Dengue and other arboviruses, basic sanitation and Funasa – 08/23/2023 – Saúde em Público

At the end of July, the WHO issued a warning about the record increase in dengue cases in the world due to global warming. The disease is already endemic in more than 100 countries and, in America, Brazil is by far the most affected. There are 2.3 million dengue notifications – 1.2 thousand of which are classified as severe dengue – and 769 deaths (73% increase over the last five years) in the first half. According to the WHO, vectors such as Aedes aegypti, among other mosquitoes, are responsible for 17% of the global burden of communicable diseases and more than 700,000 deaths per year. Almost 80% of the world’s population could be infected by some disease transmitted by these vectors.

Sanitation services are related to the incidence of these diseases. Despite mosquito infestation happening everywhere, illness is higher among the population with worse indicators of sanitation coverage. In places where water is scarce, families need to store it in containers, which are often poorly sanitized and without proper sealing, leading to these becoming suitable places for the emergence of mosquitoes. Another factor that can lead to an increase in the reproduction of these vectors is the lack of access to the collection and proper management of solid waste, which, abandoned in inappropriate places, stores rainwater and becomes environments for proliferation.

Combating diseases such as dengue, chikungunya and zika, without effective actions to improve basic sanitation, aggravates the problem. water to the detriment of effective actions to expand the regular supply. In the Contingency Plan for responding to public health emergencies due to Dengue, Chikungunya and Zika of the Ministry of Health, there are generic mentions of the need to improve sanitation in municipalities, focusing on issues related to communication and social mobilization, vector control and management . The recommendations on mapping areas of focus are directed only to Community Health Agents. In the end, the responsibility rests with the community in the figure of the neighbor who does not comply with the control measures and not with the lack of investment by the State in basic sanitation .

Law 14.026/20, a legal framework for sanitation, establishes that, by 2033, 99% of the population will have access to drinking water and 90% will have access to sewage collection and treatment, but it does not define specific goals for the management of urban solid waste – one of the main problems for the transmission of arboviruses, in addition to regular water supply. In 10 years, the share of the population with access to water increased by only 1.4 percentage points (from 82.8% to 84.2%); the expansion of the coverage of the sewage network was greater, 7.5 pp, but covers only 55.8% of the population. While the National Plan for Basic Sanitation estimated at R$ 27.6 billion per year the investment necessary for the universalization of the service, in recent years, the average annual investment was R$ 16 billion. In addition, the most deficit regions are those that receive less investment.

If, on the one hand, the figures appear to be a high investment, the return with the universalization of sanitation would result in even more expressive values ​​in the long term: according to data from the Panel Saneamento Brasil, from the Trata Brasil Institute, the reduction in health costs is estimated at BRL 1.25 billion per year. And more, because the impact of sanitation does not only occur in terms of health: a WHO study calculates that for every US$ 1.00 invested in sanitation, there is a return of US$ 5.50 through lower health costs, more productivity and fewer premature deaths.

Northeast concentrates 42% of the population without access to potable water; investment in sanitation in the region is low

Our reality, however, is far from this scenario. Also according to the Sanitation Panel, 86% of hospitalizations for malaria in 2021 took place in the North Region, with three states concentrating 63% of hospitalizations: Pará, Rondônia and Acre. Compared to the Southeast, a region with better infrastructure and sanitation coverage, the incidence of hospitalizations for dengue was 7.2 times higher in the Midwest, 3.6 times higher in the Northeast and 3.4 times in the North. In the North and Northeast regions, 40% and 25% of the population, respectively, do not have access to potable water and, for around 45% of those who have access, the supply is irregular. In absolute terms, of the 33.2 million Brazilians without access to water, 42% live in the Northeast, while expenses with investment in sanitation represent only half of the expenses incurred in the Southeast. The investment value per inhabitant that does not have access to water in the Southeast (714 R$/inhabitant) was 7 times higher than in the North (101 R$/inhabitant) and almost 5 times higher than in the Northeast (158 R$/inhabitant). hab).

National Health Foundation

In addition to the National Sanitation Secretariat, linked to the Ministry of Integration and Regional Development (MIDR), the National Health Foundation (Funasa) is also responsible for formulating and implementing sanitation plans and programs. In particular, through sanitation services in small and medium-sized municipalities and in rural, quilombola and endemic areas – such as the National Rural Sanitation Program. It should be noted, however, that the audit report of the Comptroller General of the Union (CGU) of December 2022 pointed out the absence of criteria for prioritizing places in a situation of greater vulnerability for financing works, in addition to inefficiency in transfers for sanitation and lack of inspection and supervision of actions. Previous audits also point to deviations in transfers.

The Foundation, linked to the Ministry of Health – before the Ministry of Cities, and briefly extinct at the beginning of the current government – ​​is a constant target of political dispute due to the allocation of budget amendments to sanitation works in the municipalities – and the lack of coordination and supervision of actions. Since 2019, 7 directors have passed through his presidency, mainly linked to the PSD, which has maintained control of the body in recent years. At the moment, the position is part of the government’s ministerial reform with Centrão, seeking support in the National Congress – as it has been historically – and is actively disputed by the PSD, PP, Republicans and União Brasil.

The political allotment of superintendencies, together with the lack of national coordination for the implementation of the National Basic Sanitation Plan, means that the responsibility for sanitation actions falls largely on the municipalities, whose technical and financial capacity is extremely varied. According to the Survey on Basic Municipal Information (MUNIC/IBGE), only 38.2% of the municipalities have a municipal basic sanitation policy and 28.7% have a municipal plan. The new legal framework brings changes that simplify the rites to enable the regional provision of the service. At the same time, it goes against the grain of the movement to renationalize the sanitation service in several cities around the world – such as Paris, France, and Berlin, Germany – by expanding the conditions for private participation.

Every year we discuss the number of cases, hospitalizations and deaths from dengue, chikungunya and other arboviruses, the morbidities resulting from these diseases, the fight with social mobilization campaigns to control the mosquito – and, this year, the approval of a vaccine by Anvisa . In order for the scenario of slow advances in the right of regular access to drinking water and basic sanitation to be transformed, the political agenda needs to take seriously the body responsible for sanitation precisely in small municipalities and special areas. Signals given by the Government based on Funasa’s historic political allotment and current discussions that point to history repeating itself demonstrate that we are far from this scenario.