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

经济危机在全世界都很常见，而且已证明对国家卫生系统产生多重影响;经济危机可能增加特定心理健康和贫困状况造成的疾病负担，但也会迫使卫生工作者离开公共部门和国家，寻求更好的工作条件。一些学者认为，通常是相关的政策反应--所谓的紧缩措施--对卫生系统和劳动力产生了负面影响。在巴西，自2015年以来影响该国的经济危机对卫生系统的影响尚未得到充分理解，新闻报道和传闻证据表明，服务正在关闭，医生正在放弃公共部门，特别是在农村地区。作为应对危机政策的一部分，政府正在采取措施，限制公共卫生支出，促进私人医疗保险计划的增长，并通过国际招聘填补劳动力缺口。然而，缺乏对巴西危机对卫生系统影响的客观评估，也缺乏制定应对政策的证据基础，本研究旨在探讨当前经济危机和相关紧缩措施对巴西卫生系统和劳动力的影响，特别关注公共部门医生-任何卫生系统的重要支柱-，以及如何促进关于适当卫生政策选择的辩论。我们将具体研究圣保罗州和马拉尼昂州的情况，这两个州的情况非常不同，我们预计，由于经济发展不平衡，危机的各种影响会有不同的感受。我们将通过分析现有的数据，从现有的卫生融资和医疗劳动力数据集的危机的影响，并通过在这两个国家的物理学家进行访谈和调查。研究结果将在圣保罗和马拉尼昂举行的政策对话研讨会上介绍，届时将邀请卫生政策制定者审查所产生的新证据，并考虑其他国家的卫生政策反应实例。希望这项研究将有助于确定适当的政策，以减轻危机对巴西卫生系统、卫生工作人员和服务提供的影响，特别是对圣保罗和马拉尼昂最脆弱人口的影响。研究结果还将有助于增加关于全球经济危机和卫生系统的知识。

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.