# Abstract

This study aimed to portray the effects of the Brazilian financial crisis, and especially in Rio de Janeiro in the 2013-18 period. We analyzed revenues, expenditure, service provision, and health performance indicators from free access and restricted data. We adopted the Giddens’ Structuration Theory. Revenues and expenditures shrunk, and this reduction was higher for investments and unlinked revenues. The provision of services declined, resulting in decreased primary care coverage, outpatient production, total hospital admissions, number of beds, doctors, community health workers, surgeries performed, and hospital occupancy rate. An increase was observed in waiting times for ambulances, exams and outpatient visits, as well as the number of pending requests in regulation. Health and performance indicators remained mostly unchanged, within previous parameters, corroborating the care capacity of PHC, despite financial and structural contingencies imposed by austerity. The current situation threatens the right to health, and governmental response, such as unlinking revenues, point to an increased risk of this occurrence.

Key words
Public Policy; Primary Health Care; Healthcare; Healthcare Financing; Service Indicators

# Introduction

Although health is part of social security in Brazil, assuming the condition of a universal right provided for in the 1988 Constitution, the country is at odds with others with universal systems, especially concerning government health expenditure and provision of services11 Noronha JC, Noronha GS, Pereira TR, Costa AM. Notas sobre o futuro do SUS: breve exame de caminhos e descaminhos trilhados em um horizonte de incertezas e desalentos. Ciên Saude Colet 2018; 23(6):2051-2060..

Health policy analysts agree that the biggest challenges of the Unified Health System (SUS) are of a political nature. The guarantee of public subsystem financing, the redefinition of the public-private articulation, which has favored the market through tax incentives and subsidies, and the reduction of income, power and health inequalities, are issues to be overcome22 Ocké-Reis CO. Sustentabilidade do SUS e renúncia de arrecadação fiscal em saúde. Ciên Saude Colet 2018; 23(6):2035-2042.

3 Pinto LF, Giovanella L. Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB) Ciên Saude Colet 2018; 23(6):1903-1913.

4 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Ciên Saude Colet 2018; 23(6):1723-1728.
-55 Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Ciên Saude Colet 2018; 23(6):1751-1762.. While SUS expenses increased by 0.5% in real values from 2012 to 2016, gross revenue from health plans and insurance in the same period grew by 27.0%11 Noronha JC, Noronha GS, Pereira TR, Costa AM. Notas sobre o futuro do SUS: breve exame de caminhos e descaminhos trilhados em um horizonte de incertezas e desalentos. Ciên Saude Colet 2018; 23(6):2051-2060..

However, health equipment and services expanded and diversified considerably over the 30 years of its establishment, and the number of doctors, nurses, and dentists working in the system55 Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Ciên Saude Colet 2018; 23(6):1751-1762. increased.

Concerning Brazilian PHC, advances include expanding supply, facilitating access, greater availability of regular demand services with positive impacts on the health of the population66 Bousquat A, Giovanella L, Fausto MCR, Fusaro ER, Mendonça MHM, Gagno J, Viana ALD'A. Structural typology of Brazilian primary healthcare units: the 5 Rs. Cad Saude Publica 2017; 33(8):e00037316.. Although it is not possible to isolate the effects of primary care, it is entirely plausible that the result of the 45% reduction in the standardized rates of hospitalization due to PHC-Sensitive Conditions (ICSAPS) from 2001 to 2016 is linked to the advance of the Family Health Strategy (ESF) coverage in Brazil in synergy with social policies implemented by the federal management, which provided significant poverty reduction with proven health effects33 Pinto LF, Giovanella L. Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB) Ciên Saude Colet 2018; 23(6):1903-1913.,77 Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study. PLoS Med 2018; 5(5):e1002570.. The national coverage of the ESF hiked from 4% in 1998 to 74% in 2018, incorporating more than 147 million people into the health system.

