Crisis of Capital and the Ongoing Bolsonaro’s Neo-Fascism: The Destructive Continuum of Public Health via Primary Care ()
1. Introduction
While a large part of society in Brazil is astonished in view of the impact that Covid-19 has been causing, with around 687,483 deaths (as of 10/22/2022) (Opas, 2022) after two years and seven months of the pandemic, Bolsonaro’s neo-fascism continues to dismantle several social policies, particularly the Unified Health System (SUS). Even with all the preventable deaths and the central role of Primary Health Care (PHC) regarding the capillarization of access to vaccines and other forms of prevention, the implementation of the new model of allocation of federal resources for PHC in the SUS, which defunds and values the operational logic in SUS, has persisted (Mendes, Melo, & Carnut, 2022) as if nothing had happened. This means that the Brazilian health care system, even with all this tragedy, continues to restrict its health care to people (individuals) that municipalities managed to register, distancing itself from the universal principle in which the transfer of resources should be associated with the population of the municipalities.
Furthermore, it is important to highlight that the de-funding of the SUS goes on in a continuous downturn, due to Constitutional Amendment (EC) No. 95/2016, which froze public spending for twenty years. To give you an idea, between 2018 and 2023 this health system lost about R$60.0 billion, considering data from the federal budget of the Ministry of Health (MH) for 2023, which are already pending approval in the National Congress, without including expenses for combating Covid-19. In the budget project forwarded by the government for 2023, when considering the effects of EC 95 and the volume of amendments by deputies (about 13% of the total budget), SUS financing becomes even more precarious to ensure the planning defined for the health policy approved by the National Health Council. Furthermore, it is worth remembering that while a good part of the budget resources is defined by deputies, the most used criteria in the allocation of resources is restricted to priorities of their electoral base. Thus, this budget, quite insufficient for 2023, completely disregards the importance of health, especially after the pandemic crisis with even more complicated results to respond to the health needs of the population, not restricted to coping with Covid-19.
It is in the context of the difficulties in which capital finds itself to overcome this crisis (Roberts, 2016, 2020a) that Bolsonaro’s neo-fascism1 recognizes a fertile ground to grow stronger. It is important to emphasize that neo-fascism cannot be understood as the cause of the capitalist crisis, but as product of it. Neofascism emerges as a response from the ruling class to mitigate the harm produced by neoliberal capitalism under the dominance of fictitious capital. Once in power, the crisis intensifies even more with the radicalization of neoliberalism, with multiple combined counter-reforms (labor, social security, administrative and political-economic) forming an ultraneoliberal scenario2, as well as being able to be identified in the policies that have been adopted by the Bolsonaro government.
Public health is not exempt from this radicalization process. In Brazil, the Proposal for Constitutional Amendment (PEC) 186/2019 that recreates emergency aid to vulnerable Brazilians during the pandemic, when taken up by the government to be approved in Congress, had a compensation associated with the ultraneoliberal agenda that unlinked budgetary resources for the health and education. A major offensive by sectors of the left and also by other social forces was necessary for its initial project to be modified and not to include this disengagement, which would certainly further harm a SUS already historically underfunded and, after EC-95/2016, marked by de-funding (Mendes & Carnut, 2020a). In turn, the approved PEC 186 provokes more recession, reductions in social rights, and privatizations to guarantee more resources for the Brazilian public debt (Fraga, 2021). It is a tax-cut package ordered by the neo-fascist Bolsonaro and his Minister of Economy Paulo Guedes, even before the emergence of Covid-19.
1The neo-fascism category is used to encompass the dimensions of adaptability, hybridity and mutability of the fascist phenomenon over the course of a century of history, allowing one to apprehend the new forms and contents of fascism in the 21st century (Mattos, 2020). Carnut (2020) when gathering the set of social actions that are configured as “neo-fascist practices” warns that only their “amalgam” in the social environment can be considered an indication of neo-fascism. According to the author, among many, the following stand out: anti-democratic social attitudes in discourse/practice even if democracy is not denied as a procedure; the use of a charismatic-populist figure/leadership; readaptations or reinterpretations of traditional fascist policies to new circumstances; the use of violence (symbolic/psychological/physical); the social expression, through an authoritarian and discriminatory view of the world, of legitimate dissatisfaction that attracts supporters; the political conduct by the executive of a kind of “pro-imperialist nationalism”; the radicalization of the exploitation of human resources (through atomizing managerialism) and of natural resources (considered as “ecological nonsense”), etc. Even if you have a neo-fascist at the head of the federal government, you cannot simply label him as a neo-fascist government. As Mattos (2020: p. 234) argues, one can assume the idea of the “predominance of the neo-fascist dimension, or component, to define the Bolsonaro government” and understand which nuclei of the bourgeois fractions that make up the government are, in fact, the new fascists.
2The expression “ultraneoliberal” finds empirical justification in the terms addressed by Boffo, Saad-Filho & Fine (2019) regarding the historical time understood as the “authoritarian turn” of neoliberalism, intensifying market defense policies with increased restrictions on public spending. According to these authors, neoliberalism needs radical conservatism and authoritarianism to become “ultra” since the previous phases “installation” and “subjectivation” of neoliberalism were not enough to overcome the long-lasting capitalist crisis experienced after the 2007 crash /2008. In Brazil, the post-coup governments, Temer and even more Bolsonaro, instituted the ultraneoliberal economic agenda, finding legitimacy in an extreme reactionary, anti-democratic and intolerant conservatism with the demands of the (mis)said social minorities, according to Mota & Rodrigues (2020). A striking example of this economic agenda is the introduction of Constitutional Amendment n. 95/2016 which froze primary public spending on health and education for 20 years.
It is important to argue that this whole crisis environment, neo-fascism and the expropriation of social rights and the right to health in Brazil must be understood in a material relationship between economy and politics. Considering the thought of Pachukanis (2017), in which the commodity-form, guided by the increase of value, brings together its derived forms (state form and legal form) is that it was decided to understand the capitalist crisis as the first form that overlaps the others, thus weakening the right to health (Mendes & Carnut, 2018, 2020b). Thus, we must analyze the crisis of the right to health, materialized by the continuous process of destruction of the SUS, based on the contemporary crisis of capital and its reconfiguration of the Brazilian dependent capitalist State. For this specific analysis, there is an intense attack on the constitutional principle of universality of the SUS, focusing the approach on the continuity of ultraneoliberal policies in which the most recent interests of capitalist accumulation under the supremacy of fictitious capital lies, that is, on the Primary Health Care as its priority expropriation locus.
In this context, our research problem is guided by the following question: has there been an increase in financial resources for the capital cities in Brazil, especially São Paulo and Manaus, as of the second year of implementation of the new resource allocation model for Primary Health Care (PHC)? The theoretical framework approach to this research problem involves the capitalist crisis in its three dimensions health, economic and ecological and its relationship to the role of the capitalist state, particularly in Brazil with the rise of neo-fascism in the Bolsonaro government.
Therefore, the objective of this article is to update the critical discussion about the policies adopted by the Bolsonaro government in public health, particularly with regard to the second year of implementation of its new PHC financing model, seeking to understand it in the context of the contemporary crisis of capital and its relationship with the state political form in Brazilian dependent capitalism. The article is organized in three parts. The first discusses the scope of the triple crisis of capital, sanitary, economic and ecological, and its organic relationship with the State in Brazilian dependent capitalism, allowing space for the growth of the restriction of the political regime endorsed by the rise of neo-fascism. The second addresses the reduction of budgetary resources with the escalating defunding of Health Unified System (SUS). The third part discusses the continued measures and effects of the second year of implementation of the PHC financing model, highlighting the continuity of the process of valuing an “operational SUS” to the detriment of its principle of universality, associated with the neo-fascist dimension of the Bolsonaro government in full swing.
2. The Triple Crisis of Capital, the State Political Form and Neo-Fascism in Brazil
Capitalism has been experiencing a crisis of such magnitude in contemporary times that it can be considered a triple crisis, with health, economic and ecological dimensions (Choonara, 2020), but which together make up the totality of the capitalist crisis. The effects on social areas, and especially on health, have led many countries to reconfigure their health systems in times of Covid-19, expanding them (Marques & Depieri, 2021). This has not been the case of Brazil, which, on the contrary, has been maintaining recessive fiscal adjustments in line with the government’s ultraneoliberal and neofascist policies.
2.1. The Health Crisis
The first dimension of the crisis, which reveals itself to be more apparent, terrifying the world and the Brazilian population, refers to Sars-CoV-2. In the world, after 2 years and 7 months of the pandemic, there are 2,849,714 deaths (position 10/22/2022) (Opas, 2022), with 179,459,338 cases of Covid-19, when many of these cases still evolve to severe implications of disease.
