Distortions of parliamentary amendments to the equitable allocation of federal resources to the PAB

ABSTRACT OBJECTIVE Analyze the implications of parliamentary amendments (EP) for the model of equitable allocation of resources from the Fixed Primary Care Minimum (PAB-Fixo) to municipalities in the period from 2015 to 2019. METHODS A descriptive and exploratory study was conducted on allocating federal resources to the PAB-Fixo and on the increment in the PAB by parliamentary amendment. The municipalities were classified into four groups according to degrees of socioeconomic vulnerability defined by the Ministry of Health for the allocation of PAB-Fixo resources. The transfers from the Ministry by parliamentary amendment were identified. The proportions of municipalities benefiting per group were analyzed by resources allocated from the PAB-Fixo and increment to the minimum by EP. RESULTS There were reduced resources allocated to the PAB-Fixo (from R$ 6.04 billion to R$ 5.51 billion, -8.8%) and increased increment to PAB by parliamentary amendment (from R$ 95.06 million to R$ 5.58 billion, 5.767%) between 2015 and 2019. The participation of municipalities by the group of those favored by EP was similar to that in the PAB-Fixo. In the proportion of resources for amendments, the municipalities of group I (most vulnerable) had more participation, and those of group IV had less participation if compared to the allocation of the PAB-Fixo. The distribution of resources by the parliamentary amendment did not cover all municipalities, even the most vulnerable ones, i.e., belonging to groups I and II. There was great inequality of resources per capita according to the groups of municipalities. CONCLUSION The EP distorted the model of equitable allocation of resources proposed by the Ministry of Health for the PAB-Fixo, by allocating resources in a much more significant proportion to the municipalities of group I and much less to those of group IV, which is in disagreement with this model. Furthermore, this distribution by amendments does not benefit all municipalities, not even the most vulnerable.


INTRODUCTION
In Brazil, the allocation of federal resources to states and municipalities through parliamentary amendments (EP) has been the object of analysis on public policies, with different approaches and focuses. Concerns about the political and decision-making process [1][2][3] and the effects of institutional rules on amendment distribution in the federal budget 4 are highlighted.
In the case of resources allocated to the Brazilian Unified Health System (SUS), three facts contributed to placing the topic on the current agenda of discussion on health financing: increase in amounts allocated by individual amendments since the approval of the mandatory budget in 2015, which defines the obligation of its financial execution in the Federal Constitution of 1988; expansion of the execution of budget rapporteur amendments, which are non-compulsory, by the Ministry of Health (MS), and accounting of the amendments in the Ministry's minimum expenditure on public health actions and services. Under the spending cap that freezes, in real terms, the minimum expenditure in public health actions and services of the Union, these facts favored the growth of the participation of the amendments, implying a reduction in the share of allocated resources, according to the Ministry of Health regulations 5 .
Studies indicate that EP can either contribute to the reduction of inequalities 6 or ignore redistributive allocation criteria 7 , constituting more of an instrument for mediating relations between the Powers, aiming at the governability of the federal Executive 4 . This is an essential issue since direct transfers from the federal government to state and municipal governments in the Brazilian federative context are fundamental given the unequal availability of public services and resources from subnational entities 8 . In addition, specifically for the healthcare area, the Constitution establishes that the allocation of resources must have as a principle the progressive reduction of regional disparities in the country 9 .
Regarding the allocation of federal resources to primary healthcare (APS), before the significant increase in the execution of EP, the Ministry of Health had defined a method for equitably allocating amounts to the Fixed Primary Care Minimum (PAB-Fixo). The PAB-Fixo is, from the perspective of the municipalities, an essential source of resources for financing APS, in addition to being an instrument for allocating federal resources 4 . The values of the PAB-Fixo, added to other transfers, from the MS and state governments, in addition to own municipal resources, are used for the provision of actions and services at this level of healthcare in the SUS.
Transfers from the Ministry to municipalities, also called remittances, are carried out to finance specific interventions (transfer lines) and are organized in large areas of action of the healthcare system. In 2016, the median number of MS transfer lines for 5,569 municipalities was 22, i.e., half of the municipalities received 22 transfer lines. Of these, ten were for APS funding, one of which was PAB-Fixo 10 .
The method defined by the Ministry of Health for allocating resources to the PAB-Fixo considered socioeconomic indicators in constructing a vulnerability index that categorized municipalities into four groups for the per capita distribution of resources [11][12][13][14] . The model was in effect until 2019, when the MS created the Previne Brasil Program, establishing new funding criteria for primary healthcare in the SUS, starting in 2020 15 .
