renda, menor proteção social e maior privação material ... · wal rdy h pw mu l earnh ow tus...

Vivendoemorrendocommenorrenda,menorproteçãosociale

maiorprivaçãomaterial:efeitosdarecessãoeconômica(eseusremédios)sobreasaúde

RômuloPaesdeSousa

Analisandoacrisesemserfisgadoporela

Riscosaosefazeranálisedecontextoemfaceacrisesprofundas• Abordagemjornalística.Ex:fulanização dahistóriaoudominânciadoquem.

• Partidarizaçãodaanáliseou”faláciapartidarista”.Atribuiraogovernoemexercícioproblemasestruturaisqueoantecedem.

• Erronaidentificaçãodosatorespolíticosrelevantes.• Quemsãoosatoresdomomento?Tipologiasalternativas.

1. Políticatradicional,MercadoeLavaJato;2. Mercado,Congresso(maioria)eoposição;3. Direita(maioria),centro-esquerda,judiciário/MPU/PF

Crise ehistória segundo JanetRoitman (2013)• Criseéumsinalonipresenteemtodasasformasdenarrativahojeemdia;

• Elaéevocadacomocategoriaexplicativadocontextoatual;• Textossobreacriseconfiguramumaindústriadaverdade;• Comoacriseéconsideradaobjetodoconhecimento:criseéevocadanaconstruçãodenarrativasparademarcar”momentosdeverdade”oucomoformasdesepensara”história”emsi;

• Elastambémpodemserdefinidoscomoinstânciasnasquais”oreal”sedesnuda,comoquandoumabolhaeconômicaserompe.

DefinindoausteridadeDavidBlane andGrahamWatt(2012)The Oxford Dictionary Online defines

austerity as ‘sternness or severity ofmanner or attitude’ and ‘difficult economicconditions created by governmentmeasures to reduce public expenditure’.What does this mean for general practice,and what are we doing about it?

For Deep End practitioners, working inthe 100 most deprived general practices inScotland, austerity means increasingpressures on time, diversion from clinicalissues, and difficulty in accessing services.For Deep End patients, austerity can meanincreasing stress, despair, and a forcedchoice between heating and eating.

The Deep End report on the impact ofausterity asked Deep End practices toreflect on the effects of austerity measureson patients and on patient care, during1 week in February 2012.1 Most of theissues raised relate to the direct andindirect effects of austerity policies —benefit cuts, service cutbacks, and anincreasing number of patients being takenoff Employment Support Allowance (ESA)or Disability Living Allowance (DLA).

Responses included general commentsand individual case studies. The generalcomments were grouped into four sectionsreflecting the consequences for: patienthealth; general practice; secondary careand support services; and social work andhousing. As accounts of human suffering,the anonymised case studies speak forthemselves. The examples arerecognisable in most general practices,2but in the Deep End they are commonplace.

The report is not ‘research’. It simplydescribes the reported experience of GPsworking on the front line. From conceptionto dissemination, including the collection ofreplies, drafting the report, and sending itto all Deep End practices, production of thereport took only 10 weeks.

In the following 3 weeks, the reporttravelled far and fast. It was sent to everyScottish MP and MSP, and forwarded toIain Duncan Smith MP, Secretary of Statefor Work and Pensions. The report wasdiscussed by the Scottish ParliamentWelfare Reform Committee. Deep End GPswere invited to meet with Margaret CurranMP, Shadow Secretary of State forScotland. The Mental Health Foundationhighlighted the mental health issues in thereport in a letter sent to Chris Grayling MP,Minister of State for Work and Pensions.

There has been media interest.3We were surprised by the speed at which

the report travelled. Although modest insize and scope, the findings clearly struck achord. A formal research project wouldhave taken longer and would have beenmore expensive, without necessarilyachieving the same content. Practitionerexperience provides evidence from parts ofthe service that research tends not toreach. What collated practitionerexperience may lack in research rigour, itgains in immediacy, topicality, andrelevance.

The report gives expression to frontlineGPs acting as witnesses of society. GPs arein a unique position to do this. Unlikepoliticians, GPs consistently poll high levelsof trust in the general population.4 Unlikealmost all other jobs in the public sector,GPs have an independence that allowsthem to speak out. Other groups, such ashead teachers, do this at risk of their jobs.

Should GPs be advocates as well aswitnesses? Sigerist stated:

‘They well know the factors that paralyse alltheir efforts. They are not only scientists butalso responsible citizens, and if they did notraise their voices, who else should?’5

The coalition government plans toredistribute NHS resources according toage rather than deprivation — a formulathat will widen social differences inlongevity.6 It is hard to view this move withanything but cynicism.7 Those who will behardest hit are the least likely to vote. Socialexclusion and political disengagement gohand in hand.8

The Deep End austerity report puts ahuman face on the ‘difficult economicconditions’ experienced by the mostdeprived members of society. It says lessabout the fact that these conditions are‘created by government measures toreduce public expenditure’. There is analternative, however, to the ‘sternness or

severity of manner’ displayed by ourcurrent leaders.

Using data from the InternationalMonetary Fund, Professor Danny Dorlinghas shown that the government’s proposedcuts are more severe than in all othermajor European economies; by 2015, theUK will even rank below the US in terms ofpublic spending as a proportion of GDP.9 Aswe are so often told, there is a choice, butbefore public opinion can be mobilised, itneeds to be informed.

As Julian Tudor Hart argues in hiscommentary of the RCGP OccasionalPaper General Practitioners at the DeepEnd:

‘For the immediate future, this necessarystep has no political leaders … So everythingdepends on leadership at practice level …We command far more public affection andrespect than politicians. We have listedpopulations with names, addresses, andvotes. We already have power. We mustlearn how to use it.’ 10

David Blane,Clinical Academic Fellow, General Practice andPrimary Care, University of Glasgow, Glasgow.

Graham Watt,Professor of General Practice, General Practice andPrimary Care, University of Glasgow, Glasgow.

DOI:10.3399/bjgp12X652463

“Practitioner experience provides evidence from partsof the service that research tends not to reach. Whatcollated practitioner experience may lack in researchrigour, it gains in immediacy, topicality, and relevance.”

374 British Journal of General Practice, July 2012

Altogether now?Austerity at the Deep End

The Review

• Severity of manner or attitude and difficult economicconditions created by government measures toreduce public expenditure.

• Forpractitioners,...austerity means increasingpressures on time,diversion from clinical issues,anddifficulty inaccessing services.Forpatients,austeritycan mean increasing stress,despair,and aforcedchoice between heating and eating.

Multiple authors analyzed the causal nexus betweeninequality and crises [10,11] and even IMF economistshave recently argued for restoring the bargaining powerof low income groups as the most effective strategy toprevent future meltdowns [12]. The logic goes like this:as more money flows to the top social classes in a timeof widening income gaps, the rich escalate their spend-ing and induce the rest of society to follow suit. How-ever, widening income inequalities are also associatedwith stagnation or decline in real value of workers’wages. This forces low- and middle-income workers to

over-borrow money to keep up with the consumeristlifestyle of the rich or to simply cover their materialneeds. It is no coincidence that the 2008 financial col-lapse was preceded by the rapid rise of consumer debt[12]. Times of widening inequalities also provide thewealthy with larger amounts of surplus capital to investin short-term gains and highly speculative financial as-sets. Together with heavy borrowing at the bottom ofthe income distribution, over-investment in short-termprofiteering of the super-rich promotes price distortionsand asset bubbles, especially when governments no

Figure 2 The fall and rise of financial deregulation and share of total income Going to the top 1% in the United States, 1913–2008.

Figure 1 From the Great Depression to the Great Recession: Index of Capital Mobility and Number of Banking Crises in 69Countries, 1900–2010.

De Vogli International Journal for Equity in Health 2014, 13:58 Page 3 of 7http://www.equityhealthj.com/content/13/1/58

Indexof CapitalMobility and Numberof BankingCrisesin69Countries,1900–2010

DE VOGLI, Roberto. The financial crisis, health and health inequities in Europe: the need for regulations, redistribution and social protection. International journal for equity in health, v. 13, n. 1, p. 58, 2014.

AcriseéglobaletemimpactossobreasaúdedaspopulaçõesUmarevisãosobreasexperiênciasdospaísesdoNorte

Oexperimentodagrandeausteridade

0 10 20 30 40 50

Iceland

Greece

Latvia

Croatia

Ireland

Lithuania

Spain

Luxembourg

Italy

Estonia

Mexico

France

Hungary

Cyprus

United States

Slovenia

United Kingdom

Denmark

Portugal

Netherlands

Malta

Bulgaria

Israel

Germany

Czech Republic

New Zealand

Austria

Sweden

Belgium

Romania

Canada

Japan

Turkey

Finland

Republic of Korea

Norway

Switzerland

Slovakia

Australia

Poland

Chile

Child poverty rate

2008 2012

31.422.8

22.414.5

19.213.0

16.711.1

19.514.7

9.65.3

16.813.4

12.08.8

33.030.2

21.719.0

23.220.8

32.930.6

17.216.4

12.912.1

14.914.2

18.818.4

13.212.8

15.215.0

35.135.6

25.526.1

20.421.0

12.913.9

22.823.8

9.110.2

24.025.6

11.613.4

30.132.2

14.016.7

19.722.6

15.618.6

29.334.3

17.122.2

24.730.4

19.826.3

28.236.3

22.831.1

18.028.6

15.827.6

23.638.2

23.040.5

11.231.6

League Table 1 Change in child poverty (anchored in 2008)

Rank Country Change (2008–2012)

1 Chile -8.67

2 Poland -7.90

3 Australia -6.27

4 Slovakia -5.60

5 Switzerland -4.80

6 Norway -4.30

7 Republic of Korea -3.40

8 Finland -3.20

9 Turkey -2.76

10 Japan -2.70

11 Canada -2.44

12 Romania -2.30

13 Belgium -0.80

13 Sweden -0.80

15 Austria -0.70

16 New Zealand -0.40

17 Czech Republic -0.40

18 Germany -0.20

19 Israel 0.55

20 Bulgaria 0.60

20 Malta 0.60

22 Netherlands 1.00

22 Portugal 1.00

24 Denmark 1.10

25 United Kingdom 1.60

26 Slovenia 1.80

27 United States 2.06

28 Cyprus 2.70

29 Hungary 2.90

30 France 3.00

31 Mexico 5.00

32 Estonia 5.10

33 Italy 5.70

34 Luxembourg 6.50

35 Spain 8.10

36 Lithuania 8.30

37 Ireland 10.60

38 Croatia 11.80

39 Latvia 14.60

40 Greece 17.50

41 Iceland 20.40

See data sources and notes on page 44.

