Profile of The Judicialization In Pharmaceutical Assistance And Expenses With Antineoplastics: A Cross-Sectional, Descriptive Study Based On A Set of All The Lawsuits Filed Between The Years 2016 To 2018 In of A State In Northeastern Brazil

doi:10.21203/rs.3.rs-1129316/v1

Background: The judicialization of healthcare for acquiring medication is not an isolated occurrence in Brazil, it may also be observed in other Latin American countries, regardless of the existence of a universal health system, in Brazil, the Unified Health System. The search for justice, in terms of medications, has existed ever since the high demand for treating the Acquired Immunodeficiency Syndrome, while currently, the protagonist is cancer. Since pharmaceutical assistance is the area within Unified Health System, which is responsible for maintaining access to medications, the aim of this article is to describe the profile of judicialization in the pharmaceutical assistance of a state in Northeastern Brazil of economic significance, according to the characteristics of the lawsuits, regarding: the plaintiff filing the lawsuit; the medical and health information; the expenditure on acquiring the requested medications; and the relevance of spending on antineoplastic drugs.

Methods: This was a cross-sectional, descriptive study based on a set of lawsuits filed between 2016-2018 at the Litigation Center in the State Health Department of Pernambuco.

Results: A total of 2,947 lawsuits were analyzed that contained at least one requested medication, with a predominance of males (51.7%); and in which 49.8% of the requests originated in the Unified Health System, and were primarily from patients in the Metropolitan region of the state capital. The most frequent ICDs for cancer were C61, C71 and C50. The median overall expense of the lawsuits was U$1,734.94. Considering only antineoplastic drugs, expenditure exceeded U$7,500 per lawsuit over the three years, given that the median unit price of antineoplastic drugs is approximately U$65.00 compared to U$4.00 for non-antineoplastic drugs.

Conclusion: The present study is of relevance as a matter of public health, and how the profile of judicialization behaves as a tool for managing and improving decision-making in times of economic austerity.

Health Economics & Outcomes Research

Infectious Diseases

Health Policy

Judicialization of Healthcare

Right to Health

Pharmaceutical Assistance

Antineoplastic Drugs

Drug Costs

Costs and Cost Analysis.

The judicialization of healthcare involves claims for health goods and services through the legal channels [1], which may be on an individual or collective level of health needs (access to services and supplies), which are not being met by the executive branch [2]. Based on the premise that the existence of the State must guarantee all citizens their fundamental rights in an equitable manner [3], the judicialization of healthcare as a right has divided opinions among several researchers [4].

Access to medication in Brazil occurs through the Unified Health System, known by the acronym SUS. Having been denied the right to medication to any citizen, judicial means is other way to get the medication [5]. Since the 2000s, judicialization in Brazil has taken on significant relevance due to the demand for new drugs in the treatment of Acquired Immunodeficiency Syndrome (AIDS). During this period, 92 drugs were launched [1, 4]. Currently, cancer has taken on this leading role. The occurrence of cancer is increasing globally, exerting significant pressure on populations [5] at all income levels and health systems, thereby motivating international actions, which increases the commitment for greater investment in disease control as a public health priority [6]. Regardless of the reasons related to an increase in cancer detection rates, in order to cure or treat the disease, there has been a demand for medications, causing the judicialization for access to high-cost antineoplastic drugs to figure more frequently among the lawsuits in the judiciary system [2, 5].

It should be noted that the high legal demand for medications is not an isolated fact in Brazil, it may also be observed in other Latin American countries [2], regardless of the explicit existence of a universal health system or even a universal right to health in their constitutions, such as in Peru, Argentina, Venezuela and Ecuador [7].

The department in SUS, and therefore in health policies, which manages medications is Pharmaceutical Assistance (PA), which is described as a set of actions aimed at promoting, protecting and recovering health, both on an individual and collective level, whereby medication is as essential input⁷. This is why the PA has taken center stage in the debate on lawsuits⁸. These ever-increasing rates of judicialization [4, 9] suggest the need to undertake a careful analysis of the policies and programs for accessing medication, as well as the lists of essential medicines served by Pharmaceutical Assistance, in order to ensure efficient and adequate results for healthcare [10].

