OBJETIVO: Analisar a cobertura qualitativa das políticas terapêuticas no Sistema Único de Saúde (SUS), no âmbito federal, para doenças referidas em ações judiciais. MÉTODOS: Realizou-se pesquisa exploratória com base em uma amostra de doenças referidas em ações judiciais impetradas contra a Secretaria Municipal da Saúde de São Paulo em 2005. Efetuou-se uma busca das normas que estabelecem políticas terapêuticas nas páginas eletrônicas do Ministério da Saúde e sobre os recursos terapêuticos recomendados (medicamentos e procedimentos cirúrgicos) na base de dados Diseasedex, integrante do sistema Micromedex. Elaborou-se quadro-resumo, analisando-se para cada doença a cobertura por política terapêutica federal vigente, em função da inclusão de medicamentos ou procedimentos recomendados nesta política como primeira linha de tratamento. RESULTADOS: O atendimento terapêutico está contemplado para a maioria das doenças (n = 26), seja por meio de política da atenção básica, seja por meio de política para doenças raras e/ou de alto custo, o que representa 96% das doenças da amostra estudada (n = 27). Observou-se que das 27 doenças, três delas estão contempladas por política terapêutica limitada, ou seja, a política não oferece as abordagens de primeira escolha em sua totalidade, o que corresponde a 11% da amostra. A única doença que não está contemplada por política terapêutica é o transtorno do déficit de atenção e hiperatividade. CONCLUSÃO: Existem limitações em termos de cobertura qualitativa para o tratamento de algumas doenças da amostra estudada, em âmbito federal, o que compromete a integralidade da assistência terapêutica e da atenção à saúde em alguns casos.
Políticas públicas de saúde; Decisões judiciais; Cobertura de serviços públicos de saúde; Direito à saúde
OBJECTIVE: To analyze the qualitative coverage of therapeutic policies at federal level in the Brazilian Public Health System (SUS) for diseases that were the subject of lawsuits. METHODS: An exploratory research was performed, based on a sample of diseases referred to in lawsuits against the city of São Paulo Municipal Office for Health, in 2005. A search of the standards that set forth therapeutic policies, as well as recommended therapeutic resources (surgical procedures and drugs), was performed. The database Diseasedex, part of the Micromedex system, was used as the basis for therapeutic procedures used to treat those diseases. A reference summary table was prepared to facilitate comparison between recommendations in public policies and the Diseasedex database. RESULTS: Therapeutic public policy covers the major part (n = 26) of the diseases analyzed, either by public policies for primary care or public policies for rare diseases and/or high cost treatment diseases. This represents 96% of the sample analyzed (n = 27). Only 3 of the 27 diseases in the sample are contemplated by limited therapeutic policies. This means that public policies do not offer full first-line therapy, which corresponds to 11% of the sample. There was only one disease that was not covered by public therapeutic policies: attention deficit hyperactivity disorder. CONCLUSION: There were limitations in the qualitative coverage of treatment of some diseases from the sample analyzed, which may jeopardize the comprehensiveness of therapeutic assistance and health care in some cases.
Public health policy; Legal decisions; State health care coverage; Right to health
IEspecialista em Políticas Públicas e Gestão Governamental - Ministério da Saúde, Brasília, DF
IIVice-coordenadora do Centro Paulista de Economia da Saúde, Universidade Federal de São Paulo - UNIFESP, São Paulo, SP
OBJECTIVE: To analyze the qualitative coverage of treatment policies at the federal level in the Brazilian National Health Service (SUS) for diseases that have been the subject of patient lawsuits.
METHODS: An exploratory research study was undertaken based on a sample comprising diseases referred to in lawsuits against the city of São Paulo Municipal Health Department in 2005. The Brazilian Ministry of Health's electronic pages were searched for the standards that set out treatment policies and the Diseasedex database was searched for the recommended treatment resources (surgical procedures and drugs). A table was drawn up summarizing the coverage for each disease provided by the federal treatment policy in force, on the basis of the medications or procedures recommended as first line treatment.