In Brazil, in the first months of 2022 (January 3 to March 21), the pandemic worsened with new coronavirus variants, especially the omicron variant. The number of deaths was the second highest in the world (38,744) again, only after the United States (140,223). Although this data may scare a large part of Brazilian society, it has not been enough to discredit the government and does not seem to frighten the ruling class that continues to support the Bolsonaro government, even in this dramatic situation. Added to this, there is the disregard that the Bolsonaro government, labeled as genocidal by various manifestations of intellectuals, trade unions3 and “panelaços” (citizens protesting by banging pots) of part of the Brazilian population, has been dealing with the magnitude of this health crisis. To gain a more accurate picture, in addition to the president’s daily disregard for the extent of the harm caused by Covid-19 (the waves of health problems resulting from the pandemic), since its inception, he has been urging the population to neglect security measures. There is no doubt that this is completely in tune with the “practices” of neo-fascists (Carnut, 2020) of contempt for the lives of workers associated with scientific denialism. Under the varnished discourse of “saving the economy”, his true intention is to expose the working class to the risk of contagion, minimize the problems resulting from the pandemic, decimating the most vulnerable part of this class, as a way to save, in a desperate way, the profits and interests of the bourgeoisie in the face of the long-depression capitalist crisis (Roberts, 2016).
3In early March 2021, several Brazilian intellectuals and trade unions, such as the Central Única dos Trabalhadores, Força Sindical, União Geral dos Trabalhadores, Central dos Trabalhadores e Trabalhadoras do Brasil, Nova Central Sindical de Trabalhadores, Central dos Sindicatos Brasileiros, Central Geral de Trabalhadores do Brasil, Central do Servidor and CSP-CONLUTAS signed the manifesto “Open Letter to Humanity”, in which they ask the Brazilian Federal Supreme Court (STF), the OAB and the National Congress to intervene and end the genocidal policies of Bolsonaro’s government.
In addition, the Bolsonaro government’s disdain for the pandemic is blatantly revealed when one observes the low resources allocated to confront the coronavirus. During the first year (2020) of the pandemic, spending on combating it corresponded to only R$37.6 billion (settled values), or 30.4% of the total budget of the Ministry of Health (CNS, 2020). Thus, there is no doubt that a pandemic on this scale intensifies the previously existing problems of capitalism. Choonara (2020) reminds us that in these problems the categories of race, class and gender are intertwined. After age and health risk issues, race, class and gender are the main determinants of who lives and who dies in the pandemic, particularly in a country of dependent capitalism like Brazil, with its specific historical formation shaped by structural racism (Almeida, 2018).
It can be argued, then, that this pandemic crisis further exposes the cruel face of contemporary Brazilian dependent capitalism. It is known that its historical roots, marked by social inequalities, place populations in more precarious situations of illness and death, and the impact is different according to social class, race and gender conditions (Góes et al., 2020). In this country, inequalities have race, color and ethnicity, as it is a country structured by racism, which reproduces in new circumstances material and symbolic elements embedded in the slave system. According to the 2019 National Household Sample Survey, in relation to the cut by race/color, the data indicate that the participation of the black population as informal workers, without a formal work permit, is significantly higher (47.3%) when compared to whites (34.6%). This situation was mainly caused after the 2017 labor reform of the Michel Temer coup government, which established intermittent labor (Santos et al., 2020). If the working class is heavily penalized by the health crisis, there are populations within it that are even more affected, as in the case of the black and female population. Of the 30,000 severe cases of the disease that were registered by the Ministry of Health, right at the beginning of the pandemic, in May 2020, of the total number of individuals who died from Covid-19.55% were black, mostly women; while among whites, deaths accounted for 38% (Nois, 2020).
However, although Covid-19 may trigger an unthinkable global slowdown, it is definitely not the crucial cause, as the Bolsonaro government, the hegemonic media and analysts linked to the economic mainstream have been arguing. It should be remembered that the world capitalist system was already extremely “sick” before the arrival of Covid-19. The roots of this are associated with the long period of depression, since the crash of 2007-2008, caused mainly by lower profitability of the productive sectors and an acceleration of fictitious capital.
2.2. The Economic Crisis: The Long Depression
The health crisis in this recent period merges with the economic crisis, as analyzed by Roberts (Roberts, 2016), just as the “long depression” crisis of capitalism, mainly since the crash of 2007-2008. This had already been dragging on since the second decade of the 1970s, with the fall in the rate of profit of productive capital (Roberts, 2018), based on Marx’s law of tendency (Marx, 2017) and approached from this perspective by contemporary Marxist authors such as Kliman (2012) and Callinicos (2014). To give us an idea, the profit rate in the United States, in the corporate sector of industrial and financial companies, dropped to less than 7% in the years following 2007 - 2008 (Kliman, 2012). Kliman (2015) observes that the tendency of the rate of profit to fall, by slowing down the North American capitalist economy, stimulates overproduction and speculation, while leading to a financial crisis as the immediate cause of this process. In Brazil, this behavior is also noticeable, with its profit rate in the production sector declining, between 2003 - 2014, from 28% to 23% (Marquetti et al., 2017).
Callinicos (2014)’s argument proves interesting when he points out that in the three Volumes of Karl Marx’s Capital an articulate and complete theory of crisis is developed, supported by a multidimensional conception of economic crises, grouped into three categories. The first concerns factors that “enable” the eruption of crises, arising from the exchange of commodities, the modern capital credit system, and the conditions of exchange between the two main departments of production [producer goods and consumer goods]. The second category aggregates factors that “condition” the emergence of imbalances, resulting from interactions between fluctuations in wage rates and in the size of the industrial reserve army, together with the rotation of fixed assets. The third category, which we prioritize in our analysis, is associated with the “causality” of crises. In this sense, it is possible to understand Marx’s argument regarding the law that expresses the conflict between the forces, the production relations and the most fetishized form of capital, being the law of the tendency for the rate of profit to fall, the cycle of bubbles and financial market panic.
In this third category described by Callinicos, the “causal”, the second trend of capitalist accumulation in the last 40 years is contemplated, explaining the capitalist crisis: the vertiginous growth of fictitious capital, both in the form of government bonds, of shares traded on the secondary market or derivatives of all kinds (Chesnais, 2016). The growth of global financial assets occurred intensely in the 1990s. In 2000, their stock was about 112% greater than in 1990. In 2010, the increase was 91.7% compared to 2000 and, in 2014, reached a growth of 42% when compared to 2010, corresponding to a significant figure of 294 trillion dollars (excluding derivatives) (Chesnais, 2016).
In this scenario of the capitalist crisis of overaccumulation and overproduction since the 1970s and, even after the 2007-2008 crash, there has been no production of a true way out from the crisis. The drop in the average annual growth rate of global GDP was 2.6% in the 2000s and 2.4% between 2011 and 2013 (Smith, 2019). Also, Chesnais (2019) notes that before the pandemic started, the world economic growth prospects for 2020, published by the OECD, were 2.9%. When commenting on the main capitalist economies, this author points out that at the beginning of 2020, industrial production in the United States had declined by 0.4% compared to the level of the same month of the previous year. In Germany, industrial production fell by 1.7% in October 2019. This is due to an industry dependent on exports and hit by the endogenous slowdown in growth in China, due to the poor results of neighboring countries in Europe and the impact of Brexit in European Union investment projects (Chesnais, 2019).
In Brazil, the slowdown of the economy has been showing itself in a forceful way, with six years of stagnation, two years of negative GDP, 2014 (0.5%), 2015 (−3.5%) and 2016 (−3.3%), followed by the poor results of 2017 (1.3%), 2018 (1.3%) and 2019 (1.1%) (Depe, 2019). DIEESE, when commenting on the situation in 2020, uses the recent Global Economic Prospects report by the World Bank, which estimates a 4.5% retraction for the Brazilian economy, equivalent to IBGE data for the sectoral performance of the Brazilian economy (Dieese, 2021).
In addition, even before the pandemic, the capitalist economic crisis had already had a violent impact on the Brazilian economy, indicating the following aspects: 1) a social crisis with a high unemployment rate of 12.2% in 2019, that is, 1 to every 4 workers were unemployed; 2) insignificant public spending, imprisoned by Constitutional Amendment 95 (EC-95), which froze public spending for 20 years, since 2017; 3) a vertiginous growth of 9.5% of the public debt in 2019, corresponding to 56% of the GDP, with the payment, with interest and charges, of this debt of R$478.0 billion, that is, almost 4 times more than the value committed for public actions and health services (R$125.1 billion) (Carnut et al., 2020). In this way, the capitalist crisis is very serious and places the Brazilian economy adrift, without a responsible commanding power to conduct it. The counter-reforms of the Bolsonaro government have only made it worse and made it up as a crisis caused by the coronavirus.
