Abstract

This study aims to analyze regional trends and patterns of health revenues and expenditure in the Brazilian states from 2006 to 2016. This is an exploratory and descriptive study based on secondary national data and selected indicators. Higher per capita net current revenues for all states and regions, with decreasing levels in specific years associated with the crises of 2008-2009 and 2015-2016 were observed. Per capita health expenditure showed an increasing trend, even in times of economic crisis and declining collection. Diversity of sources and heterogeneity of health revenues and expenditures, as well as different impacts of the crisis on the regional budgets, were observed. The results suggest the protective effect of constitutional health linkage, spending commitments and priorities, and compensation mechanisms of fiscal federalism revenue sources in state health expenditures. However, challenges remain for the implementation of a transfer system that reduces inequalities and establishes greater cooperation among entities, in a context of austerity and strong public health financing constraints in Brazil.

Key words
Federalism; Government Financing; State Government; Healthcare Financing; Unified Health System

Introduction

Federalism is a system that distributes the political authority of the state into multiple territorially-defined and ordained centers and allows the simultaneous exercise of self-rule and shared-rule¹1 Elazar DJ. Exploring Federalism. Tuscaloosa, AL: University of Alabama; 1987.. However, the diversity of ‘federative situations’ is significant²2 Burguess M. Comparative federalism. Theory and Pactice. London and New York: Routledge, Taylor and Francis Group; 2006., and is expressed in the institutions that characterize and influence public policies in these countries³3 Benz A, Broschek J, editores. Federal Dynamics: Continuity, Change and Varieties of Federalism. Oxford: Oxford University Press; 2013..

Among factors explaining the existing variations, international comparative studies highlight the importance of the distribution of tax competencies and fiscal sharing relationships to foster coordination and cooperation between levels of government in the federations⁴4 Watts RL. Comparing federal systems in the 1990s. Ontario: Institute of Intergovernmental Relations; 1996.. Federalism fiscal components have also been valued for understanding the authority of mid-level or regional governments (states, provinces, länder, cantons, etc.) in defining their policies (tax autonomy criteria) and decisions taken in national arenas (fiscal control criteria)⁵5 Hooghe L, Marks G, Schakel AH, Osterkatz SC, Niedzwiecki S, Rosenfield SS. Measuring Regional Authority: A Postfunctionalist Theory of Governance: Volume I. Oxford: Oxford University Press; 2016..

Brazil stands out in the international scenario with its triune arrangement, marked by territorial inequalities and shared responsibilities among entities in various areas of the public policy⁶6 Almeida MHT. O Estado no Brasil contemporâneo. Um passeio pela história. In: Melo CR, Sáez MA, organizadores. A democracia brasileira. Balanço e perspectivas para o século 21. Belo Horizonte: UFMG; 2007. p.17-37.^,77 Souza C. Instituições e mudanças: reformas da Constituição de 1988, federalismo e políticas públicas. In: Hochman G, Faria CA, organizadores. Federalismo e políticas públicas no Brasil. Rio de Janeiro: Fiocruz; 2013. p. 361-386.. The federal sphere concentrates the power to collect and decide on the formulation of policies and the direction of spending at the state and municipal levels⁸8 Arretche M. Continuidades e descontinuidades da Federação Brasileira: de como 1988 facilitou 1995. Dados 2009; 52(2):377-423., which favors its performance to induce and regulate national priorities, finance, and redistribute resources⁹9 Abrucio FL. A coordenação federativa no Brasil: a experiência do período FHC e os desafios do governo Lula. Rev Sociol Polit 2005; 24:41-67.

10 Viana ALd`A, Machado CV. Descentralização e coordenação federativa: a experiência brasileira na saúde. Ciên Saude Colet 2009; 14(3):807-817.

