Judicialization of health: lawsuits for access to medicines in Uruguaiana-RS

Introduction: In Brazil, the right to health has a constitutional and universal provision. However, the judicial route has been widely used to access health goods and services. Objective: To analyze the lawsuits of medicines filed by citizens of a Brazilian municipality. Methods: Quantitative and retrospective study evaluating 652 lawsuits filed in 2016 conducted in Uruguaiana, state of Rio Grande do Sul. The information was made available by the State Department of Health. Results: 55.5% of lawsuits filed were related to drugs provided by the public health system Sistema Único de Saúde (SUS). 44.5% did not fit into the guidelines of the Brazilian Policy for Pharmaceutical Services. Most of the lawsuits were filed by women over 60 years old. Regarding the therapeutic classification, the most requested drugs were for the nervous system. The most described pathological condition according to the ICD-10 (International Classification of Diseases) was Diabetes Mellitus. Conclusion: These data corroborate the situation found in other parts of the country, demonstrating the need to reorganize the Pharmaceutical Service Policy to ensure universal and equitable access to medicines, as described in the Federal Constitution.


INTRODUCTION
The Brazilian Federal Constitution of 1988 describe in its Article 6 the assurance of social rights for the Brazilian citizen as the guarantee of health care 1 . This right has its structure and organization defined in articles 196 to 200 of the Constitution. Integral Health care is a right of all and a duty of the state, which must generate social and economic policies to ensure universal and equal access 1 . The right to Pharmaceutical Services (PS) is part of this context and should also be understood as such, since it is part of comprehensive health care as described in the Organic Health Law 2 .
PS Policy involves a set of actions aimed at health promotion, protection and recovery for individuals and the public at large by considering drugs an essential ingredient and fostering their access and rational use [3][4][5] . Among the approaches to promote rational use and to enable the population to have access to these medicines is the use of the National List of Essential Medicines (NLEM). This instrument establishes the directory of drugs and pharmaceutical supplies within the scope of the Brazilian public health system Sistema Único de Saúde (SUS), elaborated to meet the fundamental principles Ziolkowski  Despite constitutional support, financial, administrative and managerial factors it is difficult to access to PS being fully met.
Therefore the judicial route is widely used to achieve adequate treatment 4,5 . The lawsuits for requesting medicines that are already on public lists (such as SLEM) are legitimate. There is a consensus that this is an exercise of the right to individual therapy assistance 6 practiced by the Brazilian citizen.
As other public policies, PS faces major difficulties that prevent the full implementation of its actions. Among them, extreme bureaucracy and discontinuity in the supply of inventory 7,8 can be cited. Therefore, the right to health care combined with the difficulty in access to medicines became the judicial path as an alternative to guarantee access to medicines and treatments by citizens, a phenomenon that is called Health Judicialization 7,9 .
Brazil had its first lawsuits in the early 1990s and they were essentially demands of patients with AIDS. Currently, the actions are quite diverse and for numerous pathologies 10 . In the context of lawsuits in the SUS, this is a space in which two logics collide: the jurist, which defends the guarantee of rights, and the economist, which seeks the macroeconomic balance. The Judiciary follows the first line, while the executive power approaches financial rationality 11 .
In the realization of the right to health, we have the decisive role of the legal and social institutions that work together and produce results of results in public health policies. Legal professionals are authorized to enforce the right to health, taking as an example the importance of medical and pharmaceutical knowledge in the composition of Technical Support Centers in the courts. In this sense, the recognition of the right to health has gone through medicalization, or what reveals a conflict of proximity between law and health in Brazil 12 . from the year 2016. Data was collected by trained staff using a pre-tested structured questionnaire.
The variables of interest were defined based on the "Manual -Indicators for evaluation and monitoring of drug lawsuits" organized by Pepe et al. 6

RESULTS
Altogether, 676 lawsuits registered in 2016, concerning 436 different patients, were analyzed. Of these processes, 24 were related to inputs: tapes for monitoring capillary glucose, food supplements and special diets, leaving 652 actions related to the supply of medicines.
The lawsuits were filed against the Rio Grande do Sul State Health Department and were essentially filed in the civil court, which constitutes the jurisdiction responsible for judging civil lawsuits. Of the 436 applicants over 54% were female and over 60 years of age.  (Table 1). In relation to the ATCC, classification recommended by the World Health Organization (WHO), the drugs were grouped according to the first classification level, which refers to the system in which the drug, in the specified indication, will act to achieve its effect (  (Tables 3 and 4).
In relation to actions that requested drugs listed in the Basic Component, of the 175 the most frequent requests were: carvedilol (6.29%), omeprazole (5.71%), levothyroxine sodium (5.14%), clonazepam (4.57%). As for the Specialized Component of the 172 judicial actions that included medications of this list, the combination of formoterol and budesonide (10%), clopidogrel (8.72%) and salmeterol associated with fluticasone (7.56%), were the ones that presented the highest incidence in the processes (

DISCUSSION
Of the 436 citizens who filed lawsuits, it was found that the majority were female (54.82%) corroborating with results found in Rio Grande do Sul (54%) and other studies 16,20,21 . In the Federal District, the incidence is even higher, corresponding to 70% of the judicial ations 22 . This data suggests by women's greater concern over health, which motivates them to seek the judiciary as a way of guaranteeing the supply of the medicine that has been prescribed to them 22 .
Regarding the age range of patients, prevalence in the range above 60 years was verified, with 54.1% of the judicial actions.
This result is consistent with the findings in the municipality of Santa Rosa in the same state (Rio Grande do Sul) 21 Table 1). The prevalence of pathologies found does not differ substantially from those observed in another study 6 which refers to chronic diseases, typical of a society that experiences the aging of the population.
When grouped according to the first classification level of ATCC, it is possible to observe a higher prevalence in the request of drugs that act on the Nervous System (25.31%), followed by digestive tract and metabolism (15.80%), cardiovascular (13.65%) and respiratory system (10.12%). Unlike the state of Rio de Janeiro, where studies indicated that the most frequent anatomic groups were the cardiovascular system followed by   The data of this work corroborate with the information that appears in the literature in relation to the reality found in the country, this demonstrates the importance of the technical support of professionals of the area, as for example, the pharmacist in the Judiciary when dealing with actions involving medicines and inputs 7,30,31 . In addition, it is of great importance to map out the judicialization of access to medicines in the country, since it is necessary to reorganize the PS to ensure the availability and supply of the medicines foreseen in the policies so that the judicial route is a means of access only for drugs that are not in the PS or that do not have therapeutic alternatives already available.
The data found in this article corroborate the situation found in other parts of the country, demonstrating the need to reorganize health policies to guarantee universal and equitable access to medicines, as described in the Federal Constitution. Thus, a better organization of pharmaceutical assistance, more simplified access to available services, periodic reviews of selected medicines and awareness of prescribers and members of the Judiciary about their importance in the rational use of medicines and better allocation of available resources, can contribute to reducing the judicial demand without compromising the constitutional right to health.

ACKNOWLEDGMENTS
We would like to thank the Health Department of Uruguaiana.