Repercussions of federal transfers through parliamentary amendments on the municipal management of Primary Health Care in the Metropolitan Region I of the state of Rio de Janeiro, Brazil

Abstract

This article analyzes the repercussions of federal transfers through parliamentary amendments on the management of primary healthcare in municipalities within the Metropolitan Region I of Rio de Janeiro from 2016 to 2022. This case study with exploratory and descriptive analysis of secondary data focused on the areas of destination, participation profile, and distribution of total federal transfers, both regular and through amendments, in the municipalities; and interviews with different profiles of managers in five of these municipalities. Four dimensions were analyzed: Federal transfers, fundraising strategies, planning and execution, and stakeholders’ stance. We observed a significant increase in amendment resources and decline in regular transfers, especially in the Baixada Fluminense. The predominant resources were for operational expenses, directed towards medium and high complexity. In primary healthcare, we noted discrepancies among municipalities, with high annual fluctuations and different patterns of federal transfers. Diverse fundraising strategies were observed, with mayors and secretaries playing a leading role. We identified challenges in resource execution and planning, along with conflicting positions among respondents. Parliamentary amendments drove organizational changes in municipal secretariats and raised concerns about the risks of discontinuing services and actions in primary healthcare.

Keywords:
Health Management; Healthcare Financing; Primary Health Care; Resource Allocation; Unified Health System

Resumo

Este artigo analisa as repercussões dos repasses federais por emendas parlamentares na gestão da Atenção Primária à Saúde em municípios da região Metropolitana I do Rio de Janeiro, entre 2016 e 2022. Trata-se de um estudo de caso com análise exploratória e descritiva de dados secundários, acerca das áreas de destinação e perfil de participação e distribuição das transferências federais totais, regulares e por emendas nos municípios da região; e de entrevistas com diferentes perfis de gestores, em cinco dos seus municípios. Quatro dimensões foram analisadas: repasses federais, estratégias de captação, planejamento e execução, e posicionamento dos atores. Observou-se aumento expressivo dos recursos de emendas e redução dos repasses regulares, sobretudo na Baixada Fluminense, e predominância dos recursos para custeio, direcionados à média e alta complexidade. Na atenção primária, houve discrepância entre os municípios, com altas oscilações anuais, e padrões diferenciados de transferências federais. Verificou-se diversidade de estratégias de captação de recursos, com protagonismo de prefeitos e secretários. Foram identificados desafios à execução dos recursos e ao planejamento municipal e posicionamentos conflitantes entre os entrevistados. As emendas parlamentares impulsionaram mudanças organizacionais nas secretarias municipais e suscitam preocupações acerca dos riscos de descontinuidade de serviços e ações na atenção primária.

Palavras-chave:
Gestão em Saúde; Financiamento da Assistência à Saúde; Atenção Primária à Saúde; Alocação de Recursos; Sistema Único de Saúde

Introduction

In Brazil, the 1988 Constitution restored to the legislature the prerogative of proposing amendments to the expenditures contained in the federal executive’s budget bill. This measure reinforced the adoption of political criteria in allocative decisions for the financing of public policies, in a setting of redemocratization and in opposition to the centralized control of the budgetary process in the Executive Branch during the authoritarian period (Baptista et al., 2011).

Until the 2014 Budget Guidelines Law, however, the financial execution of parliamentary amendments (PAs) was not mandatory, and much of these expenses depended on government spending (Santos; Gasparini, 2020). Starting in 2015, constitutional changes required a set portion of the budget for the mandatory execution of individual PAs, with half allocated to Public Health actions and services (ASPS) (Brazil, 2015). In the following years, allocated to individual PAs grew, and the requirement extended to state caucus amendments (Vieira, 2022).

These modifications coincided with the introduction of several austerity policies, notably the determination to freeze the Federal Government’s primary expenditures in real terms (Brazil, 2016), which led to reduced resources for the SUS (Ocké-Reis et al., 2023). The ‘spending cap’ was in effect from 2017 to 2022 (Brazil, 2022) until it was revoked with the implementation of the new fiscal framework in 2023 (Brazil, 2023).

These measures led to a significant increase in expenses of the Ministry of Health (MoH) through PAs from 2016 to 2022. This growth exceeded the amounts allocated for mandatory execution and included a significant proportion of rapporteur amendments (Piola; Vieira, 2019), mostly transferred to municipalities to cover the costs of Primary Health Care (PHC) (Vieira, 2022).

Federal SUS transfers, also known as onlendings, represent important sources of revenue that enable the implementation and management of health policies at the local level (Orair; Lima; Teixeira, 2013). In PHC, regular transfers to municipalities have fostered the adoption of national parameters for priority policies and the reorientation of the health care model through the Family Health Strategy (ESF). They have also allowed for the redistribution of financial resources and the decentralized service provision to more needy regions, expanding the number of teams and PHC units (UBS) (Castro; Machado; Lima, 2018).

The mandatory execution of PAs for ASPS in the context of restricted federal spending tends to interfere with the SUS coordination process, making it more dependent on the political rationale that permeates the allocation of amendments (Piola; Vieira, 2019). At the municipal level, this logic imposes additional challenges for management, as other strategies are required for collection, planning, and use of these resources. This is because access to PA transfers depends on coordination with the Legislative Branch (Baptista et al., 2012).

The scientific literature on public spending in Brazil focuses on periods preceding the mandatory implementation rules. Some research is geared towards understanding its effects on the reelection of parliamentarians (Mesquita et al., 2014), on the decision-making process in the National Congress (Limongi; Figueiredo, 2005), or on the allocation of resources to federative entities and public policies (Souza, 2003), including health policies (Baptista et al., 2012). Following changes in budgetary rules, other studies have sought to identify factors influencing the distribution of budget amendments for health among different localities (Baião; Couto; Oliveira, 2019; Medina et al., 2023). Also, some analyze the impact of budget amendments on the financing of the SUS at the national level (Piola; Vieira, 2019; Vieira, 2022; Vieira; Lima, 2022; Ulinski et al., 2024). However, further studies are needed to delve deeper into the meanings and effects of these amendments for the municipal management of the SUS, considering the regional diversity of the country.

Aiming to fill this gap, this article focuses on the Metropolitan Health Region I (Metro I) of the state of Rio de Janeiro (ERJ). This region encompasses Rio de Janeiro, which was the capital of Brazil for almost 200 years (1763-1960), having been the most populous city for a most of the country’s history, accumulating a significant service structure, including health services.