Although there is room for expansion and improvement of health actions and services, the SUS faces new challenges in the current context of a financial crisis that imposes budgetary constraints on social spending. The difficulties increased in 2016, after the enactment of Constitutional Amendment (EC) 95/201688 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 União; 2016., which imposes an austere agenda on the Social Security system, with a substantial impact on health. The new tax regime approved by most House and Senate parliamentarians freezes federal primary spending for the next 20 years, severely affecting established social rights. EC 95 is estimated to decrease the proportion of federal health spending from 1.8% to 1.45% or 1.2% or 0.99%, depending on the GDP growth rate11 Noronha JC, Noronha GS, Pereira TR, Costa AM. Notas sobre o futuro do SUS: breve exame de caminhos e descaminhos trilhados em um horizonte de incertezas e desalentos. Ciên Saude Colet 2018; 23(6):2051-2060.. Brazilian fiscal austerity and the consequent prospect of reduced investment in social programs (Bolsa Família Program and the ESF) may affect child mortality, as poverty is one of the most critical social determinants of child health. Austerity will also contribute to the death of children due to preventable diseases and increased child hospitalization77 Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study. PLoS Med 2018; 5(5):e1002570..

Given this scenario of scaled-up economic and social constraints, it is timely to analyze their effects on the various regions. The state of Rio de Janeiro has been the epicenter of several crises in the country; it is an oil power state, a recent host of mega-events, such as the 2016 Olympic Games, source of several political scandals, and at the same time generating innovations, especially in health99 Soranz D, Pinto LF, Penna GO. Eixos e a Reforma dos Cuidados em Atenção Primária em Saúde (RCAPS) na cidade do Rio de Janeiro, Brasil. Ciên Saude Colet 2016; 21(5):1327-1338..

Specifically, concerning Rio de Janeiro, we can observe that the crisis scenario has generated adverse effects on the management, organization, and access to health services. The consequences are worse off in Primary Health Care (PHC), whose structuring was late compared to other major capitals. The PHC gained centrality in the government agenda in 2009 with the project entitled Saúde Presente, through the partnership with Social Organizations in the management and provision of services. Besides expanding family health coverage to 70% by the end of 2016, the project invested in the training of SUS workforce, with the creation of Family and Community Medicine and Nursing in Family Health residency programs, in the improvement of management skills and tools, such as the decentralization of budget resources, and in the design of the financial incentive system with performance indicators of ESF teams99 Soranz D, Pinto LF, Penna GO. Eixos e a Reforma dos Cuidados em Atenção Primária em Saúde (RCAPS) na cidade do Rio de Janeiro, Brasil. Ciên Saude Colet 2016; 21(5):1327-1338..

This study explored the effects of the financial crisis on revenues and expenditures, production, and performance of health services in Rio de Janeiro from 2013 to 2018. The results are expected to support the formulation of new ways to ensure better health endpoints for the population.

# Methods

This is an exploratory, descriptive study with emphasis on PHC. The trend of revenues, expenses, service provision parameters, and performance and health indicators were examined from documentary analysis and simple statistical analysis of secondary data of open and restricted access. The analysis of health-related revenues and expenses in Rio de Janeiro covered the 2013-2018 period, due to the availability of data and the relevance of analyzing the trend of parameters in this period. The period of analysis of data related to the provision of health services and indicators was from 2016 to 2018. A time selection was started in 2016 due to the greater availability of all analyzed parameters and because it was the year of publication of EC 95/2016, and 2018 is the last year with full data available for comparison purposes.

Data collection was structured in five realms for the health system: financing, access, human resources, regulation and management, and care indicators. The parameters were chosen considering three aspects: the ability to measure the performance of the health system and its costs, availability in the official information systems or at the Municipal Health Secretariat of Rio de Janeiro, and comparison with similar data.

Financing data for analysis of revenues (health revenues from the municipality; Federal Government transfers of SUS funds by financing block; revenues from taxes and constitutional and legal health-related transfers) and expenditure (expenditure from municipal sources with Health Actions and Public Services (ASPS)), by type (investment and costing) were extracted from the Public Health Budget Information System (SIOPS), accessed from http://siops.datasus.gov.br (consultation per year, last two months of the year). Data were deflated using the Extended National Consumer Price Index (IPCA), converted to December 2018 values. The expenditure stage considered in the consultation was settlement since the service was provided in that fiscal year in this stage of budget implementation. This concept has been recommended in health account manuals1010 Vieira FS, Piola SF. Restos a pagar de despesas com ações e serviços públicos de saúde da União. Brasília: Ipea; 2016 (Texto para Discussão nº 2225).. The municipality’s Official Gazette was consulted to verify appointments in management positions during the study period.

