Este trabalho tem como escopo o estudo da sistemática de financiamento da saúde pública no ordenamento jurídico brasileiro. Inicialmente, firmam-se premissas acerca dos direitos fundamentais, em especial do direito à saúde, cuja efetivação demanda análises financeiro-orçamentárias. Neste sentido, são trabalhados conceitos como o de custo dos direitos, solidariedade tributária, escassez de recursos, reserva do possível e escolhas trágicas. Após, analisam-se os instrumentos tributários por meio dos quais a sociedade brasileira transfere ao Estado parte de suas riquezas para o custeio da saúde pública, bem como os instrumentos tributários que, utilizando-se da extrafiscalidade, sobreoneram ou desoneram situações ou pessoas buscando induzir comportamentos sociais favoráveis à efetivação do direito à saúde, perquirindo, ademais, as consequências destas medidas no que tange à saúde pública. Examina-se, ainda, o arranjo federativo brasileiro no tocante à repartição da receita pública entre os entes federativos, para que, em seus respectivos âmbitos de atuação, implementem tal direito social. Nesta senda, estuda-se o papel fundamental do Fundo Nacional de Saúde e das Transferências Fundo a Fundo no que tange à gestão financeira dos recursos do SUS e à busca pela redução das desigualdades regionais no que toca à qualidade na prestação das ações e serviços públicos de saúde. Investigam-se, também, os mecanismos orçamentários por meio dos quais o ordenamento jurídico brasileiro vincula a receita de determinados tributos ao gasto sob a rubrica da saúde pública, e obriga o poder público a incorrer em despesas mínimas obrigatórias com a saúde, formando o denominado orçamento mínimo da saúde. Finalmente, são levantados os gargalos atualmente existentes no Brasil, e que maculam a lógica jurídica do financiamento da saúde pública. / This thesis aims to analyze the Brazilian public health funding system. Initially, premises about the human rights are signed up, especially the right to health, whose effectiveness demands a budgetary analysis. In this regard, concepts as cost of rights, tax solidarity, scarcity of resources, under reserve of the possibilities, and tragic choices are worked. Afterward, the tax instruments by which the Brazilian society transfers to the State portion of their wealth to fund the public health are analyzed, as well as the tax instruments that, using the extrafiscality, overburden or lessburden situations or people seeking social behaviors favorable to the implementation of the right to health, looking for, moreover, the consequences of these measures in relation to public health. This work examines, also, the Brazilian federal arrangement concerning the allocation of public revenue amongst the federal entities so that within their respective spheres of action implement this social right. In this sense, this research study the role of the National Health Fund and the Fund to Fund Transfers regarding the financial management of SUSs resources and the pursuit of regional inequalities reduction, concerning the quality in the public health services. Also Investigates the budgetary mechanisms through which the Brazilian legal system binds certain public revenue to predetermined public expenditures in public health, and compels the government to incur in minimum expenditures on health, forming the so-called minimum budget of health. Finally, this research raises problems that currently exist in Brazil, and that taint the logic of the public health funding.