11 Paiva AB, Gonzalez RHS, Leandro JG. Coordenação federativa e financiamento da política de saúde: mecanismos vigentes, mudanças sinalizadas e perspectivas para o futuro. Novos Estud CEBRAP 2017; 36(2):55-81.^-1212 Segatto CI, Abrucio FL. Os múltiplos papéis dos governos estaduais na política educacional brasileira; os casos de Ceará, Mato Grosso do Sul, São Paulo e Pará. Rev Admin Publica 2018; 52(6):1179-1193..

Several studies point to the limitations of the power assigned to the state spheres in the Brazilian federation. Arretche and Schlegel¹³13 Arretche M, Schlegel R. Os estados nas federações: Tendências gerais e o caso brasileiro [artigo na Internet]. Banco Interamericano de Desenvolvimento (BID); 2014 (Documento para Discussão). [acessado 2015 Abr 12]. Disponível em: http://www.resbr.net.br/wpcontent/uploads/historico/Os_estados_nas_federacoes_Tendencias_gerais_e_o_caso_brasileiro.pdf
http://www.resbr.net.br/wpcontent/upload... affirm that the 1988 Federal Constitution (CF88)¹⁴14 Brasil. Constituição da República Federativa do Brasil de 1988. Brasília, DF: Senado Federal; 1988. allowed the recovery of state authority, lost during the authoritarian period (1964 to 1985), which interrupted the democratic regime of 1946. However, the amendments enacted since the 1990s changed CF88’s original design of intergovernmental relationships and fiscal federalism and provided for the concentration of resources and decision-making power at the federal level⁷7 Souza C. Instituições e mudanças: reformas da Constituição de 1988, federalismo e políticas públicas. In: Hochman G, Faria CA, organizadores. Federalismo e políticas públicas no Brasil. Rio de Janeiro: Fiocruz; 2013. p. 361-386.^,99 Abrucio FL. A coordenação federativa no Brasil: a experiência do período FHC e os desafios do governo Lula. Rev Sociol Polit 2005; 24:41-67.^,1515 Almeida MHT. Recentralizando a federação? Rev Sociol Polit 2005; 24:29-40.. The approved reforms have caused losses to state governments and increased the Federal Government’s coordination capacity, limiting the decision-making authority of subnational governments, especially concerning their ability to influence national decisions that affect their policies¹³13 Arretche M, Schlegel R. Os estados nas federações: Tendências gerais e o caso brasileiro [artigo na Internet]. Banco Interamericano de Desenvolvimento (BID); 2014 (Documento para Discussão). [acessado 2015 Abr 12]. Disponível em: http://www.resbr.net.br/wpcontent/uploads/historico/Os_estados_nas_federacoes_Tendencias_gerais_e_o_caso_brasileiro.pdf
http://www.resbr.net.br/wpcontent/upload... ^,1616 Arretche M. Quando instituições federativas fortalecem o governo central? Novos Estud CEBRAP 2013; (95):39-57..

Rezende¹⁷17 Rezende F. O federalismo brasileiro em seu labirinto: crise e necessidade de reformas. Rio de Janeiro: FGV; 2013. argued that this progressive deterioration of states’ position in the federation in the post-Constituent period is expressed in different aspects, such as tax, by reducing the share of states in the distribution of the fiscal pie; budget, due to the loss of freedom in the use of resources due to constitutional linkages, the burden of conditional revenues, program regulation and debt control; legislative, due to the restricted role developed by the state legislatures; regulatory, due to the dissemination of norms from the central government; political, due to the inability of state leaders to influence the vote of their representatives in the National Congress, who agree with the federal government’s agenda even when state command is opposed¹⁷17 Rezende F. O federalismo brasileiro em seu labirinto: crise e necessidade de reformas. Rio de Janeiro: FGV; 2013..

