ABSTRACT

OBJECTIVE

Analyze the implications of parliamentary amendments (EP) for the model of equitable allocation of resources from the Fixed Primary Care Minimum (PAB-Fixo) to municipalities in the period from 2015 to 2019.

METHODS

A descriptive and exploratory study was conducted on allocating federal resources to the PAB-Fixo and on the increment in the PAB by parliamentary amendment. The municipalities were classified into four groups according to degrees of socioeconomic vulnerability defined by the Ministry of Health for the allocation of PAB-Fixo resources. The transfers from the Ministry by parliamentary amendment were identified. The proportions of municipalities benefiting per group were analyzed by resources allocated from the PAB-Fixo and increment to the minimum by EP.

RESULTS

There were reduced resources allocated to the PAB-Fixo (from R$ 6.04 billion to R$ 5.51 billion, -8.8%) and increased increment to PAB by parliamentary amendment (from R$ 95.06 million to R$ 5.58 billion, 5.767%) between 2015 and 2019. The participation of municipalities by the group of those favored by EP was similar to that in the PAB-Fixo. In the proportion of resources for amendments, the municipalities of group I (most vulnerable) had more participation, and those of group IV had less participation if compared to the allocation of the PAB-Fixo. The distribution of resources by the parliamentary amendment did not cover all municipalities, even the most vulnerable ones, i.e., belonging to groups I and II. There was great inequality of resources per capita according to the groups of municipalities.

CONCLUSION

The EP distorted the model of equitable allocation of resources proposed by the Ministry of Health for the PAB-Fixo, by allocating resources in a much more significant proportion to the municipalities of group I and much less to those of group IV, which is in disagreement with this model. Furthermore, this distribution by amendments does not benefit all municipalities, not even the most vulnerable.

Health Care Rationing, legislation & jurisprudence; Unified Health System; Financing, Government; Public Expenditures on Health; Healthcare Disparities, economics

INTRODUCTION

In Brazil, the allocation of federal resources to states and municipalities through parliamentary amendments (EP) has been the object of analysis on public policies, with different approaches and focuses. Concerns about the political and decision-making process¹1. Pereira C, Mueller B. Comportamento estratégico em presidencialismo de coalizão: as relações entre Executivo e Legislativo na elaboração do orçamento brasileiro. Dados. 2002;45(2):265-301. https://doi.org/10.1590/S0011-52582002000200004
https://doi.org/10.1590/S0011-5258200200... and the effects of institutional rules on amendment distribution in the federal budget⁴4. Baptista TWF, Machado CV, Lima LD, Garcia M, Andrade CLT, Gerassi CD. As emendas parlamentares no orçamento federal da saúde. Cad Saude Publica. 2012;28(12):2267-79. https://doi.org/10.1590/S0102-311X2012001400006
https://doi.org/10.1590/S0102-311X201200... are highlighted.

In the case of resources allocated to the Brazilian Unified Health System (SUS), three facts contributed to placing the topic on the current agenda of discussion on health financing: increase in amounts allocated by individual amendments since the approval of the mandatory budget in 2015, which defines the obligation of its financial execution in the Federal Constitution of 1988; expansion of the execution of budget rapporteur amendments, which are non-compulsory, by the Ministry of Health (MS), and accounting of the amendments in the Ministry’s minimum expenditure on public health actions and services. Under the spending cap that freezes, in real terms, the minimum expenditure in public health actions and services of the Union, these facts favored the growth of the participation of the amendments, implying a reduction in the share of allocated resources, according to the Ministry of Health regulations⁵5. Piola SF, Vieira FS. As emendas parlamentares e a alocação de recursos federais no Sistema Único de Saúde. Rio de Janeiro: Ipea; 2019 [cited 2021 Nov 14]. (Texto para Discussão; nº 2497). Available from: https://bit.ly/3HiC0SH
https://bit.ly/3HiC0SH... .