The effects of the crisis were classified into four realms: access; human resources; regulation and management; and financing. The variables of access, human resources, and regulation and management realms were: e-Manager, Outpatient Information System (SIA) and Hospital Information System (SIH), National Health Facilities Registry System (SCNES), National Regulation System (SISREG), Official Gazette of Rio de Janeiro and Management Contracts. Health and performance indicators were extracted from the Live Births Information System (SINASC), National System of the National Immunization Program (SI-PNI), Mortality Information System (SIM), and Notifiable Diseases Information System (SINAN).

Although the performance analysis included indicators related to the health care network as a whole, including PHC, regulation, and hospital care, the emphasis was given to the analysis of PHC indicators, since significant financial reductions and, consequently, the most substantial contraction of services provided were applied at this level of care.

The two Municipal Health Plans (MHP) that encompassed the studied period were analyzed. For comparison purposes, the following criteria shown in the MHPs were observed: primary care; urgent care; mental health; pharmaceutical care; goal of indicators; and guidelines.

The analysis was based on Giddens’ Structural Theory1111 Giddens A. A constituição da sociedade. São Paulo: Martins Fontes; 2003., in which the structural properties of the social system are a means and result of social practices. The structure consists of rules and resources. The rules are normative regarding rights and obligations, and semantic regarding the qualitative and procedural meaning of practices. Resources are allocative for material goods and authoritative regarding power. The institutional analysis, which examines structural properties through the analysis of the way rules (legislation, protocols) and resources (human, financial, physical structure) influence social actions1111 Giddens A. A constituição da sociedade. São Paulo: Martins Fontes; 2003., was used in this study. A synthesis of data retrieved from the different sources was elaborated from the Giddens Structuring Theory, considering the structural realms.

The Research Ethics Committee of the Municipal Health Secretariat approved this research.

# Results and discussion

At this stage, financing data are presented, followed by a balance of the effects of the financial crisis on the realms of management and provision of health services in Rio de Janeiro. Next, the care indicators are shown in the studied section. Finally, we show a commented comparison of the Municipal Health Plans in force in the period and an analysis of the institutional context in the light of the Structural Theory framework.

Table 1 shows that the health revenues of the municipality decreased continuously from 2013 to 2017, reaching an accumulated decline of 16.3%, showing a 4.4% recovery only in 2018, compared to 2017.

Table 1
Income and Expenses related to Public Health Actions and Services in Rio de Janeiro Municipality, 2013-20181 (in thousands of reais).

Also, Federal Government SUS resource transfers fluctuated with falls in 2014, 2015 and 2017 of 4%, 16%, and 8%, respectively. The Federal Government transfers related to PHC and High and Medium Complexity fell in 2014, 2015 and 2017, at a rate of 2%, 9% and 5% for PHC and 8%, 16% and 9% for High and Medium Complexity, respectively. We can see a sharp shrinkage of funds when looking at the item “other transfers of SUS funds”, from almost 107 million reais in 2013 to just under 19 million in 2017, representing an 82% decline in four years. In 2018, these transfers began to increase, signaling a partial recovery, but without returning to 2013-14 levels.

Revenues from taxes and health-related constitutional and legal transfers have continued to fall in all three spheres until 2017, except for 2016 at the federal level. In 2018, these revenues resumed their upward trend, without recovering from 2013-14 levels.