8

S E C T I O N 2 T H E L E A G U E T A B L E S

I N N O C E N T I R E P O R T C A R D 1 2

UNICEF Innocenti Report Card 12Children in the Developed World

Children of the Recession The impact of the economic crisis on child well-being in rich countries

0 10 20 30 40 50

Iceland

Greece

Latvia

Croatia

Ireland

Lithuania

Spain

Luxembourg

Italy

Estonia

Mexico

France

Hungary

Cyprus

United States

Slovenia

United Kingdom

Denmark

Portugal

Netherlands

Malta

Bulgaria

Israel

Germany

Czech Republic

New Zealand

Austria

Sweden

Belgium

Romania

Canada

Japan

Turkey

Finland

Republic of Korea

Norway

Switzerland

Slovakia

Australia

Poland

Chile

Child poverty rate

2008 2012

31.422.8

22.414.5

19.213.0

16.711.1

19.514.7

9.65.3

16.813.4

12.08.8

33.030.2

21.719.0

23.220.8

32.930.6

17.216.4

12.912.1

14.914.2

18.818.4

13.212.8

15.215.0

35.135.6

25.526.1

20.421.0

12.913.9

22.823.8

9.110.2

24.025.6

11.613.4

30.132.2

14.016.7

19.722.6

15.618.6

29.334.3

17.122.2

24.730.4

19.826.3

28.236.3

22.831.1

18.028.6

15.827.6

23.638.2

23.040.5

11.231.6



1 Chile -8.67

2 Poland -7.90

3 Australia -6.27

4 Slovakia -5.60

5 Switzerland -4.80

6 Norway -4.30


8 Finland -3.20

9 Turkey -2.76

10 Japan -2.70

11 Canada -2.44

12 Romania -2.30

13 Belgium -0.80

13 Sweden -0.80

15 Austria -0.70



18 Germany -0.20

19 Israel 0.55

20 Bulgaria 0.60

20 Malta 0.60

22 Netherlands 1.00

22 Portugal 1.00

24 Denmark 1.10


26 Slovenia 1.80


28 Cyprus 2.70

29 Hungary 2.90

30 France 3.00

31 Mexico 5.00

32 Estonia 5.10

33 Italy 5.70

34 Luxembourg 6.50

35 Spain 8.10

36 Lithuania 8.30

37 Ireland 10.60

38 Croatia 11.80

39 Latvia 14.60

40 Greece 17.50

41 Iceland 20.40


8



0 10 20 30 40 50

Iceland

Greece

Latvia

Croatia

Ireland

Lithuania

Spain

Luxembourg

Italy

Estonia

Mexico

France

Hungary

Cyprus

United States

Slovenia

United Kingdom

Denmark

Portugal

Netherlands

Malta

Bulgaria

Israel

Germany

Czech Republic

New Zealand

Austria

Sweden

Belgium

Romania

Canada

Japan

Turkey

Finland

Republic of Korea

Norway

Switzerland

Slovakia

Australia

Poland

Chile

Child poverty rate

2008 2012

31.422.8

22.414.5

19.213.0

16.711.1

19.514.7

9.65.3

16.813.4

12.08.8

33.030.2

21.719.0

23.220.8

32.930.6

17.216.4

12.912.1

14.914.2

18.818.4

13.212.8

15.215.0

35.135.6

25.526.1

20.421.0

12.913.9

22.823.8

9.110.2

24.025.6

11.613.4

30.132.2

14.016.7

19.722.6

15.618.6

29.334.3

17.122.2

24.730.4

19.826.3

28.236.3

22.831.1

18.028.6

15.827.6

23.638.2

23.040.5

11.231.6



1 Chile -8.67

2 Poland -7.90

3 Australia -6.27

4 Slovakia -5.60

5 Switzerland -4.80

6 Norway -4.30


8 Finland -3.20

9 Turkey -2.76

10 Japan -2.70

11 Canada -2.44

12 Romania -2.30

13 Belgium -0.80

13 Sweden -0.80

15 Austria -0.70



18 Germany -0.20

19 Israel 0.55

20 Bulgaria 0.60

20 Malta 0.60

22 Netherlands 1.00

22 Portugal 1.00

24 Denmark 1.10


26 Slovenia 1.80


28 Cyprus 2.70

29 Hungary 2.90

30 France 3.00

31 Mexico 5.00

32 Estonia 5.10

33 Italy 5.70

34 Luxembourg 6.50

35 Spain 8.10

36 Lithuania 8.30

37 Ireland 10.60

38 Croatia 11.80

39 Latvia 14.60

40 Greece 17.50

41 Iceland 20.40


8



0 10 20 30 40 50

Iceland

Greece

Latvia

Croatia

Ireland

Lithuania

Spain

Luxembourg

Italy

Estonia

Mexico

France

Hungary

Cyprus

United States

Slovenia

United Kingdom

Denmark

Portugal

Netherlands

Malta

Bulgaria

Israel

Germany

Czech Republic

New Zealand

Austria

Sweden

Belgium

Romania

Canada

Japan

Turkey

Finland

Republic of Korea

Norway

Switzerland

Slovakia

Australia

Poland

Chile

Child poverty rate

2008 2012

31.422.8

22.414.5

19.213.0

16.711.1

19.514.7

9.65.3

16.813.4

12.08.8

33.030.2

21.719.0

23.220.8

32.930.6

17.216.4

12.912.1

14.914.2

18.818.4

13.212.8

15.215.0

35.135.6

25.526.1

20.421.0

12.913.9

22.823.8

9.110.2

24.025.6

11.613.4

30.132.2

14.016.7

19.722.6

15.618.6

29.334.3

17.122.2

24.730.4

19.826.3

28.236.3

22.831.1

18.028.6

15.827.6

23.638.2

23.040.5

11.231.6



1 Chile -8.67

2 Poland -7.90

3 Australia -6.27

4 Slovakia -5.60

5 Switzerland -4.80

6 Norway -4.30


8 Finland -3.20

9 Turkey -2.76

10 Japan -2.70

11 Canada -2.44

12 Romania -2.30

13 Belgium -0.80

13 Sweden -0.80

15 Austria -0.70



18 Germany -0.20

19 Israel 0.55

20 Bulgaria 0.60

20 Malta 0.60

22 Netherlands 1.00

22 Portugal 1.00

24 Denmark 1.10


26 Slovenia 1.80


28 Cyprus 2.70

29 Hungary 2.90

30 France 3.00

31 Mexico 5.00

32 Estonia 5.10

33 Italy 5.70

34 Luxembourg 6.50

35 Spain 8.10

36 Lithuania 8.30

37 Ireland 10.60

38 Croatia 11.80

39 Latvia 14.60

40 Greece 17.50

41 Iceland 20.40


8



0 10 20 30 40 50

Iceland

Greece

Latvia

Croatia

Ireland

Lithuania

Spain

Luxembourg

Italy

Estonia

Mexico

France

Hungary

Cyprus

United States

Slovenia

United Kingdom

Denmark

Portugal

Netherlands

Malta

Bulgaria

Israel

Germany

Czech Republic

New Zealand

Austria

Sweden

Belgium

Romania

Canada

Japan

Turkey

Finland

Republic of Korea

Norway

Switzerland

Slovakia

Australia

Poland

Chile

Child poverty rate

2008 2012

31.422.8

22.414.5

19.213.0

16.711.1

19.514.7

9.65.3

16.813.4

12.08.8

33.030.2

21.719.0

23.220.8

32.930.6

17.216.4

12.912.1

14.914.2

18.818.4

13.212.8

15.215.0

35.135.6

25.526.1

20.421.0

12.913.9

22.823.8

9.110.2

24.025.6

11.613.4

30.132.2

14.016.7

19.722.6

15.618.6

29.334.3

17.122.2

24.730.4

19.826.3

28.236.3

22.831.1

18.028.6

15.827.6

23.638.2

23.040.5

11.231.6



1 Chile -8.67

2 Poland -7.90

3 Australia -6.27

4 Slovakia -5.60

5 Switzerland -4.80

6 Norway -4.30


8 Finland -3.20

9 Turkey -2.76

10 Japan -2.70

11 Canada -2.44

12 Romania -2.30

13 Belgium -0.80

13 Sweden -0.80

15 Austria -0.70



18 Germany -0.20

19 Israel 0.55

20 Bulgaria 0.60

20 Malta 0.60

22 Netherlands 1.00

22 Portugal 1.00

24 Denmark 1.10


26 Slovenia 1.80


28 Cyprus 2.70

29 Hungary 2.90

30 France 3.00

31 Mexico 5.00

32 Estonia 5.10

33 Italy 5.70

34 Luxembourg 6.50

35 Spain 8.10

36 Lithuania 8.30

37 Ireland 10.60

38 Croatia 11.80

39 Latvia 14.60

40 Greece 17.50

41 Iceland 20.40


8



0 10 20 30 40 50

Iceland

Greece

Latvia

Croatia

Ireland

Lithuania

Spain

Luxembourg

Italy

Estonia

Mexico

France

Hungary

Cyprus

United States

Slovenia

United Kingdom

Denmark

Portugal

Netherlands

Malta

Bulgaria

Israel

Germany

Czech Republic

New Zealand

Austria

Sweden

Belgium

Romania

Canada

Japan

Turkey

Finland

Republic of Korea

Norway

Switzerland

Slovakia

Australia

Poland

Chile

Child poverty rate

2008 2012

31.422.8

22.414.5

19.213.0

16.711.1

19.514.7

9.65.3

16.813.4

12.08.8

33.030.2

21.719.0

23.220.8

32.930.6

17.216.4

12.912.1

14.914.2

18.818.4

13.212.8

15.215.0

35.135.6

25.526.1

20.421.0

12.913.9

22.823.8

9.110.2

24.025.6

11.613.4

30.132.2

14.016.7

19.722.6

15.618.6

29.334.3

17.122.2

24.730.4

19.826.3

28.236.3

22.831.1

18.028.6

15.827.6

23.638.2

23.040.5

11.231.6



1 Chile -8.67

2 Poland -7.90

3 Australia -6.27

4 Slovakia -5.60

5 Switzerland -4.80

6 Norway -4.30


8 Finland -3.20

9 Turkey -2.76

10 Japan -2.70

11 Canada -2.44

12 Romania -2.30

13 Belgium -0.80

13 Sweden -0.80

15 Austria -0.70



18 Germany -0.20

19 Israel 0.55

20 Bulgaria 0.60

20 Malta 0.60

22 Netherlands 1.00

22 Portugal 1.00

24 Denmark 1.10


26 Slovenia 1.80


28 Cyprus 2.70

29 Hungary 2.90

30 France 3.00

31 Mexico 5.00

32 Estonia 5.10

33 Italy 5.70

34 Luxembourg 6.50

35 Spain 8.10

36 Lithuania 8.30

37 Ireland 10.60

38 Croatia 11.80

39 Latvia 14.60

40 Greece 17.50

41 Iceland 20.40


8





0 10 20 30 40

Cyprus

Greece

Croatia

Romania

Italy

Bulgaria

Spain

Hungary

Portugal

Poland

United States

Slovenia

Slovakia

Belgium

Estonia

Czech Republic

Lithuania

Australia

Denmark

Netherlands

Malta

Latvia

Finland

Norway

Chile

Republic of Korea

United Kingdom

Ireland

Iceland

France

Israel

Switzerland

New Zealand

Austria

Canada

Sweden

Mexico

Luxembourg

Japan

Germany

Turkey

NEET rate (%)