Studies indicate that EP can either contribute to the reduction of inequalities⁶6. Linhares PTFS, Messenberg RP. Transferências federais e investimentos municipais em infraestrutura urbana. Bol Anal Polit Inst. 2018 [citado 2021 Nov 14];16:76-84. Available from: https://bit.ly/3ngk1V6
https://bit.ly/3ngk1V6... or ignore redistributive allocation criteria⁷7. Baião AL, Couto CG, Oliveira VE. Quem ganha o quê, quando e como? Emendas orçamentárias em saúde no Brasil. Rev Sociol Polit. 2019;27(71):e004. https://doi.org/10.1590/1678-987319277104
https://doi.org/10.1590/1678-98731927710... , constituting more of an instrument for mediating relations between the Powers, aiming at the governability of the federal Executive⁴4. Baptista TWF, Machado CV, Lima LD, Garcia M, Andrade CLT, Gerassi CD. As emendas parlamentares no orçamento federal da saúde. Cad Saude Publica. 2012;28(12):2267-79. https://doi.org/10.1590/S0102-311X2012001400006
https://doi.org/10.1590/S0102-311X201200... . This is an essential issue since direct transfers from the federal government to state and municipal governments in the Brazilian federative context are fundamental given the unequal availability of public services and resources from subnational entities⁸8. Costa-Font J, Greer SL. Territory and health: perspectives from economics and political science. In: Costa-Font J, Greer SL, editors. Federalism and decentralization in European health and social care. London (UK): Palgrave Macmillan; 2013. p. 13-43.. In addition, specifically for the healthcare area, the Constitution establishes that the allocation of resources must have as a principle the progressive reduction of regional disparities in the country⁹9. Piola SF. Transferências de recursos federais do Sistema Único de Saúde para estados, Distrito Federal e municípios: os desafios para a implementação dos critérios da Lei Complementar nº 141/2012. Brasília, DF: Ipea; 2017 [cited 2021 Nov 14]. (Texto para Discussão; nº 2298). Available from: https://www.ipea.gov.br/portal/images/stories/PDFs/TDs/td_2298.pdf
https://www.ipea.gov.br/portal/images/st... .

Regarding the allocation of federal resources to primary healthcare (APS), before the significant increase in the execution of EP, the Ministry of Health had defined a method for equitably allocating amounts to the Fixed Primary Care Minimum (PAB-Fixo). The PAB-Fixo is, from the perspective of the municipalities, an essential source of resources for financing APS, in addition to being an instrument for allocating federal resources⁴4. Baptista TWF, Machado CV, Lima LD, Garcia M, Andrade CLT, Gerassi CD. As emendas parlamentares no orçamento federal da saúde. Cad Saude Publica. 2012;28(12):2267-79. https://doi.org/10.1590/S0102-311X2012001400006
https://doi.org/10.1590/S0102-311X201200... . The values of the PAB-Fixo, added to other transfers, from the MS and state governments, in addition to own municipal resources, are used for the provision of actions and services at this level of healthcare in the SUS.

Transfers from the Ministry to municipalities, also called remittances, are carried out to finance specific interventions (transfer lines) and are organized in large areas of action of the healthcare system. In 2016, the median number of MS transfer lines for 5,569 municipalities was 22, i.e., half of the municipalities received 22 transfer lines. Of these, ten were for APS funding, one of which was PAB-Fixo¹⁰10. Benevides RPS. As transferências de recursos do Fundo Nacional de Saúde para os fundos estaduais e municipais de saúde em 2016. Brasília, DF: Ipea; 2016 [cited 2021 Nov 14]. (Nota Técnica Disoc; nº. 46). http://repositorio.ipea.gov.br/bitstream/11058/8577/1/NT_46_Disoc_Transfer%c3%aancias.pdf
http://repositorio.ipea.gov.br/bitstream... .

The method defined by the Ministry of Health for allocating resources to the PAB-Fixo considered socioeconomic indicators in constructing a vulnerability index that categorized municipalities into four groups for the per capita distribution of resources¹¹11. Ministério da Saúde (BR). Portaria Nº 1.602, de 9 de julho de 2011. Define o valor mínimo da parte fixa do Piso de Atenção Básica (PAB), para efeito do cálculo do montante de recursos a ser transferido do Fundo Nacional de Saúde aos Fundos de Saúde dos Municípios e do Distrito Federal, e divulga os valores anuais e mensais da parte fixa do PAB. Brasília, DF; 2011 [cited 2021 14]. Available from: https://bit.ly/3wMfBbi
https://bit.ly/3wMfBbi... . The model was in effect until 2019, when the MS created the Previne Brasil Program, establishing new funding criteria for primary healthcare in the SUS, starting in 2020¹⁵15. Ministério da Saúde (BR). Portaria Nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde, por meio da alteração da Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017. Brasília, DF; 2019. [cited 2021 Nov 14]. Available from: https://bit.ly/3nc7p16
https://bit.ly/3nc7p16... .

