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Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil

Authors
  • Rasella, Davide1, 2
  • Hone, Thomas2
  • de Souza, Luis Eugenio1
  • Tasca, Renato3
  • Basu, Sanjay4, 5, 6
  • Millett, Christopher2, 7
  • 1 Universidade Federal da Bahia, Instituto de Saúde Coletiva, Salvador, Bahia, Brazil , Salvador (Brazil)
  • 2 Imperial College London, Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, London, UK , London (United Kingdom)
  • 3 Pan-American Health Organization/World Health Organization Country Office for Brazil, Brasilia, Brazil , Brasilia (Brazil)
  • 4 Stanford University, Center for Population Health Sciences, School of Medicine, Stanford, California, USA , Stanford (United States)
  • 5 Stanford University, Center for Primary Care and Outcomes Research, School of Medicine, Stanford, California, USA , Stanford (United States)
  • 6 Center for Primary Care, Harvard Medical School, Boston, Massachusetts, USA , Boston (United States)
  • 7 University of São Paulo, Center for Epidemiological Studies in Health and Nutrition, São Paulo, Brazil , São Paulo (Brazil)
Type
Published Article
Journal
BMC Medicine
Publisher
BioMed Central
Publication Date
Apr 26, 2019
Volume
17
Issue
1
Identifiers
DOI: 10.1186/s12916-019-1316-7
Source
Springer Nature
Keywords
License
Green

Abstract

BackgroundBrazil’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).MethodA 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.ResultsUnder 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.ConclusionsReductions 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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