
17. Brazilian Ministry of Health (see note 11). It is important to note here, however, that not all decisions of that period concerned HIV/AIDS treatment. In fact, in what is probably the earliest decision favoring a patient by the STF, the case concerned an individual suffering from Duchenne muscular dystrophy whose treatment in the US was funded through an interim first instance court order upheld by the STF in AgrPet 1246-1- SC (1997).
18. A. Messeder, C. Osorio-de-Castro, and V. Luiza, "Mandados judiciais como ferramenta para garantia do acesso a medicamentos no setor público: A experiência do Estado do Rio de Janeiro, Brasil" ("Can court injunctions guarantee access to medicines in the public sector? The experience in the State of Rio de Janeiro, Brazil"), Cadernos de Saúde Pública 21/2 (2005), pp. 525-534.
19. D. Borges, Uma análise das ações judiciais para o fornecimento de medicamentos no mbito do SUS: O caso do Estado do Rio de Janeiro no ano de 2005, MPhil thesis (Fiocruz, 2007). Available at http://bvssp.icict.fiocruz.br/lildbi/docsonline/3/3/1233-borgesdclm.pdf.
20. F. Hoffman and F. Bentes, "Accountability for social and economic rights in Brazil," in V. Gauri and D. M. Brinks (eds), Courting social justice: Judicial enforcement of social and economic rights in the developing world (Cambridge, UK: Cambridge University Press, 2008), pp. 100-145.
21. For a review of studies surveying right-to-health litigation, see O. Ferraz, "Right-to-health litigation in Brazil: An overview of the research" (presentation at The Right to Health through Litigation? Can Court Enforced Health Rights Improve Health Policy? (workshop), Universidad Torcuato Di Tella, Buenos Aires, April 15-17, 2009). Available at http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1426011. A recent search in the database of the São Paulo Court of Appeals (one of the 27 courts of appeal of Brazil) for the terms equivalent to "right to health" and "medicines" retrieved 6,617 decisions in 2008 alone, all of which were individual claims. I thank Daniel Wang for this data.
22. For an analysis of 48 decisions by the STF, all of them successful for the litigant, see M. Barbosa, "O STF e a política de fornecimento de medicamentos para tratamento de AIDS/HIV," in D. Coutinho and A. Vojvodic (eds), Jurisprudência Constitucional: Como decide o STF? (São Paulo: Malheiros, 2009), pp. 335-350.
23. C. Collucci, "Triplicam as ações judiciais para obter medicamentos," Folha de S. Paulo (January 9, 2009).
24. The involvement of Brazilian courts, in particular the STF, in areas traditionally regarded as political has grown across the board. Health is only one of them, and even within health, litigation for medical treatment is one among many others, such as recent controversial cases like stem cell research and abortion of anencephalic fetuses. For an academic treatment of the general phenomenon, see M. Taylor, Judging policy: Courts and policy reform in democratic Brazil (Stanford, CA: Stanford University Press, 2008).
25. For a recent comparative study of countries in Africa, Asia, and Latin America with data on compliance with court orders, see D. M. Brinks and V. Gauri, "A new policy landscape: Legalizing social and economic rights in the developing world," in Gauri and Brinks (see note 19).
26. See F. Vieira and P. Zucchi, "Distorções causadas pelas ações judiciais à política de medicamentos no Brasil" ("Distortions to national drug policy caused by lawsuits in Brazil"), Revista de Saúde Pública 41/2 (2007), pp. 214-222, and Messeder et al. (see note 17).
27. A. Sen, "Why health equity?" in S. Anand, F. Peter, and A. Sen (eds), Public health, ethics, and equity (Oxford: Oxford University Press, 2006), p. 25.
28. T. Pogge, "Relational conceptions of justice: Responsibility for health outcomes," in Anand et al. (see note 26), pp. 135-161, at p. 135.
29. A. Sen, "Why health equity?" in S. Anand, F. Peter, and A. Sen (eds), Public health, ethics, and equity (Oxford: Oxford University Press, 2006), p. 25.
30. As cited in N. Daniels, Just health: Meeting health needs fairly (New York: Cambridge University Press, 2008), p. 89.
31. See, for this argument, R. Arneson, "Egalitarian justice versus the right to privacy," Social Philosophy and Policy 17/2 (2000), pp. 91-119.
32. A. Sen, "Why health equity?" in S. Anand, F. Peter, and A. Sen (eds), Public health, ethics, and equity (Oxford: Oxford University Press, 2006), p. 25.