Also, the states experienced a debt situation that was aggravated by the ‘fiscal war’ between them, the compromise of their state banks, and a rising securities debt¹⁸18 Prado S. A Federação Inconclusa: o papel dos governos estaduais na federação brasileira. In: Rezende F, organizador. O federalismo brasileiro em seu labirinto: crise e necessidade de reformas. Rio de Janeiro: FGV; 2013. p. 120-197.. Since the 1990s, the federal government has imposed a substantial fiscal adjustment on state governments in order to restore macroeconomic stability, which has weakened the ability of states to promote investments, affecting their development. Institutional reforms (privatization, administrative reform, increasing debt burdens, among others) inhibited productive investment by state governments, and the pressure from states for federal funds transfers was increased¹⁹19 Rezende F. Federalismo Fiscal no Brasil. Rev Econ Polit 1995; 15(3):5-17.. These aspects allow the understanding of the impacts of the 2008-2009 and 2015-2016 economic crises on state public finance.

The 2008 financial crisis stemmed from the high subprime exposure of the US mortgage market, which coupled with rising noncompliance, led to the decapitalization of large banks, including the closing of Lehman Brothers in September 2008. It turned into a global crisis, with significant effects on the real economy, leading to declining economic activity, unemployment, stocks’ devaluation and falling prices of manufactured goods and commodities. In Brazil, the impacts of the international crisis in this period have been minimized by adopting a wide range of policies to stimulate production and domestic demand, including measures to boost banking sector’s credit and liquidity, although the country has not been entirely immune to its effects on tax collection²⁰20 Silva FJF, Fonseca Neto FA. Efeitos da crise financeira de 2008 sobre o desemprego nas regiões metropolitanas brasileiras. Nova Econ 2014; 24(2):265-278.

21 Rucinski R, Mattei L. A Crise econômica recente e seus impactos sobre a balança comercial catarinense. In: VIII Encontro de Economia Catarinense; 2014 Mai 8-9; Santa Catarina, Brasil. APEC: Unesc; 2014.

22 Cunha JS, Andrade M, Lopes C, Nascimento M, Valverde T. Crise Mundial e a trajetória do Brasil, entre 2008 e 2015. Cad CEAS 2015; 234:4-46.^-2323 Paula LF, Pires M. Crise e perspectivas para a economia brasileira. Estudos Avançados 2017; 31(89):125-144..

The 2015-2016 crisis was more directly related to national factors and a series of governmental measures (fiscal adjustment, water crisis, currency devaluation, and the Special System for Settlement and Custody (SELIC) interest rate increase, among others), which helped to reduce economic growth capacity and generated a high fiscal cost. Other factors have intensified the recession, such as falling incomes, rising unemployment, shrinking credit markets, and falling public investments²³23 Paula LF, Pires M. Crise e perspectivas para a economia brasileira. Estudos Avançados 2017; 31(89):125-144.^,2424 Barbosa Filho FH. A crise econômica de 2014/2017. Estudos Avançados 2017; 31(89):51-60..

Studies suggest that recession and austerity policies have tended to affect states’ revenues more significantly compared to other entities in the federation²⁵25 Assunção JJ, Ortiz FAT, Pereira LFVN. A crise financeira de 2008 e a arrecadação tributária: lições para o desenho de transferências e federalismo fiscal. Brasília: STN; 2012 (Textos para Discussão nº 08).^,2626 Afonso JR, Castro, KP. A crise (do financiamento) da saúde. Conjuntura Econômica 2016; 70:22-24.. In this context, this paper aims to analyze the regional trends and patterns of health revenues and expenditures of Brazilian states in the 2006-2016 period. The crises that hit the country in the second decade of the 2000s have a federative dimension, which is expressed differently in the state budgets because of the division of tax competencies, the fiscal sharing system, and the financing mechanisms of the Unified Health System (SUS).

This study is justified by the importance of states for the setting of the federative arrangement and conducting the Brazilian health policy²⁷27 Lima LD, Machado CV, Baptista TW, Pereira AMM. O pacto federativo brasileiro e o papel do gestor estadual do SUS. In: Ugá MA, Sá MC, Martins M, Braga Neto FC, organizadores. Política de saúde no estado do Rio de Janeiro. Rio de Janeiro: Fiocruz; 2010. p. 27-58.. While some studies on SUS financing analyze the distribution of revenue sources and the composition of health expenditure²⁸28 Dain S. Os vários mundos do financiamento da saúde no Brasil: uma tentativa de integração. Ciên Saude Colet 2007; 12(Supl.):1851-1864.

