States and municipalities have billions in health funds – 03/13/2023 – Health

States and municipalities accumulate balances of more than R$ 25 billion in transfers made by the federal government to the SUS (Unified Health System). This value skyrocketed with funds intended to combat the Covid-19 pandemic and parliamentary amendments.

Health managers and researchers consider that the accumulated figure reflects several bottlenecks, such as the difficulty of managing and executing the budget and even political interference to keep the resources in cash and close the year with a positive result.

The resources come from the FNS (National Health Fund), whose function is to irrigate the coffers of the entities of the Federation for costing, investment and financing of actions of the public network. Of the total balance, R$ 10.3 billion are in state accounts. And the rest, with the municipalities.

Authors of studies on balances, Blenda Pereira and Daniel Faleiros say that there is a lack of monitoring by specialized areas, such as primary care or health surveillance, by the Ministry of Health on the destination of the funds.

“The ministry is part of the management of the SUS, it cannot just pass on the resource”, said Pereira, who is a doctoral candidate in public health at USP.

On the other hand, they claim that it is necessary to look at balance values ​​with caution. “I do not consider that the volume is high. It is equivalent to about three months of transfers [do FNS]”, said the researcher.

For the Conass (National Council of Health Secretaries), “effective monitoring by the Ministry of Health for guidance to subnational entities is fundamental”.

“It would help to prove or not the factors mentioned above and would provide technical support to subnational entities, thus contributing to greater speed in the respective processes”, said the entity in a note.

The Ministry of Health states that the responsibility for the amount lies with the entities of the Federation. “Once the resources are transferred, by the National Health Fund, to the states and municipalities, their management is up to them”, he said.

The folder also offered another hypothesis for the balances: the resources may already be committed, awaiting proof of a work, for example, to be executed.

However, there are cases in which a location could go months without receiving new transfers and would continue to receive funds. There is no rule determined by legislators or managers for transfers in situations where the accounts already have a balance more than 100% higher than the resource allocated by the ministry.

This is what happens in Goiás. The state, governed by doctor Ronaldo Caiado (União Brasil), has R$ 440 million in FNS balances. Last year, it received around BRL 390 million and spent BRL 410 million. That is, an amount less than what is on balance.

“These values [R$ 440 milhões] come from various ordinances of the Ministry of Health, which transferred resources to SES-GO [Secretaria da Saúde]and each of these instruments has specific rules for use, with defined objects”, said the secretariat in a note.

Of this amount, continued the folder, about R$ 150 million are resources destined to the Covid-19 pandemic and await the completion of bids, “whose procedure does not allow the immediate use of the resource”.

Goiás had 28,000 deaths from the virus. At the height of the pandemic, Goiânia’s health system collapsed.

Doctor in health economics from UFMG (Federal University of Minas Gerais), Daniel Faleiros says that there is a culture in the Ministry of Health of sending stamped resources to “small plans”, which hinders the execution of the budget.

“Health even passed on R$ 600 million in the pandemic that could only be used to buy mental health drugs, when the expense could have been used to buy respirators or other actions”, he said.

Another state with a much higher balance than transfers is Mato Grosso. There is R$571 million in cash. Last year, the state received transfers of R$ 385 million.

In the best execution month, Mato Grosso spent BRL 33.14 million from the fund. At this rate, the balance would last for more than a year, without needing a new contribution from the ministry.

Part of FNS transfers is mandatory. Other resources are destined by parliamentary amendments or for actions defined during the year.

The so-called amendments by the rapporteur, which were considered unconstitutional by the STF (Federal Supreme Court), increased distortions in SUS funding.

São Gonçalo, in Rio de Janeiro, has one of the highest balances among municipalities, at R$ 146 million. This reserve was R$ 60 million in May 2022. The amount more than doubled after the amendments arrived in June, months before the elections.

In a note, the city hall said that there are resources from amendments made more than five years ago and that only now, with regulation by the Ministry of Health, can they be used. The exact amount, however, was not shared.

The municipality also says there is a growing demand for public health services; hence the transfers.

“The current management has been working with planning and optimization of resources, in order to apply them assertively, to guarantee the effective improvement in the provision of services”, he said.

The FNS is governed by law and ministerial ordinances. The resources that reach the entities are stamped, that is, they have a specific destination. A rule also established that, from 2018, they would only have two objectives: investment and funding.

The ordinance that deals with the fund prohibits the use of resources to pay servers, active or inactive, and bonuses. The text also prohibits the use of money to pay advisory services or consultancies.

For investment, managers can use the resources to purchase equipment, renovation works or new construction. This type of expense is usually more laborious, as it requires bidding and depends on companies.

São Paulo, for example, has the highest balance in accounts, with R$ 2.1 billion. But the state has high execution levels, which keeps the balance relatively stable.

Sergipe, in turn, is the state with the lowest balance of FNS resources, R$ 43 million.

The FNS apportionment criterion is defined by law and aims to reduce regional inequalities. For researchers, parliamentary amendments violate this principle.

Sanitary doctor and professor at FGV, Adriano Massuda says that the SUS must find ways to improve the execution of resources and meet regional demands. He cites as a way out the creation of arrangements for contracting works and equipment,

The professor also says that funds for priority actions were cut to accommodate the amendments. “Problem is not the volume of the resource [em saldos], but the allocation. SUS is underfunded. That money should be allocated elsewhere.”

SUS FEDERAL TRANSFERS

States and municipalities receive federal funds

• Amount distributed in 2022: BRL 101 billion
• Current balance of states and municipalities: BRL 25.8 billion in December 2022
• Balance before the pandemic: BRL 17.2 billion in January 2020
• Biggest transfer in 2022: R$ 19.14 billion, in June, under the influence of amendments
• Best execution in 2022: BRL 9.98 billion in December
• Execution of funds in the year: about 74.6% in 2022

_{Source: National Health Fund}