Judicialização dos planos e seguros de saúde privados / Judicialization of private health plans and insurance

Esta edição especial da Revista de Direito Sanitário apresenta os resultados inéditos de pesquisas realizadas pelo Grupo de Estudos sobre Planos de Saúde, do Departamento de Medicina Preventiva da Faculdade de Medicina e do Centro de Estudos e Pesquisas de Direito Sanitário (Cepedisa) da Faculdade de Saúde Pública, ambos da Universidade de São Paulo.

This special issue of the Revista de Direito sanitário presents the unpublished results of the research carried out by the Study Group on Private Health Plans, of the Department of Preventive Medicine of the Faculty of Medicine and the Center for Studies and Research in Health Law, of the Faculty of Public Health, of the Universidade de São Paulo.

Evolution of Gender Disparities Among Brazilian Surgical, Anesthesia, and Obstetric Providers.

INTRODUCTION: Since 2010, most graduating physicians in Brazil have been female, nevertheless gender disparities among surgical specialties still exist. This study aims to explore whether the increase in female physicians has translated to increased female representation among surgical specialties in Brazil. METHODS: Data on gender, years of practice, and specialty was extracted from Demografia Médica do Brasil, from 2015 to 2020. The percentage of women across 18 surgical, anesthesia, and obstetric (SAO) specialties and the relative increases in female representation during the study period were calculated. RESULTS: Of the 18 SAO specialties studied, 16 (88%) were predominantly male (>50%). Only obstetrics/gynecology and breast surgery showed a female predominance, with 58% and 52%, respectively. Urology, neurosurgery, and orthopedic surgery and traumatology were the three specialties with the largest presence of men - and the lowest absolute growth in the female workforce from 2015 to 2020. CONCLUSIONS: In Brazil, where significant gender disparities persist, women are still underrepresented in surgical specialties. Female presence is predominant in surgical specialties dedicated to the care of female patients, while it remains poor in those with male patient dominance. Over the last 5 y, the proportion of women working in SAO specialties has grown, but not as much as in nonsurgical specialties. Future studies should focus on investigating the causes of gender disparities in Brazil to understand and tackle the barriers to pursuing surgical specialties.

Médicos e terceirização: percepções de trabalhadores e gestores sobre as transformações recentes no mercado de trabalho / Doctors and outsourcing: perceptions of workers and managers on recent transformations in the labor market / Médicos y tercerización: percepciones de trabajadores y directivos sobre los cambios recientes en el mercado laboral

Resumo O artigo examina as tendências recentes da forma de inserção dos médicos no mercado de trabalho à luz da regulação das relações trabalhistas na percepção de informantes-chave que atuam nos setores público e privado do sistema de saúde no estado de São Paulo. O estudo mostrou que, na percepção dos entrevistados, há uma tendência crescente de inserção de médicos como pessoa jurídica condicionada pela regulação das relações de trabalho e pela política de contratação dos estabelecimentos provedores de serviços de assistência à saúde. Em geral, a 'pejotização' de médicos foi associada à perda de autonomia desses profissionais em relação aos termos de contratação e às condições de realização do trabalho. O artigo conclui que a inserção 'pejotizada' de médicos se apresenta como parte do movimento mais geral de barateamento da força de trabalho associado à terceirização, e indica que há espaço para a exploração de políticas voltadas à gestão de trabalhadores que busquem atrair e fixar médicos no Sistema Único de Saúde.

Abstract The article examines recent trends in the way doctors enter the labor market in the light of the regulation of labor relations in the perception of key informants who work in the public and private sectors of the health system in the state of São Paulo, Brazil. The study showed that, in the perception of the interviewees, there is a growing trend of insertion of doctors as a legal entity conditioned by the regulation of labor relations and the contracting policy of establishments providing health care services. In general, the 'pejotização' (hiring free of labor rights/illegal hiring) of doctors was associated with the loss of autonomy of these professionals in relation to the terms of employment and the conditions for performing the work. The article concludes that the illegal hiring and insertion of doctors is presented as part of the more general movement of cheapening the workforce associated with outsourcing, and indicates that there is room for the exploitation of policies aimed at the management of workers who seek to attract and fix doctors in the Unified Health System.