Metro I is an urbanized area with high population density and socioeconomic and health inequalities (Kuschnir et al., 2010; Reis et al., 2023), aspects that challenge the organization and management of primary care within the SUS at the national level (Machado; Lima; Viana, 2008). Besides the capital city, the region includes eleven other municipalities in the Baixada Fluminense (BF), totaling 9,705,577 inhabitants, representing 60% of the population of the state of Rio de Janeiro (Rio de Janeiro, 2024).

This study aims to analyze the repercussions of federal transfers through amendments to the management of PHC in municipalities of the region. It seeks to answer the following question: What changes are imposed on the dynamics of municipal management given its greater dependence on political bargaining to obtain resources from amendments?

Methods

The case study method was adopted as a research strategy, considering the complex and diverse contextual elements that interact regarding health management and resource allocation by PAs (Yin, 2001). The research relied on quantitative and qualitative methods to process the information, which was organized into four dimensions and analyzed complementarily.

The first dimension - federal transfers - involved identifying the areas of allocation and the profile of participation and distribution of total, regular, and PA-specific federal transfers in the municipalities of the region, from 2016 to 2022. To this end, an exploratory and descriptive study was conducted using publicly and unrestricted secondary data obtained from the Federal Public Budget Information System (SIGA Brasil, 'expert access', https://www12.senado.leg.br/orcamento/sigabrasil) and the National Health Fund (FNS, https://portalfns.saude.gov.br/). We also used population estimates from the Brazilian Institute of Geography and Statistics (IBGE) submitted to the Federal Court of Accounts (TCU).

The data were collected for the analysis period, encompassing the first year of the constitutional mandate for the execution of amendments (2016) and the last year with available data for collection (2022). Due to the unavailability of integrated historical series data for 2022, the 2021 population estimates were also adopted for the last year of the period, avoiding distortion of the historical series due to the reduced population count in the 2022 Census (IBGE, 2023). Federal transfers were updated to 2022 real values based on the Broad National Consumer Price Index (IPCA).

From SIGA Brasil, we extracted MoH’s liquidated expenses in ASPS transferred by PAs, municipality, nature of expense, and allocation area, and made the adjustments described by Vieira (2022). From the National Health Fund (FNS), we retrieved the variables related to the net values ​​transferred to the municipalities - totals and PHC. Data were collected in May and August 2021 and in October 2023.

We calculated per capita and proportional indicators regarding total federal transfers for each municipality, for the health region, and for the state. Considering the large population weight and the volume of transfers to the capital city compared to the other municipalities in the region, we also calculated the Federal Government indicators. Total transfers correspond to the net amounts transferred from the MoH to the municipalities for ASPS, and regular transfers correspond to total expenses minus transfers from PAs for the same purpose.

The remaining dimensions of the study - fundraising; planning and execution; and managers’ stance - were based on semi-structured interviews with strategic stakeholders, identified from two profiles: 1) Municipal management: directors, management technicians, PHC coordinators, advisors and consultants from the Metro I region; and 2) Regional and state management: directors and technicians from the Intermunicipal Health Consortium of Baixada Fluminense, the State Health Secretariat (SES-RJ), the Council of Municipal Health Secretariats (COSEMS-RJ) and the Bipartite Interagency Commission (CIB-RJ).

Thirteen interviews were conducted with stakeholders from Profile 1 and seven from Profile 2 from July to December 2022. The Profile 1 interviews involved five Metro I municipalities, selected according to the pattern observed in the indicators ‘municipal per capita expenditure on PHC’ and ‘participation of transfers from PAs to PHC compared to the total transfer from the MoH to PHC’, including those with the highest and lowest values, among the possibilities of the intersection of the two indicators.

The interviews were conducted in person or remotely, lasting approximately one hour. Only the audio recordings were made, with the respondents’ previous authorization, and subsequently transcribed. The content of the interviews was analyzed based on the stages of pre-analysis, material exploration, results processing, and interpretation (Gomes, 2002). The results were interpreted using the components of the dimensions that guided the semi-structured roadmaps and those that emerged from the interviews as a reference.

Regarding fundraising, the study identified the management stakeholders involved in securing PAs for PHC, the negotiation dynamics, the relationship between the Executive and Legislative Branches, the purpose of the parliamentary amendment, and possible organizational adjustments within the municipal health secretariats. In the planning and execution dimension, the findings related to the planning process for resources from PAs, methods of execution, and their eventual incorporation into the SUS planning instruments are systematized. Regarding the managers’ stance, the study explored arguments concerning respondents’ more favorable or critical evaluations of PAs.

Results

Areas of allocation, participation, and distribution of federal SUS funds in the Metropolitan Region I

Within Metro I, federal transfers through PAs represented a significant source for financing ASPS and PHC in the segment corresponding to the BF municipalities. Comparing 2016 and 2022, only Itaguaí showed a decline in PA resources for ASPS and the capital city for PHC. In turn, regular federal transfers decreased during the period for most municipalities in the health region. In the BF, a significant increase in PA resources for ASPS (439.7%) and for PHC (328.2%) was evident, while we observed a decrease in regular federal transfers (-10.4% and -15.6%, respectively) (Table 1).

Table 1
Transfers of federal funds through parliamentary amendments (PA) to municipalities in Metropolitan Region I of the state of Rio de Janeiro from 2016 to 2022