It is in this context of capitalist economies that the recovery of profit from productive capital and significant leverage from fictitious capital, raising social pressure to worrying levels, has demanded ultraneoliberal policies from the ruling class and, at the same time, finding shelter in the advance of conservative (and many neo-fascist) social forces in an attempt to reheat accumulation, “boost” market projections, and bring about democratic narrowing by centralized profit. This has been the case for neo-fascism on the rise in the Bolsonaro government. The effort to save capital is also reflected in the intense exploitation of the environment, inexorably unbalancing it, with strong tendencies towards an intensification of the ecological crisis.
2.3. The Ecological Crisis
The first two dimensions of the crisis of capital are intertwined in a third: the ecological destruction provoked by capitalism. Wallace (2020a) emphasizes that agribusiness, on a large scale, acts in the creation and propagation of new diseases. This is because, monocultures of domestic animals, piled up in large numbers, mean high rates of transmission in environments of weakened immune responses. The increase in the occurrence of viruses is closely associated with food production and the profitability of multinational companies. “Understanding why viruses are becoming more dangerous is related to the industrial model of agriculture and livestock production” (Wallace, 2020a: p. 1)4.
4There are other contemporary Marxist authors who have been working with this framework of analysis. For their approaches, see Davis (2020) and Foster & Swandi (2020). The latter authors point out that this is one facet of a broader ecological crisis, calling it a “metabolic rift” between complex ecological systems and an equally complex productive system subordinated to a capitalist logic.
Choonara (2020) refers in his study that the authors Borges & Branford (2020) when tracking the emergence of diseases in the wake of deforestation in Brazil, intensified in the Amazon by the Bolsonaro government, found evidence that the degradation of wildlife habitats, along with hunting and trade, increased human-animal interactions and facilitated the transmission of zoonotic diseases. In this way, the connection between the forest and agribusiness, mining and human development was reinforced.
The important thing is to highlight that the coronavirus outbreak would not gain worldwide proportions if, in its origin, it were not also associated with environmental destruction and the great circulation of goods/food and people in a short period of time and space, caused by the capital’s globalization process. Environmental destruction has been caused by monocultures that, by implementing practices that are hostile to the environment, through deforestation and the intensive use of poisons for crops and medicines for animal health, enable mutations in existing viruses, making them more resistant (Wallace, 2020b).
Sars-CoV-2, the new coronavirus that causes the COVID-19 pandemic that has swept the world, represents just one of the new strains of pathogens that have suddenly emerged as threats to humans in this century (such as the African swine fever virus, Campylobacter, Cryptosporidium, Cyclospora, several new variants of influenza A, etc.), the result of various forms of manipulation of the environment and local cultures with impacts on ecosystem balances on a large scale (Wallace, 2020b). Thus, Sars-CoV-2, or any other previously mentioned pathogens, should not be approached solely from their biological courses of infection or their clinical conditions. For Wallace they should not be treated only according to the latest vaccines and other prophylaxis, however important these measures are. The networks of ecosystem relations that capital and state power manipulate for their own benefit were fundamental for the emergence and evolution of these new strains. The great variety of pathogens, with their different taxa, host of origin, modes of transmission, clinical courses and epidemiological results, traces diverse paths that have in common the forms of land use and value accumulation spread throughout the world (Wallace, 2020b).
The contradiction in this context is that most capitalist countries, through their national states, have not been dedicating the necessary energy and resources in general, nor to their health systems in particular, with the spread of the pandemic, thus making explicit the organic relationship perverse relationship between contemporary capitalism in crisis and the State. In the name of the ultraneoliberal market, the capitalist countries have been practically ignoring the warning to create obstacles to the effects of this possible disaster. Actually, what they did was: the extension of recessive adjustments, increasing drastic cuts in the resources of the Welfare State (Boschetti, 2016) in the name of helping the problems of the capitalist crisis. Under this rationale, governments ignored the insistent warnings promoted by the World Health Organization, seeking to maintain the maxim that the capitalist economy would need to be saved from the deleterious effects of the crisis, being a decision of greater interest than saving human lives (Roberts, 2020b). This has been the case of the neo-fascist Bolsonaro government.
2.4. The Crisis of the State Political Form and the Particularity in Dependent Capitalism
The triple dimension capitalist crisis, as identified, has an intense impact on the role of the capitalist State, evidencing an extension of this crisis in the state political form. It is a matter of understanding that this political form, in the representation of the State, integrates the capitalist relations of production, securing the commodity-form and the value-form of capital.
Pachukanis (2017) argues that the state political form is capitalist by nature, derived from the value-form. In fact, the central categories of Marx (2013) in Capital (commodity/value/money/capital) are not dialectically completed without the State form. Pachukanis (2017), strictly following Marx’s method, asserts that the political form must be deduced from the logic of capital, that is, from its totality, from its real movement. This author’s view is not restricted to the economic aspect of the State but contributes to overcoming the illusory nature of the idea that the State can be conceived as a neutral power above capitalist society, allowing a false understanding that it is possible to ensure equality to “subjects of rights”. This brings us back to Pachukanis’ approach on the legal form necessary for goods to be exchanged. From this point of view, Mascaro (2018) supported by Pachukanis, highlights the role of law as an inexorable element of capitalism. This author says: “the legal form derives from the commodity form, and it is precisely because of this that having and being bound to labor, exploitation and business become a capitalist having and being bound: then, one has and is bound by right” (p.18). Understanding the recent capitalist crisis requires that one also understand the law as its priority operating tool.
5The social structure of the Latin American countries is consistent with their historical condition of colony, which in the case of Brazil, leaves deep traces of backwardness in its social formation, such as the direction of foreign trade, the weight of slavery, the unequal and combined development and the autocratic character of bourgeois domination through the State (Fernandes, 1975).
It must be recognized, in this perspective, that capitalism does not institute law as a beneficial aspect, as it is part of the structural relationship of the reproduction of capital. When thinking about this analysis of the State in the dependent capitalism of Latin American countries, such as Brazil, the reflexes of the capital crisis, due to its specific character of a sub-sovereign State (Osório, 2019), with subordination to the sovereignties of the National States of the imperialist countries, the crisis of rights acquires much more degrading characteristics in the face of ultraneoliberal policies and growing neo-fascism. Osório argues that in addition to the typical fissures of a class State, the State in dependent capitalism is crossed by two processes that characterize its specificities, redefining these fissures. They are: a) its condition dependent on the social formations in which it is constituted5; b) its specific mode of exploitation in dependent capitalism, that is, super-exploitation6, which determines the relations between classes, fractions and sectors, as well as, one can add, race and gender.
In a line of contribution to the particularity of the State on dependent capitalism, Mathias & Salama (1983), based on the vision of deduction of the State from the logic of capital by Pachukanis, argue that it is fundamental to understand it from the role that their countries play in the international division of labor, they specify, in the “constituted world-economy”. It is a matter of understanding that their insertion in the totality of the logic of capitalist accumulation occurs in a subordinated way, characterizing them as “underdeveloped” countries, which for the theorists of the Marxist Theory of Dependency (MTD), would call them “dependent” in the form of transfer of value as unequal exchange for imperialist countries. The insistence of Mathias & Salama (1983)’s contribution is that in underdeveloped Latin American countries, state intervention is related to the specific role they play according to their insertion in the world economy, even though this intervention can be deduced from the category “capital”, as approached by Pachukanis (2017).
In this perspective, the authors clarify that the manifestation of the State in these countries is expressed by political regimes of “restricted legitimacy”, to ensure the maintenance of the subordinate condition in the international division of labor, a relationship of dependence. Thus, Mathias & Salama (1983) point out that, unlike the central capitalist countries where the normality of the political regime throughout the historical process is bourgeois democracy, in underdeveloped Latin American countries the state of exception is democracy, while the normal state is political regimes of “restricted legitimacy”. That said, one can understand the long permanence in the historical process of Latin American countries of dictatorships supported by the military and repressive apparatus of the State. And, even when periods of bourgeois democracy are in force, as in the case of Brazil in the period of “political transition” after the 1980s, they are completely shielded from the demands of the popular classes, as Demier (2017) warns us, with counter-reforms and counter-revolutions being, permanently, implemented.
6The term “overexploitation” used by Osório (2019) is based on the interpretation of one of the central categories of the Marxist Theory of Dependency (MTD) worked by Marini (2008). For Osório (2019), the economies of Latin American countries are strengthened by the necessary intensification of the transfer of value as an unequal exchange for imperialist countries, in which the overexploitation of the workforce is constituted as a compensation mechanism.
