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Bigoni A, Malik AM, Tasca R, Carrera MBM, Schiesari LMC, Gambardella DD, Massuda A. Brazil's health system functionality amidst of the COVID-19 pandemic: An analysis of resilience. LANCET REGIONAL HEALTH. AMERICAS 2022; 10:100222. [PMID: 35284904 PMCID: PMC8896985 DOI: 10.1016/j.lana.2022.100222] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background As of December 31, 2020, Brazil had the second-highest burden of COVID-19 worldwide. Given the absence of federal government coordination, it was up to the local governments to maintain healthcare provision for non-COVID health issues. In this descriptive study, we aimed to discuss the SUS functionality and resilience, describing the impact of the pandemic on non-COVID health services delivery while considering the regional inequalities of the allocation of financing health system, health infrastructure and health workforce. Methods We used input-output framework based on the World Health Organization (WHO) Health System Building Blocks to estimate health system functionality and resilience. An ecological assessment was designed to calculated mean relative changes to compare the first year of the pandemic in Brazil with the previous one. All data used in this study were anonymized and made available by the Brazilian Ministry of Health. Input indicators were categorized in health system financing (federal funding received as well as expenditure of both state and city governments), health system's infrastructure (hospital beds) and health workforce (healthcare workers positions). Output indicators were categorized into nine different groups of service delivery procedures. To explore the relationship between the variation in procedures with socioeconomic conditions, we used the Socioeconomic Vulnerability Index (SVI). Findings State governments had a 38·6% increase in federal transfers, while municipal governments had a 33·9% increase. The increase of ICU beds reached its peak in the third quarter of 2020, averaging 72·1% by the end of the year. The country also saw an increase in jobs for registered nurses (13·6%), nurse assistants (8·5%), physiotherapists (7·9%), and medical doctors (4·9%). All procedures underwent expressive reduction: Screenings (−42·6%); Diagnostic procedures (−28·9%); Physician appointments (−42·5%); Low and medium complexity surgeries (−59·7%); High complexity surgeries (−27·9%); Transplants (−44·7%); Treatments and clinical procedures due to injuries of external causes (−19·1%); Irrepressible procedures (−8·5%); and Childbirths (−12·6%). The most significant drop in procedures happened in the first quarter of the pandemic, followed by progressive increase; most regions had not yet recovered by the end of 2020. State-level changes in numbers of procedures point towards a negative trend with SVI. Interpretation The Brazilian Government did not consider that socioeconomically vulnerable states were at a higher risk of being impacted by the overburden of the health system caused by the COVID-19, which resulted in poorer health system functionality for those vulnerable states. The lack of proper planning to improve health system resilience resulted in the decrease of a quarter of the amount of healthcare procedures increasing the already existing health disparities in the country. Funding MCTIC/CNPQ/FNDCT/MS/SCTIE/DECIT No 07/2020.
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Affiliation(s)
- Alessandro Bigoni
- São Paulo School of Business Administration, Fundação Getulio Vargas, Avenida Dr Arnaldo 715, São Paulo, SP CEP-01246-904, Brazil
- School of Public Health – University of São Paulo, São Paulo, SP, Brazil
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Corresponding author at: School of Public Health - University of São Paulo, Avenida Dr Arnaldo 715, São Paulo, SP CEP-01246-904, Brazil.