Municipality /Region	Pop. 2021 (p/1,000 inhabitants)	% growth				% of PA/total transfers		% of PA for operational expenses	% of PA for PHC	% de EP p/ MHC	ASPS		PHC
		ASPS		PHC		ASPS	PHC				Per capita (BRL)	Coefficient of variation (%)	Per capita (BRL)	Coefficient of variation (%)
		PA	Regular	PA	Regular
Metropolitana I	10,586	409.4	-5.4	280.2	-3.4	8.3	12.4	96.4	37.5	56.2	27.73	50	10.39	60.1
Belford Roxo	515	934.3	-22	366.4	21.9	15.9	29.7	97.4	51.8	48.2	45.47	70.1	23.56	63.1
Duque de Caxias	929	2.003.90	-9.5	368.8	-34.7	23	29.4	98.7	20.7	70.0	95.97	63.8	19.83	73.9
Itaguaí	137	-42	-9.9	338.4	-10	15.7	23.9	97.1	39.9	59.3	43.96	43.3	17.54	111.4
Japeri	106	-	-17.9	-	-19.4	15.6	24.5	98.5	55.5	44.2	48.96	48	27.19	76.5
Magé	248	9.064.10	24	4627.4	13.7	25.6	29.3	98.7	45.6	53.2	98.7	73.9	44.98	88
Mesquita	177	493.9	1.4	117.7	53.6	35.3	44	94.6	51.7	46.7	105	42.7	54.23	40.5
Nilópolis	163	113.7	-36.9	83.1	-40.1	15.7	29.6	98.2	70.2	29.8	55.8	45.2	39.19	56.5
Nova Iguaçu	825	15.6	-12.6	-	-26	8.7	11.8	96.9	20.1	60.9	43.52	77.9	8.74	189.7
Queimados	152	213.2	-3.8	143	-9.6	7.2	27.1	90.8	59.0	41.0	27.41	95.5	16.16	99.1
São João de Meriti	473	430.1	-1.8	189.8	-24.9	27.3	37.1	97.9	44.2	51.0	99.11	45.5	43.83	54
Seropédica	84	120.2	-7.1	553.9	-19.7	21.7	24.5	90.4	50.3	49.5	76.99	83.6	38.71	126.1
Baixada Fluminense	3,810	439.7	-10.4	328.2	-15.6	18.1	27.9	97.5	35.9	57.4	70.73	50.5	25.38	56.6
Rio de Janeiro (capital)	6,776	175.4	-2.3	-76.5	3.2	1.2	2.5	83.7	55.4	42.8	3.54	103.7	1.96	164.4
RJ state	17,463	479.5	-5.8	443.1	1.8	10.1	17.2	93.9	42.9	53.7	38.5	46.3	16.53	51.5

• Sources: IBGE (population estimates); SIGA Brasil (PA), and National Health Fund (total and regular transfers).
• Values adjusted for 2022 prices using the Broad Consumer Price Index (IPCA).
• Captions:
• - ( - ) Zero values in 2016.
• - % growth: Proportional growth of PA resources and regular transfers to ASPS and PHC.
• - % PA/total transfers: Proportion of PA resources compared to total transfers to ASPS and PHC.
• - % PA for operational expenses: Proportion of operational resources compared to total transfers per PA to ASPS.
• - % PA for PHC: Proportion of PA resources allocated to PHC compared to total PA transfers to ASPS.
• - % PA for MHC: Proportion of PA resources allocated to MHC compared to total PA transfers to ASPS.
• - Per capita (R$): Per capita values of resources transferred by PA to ASPS and PHC.
• - Coefficient of variation (%): Coefficients of variation of the values ​​transferred by PA to ASPS and PHC in the historical series.

PA-derived funds represented 10.1% of the total transfers from the MoH to the ERJ municipalities, reaching 17.2% within PHC. In Metro I, we highlight PAs’ low participation in the capital (1.2% for ASPS and 2.5% for PHC) and quite high proportions in the BF (18.1% for ASPS and 27.9% for PHC) and some of its municipalities, such as Mesquita (35.3% for ASPS and 44% for PHC), São João de Meriti (27.3% for ASPS and 37.1% for PHC), and Duque de Caxias (23% for ASPS and 29.4% for PHC).

Regarding the PAs’ allocation areas, funding for ASPS operational expenses prevails, reaching 93.9% in the ERJ. In Metro I, only the capital city has less than 90% of PA funding for operational costs (83.7%). Among the BF municipalities, the predominance of operational funds is even more significant (97.5%). PAs for PHC, however, do not prevail in the ERJ, where most resources are allocated to medium and high complexity care (53.7%), a pattern repeated in the region and in the BF.

Regarding the distribution of PA resources, we observe a high discrepancy between the amounts collected by the municipalities. In Metro I, the PA per capita values ranged from BRL 105.00 in Mesquita and BRL 3.54 in the capital for ASPS and BRL 54.23 and BRL 1.96, respectively, for PHC. Notably, the values for BF (BRL 70.73; BRL 25.38) represented more than double that of Metro I (BRL 27.73; BRL 10.39), both for ASPS and for PHC due to the lower amounts collected by the capital compared to its population.

The coefficients of variation in the historical series of transfers for each municipality indicate the scattering of the amounts received over the years compared to the mean for the period. We note a high variation in annual transfers at the state, regional and municipal levels, exceeding 40% in all cases. The fluctuations in transfers were even more evident in PHC, with cases such as Nova Iguaçu (189.7%), Rio de Janeiro (164.4%), Seropédica (126.1%), and Itaguaí (111.4%).

The historical series of PAs’ participation compared to the total federal transfers for PHC allowed us to identify the behavior of the transfers and patterns in the municipal fundraising (Table 2). We identified a significant increase in the PAs’ participation in the total federal transfers for PHC in 2018, 2019, 2021 and 2022 in most observations, and a decrease in 2020, linked to extraordinary expenses related to COVID-19.

Table 2
Participation of parliamentary amendments for PHC compared to total federal transfers for PHC in 2016-2022 by municipality in the Metropolitan Health Region I, selected regions and the state of Rio de Janeiro

Regions / Municipalities/ State	2016	2017	2018	2019	2020	2021	2022	2016-2022
Metropolitana I	4.2	2.7	12.2	20.3	9.5	19.2	14.8	12.4
Belford Roxo	12.9	3.3	32.0	50.3	32.5	22.3	36.2	29.7
Duque de Caxias	3.9	0.4	44.1	41.1	41.5	29.1	22.8	29.4
Itaguaí	1.1	0.0	30.4	95.8	3.2	37.5	5.3	23.9
Japeri	0.0	34.1	0.0	31.5	18.3	30.4	42.1	24.5
Magé	2.2	0.0	44.2	32.7	4.6	34.0	48.6	29.3
Mesquita	20.3	49.9	44.6	65.9	65.6	37.5	26.5	44.0
Nilópolis	21.5	18.8	14.4	48.2	21.5	27.8	45.6	29.6
Nova Iguaçu	0.0	0.0	0.0	42.5	3.1	5.1	10.6	11.8
Queimados	27.0	0.0	14.9	16.4	0.0	48.4	49.9	27.1
São João de Meriti	21.1	0.3	41.2	42.8	34.5	45.7	50.9	37.1
Seropédica	11.4	0.0	16.1	1.3	0.0	51.8	51.1	24.5
Baixada Fluminense	10.0	7.7	29.7	42.7	25.0	31.5	36.1	27.9
Rio de Janeiro (capital)	0.8	0.2	1.4	2.0	0.5	10.7	0.2	2.5
Rio de Janeiro state	5.5	9.6	17.2	26.2	10.5	23.4	23.7	17.2

• Sources: SIGA Brasil and National Health Fund.
• Values adjusted for 2022 prices using the Broad Consumer Price Index (IPCA).

