TheRighttoHealthintheCourtsofBrazil10yearson:

stillworseninghealthinequities?

(draft,25.6.2017)

OctavioLuizMottaFerraz

Index:I.Introduction p3II.SocialPolicyinBrazil’sconstitutionsandlegislation(1930stotoday) p7

II.1ConfrontingtheConstitutionwithSocialReality p13II.2Universalistconstitutionalrhetoric,selectivepolicypractice? p18

III.ABriefhistoryoftheJudicializationofHealthinBrazil p20 III.1Newdata:adifferentpictureinRioGrandedoSul? p28 III.1.aJudicializationfrombelow? p32 III.1.bMostlystatefailure? p34

IV.Movingthedebateforward p36Appendix-SocialrightsandtherighttohealthintheBrazilianConstitution p39

Abstract:TheBrazilianconstitutionof1988,adoptedthreeyearsaftertheendofthemilitary

dictatorship(1964-1985)isgenerousintherecognitionofhumanrights,bothoftheciviland

politicalandthesocialandeconomickinds(arts.5to15).Ithasalsostrengthenedsignificantly

the powers of the judicial branch, including in the chapter of fundamental rights and

guaranteesthat"nolawcanexcludefromtheconsiderationoftheJudiciaryaviolationora

threattoaright"(art.5,XXXV),specifyingaseriesofremediesfortheprotectionofrightsand

collectiveinterests(habeascorpus,LXVIII;writofmandamus,LXIX;actiopopularis,LXXIII)and

guaranteeinglegalaidforthoseincapableofaffordinglitigation(LXXIV).Inthespecificfield

ofsocialandeconomicrights,althoughtheinstrumentsoflitigationhavebeenavailablesince

at least the 1988 constitution, the prevalent jurisprudence considered these rights as

"programmaticnorms",i.e.notamenabletodirectjudicialenforcement,foraboutadecade.

Thismoredeferentialapproachwashowevergraduallyreplacedbyamoreassertiveonethat

finallyconsolidatedintotheviewthatsocialandeconomicrights,asconstitutionalnorms,are

justasenforceableascivilandpoliticalones.Thisledtoagrowthinlitigationinthefieldsof

healthandeducation,andtoalesserextentinotherrightssuchashousing(includingonlyin

a2000amendment)and theminimumwage. In the fieldofhealth,onecan talkofa real

explosionoflitigationwhereclaimantssoughtthroughthejudiciary,byandlargesuccessfully,

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theprovisionofawiderangeofmedicaltreatmentsandgoods,thatcametobeknownasthe

"judicializationofhealth".AccordingthethemostrecentestimationbytheBrazilianNational

CouncilofJustice,thereweremorethan400thousandcasesinthecourtsin2013,spread

acrossBrazilbutconcentratedmostlyinafewstatesintherichersouthandsoutheastofthe

country.In2009and2011Ipublishedtwostudiesofthejudicializationofhealthwiththedata

availableatthetimeandcametotheconclusion,tentativebutinmyviewplausible,thatthe

judicialization of health in Brazil was likely worsening the already pronounced health

inequitiesofthecountry.Almost10yearson,Irevisitthatconclusiontoseeifthingshave

changed.Thisisinmyviewwarrantedforacombinationofreasons.Firstly,becausedespite

attempts to manage the problem of judicialization, it has only gotten worse in the past

decade,withmoststatesandmunicipalitiesacrossthecountryreportingasteeprisebothin

volumeof litigationandinexpenditurewith litigation.Secondly,becausesinceIpublished

thestudiesmentionedseveralnewandinterestingoneshaveappearedthrowingmorelight

ontheissueandallowingforamorecomprehensiveanalysis.Lastbutnotleast,becauseone

ofthesestudieshasdirectlychallengedmyconclusionclaimingthat judicialization"largely

servesthedisadvantaged", i.e."lowincomeplaintiffs includingtheverypoor".Ifthiswere

correct, we would be able to celebrate the judicialization of health in Brazil as a

transformativetoolintheserviceofthevulnerable.Unfortunately,asIargueinthispaper,

thisisnotwhatthenewandinterestingdataallowsustoconclude,notevententatively.This

isnotonlybecausethedataisnotcomprehensiveenough(arecurrentprobleminempirical

research,especially indevelopingcountries)butalsobecause theavailabledatadoesnot

allow such conclusions. In the concluding session I indicate what kind of data would be

needed,andwhatthedatawouldneedtoshowtojustifythatmoreauspiciousconclusion.

Thatmaybealsoused,Ihope,asaninspirationalguidetowhatwemightcallprogressive

judicialization.

3

I.Introduction

“Brazilisnotapoorcountry,butacountrywithalotofpoor.”1Thisstatementwasmadein

anarticlepublishedintheyear2.000bythreeleadingresearchersofinequalityinBrazil.Their

mainaimwastoshowthataswellastofocusoneconomicdevelopment,Brazilwouldneed

toimplementredistributivepoliciesifitwastosucceedinreducingpovertysignificantlyand

sustainably.Atthatjuncture,povertyremainedstubbornlyhighabove30%ofthepopulation,

affectingsome50millionpeople,andkeptgoingupanddownintheprecedingtwodecades,

fluctuatingbetween28%and45%dependingonthestateoftheeconomy.2Giventhat,as

theyalsoshowedinthearticle,Brazilwasnotapoorcountry,therewasplentyofscopeto

add redistribution to economic growth as away of bringing poverty down to acceptable

levels.

Moveforwardto2013(justbeforetheeconomiccrisishithard),andthesituationhad

significantlyimproved.Povertywasdownto9%ofthepopulation,3anditisundisputedthat

thishasbeenachievednotonlybyeconomicgrowthbutalsoredistributivepoliciesadopted

since the early 2000s, in particular the recurrent rises of the legalminimumwage above

inflationandotherprogressive socialpolicies fundedby taxation, inparticular conditional

cashtransfers(ProgramaBolsaFamilia)andnon-conditionalonesreceivedbythoseunable

to work due to disability or old age (Beneficio de Prestacao Continuada - “BCP”).4 The

followinggraphshowstheprogressinBrazilintermsoftheIndexofHumanDevelopmentof

theUnitedNations,whichcombinesindicatorsonincome,healthandeducation.

(includegraphhere)

1“OBrasilnãoéumpaíspobre,masumpaíscommuitospobres.”Barrosetal(2000).DesigualdadeePobrezanoBrasil:retratodeumarealidadeinaceitável.RBCSVol.15no42fevereiro/20002idem.Theactualfigureswere:39,6%in1977;reachingthehighestpointof51%in1983;goingdownto28,2%in1986;goingupagainto45,3%in1988andthenfallingto33,9in1995andfurtherto33%in1998(50millionpeople).39,6%ifonetakestheWorldBankUS$3,30threshold,or8,9%ifonetakesthelowernationalthreshold.http://data.worldbank.org/indicator/SI.POV.NAHC/countries/BR?display=graph4Thishasbeen,ofcourse,atrendinallofSouthAmericasincethe2000.http://www.theguardian.com/news/datablog/2015/mar/27/income-inequality-rising-falling-worlds-richest-poorest

4

Thereisundoubtedlyalottocelebrate,andtheelectoralsuccessoftheBrazilianWorkers

Party(PT)in4consecutiveelectionssolidlygroundedonthevoteofthepoorestinsociety

(broughttoanendbyanquestionableimpeachmentprocess)5,isevidencethatthesepolicies

have indeed benefited the needy. It is however important to put this improvement in

perspective to see the remaining difficulties and perils of retrogression that undoubtedly

exist. Brazil still way behind in its constitutional promises of social improvement, which

started as far back as the 1930s and culminated with the current 1988 comprehensive

constitutionalsocialprotectionsystem.Evenintermsofpovertytheabsolutenumbersare

still staggering, at around 20 million people in 2014, and projected to get worse if the

economic crisis persists, as it seems likely to be the case.6 As regards inequality, despite

celebrateddecreasesinthepastcoupleofdecades,thebasewassohighthatBrazilremained

oneof themostunequalcountries in theworld.Moreover,somebegin toquestion if the

decreasewasrealorartificiallygeneratedbyincompletedata.7

Moreover,thestrongandcelebratedfocusplacedonso-calledtargetedanti-poverty

policies in the recentdecadeshasnotbeenaccompaniedbyanequalenthusiasm for the

universalonespromisedintheconstitution,suchaseducationandhealthservices,where,

arguably,therealtransformativeimpactresides.AsstarklyputbyLenaLavinasinaninsightful

articleonwhatshecalls“21stCenturyWelfare”inLatinAmerica:

“Thedynamicofprivatizationhasbeenboosted,andtheconceptofuniversality in

socialprovisionundermined.Athirdof theadultBrazilianpopulationbelieves that

publicservicesshouldbelimitedtothedestitute,andthereforenarrowedinscope

andquality;althoughalargemajority—75percent—supportssomeredistributionin

favourofthepoor,theydosoonlyifitistiedtoconditionalitiesandcontrols,with

5seeOctavioFerraz,“Acoupd’etatinBrazil?”,Prospect,May272016,https://www.prospectmagazine.co.uk/world/brazil-rousseff-impeachment-legitimate-legal6https://nacoesunidas.org/numero-de-pobres-no-brasil-tera-aumento-de-no-minimo-25-milhoes-em-2017-aponta-banco-mundial/7MarceloMedeiros,PedroSouzaeFabioCastro.“TheUpperTipofIncomeDistributioninBrazil:FirstEstimateswithIncomeDataandaComparisonwithHouseholdSurveys(2006-2012)”,DADOS–RevistadeCiênciasSociais,RiodeJaneiro,vol.58,no1,2015,pp.7a36,claiming,basedonthefirstestimateoftheconcentrationofincomeamongtherichestinBrazilcalculatedbasedonincometaxreturnstatementsratherthanhouseholdsurveysthattendtosub-estimatetheincomeoftherichestthat“…incomedatarevealsconcentrationatthetopthatissubstantiallygreaterthanothersourcesand,ingeneralterms,remainedstableintheperiodanalyzed.”

5

non-compliance bringing loss of benefits. The link between social provision and

selectivityhasbecomestrong,astheideaofuniversalrightstodecommodifiedpublic

serviceswanes.”8

Thefrustration(borderingonirony),atleastforsociallymindedlawyers,isthatthe

flagship,widelycelebratedanti-povertysocialpolicyofthepastdecadesandtheonethatno

political party of whatever hue now dares to scrap, the Bolsa Familia, necessary but

insufficient,isnotevenamongthesocialrightsrecognizedinthegenerous1988constitution.

Onehastheawkward,somewhatparadoxicalsituation,thus,ofnotbeingabletoresortto

theconstitutionintheeventofanattemptbyaconservativegovernmenttoscrapit,butalso

notneedingtodoit(assucheventseemspoliticallyunlikelynow),whereas,asregardsall

other social, universal rights guaranteed by the constitution, although that legal avenue

remainswideopen (forhow long though?),andextremelynecessarygiven theneglectof

thoserights, it isseeminglyineffective,whennotpernicious,assomestudieshaveshown,

particularlyasregardsthesocialrighttohealth.

Itiswithinsuchcontextthatweoughttoinsertanydiscussionoftheimpactofsocial

rightslitigationintheactualenjoymentofsocialrightsbythepopulationinBrazil.Acontext

ofdiminishingbutpersistentpoverty,diminishingbutstubbornlyhighinequality,andarecent

historyofmuchgreaterenthusiasmfortargetedasopposedtouniversalsocialpolicies.