To subject the constant despotisms of capital in crisis and ensure the Latin American counterrevolution, Osório (2019) and Marini (1978) attest to the recurrence of the apology for violence, with the emergence of the counterinsurgent State. This State presents a hypertrophy of the Executive Branch and constitutes a corporate State of the monopoly bourgeoisie and the Armed Forces, regardless of its political regime, often approaching fascism, without being able, of course, to be characterized as a Fascist State in its classic terms. In fact, resorting to an analysis by Fernandes (1975) with that of Marini (1977), one can say that the very present mark of this State in Brazil has also been that of an Autocratic State, in order to ensure a “preventive counterrevolution”, so that the weak and composite Brazilian bourgeoisie moves through backward oligarchic interests and associated with imperialism. For this, its intention is to neutralize, preventively, any force of popular protest (Fernandes, 1976, 1975).
2.5. The Neo-Fascist and Autocratic Dimension of the Bolsonaro Government
First of all, it is important to recognize, under a broader referential analysis, that the role of neo-fascism is intrinsically related to the general movement of capital and its crisis of profitability of the productive sectors and a vertiginous increase of fictitious capital, seeking to face this situation. For Robinson (2019), 21st century fascism can be understood in the triangulation between transnational capital, the repressive political power of the State and the neo-fascist forces in civil society. His projects refer to a more forceful response to the capitalist crisis, rebuilding the legitimacy of the State, making it more restricted, in the line of argument that we pointed out in the previous item of the article.
This does not mean that neo-fascists, unlike the fascism of the 1930s and 1940s, who criticized “institutional rites” and “parliamentary politics” (Pachukanis, 2021), reject bourgeois institutions. On the contrary, they use formal democratic procedures, such as electoral processes, to secure their political actions at the State level (Carnut, 2020). However, when they reach State power7, they end up governing, very often, through authoritarian mechanisms, which legally depend on the domestic situation. In the case of Brazil, the Decrees, widely adopted, for example, by the Bolsonaro government, recall the Decrees-Laws from the times of the military dictatorship8.
7In a comparison with the historical fascism of the interwar period, Pachukanis (2021) clarifies that fascists do not achieve political power alone, they need a mobilized popular mass and support from different fractions of the bourgeoisie. Although in a different period, this reflection is important to understand Bolsonaro’s rise to government in 2018.
8The Bolsonaro government issued 536 decrees in his first year in office. There were 129 more acts than those published in the same period by Fernando Henrique Cardoso, 154 more than Luiz Inácio Lula da Silva, and 297 more than Dilma Rousseff (Cavalcanti, 2020).
9For an overview of all these dimensions of Bolsonaro and his government, see also Webber (2020).
Two years into his administration, the international press and part of the Brazilian left-wing still hesitate to classify him as a neo-fascist ultra-rightist. Mattos (2020) uses a set of arguments in which he synthesizes the particularity of Bolsonaro’s neo-fascism, advancing in a characterization in which he breaks down the different dimensions of his ideology, the collective movements that support him and his political organization, as well as practices in government and the particular configuration of the current political regime. For the purpose of this article, it was restricted to briefly commenting on the last two dimensions that contribute to qualify the context of the second part of this article on the continuous destruction of the SUS under Bolsonaro’s neo-fascism9.
The most direct example to describe the political practices of the Bolsonaro government is related to the economic agenda of withdrawing workers’ rights, intensifying the overexploitation of the workforce and the use of public funds primarily for the control of private accumulation. In this sense, there was a flood of ultraneoliberal reforms sent to Congress in the first year of the government (tax, administrative, trade union and social security), the latter being approved in that period.
The approved PEC 186/2019 stands out, in which it conditions the granting of new financial aid to the population during the second year of the pandemic, promoting direct attacks on the rights of public servant10. Still, PEC 196/2019 deserves to be highlighted, which hits the union organization hard, eliminating its uniqueness, repressing its mobilizations, rejecting the limited “right to strike” established by law, chasing union leaders and ending the union contribution. In addition, it is worth mentioning the measures of drastic funding cuts in resources to higher education institutions and agencies that support scientific production and postgraduate programs that do not cease to cease due to Bolsonaro’s obscurantist attitude. And, also, from the point of view of coherence between the ideological discourse of neo-fascism and the effective policies implemented, it cannot be attributed to Bolsonaro the fact that he has hidden what he has been doing in criticizing environmentalism, in partnership with large construction companies to destroy areas of protection and support a violent advance of agribusiness in the Amazon11.
This combination of neo-fascist ideology with concrete policies of restriction and confrontation of social rights is articulated, as it should be, with the ultraneoliberal attack on public health, through the reduction of budgetary resources to the Ministry of Health in full force of the coronavirus pandemic, presidential decrees restricting primary health care to the private sector and the new financing model for this level of care, which will be discussed in the second part of this article. In a synthetic and useful way for our analysis of the political regime in the Bolsonaro government, Mattos (2020) is precise: “the political regime is, for now, dominantly bourgeois-democratic, ‘deteriorated, in crisis’ and ‘shielded’ from the demands of the subalterns. However, it already contains elements of the authoritarian (militarized) and fascist face that Florestan referred to when examining the dictatorship (p. 236).”
10PEC 186/19, which had been in process since 2019 as part of the administrative reform proposal of the Bolsonaro government, was approved in two rounds, in both legislative houses, being enacted on March 15, 2021, after emergency aid to the population affected by the pandemic was included in the text. The release of the financial aid was linked to the approval of fiscal adjustments and the withdrawal of the rights of public servants, which made many parliamentarians refer to the text as the PEC of blackmail (Andes, 2021).
11For a detailed description of these measures in general see Mattos (2020). For the scale of the Bolsonaro government’s environmental disaster see Levis et al. (2020).
The association between the triple crisis of capital in the contemporary phase, the relationship between capital and the State in dependent capitalism and the neo-fascist and autocratic dimension of the Bolsonaro government, with changes in the political regime (discussed in this Section 2), allow an understanding of this context and its association with the process of destruction of public health. It is believed that the ruling class, both external and internal, has maintained its intention to expand the accumulation process through the expropriation of social rights (Boschetti, 2016) and, specifically, health. In this way, the clashes against the universality of the SUS do not cease, whether due to the reduction of budgetary resources (Section 3) and the continued development of a financing model for Primary Health Care (PHC) that has been characterizing an “operational SUS”12,13 (Section 4).
3. The Ongoing Bolsonaro’s Government Neo-Fascism: The Escalating Defunding of SUS
With the advent of the beginning of the pandemic, the SUS had already been experiencing recurrent clashes and strong signs of a decrease in its financial sustainability throughout its three decades of existence, configuring its underfunding, mainly in terms of federal resources. Significant evidence of this underfunding refers to the expenditure of the Ministry of Health (MH) on public health actions and services, which remained at the level of 1.7% of GDP between 1995 and 2018. As of 2019, it is noticeable the advance of the SUS de-funding process, with EC 95/2016 which froze public spending, declining MH spending to 1.6% of GDP, remaining at the same level in 2020 and still decreasing to 1.5% of GDP, in 2021, without including Covid-19 expenses (Mendes & Carnut, 2020a).
[1] 2We borrowed Chauí (1999)’s concept of the “Operational University” to describe the process the SUS has been going through under Bolsonaro’s neo-fascist government, particularly with the new financing model for Primary Health Care. Chauí, at the time of his analysis, draws attention to the transformation of higher education under the effects of neoliberalism, in a broad and continuous process of its dismantling via the logic of an organization with mercantile interests. It is important to say that for the use of the “Operational SUS”, in times of ultraneoliberal/neofascist policies, it must be admitted that this term gains more intense and harsh dimensions in line with the contemporary stage of capitalism in crisis. For more details see Chauí (1999).
[1] 3Since it is not the central object of this article, it should be mentioned that the radical nature under which Primary Health Care (PHC) was originally built and integrated into the SUS, since its inception in 1988, was lost throughout this stage of contemporary capitalism in crisis. In its genesis, the concept derives from the height of the discussion in the 1970s on the economic and social determination of health, of a Marxist nature, which rescued the criticism of the biomedical model of health care and the limited capacity of the health sector to solve its problems when it is not strongly articulated, in a totalizing key, with other social sectors. For more details on how this radicalism waned, see Mendes, Carnut, & Guerra (2018).