In Metro I, we identified three patterns of PAs’ participation for PHC compared to the total transfers to this care level. The first is PAs’ low participation for PHC, which is the case for the ERJ, although it reached a participation of 10.7% in 2021. The second is a high and sustained PAs’ participation for PHC, with participation always above 20% in at least four consecutive years of the series, as is the case with the consolidated data for the BF from 2018 to 2022, and Belford Roxo (2018-2022), Duque de Caxias (2018-2022), Nilópolis (2019-2022), São João de Meriti (2018-2022) and, most notably, Mesquita throughout the entire period. The third pattern is that of significant fluctuations in Japeri, Magé, Nova Iguaçu, Queimados, and Seropédica, from 2016 to 2021, and, most notably, in Itaguaí throughout the entire series.

Fundraising, planning, execution, and managers’ stance regarding Parliamentary Amendments for PHC

The PA patterns evidenced in the historical series of federal transfers to the municipalities of Metro I express the differentiated way of raising funds compared to regular transfers. This process involves different stakeholders from the Executive and Legislative Branches in the three spheres of government and negotiation strategies.

The mayors played a leading role in conducting political negotiations, including visits to parliamentarians’ offices, accompanied by health secretaries, to directly approach Representatives and Senators. Technical advisors occasionally participated in these visits to present needs and priorities, and deliver official letters outlining their requests. More frequently, other directors, advisors, and technical staff from the SMS participated in the drafting of projects and the input of PA data into the required information systems, acting in this process only after the conclusion of negotiations between municipal managers and parliamentarians.

The mayor's good relationship with parliamentarians from the same party or allied base was highlighted as a factor that ensures greater receptiveness to demands. However, approaches to parliamentarians from other parties and ideological spectrums were mentioned. The participation of councilors was mentioned with a double connotation. If, on the one hand, they support the search for funds, on the other, they aim to serve a specific locality, regardless of the need or priority defined by the municipal administration.

Federal Representatives and Senators also initiate this process by seeking out municipalities to nominate PAs, interested in serving their electorate. There is also mention of the regular allocation of amendments by these same parliamentarians to specific municipalities over the years, which is reflected in the high and sustained participation of PAs in the financing of PHC.

At the state level, some federal public works projects require approval from the Bipartite Interagency Commission (CIB), involving officials from the Rio de Janeiro State Health Secretariat (SES-RJ) and COSEMS-RJ representatives in the agreement on proposals submitted by municipalities. The SES-RJ technical areas analyze the documentation considering MoH guidelines and ordinances. The technical analysis was considered limited, as it is based on insufficient elements and on PAs already negotiated and registered in the system, potentially “harming” municipalities in obtaining federal resources in the event of a “negative” analysis by the SES. A more thorough evaluation would be the responsibility of the federal government, and significant divergence was reported between the opinions issued, in a process seen as confusing and diverging from published regulations.

The importance of defining PAs' purpose was highlighted in the negotiation process, involving the interests of parliamentarians and managers, health needs, and the rules established by the MoH for the transfer of funds in different modalities. A certain ease in reaching a consensus on the purposes was reported. However, cases of inadequacy were mentioned, culminating in difficulty or non-execution of resources. In these situations, a preponderance of parliamentarian influence was reported, requiring greater effort from municipalities in negotiating and preparing projects and justifications to guarantee the receipt and execution of PAs.

Representatives from municipal administrations reported some saturation of investment resources, with no further technical justification for acquiring equipment due to funds from previous years' amendments, including an excess of equipment in stock. Resources for operational expenses as temporary increases for PHC and MHC services were identified as priorities and motivated changes in the organization of work processes in the SMS. Efforts were reported to expand the limits for PA fundraising, based on the amounts transferred regularly in previous years, including the systematic monitoring of service registrations and production records in information systems, as well as the implementation of monitoring and evaluation strategies.

Other organizational strategies were also reported, such as setting up specific teams, hiring consultants, and improving bidding processes. Regarding hiring specialized consultants, the work is geared towards both investment resources, with the presentation of construction projects, including descriptive reports and monitoring of execution, and operational costs, with training of professionals to handle information systems.

Reorganizing the structure and management processes in the SMS also supports planning processes, such as sizing investments and mobilizing technicians and political figures around a strategic municipal agenda. However, representatives from municipalities, as well as at regional and state levels, reported difficulties faced by the SMS in executing the proposal registration and project development stages due to a shortage of professionals.

Concerns were raised about the potential decrease in received funds, given that SMS often already relies on PA resources, and this funding type fluctuates over years. The caps or limits for PA funding for operational costs for PHC and MHC services have become, in this context, "fundraising targets". The importance of developing plans with specific quantitative and qualitative targets to be incorporated into planning instruments and made available on transparency portals was highlighted. Although not all municipalities develop these plans, they would be crucial for accountability and responses to oversight bodies.

The resources for Strategic Planning (SP) must be integrated into the planning instruments constitutionally mandated and those established within the SUS. To this end, an increase in resources has been reported as a reinforcement of the programmatic and budgetary actions already indicated in the health plans. Planning teams generally promote the necessary changes, reconciling the objectives and resources of the PA negotiated and approved in the annual programs, and efforts are also made to provide accountability in the annual management reports reviewed by the municipal councils.

Regarding execution, operating funds are reportedly primarily used to pay suppliers, and the redirection of own resources to pay personnel is frequent. Regarding PAs related to investments, one of the strategies mentioned was to keep price registration records open for several pieces of equipment in order to expedite the execution of amendments as extraordinary resources. The municipality’s effort to establish itself as a good executor of PAs generates the expectation of preferential treatment in the allocation of resources by parliamentarians, even from groups not aligned in the political landscape.

In general, PAs intended for the construction, renovation, and expansion of units were considered more difficult to execute, with insufficient resources for completion, resulting in unfinished works due to a lack of municipal counterpart funding. Another problem mentioned was the application of funds to purposes other than those approved and the resulting difficulties in providing accountability.

