Federal spending on social policies and the social determinants of health: where are we going?

Ensuring the highest possible level of health for the population depends on public investments in social policies, since health is determined by factors related to the conditions in which people live and work, the so-called Social Determinants of Health (SDH). Thus, this article aims to quantify Brazils federal spending on sectoral social policies in the last decade in order to analyze its recent trajectory in a context of economic crisis and fiscal austerity, and to discuss the risk of worsening the health status of the population. To this end, financial data as from the federal executive branch retrieved from Siga Brasil system were used. The results show a reduction in spending on seven of the ten policies analyzed between 2013 and 2019. There was an increase in spending for policies linked to social security, which are related to constitutionally registered rights, with a tradition of enforcing compliance through the justice system. These findings reveal that, despite the increase in expenditure for these policies, other important policies carried out within SDH were de-financed, making it difficult to achieve progress in the health condition of the population, while putting them at risk of setback.


Introduction
Brazil has experienced relevant social advances since the Federal Constitution of 1988 (CF 1988) by means of the social policy, although, under that policy, improvements have been carried out differently among sectoral policies 1 and characterized by contradiction. Such contradiction exemplifies the need for the State to expand the provision of public health and education services so to comply with constitutionally established rights. However, concomitantly to that expansion, the State emboldens the private supply of services also by means of health tax waiver, as by public subsidy to students enrolled in universities, fomenting the profitability of entrepreneurs from both sectors 2 .
Although the contradiction was and remains present in social policy, advances are undeniable and may risk to be threatened. Since the beginning of the last decade, the country has been living a turbulent period in the economic and political fields, advancing potential impacts on the social area by also the unfeasibility of advancements as the causing of setbacks in that field. Gross Domestic Product (GDP) decreased by 3.15% in 2015 and by 2.93% in 2016. During that period, the economic recession served as fuel for the political crisis 3 , which lasts until today. On the explanation of responding to the economic crisis, drastic fiscal austerity measures have been adopted, having as their maximum example, at least to date, the enactment of Constitutional Amendment (EC) No. 95 in 2016, which 'freezes' the Union's primary expenditures until 2036 4 .
The risks resulting from EC 95 for the granting of the right to health 5 and social assistance 6 were alerted still in the course of EC proceedings in the National Congress. It was also warned about its potential to damage the economy and public policies in general 7 . Nevertheless, the amendment passed, making it clear that the objective behind the measure was not the adjustment of public accounts, which would require a sooner inception, but rather to unlink health and education expenses from revenues and reduce the size of the State 8, 9 .
Although EC 95 is the strictest fiscal adjustment measure adopted in Brazil and in the world 10 , there is the possibility that more radical actions be implemented, worsening the financing of social policies in the country. More recently, the federal government proposed the Plan Mais Brasil, submitted to the National Congress by senators from the government' base in the form of three Proposals for Amendment to the Constitution (PEC), with the purpose of unlinking and de-indexing expenses and releasing the Federation entities from its enforcement. The Plan is comprised of PEC 186 (Emergency), PEC 187 (Public Funds) and PEC 188 (Federative Pact) 11 .
Those proposals intensify the implementation of the ongoing fiscal austerity policy, less on revenue and more on public spending, particularly impacting social spending. Under the understanding of the Federal Prosecutor's Office for Citizen's Rights at the Public Prosecution Ministry, they are unconstitutional proposals, incompatible with the CF 1988, because they advocate the control of public debt over the fundamental rights and guarantees provided for therein 12 . However, even if those PEC clearly cause setbacks in the social field, they can pass, as occurred with EC 95, which is blatantly unconstitutional for de-funding policies aimed at ensuring social rights 13 .
Sectoral social policies are elements of social policy and consist in programs and actions of the State so to ensure the supply of goods and services, transfer of income, and market regulation, whose main objectives are both to protect the citizen against the risks of becoming a life of dependence and vulnerability and to create opportunities 1,14 . They are relevant to guarantee the highest possible level of physical and mental health to each individual, something internationally recognized as a human right 15 . This is due to fact that the health of people is determined by factors related to the conditions in which they live and work, the so-called Social Determinants of Health (SDH) 16 .