Este trabalho tem como escopo o estudo da sistemática de financiamento da saúde pública no ordenamento jurídico brasileiro. Inicialmente, firmam-se premissas acerca dos direitos fundamentais, em especial do direito à saúde, cuja efetivação demanda análises financeiro-orçamentárias. Neste sentido, são trabalhados conceitos como o de custo dos direitos, solidariedade tributária, escassez de recursos, reserva do possível e escolhas trágicas. Após, analisam-se os instrumentos tributários por meio dos quais a sociedade brasileira transfere ao Estado parte de suas riquezas para o custeio da saúde pública, bem como os instrumentos tributários que, utilizando-se da extrafiscalidade, sobreoneram ou desoneram situações ou pessoas buscando induzir comportamentos sociais favoráveis à efetivação do direito à saúde, perquirindo, ademais, as consequências destas medidas no que tange à saúde pública. Examina-se, ainda, o arranjo federativo brasileiro no tocante à repartição da receita pública entre os entes federativos, para que, em seus respectivos âmbitos de atuação, implementem tal direito social. Nesta senda, estuda-se o papel fundamental do Fundo Nacional de Saúde e das Transferências Fundo a Fundo no que tange à gestão financeira dos recursos do SUS e à busca pela redução das desigualdades regionais no que toca à qualidade na prestação das ações e serviços públicos de saúde. Investigam-se, também, os mecanismos orçamentários por meio dos quais o ordenamento jurídico brasileiro vincula a receita de determinados tributos ao gasto sob a rubrica da saúde pública, e obriga o poder público a incorrer em despesas mínimas obrigatórias com a saúde, formando o denominado orçamento mínimo da saúde. Finalmente, são levantados os gargalos atualmente existentes no Brasil, e que maculam a lógica jurídica do financiamento da saúde pública. / This thesis aims to analyze the Brazilian public health funding system. Initially, premises about the human rights are signed up, especially the right to health, whose effectiveness demands a budgetary analysis. In this regard, concepts as cost of rights, tax solidarity, scarcity of resources, under reserve of the possibilities, and tragic choices are worked. Afterward, the tax instruments by which the Brazilian society transfers to the State portion of their wealth to fund the public health are analyzed, as well as the tax instruments that, using the extrafiscality, overburden or lessburden situations or people seeking social behaviors favorable to the implementation of the right to health, looking for, moreover, the consequences of these measures in relation to public health. This work examines, also, the Brazilian federal arrangement concerning the allocation of public revenue amongst the federal entities so that within their respective spheres of action implement this social right. In this sense, this research study the role of the National Health Fund and the Fund to Fund Transfers regarding the financial management of SUSs resources and the pursuit of regional inequalities reduction, concerning the quality in the public health services. Also Investigates the budgetary mechanisms through which the Brazilian legal system binds certain public revenue to predetermined public expenditures in public health, and compels the government to incur in minimum expenditures on health, forming the so-called minimum budget of health. Finally, this research raises problems that currently exist in Brazil, and that taint the logic of the public health funding.

Local Health Departments (LHDs) are administrative unit of a local or state government, concerned with the health of a community or county. There are approximately 2,800 agencies or units that meet the profile definition of LHD. These LHDs vary in size and composition depending on the population they serve. However, all these communitybased agencies share a common mission of “protecting and improving community wellbeing by preventing disease, illness, and injury while impacting social, economic, and environmental factors fundamental to excellent health”. One of the ongoing challenge of a focus on community-level, population-based prevention is the manner in which local public health agencies have been funded. Most LHDs funding comes from federal funds, supplemented by state and local funds. Many of these funds come to LHDs through competitive grants programs. This study was therefore undertaken to investigate the sources of funding for the Local Public Health Agencies, according to geography specifically rurality. We utilized the data already compiled by the National Association of County & City Health Officials (NACCHO) in 2013. The population served by these health agencies were compared to the funding sources, and one –way ANOVA to estimate the significance between these variables. Our dependent variables were assigned to be the funding sources, while the independent variables were the two population categories –rural and urban. A categorical variable reflecting three levels of rurality was constructed using RUCA codes. “Urban” included census tracts with towns with populations >50,000. “Large rural” included census tracts with towns of between 10,000 and 49,999 population and census tracts tied to these towns through commuting. “Small rural” included census tracts with small towns of fewer than 10,000 population, tracts tied to small towns, and isolated census tracts. Furthermore, we also determined the proportion of revenue from these funding sources received by these three population groups. All analyses were completed using SPSS. There were no differences in the amount of revenues received by both the large and small rural and urban agencies from the State & Federal sources (p value = 0.182). However, urban agencies receive more funding from Medicare and Medicaid services (19.9%) compared to small rural with 6.9% (p<0.001). Comparatively, the amount of revenue generated by rural agencies is just a fraction of what the urban agencies generate. Residents of rural areas in the United States tend to be older and poorer, report more risky health behaviors, have more barriers to accessing health care, and have worse health status and health outcomes than do their urban counterparts. These rural LHDs have fewer resources and face strenuous challenges in carrying out their activities of keeping the community safe due to limited revenues. Until public health agencies are firmly connected to payment and funding mechanisms across the health system, communities, the overall health system and accountable care organizations will not see the true benefits of population-focused, community-based, prevention services.