InthispaperIfocusonthefieldofrighttohealthlitigationas,inthepastcoupleof

decades, it has achieved significant proportions in terms of both volume and budgetary

impact,aswellasgivenrisetoafierceandpolarizeddebatebetweenwhatwecouldcalla

proandanantijudicializationcamp.SofarIhavetendedtosidewiththeantijudicialization

group,notduetoaprincipledobjectiontotheinvolvementofjudgeswithsocialpolicies9,but

ratherduetothenegativeempiricaleffects(actualandpotential) Iperceiveanalyzingthe

available, albeit incomplete and fragmented data on the issue. From the studies so far

conducted I think there isenoughevidence tomakeone“juriskeptical” (touseGauriand

8LenaLavinas,21stCenturyWelfare,TheNewLeftReview,84,Dec2013,https://newleftreview.org/II/84/lena-lavinas-21st-century-welfare,seealsoLenaLavinas,BarbaraCoboetal.,MedindooGraudeAversãoàDesigualdadedaPopulaçãoBrasileira—umsurveynacional,mimeo,November2012,p.137.9ForalongerdiscussionofmyviewonthisseeOctavioFerraz,“HarmingthePoorthroughSocialRightsLitigation”,TexasLawReview,Issue7ofVolume89,2011

6

Brinksterminology)10,i.e.atleastverycautiousofhailingjudicializationasanunquestionably

benignpracticewithnonegativeconsequencestoworryabout.Ifthedatachanged,however,

Iwould bemore than happy to also changemy opinion, in genuine Keynesian fashion.11

Despitebeingcurrently sceptical in theBraziliancase, Iamnotsceptical ingeneralof the

potentialtransformativeeffectoflitigationwhentheconditionsarepropitious.12

Itwaswith great curiosity and expectation, thus, that Iwelcomeda recent article

publishedintheprestigiousHealthandHumanRightsJournaloftheHarvardPublicHealth

School claiming that the anti judicialization conclusionswere all butmyths, and that the

judicializationofhealthinBrazilisactuallyaprocess“frombelow”,that“largelyservesthe

disadvantagedwhoturntothecourts…”13.Now,thisisaverystrongassertion,evenstronger

thantheusualpronouncementsoftheprojudicializationcamp.14Moreover,itismadeinthe

context of an empirical study carried out by reputable and well resourced academics. It

certainlymeritsthereforeverycloseconsiderationand,ifwarranted,alsoachangeinopinion.

Thepaperproceedsasfollows.Itstartsbysettingoutthelegalframeworkinwhich

healthisinsertedinBrazilandthroughwhichitisclaimedasamatterofright.Tounderstand

it,itisuseful,Ithink,tohaveabriefideaoftheincrementalexpansionandconsolidationof

socialrightsingeneralintheBrazilianconstitutionallandscapeandtheiractualenjoymentby

thepopulationontheground(sectionII),followedbyabriefhistoryofthejudicializationof

healthunderthecurrent1988constitution(sectionIII).Withthatinplace,thepapermoves

ontoanalysetheavailabledataontheimpactoflitigationintheactualenjoymentoftheright

tohealthbythepopulationandwhatconclusions,eveniftentative,canbedrawnfromthat

data,includingthemostrecentstudyreferredtointhepreviousparagraph(sectionIV).The

overallconclusionisthatmuchmoredatathatwecurrentlyhavewouldbeneededtoenable

10DanielBrinksandVarunGauri.“Law’sMajesticEquality?DistributiveImpactofLitigatingSocialandEconomicRights”,WorldBank,2012,PolicyResearchWorkingPaper599911Astheanecdotegoes,JohnMaynardKeynesissupposedlysaid:“Whenthefactschange,Ichangemymind.Whatdoyoudo,sir?”.Avariationwasactuallysaidbyanotherfamouseconomist,NobelLaureatePaulSamuelson:“Whenmyinformationchanges,Ialtermyconclusions.”SeeJohnKay,FT4.8.2915,“Keyneswashalfrightaboutthefacts”https://www.ft.com/content/96a620a8-3a8d-11e5-bbd1-b37bc06f590c?mhq5j=e112ForimportantclassicstudiesthatdelvedintotheanalysisoftheseconditionsseeCharlesEpp,TheRightsRevolution,UniversityofChicagoPress,1998andStuartScheingold,ThePoliticsofRights,UniversityofMichiganPress,1984.13Biehletal.HealthandHumanRights,2016,at210.14SeeFlaviaPiovesan,inLangford…

7

us to go beyond tentative assertions yet, with the currently available data, no major

departurefromthejuriskepticalstanceiswarranted.SectionVconcludesbyindicatingwhat

ismissinginthedataandintheanalyticalframeworkcurrentlyavailableforamorerobust

conclusion to be reached on the vexed question of the transformative impact of right to

health litigation inBrazilandsketchingamodelofwhatoughttoberegardedprogressive

judicialization.

II.SocialPolicyinBrazil’sconstitutionsandlegislation(1930stotoday)

ItisgenerallyagreedthattheBrazilianwelfarestatehasstartedinearnestinthefirst

governmentofGetulioVargas,whichspanned15yearsfrom1930to1945.15Forthefirsttime

initshistoryBrazilwitnessednationalwelfarepolicies(beforethattherehadbeenalimited

andfragmentedexperiencewithCAPs-CaixadeAposentadoriaePensão-Retirementand

PensionsFundsinstitutedfordistinctsectorsofindustry-thefirstin1923fortheworkersof

theRailways).Evenbeforethe1934constitutionsomemeasuresprotectingworkers’rights

wereintroducedbyVargasthroughdecree,suchasthe8hoursworkingdayandtheminimum

wageguarantee(Decreto19.398,11.11.1930).

ButtheConstitutionof1934,stronglyinspiredbytheWeimarConstitutionof1919,

gavethesepoliciesthehighestpossiblelegalstatus.Itwassupposedtoleavebehind40years

of“coronelismo”(rulebypowerfullocallandowners)thatmarkedthehistoryoftheBrazilian

Republic till then), instituting democratic principles of power alternation, secret vote

(extendedforthefirsttimetowomen)andtheimpossibilityofreelectionofpresidentGetulio

Vargas,whohadgainedpower in1930 throughamilitary coup thatdeposed theelected

president.Inthesocialarena,itisthefirsttoincludean“Economicandsocialorder”chapter,

restricting the right to private property and allowing state intervention in the economy,

changing thus the liberal model of the 1891 constitution, inspired in the American

constitution. Italsocontainedseveral specific socialclauses. Inarticle10, it set thebroad

competenceofthefederalunionandthestatesto“lookafterhealthandpublicassistance”

15Althoughsomeincipientrootswerealreadyinplacesincethe1824ImperialConstitution,suchasfreeprimaryeducation(1-4grade),socialandhealthassistancetotheneedyandcharitablehousestotheorphansandabandoned.(XXXI,XXXIIandXXXIII).

8

(10,II);“overseetheapplicationofsociallegislation”(V);“extendpubliceducationinallits

levels”(VI).Inlaterarticlesitguaranteesthe“rightsofallBraziliansandresidentforeigners

to liberty,subsistence, individualsecurityandproperty” (art.113);authorises thestateto

interveneintheeconomythroughmonopolisationofactivities(116);promotionofpopular

economy and nationalisation of banks (117); control of private use and progressive

nationalisationofwaterfalls,mineralandotherresourcesfoundunderground(118/19);and

allotherservicesnecessarytoimplementthenewsocio-economicorder(.)...Itwasalsoset

asadutyofthestatetofacilitatea“dignifiedexistence”toeveryone(art.115).

Art.121containsalonglistofworkers’rights,whichgainthusconstitutionalstatus

andareplacedbeyondthediscretionoftheordinarylegislator.Specificcourtsarecreatedto

enforcetheserights(art.122,JustiçadoTrabalho).Socialassistancetotheneedy(art.138),

protection tomaternity and children (141), education (149, 150 and 151), all also gained

constitutional status, as well as a right to sanitary assistance in hospitals and through

preventivemedicine(art.165,XV).Complementingthepowerofthestatetointerveneinthe

markets, art. 160 declares “the social function of property” and authorises the state to

expropriateitwithjustcompensation,thatcanbepaidvia“titlesofpublicdebt”(art.161,

para16).

Butthisgenerouslysocialconstitutionwastolastonlyacoupleofyears,asalreadyin

the end of 1935 Getulio Vargas suspended all rights of political participation on alleged

groundsofcommunistthreatstotheBrazilianstate,andpromulgatedanewauthoritarian

constitution(The“Polaca”,asitwasstronglyinfluencedbythePolishconstitution),whichwas

torestricttherighttostrikeandputalltradeunionsunderthesupervisionandcontrolofthe

MinistryofWork,lastingtilltheendofhisdictatorshipin1945.Manyofthesocialprotections

survivedinordinarylegislationthough,andVargasisstillpraisedtodayasthe“Fatherofthe

Poor”, and his Consolidate Laws of Work (Consolidação das Leis do Trabalho - “CLT”)

promulgatedin1943survivetothisday,despiteconstantattackbybusinessgroups.

Thenewconstitutionof1946reenactedthedemocraticprinciplessuspendedduring

theVargasdictatorshipandincorporatedseveralnewsocialrights(establishingsocialjustice

9

andpromotionofworkasthegroundsoftheBraziliansocialandeconomicorder).16Butit

wasagaintobeinterruptedbyanotherauthoritarianspellwhichlastedfrom1964till1985,

duringwhichanotherauthoritarianconstitutionwasenacted,in1967.17

Itwouldbewrongtoassume,however,thatduringthetwoauthoritarianperiodssocialrights

havebeentotallydisregarded.Onthecontrary,unlikecivilandpoliticalrights,whichhave

beenclearlyandsignificantlylimited(nottosaytotallysuspendedoreliminated),socialrights

haveactually improvedbothunderVargas (as alreadymentioned)andunder themilitary

regimeof1964-1985.Indeed,theconstitutionsof1967anditsextensiveamendmentin1969

includedalonglistofsocialclauses.Theybyandlargerepeated,oftenliterally,theclausesof

the 1934 and 1946 constitutions, but also extended them. Moreover, in terms of

constitutionalstatus,theseclausesareformulatedunambiguouslyasindividualrightsforthe

firsttime.InwhatisperhapsthefirstmonographonsocialrightsinBrazil,PauloLopoSaraiva

makes the following interesting comparison between provisions of the democratic

constitutionof1946andtheauthoritarianconstitutionof1967:

1946Constitution:art.157:“Labourandsociallegislationshallabidebythefollowing

precepts,aswellasothersthataimattheimprovementofworkersconditions.”

1967Constitution:“Theconstitutionguaranteestotheworkersthefollowingrights,

aswellasothersthat,throughlegislation,aimattheimprovementofworkers’social

conditions”.

Asitcanbereadilyseen,therewasaturnfromthediscourseofprinciplesoflegislation

(“directive principles”) to that of individual rights. The authoritarian constitutionof 1967,

repeatedlyamendedafter1969,wasthereforethefirsttorecognisesocialrightsasindividual

guarantees.Buttheyweremoreorlessrestrictedtowhattodaywewouldregardasamere

16LabourRights:Art.157,I,IV,IX,X,XI,XV,XVIIandeducationrightsArts.158e159,withaninterestinginnovationimposingoncompanieswithmorethan100employeesthedutytoprovidefreeprimaryeducationforworkersandtheirchildren.(Art.166,II,III,IV)AlsonoteworthywasArt.147,institutingtheso-calledsocialfunctionofpropertyanditsjustdistributionwithequalopportunityforall.17Anevenmoreauthoritariansetofruleswasimplementedthroughseveralso-calledInstitutionalActs(AtosInstitucionais)andthennolessthan27amendmentstotheconstitution,thefirstofwhich,in1969,incorporatedintheconstitutionaltextall5AIsanditthereforeregardedbymanyasanotherconstitution.Themostinfamous,theAI5,declaredastateofemergencyandsuspendedHabeasCorpus.

10

sub-categoryofsocialrights,namelylabourorworkers’rights,withtheexceptionoftheright

to education and a limited right to “sanitary assistance” for the worker. That prompted

Saraiva to defend, innovatively for the time, the use of art. 153, para 36 of the 1967-69

Constitutionasameansofincorporatingnon-enumeratedsocialrights,inparticularrightto

work and a right to housing. Art. 153more or less repeated a formulation present in all

constitutions since thebeginningof theRepublic thatallowed for the recognitionofnon-

enumeratedrights:

“Theexpressspecificationofrightsandguarantees includedinthisConstitutiondo

notexcludeotherrightsandguaranteesimpliedintheregimeandintheprinciples

adoptedbytheConstitution.”

Saraiva’smain argumentwas that this article, in conjunctionwith art. 160,which

regulated the so- called Economic and Social Order, should be interpreted as logically

implying,alongsidetheextensivelistofworker’srightsofarticle165,alsoarighttodecent

housingandarighttowork(themissingsocialrightsoftheconstitution).Heemphasisedin

particular the proclaimed aim of the economic and social order to realise national

developmentand social justice, aswell as theprincipleof “expansionofproductivework

opportunities”.18

Themererecognitionoftheseadditionalrights,however,evenifaccepted,wasnot

sufficient, as the 1967-69 constitution, despite its more assertive social rights language,

remained, as all previous constitutions, largely rhetorical in terms of the effectiveness of

social rights. The following commentary on the Constitutions of 1934 and 1946 by a

contemporaneousacademicillustrateswellthepoint:

“Thespiritisthesameandtheinefficacyofthepromisedsocialmeasuresidentical.