Resumen El artículo examina las tendencias recientes acerca de como se dá la inserción de los médicos en el mercado de trabajo, a la luz de la regulación de las relaciones laborales, en la percepción de informantes clave que actúan en los sectores público y privado del sistema de salud del estado de São Paulo, Brasil. El estudio mostró que, en la percepción de los entrevistados, existe una tendencia creciente hacia la inclusión de los médicos como persona jurídica condicionada por la regulación de las relaciones laborales y por la política de contratación de los establecimientos que prestan servicios de asistencia a la salud. En general, la 'pejotización' de los médicos estuvo asociada a la pérdida de autonomía de estos profesionales en relación a los términos de contratación y a las condiciones de ejercicio del trabajo. El artículo concluye que la inserción 'pejotizada' de los médicos se presenta como parte del movimiento más general de abaratamiento de la mano de obra asociado a la tercerización, e indica que hay espacio para la exploración de políticas dirigidas a la gestión de trabajadores que busquen atraer y retener a los médicos en el Sistema Único de Salud.

Flexibilização legislativa para a certificação de hospitais sem fins lucrativos no Brasil / Legislative flexibilization for cerification of non-profits hospitals in Brazil

Para as entidades beneficentes de assistência social que prestam serviços ao Sistema Único de Saúde, a Constituição Federal de 1988 previu a concessão de imunidade tributária, desde que atendidos os requisitos previstos em lei. Ocorre que há uma primeira dificuldade em estabelecer os conceitos de entidade filantrópica e entidade beneficente de assistência social, bem como as diferenças entre eles. O objetivo deste trabalho foi realizar uma revisão e uma reflexão sobre a diferença doutrinária entre os conceitos de filantropia e beneficência social, discutir o processo histórico de certificação dos hospitais sem fins lucrativos que prestam serviços ao Sistema Único de Saúde para obtenção de imunidade tributária e identificar as consequências disso para a seguridade social (previdência, saúde e assistência social) no Brasil. Esta reflexão se faz de suma importância, principalmente em momentos de escassez de recursos financeiros em que há tentativas de fragilizar o sistema de seguridade social do país. A Constituição Federal de 1988 adotou o termo "entidade beneficente de assistência social" para a concessão de imunidade tributária, conceito que se distingue do de filantropia por envolver três características essenciais da assistência social: serviços de natureza essencial, gratuidade e acesso generalizado a quem necessita. Essa ampliação de conceito e as flexibilizações legislativas ocorridas ao longo dos anos para permitir a concessão de certificado ­ e, consequentemente, a obtenção de imunidade tributária ­ prejudicam a arrecadação de recursos para a seguridade social e podem ocasionar desvantagens para o Sistema Único de Saúde.

For charitable social assistance entities that provide services to the Brazilian Nacional Health System, the Federal Constitution of 1988 provided for the concession of tax immunity, as long as the requirements established by Law were met. There is a first difficulty in establishing the concepts of philanthropic entity and charitable entity of social assistance, as well as the differences between them. The objective of this paper was to conduct a review and a reflection on the doctrinal difference between the concepts of philanthropy and social charity, discuss the historical process of certification of non-profit hospitals that provide services to the Brazilian National Health System, to obtain tax immunity and identify the consequences of this for social security (pension, health and social assistance). This reflection is of utmost importance, especially in times of scarcity of financial resources, in which there are attempts to weaken the social security system of the country. The Federal Constitution of 1988 adopted the term "social assistance beneficent entity" for the concession of tax immunity, a concept that is distinguished from philanthropy because it involves three essential characteristics of social assistance: services of an essential nature, gratuitousness, and generalized access to those in need. This broadening of the concept and the legislative flexibilities that have occurred over the years to allow the concession of the certificates - and, consequently, the obtainment of tax immunity - impairs the collection of resources for social security and can cause disadvantages for the Brazilian National Health System.

How the 'plates' of a health system can shift, change and adjust during economic recessions: A qualitative interview study of public and private health providers in Brazil's São Paulo and Maranhão states.

BACKGROUND: Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world's most affected countries, and its health system was already experiencing the aftermath of the 2015 recession. METHODS: Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (São Paulo) and impoverished (Maranhão) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings. RESULTS: We found the concept of 'health sector crisis' to be politically charged among healthcare providers in São Paulo and Maranhão. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible-if insecure-working arrangements. Following a drop in employment and health plans, private health insurance companies have streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but were also credited for having moved to cater for higher-income customers in Maranhão. CONCLUSIONS: The 'plates' of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID economic recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded.

How many and which physicians? A comparative study of the evolution of the supply of physicians and specialist training in Brazil and Spain.

