Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil

Universal Health Coverage (UHC) is high on the global health agenda and a key target included among the Sustainable Development Goals (SDGs) [1, 2]. The 40th anniversary of the Alma-Ata declaration [3] this year is a timely reminder that Primary Health Care (PHC) is considered essential to achieve UHC [4]. Evidence suggests that health systems with well-developed PHC are best placed to deliver an affordable package of care with greater population coverage, producing better and more equitable health outcomes [5–7].

Progress towards UHC is threatened by constrained public financing resulting from economic crises in some middle-income countries. An important example is Brazil, where an economic crisis has endured since 2014. The federal government has introduced a long-term programme of fiscal austerity limiting public expenditure for social welfare programmes (Box 1). These austerity measures are reducing federal spending on the Sistema Único de Saúde (SUS), Brazil’s public healthcare system [8–10].

The Estratégia Saúde da Família (ESF; Family Health Strategy) is the primary vehicle for achieving UHC within the SUS and is one of the largest PHC programmes of the world [11]. ESF coverage has expanded from 6.6% in 1998 to 63.7% in 2016 (covering 123 million people). Since 2013, the ESF has been strengthened through the Mais Médicos (More Doctors) programme (MMP) aiming to address under-provision of doctors in remote and deprived urban areas. Approximately 18,000 doctors were installed in ESF clinics in underserved locations, with the majority coming from Cuba [12] (Box 2). The ESF encompasses key principles of PHC including community-based care, multi-disciplinary teams, and a focus on prevention and health promotion [13]. Prior studies associated expanding ESF coverage with reduced infant mortality [14], adult mortality from conditions amenable to health care [15, 16], and health inequalities [17]. Further expansion of the PHC coverage within Brazil would be expected to improve efficiency and equity of the health system [18].

Mortality from ambulatory care-sensitive conditions (ACSCs) was evaluated as health outcomes given evidence of reductions following ESF expansion [17]. ACSCs are conditions which should be preventable with access to quality and timely primary care, and are based on a list of ICD-10 codes published by the Brazilian Ministry of Health [22] (text 3, Additional file 1). They include infectious diseases, nutritional deficiencies, asthma and chronic-obstructive pulmonary disease (COPD), cardiovascular disease, diabetes, epilepsy, and gastric ulcers for those under 70 years of age, also defined as premature deaths [17, 22]. Despite that the list of ACSC was originally created for hospitalizations, it has been used in mortality studies [16, 17] because it is preferred to amenable mortality lists not specific to the Brazilian context. Additionally, potential future inequalities are modelled both between municipalities in terms of ACSC mortality rates and within municipalities in terms of racial health inequalities between black/pardo and white ACSC mortality rates, given Brazil’s high and persistent socioeconomic and health inequalities and the tenth SDG, which aims to reduce inequalities within and among countries [2].

We created a synthetic cohort of 5507 municipalities for the years 2017–2030 using municipal-level discrete-time microsimulation modelling [32] with a longitudinal dataset of municipalities already used in retrospective PHC impact evaluations [16, 17]. Microsimulation forecasting allows the modelling of individual-specific characteristics, using individual-specific previous trends, associated outcome probabilities, subpopulation effects, correlation structures between variables, and non-linear effects.

The microsimulation was based on the conceptual model, the cohort structure and the parameters of a previous retrospective study on the impact of ESF on mortality from ACSC [17]. As in this retrospective analysis, longitudinal fixed effects regression methods were used [34], with as independent variables the same municipal-level demographic and socioeconomic factors, including the effects of healthcare system variables and of large-scale public interventions—such the Brazilian conditional cash transfer Bolsa Familia Programme (BFP)—to predict changes in future ACSC mortality. The forecast scenarios of economic crisis and fiscal austerity were derived from a validated model employed to study the effects of socioeconomic changes and policy options in Brazil and used in a recently published study to simulate under-5 mortality scenarios [33]. The modelling approach was undertaken in two stages: (i) the generation of a synthetic cohort of municipalities with independent municipal-level variable values up to 2030, for BFP and ESF coverage from real data up to 2016 and forecast projections according to scenarios for the period 2017–2030 and for socioeconomic and healthcare variable extrapolated values since 2011 (due to lack of municipal-level data) based on 2000–2010 municipal-level trends, and (ii) the prediction of ACSC mortality rates (the dependent variable) based on the independent variable values and regression model starting from 2010 (using the years before 2017 to calibrate and validate the model). An overview of the methods is provided here, but further details and a theoretical framework are described in Additional file 1, including the modelling calibration process, internal and external validation, parameter distributions for Monte Carlo simulations, and model equations in accordance with the international model reporting guidelines (ISPOR-SMDM) [35].