Allispromised,butonlyinthosearticleswithoutexecutiveforce,whichworksimply

as vagueaspirations and that, in reality, donot gobeyondmere aphorisms,mere

18Art.160.Theeconomicandsocialorderhasasitsaimtherealizationofnationaldevelopmentandsocialjustice,groundedonthefollowingprinciples:I-freeinitiative(“freemarkets”);II-valuingofworkasaconditionofhumandignity;III-socialfunctionofproperty;IV-harmonyandsolidaritybetweenthesocialcategoriesofproduction;V-repressionofabuseofeconomicpower,definedasdominationofmarkets,eliminationofcompetitionandarbitraryraiseofprofits;andVI-expansionofopportunitiesforproductivework.

11

common sense phrases, but entirely lacking legal protection to make them

executable.”19

ThatwasexactlythecomplaintofSaraivaagainstthe1967-69constitution.Itmade

nodifference,therefore,whethertheconstitutionhadbeenpromulgatedbyademocratic

assembly,asin1934and1946,orenactedbyanauthoritarianregime,asin1967,orwhich

kind of language it adopted (directive principles or individual rights). The lack of

correspondencebetweentheconstitutionalnormsandreality,andthelackofeneffective

mechanism of implementation,was exactly the same. Thiswas in part due to the socio-

economic reality of the country, back then still a developing one, but also to the regime

adoptedinrespectoftheapplicabilityofsocialrightsnorms.Itwasunanimouslyaccepted,

then,thatthesewereconstitutionalnormsoflimitedefficacy,so-calledprogrammaticnorms,

dependingsolelyonthediscretionofthelegislatortobefullyimplemented.

Thisunderstandingwouldpartlysurvivethepromulgationofthecurrentconstitution,

of 1988, which not only reintroduced the democratic regime in Brazil through the re-

establishmentofallcivilandpoliticalrights,butalsoincludedacomprehensivelistofsocial

andeconomicones.Foritsfirsttenyearsorso,theprogrammaticnormapproachremained

prevalent.ButgraduallytheBrazilianjudiciaryabandonedthismoredeferentialapproachand

startedtointerferemoreassertivelyinsocialpolicyareas,especiallyhealthandeducation,

orderingtheBrazilianstatetoprovidethousandsofindividualswithmedicaltreatmentand

schoolplaces(inparticularinpre-schools),movingthusfromtheviewoftheconstitutional

norms as merely “programmatic” to one that sees them as giving rise to immediately

claimableindividualrights(direitospúblicossubjetivos).20

19Oespíritoéomesmoeainocuidadedasmedidassociaisprometidaséidêntica.Prometem-semundosefundos,mastão-sónaquelesartigossemforçamandamental,quefuncionamapenascomovagaaspiraçãoeque,naverdade,nãopassamdemerosaforismos,merasfrasesdebomsenso,masinteiramentedesprotegidasdeprovidênciaslegaisquelhesdêemexecução”.FábioLucas,apudJoséAfonsodaSilva,Curso,p.133.20Whatstillsurvives,though,isarhetoricofseparationofpowers,inwhichtheJudiciaryacceptsthatitsroleisnottogovernthecountryorsetpublicpolicies,butonlytomakesure,incasesofclearviolationoftheConstitution,thatitsnormsarerespectedbythepoliticalpowers.ButitishardtofindcoherenceintheimplementationofthisprincipleinthebodyofJurisprudenceonsocialrights.InarecentstudyofsocialrightsdecisionattheSupremeFederalTribunal,itwasfoundthatdifferentjudgestakeamoreorlessdeferentialapproachvisavisthepoliticalpowers,notexplainedbyanyobjectivecharacteristicofthecasebeingdecided.seeFerraz"BetweenActivismandDeference:SocialrightsadjudicationintheBrazilianSupremeFederalTribunal",inAlviar,H.,L.WilliamsandK.Klare(eds)Social&EconomicRightsinTheoryandPractice:Acritical

12

Intermsofitscontent,the“CitizenConstitution”asitisoftencalled,adoptedafter

theendofthemilitaryregime,includesamongthetraditionalbillofcivilandpoliticalrights

andguarantees,acomprehensive listof socialandeconomic rights,muchwider thanany

previousconstitution,includingtherightstohealth,housing,education,work,leisure,social

securityandassistancetotheneedy(art.6),aswellasthetraditional (thoughalso longer

now)listofworkers’rights,presentasdirectiveprinciplessincethe1934constitutionandas

individual rights since the 1967 one. Moreover, it also establishes in great detail which

policies,andofwhatnature,arerequiredfromthestatetoimplementtheserights,through

anentiresectionoftheconstitution,titled“TheSocialOrder”,andcomprisingnolessthan

40articles.Theinauguralarticle,193,startsbystatingthat“thesocialorderhasasitsground

theprimacyofwork,andasitsgoalswelfareandsocialjustice”.Itfollowsbystatingthatsocial

securityshouldguaranteetherights relatedtohealth,pensionsandsocialassistance (art.

194),whoseaimsare“universalcoverageanddelivery”(194,I);“uniformityandequivalence

of benefits and services between the urban and rural population” (II); “selectivity and

distributivityintheprovisionofbenefitsandservices”(III);non-diminutionofbenefits(IV);

equityinparticipationandfunding(V);diversityinthefundingbasis(VI);anddemocraticand

decentralisedadministration(VII,includedviaEC20/1998).21

Animportantdifferencebetweenthepensionsystem,healthandsocialassistanceis

inthemeaningofuniversalityineachofthem.Whereashealthisuniversalinthebroadest

senseoftheterm,i.e.accessibletoallirrespectiveofpaymentoranyotherconditionbeyond

simpleregistrationinthehealthsystem,pensionsareuniversal“onconditionofcontribution”

andfulfilmentofspecificcontributioncriteria(periodofcontribution),andsocialassistance

universaland independentofcontribution,yetonconditionof fulfillingoneof theneeds’

criteriaestablishedintheconstitution,namelymaternity,infancy,adolescence,oldageand

disability.(art.203)Ofthose,however,onlyoldageanddisability,aswesawabove,have

been expressly contemplated in the constitutionwith a specific benefit of oneminimum

wage.Protectionofchildrenandadolescents,maternityandpromotionofintegrationinthe

jobmarketwereleftopen,whichexplainsperhapsitslesserpriorityinsocialpolicy.

Assessment,(2014,Routledge)21ThesewerefurtherspecifiedinLawNo8.212,of24.7.1991

13

Education, culture, sports, culture, sciencesand technology, social communication,

environment,family,children,adolescentsandelderly,andindigenouspeoplearetheother

threeareasofthesocialorder,regulatedinaseparatechapters(IIItoVIII).Education,like

health,isdefinedasarightofeveryoneandadutyofthestate(butalsothefamilyandin

collaborationwithsociety,art.205),andshouldbefreeinpublicinstitutionsfromtheageof

4to17.22Pre-school(fromzeroto5years)isalsoadutyofthestate(art.208,IV),although

notnecessarilyfree,althoughforworkers’childrenthishasbeenincludedviaconstitutional

amendment.23 Another important constitutional provision obliges all government units

(federal, state and municipal) to invest a minimum percentage of their tax income in

education(18%,25%and25%respectively).24Apotentialsourceofconstitutionalconflictis

theprovisionincludedinarticle227thatstatesthatchildrenandadolescentshave“absolute

priority” in the protection of their rights to “life, health, food, education, leisure,

professionalization,culture,dignity,respect,libertyandsocialandfamilialconviviality”.The

elderlyaregiven,intheconstitution,therighttofreetransportaftertheageof65(art.230,

para2).Theindigenouspeoplewereguaranteedtherighttooccupytheirancestrallandand

havethemdemarcated.(art.231and232).

II.1ConfrontingtheConstitutionwithSocialReality

Itmaynotbestrictlynecessarytoremindthisaudiencethattherealityontheground

isnotexactly the sameas thatpromised in the constitution, far from that.Although Ido

believethattheconstitutionalisationofsocialrightshasbeenapositiveforceinthesignificant

improvementinthesocio-economicconditionoftheBrazilianpopulationinthepasttwoand

halfdecades,itisnecessarytolookintotherealworldofsocialpolicytohaveanaccurate

graspoftheBrazilianactualsituation.25

Onthepositiveside,oneshouldnotethefactthatfrom1988to2008,thatis,inthe

22ThiswasanextensiondonebyAmendment59,of2009.Theoriginal1988constitutionstatedthateducationshouldbefreeatthefundamental(“primary”)level(art.208,I)andprogressivelyfreeatthesecondarylevel.23EC53/2006.art,7,XXV-freeassistancetothechildrenanddependentssincebirthtill5(five)yearsofageincrechesandpre-school.24Art.212.TheFederalgovernmentshallinvest,annually,neverlessthaneighteen,andtheStates,FederalDistrict,andmunicipalitiestwenty-fiveporcent,atleast,oftaxrevenue,includingthatoriginatingintransfers,inthemaintenanceofeducationdevelopment.25see,Ferraz.“TheBrazilian“SecondBillofRights”:acauseforcelebration?”E-Publica,RevistaEletronicadeDireitoPublico,Number3|SpecialIssue|December2014.

14

firsttwentyyearsofthecurrentconstitution,socialexpendituretriplicated,growingalmost

twiceasfastastheeconomyandthepopulation,overcomingthethresholdof20%ofGDPat

theendofthisperiodwhich,assomeclaim,istheminimumlimitbeyondwhichitisjustified

tocallastatetrulysocial.(Kerstenetzky,2012:211).Moreover,thissignificantgrowthhas

happened,itisworthemphasising,despitethepressuresoffiscalausterityandadjustment

thataccompaniedtheeconomiccrisesfacedinthisperiod.26Suchphenomenoncanbepartly

explained by the universalisation of the right to vote in the 1988 constitution, which

incorporatedtheilliterate,makingthepooraveragevoterforthefirsttime,butalsobythe

factthatthebulkofsocialexpendituregoestopensions,whosebeneficiariesconstituteawell

organisedandrelativelywell-informedconstituency.(moreonthislater).27

Aswehavealreadyseeninthefirstsection,thequalitativeimprovementsofthenew

constitutional order were the universalisation of pensions (extending access to the rural

sector),socialassistancetotheneedy,universalisationofprimaryandsecondaryeducation

andhealth,andestablishmentoftheminimumwageasthefloortoallconstitutionalbenefits,

allofwhichwasexpresslyspecifiedintheconstitution,oftenwithspecificpublicpoliciesto

beadoptedforitsimplementation(e.g.TheUnifiedHealthSystem,theBPC,thecriteriafor

pensions etc). The reality, however, shows a higher improvement in the field of targeted

transfers, in particular the non- constitutional CCT programme Bolsa Familia than in the

universalized(yetstillhighlydivided)servicesofhealthandeducation,whoseredistributive

potentialarearguablymuchhigher(moreonthislater).

Kerstenetzky proposes thus to call the current Brazilianwelfare system as one of

“extended universalism” in contrast to a real “redistributive universalism”, which nicely

capturestheimportantimprovementtowardsexpansionanduniversalisation,butalsothe

existingdisconnectbetweentheconstitutionaldreamandthecoldreality.Assheexplains,

“itisunquestionablethattheCardosoyearsbroughtsocialpoliciesandtherecognitionofthe

so-called‘socialdebt’totheforefrontofgovernmentattention”(227),evenifthepaymentof

thisdebtwasplaguedbyslowimprovementandsomeretrogressiontiedtoeconomiccycles.

26Itisworthrecalling,forinstance,thattheagreementwiththeIMFpromptedbythefinancialcrisesof1998and2003endedonlyin2005.27Kerstenetzkialsosuggeststhattheexpansionofsocialexpenditurehasapositiveeffectintheeconomywhichgeneratesa“virtuouscycle”,makingmoresocialexpenditurepossible.at212

15

The Cardoso period was marked by a “recalibragem” (recalibration) of existing policies,

throughtheconversionofuniversalsocialservicesintotargetedones(focusingattentionon

basiceducationandhealthfor instance)andthecreationoftargetedtransfers.Therewas

also a significant expansion in the assistance area, with the implementation of the

constitutionalBPC,and the settlementof600 thousand families throughagrarian reform.