With increased parliamentary amendments’ participation in the APS financing, through a temporary increment in the PAB, there was an increased difference between the average values of the PAB-Fixo for the municipalities, according to their population size. Without the increment in the Primary Care Minimum, the difference between the averages of the per capita allocation of the municipalities was R$ 5.63 (24.8%) comparing the municipalities that received less and more resources in 2018. With the increment in the PAB, this difference was R$ 92.00 (367%)⁵5. Piola SF, Vieira FS. As emendas parlamentares e a alocação de recursos federais no Sistema Único de Saúde. Rio de Janeiro: Ipea; 2019 [cited 2021 Nov 14]. (Texto para Discussão; nº 2497). Available from: https://bit.ly/3HiC0SH
https://bit.ly/3HiC0SH... .

These differences raise doubts about the consequences of allocating resources for a temporary increment in the Primary Care Minimum by EP and about the MS’s effort to allocate resources to municipalities within the scope of APS equitably. Were the municipalities favored by the EP the most vulnerable per the Ministry of Health’s categorization for the allocation of the PAB-Fixo? Did the EPs correspond in the distribution of resources with the allocation groups defined by the Ministry (proportion of beneficiaries per group and allocated amounts)?

Thus, this article aims to analyze the implications of EP for the model of equitable allocation of resources from the PAB-Fixo to municipalities established by the MS from 2015 to 2019. This approach is justified due to the topic’s relevance for discussion on health financing, the scarcity of scientific research that addresses EP to the SUS budget, and, more specifically, the lack of studies that answer the mentioned questions.

METHODS

The descriptive and exploratory study conducted is based on the modern theory of the public budget, which defines it as a management instrument of i) political nature, as it expresses choices; ii ) economic, as it portrays the allocation of resources; iii ) managerial because it constitutes a plan, and iv ) legal because it is law¹⁶16. Giacomoni J. Orçamento governamental: teoria, sistema, processo. São Paulo: Atlas; 2018.. Analyzes of public administration’s budget-financial execution make it possible to identify governments’ priorities in allocating resources, assess their planning and management capacity, and the compliance of their acts with budget laws¹⁶16. Giacomoni J. Orçamento governamental: teoria, sistema, processo. São Paulo: Atlas; 2018.,¹⁷17. Oliveira FA. Economia e política das finanças públicas no Brasil: um guia de leitura. São Paulo: Hucitec; 2009..

This article investigated the consequences of EP that increase resources to the Primary Care Minimum for the resource allocation model adopted by the MS for the PAB-Fixo¹¹11. Ministério da Saúde (BR). Portaria Nº 1.602, de 9 de julho de 2011. Define o valor mínimo da parte fixa do Piso de Atenção Básica (PAB), para efeito do cálculo do montante de recursos a ser transferido do Fundo Nacional de Saúde aos Fundos de Saúde dos Municípios e do Distrito Federal, e divulga os valores anuais e mensais da parte fixa do PAB. Brasília, DF; 2011 [cited 2021 14]. Available from: https://bit.ly/3wMfBbi
https://bit.ly/3wMfBbi... . In this model, the per capita transfers were defined according to a score from 0 to 10, calculated for each municipality, considering the following indicators: gross domestic product per capita, percentage of the population with health insurance, percentage of the population with Bolsa Família, percentage of the population in extreme poverty, and population density. The index created from these indicators reflects the degree of socioeconomic vulnerability of the population of each municipality, where zero indicates the maximum degree of vulnerability, i.e., worse socioeconomic conditions. The municipalities were classified into four groups, in a gradient of socioeconomic vulnerability, from highest to lowest:

1. Group I: a score lower than 5.3 and a population of up to 50 thousand inhabitants – minimum of R$ 28.00 per inhabitant per year (inhab/year);

