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

Lead Research Organisation: Queen Mary, University of London
Department Name: Blizard Institute of Cell and Molecular

Abstract

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.

Technical Summary

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.

Planned Impact

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.

Publications

10 25 50
 
Description Before COVID-19 there are two key findings we have achieved so far in our research, backed up by our latest publications:
(a) public medical schools in Brazil are not better than private ones in training primary care physicians, and;
(b) the recent economic crisis has had a more transformative effect on the health systems of rich states (São Paulo) and poor ones (Maranhão).

We believe these two findings are still valid, but will need to be examined through the lenses of the epidemic. We believe that the epidemic may have had an amplifying effects on the health labour markets, with more employment opportunities presenting themselves for physicians. If confirmed by our upcoming survey, such findings will be very much inline with what we believe are the anticipated effects of economic crises.
Exploitation Route We have now published seven papers to disseminate these preliminary outcomes of the research project. It is expected that other scholars and policy-makers from Brazil and other LMICs will build on the findings from this project, further this line of research, and/or influence health policy-making.
Sectors Healthcare

 
Description We have engaged with the Pan American Health Organization office to disseminate some of the results of the project. After the pandemic, we have re-focused our project to concentrate on the impact of COVID-19 on physicians. The research team (Brazil+UK) are now developing a new research MRC application on the topic. We have also been invited by international academic consortia to speak about the topic (see public engagement section).
First Year Of Impact 2021
Sector Healthcare,Pharmaceuticals and Medical Biotechnology
Impact Types Cultural,Societal,Policy & public services

 
Description Members of the research group (Mário Scheffer) was called to give evidence to the government on the issue of training of medical doctors and on the impact of the economic crisis
Geographic Reach National 
Policy Influence Type Gave evidence to a government review
 
Title Interview guide for qualitative data collection on the impact of crisis on local health systems - in Portuguese 
Description Based on the literature on economic recession and health systems, we developed a conceptual framework to understand the repercussions of economic recessions on local health systems. An interview questionnaire has been developed and piloted in São Luís de Maranhão in December 2018, and is currently being applied to a sample of 50 interviewees in the Maranhão and São Paulo states. 
Type Of Material Improvements to research infrastructure 
Year Produced 2018 
Provided To Others? No  
Impact Depending on the results of the qualitative research phase for our project, we hope this data collection instrument will become a research tool to explore the effects of economic recessions on local health systems, particularly for Portuguese speaking countries. 
 
Title Training in qualitative data analysis (Nvivo) in Portuguese 
Description Training sessions were organised to train the São Paulo and Maranhão teams in the analysis of qualitative data from the interviews, and on the use of the software Nvivo. 
Type Of Material Improvements to research infrastructure 
Year Produced 2019 
Provided To Others? Yes  
Impact The USP and UFMA teams were trained in the use of and purchased the NVivo software, which has been either been used in the past in their respective departments. The two teams will help develop the use of qualitative data analysis in their departments by collaborating with other research groups and supporting ongoing qualitative research in their universities. 
 
Title Qualitative database of interviews with policy-makers in São Paulo and Maranhão 
Description This is a database of 45 interviews with policy-makers form São Paulo and Maranhão States on the effects of the economic crisis on the health system in Brazil. The database is in NVivo software, and has been coded to enable the analysis published in one of our latest published papers - Russo et al (2020) in PLOS One. 
Type Of Material Data analysis technique 
Year Produced 2019 
Provided To Others? No  
Impact 1. Publication in academic journal - Russo et al, 2020 2. Evidence base for definition of survey questionnaire to be implemented in 2021 
 
Description Collaboration with Imperial College to research the impact of the crisis on health in Brazil 
Organisation Imperial College London
Department School of Public Health
Country United Kingdom 
Sector Academic/University 
PI Contribution Research collaboration with the School of Public Health at Imperial College.
Collaborator Contribution A presentation was organised with research staff from Imperial College's School of Public Health (Christopher Millet and Thomas Hone) to develop a research collaboration to study the impact of the economic recession on the health system and population health in Brazil. Future research meetings have been planned, as well as a formal presentation at the School of Public health by Giuliano Russo. Imperial College is involved in a similar Newton Fund-MRC project on primary care in Brazil.
Impact Meeting and preliminary findings presentation in Queen Mary University of London on 18th December 2018.
Start Year 2018
 
Description Collaboration with PAHO to disseminate study results 
Organisation Pan American Health Organization
Department PAHO Research Promotion and Development
Country United States 
Sector Charity/Non Profit 
PI Contribution Meetings have been organised between our organisations to discuss the preliminary research findings from our study. A blog (in Portuguese) was published by our group on this study to disseminate its results.
Collaborator Contribution PAHO helped elaborate a blog on our study, and hosted it in its webpages - Innovation webpage for NHS management.
Impact The blog is the first of many planned in collaboration with PAHO. The organisation will also help engage civil society and policy-makers for our perspective policy-dualogues.
Start Year 2018
 
Description Blog in SUS website on the impact of the economic crisis on the health sysstem 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Elaboration of a dissemination blog in collaboration with the Pan American Health Organisation
Year(s) Of Engagement Activity 2018
URL https://apsredes.org/pesquisa-avalia-os-efeitos-da-crise-economica-na-forca-de-trabalho-do-setor-sau...
 
Description Meeting with UFMA departments to disseminate project 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact Soon after the internal approval of the project, five presentations were made by the Maranhão team to different departments of the Maranhão Federal University, with the aim of disseminating the award of the grant, and recruit participants (see dates below).

19/06/2018
03/07/2018
28/08/2018
25/09/2018
06/11/2018
Year(s) Of Engagement Activity 2018
 
Description Participation in international conference by University of Alicante on Brazil, the economic crisis and the pandemic 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact 150 people attended online this conference on Brazil and COVID-19 organised by the University of Alicante, Spain. Giuliano Russo, Mario Scheffer and Lígia Bahia were keynote speakers.
Year(s) Of Engagement Activity 2021
URL https://www.youtube.com/watch?app=desktop&v=PnekX_Myy9s&ab_channel=UniversidadMiguelHern%C3%A1ndezde...
 
Description Project kick-off meeting in São Paulo 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Soon after the approval of the project, a project kick-off meeting was organised in São Paulo to meet the research team members and plan the steps ahead. Also members from Rio de Janeiro State university were invited to this meeting to start collaboration with their own programme of work on the effects of the economic crisis on the health sector in Brazil.
Year(s) Of Engagement Activity 2018
 
Description Second project meeting in São Luís, Maranhão State 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact In December 2018 the second project meeting took place in São Luís de Maranhão. The meeting was aimed at (a) advancing the works and collecting local data for one of the papers plannedM (b) finalising the qualitative interviews questionnaire and sample frame; (c) train the brazilian team to the qualitative interviews methodology, and; (d) pilot and start the interviews with relevant actors of the public sector in Maranhão.
Year(s) Of Engagement Activity 2018
 
Description Working group meeting in São Paulo 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact For this working group meeting the team members met in São Paulo to discuss the preliminary findings for the interviews, receive training in qualitative analysis, and design the survey questionnaire. Practitioners and policy makers from São Paulo state participated in the discussion of the findings, contributing to the identification of further key informants to be interviewed.
Year(s) Of Engagement Activity 2019
 
Description Workshop in Maranhão 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact This event was organised to (a) analyse the qualitative data from the interviews; (b) develop the structure of the qualitative paper to be written on the impact of the crisis from the interviews, and; (c) finalise the response to the reviewers for one of the papers submitted for publication.
Year(s) Of Engagement Activity 2019