Um federalismo não tão cooperativo : conflitos alocativos no financiamento do direito à saúde no Brasil

Abstract

The central objective of this dissertation is to analyze the dilemmas of public health financing in Brazil, discussing to what extent the cooperative federalism outlined in the constitutional text is effective in practice. To this end, the historical and legislative development, as well as the various phases and temporal and regional contexts of Brazilian public health are reviewed throughout this study. The study is based on the evolution of federalism in Brazil and its institutional relations with health policies, considering the organization and action of the State based on the regional, social and economic peculiarities of the country. Conceptually, it articulates classic theoretical elements that characterize federalism, as provided in the Constitution of 1988 and, on the other hand, the disruption of various aspects of the centralizing model, due to the decentralizing character of public policies resulting from the proposed model. Furthermore, it presents the reflections of national federalism in the process of resource allocation of the Unified Health System, besides subsidizing other debates, as is the case of insufficient resources to make the system viable and how this underfinancing affects the efficiency, efficacy, and effectiveness of the Unified Health System. The study is justified by the need to monitor the evolution of federalism in the country, especially because, despite the model adopted, the effective distribution of political authority still suggests strong centralizing traces of the Unitary State, in contrast to the attempt at cooperative action among the federative entities. The fact that the financing of the health system does not consider the socioeconomic inequalities between the federation entities reflects directly on the system's management and, consequently, on the centralized coordination capacity of the Union, demanding the need for reforms in its financing structure, with the objective of guaranteeing the integrity, universality and effectiveness of the system.