In order to address the legal issues and mitigate the effects of these lawsuits on health management in the different spheres of Brazilian public management, the State Health Departments (SES) in a number of states have developed their management strategies. Nantes and Dobashi¹¹ mentioned the creation of a “litigation coordination”, linked to the state management office in Mato Grosso do Sul, made up of a multidisciplinary team working with the State Attorney's Office (a model on which examples may already be observed in other states, such as in Rio de Janeiro [12] and Pernambuco [13]), including drug acquisition processes.

Even though the SES have been structured, judicialization is currently on the increase, since it is an alternative for obtaining a health product/service or treatment that has been refused, either because it is not included in the National List of Essential Medicines (RENAME) or because of budgetary reasons [14]. The demands of lawsuits have taken on legal and financial importance, whereby the majority of requests have been for medication [15, 16]. However, with limited resources in health financing, this decision is ultimately not offered in an absolute manner [4].

In 2016, in the State of Pernambuco, it could be noted that, in relation to lawsuits, the purchase of medications is the most outstanding, representing around 63.5% of the lawsuits filed against the State Health Department [14]. According to Judgment 1,787 from the Federal Court of Accounts (TCU) (2017) [15], most expenditure on judicialized medications by the Ministry of Health are items that have not been incorporated into SUS.

In order to provide a better resolution for the quantitative demand for lawsuits in Pernambuco, health lawsuits are dealt with by the Center for Technical Assistance in Health (NATS), which was established by means of a technical cooperation agreement (Agreement Nº 048/2011) [17] between the Pernambuco State Health Department (SES-PE), the Pernambuco Court of Justice (TJPE) and the Litigation Center (NAJ), in 2014, functioning as a management tool that solves problems by ensuring access to citizens and reducing demands [12], as recommended by the National Council of Justice (CNJ).

Given the importance and topicality of this subject, the lack of clarity regarding its dimension and temporal and spatial characteristics, in addition to the inequality of information available in different regions of Brazil, especially in the Northeast of Brazil, cited by Nunes and Ramos Júnior [13], and in the hypothesis that there are particularities in the profile of judicialization in healthcare in the Northeastern states of Brazil, with a strong emphasis on antineoplastics in health expenditures.

This article aims to describe the profile of the judicialization of medication in the State of Pernambuco, according to the characteristics of the lawsuits [18], with regarding to: the plaintiff filing the lawsuit; the medical and health information, the expenditure on acquiring the required medications and the relevance of expenditure on antineoplastic drugs.

This was a cross-sectional, descriptive study based on a set of all the lawsuits filed between the years 2016 to 2018 at the NAJ in the SES/PE.

Data were initially collected by a trained, qualified team from the Litigation Center, based on internal forms that contain detailed information on each lawsuit that involved the State as a defendant.

The original proposal by Pepe et al [19, 20] was adapted to generate the study variables that made up the database, which defined the characteristics of the plaintiff (gender and municipality of residence), as well as those that defined the medical-health characteristics of the lawsuits [origin of medication prescriptions according to the legal nature of the National Register of Health Establishments (CNES)]; the main diagnosis, according to the International Classification of Disease - Tenth Revision (ICD 10); and expenses incurred with acquiring the requested medications.

The inclusion criteria were lawsuits filed against the State of Pernambuco, received at the Litigation Center, and which mentioned at least one drug in the lawsuit, and that the suggested dose could be priced in the informed study period. Lawsuits were excluded if they presented insufficient information or were for combined and/or formulated drugs that could not be priced individually.

The medications were informed according to their first prescription, essentiality, or even classified according to the Anatomical Therapeutic Chemical System (the ATC code).

Expenditure on the judicialization of medications during the period 2016-2018 was estimated using the quantity sent for acquisition/purchase during the period, in the Pharmaceutical Assistance Management System (SISGAF) of the NAJ, and the acquisition prices from the Minutes of the SES/PE Price Registration. The amounts in Brazilian Real (R$) were later converted into US dollars using the Institute of Applied Economic Research (Ipea) source, (R$)/US dollar (US$) with a mean value in 2020 (R$5.1558), in order to facilitate a comparison of these data with those of other countries.

For prices that were not identified, the Health Price Bank (BPS) was used as a parameter. Considering the study period, all prices were updated after consulting the BPS dated December 2019, or lacking this, by consulting the factory price suggested on the distributors' website. This methodology was used to mitigate possible price variations during the consultation period.