29 Servo L, Piola SF, Paiva AB, Ribeiro JA. Financiamento e Gasto Público de Saúde: histórico e tendências. In: Melamed C, Piola SF, organizadores. Políticas Públicas e Financiamento Federal do Sistema Único de Saúde. Brasília: IPEA; 2011. p. 85-108.^-3030 Mendes A, Funcia FR. O SUS e seu financiamento. In: Marques RM, Piola SF, Roa AC, organizadores. Sistema de Saúde no Brasil: organização e financiamento. Rio de Janeiro: ABrES, Brasília: MS, Departamento de Economia da Saúde, Investimentos e Desenvolvimento; 2016. p. 139-168., few studies address the different effects of fiscal federalism on health financing and spending capacity of subnational entities³¹31 Lima LD. Federalismo, Relações fiscais e financiamento do Sistema Único de Saúde: a distribuição de receitas vinculadas à saúde nos orçamentos municipais e estaduais. Rio de Janeiro: Museu da República; 2007.

32 Scatena JHG, Viana ALD, Tanaka OY. Sustentabilidade financeira e econômica do gasto público em saúde no nível municipal: reflexões a partir de dados de municípios mato-grossenses. Cad Saude Publica 2009; 25(11):2433-2445.

33 Lima LD, Andrade CLT. Condições de financiamento em saúde nos grandes municípios do Brasil. Cad Saude Publica 2009; 15(10):2237-2248.^-3434 Levi ML, Scatena JHG. Evolução recente do financiamento do SUS e considerações sobre o processo de regionalização. In: Viana AL, Lima LD, organizadoras. Regionalização e Relações Federativas na Política de Saúde no Brasil. Rio de Janeiro: Contra Capa; 2011. p. 81-113..

Notably, the possible impacts of the Brazilian economic crises have not yet been sufficiently explored in the production of the Collective Health, leaving gaps that prevent the understanding of their effects on the state funding of SUS.

Methods

This is an exploratory and descriptive study oriented to analyze the health financing and spending conditions of the Brazilian states.

Two databases were built on the income and expenses of the 26 Brazilian states. The Federal District was not included in this study because it is a “city-state” and has tax competencies, and budget binding and detailing criteria different from the Brazilian states. The databases’ variables are monetary values (in national currency) of public revenues and expenditures made by the Brazilian states from 2006 to 2016. This period was chosen because it allows the analysis of a historical series of budget implementation at a time of ascent and rising budgetary constraint in the face of the 2008-2009 and 2015-2016 economic crises.

The revenue database was constructed from data obtained from the budget implementation reports of the Brazilian Finance Information System (FINBRA). In some cases, when verifying data from some hugely discrepant items, a comparison was made with reports informed on each state transparency website, and the National Treasury Secretariat (STN) reports. In 2013, in the state of Mato Grosso, it was necessary to adjust the ICMS deduction related to the FUNDEB. In the FINBRA report, the deduction was around 66%, and was adjusted to 20%, which is the established percentage, and confirmed on the state transparency website. The health expenditure base was built from data obtained through the Public Health Budget Information System (SIOPS). For comparability purposes, the monetary values of the specific items used in the calculation of the indicators were deflated for December 2016 using the Extended National Consumer Price Index (IPCA) of the Brazilian Institute of Geography and Statistics (IBGE), which was also the total resident population data source.

FINBRA is the responsibility of STN and SIOPS of the Ministry of Health. These databases were chosen because they are in the public domain and open access, and gather all the realized revenues and committed expenses of all Brazilian states. The following indicators were used in this paper: per capita net current revenue (NCRpc); per capita health expenditure (HEpc); percentages of directly collected revenues (DCR), redistributive transfers (RT), compensatory transfers (CT), and health-related revenues (HRR) in the net current revenues. The classification of transfers was based on the typology proposed by Prado³⁵35 Prado S. Transferências Intergovernamentais na Federação Brasileira: avaliação e alternativas de reforma. Fórum Fiscal dos Estados Brasileiros. Caderno Fórum Fiscal 2006; 6(1):11-39..

