Mudanças políticas, legais e fiscais e o financiamento da saúde no Brasil: um estudo descritivo e exploratório do período 2016-2022

Abstract

The study aimed to identify political, legal and fiscal changes that occurred in the period 2016- 2022 that may have influenced the dynamics of health financing in Brazil. The Brazilian health system was considered a hybrid model, in its public and private aspects or segments. It was a descriptive and exploratory research inspired by elements of historical institutionalism. There was a literature review of works and authors in the fields of Public Health and social, political and economic sciences, in addition to normative and legal acts, in a bibliographic collection suggested and accumulated during the study. The analysis matrix was based on the typology adopted by Mahoney and Thelen (2010) for institutional changes. The study mapped the main events (or the most representative ones) that could represent the change process. It was observed, however, that not all proposals actually materialized. Actors worked in the political arena not only in favor of changes, but also to prevent them, according to their interests. In the asymmetry of powers, political agents exercised their institutional power, attracting and being attracted by different actors, especially by Supplementary Health entrepreneurs who demonstrated great organizational potential in their associations and representations. In the asymmetry of powers, political agents exercised their institutional power, attracting and being attracted by different actors, especially by Supplementary Health entrepreneurs who demonstrated great organizational potential in their associations and representations. Social defense and SUS entities and associations, on the contrary, did not achieve effective political participation that could promote changes contrary to the country's political and fiscal conduct. Professional health entities also moved through institutions in the interests of their categories. In the end, five changes in influence on health financing in the period were identified: the spending ceiling fiscal rule; the suspension of the spending cap on an emergency basis; the withdrawal by private health plan operators of part of the amounts invested in a technical reserve; the approval of the exhaustive list of procedures for private health plans; and the national financial floor for nursing. With the exception of the latter, whose change was identified as a conversion to the rule, all occurred due to a drift from the rule. It was concluded that the process of change within the Brazilian health system is gradual and faces structural challenges in a historical scenario shaped by an antagonistic dispute between the privatist and universalist projects within it.