With increased parliamentary amendments' participation in the APS financing, through a temporary increment in the PAB, there was an increased difference between the average values of the PAB-Fixo for the municipalities, according to their population size. Without the increment in the Primary Care Minimum, the difference between the averages of the per capita allocation of the municipalities was R$ 5.63 (24.8%) comparing the municipalities that received less and more resources in 2018. With the increment in the PAB, this difference was R$ 92.00 (367%) 5 .
These differences raise doubts about the consequences of allocating resources for a temporary increment in the Primary Care Minimum by EP and about the MS's effort to allocate resources to municipalities within the scope of APS equitably. Were the municipalities favored by the EP the most vulnerable per the Ministry of Health's categorization for the allocation of the PAB-Fixo? Did the EPs correspond in the distribution of resources with the allocation groups defined by the Ministry (proportion of beneficiaries per group and allocated amounts)?
Thus, this article aims to analyze the implications of EP for the model of equitable allocation of resources from the PAB-Fixo to municipalities established by the MS from 2015 to 2019. This approach is justified due to the topic's relevance for discussion on health financing, the scarcity of scientific research that addresses EP to the SUS budget, and, more specifically, the lack of studies that answer the mentioned questions.

METHODS
The descriptive and exploratory study conducted is based on the modern theory of the public budget, which defines it as a management instrument of i) political nature, as it expresses choices; ii ) economic, as it portrays the allocation of resources; iii ) managerial because it constitutes a plan, and iv ) legal because it is law 16 . Analyzes of public administration's budget-financial execution make it possible to identify governments' priorities in allocating resources, assess their planning and management capacity, and the compliance of their acts with budget laws 16,17 .
This article investigated the consequences of EP that increase resources to the Primary Care Minimum for the resource allocation model adopted by the MS for the PAB-Fixo [11][12][13] . In this model, the per capita transfers were defined according to a score from 0 to 10, calculated for each municipality, considering the following indicators: gross domestic product per capita, percentage of the population with health insurance, percentage of the population with Bolsa Família, percentage of the population in extreme poverty, and population density. The index created from these indicators reflects the degree of socioeconomic vulnerability of the population of each municipality, where zero indicates the maximum degree of vulnerability, i.e., worse socioeconomic conditions. The municipalities were classified into four groups, in a gradient of socioeconomic vulnerability, from highest to lowest: a. Group I: a score lower than 5.  13 , thus obtaining the annual per capita transfer value.
The assumption was made that the values published in the ordinances result from applying the criteria and methods adopted by the Ministry for the equitable allocation of resources in the PAB-Fixo.
Two MS determinations regarding the transfers of the PAB-Fixo were analyzed for the possible impact on the groups' inference. The first is that the Ministry established that the municipalities would not suffer a reduction in the value of the PAB-Fixo due to population variation. Comparing the transferred amount contained in the transfer file of the National Health Fund (FNS) of 2018 concerning the MS/GM Ordinance No. 3,947 13 showed that the FNS transfer of the 455 municipalities that had a reduction in the reference population (2016 compared to 2012), compared to the ordinance, was higher for 450 municipalities and the same for five of them. Therefore, the values of the ordinance do not seem to contain adjustments due to population reduction.
The second is that, in 2013, the MS decided to integrate the values of the Compensation of Regional Specificities (CER) strategy of the PAB-Variável to the PAB-Fixo 11,18 . As a result, it became more complicated to reproduce the comparison mentioned above for cases of reduction in the reference population (2012 compared to 2010) 13 . However, when comparing the per capita value calculated from the annual value of the PAB-Fixo of Ordinance MS/GM No. 1,409 and that obtained from the FNS transfer files, including the CER strategy, greater consistency is observed in the first case, with values greater than R$ 23.00 per capita/year. The same does not occur when information from the transfer file of the National Health Fund is used, as transfer values lower than this minimum are obtained. This result indicates that the value of the ordinance encompasses the entire value of the CER strategy, and its use in the inference of groups is more appropriate.
The increment values in the PAB transferred by the Ministry of Health to each municipality were obtained from the FNS transfer files. This increment concerns federal resources allocated by EP 5 . For comparison in the analyzed period, the resources destined for the PAB-Fixo and the increment in the Primary Care Minimum were monetarily updated for 2020, using the average annual Broad Consumer Price Index (IPCA).