Specific items of realized revenues and committed expenditures from 2006 to 2016 were used to calculating the indicators. Box 1 breaks down the indicators calculated for each of the states and their aggregates – total Brazil, and North (N), Northeast (NE), Midwest (MW), Southeast (SE) and South (S) regions – in the several years of the series.

A simple descriptive analysis of the time series of the revenue and expenditure indicators was made. Aggregate indicators were calculated as the national and region-by-region synthesis, i.e., the ratio of aggregates (total states financial values in the numerator divided by the respective total numbers of inhabitants in the denominator). Thus, it is different from what would be a measure of central tendency of the observed values in the units (for example, the simple mean).

The net current revenue variation was compared with that of gross domestic product (GDP) for the period obtained from the IBGE. Also, the relative dispersion was calculated, which allows the analysis of inequalities, through the coefficient of variation, calculated as the ratio between the standard deviation and the mean (from the regions considering the dispersion between the states of each one and as a whole, and in turn, within the national framework, considering the dispersion among the five regions).

Results

A growing trend in the NCRpc of the Brazilian states was recorded from 2006 to 2016, with downturns in specific years (2009, 2015 and 2016) (Figure 1). However, in general, the NCRpc levels in 2016 were higher than in 2006. HEpc showed different behavior of revenue, with an upward trend over the years and a sharp increase from 2014.

Table 1 shows the real growth rate of Brazilian GDP and total NCR for all states and their regional aggregates. In the period analyzed, the NCR had a higher growth rate than the national GDP for states and regions, except the SE. However, the aggregate of the states evidenced negative growth rates in 2009 (-1.7), 2015 (-5.9) and 2016 (-1.6) and, except for 2016, below the growth rate of the Brazilian GDP, which in these years was also negative (-0.1; -3.5 and -3.3; respectively). In 2009, N, MW, and SE results followed this national trend. In 2015, all regions had negative NCR growth rate values and lower than the Brazilian GDP, except for the S region. The MW region evidenced the most considerable value fluctuations (Table 1).

Directly collected funds were the primary sources of state budget revenue (on average, about 69% of NCR), followed by redistributive transfers (on average, about 15%) (Figure 1). There was no significant variation in the proportional share of the different sources of NCR, except for the slight decrease in funds directly collected in 2008, 2011 and 2014, and the fluctuations over the years in the case of other sources of revenue (range from 9% to 13%). Health-related revenues accounted for about 4% of NCR.

Figure 2 shows different regional patterns of state revenue and total health expenditure indicators. The SE and MW regions had the highest NCRpc values. This indicator showed a growing trend in practically all regions with a decrease in specific years (2009, 2013 and 2015), except in the SE region, whose decrease in revenue can be observed from 2013. HEpc followed the growing trend, however, without fluctuations, except in 2011 (MW region) and 2013 (SE and S regions). Region N had the highest health expenditure, and the NE Region, the lowest (Figure 2).

Concerning the proportional share of revenue sources, the states of the N and NE had the highest rates of redistributive transfers (on average, about 42% and 38%, respectively), compared to other regions (14% in the MW, 3% in the SE and 7% in the S), which had higher rates of funds directly collected (on average, 75%, 78%, and 78% respectively). Health-related revenues were low in all regions, ranging from 1% (MW) to 5% (NE). The other sources of revenue were those with the most considerable variations between regions (Figure 2).

In 2009, all regions showed a reduced proportional share of redistributive transfers, except the South. The MW states showed the most considerable fluctuations in the proportion of redistributive transfers and revenues from other sources during the period studied (Figure 2).

