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Health in the balance

Spending cuts in primary care could curb decline in premature mortality, modeling shows

The Brazilian Federal Government’s fiscal austerity program could slow the rate of decline in premature mortality in Brazil over a period extending to 2030. Premature mortality measures the number of deaths of individuals younger than 70—often associated with respiratory infections, high blood pressure, malnutrition, and other health problems—that could have been prevented had those individuals had access to primary care either at home or at local clinics. These conclusions were drawn by an international group led by Italian biologist Davide Rasella, of the Institute for Collective Health at the Federal University of Bahia (UFBA). He and his team modeled the potential impacts on coverage provided by two primary healthcare programs, Estratégia Saúde da Família (ESF) and Mais Médicos, after a constitutional amendment imposed a 20-year cap on government spending in 2016.

Using mathematical and statistical modeling, they estimated the effects of government spending cuts in healthcare on 5,507 Brazilian municipalities. Their modeling work was based on data available from the World Bank, the Brazilian Ministry of Health, the Brazilian Institute of Geography, and Statistics (IBGE) and the Institute for Applied Economic Research (IPEA). The study, published in April in BMC Medicine, modeled potential impact over the next 10 years in four scenarios. In one scenario, ESF coverage remains relatively constant at 80.4% of the population in 2030—compared with 84.7% currently. In a second scenario, ESF coverage is reduced to 37.8%, but the Mais Médicos program is maintained. A third, worst-case scenario models the termination of Mais Médicos and a reduction of ESF coverage to 16% of the population. In the fourth, best-case scenario, both programs provide universal coverage.

In all modeled scenarios, including the worst-case scenario, projections indicate a reduction in mean premature mortality in Brazil through 2030 from a current baseline of 45 annual deaths per 100,000 population. The rate of decline, however, is slowed as healthcare spending is contracted. In the best-case scenario, with universal access to services available from both programs, mortality decreases to 38 deaths per 100,000 population in 2030. In the scenario with the harshest budget cuts, mortality declines more modestly to 43 deaths per 100,000 population. According to the study, the severest austerity scenario would result in 48,546 more premature deaths over the following decade compared with current levels of program coverage.

Rasella warns that the impact from reducing ESF coverage would be hardest on the poorest municipalities of Brazil. The researchers also note that premature death rates due to complications associated with infectious diseases and malnutrition would be 11.7% higher in the worst-case scenario compared with current coverage levels in these regions. “Shrinking ESF coverage would affect population groups that are the most vulnerable from a social and economic standpoint and have the worst mortality rates compared to the rest of the population,” says Rasella.

What is more, these projections capture only a portion of the effects from reduced spending on ESF and Mais Médicos—premature mortality accounts for only 10–15% of total deaths in Brazil. A 2018 study in PLOS Medicine by the UFBA group, using the same methodology, estimated that lower spending on ESF and Bolsa Família would result in 19,732 more deaths among children under 5 over the period to 2030.

An ideal model
The ESF program was introduced in 1994 and has become one of the primary gateways into the Brazilian National Healthcare System (SUS). Multidisciplinary teams of healthcare professionals provide services covering prevention, recovery, and rehabilitation from illnesses and other health complaints. The program currently has 43,000 teams on the ground visiting patients at their homes. “Over the previous 25 years, ESF has proven to be the ideal model for primary care and has supported a reduction in preventable child deaths and hospitalizations,” says Rosália Neves of the Federal University of Pelotas (UFPel), in Rio Grande do Sul, one of the authors of a 2018 paper about ESF in Epidemiologia e Serviços de Saúde. The study reports that ESF coverage gradually expanded after initial implementation, growing from 45.3% of the population in 2006 to 64%, or 123 million people, in 2016. But coverage levels have recently begun to decline. The Brazilian Ministry of Health estimates that 3 million people lost coverage from November 2018 to May this year.

Mais Médicos is a more recent program. The initiative, launched by the Federal Government in 2013 to increase the number of physicians practicing in underserved and remote areas of Brazil, costs an average of R$1.1 billion per year, according to a paper in Revista Pan-americana de Saúde Pública. Many of the 18,000 professionals in the program are from Cuba. An estimated 2,000 of the 8,000 Cuban doctors who came to Brazil are likely to stay in the country (not all practicing within Mais Médicos).

Physician Victor Wunsch, a professor at the School of Public Health at the University of São Paulo (FSP-USP) who was not part of Rasella’s research group, believes studies like these are useful in alerting policymakers to the consequences of policy decisions taken today. He notes, however, that they are not always taken into account in decision-making. “Epidemiologists themselves are often skeptical of accepting modeling results, as political and economic circumstances can change dramatically in short spaces of time”, says Wunsch. “But the BMC Medicine paper provides a helpful picture of the likely future health impacts of current government policy.”

In addition to a higher rate of premature deaths among economically active adults—the impact modeled in this study—Wunsch notes that any reduction in primary care coverage within the SUS can also have wider effects on families and society that are difficult to measure. “High-quality outpatient care helps to reduce hospitalizations and provides significant savings in public healthcare spending,” he says.

Scientific articles
RASELLA, D. et al. Mortality associated with alternative primary healthcare policies: A nationwide microsimulation modelling study in Brazil. BMC Medicine. Vol. 17, pp. 1–11. Apr. 2019.
Neves, R. G. et al. Time trend of Family Health Strategy coverage in Brazil, its regions and federative units, 2006–2016. Epidemiologia e Serviços de Saúde. Vol. 27, no. 3, pp. 1–8. Sept. 2018.
RASELLA, D. et al. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLOS Medicine. May 2018.