The data were organized in electronic spreadsheets and summarized with basic descriptive statistics. The Z test was applied with the support of the RStudio software, version 2021.09.0, considering a 95% confidence interval (95%CI) to compare the proportions of municipalities and resources between the PAB and its increment in the four groups 19 .

RESULTS
In 2015, 83.6% of the municipalities (n = 5,570) were classified in groups I (n = 2,604) and II (n = 2,051) in terms of PAB-Fixo (Table 1 and Table 2). In 2019, this percentage grew (to 91.3%), with 3,958 municipalities in group I and 1,130 in group II.
In group 1, with greater socioeconomic vulnerability, more than half of the municipalities belong to the Central-West and Northeast regions, with a population equal to or less than 50 thousand inhabitants (PAB-Fixo 2015 reference) ( Table 1). Regarding the municipalities benefiting from EP, between 2015 and 2017, the proportion of those favored in these regions was below 50% for members of group I, with municipalities in the Southeast and South regions being more prevalent. In 2018 and 2019, there was a greater balance between the proportion of beneficiaries per group and region. This occurred for the PAB-Fixo and the increment in the PAB.  By population size, the allocation of resources by EP was close to that defined for the Primary Care Minimum in the case of group I ( Table 2). In 2015, 10.5% of municipalities with over 500 thousand inhabitants and 4.8% with up to 5 thousand inhabitants were favored by EP. In 2017 and 2019, these percentages increased to 57.6% and 68.4%, and to 92.7% and 88.0%, respectively.
Between 2015 (value valid until 2017) and 2019 (value valid in 2018 and 2019), there was a reduction in the resources allocated to the PAB-Fixo, in real terms ( Table 3). The PAB-Fixo went from R$ 6.04 billion to R$ 5.51 billion at 2020 prices (-8.8%). In the same period, the increment in the PAB went from R$ 95.06 million to R$ 5.58 billion, with a growth of 5,767%.   hypothesis of equality between the classes regarding the proportions of municipalities cannot be rejected since the p-value is greater than 0.05. Thus, for the group of EP beneficiaries, the participation of municipalities per group was similar to the participation of municipalities in the PAB-Fixo per group.  However, concerning the proportions of resources, a statistically significant p-value is observed at the 0.1% level, indicating that the 2015 PAB-Fixo classes and the average of the 2015-2017 increment are different for group IV, and at the 1% level for group I of these same classes. Likewise, for groups I and IV of the 2018 PAB-Fixo classes and the average of the 2018-2019 increment. In other words, in the resources allocated by EP, the municipalities of group I had greater participation, and those of group IV had lower participation compared to the participation of these groups in PAB-Fixo resources.
There is a significant increase in the PAB-Fixo plus the increment in the PAB from 2017 (Figure). When comparing the groups, for the municipalities in group I, the average per capita value of the PAB-Fixo with increments went from R$ 66.00 to R$ 108.00 (64.3%) between 2015 and 2019. For group IV, the increase was 11.8%, from R$ 35.00 to R$ 39.00 in the same period.
The  causes a greater distance between the average and median of the analyzed values. Finally, the reduction, in real terms, of the averages and medians per capita of the PAB-Fixo stands out. On average, considering all municipalities, it went from R$ 34.00 in 2015 to R$ 29.00 in 2019 (-14.7%).

DISCUSSION
Some methodologies have been developed within the scope of health systems for the equitable allocation of resources 20 . In this sense, different meanings of equity have been used, such as i) the complete equalization of opportunities to access the same number of services concerning needs, ii) ensuring that no particular group is disadvantaged, and iii) everyone has an equal opportunity to lead a healthy life 21 .
Equity is also cited as a fair opportunity for all, equal access to health services based on needs, and the absence of systematic health inequalities between socioeconomically different groups, reported in the literature as the most used criterion by decision-makers on healthcare allocation of resources 22 .
In Brazil, the idea of equitable allocation of resources is intrinsically associated with health needs. In general, while the authors defend centrality and recognize the complex form of the concept of health needs for allocating resources, they do not make it explicit. However, it is possible to assume its reach beyond the system's borders due to using socioeconomic, demographic, and health indicators in the methodologies proposed or analyzed [23][24][25] .