The stakeholders' stance regarding the PAs showed a marked difference between the two profiles of respondents. A positive view prevailed among the SMS, who considered them of great importance for expanding funding. From this perspective, PAs enable projects to expand PHC coverage, involving the purchase of equipment, implementation and renovation of PHC units, and increased operational funds. PAs for operational expenses are celebrated, seen as an opportunity to supplement the federal resources regularly transferred by the MoH, thus "relieving" municipal accounts.

These same stakeholders highlighted negative aspects, such as the competitive landscape between municipalities and the difficulties imposed on the planning process. There were reservations regarding the possibility of the political process “overriding” the technical decision in defining the project’s purpose and location. With less emphasis, the unequal access to parliamentarians and the amounts of funding allocated among municipalities were mentioned.

For respondents working at the state or regional level, a critical perspective prevailed. Given the historical SUS underfunding, these PAs have become “essential” and would likely remain so until more substantial changes occur in federal funding for the SUS. Some mentioned that they were considered an additional resource to the health budget before the mandatory implementation of individual amendments and now they represent competition. With the change, concerns were raised regarding planning and instability in receiving funds, which could adversely affect ongoing health actions and services.

The main problem identified was the unequal allocation of resources among municipalities, which would not meet health needs. Scarce resources would be scattered and would hinder the shaping of regional and state designs for a health policy, as well as national strategies. The distribution rationale would be centered on the executive’s ability to coordinate with parliamentarians in an arrangement that, in many cases, would exceed the legislative functions in defining public policies. Lack of transparency, such as the “secret budget”, is cited to reinforce distrust and the negative view of the PAs. A summary of the findings can be seen in Box 1.

Box 1
Summary of results by category and principal components

Category	Principal Components	Main findings
Federal transfers	Relevance	• Significant increase in resources from PAs for ASPS in contrast to the reduction in regular federal transfers. • PAs represented 10.1% of total federal transfers to municipalities for ASPS and 17.2% for PHC in the state of Rio de Janeiro (ERJ). • Metro I: BF higher share of PAs than in ERJ; low participation of PAs in the capital.
	Allocation areas	• PAs for the operational expenses of ASPS predominates in ERJ, and are even more significant in Metro I and BF. • PHC is not the predominant area for the allocation of PA resources in ERJ and has lower levels in Metro I and BF.
	Resource distribution	• High discrepancy in the per capita values collected by municipalities through PAs for ASPS and PHC. • The per capita values of PAs for BF represent more than double the total for Metro I. • High fluctuation between the annual transfers through PAs for each municipality in the historical series.
	Behavior and patterns in the historical series.	• Increased participation of PAs for PHC in 2018 and 2019, with a significant decrease in 2020. • Three patterns of PA participation for PHC in 2016-2022: 1) Low: municipality of Rio de Janeiro; 2) High and sustained: Belford Roxo, Duque de Caxias, Mesquita, Nilópolis and São João de Meriti; 3) Significant fluctuations: Itaguaí, Japeri, Magé, Nova Iguaçu, Queimados, and Seropédica.
Fundraising	Stakeholders involved	• Mayors → leading role in negotiation. • Health Secretaries → negotiation and internal mobilization within the SMS. • Technical advisors → presentation of requests/delivery of official letters. • SMS technical staff → preparation of projects and data entry into information systems. • Directors of the SES and COSEMS representatives → agreement within the CIB. • SES and MoH technicians → limited technical analysis. • City Councilors → support in fundraising, negotiation, and seeking to serve specific localities. • Federal parliamentarians → allocation of amendments and support for their local base.
	Negotiation and relationship between the Executive and Legislative branches	• Visits to parliamentary offices and delivery of official letters outlining the municipality's requests. • Presentation of the municipalities' needs and priorities. • Sharing the same party or allied base as facilitating factors. • Approaching parliamentarians from other ideological spectrums. • Initiative also on the part of parliamentarians. • Regular allocation of resources by the same parliamentarian to the same municipality.
	Subject of the parliamentary amendment	• Definition by consensus or with legislative preponderance. • Saturation of resources for equipment acquisition. • Priority funding for operational expenses: increased revenue, speed of receipt, and ease of execution.
	Organizational adjustments	• Efforts to increase the caps for receiving PAs for funding PHC and MHC. • Establishment of specific teams for PAs in SMS, recruitment of specialized consultants, and improvement of bidding processes. • Shortage of qualified human resources for handling information systems for entering PA proposals and preparing projects.
Planning and execution	Planning process	• Setting fundraising targets. • Concern about the reduction in amounts received compared to previous years or to fundraising expectations. • Plans for PAs to fund PHC are commonly not developed.
	SUS planning instruments	• Increased resources for budgetary actions already included in municipal health plans. • Changes to ongoing annual programs. • Accountability in annual management reports reviewed by municipal health councils.
	Execution	• PAs allocated for payment to suppliers. • Redirection of own resources for personnel payment. • Expectation that the successful execution of PAs increases fundraising in subsequent years. • Unfinished works due to insufficient investment resources.
Stakeholders’ stance	Favorable prospects	• Predominantly positive view of municipalities. • Great importance of PAs in expanding resources for PHC. • Supplementation of resources from regular federal transfers in the SUS. • They enable projects for the expansion and improvement of the PHC structure.
	Critical perspective	• Predominance of critical views among state and regional representatives. • Setting of competition among municipalities for resource allocation. • Difficulty in forecasting resources and integrating them with planning instruments. • Overlapping of political definition over technical analysis in the choice of the object and location to which it is allocated. • Unequal access to parliamentarians and the amounts allocated among municipalities. • PAs compete with regular transfers in financing the SUS. • Inequity and lack of transparency in the allocation of funds. • Fragmented resources and harm to the establishment of regional and state arrangements.

• Source: Prepared by the authors.

Discussion

This article aimed to identify the changes imposed by parliamentary amendments on the dynamics of municipal management of PHC in the face of greater dependence on political articulations for the acquisition of federal resources. The results showed diverse repercussions of the transfers through PAs for the PHC financing, which boosted new work dynamics and organization among the municipal management of the SUS in the Metro I region of the ERJ.