In the data analysis, a comparison of expenditure according to the characteristics of the lawsuits and according to the type of medication (non-antineoplastic and antineoplastic) were applied to the Kruskal-Wallis test to compare the medians, and to the Pearson's Chi-square test to compare proportions. The Shapiro-Wilks test was used to verify the hypothesis of normality of the variable related to expenditure, with the hypothesis of normality being rejected. The statistical significance adopted in the study was 5% (p < 0.05). Data were analyzed using Stata 14.

Once the values were identified for the variables of interest, indicators for the municipality where the lawsuits originated, the figures were then built. A spatial distribution of these indicators was conducted by constructing quantitative thematic maps in order to observe the dynamics of the indicators in space. The digital map in shapefile format was downloaded from the Brazilian Institute of Geography and Statistics (IBGE) website and the calculated rates were added to this base. The software used was QGIS 3.16.10 and the class intervals of the quantitative thematic maps were categorized into quartiles.

From the database of the Litigation Center/SES/PE, 2,947 lawsuits filed against the State were observed, which involved at least one requested medication, between the years 2016-2018, the characteristics of which are presented in Table 1.

Table 1

Characteristics of lawsuits, plus medicines, filed against the State of Pernambuco (2016 to 2018)
Characteristics	Number (%)
Number of lawsuits	2,947
Sex
Male	1,522 (51.7%)
Female	1,425 (48.3%)
Origin
Private	667 (23.4%)
SUS	1,419 (49.8%)
Philanthropic	762 (26.8%)
Not informed	97
Number of medications
One	2,903 (98.5%)
Two	33 (1.1%)
Three or more	11 (0.4%)
Antineoplastics Drugs
Yes	1,182 (41.4%)
No	1,671 (58.6%)
Not informed	94

A slight predominance of males (51.7%) was observed, primarily from SUS (49.8%) requests, followed by philanthropic hospitals (26.8%). Most lawsuits involved at least one requested medication (98.5%) and 41.4% of these medications were antineoplastic.

Table 2

Expenditure, in dollars, of the lawsuits with medications during the period between 2016 and 2018
Characteristics	General (n = 2.947)	Antineoplastic Drugs (n = 1.182)	Non-Antineoplastic Drugs (n = 1.671	p-value
Total expenditure with the lawsuit	1,734.94 (232 – 7,792)	7,508.83 (2,402 – 15,571)	585.36 (86 – 2,635)	<0.001
Unit price of medication
In dollar	17.99 (1.94 – 142.23)	64.91 (14.60 – 359.40)	4.09 (0.53 – 65.87)	<0.001
Sex	p-value^a = 0,019	p-value^a = 0,131	p-value^a = 0,007
Male	2,120.33 (245.16 – 8,761.78)	8,654.14 (2,875,.79 –15,578.96)	468.40 (54,11 – 2,546.65)	<0.001
Female	1,405.02 (220.92 – 6,621.09)	6,492.30 (1,928.70 –15,410.61)	618.53 (115.21 – 2,956.67)	<0.001
Origin	p-value^a < 0.001	p-value^a = 0.071	p-value^a = 0.251
Private	993.83 (168.74 – 4,948.80)	7,785.41 (3,244.89 –15,949.03)	595.06 (116.96 – 1,646.50)	<0.001
SUS	2,482.45 (224.41 – 9,374.88)	7,964.82 (2,875.79 –15,410.61)	589.43 (81.66 – 3,556.58)	<0.001
Philanthropic	2,128.67 (315.25 – 8,633.58)	6,475.23 (1,752.20 –14,170.84)	448.04 (52.37 – 2,634.51)	<0.001
Number of medications
One	2,903 (98.5%)	1,255 (99.7%)	1,719 (97.8%)	<0.001
Two	33 (1.1%)	0 (0%)	31 (1.8%)
Three or more	11 (0.4%)	4 (0.3%)	7 (0.4%)
Maximum time of remaining in treatment
In months	6 (3 – 9)	5 (3 – 9)	6 (3 – 9)	<0.001
N.B.: The amounts in Real were converted into US dollar using the commercial exchange selling rate: Real (R$)/US dollar (US$), mean value 2020 (R$5,1558). Source: Ipea: http://www.ipeadata.gov.br/ExibeSerie.aspx?serid=31924, Viewed in August 2021.

Table 2 highlights the expenditure, in dollars, on lawsuits filed against the State requesting some form of medication during the study period. The median general expenditure of lawsuits (regardless of the drug class), in dollars, was U$1,734.94. However, when considering only the antineoplastic drugs, expenditure exceeded U$7,500 per lawsuit, given that the median value of the unit price of the antineoplastic drugs was approximately $65.00 and the median non-antineoplastic drugs was approximately $4.00.