2. Group II: scores between 5.3 and 5.8 and population of up to 100 thousand inhabitants or scores lower than 5.3 and population between 50 and 100 thousand inhabitants – minimum of R$ 26.00 inhab/year;

3. Group III: scores between 5.8 and 6.1 and population of up to 500 thousand inhabitants or scores lower than 5.8 and population between 100 and 500 thousand inhabitants – minimum of R$ 24.00 inhab/year;

4. Group IV: not included in the previous items and the Federal District (Brasília) – minimum of R$ 23.00 inhab/year.

Since the Ministry of Health did not publish the list of municipalities by group, the classification of each of them had to be inferred from the division between the annual PAB-Fixo value by the 2012 reference population for the period from 2015 to 2017 (Annex II of Ordinance MS/GM No. 1,409, of 2013)¹²12. Ministério da Saúde (BR). Portaria Nº 1.409, de 10 de julho de 2013. Define o valor mínimo da parte fixa do Piso de Atenção Básica (PAB) para efeito do cálculo do montante de recursos a ser transferido do Fundo Nacional de Saúde aos Fundos de Saúde dos Municípios e do Distrito Federal, e divulga os valores anuais e mensais da parte fixa do PAB. Brasília, DF; 2013 [cited 2021 Nov 14]. Available from: https://bit.ly/3ImdpNT
https://bit.ly/3ImdpNT... , and between the value of the annual PAB-Fixo by the reference population of 2016, for 2018 and 2019 (Annex II of Ordinance MS/GM No. 3,947, of 2017)¹³13. Ministério da Saúde (BR). Portaria Nº 3.947, de 28 de dezembro de 2017. Atualiza a base populacional para o cálculo do montante de recursos do componente Piso da Atenção Básica Fixo PAB Fixo da Portaria 1.409/GM/MS, de 10 de julho de 2013 e do Anexo I; e altera o Anexo II. Brasília, DF; 2017 [cited 2021 Nov 16]. Available from: https://bit.ly/3kViamY
https://bit.ly/3kViamY... , thus obtaining the annual per capita transfer value. The assumption was made that the values published in the ordinances result from applying the criteria and methods adopted by the Ministry for the equitable allocation of resources in the PAB-Fixo.

Two MS determinations regarding the transfers of the PAB-Fixo were analyzed for the possible impact on the groups’ inference. The first is that the Ministry established that the municipalities would not suffer a reduction in the value of the PAB-Fixo due to population variation. Comparing the transferred amount contained in the transfer file of the National Health Fund (FNS) of 2018 concerning the MS/GM Ordinance No. 3,947¹³13. Ministério da Saúde (BR). Portaria Nº 3.947, de 28 de dezembro de 2017. Atualiza a base populacional para o cálculo do montante de recursos do componente Piso da Atenção Básica Fixo PAB Fixo da Portaria 1.409/GM/MS, de 10 de julho de 2013 e do Anexo I; e altera o Anexo II. Brasília, DF; 2017 [cited 2021 Nov 16]. Available from: https://bit.ly/3kViamY
https://bit.ly/3kViamY... showed that the FNS transfer of the 455 municipalities that had a reduction in the reference population (2016 compared to 2012), compared to the ordinance, was higher for 450 municipalities and the same for five of them. Therefore, the values of the ordinance do not seem to contain adjustments due to population reduction.