| | - Ana Maria Malik
- São Paulo School of Business Administration, Fundação Getulio Vargas, Avenida Dr Arnaldo 715, São Paulo, SP CEP-01246-904, Brazil
| | - Renato Tasca
- São Paulo School of Business Administration, Fundação Getulio Vargas, Avenida Dr Arnaldo 715, São Paulo, SP CEP-01246-904, Brazil
| | - Mariana Baleeiro Martins Carrera
- São Paulo School of Business Administration, Fundação Getulio Vargas, Avenida Dr Arnaldo 715, São Paulo, SP CEP-01246-904, Brazil
| | - Laura Maria Cesar Schiesari
- São Paulo School of Business Administration, Fundação Getulio Vargas, Avenida Dr Arnaldo 715, São Paulo, SP CEP-01246-904, Brazil
| | - Dante Dianezi Gambardella
- São Paulo School of Business Administration, Fundação Getulio Vargas, Avenida Dr Arnaldo 715, São Paulo, SP CEP-01246-904, Brazil
- Real e Benemérita Associação Portuguesa de Beneficência, São Paulo, SP, Brazil
| | - Adriano Massuda
- São Paulo School of Business Administration, Fundação Getulio Vargas, Avenida Dr Arnaldo 715, São Paulo, SP CEP-01246-904, Brazil
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Lopes MCC, Oliva CCC, Bezerra NMS, Silva MT, Galvão TF. Relationship between depressive symptoms, burnout, job satisfaction and patient safety culture among workers at a university hospital in the Brazilian Amazon region: cross-sectional study with structural equation modeling. SAO PAULO MED J 2022; 140:412-421. [PMID: 35508009 PMCID: PMC9671242 DOI: 10.1590/1516-3180.2021.0614.15092021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Workplaces can be sources of mental distress. In healthcare services, this can also affect patients. OBJECTIVE To assess the prevalence of and factors associated with depressive symptoms, burnout, job satisfaction and patient safety culture and the relationships between these constructs, among healthcare workers. DESIGN AND SETTING Cross-sectional study in a university hospital in Manaus, Brazil. METHODS Randomly selected workers were interviewed based on Brazilian-validated tools. We calculated the prevalence ratio (PR) and 95% confidence interval (CI) of depressive symptoms and burnout using Poisson regression with robust variance; and the β-coefficient of safety culture and job satisfaction using linear regression. Outcome relationships were assessed using partial least-squares structural equation modeling. RESULTS 300 professionals were included; 67.3% were women. The prevalence of depressive symptom was 19.0% (95% CI: 14.5; 23.5%) and burnout, 8.7% (95% CI: 5.2; 12.3%). Lack of work stability increased depression (PR = 1.88; 95% CI: 1.17; 3.01) and burnout (PR = 2.17; 95% CI: 1.03; 4.57); and reduced job satisfaction (β = -11.93; 95% CI: -18.79; -5.07). Depressive symptoms and burnout were positively correlated, as also were job satisfaction and safety culture (P < 0.001); job satisfaction was negatively correlated with burnout (P < 0.001) and depression (P = 0.035). CONCLUSION Impermanent employment contracts increased depression and burnout and reduced job satisfaction. Job satisfaction reduced poor mental health outcomes and increased safety culture. Job satisfaction and safety culture were directly proportional (one construct increased the other and vice versa), as also were depression and burnout. Better working conditions can provide a virtuous cycle of patient safety and occupational health.
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Affiliation(s)
- Marcélia Célia Couteiro Lopes
- MSc. Pharmacist, Postgraduate Pharmaceutical Sciences Program, Universidade Federal do Amazonas (UFAM), Manaus (AM), Brazil.
| | - Carmen Conceição Carrilho Oliva
- MSc. Pharmacist, Postgraduate Pharmaceutical Sciences Program, Universidade Federal do Amazonas (UFAM), Manaus (AM), Brazil.
| | - Nádia Maria Soares Bezerra
- MBA. Health Inspector, Department of Health Surveillance, Municipal Health Department of Manaus, Manaus (AM), Brazil.
| | - Marcus Tolentino Silva
- MSc, PhD. Professor, Postgraduate Pharmaceutical Sciences Program, Universidade de Sorocaba (UNISO), Sorocaba (SP), Brazil.
