Public budget for the health of the black population: a task to be done – Public Health

Clara Marinho Pereira and Julia Rodrigues

The majority of the Brazilian population declares itself black: there are 89.7 million browns and 19.2 million blacks, according to the Continuous National Household Sample Survey (PNAD) of the Brazilian Institute of Geography and Statistics (IBGE) for the 3rd quarter of 2020. However, given the vulnerabilities caused by racism, the impacts of the new coronavirus pandemic in Brazil have been disproportionately greater on the health of the black population for at least four reasons.

First, because the black population had fewer opportunities to isolate themselves. Without public policies to contain the contamination in communities and favelas, the virus quickly spread among the poorest. It is worth remembering that 67% of the residents of Brazilian communities and favelas are black.

Second, because the black population is the majority in the economic segments considered essential for the maintenance of collective life, which is labor-intensive. Data from the 2018 Annual Social Information Report (RAIS) show that, in urban sanitation, 55.4% of the total number of jobs were made up of black people; in security, 52.9%; and in civil construction, 50.2%, among many other services. In everyday life, each black worker is exposed to contact with dozens, even hundreds of people.

Third, because the black population is also the majority in informality. Data from 2019 from the IBGE show that 47.4% of black workers in Brazil are included in the informality, against 34.5% of the white population. With economic activity restricted or affected by the circulation of the virus, the circuits of work and daily earnings were weakened, quickly throwing workers into poverty, misery and hunger; a situation that hinders the isolation and capacity of black people to have an adequate immune response when infected.

Fourth, when contaminated, blacks take longer to access health services. Often unable to miss work, or without money to pay for transportation to the health center, blacks end up delaying the search for medical assistance. When they do, the situation is already aggravated.

Not by chance, blacks die more than whites. According In a study carried out by Instituto Pólis, the standardized mortality rate from the disease for the black population was 172 deaths for every 100,000 inhabitants between March and July 2020 in the city of São Paulo – the most populous city in the country. The number is 60% higher than the standardized mortality rate for the city’s white population, which stood at 115 deaths for every 100,000 inhabitants.

In a more recent nationwide study, dated September 2021, researchers from the Solidarity Research Network show, based on the Ministry of Health’s Mortality Information System, that black men die more from Covid-19 than white men, regardless of occupation and even when they are at the top of the labor market. Black women, on the other hand, die more than all other groups (white women, white men and black men) at the base of the labor market, regardless of occupation.

However, vaccination started with little attention to these aspects, moving from the center to the peripheries; from affluent groups to the most vulnerable, which shows, once again, the selective use of evidence to inform public policy. The “evidence” is often mobilized to reinforce previous structures of power, and not to question the best use of their resources.

With Covid-19 still on the horizon, what are the chances of streamlining the health spending debate going forward? Here, the exercise of looking back is proposed, in order to understand future possibilities.

The National Policy for Comprehensive Health of the Black Population, built by civil society in partnership with the federal government, establishes a set of guidelines for public health services to accept the specificities of the black population in their offer, recognizing racism as a social determinant health conditions, that is, how racism impacts the occurrence of health problems and amplifies its risk factors.

Despite the immense efforts made since the mid-1990s to build this framework for public intervention, the Brazilian State has not been diligent in giving visibility to its actions in ensuring the well-being of the black population.

One of the main instruments for the State to act is the public budget. It is through it that the government’s priorities are communicated to society and resources are allocated for their implementation.

The federal government’s Multi-Year Plan (PPA) for the 2016-2019 cycle of the federal government had a specific program to tackle racial issues: the 2034 Program – Promoting Racial Equality and Overcoming Racism, which had as one of the goals “Contributing to implementation of the National Policy for Comprehensive Health of the Black Population, including the updating of its Operational Plan” (Target 4MC). In the PPA for the 2020-2023 cycle, there is a complete erasure of the racial issue, with no program, objective or goal addressed to the theme.

From the point of view of the Annual Budget Law (LOA), resources are, in most cases, allocated to generic actions, with the objective of facilitating their disbursement. However, this practice makes social control extremely difficult, as it makes it impossible to monitor expenses based on gender, race, age and sexual orientation. At the Ministry of Health, this phenomenon (generic actions) is recurrent, and it is difficult even to obtain the geographic location of the expenditure.

Until 2020, however, it was possible to see a (minimal) concern of the Ministry with the promotion of equity, due to the existence of the budget action 20YM – Implementation of Policies for the Promotion of Equity in Health, whose objective was to promote the right to health for population segments exposed to health inequities, such as gypsies, LGBT, rural, forest and water populations, black population, homeless population, albino population and SUS managers. In 2016, this action reached R$46.5 million reais, in 2018 it dropped to R$8.8 million and, in 2020, it reached R$28 million.

However, in line with the erasure of racial issues in the PPA 2020-23, the 20YM action is no longer included in the Budget Law Project (PLOA) for the year 2021, forwarded by the Executive Branch. It was transformed into a managerial classification (called the Budget Plan, which can be modified at any time) of action 21CE – Implementation of Primary Health Care Policies. indicating that, in real terms, the amounts decrease each year.

Contradictory, therefore, just when the racial issue in health is exacerbated by data, research findings and tragedies, it is when it is most absent from identification and social control in the budget, as well as from links with medium-term public planning.

Any attempt to ensure the right to health of the majority of the Brazilian population that does not comply with the implementation of the National Policy for Comprehensive Health of the Black Population, combined with the allocation of resources in the budget, will be doomed to the usual questioning: is it really the case that the Brazilian State is committed with equal care in the Unified Health System (SUS)?

Today, unfortunately it seems that the answer is “No”. Doing more of the same will only bring more deaths and iniquities.

Clara Marinho Pereira He is a Master in Economic Development and a United Nations Fellow for the African Decade.

Julia Rodrigues is an Economist, Doctoral Student in Political Science and Budget Consultant.