The purpose of this article is to characterize the process of financial throttling of the Unified Health System (SUS) as a result of the lack of funding promoted by Constitutional Amendment (EC) No. 95/2016, as well as to maintain this process even during the COVID-19 pandemic. I addressed this topic in the USCS Nineteenth Discharge Letter, available in full at www.uscs.edu.br/noticias/cartasconjuscs.
From 2018 until the start of the COVID-19 epidemic, the federal SUS lost R$22.5 billion as a result of EC 95/2016, known as the ‘spending cap’ (with negative effects on health funding by state and about two-thirds of the Ministry of Health budget being transfers from money to money).
This federal shortfall in funding for SUS expresses one of the situations that characterizes the SUS financial bottleneck: the withdrawal of federal resources, the total of which were already insufficient to meet the health needs of the population – after all, public spending on health in the three areas per capita total of The government is R$3.79 per day and represented 4.0% of GDP in 2019 (nearly half of 7.9% in the UK, according to WHO data).
The need for additional resources was expressed by the National Council of Health (CNS), which coordinated community mobilization for 10% of total current revenue (a movement known as “Health + 10”, with more than 2.2 million signatures filed with the National Congress with PLP Bill 321 in 2013). If approved, these additional resources (about R$40 billion), as decided by the National Health Council, will be used to strengthen primary health care measures, so that they can become the regulator of the health care network, and to assess the value. SUS professionals.
According to Funcia (2019), these additional resources could have been used jointly to quadruple the basic care floor (PAB Fixo), basic pharmacy, and expand the health and community health agents program by 50%. Family Health Program (PACS) / PSF and quadrupling the amount of expenditures allocated to the Emergency Mobile Service (SAMU) by the Ministry of Health, in addition to these actions, it will also be possible to expand the “Mais Médicos Program”.
What will be the sources of funding? Funcia (2019) noted two common metrics for this purpose: citizen review of public debt and revenue assignment review, especially those related to the health function. Moreover, according to Alves et al. (2020), if there is an effective management of the active debt of the union, it is possible to raise much more than R$ 24 billion in 2019, considering that the stock was R$ 2.4 trillion (and of this total, R$ 800 billion classified in conditions positive receipt).
But the unfunded SUS since 2018 has reduced resources for the “More Doctors Program” (now called Doctors for Brazil) and for primary care, focusing on the new funding model for primary care that was created at the end of 2019, with a negative model. Effects on maintenance and expansion of family health teams, among others.
Significantly, there was a decrease in the per capita federal minimum in the SUS in 2017-2019 (and up to 2021), as well as in per capita federal investment – from R$595.00 in 2017 to R$583.00 in 2019 (values calculated at 2019 prices). ).
Apparently, the Covid-19 pandemic presents a tangible opportunity for the federal government to adequately fund the SUS, given the easing of the ceiling on primary spending and other fiscal rules as a result of the State of Public Disaster Decree in 2020.
However, this was not what was seen in the allocation of additional resources to the Ministry of Health (MS), as well as in the related budget and financial implementation – according to several editions of the Cofin Bulletin of the National Health Council, in the other hand, there has been a lot of slow in using Budget resources allocated to combating Covid-19 (which occurred mainly in July and August 2020, after the number of cases and deaths increased a lot), such as the delay in allocating resources for the vaccine (20 billion Rls were added to the budget only in the second half of December ( December 2020).
This situation, which also characterizes the SUS financial bottleneck, was exacerbated by MS’s decision to send the part of the 2021 budget without a penny programmed to counter Covid-19, which was made possible by opening extraordinary credits, a measure that can only be adopted for emergency and unexpected expenses ( As it was in 2020, different from the situation in 2021).
There was a decrease in transfers from the National Health Fund to state and municipal health funds, including funding for Covid-19 response measures – respectively, down 17% and 63% in the first quarter of 2021 compared to the third 2020 despite an increase in The number of injuries and deaths in that period.
Finally, in the budget schedule for 2022, only R$7.1 billion has been allocated to combating Covid-19, which is insufficient compared to the amounts committed in 2020 and 2021 (so far).
Therefore, given the health crisis and specialists’ concerns about the slowdown in the mass vaccination process, given the necessity to implement the third dose and the tangible possibility of annual vaccination for a few years, the issuance of the Ministry of Health budget continues to be addressed under the terms of fiscal austerity: even with the flexibility of the rules in 2020 and the way in which it was found for “Circumventing” the cap on primary expenditures In 2021, there are no federal resources available for budget planning and financial management of the federal SUS with states and municipalities.
On the contrary: this situation is an expression of the National Health Plan 2020-2023, which has no goal or objective to combat the epidemic. The suggestion of Moretti et al. (2020): “In the context of growing poverty and inequality in Brazilian society, the federal government needs to immediately repeal the spending cap and the rule established for the Federal Health Floor (Constitutional Amendment No. 95/2016) to counteract the recession and the coronavirus.”
While that doesn’t happen, the SUS financial throttling framework continues and gets worse. even when?
Alves, Robbins; Elvis Helder; VIGNOLI, Francisco H.; FUNCIA, Francisco R.; Assessment of Active Debt for Federation and Municipalities in the Greater ABC Region. Conjuscs Letter nº 14, October / 2020.
FUNCIA, Francisco R. SUS Underfunding and the Federal Budget: Preliminary References for Allocating Additional Resources. Science and Public Health 24 (12), Dec. 2019. Available at https://www.scielo.br/j/csc/a/n77WSKwsWhzyBHGXtgLfFMj/?lang=pt
Moretti, Bruno; Aoki, Carlos; Aragon, Erica; FUNCIA, Francisco; Benevides, Rodrigo. Change the economic policy and strengthen the SUS to avoid chaos. 03/30/2020. Available in https://www.abrasco.org.br/site/noticias/mudar-a-politica-economica-e-fortalecer-o-sus-para-evitar-o-caos/46220/
Francisco R. Foncia He is an Economist and MA in Political Economy from PUC-SP, PhD student in Management in the Graduate Program in Management (PPGA) at the Universidade Municipal de São Caetano do Sul (USCS), Researcher at the Observatory of Public Policy, Entrepreneurship and Conditions at USCS (Conjuscs) Professor of Economics and Medicine Courses at USCS, Vice President of the Brazilian Association of Health Economics (ABrES) and Technical Adviser to the Committee on Budget and Finance of the National Health Council (Cofin/CNS). Minister of Finance in Diadema since January 1, 2021.
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