With the de-funding process of this system since the approval of EC n. 95/2016, in which the expenditure of the Ministry of Health was frozen at 15% of the Net Current Revenue of the federal government in 2017, updated annually only by the variation of the IPCA/IBGE inflation index, until 2036, the drop in SUS resources is becoming more and more intense. To get the dimension of the magnitude of this measure, the loss of resources between 2018 and 2023 accumulated the amount of approximately R$60.0 billion, in which the most recent years, in the midst of the pandemic crisis, the losses with EC 95 for the SUS they were even more significant, namely: less R$27.7 billion, in 2021; minus R$12.7 billion in 2022; and less R$22.7 billion already foreseen for the 2023 budget (Funcia, 2022).
Thus, if, even before the coronavirus health crisis, investment in public health spending was taking place without the interdictions made in its federal budget, with the historic underfunding and the de-funding process of the SUS, public services could have the chance to have greater installed capacity to face the pandemic.
In the budget proposal for 2023 by the Ministry of Health, a combination that is especially predatory to public health can be noted, continuing the de-funding, resulting from the effects of EC 95 and the capture of the budget by the budget rapporteur’s amendments in the Chamber of Deputies. In addition to the loss of R$22.7 billion (EC 95) for the SUS in 2023, R$9.9 billion of the budget is allocated to amendments by the rapporteur, exclusively for directing resources to actions decided by him, without considering SUS planning, and, also, R$9.6 billion of tax amendments (individual and political parties) within the constitutionally mandatory minimum that must be allocated to public health actions and services. In this sense, for this high amount of amendments to be absorbed (R$19.5 billion), there was an abrupt decrease in health allocations, such as the National Immunization Program (vaccines to face the pandemic), whose budget declined from R$13.6 billion in 2022 to R$8.6 billion in 2023 (Funcia, 2022).
4. The Ongoing Bolsonaro’s Government Neo-Fascism: The Measures and Effects of the Second Year of Implementation of the New PHC Financing Model
After the first year of implementation of the new financing model for primary health care (PHC) of the SUS, it is possible to determine the verification of the central argument that, in a previous article (Mendes & Carnut, 2020b), is denounced. It is a reform that intensifies the transformation of the health system towards care aimed at the poor (only those registered) with few resources, under the dictates of the World Bank of valuing “efficiency” (for whom?) and rationality, dismantling PHC in line with the universal SUS, without considering the aspects of improved access and equity of health services that are so necessary for universal health systems (Silva, Mendes, & Carnut, 2022) and making room for it to be appropriated by private capital.
There is no doubt that, after the implementation of the new model in 2020, the logic of the “Operational SUS” has been structured. This means that the attributes of “modernization” and rationalization of state activities of the SUS are prized, associated with the interests of the market, reinforcing health care focused on privileges and needs, prioritizing the most vulnerable population, and, therefore, depriving universality of funding, in order to gradually consolidate a “Health Organization”, with practices that reinforce administrative and managerial instruments, far from the SUS, which considers the right to health to be central and universal.
The Previne Brasil Program, which inferred a profound change in the budget allocation model of the SUS Primary Care Policy, was instituted after the publication of Ministry of Health Ordinance n. 2.979 in November 2019 (Brasil, 2019b). There was no prior discussion of this Ordinance in the National Health Council, despite the change imposing significant changes to the 2020 Annual Health Program of the Ministry of Health, a situation regulated by Complementary Federal Law n. 141/2012 (Brasil, 2012). Thus, disrespect for democratic procedures seems to be in tune with the characteristic of neo-fascism.
Transfers have been maintained monthly (despite most of the resources being calculated on a quarterly basis), being transferred in the fund-to-fund modality, starting to be structured in three components: 1) Weighted Capitation; 2) Payment for Performance; and, 3) Incentives for Strategic Actions. For our analysis, we will focus the discussion on the first two components that are new and correspond to most of the transferred features.
Due to this new financing model, some federal transfer lines to States and Municipalities of the Primary Care Group underwent changes in parameters and values. The most emblematic of these was the extinction of the Fixed Basic Health Care Package (Fixed PAB), a transfer line that allocated 23 to 28 reais (inversely proportional to municipal socioeconomic indicators) per inhabitant/year, in monthly and regular transfers to the set of municipalities, that is, for the entire population, respecting the character of universal care. Such values represented 28% of the budget allocation of the Primary Care Secretariat. This is because the new component of the “Weighted Capitation” starts to replace the amounts passed on by the Fixed PAB, transfers from the Family Health Strategy (monthly amount for qualification of the Teams), monthly transfers to the Extended Family Health Care Center (NASF) qualified and monthly amount per qualification of Primary Care Managers.
The extinction of funding directly related to the NASF represents an important change in the conduct of financing, in the sense that there is no longer any incentive to implement multidisciplinary actions, typical of the universal and comprehensive model of the SUS. Later in 2020, Technical Note No. 03/2020 of the Ministry of Health’s Primary Care Secretariat, shows that the Ministry of Health in fact extinguished the transfer directly related to the implementation and funding of the NASF, even harming municipal qualification claims that were awaiting analysis and approval (Saps, 2020).
The Weighted Capitation component gathers the largest volume of resources within the budget forecast for the Primary Care area of the Ministry of Health, representing approximately 52% of the budget projection for 2020. The Weighted Capitation is structured in the logic of the “person/user” registration. In this, the unit value per valid registration differs (given the weighting characteristic) according to two classifications: user characterization (demographic and socioeconomic criteria) and municipal typology. To this end, the municipalities were classified according to a study published by the Brazilian Institute of Geography and Statistics (IBGE) called “Classification and Characterization of Rural and Urban Spaces in Brazil: a first approximation”, from 2017 in 05 rural-urban typologies: Urban, Intermediate Adjacent, Rural Adjacent, Intermediate Remote and Rural Remote. The aforementioned municipal typology and the type of team implemented14 (Primary Care Team or Family Health Strategy Team) define the maximum number of people that the municipality can register. That is, despite the allocation model of this component being based on the registration of people, the registrations carried out by municipal teams will only be counted for financing purposes if the municipality has a sufficient number of teams approved by the Ministry of Health for financing purposes (according to parameter) for the volume of registrations made, something that makes it difficult to receive the resource, a parameter clearly with a restrictive purpose. The expansion of the registration parameter, and consequent expansion of the potential financing margin of this component, depends on the expansion of the health teams and their qualification by the Ministry of Health itself, which, if it does not enable it, will not pass it on either.
Another aspect is more evident: the “operability” that makes it difficult to receive the resource. In the case of differentiation by registration, the existence of socioeconomic vulnerability criteria (person benefiting from the Bolsa Família Program (PBF); person with Continuous Cash Benefit Programme (BPC); or person with social security benefit in the amount of up to two minimum wages) and demographic profile (registered persons aged up to 5 (five) years and aged 65 (sixty-five) years or more) determines a differentiated weight of 1.3. It is important to highlight that the weights based on socioeconomic characteristics and demographic profile do not accumulate. This rule determines a restriction on the scope of the weighting criteria, since overlapping criteria are frequent, for example: people over 65 often have social security benefits with values up to 2 minimum wages, thus preventing them from receiving the resource and, in fact, valuing the poorest (neo-targeting).
[1] 4Implemented team is the team that was accredited and approved by the Ministry of Health, thus counting on federal co-financing. It should be noted that requests for accreditation of teams from the municipalities are not always met or may be carried out. There are teams, therefore, that do not have federal resources for their financing and that cannot be counted as a parameter for expanding the goal of potential registration of the municipality.
[1] 5The initial weight of the Intermediate Adjacent and Rural Adjacent typologies was 1.45. However, in September 2022, based on the provisions of Ordinance No. 254/2022, the weight of the referred typologies was increased, becoming 1.45455 as of the financial competence of September 2021. It should be noted that this change was added to the extinction of the transition and/or attenuating measures of the Weighted Capitation Component, in which, from then on, the municipalities started receiving the Component’s values based on the number of effectively valid registrations.
The weights linked to the municipal typology vary progressively from Urban to Remote Rural, evolving in: 1) for the Urban classification (that is, there is no incremental weight for this typology); 1.4545515 for the classification Intermediate Adjacent and Rural Adjacent; 2) for the Remote Intermediate and Remote Rural classification. States with the largest urban centers concentrate their population in municipalities of the Urban typology, that is, without increasing weight. In the state of São Paulo, for example, approximately 54% of the municipalities were classified in the urban typology, however, the combined population of these municipalities represents approximately 94% of the State’s population. This represents a restriction on the volume of resources for these municipalities, as they are linked to the lowest weight.