In the case of general expenditure, there was a statistically significant difference when comparing the medians by sex. Males presented a higher median cost, and there was no significant difference between the antineoplastic drugs (p = 0.131). There was a statistical significance when expenditure on non-antineoplastic drugs was compared between the sexes, presenting a higher cost among females.

For the variable origin of lawsuit, there was a statistical significance in the comparison of general expenditure with medications, demonstrating a higher expenditure for lawsuits filed by SUS (U$2,482.45) and by philanthropic entities (U$2,128.67), when compared to private entities.

For the most part (98.5%), the lawsuits studied in this period presented just one judicialized medication, with an median treatment duration of 6 months, with a small reduction for antineoplastic drugs, which was 5 months.

The top five most frequent ICDs of these lawsuits were: C61-Malignant neoplasm of the prostate (9.0%); C71-Malignant neoplasm of cerebral ventricle (4.2%); C50-Malignant neoplasm of breast (3.8%); N18.8-Other Chronic kidney failure (3.7%); and C64-Malignant neoplasm of the kidney (3.5%).

Among the 15 most requested drugs, the most common were Abiraterone, Cinacalcet, Somatropin 12UI, Sorafenib, Bevacizumab, and Enzalutamide. Cinacalcet and Somatropin 12UI are not used for neoplasms.

Analyzing the geographic distribution of the lawsuits with regard to the municipality from which they originated, it may be observed that in Figure 1 the general profile of the incidence of lawsuits, per thousand inhabitants, presents a greater representation in municipalities with significant economic relevance for the State, either in the metropolitan region, near the state capital, or in the deep interior of the state.

During the period studied, the median total expenditure on judicialization in the 184 municipalities was US$20,500 dollars (6,700 – 92.500), with a minimum of US$500 and a maximum of US$7,600 (State Capital). A total of 171 municipalities filed at least one lawsuit for some medication (171/184 = 93%) against the State of Pernambuco. The median number of lawsuits in relation to the 184 municipalities during the period of 3 years: 5 (2 - 11), maximum of 876 lawsuits (State Capital), a mean of 292 lawsuits per year in Recife.

In terms of the median number of lawsuits for antineoplastic drugs in relation to the municipalities over a 3-year period: 2 (1 - 4.5), there was a maximum of 388 lawsuits in Recife (State Capital). There were 140 municipalities from which originated at least one lawsuit (140/184 = 76%) filed against the State of Pernambuco.

When analyzing the distribution of lawsuits by municipalities in Pernambuco, (Figure 2), it may be observed that the median per capita expenditure during the period with antineoplastic drugs was US$0.8 per inhabitant (0.4 - 1.9), a maximum of 12 dollars per inhabitant (Jaqueira) and Recife (2.9 dollars).

Discussing the judicialization of health in Brazil is a relevant, albeit very complex, issue, especially regarding access to medication, since after decades of study, tracing a national profile is still a long way off. For example, there is a divergence in the literature regarding who seeks the judiciary requesting health services and products: poor or rich?. There is also a divergence concerning what they require: drugs and services that make part of the lists, protocols and contracts or not?. It even diverges on the effects of these lawsuits on the general policies of public and private healthcare: what is the magnitude of the disturbances caused? [21].

In order to fill a data gap in the Northeastern Region of Brazil, the present study has analyzed the lawsuits that have been filed against the State of Pernambuco. With an understanding that this was a convenience sample, it was not possible to address any trends that may have increased or reduced the impacts of these lawsuits on the state’s health management, although it was possible to describe the characteristics and behavior of expenditure on medications and the relevance of antineoplastic drugs in a Northeastern Brazilian state that ranks as one of the richest (GDP) in the region. The following comparisons with other findings in the literature have limitations, since the studies present different methodologies for collecting and describing the profile characteristics of judicialization, as recently cited by Oliveira et al. [22] (2021).

The profile of the judicialization of healthcare in the State of Pernambuco presented an approximately equal distribution of requests between the sexes, and there was no consistent difference, nor any pattern in other studies, seeing that, in the Brazilian Federal District (DF), Diniz et al. [23] identified 51% of males. However, females were more prevalent in the states of Minas Gerais, with 60.2% [24], Ceará with 52.5% [13] and in a municipality of São Paulo (SP), 52.4% [25].