Table 2 shows the coefficient of variation of NCRpc and HEpc for the set of states and their regional aggregates, as well as between regions. In both indicators, the differences were marked and fluctuated throughout the period and were more pronounced in the case of HEpc. However, a declining inequality was observed, especially concerning HEpc, in 2016 compared to 2006.

It is noteworthy that the inequalities of NCRpc were more significant in the states of the N and MW region, as well as that of HEpc in the SE states. Fluctuations of coefficients were noted over the period, tending to reduce inequality, especially in the NE and SE. In both indicators analyzed, the lowest inequality between states of the S region is striking (Table 2).

Discussion

This study analyzed the trends and regional patterns of state health revenues and expenditures from 2006 to 2016 to identify possible repercussions of the economic crises, in the face of the division of tax competencies, the tax sharing system, and SUS funding mechanisms.

A growing trend of revenues was observed, with falls in specific years associated with the 2008-2009 and 2015-2016 crises. Several studies suggest that the Federal Government’s tax collection difficulties during this period compromised the calculation bases of the State Participation Fund (FPE) – the Industrialized Products Tax (IPI) and the Income Tax (IR) – which represents a significant portion of state revenues²⁵25 Assunção JJ, Ortiz FAT, Pereira LFVN. A crise financeira de 2008 e a arrecadação tributária: lições para o desenho de transferências e federalismo fiscal. Brasília: STN; 2012 (Textos para Discussão nº 08).^,2626 Afonso JR, Castro, KP. A crise (do financiamento) da saúde. Conjuntura Econômica 2016; 70:22-24.. Afonso and Castro²⁶26 Afonso JR, Castro, KP. A crise (do financiamento) da saúde. Conjuntura Econômica 2016; 70:22-24. point out that, after 2008, the course of federal collection and spending was shallow, with a structural break of the trend that prevailed in the first decade of 2000. Notably, a concomitant increase of public spending was observed in these years, especially in a context of the exceptional performance of the development of national tax revenues, in which the gross tax burden achieved levels exceeding two-thirds of GDP.

The measures adopted by the federal government to contain the 2008 crisis through tax exemptions also compromised the composition of FPE³⁶36 Torrezan RGA. Federalismo Fiscal e a desconstrução dos estados: uma análise sob a perspectiva do endividamento público [dissertação]. São Paulo: Universidade Estadual Paulista Júlio de Mesquita Filho; 2017.. Together with the non-updated FPE¹⁷17 Rezende F. O federalismo brasileiro em seu labirinto: crise e necessidade de reformas. Rio de Janeiro: FGV; 2013. apportionment criteria, these measures led to lower levels of transfers to the Brazilian regions. The states of the N, NE and MW were the most affected by the changes, with a loss of R$ 108.4 billion in the 2008-2012 period, as estimated by the Federal Court of Accounts³⁷37 Brasil. Tribunal de Contas da União (TCU). Acompanhamento, recomendações e ciência aos autos referente às contas do governo exercício de 2013. Brasília: TCU; 2013..

Nevertheless, redistributive transfers through participatory funds play an essential role in reducing interregional disparities in state budget revenues. The calculation method adopted for the transfer of these resources benefits the governments with lower direct tax collection power³⁵35 Prado S. Transferências Intergovernamentais na Federação Brasileira: avaliação e alternativas de reforma. Fórum Fiscal dos Estados Brasileiros. Caderno Fórum Fiscal 2006; 6(1):11-39., which explains the high dependence of the states of the N and NE regions on the FPE, evidenced in this study. However, in a recent study, Arretche³⁸38 Arretche M. Transferências fiscais no Brasil. In: Menezes Filho N, Souza AP, organizadores. A Carta: para entender a Constituição Brasileira [e-book]. São Paulo: Todavia; 2019. p. 604-960. showed that FPE transfers have limited effects over the reduction of inequalities, as they do not favor states with a higher concentration of vulnerable populations.

