Health system financing paradigm in the state of São Paulo: a regional analysis

ABSTRACT OBJECTIVE To analyze the allocation of financial resources in the Brazilian Unified Health System (SUS) in the state of São Paulo by level of care, health region, source of funds and level of government. METHODS This is an exploratory study based on 2014 data extracted from the Public Health Budget Database, presented in absolute terms, relative terms and per capita . RESULTS In 2014, R$52.1 bi were spent on public health, 58.0% having corresponded to the expenditures of the municipalities and 42.0% to those of the state government. Regional per capita spending varied from R$561.75 to R$824.85. As for the per capita spending on primary health care, which represented 37.5% of the municipalities’ total expenditure, the lowest value was found in the city of São Paulo and the highest, in Araçatuba. Campinas had the highest per capita expenditure on medium and high complexity care, while Presidente Prudente had the lowest. The highest regional percentage of the current net revenue spent on health was verified in Registro, and the lowest, in the city of São Paulo. CONCLUSIONS The paradigm of the health sector’s financing in São Paulo revealed that the expenditure on primary health care, level elected by health policy as strategic because it depends on coordination and integral health care in the attention networks, was not considered a priority in relation to the expenditure with the medium and high complexity, exposing the iniquities in the state’s regions.


INTRODUCTION
The Brazilian Unified Health System (SUS), defined as a right of all and a duty of the State, must be guaranteed through economic and social policies 1 . With the intent of correcting a profound social deficit, accumulated over decades, the text of the Constitution established social security in Brazil and showed how the health sector's development depends intrinsically on social and economic policies. In this way, when analyzing the health sector, Soares 2 states that it is not "possible to treat health policy issues in isolation, and without considering their articulation and reliance on economic issues, because the level of investments to be made in this policy, for instance, derives from them" (p. 31). The definitions about the health sector's financing, which do not appear in the Federal Constitution of 1988 1  The articulation between health policy and economic policy was not enough to increase federal government spending on health care during Brazil's period of economic growth. According to Soares 2 , the federal public sector's spending in the period from 1995 to 2012 remained practically constant, rotating around 1.7% of the gross domestic product (PIB), and decreasing its share percentage in relation to the Union's general budget (OGU), the current gross revenue (RCB) and the current net revenue (RCL). This policy of containment of public spending on health contributed to the federal government to increase the primary surplus, which grew 659.0% in the period, to ensure the payment of the interest on the domestic debt, which grew 264.0% in the period.
The economic results sought for and obtained since the mid-1990s are aligned with the political and economic project that brought to Brazil, among other things, the idea of the centrality of the fiscal policy with priority given to the realization of primary surpluses, having as consequence the financialization of public budgets 2 .
This policy, despite the constitutionalization of the right to health, maintained the historical underfunding of the public health sector in the country, and deepened the funding crisis by allowing the inflection of the levels of government share in the sector's spending at the expense of subnational levels of government, states and municipalities, which have lower tax collection capacity. The transition of public health funding in Brazil, which becomes clearer in the 1990s, reveals a movement toward a greater relative share of the states and, mainly, of the municipalities in the total expenses. The federal government's spending on health care, which accounted for 74.4% of the total expenses in Brazil in 1990, started representing only 45.5% in 2012, while the states' spending rose from 13.5% in 1990 to 26.8% in 2012, and the municipalities' spending rose from 12.1% to 28.2% in the same period 2 .
This transition in spending was accompanied by the transition in the obligations of execution of public health actions and services (PHAS), with greater responsibilities assigned to the states and municipalities. It reveals the inequity in the system's financing, as these governments start spending a significant and ever-increasing share of their budgets on the health sector, mainly the municipalities -for which the limit of spending of their RCL on PHAS 6 is 15% 6 , and which spent, on average, 22.9% in 2014 9 .
The foundations of the Brazilian health system are rooted in the recommendations outlined in the Dawson Report 10 of the beginning of the 20th century and in the Alma-Ata Declaration 11 of the end of the 1970s which, among other things, identify in primary health care (PHC) the power to coordinate and organize the health care network 12 . PHC has the important role of organizing and rationalizing the resources of the entire system 13 . The consolidation of this model -which aims to, among other things, restructure the health system's financing -gained momentum mainly since the editing of the 1993 Basic Operating Standard (NOB 93), which triggered the process of regular and automatic transfer of the federal government's resources to municipalities and states, expediting the process of municipal investments at this level of care 14 .
The discussions developed under the scope of SUS's inter-manager committees, which culminated in the publication of the Health Compact 15 and of the National Policy of Basic Attention 16 in 2006, were central in the development and definition of priorities and resources for PHC policies in Brazil. The search for equity in health, with the aim of complying with SUS's regulatory and legal framework, includes, among other things, the analysis of the sector's financing.
Thus, the objective of this study was to analyze the allocation of resources in the Brazilian Unified Health System in the state of São Paulo and, from the perspective of the investments made by level of care, health region, source of funds and level of government, discuss the institution and the instituted in public health policy.

