Nos últimos anos constata-se no Brasil um aumento do número de decisões judiciais obrigando o poder público a fornecer medicamentos, insumos, equipamentos e cirurgias. Os juízes tendem a desconsiderar o impacto orçamentário de suas decisões e entendem que todos os entes da federação podem ser igualmente responsabilizados pelo fornecimento de qualquer item pedido pelo paciente. O presente estudo analisa o impacto dessas decisões para a gestão orçamentária da política de saúde no município de São Paulo por meio de uma estimativa de gastos com a judicialização para o ano de 2011 a partir dos dados disponibilizados pelo município e as publicações no Diário Oficial concernentes à compra de medicamentos e insumos sem licitação pela Secretaria Municipal de Saúde. De acordo com as estimativas do presente trabalho, o gasto do município com judicialização da saúde em 2011 é o equivalente a 6% do que o município gastou com sua política de assistência farmacêutica e 10% do total gasto com fornecimento de medicamentos e material hospitalar, ambulatorial e odontológico. Além do mais, cerca de 55% desse gasto são destinados ao fornecimento de medicamentos de responsabilidade de estados ou União, e por volta de 45% para tratamentos não contemplados pelo Sistema Único de Saúde.Pa l a v r a s -c h a v e : Judiciário; políticas de saúde; município de São Paulo; federalismo.

Abstract:As health policy-makers around the world seek to make progress towards universal health coverage they must navigate between two important ethical imperatives: to set national spending priorities fairly and efficiently; and to safeguard the right to health. These imperatives can conflict, leading some to conclude that rights-based approaches present a disruptive influence on health policy, hindering states' efforts to set priorities fairly and efficiently. Here, we challenge this perception. We argue first that these points of tension stem largely from inadequate interpretations of the aims of priority setting as well as the right to health. We then discuss various ways in which the right to health complements traditional concerns of priority setting and vice versa. Finally, we set out a three-step process by which policy-makers may navigate the ethical and legal considerations at play.

This article first analyses how courts, by applying the right to health as a trump against rationing decisions, have become a relevant healthcare policy-maker in Brazil. Based on empirical findings, it argues that right to health litigation makes the Brazilian public health system less fair and efficient. It then discusses three responses to the negative impact of litigation on the health system: the public hearing held by the Supreme Federal Court and the test established thereafter; the recommendations by the National Council of Justice aimed at building courts' institutional capacity; and Federal Law 12.401/11, which created a new health technology assessment system. Based on a comparative institutional analysis, it concludes that the latter response is the most adequate because it keeps the substantial decisions on the allocation of healthcare resources in the institution that has better capacity to make them and facilitates the judicial control of procedure. This is not the final published version and changes have been made in the editing stages. The final version of this article is available in http://hrlr.oxfordjournals.org/content/15/4/617 2 Right to health litigation in Brazil has already been discussed in the literature on social rights adjudication. 1 This article, however, presents a more comprehensive review of the empirical findings which provides more solid grounds for answering three questions: what is demanded by claimants; the economic impact of the decisions on the public health budget; and how courts judge these cases. The data reveal that litigation in Brazil has reached an impressive scale and has made of courts a major player in the allocation of healthcare resources, but in a way that makes the public health system less fair and efficient.The second part of this article compares three responses and the institutions they create to control the negative impact of litigation on the public health system: the public hearing held by the Supreme Federal Court (STF) and the test established thereafter to define a sphere of judicial self-restraint; the recommendations by the National Council of Justice (CNJ) aimed at building courts' institutional capacity; and the enactment of Federal Law 12.401/11, which created a new health technology assessment system.Claims for the provision of health treatments, although not necessarily using the language of the right to health, are certainly not a phenomenon restricted to Brazil. In many jurisdictions the expansion of judicial power to cover issues of social policies, the increase in the cost of healthcare, and better informed and less acquiescent patients have all brought to courts discussions about priority-setting in healthcare that were in the past left to the entire discretion of legislatures and health authorities. 2

Este artigo analisa os temas da escassez de recursos, custos dos direitos e cláusula de reserva do possível na jurisprudência do Supremo Tribunal Federal brasileiro. Por meio do estudo dessas decisões, procuro, primeiramente, descobrir em que tipo de matéria esses temas são comumente debatidos nos julgamentos do Supremo Tribunal Federal. Em um segundo momento, procuro entender a forma como o tribunal trata esses temas em sua jurisprudência e os critérios utilizados em suas análises. Por fim, busco examinar se a análise jurídica dos ministros leva em consideração preocupações relativas às conseqüências econômicas e distributivas das decisões. A pesquisa de acórdãos foi feita com base nestes três temas: direito à saúde, direito à educação e intervenção federal por não pagamento de precatórios. Em uma primeira fase, analiso o tratamento dado aos custos dos direitos, à reserva do possível e à escassez de recursos dentro de cada um desses temas. E, em um segundo momento, cruzo os resultados obtidos em cada tema para mostrar as diferenças de tratamento.

The World Health Organization report Preventing Suicide: A Global Imperative provides governments with guidance for comprehensive suicide prevention strategies. However, it does not mention the role that compulsory admission to hospital of psychiatric patients should have in policies for suicide prevention. This was a missed opportunity for international discussion and guidance about a measure that, although widely used, is becoming increasingly controversial in light of the existing evidence and human rights norms.