Fiscal austerity and municipal health spending: an interrupted time series study

Maia, Leo Ramos; Campos, Mônica Rodrigues; Castanheira, Débora

doi:10.11606/s1518-8787.2024058005772

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Original Article • Rev. Saúde Pública 58 • 2024 • https://doi.org/10.11606/s1518-8787.2024058005772 copy

Fiscal austerity and municipal health spending: an interrupted time series study

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To analyze the impact of the fiscal austerity policy (PAF) on health spending in Brazilian municipalities, considering population size and source of funds.

METHODS

The interrupted time series method was used to analyze the effect of the PAF on total expenditure, resources transferred by the Federal Government, and own/state per capita resources allocated to health in the municipalities. The time series analyzed covered the period from 2010 to 2019, every six months. The first semester of 2015 was adopted as the start date of the intervention. The municipalities were grouped into small (up to 100,000 inhabitants), medium (101,000 to 400,000 inhabitants), and large (over 400,000 inhabitants). The data was obtained from the Sistema de Informações sobre Orçamentos Públicos em Saúde (Information System on Public Health Budget).

RESULTS

The results for the national average of municipalities show that the PAF had a negative impact on the level of total expenditure and own/state resources allocated to health in the first half of 2015, without causing statically significant changes in the trends of any of the indicators analyzed in the period after 2015. Small municipalities saw a drop in total expenditure, while large municipalities saw a drop in own/state resources, and medium-sized municipalities saw a drop in both variables. There was no statistically significant drop in the volume of funds transferred by the Federal Government in the immediate aftermath of the implementation of the PAF in any of the municipal groups analyzed. In the medium-term, the PAF only had a negative impact on the large municipalities, which saw significant reductions in the trends of own/state resources and those transferred by the Union for health.

CONCLUSION

In general, the impact of the PAF on health financing in municipalities was immediate and based on the decrease in own/state resources allocated to health. In large municipalities, however, the impact lasted from 2015 to 2019, mainly affecting health expenditure from federal funds.

Financing Health Systems; Fiscal Policy; Public Spending on Health; Cities

Variables	Brazil	SMA	MED	LAR
Sociodemographics
% of population	100%	42.60%	22.60%	34.80%
No. of municipalities	5,569	5,245	261	63
Life expectancy at birth^a	73.94	73.33	75.42	75.52
Human Development Index^a	0.727	0.66	0.744	0.77
Degree of urbanization^a	85.30%	62.90%	95.50%	99.30%
Health
Number of doctors per 1,000 inhabitants^b	2	0.6	1.7	2.9
Primary Care Coverage^b	74.20%	100%	70.80%	57.40%
Supplementary health coverage^b	22.90%	3.50%	21.80%	34.80%

Indicator	Baseline			Post-PAF		Percentage difference^a
	(2010.1–2014.2)			(2015.1–2019.2)		Percentage difference^a
	2010.1	2014.2	Trend^b	Post-PAF level (95%CI)	Post-PAF trend (95%CI)	2015.1	2019.2
All municipalities
Total expenses	63.73	92.41	2.07*	-6.73*	-1.13	-9,23	-11,55
Total expenses	63.73	92.41	2.07*	(-12.46 to -1.00)	(-2.99 to 0.73)	-9,23	-11,55
Resources transferred by the Union	25.59	32.53	0.66*	-2.04	0.37	-12,14	-11,88
Resources transferred by the Union	25.59	32.53	0.66*	(-6.66 to 2.56)	(-0.70 to 1.44)	-12,14	-11,88
Own and state resources	38.14	59.88	1.40*	-6.46*	-0.47	-6,69	-16,76
Own and state resources	38.14	59.88	1.40*	(-10.43 to -2.48)	(-1.22 to 0.28)	-6,69	-16,76
Small municipalities (up to 100,000 inhabitants)
Total expenses	63.11	92.43	2.33*	-10.39*	-0.31	-12,89	-12,27
Total expenses	63.11	92.43	2.33*	(-16.20 to -4.59)	(-1.45 to 0.83)	-12,89	-12,27
Resources transferred by the Union	17.83	28.64	0.98*	-2.15	1.01*	-13,1	-7,42
Resources transferred by the Union	17.83	28.64	0.98*	(-8.60 to 4.29)	(0.06 to 1.97)	-13,1	-7,42
Own and state resources	45.28	63.79	1.33	-2.78	0.5	-10,01	1,6
Own and state resources	45.28	63.79	1.33	(-10.20 to 4.64)	(-0.82 to 1.83)	-10,01	1,6
Medium-sized municipalities (from 100,001 to 400,000 inhabitants)
Total expenses	58.83	84.2	1.97	-5.33*	-1.1	-8,14	-11,87
Total expenses	58.83	84.2	1.97	(-10.00 to -0.67)	(-2.61 to 0.40)	-8,14	-11,87
Resources transferred by the Union	24.78	29.87	0.51*	0.78	-1.1	0,06	-15,84
Resources transferred by the Union	24.78	29.87	0.51*	(-5.10 to 3.52)	(-4.61 to 2.45)	0,06	-15,84
Own and state resources	34.05	54.33	1.36	-6.55*	-0.36	-7,61	-16,12
Own and state resources	34.05	54.33	1.36	(-9.35 to -3.76)	(-0.91 to 0.18)	-7,61	-16,12
Large municipalities (more than 400,001 inhabitants)
Total expenses	69.23	100.61	2.08*	-5.52	-1.54	-7,74	-14,34
Total expenses	69.23	100.61	2.08*	(-11.61 to 0.57)	(-3.51 to 0.43)	-7,74	-14,34
Resources transferred by the Union	34.16	39.07	0.48*	-1.37	-2.53*	-12,35	-27,52
Resources transferred by the Union	34.16	39.07	0.48*	(-3.74 to 1.00)	(-4.48 to -0.59)	-12,35	-27,52
Own and state resources	35.07	61.54	1.51*	-5.29*	-0.68*	-5,28	-13,38
Own and state resources	35.07	61.54	1.51*	(-7.61 to -2.98)	(-1.01 to -0.35)	-5,28	-13,38

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[1] Correspondence
: Leo Maia Escola Nacional de Saúde Pública Sérgio Arouca Av. Brasil, 4.365 - Pavilhão Haity Moussatché - 21040-900 - Rio de Janeiro, RJ, Brasil; E-mail: leormaia96@gmail.com