However, the crisis did not have the same impact on health expenditures that tended to increase in all states and regions, even in times of declining revenues. This increase may be associated with the validity of the regulation of Constitutional Amendment Nº 29 (EC29) that defines minimum rates of application of the Federal Government, states and municipalities, in actions and public health services since 2000.

Studies show the protective effect of the Amendment on the Brazilian public health spending, and its repercussion for the significant increase in the participation of state and municipal governments in SUS financing²⁹29 Servo L, Piola SF, Paiva AB, Ribeiro JA. Financiamento e Gasto Público de Saúde: histórico e tendências. In: Melamed C, Piola SF, organizadores. Políticas Públicas e Financiamento Federal do Sistema Único de Saúde. Brasília: IPEA; 2011. p. 85-108.^,3939 Piola SF, França JRMF, Nunes A. Os efeitos da Emenda Constitucional 29 na alocação regional dos gastos públicos no Sistema Único de Saúde no Brasil. Ciên Saude Colet 2016; 21(2):411-421.. In 2000, when the EC Nº 29 was approved, the states accounted for 18.6% of public resources allocated to the SUS. In 2010, this share increased to 26.4%, corresponding to an increased contribution of funds of about 200% (from R$ 12 billion in 2000 to R$ 36.3 billion in 2010)³⁹39 Piola SF, França JRMF, Nunes A. Os efeitos da Emenda Constitucional 29 na alocação regional dos gastos públicos no Sistema Único de Saúde no Brasil. Ciên Saude Colet 2016; 21(2):411-421..

Increased health spending also expresses the commitments and priorities of governments in developing their policies, coordinating nationally induced strategies, and regionalizing health in the context of the 2000s²⁷27 Lima LD, Machado CV, Baptista TW, Pereira AMM. O pacto federativo brasileiro e o papel do gestor estadual do SUS. In: Ugá MA, Sá MC, Martins M, Braga Neto FC, organizadores. Política de saúde no estado do Rio de Janeiro. Rio de Janeiro: Fiocruz; 2010. p. 27-58.. This process resulted in increased investment and strengthened partnerships and public-private articulation in the organization of networks and the provision of specialized services⁴⁰40 Santos AM, Giovanella L. Governança regional: estratégias e disputas para gestão em saúde. Rev Saude Publica 2014; 48(4):622-631.^,4141 Romano CMC, Scatena JHG, Kehrig RT. Articulação público-privada na atenção ambulatorial de média e alta complexidade do SUS: atuação da Secretaria de Estado de Saúde de Mato Grosso. Physis 2015; 25(4):1095-1115..

Noteworthy are the differences found for the set of states and their regional aggregates. While the trends in NCRpc and HEpc in the period were similar, the revenue and expenditure levels were different among regions, as evidenced by the results of the coefficients of variation. These results suggest possible differentiated effects of the crisis due to budget revenue components, as well as the priorities given by the Brazilian states to the governmental expenses.

Worth mentioning is that the challenge of balancing public finances is particularly marked for states, given the fiscal austerity policies adopted by the federal government and their effects on SUS financing mechanisms. Vieira⁴²42 Vieira FS. Crise Econômica, Austeridade Fiscal e Saúde: Que lições podem ser aprendidas? Brasília: IPEA; 2016 (Nota Técnica nº 26). affirms that, in times of crisis, countries tend to reduce public spending to tighten the fiscal environment or adhere to conditions granted by international lending institutions. In this study, the low proportion of health-related revenues in state budgets may be related to the prioritization of municipalities in the decentralization process, but also the containment of federal expenditures, which tends to be aggravated by the freezing of primary Federal Government spending provided for in the Constitutional Amendment 95⁴³43 Brasil. Emenda Constitucional nº 95. Brasília, DF: Casa Civil; 2016..

