Financiamento da saúde no município de Vitória/ES: uma análise da atenção básica

Abstract

Health financing in Brazil is a complex process that implies intervention by the State to minimize inequalities of access and guarantee the right to health care in the Unified Health System (SUS). It is also articulated to the Brazilian fiscal federalism organization, which imposes administrative autonomy, but does not attribute collecting autonomy to it. It is associated with the policy of economic stabilization and containment of health expenditures that aggravate the underfinancing of the system. Then, health financing, specially that of primary care, has been configured as a constant challenge to be faced by municipal health systems for their sustainability and consolidation. In this direction, this research aimed to analyze the health financing in the municipality of Vitória, with emphasis on primary care, from the years 2009 to 2019. To this end, we chose documentary and quantitative research to investigate the revenues and expenditures in health. Data from the municipal financial budget programming were obtained by surveying the Multi-Year Plan, the Budget Guidelines Laws, and the Annual Budget Laws, as well as the health planning instruments – the Municipal Health Plan, the Annual Health Programming, and the Annual Management Report. Concerning data on revenues and public spending on health they were analyzed based on indicators from the Information System of Public Health Budgets of the Health Ministry. The municipal financial budget planning showed the insertion of Health function in the documents, revealing to be a priority in the government agenda; however, it presented weaknesses regarding its elaboration, and integration - establishment of physical and financial goals and demonstration of the results obtained - and disarticulation in the forecast of resources among the instruments. The description of primary care subfunction in the documents, which was aggregated to other actions or programs and not portrayed as a budget action, despite being a municipal responsibility, fell short of what was expected as a political priority. From the analysis of the municipal revenue capacity, a decreasing annual per capita average (17.77%) was verified, with less availability of financial resources for the development of health policy in the period. The total revenue displayed an average of R$ 5,176.91 per inhabitant/year. There was an effort to increase taxes in relation to its own taxes, though the dependence on constitutional transfers from the federated entities was maintained. The additional transfers represented a small source of participation (6.70%) and there was a decrease in federal resources directed to the basic attention subfunction (32.48%). The average total per capita spending corresponded to R$ 1,091.84 per inhabitant/year, with a reduction in the total spending per inhabitant of 7.83%, caused, mainly, by the decrease in available income. The per capita spending with own resources corresponded to an average of R$ 811.02 per capita/year, which represented 74.28% of the total per capita spending of the municipality, being the main financer of the system. In the direction of spending, there was a predominance of current expenses, primarily for personnel payment, in relation to capital expenses. In the spending per level of health care, primary care showed a drastic reduction in spending per capita/year (43.47%). The average expenditure on basic care was R$ 93.13 per capita/year, which represented 8.52% of the total per capita expenditure on the municipality's health. Hence, health care financing in the municipality of Vitória is marked by dependence on constitutional transfers from the federated entities, a pattern that is articulated to the federative relations and imbalances and also their oscillations in the amounts of resources received; by the actions of the municipal government - directly and intentionally - through the insertion of health in the budget planning, the expansion of revenues earmarked for this function and the reduction of the directing of public resources to the basic care subfunction.