From another perspective, it is important to highlight that the additional weight by municipal typology ends up being neutralized by the proportional reduction in the volume of registrations by type of team that each typology adds to the potential margin. Thus, the municipalities considered more vulnerable end up being able to capture (considering the maximum parameters) practically the same values of the typologies considered less vulnerable. In such a way, the large urban centers lose, but the most vulnerable municipalities are not protected either. That is, the parameters have a much more restrictive character than their properly equitable purpose.
In the Weighted Capitation component, an important concept is defined: the Potential Registration Goal. This concept determines the maximum volume of registration that a municipality can reach as a funding limit for the component. This parameter was used from fiscal year 2020 until September 2021, to parameterize the transition and/or mitigating measures of this component. The potential registration goal is obtained by multiplying the number of Family Health Teams and Primary Care Teams (approved by the Ministry of Health for co-financing purposes) by the registration parameter related to them (which differs according to the type of team and municipal typology). Initially, the Potential Registration Goal was limited to the population registered in the updated IBGE Census.
[1] 6The Ordinance of the Ministry of Health n. 247/2021 established the extinction of the population limit registered in the updated IBGE Census as the limit of the Potential Registration Target as of the 2021 financial year.
[1] 7In 2021, the first Ordinance that partially approved requests for accreditation of new Family Health Teams was n. 45/2021, July 2021.
However, as of the 2021 financial year, this limit was artificially extinguished16. It is classified as artificial because, until August/21, the transfer parameter of the Weighted Capitation was based on the Potential Registration Goal, with expansion restricted by the delay in the approval process of municipal requests for accreditation of new teams17. As of September 2021, with the extinction of the mitigating measure, the parameter of the volume of entries valid for the purpose of receiving the Weighted Capitation Component being in effect, a conditionality was established for receiving entries above the potential target: the achievement of a score of 7 or higher in the Final Synthetic Indicator (ISF), which consolidates the general score of the municipality in the indicators used as the basis for financing the Payment-for-Performance Component.
It should be noted that the registration parameters related to the Family Health Teams (ESF) and Primary Care Teams (EAP-20 hours and EAP-30 hours) are proportional to the minimum weekly workload, regardless of the municipal typology (Brasil, 2019b). In this way, as the valid registration is the component’s funding parameter, and as there is no other direct incentive related to the co-financing of the teams, this proportionality produces equivalent values between the two team models. Furthermore, considering the restricted supply of the medical workforce in the minimum parameters of the ESF and the higher percentage covered in the cost of EAP by federal co-financing (in view of its reduced minimum expected composition, only doctor and nurse), it is evident that there is prioritization in the parameters of the Previne Brasil Program to the Family Health Strategy, contrary to the priority registered by the National Primary Care Policy18.
The per capita base value of the Weighted Capitation component was only published on January 31, 2020, when the Previne Brasil Program was already in effect. The publication took place through Ordinance of the Ministry of Health n. 169/2020 (BRASIL, 2020), which established the base per capita value of the Program at R$50.50. The delay in publishing the ordinance also jeopardized the receipt of the first installment of the Weighted Capitation Component, which only occurred in the first half of February 2020. This delay, added to the change in the transfer regime (The Fixed PAB was transferred within the same month of competence until 2019) strongly impacted the cash flow of the municipalities, since there were no inflows from this component (transfer component with the highest percentage representation within transfers from the Primary Care Group), in the month of January 2020.
Another important aspect is the emphasis on managerial tools, as in the case of “performance” that reinforce the operational emphasis. The “Payment for Performance” component has as a parameter the results achieved from a list of indicators (with different weights) established by the Ministry of Health in each fiscal year in a progressive manner, conditioning the expansion of the indicators to the budget increase for the component. The ordinance also determines that the results obtained by each of the accredited teams in the MH systems will be summed in a Final Synthetic Indicator (ISF) that should guide the volume of resources to be transferred by municipality. As for the Weighted Capitation component, the calculation of this component’s indicators is carried out every four months, with the monthly payment for each four-month period corresponding to the immediately preceding four-month period.
[1] 8National Primary Care Policy, Ministry of Health Ordinance n. 2.436/2017, Article 4: Art. 4th The PNAB has Family Health as its priority strategy for expanding and consolidating Primary Care.
When turning to a specificity of the Weighted Capitation Component, at the end of the 2019 financial year, Ordinance No. 3.263/2019 (Brasil, 2019g) of the Ministry of Health is published, which established the transfer of just under nine thousand reais per team to all municipalities in the country as an incentive to implement and strengthen user registration actions. Municipalities should reach the level of 70% of the potential registration target by May/2020, otherwise they would have the discount referring to 30% of the amounts received for the PHC19. Under the determination of Ministry of Health Ordinance No. 2.979/2019, the year 2020, being the first year of implementation of the Program, was characterized by a series of exceptional measures, such as “transition stages”, which aimed to “attenuate” the possible budgetary and financial losses of the municipalities in relation to the resources received in the 2019 fiscal year.
Still, these measures have not been applied to all municipalities in the same way. A calculation methodology was established to identify which municipalities would have a loss, maintenance or gain with the implementation of the program compared to the 2019 receipts. Thus, in the projection for 2020, the calculation methodology used the following parameters, in each financing component, to project the possible receipts for the 2020 fiscal year: 1) Weighted Capitation: the potential registration goal was considered, that is, the calculation methodology projected that the municipalities would reach the best value of the component, as if they were able to register all the people that the sum of the parameters of their respective Family Health and Primary Care Teams approved up to the limit of the population registered in the 2019 IBGE census; 2) Payment for-performance: the methodology also considered that the municipalities would reach the potential result of 100% of the achievement of the indicators per team.
As noted, the calculation methodology was based on a series of parameters for the 2020 projection, leading the result to an alleged surplus in relation to receipts for 2019. This is because in all components (both Weighted Capitation and Payment-for-Performance) calculation parameters were adopted that were too optimistic or did not match the actual increase in values. One can see the intention of the MH to ensure the credibility of the new financing model with the municipal secretaries.
Afterwards, in September 2021, this calculation methodology was incorporated into the structuring Ordinance of the Previne Brasil Program20. And it provided the basis for the creation of yet another transfer line within the Weighted Capitation Component, the so-called correction factor. In this way, in each four-month period, the municipalities that suffered losses as a result of this calculation methodology began to receive this monthly “difference”.
[1] 9The period for effecting the said discount has been extended. But, based on what Ministry of Health Ordinance No. 407/2022 defined, the discount occurred in two quotas, in 270 municipalities, for a total value of more than 13.5 million reais.
20This incorporation was also the effect of the Ministry of Health Ordinance No. 2254/2021.
21This change was established by Ministry of Health Ordinance No. 99/20. In 2021 there is a second publication related to the systematic registration of teams, Ministry of Health Ordinance No. 37/2021
In February 2020, in full movement of the municipalities in the search for the expansion of registration levels, the Ordinance was published that redefined the registration of Primary Care and Mental Health Teams in the National Registry of Health Facilities (CNES). In this way, managers and teams needed to adapt their SCNES base with the new Team codes created by the aforementioned ordinance. However, the official system of the Ministry of Health adapted to what was established in the referred ordinance only in updating the version of May/20 with a deadline for making the changes until the competence of August/20 of the SCNES21. It is verified here the excess of Ordinances issued by the MH, intensifying the bureaucracy for the desired objective of expanding the register. This reinforces the appreciation of the instrumental mechanisms associated with the logic of an “Operational SUS”.
With the first months of the coronavirus pandemic (February to June 2020), municipal management started to focus on planning and executing actions to combat the pandemic, having to deal with a troubled political environment, without a centralized conduction of these actions by the MH. Federal extraordinary resources arrive in greater volume only from August, belatedly to the peak of the pandemic in Brazil. However, MH transfers were highly stratified by areas, with lengthy qualification processes and insufficient allocations to non-priority providers, jeopardizing application by municipalities.
Thus, the difficulties surrounding the validation process of the registration of users, the reorganization of the local databases regarding the registration of teams in health facilities and the overwhelming demand for actions to confront the pandemic form a context that starts to put pressure on the MH. At that moment, the Minister of Health Luiz Henrique Mandetta and his respective Secretary of Primary Care, Erno Harzeim, responsible for creating the new financing model (Harzheim, 2019), were no longer able to improvise more transitional measures considered necessary in line with strengthening the “Operational SUS”. This is because it was found that 80% of the municipalities in the country, classified as potential winners, reached only 67.5% of the registration potential parameter in the second quarter of 2020. Instability at the helm of MH became frequent in the Bolsonaro government, the exchange of two ministers in a very short period of time, in line with his contempt for public health and his denial of the pandemic.
