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

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 incre...

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Main Authors: Davide Rasella, Thomas Hone, Luis Eugenio de Souza, Renato Tasca, Sanjay Basu, Christopher Millett
Format: Article
Language:English
Published: BMC 2019-04-01
Series:BMC Medicine
Subjects:
Online Access:http://link.springer.com/article/10.1186/s12916-019-1316-7
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spelling doaj-e368f25c42314a3aba698a8a1ea225c52020-11-25T03:09:13ZengBMCBMC Medicine1741-70152019-04-0117111110.1186/s12916-019-1316-7Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in BrazilDavide Rasella0Thomas Hone1Luis Eugenio de Souza2Renato Tasca3Sanjay Basu4Christopher Millett5Instituto de Saúde Coletiva, Universidade Federal da BahiaPublic Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College LondonInstituto de Saúde Coletiva, Universidade Federal da BahiaPan-American Health Organization/World Health Organization Country Office for BrazilCenter for Population Health Sciences, School of Medicine, Stanford UniversityPublic Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College LondonAbstract 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.http://link.springer.com/article/10.1186/s12916-019-1316-7Primary careHealth system financingBrazilMortalityMicrosimulation
collection DOAJ
language English
format Article
sources DOAJ
author Davide Rasella
Thomas Hone
Luis Eugenio de Souza
Renato Tasca
Sanjay Basu
Christopher Millett
spellingShingle Davide Rasella
Thomas Hone
Luis Eugenio de Souza
Renato Tasca
Sanjay Basu
Christopher Millett
Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil
BMC Medicine
Primary care
Health system financing
Brazil
Mortality
Microsimulation
author_facet Davide Rasella
Thomas Hone
Luis Eugenio de Souza
Renato Tasca
Sanjay Basu
Christopher Millett
author_sort Davide Rasella
title Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil
title_short Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil
title_full Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil
title_fullStr Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil
title_full_unstemmed Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil
title_sort mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in brazil
publisher BMC
series BMC Medicine
issn 1741-7015
publishDate 2019-04-01
description 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.
topic Primary care
Health system financing
Brazil
Mortality
Microsimulation
url http://link.springer.com/article/10.1186/s12916-019-1316-7
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