BACKGROUND: In the face of the medical workforce shortage, several countries have promoted the opening of medical schools and the expansion of undergraduate and specialization education in medicine. Few studies have compared the characteristics and effects of expanding the supply of general practitioners and specialist physicians between countries. Brazil and Spain, two countries with distinct historical processes and socioeconomic scenarios, yet both with universal public health systems and common aspects in training and medical work, have registered a significant increase in the number of physicians and can be used to understand the challenges of strategic planning for the medical workforce. METHODS: This study provides a descriptive approach using longitudinal data from official databases in Brazil and Spain from 1998 to 2017. Among the comparable indicators, the absolute numbers of physicians, the population size, and the physician's ratio by inhabitants were used. The number of medical schools and undergraduate places in public and private institutions, the supply of residency training posts, and the number of medical specialists and medical residents per 100 000 inhabitants were also used to compare both countries. Seventeen medical specialties with the highest number of specialists and comparability between the two countries were selected for further comparison. RESULTS: Due to the opening of medical schools, the density of physicians per 1 000 inhabitants grew by 28% in Spain and 51% in Brazil between 1998 and 2017. In that period, Spain and Brazil increased the supply of annual undergraduate places by 60% and 137%, respectively. There is a predominance of private institutions providing available undergraduate places, and the supply of medical residency posts is smaller than the contingent of medical graduates/general practitioners each year. CONCLUSION: Both countries have similar specialist densities in cardiology, dermatology, and neurosurgery specialties. However, family medicine and community in Spain has 91.27 specialists per 100 000 inhabitants, while in Brazil, the density is only 2.64. The comparative study indicated the complexity of the countries' decisions on increasing the medical supply of general practitioners and specialist physicians. Research and planning policies on the medical workforce must be aligned with the actual health needs of populations and health systems.

What explains wage differences between male and female Brazilian physicians? A cross-sectional nationwide study.

OBJECTIVE: In many countries an increase in the number of women in medicine is accompanied by gender inequality in various aspects of professional practice. Women in medical workforce usually earn less than their male counterparts. The aim of this study was to describe the gender wage difference and analyse the associated factors in relation to Brazil's physicians. PARTICIPANTS: 2400 physicians. SETTING: Nationwide, cross-sectional study conducted in 2014. METHODS: Data were collected via a telephone enquiry. Sociodemographic and work characteristics were considered factors, and monthly wages (only the monthly earnings based on a medical profession) were considered as the primary outcome. A hierarchical multiple regression model was used to study the factors related to wage differences between male and female physicians. The adjustment of different models was verified by indicators of residual deviance and the Akaike information criterion. Analysis of variance was used to verify the equality hypothesis subsequently among the different models. RESULTS: The probability of men receiving the highest monthly wage range is higher than women for all factors. Almost 80% of women are concentrated in the three lowest wage categories, while 51% of men are in the three highest categories. Among physicians working between 20 and 40 hours a week, only 2.7% of women reported receiving >US$10 762 per month, compared with 13% of men. After adjustment for work characteristics in the hierarchical multiple regression model, the gender variable estimations (ß) remained, with no significant modifications. The final effect of this full model suggests that the probability of men receiving the highest salary level (≥US$10 762) is 17.1%, and for women it is 4.1%. Results indicate that a significant gender wage difference exists in Brazil. CONCLUSION: The inequality between sexes persisted even after adjusting for working factors such as weekly workload, number of weekly on-call shifts, physician office work, length of practice and specialisation.

Internal migration of physicians who graduated in Brazil between 1980 and 2014.

BACKGROUND: The internal migration of physicians from one place to another in the same country can unbalance the supply and distribution of these professionals in national health systems. In addition to economic, social and demographic issues, there are individual and professional factors associated with a physician's decision to migrate. In Brazil, there is an ongoing debate as to whether opening medicine programmes in the interior of the country can induce physicians to stay in these locations. This article examines the migration of physicians in Brazil based on the location of the medical schools from which they graduated. METHODS: A cross-sectional design based on secondary data of 275,801 physicians registered in the Regional Councils of Medicine (Conselhos Regionais de Medicina-CRMs) who graduated between 1980 and 2014. The evaluated outcome was migration, which was defined as moving away from the state where they completed the medicine programme to another state where they currently work or live. RESULTS: 57.3% of the physicians in the study migrated. The probability of migration ratio was greater in small grouped municipalities and lower in state capitals. 93.4% of the physicians who trained in schools located in cities with less than 100,000 inhabitants migrated. Fewer women (54.2%) migrated than men (60.0%). More than half of the physicians who graduated between 1980 and 2014 are in federative units different from the unit in which they graduated. Individual factors, such as age, gender, time of graduation and specialty, vary between the physicians who did or did not migrate. CONCLUSIONS: The probability of migration ratio was greater in small municipalities of the Southeast region and strong in the states of Tocantins, Acre and Santa Catarina. New studies are recommended to deepen understanding of the factors related to the internal migration and non-migration of physicians to improve human resource for health policies.