In the Weighted Capitation Component, the transition measure that established the transfer based on the potential registration goal until the financial competence of April/2020 (first four months) was extended 3 times. First, the component transition measure was extended until the financial competence of July/2020. Subsequently, the transfer based on the potential registration target was extended until the financial period of October/2020. And finally, the measure was extended until the financial competence of December/2020. In this way, during all the financial competences of the year, the municipalities listed in the Ordinance of the Ministry of Health No. 172/2020, received in the Weighted Capitation Component the amounts according to their respective potential registration goal, that is, the best amount to be received considering the Family Health and Primary Care teams implemented and approved by the Ministry of Health. However, registrations were suspended in specific situations regulated by the Program’s structuring Ordinance (in general terms, percentage suspension due to incompletion of teams for 60 days or more, proportional to the number and type of professional).
In December, the Ministry of Health Ordinance No. 60/2020 (Brasil, 2020c) was published, bringing together and updating all the rules for validating the Primary Care teams and services that are used by the Ministry of Health as the basis for transfers from the Previne Brazil Program. Until this moment, this regulation was not completely clear and in some points needed to be adapted to the logic of the Program.
At the end of the 2020 financial year, despite the discussion and agreement at the last meeting of the Tripartite Inter-management Commission (CIT) for the year, no ordinance had been published defining how the rules for transfers related to the 2021 powers would be, since all rules for the fiscal year 2020 (which includes the transitional measures) were effective until December 2020. The rule is then published only at the end of January, jeopardizing the regularity of payments of the Weighted Capitation and Payment-for-Performance components of municipalities.
Thus, in 2021, the Ministry of Health Ordinance No. 166/2021 (Brasil, 2021) structured the general and initial parameters for transfers from the Program in that same year, unifying the funding parameters for the set of municipalities and establishing a staggered schedule for the extinction of the transitional (or mitigating) measures for each component.
Therefore, initially in the Weighted Capitation Component, the transition/mitigating measure based on the potential registration goal would only apply in the first four months, from then on, the parameter would become the actual number of valid registrations. Also expected to be in effect for the first four months, the aforementioned ordinance instituted the Financial Incentive based on a Population Criterion (R$5.95 per capita year, same per capita value created in the 2020 fiscal year).
22For the 2021 financial year, no new indicators were inserted, maintaining the 7 indicators monitored in 2020.
In the Payment for Performance Component, the transition/mitigating measure based on the receipt equivalent to the potential result of 100% of the scope of the Final Synthetic Indicator of the municipality would be in effect until the second four months. Thus, from the September financial competence, the municipalities would then start to receive according to the actual results achieved in the indicators22.
The said ordinance also created the Correction Factor Financial Incentive. It is a device that proposed to recompose possible decreases in values from the comparison between the receipts of financial competences in 2019 with the results of the Program projected from the same calculation methodology which classified municipalities for different models of financing parameters in the 2021 fiscal year, and which is based on a projection of the program’s best values, with emphasis on achieving 100% of the ISF and the potential registration goal.
However, as described, given the structuring of the methodology and the coverage of the mitigating measures programmed by the ordinance, if the municipalities did not reach the potential registration target by April/2021 and if they did not reach 100% of the scope of the Final Synthetic Indicator until August/2021, there would be a loss in relation to receipts in 202023, demonstrating, once again, how the “tangle” of rules and operations are more suited to punishing and, therefore, not allocating financial resources at the expense of aid and resource allocation.
During the financial year, with the advance of the Pandemic and the increase in the number of cases and deaths from COVID-19, which registered the highest levels in March and April 2021, political pressure from municipalities increased on the federal government. In this way, the mitigating measures on the Weighted Capitation were extended until the second quarter. The mitigating measures on the Payment-for-Performance Component and the transfer lines of the Correction and Incentive Factor with Population Criterion were extended until the end of the 2021 fiscal year24. Both extensions are the effect of Ministry of Health Ordinances No. 2.254 (Brasil, 2021a) and 2.396 of September 2022 (Brasil, 2021b).
23It is also worth noting that, according to data from the E-manager PC system, in the last four months of 2020, all municipalities in the country reached only 78% of the potential goal for registration. As for the average municipal result of the Final Synthetic Indicator (ISF) in the same period, according to data from E-manager PC, considering the teams evaluated in this four-month period, the average is even more distant from the parameter considered in the calculation methodology published by the Ministry of Health Ordinance No. 166/2021, being approximately 4 points. Therefore, and considering that in March 2021 Brazil went through the worst moment of the New Coronavirus Pandemic, with an increase in the number of cases and deaths, and that the problems experienced with the information systems of the Ministry of Health were not yet fully solved, the possibility of loss as of the competence of May/2021 became even more feasible.
24The financial incentives of the Correction and Incentive Factor with Population Criterion started to incorporate the structuring regulation of the program as of fiscal year 2022, given the publication of the Ministry of Health’s Ordinance No.2.254/2022.
25However, the approval of these teams does not increase the Potential Registration Goal, and only the EAPP and ECR registrations now guarantee automatic attribution of the additional weight (30%) referred to as socioeconomic vulnerability to all the registrations.
The alteration of the component’s transfer parameter is followed by other measures, which are now incorporated into the Program’s structuring Ordinance: inclusion of Street Clinic Teams, Riverside Family Health Teams and Prison Primary Care Teams as teams that can have their records computed for the Weighted Capitation Component25; accounting of records exceeding the potential goal for municipalities that reach a score equal to or greater than 7 (seven) in the Final Synthetic Indicator; transfer of 10% to 50% of the difference between the valid registrations and the potential goal to municipalities that do not reach the potential number of registrations according to the registration performance of the respective IBGE geographic classification typology; expansion of the weighting of the geographical classification of intermediate and adjacent rural municipalities from 1.45 to 1.45455; incorporation of the methodology for comparing the values of the Previne Brasil Program and the values received by the municipalities in 2019.
Thus, for the first time in the Program, as of the third quarter, Weighted Capitation is transferred based on the volume of valid registrations. The extinction of the mitigating measure on the Weighted Capitation, given its representativeness over the volume of forecast resources and the small extension of the new measures incorporated to the structure of the Program (as of September/2021), affected the municipalities’ receipts.
Scenarios for a Trend in Financing PHC: Year II
The effect of the current parameters of the Previne Brasil Program for the 2021 fiscal year can also be observed through the concrete analysis of gains and losses in the municipalities of São Paulo and Manaus, in continuity with what has already been hypothetically observed for the 2020 fiscal year by Mendes, Melo & Carnut (2022). As explained, the choice of the two municipalities is emblematic for the conjuncture of the New Coronavirus pandemic in the country, either due to the shortage of essential supplies for urgent care, or due to the magnitude of the number of cases and relationship with the PHC operational conditions in the strategies to mitigate the spread of the virus in the community.
The temporality of the study by Mendes, Melo, & Carnut (2022) did not allow the analysis of the resources effectively received in the 2020 fiscal year. Thus, 3 hypothetical scenarios were elaborated for the analysis of the Weighted Capitation values in comparison to the transfer lines replaced by the Program. These scenarios were delimited by the validity of the transitional measures: hypothesis of absence of measures; hypothesis of existence of the measures in the initially foreseen term; and hypothesis of extension of the measures until the end of the fiscal year. In this exercise, the loss of resources for both municipalities, Manaus and São Paulo, was demonstrated (Mendes, Melo, & Carnut, 2022).
In turn, in the current exercise developed here, we gather in Table 1 and Table 2 the resources received through the Previne Brasil Program in the years 2020 and 2021 compared to the resources received by the transfer lines replaced by it. Therefore, more than an update of the study by Mendes, Melo, & Carnut (2022), Table 1 and Table 2 show the financial effects of the Program’s regulations on the selected municipalities.
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Table 1. Transfers from the Weighted Capitation, Payment-for-Performance component received in the 2020 fiscal year compared to the amounts transferred in 2019 through the transfer lines replaced by the Previne Brasil Program. Municipalities of São Paulo and Manaus, Brazil.
Source Fiscal Year 2019: PMAQ and Fixed PAB—National Health Fund; NASF and ESF—E-manager PC. Source Year 2020: E-manager PC—cut by financial competence. Values for the 2019 fiscal year corrected by the IPCA—IBGE (accumulated from 12/2019 to 11/2021 in the percentage of 15.51%). * São Paulo and Manaus in the 2020 financial year were included in the financing model based on the Ordinance of the Ministry of Health n˚172/2020. **instituted by the Ordinance of the Ministry of Health nº 3.830/2021.
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Table 2. Transfers from the Weighted Capitation, Payment-for-Performance component received in the 2021 fiscal year compared to the amounts transferred in 2019 through the transfer lines replaced by the Previne Brasil Program. Municipalities of São Paulo and Manaus, Brazil.