33. Ibid. See also M. Barreto and R. Aquino, "Recent positive developments in the Brazilian health system," American Journal of Public Health 99/1 (2009), p. 8.
34. For the idea of transformative constitutionalism, see S. Liebenberg, Needs, rights, and transformation: Adjudicating social rights, NYU Center for Human Rights and Global Justice Working Paper 8 (New York: New York University, 2005). Available at http://www.chrgj.org/publications/docs/wp/Liebenberg%20-%20Needs,%20Rights%20and%20Transformation.pdf.
35. Brazilian 1988 Constitution, English version, from the Political Database of the Americas, Center for Latin American Studies, Georgetown University, November 2008. Available at http://pdba.georgetown.edu/Constitutions/Brazil/english96.html#mozTocId339966.
36. As cited in N. Daniels, Just health: Meeting health needs fairly (New York: Cambridge University Press, 2008), p. 89.
37. J. Galvao, "Brazil and access to HIV/AIDS drugs: A question of human rights and public health," American Journal of Public Health 95/7 (2005), pp. 1110-1116.
38. P. Mazenotti, "Programa DST/Aids usou quase todos os recursos previstos para 2005, diz diretor" (January 5, 2006). Available at http://www.direitos.org.br/index.php?option=com_content&task=view&id=753&Itemid=1.
39. R. Aquino, N. de Oliveira, and M. Barreto, "Impact of the Family Health Program on infant mortality in Brazilian municipalities," American Journal of Public Health 99/1 (2009), pp. 87-93; for the costs and population served, see National Commission on Social Determinants of Health (see note 5), p. 67.
40. P. Lotufo, "Coffee, samba, football and... inequalities: Reflections on mortality in São Paulo, Brazil," São Paulo Medical Journal/Revista Paulista de Medicina 119/3/9 (2001), pp. 4-6. Available at http://www.scielo.br/scielo.php?pid=S1516-31802001000300001&script=sci_arttext
41. M. Drumond and M. Barros, "Desigualdades socioespaciais na mortalidade do adulto no Município de São Paulo/Social inequalities in adult mortality in the City of S. Paulo," Revista Brasileira de Epidemiologia 2/1-2 (1999), pp. 34-49. Available at http://www.scielo.br/pdf/rbepid/v2n1-2/04.pdf.
42. R. Aquino, N. de Oliveira, and M. Barreto, "Impact of the Family Health Program on infant mortality in Brazilian municipalities," American Journal of Public Health 99/1 (2009), pp. 87-93; for the costs and population served, see National Commission on Social Determinants of Health (see note 5), p. 67.
43. Additional conditions should also be present. The health benefits claimed in court would have to be of a kind that effectively diminish health inequities (for example, primary attention and social determinants), and the resources to fund these benefits would have to either come from additional investment in health or be diverted from health programs that benefit higher socioeconomic groups, such as the fourth and fifth quintiles of income. There is some indication that neither of these conditions applies, but this will not be discussed in any length here given that the first necessary condition (that is, the socioeconomic profile of litigants), for which there is stronger evidence as discussed in the text, does not apply.
44. S. Gloppen "Litigation as a strategy to hold governments accountable for implementing the right to health," Health and Human Rights: An International Journal 10/2 (2009), pp. 28. Available at http://hhrjournal.org/index.php/hhr/article/view/79/164. Brinks and Gauri (see note 24), pp. 336-337.
45. Around 41 million Brazilians were covered by private health insurance at the end of 2008 (21.1% of the population), according to the official data of the Agência Nacional de Saúde Suplementar (ANS), the organization that regulates private health care in Brazil, available at http://www.ans.gov.br/portal/site/informacoesss/iss_dados_gerais.asp. Although some workers have their insurance funded by employers, very few of these individuals will likely be in the lower two quintiles of income, where most individuals are either unemployed, employed in the informal sector, or have very low-paid jobs that are unlikely to include private health insurance (see note 44).
46. Brazilian Institute of Geography and Statistics (IBGE), Síntese de Indicadores Sociais - 2007. Available at http://www.ibge.gov.br/home/presidencia/noticias/noticia_impressao.php?id_noticia=987; see especially Fig. 4.4.
47. This pattern was also found in S. Marques and S. Dallari, "Garantia do direito social à assistência farmacêutica no Estado de São Paulo" ("Safeguarding of the social right to pharmaceutical assistance in the state of São Paulo, Brazil"), Revista de Saúde Pública 41/1 (2007), pp. 101-107.