The CF 1988 defines that the right to health will be granted by means of economic and social policies 17 , while a federal law recognizes as determinants and conditioning factors of health: food, housing, basic sanitation, environment, work, income, education, physical activity, transportation, leisure and access to essential goods and services 18 .
Thus, considering that the population health depends not only on public investments for the supply of health goods and services but also on investments in other sectors of social policy, such as social assistance, education, housing, among others, the object of this article is to quantify Brazil's federal spending on sectoral social policies from 2010 to 2019, so to analyze its late trajectory in a context of economic crisis and fiscal austerity, and to discuss the risk of worsening health conditions of the population.

Material and methods
Studies on the budgetary and financial execution of public administration are grounded on the modern theory that defines public budgeting as a management tool, by which government programs are explained in monetary terms 19 . As the budget estimates the revenues to finance public policies and quantify the spending on these policies, budgeting is an important source of information for the analysis of resource allocation and, consequently, for the examining of government priorities in the enforcement of public policies 20 .
As for the calculation of federal expenditure, the following sectoral social policies were admitted: social assistance, culture, rural development, education, housing, social security, sanitation, health, work and income, and urbanism 1 .
The expenses of each policy were calculated as from the sub-functions linked to each function, and its adjustments, since that structure of expense classification is considered a good estimate of sectoral policy spending. Within the budget, a function is the highest level of aggregation of the public administration performing areas, and, in general, is related to the mission of each body. In turn, the sub-function identifies the basic nature of actions organized around the functions 21 . The Ordinance of the Ministry of Planning No. 42, of April 14, 1999, lists the functions and respective sub-functions 22 .
The expenditure calculation was caried out by means of sub-functions instead of the functions, because, in general, the budget-financial programming of an organism is classified into a single function, while the sub-function is selected as to the governmental action. As the aim is to identify the expenditure on a given policy, regardless of the organism performing the actions, the sub-function was the structure adopted. Still, some adjustments were made to better identify expenses.
For example, function 12, education, was linked to the following sub-functions: 361 -elementary school, 362 -high school, 363 -vocational education, 364 -university education, 365 -childhood education, 366 -education of young people and adults, 367 -special education, and 368 -basic education. When only this structure of expenditure classification is adopted, part of the expenditure would be disregarded since it is recorded as function 28, special charges, subfunction 847 -transfers to basic education, for which the Union supplements the Fund for the Development and Maintenance of Elementary Education and Recognition of the Teaching Profession (Fundeb). Thus, some adjustments were made as for expenses by sub-function, taking into account programs and budget actions. Table 1 shows the relation between sectoral social policies, sub-functions and the adjustments implemented.  *Ipea 1 approaches 'housing and urbanism' as a combined sectorial social policy. In this paper, we chose to separate the two policies to enable the monitoring of housing expenses, given its importance. The financial enforcement data of the Federal Executive Branch were retrieved from Siga Brasil system 23 , carried out by the Federal Senate for the period 2010-2019. That period was chosen because ten years are considered a medium term as for the implementation of public policies, covers more than one government term and because an important economic recession lasted some years, impacting the tax collection. The chosen expenditure enforcing variables were: function, sub-function, program, action and Expense Grouping (GND); the collected enforcing values comprised the expenses paid and the remainders of each financial year. The sum of those values was absorbed in the analysis of expenditure evolution. The scheme of payment is the one adopted to ascertain the primary expenditures defined by EC 95.
Expenses were accounted as per current values so to easy the comparison of the results to those of future studies; and at 2019 prices, for allowing the analysis of the spending evolution within the last decade. Values were deflated by the Extended National Consumer Price Index (IPCA), issued by the Brazilian Institute of Geography and Statistics (IBGE).

Results and comments
Spending on sectoral social policies is presented in Brazil faced severe economic recession in the middle of the 2010 decade forcing the federal government to adopted fiscal austerity measures. Thus, the 2019 expenditure comparison with that of 2013', the year immediately before the beginning of the recession, provides a broader picture of the crisis and austerity effects on federal spending on social policies. The results of that parallel are depicted in graph 1, making clear that only social assistance policies (9.3%), social security (16.5%) and health (16.5%) increased their spending. The remainders experienced a loss of resources, as did culture (-30.2%), rural development (-5.0%), education (-11.1%), housing (-74.6%), sanitation (-53.2%), work and income (-6.1%) and urbanism (-3.0%).  Results show that, among the ten sectoral social policies examined, five underwent a reduction in resources in the last decade. However, the spending variation concerning the year 2013, the year immediately preceding the recent economic recession, and that of 2019' revealed that the number of policies bearing expenditure decreasing rises to seven. Among those enjoying increased expenses during that period are policies related to social assistance, social security and health.
