Balances of federal transfers in SUS: what we have and what to expect from the COVID-19 increment

We analyzed the balances from the transfers from the Ministry of Health (MH) to subnational entities, to finance the Unified Health System (SUS), including for COVID-19. We verified the representativeness of these in relation to the transfers from the MH to public health actions and services, between 2019and 2020. We analyzed the MH ordinances that gave rise to the COVID-19 transfers, classifying them as: quantity; object; apportionment criterion; amount of installments; execution linked to MH strategies; value. More than 70.000 current accounts were accounted for, and some subnational entities had more than 100. In 2019, balances reached R$16.29 billion (annual increase of 10.2%), representing 19.9% of the total transferred. In 2020, they reached R$23.83 billion (an increase of 46.3%), representing 21.1% of all transfers, with a monthly trend of continued growth. More than 616 ordinances, with 28 different objectives, transferred R$32.30 billion to COVID-19. The resource, originally freely available, had R$11.88 billion (36.8%) linked to the strategies of the MH: R$1.36 billion (99.9%) linked to the Structuring Block, and R$10.52 billion (34.0%) linked to the Maintenance Block. There are several causes that give rise to the accumulation of balances, however the quality, quantity and complexity of the SUS normative framework strongly contribute to an execution of resources that is not very fast, effective, efficient and useful.


Introduction
With the promulgation of the Federal Constitution 1 in 1988, the right to health was guaranteed to the entire population of Brazil.To meet this determination, the Unified Health System (SUS) was created, having universality, comprehensive care and the promotion of equity as basic principles 2 .From the intergovernmental financial relations point of view, the creation of the SUS was materialized through a tripartite financing agreement, integrating resources from the Union of States, Federal District and Municipalities 3 .However, it was only in 2000 that Constitutional Amendment nº 29 4 regulated the financing responsibilities, and only in 2012, Complementary Law nº 141 5 define which expenses are considered to be Public Health Actions and Services (ASPS), in addition to regulating the regular and automatic transfers of federal resources to subnational entities 6 .In the last 10 years, the composition of SUS expenses has been, on average: 43% under the responsibility of the Union, 26% of the States and 30% of the Municipalities 7 .
Regarding the application of federal resources, transfers to subnational entities occupy a prominent position in the budget execution of the Ministry of Health (MH), allocating the largest volume of resources for the maintenance of ASPS.The MH makes transfers from the National Health Fund (FNS) to the health funds of subnational entities, considering a series of norms and budgetary principles pertinent to public administration, as well as a set of norms and agreements in the scope of the SUS, which, among others, impose obligations on subnational managers and prohibit acts that aim at purposes other than those foreseen 8, 9 .In 2019, the Union recorded a total expenditure of R$ 122.3 billion with ASPS, with 69% transferred to subnational entities for Structuring (2.0%) and Maintenance (98.0%) 10 .However, data from the MH record, in December 2019, an amount of R$ 16.3 billion in balances in the current accounts of these transfers.These balances represent the difference between the volume of transferred funds and the expenses actually paid in a given period, a phenomenon known as "cost pooling".Many can be the causes of the large volume of pooled resources, however, according to the Brazilian National Treasury Secretariat, one of the main reasons is the excess of earmarking of revenues and expenses, especially in the areas of Health, Defense and Education 11 .
In 2020, the budget of the MH, which accounted for R$ 124.20 billion for the execution of ASPS, received an increase of R$ 64.12 billion in extraordinary credits 12 , directed to the FNS.Unlike ordinary credits, such additional resources were not included in the Annual Budget Law and were only authorized due to the recognition of the state of public calamity installed in Brazil 13 , resulting from the new Coronavirus pandemic.These extraordinary resources were made available for the financing of ASPS, exclusively dedicated to confronting COVID-19, allocated for the direct execution of the MH, transfers abroad, to philanthropists and to States, Federal District and Municipalities, which also increased the volumes of balances.
In order to make feasible the use of pooled resources, including for actions against COVID-19, a Complementary Law 14 was enacted, which made it possible to execute the remaining balances during the calamity period.However, still in 2020, the volume of balances reached R$ 31.73 billion 15 .In this context, this study presents unprecedented contributions regarding investigations on the legality, transparency and linkage of resources directed to the SUS, which must be carried out in compliance with the precepts of autonomy and administrative efficiency.