Expenditureinhealthandeducation,however,didnotincreasemuch.Therewasalsosome

progress in the participation of civil society (with the creation of conselhos populares,

“citizens councils”), and better distribution of competences and resources, decentralising

themfromthefederalleveltothestateandmunicipalones.Yet,asawhole,theperiodis

markedby“limitedprogressinsocialservices,inattentiontostrategicinvestmentsuchaspre-

schooleducation,andverticalinequityinthepensionsystem”.(at228)

This is reflected in the small progress on poverty and inequality (idem). Gains in

primary school enrolment, which achieved virtual universality, were not accompanied by

improvementinthequalityofeducation,withBrazilrankinglastoralmostinthePIS/OCDE

testin2000and2003.Theaverageyearsofschoolingincreasedonlyoneyear,toashockingly

low6yearsamongBraziliansof25orless.AsKerstenetskyproperlyobserves,itisimpossible

toknowiftheselimitedimprovementswereallthatwaspossibleunderthedifficulteconomic

conditions,asnoalternativeeconomicpolicywastested,ofthesortthatthenextgovernment

was about to attempt. This period, which went from 1994 to 2002, i.e. social-democrat

presidentFernandoHenriqueCardosotwomandatesisevocativelycalledbyher“Citizenship

andAusterity”.

Thefollowingperiod,whichstartedin2003withtheelectionofLabourParty’sLulaas

presidentandisstillongoing(afterwinninganre-electionin2007,Lulawassucceededbyhis

colleagueDilmaRoussefin2011,whowasherselfre-electedin2015foramandateoffour

years), isnamedbyKerstenetsky“CitizenshipandProsperity”,as it is characterised inher

viewbyanaccelerationofeconomicgrowthbased ingreatmeasureon theexpansionof

socialpolicyandexpenditure,inparticular,again,transferprogrammes,butalsoanincrease

intheminimumwage,withanunprecedenteddecreaseinpovertyandinequality.

ThemostfamoustransferprogrammeofthisLabourEraistheBolsaFamilia“Family

Grant”.ItunifiedinasingleprogrammetheBolsaEscola(“SchoolGrant”)andthegas-aidof

16

thepreviousgovernment,andvirtuallydoubleditsscopeintermsofindividualsbenefited.

Theprogrammeprovidesincomecomplementationforindividualswhoseincomefallsbelow

adefinedthreshold(R$74,00,aroundUS$20,00asIwrite),but is limitedtofamilieswith

children, and is conditional on school attendance and visits to the doctor. But just as

significant,ifnotmore,wasthedecisiontosignificantlyincreasetheminimumwageabove

inflation,whichwasofficializedin2007inthePactfortheValorisationoftheMinimumWage

(indexing it to inflation and GDP growth). Contrary to some predictions, these constant

increaseshavefuelledmoreformalemploymentandraisedtheaverageearningsofworkers.

Kerstenetskyseesthisasasignificantshift towhatshecalls“economicallyorientedsocial

policies”,whichattempttogenerateavirtuouscyclethroughtheexpansionofconsumption

bythepoor.

Itisimportanttonote,however,thatevenduringanunprecedentedperiodofgrowth

andformalisationinemployment28,theinformalsector(whichisvirtuallyexcludedfromthe

pensionssystem),remainedat41,7%oftheemployedpopulation(downfrom45,9%)29,and

thatafter2009growthhasbeenslower,andhasturnedintoarecessionin2015,withfast

riseinunemploymentandpredictionsofacontractionof3%ofGDPthisyear,withfurtherif

lower contraction next year.30 Alongside these so-called “economically oriented social

policies”,therewerealsoseveral“sociallyorientedeconomicpolicies”,suchasthe“credito

consignado”(creditwhoserepaymentcomesstraightoffsalaries),thesubsidisedcredit(for

homesandagriculture), the loweringof interest ratesandthetaxexemption forcarsand

flower, several other targeted tax exemptions, simplified rules for small businesses, and

subsidisedenergytariffs.31

Butremainingdeficienciesinthesystemaremany.40%oftheeconomicallyactive

populationisstillwithnoformalsocialprotection,inparticularruralinformalworkers.There

28Thisworkedparticularlywellduringasustainedperiodof14consecutivequarters(3,5years)from2006-2009duringwhichthedomesticmarketrespondedfor60%oftheaggregatedemand,overcomingeconomicgrowthby1%(6,1%,5,1%onaverage).29idem,at23530Thisisofcourseinquestionnowthatthefinancialcrisishasledthepresidenttoreversemanyofthesecountercyclicalpoliciesandadopt(ortrytoadopt,againsttheresistanceofParliament),austeritymeasures.31Thisisofcourseinquestionnowthatthefinancialcrisisledtheformerandcurrentpresidenttoreversemanyofthesecountercyclicalpoliciesandadopt(ortrytoadopt,againsttheresistanceofParliament),austeritymeasures.

17

aresignificantinequalitieswithinthepensionsystem,inparticularbetweenpublicservants,

who still benefit from final salary schemes,andprivateworkers,whosepensionshavean

upper limit. Those reliant on social assistance can also slip through the net, due to

unawareness that these programmes exist, mistakes in their qualification, or lack of

qualification for inclusion criteria. For instance, the BPC is given to elderly (65+) and the

incapacitatedwhoearnbellowaquarteroftheminimumwage,whereastheBolsaFamiliais

given to families with children who earn less than 1/2 the minimum wage. So, elderly,

disabledoradultswithoutchildrenwhoearnbetween1/4and1/2oftheminimumwagedo

not qualify for any of the social assistance programmes. Expenditurewith education and

healthremainataround10%ofGDP,uponly1%fromthepreviousperiodendedin1994,

beingvery low inper capita terms,evenwhencompared toneighbouringLatinAmerican

countries,anddespitebeingconstitutionalrights.

Therewereprogrammesfortheexpansionofplacesinlowerandhighereducation

(both in private institutions, through scholarships and fiscal exemptions (PROUNI) and in

publicinstitutions,REUNI,takingtheproportionofhighereducationstudentsfrom6,5%in

1998to13%in2007),butthequalityremainslow,with10%illiteracyandmorethen50%of

children aged 14 not able to read and write properly. The average years of education

remained very low, at 7,1 in 2009, not even achieving theminimum8 years of the 1967

Constitution[?check??]Inhealththeproblemsarealsosignificant.55%ofexpenditureisstill

private,only28,7%ofthepopulationusesexclusivelythepublicsystem,whilethosewhouse

theprivateinsurancesystemmaydeductpartoftheirexpensesfromtheirincometaxand

private companies are also able to make deductions when providing health services to

employees.Notevenpublicservantsusethepublicsystem.Theidealofanuniversalsystem

fundedthroughtaxationisthereforeratherfarawayfromthereality.

The universalising project of the constitution is therefore clearly incomplete. In

practice,socialpoliciesofthesuccessiveleftleaninggovernmentsofthepast25yearshave

focused heavily on the very poor with low cash transfers while providing underfunded

“universal”servicesandgivingsubsidiesforthebetterofftooptoutofthem.Thisvicious

cycleofselectivity,segmentationandinequalitycouldperhapsbebrokenbytheemergence

oftheso-called“newmiddleclass”,whichcouldstartdemandingmorefromthestateinthe

18

areasofhealthandeducation(assomebelievetheJune2013demonstrationsillustrate).But

thereisalsotherisk,plausibleinmyview,couldalsosimplyemulatetheupperclassandopt

outofthepublicsystemassoonastheyareablethatthisnewmiddleclasswillratheremulate

thebehaviouroftheeconomyelitesandoptoutofthepublicsystemsofeducationandhealth

assoonas theyareable toafford it,whichwouldperpetuate thecurrentdividebetween

publicservicesoflowerqualitytothepoorandprivateservicesofbetterqualitytothebetter

off.32

II.2Universalistconstitutionalrhetoric,selectivepolicypractice?

Thehistoryofsocialpolicy inBrazilian law inthepast85yearshasbeenagradual

move from limited, contributory and fragmented schemes, introduced mostly through

ordinarylawdirectedbyconstitutionalprinciples,towardsamore(thoughnotcompletely)

comprehensive, non-contributory and unified systems grounded on individual rights with

constitutionalstatus.Yet,aswehaveseenintheintroduction,muchmoreprogresshasbeen

made,especially in recentyears, incontributoryand targetedpartsof thesystemthan in

universalservices.Fundingforhealthandeducationhasgrownalittlebutstilladduptolow

percentagesofGDPandsmallamountsintermsofGDPpercapitawhencomparedtomore

developedcountriesandeventosomeofasimilarlevelofdevelopment.

Thismaybeawidespreadtendencyinsocialpolicyintheso-calleddevelopingworld,

whatLenaLavinashascalledan“hegemonicparadigmofthe21stcentury”,basedontargeted

programmesofconditionalcashtransfersandexpandedhouseholddebt,suchastheBolsa

Familiaandotherprogrammesreferredabove.Butitwouldnotbeaccuratetoconcludethat

meagrecashtransferpolicieshaveallbutreplacedthedreamofuniversalisation.Onemust

becareful,however,nottojumptohastyconclusionsthatuniversalpolicieshaveallbutgiven

placetoCCTs.CCTshavesurelybeenthemostvisibleandtalkedaboutinnovationofrecent

yearsandtheflagshippolicyoftheWorkersParty,asalreadymentionedintheintroduction

32Fortheconceptofthe“newmiddleclass”,seeMarceloNeri(2011).Otherbottlenecksareintheareaofactivelabourpolicies(almostinexistentat0,02%ofGDP,comparedto0,4%intheUSAand1,3%inFranceandDenmark)andlanddistribution(Giniof0,8).Oneadditionalimportantconstitutionalchangetobenotedistheestablishmentofcompulsorypubliceducationfromtheageof4to17,whichreintroducedtoarticle208,I,throughAmendment59/2009,thedutyofthestatetoprovidefreesecondaryeducation(thathadbeentakenoutbyamendment14/1996),andincreasingthestatedutytopre-schooling.

19

above. It is also indeed very limited in terms of expenditure, at less than 0,5% of GDP,

althoughnotincoverage,reachingdirectly13,8millionfamilies,andthusalmost50million

individuals,i.e.about1/4oftheBrazilianpopulation.33

Yet,aswehaveseen,universalservicessuchashealthandeducationhavenotbeen

“paredtothebarestbones”.Itwouldalsobeanexaggerationtosaythata“downsizingof

socialprotectioninthenameofthepoor”istakingplaceinBrazil.Onthecontrary,alongside

Bolsa Familia,which has performed an important role in takingmillions of people out of

extremepoverty,healthandeducation,althoughunderfunded,consume10%ofGDP,notan

insignificantamount, thepensionsystem,although lessprogressive,another12%ofGDP,

alsotakingmillionsoutofpoverty,theBPCisnowbenefitingmorethan4millionelderlyand

disabledindividuals,and,perhapsmostimportantofall,thepolicyofupdatingtheminimum

wageinmorethan76%inthepastdecade,whichisthebasicincomeofsome46,7million

Brazilians,hasbenefitedmanyaswell.34

As awhole, theBrazilianwelfare system, composedboth by constitutional under-

enforced universal and target obligations and the non-constitutionalized Bolsa Familia

programme, performs an important yet underachieving reduction in the persisting

inequalitiesofthecountry.AccordingtoLustig(2011),socialexpenditure inBrazilreduces

GINIinequalityby7,3%,makingitonlymoderatelyredistributive(seealsoOECDstudy).35A

morebalancedviewwouldbetoconclude,withKerstenetzky,thatwearelivingnowundera

“expandeduniversalism”.

33ProgramaBolsaFamília:umadécadadeinclusãoecidadania/organizadores:TerezaCampello,MarceloCôrtesNeri.–Brasília:Ipea,201334In1996,whenitstarted,theBenefíciodePrestaçãoContinuada(BPC)reached346thousandindividuals.InApril2015,itreachedmorethan4,02million(1,84elderlyand2,18milliondisabled.http://blog.mds.gov.br/redesuas/?page_id=770Fordataontheminimumwage,seehttp://www.brasil.gov.br/economia-e-emprego/2015/07/pais-comemora-aumento-real-de-76-do-salario-minimo-na-ultima-decada35Thisisexplainedbythreemainfactors:i.thepoorpaymoretaxesgiventheheavyfocusonindirectconsumptiontaxesintheBraziliansystem;ii.theamounttoredistributeisnotlarge;andiii.thelowprogressivityoftheexpenditure(despitebeingprogressive).