METHODS
This is an exploratory study based on the collection and analysis of 2014 data on the implementation of the health sector budget in the municipalities and government of the state of São Paulo. The Public Health Budget Database (SIOPS), which allows the institutional estimation and dissemination of health spending data, was used as main basis for the collection of secondary information.
The budgetary execution data were extracted of the Budgetary Execution Summary Report (RREO) do SIOPS, organized and presented per capita and in absolute and relative terms. Priority was given to the study of comparisons between the investments in PHC actions, medium and high complexity (MHC) actions and health surveillance actions, without disregarding the expenses on other budgetary sub-functions.
As public health policies in Brazil use the term "basic health care" (BHC) and not "PHC", we adopted the theoretical framework of Mello et al. 17 , who describe "basic care", "primary care" and "primary health care" as "concepts that are indistinguishable from each other" (p. 210). To facilitate the differentiation between the levels of care, the term "MHC" was used to refer to the budgetary sub-function "hospital and outpatient care", the term "health surveillance" to refer to the total expenditure on the associated sub-functions of "health surveillance" and "epidemiological surveillance", and the term "pharmaceutical services" to refer to the budgetary sub-function "prophylactic and therapeutic support." This decision was made according to the methodology used by Brazil in its chart of accounts of public finances and in the satellite health accounts that make up the National Accounts System, which defines the budgetary sub-functions related to the levels of care, treating the system's financing in blocks and also in relation to these sub-functions. In the health sector's case, these sub-functions are defined in the financial and budgetary management system as: basic health care, hospital and outpatient care, sanitary surveillance, epidemiological surveillance, prophylactic and therapeutic support, feeding and nutrition and other sub-functions. As health policies, planning and programming in the state of São Paulo are carried out by a coordinated regional structure composed of 17 regional health departments, the analysis of the data sought to establish comparisons between them.

RESULTS
Initially, it is important to highlight that the appropriation of health spending on inadequate sub-functions was noted. Of the 645 municipalities in São Paulo, 18 allocated resource expenditures relating to PHC actions in the MHC sub-function, and five allocated the PHC sub-function's resources under the heading "other sub-functions." The inadequate allocation of expenditure on MHC by 31.8% of the total number of municipalities and of expenditure on health surveillance actions by 21.2% of them was also found. These inadequacies justify the significant percentage of resources allocated under the heading "other sub-functions." It was also found that the state government allocated the spending on the payroll of the human resources who develop health surveillance actions in the MHC sub-function. By analyzing the data according to health region (Table 2), it is possible to note that the total regional per capita spending ranged from R$597.71 to R$896.11, Franca being the region with the lowest spending, and Campinas the one with the highest. In relation to PHC, three regions showed per capita expenditures below the state average, the city of São Paulo being the one that invested the least in it (R$212.51). Of the regions that invested above the state average, the highlight is the region of Araçatuba (R$490.72), followed by the regions of Presidente Prudente, São José do Rio Preto, Registro, Marília, Barretos, Bauru, Ribeirão Preto, Franca, Taubaté, Araraquara, Santos and Sorocaba.   The relative regional share in municipal spending on PHCS is presented in Table 3, using as markers the regions with highest spending. The data demonstrate heterogeneity in spending, with the regions of Araçatuba, Campinas, Ribeirão Preto, Campinas and Piracicaba having invested the most in PHC, MHC, health surveillance, pharmaceutical services and other sub-functions, respectively. The ones that invested the least were the city of São Paulo, which represents 43.3% of the spending on PHC in the region of Araçatuba; Presidente Prudente, which represents 24.4% of the spending on MHC in the region of Campinas; Sorocaba, which represents 23.3% of the spending on health surveillance in the region of Ribeirão Preto; São João da Boa Vista, which represents 8.8% of the spending on pharmaceutical services in the region of Campinas; and Franca, which represents 1.0% of the spending on other sub-functions in the region of Piracicaba.
Considering that "Primary Health Care is characterized by a set of health actions, within individual and collective contexts, that involve the promotion and protection of health, the prevention of diseases, diagnosis, treatment, rehabilitation, harm reduction and the maintenance of health [...]" 20 (p. 3), beyond the recommendations of the Dawson 10 and Alma-Ata 11 Reports that preventive, protective and promotive actions should be part of the first level of health care, in this study, PHC data (including the values associated with the sub-functions of health surveillance, pharmaceutical services and food and nutrition) were compared to MHC data ( Figure). In this more comprehensive analysis, it is found that there is no significant change in PHC spending in relation to the regional comparative data in Table 3 when using its expanded concept, and that the iniquities in the spending on these levels of care in the state of São Paulo's health regions persist.
In relation to the sources of funding that supported the health expenditures of the state of São Paulo's municipalities in 2014 (Table 4), the investments made with own resources totaled R$21.6 billion, which corresponds to 72.1% of all investment on PHAS in the municipalities, while the intergovernmental transfers carried out by the federal and state government to the municipalities totaled R$7.8 billion, and the heading "other sources", R$721 million. Together, these two sources corresponded to 27.9% of the total invested. It should be noted that in 2014, in relation to 2012, the relative share of the federal government's total spending    on health care fell from 40.5% to 37.4%, and that the share of PHC in the total federal funds transferred to the states and municipalities was reduced from 34.0% to 31.0%.
The region of Campinas was the one that most invested own resources in health in relation to the region's total expenditure (76.8%), followed by Registro (74.4%) and Franca (74.1%). The lowest relative shares in the total spending on health were found in the regions of Barretos (62.6%), Ribeirão Preto (63.1%) and Marília (62.7%).
These percentages indicate that in the state of São Paulo, the municipalities' shares in the maintenance of PHCS correspond to values that are mostly higher than those of other levels of government. The municipal investments directly impacted the percentage of RCL resources -own resources of the municipality -spent on health, 23.8% on average, above the minimum 15% percentage set by EC 29 . As for the state of São Paulo's government, it spent 12.5% of its RCL on PHCS (