Health services management modalities in the Brazilian Unified National Health System: a narrative review of research production in Public Health (2005-2016). / Modalidades de gestão de serviços no Sistema Único de Saúde: revisão narrativa da produção científica da Saúde Coletiva no Brasil (2005-2016).

The current study aimed to systematically analyze trends and priorities in the theoretical and conceptual approaches and empirical studies on specific health services management modalities in the Brazilian Unified National Health System. A narrative review of the literature identified, in 33 publications, the location and nature of services, management models, methodological procedures, and study outcomes. The research deals mainly with the models' conceptual and legal characteristics and management practices, in addition to addressing contracts, procurement, human resources, financing, and control mechanisms. In conclusion, the literature is limited and concentrated in the State of São Paulo, showing little theoretical diversity and methodological weaknesses, while it is nonconclusive as to the superiority of one management model over another. New evaluation studies are needed that are capable of comparing different models and assessing their performance and their effects on the quality of health services' provision, the population's health, and the health system's organization.

Judicialização em planos de saúde coletivos: os efeitos da opção regulatória da agência nacional de saúde suplementar nos conflitos entre consumidores e operadoras / Judicialization of collective health insurance plans: The effects of the Brazilian National Regulatory Agency for Private Health Insurance and Plans regulatory choice in conflicts between consumers and private health insurance providers

Este estudo aborda a judicialização na saúde suplementar por meio da análise de ações judiciais contidas na base pública on-line do Tribunal de Justiça do Estado de São Paulo. Com a aplicação de formulário, foram analisadas 4.059 ações relacionadas a contratos coletivos de planos de saúde, ajuizadas no Município de São Paulo nos anos de 2013 e 2014. Além de quantificar e descrever o perfil das demandas levadas à Justiça, buscou-se a análise qualitativa de decisões judiciais. O estudo identificou que os principais problemas judicializados são exclusão de coberturas, manutenção do aposentado no contrato coletivo e reajuste de mensalidade de idosos por mudança de faixa etária e por aumento de sinistralidade. Conclui-se que a regulação e a jurisprudência são desarmônicas, apresentando-se sugestões de mudanças regulatórias necessárias para diminuição de conflitos que permeiam o mercado de planos e seguros de saúde.

This study aims to approach judicialization in private health insurance through the analysis of lawsuits contained in the public online database of the Court of Justice of the State of São Paulo. Through the application of a form, 4,059 lawsuits were analyzed, all related to collective contracts of private health insurance, filed in the city of São Paulo during 2013 and 2014. Besides of quantifying and describing the profile of the demands brought to justice, a qualitative analysis of judicial decisions was performed. The study identified the main issues judicialialized as coverage reductions, the maintenance of members of collective contracts even after retirement, and increases in monthly payments for members as they become older and charges for increased risk. Concluding that regulations and jurisprudence are discordant, the study suggests regulatory changes aiming at the reduction of conflicts that permeate the private health insurance market.

Internal migration of physicians who graduated in Brazil between 1980 and 2014

Background: The internal migration of physicians from one place to another in the same country can unbalance the supply and distribution of these professionals in national health systems. In addition to economic, social and demographic issues, there are individual and professional factors associated with a physician’s decision to migrate. In Brazil, there is an ongoing debate as to whether opening medicine programmes in the interior of the country can induce physicians to stay in these locations. This article examines the migration of physicians in Brazil based on the location of the medical schools from which they graduated. Methods: A cross-sectional design based on secondary data of 275,801 physicians registered in the Regional Councils of Medicine (Conselhos Regionais de Medicina-CRMs) who graduated between 1980 and 2014. The evaluated outcome was migration, which was defined as moving away from the state where they completed the medicine programme to another state where they currently work or live. Results: 57.3% of the physicians in the study migrated. The probability of migration ratio was greater in small grouped municipalities and lower in state capitals. 93.4% of the physicians who trained in schools located in cities with less than 100,000 inhabitants migrated. Fewer women (54.2%) migrated than men (60.0%). More than half of the physicians who graduated between 1980 and 2014 are in federative units different from the unit in which they graduated. Individual factors, such as age, gender, time of graduation and specialty, vary between the physicians who did or did not migrate. Conclusions: The probability of migration ratio was greater in small municipalities of the Southeast region and strong in the states of Tocantins, Acre and Santa Catarina. New studies are recommended to deepen understanding of the factors related to the internal migration and non-migration of physicians to improve human resource for health policies.

