Conitec makes controversial public consultation to limit spending on SUS

The Ministry of Health is accepting contributions from civil society until July 11 in one of the most controversial public consultations put on the agenda in 2022.

The objective is to discuss a document prepared by the ministry that proposes the use of cost-effectiveness thresholds for the recommendations of the National Commission for the Incorporation of Technologies in the SUS (Conitec).

In practice, a spending cap would be implemented for new drugs in the SUS — millionaire drugs for rare diseases, for example, would be treated as exceptions.

Arguing greater transparency in decisions that affect the SUS, the Ministry of Health proposes establishing a reference value for a GDP per capita, equivalent to R$ 40,688 (2021 value). If alternative thresholds are needed, such as children with rare diseases, spending up to three times the reference value is accepted.

“Discussions related to advanced technologies (gene therapies or curatives) or those indicated for ultra-rare diseases (up to 1 case in every 50,000 people) will be based on specific criteria, to be defined later by Conitec”, says the document.

In a note, the Brazilian Federation of Rare Disease Associations states that the text is vague, and it is not clear how it was prepared. “The controversial points mentioned in the document were not effectively agreed and the result is interpreted in a questionable way, as can be seen in the definition of the ceiling of alternative thresholds”, says Febrararas.

The association recalls that the methodology of defining a threshold based on GDP was abandoned by the World Health Organization (WHO) in 2016 for not having the necessary specificity, and which can lead to a wrong decision on the use of health resources.

“The apprehension at the entrance of new health technologies, such as advanced therapies, is understandable. It is essential to emphasize, however, that untimely actions such as the elaboration of a document with
non-transparent methodological basis can generate serious problems for public health. As the SUS constitution itself defines, civil society controls the services provided by the public health system. In this way, Febrararas – as a representative of Brazilians with rare diseases – publicly manifests itself against the positions presented in this document”, says the note.

The group says that models similar to SUS in other countries show that vetoing new treatments is not what brings efficiency to the health system, but modernization in management.

The report questioned whether the Ministry of Health is in favor of implementing the threshold, whether the decision would only apply to future incorporations and what the next steps are after the deadline, but received no response until the publication of this news.

Rare patient at risk

In an interview with metropolises, the president of Febrararas and Casa Hunter, Antoine Daher, explains that if the threshold is approved, treatments for rare diseases, cancer and other chronic conditions will be affected. He considers the proposal a step backwards.

“This proposal is particularly harmful to rare diseases because of their specificities. We are talking about drugs that required cutting-edge research, associated with a reduced number of patients. High-cost products, precisely because of the combination of these elements”, he explains.

According to him, the cost-effectiveness threshold should make the budget for each disease clear and transparent, justifying the definition and criteria. However, for newer technologies, this ceiling cannot be set.

For Daher, the incorporation of advanced therapies does not threaten the SUS, and the approval may leave out patients who need medicines above the threshold, which violates the constitutional right of access to health.

“If a proposal like this is approved, we will create barriers to the arrival of new technologies for Brazilian patients. Triple the value for adults or children will not allow Conitec to incorporate more products for the treatment of rare diseases in Brazil. It’s a big limiter, actually,” she says.

The president of Febrararas and Casa Hunter also recalls that the National Supplementary Health Agency (ANS) follows Conitec’s decisions, also limiting access to patients who have health insurance.

Discussion about funding

SUS funding is one of the main discussions in public health. While the Federal Constitution guarantees that the State is responsible for providing any treatment to the patient, organization and funding are lacking.

Last year, government spending on public health was 3.8% of GDP, which represents R$1,600 per person. The United Kingdom, which has a public health system that inspired the creation of the SUS, spent the equivalent of R$20,000 per person.

In a panel promoted by Instituto Lado a Lado Pela Vida last Tuesday (28/6), former Minister of Health Nelson Teich stated that the problem needs to be dealt with in accordance with reality.

“If we don’t face the situation with the necessary complexity, what we will have are those romantic projects that will never solve anything. The problem with not having the resources to incorporate everything is having to make choices. Today, the system is not coordinated by a manager, it is coordinated by market forces, which will always focus on the individual and profit and never on people. The market is balanced on money, it is not balanced on care”, explained the oncologist.

He also highlights that the biggest problem is not exactly access, but delivery: when a part of the treatment is not done well, the bill becomes more expensive at the end of the process. Teich argues that the incorporation needs to be reviewed to avoid even more inequalities in the system.

New proposals

The coordinator of the Center for Strategic Studies in the Health Sector at USP, Marcelo Caldeira Pedroso, suggests that the solution involves a better partnership between public and private services, especially in secondary and tertiary care. “One way out is to revisit the system as a whole, for greater integration between the SUS and the private network”, he explains.

The executive secretary of the National Council of Municipal Health Secretariats (Conasems), Mauro Guimarães Junqueira, recalls that another important point of discussion is the division of the budget: in the current model, only 18% stays with the municipalities, which end up responsible for millionaire acquisitions. without conditions.

“It is necessary to discuss the federative pact and redefine the percentages of resources and what each federated entity should do. It is not up to the municipality to finance, for example, a high-cost medication for a patient, sacrificing the entire population, which will be left without resources for other treatments. Municipalities spend R$ 35 billion a year on health, 80% of all IPTU (Property and Territorial Urban Tax) collected is placed in the public network. Municipalization has gone beyond the limit”, he warns.

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