How is the current crisis reshaping Brazil's health system? Strengthening health workforce and provision of services in São Paulo and Maranhão

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Economic crises are very common worldwide, and they have been shown to carry multiple effects on national health systems; they can increase the burden of disease from specific mental health and poverty-related conditions, but also drive health workers away from the public sector and the country in search of better working conditions. Some scholars have suggested that it is often the associated policy responses - the so-called austerity measures - that carry a negative impact on health systems and workforces.In Brazil, the health system effects of the economic crisis that has affected the country since 2015 have not been fully understood, with press reports and anecdotal evidence suggesting that services are being shut down and physicians are abandoning the public sector, particularly in rural areas. As part of its policy response to the crisis, the Government is introducing measures to limit public health spending, promote the growth of private health insurance plans, and fill the gaps in the workforce through international recruitment. However, an objective assessment of the health systems effects of Brazil's crisis is lacking, and so is the evidence base to elaborate policies to address them.The present study aims at exploring the impact of the current economic crisis and of the associated austerity measures on the health system and workforce in Brazil, with a specific focus on public sector physicians - an essential pillar of any health system-, and on how to foster the debate on suitable health policy options. We will look specifically at the cases of São Paulo and Maranhão states, two very diverse settings where we expect the diverse effects of the crisis to be felt differently because of their uneven economic development. We will do so by analysing the existing data on the effects of the crisis from available health financing and medical workforce datasets, and by conducting interviews and surveys among phsycians in the two states. The study findings will be presented in facilitated policy dialogues workshops in São Paulo and Maranhão, where health policy-makers will be invited to review the fresh evidence produced, and to consider examples of health policy responses from other countries. It is hoped that this study will help identify suitable policies to alleviate the effects of the crisis on the health system, health workforce and provision of services in Brazil, particularly for the most vulnerable populations in São Paulo and Maranhão. The study findings will also contribute to the growing body of knowledge on economic crises and health systems world-wide.