Investments in the health area have fallen in recent years in the state of São Paulo during the administration of Governor João Doria (PSDB).
Investments are what is spent on works, purchase of equipment and other improvements that do not include fixed expenses — such as payment of salaries and pensions and disbursements with general expenses.
The article surveyed data on investments in health in the state since 2011. Between 2011 and 2018, during the tenures of Geraldo Alckmin (PSDB) and Márcio França (PSB), the annual average of investments made by the Health Department was R$ 1,054 billion, in corrected amounts. In the first two years of the Doria government, this average dropped to R$ 811 million — an amount 23% lower.
Even if management invests the entire amount foreseen in 2021 (R$ 1.175 billion), the average investment will still be lower than in previous years. The tendency, however, is that not even that will happen, since the government has so far used only 31% of this amount.
The administration argues that during the pandemic period it made a series of spending increases that are not considered investments, such as the creation of temporary beds, but that will bring long-term benefits to the population. The government also said that the decrease in investments in 2019 was necessary because of an adjustment in the accounts.
For specialists, however, the investment indicator is important to assess the use of public money. According to some of them, when there is an increase in expenses that are not investments, this generally means that the funds were transferred to social organizations — which would not bring permanent legacies to the state health, which is already very lacking in services, and would make monitoring difficult. .
Even when it comes to general health expenses and not just investment, they fell in the state in 2019, the first year of Doria’s administration.
In 2020, the budget also provided for an amount below what was spent in previous years. But the pandemic changed the scenario and the state administration recorded an expenditure of R$ 28.7 billion last year, the highest in health at least since 2011.
Despite this increase in general expenditures, the investment percentage in 2020 represented only 3% of total expenditures — an increase from 2019 figures, but below the 4% of the previous decade.
In the division of obligations in the area of public health, the municipalities get the so-called primary care, which includes services such as basic health units. The state is left with the secondary and tertiary demands.
Specialized care clinics, for example, are part of secondary care. State-of-the-art hospitals are tertiary care.
Walter Cintra Ferreira, sanitary doctor and professor of health services management at FGV EAESP, says that there is a problem with the underfunding of the SUS, the Unified Health System. Although the tertiary sector still has some problems in the state, he believes that it is in the secondary that is the biggest bottleneck.
“In the state of São Paulo, we have a great deficiency in secondary care, whether from the standpoint of specialized care, outpatient care, or in hospital care. This is necessarily a function of the state government”, says Ferreira. “There are lines of procedures for hernia surgeries, cataracts, orthopedic prostheses, there is a gap and a waiting line”, he says.
For the physician, it is worrying that there is a drop in investment in this situation. “At the very least you have an issue that is the replacement of equipment, renewal of the technological park, we cannot say that we are in a comfortable situation”, he says.
Part of the tertiary care in the state is the hospitals and clinics. They had a drop in investments in the year of the pandemic and, according to the 2021 budget, should not return to previous levels.
For example, in 2019, USP’s Hospital das Clínicas had investments above those of previous years, in the order of R$ 76 million. This amount dropped to R$7 million in 2020. This year, the updated reserve for investment in the hospital is R$35 million — of which only R$12 million has actually been used so far.
The HC includes specialized institutes that are among the main ones in Brazil, such as InCor (Institute of the Heart) and ICESP (Institute of Cancer of São Paulo). The report found that, in the latter, employees have been complaining about financial and structural difficulties, for example.
Victor Dourado, president of Simesp (Doctors Union of São Paulo), says that the country as a whole has been going through a process over the years of decreasing investments in public health, which has led to infrastructure problems.
In his view, with the scenario of reduced investments in the sector, the perspective is that the public system will be even more pressured in the coming years. “If we are like this now, imagine with the progressive incorporation of more people [dependentes do SUS]. With an increase in post-pandemic sequelae, dammed demand, elective surgeries. We updated the concept of collapse”, says Araújo.
The doctor also criticizes the government’s choice of a progressive increase in transfers to social organizations. For him, this leads to a precariousness of the state structure. “You increase the resources of these companies, which increasingly function as de facto private companies,” he said. “At the end of the pandemic, nothing was left behind. The resources used were agreements for the OSs and the balance for the public service does not exist”.
Economist Lucas Andrietta, a professor at the preventive medicine department at the USP School of Medicine, says that investment remains a very important variable for analyzing both health management and the underfunding that affects the area in Brazil.
“São Paulo has a tendency to increase expenditure for private entities, such as social organizations, and this has been replacing year by year the contraction of civil servants, and this also reflects in the investment indicator. It is a worrying movement, because social organizations are a model that has advanced a lot , but with a series of problems,” he says. He cites, for example, the difficulty of monitoring these entities from the point of view of transparency.
For the economist, another worrying point is the lack of signaling by the states of an increase in investments to structurally adapt to the increase in SUS demand in the post-pandemic period. “There is a downward trend in health expenditure. These new needs that the pandemic brought will end up running out of resources to be properly addressed.”
The Executive Secretary of Health of the Government of São Paulo, Eduardo Ribeiro, stated that the offer of services in the area has increased, although not always through investment.
“The way in which the state government has been implementing investment in a structure to fight the pandemic takes place in a less traditional way than it had been doing,” he says.
As an example, he claims that before the pandemic to open 300 ICU beds in a large hospital in São Paulo, the state government had to buy all the necessary structure and adapt the rooms that would be used.
In the pandemic, he said that the option was to rent the equipment and hire the services on a temporary basis. “This meant that a large amount of resources were used in new services without this being part of the investment category,” he said. “We are making movements that reduce traditional investment while expanding the offer,” he added.
Regarding the drop in spending in 2019, he says that this happened because it was necessary to put a brake on storage. “The management was faced with a situation of public accounts that inspired a lot of care,” he said.
The executive secretary also defends the model of hiring by social organizations, as long as they are good partnerships and with control, and denies that the expenses made will not leave legacy. He cites, for example, that the state began the pandemic with 3,500 beds, the largest public ICU network, but that it reached 12,500 at the height of the fight against Covid. “We will not go back to having just those 3,500 beds.”
Ribeiro also claims that the state is now in a challenging post-pandemic moment. “We need to resume non-Covid activity in a more robust and accelerated way. This requires us to transform part of the transitional structure of the pandemic into what we are calling legacy.”
He also cited definite improvements made in the clinics’ hospitals and also a greater focus on specialized care not related to the coronavirus. “The entire network will experience a moment of strengthening of non-Covid activities from now on”, also citing equipment that had accelerated construction.