The health system’s bottlenecks, such as the shortage of medicines and the lack of specialists, are some of the factors that have motivated judicialization. According to research data ” Judicialization and Society: actions for access to quality public health“, published by the National Council of Justice (CNJ), the number of new cases has increased each year, with a total that exceeds 2.5 million cases between the years 2015 and 2020.
The survey is part of the action plan of the National Health Forum, which, together with the suggestions of the State Health Committees, will prepare a National Plan with indicators of improvements in the provision of health services and reduction of judicialization. Based on Justice data in Numbers, from the National Database of the Judiciary Branch (DataJud), from the Ministry of Health and in questionnaires answered by magistrates, courts and municipal and state health secretariats, the survey measures the health care network available in the country, as well as the judicialization of the sector.
The president of the CNJ, Minister Luiz Fux, emphasizes the importance of knowing the reality of Brazilian public health, so that the Judiciary can advance in public policies and mitigate the consequences of excessive judicialization of cases revealed by the survey. “This is fundamental for a better jurisdictional provision for the citizen and, at the same time, allows the Judiciary to collaborate, in whatever way possible, with the Executive Branch to realize the complete access to health, recommended by the Federal Constitution.”
The supervisor of the Executive Committee of the National Forum, councilor Candice Jobim, also reinforces that the idea is to map the functioning, structure and care in primary care to understand the interinstitutional dialogue between the justice system and public administration. “The national plan will be built with the participation of state and municipal managers who participate in the State Health Committees for the development of policies that are not just imposed by judicial decisions.”
The survey questionnaires were made available online and answered by adhesion. Among the 32 courts surveyed, 30 sent responses, reaching 1059 state and 184 federal magistrates. Twenty-one state health departments also participated (out of a total of 27). From a sample of 763 municipalities from all regions, defined based on a study by the Brazilian Institute of Geography and Statistics (IBGE) and considered the most influential places in the search for low, medium and high complexity health services, 30% (228 municipalities) participated in the study.
// Check out the full study Judicialização e Sociedade: actions for access to quality public health
The study allowed us to verify the impact of the pandemic on the provision of health services and also on judicialization in recent months. About health services, information was collected from the Outpatient Information System (SIA) of the SUS, which records the care provided in the outpatient health establishment, with information about the patient, the procedures performed and the health establishment. In 2019, the SIA registered about 368,000 outpatient procedures. In 2020, there was a drop of 41.9%.
This reduction in hospitalization permits and elective consultations in the SUS coincides with the pandemic period. The same was verified in relation to Authorizations for Hospital Admissions (AIH), which are classified into Basic Care, Medium Complexity and High Complexity procedures. Between January 2019 and October 2020, the SUS registered about 19.5 million AIH: 11.5 million in 2019 and 7.9 million in 2020, representing a decrease of 18.5%.
As highlighted in the research, “with the proliferation of the virus in different layers of the population throughout Brazil, public and private hospitals registered a high demand for the Covid-19 disease, having to provide physical space, beds, resources and professionals for care of this disease and refuse other cases due to lack of infrastructure. The reduction in the number of hospital admission permits for High and Medium Complexities in 2020 for other diseases seems to be influenced by the pandemic, since hospitalizations for treatment of infection by the new coronavirus increased in the period analyzed”.
The survey also pointed out the impact of the pandemic on judicialization. In the Federal Courts, the record of an increase in the number of cases in 2020 stands out. The regional federal courts (TRF) have 265,468 cases in the historical series (2015 to 2020). In 2015, there were 36,673 new cases, but in 2020 there were 58,744, which is the year with the highest incidence. In the period from 2015 to 2020, the TRF4, which covers the states of Rio Grande do Sul, Santa Catarina and Paraná, was the court with the most cases: a total of 93,402.