RESULTS: Public treatment policies cover the greater part (n = 26) of the diseases analyzed, either through public policies for primary care or public policies for rare diseases and/or high treatment cost diseases. This represents 96% of the sample analyzed (n = 27). It was observed that 3 of the 27 diseases, which corresponds to 11% of the sample, are covered by deficient treatment policies. This means that public policies do not offer full first-line therapy. There was only one disease that was not covered by a public treatment policy: attention deficit hyperactivity disorder.
CONCLUSION: The qualitative treatment coverage for some diseases in the sample analyzed was deficient, which could compromise the integral nature of treatment and healthcare in some cases.
Key words: Public health policy. Legal decisions. State healthcare coverage. Right to health.
Brazil's healthcare legislation (Lei Orgânica da Saúde, Law number 8,080 of 1990)1 states that the care provided by the Brazilian National Health Service (SUS - Sistema Único de Saúde) must be integral and must include pharmaceutical treatment. The term "integral healthcare provision" (assistência terapêutica integral) has no legal definition. It is associated with the idea that care is provided through the medium of providing treatments for patients. At this point, it is worth making some observations about the meaning of the word "integral" that is used to qualify this care. Within the SUS, "integral" relates to a coordinated conjunction of interventions to promote, prevent and recover health, and these interventions and services are considered at three different levels of complexity. This implies analyzing and meeting all of people's healthcare requirements, from the most basic to the most complex.2,3
Given that the market in medications and healthcare products is extremely large, it can be imagined what the consequences for the Brazilian National Health Service would be if the concept of integral healthcare were to be interpreted in a manner different to that described above. To do so, it is enough to consider the size of these markets, which, according to data from a retail prices magazine, consist of 14,286 medications and 48,720 hospital supply items (already broken down into their different presentations).4
If the word "integral", as used to qualify healthcare treatment, were to acquire the meaning of "everything that is available on the market", it is obvious what the effect of this interpretation would be for the SUS. The consequences of this can already be observed in the increase in lawsuits filed against Health Departments by citizens demanding medications and other products.5-7
In principle, these suits can be divided into two groups: a) justified; and b) unjustified. Recent studies have demonstrated that a proportion of these lawsuits request the provision of medications that are on the list of publicly-provided products.5-7 It would seem reasonable and, as such justified, that these requests are made through legal channels in the event that the failure to supply these medications is the result of poor management of pharmaceutical provision on the part of the Department of Health, since treatment using the pharmaceutical product requested is provided for in a healthcare policy. It would also seem reasonable to think that an absence of a treatment policy for a given disease would constitute a reason for considering such a request as being justified, as long as an effective and/or efficacious treatment option exists that is safe and is available nationally and which the health system can finance.
On the other hand, it would not appear reasonable for people to request medications and healthcare products when there is already an established and high-quality treatment policy. Nor would it appear reasonable to request products of doubtful efficacy and of a cost that is prohibitive to the health system, thereby compromising thousands of other people's access to medications by exhausting the budget.
At this point it is necessary to consult the Brazilian Constitution of 1988,8 which states that the right to health will be guaranteed through social and economic policies. It is clear that the Constitution defines public policy as the mechanism through which this right will be upheld.
Saravia defines public policy as the flow of decisions aimed to maintain the social equilibrium or to introduce disequilibria intended to change that situation.9 Therefore, considering that public policies are the means through which the right to health is to be realized, it is necessary to analyze these policies from the perspective of their coverage of diseases and conditions and their adherence to recommendations found in published scientific data on the use of treatment resources for these diseases and conditions.
While it is understood and accepted that this is an area of discussion that still needs to mature, this study ventures to initiate the debate, taking as its objective an analysis of the qualitative coverage of therapeutic policies within the SUS, on the federal level, based on the constellation of diseases mentioned in lawsuits filed against a Municipal Health Department. The concept of qualitative coverage comprises two dimensions. The first is related to the extent to which treatment policies exist for the diseases in the sample, as embodied in regulatory acts (for example, ministerial directives). The second is related to the adherence of the treatments recommended in national health policies to those listed in a database of published scientific data as the first line treatment for the diseases and considering specific population groups.
