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Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil
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 prim...
Autores principales: | , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
BioMed Central
2019
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6485171/ https://www.ncbi.nlm.nih.gov/pubmed/31023330 http://dx.doi.org/10.1186/s12916-019-1316-7 |
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author | Rasella, Davide Hone, Thomas de Souza, Luis Eugenio Tasca, Renato Basu, Sanjay Millett, Christopher |
author_facet | Rasella, Davide Hone, Thomas de Souza, Luis Eugenio Tasca, Renato Basu, Sanjay Millett, Christopher |
author_sort | Rasella, Davide |
collection | PubMed |
description | 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. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s12916-019-1316-7) contains supplementary material, which is available to authorized users. |
format | Online Article Text |
id | pubmed-6485171 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2019 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-64851712019-05-03 Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil Rasella, Davide Hone, Thomas de Souza, Luis Eugenio Tasca, Renato Basu, Sanjay Millett, Christopher BMC Med Research Article 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. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s12916-019-1316-7) contains supplementary material, which is available to authorized users. BioMed Central 2019-04-26 /pmc/articles/PMC6485171/ /pubmed/31023330 http://dx.doi.org/10.1186/s12916-019-1316-7 Text en © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. |
spellingShingle | Research Article Rasella, Davide Hone, Thomas de Souza, Luis Eugenio Tasca, Renato Basu, Sanjay Millett, Christopher Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil |
title | 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_short | 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 |
topic | Research Article |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6485171/ https://www.ncbi.nlm.nih.gov/pubmed/31023330 http://dx.doi.org/10.1186/s12916-019-1316-7 |
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