The significant expansion of resources, essentially for operational expenses, transferred by the MoH via PAs from 2016 to 2022, was accompanied by a decline in regular transfers to the ERJ and Metro I. This trend was most pronounced in the BF, where the reduction in programmatic resources also affected PHC. In 2022, the PAs accounted for 15% of the total transfers to PHC for the municipalities in Metro I and 36% for the BF, indicating a different behavior from the capital in its health region.

This growth in PA resources follows the national pattern, which showed an 87.9% increase in liquidated amounts from 2016 to 2020 (Vieira, 2022). However, two differences are identified in the BF: the amendments are mostly destined for medium and high complexity healthcare services, and the municipalities are medium and large-sized, while, nationally, most resources went to PHC (Piola; Vieira, 2019) and to municipalities with a population of up to 50,000 inhabitants (Vieira; Lima, 2022). The high relevance of amendments in the BF reflects the regional context, marked by a combination of metropolitan characteristics with a tradition of clientelistic practices and low socioeconomic indicators (Silveira; Ribeiro, 2017).

The drop in regular transfers is one of the consequences of the austerity measures exacerbated from 2014 onwards, such as the real reduction in health spending by the three government levels in the 2015-2016 biennium (Piola; Benevides; Vieira, 2018) and the increased fiscal dependence on municipalities to fund ASPS services from 2015 onwards (Cruz; Barros; Souza, 2022). According to Piola and Vieira (2019), the predominance of PA funding for operational costs also fits into this context, in which no additional resources were foreseen for the maintenance of new services and the difficulty in completing the construction of health units was accentuated. These authors argue that this situation altered the preference of parliamentarians to allocate resources for construction and equipment. The municipalities, in turn, became politically dependent on parliamentarians to keep ongoing actions.

From the managers' perspective, PA funding for operational expenses have become a necessary way to increase the receipt of federal funds, contrasting with investment funds, which have resulted in “equipment in stock” and unfinished projects. In the BF region, which has populous municipalities with a low proportion of the population registered in PHC (e-Gestor, 2024), such as Belford Roxo (23.2%), Duque de Caxias (21.3%), and Nova Iguaçu (33.2%), the limited access to investment resources hinders the expansion of coverage through the construction of new PHC units. Notably, in the trajectory of PHC within the SUS, a poor structure, marked by the coexistence of the traditional model and the Family Health Strategy (ESF), was observed in the metropolitan municipalities of the ERJ (Machado; Lima; Viana, 2008).

PA predominance for medium and high complexity services in the BF seems to reflect the higher priority given by parliamentarians and managers to expanding access to specialized consultations, procedures, and examinations, as well as hospital care, which traditionally confers greater visibility among voters. The lower prioritization of PHC, in turn, may be associated with the dormitory-like character of most of its cities (Silveira; Ribeiro, 2017), marked by commuting to the capital during PHC unit’s working hours.

Bezerra (2000) states that the preference of parliamentarians for allocating resources to municipalities is part of a context of personal debts and credits, in which parliamentarians reciprocate to the localities where they received the most votes and to the local leaders who supported them. This is a way of keeping ties with their electoral bases and compensating for the distance caused by performing their duties in the federal capital. The leading role of mayors in securing PA resources mentioned in the interview’s points to the mediation between the local population and the Legislative representatives, highlighting the link between the benefit and the actions of the federal parliamentarian, especially when there is party alignment (Baião; Couto, 2017).

The new dynamics imposed by the PAs for securing a significant portion of federal resources for the SUS imply marked fluctuations in the amounts received annually by the same municipalities and significant differences in per capita amounts within the same health region. The difficulties in providing for amounts and the recurrent adjustments and inclusion of new actions in planning instruments hinder the preservation of ongoing health actions and services, leading to people’s difficulties in access and to discontinuous care. If the decentralization condition in the establishment of the SUS involved guaranteeing the receipt of regular federal resources with transfers mediated by aspects of the health policy itself and living conditions (Ugá et al., 2003), PAs present new challenges and generate insecurity for municipal managers, even if they have a positive evaluation of them.

The discrepancy between the amounts collected by municipalities and the lack of equity criteria points to a recurring concern in the PAs allocated resources for PHC (Vieira; Lima, 2022). In this study, the stakeholders at the regional and state levels expressed the greatest concern about the asymmetrical distribution of resources without considering aspects related to equity in financing capacity and health needs.

In the context of Metro I, sharing PA resources may exacerbate intra-metropolitan inequalities in the distribution of services identified by Reis, Albuquerque, and Lima (2023), with the capital having a much higher proportion of the population registered in PHC than the BF. According to these authors, there is a tendency for units to concentrate in more privileged areas, generating a less equitable distribution, in a context where urban inequalities and the supply of health services converge.

The maintenance of high PA funding levels in the historical series of a group of municipalities in the region identified in this study sheds light on a differentiated pattern for municipal financing of the SUS. Beyond the significant increase in revenue for the health system through political lobbying, the consistent securing of high amounts over the years suggests some dependence on this source, which may even make efforts to meet the criteria for joining and maintaining federal PHC programs secondary. If, on the one hand, municipalities seek to increase their revenues and achieve their “fundraising goals” through amendments, on the other hand, parliamentarians seek to reciprocate the votes received. Bezerra (2000) affirms that keeping ties with the constituencies must be regularly updated, which also contributes to understanding PAs’ annual allocation by the same parliamentarians to the same municipalities reported in the interviews.

Unlike cases of instability in fund transfers, an aspect that could be expected in PA financing, these municipalities seem to be able to provide parliamentarians with a greater political return, or electoral credit (Baião; Couto, 2017). Silveira and Ribeiro (2017) state that a populist leadership tradition is observed in BF municipalities, who preserve popularity and remain in power by granting specific benefits to particular localities.

PAs’ significant participation in the BF contrasts with the situation in Rio de Janeiro and reflects, on the one hand, the greater capacity of the capital to attract resources through regular transfers within the SUS - broad and diverse installed capacity and high PHC coverage - and, on the other hand, the difficulty in obtaining electoral returns. Ames (2003) cites the capitals of São Paulo and Rio de Janeiro as unattractive destinations for directing amendments due to the high dispersion of votes, attributed to the diversity of candidates in the campaign and the higher proportion of immigrants.

