How the ‘plates’ of a health system can shift, change and adjust during economic recessions. A qualitative interview study of public and private health providers in Brazil’s São Paulo and Maranhão states

Abstract

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.

Demographic and professional risk factors of COVID-19 infections among physicians in low- and middle-income settings; findings from a representative survey in two Brazilian states

“…We did not collect information on availability and use of Personal Protective Equipment (PPE) among our physicians, which is considered in the COVID-19 literature a key risk factor for infections. (14) Finally, Maranhão and São Paulo represent very particular settings in terms of income distribution, organisation of healthcare services, and labour markets characteristics;(34) therefore, the study findings may not be entirely generalisable to the rest of Brazil, let alone to other low- and middle-income countries. Despite these limitations, a few conclusions can be safely drawn from our work.…”

“…(47) In the case of Brazilian’s physicians it is more likely that blurred boundaries between public and private employment may have made it difficult to accurately distinguish between physicians of the Unified National Healthcare System (SUS), from those of the private sector. As previous research has shown that the majority of Brazilian doctors simultaneously engage in a multiplicity of public as well as private forms of employment (48), and that private organisations often provide services within SUS (34), it is likely that the majority of physicians in our sample carried out functions simultaneously in public and private sector institutions, making it very difficult to identify the individual effects of the pandemic on either sectors.…”

Advances and weaknesses of the work process of the oral cancer care network in Brazil: A latent class transition analysis

“…The PMAQ‐CEO data are from 2014 and 2018. After this period, political (such as changes in the federal government), 29 economic (economic crisis and changes in SUS financing), 30,31 and health (such as the COVID‐19 pandemic) 32 events may have had repercussions on the work processes of the CEO, so that the extrapolation of our findings for today must be done with caution. On the other hand, strengths of this study include the assessment of specialized public oral health services that provide care for OC in all Brazilian States, the use of standardized assessments, the use of innovative analytical methods, and the longitudinal design.…”

“…The deterioration of quality may reflect the approval of Constitutional Amendment N° 95/2016, which resulted in freezing education and health expenditure over two decades. The implementation of fiscal austerity measures is known to trigger adverse health outcomes 30,44 . Restrictive health financing measures can contribute to a worse quality of work processes compromising the quality of CEO.…”

“…The implementation of fiscal austerity measures is known to trigger adverse health outcomes. 30,44 Restrictive health financing measures can contribute to a worse quality of work processes compromising the quality of CEO. This is in agreement with evidence from studies that analysed PHC and showed a decrease in the number of programmatic dental consultations between 2015 and 2017.…”