Doctorate – Pharmaceutical Care to Diabetes Mellitus Patients: Impact Evaluation of the “Pharmacia Popular” Program and Acess Through Healt Litigation
Advisor: Profa. Dra. Maria Dolores Montoya Diaz
Comission: Profs. Drs. Natália Pires de Vasconcelos, Fernando Antonio Slaibe Postali and Fernando Mussa Abujamra Aith
Link YouTube: https://youtu.be/CtYvHHk6QN8
The widespread access to the appropriate medication in the treatment of Diabetes Mellitus(DM) is essential to the reduction of complications and comorbidities, aiding in theimprovement of the patient’s health and life expectancy. In this thesis, I examine two ways that people who suffer from this chronic disease have of accessing theirmedication inBrazil: the Programa Federal Farmácia Popular (PFP—“Farmacia Popular” Program); and Health Litigation.
In the first part, I examine the impact of PFP on the municipal rates of internment and of death from DM, comorbidities and complications associated with this chronic disease, which has high and increasing prevalence around the world and particularly in developing countries, such as Brazil. In order to do so, I used two original databases established on data from the Health Ministry and Fiocruz, accessed by way of Lei de Acesso à Informação (LAI—Public Information Access Law), to implement a fixed effects with control variables model. The specification was implemented in order to remove the effects of other public health policies related to primary attention (among which is included DM), as well as demographic, epidemiological, economic, and social factors from the results. The results indicate that the program impacted the hospitalization rates in the 45 years or older population in the expected direction (reduction) of Diabetes Mellitus (−0, 056), Hypertensive Diseases (−0, 074), and Cardiac Insufficiency (−0, 111); concerning the mortality rates, there was an increase related to Hypertensive Diseases (−0, 012) and Cerebrovascular Diseases (−0, 018). Moreover, it was also possible to identify heterogeneous effects according to gender (greater impact on women), age (differential impact above 65 years old), region and municipality development profile (measured by MHDI). Finally, the results reveal that there was a lesser impact on cities with lesser development (MHDI < 0.5) and especially in the North region. This last point may be related to the greater concentration of PFP in certain regions, a result of the expansion of the accredited modality by free demand from private establishments. In the second part, I offer a detailed analysis of the access to medication through the health litigation by DM patients, based on the data obtained from the Sistema de Coordenação das Demandas Estratégicas do SUS (S-Codes—Coordination of SUS Strategic Demands System) in the State of São Paulo. According to the estimates presented herein, between 2011 and 2017, these demands increased at an annual rate of 26% per year and represented, in 2017, 25% of the total amount spent on the execution of judicial determinations in the State, with 52% of those concentrated in 10 cities. By comparing the total costs and the average costs per patient, it was also possible to verify that, in 2017, the judicial route attended roughly 0.1% of the total PFP patients, but cost roughly 12% of the total amount spent by the Federal government. According to a georeferencing analysis based on data from the ZIP code of the plaintiff and from the Índice Paulista de Vulnerabilidade Social (IPVS—Paulista Index of Social Vulnerability), the plaintiff profile reveals that only 15% of those are in a high vulnerability group (11% are in an average, 0.02% in a high rural, 2.7% in a high urban, and 0.9% in a very high urban vulnerability group). The judicialization is mainly driven by the demand for insulin analogs, which are, on average, 770% more expensive than the replacement available through SUS or PFP, and it generally includes, for the convenience of the patient, items that are freely available through public policies. In the majority of the cases, the place where the treatment is taking place is a private hospital/private doctor (64%) and the attorney is a public lawyer (80%), and, when taken together, we have that: (i) 53% of the motions are required by a private lawyer and a private doctor; (ii) 10% are required by a private doctor and a public lawyer; (iii) 9% are required by a public doctor and a public lawyer; and (iv) 19% are required by a public doctor and a private lawyer.
Furthermore, using original databases established on data from S-Codes (through LAI) and using as a control data from Datasus, Rais, and IBGE, I conducted two empirical analyses based on dichotomous choice probit nonlinear regression models. In the first analysis, I measured the variables associated with the probability of judicialization among DM patients at the city level. After applying robustness tests, it was possible to verify that there is a significant effect of the variables of access to SUS (negative), health care expenditure (negative), and doctor supply (positive). On the other hand, there was no significant effect of the proxy variable of access to the justice system, which was calculated by the total of private and public lawyers per capita, GDP per capita and the PFP. In the second analysis, I measured the main characteristics associated with the plaintiffs who seek access to the medication for DM treatment through free justice (public attorney).
According to the results, the judicial demand requested by a public lawyer, though it is a small part of the total amount, is positively associated with greater vulnerability plaintiffs and a local public hospital or UBS (SUS physician prescription).
*Abstract provided by the author