With regard to data on the origin of the lawsuit, SUS demonstrated the highest percentage, similar to that identified in São Paulo (48%) [16], in the Federal District (85%) [23], as well as in Ceará [13] (76.3%), highlighting that in the Federal District and Ceará studies there was no distinction between public and philanthropic, although there were divergent findings in Minais Gerais (70.5%) [24] for the private sector.

The study by Machado et al. [24] identified that 66.3% of the lawsuits had requested at least one medication, while in the present study the percentage was 98.5%, corroborating that there is no pharmacotherapeutic “pool” being over judicialized. With regard to the low demand identified for antineoplastic drugs, this was not a particular characteristic of this study, since according to the classification of the main anatomical group of the ATC code, antineoplastic agents and immunomodulators make part of the main groups legally requested. However, they are generally not the most prevalent, as mentioned by Chieffi and Barata [16], who identified only 33% for antineoplastic drugs, which are nonetheless generally the most expensive treatments.

Considering that the median public expenditure per capita on healthcare in Brazil is around R$1,400 per year [26] (approximately US$271.53), it is evident that these lawsuits with antineoplastic drugs (US$7,508.8) may significantly impact the public health budget.

Since the values were detailed, it is possible to identify the unit price of medication, bearing in mind that price and therapeutic choice is one of the main inducers of spending on medication. Inference along these lines is widely discussed by Vieira [27] (2019), who clearly defined what induces public expenditure with medication; the three main inductions being: price, quantity and therapeutic choices, whereby variations in quantity and therapeutic choices are particularly significant for increasing expenditure on medications,.

On examining the most requested drugs, it should be noted that Cinacalcet and Somatropin 12UI are not primarily prescribed for neoplasms, even though there has been a history of Cinacalcet being prescribed for the treatment of parathyroid carcinoma and primary hyperparathyroidism and are included among the top 15, depending on the number of times it was requested. In the case of Abiraterone, Sorafenib and Bevacizumab, drugs suggested for oncology treatment, these are similar to those identified in other studies such as Vidal et al. [2] (2017), in INCA-RJ and Barreto et al. [20] (2019) in SES-PE.

Abiraterone, after several studies and requests in 2019, was incorporated into SUS by the Ministry of Health in the Ordinance Secretariat of Science, Technology, Innovation and Strategic Health Inputs - SCTIE N0 38/2019 [28]. In 2015, Cinacalcet, which is recommended for secondary hyperparathyroidism (HPTS) through to chronic kidney disease, was incorporated into SUS by Ordinance SCTIE/MS No. 48/201529, and is also recommended for parathyroid carcinoma and primary hyperparathyroidism, but has not been incorporated for this purpose. This is why the use of off-label medications is always the subject of discussion, not only in SUS but also by the National Health Agency (ANS), which regulates the supplementary system [2].

An analysis of the profile regarding the territorial arrangement enables a direct correlation to be made between the municipality and the socioeconomic and health management region of the state, since Recife (29.4%), Jaboatão dos Guararapes (7.4%), Olinda (5.3%) and Paulista (4.3%) are located in the Metropolitan Region of Recife, as with Regional Health I, when grouped together, correspond to approximately 57.1% of the lawsuits. Studies, such as that by Nunes and Ramos Júnior [13], reported similar findings to those of this study, and identified more than 77% of the lawsuits referred to the municipality of residence, which in their case was Fortaleza, the capital of Ceará.

The data described from the municipalities of residence of the plaintiffs validate the characteristic of the state's profile, but it is not possible to attest that the socioeconomic profile of the plaintiffs interfered with the profile of judicialization in Pernambuco, nor was it the object of this study.

Figueiredo et al. [30], in a national study, with data retrieved from 2014, presented the total expenditure per capita on health in Brazil, which reached US$ 947, and that, when considering just one disease, such as cancer, reached US$ 12, suggests attention and relevance in detailed studies on the impact of diseases that place most pressure on health expenditure. In the same work published by Figueiredo, it was sadly reported that Brazil presented the lowest per capita daily public expenditure for covering public health actions and services of its population, (R$ 2.60 - U$ 0 .50), which is below expectations compared to other countries that have universal health systems.

Lastly, with the 2,947 medication lawsuits reported in this study, it has been possible to describe and discuss the profile of judicialization in healthcare in a state in the Northeast of Brazil, including relevant financial aspects for future lessons regarding financial impacts on public health management.