Objective
Analyze the financial balances from transfers from the MH to subnational entities, within the scope of SUS financing, between the years 2019 and 2020, including resources intended for the confrontation of COVID-19, pointing out possible causes of this phenomenon.

Study design
It is a descriptive analysis aimed at the evolution of the volume of financial balances related to federal transfers in the SUS, correlating them in an argumentative way, with the normative framework of the financing of the system.Such transfers are destined to finance ASPS and occur in demand deposit accounts (current accounts), opened by the FNS 10 in federal financial institutions -Banco do Brasil and Caixa Econômica Federal -remaining under the management of subnational entities.
In order to achieve the objective of the study, the total values of these transfers and the remaining balances were verified monthly during 2019 and 2020 for States, Federal District, and Municipalities.The representativity of the balances in relation to the transfers that took place; the amount and evolution of the number of current accounts, and the values of the balances were also verified.Using Microsoft Excel® and based on the values of the balances from January 2019 to March 2020, a trend curve was calculated for the evolution of the balances from April 2020 to January 2021.Thus, it was possible to verify and compare the dynamics of pre-pandemic pooling, and in 2020.
With the intention of knowing and verifying possible ramifications due to the contribution of resources to COVID-19, the rules that gave rise to the transfers of the MH (Ordinances) were classified according to: (1) Transfer block that allows knowing the type of expense for which resources were transferred, whether for structuring or maintenance actions; (2) Number of Ordinances that gave rise to the transfers, which allows knowing the volume of regulations that managers had to deal with during the pandemic; (3) Object of each Ordinance, which makes it possible to know the destination of the resources transferred, indicating whether it is for general use or if it is linked to a specific MH; (4) Form of apportionment of the resource that presents the criteria used for the distribution of values and allows knowing the complexity of the regulations that managers had to deal with during the pandemic); (5) Frequency of transfer installments, aimed at determining whether the transfers would be in a single installment or divided, indicating the complexity of planning and executing the funds received; (6) Type of linkages for the use of resources, aimed at accounting for the volume of rules that bind the execution of resources, in addition to the legal linkage of the work program, to the specific strategies of the MH, and; (7) Total annual value of transfers.Such descriptive analysis was performed to organize, summarize and describe the most important aspects of this set of observed characteristics.

Data sources
The data used in this study were collected from the computerized systems of the federal government.Data related to the MH budget were extracted from the Integrated Planning and Budget System (SIOP) 12 , which supports the Federal Government's Planning and Budget processes.Data relating to current accounts and financial balance values were extracted from the Portal Localiza SUS/MS 15 , a digital platform of the MH, with daily updates, which gathers electronic panels that present information on the fight against COVID-19.Data on financial transfers, with information on amounts of current accounts and balance values, are primarily sourced from the National Health Fund.Data regarding the transfer values to COVID-19 were extracted from the FNS 10 , manager of the MH resources, responsible for developing mechanisms that make information available to society regarding transfers within the SUS.All query parameters and their respective sources are described in Chart 1.

Current accounts
In 2020, the total number of current accounts in the States, receiving only federal transfers was 1.271, and 70.037 in the Municipalities.Individually, the state of Pará and the municipalities of João Pessoa/PB, São Paulo/SP and Teresina/PI registered more than 100 current accounts.

Balances
Between January/2019 and March/2020, there was a certain stability of growth, when from then on, due to the contribution of transfers destined to confront COVID-19, there was a significant increase.In the 12 months of 2019 there was an increase of R$ 1.51 billion (10.2%) and in 2020 of R$ 6.69 billion (46.3%).The projection of data for this scenario shows an upward trend (R 2 =73,3%).In December/2019, the R$ 16.29 billion in balances represented 19.9% of the total transferred in the year and in December/2020 the R$ 23.83 billion represented 21.1% (Graphic 1).

