Parliamentary amendments in Health – 10/09/2023 – Health in Public

Parliamentary Amendments (EP) have become increasingly important in the health budget. According to a Technical Note from the Institute of Health Policy Studies (IEPS), in 2014 (the year in which the amendments began to be identified in the budget), its allocation was R$7.6 billion. In 2023, this amount practically doubled, totaling R$14.6 billion. In the same period, the relative share of amendments in the budget of the Ministry of Health (MS) also increased, by 4 percentage points, accounting for 8% of the department’s total allocation.

Although EPs represent the constitutional instrument through which parliamentarians participate in the preparation of the budget, their growth, combined with the mandatory nature of their execution, requires attention. This is because inspection during and after its transfer is not always carried out. An emblematic case was in the three-year period from 2020 to 2022 – the period of validity of the Rapporteur Amendments (RP-9), when the RP-9 allocation accumulated R$14.7 billion. In this type of amendment, there is no way to identify the parliamentarian responsible for its allocation nor the actual destination of the amount. In other words, resources are sent to areas that are fundamental to the functioning of the SUS, but without clarity on which projects from the different budgetary subfunctions (such as Primary, Medium and High Complexity Care) received the application, nor their real effectiveness.

Because of this, and due to its scope and the lack of transparency in the allocation of expenses, the Federal Supreme Court (STF) considered RP-9 as unconstitutional. These resources were converted to discretionary expenses (RP-2) and Individual Amendments (RP-6). While these changes were agreed upon, other questionable practices remain. The main one is the increasingly present influence of political guidelines to the detriment of technical criteria in the composition and allocation of amendments.

Health was the department with the highest average volume of amendments committed in the period from January to May 2022 and 2023

We have been following the constant negotiations between the Federal Legislature and Executive to advance their respective agendas. Most of them involve the Ministry of Health which, by law, receives 50% of individual amendments, which makes it the department that most benefits from parliamentary amendments. Bulletin no. 5/2023 of the IEPS, released this Monday (09/10), contributes to this discussion through three relevant findings: i) health was the department with the highest average volume of amendments committed in the period from January to May 2022 and 2023; ii) most of the resources were allocated to paying for individual amendments; eiii) The amounts committed were mainly oriented towards current expenses.

It is expected that the commitment of individual amendments will be the majority, but in 2023, so far, they represent the totality of health amendments. Unlike bench and committee amendments, individual amendments, in general, leave room for particular political interests, which may go against the population’s health needs, the efficient spending of public resources and compromise their equitable distribution between states and municipalities.

In other words, parliamentarians, who should act to collaborate with management, adapting the resources for amendments to what was planned by the municipal or state Executive, in some cases do not follow this rule, enabling greater regional disparities due to the lack of criteria for allocation of these resources. This characteristic, combined with the lack of transparency in the allocation and monitoring of the execution of its resources, makes its efficient management difficult and makes it impossible to evaluate actions. Therefore, different questions arise: how to ensure that these resources are allocated to municipalities with fewer resources and infrastructure? How to assess whether they are achieving the expected results?

The lack of criteria in allocating the volume of resources increases regional disparities, going against the provisions of Complementary Law no. 141/2012, which may also create difficulties for those entities with low collection capacity. On the other hand, there are instruments that could be used as evaluation mechanisms, such as the Annual Health Program (PAS) and the Annual Management Report (RAG), but which are little used due to the inefficiency of monitoring and the lack of integration with other budget instruments, which makes monitoring and evaluating results difficult.

It is clear that monitoring these transfers, as well as other budgetary modalities, is costly and presents major obstacles. However, neglecting this process means leaving the health of an increasing number of Brazilians adrift, especially in a scenario in which municipal administrations need to resort to their own resources to meet the health demands of their population.

One of the ways of monitoring these transfers can be from their origin. EPs are mostly passed on through fund-to-fund transfers, that is, through the National Health Fund (a body linked to the Ministry of Health, responsible for implementing resources at the federal level), to the Municipal Health Funds. In the latter, they are the municipal managers are responsible for its execution, in accordance with the principles established by SUS legislation. Monitoring this process is a way of identifying whether the amendments are following a trajectory in line with the strategic principles established by managers.

Furthermore, the very objective of PE is distorted when today these complementary resources, which should reinforce or promote public health policies in different regions and contribute to reducing inequalities, are used to pay staff and not for investments – which has been observed in practice.

In addition to expanding the health budget in Brazil, aiming to support municipalities in their financial sustainability, it is necessary to combine the efforts of different institutions, from supervisory bodies to municipal and state managers, to qualify the allocation of amendments and reduce the preponderance of interests individual and/or private in relation to the needs for improvements in Brazilian public health.

More than joining efforts, it is essential that these actors act in an integrated manner, connecting planning and budgeting instruments. These changes are fundamental to improving governance and compliance, as they guarantee transparency to society on how public resources are transformed into quality services available to them. In short, through this set of initiatives, we will move towards a more decisive SUS, which can serve the entire Brazilian population, especially those most in need.

Victor Nobre is an Institutional Relations Assistant at IEPS; Marcella Semente is an Institutional Relations Analyst at IEPS; Antonio Carlos Junior is technical advisor and coordinator of Administration and Finance at CONASS and former executive director of the National Health Fund – FNS

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