| | - Tais Freire Galvão
- MSc, PhD. Professor, School of Pharmaceutical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
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Tiguman GMB, Silva MT, Galvão TF. Health services utilization in the Brazilian Amazon: panel of two cross-sectional studies. Rev Saude Publica 2022; 56:2. [PMID: 35239925 PMCID: PMC8849293 DOI: 10.11606/s1518-8787.2022056003663] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/19/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the use of health services among adults living in Manaus, Amazonas. METHODS This was a panel of two cross-sectional studies conducted in Manaus in 2015 and 2019. Individuals aged ≥ 18 years were selected by probabilistic sampling and interviewed at home. The study outcomes were doctor visits and hospitalizations in the previous 12 months, and unmet surgical needs. Variations between 2015 and 2019 were tested using chi-squared goodness-of-fit test. Poisson regression with robust variance was employed to calculate the prevalence ratios (PR) of the outcomes with 95% confidence intervals (95%CI). RESULTS The surveys included 5,800 participants in total. Visits to the doctor decreased from 2015 (78.7%) to 2019 (76.3%; p < 0.001), hospital admissions increased from 2015 (7.9%) to 2019 (11.5%; p < 0.001), and unmet surgical needs decreased in the period (15.9% to 12.1%; p < 0.001). These variations were particularly observed in vulnerable individuals – sicker; poorer; non-whites; and those belonging to lower social classes, with less access to education, formal jobs, and health insurance (p < 0.05). Doctor visits were higher in people with fair health status (PR = 1.09; 95%CI 1.06–1.12), health insurance (PR = 1.13; 95%CI 1.09–1.17), and chronic diseases (p < 0.001) but lower in men (PR = 0.87; 95%CI 0.84–0.90) and informal workers (PR = 0.89; 95%CI 0.84–0.94). Hospitalizations were higher in people with worse health statuses (p < 0.001), without partners (PR = 1.27; 95%CI 1.05–1.53), and with multimorbidity (PR = 1.68; 95%CI 1.33–2.12) but lower in men (PR = 0.55; 95%CI 0.44–0.68), older adults (p < 0.001), informal workers (PR = 0.67; 95%CI 0.51–0.89), and unemployed (PR = 0.72; 95%CI 0.53–0.97). Unmet surgical needs were higher in older adults (p < 0.001), middle-class people (PR = 1.24; 95%CI 1.01–1.55), worse health statuses (p < 0.001), and chronic diseases (p < 0.001) but lower in men (PR = 0.76; 95%CI 0.65–0.86). CONCLUSIONS From 2015 to 2019, less people visited the doctor, more were admitted to hospitals, and less were in need of surgery or aware of that need, potentially indicating poorer access to health services.
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Affiliation(s)
| | - Marcus Tolentino Silva
- Universidade de Sorocaba. Programa de Pós-Graduação em Ciências Farmacêuticas. Sorocaba, São Paulo, Brasil
| | - Taís Freire Galvão
- Universidade Estadual de Campinas. Faculdade de Ciências Farmacêuticas. Campinas, São Paulo, Brasil
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Baldin Tiguman GM, Silva MT, Galvao TF. Use and self-medication with antibiotics among adults in the Brazilian Amazon: a panel of two cross-sectional studies, 2015 and 2019. Expert Rev Anti Infect Ther 2020; 18:1263-1270. [PMID: 32700582 DOI: 10.1080/14787210.2020.1798228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to investigate the prevalence of antibiotics use and self-medication among adults living in Manaus, Amazonas in 2015 and 2019. RESEARCH DESIGN AND METHODS Analysis of two cross-sectional studies conducted in Manaus in 2015 and 2019. Adults aged ≥18 years were interviewed at home following a three-phase probabilistic sampling (census tracts, household, and individual). Primary outcome was the use of antibiotics in the previous 15 days. Poisson regression with robust variance was employed to calculate the prevalence ratios (PR) of antibiotics use adjusted by independent variables. RESULTS The prevalence of antibiotics use in the previous fortnight was 3.7% (95%CI 3.1-4.4%; n=3,479) in 2015 and 8.0% (95%CI 6.7-9.3%; n=2,321) in 2019. Self-medication increased from 19.2% (95%CI 12.4-26.0%; n=130) in 2015 to 30.7% (95%CI 22.5-38.8%; n=187) in 2019. Beta-lactams were the most used (252/317) and self-medicated (60/317) antibiotics in both surveys. Use of antibiotics was higher in 2019 (PR=2.05; 95%CI 1.60-2.64) compared to 2015 and among women (PR=1.66; 95%CI 1.16-2.39) compared to men. CONCLUSIONS Antibiotics use and self-medication in Manaus increased from 2015 to 2019. Enforcement of health regulation is needed to improve compliance and minimize potential risks.