Source Fiscal Year 2019: PMAQ and Fixed PAB—National Health Fund; NASF and ESF—E-manager PC. Source Year 2020: E-manager PC—cut by financial competence. Values for the 2019 fiscal year corrected by the IPCA—IBGE (accumulated from 12/2019 to 11/2021 in the percentage of 15.51%). *** São Paulo and Manaus in 2021 were not included in the Ministry of Health Ordinances 214/2021, 1.221/2021, and 3.194/2021, which ratified the list of municipalities benefited by the Correction Factor.
According to what was observed, São Paulo recorded a real loss in both years in relation to receipts in 2019. It is worth noting that although the percentage loss in 2020 was not so significant, in fiscal year 2021, the loss represented more than 20% of the funds received in 2019. From what was observed, the growth of the loss from 2020 to 2021 is related in almost the same percentage magnitude to both the Weighted Capitation Component (which was negatively impacted by the extinction of the mitigating measure as of September/21) and the Pay-for-Performance Component (given the absence of additional transfer in fiscal year 2021).
Manaus, however, did not suffer losses with the change in the financial allocation model imposed by Previne Brasil, having as one of the most important variables for this result the great representativeness of the per capita transfer line. In the 2020 fiscal year, the per capita transfer line was responsible for approximately 92.5% of the calculated surplus and in 2021 for 51% of the effective gain. These data demonstrate, once again, the importance of the per capita transfer in terms of maintaining the regularity of financing, being essential for the long-term sustainability of primary care services to the detriment of an exante logic, as in the case of the allocation conditioned, a priori, by capitation criteria.
The analysis showed that the extension of the transition measures would benefit the municipality of Manaus, but even so, the transition measure based on the per capita transfer would not protect the municipality of São Paulo from damage significantly impacted by the extinction of the PAB Fixed values, demonstrating the weight of lack of funding caused by such a measure in primary care in this municipality. The importance of creating the Population-based Incentive in maintaining the level of resources was also highlighted.
Another important point to be emphasized is that, in comparison with data presented in the hypothetical scenarios described by Mendes, Melo, & Carnut (2022), there was no estimation of data related to the other components of the allocation model, as in the case of the Payment-for-Performance Component. This is an essential caveat, because if this component did not exist, the loss of resources would be even greater in the case of São Paulo.
However, it is imperative to highlight that there is an important difference in the evolution of the number of Family Health Teams (ESF) covered by federal co-financing in the period between the two municipalities, as shown in Table 3.
While São Paulo maintained in 2020 and 2021 the percentage of existing ESFs in the network covered with federal co-funding, on average 91.5%, Manaus increased this percentage from 2020 to 2021 from 88.3% to 98.2% respectively. This expansion benefited the municipality in the amounts received in the Weighted Capitation Component, since it is the necessary parameter for expanding the Potential Registration Goal. It should be mentioned that the federal government, due to the serious situation of the pandemic in this municipality, facilitated the qualification of ESF with the MH, constituting an exception when compared to other municipalities that did not have the same facility. Thus, as shown in Table 1, when comparing 2020 to 2021, Manaus obtained an increase in Weighted Capitation values of approximately 24.7%, which added up to approximately R$ 16 million in transfers in the period, main variable in the surplus calculated.
According to data compiled by the Brazilian Association of Health Economics and the Institute of Economics at the Federal University of Rio de Janeiro (Funcia et al., 2022), the average number of ESF covered by federal co-financing from the Previne Brasil Program (from 2020 to 2022) suffered a reduction compared to previous periods, going from 98% to 91.2%. In this sense, the situation in Manaus is far above the average, propitiated by the contribution of ESF qualification by the Ministry of Health.
The 2022 financial year begins with the publication of Ministry of Health Ordinance No. 102/2022 (Brasil, 2022) which establishes, together with a set of Technical Notes, the staggered extinction of the transition measures for the Payment-for-Performance Component. The schedule determines that, every four months, a set of indicators will be transferred according to the achievement of the established goals, in such a way that, by the end of the year, the mitigating measures on the component are completely extinguished.
Thus, the schedule is by the end of 2022 the Previne Brasil Program will come into play without any exceptional measures, so that the direct impacts of the program on the volume of PHC transfers to municipalities can be analyzed. However, it should be noted that the Program today combines a set of parameters that did not make up the original 2019 structure, with emphasis on the effects of the creation of the per capita transfer line.
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Table 3. Evolution of the Percentage of Family Health Teams (ESF) covered by federal co-funding 2019, 2020 and 2021, Municipalities of São Paulo and Manaus, Brazil.
Source: SCNES and E-manager PC.
5. Final Considerations
The research summary
Our research shows that there has not been an increase in financial resources for the capital cities in Brazil, especially in São Paulo, according to the second year of implementation of the new resource allocation model for Primary Health Care (PHC). São Paulo added in the two years, in 2020 and 2021, real loss in relation to the resources received from 2019. Manaus, however, only did not suffer losses with the change of the financial allocation model because Bolsonaro’s federal government made a political choice to extend the transitional measures of the model to this municipality.
Also, unlike São Paulo, Manaus increased the percentage of Family Health Teams in the network covered with federal co-funding from 2020 to 2021, from 88.3% to 98.2%, respectively. This was possible due to the contribution of the Federal Government in allowing, in a fast manner, the qualification of these teams, facilitating the resource incentives that this procedure makes available. It was also identified that Manaus obtained an increase in the values of the Weighted Capitation component of this new resource allocation model of approximately 24.7%.
From all this, it can be concluded that, in face of the problems that this municipality had with the Covid-19 pandemic and its negative publicity in the media, the federal government acted directly to prevent financial losses in this municipality and not to be once again accused of negligence with this municipality. Otherwise, this municipality would also lose resources with the new allocation model in Primary Health Care.
General remarks
The destruction of universality in the SUS via PHC has followed its course in a continuum that does not seem to meet resistance. If what happens in São Paulo, the largest urban center in the country, in fact represents a trend (it is believed that it does), the de-funding process produced by the new PHC model is likely to happen in other urban centers in an unequal and combined way, according to their specific realities.
The insistence on this type of resource allocation model for PHC, which from afar beckons to reinforce the “Operational SUS”, demonstrates how this bureaucratic and difficult de-funding process prevents budget execution, even in large municipalities that have a reasonable technical staff to manage this new model. In other words, this emptying of resources has justified paths to privatization within the system that uses the context of the triple crisis of capital to reorder forms of allocation that simulate more financial resources but reallocate according to criteria that are difficult to operationalize at the local level. And when, if it manages to carry them out, the model has advocated a new stratification within the clientele (neo-targeting) which, once again, leaves a considerable portion of the population at the margin in favor of those in whom the goals privilege.
This article demonstrates that the de-funding of PHC in the SUS continues to indicate the traces of destruction and the damage that neo-fascist governments do when they rise to power. Under the yoke of a perverse mechanism of bureaucratization that maintains the logic of the rigidity of “controlist”, hierarchical, disciplinary and selective public administration, the allocation of resources at this level of care is a victim of a militarized ethos. If this continues in the new federal government to come in Brazil, from 2023 onwards, which is regrettably likely, the segmentation of the “clientele” in the PHC will follow its course induced by the model itself, thus generating more exclusion. But not an exclusion as it used to happen at the time of INAMPS (before the introduction of SUS, in 1988), in which beneficiaries had access and the great mass had no access. It is an inverted exclusion, readapted to new circumstances, in which PHC services are restricted to the extremely poor and the rest of the population at the mercy of the market. The most worrying thing about all of this is that, even under a newly elected, supposedly progressive government, with Lula, it is possible that the international situation and the triple crisis of capital will obscure the chances of change in favor of financing the SUS. If this new government does not pay attention to these problems analyzed here and take immediate repeal action, it will lose the chance to reorient the SUS toward a strong and, certainly, universal PHC.
Research contribution
To sum up, it is important to highlight the main contribution of this research according to the following aspects: 1) Broaden criticism of the new model of resource allocation to primary health care, adopted by the Bolsonaro government; 2) Allow more systematic monitoring of the implementation process of this new model, especially in capital cities, such as São Paulo and Manaus; 3) Ensure important knowledge about the new model of resource allocation, recognizing its limits to the universal health system in Brazil; 4) To call the attention of health policy makers, especially the newly elected federal government, which begins in 2023, about the need to change this resource allocation model; 5) To allow the establishment of a dialogue for the adoption of another allocation model for primary health care that ensures better access and equity for the Brazilian population, considering the principles of our universal health system in a scenario of a contemporary economic crisis.