Methodologies for the equitable allocation of resources generally reflect the idea that it is necessary to consider the unequal living conditions of the population to allocate resources unequally. The purpose is to allocate more resources to the most disadvantaged groups from demographic, social, economic, and health points of view.
In the SUS, implementing the PAB-Fixo is among the initiatives adopted by the MS to promote the reduction of regional inequalities through an unequal allocation of federal resources for health 26 . Although the initiative may eventually be criticized regarding the method adopted and the results obtained, its merits cannot be ignored when introducing the idea of equitable allocation of resources in the SUS. This system presents a pattern of shared responsibility among the entities in financing primary care services. However, it is up to the Ministry of Health to distribute financial resources to compensate for inequalities between municipalities, mainly responsible for managing these services 9 .
This study demonstrates that, in terms of favored municipalities, the EP followed the allocation groups defined by the MS, benefiting them in a similar proportion to the distribution made for the PAB-Fixo. However, the PAB-Fixo favors all municipalities, unlike the EP, even though its coverage has increased in the period analyzed.
Concerning the PAB-Fixo allocation model, the analysis of the allocated resources shows that the resources of EP were allocated in more significant proportions to the municipalities of group I and lesser proportions to those of group IV. In other words, municipalities with a population of up to 50 thousand inhabitants, more socioeconomically vulnerable, were prioritized with the contributions by EP, to the detriment of less vulnerable municipalities, with a population above 50 thousand inhabitants.
As a result, there is a greater distance between the per capita values of the PAB when the increment resources are added. Populations of smaller municipalities are benefiting from much more resources for APS financing than those of larger, less vulnerable municipalities.
In principle, such a situation is desirable concerning equitable allocation. However, it is necessary to consider the current situation of SUS financing and the possible impacts of the allocation of resources by EP, given the considerable constraint imposed on the Ministry budget by the spending cap for primary federal expenditures and the freezing of the federal minimum application in public health actions and services 27 . As expenses for EP are accounted for in the minimum application, greater allocation of resources by EP reduces the share of the Ministry of Health's allocation in actions and services. It may imply the reallocation of resources from other areas. In the case analyzed, from EP to increment to the PAB.
It is also important to highlight that even among the municipalities in group I, those benefiting from EP received much more per capita resources than those not. As a result, the amendments generated unequal treatment among the most vulnerable.
The very different per capita value between the groups of municipalities implies a differentiated benefit among their populations. Public health actions and services must be guaranteed in all municipalities, and in smaller ones, the costs of offering them are usually higher 28 . However, it is necessary to remember that there are difficulties in structuring them on the outskirts of medium and large-sized cities 29 . The financial crisis from 2014 to 2016, and more recently, the impacts of the pandemic on the Brazilian economy, caused a drop in municipal revenue and, thus, more significant difficulties in allocating resources to health. Municipalities already apply them far above the mandatory minimum percentage 30 .
Ultimately, an allocation of federal resources that does not consider the differentiated fiscal capacity of entities can also cause inequity, even if its objective is equity. The adoption of technical criteria has been identified as necessary to mitigate this problem 31 . This issue needs to be deepened in future studies for the case of EP in general.
Other issues that must be considered concerning the use of EP to guarantee the support base of the federal government, in the National Congress, in an unprecedented way, considering the high number of resources involved and the massive lack of transparency in its execution. This lack, especially of the rapporteur's parliamentary amendments, was questioned in the Federal Supreme Court (STF), which ordered Congress to publish the list of favored members and parliamentarians in addition to the amounts allocated 32 .
The consequences of an allocation of resources that considers strictly political criteria can be very harmful to the SUS, given the context of budget constraint already mentioned. In addition to causing more significant inequalities, it can be more inefficient, which is unacceptable given the limited resources for financing public health in the country.
This work points out the inference of resource allocation groups as a limitation, which generates some uncertainty about the category of each municipality. The lack of transparency about the Ministry of Health's method constitutes a barrier not only to the knowledge of the classification of these entities but also to any study aiming to investigate this initiative of equitable allocation of resources.
Finally, it should be noted that only the implications of the EP on the model adopted by the Ministry for the PAB-Fixo were analyzed. The model itself has not been evaluated. In conclusion, the parliamentary amendments distorted the model of equitable allocation of resources thought by the MS for the PAB-Fixo, by allocating resources in a much more significant proportion to the municipalities of group I and much less to those of group IV, in disagreement with this model, and for not benefiting all municipalities, not even the most vulnerable.