DISCUSSION
The paradigm of the health sector's financing in the state of São Paulo revealed the protagonism of municipalities in the total investments in public health actions and services. Primary health care, a level elected by public health policy in Brazil as strategic because it depends on coordination and integral health care in care networks, received priority in the application of resources in some regions of the state; however, as well as in the level of attention of medium and high complexity, this occurred unevenly and with low coverage.
The level of investment made by the municipalities was very close to the limit set by the regulatory and legal framework of the field of health. Based on this, great difficulty of expansion for the resolution of SUS's central problems in the state, low coverage and correction of regional inequities, are expected.
These problems emerged and have been worsening, internally, due to the limited assistance from the state government for the increase of the spending on PHC, as it focuses its investments on MHC instead, and externally, due to the impossibility of expansion of federal resources, because the federal government has been reducing its relative share in the total spending on health and the relative share of primary care resources, in what concerns fund to fund transfers, in the total expenses.
The health system in Brazil, which has faced chronic underfunding since its constitutionalization, is threatened by the sector's lack financing due to the implementation of an austere economic policy, that presides over social policies. This policy is centered on fiscal adjustment with containment of primary spendings 21 in the twenty years of validity of Constitutional Amendment 95/2016 (from 2017 to 2036), which, according to studies, should cause the health sector to lose R$415 billion for the financing of PHAS 22 . In this way, the maintenance of the downward trend in the relative participation of the Union in the total spending on PHCS is expected, as well as reduction of PHC investments proportionally to the other levels of care, and maintenance of regional inequities in spending.
In this scenario, this study reveals the unsustainability of the state of São Paulo's health care policy in the next few years, showing that the share of the state's municipalities in PHC spending is 96.3%, even at the limit of the municipal RCL's average capacity of investments in health (23.8%).
The allocation of spending in inappropriate headings may lead to bias in the analysis of the data, representing a limitation of the study. Based on this, policymakers should qualify the information entered in SIOPS, seeing as this system is a source of information for the development of public health policies in Brazil, and the basis for national and international studies comparing investments in the field of health between levels of government and countries.
The analysis undertaken in this study leads to the consideration that the reformulation of the health care model established in the state of São Paulo's public policies must be subjected to the actual implementation of regionalization, with the consequent clear definition of the levels of government responsibility for health services and actions, and the redistribution of financing to achieve greater fairness in the allocation of resources and in the access of the population to the actions and services at all levels of care.
One of the achievements of the field of health and teaching of the Brazilian health reform movement, embodied in the constitutional text, is that health is realized via economic and social policies; thus, the solutions to current health dilemmas in Brazil and the reformulations proposed cannot, should not be and are not restricted to the sector. In this way, the discussion on SUS's financing must be carried out in the context of social security, of the reassessment of the federal pact and of the tax reform.
Finally, it is important that studies articulating and expanding the scope of this research to the national level are conducted, contributing to the discussion and correction of systemic inequities, and supporting the health care model with focus on primary health care as the level responsible for the managing and coordinating of the health care network in Brazil.