20

III.ABriefhistoryoftheJudicializationofHealthinBrazil(volume,costsandequity)

Itisextremelydifficulttoputtogetheracomprehensivepictureofthejudicializationofhealth

inBrazil.Thisisduenotonlytothelackofcomprehensiveandreliabledatathatoftenplagues

empiricalstudiesingeneral,butalsotothecomplexandfragmentednatureoftheBrazilian

publichealthsystem.Thedutytoprovidehealthactionsandservicesisheldconcomitantly

by the Federal Union, the 27 state units and themore than 5.550municipalities. A truly

comprehensivestudywouldneedtocover lawsuitsagainstallofthem.Nosuchstudyhas

beencarriedoutsofar.Oneneedsthereforetorelyonthefragmenteddataavailablefrom

partialstudiesconductedindifferentstatesandmunicipalities.

Inastudycarriedoutin2009and2010foraprojectcoordinatedbyHarvardPublic

Health School and the Christen Michelsen Institute in Bergen, Norway ("Harvard-Bergen

study"fromnowon),informationprovidedbytheFederalMinistryofHealthshowedthatthe

Federal Union had responded to 5,323 lawsuits between 2003 and 2009, resulting in an

expenditureofR$159.03million(US$80million).36Morerecentdatapublicisedbythesame

Ministrydisplaysariseof25%from2009to2012(10.498to13.051).IntheHarvard-Bergen

study, information from the São Paulo State revealed an expenditure of R$400 million

(US$200million)2008,RioGrandedoSul,R$78million (US$39million),andMinasGerais

anotherR$40million(US$20million)in2008.Intermsofvolumeoflitigation, information

fromRiodeJaneirorevealed2,245casesin2006,upfrom1,144in2002);RioGrandedoSul

(1,846casesin2002and7,970in2007);SantaCatarina(24in2002to2,511in2007);the

Federal District - Brasilia (281 in 2003 to 682 in 2007) and the state of São Paulo (4,123

lawsuitsin2006alone).Ontheaggregatenumberofpatientsreceivingtreatmentthrough

judicialorders,therewasdataonSãoPaulo(25,000in2009),andRioGrandedoSul(20,527

inin2008).

As regards municipalities, where data is evenmore difficult to compile given the

existenceofmorethan5.500administrativeunits,anelectronicsurveywasconductedwith

municipalsecretariatsofhealthbetweenNovember2009andMarch2010,senttoallthen

36OctavioFerraz,“HealthInequalities,RightsandCourts:TheSocialImpactofthe“JudicializationofHealth”inBrazil”,inYaminandGloppen(eds,),LitigatingtheRighttoHealth:Cancourtsbringmorejusticetohealthsystems?,HarvardUniversityPress,2011.

21

5,566Brazilianmunicipalitiesaskingwhetherthejudicializationofhealthwasanimportant

issue in that municipality and, if so, requesting data on the volume and costs of health

litigation.Responseswerereceivedfrom1,337municipalities (24%of thetotal).Of these,

34% said that the judicialization of healthwas growing andwas an important issue; 23%

respondedthatitwasgrowingbutwasnotyetanimportantissue;and43%statedthatthey

didnothavethatproblem.624municipalitiesreportedonthenumberofindividualscurrently

receivingtreatmentthroughjudicialorders.Theaggregatetotalwas44,708(anaverageof

71.64perrespondentmunicipality),andthetotalvolumeoflawsuitsstoodat12,766in2007,

15,735in2008,and14,560inthefirstsixmonthsof2009.CostsalsogrewfromR$47million

(US$24million)in2007toR$73million(US$37million)in2008,andhadalreadyreachedR$57

millioninthefirstsixmonthsof2009.Inaddition,mostoftheclaimswereformedication,

confirmingthesametrendfoundatthefederalandstatelevels.

These data collected in 2009-2010, even if incomplete and fragmented, also gave

some credence to an argument often raised by public health professionals and health

administratorsthattheBrazilianmodelofrighttohealthlitigationhadimportantproblems

intermsofrationalandequitableexpenditureofresources.Astheavailabledatashowed:

"...thevastmajorityofright-to-healthcasesinBraziltodatehavebeenfiled

byindividualclaimantsandhaveconcernedtheprovisionofcurativemedical

treatment (mostlymedicines)which canbeenjoyed individually.As to the

outcomeof litigation, theBrazilianmodel is characterizedby anextremely

highsuccessrateforclaimants....mostBrazilianjudgesandcourts,including

theSTF,seetherighttohealthasanindividualentitlementtothesatisfaction

of all one’s health needs with the most advanced treatment available,

irrespectiveofcosts."37

The available data also showed "a strong positive correlation between high

socioeconomic statusandvolumeof claims". Themost striking findingemerged from the

37O.L.M.Ferraz,“Therighttohealthinthecourtsofbrazil:worseninghealthinequities?,HealthandHumanRights,AnInternationalJournal,Vol11,No2(2009)

22

lawsuitsagainsttheFederalUnion,wheretenstateswiththehighestHDI(above0.8)together

generated93.3%oflawsuits(4,013),whereastheotherseventeenstateswiththelowestHDI

(below0.8)togetheroriginatedameagre6.7%oflawsuits(330).38

Mytentativeconclusionbasedonthesefindingsasregardstheequityofthesystem

werethese.

"... themodel’soverallsocial impact isnegative.Ratherthanenhancingthe

provision of health benefits that are badly needed by the most

disadvantaged—suchasbasicsanitation,reasonableaccesstoprimaryhealth

care,andvaccinationprograms—thismodeldivertsessentialresourcesofthe

healthbudgettothefundingofmostlyhigh-costdrugsclaimedbyindividuals

whoarealreadyprivilegedintermsofhealthconditionsandservices."39

38“Itisimportanttonotethatthisstrongcorrelationremainswhenweadjustforpopulationsize.Thecountry’saverage,basedonthelawsuitsinthedatabaseoftheSCTIE-MS,isonelawsuitagainstthefederalgovernmentforevery42,364inhabitants.Butthereishugevariationwhenonedisaggregatesthatnumberbyregion.Thenortheast,thepoorestregionofBrazil,hasaverylowratiooflawsuitstoinhabitants(1/177,704)—overfourtimeslowerthanthecountry’saverage—whereasthesouth,theregionwiththehighestHDI,isthechampionoflitigation,witharatioof1/11,902—almostfourtimeshigherthanthecountry’saverage.Figure4.5showstheratiosforallregionsofthecountry.”,idem.39Ibid,Ferraz(2011),note23above.

23

Severalnewstudieshavebeenconductedsincethen.Theyallindicatethatthevolume

andcostsoflitigationcontinuetogrowsignificantlyandthatthesocialgradientmentioned

abovecontinuestooperate.TheMinistryofHealthestimatesthatin2016thejudicialization

ofhealthwillcostR$7billiontotheFederalUnion,Statesandmunicipalitiescombined40,

almost4%ofthebudget.41TheOfficeoftheAdvocateGeneral(AdvocaciaGeraldaUnião-

AGU)estimatesthatbetween2010and2015theexpenditureoftheMinistryofHealthwith

judicialization grew staggering 727%. The 20 most costly medicines purchased through

judicializationcostR$959millionperyeartotheFederalGovernment.42Intermsofpercapita

expenditure, judicialization consumes approximately 8,5 times more resources than the

healthsystem.43

40Insomemunicipalitiestheexpenditurewithjudicializationishigherthantotalexpenditurewiththepopulation.E.g.Tubarão(SC)expenditurewithbasicpharmacyR$971.000in2011,expenditurewithjudicializationR$975.00041http://www2.planalto.gov.br/acompanhe-planalto/noticias/2016/09/governo-eleva-orcamento-de-2017-para-saude-e-educacao42Idem.TwoofthemostexpemsivedrugsareIdursulfase2mg/ml,forHunter'sdisease,R$622mil.Brentuxmab50mg,forcancer,R$538mil.ForagoodstudyofjudicializationfocusedonthesedrugsseeD.Diniz,M.Medeiros,andI.V.D.Schwartz,“Consequênciasdajudicializaçãodaspolíticasdesaúde:custosdemedicamentosparaasmucopolissacaridoses,”CadernosdeSaúdePública28/3(2012),pp.479-48943Ifoneconsidersthatthesystemcatersforabout75%oftheBrazilianpopulation,i.e.150millionpeopleapproximately,whereasjudicializationreachesapproximately47000thousandindividuals.

24

In the most comprehensive study carried out so far, the National Justice Council

(ConselhoNacionaldeJustiça)foundthestaggeringnumberof854.506lawsuitsrelatedin

somewaytothetopicofhealthinallcourtsandtribunalsofBrazilin2015.44Outofthose,

morethan470.000(justbelow50%)wereagainstthestatehealthsystem(SUS),therestwere

against theprivate system.Of the lawsuitsagainst thepublic system,42%wereexclusive

claimsformedicines;another32%wereclaimsforhospitaltreatmentandmedicines;12%

wereexclusiveclaimsforhospital treatmentand16%wereclassifiedgenericallyashealth

servicesclaims.45

44Justiçaemnúmeros2016:ano-base2015/ConselhoNacionaldeJustiça–Brasília:CNJ,2016.Disponívelemhttp://www.cnj.jus.br/programas-e-acoes/pj-justica-em-numerosDatacompiledandaggregatedbyClenioJairSchulze,in"Novosnúmerossobreajudicializaçãodasaúde",http://emporiododireito.com.br/novos-numeros-sobre-a-judicializacao-da-saude-por-clenio-jair-schulze/accessedon10.5.2017.45ThedatabaseoftheCNJcanbefurtherexploredtoextractdataonageoflitigants.

HealthBudgetTotal,183,96%

Judicialization,7,4%

HealthExpenditure2016

HealthBudgetTotal Judicialization

25

Thepicturewhenacorrelationisruninthesedatabetweensocio-economicindicators

andvolumeoflitigationissimilartothatfoundinthe2009-2010Harvard-Bergenstudy.

Source:OwnformulationwithdatafromCNJ,2014

200090151856

60696 61655

474297

050000100000150000200000250000300000350000400000450000500000

Medicines Hospitaltreatmentandmedicines

HospitalTreatment

HealthServices Total

Lawsuits2015

Lawsuits2015

RS,113953,34%

MG,66751,20%RJ,46883,

14%

SP,44690,14%

SC,18188,6%

ES,8991,3%

DF,2575,1%

PR,2609,1%

MS,1081,0%

MT,6644,2%

GO,309,0%

allothers,17956,5%

LawsuitsagainstStates2014

RS MG RJ SP SC ES DF PR MS MT GO allothers

26

Asitcanbeseen,mostoflitigationatthestatelevelconcentratesonafewstatesof

thewealthier south and south-east regions of the country. RioGrande do Sul andMinas

Geraistogether,alone,accountfor54%ofthelawsuitsrelatedtohealth.IfweaddRiode

JaneiroandSaoPaulo,wegetastaggering82%ofthelawsuitsconcentrateinfourofthemost

developed states of Brazil (all stateswith high HDI). Conversely, if we focus on the least

developedstatesinBrazil,Para,PiauiandMaranhao,46theyaccount,together,foramere916

cases,thatis,0.2%ofthetotaloflitigationinBrazil.ThesocialgradientfoundattheFederal

level repeats itself at the state level. As it probably does within states and in many

municipalitiesaswell,althoughthedatahereislesscomplete.Thebestwayofseeingthisis

by correlating the address of the claimant with an indicator of social development. The

originalstudytohavedonethiswasmost likely thatofVieiraandZucchiwithall lawsuits

againstthemunicipalityofSaoPauloin2005.Astheygraphicallyshowedusingthemapof

thecityofSaoPaulo, therewasastrongcorrelationbetweenthe IEX,and indexof social

exclusion,andvolumeoflitigation.ThehighertheIEX,thelowerthenumberoflawsuitsto

befoundinaparticulardistrictofthecity.47

46Alagoas,thepooreststate,hasnotprovideddatathroughtheelectronicsystem,likePernambuco,AmazonasandParaiba.ThepressofficerfortheAlagoasCourtofAppealinformed6303casesrelatedtohealth,anumberthatsurprisesandwouldthereforewarrantfurtherinvestigation.47VieiraFS,ZucchiPDistortionstonationaldrugpolicycausedbylawsuitsinBrazilRevSaudePublica.2007Apr;41(2):214-22,CadSaudePublica.2010Mar;26(3):461-71.Otherstudieshavefollowedasimilarstrategyandarrivedatsimilarconclusions.See,forSantaCatarina,“Analisandoadistribuiçãoespacialdosmunicípiosdoestadoondehouveaçõesmovidas,verificamosqueháconcentraçãonasregiõespróximasaosmunicí-piosdagrandeFlorianópolis,ValedoItajaíeChapecó.Constatou-se,ainda,atravésdotestedecorrelaçãodeSpearman,queosmunicípioscommelhoresindicadoressocioeconômicosapresentarammaiornúmerodeaçõesdeferidasporhabitante.”Boingetal.“ThejudicializationofaccesstomedicinesinSantaCatarinaState:achallengeforthemanagementofthehealthsystem”,R.Dir.sanit.,SãoPaulo,v.14,n.1,p.82-97,mar./jun.2013See,forParana,“Em2009,entreas142comarcasdoParaná,74(52,1%)originaramaçõesjudiciaisrequerendomedicamentos,sendoascomarcasdeCuritiba(20,5%),Londrina(16,3%),RegiãoMetropolitanadeCuritiba(8,9%),Cascavel(6,2%)eMaringá(6,2%)asmaisfrequentes.”PereiraandPepe,“JudicialaccesstomedicineinParaná:applyingamethodologicalmodelforlawsuitanalysisandmonitoring”,R.Dir.sanit.,SãoPaulov.15n.2,p.30-45,jul./out.2014