Ordinary resources
In 2019, the FNS had a budget allocation of R$ 127.19 billion, with forecast transfers to subnational entities of R$ 82.98 billion (65.2%).The total execution was 90.6%, with 48.6% of the resources destined to the Municipalities; 16.7% to the States; 31.1% of direct applications; and the rest to other application modalities.
In 2020, the budget allocation was R$ 184.49 billion, with estimated transfers of R$ 113.57 billion (61.6%).The total execution was 80.8%, with 45.4% destined to the Municipalities; 16.1% to the States; 50.8% direct applications of the MH; and the rest to other modalities (Table 1).

Extraordinary resources
Considering in 2020 only the resources allocated to COVID-19 (extraordinary additional credits), the budget allocation was R$ 64.17 billion, with expected transfers of R$ 33.26 billion (51.8%).The total execution was 61.5%, with 36.4% destined to the Municipalities; 15.4% to the States; 22.8% direct applications of the MH; and the rest to other modalities (Table 1).Fundto-fund transfers were carried out as of March, reaching the highest volume between June/2020 (R$ 6.42 billion; 20%) and August/2020 (R$ 9.12 billion; 28%).The transfers were regulated by 616 ordinances which allocated funds for actions to combat COVID-19, through the Structuring (R$ 1.36 billion; 4.2%) and Maintenance (R$ 30.93 billion; 95, 8%) blocks.The transfers had 28 different objectives, most (70%) transferred in a single installment.Values were classified into significant groups.It was found that most transfers for Maintenance had free allocation to meet local needs (R$ 18.35 billion; 59.3%), followed by transfers directed to Medium and High Complexity actions (R$ 7.30 billion; 23.6%), Parliamentary Amendments (R$ 2.24 billion; 7.2%), Primary Care (R$ 1.51 billion; 5.0%), Surveillance (R$ 857.67 million; 2.8%), Pharmaceutical Assistance (R$ 649.83 million; 2.1%) and not informed (R$ 1.58 million).Of these resources, 33% had their use linked to some strategy of the MH, such as the Health at School program or medications for mental health.
It should be noted that two other Ordinances published in the last days of December/2020 were not calculated here, as the resources were transferred in January/2021.Ordinance 3874/2020 transferred to the States the total of R$ 864.00 million, destined to meet the assistance demands caused by COVID-19.In turn, Ordinance 3874/2020 transferred to the Municipalities the total of R$ 143.90 million, destined to the Reference Community Centers, both in a single installment, through the Maintenance Block.

