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.
Why was this study done?
- There is little evidence on the health impacts of economic crisis and fiscal austerity measures in low- and middle-income countries with fragile social protection systems and high poverty rates. Furthermore, there is poor understanding of how austerity measures could threaten attainment of the Sustainable Development Goals (SDGs) in these countries.
- A platform of long-term fiscal austerity measures is underway in Brazil in response to acute economic and political crises. Little is known about the possible impact of the planned reductions (as percentage of country GDP) in expenditure on social welfare programmes over the next two decades on health outcomes.
What did the researchers do and find?
- We forecast the effects of the economic crisis and austerity measures on two key social welfare programmes (the Bolsa Família Programme [BFP] and Estratégia Saúde da Família [ESF]) and on child morbidity and mortality in Brazil using a synthetic cohort of 5,507 municipalities using a robust modelling technique—discrete-time microsimulation—with municipality-specific time trends and parameters.
- Our forecasts indicate that over the period 2017–2030, reducing coverage of the BFP and ESF, compared with maintaining their coverage, could result in a higher child mortality rate—up to 8.6% higher in 2030. These austerity measures would then be responsible for almost 20,000 avoidable childhood deaths and 124,000 avoidable childhood hospitalisations between 2017 and 2030.
- According to our estimates, poorer municipalities would be disproportionately affected, ensuring that Brazil’s already high inequalities would persist until at least 2030. In contrast, maintaining BFP and ESF coverage would contribute to reducing these high inequalities, in line with the SDGs.
- A range of sensitivity analyses show that, even under different simulated intensities and durations of economic crisis and reductions in BFP and ESF coverage, the numbers of avoidable childhood deaths and hospitalisations under austerity measures are expected to be high.
What do these findings mean?
- Our study suggests that reduced coverage of poverty-alleviation and primary care programmes may result in a substantial number of preventable child deaths and hospitalisations in Brazil.
- These austerity measures will disproportionately impact child mortality in the poorest municipalities, disrupting previous declines in inequality in child health outcomes.
- The implementation of austerity measures in LMICs during economic crises is likely to threaten achievement of the SDGs related to poverty reduction, improving health, and reducing health inequality.
Citation: Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C (2018) Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med 15(5): e1002570. https://doi.org/10.1371/journal.pmed.1002570
Academic Editor: Lars Åke Persson, London School of Hygiene and Tropical Medicine, UNITED KINGDOM
Received: January 14, 2018; Accepted: April 20, 2018; Published: May 22, 2018
Copyright: © 2018 Rasella et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All data used in the analyses for the retrospective and forecast cohort are available from public websites hosted by Brazilian government agencies. Municipal-level datasets were extracted and downloaded. Data on mortality were obtained from http://www2.datasus.gov.br/DATASUS/index.php?area=0205&id=6937. Data on health services and health system resources were obtained from http://www2.datasus.gov.br/DATASUS/index.php?area=0204. Data on primary care coverage were obtained from http://dab.saude.gov.br/portaldab/historico_cobertura_sf.php and are also available from http://www2.datasus.gov.br/DATASUS/index.php?area=0202. Bolsa familia coverage can be obtained from http://aplicacoes.mds.gov.br/sagi-data/misocial/tabelas/mi_social.php. Population estimates were obtained from http://www.ibge.gov.br/home/estatistica/populacao/estimativa2015/estimativa_dou.shtm and also http://www2.datasus.gov.br/DATASUS/index.php?area=0206&id=6942. Data on illiteracy, poverty, and urbanisation were obtained from http://www.atlasbrasil.org.br/2013/en/download/.
Funding: This study received funding from the Wellcome Trust Training Fellowships in Public Health and Tropical Medicine scheme, DR the recipient Fellow (Grant reference number: 109949/Z/15/Z; https://wellcome.ac.uk/). CM is funded by a Research Professorship award from the National Institute for Health Research, (Grant reference number: RP_2014-04-03; https://www.nihr.ac.uk/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: SB receives a stipend as a specialty consulting editor for PLOS Medicine and serves on the journal's editorial board. The authors have declared that no other competing interests exist.
Abbreviations: BFP, Bolsa Família Programme; EC95, Constitutional Amendment 95; ESF, Estratégia Saúde da Família; IRR, incidence rate ratio; LMICs, low- and middle-income countries; SDGs, Sustainable Development Goals; U5HR, under-five hospitalisation rate; U5MR, under-five mortality rate
Several studies have examined the effects of economic crises on health outcomes in high-income countries , but very little evidence covers low- and middle-income countries (LMICs). Some studies suggest that economic crises in LMICs may have particularly detrimental impacts on child health [2,3], but evidence remains sparse. This is an important knowledge gap given that the global economic crisis has now affected many LMICs and may impede progress towards the Sustainable Development Goals (SDGs). Poverty is one of the most important social determinants of child health, and poverty-reduction programmes have contributed to the decrease of under-five morbidity and mortality in several countries [4,5].
The Brazilian economy experienced one of its strongest economic crises in recent years, with GDP falling by more than 8% since mid-2014 [6,7]. Amid a deep political crisis, a new government came to power on a platform to stabilise the public finances through long-term fiscal austerity measures that will substantially reduce expenditure on social welfare programmes as a percentage of the country’s GDP. The most impactful austerity measure is the Constitutional Amendment 95 (EC95), which will not be limited to the economic crisis, but will last for the next 20 years, reducing the dimension of the already fragile welfare state in Brazil (Box 1) [8,9].