The renewed emphasis on legislative participation in the Federal Government’s budget through the mandatory execution of PAs does not relegate the MoH solely to the role of executor. Beyond a technical analysis deemed weak in the interviews, there is an effort to link PA resources to federal government actions through regulations for SUS managers and parliamentarians (Brazil, 2021). However, the weaknesses and discrepancies in the technical analyses of the SES and the MoH, cited in the interviews, contribute to the increased tension in relations between the federated entities. This situation highlights changes in the relationship between the Executive and Legislative Branches and intergovernmental relations, which complicate the dynamics of federal resource transfers within the SUS.

Municipalities’ fundraising through PAs, therefore, mobilizes the participation of diverse stakeholders, with different perspectives, and several stages until the delivery of health services or actions to the population. This study emphasized the coordination between parliamentarians and representatives of the Executive Branch at the three government levels - mayors, health secretaries, and technical teams from the SMS, SES, and MoH. In this setting of multiple interactions, we observed the growing relevance of PA resources and changes in intergovernmental relations and between the Executive and Legislative Branches, which shape the financing of health policy today. Municipal administrations are responsible for diversifying their strategies to increase revenue for the SUS and readjusting their organizational processes, especially regarding the planning and execution of resources.

In a context that restricted the funding of social policies and expanded the allocation of resources by parliamentarians, regular transfers were reduced, and political negotiations became a condition for increasing federal resources for the management of the health system by municipalities. These political negotiations are inherent to intergovernmental relations and relations between branches of power in democracies, and our clientelist tradition and the maintenance of oligarchic power are the critical points. PAs for health highlight the dilemmas of our historical trajectory, which shape our political system and affect the implementation of public policies for the population.

Final considerations

Federal transfers of funds through parliamentary amendments for PHC in Metropolitan Region I of Rio de Janeiro from 2016 to 2022 impacted the dynamics of resource acquisition by municipal administrations, with mayors leading the way and technical teams and political and managerial stakeholders playing varying roles. This process differed among municipalities due to political-ideological and partisan alignment, relationships between municipal management and parliamentarians, and the behind-the-scenes negotiations of the amendments.

Targets for attracting and streamlining the use of resources drove actions to reorganize work processes and integrate them with planning, in a context marked by a predominant positive vision and stance of municipal managers vis-à-vis PAs, contrasted with a more critical view from stakeholders with state and regional operations.

Transfers of funds through amendments to the state of Rio de Janeiro, Metropolitan Region I, and the Baixada Fluminense, primarily for operational costs and medium- and high-complexity services, have increased significantly, with a reduction in regular transfers and differentiated patterns of participation by PAs in the total resources transferred per municipality during the period.

The study addressed the case of Metropolitan Region I of Rio de Janeiro, with limitations regarding the generalization of its results, contingent on the period and contexts that explain the repercussions of federal transfers through PAs in that reality. The findings, however, highlight the implications of the increasing presence of amendments for SUS financing, emphasizing the possible effect of replacing regular transfers and concerns regarding the maintenance of the volume of resources collected annually.

Acknowledgments

AS Silva was a CAPES-Print scholarship recipient. LD Lima is a CNPq research productivity fellow and a FAPERJ Scientist of Our State, and relies on the support of these agencies for the development of studies on the subject.