48. F. Terrazas, O Poder Judiciário como voz institucional dos pobres: O caso das demandas judiciais por medicamentos, MPhil thesis (University of São Paulo, 2008).
49. A. Messeder, C. Osorio-de-Castro, and V. Luiza, "Mandados judiciais como ferramenta para garantia do acesso a medicamentos no setor público: A experiência do Estado do Rio de Janeiro, Brasil" ("Can court injunctions guarantee access to medicines in the public sector? The experience in the State of Rio de Janeiro, Brazil"), Cadernos de Saúde Pública 21/2 (2005), pp. 525-534.
50. By "public lawyers," I mean two different groups of lawyers paid by the state: defensores públicos ("public defenders"), whose duty is to represent claimants unable to afford private legal services, and promotores públicos ("public promoters"), whose duty is broader, including the defence of so-called public and diffuse interests, such as the environment, the economic order, and architectural heritage.
51. F. Hoffman and F. Bentes, "Accountability for social and economic rights in Brazil," in V. Gauri and D. M. Brinks (eds), Courting social justice: Judicial enforcement of social and economic rights in the developing world (Cambridge, UK: Cambridge University Press, 2008), pp. 112-113 and p. 142.
52. D. Wang, Poder Judiciário e participação democrática nas políticas públicas de saúde, MPhil thesis (University of São Paulo, 2009), p. 83.
53. The same was found by J. Sant'ana, Essencialidade e assistência farmacêutica: Um estudo exploratório das demandas judiciais individuais para acesso a medicamentos no estado do Rio de Janeiro, MPhil thesis (Fiocruz, 2009).
54. F. Hoffman and F. Bentes, "Accountability for social and economic rights in Brazil," in V. Gauri and D. M. Brinks (eds), Courting social justice: Judicial enforcement of social and economic rights in the developing world (Cambridge, UK: Cambridge University Press, 2008), pp. 113.
55. As has occurred in São Paulo during a brief period in which some lower court judges started to condition successful claims on the presentation of a public doctor's prescription; interview with Adriana Daidone, a private attorney in São Paulo who represents hundreds of individual claimants in right-to-health litigation (July 29, 2009).
56. A. Chieffi and R. Barata, "Judicialização da política pública de assistência farmacêutica e eqüidade" ("Judicialization of public health policy for distribution of medicines"), Cadernos de Saúde Pública 25/8 (2009), pp. 1839-1849.
57. See F. Vieira and P. Zucchi, "Distorções causadas pelas ações judiciais à política de medicamentos no Brasil" ("Distortions to national drug policy caused by lawsuits in Brazil"), Revista de Saúde Pública 41/2 (2007), pp. 214-222
58. A. Chieffi and R. Barata, "Judicialização da política pública de assistência farmacêutica e eqüidade" ("Judicialization of public health policy for distribution of medicines"), Cadernos de Saúde Pública 25/8 (2009), pp. 1839-1849.
59. F. Terrazas, O Poder Judiciário como voz institucional dos pobres: O caso das demandas judiciais por medicamentos, MPhil thesis (University of São Paulo, 2008).
60. In Terrazas's sample (see note 45), 25% had completed higher education, and 5.63% held postgraduate degrees. For data on the educational level of the population as a whole, see São Paulo State Government, Pesquisa Condicoes de Vida 2006 (São Paulo: Fundacao SEADE, 2006). Available at http://www.seade.gov.br/produtos/pcv/pdfs/escolaridade.pdf.
61. Brinks and Gauri (see note 24), pp. 336-337. They also suggest, very tentatively, that the indirect effects of litigation (for example, via changes in health policy) might have a higher potential to benefit less advantaged individuals. For the reasons mentioned in the main text, I am highly skeptical of this possibility.
62. Interview with Maria Cecilia Correa, public health expert in the São Paulo State Health Department, coordinator of the right-to-health litigation unit (CODES), (July 22, 2009).
63. D. Menchen, "SUS vacinarácontra pneumococo em 2010," Folha de S. Paulo (August 18, 2009).
64. D. Wang, Poder Judiciário e participação democrática nas políticas públicas de saúde, MPhil thesis (University of São Paulo, 2009), p. 83.
65. For this suggestion, see F. Hoffman and F. Bentes, "Accountability for social and economic rights in Brazil," in V. Gauri and D. M. Brinks (eds), Courting social justice: Judicial enforcement of social and economic rights in the developing world (Cambridge, UK: Cambridge University Press, 2008), pp. 145. They also discuss in their research the possible explanations for the insignificant number of such type of actions at present.