2008 2013

37.025.5

8.46.3

8.56.9

6.25.0

21.521.1

7.87.57.17.1

9.69.6

12.913.7

6.37.1

29.830.7

10.211.2

4.55.5

14.916.1

14.615.8

11.813.0

12.113.3

19.020.5

7.89.3

4.15.6

4.36.0

3.45.1

8.310.0

9.912.2

8.811.1

6.79.1

10.112.7

8.711.311.1

13.76.5

9.212.0

15.09.0

12.211.5

15.410.3

14.217.4

21.614.3

18.616.6

22.211.6

17.210.1

18.611.7

20.69.7

18.7

League Table 2 Youth aged 15 to 24 not in education, employment or training (NEET), percentage


1 Turkey -11.5

2 Germany -2.1

3 Japan -1.5

4 Luxembourg -1.2

5 Mexico -0.4

6 Sweden -0.3

7 Austria 0.0

7 Canada 0.0

9 New Zealand 0.8

10 Switzerland 0.8

11 Israel 0.9

12 France 1.0

12 Iceland 1.0

14 Ireland 1.2

14 Latvia 1.2

14 Republic of Korea 1.2


18 Chile 1.5

18 Finland 1.5

18 Norway 1.5

21 Denmark 1.7

21 Malta 1.7

21 Netherlands 1.7

24 Australia 2.3

25 Lithuania 2.3

26 Czech Republic 2.4

27 Belgium 2.6

27 Estonia 2.6

27 Slovakia 2.6

30 Slovenia 2.7


32 Poland 3.2

33 Hungary 3.9

33 Portugal 3.9

35 Bulgaria 4.2

36 Spain 4.3

37 Italy 5.6

37 Romania 5.6

39 Croatia 8.5

40 Greece 8.9

41 Cyprus 9.0


1 0



0 10 20 30 40

Cyprus

Greece

Croatia

Romania

Italy

Bulgaria

Spain

Hungary

Portugal

Poland

United States

Slovenia

Slovakia

Belgium

Estonia

Czech Republic

Lithuania

Australia

Denmark

Netherlands

Malta

Latvia

Finland

Norway

Chile

Republic of Korea

United Kingdom

Ireland

Iceland

France

Israel

Switzerland

New Zealand

Austria

Canada

Sweden

Mexico

Luxembourg

Japan

Germany

Turkey

NEET rate (%)

2008 2013

37.025.5

8.46.3

8.56.9

6.25.0

21.521.1

7.87.57.17.1

9.69.6

12.913.7

6.37.1

29.830.7

10.211.2

4.55.5

14.916.1

14.615.8

11.813.0

12.113.3

19.020.5

7.89.3

4.15.6

4.36.0

3.45.1

8.310.0

9.912.2

8.811.1

6.79.1

10.112.7

8.711.311.1

13.76.5

9.212.0

15.09.0

12.211.5

15.410.3

14.217.4

21.614.3

18.616.6

22.211.6

17.210.1

18.611.7

20.69.7

18.7



1 Turkey -11.5

2 Germany -2.1

3 Japan -1.5

4 Luxembourg -1.2

5 Mexico -0.4

6 Sweden -0.3

7 Austria 0.0

7 Canada 0.0

9 New Zealand 0.8

10 Switzerland 0.8

11 Israel 0.9

12 France 1.0

12 Iceland 1.0

14 Ireland 1.2

14 Latvia 1.2



18 Chile 1.5

18 Finland 1.5

18 Norway 1.5

21 Denmark 1.7

21 Malta 1.7

21 Netherlands 1.7

24 Australia 2.3

25 Lithuania 2.3


27 Belgium 2.6

27 Estonia 2.6

27 Slovakia 2.6

30 Slovenia 2.7


32 Poland 3.2

33 Hungary 3.9

33 Portugal 3.9

35 Bulgaria 4.2

36 Spain 4.3

37 Italy 5.6

37 Romania 5.6

39 Croatia 8.5

40 Greece 8.9

41 Cyprus 9.0


1 0



0 10 20 30 40

Cyprus

Greece

Croatia

Romania

Italy

Bulgaria

Spain

Hungary

Portugal

Poland

United States

Slovenia

Slovakia

Belgium

Estonia

Czech Republic

Lithuania

Australia

Denmark

Netherlands

Malta

Latvia

Finland

Norway

Chile

Republic of Korea

United Kingdom

Ireland

Iceland

France

Israel

Switzerland

New Zealand

Austria

Canada

Sweden

Mexico

Luxembourg

Japan

Germany

Turkey

NEET rate (%)

2008 2013

37.025.5

8.46.3

8.56.9

6.25.0

21.521.1

7.87.57.17.1

9.69.6

12.913.7

6.37.1

29.830.7

10.211.2

4.55.5

14.916.1

14.615.8

11.813.0

12.113.3

19.020.5

7.89.3

4.15.6

4.36.0

3.45.1

8.310.0

9.912.2

8.811.1

6.79.1

10.112.7

8.711.311.1

13.76.5

9.212.0

15.09.0

12.211.5

15.410.3

14.217.4

21.614.3

18.616.6

22.211.6

17.210.1

18.611.7

20.69.7

18.7



1 Turkey -11.5

2 Germany -2.1

3 Japan -1.5

4 Luxembourg -1.2

5 Mexico -0.4

6 Sweden -0.3

7 Austria 0.0

7 Canada 0.0

9 New Zealand 0.8

10 Switzerland 0.8

11 Israel 0.9

12 France 1.0

12 Iceland 1.0

14 Ireland 1.2

14 Latvia 1.2



18 Chile 1.5

18 Finland 1.5

18 Norway 1.5

21 Denmark 1.7

21 Malta 1.7

21 Netherlands 1.7

24 Australia 2.3

25 Lithuania 2.3


27 Belgium 2.6

27 Estonia 2.6

27 Slovakia 2.6

30 Slovenia 2.7


32 Poland 3.2

33 Hungary 3.9

33 Portugal 3.9

35 Bulgaria 4.2

36 Spain 4.3

37 Italy 5.6

37 Romania 5.6

39 Croatia 8.5

40 Greece 8.9

41 Cyprus 9.0


1 0



Efeitosdacriseeconômicaemedidasdeausteridadesobreasaúdedoseuropeus:•Ansiedade,depressãoealcoolismo•Doençastransmissíveis•Suicídio•Percepçãonegativadoestadodesaúde

Health Policy 113 (2013) 13– 19

Contents lists available at ScienceDirect

Health Policy

journa l h om epa ge: www.elsev ier .com/ locate /hea l thpol

Perspective

Austerity and health in Europe!!

GianLuca Quaglioa,∗, Theodoros Karapiperisa, Lieve Van Woensela,Elleke Arnolda, David McDaidb

a Science and Technology Options Assessments (STOA), European Parliament, Brussels, Belgiumb LSE Health and Social Care and European Observatory on Health Systems and Policies, London School of Economics andPolitical Science, London, UK

a r t i c l e i n f o

Article history:Received 30 July 2013Received in revised form 9 September 2013Accepted 16 September 2013

Keywords:AusterityEconomic crisisEuropean health systemsPublic health policies

a b s t r a c t

Many European governments have abundantly cut down public expenditure on health dur-ing the financial crisis. Consequences of the financial downturn on health outcomes havebegun to emerge. This recession has led to an increase in poor health status, raising ratesof anxiety and depression among the economically vulnerable. In addition, the incidenceof some communicable diseases along with the rate of suicide has increased significantly.The recession has also driven structural reforms, and affected the priority given to publicpolicies. The purpose of this paper is to analyse how austerity impacts health in Europe andbetter understand the response of European health systems to the financial crisis.

The current economic climate, while challenging, presents an opportunity for reformingand restructuring health promotion actions. More innovative approaches to health shouldbe developed by health professionals and by those responsible for health management. Inaddition, scientists and experts in public health should promote evidence-based approachesto economic and public health recovery by analyzing the present economic downturn andprevious crisis. However, it is governance and leadership that will mostly determine howwell health systems are prepared to face the crisis and find ways to mitigate its effects.

© 2013 The Authors. Published by Elsevier Ireland Ltd.

1. Introduction

The economic downturn has affected much of Europeseverely. In 2009 real gross domestic product (GDP) growthrate fell in European Union Member States with a meandecrease of 4.3% [1]. In parallel, unemployment increasedconsiderably from 7.2% in 2007 to 11% in July 2013,

!! Open Access for this article is made possible by a collaborationbetween Health Policy and The European Observatory on Health Systemsand Policies.

∗ Corresponding author at: Science and Technology Option Assessment,European Parliament, Directorate General for Internal Policies, Rue Wiertz60, B-1047 Brussels, Belgium. Tel.: +32 2 28 41 061.

E-mail address: [email protected] (G. Quaglio).

although unemployment rates have varied widely fromlows of 4.8% and 5.3% in Austria and Germany, to 26.3%and 27.6% in Spain and Greece respectively [1]. Because ofthe European sovereign-debt crisis, many European UnionMember States have adopted harsh austerity policies andhave substantially cut down in public expenditure. Growthin health spending per capita fell in real terms in 2010 inalmost all European countries, reversing a trend of steadyincreases. Namely, from an annual average growth rateof 4.6% per year between 2000 and 2009, towards a fallin health spending per capita of 0.6% in 2010 [2]. As aresult of the downturn in health spending in 2010, the per-centage of GDP devoted to health stabilised or declinedslightly in many EU Member States. Nonetheless in 2010,European Union Member States devoted on average 9.0%of their GDP to health spending, up significantly from7.3% in 2000, but down slightly from the peak of 9.2%in 2009 [3].

0168-8510 © 2013 The Authors. Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.healthpol.2013.09.005

Open access under CC BY-NC-ND license.