Of the approximately 2.5 million health-related lawsuits, a large part is concentrated in the State Court (2,250,733). In the state courts, in 2015, new cases totaled 322,395, but in 2019 there was an increase, reaching a total of 427,633 cases. Considering the entire historical series, from 2015 to 2019, the Courts of Justice with the highest number of new cases were in São Paulo (488,840), Minas Gerais (444,123) and Rio Grande do Sul (287,718).
Medicines and care
According to the study, ‘Medications’ and ‘Medical-Hospital Treatment’ are among the issues most demanded by the Judiciary. Responses from state and municipal health secretariats indicate that most have the Essential Medicines List (Rename and Renume), which are covered by the Unified Health System (SUS), but still suffer from a shortage of these medicines. “The shortage of drugs on the state list demonstrates a weakness in the provision and maintenance of supplies that would be the responsibility of the state itself”, warns the research report.
Possible causes include: high demand, poor resource management or lack of logistics. Bidding problems and the delay in supplying medication after authorization were also cited by respondents as causes of shortages in drug lists. These problems are present in more than 70% of state secretariats, and in 43% of municipal secretariats.
The lack of specialized professionals was also pointed out by the municipal and state health secretaries participating in the research as the second greatest difficulty in fulfilling the demanded actions. First, there is the lack of sufficient or unforeseen resources in the budget, which is also related to the purchase of medicines.
According to the survey, the most judicialized medical specialty is “Orthopedics and Traumatology”, followed by ophthalmology. According to data from the National Register of Health Establishments (CNES) of the Ministry of Health, until October 2020, Brazil had 3,101,793 health professionals in public and private health establishments affiliated with the Unified Health System (SUS). Cardiology, oncology and urology are also deficient specialties in the states. In the municipalities, psychiatry, cardiology and neurology are the most demanded areas.
According to the survey, “in addition to the difficulty of having an adequate contingent of professionals in the various locations of the country, which generates the demand for judicialization by the citizen who needs a medical specialty, there is also a context of heterogeneous structure in the regions of the country for various health services provided by federated entities”. For example, São Paulo has the highest rate of doctors per thousand inhabitants, with a ratio of five doctors per thousand inhabitants, while the state of Maranhão has the lowest rate: 1 doctor per thousand people.
The waiting time for care at SUS is one of the biggest concerns of those who use it. According to the responses from the health departments, about 60% of the states stated that the average time to carry out consultations in the specialties of orthopedics, ophthalmology and oncology is less than a month. Consultations with cardiologists can take up to six months. The same pattern was observed in the responses from the municipalities. The exception was for consultations with ophthalmologists and cardiologists, which take from 30 to 90 days.
Injunctions and decisions
With the help of data from DataJud in the period from 2015 to 2020, it is possible to have an insight into the movements of processes involving the theme of Health. The granting of injunctions is, on average, 80%, except for the theme “Health Plan “, which is below this index. ‘Mental Health and Hospitals’ and ‘Other Health Units/Admissions/ICU and ICU’ had the highest grant percentages, above 86%.
The origin rate also followed the pattern of high rates. For admission requests, for example, the percentage of deferrals in relation to new cases and tried cases is 84%, followed by medicines, which is 83%. Applications with the theme “health plans”, however, registered a percentage of 43% of acceptance.
The survey also records that the average time to judge the processes – from the first move until the sentence of the process – is 9 months in the State Court, and 10 months in the Federal scope.
In the first instance of the State Court, the average time until the first sentence of the process was, approximately, 12 months. The cases received and recognized by the Special Courts recorded an average time of the knowledge phase of around 8.5 months. In the second instance, in turn, the average trial time was 7.5 months.
In the Federal Court, the cases received in the first degree presented an average of 13 months from the first motion to the first sentence, while those in the second degree registered about 10.5 months. The Special Courts had an average time of 8 months until the first sentence. The first instance presents greater variability of trial time, around 8.5 months; while the Appeal Class does not reach 5 months.
Source: CNJ News Agency
Photo: Luiz Silveira/CNJ