27

Averysimilarpicturewasfoundinotherstudies,suchasthosecarriedoutbyChieffi

andBarataalsoinSaoPaulo48andbyGomesetalinthestateofMinasGerais.495051Inthe

latter,theauthorslookedatmorethan6.000casesregisteredattheSecretariatofHealth

from1999to200952.Theyanalysedonly,forthisstudy,thoserelatedtoproceduresrather

thanmedicines,endingupwithasampleof783cases(12,8%).Casesconcentratedinasmall

numberofmunicipalities(14%,122/853)and,withinthese,22,3%originatedinthecapital,

48UsingadifferentcohorttoFabiolaVieiraandamuchlargersampleof2.927lawsuits,theauthorsreachedaverysimilarstrongcorrelationbetweenplaceofresidenceandvolumeoflawsuits:74%ofthelawsuitscamefromthe3wealthierareasofthe6intowhichthecityisdivided,morethan50%fromthewealthiesttwo,whichahigherconcentrationinarea2(35%).AnaLuizaChieffiandRitaBarradasBarata,'"Judicialization"ofpublichealthpolicyfordistributionofmedicines',Cad.SaúdePúblicavol.25no.8RiodeJaneiroAug.200949Gomesetal(2014)Accesstomediumandhigh-complexityproceduresintheBrazilianUnifiedNationalHealthSystem:amatterofjudicialization,Cad.SaúdePública,RiodeJaneiro,30(1):31-43,jan,201450Tocitejustafew.F.VieiraandP.Zucchi,“DistorçõescausadaspelasaçõesjudiciaisàpolíticademedicamentosnoBrasil”(DistortionstonationaldrugpolicycausedbylawsuitsinBrazil),RevistadeSaúdePública41/2(2007),pp.214–222;A.ChiefandR.Barata,“Judicializaçãodapolíticapúblicadeassistênciafarmacêuticaeeqüidade”(“Judicializationofpublichealthpolicyfordistributionofmedicines”),CadernosdeSaúdePública25/8(2009),pp.1839–1849;D.W.L.WangandO.L.Ferraz,“ReachingOuttotheNeedy?AccesstoJusticeandPublicAttorneys’RoleinRighttoHealthLitigationintheCityofSãoPaulo,”SURInternationalJournalonHumanRights10/18(2013),pp.159-179);“TherighttohealthinthecourtsofBrazil:worseninghealthinequities?”,HealthandHumanRights11(2009),pp.33–45;O.Ferraz,“HealthInequalities,RightsandCourts:TheSocialImpactofthe“JudicializationofHealth”inBrazil”,inYaminandGloppen(eds,),LitigatingtheRighttoHealth:Cancourtsbringmorejusticetohealthsystems?,HarvardUniversityPress,201151Thesefindingsarefarfromsurprisingorunique.Theliteratureontheobstaclesfacedbylitigationstrategiesasaneffectiveprogressivetoolisnowlarge.Tocitejustoneclassic,seeMarcGalanter,WhytheHavesComeOutAhead?SpeculationsontheLimitsofLegalChange,Law&SocietyReview,Vol.9,No.1,LitigationandDisputeProcessing:PartOne(Autumn,1974),pp.95-16052Confirmingthatjudicializationgrewfastertowardstheendofthe2000s,morethan80%ofthelawsuitsintheirsampleoccurredinthelastthreeyearsoftheperiod(2007-2009).

28

BeloHorizonte,whichhasthesecondhighest IHDofthestate,and inDivinopolis (19,8%),

withthe21sthighestHDI.

III.1Newdata:adifferentpictureinRioGrandedoSul?

ThedebateonthejudicializationofhealthinBrazilhastraditionallybeenfoughtinthe

pagesofnewspapers.Everysooftenapieceofnewsispublishedeitheronanewindividual

casegrantedbythecourtsagainstthestateforacertainmedicineorprocedure,oronthe

growingaggregatevolumeandcostsofjudicializationinacertainstate,municipalityorthe

FederalUnion.Suchreportsareoftenaccompaniedbyagenericstatementbyagovernment

official, often the Minister or a Secretary for Health about the negative effects of

judicializationonthebudget.Indepthandrigorousacademicstudiesofthephenomenonare

fewandfarbetween.Yettheyhaveincreasedinnumberandqualityinthepastdecade,as

discussedintheprevioussection,enablingustoformabetterpicturetodaythanwehadten

orfifteenyearsago.Theyalsoallowusreflectabouthowfuturestudiescouldbedesignedin

ordertoovercomesomeoftheproblemswenoticeintheexistingones.

Biehl,SocalandAmon’srecentlypublished“TheJudicializationofHealthandtheQuest

forStateAccountability:Evidencefrom1,262LawsuitsforAccesstoMedicinesinSouthern

Brazil”53 isanother importantcontributiontothedebate. It is important toanalyse it ina

separatesubsectionbecauseoftheirstrongandboldclaimthattheirdatashowasignificantly

different picture to that found in other studies. They have also claimed that their data

challengewhat they provocatively label four “myths” propagated by the press and other

studies. It isnotmypointheretotakeissuewiththeirmischaracterizationofsomeofthe

positionstheylabelmyths(includingmyown)norwiththeirmisuseoftheconceptofamyth.

Ihavedoneitelsewhere,andtheyhaveresponded.54Myaimhereistoanalysetheirown

data in order to gauge if they justify a change in the overall tendency of the academic

literatureinseeingrighttohealthlitigationasaproblematicpractice.

The first important thingtonote is that theirdata is limitedtoRioGrandedoSul,a

singlestateofthe27ofBrazil.AsIclarifiedabove,giventhatconstitutionalresponsibilityfor

53HealthandHumanRights,vol.18,n.1,2016.54See…

29

healthisequallysharedamongtheFederalUnion,thestates,andallmunicipalities(5.570as

of2016),wearetalkingof5.598potentiallydifferent“judicializations”.Iamnotsuggesting,

ofcourse,thatonlyifwehavedataonallmunicipalities,statesandtheFederalUnionwecan

draw general conclusions about the judicialization of Brazil as a whole. I am however

suggesting that one should be particularly careful about the representativeness of one’s

samplegiventhegeographicalsize,socio-economicdiversityandadministrativecomplexity

ofBrazil.

Given that important caveat, the next important step is to try to establish how

representative theRioGrandedo Sul data is of thephenomenonof the judicializationof

healthinBrazilbeforedrawinganyconclusionsfromitsdata.If,byhypothesis,wecameto

theunlikelyconclusionthatRioGrandedoSulisaperfectmicrocosmofthejudicializationof

healthinBrazil,wecouldtaketheresultofthestudy(assumingweacceptthedataasreliable

andcomprehensive)asadefinitiveportraitofthephenomenoninthecountry.Attheother

endofthespectrumweoughttoconsiderRioGrandedoSul,asinglestateamong27,anda

singleunitamong5.598inalargeanddiversecountryastoosmallandpeculiartoallowany

extrapolationofitsdatatoageneralpictureofthewholecountry.TheadequateplaceofRio

GrandedoSulisprobablysomewherein-betweenthetwoextremesofthatspectrum.Finding

theexactspotwouldbeobviouslyimpossible,andfindingevenaroughspotwouldtakeup

thewholepaper.ButabriefcontextualizationofRioGrandedoSulwithinBrazilwillsuffice,I

think,toconvincethereaderthatanyattempttogeneralizeitsfindingswouldbefraughtwith

obstacles.

Rio Grande do Sul (RS) is a state in the relatively richer south of Brazil55, with a

reasonablylargepopulationof11.286.500(around5.4%oftheBrazilianpopulation)anda

comparativelyhighpercapitahouseholdincomeofR$1.554,00,thethirdhighestinBrazil,

whoseaveragestandsatR$1.226,00,56rangingwidely(4times),givenpronouncedregional

55Asaruleofthumb,ofthefivemacro-regionsofBrazil,thesouthandthesouth-eastaretherichest,almosttwiceasrichonaveragethanthestatesofthenorthandthenorth-east.Thecentre-westisin-between,buthasthecapitalBrasilia(DF)whichhasthehighestpercapitahouseholdincomeofthecountry,pullinguptherestoftheregion,aswellasimportantagriculturalstatessuchasMatoGrossodoSul,whoseincomepercapitaisnotfarfromthatofthestatesofthesouth-eastandsouth.56http://www.ibge.gov.br/estadosat/perfil.php?sigla=rs

30

disparities, from R$ 2.351,00 (DF) to R$ 575,00 (MA).57 The samewide variation seen in

incomerepeatsineducationandhealth,astheIHDattests.TheIHDofRSisthe5thhighestof

Brazil, at 0,779, considered high according to theUNDP criterion. The country average is

0,76158rangingfrom0,839(veryhighDF)to0,667(medium,AL).

Inlightofsuchsignificantsocio-economicdisparitiesamongthe27statesofBraziland

thehighpositionofRioGrandedoSul,amongthetop5intermsofhumandevelopmentand

top3intermsofeconomicdevelopment,itseemsimmediatelyclearthatitwouldbehighly

problematictotakethatstateasagoodindicatorofthejudicializationofhealthinBrazil.This

is especially sowhenoneof themainarguments is that judicialization is a “process from

below”.(Iwillreturntothisimportantissuelater).

Ithinkwecansafelyconclude,thus,thatwhateverthedataonRioGrandedoSulshow,

itwillbeusefulmostlyasapictureofwhatishappeninginthatparticularstate,generating

potentialcomparativeinsightswiththedatacollectedinotherstates,butnotmuchbeyond

that.Thisseemstobeacceptedbytheauthorsthemselvesinthefollowingpassageoftheir

article:

“RioGrandedoSulhasamuchhighervolumeofright-to-healthlitigationthanother

Brazilianstates,withmorecasesthanthenextfourstateswiththemostlitigation(São

Paulo, Rio de Janeiro, Ceará, and Minas Gerais, respectively) combined. These

differences reflect the varied performance of the decentralized health care system

throughoutthecountry,aswellasthesignificantdifferencesineconomy,demography,

and administrative capacity within and across the 26 Brazilian states. … the

heterogeneityofright-to-healthlitigationacrosstheBrazilianstatesindicatestheneed

foramorenuancedandin-depthanalysisofitsdriversandimplicationsatlocallevels.”