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Affiliation(s)
| | - Marcus Tolentino Silva
- Post-Graduate Program of Pharmaceutical Sciences, University of Sorocaba , Sorocaba, Brazil
| | - Tais Freire Galvao
- Faculty of Pharmaceutical Sciences, State University of Campinas , Campinas, Brazil
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Francesconi GV, Tasca R, Basu S, Rocha TAH, Rasella D. Mortality associated with alternative policy options for primary care and the Mais Médicos (More Doctors) Program in Brazil: forecasting future scenarios. Rev Panam Salud Publica 2020; 44:e31. [PMID: 32256546 PMCID: PMC7111268 DOI: 10.26633/rpsp.2020.31] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 05/17/2019] [Indexed: 02/06/2023] Open
Abstract
Objective. To forecast the impact of alternative scenarios of coverage changes in Brazil’s Family Health Strategy (Estratégia Saúde da Família) (ESF)—due to fiscal austerity measures and to the end of the Mais Médicos (More Doctors) Program (PMM)—on overall under-5 mortality rates (U5MRs) and under-70 mortality rates (U70MRs) from ambulatory care sensitive conditions (ACSCs) up through 2030. Methods. A synthetic cohort of 5 507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data. Reductions in ESF coverage, and its effects on U5MRs and U70MRs from ACSCs, were forecast based on two probable austerity scenarios, as compared to the maintenance of current ESF coverage. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, variables related to health care, and program duration effects. Results. In comparison to maintaining stable ESF coverage, with the decrease in ESF coverage due to austerity measures and PMM termination, the mean U5MR and U70MR would be 13.2% and 8.6% higher, respectively, in 2030. The end of PMM would be responsible for a mean U5MR from ACSCs that is 4.3% higher and a U70MR from ACSCs that is 2.8% higher in 2030. The reduction of PMM coverage due only to the withdrawal of Cuban doctors who have been working in PMM would alone be responsible for a U5MR that is 3.2% higher, and a U70MR that is 2.0% higher in 2030. Conclusions. Reductions in primary health care coverage due to austerity measures and the end of the PMM could be responsible for many avoidable adult and child deaths in coming years in Brazil.
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Affiliation(s)
- Gabriel Vivas Francesconi
- Pan American Health Organization/World Health Organization Pan American Health Organization/World Health Organization BrasíliaDistrito Federal Brazil Pan American Health Organization/World Health Organization, Brasília, Distrito Federal, Brazil
| | - Renato Tasca
- Pan American Health Organization/World Health Organization Pan American Health Organization/World Health Organization BrasíliaDistrito Federal Brazil Pan American Health Organization/World Health Organization, Brasília, Distrito Federal, Brazil
| | - Sanjay Basu
- Center for Population Health Sciences School of Medicine, Stanford University StanfordCalifornia United States of America Center for Population Health Sciences, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Thiago Augusto Hernandes Rocha
- Pan American Health Organization/World Health Organization Pan American Health Organization/World Health Organization BrasíliaDistrito Federal Brazil Pan American Health Organization/World Health Organization, Brasília, Distrito Federal, Brazil
| | - Davide Rasella
- Public Health Institute Federal University of Bahia SalvadorBahia Brazil Public Health Institute, Federal University of Bahia, Salvador, Bahia, Brazil
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Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, de Souza Noronha KVM, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini LA, Atun R. Brazil's unified health system: the first 30 years and prospects for the future. Lancet 2019; 394:345-356. [PMID: 31303318 DOI: 10.1016/s0140-6736(19)31243-7] [Citation(s) in RCA: 368] [Impact Index Per Article: 73.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/18/2019] [Accepted: 05/10/2019] [Indexed: 12/28/2022]
Abstract
In 1988, the Brazilian Constitution defined health as a universal right and a state responsibility. Progress towards universal health coverage in Brazil has been achieved through a unified health system (Sistema Único de Saúde [SUS]), created in 1990. With successes and setbacks in the implementation of health programmes and the organisation of its health system, Brazil has achieved nearly universal access to health-care services for the population. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale universal health coverage in a highly unequal country with relatively low resources allocated to health-care services by the government compared with that in middle-income and high-income countries. Analysis of the past 30 years since the inception of the SUS shows that innovations extend beyond the development of new models of care and highlights the importance of establishing political, legal, organisational, and management-related structures, with clearly defined roles for both the federal and local governments in the governance, planning, financing, and provision of health-care services. The expansion of the SUS has allowed Brazil to rapidly address the changing health needs of the population, with dramatic upscaling of health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and suboptimal private sector-public sector collaboration. Fiscal policies implemented in 2016 ushered in austerity measures that, alongside the new environmental, educational, and health policies of the Brazilian government, could reverse the hard-earned achievements of the SUS and threaten its sustainability and ability to fulfil its constitutional mandate of providing health care for all.