Health Policy 113 (2013) 13– 19


Health Policy


Perspective







a b s t r a c t




1. Introduction









Health Policy 113 (2013) 13– 19


Health Policy


Perspective







a b s t r a c t




1. Introduction









Health Policy 113 (2013) 13– 19


Health Policy


Perspective







a b s t r a c t




1. Introduction









Health Policy 115 (2014) 111–119


Health Policy


Review

Effects of the economic crisis on health and healthcare inGreece in the literature from 2009 to 2013: A systematicreview

Effie Simou ∗, Eleni KoutsogeorgouDepartment of Epidemiology and Biostatistics, National School of Public Health, Athens, Greece


Article history:Received 13 May 2013Received in revised form 23 January 2014Accepted 1 February 2014

Keywords:Economic recessionPublic healthHealth careHealth care reformGreece

a b s t r a c t

Background: Due to the current economic crisis in Greece, effects on health and healthcarehave been reported. The aim of this study was to present a systematic overview of theconsequences that the financial crisis has had for health and healthcare in Greece.Methods: Systematic literature review was conducted in order to identify articles that werepublished from January 2009 to March 2013 and explicitly referred to the effects of eco-nomic crisis on health or healthcare, in Greece. Data extraction and synthesis was performedwith the use of thematic analysis.Findings: Thirty-nine studies were considered for further analyses. Various existing andpotential relevant effects were identified, including reductions in public health expenditureand changes in healthcare services and the pharmaceutical market, with an increasingnumber of admissions in public healthcare sector, and efficiency and organizational-relatedissues being evident, overall. Indications were found for post-crisis deterioration of publichealth with increasing rates of mental health, suicides, and epidemics, and deterioration ofself-rated health.Conclusion: The recent efforts to reform the Greek National Health System have beenfocusing mainly on short-term effects by reducing expenditure, while the measuresimposed seem to have dubious long-term consequences for Greek public health andhealthcare.


1. Introduction

Since the year 2009, Greece has been undergoing oneof the most severe debt crises in its history which led in2010 to the signing of a Memorandum of Economic andFinancial Policies with the so-called “Troika” – comprising

∗ Corresponding author at: Department of Epidemiology and Biostatis-tics, National School of Public Health, 196, Leoforos Alexandras, 11521Athens, Greece. Tel.: +30 2132010376; fax: +30 2106444870.

E-mail address: [email protected] (E. Simou).

by the European Commission, the European Central Bankand the International Monetary Fund – in exchange to aD 110 billion loan referred to as financial rescue package orbailout programme. The Memorandum included borrow-ing requirements agreed between the Troika and the Greekgovernment, ratified also by the Greek Parliament in May2010 [1]. Socio-economic consequences of the debt crisisemerged immediately with unemployment rates reaching14.2% and the Gross Domestic Product (GDP) of the coun-try falling to −3.5% in 2010, with figures for 2011 beingeven more alarming [2]. Following the signing of Memo-randum – and other financial rescue packages after that –a sequence of austerity measures has been imposed on theGreek population since 2010 requiring both emergency and

0168-8510 © 2014 The Authors. Published by Elsevier Ireland Ltd.

http://dx.doi.org/10.1016/j.healthpol.2014.02.002



Consequences forhealth•Mentalhealth•Suicides•Epidemics•Self-rated health•Otorhinolaryngologic disorders (vertigemezumbido)

Is austerity to blame?• Marmot said itwas hardto drawfirm conclusions about thecause.

• But,itwas "entirely possible"austerity had played arole.

• Socialfactors such aseducation,employment and workingconditions and poverty allaffected life expectancy byinfluencing lifestyles.And asausterity was placing pressureson these,they may inturn beinfluencing life expectancy.

• NHSand socialcare have beenmiserly funded,which meantthe quality of life forolderpeople would have deterioratedand could well affect their lifeexpectancy.

26/09/17 19)09IDT - Responsive

Página 1 de 1http://www.bbc.co.uk/indepthtoolkit/charts/Life_expect_2?ifra…6&parentUrl=http%3A%2F%2Fwww.bbc.com%2Fnews%2Fhealth-40608256

Males Females

Rise in life expectancy in EnglandAnnual increase in years

Source:Institute of Health Equity

In2015average life expectancy inBritain was 79.6years formenand 83.1years forwomen.

InHongKong,life expectancy formen is 81.1years formenand 87.3forwomen.

http://www.bbc.com/news/health-40608256

ConclusionsThe 2009 sovereign debt crisis in Europe illustrated,quite clearly, what can be the health effects experiencedby societies affected by rising unemployment and finan-cial distress. Crises can increase suicides, widen inequi-ties in wealth and undermine the social fabric of society.The crisis is certainly not over, and prospects for eco-nomic recovery especially in countries particularly af-fected by the crisis such as Greece, Portugal, Italy,Ireland and Spain remain uncertain. Unless governmentsintervene boldly to protect the most vulnerable populations

from its effects, the Eurozone crisis will continue to kill inthe years to come. However, evidence showing that timesof economic recessions need not to result in decreases inlife expectancy, and can actually reduce mortality, is en-couraging. By adopting redistributive policies and investingin strong social protection, governments can promotesustainable health and even abandon GDP as a primarynational goal, to prioritize human rather than eco-nomic development. This may increasingly become ne-cessary, if modern civilization has any serious hope toovercome the converging global ecological crises - climate

a)

b)

Figure 4 Temporal association between unemployment and suicides from 2000 to 2010 in Italy (a) and correlation betweenunemployment and suicides by Expenditure on Social Services and Benefits per capita in 20 Italian regions (b).


ConclusionsThe 2009 sovereign debt crisis in Europe illustrated,quite clearly, what can be the health effects experiencedby societies affected by rising unemployment and finan-cial distress. Crises can increase suicides, widen inequi-ties in wealth and undermine the social fabric of society.The crisis is certainly not over, and prospects for eco-nomic recovery especially in countries particularly af-fected by the crisis such as Greece, Portugal, Italy,Ireland and Spain remain uncertain. Unless governmentsintervene boldly to protect the most vulnerable populations

from its effects, the Eurozone crisis will continue to kill inthe years to come. However, evidence showing that timesof economic recessions need not to result in decreases inlife expectancy, and can actually reduce mortality, is en-couraging. By adopting redistributive policies and investingin strong social protection, governments can promotesustainable health and even abandon GDP as a primarynational goal, to prioritize human rather than eco-nomic development. This may increasingly become ne-cessary, if modern civilization has any serious hope toovercome the converging global ecological crises - climate

a)

b)

Figure 4 Temporal association between unemployment and suicides from 2000 to 2010 in Italy (a) and correlation betweenunemployment and suicides by Expenditure on Social Services and Benefits per capita in 20 Italian regions (b).


b)Correlation between unemployment and suicidesby expenditureon socialservices and benefits percapitain20Italian regions

a) Temporalassociation between unemployment andsuicidesfrom 2000to 2010inItaly

DE VOGLI, Roberto. The financial crisis, health and health inequities in Europe: the need for regulations, redistribution and social protection. Internationaljournal for equity in health, v. 13, n. 1, p. 58, 2014.

Health Policy 115 (2014) 111–119


Health Policy


Review

Effects of the economic crisis on health and healthcare inGreece in the literature from 2009 to 2013: A systematicreview

Effie Simou ∗, Eleni KoutsogeorgouDepartment of Epidemiology and Biostatistics, National School of Public Health, Athens, Greece


Article history:Received 13 May 2013Received in revised form 23 January 2014Accepted 1 February 2014

Keywords:Economic recessionPublic healthHealth careHealth care reformGreece

a b s t r a c t

Background: Due to the current economic crisis in Greece, effects on health and healthcarehave been reported. The aim of this study was to present a systematic overview of theconsequences that the financial crisis has had for health and healthcare in Greece.Methods: Systematic literature review was conducted in order to identify articles that werepublished from January 2009 to March 2013 and explicitly referred to the effects of eco-nomic crisis on health or healthcare, in Greece. Data extraction and synthesis was performedwith the use of thematic analysis.Findings: Thirty-nine studies were considered for further analyses. Various existing andpotential relevant effects were identified, including reductions in public health expenditureand changes in healthcare services and the pharmaceutical market, with an increasingnumber of admissions in public healthcare sector, and efficiency and organizational-relatedissues being evident, overall. Indications were found for post-crisis deterioration of publichealth with increasing rates of mental health, suicides, and epidemics, and deterioration ofself-rated health.Conclusion: The recent efforts to reform the Greek National Health System have beenfocusing mainly on short-term effects by reducing expenditure, while the measuresimposed seem to have dubious long-term consequences for Greek public health andhealthcare.


1. Introduction

Since the year 2009, Greece has been undergoing oneof the most severe debt crises in its history which led in2010 to the signing of a Memorandum of Economic andFinancial Policies with the so-called “Troika” – comprising

∗ Corresponding author at: Department of Epidemiology and Biostatis-tics, National School of Public Health, 196, Leoforos Alexandras, 11521Athens, Greece. Tel.: +30 2132010376; fax: +30 2106444870.

E-mail address: [email protected] (E. Simou).

by the European Commission, the European Central Bankand the International Monetary Fund – in exchange to aD 110 billion loan referred to as financial rescue package orbailout programme. The Memorandum included borrow-ing requirements agreed between the Troika and the Greekgovernment, ratified also by the Greek Parliament in May2010 [1]. Socio-economic consequences of the debt crisisemerged immediately with unemployment rates reaching14.2% and the Gross Domestic Product (GDP) of the coun-try falling to −3.5% in 2010, with figures for 2011 beingeven more alarming [2]. Following the signing of Memo-randum – and other financial rescue packages after that –a sequence of austerity measures has been imposed on theGreek population since 2010 requiring both emergency and





Consequences forhealthcare• Public health expenditure and management • Healthcare workforce• Healthcare services• Pharmaceutical market• Biomedical research.

1– Oorçamentodasaúdenãofoipreservadonascrises.Emalgunscasos,receberamosmaiorescortes,especialmenteondeocorreramacordosdeempréstimocomoFMI.2– Oscortescomosgastosemsaúdenãosãoinevitávelconsequênciade:recessões,mudançaanualdoPIBpercapita,perdascumulativasnoPIB.3– Aideologiadospartidosgovernantesestáassociadaaoscortesnasaúde.4– Entreospaísesobservados,oaumentodadívidapública,independentementedeseuvolume,estáassociadoaoaumentodoscortesemsaúde.5– A tomadadeempréstimojuntoaoFMIestáfortementeassociadaadecisãodepromoverosgastosnasaúde.6– Paísesadeptosdosistemadesegurosocialforammenossuscetíveisàspolíticasdeausteridade,masforammaissuscetíveisaosdeclíniodoPIBpercapita.

Health Policy 115 (2014) 1–8


Health Policy


The political economy of austerity and healthcare:Cross-national analysis of expenditure changes in 27European nations 1995–2011!!

Aaron Reevesa,∗, Martin McKeeb, Sanjay Basub,c, David Stucklera,b

a Department of Sociology, University of Oxford, Manor Road Building, Manor Road, Oxford OX1 3UQ, UKb London School of Hygiene and Tropical Medicine, London, UKc School of Medicine, Stanford University, Palo Alto, CA, USA


Article history:Received 24 July 2013Received in revised form13 November 2013Accepted 13 November 2013

Keywords:Political economyAusterityRecessionIMFHealthcare

a b s t r a c t

Why have patterns of healthcare spending varied during the Great Recession? Usingcross-national, harmonised data for 27 EU countries from 1995 to 2011, we evaluatedpolitical, economic, and health system determinants of recent changes to healthcare expen-diture. Data from EuroStat, the IMF, and World Bank (2013 editions) were evaluated usingmultivariate random- and fixed-effects models, correcting for pre-existing time-trends.Reductions in government health expenditure were not significantly associated with mag-nitude of economic recessions (annual change in GDP, p = 0.31, or cumulative decline,p = 0.40 or debt crises (measured by public debt as a percentage of GDP, p = 0.38 or percapita, p = 0.83)). Nor did ideology of governing parties have an effect. In contrast, each$100 reduction in tax revenue was associated with a $2.72 drop in health spending (95%CI: $1.03–4.41). IMF borrowers were significantly more likely to reduce healthcare budgetsthan non-IMF borrowers (OR = 3.88, 95% CI: 1.95 –7.74), even after correcting for potentialconfounding by indication. Exposure to lending from international financial institutions,tax revenue falls, and decisions to implement cuts correlate more closely than underlyingeconomic conditions or orientation of political parties with healthcare expenditure changein EU member states.