The second is that, in 2013, the MS decided to integrate the values of the Compensation of Regional Specificities (CER) strategy of the PAB-Variável to the PAB-Fixo¹¹11. Ministério da Saúde (BR). Portaria Nº 1.602, de 9 de julho de 2011. Define o valor mínimo da parte fixa do Piso de Atenção Básica (PAB), para efeito do cálculo do montante de recursos a ser transferido do Fundo Nacional de Saúde aos Fundos de Saúde dos Municípios e do Distrito Federal, e divulga os valores anuais e mensais da parte fixa do PAB. Brasília, DF; 2011 [cited 2021 14]. Available from: https://bit.ly/3wMfBbi
https://bit.ly/3wMfBbi... ,¹⁸18. Ministério da Saúde (BR). Portaria Nº 1.408, de 10 de julho de 2013. Incorpora os recursos financeiros destinados ao financiamento da estratégia Compensação de Especificidades Regionais CER à parte fixa do Piso de Atenção Básica (PAB Fixo) e revoga dispositivos da Portaria nº 204/GM/MS, de 29 de janeiro de 2007, e da Portaria nº 399/GM/MS, de 22 de fevereiro de 2006. Brasília, DF; 2013 [cited 2021 Nov 16]. Available from: https://bit.ly/3nzjRIu
https://bit.ly/3nzjRIu... . As a result, it became more complicated to reproduce the comparison mentioned above for cases of reduction in the reference population (2012 compared to 2010)¹³13. Ministério da Saúde (BR). Portaria Nº 3.947, de 28 de dezembro de 2017. Atualiza a base populacional para o cálculo do montante de recursos do componente Piso da Atenção Básica Fixo PAB Fixo da Portaria 1.409/GM/MS, de 10 de julho de 2013 e do Anexo I; e altera o Anexo II. Brasília, DF; 2017 [cited 2021 Nov 16]. Available from: https://bit.ly/3kViamY
https://bit.ly/3kViamY... . However, when comparing the per capita value calculated from the annual value of the PAB-Fixo of Ordinance MS/GM No. 1,409 and that obtained from the FNS transfer files, including the CER strategy, greater consistency is observed in the first case, with values greater than R$ 23.00 per capita/year. The same does not occur when information from the transfer file of the National Health Fund is used, as transfer values lower than this minimum are obtained. This result indicates that the value of the ordinance encompasses the entire value of the CER strategy, and its use in the inference of groups is more appropriate.

The increment values in the PAB transferred by the Ministry of Health to each municipality were obtained from the FNS transfer files. This increment concerns federal resources allocated by EP⁵5. Piola SF, Vieira FS. As emendas parlamentares e a alocação de recursos federais no Sistema Único de Saúde. Rio de Janeiro: Ipea; 2019 [cited 2021 Nov 14]. (Texto para Discussão; nº 2497). Available from: https://bit.ly/3HiC0SH
https://bit.ly/3HiC0SH... . For comparison in the analyzed period, the resources destined for the PAB-Fixo and the increment in the Primary Care Minimum were monetarily updated for 2020, using the average annual Broad Consumer Price Index (IPCA).

The data were organized in electronic spreadsheets and summarized with basic descriptive statistics. The Z test was applied with the support of the RStudio software, version 2021.09.0, considering a 95% confidence interval (95%CI) to compare the proportions of municipalities and resources between the PAB and its increment in the four groups¹⁹19. Ross SD. Como fazer teste para duas proporções no R: Teste z para duas proporções. 2019. [cited 2021 Nov 20]. Available from: https://rstudio-pubs-static.s3.amazonaws.com/524071_2d9c3b2c3c1349c7a05d051dcc1aae84.html
https://rstudio-pubs-static.s3.amazonaws... .

RESULTS

In 2015, 83.6% of the municipalities (n = 5,570) were classified in groups I (n = 2,604) and II (n = 2,051) in terms of PAB-Fixo (Table 1 and Table 2). In 2019, this percentage grew (to 91.3%), with 3,958 municipalities in group I and 1,130 in group II.

In group 1, with greater socioeconomic vulnerability, more than half of the municipalities belong to the Central-West and Northeast regions, with a population equal to or less than 50 thousand inhabitants (PAB-Fixo 2015 reference) (Table 1). Regarding the municipalities benefiting from EP, between 2015 and 2017, the proportion of those favored in these regions was below 50% for members of group I, with municipalities in the Southeast and South regions being more prevalent. In 2018 and 2019, there was a greater balance between the proportion of beneficiaries per group and region. This occurred for the PAB-Fixo and the increment in the PAB.

By population size, the allocation of resources by EP was close to that defined for the Primary Care Minimum in the case of group I (Table 2). In 2015, 10.5% of municipalities with over 500 thousand inhabitants and 4.8% with up to 5 thousand inhabitants were favored by EP. In 2017 and 2019, these percentages increased to 57.6% and 68.4%, and to 92.7% and 88.0%, respectively.