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Affiliation(s)
- Marcia C Castro
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Adriano Massuda
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Collective Health, Health Sciences Sector, Federal University of Paraná, Curitiba, Brazil
| | - Gisele Almeida
- Health Systems and Services Unit, Pan American Health Organization/Regional Office of the World Health Organization, Washington, DC, USA
| | - Naercio Aquino Menezes-Filho
- Center for Public Policy, Insper, São Paulo, Brazil; Department of Economics, University of São Paulo, São Paulo, Brazil
| | - Monica Viegas Andrade
- Center for Development and Regional Planning, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Rudi Rocha
- São Paulo School of Business Administration, Fundação Getulio Vargas, São Paulo, Brazil
| | - James Macinko
- UCLA Fielding School of Public Health, Center for Health Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Thomas Hone
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Renato Tasca
- Health Systems and Services Unit, Pan American Health Organization, Brasília, Brazil
| | - Ligia Giovanella
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Ana Maria Malik
- São Paulo School of Business Administration, Fundação Getulio Vargas, São Paulo, Brazil
| | - Heitor Werneck
- Agência Nacional de Saúde Suplementar, Rio de Janeiro, Brazil
| | - Luiz Augusto Fachini
- Center for Epidemiological Research, Universidade Federal de Pelotas, Pelotas, Brazil
| | - Rifat Atun
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
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Rasella D, Hone T, de Souza LE, Tasca R, Basu S, Millett C. Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil. BMC Med 2019; 17:82. [PMID: 31023330 PMCID: PMC6485171 DOI: 10.1186/s12916-019-1316-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/27/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Brazil's Estratégia Saúde da Família (ESF) is one of the largest and most robustly evaluated primary healthcare programmes of the world, but it could be affected by fiscal austerity measures and by the possible end of the Mais Médicos programme (MMP)-a major intervention to increase primary care doctors in underserved areas. We forecast the impact of alternative scenarios of ESF coverage changes on under-70 mortality from ambulatory care-sensitive conditions (ACSCs) until 2030, the date for achievement of the Sustainable Development Goals (SDGs). METHOD A synthetic cohort of 5507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data and estimates from a previous retrospective study evaluating the effects of municipal ESF coverage on mortality rates. Reductions in ESF coverage, and its effects on ACSC mortality, were forecast based on two probable austerity scenarios, compared with the maintenance of the current coverage or the expansion to 100%. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, healthcare-related variables, and programme duration effects. RESULTS Under austerity scenarios of decreasing ESF coverage with and without the MMP termination, mean ACSC mortality rates would be 8.60% (95% CI 7.03-10.21%; 48,546 excess premature/under-70 deaths along 2017-2030) and 5.80% (95% CI 4.23-7.35%; 27,685 excess premature deaths) higher respectively in 2030 compared to maintaining the current ESF coverage. Comparing decreasing ESF coverage and MMP termination with achieving 100% ESF coverage (Universal Health Coverage scenario) in 2030, mortality rates would be 11.12% higher (95% CI 9.47-12.76%; 83,937 premature deaths). Reductions in ESF coverage would have stronger effects on mortality from infectious diseases and nutritional deficiencies and would disproportionately impact poorer municipalities, with the concentration index for ACSC mortality 11.77% higher (95% CI 0.31-22.32%) and also ending historical declines in racial health inequalities between white and black/pardo Brazilians. CONCLUSIONS Reductions in primary healthcare coverage due to austerity measures are likely to be responsible for many avoidable deaths and may preclude achievement of SDGs for health and inequality in Brazil and in other low- and middle-income countries.