1. Introduction

Virtually all European countries have experienced eco-nomic recessions since 2007. Those nations with largefinancial centres, including the UK, were among the firstto be affected, with many other nations’ banking sectors


∗ Corresponding author. Tel.: +44 1865 281 740.E-mail address: [email protected] (A. Reeves).

soon caught in the ensuing turmoil. In several, politiciansused large financial stimulus packages to bail out banks,absorbing their debts into the public sector’s balance sheet.In parallel, recessions led to increasing job losses and fallingincomes, leading to declining consumer spending and asso-ciated tax revenues. This resulted in large increases ingovernment deficits (where annual government spendingexceeded revenues), increasing national public debts. Howbest to respond to these combined threats of large falls inoutput, unemployment, and escalating debts and deficitshas been a topic of vociferous debate.

The European Commission, European Central Bank,and International Monetary Fund (so-called ‘troika’),along with leaders of many European nations, placed anexplicit priority on deficit reduction. In a letter to Europe’sfinance ministers on 13th Feb 2013 the European Union’s





Health Policy 115 (2014) 1–8


Health Policy


The political economy of austerity and healthcare:Cross-national analysis of expenditure changes in 27European nations 1995–2011!!

Aaron Reevesa,∗, Martin McKeeb, Sanjay Basub,c, David Stucklera,b

a Department of Sociology, University of Oxford, Manor Road Building, Manor Road, Oxford OX1 3UQ, UKb London School of Hygiene and Tropical Medicine, London, UKc School of Medicine, Stanford University, Palo Alto, CA, USA


Article history:Received 24 July 2013Received in revised form13 November 2013Accepted 13 November 2013

Keywords:Political economyAusterityRecessionIMFHealthcare

a b s t r a c t

Why have patterns of healthcare spending varied during the Great Recession? Usingcross-national, harmonised data for 27 EU countries from 1995 to 2011, we evaluatedpolitical, economic, and health system determinants of recent changes to healthcare expen-diture. Data from EuroStat, the IMF, and World Bank (2013 editions) were evaluated usingmultivariate random- and fixed-effects models, correcting for pre-existing time-trends.Reductions in government health expenditure were not significantly associated with mag-nitude of economic recessions (annual change in GDP, p = 0.31, or cumulative decline,p = 0.40 or debt crises (measured by public debt as a percentage of GDP, p = 0.38 or percapita, p = 0.83)). Nor did ideology of governing parties have an effect. In contrast, each$100 reduction in tax revenue was associated with a $2.72 drop in health spending (95%CI: $1.03–4.41). IMF borrowers were significantly more likely to reduce healthcare budgetsthan non-IMF borrowers (OR = 3.88, 95% CI: 1.95 –7.74), even after correcting for potentialconfounding by indication. Exposure to lending from international financial institutions,tax revenue falls, and decisions to implement cuts correlate more closely than underlyingeconomic conditions or orientation of political parties with healthcare expenditure changein EU member states.


1. Introduction

Virtually all European countries have experienced eco-nomic recessions since 2007. Those nations with largefinancial centres, including the UK, were among the firstto be affected, with many other nations’ banking sectors


∗ Corresponding author. Tel.: +44 1865 281 740.E-mail address: [email protected] (A. Reeves).

soon caught in the ensuing turmoil. In several, politiciansused large financial stimulus packages to bail out banks,absorbing their debts into the public sector’s balance sheet.In parallel, recessions led to increasing job losses and fallingincomes, leading to declining consumer spending and asso-ciated tax revenues. This resulted in large increases ingovernment deficits (where annual government spendingexceeded revenues), increasing national public debts. Howbest to respond to these combined threats of large falls inoutput, unemployment, and escalating debts and deficitshas been a topic of vociferous debate.

The European Commission, European Central Bank,and International Monetary Fund (so-called ‘troika’),along with leaders of many European nations, placed anexplicit priority on deficit reduction. In a letter to Europe’sfinance ministers on 13th Feb 2013 the European Union’s





0

2

4

6

8

10

12

Hun

gary

Swed

en

Cze

ch R

epub

lic

Rom

ania

Pola

nd

Bul

garia

Switz

erla

nd

Mal

ta

Aus

tria

Fran

ce

Italy

Ger

man

y

Cyp

rus

Port

ugal

Bel

gium

Nor

way

Net

herla

nds

Slov

enia

Gre

ece

Spai

n

Den

mar

k

Slov

akia

Uni

ted

King

dom

Latv

ia

Icel

and

Finl

and

Luxe

mbo

urg

Lith

uani

a

Esto

nia

Irela

nd

Cha

nge

in p

ublic

exp

endi

ture

(GD

P pe

rcen

tage

poi

nts)

Figure 15 Change in public expenditure, 2007–2009

While Europe retrenched, Chile, Japan, Republic of Korea and the United States maintained expansionary policies to support their economies. Norway was Europe’s sole exception, while in Sweden and Switzerland the consolidation measures that were implemented amounted to less than 0.5 per cent of GDP.

In countries that made a similar fiscal effort and were equally exposed to the recession (see Box 1 in Section 3 for exposure criteria), the impact of the spending is mixed.

An assessment of government responses suggests that their effectiveness was related to the

initial margin of action, as well as to the magnitude and design of the government initiatives. Targeting cash payments at the poorest families with children helped to protect vulnerable families and boost the economy at the same time. Some examples:

» Chile and Mexico had experienced extraordinary economic and social improvements in the decade before the financial crisis, but in 2008–2009 they were hit hard by recession-induced trade declines. Chile, which had more fiscal space, spent twice as much as Mexico on its stimulus package, supporting families with children

by expanding existing social protection programmes, extending cash transfers to the poorest families with children, and expanding labour market measures such as unemployment insurance. Mexico introduced a similar stimulus package in the early years of the recession, but worsening fiscal conditions pushed the country into a consolidation process from 2010 onwards.

» Australia’s increase in spending on families had a more positive impact than the ambitious tax cuts implemented in New Zealand, where poverty and inequality stagnated (see Box 4).

Source: Eurostat.

2 8

S E C T I O N 4 U N E V E N R E S P O N S E S




EnaAméricaLatina?

Proteger avanços e evitar retrocessos como em crises anteriores

AMÉRICA LATINA Y EL CARIBE: COMPARACIÓN ENTRE EL PIB PER CÁPITA Y LA INCIDENCIA DE LA POBREZA, 1980-2015

4.339

4.085 4.038

4.339

4.533

4.657

4.570

4.802

5.156

5.523

5.390

5.654

5.852

6.053 6.053 5.962

40,5

43,3

48,4

45,7

43,5 42,5

44,2

42,0

34,0 33,5

31,1 29,7

28,2 28,1 28,2 29,2

25

30

35

40

45

50

3800

4300

4800

5300

580019

78

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

2016

Incidencia de la pobreza

PIB

per

cáp

ita

PIB per cápita

Pobreza

Recuperación en el nivel de pobreza: 25 años versus

Recuperación del PIB per cápita: 15 años

Fuente: Comisión Económica para América Latina y el Caribe (CEPAL), sobre la base de información oficial.

CEPAL,2017

16 Comisión Económica para América Latina y el Caribe (CEPAL)

que protección social, educación y salud son las funciones prioritarias en términos de la asignación de recursos, con niveles que en 2015 llegaron, como promedio de los países considerados, al 5,0%, el 4,6% y el 3,4% del PIB, respectivamente (véase el gráfico 4).

Gráfico 3 América Latina (19 países): gasto social del gobierno central y del sector público, 2000-2015a b

(En porcentajes del PIB y del gasto público total)

11,011,6 11,3 11,4 11,1 11,0 11,5 11,5

12,3

13,6 13,8 13,6 13,6 13,8 14,1 14,5

7,78,5 8,5 8,6 8,4 8,5 8,6 8,6 9,0

10,0 9,7 9,6 9,7 9,9 10,0 10,5

47,8 48,8 48,8 49,8 50,5 50,2 50,1 51,2 50,9 52,9 53,3 52,7 51,6 52,8 52,4 53,5

30

40

50

60

70

80

90

100

0

3

6

9

12

15

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Gasto público social del sectorpúblico como porcentajedel PIB (eje izquierdo)

Gasto público social del gobiernocentral como porcentajedel PIB (eje izquierdo)

Gasto público social como porcentajedel gasto público total del gobiernocentral (eje derecho)

Gasto público social como porcentaje del gasto público totaldel sector público (eje derecho)

45,2 45,6 45,7 46,5 46,6 45,8 47,0 48,6 48,551,4 52,0 51,4 50,0 51,3 50,9 51,9

Fuente: Comisión Económica para América Latina y el Caribe (CEPAL), sobre la base de información oficial de los países.a Promedio simple de 19 países: Argentina, Bolivia (Estado Plurinacional de), Brasil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Haití, Honduras, México,

Nicaragua, Panamá, Paraguay, Perú, República Dominicana, Uruguay y Venezuela (República Bolivariana de). Para Panamá se cuenta con información hasta 2014 y para Venezuela (República Bolivariana de) hasta 2009.

b Los países que se incluyen con una cobertura mayor que la de gobierno central son: Argentina, Bolivia (Estado Plurinacional de), Brasil, Colombia, Costa Rica, Ecuador, El Salvador, México y Perú.