Own resources invested in Health Actions and Public Services (ASPS) exceeded the mandatory 15% for the municipal level in the entire period, reaching 25.7% in 2017. However, after a fluctuation with increases of 7% in the 2013-14 period, and 22% in the 2015-16 period, significant reductions of about 800 million in the accumulated total were observed in the last two years. Although there was no loss of revenue, the municipality reduced the percentage of its health resources in 2018, down from 25.7% to 21.1%. Investment expenses, which increased significantly by 50%, 237% and 71% in 2014, 2015 and 2016, respectively, fell sharply in 2017 from just over 154 million reais for 2016 to 2.4 million in 2017, a reduction of 98%. In 2018, this expense matched the 2014 level with R29.6 million invested. Costing expenditure that suffers reductions between 2013 and 2017, except for 2016, fall another 424 million in 2018. The data shown in Box 1 seek to provide a broad overview of the impact of the fiscal crisis on the health sector in the city of Rio de Janeiro. In the Access realm, we observed that although the population coverage by PHC between 2016 and 2017 still showed an increase of 3.3%, in the 2017-2018 period, it ends up falling 8.4%. Considering that an ESF coverage of more than 70%, if sustained for four years, can reduce child mortality, which in the case of Rio de Janeiro has already reached a reduction of 22%1212 Aquino R, Oliveira NF, Barreto ML. Impact of the Family Health Program on Infant Mortality in Brazilian Municipalities. Am J Public Health 2009; 99(1):87-93., the fall of ESF coverage to a level less than 70% was a setback. Oral Health coverage suffered the most significant impact, with systematic reductions of 4.5% and 11.5% in the period observed. Total outpatient production, which affects all points of care, fell by 6.8% in the 2016-17 period, with a partial recovery of 3.7% in the 2017-18 period. Total hospitalizations, a parameter that reflects the production volume of hospital care, hiked 6% in 2016-17; however, it decreased by 5.2% in 2017-18. The Human Resources realm evidenced a systematic decline in the number of doctors, both those working in PHC and involved with high and medium complexity care. The contingent of Community Health Workers (ACS) also shrunk. In the 2016-2017 period, reductions were less intense, with a decrease of 1.2%, 1.8% and 2.4% in the number of PHC doctors, non-PHC doctors, and ACS, respectively. However, the reductions were 11.1%, 9.4%, and 10.4%, respectively, between 2017 and 2018. The provision and settlement of doctors in socially deprived areas affect especially PHC, where only 23.5% of Brazilian doctors work1313 Fontes LFC, Conceição OC, Jacinto PA. Evaluating the impact of physicians' provision on primary healthcare: Evidence from Brazil's More Doctors Program. Health Econ 2018; 27(8):1284-1299.. In 2012, Rio de Janeiro started to invest heavily in the qualification and fixation of family doctors through the various family and community health residency programs. The threats of team downsizing that began in 2018, generating strikes in Rio de Janeiro’s PHC, generated insecurity for the successful project of training of medical specialists for the ESF, reducing the demand and filling of vacancies of the SMS Rio Family Medicine Residency Program. Even in a country whose health care system is not universal and PHC is not a care regulator, such as in the U.S., recent studies have shown an association between increased numbers of primary care physicians and reduced mortality from cardiovascular disease, cancer, and respiratory disease, and increased life expectancy1414 Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, Phillips RS. Association of Primary Care Physician Supply with Population Mortality in the United States, 2005-2015 JAMA Intern Med 2019; 179(4):506-514.. The falling number of ACS shows an alignment with the 2017 PNAB, which provides fewer professionals per team, allowing the local manager to cut jobs to reduce costs. A systematic review on the performance of community workers in low- and middle-income countries showed the increased quality of interventions, such as behavioral changes in patients, better use of services, adherence to protocols and treatments, and technical competence of the agents1515 Ballard M, Montgomery P. Systematic review of interventions for improving the performance of community health workers in low-income and middle-income countries. BMJ Open 2017; 7:e014216.. A systematic review of Brazilian studies has shown that ACS carry out beneficial interventions in various fields, especially in maternal and childcare. Several factors explain the potential benefit of ACS: as they are residents, they establish strong commitment and trust with the population they serve; they know local resources, favoring social mobilization; and are adept at producing cultural skills, a crucial attribute