Main expenses within social assistance policy are the Continuous Cash Benefit (BPC) and the Bolsa Família Program (PBF). BPC is addressed both to elderly people receiving a monthly per capita family income of less than a quarter of the minimum wage and to people with disabilities who are unable for independent living and work. The value of the benefit is the minimum wage 24 . PBF is a program of income transfer for families receiving monthly per capita income up to R$89.00 and monthly per capita income between R$89.01 and R$178.00, provided they are responsible for children or adolescents between zero 17 years old 25 .
Spending on social assistance in 2019 was R$8.3 billion higher than in 2013. During that period, PFB expenditure decreased from R$34.4 billion to R$32.5 billion (-5.5%), whilst BPC' increased 31.2%, ranging from R$44.6 billion to R$58.5 billion. Thus, BPC increasing led the broadening of social assistance policy.
PBF expenditures are noncompulsory, that is, the federal government have control over them. However, as BPC margin of control is tighter, since the benefit is provided for in CF 1988 as a right and that access to it has been claimed by means of lawsuits in recent years 26, 27 . The reduction in PBF spending helps explain the increase in the waiting list concerning the benefit granting, whose expansion has been disseminated throughout the media, prompting the Federal Public Prosecution Ministry to question the Ministry of Citizenship on the subject 28 . As a consequence, it may have contributed to the increase in the country extreme poverty, which has reached 4.5 million people since 2014, totaling 13.5 million people living with up to R$145.00 per month in 2019 29 .
Data retrieved from the PBF database, the Family Health Strategy (ESF), the poverty index, and from the possible effects of EC 95 estimated that mortality of children under five years of age will be higher under that amendment than that under current levels of social protection. Almost 20 thousand more avoidable deaths may occur between 2017 and 2030 30 . Additionally, ESF coverage reduction and the cessation of Mais Médicos Program (PMM) anticipate that mortality rate due to conditions susceptible to primary care will be 8.6% higher than that existing under carrying on of ESF coverage and PMM' 31 .
With regard to social security, a social policy of a contributory nature, the control of expenditure growth is also limited. Once the individuals have met the requirements for access to the benefit, following each case rule, the concession may be required by the citizen at any time. Total spending increased by R$99. Another factor that drives spending are the lawsuits to grant benefits 26,27 as for social security and care, as previously mentioned. The General Accounting Office (TCU) ascertained that the expenditure of the National Institute of Social Security (INSS) on pensions, sickness benefits, among other benefits disputed by means of lawsuits, achieved R$92 billion 33 between September 2017 and July 2018.
As for health policy, the linkage of the minimum investment of resources to the GDP nominal variation between 2013 and 2015, the smaller elasticity of health spending 34 , the growth of citizens' lawsuits for access to health technologies 35 , and the federal government effort to pay expenses enrolled in remainders payable in 2018 and 2019 explain the growth in expenses paid (R$17.8 billion) between 2013 and 2019. It is noteworthy that the health expenditure found in this study differs from that accounted as for the calculation of the minimum investment in health, which is spent on Public Health Actions and Services (ASPS).
The expenses listed in this article comprise those incurred by the various organisms of the Federal Executive Branch, among which the expenses on medical assistance for government employer that are not classified as ASPS'. Besides, ASPS expenses are enforced solely by the Ministry of Health and are calculated by the stage of expenditure allotment. Another issue is the comparison between current expenditure made by ASPS under EC 95 validity, and the one that should be enforced if EC 86 were still in force. Compared to the EC 86 ruling, it is observed that the EC 95 rule of investment implies less allocation of resources to the Unified Health System (SUS), that is, R$13.2 billion less in 2019 36 , an outcome predicted and announced when the EC 95 was processed in 2016 5 .