Gráfico 4 América Latina (19 países): gasto social del sector público por funciones, 2000-2015ª b

(En porcentajes del PIB)

Protección del medio ambiente

ViviendaSalud

Actividades recreativas

EducaciónProtección social

0,1

0,8

2,5

0,1

3,7

3,7

0,1

0,9

2,7

0,1

4,0

3,8

0,1

1,1

2,6

0,1

3,9

3,4

0,1

1,0

2,7

0,1

4,0

3,5

0,1

1,1

2,5

0,1

3,9

3,4

0,1

1,2

2,6

0,1

3,6

3,4

0,1

1,2

2,7

0,1

4,0

3,4

0,1

1,1

2,6

0,1

4,0

3,5

0,1

1,0

2,8

0,2

4,2

3,9

0,2

1,1

3,1

0,2

4,5

4,5

0,3

1,1

3,2

0,2

4,5

4,6

0,3

1,0

3,1

0,2

4,4

4,6

0,3

1,0

3,1

0,2

4,4

4,6

0,3

1,0

3,2

0,3

4,5

4,6

0,3

1,0

3,3

0,3

4,6

4,6

0,2

1,0

3,4

0,2

4,6

5,0

0

2

4

6

8

10

12

14

16

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Fuente: Comisión Económica para América Latina y el Caribe (CEPAL), sobre la base de información oficial de los países. a Promedio simple de 19 países: Argentina, Bolivia (Estado Plurinacional de), Brasil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Haití, Honduras, México,

Nicaragua, Panamá, Paraguay, Perú, República Dominicana, Uruguay y Venezuela (República Bolivariana de). Para Panamá se cuenta con información hasta 2014 y para Venezuela (República Bolivariana de) hasta 2009.

b Los países que se incluyen con una cobertura mayor que la de gobierno central son: Argentina, Bolivia (Estado Plurinacional de), Brasil, Colombia, Costa Rica, Ecuador, El Salvador, México y Perú.

Tendência à diminuição do orçamento destinado às políticas sociais

AMÉRICA LATINA (13 PAÍSES): GASTO SOCIAL EXECUTADO E ORÇADO DO GOVERNO CENTRAL, POR FUNÇÕES, 2015-2017 a

(Em porcentagens do PIB)

0,1 0,1 0,1 0,8 0,7 0,7

2,3 2,2 2,1

0,1 0,1 0,1

3,7 3,7 3,6

4,0 3,8 3,8

0

2

4

6

8

10

12

2015 2016 2017

Protección social

Educación

Actividades recreativas

Salud

Vivienda

Protección del medioambiente

-0.6

10.6 11.0 10.4

Fonte: Comissão Econômica para América Latina Caribe (CEPAL), a partir de informações oficiais dos países. a Média simples de 13 países. Os países incluídos são: Argentina, Brasil, Colômbia, Costa Rica, El Salvador, Guatemala, Honduras, México, Nicarágua, Panamá (apenas dados orçamentários), Peru, República Dominicana e Uruguai.

Pobrezaedesemprego

65

Gráfico 31: Gasto social com transferências diretas de renda e redução da pobreza – 2002 a 2014.

Fonte: IBGE – PNAD e SIAFI/SIDOR. Elaboração própria dos autores.

Sob a ótica regional, em 2002, conforme ilustra a Figura 2, diversos Estados brasileiros apresentavam mais de 20% da população vivendo abaixo da linha da pobreza e, em alguns estados, essa proporção de pobres era de quase 50%. Já em 2014, observou-se uma expressiva redução nos níveis de pobreza para todos os estados brasileiros, com destaque para os do Nordeste.

Figura 2: Distribuição da população com renda familiar mensal abaixo da linha de pobreza – 2002 e 2014

Fonte: IBGE – PNAD. Elaboração própria dos autores.53

A fim de explicar parte do efeito que o gasto com transferências sociais diretas proporcionou na sociedade, entre o período de 2002 e 2014, realizou-se um exercício de estimativa de impacto com foco nos indicadores de renda e pobreza, com base nos dados da PNAD, por meio de um modelo semelhante ao de Barros et al. (2006). O Anexo contempla maiores detalhes sobre a construção da base de dados, bem como a metodologia utilizada.

53 Para a elaboração das figuras, foram consideradas as famílias em situação de pobreza aquelas com renda familiar mensal per capita de até R$ 154,00, conforme valor vigente do Decreto nº 5.209, de 17 de setembro de 2004. As rendas da PNAD foram atualizadas para 2014.

2002 2014

112

343

14,6%

4,6%

0

50

100

150

200

250

300

350

400

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

2002 2003 2004 2005 2006 2007 2008 2009 2011 2012 2013 2014

R$ bi

lhões

[Valo

res d

e 201

4]

Prop

orçã

o da

pobr

eza

Gasto Social Direto (R$ dez/2014) Propoção da pobreza

1

Gasto Social do Governo Central

2002 a 2015

Apresentação

A temática gasto social é frequentemente discutida na sociedade brasileira, especialmente em momentos de retração econômica e dificuldades fiscais. Questionamentos surgem a respeito da eficiência, eficácia e efetividade dos programas de governo e do montante dispendido com as rubricas em geral, não apenas as consideradas de cunho social. Entretanto, a complexidade do arcabouço orçamentário brasileiro dificulta uma visão global sobre a composição do gasto público e a análise do significado econômico de tais dispêndios.

Nesse sentido, a Secretaria do Tesouro Nacional – STN apresenta estudo sobre a dinâmica do gasto social brasileiro entre 2002 e 2015, tendo como escopo o Governo Central1. A análise revisita publicação de 2003 intitulada “Gasto Social do Governo Central – 2001 e 2002”2 produzida originalmente pela Secretaria de Política Econômica – SPE, do Ministério da Fazenda, e que tratava do gasto social bruto do Governo Central.

O presente estudo traz uma análise programática da despesa, tendo como objetivo principal compreender a magnitude e a composição do gasto social federal. Por gasto social, entende-se aquele destinado a atender às pessoas em situação de vulnerabilidade econômica, bem como os dispêndios que proporcionam oportunidades de promoção social. Em linhas gerais, o trabalho mostra que houve aumento do gasto de natureza social para o período analisado, acompanhado por uma melhora dos indicadores sociais, com especial destaque para os anos recentes.

Sumário Executivo

A Secretaria do Tesouro Nacional analisou o gasto social brasileiro a partir de 2002, evidenciando a composição desse gasto em sete categorias: assistência social; educação e cultura; organização agrária; previdência social; saneamento básico e habitação; saúde; e trabalho e emprego. A base de dados elaborada nesse trabalho da STN estabelece o entendimento desta sobre o conceito de gasto social e seus componentes. A disponibilização desta base ao público possibilita a análise e disseminação das informações relativas ao gasto social pela sociedade.

1 Para fins de compilação das estatísticas fiscais brasileiras, o Governo Central é composto por todas as unidades que integram o Orçamento Fiscal e da Seguridade Social, exceto o Banco Central do Brasil, que, dadas suas características, compõe o subsetor de Corporações Públicas Financeiras, de acordo o Manual de Estatísticas de Finanças Públicas (GFSM 2014, na sigla em inglês). 2 http://www.fedepsp.org.br/superior/gasto_social_01_02.pdf

SECRETÁRIO DO TESOURO

NACIONAL

Otavio Ladeira de Medeiros SUBSECRETÁRIO DE

PLANEJAMENTO E

ESTATÍSTICAS FISCAIS

William Baghdassarian COORDENAÇÃO-GERAL DE

ESTUDOS ECONÔMICO-

FISCAIS – CESEF

Fabiana Magalhães Almeida Rodopoulos Alex Pereira Benicio COORDENAÇÃO TÉCNICA

Guilherme Ceccato

EQUIPE TÉCNICA Artur Henrique da Silva Santos Eduardo Henrique Leitner Fernando Cardoso Ferraz Gustavo Santos Masili Janete Duarte Karla de Lima Rocha Otávio José Guerci Sidone Rafael Perez Marcos Rodrigo de Castro Luz Sergio Ricardo de Brito Gadelha

1


2002 a 2015

Apresentação




Sumário Executivo




NACIONAL


PLANEJAMENTO E



ESTUDOS ECONÔMICO-

FISCAIS – CESEF


Guilherme Ceccato


66

Por meio do exercício realizado foi possível inferir a participação de diversas fontes de renda na redução do coeficiente de GINI da renda familiar per capita e da proporção da pobreza, que reduziram de 0,594254 e 0,1462 em 2002 para 0,5227 e 0,0462 em 2014, respectivamente. Conforme indicado na Figura 3, o gasto com transferências sociais diretas contribuiu para 47% da redução do coeficiente de GINI no período, bem como para 32% da redução da proporção da pobreza.

Figura 3: Impacto de diversas fontes de renda na redução do índice GINI e da proporção de pobres - 2002 a 2014.

Fonte: IBGE – PNAD. Elaboração própria dos autores.

Além disso, o modelo utilizado permitiu inferir o efeito dos tipos de gastos com transferências sociais diretas em diferentes indicadores de pobreza. Como medidas de pobreza, utilizou-se as desenvolvidas por Fosteret al. (1984), chamadas aqui de proporção, hiato55 e severidade da pobreza56. Como critério comparativo desses indicadores, a proporção da pobreza captura a quantidade de famílias abaixo da linha da pobreza em relação à toda população. O hiato da pobreza indica a distância média (em percentual de renda) que as famílias em condição de pobreza estão da linha de pobreza. Dessa forma, essa medida captura, além da quantidade de famílias consideradas pobres, a dimensão da distância que as rendas dessas famílias estão da linha de pobreza. Por sua vez, a severidade é uma medida parecida com o hiato, diferenciando-se apenas por ampliar o peso das famílias com rendas mais baixas. Assim, ao comparar o papel das fontes de renda na redução desses indicadores, pode-se inferir a focalização dessas fontes de renda na sociedade. Quanto mais o resultado cresce

54 Estimativa diferente da disponível no gráfico 29, por decorrência da abrangência da informação de renda. Enquanto que no gráfico 29 utilizou a renda per capita domiciliar, a estimativa apresentada no texto correspondente à renda familiar per capita. 55 Hiato da Pobreza é a porcentagem da renda da população necessária para levar todos os pobres até a linha de pobreza. P(X, z) =1𝑁∑ (𝑧−𝑥𝑛

𝑧) ∙ 𝐼𝑥𝑛<𝑧

𝑁𝑛=1 , em que N é o número de indivíduos. 𝐼𝑥𝑛<𝑧 é uma função indicadora que vale 1 quando a renda do n-ésimo indivíduo (xn) é

menor do que a linha de pobreza (z) e vale zero caso contrário. 56 A Severidade da Pobreza é calculada pela seguinte equação: P(X, z) = 1

𝑁∑ (𝑧−𝑥𝑛

𝑧)2∙ 𝐼𝑥𝑛<𝑧

𝑁𝑛=1 , em que N é o número de indivíduos. 𝐼𝑥𝑛<𝑧 é

uma função indicadora que vale 1 quando a renda do n-ésimo indivíduo (xn) é menor do que a linha de pobreza (z) e vale zero caso contrário. Dessa forma, com relação ao Hiato da Pobreza, a Severidade da Pobreza dá um peso maior às famílias mais distantes da linha da pobreza no cálculo do índice.