Under austerity scenarios of decreasing ESF coverage with and without MMP termination, ACSC premature mortality rates would be expected to be 8.6% and 5.8% higher respectively in 2030 compared with maintaining the current ESF coverage. Excess premature deaths from ACSCs in the first—most probable—scenario will be almost 50,000 between 2017 and 2030. Compared with achieving 100% ESF coverage (UHC scenario), mortality rates would be 11.1% higher in 2030 if the ESF contracts and the MMP ends, corresponding to almost 85,000 premature deaths. Reductions in ESF coverage under austerity scenarios would disproportionately impact the poorest municipalities. Existing trends of reducing inequalities in mortality between richest and poorest municipalities and white and black/pardo Brazilians would end with ESF coverage reductions.

The avoidable death estimates of the study should be considered an underestimation of the overall mortality impact of ESF coverage reductions, because they include only under-70 deaths (which represent around 55% of the total Brazilian deaths), and they evaluate only deaths from ACSC (around 13% of the premature deaths), whilst ESF should have smaller effects also on othermortality causes [15].

To our knowledge, this is the first study to forecast the impact of austerity measures on PHC coverage and health outcomes in a middle-income country. Our findings are consistent with the evidence, including studies from MICs, that show investments and pro-equity implementation of PHC can improve health and reduce inequalities [5, 6, 44]—including greater mortality reductions in low-income and black populations [17, 45, 46]. In Europe, in response to the 2008 Great Recession, many countries reduced coverage of public health care—including introducing user charges, reducing services covered, or restricting populations covered [47, 48]. Cuts in public health spending occurred in many European countries under austerity measures, most notably in Greece, Ireland, Latvia, and Portugal [49], which were associated increases in self-reported unmet medical need [50, 51]. Many European countries additionally introduced cost-sharing policies sharply increasing out-of-pocket expenditure on medications and visits to primary care services [52]. These policies are likely to have an adverse impact on health outcomes given that cost has been shown to be an important barrier to optimal medication use and primary care clinic attendance in European settings [53, 54].

There are multiple strengths to this study. We developed a synthetic 14-year cohort of 5507 municipalities based on routinely collected data widely used in previous impact evaluation studies in Brazil [16, 17]. The permitted creation of a correlation structure between variables and modelling of municipality-specific parameters and variable trends based on real data, which have been calibrated with the national-level data. The external validation of the models—using a different data source than the one used for the calibration process—is another strength of the study, together with the extensive sensitivity analyses employed. Our estimates of PHC impacts on mortality are consistent with numerous previous Brazilian studies [15–17, 55, 56]—strengthening forecast theoretical, and modelled, relationships.

One limitation of the study is the assumption that estimates of ESF coverage will decline in proportion to federal funding cuts. The elasticity of ESF coverage in response to federal transfers is assumed in this study to be directly proportional given the heavy reliance of municipalities on federal budgets for health, but shows in sensitivity analyses that varying this relationship does not alter the differences between ESF scenarios substantially. We used mortality from ACSCs as our outcome measure, rather than healthcare-amenable mortality [57], to focus on conditions defined as amenable to PHC within the Brazilian context, to exclude conditions strongly influenced by hospital-based care, to increase the accuracy and reliability of the models, and to be in line with retrospective studies [16, 17]. Despite the fact that, considering the most recent studies [14–17]—ESF has shown its strongest effects on ACSC, we are probably underestimating the overall effects of ESF coverage reductions on the health of the population by selecting only this group of causes. Another limitation of the study is the assumption that ESF units with MMP physicians have the same effectiveness as ESF units in general. This assumption is informed by the fact that MMP physicians are working in similar ESF units, with the same supporting instruments and infrastructure. They are also working to the same clinical guidance for ACS conditions.

The ESF is an internationally recognised model of PHC which aspires to deliver key features of Alma-Ata vision—restated in the draft 2018 Astana declaration (Alma-Ata 2.0) [3, 58]—including proactive and continuous community-based care which is geographically accessible and low cost. Despite facing severe financing and human resource constraints, the ESF has delivered substantial health benefits to the Brazilian population [11, 14]. Brazil’s programme of long-term austerity measures will substantially reduce ESF coverage and associated health benefits especially among the country’s poor—undermining progress towards achievement of SDGs 3 and 10, including achievement of UHC. In this sense, the health and equity impacts of austerity policies in Brazil should be closely monitored to optimise policy learning globally.

Our findings suggest that austerity measures affecting PHC could contribute to a large number of avoidable deaths and may preclude achievement of SDGs for health and inequality in Brazil and in other low- and middle-income countries.