This is exploratory research starting from the identification of diseases referred to in lawsuits against the Municipal Health Department of São Paulo during 2005,7 which will make up the sample of diseases studied here.
Working from this list of diseases, searches were run on the Ministry of Health (http://www.saude.gov.br) web site for the regulations that set out the pharmaceutical treatment programs and the SUS Unified Table of Procedures, Medications and Ortheses, Prostheses and Special Materials (OPM)10 was used to identify treatments described in clinical or hospital procedures that list the medications and procedures that are financed by SUS and offered to its patients. Furthermore, the National List of Essential Medicines (2006)11 was used to consult recommendations on the treatment of the diseases considered most prevalent, due to the fact that this list is used to guide the acquisition, prescription and dispensation of medications on the SUS.
Finally, the coverage and qualitative agreement between the prevailing federal treatment policies and the treatment recommendations found in the Diseasedex database was analyzed for each disease, i.e., the compatibility between the medications or procedures recommended in the database as first line treatment
The results of these investigations, both into the existence of treatment policies and about the treatment recommendations, are provided in Table 1.
In this study it was found that, whether in the form of primary care policies or in the form of policies for diseases that are rare and/or generate high costs, treatment is described for the majority of the diseases studied (n = 26), which equates to 96% of the sample (n = 27), as can be observed in Table 1. However, it was also observed that three (11%) of these 27 diseases are covered by deficient treatment policies, i.e., the policies do not offer the entirety of the first-choice treatment options. The only disease that is not covered by a treatment policy is attention deficit hyperactivity disorder (ADHD).
One initial point that should be made clear is that this paper is discussing the extent to which treatment policies are adequately covering the range of diseases studied and the extent to which they are in consonance with the prevailing model, which looks to scientific evidence for the basis on which to define the best treatment options. One is not dealing here with a holistic therapeutic approach, centered on the patient rather than the disease. The objective is to provide a snapshot of the manner in which the majority of healthcare is currently organized, according to the biomedical model, and use it to analyze the treatment policies in force on the basis of the aspects described above.
This analysis is needed for two reasons. First, there may be cases in which the manager responsible for defining the policy does not keep up-to-date with scientific development and knowledge or may not achieve the necessary and alacrity in introducing new technologies. This would result in the SUS continuing to provide the population with technology that is no longer the best treatment choice, since there would be evidence, i.e. proof, of alternatives offering greater safety, efficacy and/or efficiency and with better cost-effectiveness ratios.
The second reason is that there may also be cases in which no treatment policy has been defined for less prevalent diseases and so patients are left with no access to these resources, even when such exist on the domestic market and have been proven to be safe, efficacious, effective and cost-effective.
At this point, it is also necessary to point out that the treatment of these diseases is also affected by the treatment setting, whether in clinics and/or hospitals, or exclusively in hospital. Where cases are treated in hospital, the majority of treatment policies are defined by the institution providing care, since they will define what medications will be administered to patients. Where treatment is surgical, the policy followed is that laid out in the SUS Unified Table of Procedures, Medications and OPM, as defined by the Ministry of Health .10 It is also the Ministry of health that establishes treatment policies for care in clinics, within specific programs.30
Clearly, the fact that the parameter of comparison chosen for these treatment policies was a single database (Diseasedex) restricts the analysis, since it rules out confirming information from several different sources. It is also a limitation to define a treatment policy as adequate merely because the first line treatment laid out in that policy agrees with the database, since, due to idiosyncrasies, certain people may not respond to the medications chosen. Nevertheless, despite the existence of these restrictions, it is important to, in an initial approach to the subject, analyze the extent to which, and the manner in which, the policies that have been established achieve or fall short of the goal of guaranteeing integral therapeutic care. Dissonance between the criteria defined for this analysis, in this study, would indicate that the policy is very likely in need of reformulation or, in the case it does not exits, of formulation.
