How will the upcoming presidential elections impact public healthcare funding in Brazil?
By: Alessandra Pignalosa
The main electoral research institutes in Brazil (Datafolha, Ipec, BTG/FBS, Genial/Quaest, Ipespe, and Paraná Pesquisa) have shown a clear lead of former president Luiz Inácio Lula da Silva (PT) over current president Jair Messias Bolsonaro (PL) in the presidential race. Amidst the growing political tension among their voters and recurrent attacks from Bolsonaro against the Brazilian electoral system, the discussion about the candidates’ government plans is put aside. Understanding them is, however, key to pointing out which instruments will be used to solve the numerous challenges imposed on post-pandemic Brazil, especially within the healthcare area.
It is no news that the Unified Health System (SUS) is underfunded. Data from the Organization for Economic Co-operation and Development (OECD) revealed that Brazil spent, in 2019, US$1,514 on health per capita, which places it 38th on the organization’s list (of 45 countries). This amount represents 37% of the OECD’s average of US$4,087 and is far from meeting the needs of the Brazilian population. Despite this, in proportional terms, health expenditures in the country represent 9.6% of the Gross Domestic Product (GDP), high enough to overtake the OECD average of 8.8% (Conta-Satélite de Saúde – CSS, 2019).
The ace-in-the-hole falls back into the differentiation between public expenditure, which comes from the three federative entities, and private expenditure, originated from the payment of health plans or funded directly by individuals. Out of the 9.6% of the GDP spent on health, 3.8% is destined to finance the SUS, used by 75% of the population, while the rest, 5.8%, is destined to 25% of Brazilians (CSS, 2019). In other words, a quarter of the population accounts for 60% of health expenditures, while the other three quarters share the remaining 40% of resources – this is inequity in its purest form.
The fact is that these percentages have varied little in 10 years, at least speaking about public expenditure on health, which varied from 3.6 to 3.8% of the GDP, compared to the 1.4% increase in private expenditure between 2010 and 2019 (CSS). The great challenge for the next administration, in this scenario, will be to deal with the inevitable growing demand for public health services given the aging population and the advancement of health technologies (ROCHA et al., 2021). The budget will continue to be pressured by the need of sustained investment in prevention tools, primary care and innovative treatment.
The increase in public spending in healthcare will be essential to absorb this trend and will depend, virtually, on a political and social decision. That said, a full understanding of the proposals of the two main presidential candidates is of paramount importance, but even up to a few weeks before the election, this topic has barely been addressed in interviews and debates.
Bolsonaro promises to continue prioritizing Primary Care, without neglecting Specialized Care, with initiatives such as the Social Pharmacy, the National Immunization Program (PNI) and Health Education, to invest more resources in community health agents, to continue to meet the demands arising from population aging, to consolidate the National Program to Support Oncological Care (PRONON – now suspended), to continue the Physical Activity Incentive Program, to continue and consolidate the use of the National Health Card, to strengthen the Digital Health and Telehealth Programs, to improve the SUS’ management, expanding the articulation between the public and private sectors and to expand the offer of health services to indigenous communities.
As the popular saying goes ‘talk is cheap’ – the truth, however, can be seen in the suspension of the PRONON in 2020 (without any effort by the Federal Government to reinstall it since then), in the active dismantling of the PNI, in the corroboration of the anti-vaccine movement and in the intention to cut more than 50% of the resources allocated to the Social Pharmacy program in 2023 (reversed after strong social commotion). In addition, Bolsonaro shows no intention to expand public expenditure on health – on the contrary, there was a 42% cut in discretionary funds for the Ministry of Health in the budget proposal for 2023, granting the corresponding amount to the rapporteur’s amendments, which can be used at the parliamentarians’ own convenience. The scenario, therefore, does not look promising from this side of the field.
With generalist proposals, Lula defends meeting the health demands that were put on hold during the COVID-19 pandemic, resuming the national vaccination program, strengthening the public and universal characteristics of the SUS and improving its management, valuing and training health professionals, resuming programs such as More Doctors and Social Pharmacy, rebuilding and fostering the Health Economic and Industrial Complex and paying special attention to women in vulnerability. Resembling a letter of intent, the document does not detail how the candidate will achieve these general objectives and, once again, the maxim prevails ‘talk is cheap’.
More than once, Lula has criticized the lack of public investments in health and has promised that, if elected, he will end the expenditure cap—in force since 2017 by Constitutional Amendment No. 95 to limit the Federal Government’s spending over the following 20 years and allow its expansion only according to inflation. Even if Lula delivers what he promised, it will require the creation of other fiscal balance measures that have not yet been clarified.
Thus, for the two main contenders for the head of the Executive branch, there are, on the one hand, contradictory proposals and lack of intention to increase public health expenditure and, on the other hand, generalist proposals that do not detail the stepping stones. Right in the middle are the voters, which will probably take a shot in the dark, hoping for the best — or, at least, not to shoot themselves in the foot. This scenario will require continued advocacy actions from all types of stakeholders towards official activity to address healthcare challenges in a sustained and efficient manner. Speyside will be monitoring closely the roll-out scenario after the elections at Federal and State level to identify the main opportunities and obstacles which can arise for the healthcare area.
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