Modalidades de gestão de serviços no Sistema Único de Saúde: revisão narrativa da produção científica da Saúde Coletiva no Brasil (2005-2016) / Modalidades de gestión de servicios de salud en el Sistema Único Salud de Brasil: revisión narrativa de la producción científica de la Salud Colectiva (2005-2016) / Health services management modalities in the Brazilian Unified National Health System: a narrative review of research production in Public Health (2005-2016)

O presente trabalho busca sistematizar tendências e prioridades das abordagens teórico-conceituais e das investigações empíricas sobre modalidades específicas de gestão de serviços no âmbito do Sistema Único de Saúde no Brasil. Foi realizada uma revisão narrativa da literatura que identificou, em 33 publicações, a localização e a natureza dos serviços, os modelos de gestão, os procedimentos metodológicos e os desfechos dos estudos. A produção trata principalmente de aspectos conceituais, legais e práticas gerenciais dos modelos, além de abordar contratos, compras, recursos humanos, financiamento e mecanismos de controle. Concluiu-se que a literatura analisada é restrita, concentrada no Estado de São Paulo, com baixa diversidade de teorias e fragilidades de aportes metodológicos, sendo inconclusiva quanto à superioridade de um modelo de gestão sobre outro. São fundamentais novas pesquisas avaliativas capazes de comparar os diferentes modelos e julgar seus desempenhos e efeitos na qualidade da assistência prestada, na saúde da população e na organização do sistema de saúde.

El presente estudio tuvo como objetivo analizar sistemáticamente las tendencias y prioridades en los enfoques teóricos y conceptuales y estudios empíricos sobre modalidades específicas de gestión de los servicios de salud en el Sistema Único de Salud de Brasil. Una revisión narrativa de la literatura identificó, en 33 publicaciones, la ubicación y la naturaleza de los servicios, los modelos de gestión, los procedimientos metodológicos y los resultados del estudio. La investigación se ocupa principalmente de las características conceptuales y legales y las prácticas de gestión de los modelos, además de abordar los contratos, las adquisiciones, los recursos humanos, el financiamiento y los mecanismos de control. En conclusión, la literatura es limitada y concentrada en el Estado de São Paulo, mostrando poca diversidad teórica y debilidades metodológicas, mientras que no es concluyente en cuanto a la superioridad de un modelo de gestión sobre otro. Se necesitan nuevos estudios de evaluación que sean capaces de comparar diferentes modelos y evaluar su desempeño y sus efectos sobre la calidad de la provisión de servicios de salud, la salud de la población y la organización del sistema de salud.

The current study aimed to systematically analyze trends and priorities in the theoretical and conceptual approaches and empirical studies on specific health services management modalities in the Brazilian Unified National Health System. A narrative review of the literature identified, in 33 publications, the location and nature of services, management models, methodological procedures, and study outcomes. The research deals mainly with the models' conceptual and legal characteristics and management practices, in addition to addressing contracts, procurement, human resources, financing, and control mechanisms. In conclusion, the literature is limited and concentrated in the State of São Paulo, showing little theoretical diversity and methodological weaknesses, while it is nonconclusive as to the superiority of one management model over another. New evaluation studies are needed that are capable of comparing different models and assessing their performance and their effects on the quality of health services' provision, the population's health, and the health system's organization.

Brazilian infectious diseases specialists: who and where are they?