For example, we can observe the case of ADHD, which is defined in the Diseasedex database
The fact that this disease is not covered by a treatment policy indicates that, where state and municipal health departments have not introduced technology to care for the disease, many children may be without access to treatment. To provide an idea of what this means; the population of children aged five to 14 years in Brazil was 37.8 million, in 2007, according to the Brazilian Institute of Geography and Statistics (IGBE - Instituto Brasileiro de Geografia e Estatística).
When it comes to treatment of cancer, it should be pointed out that the services are organized in a different manner. Patients are treated at what are known as High Complexity Oncology Centers (Cacon - Centros de Alta Complexidade em Oncologia) and High Complexity Oncology Treatment Units (Unacon - Unidades de Assistência em Alta Complexidade em Oncologia).15 These healthcare units are service providers to the SUS and are remunerated by means of procedures laid out in the Unified Table of Procedures, Medications and OPM,10 in order to provide the patient with integral care. This means providing consultations, tests, hospital admission and medications for cancer treatment, plus their adjuvants, even when the patient uses these pharmaceutical products in outpatients or a clinic, as laid out in the prices for chemotherapy procedures defined within the Unified Table.36 Only opioid analgesics (codeine, morphine, and methadone) are excluded from this coverage, since they are part of the Exceptional Dispensation Medicines Program (Programa de Medicamentos de Dispensação em Caráter Excepcional).37
The three diseases that are partially covered, i.e., the qualitative coverage as measured by the Diseasedex database does not provide for supply of those medications considered the first choice treatments, even taking specific population groups into account, are: chronic obstructive pulmonary disease (COPD), depression and ankylosing spondylitis.
According to the Diseasedex database, the following alternatives are employed to treat chronic obstructive pulmonary disease: short-acting beta-2 agonists; b) long-acting beta-2 agonists; c) short-acting anticholinergics; d) long-acting anticholinergics; e) methylxanthine; f) inhaled glucocorticoids; g) systemic glucocorticoids. The medications provided on the Pharmaceutical Support Within Primary Care Program (federal) are beclomethasone (inhaled glucocorticoid), salbutamol (short-acting beta-2 agonist and prednisone (systemic glucocorticoid). The Diseasedex database does not define a hierarchy between these pharmaceuticals, which was also observed for the treatment protocol for COPD produced by the State of São Paulo Health Department,38 differentiating usage according to the severity of symptoms, such as dyspnea and limitation to physical capacity, rather than in relation to the disease. Therefore, it cannot be stated that certain of the pharmaceuticals listed on the Diseasedex database are considered the first line treatment, which evidently leads to the consideration that all of the pharmacological groups are relevant to treatment of this disease. Therefore, the treatment provided for by the federal program (three medications) is inadequate for treating these patients.
With relation to treating depression, the federal program is limited in that it does not provide the first choice medication for treating children, adolescents and expectant mothers, i.e., fluoxetine. This often means that treatment will be chosen that is less appropriate for these groups and, therefore, is a failure of the treatment policy itself.
In the case of ankylosing spondylitis, the restriction in therapeutic provision is even greater. Of the drugs listed in Diseasedex, only one is included in the Pharmaceutical Support Within Primary Care Program - ibuprofen - a non-steroidal anti-inflammatory, which can be used for pain control. Although many of the medications listed on the rheumatoid arthritis clinical protocol can be used to treat spondylitis, that treatment policy does not cover using them for spondylitis patients. This situation means that there is a significant limitation in terms of integral healthcare provision to these patients.
It was further observed that for the majority of diseases, including those for which the treatment policy is limited, the list of medications included on the National List of Essential Medicines11 is longer, i.e., it includes a larger number of medicines. Nevertheless, there are two important points that should be highlighted.
The first is that the National List of Essential Medicines embodies the World Health Organization's concept of essential medicines,11 which is a list of medicines that meet the priority health needs of the population and which should be available at all times, in appropriate doses, to all levels of society.39 Therefore, the National List of Essential Medicines is not intended to provide complete coverage of the constellation of diseases that affect the Brazilian population, since it only selects medicines to treat priority diseases.
