Health Budget: 10 years of stagnation – 06/12/2023 – Saúde em Público

In the coming years, the tension between the demand for health services and the financial sustainability of the Unified Health System (SUS) will grow. Population aging, the increase in the prevalence of chronic diseases and their risk factors, and the emergence of new epidemics are some of the challenges to be faced, in the short term, by the health system. According to IBGE data, between 2012 and 2021, the number of elderly Brazilians increased by 39%, reaching 14.7% of the country’s resident population. Diabetes mellitus and obesity have been characterized as the most prevalent chronic diseases in Brazilian capitals, with a considerable increase in recent decades.

The prevalence of risk factors associated with these conditions has also increased, as shown by the recent records in alcohol consumption, ultra-processed foods and physical inactivity in the country, especially in the period of the Covid-19 pandemic.

There is an indispensable factor for these and other demands to be met: the health budget. This needs to be adequate to the demands of the population, otherwise the public system may face serious problems in coordinating its public policies. The shortage of essential medicines in the Popular Pharmacy Program and the poor results of the National Immunization Program (PNI) are recent examples of this. And as in health prevention is cheaper and more efficient than cure, budget oversight, in the short term, further increases the demand for funding in the long term.

This impasse between budget mismanagement and health demands is what has been happening in Brazil. Analyzing the federal health budget, Technical Note n.29 prepared by the Institute of Studies for Health Policies (IEPS), in partnership with Umane, identifies four reasons that corroborate the presented dilemma: i) the federal health budget is stagnant since 2013; ii) investment in health is insufficient to expand SUS coverage; iii) the increase in resources allocated via parliamentary amendments, politically defined, to the detriment of discretionary expenses, which follow strategic guidelines from the Ministry of Health; and iv) the significant growth of tax benefits for private health.

Regarding the first point, between 2013 and 2023, the federal health budget grew by only 2.5%, reaching R$ 182.6 billion. This value, in addition to being lower than the average of the last nine years, R$ 186.6 billion, was boosted by emergency resources destined to combat Covid-19. Disregarding these resources, the health budget grew less than 1% in the last ten years. The growth is very low and points to a stagnation in the allocation of expenditures on Health.

Analyzing the budget in terms of current expenses and investment, which represent expenses for funding SUS services and investments in expanding and improving the physical infrastructure of the system, the panorama is also challenging. In the last ten years, investments in Health contracted 64.2%, from R$ 16 billion in 2013 to R$ 6 billion in 2023. Its relative participation reaches only 3% of the total Health budget in 2023. In practice, the low investment prevents renovations and construction of basic health units, hospitals, UPAs, research and technological development centers, and basic sanitation structures in indigenous villages, for example.

Parliamentary amendments: political criteria for resource allocation has grown in recent years

The growing participation of parliamentary amendments in the budget, to the detriment of discretionary expenses, is the third problem pointed out by the IEPS. Parliamentary amendments are essentially guided by the interest of parliamentarians, while discretionary expenses are allocated by technical criteria established by the Ministry of Health. Thus, as the proportion of parliamentary amendments to the budget increases and the participation of discretionary ones decreases, political criteria for resource allocation prevail, distancing budget planning from territorial needs. Between 2014 and 2023, disregarding Covid-19 spending, parliamentary amendments increased its share in the Health budget from 4.2% to 8.2%. Discretionary spending represented 17.4% of total health resources in 2014, and only 14.8% in 2023.

Finally, the study discusses the risks associated with the growth of tax breaks in health. Between 2013 and 2023, there was an 88% increase in subsidies linked to all health items, which rose from BRL 37.6 billion to BRL 70.7 billion. Of this total, R$ 24.5 billion will be allocated to private medical expenses, benefiting only those who do not depend exclusively on the SUS to access health services. With the stagnant SUS budget, how is it possible to justify such an increase in the level of tax exemptions in favor of meeting the demands of private health?

The fact is that in the coming years the demand for health will grow. And even if we have room to improve the management of the resources already available, without budget prioritization, the balance between supply and demand will come at the expense of queues, shortages and, more seriously, the worsening of the quality of life of Brazilian men and women. .

Breaking this cycle is urgent and the opportunity is now. In the coming months, the new government is approaching the deadline for formulating the new Pluriannual Plan (PPA), a unique opportunity to organize priorities and define goals that will anchor the SUS budget over the next four years. It is fundamental that the planning is, in fact, oriented to the main challenges of the SUS. In the absence of this direction, efforts to improve Brazilian health will hardly find the desired trajectory.

Victor Nobre holds a bachelor’s degree in economics from IE/UFRJ and public policy assistant at the Institute of Studies for Health Policies (IEPS); Manuel Faria was a public policy analyst at the Institute of Studies for Health Policies (IEPS); Antonio C. Oliveira Junior is a technical advisor and coordinator of Administration and Finance at CONASS and former executive director of the National Health Fund (FNS).

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