for PHC1616 Giugliani C, Harzbeim E, Duncan MS, Duncan BB. Effectiveness of Community Health Workers in Brazil. A Systematic Review. J Ambulatory Care Manage 2011; 34(4):326-338.. In a financial crisis scenario, the contract-based management model with a social organization is more susceptible to adjustments and contingency due to the flexibility of the contracts, than linked municipal expenses, such as the statutory civil servant’s payroll, and may aggravate budgetary issues as a whole, especially the provision of health professionals. In the Regulation and Management realm, the emergency response time of ambulances in PHC increased significantly over the entire period studied, increasing by 48.4% between 2016 and 2017, and subsequently by 60.2% between 2017 and 2018. This increase is of concern because of the potential damage to the patient’s clinical condition and survival. Municipal beds registered in SCNES decreased by 3.6% between 2016 and 2017, and by 5.8% between 2017 and 2018. The supply of beds to the regulatory system fell by 18.4% in the 2016-17 period, and 15.8% in the 2017-18 period. This scenario of lower bed availability for the regulatory system exacerbates the difficulty of access to the hospital bed in the municipal Urgent Care Network1717 Konder MT, O'Dwyer G. As Unidade de Pronto Atendimento como unidades de internação: fenômenos do fluxo assistencial na rede de urgências. Physis Revista de Saude Coletiva 2019; 29(2):e 290203.. Vacancies for exams and visits with specialists decreased by 9.9% in the 2016-17 period and by 5.6% in the 2017-18 period. The monthly average of pending requests in the regulatory system increased by 58% between 2017 and 2018. Chart 1 Effects of the health crisis in the city of Rio de Janeiro, from 2016 to 2018. The occupancy rate of municipal hospital units fell by 4.6% between 2017 and 2018. The surgeries performed decreased by 10.3% in the 2016-17 period, and by 7.0% in the 2017-18 period, totaling 16.5% for the period. The occupancy rate of municipal hospitals remains outside the ideal range recommended by the international literature, between 75 and 85%1818 National Institute for Health and Care Excellence (NICE). Chapter 39: Bed occupancy. In: Emergency and acute medical care in over 16s: service delivery and organization [livro na Internet]. 2018 Mar (NICE Guideline 94). [acessado 2019 Mar 19]. Disponível em: https://www.nice.org.uk/guidance/ng94/evidence https://www.nice.org.uk/guidance/ng94/ev... , with a downward trend between 2017 and 2018. The lower surgical production in municipal units will have repercussions on the current long elective surgery waiting lists. Fewer supply of exams and visits with specialists combined with the increased monthly mean of pending requests for exams and visits in the regulatory system reflect a restricted supply, with ensuing reduced access. Regarding drug dispensation in PHC, the mean percentage of essential drugs dispensed whose stock was cleared arrived at 27.5%, 43.2% and 25.5% in 2016, 2017 and 2018, respectively. In 2016, the number of drugs with zero monthly stock ranged from 13 to 94, out of 175. In 2017, it ranged from 9 to 125, and from 26 to 63 in 2018. Concerning health and performance indicators in PHC (Box 2), favorable results were maintained, as in ICSAPS, in the proportion of HIV-positive users with undetectable viral load and the cure rate of new pulmonary tuberculosis cases with laboratory confirmation. The proportion of ICSAPS is one of the results that undeniably illustrates the benefit of PHC investment in the municipality in recent years, which has evidenced a lower hospitalization rate, particularly for cardiovascular disease and asthma, including vaccine-preventable diseases, cardiovascular disease, diabetes, nutritional deficiencies, and chronic lung diseases1919 Pimenta L, Dutra VGP, Castro ALB, Guimarães RM. Analysis of conditions sensitive to primary care in a successful experience of primary healthcare expansion in Brazil, 1998-2015. Public Health 2018; 162:32-40.. The result remains stable since the decline presented after the first years of the implementation of the ESF in Rio de Janeiro1919 Pimenta L, Dutra VGP, Castro ALB, Guimarães RM. Analysis of conditions sensitive to primary care in a successful experience of primary healthcare expansion in Brazil, 1998-2015. Public Health 2018; 162:32-40., remaining below the Brazilian average. Concerning new cases of congenital syphilis in children under one year, a reduction of 488 cases was recorded in the 2016-18 period. In the field of infectious diseases, the cure rate of pulmonary tuberculosis, a challenge faced by Rio de Janeiro for decades, increased in 2018. The increase in the PHC service portfolio, which has incorporated the management of most cases of people living with HIV in recent years, shows good results in the control of the disease, with a tendency to increase the proportion of users with