References

• AMES, B. Os entraves da democracia no Brasil. Rio de Janeiro: Editora FGV, 2003.
• BAIÃO, A. L.; COUTO, C. G. A eficácia do pork barrel: a importância de emendas orçamentárias e prefeitos aliados na eleição de deputados. Opinião Pública, v. 23, n. 3, p. 714-753, 2017.
• BAIÃO, A. L.; COUTO, C. G.; OLIVEIRA, V. E. Quem ganha o quê, quando e como? Emendas orçamentárias em saúde no Brasil. Revista De Sociologia E Política, v. 27, n. 71, 2019.
• BAPTISTA, T. W. F. et al. O orçamento federal e as emendas parlamentares da saúde no PPA 2004-2007: uma discussão a partir das regras institucionais. In: MELAMED, C.; PIOLA, S. F. (Org.) Políticas públicas e financiamento federal do Sistema Único de Saúde. Brasília: Ipea, 2011. p. 287-316.
• BAPTISTA, T.W.F. et al. As emendas parlamentares no orçamento federal da saúde. Cadernos de Saúde Publica, v. 28, n. 12, p. 2267-2279, 2012.
• BERTHOLINI, F.; PEREIRA, C.; RENNO, L. Pork is policy: Dissipative inclusion at the local level. Governance, v. 31, n. 4, p. 701-720, 2018.
• BEZERRA, M. O. Representação política e acesso aos recursos federais. Revista do Serviço Público, v. 51, n. 2, p. 72-93, 2000.
• BRASIL. Emenda Constitucional nº 86, de 17 de março de 2015. Altera os arts. 165, 166 e 198 da Constituição Federal, para tornar obrigatória a execução da programação orçamentária que especifica. Diário Oficial da República Federativa do Brasil. Brasília, DF, 17 mar. 2015.
• BRASIL. Emenda Constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da República Federativa do Brasil. Brasília, DF, 15 dez. 2016.
• BRASIL. Emenda constitucional nº 126, de 21 de dezembro de 2022. Altera a Constituição Federal, para dispor sobre as emendas individuais ao projeto de lei orçamentária, e o Ato das Disposições Constitucionais Transitórias para excluir despesas dos limites previstos no art. 107; define regras para a transição da Presidência da República aplicáveis à Lei Orçamentária de 2023; e dá outras providências. Diário Oficial da União, 21 dez. 2022.
• BRASIL. Lei Complementar n° 200, de 30 de agosto de 2023. Institui regime fiscal sustentável para garantir a estabilidade macroeconômica do País. Diário Oficial da União, 30 ago. 2023.
• BRASIL. Ministério da Saúde. Fundo Nacional de Saúde. Cartilha para apresentação de propostas ao Ministério da Saúde - 2021. Brasília: Ministério da Saúde, 2021.
• BRASIL. Emenda Constitucional nº 126, de 21 de dezembro de 2022. Altera a Constituição Federal, para dispor sobre as emendas individuais ao projeto de lei orçamentária […] Diário Oficial da União, 21 dez. 2022;
• CASTRO, A. L. B.; MACHADO, C. V.; LIMA, L. D. Financiamento da Atenção Primária à Saúde no Brasil. In: MENDONÇA, M. H.nM. et al. (Org.). Atenção Primária à Saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: Fiocruz, 2018. p. 73-93.
• CRUZ, W. G. N.; BARROS, R. D.; SOUZA, L. E. P. F. Financiamento da saúde e dependência fiscal dos municípios brasileiros entre 2004 e 2019. Ciência & Saúde Coletiva, v. 27, n. 6, p. 2459-2469, 2022
• E-GESTOR ATENÇÃO BÁSICA. Secretaria de Atenção Primária à Saúde. Ministério da Saúde. Acesso em 30 Mar. 2024. Disponível em: https://egestorab.saude.gov.br/
  » https://egestorab.saude.gov.br
• GOMES, R.A. A análise de dados em pesquisa qualitativa. In: MINAYO, M.C.S. (Org.). Pesquisa social: teoria, método e criatividade. Petrópolis: Editora Vozes, 2002. p. 67-80.
• INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATISTICA (IBGE). Censo Demográfico 2022: Características da população e dos domicílios. Rio de Janeiro: IBGE, 2023.
• KUSCHNIR, R. et al. Regionalização no estado do Rio de Janeiro: o desafio de aumentar acesso e diminuir desigualdades. In: UGÁ, M. A. D. et al. (Org.). A gestão do SUS no âmbito estadual: o caso do Rio de Janeiro. Rio de Janeiro: Editora Fiocruz, 2010, p. 215-240.
• LIMONGI, F.; FIGUEIREDO, A. C. Processo orçamentário e comportamento legislativo: emendas individuais, apoio ao executivo e programas de governo. Dados, v. 48. n. 4, p. 737-776, 2005.
• MACHADO, C. V.; LIMA, L. D.; VIANA, L. S. Configuração da Atenção Básica e do Programa Saúde da Família em grandes municípios do Rio de Janeiro, Brasil. Cadernos de Saúde Pública, v. 24 Sup 1, S42-S57, 2008.
• MEDINA, S.A. et al. Alocação das emendas parlamentares individuais: correção de assimetria em saúde ou ganho político? Revista Eletrônica de Administração, v. 29, n. 1, p. 98-125, 2023.
• MESQUITA, L. et al. Emendas individuais e concentração de votos: uma análise exploratória. Teoria e Pesquisa, v. 23, n. 2, p. 82-106, 2014.
• OCKÉ-REIS, C. O. et al. Evolução do piso federal em saúde: 2013-2020. Brasília, DF: Ipea, 2023. (Nota Técnica, n. 109).
• ORAIR, R. O.; LIMA, L. S.; TEIXEIRA, T. H. Sistema de transferências para os municípios brasileiros: avaliação dos impactos redistributivos. In: BOUERI, R.; COSTA, M. A. (Eds.). Brasil em desenvolvimento 2013: Estado, planejamento e políticas públicas. Brasília: Ipea, 2013. p. 235-257.
• PIOLA, S. F.; BENEVIDES, R. P. S.; VIEIRA F. S. Consolidação do gasto com ações e serviços públicos de saúde: trajetória e percalços no período de 2003 a 2017. Brasília: Ipea, 2018.
• PIOLA, S. F.; VIEIRA, F. As emendas parlamentares e a alocação de recursos federais no Sistema Único de Saúde. Texto para discussão; n. 2497. Brasília, Rio de Janeiro: Ipea, 2019.
• REIS, G. J.; ALBUQUERQUE, M. V.; LIMA, L. D. de. Distribuição espacial de unidades de saúde e condições de vida urbana na região metropolitana do Rio de Janeiro. Hygeia - Revista Brasileira de Geografia Médica e da Saúde, v. 19, p. e1936, 2023. Disponível em: https://seer.ufu.br/index.php/hygeia/article/view/68564
  » https://seer.ufu.br/index.php/hygeia/article/view/68564
• RIO DE JANEIRO. Secretaria de Estado de Saúde. Plano Estadual de Saúde 2024-2027, Rio de Janeiro: SES-RJ, 2024.
• SANTOS, N. C. B.; GASPARINI, C. E. Orçamento impositivo e relação entre poderes no Brasil. Revista Brasileira de Ciência Política, v. 31, n. 10, p. 339-396. 2020.
• SILVEIRA, L. A.; RIBEIRO, M. A. C. Situando Duque de Caxias no contexto metropolitano da Baixada Fluminense: de cidade-dormitório a cidade plena. In: MARAFON, G. J.; RIBEIRO, M. A. (Org.). Revisitando o território fluminense, VI. Rio de Janeiro: EDUERJ, 2017.
• SOUZA, C. M. D. Federalismo e conflitos distributivos: disputa dos estados por recursos orçamentários. Dados. v.46, n. 2, p. 345-384, 2003.
• UGÁ, M. A. et al. Descentralização e alocação de recursos no âmbito do Sistema Único de Saúde (SUS). Ciência & Saúde Coletiva, v. 8, n. 2, p. 417-437, 2003.
• ULINSKI, K. G. B. et al. Efeitos das emendas parlamentares no financiamento municipal da atenção primária à saúde do Sistema Único de Saúde. Cadernos de Saúde Pública, v. 40, n. 3, 2024.
• VIEIRA, F. S. Emendas Parlamentares ao Orçamento Federal do Sus: método para estimação dos repasses a cada município. Brasília: Rio de Janeiro: Ipea, 2022 (Texto para Discussão, n. 2.732).
• VIEIRA, F. S.; LIMA, L. D. Distorções das emendas parlamentares à alocação equitativa de recursos federais ao PAB. Revista de Saúde Pública, v. 56, n. 123, 2022.
• YIN, R. K. Estudo de caso: planejamento e métodos. Tradução de Robert K. Yin; Daniel Grassi. 2.ed. Porto Alegre: Bookman, 2001.

• All research data are available in this text.
• Funding
  This study was funded by the National Council for Scientific and Technological Development (CNPq), File N°309295/2021-1; by the Carlos Chagas Filho Foundation for Research Support of the State of Rio de Janeiro (FAPERJ), File N°SEI E-26/204.194/2024; and by the Oswaldo Cruz Foundation (Fiocruz) - Program of Public Policies, Care Models and Management of the Health System and Services (PMA), File N°25380.101539/2019-05.
• Reviewers:
  Evilásio Salvador and José Mendes Ribeiro

• Editor:
  Rondineli Mendes Silva

Data availability

All research data are available in this text.

Publication Dates

• Publication in this collection
  17 July 2026
• Date of issue
  2026

History

• Received
  23 May 2024
• Reviewed
  12 Sept 2025
• Accepted
  07 Oct 2025