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Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study

Author

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  • Davide Rasella
  • Sanjay Basu
  • Thomas Hone
  • Romulo Paes-Sousa
  • Carlos Octávio Ocké-Reis
  • Christopher Millett

Abstract

Background: Since 2015, a major economic crisis in Brazil has led to increasing poverty and the implementation of long-term fiscal austerity measures that will substantially reduce expenditure on social welfare programmes as a percentage of the country’s GDP over the next 20 years. The Bolsa Família Programme (BFP)—one of the largest conditional cash transfer programmes in the world—and the nationwide primary healthcare strategy (Estratégia Saúde da Família [ESF]) are affected by fiscal austerity, despite being among the policy interventions with the strongest estimated impact on child mortality in the country. We investigated how reduced coverage of the BFP and ESF—compared to an alternative scenario where the level of social protection under these programmes is maintained—may affect the under-five mortality rate (U5MR) and socioeconomic inequalities in child health in the country until 2030, the end date of the Sustainable Development Goals. Methods and findings: We developed and validated a microsimulation model, creating a synthetic cohort of all 5,507 Brazilian municipalities for the period 2017–2030. This model was based on the longitudinal dataset and effect estimates from a previously published study that evaluated the effects of poverty, the BFP, and the ESF on child health. We forecast the economic crisis and the effect of reductions in BFP and ESF coverage due to current fiscal austerity on the U5MR, and compared this scenario with a scenario where these programmes maintain the levels of social protection by increasing or decreasing with the size of Brazil’s vulnerable populations (policy response scenarios). We used fixed effects multivariate regression models including BFP and ESF coverage and accounting for secular trends, demographic and socioeconomic changes, and programme duration effects. With the maintenance of the levels of social protection provided by the BFP and ESF, in the most likely economic crisis scenario the U5MR is expected to be 8.57% (95% CI: 6.88%–10.24%) lower in 2030 than under fiscal austerity—a cumulative 19,732 (95% CI: 10,207–29,285) averted under-five deaths between 2017 and 2030. U5MRs from diarrhoea, malnutrition, and lower respiratory tract infections are projected to be 39.3% (95% CI: 36.9%–41.8%), 35.8% (95% CI: 31.5%–39.9%), and 8.5% (95% CI: 4.1%–12.0%) lower, respectively, in 2030 under the maintenance of BFP and ESF coverage, with 123,549 fewer under-five hospitalisations from all causes over the study period. Reduced coverage of the BFP and ESF will also disproportionately affect U5MR in the most vulnerable areas, with the U5MR in the poorest quintile of municipalities expected to be 11.0% (95% CI: 8.0%–13.8%) lower in 2030 under the maintenance of BFP and ESF levels of social protection than under fiscal austerity, compared to no difference in the richest quintile. Declines in health inequalities over the last decade will also stop under a fiscal austerity scenario: the U5MR concentration index is expected to remain stable over the period 2017–2030, compared to a 13.3% (95% CI: 5.6%–21.8%) reduction under the maintenance of BFP and ESF levels of protection. Limitations of our analysis are the ecological nature of the study, uncertainty around future macroeconomic scenarios, and potential changes in other factors affecting child health. A wide range of sensitivity analyses were conducted to minimise these limitations. Conclusions: The implementation of fiscal austerity measures in Brazil can be responsible for substantively higher childhood morbidity and mortality than expected under maintenance of social protection—threatening attainment of Sustainable Development Goals for child health and reducing inequality. In a modeling study, Davide Rasella and colleagues investigate the possible consequences for child illness and mortality of different levels of coverage by social protection programs in Brazil.Why was this study done?: What did the researchers do and find?: What do these findings mean?:

Suggested Citation

  • Davide Rasella & Sanjay Basu & Thomas Hone & Romulo Paes-Sousa & Carlos Octávio Ocké-Reis & Christopher Millett, 2018. "Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study," PLOS Medicine, Public Library of Science, vol. 15(5), pages 1-20, May.
  • Handle: RePEc:plo:pmed00:1002570
    DOI: 10.1371/journal.pmed.1002570
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    Cited by:

    1. Stephanie Lange & Claire-Marie Altrock & Emily Gossmann & Jörg M. Fegert & Andreas Jud, 2022. "COVID-19—What Price Do Children Pay? An Analysis of Economic and Social Policy Factors," IJERPH, MDPI, vol. 19(13), pages 1-15, June.
    2. Letícia Xander Russo & Anthony Scott & Peter Sivey & Joilson Dias, 2019. "Primary care physicians and infant mortality: Evidence from Brazil," PLOS ONE, Public Library of Science, vol. 14(5), pages 1-16, May.
    3. Nikas, A. & Koasidis, K. & Köberle, A.C. & Kourtesi, G. & Doukas, H., 2022. "A comparative study of biodiesel in Brazil and Argentina: An integrated systems of innovation perspective," Renewable and Sustainable Energy Reviews, Elsevier, vol. 156(C).
    4. Antonio Fernando Boing & S. V. Subramanian & Alexandra Crispim Boing, 2019. "Reducing socioeconomic inequalities in life expectancy among municipalities: the Brazilian experience," International Journal of Public Health, Springer;Swiss School of Public Health (SSPH+), vol. 64(5), pages 713-720, June.
    5. Tais Freire Galvao & Gustavo Magno Baldin Tiguman & Mónica Caicedo Roa & Marcus Tolentino Silva, 2019. "Inequity in utilizing health services in the Brazilian Amazon: A population‐based survey, 2015," International Journal of Health Planning and Management, Wiley Blackwell, vol. 34(4), pages 1846-1853, October.
    6. Natalia Nunes Ferreira‐Batista & Adriano Dutra Teixeira & Maria Dolores Montoya Diaz & Fernando Antonio Slaibe Postali & Rodrigo Moreno‐Serra & James Love‐Koh, 2023. "Is primary health care worth it in the long run? Evidence from Brazil," Health Economics, John Wiley & Sons, Ltd., vol. 32(7), pages 1504-1524, July.
    7. Olívia Lucena de Medeiros & Jorge Otávio Maia Barreto & Matthew Harris & Letícia Xander Russo & Everton Nunes da Silva, 2020. "Delivering maternal and childcare at primary healthcare level: The role of PMAQ as a pay for performance strategy in Brazil," PLOS ONE, Public Library of Science, vol. 15(10), pages 1-18, October.
    8. Giuliano Russo & Maria Luiza Levi & Maria Teresa Seabra Soares de Britto e Alves & Bruno Luciano Carneiro Alves de Oliveira & Ruth Helena de Souza Britto Ferreira de Carvalho & Lucas Salvador Andriett, 2020. "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 sta," PLOS ONE, Public Library of Science, vol. 15(10), pages 1-20, October.
    9. Pedro Gerber Machado & Julia Tomei & Adam Hawkes & Celma de Oliveira Ribeiro, 2020. "A Simulator to Determine the Evolution of Disparities in Food Consumption between Socio-Economic Groups: A Brazilian Case Study," Sustainability, MDPI, vol. 12(15), pages 1-24, July.

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