57http://www1.folha.uol.com.br/mercado/2017/02/1861675-20-estados-tiveram-renda-per-capita-abaixo-da-media-em-2016-diz-ibge.shtmlForacomparativebasis,theUK,oneofthemostunequaldevelopedcountries,themediumhouseholdpercapitaincomevaries1,5timesfrom£25,293(London)to£15,913(NorthernIreland).ToachievethemagnitudeoftheregionalvariationinBraziloneneedstodisaggregatebylocalarea£52,298(KensingtonandChelsea)and£12,779(Nothingham).https://www.ons.gov.uk/economy/regionalaccounts/grossdisposablehouseholdincome/bulletins/regionalgrossdisposablehouseholdincomegdhi/201558https://noticias.uol.com.br/cotidiano/ultimas-noticias/2016/11/22/df-sao-paulo-e-santa-catarina-lideram-desenvolvimento-humano-entre-estados.htm

31

(at218)59

Letmethenturntotheauthorsmainclaimandassessitwithintheselimits.Unlikewhat

someofthestudiescarriedoutinSaoPaulo,RiodeJaneiro,MinasGeraisandotherplaces

havefound,theauthors’conclusionisthatinRioGrandedoSulrighttohealthlitigationdoes

not favourmostlythebetteroff,doesnot focusonhighcostoff-formularymedicinesand

doesnotdisrupthealthpolicy.Onthecontrary:

“the resultsofourstudy…revealaprocessof judicialization frombelow,stemming

frompoorandolderindividualswhodonotliveinmajormetropolitanareas,andwho

depend on the state to provide their legal representation. We did not find that

judicialization represented a phenomenon of “Robin Hood in reverse”; quite the

contrary:wefoundevidencethatjudicializationlargelyservesthedisadvantagedwho

turntothecourtstosecureawiderangeofmedicines,morethanhalfofwhichareon

government formularies and should be available in government health centers.” (at

216)

If this isanaccurateandplausible interpretationofthedata inRioGrandedoSul, it

does showa surprisingly different picture fromother places in Brazil emerging in studies

carriedoutinSaoPauloandMinasGeraisforexample,thatfoundaprevalenceoflitigants

representedbyprivatelawyers,livinginplacesoflowsocio-economicexclusionandclaiming

expensivemedicinesnotcoveredongovernmentformularies.(e.g.VieiraeZucchi;Chiefiand

Barata,SilvaandTerrazzas,Gomesetal). Itdoesnotshow,ofcourse, that thesescholars

importantfindingsareincorrect,letalonethattheyaremyths.60

Butdoesthedatacollectedbytheauthorsactuallyjustifytheirstrongconclusionseven

ifrestrictedtoRioGrandedoSul?

Inmyview,theconclusionsarestrongerthanthedatasupportfortwomainreasons.

59Butitishardtoreconcilethisbalancedconclusionwithotherpassageswhere“myths”arechallengedandwheretheauthorsseemtoextrapolatetheirconclusiontotherestofBrazil.“OurstudychallengedmythsaboutthenegativeimpactofjudicializationonbothpublichealthadministrationandonthebroaderquestionofequitableaccesstocareinBrazil.WhiledirectlybasedonworkinthesouthofBrazil,theinforma-tionpresentedhereisalsorelevanttonationalandinternationaldiscussionsofhowtoadvancethegoalofuniversalhealthcoverage.”At218.60Biehletaldon’tevendiscussthefindingsofthesestudiesintheirarticle.

32

Firstly,althoughimpressive,thedataonRioGrandedoSul isstill incomplete,andinparts

significantly thinner than the data collected in the studies that arrived at different

conclusions.Secondly,theauthorsgivetoomuchweightosomeindicatorsthatarenotvery

reliablefortheintendedpurposes.

III.1.aJudicializationfrombelow?

Take,first,thecrucialissuesocio-economicprofileoflitigants,extremelyrelevantifone

istryingtogaugeif judicialization isaprocessfrombelow,drivenbyelites,etc.Studies in

other states have used a combination of indicators to try and reach a reasonably robust

pictureofthiselusiveaspectoflitigation.Theseincluded:theindexofsocialvulnerability,the

indexofhumandevelopment,directdataonclaimant’sincome(self-reportedinthelawsuit),

aswellasmoreindirect indicatorssuchastypeof legalrepresentation(private lawyersor

stateattorneys)andtypeofhealthserviceused(privateorpublic).

IntheirstudyofRioGrandedoSul,theauthorshavereliedexclusevelyontypeoflegal

representationandaccesstolegalaid,whichareperhapstheleastreliabletoindicatethe

socio-economicprofileofthelitigant,andincompletedataonoccupation.

Graph2:Percentageofclaimsrepresentedbyprivatelawyers(variousstudies)

74

60.3 5954

32.2

20.3

0

10

20

30

40

50

60

70

80

SaoPauloState MinasGerais SantaCatarina SaoPauloCity RioGrandedoSul

RiodeJaneiro

Privatelawyer

33

Astheauthorsthemselvesappropriatelystate,thepublicdefensory,responsiblefor57%of

claimsintheirsample61,“providesfreelegalassistancetopeopleclassifiedaslow-income(definedas

earningthreetimesthenationalminimumwageorless)”.Theauthorsdonotdiscuss,asotherstudies

do,thesituationofpovertyinBrazilandRioGrandedoSulsoastoallowthereadertounderstand

what3 timestheminimumwageactuallymeans. It isa reasonablyhighthreshold.AtR$2.640,00

(aroundUS$760,00amonthand3xR$880,00,theminimumwage), it ismuchhigherthanthe

averageincomeinRioGrandedoSul,atR$1,435,00(US$420,00)62atthetimeoftheirstudy(R$

1.554,00now),andalmost35timeshigherthantheextremepovertythreshold inBrazil (R$77,00,

US$22,00).63

Thesamecanbesaidofaccesstolegalaid,whichwasgrantedinstaggering91%ofthe

lawsuits.AsanyonefamiliarwithlitigationinBrazilknows,it isextremelyeasytogetlegal

fee’sexemptioninBrazil,sufficingtomakeaself-declarationof“legalpoverty”whichisrarely

challengedorrejectedincourt.Thatinturnexplainswhyeventhoseresourcefulenoughto

retainprivatelawyersareabletoaccesslegalaid.

The indicatorrelatedtooccupationusedbytheauthorsoffers littlehelp,asthefive

categorieschosenarenotfinelygrainedenough(professional,manual,retired,unemployed

andstudent).Ifoneaddstheretired(32%)whocanbeinanysocio-economicbrackettothe

26.9%ofthesamplewherenoinformationisavailable,onehas58.9%ofthesamplewhereit

is not possible todrawany conclusionwhatsoever about socio-economic status from the

sample. Manual or service sector workers (14.5%) could, again, fit into several different

incomebrackets,althoughtheytendtohavelowersalariesthanprofessionals(4,7%).Even

theunemployed(21%)arenotinthemselvesaverygoodindicatorwithoutfurtherdataabout

theiractualpredicamentintermsofincome.Studentsfallintothesameproblem,buttheir

participationinthesampleissonegligiblethatonecansafelydisregardthem(0.9%).

It seems clear to me, thus, that the data collected by the authors on legal

61Another9,4%wererepresentedby“federallegalcounsel”(7%)anduniversityclinics(2,4%).At213.62"Gaúchotematerceiramaiorrendadomiciliardopaís"ZHNotíciasavailableathttp://zh.clicrbs.com.br/rs/noticias/noticia/2016/02/gaucho-tem-a-terceira-maior-renda-domiciliar-do-pais-4984327.htmlNEEDFULLCITATION.63ItshouldalsobenotedthatthePDthresholdisoftennotfollowedinrighttohealthcases,especiallythoseclaimingdrugsthatarecostly,whenpublicdefenderstendtorelaxtheadmissibilitycriteriaforacceptingtorepresentthelitigant.

34

representation, legal aid and occupation is insufficient to allow any minimally robust

conclusionaboutthesocio-economicprofileoflitigants,letalonetoclaimthatjudicialization

inRioGrandedoSulisaprocessfrombelow,that“largelyservesthedisadvantaged.”

III.1.bMostlystatefailure?

Differentproblemsaffect theauthors’claimthat judicialization inRioGrandedoSul

does not follow the pattern seen in other places of concentration in high cost and off-

formulary medicines. Firstly, the data presented by the authors do not show such a

significantlydifferentpicturefromotherplacesastheymakeouttoexist.Secondly,thebinary

classificationintoonandoffformularydrugsisnotsufficienttocapturethefullcomplexityof

healthpolicy inordertodeterminewhetheramedicineshouldbeprovidedornotbythe

state.Itisfartoosimplistictoclaim,thus,thatsincemorethanhalfofthedrugsclaimed“are

ongovernmentformulariesandshouldbeavailableingovernmenthealthcenters.”

Theauthorspresenttheirfindingsintwodifferentways.Firstly,theymentionthetotal

number of drugs requested (3.468), which is much higher than the number of lawsuits

analysed(1.262)asonelawsuit(oftenonepatient)canandoftenclaimmorethanonedrug.

Whenanalysingbydrugratherthanby lawsuit,theauthorsfindahigheryetnottoohigh

percentageofmedicineson formularyrequested inRioGrandedoSulwhencomparedto

otherstates(44%).

56.1

66.2 66.6

44

0

10

20

30

40

50

60

70

MinasGerais SãoPaulo RiodeJaneiro RioGrandedoSul

off-list

off-list

35

Theythenpresentthedataorganisedbylawsuitratherthanmedicine,showingthat41%of

the plaintiffs requested on-formularymedicines exclusively, 27% requested off-formulary

medicinesexclusively,and32%requestedboth.Byaddingthe41%ofexclusiveon-formulary

requestswiththe32%ofwhatcouldbecalled“mixedrequests”,theyreachtheimpressive

numberof73%oflawsuitsthathaverequestedatleastoneon-formularydrug.Onecould

howeverask:whynotaddthosethathaverequestedatleastoneoff-formularydrug?That

wouldalsoresultinanimpressive59%oflawsuitsrequestingoff-formularydrugs,anumber

notdissimilartothatfoundinotherstudies.Moreover,itisnotatallwarrantedtoconclude,

astheauthorsdo,thatbecausein73%oftheclaimsthereweredrugs“partofgovernmental

drugformularies”theseclaimswereoriginatedbyafailureofthestatetoprovidethesedrugs.

Theliteraturementionsatleastthreeplausibleexplanationsforwhyaclaimantmayendup

addingtoitsjudicialdemandanon-formularydrugevenwhenthatdrugisavailableinthe

publicsystem(e.g.herdoctordidnotfollowthetherapeuticguidelines64,theon-formulary

drugwasclaimedsimplyaspartofthetreatmentthatincludedtheoff-formularydrug,the

claimantisnotahabitualuserofthepublicsystem).65

Inanyevent,thefactisthatthisbinaryclassificationintoonandoffformularyisnotas

usefultoassessthelegitimacyofrighttohealthlitigationasitisusuallythoughttobe.Itis

truethatinclusioninthestate’slist(on-formulary)providessomeindicationofstatefailure

whereasnoninclusion(off-formulary)providessomeindicationofthecontrary.Yetneither

providesdefiniteindicationofoneortheother.Ihavealreadymentionedacoupleofreasons

whyevenadrugthat ison-formularymaynonethelessnotbeprovided, legitimately, toa

claimant(off-labeluseandlackofcompliancewithclinicalguidelines).Anotherpossibilityis

thatthepatientisnotbeingtreatedinapublicreferencehospitalbutwantstoaccessdrugs

onlyavailableinthesepublicinstitutions(cancerdrugsoftenfallinthiscase,asregulations

64Somelawsuitsrequestbrandnamemedicineswhosegenericsareavailableintheofficiallists.Agoodexampleisacetylsalicylicacid("Aspirin,""ASA")thatispartoftheofficiallistbutisoneofthemostfrequentlylitigateddrugsintheauthors'sample.InthestateofSãoPaulo,whereitalsogeneratessignificantlitigation,amoredetailedstudyshowedthat1,725lawsuitsin2014requested22differentbrandnamesorpresentationsofASAtotheonesofferedinthepublicsystem.Offeringagenericversionofadrugcanbehardlyregardedasanobviouspolicyfailure.SecretariatofHealthoftheStateofSaoPaulo,May2015(onfilewithauthor)65ForalongerdiscussionseeFerraz,O.“Brazil:Healthinequalities,rightsandcourts”,inYaminandGloppen(HarvardUniversityPress:2011),at95-6.

36

limittheirprovisiontoreferencepublichospitals).Withoutmorefinegrainedinvestigationit

isthereforeunwarrantedtoconclude,astheauthorsdid,thatanylawsuitclaiminganon-

formularydrugrepresentsastatefailuretocomplywiththeclaimant’srighttohealth.

Itwouldbeequallyunwarrantedtoconcludethatanyrequestforanoff-formularydrug

isautomaticallyillegitimate.Thereareatleastthreedifferenttypesofclaimshere.Themost

obviously illegitimate typeof claimsare those inwhich claimantsdemandmedicines that

stateauthoritieshavealreadyrejectedsimplybecausethereisnoscientificevidenceoftheir

efficacy(egtheinfamouscancerpill,theeyesurgicalprocedureinCubaetc).Wemaycall

these“rogue”drugsorprocedures’claims.Buttherearealsoclaimsforoff-formularydrugs

that are scientifically proven to be effective. Here we must distinguish among several

differentcases.Drugsorotherinterventionsthat,despitebeingeffective,havetherapeutic

alternatives that are equally effective but are less costly (i.e. are more cost-effective),

effectivedrugsorotherinterventionswhosetherapeuticalternativesarenotaseffectivebut

are much less costly, and drugs and other interventions that have no therapeutic

alternative.66The first typeofclaim,again, seemsclearly illegitimate,as itasks thepublic

systemtospendmoremoneythanitcantoachievetheexactsameoutcome.Theothertwo

aremorecomplex,andrequireadifficultassessmentofwhatapublicsystemoughttoprovide

withitslimitedresources,whichisthecrucialandmostdifficultquestioninthedetermination

ofthecontentoftherighttohealth.