Secondly, the National List of Essential Medicines is not a list of drugs that must be provided by SUS health services. It is a list that is intended to guide the provision, prescription and dispensation of essential medicines within the system, providing guidance for the choice of medicines to be included in federal, state and municipal treatment policies (pharmaceutical support programs).40 For this reason, only medications listed in the different treatment policies; whether of a wide scope, such as primary care policies, or with a more specific focus, such as the Protocols for each disease covered by the Exceptional Dispensation Medicines Program.
What this study has shown is that there are deficiencies in terms of the qualitative treatment coverage for some of the diseases in the sample studied, on the federal level, which compromise the integral nature of treatment and healthcare in some cases and which, as a consequence, compromise the guarantee of the right to health. If there is no treatment policy or the policy is flawed, the universal and integral nature of healthcare is compromised.
Since the right to health must be guaranteed through policies,8 it is necessary to select those treatment resources which offer complete qualitative coverage for the treatment of these diseases, based on the best and strongest available evidence on their efficacy, safety, efficiency, and cost-effectiveness and to the extent that society is able to bear the costs. This is the basic condition for the state to be in a position to defend the argument that the right to health can indeed only be guaranteed through public policies and to be able to respond to the large number of lawsuits that do not distinguish between guaranteeing rights (suits requesting treatment resources that are included in policies or for diseases that are not covered by policies) and requests/consumption of specific technologies, despite treatment for the disease in question being covered by a treatment policy specifying the use of other technologies.
1Brasil. Lei nº 8.080 de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/PORTARIAS/PORT2002/PT-859.htm
2Ministério da Saúde. Secretaria Nacional de Assistência à Saúde. ABC do SUS. Doutrinas e princípios. Brasília (DF): Ministério da Saúde; 1990.
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10Portaria SAS nº 7 de 4 de janeiro de 2008. Inclui os códigos dos procedimentos relacionados na tabela de procedimentos, medicamentos e OPM do SUS. [citado 20 Jul 2008]. Disponível em: http://sihd.datasus.gov.br/
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13Portaria SCTIE/MS nº 66 de 06 de novembro de 2006. Aprova o protocolo clínico e diretrizes terapêuticas: artrite reumatóide. [citado 20 Jul 2008]. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/pcdt_artrite_reumatoide_2006.pdf
14Portaria GM/MS nº 2.577 de 25 de outubro de 2006. Aprova o componente de medicamentos de dispensação excepcional. [citado 20 Jul 2008]. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/PT_2577_Comp_Medicam_Disp_Excep.pdf
15Portaria GM/MS nº 2.439 de 8 de dezembro de 2008. Institui a Política Nacional de Atenção Oncológica: promoção, prevenção, diagnóstico, tratamento, reabilitação e cuidados paliativos, a ser implantada em todas as unidades federadas, respeitadas as competências das três esferas de gestão. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2005/GM/GM-2439.htm
16Portaria GM nº 3536, de 2 de setembro de 1998. Determina a implantação do sistema de autorização de procedimentos de alta complexidade na área de oncologia (APAC/ONCO). [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/portarias/port98/GM/GM-3536.html
17Portaria SAS/MS nº 741 de 19 de dezembro de 2005. Define as Unidades de Assistência de alta complexidade em oncologia, os Centros de Assistência de alta complexidade em oncologia e os Centros de Referência de alta complexidade em oncologia e suas aptidões e qualidades. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2005/PT-741.htm
18Portaria GM/MS nº 3.237 de 24 de dezembro de 2007. Aprova as normas de execução e de financiamento da assistência farmacêutica na atenção básica em saúde. [citado 20 Jul 2008]. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/portaria_3237_atencao_basica.pdf