Renda per capitafamilia

Renda do TrabalhoGINI: 44%

Prop. da Pobreza: 62%

Renda do Não TrabalhoGINI: 49%


Renda previdenciária pública maior que 1 SM

GINI: -4%Prop. da Pobreza: 1%

Renda PrivadaGINI: 6%


Tansferência Social Direta GINI: 47%


OutrosGINI: 7%


1


2002 a 2015

Apresentação




Sumário Executivo




NACIONAL


PLANEJAMENTO E



ESTUDOS ECONÔMICO-

FISCAIS – CESEF


Guilherme Ceccato


1


2002 a 2015

Apresentação




Sumário Executivo




NACIONAL


PLANEJAMENTO E



ESTUDOS ECONÔMICO-

FISCAIS – CESEF


Guilherme Ceccato


1


2002 a 2015

Apresentação




Sumário Executivo




NACIONAL


PLANEJAMENTO E



ESTUDOS ECONÔMICO-

FISCAIS – CESEF


Guilherme Ceccato


1


2002 a 2015

Apresentação




Sumário Executivo




NACIONAL


PLANEJAMENTO E



ESTUDOS ECONÔMICO-

FISCAIS – CESEF


Guilherme Ceccato


67

quando se compara a proporção, o hiato e a severidade da pobreza, nessa ordem, mais focalizada é a fonte de renda analisada.

Assim, considerando que, além da proporção da pobreza apresentada anteriormente, as medidas de hiato e severidade reduziram, respectivamente, de 0,0549 e 0,0292 em 2002 para 0,0185 e 0,0102 em 2014, evidenciou-se as diferenças entre o impacto da renda do trabalho e do gasto com transferências sociais diretas nesses indicadores de pobreza. Conforme mostra o Gráfico 32, a renda do trabalho teve uma alta participação na redução da proporção da pobreza no período 2002 a 2014. No entanto, o impacto do gasto com transferências sociais diretas foi superior ao da renda de trabalho na redução do hiato e da severidade para o período em questão. Pode-se, ainda, observar que o componente do gasto com transferência social direta que é mais relevante para a melhora dos índices de pobreza é o gasto com transferências sociais diretas menores que o salário mínimo. O efeito desse gasto aumenta à medida que se compara os indicadores de pobreza, o que reflete maior sua focalização.

Gráfico 32: Impacto da renda do trabalho e do gasto com transferências sociais diretas na redução da proporção, do hiato e da severidade da pobreza – 2002 a 2014.

Fonte: IBGE – PNAD. Elaboração própria dos autores. Notas: (1) A estimativa do efeito das “transferências sociais diretas maior ou igual ao SM” correspondem à soma de: (i) estimativa marginal das transferências igual ao SM; (ii) estimativa marginal das transferências maiores que o SM; e (iii) associações entre as transferências maiores, iguais e menores que o SM. (2) Os valores não totalizam 100% por não contemplar todos os fatores determinantes da redução da pobreza e da concentração de renda, tal como apresentado na figura 3 e no Anexo deste Relatório.

Parte da explicação do efeito estimado no Gráfico 32 é decorrente da relevância que essas transferências representam no orçamento do governo. Dado tudo mais constante, se o percentual dispendido com um tipo de gasto for menor que os demais, seu efeito tende a ser prejudicado em relação aos outros gastos. De acordo com o gráfico 33, no início do período analisado, os gastos com aposentadorias e pensões superiores ao salário mínimo representavam 73,4% das transferências governamentais diretas57, enquanto o gasto com transferências sociais diretas era responsável por 26,6% do gasto com transferências governamentais diretas, sendo 23,7% com transferências de valor igual ao salário mínimo, 2,1% com transferências de valor menor que o salário mínimo e 0,8% com transferências de valor maior que o salário mínimo.

Considerando a evolução das participações ao longo do período analisado, percebe-se uma tendência de aumento relativo do gasto com transferência social direta, com destaque para os valores iguais ao salário mínimo, em detrimento das 57 Inclui, além das transferências sociais diretas, os gastos com aposentadorias e pensões superiores ao salário mínimo.

21%

42%

66%11%

7%

3%62%

37%

12%

0%

10%

20%

30%

40%

50%

60%

70%

80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Transferências sociais diretas menor que 1 SM Transferências sociais diretas maior ou igual ao SMrenda do trabalho

Renda Transf Renda Transf Renda Transf Trabalho Sociais Diretas Trabalho Sociais Diretas Trabalho Sociais Diretas

32%

49%

69%

Proporção Hiato Severidade

9

3. Análise Geral da Evolução do Gasto Social A partir do exposto nos capítulos anteriores, a base de dados criada permite decompor o gasto social sob diferentes óticas, o que enriquece o estudo e proporciona uma análise em diferentes perspectivas. Neste capítulo será feita uma análise geral dos dados, enquanto que os capítulos posteriores farão uma análise mais aprofundada das categorias consideradas como tendo natureza social.

Uma ressalva inicial torna-se necessária: daqui em diante será adotado o conceito de gasto social direto como sendo aquele que é executado diretamente pelo Governo Central, bem como as transferências vinculadas a gastos sociais realizadas por essa esfera de governo aos governos estaduais e municipais. De outro lado, conforme destacado no capítulo anterior, foram também levados em consideração os gastos tributários de caráter social implementados pelo Governo Central brasileiro.

Gráfico 1 – Composição dos gastos do Governo Central – Gastos diretos e tributários - Brasil – 2002 a 2015 – % dos gastos totais

Fonte: SIAFI/SIDOR, Demonstrativos dos Gastos Tributários - DGT.

Os gráficos acima mostram o aumento da participação dos gastos considerados de caráter social no montante total da despesa do Governo Central. Pode-se observar que os gastos sociais passaram a corresponder a 67,3% do total da despesa em 2015, frente a 59,9% em 2002. Em relação aos gastos tributários, o aumento da participação dos gastos sociais foi ainda mais significativo, passando de 17,0% em 2002 para 38,6% em 2015.

Gráfico 2 – Gasto social do Governo Central – Gastos diretos e tributários – Brasil – 2002 a 2015 – % PIB

Fonte: SIAFI/SIDOR, Demonstrativos dos Gastos Tributários - DGT.

12,6% 12,4% 12,8% 13,4% 13,6% 13,6% 13,3% 14,4% 14,0% 14,0% 14,5% 14,6% 15,2% 15,7%

0,3% 0,2% 0,4% 0,5% 0,6% 0,7% 0,7%1,1% 1,0% 1,0% 1,3% 1,3%

1,8% 1,8%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Gasto Direto Gasto Tributário

60% 64% 64% 64% 64% 64% 62% 66% 65% 66% 68% 69% 68% 67%

40% 36% 36% 36% 36% 36% 38% 34% 35% 34% 32% 31% 32% 33%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Gastos Diretos

Gasto social Gasto não social

17% 15%36% 37% 32% 35% 30% 29% 28% 32% 35% 33% 40% 39%

83% 85%64% 63% 68% 65% 70% 71% 72% 68% 65% 67% 60% 61%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Gastos Tributários

Tributário Social Tributário Não Social

11

Categorias 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Trabalho e Emprego 0,5% 0,5% 0,5% 0,6% 0,7% 0,7% 0,7% 0,9% 0,8% 0,8% 0,8% 0,9% 1,4% 1,2%

Gasto direto 0,5% 0,5% 0,5% 0,6% 0,7% 0,7% 0,7% 0,9% 0,8% 0,8% 0,8% 0,9% 0,9% 0,8%

Gasto tributário 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,4% 0,4%

Total 12,8% 12,6% 13,2% 13,9% 14,2% 14,2% 14,1% 15,4% 14,9% 15,0% 15,8% 15,8% 17,0% 17,5%

Gasto direto 12,6% 12,4% 12,8% 13,4% 13,6% 13,6% 13,3% 14,4% 14,0% 14,0% 14,5% 14,6% 15,2% 15,7%

Gasto tributário 0,3% 0,2% 0,4% 0,5% 0,6% 0,7% 0,7% 1,1% 1,0% 1,0% 1,3% 1,3% 1,8% 1,8% Fonte: SIAFI/SIDOR, Demonstrativos dos Gastos Tributários – DGT, IBGE. Notas:

1. Inclui a execução orçamentária do Fundo de Financiamento Estudantil (FIES). Importante destacar que o FIES não é, por definição, uma despesa direta, mas sim uma inversão financeira, ou seja, um empréstimo que o Governo Central faz aos estudantes, e que deverá ser quitado por eles no futuro.

2. Inclui a emissão de Títulos da Dívida Agrária - TDA.

Cabe salientar que foram incluídos na categoria Previdência Social os dois regimes previdenciários mais comuns no Brasil (Regime Geral de Previdência Social – RGPS e Regime Próprio de Previdência Social – RPPS). Ainda, em termos de distribuição do gasto social direto entre as suas rubricas, pode-se constatar pela Tabela 2 que essa categoria sempre representou percentual superior a 50% do total dispendido pelo governo brasileiro com os gastos sociais, apesar de nos últimos anos da série ser possível visualizar um decréscimo nessa categoria, compensado pelo acréscimo na participação dos gastos com Assistência Social e Educação e Cultura.

Tabela 2 – Composição do gasto social do Governo Central – Brasil – 2002 a 2015 – % do total (diretos e tributários)

Categorias 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Assistência Social 3,7% 4,4% 6,0% 6,4% 6,9% 7,2% 7,4% 8,6% 9,0% 8,7% 8,9% 9,3% 8,9% 8,8%

Educação e Cultura 13,2% 12,3% 11,5% 11,2% 11,3% 12,2% 13,0% 13,0% 13,7% 14,3% 14,7% 14,7% 15,3% 15,4%

Organização Agrária 1,5% 1,2% 2,1% 2,0% 1,9% 1,8% 1,2% 1,2% 0,8% 1,0% 0,8% 0,8% 0,5% 1,2%

Previdência Social 62,3% 64,7% 62,7% 63,7% 62,4% 60,6% 59,3% 57,4% 57,1% 56,1% 54,9% 54,7% 52,3% 53,2%

Saneamento Básico e Habitação

1,1% 0,5% 0,6% 0,5% 0,5% 0,7% 1,2% 1,5% 1,3% 2,1% 2,6% 2,7% 2,7% 2,8%

Saúde 14,0% 12,8% 13,4% 12,2% 12,4% 12,6% 12,8% 12,7% 12,6% 12,3% 12,7% 12,3% 12,2% 11,8%


Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Fonte: SIAFI/SIDOR, Demonstrativos dos Gastos Tributários – DGT.

