Experts criticize mechanism, which is spent with little technical criteria
09/28/2022
Congress has been increasing its power over public health budgets year after year. Today, for every R$10 spent by the federal government in this field, deputies and senators control R$1.10. Eight years ago, they decided on the destination of R$0.20. Of this total, about 85% goes to regular expenditures and only 15% are investments. With a new feature: the so-called secret budget, or public funds earmarked for discretionary use by lawmakers, can be used to pay salaries.
The increase in lawmakers’ control over the health budget has happened amid cuts in essential sectors of the ministry. The federal program that subsidizes medicines and gives others for free will have its budget cut by 59% next year. Revenues for initiatives against cancer have been cut by 45% for 2023. This year, the amendments represent more than three times the ministry’s total funds for investments, of only R$4.7 billion.
The strengthening of Congress in the decision about this budget has helped some cities with strong political sponsors in Brasília to expand the service to the population, but it is criticized by experts for hindering the management and planning of the sector and leaving the municipalities “dependent” on the Congress.
“Public health policy is made with planning. How can I invest or expand care if I have no guarantee that I will have the money next year? The congressional earmarks completely disorganize the system,” said Geraldo Reple Sobrinho, the municipal health secretary of São Bernardo (São Paulo) and head of the Council of Health Secretaries of São Paulo (Cosems-SP).
This uncertainty ends up creating a “dependency” of the municipality on lawmakers. In healthcare, 70% of the expenses are with human resources. If the city expands the service and hires more employees with the money sent by a lawmaker this year, but the money is not granted the following year, the government accounts will be in serious difficulty and services will have to be cut. This is different from an investment amendment, which does not require more money after the purchase of the equipment or the end of the work.
Mr. Reple Sobrinho says that the ideal would be that the funds were in the Ministry of Health’s budget with clear destinations and transfer rules for each entity. “If today I receive R$1 million in earmarks and next year the deputy is no longer with the mayor or lost the election, the city will have nothing and the population will be unassisted,” he warned.
The use of amendments for spending on healthcare costs of municipalities and state governments exists since the individual earmarks became mandatory in 2015, but they cannot be used to pay salaries or other expenses of a permanent nature. In the case of secret budget, created in 2020, there is no such prohibition. These transfers are used to attract the support of mayors, who serve as important canvassers. The secret budget also helped to increase the power of Congress over the federal health budget, to 11% now from 3% in 2014.
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Gil Castello Branco — Foto: Ruy Baron/Valor
Gil Castello Branco, General Secretary of NGO Contas Abertas, points out that the situation “will reach its extreme limit” next year. The 2023 budget proposal has already been sent to Congress allocating R$10.4 billion for lawmakers to decide how they will be distributed in the Ministry of Health through the secret budget — because if this were not done, the government would not even be able to meet the minimum spending in the area, determined by the spending cap.
“This is very bad. The Constitution requires a series of epidemiological and socioeconomic requirements for the government to distribute health money. If it is distributed by the legislators without any technical criteria, which is what has been happening with the rapporteur’s amendments, you will lose the quality of spending,” said Mr. Castello Branco.
This is also the concern of the executive secretary of the National Council of Municipal Health Secretaries (Conasems), Mauro Junqueira. “If the lawmaker wants to use amendments, it should be something extra, not included in the ordinary funds of the Ministry of Health, the constitutional minimum,” he said. “The funds from amendments should be an extra. In this case, they would be important,” he said.
Together with the R$10.4 billion in amendments from the rapporteur for health, deputies, and senators will indicate more R$5.85 billion in congressional earmarks (because 50% of them must go to health). These two instruments alone will guarantee that they maintain control over 10.8% of the ministry’s funds, the same level as in 2022. In addition, they will still have the right to choose the destination of R$7.7 billion from the amendments of the state caucuses, which are not binding and can go to any area of the government.
Chamber of Deputies Speaker Arthur Lira (Progressive Party, PP of Alagoas) has argued that the growth of congressional earmarks has changed the reality of municipal services and that, when he arrives in any city, the first to thank him is always the health secretary. In an event at BTG Pactual last month, Mr. Lira said officials in Brasília do not know the reality of the municipalities as well as the legislators and that he intends to hold an event after the election for municipal secretaries to disclose what has been done with the funds.
One city is Flexeiras, in Alagoas, with 8,700 voters, where the PP mayor supports Mr. Lira. The municipal health secretary, Tatiana Lins, says that the amendment sent by the speaker (R$2.8 million) allowed to equip a basic health unit with an electrocardiogram and hire doctors to attend 10 specialties, performing triage before referring patients for more complex care in the state capital Maceió — a trip carried out in four new cars acquired with the funds transferred to the city.
The president of Cosems of Alagoas and health secretary of Jundiá, Rodrigo Ferreira de Lima, however, said that “the logic of the rapporteur’s amendment does not always respect” the necessary planning for the area and caused in the colleagues an “urgency” to seek those funds to assure local care. “You stop aiming to meet the collective planning and start meeting political demands.”
He also points out that there is a disparity among municipalities. Mar Vermelho (Alagoas), for example, with 3,400 inhabitants, spent R$1,212 per capita on health last year, while Messias, with 18,000, spent R$617 per capita. The reason? Mar Vermelho received R$899,300 from the rapporteur’s amendment for health, while Messias, with six times more residents, received only R$115,000 more.
“In Alagoas, when you have a stronger political sponsor, you receive more. But the health situation of that municipality is not analyzed, not the real need. You take [money] from high complexity and give it to a city of 5,000 inhabitants, whose main priority is the payroll,” said Mr. Ferreira de Lima.
Speaker Arthur Lira declined to comment.
The Minister of Health, Marcelo Queiroga, avoided criticizing this model, which is supported by the Bolsonaro administration in exchange for the approval of measures of its interest in Congress, but says that, “by the logic of the administrator,” to see the budget of his area depending on the amendments of rapporteur “is one more factor” to be considered. “The fact that Congress allocates earmarked funds does not necessarily mean that this allocation will be improper. We need to talk to reach an agreement,” he told Valor.
Mr. Queiroga says he criticized when Congress determined the purchase of equipment for a health unit in a small town. “Lawmakers do not do this to harm the health system. They do so to serve his base. I’ll have to turn on my head to be able to tell the lawmaker: ‘Look, you can help your base more if, instead of putting these funds here in this town, you put it in another town in the region’,” he said.
*By Raphael Di Cunto, Fabio Murakawa
Source: Valor International