Between 2015 (value valid until 2017) and 2019 (value valid in 2018 and 2019), there was a reduction in the resources allocated to the PAB-Fixo, in real terms (Table 3). The PAB-Fixo went from R$ 6.04 billion to R$ 5.51 billion at 2020 prices (-8.8%). In the same period, the increment in the PAB went from R$ 95.06 million to R$ 5.58 billion, with a growth of 5,767%.

In 2017, the increment was equivalent to 35.5% of PAB-Fixo resources (R$ 2.15 billion in R$ 6.04 billion). In 2019, this percentage was 101.2% (R$ 5.58 billion in R$ 5.51 billion). Of the amount allocated by EP (increment) in 2015, 69.9% was allocated to groups I and II (R$ 66.5 million in R$ 95.06 million). In 2019, they increased to 76.5% for the same groups (R$ 4.26 billion in R$ 5.58 billion).

Per Table 3, in 2015, 5% of the municipalities in group I benefited, on average, with R$ 31.00 per capita (at 2020 prices) incrementing to PAB. They received R$ 35.00 per capita from the PAB-Fixo plus R$ 31.00 per capita for EP. In the same year, 95% of the municipalities in this group had only R$ 35.00 per capita from the PAB-Fixo. In 2019, 92% of the municipalities in group I were favored by EP and had an additional Primary Care Minimum of R$ 80.00 per capita on average, while 8% of the municipalities in this group had only the PAB-Fixo (R$ 30.00 per capita).

Table 4 compares the proportions of municipalities and resources allocated to the PAB-Fixo classes and increment to the PAB by groups. It can be seen that the null hypothesis of equality between the classes regarding the proportions of municipalities cannot be rejected since the p-value is greater than 0.05. Thus, for the group of EP beneficiaries, the participation of municipalities per group was similar to the participation of municipalities in the PAB-Fixo per group.

However, concerning the proportions of resources, a statistically significant p-value is observed at the 0.1% level, indicating that the 2015 PAB-Fixo classes and the average of the 2015–2017 increment are different for group IV, and at the 1% level for group I of these same classes. Likewise, for groups I and IV of the 2018 PAB-Fixo classes and the average of the 2018–2019 increment. In other words, in the resources allocated by EP, the municipalities of group I had greater participation, and those of group IV had lower participation compared to the participation of these groups in PAB-Fixo resources.

There is a significant increase in the PAB-Fixo plus the increment in the PAB from 2017 (Figure). When comparing the groups, for the municipalities in group I, the average per capita value of the PAB-Fixo with increments went from R$ 66.00 to R$ 108.00 (64.3%) between 2015 and 2019. For group IV, the increase was 11.8%, from R$ 35.00 to R$ 39.00 in the same period.

The Figure also shows that the averages and medians of the PAB-Fixo present low variation, which does not occur when the increment values are added. This indicates that there are municipalities with a very high increment in the PAB per capita, which causes a greater distance between the average and median of the analyzed values. Finally, the reduction, in real terms, of the averages and medians per capita of the PAB-Fixo stands out. On average, considering all municipalities, it went from R$ 34.00 in 2015 to R$ 29.00 in 2019 (-14.7%).

DISCUSSION

Some methodologies have been developed within the scope of health systems for the equitable allocation of resources²⁰20. Carnut L, Mendes A, Leite MG. Metodologias para alocação equitativa de recursos financeiros em saúde: uma revisão integrativa. Saude Debate. 2020;44(126):902-18. https://doi.org/10.1590/0103-1104202012624
https://doi.org/10.1590/0103-11042020126... . In this sense, different meanings of equity have been used, such as i) the complete equalization of opportunities to access the same number of services concerning needs, ii) ensuring that no particular group is disadvantaged, and iii) everyone has an equal opportunity to lead a healthy life²¹21. Lane H, Sarkies M, Martin J, Haines T. Equity in healthcare resource decision making: a systematic review. Soc Sci Med. 2017;175:11-27. https://doi.org/10.1016/j.socscimed.2016.12.012
https://doi.org/10.1016/j.socscimed.2016... .

