IntroductionAlthough economic crises are common in low/middle-income countries (LMICs), the evidence of their impact on health systems is still scant. We conducted a comparative case study of Maranhão and São Paulo, two unevenly developed states in Brazil, to explore the health financing and system performance changes brought in by its 2014–2015 economic recession.MethodsDrawing from economic and health system research literature, we designed a conceptual framework exploring the links between macroeconomic factors, labour markets, demand and supply of health services and system performance. We used data from the National Health Accounts and National Household Sample Survey to examine changes in Brazil’s health spending over the 2010–2018 period. Data from the National Agency of Supplementary Health database and the public health budget information system were employed to compare and contrast health financing and system performance of São Paulo and Maranhão.ResultsOur analysis shows that Brazil’s macroeconomic conditions deteriorated across the board after 2015–2016, with São Paulo’s economy experiencing a wider setback than Maranhão’s. We showed how public health expenditures flattened, while private health insurance expenditures increased due to the recession. Public financing patterns differed across the two states, as health funding in Maranhão continued to grow after the crisis years, as it was propped up by transfers to local governments. While public sector staff and beds per capita in Maranhão were not affected by the crisis, a decrease in public physicians was observed in São Paulo.ConclusionOur case study suggests that in a complex heterogeneous system, economic recessions reverberate unequally across its parts, as the effects are mediated by private spending, structure of the market and adjustments in public financing. Policies aimed at mitigating the effects of recessions in LMICs will need to take such differences into account.
O artigo descreve a trajetória percorrida para responder aos desafios teóricos e metodológicos da pesquisa sobre empresas e grupos empresariais do setor saúde no Brasil que reorganizaram suas estruturas societárias, diversificaram atividades e ampliaram operações financeiras. Tais movimentos de concentração e expansão empresarial foram analisados mediante a aproximação do referencial da financeirização do capitalismo contemporâneo à análise de empresas e grupos empresariais selecionados. As estratégias empresariais foram classificadas em três dimensões: estrutura patrimonial societária, financeira contábil e influência na agenda pública. Seus respectivos indicadores orientam a organização de informações de distintas fontes para empresas e grupos empresariais no período de 2008 a 2017. O estudo traça um perfil do intenso e complexo processo de reorganização empresarial do setor saúde. Contudo, a natureza exploratória da investigação, bem como as dificuldades de acesso a informações e seleção de empresas e grupos empresariais tornam suas constatações necessariamente provisórias.
Resumo O objetivo do artigo é cotejar a literatura sobre financeirização e compreender sua expressão no debate sobre as políticas sociais brasileiras, especialmente na saúde, entendendo a dominância financeira como novo modo de ser do regime global de produção de riqueza. Enfatiza-se evidências da financeirização, seus conceitos e sua expressão no caso brasileiro. Aponta-se lacunas em estudos atuais sobre o welfare state e possíveis aproximações com o tema da financeirização. Destaca-se estudos com essa proposta no Brasil, identificando tendências na assistência social, previdência, habitação, educação e, particularmente, na saúde. A revisão evidencia a relevância do tema e os limites das abordagens setoriais no Brasil. Postula-se que, na saúde, a mudança no padrão setorial de acumulação acompanhou o aprofundamento da financeirização. Essa nova configuração debilita abordagens restritas ao orçamento público e ao papel do Estado, e solicita seu aprimoramento por pesquisas empíricas sobre a conformação e a agenda política dos agentes privados.
Background. Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world’s most affected countries, and its health system was already living the aftermath of the 2015 recession. Methods. Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (São Paulo) and impoverished (Maranhão) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings.Results. We found the concept of ‘health sector crisis’ to be politically charged among healthcare providers in São Paulo and Maranhão. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible – if insecure – working arrangements. Following a drop in employment and health plans, private health insurance companies streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but also credited for having moved to cater for higher-income customers in Maranhão.Conclusions. The ‘plates’ of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded.
Resumo O artigo examina as tendências recentes da forma de inserção dos médicos no mercado de trabalho à luz da regulação das relações trabalhistas na percepção de informantes-chave que atuam nos setores público e privado do sistema de saúde no estado de São Paulo. O estudo mostrou que, na percepção dos entrevistados, há uma tendência crescente de inserção de médicos como pessoa jurídica condicionada pela regulação das relações de trabalho e pela política de contratação dos estabelecimentos provedores de serviços de assistência à saúde. Em geral, a ‘pejotização’ de médicos foi associada à perda de autonomia desses profissionais em relação aos termos de contratação e às condições de realização do trabalho. O artigo conclui que a inserção ‘pejotizada’ de médicos se apresenta como parte do movimento mais geral de barateamento da força de trabalho associado à terceirização, e indica que há espaço para a exploração de políticas voltadas à gestão de trabalhadores que busquem atrair e fixar médicos no Sistema Único de Saúde.
Este artigo discute a dinâmica do subsetor de Serviços de Apoio Diagnóstico e Terapêutico (SADT) no Brasil entre 2008 e 2016. Por meio de uma abordagem exploratória, a pesquisa buscou operacionalizar conceitos-chave na literatura sobre o padrão de acumulação que caracteriza o capitalismo contemporâneo. A pesquisa investigou a atuação de seis empresas de diagnósticos brasileiras em três dimensões principais: (1) patrimonial; (2) contábil-financeira; e (3) política. Os resultados mostram um subsetor em franco crescimento, via aumento do volume e dos preços de serviços comercializados. As evidências corroboram traços de um padrão de acumulação financeirizado, notadamente estratégias agressivas de fusões e aquisições por parte de empresas líderes e, como resultado, a centralização. Algumas outras características associadas ao conceito de financeirização, porém, parecem não ter relevância. Discute-se ainda o horizonte concorrencial nas atividades do subsetor de SADT e seus possíveis efeitos para o esforço de consolidação do Sistema Único de Saúde (SUS).
Este é um artigo publicado em acesso aberto sob uma licença Creative Commons.
Background Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world’s most affected countries, and its health system was already experiencing the aftermath of the 2015 recession. Methods Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (São Paulo) and impoverished (Maranhão) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings. Results We found the concept of ‘health sector crisis’ to be politically charged among healthcare providers in São Paulo and Maranhão. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible–if insecure–working arrangements. Following a drop in employment and health plans, private health insurance companies have streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but were also credited for having moved to cater for higher-income customers in Maranhão. Conclusions The ‘plates’ of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID economic recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded.
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