19Portaria SCTIE/MS nº 68 de 06 de novembro de 2006. Aprova o protocolo clínico e diretrizes terapêuticas: diabetes insípido. [citado 20 Jul 2008]. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/pcdt_diabetes_insipido_2006.pdf
20Consulta Pública SAS/MS nº 13, de 12 de novembro de 2002. Protocolo clínico e diretrizes terapêuticas. Dislipidemias em pacientes de alto risco de desenvolver eventos cardiovasculares. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/dsra/protocolos/do_d07_01.pdf
21Portaria SAS/MS n º 864, de 05 de novembro de 2002. Protocolo clínico e diretrizes terapêuticas. Epilepsia refratária. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/dsra/protocolos/do_e15_01.pdf
22Portaria GM/MS nº 867 de 9 de maio de 2002. Institui, no âmbito do Sistema Único de Saúde, o Programa de Assistência aos portadores de glaucoma. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2002/Gm/GM-867.htm
23Portaria SAS/MS nº 338de 08 de maio de 2002. Inclui, nas tabelas de serviço e classificação de serviços do sistema de informações ambulatoriais do SUS - SIA/SUS, os códigos abaixo discriminados: serviço de diagnose/terapia em oftalmologia. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/PORTARIAS/PORT2002/PT-338.htm
24Portaria SAS/MS nº 860, de 04 de novembro de 2002. Protocolo clínico e diretrizes terapêuticas. Hepatite viral crônica B. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/dsra/protocolos/do_h22_01.pdf
25Portaria SAS/MS nº 469, de 23 de julho de 2002. Protocolo clínico e diretrizes terapêuticas. Profilaxia da reinfecção pelo vírus da hepatite B pós-transplante hepático. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/dsra/protocolos/do_p29_01.pdf
26Portaria SAS/MS nº 863, de 04 de novembro de 2002. Protocolo clínico e diretrizes terapêuticas. Hepatite viral crônica C. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/dsra/protocolos/do_h23_01.pdf
27Portaria SCTIE/MS nº 70 de 06 de novembro de 2006. Aprova o protocolo clínico e diretrizes terapêuticas: hepatite autoimune. [citado 20 Jul 2008]. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/pcdt_hepatite auto imune_2006.pdf.
28Portaria SAS/MS nº 845, de 31 de outubro de 2002. Protocolo clínico e diretrizes terapêuticas. Hiperfosfatemia na insuficiência renal crônica. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/dsra/protocolos/do_h24_01.pdf
29Portaria SAS/MS nº 470, de 23 de julho de 2002. Protocolo clínico e diretrizes terapêuticas. Osteoporose. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/dsra/protocolos/do_o28_01.pdf
30Portaria GM/MS nº 204 de 29 de janeiro de 2007. Regulamenta o financiamento e a transferência dos recursos federais para as ações e os serviços de saúde, na forma de blocos de financiamento, com o respectivo monitoramento e controle. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2007/GM/GM-204.htm
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36Portaria SAS/MS nº 296 de 15 de julho de 1999. Mantém os formulários /instrumentos e regulamenta sua utilização na sistemática de autorização e cobrança dos procedimentos ambulatoriais de quimioterapia e de radioterapia. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/PORTARIAS/Port99/PT- 0296.html
37Portaria SAS/MS nº 859 de 12 de novembro de 2002. Aprova o protocolo clínico e diretrizes terapêuticas - uso de opiáceos no alívio da dor crônica - codeína, morfina, metadona, na forma do anexo desta portaria. [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/PORTARIAS/PORT2002/PT-859.htm
38Resolução SS-SP nº 278 de 26 de julho de 2007. Aprova o protocolo para tratamento dos portadores de Doença Pulmonar Obstrutiva Crônica - DPOC, atendidos pelo Sistema Único de Saúde - SUS, do Estado de São Paulo. [citado 20 Jul 2008]. Disponível em: http://portal.saude.sp.gov.br/resources/geral/acoes_da_sessp/assistencia_farmaceutica/vsr/resolucao_e_protocolo_dpoc.pdf
39Organización Mundial de la Salud (OMS). Selección de medicamentos esenciales. Perspectivas Políticas sobre Medicamentos de la OMS. Ginebra: OMS; 2002. n. 4.
40Portaria GM/MS nº 2.475 de 13 de outubro de 2006. Aprova a 4ª edição da Relação Nacional de Medicamentos Essenciais (Rename). [citado 20 Jul 2008]. Disponível em: http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2006/GM/GM-2475.htm
Publication in this collection
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Date of issue
06 Apr 2009
22 July 2008