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

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.

Brazil has been in economic recession for the last two years, and the Government is starting to introduce measures to limit public spending on social sectors and deregulate the health insurance market. We propose a theory-based conceptual framework to understand the multiple reverberations of the crisis on health system and health workers. The specific objectives of the study are: (a) to analyse the available data on health financing and medical workforce; (b) generate hypotheses on how the current economic crisis and associated policy responses will affect the health workforce; (c) test quantitatively such hypotheses in a representative sample of physicians, and; (d) organise policy dialogues to discuss the study findings and suitable policy options.

Existing health financing and medical demography datasets will be explored through descriptive and multivariate analysis to establish a relationship between the health financing, health system outputs, and service utilisation. Semi-structured and in-depth interviews will be conducted in São Paulo and Maranhão states with health professionals, policy-makers and hospital managers. Theory-driven content analysis will be used to qualitatively analyse interviews' contents. Two surveys will be conducted in a representative sample of physicians to test the hypotheses on the impact of the crisis on Brazil's health workforce. Data will be collected through telephone interviews on: (1) Physicians' characteristics; (2) Changes in time allocation and outputs; (3) Changes in private sector and dual practice engagement; (4) Intentions to leave the public sector and retire. Ordinal and logistic regression models will be used to link such changes with physicians' characteristics and health workers' perceptions of the crisis.

Two policy dialogue workshops facilitated by PAHO will be organised with national and international health stakeholders to disseminate the study findings, and inform the development of policy measures.

Ensuring that the present research has an impact is crucial for all the researchers involved, and the proposal has been designed to maximise the uptake of findings by its beneficiaries.

We expect the government's current health policy response to incorporate the findings from this research project. The central assumption of our approach is that economic crises have very diverse repercussions on health system and workforce; international evidence suggests that inadequate policy responses can affect these more than the crisis itself, but also that health systems and health workers are more resilient than originally thought. Depending on the research findings, we expect specific interventions to be discussed and hopefully introduced in São Paulo and Maranhão states, such as: (a) subsidies to retain and redistribute health workers in the health services most penalised by the crisis; (b) demand-side interventions to encourage the selection of the most cost-effective services by vulnerable groups, or; (c) supply-side measures to harness the private sector towards providing affordable services in underserved areas.

The key beneficiaries of the study proposal will be expected to make these changes happen. Policy-makers, health practitioners and health sector stakeholders have been involved in this proposal since its inception, and will be the beneficiaries of the policy dialogue workshops planned for the end of the research programme. The National Council of State Health Secretaries (CONASS), the Health Secretariats of São Paulo and Maranhão States were approached during the MRC-CONFAPI workshop in Brasilia to discuss the aims of the study, and expressed their support and participation to the research project. The policy dialogues workshops will aim at developing a political consensus on the consequences of the crisis on health systems and workforce, as well as on the measures to take to counterbalance them. The Pan American Health Organization has expressed his availability to collaborate in the organisation of these workshops (see letters of support).

Policy-makers, Brazil's medical workforce, national and international academics, and health system users from disadvantaged sections of the country, will be the main beneficiaries for this research project. Brazil's federal and state policy-makers will be the direct recipients of the findings from this study through the organisation of policy dialogue workshops, and world academics working on health systems and crises will benefit from the dissemination of the study findings from this Brazil's case study. Brazil's physicians will also benefit from this study through: (a) increasing understanding of the mechanisms through which the crisis is affecting them, and; (b) improved working conditions, as the policies identified in the policy dialogues will seek to retain and better distribute them, and improve their working environment, earnings and opportunities for professional development. Finally, vulnerable, rural and low-income health systems users in Brazil are intended to be the ultimate beneficiaries of this study through its focus on increasing access to services.

This being a collaborative research call, the Brazilian and British academic institutions directly involved in this research collaboration will also benefit from the mutual learning and capacity development activities organised through the project. This project will strengthen the capacity of the whole team to undertake health systems research by: (a) engaging with existing health financing and medical demography databases; (b) developing data collection tools; (c) managing and analysing qualitative and quantitative primary data, and; (d) providing on-the job-training and mentoring by senior staff through the project.