Descentralização fiscal e financiamento da saúde pública: Uma análise em municípios brasileiros

Abstract

This dissertation examines the relationship between fiscal decentralization and the sustainability of public health financing in Brazilian municipalities, focusing on Uberlândia/MG and comparable cities (Sorocaba, Ribeirão Preto, and Duque de Caxias) from 2019 to 2023. Although Brazil’s fiscal federalism has advanced in decentralizing resources and responsibilities, it still faces significant challenges in ensuring equity and efficiency in health financing, particularly in medium-sized municipalities that serve as regional hubs. The research employed a mixed-methods approach, combining qualitative and quantitative techniques with the analysis of secondary data from official sources. Financial indicators (own-source revenues, constitutional transfers, transfers from the Unified Health System – SUS, and health expenditures) and socioeconomic criteria (per capita GDP and the structure of health services) were analyzed. Findings reveal that Uberlândia stands out for its financial robustness, with above-average investments in both primary care and medium- to high-complexity services, reflecting its role as a regional center. However, dependence on intergovernmental transfers limits its budgetary autonomy and exposes the municipality to vulnerabilities under funding reductions. In contrast, Duque de Caxias faces more severe structural challenges, such as a shortage of hospital beds and reliance on services provided by the state capital, highlighting regional disparities in healthcare access. The analysis also shows that, while municipalities comply with the constitutionally mandated minimum health investment (15% of revenues), the allocated amounts remain insufficient, particularly after Constitutional Amendment No. 95/2016 (Spending Cap), which froze public spending for 20 years. Moreover, the low execution of infrastructure investments and the predominance of current expenditures, such as outsourcing and management partnerships, undermine the long-term sustainability of SUS. In conclusion, fiscal decentralization in Brazil represents progress in democratizing public administration, but its effectiveness depends on fairer resource distribution, stronger federative cooperation, and enhanced local administrative capacity. The study contributes to debates on fiscal policy and public health by highlighting the need to revise transfer criteria and develop strategies to reduce regional inequalities in healthcare access. It aligns with Sustainable Development Goal (SDG) 3 – Good Health and Well-Being by providing empirical evidence to support the design of more equitable and sustainable public policies aimed at ensuring universal, high-quality healthcare.