Abstract Background The infectious diseases specialist is a medical doctor dedicated to the management of infectious diseases in their individual and collective dimensions. Objectives The aim of this paper was to evaluate the current profile and distribution of infectious diseases specialists in Brazil. Methods This is a cross-sectional study using secondary data obtained from institutions that register medical specialists in Brazil. Variables of interest included gender, age, type of medical school (public or private) the specialist graduated from, time since finishing residency training in infectious diseases, and the interval between M.D. graduation and residency completion. Maps are used to study the geographical distribution of infectious diseases specialists. Results A total of 3229 infectious diseases specialist registries were counted, with 94.3% (3045) of individual counts (heads) represented by primary registries. The mean age was 43.3 years (SD 10.5), and a higher proportion of females was observed (57%; 95% CI 55.3–58.8). Most Brazilian infectious diseases specialists (58.5%) practice in the Southeastern region. However, when distribution rates were calculated, several states exhibited high concentration of infectious diseases specialists, when compared to the national rate (16.06). Interestingly, among specialists working in the Northeastern region, those trained locally had completed their residency programs more recently (8.7 yrs; 95% CI 7.9–9.5) than physicians trained elsewhere in the country (13.6 yrs: 95% CI 11.8–15.5). Conclusion Our study shows that Brazilian infectious diseases specialists are predominantly young and female doctors. Most have concluded a medical residency training program. The absolute majority practice in the Southeastern region. However, some states from the Northern, Northeastern and Southeastern regions exhibit specialist rates above the national average. In these areas, nonetheless, there is a strong concentration of infectious diseases specialists in state capitals and in metropolitan areas.

Brazilian infectious diseases specialists: who and where are they?

BACKGROUND: The infectious diseases specialist is a medical doctor dedicated to the management of infectious diseases in their individual and collective dimensions. OBJECTIVES: The aim of this paper was to evaluate the current profile and distribution of infectious diseases specialists in Brazil. METHODS: This is a cross-sectional study using secondary data obtained from institutions that register medical specialists in Brazil. Variables of interest included gender, age, type of medical school (public or private) the specialist graduated from, time since finishing residency training in infectious diseases, and the interval between M.D. graduation and residency completion. Maps are used to study the geographical distribution of infectious diseases specialists. RESULTS: A total of 3229 infectious diseases specialist registries were counted, with 94.3% (3045) of individual counts (heads) represented by primary registries. The mean age was 43.3 years (SD 10.5), and a higher proportion of females was observed (57%; 95% CI 55.3-58.8). Most Brazilian infectious diseases specialists (58.5%) practice in the Southeastern region. However, when distribution rates were calculated, several states exhibited high concentration of infectious diseases specialists, when compared to the national rate (16.06). Interestingly, among specialists working in the Northeastern region, those trained locally had completed their residency programs more recently (8.7yrs; 95% CI 7.9-9.5) than physicians trained elsewhere in the country (13.6yrs: 95% CI 11.8-15.5). CONCLUSION: Our study shows that Brazilian infectious diseases specialists are predominantly young and female doctors. Most have concluded a medical residency training program. The absolute majority practice in the Southeastern region. However, some states from the Northern, Northeastern and Southeastern regions exhibit specialist rates above the national average. In these areas, nonetheless, there is a strong concentration of infectious diseases specialists in state capitals and in metropolitan areas.

Interaction between pharmaceutical companies and physicians who prescribe antiretroviral drugs for treating AIDS.

CONTEXT AND OBJECTIVE: Given that Brazil has a universal public policy for supplying medications to treat HIV and AIDS, the aim here was to describe the forms of relationship between physicians and the pharmaceutical companies that produce antiretrovirals (ARVs). DESIGN AND SETTING: Cross-sectional epidemiological study conducted in the state of São Paulo. METHODS: Secondary database linkage was used, with structured interviews conducted by telephone among a sample group of 300 physicians representing 2,361 professionals who care for patients with HIV and AIDS. RESULTS: Around two thirds (64%) of the physicians prescribing ARVs for HIV and AIDS treatment in the state of São Paulo who were interviewed declared that they had some form of relationship with pharmaceutical companies, of which the most frequent were receipt of publications (54%), visits by sales promoters (51%) and receipt of small-value objects (47%). CONCLUSIONS: Two forms of relationship between the pharmaceutical industry and physicians who deal with HIV and AIDS can be highlighted: facilitation of professionals' access to continuing education; and antiretroviral drug brand name promotion.

[Professional background and experience of antiretroviral prescribing physicians in the State of São Paulo]. / Formação e experiência profissional dos médicos prescritores de antirretrovirais no Estado de São Paulo.