undetectable viral load. PHC services were responsible for the insertion of 10,242 intrauterine devices (IUDs) in the three-year period evaluated. Providing long-term contraceptive methods, such as the IUD, is a strategic action for reproductive planning, as it has the best birth control results, with high adherence and low complication and failure rates. When targeted at the group of women at the highest reproductive risk, it has the potential to reduce morbidity and mortality directly associated with pregnancy. Also related to the puerperal pregnancy cycle and its care in PHC, improved indicators related to the incidence of congenital syphilis and pregnancy in adolescents were recorded. Other indicators show a still unsatisfactory performance in the period considered, as in the case of the proportion of pregnant women with six or more prenatal visits and pentavalent vaccination coverage, with a steeper fall from 2017. The reason for collecting cervical cytopathological exams also persists to a very low and falling proportion. For the indicator of vaccination coverage, which shows a significant decrease in 2018, a measurement bias resulting from the change of information system recommended by the Ministry of Health is observed. In that year, the municipality of Rio de Janeiro adhered to the National Immunization Program Information System (SI-PNI), and registration in this new system is responsible for the significant drop in the value of immunization coverage recorded. Parameters such as the coverage of cervical cytopathological exams and the proportion of people with diabetes with adequate metabolic control, strategic actions of PHC services, both underperforming, indicate the need for step-up and qualification of care actions at these points of care. These results do not allow us to evaluate the cost-effectiveness of the investment in PHC unfavorably, but only realize that it must be maintained, monitoring its quality and effectiveness, in order to achieve the expected performance. These are hard-to-reach goals that require sustained long-term public policies, with unsatisfactory results even in rich countries with well-structured health systems and strong PHC2020 Lipska KJ, Yao X, Herrin J, McCoy RG, Ross JS, Steinman MA, Inzucchi SE, Gill TM, Krumholz HM, Shah ND. Trends in Drug Utilization, Glycemic Control, and Hypoglycemia. Diabetes Care 2017; 40(4):468-475.. Outcome indicators, such as child and maternal mortality, have often been used as an argument to minimize the impact of ESF expansion and to justify PHC reform in Rio de Janeiro, as they have not fallen significantly. These indicators, however, are multifactorial, and are significantly influenced by social determinants and the performance of other points in the network, and take more time to reflect changes implemented in health systems2121 Wheathey L. Factors affecting child mortality [Tese]. Chattanooga: University of Tennessee; 2015.. Chart 2 Selected PHC care indicators in the municipality of Rio de Janeiro, 2016-2018. Box 3 shows a commented comparison of the 2014-2017 and 2018-2021 Municipal Health Plans (MHP) periods. We opted for the analysis MHPs considering that they represent the intentionality of the government agreed with the Municipal Health Council, giving visibility to the point of dialogue of the manager with social control. Two MHPs encompassed the 2016-2018 period and had two different party administrations. The main differences identified were found in the proposed PHC and urgent care. As analyzed in the Box 3, the background included a promise of expanded ESF and NASF. Concerning urgencies, the focus shifts from UPA to hospitals. Changes were observed in the organization chart planning, with the creation of new under-secretariats in both governments. In the foreground, guidelines were more operational and did not address funding and scientific and technological development. In the background, noteworthy are the PHC guidelines and discrete proposal for expansion. The other guidelines are more conceptual than operational. The proposed PHC of the 2018-2021 Municipal Health Plan was not preferred, considering that 2018 is the onset of the validity of the Plan. The analysis of health and performance indicators is consistent with the speech of Mayor Crivella in the opening speech of the 3rd Session of the 10th Legislature, Rio de Janeiro, February 15, 2019. By 2019, SMS has programmed adjustments to its planning to balance the proposed budget. This will meet the challenge of maintaining a large and complex Hospital Network, redesigning Primary Care coverage, further qualifying care, and streamlining costs. What has been called “redesigning Primary Care coverage” has resulted in the suppression of family health, oral health, and NASF teams. The option of municipal management to decrease health revenues followed the federal trend, but it was an option of management that even contradicted