Léo Ramos ChavesA group of Brazilian and Swedish researchers has analyzed the evolution of drug procurements by the Brazilian government between 2006 and 2013. They found that not only has drug spending grown, but its profile has also changed. According to the study, published in the journal PLOS One in April 2017, treatments for infectious diseases got the biggest slice of government funds until 2009. Starting in 2010, the top spot was taken over by antineoplastic agents–i.e., drugs used to fight cancer–and immunosuppressants, which are prescribed to fight autoimmune diseases and prevent the rejection of transplanted organs. These two categories of drugs consumed R$183 million from Brazil’s public coffers in 2006, and R$3.7 billion in 2013.
The study does not reflect an increase in prevalence of these illnesses among Brazilians, but rather the recent availability of drugs to treat them through the National Healthcare System (SUS), and the staggering financial cost it entailed. In terms of volumes purchased, treatments for cardiovascular diseases accounted for slightly over a third of all drugs procured by the government between 2006 and 2013. “In Brazil, the diseases that most often afflict the population are still hypertension and heart attacks, not to mention diabetes, but the medications to treat those illnesses have become cheaper over time. At the same time, the SUS added drugs for less prevalent diseases and started providing them through the public healthcare system,” says Tatiana Chama Borges Luz, a researcher with the Transdisciplinary Study Group for Health and Environment Education at the Oswaldo Cruz Foundation (Fiocruz), in the state of Minas Gerais, and main author of the study.
Brazilian federal spending on drug procurements for the national healthcare system increased significantly in recent years, the study shows. Whereas R$2.63 billion were allocated to drug purchases in 2006, a total of R$7.15 billion was spent in 2013, a 271% increase. Out of the total amount spent in that period, around R$34 billion–almost 50%–went into three categories of drugs: immunosuppressants, antineoplastics and certain antivirals to treat diseases like AIDS, herpes and influenza. “Some categories, like immunosuppressants, became more expensive due to the use of new technologies,” says Luz.
The study indicates that government drug spending practically tripled, but the volumes procured merely doubled between 2006 and 2013. “Expenditure grew without an equivalent increase in coverage. This uptrend in pharmaceutical spending is seen worldwide, but to different degrees,” says the researcher. In Canada, government spending on pharmaceutical drugs rose at an average annual rate of 4.5% from 2006 to 2011, while Brazil and China reported increases of 13.3% and 14.9% in the same period, respectively. According to Luz, the Brazilian government should examine its expenditures in order to find a more efficient way of distributing its resources. Data from the National Commission for Technology Incorporation at SUS (Conitec), affiliated with Brazil’s Ministry of Health, show that 60% of all medications added to the public healthcare system between 2012 and 2016 were high-cost drugs.
Immunosuppressants head the list of drugs responsible for the biggest increases in spending, rocketing up 25,000% between 2006 and 2013. This category includes inhibitors of tumor necrosis factor alpha (TNF-alpha) and interleukins. These drugs are used to treat diseases like rheumatoid arthritis, for example, which has a prevalence of 0.5% to 1% in the Brazilian population. They are also prescribed to patients with Crohn’s disease, which afflicts approximately six out of 100,000 Brazilians. Price was the main factor in the increased expenditure on immunosuppressants; the increase in quantity was not as steep. “Autoimmune diseases currently afflict roughly 8% to 10% of the adult [Brazilian] population, and are less frequent in children,” explains Magda Carneiro-Sampaio, professor of clinical pediatrics at the University of São Paulo School of Medicine (FMUSP).
She says that the drugs known as immunobiological agents, a subgroup of immunosuppressants, are indicated for use against various autoimmune diseases and are high-cost medications. “Many of them are monoclonal antibodies whose development requires major investments,” Carneiro-Sampaio explains. In addition to their high cost, she says, immunosuppressant use has become more frequent, probably due to the increasing number of transplants and improved capability of diagnosing autoimmune diseases.
Anticancer drugs have also increased in price in Brazil, in line with a global trend. Data released by the American Society of Clinical Oncology in 2015 showed that cancer treatments can currently cost around $10,000 per month, on average. “The main innovations in this field are targeted therapies–which interfere with specific molecular alterations caused by tumors–and immunotherapy, which aims to reestablish the patient’s immune response against a cancer. Both strategies have been shown to be more effective and less toxic than classic chemotherapy,” says Helano Freitas, scientific coordinator of clinical research at the A.C.Camargo Cancer Center, in the city of São Paulo. According to Freitas, newer anticancer drugs are arriving on the Brazilian market at costs of R$30,000 to R$35,000 per month.
He explains that the rising cost is due, among other factors, to technological advances and the hefty investments funneled into new therapies. “With the advance of precision medicine, common diseases like adenocarcinoma of the lung are transforming into multiple rare diseases, according to the type of molecular alteration detected,” says Freitas. In certain situations, he explains, drugs designed for a specific profile of a disease can be prescribed, increasing the chances of controlling it in the long term. “Society needs to discuss the pharmacoeconomic aspects involved in these new therapies. The results of these treatments are encouraging, but the costs are becoming impossible to pay,” says Freitas.
Eloísa Bonfá, clinical director of the Hospital das Clínicas at FMUSP, says that the development of targeted therapies is particularly painstaking, involves genetic engineering and demands major investments. “This generates a very high cost and hinders access to the drug, often leading to legal action by patients who need medications that have not been incorporated by SUS,” she says. “Our research certainly includes amounts spent on legal awards, although we still do not know how much,” says Tatiana Luz from Fiocruz. This “judicialization of health” is present throughout Brazil. In 2015 alone, the São Paulo State government spent R$1.2 billion on drugs and supplies for 57,000 patients who took their cases to court (see Pesquisa FAPESP Issue No. 252).
“The study by Fiocruz should be broadly disseminated among decision-makers at the federal level,” suggests Carlos Octávio Ocké-Reis, chairman of the Brazilian Association of Health Economics and researcher at the Institute for Applied Economic Research (IPEA). Having directed the Health Economics Department of the Brazilian Ministry of Health from 2015 to 2016, he says that many players in the healthcare system are pressuring the government to make new drugs available, including doctors, health insurance companies and the pharmaceutical industry. “The gaps in the regulatory system for SUS favor this pressure. One proposal would be for the government to enhance its regulatory capacity in order to gain bargaining power when negotiating with the industry and defining which drugs will be made available through the public system,” Ocké-Reis suggests.
CHAMA Borges Luz, T. et. al. Trends in medicine procurement by the Brazilian federal government from 2006 to 2013. PLOS One. April 2017.