OBJECTIVE: Analysis of the professional profile of physicians who prescribe antiretroviral drugs (ARV) to HIV infected persons in the State of São Paulo. METHODS: Databases from different sources, namely Ministry of Health, São Paulo State Regional Medical Council, National Commission on Medical Residency and the Lattes platform, were consulted. Data concerning socio-demographic characteristics, academic and professional background and experience for the period from October 2007 to May 2009 were analyzed. RESULTS: The regular ARV prescription for 74 thousand patients was issued by 1,609 physicians whose characteristics are: evenly distributed according to gender, aged between 30 to 49 years, live in the metropolitan area of Greater São Paulo, graduated 16.1 years ago on the average, come from 93 different Brazilian medical schools, hold a specialty diploma in 67.5% of cases, most of them in the field of Infectious Diseases (38.9%). The mean number of patients per physician was 10, though 51.6% of physicians prescribed for 20 or more patients. Of these physicians 62% reported specific knowledge or experience with HIV care, although 2.7% of all prescriptions were issued by physicians without this specific qualification. Regions of high AIDS incidence showed a smaller number of prescribing physicians. The cities of Registro and Ribeirão Preto showed the highest concentration of physicians lacking proper credentials. CONCLUSION: The absolute majority of HIV patients receives their prescriptions from duly trained and experienced physicians. Nevertheless, the large number of non-qualified physicians together with the reduced number of physicians in HIV high incidence regions make up the major challenge for comprehensive and adequate care of HIV patients.

Formação e experiência profissional dos médicos prescritores de antirretrovirais no Estado de São Paulo / Professional background and experience of antiretroviral prescribing physicians in the State of São Paulo

OBJETIVO: Analisar o perfil dos médicos que prescreveram antirretrovirais (ARV) no Estado de São Paulo para o tratamento de pessoas infectadas pelo HIV. MÉTODOS: Foram analisadas as características sociodemográficas, de formação técnico-científica e a experiência dos profissionais que prescreveram os ARV entre outubro de 2007 e maio de 2009, utilizando-se informações obtidas nos bancos de dados do Ministério da Saúde, Conselho Regional de Medicina do Estado São Paulo, Comissão Nacional de Residência Médica e plataforma Lattes. RESULTADOS: A prescrição regular de ARV para 74 mil pacientes foi realizada por 1609 médicos, que apresentam distribuição similar segundo sexo, têm entre 30 anos e 49 anos, residem principalmente na região metropolitana de São Paulo, são formados em média há 16,1 anos, em 93 escolas médicas do país e possuem alguma formação em especialidades médicas (67,5 por cento), especialmente em infectologia (38,9 por cento). Cada médico prescreveu ARV em média para 10 pacientes, sendo que 51,6 por cento prescreveram para 20 ou mais pacientes. Entre os profissionais, 62 por cento reúnem conhecimento específico ou experiência para o tratamento de pessoas com HIV, sendo que 2,7 por cento das prescrições foram realizadas por profissionais que não apresentaram nenhuma dessas condições. Regiões com alta incidência de Aids apresentaram menor número de prescritores, como Barretos e Baixada Santista, reunindo as maiores concentrações de profissionais sem conhecimento específico ou experiência no Estado de São Paulo. CONCLUSÃO: A maioria das pessoas com HIV recebem prescrições de médicos que apresentam os requisitos de conhecimento e/ou experiência. Porém, o grande número de prescritores sem as qualificações mínimas e o reduzido número de médicos em regiões de maior incidência de Aids implicam importantes desafios para universalizar adequada atenção à saúde de pessoas com HIV.

OBJECTIVE: Analysis of the professional profile of physicians who prescribe antiretroviral drugs (ARV) to HIV infected persons in the State of São Paulo. METHODS: Databases from different sources, namely Ministry of Health, São Paulo State Regional Medical Council, National Commission on Medical Residency and the Lattes platform, were consulted. Data concerning socio-demographic characteristics, academic and professional background and experience for the period from October 2007 to May 2009 were analyzed. RESULTS: The regular ARV prescription for 74 thousand patients was issued by 1,609 physicians whose characteristics are: evenly distributed according to gender, aged between 30 to 49 years, live in the metropolitan area of Greater São Paulo, graduated 16.1 years ago on the average, come from 93 different Brazilian medical schools, hold a specialty diploma in 67.5 percent of cases, most of them in the field of Infectious Diseases (38.9 percent). The mean number of patients per physician was 10, though 51.6 percent of physicians prescribed for 20 or more patients. Of these physicians 62 percent reported specific knowledge or experience with HIV care , although 2.7 percent of all prescriptions were issued by physicians without this specific qualification. Regions of high AIDS incidence showed a smaller number of prescribing physicians. The cities of Registro and Ribeirão Preto showed the highest concentration of physicians lacking proper credentials. CONCLUSION: The absolute majority of HIV patients receives their prescriptions from duly trained and experienced physicians. Nevertheless, the large number of non-qualified physicians together with the reduced number of physicians in HIV high incidence regions make up the major challenge for comprehensive and adequate care of HIV patients.