Na seção 4.4 deste trabalho será aprofundada a análise do gasto social com Previdência Social e serão apresentadas duas óticas de análise do gasto direto chamadas de “visão geral” e “visão restrita”. Na visão geral foram computados todos os dispêndios diretos realizados com Previdência Social, enquanto que na visão restrita são consideradas apenas as parcelas dos benefícios de características previdenciárias que não superam o limite de um salário mínimo por mês. Esse corte se justifica porque muitos beneficiários recebem valores acima do que seria necessário para prover o acesso a bens

11

Categorias 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015


Gasto direto 0,5% 0,5% 0,5% 0,6% 0,7% 0,7% 0,7% 0,9% 0,8% 0,8% 0,8% 0,9% 0,9% 0,8%

Gasto tributário 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,4% 0,4%

Total 12,8% 12,6% 13,2% 13,9% 14,2% 14,2% 14,1% 15,4% 14,9% 15,0% 15,8% 15,8% 17,0% 17,5%

Gasto direto 12,6% 12,4% 12,8% 13,4% 13,6% 13,6% 13,3% 14,4% 14,0% 14,0% 14,5% 14,6% 15,2% 15,7%

Gasto tributário 0,3% 0,2% 0,4% 0,5% 0,6% 0,7% 0,7% 1,1% 1,0% 1,0% 1,3% 1,3% 1,8% 1,8% Fonte: SIAFI/SIDOR, Demonstrativos dos Gastos Tributários – DGT, IBGE. Notas:

1. Inclui a execução orçamentária do Fundo de Financiamento Estudantil (FIES). Importante destacar que o FIES não é, por definição, uma despesa direta, mas sim uma inversão financeira, ou seja, um empréstimo que o Governo Central faz aos estudantes, e que deverá ser quitado por eles no futuro.

2. Inclui a emissão de Títulos da Dívida Agrária - TDA.

Cabe salientar que foram incluídos na categoria Previdência Social os dois regimes previdenciários mais comuns no Brasil (Regime Geral de Previdência Social – RGPS e Regime Próprio de Previdência Social – RPPS). Ainda, em termos de distribuição do gasto social direto entre as suas rubricas, pode-se constatar pela Tabela 2 que essa categoria sempre representou percentual superior a 50% do total dispendido pelo governo brasileiro com os gastos sociais, apesar de nos últimos anos da série ser possível visualizar um decréscimo nessa categoria, compensado pelo acréscimo na participação dos gastos com Assistência Social e Educação e Cultura.

Tabela 2 – Composição do gasto social do Governo Central – Brasil – 2002 a 2015 – % do total (diretos e tributários)

Categorias 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Assistência Social 3,7% 4,4% 6,0% 6,4% 6,9% 7,2% 7,4% 8,6% 9,0% 8,7% 8,9% 9,3% 8,9% 8,8%

Educação e Cultura 13,2% 12,3% 11,5% 11,2% 11,3% 12,2% 13,0% 13,0% 13,7% 14,3% 14,7% 14,7% 15,3% 15,4%

Organização Agrária 1,5% 1,2% 2,1% 2,0% 1,9% 1,8% 1,2% 1,2% 0,8% 1,0% 0,8% 0,8% 0,5% 1,2%

Previdência Social 62,3% 64,7% 62,7% 63,7% 62,4% 60,6% 59,3% 57,4% 57,1% 56,1% 54,9% 54,7% 52,3% 53,2%

Saneamento Básico e Habitação

1,1% 0,5% 0,6% 0,5% 0,5% 0,7% 1,2% 1,5% 1,3% 2,1% 2,6% 2,7% 2,7% 2,8%

Saúde 14,0% 12,8% 13,4% 12,2% 12,4% 12,6% 12,8% 12,7% 12,6% 12,3% 12,7% 12,3% 12,2% 11,8%


Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Fonte: SIAFI/SIDOR, Demonstrativos dos Gastos Tributários – DGT.

Na seção 4.4 deste trabalho será aprofundada a análise do gasto social com Previdência Social e serão apresentadas duas óticas de análise do gasto direto chamadas de “visão geral” e “visão restrita”. Na visão geral foram computados todos os dispêndios diretos realizados com Previdência Social, enquanto que na visão restrita são consideradas apenas as parcelas dos benefícios de características previdenciárias que não superam o limite de um salário mínimo por mês. Esse corte se justifica porque muitos beneficiários recebem valores acima do que seria necessário para prover o acesso a bens

ComposiçãodogastosocialdoGovernoCentral–Brasil–2015–%dototal(diretosetributários)

47

Período Gastos Diretos % Total Gastos Tributários % Total Total Saúde

2014 104,1 79,9% 26,2 20,1% 130,2 2015 97,0 79,5% 25,0 20,5% 122,0

Fonte: SIAFI/SIDOR, FGV.

Os gastos com saúde como proporção do PIB oscilaram entre 1,6% e 2,1% no período estudado conforme pode ser observado no gráfico 13. A relativa estabilidade desses gastos como percentual do PIB explica-se pela Emenda Constitucional nº 29/2000, que prevê que o volume de recursos a serem aplicados pela União em ações e serviços públicos de saúde (ASPS) deve ser corrigido anualmente por, pelo menos, a variação do PIB nominal do ano anterior. Ou seja, esta medida legal estabeleceu um piso para a variação do gasto com saúde. Na prática, as variações nominais do PIB e as variações da despesa executada com ASPS não se distanciaram muito (com exceção do ano de 2009) no período estudado. Apesar disso, pode-se identificar tendência de crescimento nesta rubrica.

Em relação aos gastos tributários em saúde, observou-se crescimento real de 374,9% entre 2002 e 2015 em termos reais, atingindo o montante de R$ 25,0 bilhões em 2015 (0,4 % do PIB), sendo, dentre outros, R$ 11,9 bilhões mediante deduções das despesas médicas do Imposto de Renda Pessoa Física – IRPF; R$ 4,3 bilhões destinados à assistência médica, odontológica e farmacêutica a empregados; e R$ 4,1 bilhões destinados a medicamentos.

Gráfico 13 – Evolução do gasto com saúde – Brasil – 2002 a 2015 – % do PIB

Fonte: SIAFI/SIDOR, IBGE.

A tabela 37 detalha os gastos tributários com saúde para a série histórica em estudo.

Tabela 37 – Gasto tributário com saúde – Brasil – 2002 a 2015 - R$ Milhões – A preços de dezembro de 2015 (IGP-DI)

Categoria 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Despesas Médicas 5.272 2.650 3.228 3.584 3.648 3.741 4.660 4.754 4.576 5.778 11.777 11.344 11.873 11.859 Assistência Médica, Odontológica e Farmacêutica a Empregados

- - 1.287 1.339 1.737 3.102 2.967 3.567 4.075 3.848 3.818 3.964 4.123 4.280

Entidades Sem Fins Lucrativos - Assistência Social e Saúde

- - 2.300 1.742 2.102 2.699 2.521 3.169 3.560 2.829 3.104 3.147 3.170 3.448

Medicamentos - 1.775 1.801 2.579 3.035 3.207 3.296 7.748 3.451 3.878 4.223 3.944 4.635 4.106

Demais - - - - - - - - 1.309 1.360 1.143 1.630 2.388 1.342

Total 5.272 4.425 8.616 9.245 10.522 12.749 13.443 19.238 16.972 17.694 24.065 24.030 26.189 25.035 Fonte: Demonstrativos dos Gastos Tributários – DGT, FGV.

1,65% 1,50% 1,53% 1,47% 1,51% 1,52% 1,51% 1,58% 1,56% 1,54% 1,59% 1,56% 1,65% 1,64%

0,16%0,12% 0,24% 0,23% 0,25% 0,28% 0,29%

0,38% 0,32% 0,31% 0,41% 0,39%0,42% 0,42%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Gasto direto Gasto tributário

47


2014 104,1 79,9% 26,2 20,1% 130,2 2015 97,0 79,5% 25,0 20,5% 122,0








Categoria 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015


- - 1.287 1.339 1.737 3.102 2.967 3.567 4.075 3.848 3.818 3.964 4.123 4.280


- - 2.300 1.742 2.102 2.699 2.521 3.169 3.560 2.829 3.104 3.147 3.170 3.448

Medicamentos - 1.775 1.801 2.579 3.035 3.207 3.296 7.748 3.451 3.878 4.223 3.944 4.635 4.106

Demais - - - - - - - - 1.309 1.360 1.143 1.630 2.388 1.342


1,65% 1,50% 1,53% 1,47% 1,51% 1,52% 1,51% 1,58% 1,56% 1,54% 1,59% 1,56% 1,65% 1,64%

0,16%0,12% 0,24% 0,23% 0,25% 0,28% 0,29%

0,38% 0,32% 0,31% 0,41% 0,39%0,42% 0,42%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015


47


2014 104,1 79,9% 26,2 20,1% 130,2 2015 97,0 79,5% 25,0 20,5% 122,0








Categoria 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015


- - 1.287 1.339 1.737 3.102 2.967 3.567 4.075 3.848 3.818 3.964 4.123 4.280


- - 2.300 1.742 2.102 2.699 2.521 3.169 3.560 2.829 3.104 3.147 3.170 3.448

Medicamentos - 1.775 1.801 2.579 3.035 3.207 3.296 7.748 3.451 3.878 4.223 3.944 4.635 4.106

Demais - - - - - - - - 1.309 1.360 1.143 1.630 2.388 1.342


1,65% 1,50% 1,53% 1,47% 1,51% 1,52% 1,51% 1,58% 1,56% 1,54% 1,59% 1,56% 1,65% 1,64%

0,16%0,12% 0,24% 0,23% 0,25% 0,28% 0,29%

0,38% 0,32% 0,31% 0,41% 0,39%0,42% 0,42%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015


1


2002 a 2015

Apresentação




Sumário Executivo




NACIONAL


PLANEJAMENTO E



ESTUDOS ECONÔMICO-

FISCAIS – CESEF


Guilherme Ceccato


1


2002 a 2015

Apresentação




Sumário Executivo




NACIONAL


PLANEJAMENTO E



ESTUDOS ECONÔMICO-

FISCAIS – CESEF


Guilherme Ceccato


Estimativasdealgunsimpactosnasaúde

Comodesenvolverummodelopreditor dacrise?• Quaisvariáveissociaisserãoafetadas?• Porquantosanos?• Emqualtendência?• Comoseráadistribuiçãonosmunicípios(modeloheterogêneo)?

• Qualoefeitododecréscimodofinanciamento(reduçãodacobertura,reduçãodaqualidadedosserviços,aumentodaeficiênciadogasto)?

‘Medicine is a social science, and politics is nothing else butmedicine on a large scale. Medicine...has the obligation topoint out problems and to attempt their theoreticalsolution...The physicians are the natural attorneys of the poor, and social problems fall to a large extent within theirjurisdiction.’

’Thedominant strategy is to dowhatever is necessary to protectoneself against the losses threatened by highand erraticinflation...This is aworldofmauve qui put,and playing this gamereinforcesthe very conditions under which itis played.Thefirst,morebasicphenomenon is generalized desolidarization.’

VIRCHOW

REILLY,R.Gregory;MCKEE,Martin.Decipio’:Examining Virchow inthecontext of modern ‘democracy. Publichealth,v.126,n.4,p.303-307,2012.

O’DONNELL

O'DONNELL,Guillermo.On thestate,democratization and someconceptualproblems:ALatinAmericanview with glances atsomepostcommunistcountries.WorldDevelopment,v.21,n.8,p.1355-1369,1993.

renda, menor proteção social e maior privação material ... · wal rdy h pw mu l earnh ow tus...

Documents