The differential impact of economic recessions on health systems in middle-income settings: a comparative case study of unequal states in Brazil
The differential impact of economic recessions on health systems in middle-income settings: a comparative case study of unequal states in Brazil
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DOI：
10.1136/bmjgh-2019-002122
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发表时间：
2020-02-01
影响因子：
8.1
通讯作者：
Russo, Giuliano
中科院分区：
文献类型：
--
作者：
Andrietta, Lucas Salvador;Levi, Maria Luiza;Russo, Giuliano
导言虽然经济危机在低收入/中等收入国家很常见，但其对卫生系统的影响的证据仍然很少。我们对巴西发展不均衡的马拉尼豪州和圣保罗州进行了比较案例研究，以探讨其2014-2015年经济衰退带来的卫生筹资和系统绩效变化。方法借鉴经济和卫生系统研究文献，设计一个概念框架，探讨宏观经济因素、劳动力市场、卫生服务需求和供给与系统绩效之间的关系。我们使用了来自国家健康账户和国家家庭抽样调查的数据来检查2010-2018年期间巴西医疗支出的变化。使用国家补充卫生局数据库和公共卫生预算信息系统的数据来比较和对比圣保罗和马拉尼昂的卫生筹资和系统绩效。结果我们的分析显示，2015-2016年后，巴西的宏观经济状况全面恶化，圣保罗的经济比马拉尼昂经历了更大的挫折。我们展示了公共卫生支出是如何持平的，而私人医疗保险支出由于经济衰退而增加。这两个州的公共融资模式不同，因为马拉尼奥州的医疗资金在危机年代后继续增长，因为它是通过向地方政府转移资金来支撑的。虽然马拉尼昂的公共部门工作人员和人均床位没有受到危机的影响，但圣保罗的公共医生数量有所减少。结论我们的案例研究表明，在一个复杂的异质系统中，经济衰退在各个部分的影响是不平等的，因为影响是由私人支出、市场结构和公共融资调整中介的。旨在减轻低收入国家经济衰退影响的政策将需要考虑到这些差异。
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.