This study has produced a profile of judicialization in the Brazilian state of Pernambuco, detailing the behavior of the plaintiffs who, due to the need for drug treatment, sought their constitutional rights to health. It is evident that there is a need to broaden information on the growing demand for drugs through the judiciary. However, the requests for antineoplastic drugs, and the fact that they are concentrated within the Metropolitan Region of Recife, the state capital, needs to be investigated, in order to decide whether, through the lawsuits, the right of all citizens, regardless of their socioeconomic origin, has been preserved.

It is important to continue with new studies of this nature, since, over time, and from several other previously published studies, it has been observed that judicialization, regardless of the legal, economic, or even social perception when individual rights are to the detriment of the collective, are posed as a concrete fact for health management. Furthermore, if this is not able, in its own right, to contribute to a change in health policy, it should be considered as a constructive, analytical process in order to adjust management models in healthcare so that, in the near future, health policies are more contemplative of technological advances in medicines for the treatment of cancer and other diseases.

Furthermore, as if the underfunding of the health system were insufficient, since it was created by the 1998 Constitution, the situation has been further aggravated by policies of fiscal austerity imposed on Brazil. Therefore, this is of significant relevance to the theme discussed in this study, so that the financial impacts of judicialization are always scientifically demonstrated, together with an effort to clarify expenditures as a strategy to strengthen new public policies that will reinforce efforts to ensure a truly universal and public health system.

AIDS: Acquired Immunodeficiency Syndrome; CEP: Research Ethics Committee; CNES: National Register of Health Establishments; CNJ: National Council of Justice; DF: Brazilian Federal District; HPTS: Secondary Hyperparathyroidism; IBGE: Brazilian Institute of Geography and Statistics; NAJ: Litigation Center; NATS: Center for Technical Assistance in Health; PA: Pharmaceutical Assistance; RENAME: National List of Essential Medicines; SES-PE: Pernambuco State Health Department; SES: State Health Departments; SISGAF: Pharmaceutical Assistance Management System; SP: São Paulo; TCU: Federal Court of Accounts; TJPE: Pernambuco Court of Justice; UPE: Universidade de Pernambuco; SUS: Unified Health System.

Ethics approval and consent to participate

The study was approved by the Research Ethics Committee (CEP) at the Universidade de Pernambuco (UPE), on July 3, 2018, with CAAE: 91652318.3.0000.5207. Considering that the study did not directly involve human beings, but rather used public data, the aforementioned Committee decided to approve the project, exempting the informed consent form.

All methods were carried out in accordance with relevant guidelines and regulations as suggested by the CEP.

Consent for publication

Not applicable

Availability of data and materials

The database that support the findings of this study are available from SES: State Health Departments but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of SES.

The data were attached to part of the manuscript, preserving the identity of the individuals <Profile of the judicialization in pharmaceutical assistance – database >

Competing interests

The authors declare that they have no competing interests

Funding

This study was financed by the Coordenação de Aperfeiçoamento de Pessoal de

Nível Superior - Brasil (CAPES) - Finance code 001.

Authors' contributions

Regarding the authors' contribution:

FO contributes by leading with: Conceptualization, Data curation, Formal analysis, Research, Methodology, Project administration, Writing - original draft, Writing - review and editing.

UM contributes by leading with: Study Resources, Supervision and Validation. Likewise with the other authors, with: Conceptualization, Formal analysis, Writing - original draft, Writing - revision and editing.

JLS contributes equally with the other authors in: Formal analysis, Methodology, Validation and Writing - original draft.

AM contributes equally with the other authors in formal data analysis and Writing - review and editing.

HG contributes equally with the other authors in formal data analysis and Writing - original draft.

GJF contributes equally with other authors in formal data analysis and Writing - original draft.

All authors approved the final version sent.

Acknowledgments

We would like to thank SES-PE (Pernambuco State Health Department) for approving data collection for this article. We are also grateful to UPE (University of Pernambuco) and the Graduate Program in Health Sciences for their support in the development of the study.

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No competing interests reported.

Profile of The Judicialization In Pharmaceutical Assistance And Expenses With Antineoplastics: A Cross-Sectional, Descriptive Study Based On A Set of All The Lawsuits Filed Between The Years 2016 To 2018 In of A State In Northeastern Brazil

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Abstract

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Method

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Discussion

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