Exclusive: Health spending in Brazil states as small as USD 20 cents a day

. Jul 01, 2020
health The desperate underfunding of Brazil's public health system Photo: GrandeDuc/Shutterstock

When Brazil’s public healthcare system turned 30 years old, back in 2018, we at The Brazilian Report took a deep dive into its merits and shortcomings. Arguably the world’s biggest public health network, the SUS (Unified Healthcare System) reaches more than 70 percent of the population. It made Brazil a reference in the international health community, according to the World Bank, and an example to other countries that are trying to establish more equitable health systems. But one thing is preventing the SUS from reaching its full potential: massive underfunding.

An exclusive study by The Brazilian Report shows that, in 13 of Brazil’s 27 states, daily investments in healthcare services amounted to less than BRL 1 (USD 0.19) per capita between 2017 and 2019. 

The study was based on official data of the SIOPS, Brazil’s Information System on Public Health Budgets. Numbers from 2020 are incomplete, as some states have yet to register their spending — which led us to discount these figures from our research.

</p> <h2>Less than BRL 1 per day on health</h2> <p>The states of Alagoas, Bahia, Ceará, Goiás, Maranhão, Minas Gerais, Pará, Paraíba, Paraná, Pernambuco, Piauí, Rio de Janeiro, and Rio Grande do Norte all spent between BRL 0.75 and BRL 0.95 a day, per person, on public healthcare actions in 2019. In previous years, these state administrations spent between BRL 0.65 and BRL 0.92.</p> <p>According to <a href="">Brasil.IO</a>, a web-based platform that compiles state-level coronavirus data, three of these states have the country&#8217;s highest Covid-19 lethality rates, expressed as a percentage of total confirmed cases. Nine percent of patients have died in Rio de Janeiro, 8 percent in Pernambuco, and 6 percent in Ceará.</p> <p>In the state of Rio de Janeiro, which has recently surpassed <a href="">10,000 deaths</a> in less than four months since the beginning of the epidemic, healthcare spending between 2017 and 2019 amounted to an average of just BRL 287.47 (USD 53.70) per capita per year.</p> <div class="flourish-embed flourish-chart" data-src="visualisation/3040215" data-url=""><script src=""></script></div> <h2>Rules for healthcare spending</h2> <p>Brazil&#8217;s Constitution is strict on how healthcare budgets must be managed by all levels of government. In the federal sphere — which distributes vaccines across the country, and implements policies on high-complexity medications, research, and labs — 15 percent of net current revenue must be earmarked for health, which is the same for municipal governments. These city-level administrations are responsible for basic services, vaccination campaigns, and low-complexity tests, such as X-rays or electrocardiograms. Meanwhile, states are allowed to spend less, earmarking 12 percent of their revenue for health.</p> <p>Last year, the official books of the state of Rio de Janeiro show that the administration barely exceeded its minimum spending on healthcare, at 12.05 percent of its revenue. However, the State Accounts Court — which monitors public spending&nbsp;—&nbsp;unanimously rejected Governor Wilson Witzel&#8217;s accounts for 2019. Among the 100 irregularities found by auditors concerns health spending: the court claims only 11.46 percent of revenue was effectively used.</p> <p>&#8220;Many states pull all sorts of financial maneuvers to comply with minimum requirements. Many of them are ludicrous —&nbsp;such as listing food for prison inmates as health spending. That should go under the public security budget, not healthcare,&#8221; says Gonzalo Vecina Neto, an expert in public accounts who works at the University of São Paulo&#8217;s Health Policymaking and Management Department.</p> <p>Rio&#8217;s mismanagement of the health sector could even cost Governor Wilson Witzel his job. After burning bridges with his colleagues in the State Congress, Mr. Witzel is currently facing an impeachment process that he is likely to lose.</p> <div class="flourish-embed flourish-map" data-src="visualisation/3042286" data-url=""><script src=""></script></div> <h2>The bottom of the pile</h2> <p>Northeastern states Bahia and Maranhão posted the lowest per capita spending on health during the period under study. Both cases highlight Brazil&#8217;s regional discrepancies in healthcare.</p> <p>No other Brazilian state has more people living with less than USD 5 per day than Maranhão. A 2019 <a href="">study</a> showed that 12.2 percent of families in the state were under the poverty line. That helps explain why, despite dedicating 14 percent of their revenue to healthcare — the seventh-highest in the Brazil — Maranhão can only spend BRL 0.75 per day for each of its inhabitants.</p> <p>Bahia and Maranhão also have the lowest rate of doctors per 1,000 residents in the Northeast region. Bahia has 1.64 doctors per 1,000 people, a rate that drops to just 1.08 in Maranhão — the national rate, meanwhile, sits at 2.5.</p> <p>Bahia&#8217;s state authorities declined a request for comment. Maranhão officials told <strong>The Brazilian Report</strong> that &#8220;one must take into account the fiscal and economic indicators of the state, and observe the historical material limitation the state faces.&#8221;</p> <p>&#8220;Considering available resources at its disposal, Maranhão is one of the states which invests the most in healthcare. Per capita analyses are inadequate for comparing states as they level very distinct economic realities,&#8221; said the Health Secretariat, in a statement. &#8220;For the future, we will continue with our vision of being one of the states which invests the biggest chunk of its budget, and fights against the underfinancing of Brazil&#8217;s public healthcare network.&#8221;</p> <h2>Challenges facing Brazil&#8217;s health system</h2> <p>Paula Carnevale, a public health expert who heads the Anhembi Morumbi University Medical School, believes that the biggest challenge facing the country is the lack of funding &#8220;and the perspective of even more budget cuts in the future.&#8221; In her opinion, &#8220;a non-predictable surge in demand, like the one caused by the coronavirus pandemic, can make a bad situation worse.&#8221;</p> <p>&#8220;While Brazil&#8217;s spending on healthcare is on par with developed countries, at over nine percent of GDP, only half of that comes from public administrations. In Western countries with single-payer systems, that amounts usually hovers around 80 percent,&#8221; said Ms. Carnevale.</p> <p>For Mr. Vecina Neto, there is an additional problem: the poor management of the resources that are available. &#8220;Brazil&#8217;s public administrators are awful. And that&#8217;s not only in healthcare, but also public security, education … that&#8217;s what is draining the funds.&#8221;

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Beatriz Farrugia

Beatriz Farrugia has ten years of experience working for international news agencies. She is a former editor at ANSA and holds a post-graduate degree in International Relations from Fundação Getulio Vargas

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