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 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.

Keywords: Brazil; Health system financing; Microsimulation; Mortality; Primary care.

Fig. 1

Mean municipal mortality rates from ambulatory care-sensitive conditions (ACSCs) under four ESF scenarios (2010–2030). ACSC mortality expressed per 100,000 inhabitants; the four ESF scenarios are (from highest to lowest ACSC mortality rates in 2030) as follows: ESF contraction and termination of Mais Médicos (scenario 3) (red line), ESF contraction (scenario 2) (blue line), static ESF coverage (scenario 1) (grey line), and UHC (scenario 4) (green line). ESF Estratégia Saúde da Família (Family Health Strategy)

Fig. 2

Mean municipal mortality rates for subgroups of ambulatory care-sensitive conditions (ACSCs) under ESF scenarios for 2010–2030: cardiovascular diseases (dotted line), infectious diseases (dashed line), and nutritional deficiencies and anaemia (full line). ACSC mortality expressed per 100,000 inhabitants; the three ESF scenarios are (from highest to lowest ACSC mortality rates in 2030 for all three graphs) as follows: ESF contraction and termination of Mais Médicos (scenario 3) (red line), ESF contraction (scenario 2) (blue line), and static ESF coverage (scenario 1) (grey line); ESF Estratégia Saúde da Família (Family Health Strategy)

Fig. 3

Mean municipal ESF coverage and ACSC mortality rates by poverty quintiles of municipalities under ESF scenarios (2010–2030). ESF coverage expressed as percentage; ACSC mortality expressed per 100,000 inhabitants; the quintiles of municipalities by 2010 poverty rate are (from highest to lowest poverty rates in 2010) as follows: black—first quintile (poorest), brown—second quintile, yellow—third quintile, orange—fourth quintile, and red—fifth quintile (richest); the three ESF scenarios are ESF contraction and termination of Mais Médicos (scenario 3) (full line), ESF contraction (scenario 2) (dashed line), and static ESF coverage (scenario 1) (dotted line). ESF Estratégia Saúde da Família (Family Health Strategy), ACSC ambulatory care-sensitive condition

Fig. 4

Standardised rate ratios (SRRs) for ACSC mortality from between black/pardo and white populations under ESF scenarios for 2010–2030. Standardised rate ratios (SRRs) of ACSC mortality is black/pardo ACSC mortality divided by white ACSC mortality; the three ESF scenarios are ESF contraction and termination of Mais Médicos (scenario 3) (red line), ESF contraction (scenario 2) (blue line), and static ESF coverage (scenario 1) (grey line). ESF Estratégia Saúde da Família (Family Health Strategy), ACSC ambulatory care-sensitive condition