Federalismo, relações fiscais e financiamento do Sistema Único de Saúde: a distribuição de receitas vinculadas à saúde nos orçamentos municipais e estaduais

• Main Author: Lima, Luciana Dias de
• Publication Date: 2006
• Format: Doctoral thesis
• Language: por
• Source: Biblioteca Digital de Teses e Dissertações da UERJ
• Download full: http://www.bdtd.uerj.br/handle/1/4689
• topic: Federalism; Health policy decentralization; Financing of the Unified Health System; Health management; Federalismo; Descentralização da política de saúde; Financiamento do Sistema Único de Saúde; Gestão em saúde; CNPQ::CIENCIAS DA SAUDE::SAUDE COLETIVA

The thesis deals with the relationship between fiscal federalism and the financing of the Unified Health System (SUS), from 1990 until 2002. It is built on the assumption that critical decisions of subnational actors in the federation are bounded by criteria and conditions that rule the distribution, the appropriation and the use of sector resources and of their own fiscal resources that are bound to the health policy by the Constitutional Amendment nr. 29/2000. The outcomes of the rules that define the decentralized financing of SUS are analyzed in the thesis by comparing and correlating the amounts of the public revenues informed by municipalities and states through the Information System on Public Budgets for Health in the year 2002. By comparing municipalities of the Northern and Northeastern Regions and those with population varying from 20,000 to 100,000 people with other groups it is verified that: (1) they have fewer chances to invest more of their own resources in health as an effect of the constitutional binding, given that the availability of these sources is relatively low; (2) they must develop a strong fiscal effort and compromise a larger part of their budgets in order to guarantee the matching of their resources to their health spending needs; and (3) they are the municipalities that the depend the most from health federal transfers in order to expand the resources destined to SUS and, because of that, they are subject to Ministry of Health s induction and control mechanisms. As far as the states are concerned, there are important regional differences. The financial situation of the Northeastern states is particularly critical. Although the degree of binding of resources to the health sector in Brazil is comparable to other countries, it is possible to notice the heterogeneous conditions of financing, the fragmentation of the transfer mechanisms and the strong determination in the use of resources. Despite the importance of the regular federal transfers of SUS in the subnational budgets, it is noticeable the frailty of the decentralization mechanisms in place. Health is supported by a great variety of fiscal and sectorial resources that suggest a net of fiscal and budget relationships and inter-dependency involving the three levels of government. However, the problems relating to fiscal redistribution and resource expansion still exists in the beginning of the years 2000. The final budgetary balance of the subnational governments is one where the differences in the total revenues bound to health are very important when the municipalities are analyzed by groups of regions, states, population, capital and non-capital. The findings indicate the problems of the Brazilian fiscal system, that is unable to compensate for the more permanent and structural fiscal and budgetary imbalances among the levels of government. They also suggest contradictory effects of the public financing of health that reacted and solidified in a federation that is characterized by profound inequalities, in a political and economic framework that is adverse to the expansion of the role of the State.