As for policies undergone expenses reduction, it is interesting to observe the case of education, which experienced a decrease in spending between 2013 and 2019 (-11.1%, R$9.2 billion), as follows: vocational education, from R$13.4 billion to R$12.8 billion (-4.9%); basic education, from R$8.1 billion to R$5.6 billion (-30.6%); university education, from R$35.3 billion to R$34.7 billion (-1.8%); and transfers to Fundeb, from R$18.7 to R$16.7 billion (-10.7%). Prior to EC 95 inception, the Union allotted expenditure for Maintenance and Development of Education (MDE) at a level significantly higher than the minimum investment, which is constitutionally mandatory. The amendment became a concern that the federal government investment gets closer to the education floor, implying loss of resources compared to previous years 10 .
Taking for granted the figures presented in this paper, there seems to be a potential risk of this happening, with the aggravating factor that the minimum investment in MDE as from 2018 will be 'frozen' until 2036 by a value corresponding to the 2017 floor value in actual terms. Prior to EC 95 ruling, the minimum investment fluctuated according to tax revenue. It should also be noted the significant loss of resources addressed to basic education, which includes expenses with the acquisition and production of books and teaching materials, school transportation, improvement of school infrastructure, among others. The same resource reduction did not impact health since federal spending in this field has always stayed at the limit of the minimum investment, a characteristic that caused some authors to conclude that health floor investment became the ceiling investment 37 . Thus, the Union cannot significantly reduce health expenditure because it would not comply with CF 1988.
As for sanitation, the fall in expenses achieved R$2.1 billion. Sanitation comprises water supply services, sewage, solid waste handling and urban rainwater drainage. The lack of investment in that policy is accounted as the main cause for the non-universal sanitation in Brazil, and places the country in 112th position in the ranking of sanitation infrastructure 38 . Public investment was already poor and has been reduced in recent years, with no prospect of expenditure increasing under the 'freezing' of the Union's primary expenditure by EC 95.
Concerning the rural development policy, there was a decreasing R$624.1 million between 2013 and 2019. Actions aimed at strengthening family farming suffered a spending decrease from R$385.1 million to R$266.3 million (-30.9%); and those assigned to the acquisition of family farming production decreased from R$713.3 million to R$234.9 million (-67.1%). The expenditure reduction following that policy, concomitantly to the weakening of the organisms responsible for its enforcement, reveals a high risk of discontinuity of programs addressed to rural populations 39 .
As for housing policy, spending on the budget program Moradia Digna (Dignified Housing) in 2019 was R$13.8 billion lower than in 2013 (-74.7%), which is basically the value addressed to Minha Casa, Minha Vida (My House, My Life) Program. Expenses decreased from R$18.4 billion to R$4.7 billion. That situation is worrisome, since the housing deficit in 2015 achieved more than 6.3 million homes. This is the estimate of housing necessary to supply the need of people living in precarious constructions, cohabiting with their families, by lack of option, and living in non-residential accomodations 40 .
Concerning the policy of urbanism, focused on planning, infrastructure and urban public transportation, the volume of resources allocated was already low in 2013 and remained low in 2019 after suffering an additional reduction (-3%).
With regard to capital expenditure (investments) under the effects of the economic crisis and EC 95, an overall avoidance was expected. And that's exactly what happened. The reduction in investment expenses for all sectoral social policies was R$8.2 billion, from R$20.8 billion in 2013 to R$12.7 billion in 2019 (-39.3%). The spending analysis by policy and group of expenditures, that is, cost -personnel expenses and other current expenses -and investment -capital expenses -, and the comparison between the expenditure incurred in 2019 to that of 2013' reveals an interesting situation (graph 2).
As for policies whose total spending increased, i.e., social assistance, social security and health, which are the highest expenditures of the federal government, there was a reduction in investments on pension policy (-99.98%) and health care (-63.3%), and an increase in social assistance (71.9%). The latter experienced an increase in expenditure on regional development and on the Unified Social Assistance System (Suas). Investments on culture and work and income policies increased by 67.7% and 173.0% respectively. As for culture, expenses contributed to the expenses for the preservation of cultural heritage of historical cities, totaling R$117.7 million in 2019 out of the R$164.4 million invested in that policy (71.6%).