Equity is also cited as a fair opportunity for all, equal access to health services based on needs, and the absence of systematic health inequalities between socioeconomically different groups, reported in the literature as the most used criterion by decision-makers on healthcare allocation of resources²²22. Guindo LA, Wagner M, Baltussen R, Rindress D, Til J, Kind P, et al. From efficacy to equity: literature review of decision criteria for resource allocation and healthcare decisionmaking. Cost Eff Resour Alloc. 2012;10(1):9. https://doi.org/10.1186/1478-7547-10-9
https://doi.org/10.1186/1478-7547-10-9... .

In Brazil, the idea of equitable allocation of resources is intrinsically associated with health needs. In general, while the authors defend centrality and recognize the complex form of the concept of health needs for allocating resources, they do not make it explicit. However, it is possible to assume its reach beyond the system’s borders due to using socioeconomic, demographic, and health indicators in the methodologies proposed or analyzed²³23. Porto S, Martins M, Travassos C, Viacava F. Avaliação de uma metodologia de alocação de recursos financeiros do setor saúde para aplicação no Brasil. Cad Saude Publica. 2007;23(6):1393-404. https://doi.org/10.1590/S0102-311X2007000600014
https://doi.org/10.1590/S0102-311X200700... .

Methodologies for the equitable allocation of resources generally reflect the idea that it is necessary to consider the unequal living conditions of the population to allocate resources unequally. The purpose is to allocate more resources to the most disadvantaged groups from demographic, social, economic, and health points of view.

In the SUS, implementing the PAB-Fixo is among the initiatives adopted by the MS to promote the reduction of regional inequalities through an unequal allocation of federal resources for health²⁶26. Souza RR. Redução das desigualdades regionais na alocação dos recursos federais para a saúde. Cienc Saude Colet. 2003;8(2):449-60. https://doi.org/10.1590/S1413-81232003000200010
https://doi.org/10.1590/S1413-8123200300... . Although the initiative may eventually be criticized regarding the method adopted and the results obtained, its merits cannot be ignored when introducing the idea of equitable allocation of resources in the SUS. This system presents a pattern of shared responsibility among the entities in financing primary care services. However, it is up to the Ministry of Health to distribute financial resources to compensate for inequalities between municipalities, mainly responsible for managing these services⁹9. Piola SF. Transferências de recursos federais do Sistema Único de Saúde para estados, Distrito Federal e municípios: os desafios para a implementação dos critérios da Lei Complementar nº 141/2012. Brasília, DF: Ipea; 2017 [cited 2021 Nov 14]. (Texto para Discussão; nº 2298). Available from: https://www.ipea.gov.br/portal/images/stories/PDFs/TDs/td_2298.pdf
https://www.ipea.gov.br/portal/images/st... .

This study demonstrates that, in terms of favored municipalities, the EP followed the allocation groups defined by the MS, benefiting them in a similar proportion to the distribution made for the PAB-Fixo. However, the PAB-Fixo favors all municipalities, unlike the EP, even though its coverage has increased in the period analyzed.

Concerning the PAB-Fixo allocation model, the analysis of the allocated resources shows that the resources of EP were allocated in more significant proportions to the municipalities of group I and lesser proportions to those of group IV. In other words, municipalities with a population of up to 50 thousand inhabitants, more socioeconomically vulnerable, were prioritized with the contributions by EP, to the detriment of less vulnerable municipalities, with a population above 50 thousand inhabitants.

As a result, there is a greater distance between the per capita values of the PAB when the increment resources are added. Populations of smaller municipalities are benefiting from much more resources for APS financing than those of larger, less vulnerable municipalities.

In principle, such a situation is desirable concerning equitable allocation. However, it is necessary to consider the current situation of SUS financing and the possible impacts of the allocation of resources by EP, given the considerable constraint imposed on the Ministry budget by the spending cap for primary federal expenditures and the freezing of the federal minimum application in public health actions and services²⁷27. Aragão E, Funcia F. O SUS e as políticas de austeridade: o Brasil na contramão mesmo após a crise gerada pela pandemia da COVID-19. Rev Bras Planej Orçam. 2021 [cited 2021 Nov 20];11(1):49-61. Available from: https://www.assecor.org.br/files/4716/2126/6033/2021_revista_RBPO-vol11_art3.pdf
https://www.assecor.org.br/files/4716/21... . As expenses for EP are accounted for in the minimum application, greater allocation of resources by EP reduces the share of the Ministry of Health’s allocation in actions and services. It may imply the reallocation of resources from other areas. In the case analyzed, from EP to increment to the PAB.