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Affiliation(s)
- Davide Rasella
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia Brazil
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Thomas Hone
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | | | - Renato Tasca
- Pan-American Health Organization/World Health Organization Country Office for Brazil, Brasilia, Brazil
| | - Sanjay Basu
- Center for Population Health Sciences, School of Medicine, Stanford University, Stanford, California USA
- Center for Primary Care and Outcomes Research, School of Medicine, Stanford University, Stanford, California USA
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts USA
| | - Christopher Millett
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
- Center for Epidemiological Studies in Health and Nutrition, University of São Paulo, São Paulo, Brazil
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Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med 2018; 15:e1002570. [PMID: 29787574 PMCID: PMC5963760 DOI: 10.1371/journal.pmed.1002570] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 04/20/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Since 2015, a major economic crisis in Brazil has led to increasing poverty and the implementation of long-term fiscal austerity measures that will substantially reduce expenditure on social welfare programmes as a percentage of the country's GDP over the next 20 years. The Bolsa Família Programme (BFP)-one of the largest conditional cash transfer programmes in the world-and the nationwide primary healthcare strategy (Estratégia Saúde da Família [ESF]) are affected by fiscal austerity, despite being among the policy interventions with the strongest estimated impact on child mortality in the country. We investigated how reduced coverage of the BFP and ESF-compared to an alternative scenario where the level of social protection under these programmes is maintained-may affect the under-five mortality rate (U5MR) and socioeconomic inequalities in child health in the country until 2030, the end date of the Sustainable Development Goals. METHODS AND FINDINGS We developed and validated a microsimulation model, creating a synthetic cohort of all 5,507 Brazilian municipalities for the period 2017-2030. This model was based on the longitudinal dataset and effect estimates from a previously published study that evaluated the effects of poverty, the BFP, and the ESF on child health. We forecast the economic crisis and the effect of reductions in BFP and ESF coverage due to current fiscal austerity on the U5MR, and compared this scenario with a scenario where these programmes maintain the levels of social protection by increasing or decreasing with the size of Brazil's vulnerable populations (policy response scenarios). We used fixed effects multivariate regression models including BFP and ESF coverage and accounting for secular trends, demographic and socioeconomic changes, and programme duration effects. With the maintenance of the levels of social protection provided by the BFP and ESF, in the most likely economic crisis scenario the U5MR is expected to be 8.57% (95% CI: 6.88%-10.24%) lower in 2030 than under fiscal austerity-a cumulative 19,732 (95% CI: 10,207-29,285) averted under-five deaths between 2017 and 2030. U5MRs from diarrhoea, malnutrition, and lower respiratory tract infections are projected to be 39.3% (95% CI: 36.9%-41.8%), 35.8% (95% CI: 31.5%-39.9%), and 8.5% (95% CI: 4.1%-12.0%) lower, respectively, in 2030 under the maintenance of BFP and ESF coverage, with 123,549 fewer under-five hospitalisations from all causes over the study period. Reduced coverage of the BFP and ESF will also disproportionately affect U5MR in the most vulnerable areas, with the U5MR in the poorest quintile of municipalities expected to be 11.0% (95% CI: 8.0%-13.8%) lower in 2030 under the maintenance of BFP and ESF levels of social protection than under fiscal austerity, compared to no difference in the richest quintile. Declines in health inequalities over the last decade will also stop under a fiscal austerity scenario: the U5MR concentration index is expected to remain stable over the period 2017-2030, compared to a 13.3% (95% CI: 5.6%-21.8%) reduction under the maintenance of BFP and ESF levels of protection. Limitations of our analysis are the ecological nature of the study, uncertainty around future macroeconomic scenarios, and potential changes in other factors affecting child health. A wide range of sensitivity analyses were conducted to minimise these limitations. CONCLUSIONS The implementation of fiscal austerity measures in Brazil can be responsible for substantively higher childhood morbidity and mortality than expected under maintenance of social protection-threatening attainment of Sustainable Development Goals for child health and reducing inequality.
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Affiliation(s)
- Davide Rasella
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
- * E-mail:
| | - Sanjay Basu
- Center for Population Health Sciences, School of Medicine, Stanford University, Stanford, California, United States of America
- Center for Primary Care and Outcomes Research, School of Medicine, Stanford University, Stanford, California, United States of America
- Department of Health Research and Policy, School of Medicine, Stanford University, Stanford, California, United States of America
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Thomas Hone
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Romulo Paes-Sousa
- René Rachou Institute, Fiocruz Minas, Belo Horizonte, Minas Gerais, Brasil
| | | | - Christopher Millett
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
- Center for Epidemiological Studies in Health and Nutrition, University of São Paulo, São Paulo, Brazil
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