Regarding labor and income policy, of the R$103.8 million invested in 2019, R$97.5 million (93.9%) were allocated to the purchase of equipment and to other capital expenditures as for the Ministry of Defense. In 2013, resources invested were mainly addressed to labor, employment and income programs, regional development and solidarity economy (86.4% of capital expenditures). In 2019, investments on those programs accounted for only 4% of the capital expenditure of that policy.
The labor and income policy reveals a limitation of this study that is to measure the expenditure on each policy from the enforcement of public administration by sub-functions, even though some adjustments have been carried out. It seems more appropriate that expenses with the purchase of equipment for the Ministry of Defense had been recorded in the sub-functions linked to function 5 -national defense, rather than in the sub-functions linked to function 11 -work. That choice ends up distorting the information about investments, since they are supposed to have been allocated to programs aimed at generating jobs and income, when, in fact, that was not the case. Anyway, as the classification of expenses by subfunction, in general, undergoes little changes from one year to another, this methodology remains a good estimate of the expenditure with public policies, despite that limitation.
Another issue to be regarded in future studies is the inequity on spending within each social policy. In this work, the federal government's expenditures on goods, services and benefits paid to their civil and military employees were accounted in the expenditure of each policy, in case they were classified in the respective sub-functions. It is a social expenditure, although addressed to a restricted portion of persons. One example is the expenditure on medical care for the federal government employees, which responded for R$5.2 billion in the total of R$125.9 billion accounted for the sectoral health policy.

Final remarks
As the results of this study reveal, significant social policies faced resource reduction in recent years as consequence of the economic recession and fiscal austerity policy, whose implementation began in 2015 and was intensified as from 2016. As social inequalities are huge in Brazil, the sharp reduction of federal funding for such policies may impact significantly the social protection and promotion in the country. The reason relies on the fact that the Union owns the highest fiscal capacity, while states and municipalities can hardly allocate the amount of resources that ceased to be invested by the federal government, especially under the current crisis in their finances. The recent economic crisis and the implementation of fiscal austerity measures caused negative effects to Brazil. In practice, it is to note that the growing expenditures are linked to constitutional rights within the scope of social security, and undergo the tradition of compliance enforceability by means of the Justice system: BPC in social assistance, social security benefits and access to health goods and services. As for health, factors other than the mandatory minimum expenditure and lawsuits put pressure on expenses 34 . Expenses with goods, actions and services related to other social policies decreased within the period analyzed, even though social rights linked to those policies are also inscribed in CF 1988.
Literature review studies evince that the choice for fiscal austerity policy at a time of economic crisis can impose disastrous consequences on the population health 41, 42 . That combination hinders the universal access to health services and threats the progress achieved in this field 43, 44 . Additionally, it reduces the country's likelihood of achieving also the noncommunicable disease control goals 45 as those concerning the Sustainable Development Goals -Agenda 2030 46 .
In a way to guarantee the constitutional right to health in Brazil, ensuring population's access to health goods and services is not enough. Policies acting over SDH must be implemented. World Health Organization report suggests that key policies able to focus on SDH and health inequities are related to improving: i) early childhood development -early childhood education, health care, protection against poverty, support for parents working outside home, and gender equality stimulation; (ii) access to fair employment and decent work -creating employment opportunities in disadvantaged areas, implementing good quality active labor market programs and improving working conditions; iii) social protection by means of income transferring -increasing social investment on income transfer programs, improving the effectiveness of programs, their coordination and management, so to make them more efficient and simpler for beneficiaries; and iv) the living environment -protecting citizens from illegal eviction, increasing the possibility of housing affordance and implementing effective urban planning to promote cleaner, more energy-efficient and healthier transportation and housing 47 .
The recent financing framework for sectoral social policies in Brazil indicates greater difficulties in achieving progress for the population's living and working conditions, and, more than that, anticipates a high risk of regression in those fields, negatively impacting the health condition of Brazilians.
As from the adoption of the necessary measures of social distancing to cope with Covid-19 pandemic, the economy in the world and in Brazil tends to worsen. Governments in several countries have stepped up the adoption of measures to stimulate the economy and preserve worker income. Unfortunately, however, what is most seen by government members in Brazil are proposals for more reform, so to reduce the size of the State, to reduce wages of workers in public and private sectors, and tighten austerity control over the primary deficit. If this trend does not change, we are moving rapidly towards a future of more social inequalities and greater health inequities.