Aids, tecnologia e acesso sustentável a medicamentos: a incorporação dos anti-retrovirais no Sistema Único de Saúde / Aids, technology and sustainable access to medicine: the incorporation of antiretroviral drugs in the Single Health System

A presente tese traz, além de conceitos sobre a incorporação de tecnologias na saúde, uma abordagem da regulação institucional brasileira, junto com a descrição da história e do funcionamento dos medicamentos para tratamento da aids. Na segunda parte do trabalho, a partir de uma série de entrevistas, são descritos e analisados os percursos e processos da incorporação dos medicamentos anti-retrovirais no Brasil, a política pública na qual estão inseridos assim como a intermediação do programa governamental na introdução desta tecnologia. São identificadas também as instituições, grupos ou corporações - empresas farmacêuticas, Ministério da Saúde, médicos, pessoas que vivem com HIV e aids e Poder Judiciário, que atuam em três percursos da incorporação da tecnologia em questão. No percurso científico, há a validação da tecnologia através da realização de pesquisas com seres humanos e da elaboração de diretrizes clínicas. A fase regulatória da tecnologia, com seu registro oficial e sua etapa prescritiva, quando também ocorrem a promoção e marketing das empresas farmacêuticas e as ações judiciais que obrigam o poder público a fornecer os medicamentos, caracterizam o percurso transicional. Já no percurso mercantil conformam-se os aspectos relacionados à demanda, oferta, produção, preço, compra e venda dos anti-retrovirais. O estudo indica a ausência de uma atuação regulatória integrada e sistêmica do Estado sobre todos os percursos da incorporação dos anti-retrovirais...

This thesis brings, in addition to concepts about the incorporation of technologies in health, an approach to the Brazilian institutional regulation, together with the description of the history and the functioning of medicines for the treatment of aids. In the second part of the work, based on a series of interviews, the courses and processes of the incorporation of antiretroviral drugs in Brazil are described and analyzed, just like the public policy in which they are inserted and the intermediation of the government program in the introduction of this technology. Also, we identify the institutions, groups or corporations - pharmaceutical companies, Surgeon General, doctors, people who live with HIV and aids and Judiciary Power -, who work in three courses of the incorporation of the technology in question. In the scientific course, there is the validation of the technology through research with human beings and the preparation of clinical guidelines. The regulatory phase of the technology, with its official register and its prescriptive stage, when the promotion and marketing of the pharmaceutical companies also occur, and also the legal actions that make the government provide the drugs, characterize the transition course. As for the mercantile course, it contains the aspects related to demand, supply, production, price, purchase and sale of antiretroviral drugs. The study shows the absence of an integrated, systemic regulatory action of the State on all the courses of the incorporation of the antiretroviral drugs. It also points out important aspects for better understanding the introduction of new technologies in the Unified Health System, whereas it suggests the need of new strategies in order to guarantee the sustainability of the Brazilian policy of universal access to the treatment of aids.

AIDS, tecnologia e acesso sustentável a medicamento: a incorporação dos anti-retrovirais no Sistema Único de Saúde

O estudo apresenta conceitos sobre a incorporação de tecnologia na saúde, uma abordagem da regulação institucional brasileira, junto com a descrição da história e do funcionamento dos medicamentos para tratamento da AIDS. Descreve e analisa os processos da incorporação dos medicamentos anti-retrovirais no Brasil, a política pública na qual estão inseridos assim como a intermediação do programa governamental na introdução desta tecnologia

Os planos de saúde nos tribunais: uma análise das ações judiciais movidas por clientes de planos de saúde, relacionadas à negação de cobrerturas assistênciais no Estado de São Paulo

O estudo analisa e descreve as demandas levadas ao Poder judiciário por usuários de plano de saúde que reclamam de assistência ou restrição de atendimento. Também são avaliados o comportamento e as argumentações da Justiça nas decisões, assim como as possíveis de cobreturas praticadas pelos planos de saúde