The differential impact of economic recessions on health systems in middle-income settings: a comparative case study of unequal states in Brazil

Author(s)

Andrietta, Lucas Salvador ^[1] ; Levi, Maria Luiza ^[2] ; Scheffer, Mario C. ^[1] ; Soares de Britto e Alves, Maria Teresa Seabra ^[3] ; Carneiro Alves de Oliveira, Bruno Luciano ^[3] ; Russo, Giuliano ^[4]

Affiliation

^[1] Univ Sao Paulo, Dept Med Prevent, Fac Med, Sao Paulo, SP - Brazil

^[2] Univ Fed ABC, Ctr Engn Modelagem & Ciencias Sociais Aplicadas, Santo Andre, SP - Brazil

^[3] Univ Fed Maranhao, Dept Saude Publ, Sao Luis, Maranhao - Brazil

^[4] Queen Mary Univ London, Ctr Primary Care & Publ Hlth, London - England

• Document type: Journal article
• Source: BMJ GLOBAL HEALTH; v. 5, n. 2 FEB 2020.
• Web of Science Citations: 0

Abstract

Introduction Although economic crises are common in low/middle-income countries (LMICs), the evidence of their impact on health systems is still scant. We conducted a comparative case study of Maranhao and Sao Paulo, two unevenly developed states in Brazil, to explore the health financing and system performance changes brought in by its 2014-2015 economic recession. Methods Drawing from economic and health system research literature, we designed a conceptual framework exploring the links between macroeconomic factors, labour markets, demand and supply of health services and system performance. We used data from the National Health Accounts and National Household Sample Survey to examine changes in Brazil's health spending over the 2010-2018 period. Data from the National Agency of Supplementary Health database and the public health budget information system were employed to compare and contrast health financing and system performance of Sao Paulo and Maranhao. Results Our analysis shows that Brazil's macroeconomic conditions deteriorated across the board after 2015-2016, with Sao Paulo's economy experiencing a wider setback than Maranhao's. We showed how public health expenditures flattened, while private health insurance expenditures increased due to the recession. Public financing patterns differed across the two states, as health funding in Maranhao continued to grow after the crisis years, as it was propped up by transfers to local governments. While public sector staff and beds per capita in Maranhao were not affected by the crisis, a decrease in public physicians was observed in Sao Paulo. Conclusion Our case study suggests that in a complex heterogeneous system, economic recessions reverberate unequally across its parts, as the effects are mediated by private spending, structure of the market and adjustments in public financing. Policies aimed at mitigating the effects of recessions in LMICs will need to take such differences into account. (AU)

• FAPESP's process: 17/50356-7 - How is the current economic crisis shaping Brazil's health system? Strengthening health workforce and provision of services in São Paulo and Maranhão
• Grantee: Mário César Scheffer
• Support Opportunities: Research Grants - Research in Public Policies