The above discussion, even if briefer than the complexity of the topic requires, is

nonethelesssufficient,Ithink,todemonstratetheinadequacyoftheconclusionthatinRio

GrandedoSulmostlitigationislegitimatesimplybecausealargeproportionofclaimsinvolve

on-formularydrugs.

IV.Conclusion:movingthedebateforward

IntheprecedingsectionsofthispaperIhaveattemptedtoprovideastateoftheartaccount

ofthejudicializationofhealthanditsimpactinBrazil.IhaveshownhowsocialpolicyinBrazil

66ForagoodnuancedanalysisofdifferenttypesofclaimsseeFigueiredoTA,Osorio-de-CastroCG,PepeVL,“Evidence-basedprocessfordecision-makingintheanalysisoflegaldemandsformedicinesinBrazil”,CadSaudePublica.2013Nov;29Suppl1:S159-66.

37

gotstrongerfromthe1930sgovernmentofGetulioVargas(“TheFatherofthePoor”)and

becameincreasinglyconstitutionalizedwitheachnewconstitution(1946,1964,1969)untilit

reachedakingofclimaxwiththe1988“CitizenConstitution”adoptedaftertheendofthe

militaryregime.Ihavealsotriedtoshowthat,despitethesignificantprogressontheground

experienced in the past few decades in terms of social development, there remains an

importantgapbetweensocialconditionsandconstitutionalpromises,andhowtheuniversal

constitutionalbenefitsofhealthandeducationhaveexperiencedmuchlessimprovementin

therecentpastthanthenon-constitutionaltargetanti-povertypoliciessuchasBolsaFamilia.

Iarguedthatthejudicializationofsocialandeconomicrightsingeneral,andthatofhealthin

particular,ismoreprofitablyanalysedwithinthisbroadercontext.

Ithentriedtoprovideabriefhistoryofthejudicializationofhealthanditsimpacton

thegroundbasedonthefewavailableempiricalstudiescarriedoutsofar.Iconcludedthat

thegeneraltendencyoftheexpertliterature(myself included)toseetheBraziliancaseas

problematicfromtheperspectivesofbothequityandadministrativerationalityarestillvalid

despitearecentvociferouschallengetoit.

IntheseconcludingremarksIwouldliketooffer,inadmittedlysketchyform,apositive

recommendationabouthowtogaugewhenlitigationisprogressiveinthefieldofhealth.That

couldbeuseful,Ibelieve,notonlyformorerobustanalysisoftheexistingpractice,butalso,

hopefully,asaninspirationforfuturelitigationprojects.

Thereseemstobegrowingconsensusonthegeneralaim:theeffectiveprotectionof

the right to health of the whole population through the equitable distribution of the

necessarilylimitedresourcesofthepublichealthsystem.Butthereislessagreementofwhat

specifichealthgoodsandbenefitsanequitabledistributionwouldentail.It is towardsthis

consensus thatweshould inmyviewnowwork.Beyonddetermining the socio-economic

profileofclaimantsandthestatusofthegoodsandservicestheyclaim(onoroff-formulary),

weneedtodevelopcriteriatoassesswhetherthesegoodsandservicesoughttobepartof

thecoverageinthepublichealthsystemornotasacorollaryoftherighttohealth.Thisisno

easytask,butitstartswithunderstandingtheneedofprioritisationandafocusontheneeds

oftheworseoff(especiallywherehealthinequalitiesaresohighlikeinBrazil).

38

ThecurrentBrazilianmodel,andthatincludesRioGrandedoSul,seemstodoneither

inmyview.67Thatmodelneedsthereforetochange,evenifitmayattimesleadtopositive

outcomesof thesortBiehl,SocalandAmonargue tohaveoccurred (withoutprovingas I

arguedabove)inthecaseofRioGrandedoSul.TorecapthemainfeaturesoftheBrazilian

model:

Thedefiningfeaturesofthis“Brazilianmodel”arerelatedtotheprofileofclaims(the

litigatorandtheobjectoflitigation)andtheoutcomeoflitigation(theratesofsuccess

andfailureoflitigation).Astotheprofileofclaims,thevastmajorityofright-to-health

casesinBraziltodatehavebeenledbyindividualclaimantsandhaveconcernedthe

provision of curativemedical treatment (mostlymedicines) which can be enjoyed

individually.Astotheoutcomeoflitigation,theBrazilianmodelischaracterizedbyan

extremelyhighsuccessrateforclaimants.Thismodel,Isuggest,isencouragedbythe

dominant interpretation of the right to health by the Brazilian judiciary. As noted

above,mostBrazilianjudgesandcourts,includingtheSTF,seetherighttohealthas

anindividualentitlementtothesatisfactionofallone’shealthneedswiththemost

advancedtreatmentavailable,irrespectiveofcosts.68

Asitcanbeseen,Ididnotincludeinthemodelthesocio-economicprofileoflitigants,

butratherthatoftheclaims:individualizedclaimsforcurativetreatment(mostlymedicines).

Theremaywellbe,Irepeat,casesfromseveraljurisdictionsinwhichthisindividualizedclaims

donotfavourthebetteroffbyforcingthestatetoprovidethemwithoff-formularyhighcost

treatment,butinmanycasesitdoes,andthisiswhatmanyofthestudiesconductedsofar

haveshown,includingmostlikelyBieh,SocalandAmon’s(recallthat32%oftheirsampleof

caseswerefiledbyprivatelawyers).Thisisduetothesecond,andperhapsmostpernicious,

mainfeatureoftheBrazilianmodel:theoutcomeoflitigationisalmostalwayssuccessfulfor

thelitigant.Thatis,nomatterwhoisclaimingandwhatisbeingclaimed,thelikelihoodof

successisthesame,i.e.extremelyhigh.Thatenablesasignificantnumber(higherorlowerin

different states)ofbetteroff individuals toaccesshigh-cost treatmentsandoff-formulary

67ForagoodoverviewoftheproblemanditspotentialsolutionsseeVoorhoeveA,OttersenT,NorheimOF.Makingfairchoicesonthepathtouniversalhealthcoverage:aprécis.HealthEconPolicyLaw.2016Jan;11(1):71-7.68Seenote37above.

39

drugsthatshouldnotbeprovidedinthestatesystemaccordingtofairprinciplesofpriority

setting.

Thechallengeaheadforallthosewhosupportsocialandeconomicrightsingeneral

andtherighttohealthinparticularistochangetheBrazilianmodelsothatitpreventsthis

kindof pernicious judicialization fromhappening andencourages amorepositive kind to

flourish.Afurtherchallengeistodevelopmorespecificcriteriatoidentifywhatshouldbe

countedaspositivejudicialization,whichismuchharderandmorecontroversial,ofcourse,

thanidentifyingtheopposite,perniciouskind.

Appendix-SocialrightsandtherighttohealthintheBrazilianConstitution

The Brazilian Constitution of 1988 is one of themost “generous” in terms of social and

economicrights(SERs),i.e.rightstohealth,education,housing,workandworkingconditions,

socialsecurityetc.69Butitisnotunique.Itfollows,inthatrespect,alongstandingtradition

ofwhatisoftentermed“socialconstitutionalism”inLatinAmericaasawhole70,whichhas

spread,toalargerorlesserextenttootherdevelopingcountries,especiallyinAfrica,inthe

wakeoftheendofWorldWarIIanddecolonization,butalsotoEasternEuropeancountries,

afterthefallofcommunism.71

69TheBrazilianconstitutionof1988,nicknamedthe“CitizenConstitution”,notonlybroughtbackthecivilliberties(art.5)thathadbeencurtailedduringthetwodecadesofmilitaryrule(1964-1985),butalsoincludedanextensivelistofsocialandeconomicrightssuchashealth,education,socialsecurityandassistance(art.6),andalonglistoflabourrightsincludingaminimumwage(arts.7ff).70ESRshavebeenfeaturinginLatinAmericanconstitutionsforalongtime.TheMexicanConstitutionof1917isregardedasthefirstintheworldtoincludetheserights,pioneeringthedevelopmentofamoresocialconstitutionalism(Gargarella,2013)Brazilfollowedin1937;Boliviain1938;Cubain1940;Uruguayin1942;EcuadorandGuatemalain1945;ArgentinaandCostaRicain1949.(idem)MostLatinAmericancountrieshaverecognizedtherighttohealthintheirdomesticlaw(oftenintheconstitution)orthroughinternationaltreaties(oftenboth).Outofthecurrent21countriesthathaveratifiedthenewcomplaintmechanismoftheUNOptionalProtocoltotheInternationalCovenantonEconomic,SocialandCulturalRights(ICESCR)fivearefromLatinAmerica(anotherfourhavealreadysignedit).LatinAmericaisalsolikelytheregionoftheworldwiththehighestlevelofright-to-healthlitigation.(YaminandGloppen,2011).71Afterthe1940sthishasactuallybeenthenormincountriesthatadoptednewconstitutionaldocuments,mostlyinAfricaandEasternEuropeaswellasinLatinAmerica.Someeventalkofa"Southern"modelofsocialconstitutionalism,“distinctforitsemphasisonrobust,substantivenotionsofdistributivejustice,incontrastto

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Despite some persistent resistance by many to the idea that goods like health,

educationetccanbealsotheobjectofindividualrightsratherthanmattersofsocialpolicy,

itseemsaccuratetosaythatthereisawidespreadconsensustodaythattheyare.Aswellas

inmorethan160constitutionsaroundtheworld(Brinks,GauriandShen,2015),theserights

are included in the UN Universal Declaration of Human Rights 1948 and in several

internationallawtreaties,mostnotablytheUNInternationalCovenantonEconomic,Social

andCulturalRights(ICESCR),ratifiedbynolessthan165countriesaroundtheworld.72The

right to health, as it is known, is recognized in article 14 of the ICESCRs in the following

manner.

Article121.TheStatesPartiestothepresentCovenantrecognizetherightofeveryoneto theenjoymentof thehighestattainablestandardofphysicalandmentalhealth.2. The steps to be taken by the States Parties to the present Covenant toachievethefullrealizationofthisrightshallincludethosenecessaryfor:(a)Theprovisionforthereductionofthestillbirth-rateandofinfantmortalityandforthehealthydevelopmentofthechild;(b)Theimprovementofallaspectsofenvironmentalandindustrialhygiene;(c)Theprevention,treatmentandcontrolofepidemic,endemic,occupationalandotherdiseases;(d)Thecreationofconditionswhichwouldassuretoallmedicalserviceandmedicalattentionintheeventofsickness.

BrazilratifiedtheICESCRsonlyin1992,thatis,fouryearsafterithadrecognisedthe

right tohealthandothersocialandeconomicrights in itsdomestic lawthorughthe1988

constitution.Therelevantarticlesarearticle6and,inthespecificfieldofhealth,articles196

to200.

article 6. Education, health, food, work, housing, leisure, security, social security,

protectionofmotherhoodandchildhood,andassistancetothedestitutearesocial

rights,assetforthbythisConstitution.

themorecivilandpoliticalrights–orientedconstitutionsoftheGlobalNorth”(Bilchitz2013;Brinks&Gauri2014;Brinksetal,2015:294).72ThenotableexceptioninthedevelopedworldisofcoursetheUnitedStatesofAmerica,whohavesignedtheICESCRsin1977buttothisdatehasfailedtoratifyit.Thesameistrue,ofcourse,ofallhumanrightstreatiesapartfromtheICCPR,ICERD,CAT,andthetwofirstprotocolstotheCRC.http://indicators.ohchr.org/

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article196.Healthisarightofallandadutyofthestateandshallbeguaranteedby

meansofsocialandeconomicpoliciesaimedatreducingtheriskofillnessandother

hazards and at the universal andegalitarian access to actions and services for its

promotion,protectionandrecovery.73[myemphasis]

73MydirecttranslationfromthePortuguese:“Art.196.AsaúdeédireitodetodosedeverdoEstado,garantidomediantepolíticassociaiseeconômicasquevisemàreduçãodoriscodedoençaedeoutrosagravoseaoacessouniversaleigualitárioàsaçõeseserviçosparasuapromoção,proteçãoerecuperação.”