Discussion
With an annual allocation of more than R$ 120.00 billion and an execution of 90.0%, the FNS transfers around 65% of its resources to subnational entities.However, part of these resources are pooled in the State Health Funds, Federal District and Municipalities, with a strong growth trend, as they jumped from R$ 13.85 billion in early 2019 to R$ 31.09 billion in mid-2020.
In 2020, with the advent of COVID-19, there was a federal contribution of R$ 64.17 billion in extraordinary resources, of which 51.8% were transferred to subnational entities.This contribution brought with it an innovation: the purpose defined in the Work Program of the 21C0 Union General Budget dedicated to confronting COVID-19.Unlike other budgetary actions, 21C0 permeated all health areas, allowing its resources to be executed in ASPS in primary and specialized care, health surveillance, pharmaceutical assistance, acquisition of supplies, inputs and hospital products.That is to say that it would be possible for States, Federal District and Municipalities to use such resources, within the law, as quickly as possible, to meet the local demands established in the regional coping plans of COVID-19, without any kind of plastering or linkage to specific objectives of programs, actions, activities, projects, special operations of the MH.
However, there was a recurrent posture of the MH (responsible for the largest slice of SUS financing) according to which, even in the face of an international public health emergency, the execution culture remained tied not only to the purpose defined in the Work Program, but also to the interests of the MH's final areas, limiting the autonomy of management and execution of the resources received by the subnational entities [16][17][18][19] .Consequently, of the R$ 32.30 billion transferred to subnational entities, R$ 11.88 billion (36.8%) had its execution plastered, among them: R$ 649.83 million (Ordinance 2516/20) for the purchase of medicines of mental health; R$ 454.33 million (Ordinance 1857/20) for Health at School; R$ 2.24 billion (75 Ordinances) linked to objects of Parliamentary Amendments.Under penalty of incurring a misuse of purpose, the execution of resources by subnational entities must comply with the object and the pacts disciplined in the normative acts that regulated each of the transfers at the time of receipt of resources in the health fund of subnational entities 20 .In practical terms, if it has not been necessary to purchase mental health drugs or increase the resources allocated to Health at School, exclusively to deal with COVID-19, the resources received will eternally remain as balances.
In the case of extraordinary resources, the complex regulatory entanglement of the MS contemplated, only in 2020, more than 616 ordinances, which in the midst of a pandemic, established to the managers of 5.596 subnational health funds approximately 30 different objectives, more than 16 ways of calculating the apportionment of resources and various ties for the execution of these.In the Structuring Block, which has the highest relationship with large volumes of balances, 99.9% of COVID-19 transfers, accounting for R$ 1.36 billion, had their execution stymied, and in the Maintenance Block 34.0%, accounting for R$ 10.52 billion.
Regarding the execution of ordinary resources, the situation is no different.The SUS budget-financial processes are regulated by the Law 8080/1990 21 , intergovernmental transfers of resources by Law 8142/1990 22 , fiscal responsibility rules by Complementary Law 101/2000 9 , the public budget by Law 4320/1964 8 and the planning and budgeting of the SUS by Complementary Law nº 141/2012 5 .As if that were not enough, the normative framework for financing and transfers from the SUS was compiled by Consolidation Ordinance nº 6/2017 23 , which currently has impressive 1.171 articles and 99 annexes.There is no doubt that there are several sources for the accumulation of balances, however the production of numerous and complex internal regulations, which tie the execution of resources beyond the purposes established in the budget programs, presents itself as an efficient cause of the pooling of resources in SUS.
Quantity, quality and regulatory complexity have become barriers to the achievement of important principles of public administration: legality and efficiency.Between 2014 and 2019, the total amount of pooling of transferred resources jumped from R$ 5.4 billion 24 to R$ 16.29 billion, reaching, in August/2020, the incredible figure of R$ 31.74 billion.In 2019, the volume of balances represented 19.9% of the total transfers of the MH and, in 2020, it reached 21.1%, with an upward trend.
In general, the values of balances in the Maintenance Block, resources for carrying out the ASPS on a daily basis, are of greater interest for analysis because they represent 98.0% of the total volume of transfers.In view of the total amounts transferred in 2019, these represent for 58% of the municipalities the amount received in 2.4 months and for 56% of the states, 2.7 months.There are indications, verified in individual consultations to the FNS electronic portal, that some municipalities receive, in current accounts that should have already been closed, deposits that do not come from the FNS.It is believed that such credits come from the States, however, research is necessary to know the origin, volume and how much they represent in the total pooling.
On the other hand, the amounts transferred through the Structuring Block refer to capital transfers, whose execution requires specific administrative processes, often hampered by obstacles such as, for example, bidding or related processes, the non-delivery of contracted goods or services, technical or environmental problems, or the non-receipt of agreed resources, or even judicial or control agency proceedings 25 .
There is no doubt that in 2020 part of the increase in balances comes from extraordinary resources to fight COVID-19.One of the causes of the pooling was the slowness of transfers, which provided large volumes in the months of June (20%) and August (28%).However, a structural cause has to do with the obstacles established by norms that linked 34% of the resources execution to strategies and programs of the MH, far beyond the legal binding of purpose, defined in the Budget Work Program, a common practice in the SUS also for the ordinary resources.At the beginning of the pandemic, Complementary Law nº 172/2020 14 was enacted, aiming to enable the execution of the remaining balances.Thus, in view of the fulfillment of the respective agreed objects, the inclusion of resources in the Annual Health Program and in the local Annual Budget Law and making the respective Health Councils aware of the changes, it was possible for subnational managers to redirect the remaining resources, allocating them to implementation of the ASPS established in their local health plans.However, the mechanism only allowed for changes during the term of Legislative Decree nº 6/2020 26 , differently from what was foreseen in the original project: the reprioritization at the end of each fiscal year 27 .In order to make possible the execution of tens of billions of Reals destined to COVID-19, by the end of 2020, the Presidential Decree nº 10.579/2020 28 and later the Complementary Law nº 181/21 29 established that the subnational entities could execute these resources until December/2021.
The legislative authorization for a limited time is appropriate, but does not solve the problem.In this study, it calls attention to the fact that the MH established, in the middle of the pandemic, more than 16 ways of calculating the apportionment of resources.If there were in SUS an established and widely used apportionment methodology, as well as a bottom-up planning and budgeting process, both based on the health needs of the population, considering the epidemiological, demographic, socioeconomic, spatial, and supply capacity dimensions of health actions and services 5 , the entire budgeting process would be much more effective.
In this regard, it is worth noting the understanding of the Planning and Budget Secretariat (SPO) of the Executive Secretariat of the MH, according to which all transfers made to subnational entities in the fund-to-fund modality could oc-cur through a maximum of 16 budget schedules for each block of financing 30,31 .This study has as limitations those inherent to the SUS databases and the fact that 0.01% of the transfer values do not record information capable of classifying them.Another limitation concerns the failure to carry out an analysis of the execution, by subnational entities, of the resources transferred.However, due to the volume of data and information, derived from a naturally complex topic, the authors decided to make this limitation a theme for further studies.
There can be several causes that give rise to the accumulation of balances but, without a doubt, the quality, quantity and complexity of the SUS normative framework strongly contribute to the pooling of resources.If the fund-to-fund federal financial transfers occurred according to previously established apportionment criteria, already determined by Law, and by means of a maximum of 16 budget schedules, already defined by the MH, undoubtedly the execution of the resources received by the subnational entities would be wider, faster, effective, efficient, and useful, with greater adherence to meet local demands and with much lower pooling levels than the current ones.