It is also important to highlight that even among the municipalities in group I, those benefiting from EP received much more per capita resources than those not. As a result, the amendments generated unequal treatment among the most vulnerable.

The very different per capita value between the groups of municipalities implies a differentiated benefit among their populations. Public health actions and services must be guaranteed in all municipalities, and in smaller ones, the costs of offering them are usually higher²⁸28. Vieira RS, Servo LMS. Estimativas de custos dos recursos humanos em atenção básica: Equipes de Saúde da Família (ESF) e Equipes de Saúde Bucal (ESB). Brasília, DF: Ipea; 2013. (Nota Técnica Disoc; nº 16). https://bit.ly/39OfHVj
https://bit.ly/39OfHVj... . However, it is necessary to remember that there are difficulties in structuring them on the outskirts of medium and large-sized cities²⁹29. Malta DC, Santos MAS, Stopa SR, Vieira JEB, Melo EA, Reis AAC. A Cobertura da Estratégia de Saúde da Família (ESF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Cienc Saude Colet. 2016;21(2):327-38. https://doi.org/10.1590/1413-81232015212.23602015
https://doi.org/10.1590/1413-81232015212... . The financial crisis from 2014 to 2016, and more recently, the impacts of the pandemic on the Brazilian economy, caused a drop in municipal revenue and, thus, more significant difficulties in allocating resources to health. Municipalities already apply them far above the mandatory minimum percentage³⁰30. Vieira FS, Piola SF, Benevides RPS. Vinculação orçamentária do gasto em saúde no Brasil: resultados e argumentos a seu favor. Brasília, DF: Ipea; 2019 [cited 2021 Sep 27]. (Texto para Discussão; nº 2516). Available from: http://repositorio.ipea.gov.br/bitstream/11058/9428/1/td_2516.pdf
http://repositorio.ipea.gov.br/bitstream... .

Ultimately, an allocation of federal resources that does not consider the differentiated fiscal capacity of entities can also cause inequity, even if its objective is equity. The adoption of technical criteria has been identified as necessary to mitigate this problem³¹31. Carnut L, Andre ECG, Mendes A, Meira ALP. Emendas parlamentares em saúde no contexto do orçamento federal: entre o ‘é’ e o ‘dever ser’ da alocação de recursos. Saude Debate. 2021;45(129):467-80. https://doi.org/10.1590/0103-1104202112917
https://doi.org/10.1590/0103-11042021129... . This issue needs to be deepened in future studies for the case of EP in general.

Other issues that must be considered concerning the use of EP to guarantee the support base of the federal government, in the National Congress, in an unprecedented way, considering the high number of resources involved and the massive lack of transparency in its execution. This lack, especially of the rapporteur’s parliamentary amendments, was questioned in the Federal Supreme Court (STF), which ordered Congress to publish the list of favored members and parliamentarians in addition to the amounts allocated³²32. Supremo Tribunal Federal. Arguição de Descumprimento de Preceito Fundamental – ADPF 850. Relator Min. Rosa Weber. Brasília, DF: STF; 2021 [cited 2021 Dec 5]. https://bit.ly/3FJxI4G
https://bit.ly/3FJxI4G... .

The consequences of an allocation of resources that considers strictly political criteria can be very harmful to the SUS, given the context of budget constraint already mentioned. In addition to causing more significant inequalities, it can be more inefficient, which is unacceptable given the limited resources for financing public health in the country.

This work points out the inference of resource allocation groups as a limitation, which generates some uncertainty about the category of each municipality. The lack of transparency about the Ministry of Health’s method constitutes a barrier not only to the knowledge of the classification of these entities but also to any study aiming to investigate this initiative of equitable allocation of resources.

Finally, it should be noted that only the implications of the EP on the model adopted by the Ministry for the PAB-Fixo were analyzed. The model itself has not been evaluated. In conclusion, the parliamentary amendments distorted the model of equitable allocation of resources thought by the MS for the PAB-Fixo, by allocating resources in a much more significant proportion to the municipalities of group I and much less to those of group IV, in disagreement with this model, and for not benefiting all municipalities, not even the most vulnerable.

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