Funcia⁴⁴44 Funcia FR. Transferências Financeiras do Fundo Nacional de Saúde para estados e municípios em 2017: efeitos da limitação de pagamentos imposta pelo teto de despesas primárias da emenda constitucional 95/2016 e evidência dos riscos da portaria MS 3992/2017. Revista Eletrônica Domingueira da Saúde [publicação na Internet]. 2018 Jun (Domingueira nº 17). [acessado 2015 Abr 12]. Disponível em: http://idisa.org.br/domingueira/domingueira-n-17-junho-2018#a0
http://idisa.org.br/domingueira/domingue... showed that, in 2017, the health financing of the population has already suffered losses. Federal expenditures concerning health actions and services were adversely affected: (a) concerning amounts paid by the Ministry of Health, which, although committed, settled expenses below the Constitutional level; (b) concerning financial transfers from the National Health Fund to the State and Municipal Health Funds, which showed real decrease with nominal variations below the IPCA/IBGE; (c) and concerning variations related to financial transfers of financing blocks that evidenced nominal and real decrease in four of the six blocks⁴⁴44 Funcia FR. Transferências Financeiras do Fundo Nacional de Saúde para estados e municípios em 2017: efeitos da limitação de pagamentos imposta pelo teto de despesas primárias da emenda constitucional 95/2016 e evidência dos riscos da portaria MS 3992/2017. Revista Eletrônica Domingueira da Saúde [publicação na Internet]. 2018 Jun (Domingueira nº 17). [acessado 2015 Abr 12]. Disponível em: http://idisa.org.br/domingueira/domingueira-n-17-junho-2018#a0
http://idisa.org.br/domingueira/domingue... .

With the economy facing a threat of prolonged recession, this tightening of fiscal and monetary austerity policies will tend to decrease the consumption of household and private investment, leading to a vicious circle of deceleration or even falling tax revenues, lower economic growth and a higher burden of net public debt on national income⁴⁵45 dos Economistas. Manifesto dos economistas pelo desenvolvimento e pela inclusão social. Carta Maior [página na Internet]. 2014 [acessado 2015 Abr 12]. Disponível em: https://www.cartamaior.com.br/?/Editoria/Economia/Manifesto-dos-economistas-pelo-desenvolvimento-e-pela-inclusao-social/7/32180
https://www.cartamaior.com.br/?/Editoria... . Also, austerity materializes as an obstacle to reducing inequalities (UNCTAD) and the human rights of the population (UN, 2018), with severe implications for the right to health⁴⁶46 Dweck E, Oliveira ALM, Rossi, P. Austeridade e retrocesso: Impactos sociais das políticas fiscais no Brasil [livro na Internet]. São Paulo: Brasil Debate e Fundação Friedrich Ebert; 2018. [acessado 2019 Mar]. Disponível em: http://campanha.org.br/wp-content/uploads/2018/08/DOC-AUSTERIDADE_doc3-_L9.pdf
http://campanha.org.br/wp-content/upload... ^,4747 Santos IS, Vieira FS. Direito à saúde e austeridade fiscal: o caso brasileiro em perspectiva internacional. Ciên Saude Colet 2018; 23(7):2303-2314..

This paper has highlighted the diversity of sources and the heterogeneity of health revenues and expenditures, as well as the differential impacts of the crisis on state budgets in the regions. The maintenance of health expenditure growth in times of economic crisis and collection difficulties may be associated with the protective effect of the constitutional health linkage devices, spending commitments and priorities, as well as the mechanisms of compensation of fiscal federalism revenue sources. However, there are still challenges concerning the establishment of a transfer system that will reduce inequalities and establish greater cooperation between levels of government, in a context of austerity and substantial restrictions on Brazilian public health financing.

Acknowledgments

PC Contarato is a Ph.D. Fellow, and LD Lima is a Productivity Fellow of the National Council for Scientific and Technological Development (CNPq). The research was funded by the Academic Excellence Program of the Coordination for the Improvement of Higher Education Personnel (PROEX-CAPES) Program. This paper is the sole responsibility of the authors and does not necessarily reflect the opinion of the institutions to which they are linked. We are grateful to Professor Doctor Sol Garson for the support received in structuring the database.

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