the Municipal Health Plan, which indicated a slight increase in ESF and NASF coverage. Box 4 shows the Institutional Analysis of Giddens Structuring Theory, based on the rules and resources that underpin the structure, the scenario found, and the resulting actions. According to Giddens1111 Giddens A. A constituição da sociedade. São Paulo: Martins Fontes; 2003., there is no dualism between social object and human action. Social change may or may not occur, depending on how actors use the rules and resources available for their actions. In the case of the administration of Rio de Janeiro, any emancipatory action was constrained by the structural restrictions. Primary good performance in recent years has not been a sufficient condition for a political option to maintain investment despite the crisis. By systematizing the conceptual elements of the Structuring Theory, we found that the circumstances of the municipality’s management actions were supported by different rules and resources that affected health care. However, it is essential to consider that institutional analysis transcends the municipal level action. Chart 3 Highlights of the 2014/2017 and 2018/2021 Municipal Health Plans and comparative analysis. Chart 4 Institutional analysis from Giddens Structuring Theory. Well-implemented social and economic policies improve health and reduce inequalities2222 Friel S, Marmot MG. Action on the Social Determinants of Health and Health Inequities Goes Global. Ann Rev Public Health 2011; 32:225-236.. Austerity and the neoliberal reform landscape in Europe are threatening the sustainability and universality of universal systems2323 Giovanella L. "Austerity" in the English National Health Service: fragmentation and commodification - examples not to follow. Cad Saude Publica 2016; 32(7):e00092716.,2424 Giovanella L, Stegmüller K. The financial crisis and health care systems in Europe: universal care under threat? Trends in health sector reforms in Germany, the United Kingdom, and Spain. Cad Saude Publica 2014; 30(11):2263-2281.. In the national scenario, the EC 95/2016 and the new National Primary Care Policy (PNAB)2525 Brasil. Ministério da Saúde (MS). Portaria nº 2.436 de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica. Diário Oficial da União; 2017. were identified as conditioning factors in the directions adopted in the health policy of the municipality of Rio de Janeiro during the analyzed period. EC 95/2016 is the result of a contested diagnosis of fiscal imbalance, represents what has been understood as a rationalizing economic measure. The freezing of the federal health and education budget may cause an estimated withdrawal of about US 200 billion from the SUS budget2626 Vieira FS, Benevides RPS. Os impactos do novo regime fiscal para o financiamento do Sistema Único de Saúde e para a efetivação do direito à saúde no Brasil [nota técnica na Internet]. Brasília: IPEA; 2016 (Nota Técnica nº 28). [acessado 2017]. Disponível em: http://www.ipea.gov.br/portal/images/stories/PDFs/nota_tecnica/160920_nt_28_disoc.pdf
http://www.ipea.gov.br/portal/images/sto...
over the next 20 years. The latest version of the PNAB puts at risk the advances made by the ESF, such as care universality, integrality, and equality2727 Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saude Debate 2018; 42(116):11-24.. Besides enhancing the lack of care, it enables policy choices that prioritize resources for medium and high complexity over PHC2727 Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saude Debate 2018; 42(116):11-24..

# Final considerations

The financial crisis announced by the municipal manager in Rio de Janeiro is a political and social crisis. Austerity implied a reduction in health system performance and elected to disrupt the centrality of the primary care consolidation agenda with a realignment of emphasis on hospital care.

The representativeness of the municipality before the country increases the risk of a constitutional right to health lability, deteriorating the meaning of the outcomes presented.

Among the study limitations is the restricted time interval of analysis, assuming a setback in the health benefits from the newly implemented ESF if the current divestment persists.

The SUS at risk is an invaluable loss, and the panorama recently experienced in Rio de Janeiro is a threat to a population living with all the social and environmental ills of the large metropolises. The possible proposal to unlink the health budget is an extensive deterioration of the current scenario.

# References

• 1
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• 2
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• 3
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• 5
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• 6
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# Publication Dates

• Publication in this collection
25 Nov 2019
• Date of issue
Dec 2019