Collaborations
DR Faleiros and BLS Pereira: Study design and governance; Write-up and ongoing critical review of the article; Materials/analysis tools; Ongoing study review and feedback regarding design, data collection, analysis and critical review of the manuscript; All authors had full access to all of the data and take responsibility for the integrity of the data and the accuracy of the data analysis.
Abbreviations: C. Alloc: Current Allocation; Repres: Representativeness of the modality value compared to the total value; Comm.: Committed Amount; Paid: Amount paid Source: Integrated Planning and Budget System -SIOP.Access: Jan/2021.

Chart 1 .
Materials and Methods: Data Source.

Table 1 .
Application modality of the resources of the budgetary unit National Health Fund, destined to confront the public health emergency -COVID-19 (SUS/2019-2020).

Table 2 .
Transfers from the Ministry of Health to subnational entities in the context of the Public Health Emergency of National Importance arising from Covid-19 (SUS/2020).
Abbreviations: PHC -Primary Health Care; CEO -Dental Specialty Centers; eAP -Primary Care Team; eAPP -Prison Primary Care Team; eCR -Street Office team; eSB -Oral Health Team; eSFR -Riverside Family Health; HPP -Small Hospitals; HDI -Municipal Human Development Index; MAC -Medium and High Complexity Care; PAB -Primary Care Expenditure Floor; NIP -National Immunization Program; RAPS -Psychosocial Care Network; SVO -Death Verification Services; BHU -Basic Health Unity; UBSF -Basic River Health Unit; FHU -Family Health Unities; ICU -Intensive Care Unit.N/I -Not informed.Source: National Health Fund/Ministry of Health.Access: Jan/2021.

Table 2 .
Transfers from the Ministry of Health to subnational entities in the context of the Public Health Emergency of National Importance arising from Covid-19 (SUS/2020).