Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study
File(s)
Published version
Author(s)
Type
Journal Article
Abstract
Background.
Since 2015, a major economic crisis in Brazil has led to increasing poverty and the implementation of long-term fiscal austerity measures which 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 compared how reduced coverage of BFP and ESF, or an alternative scenario where the level of social protection under these programmes is maintained, may affect the under-five mortality rate (U5MR) and socio-economic 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 was based on the longitudinal dataset and effect estimates from a previously published study which evaluated the effects of poverty, BFP, and 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 U5MR, and compare with scenarios where these programmes maintain the levels of social protection by increasing or decreasing with the size of Brazil's vulnerable populations. 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 BFP and ESF, in the most likely economic scenario the U5MR is expected to be 8.57% (CI: 6.88%- 10.24%) lower in 2030 than under fiscal austerity - a cumulative 19,732(CI: 10,207- 29,285) averted under-five deaths between 2017-2030. U5MRs from diarrhoea, malnutrition and lower respiratory tract infections are projected to be 39.3% (CI: 36.9%- 41.8%), 35.8% (CI:31.5%-39.9%) and 8.5% (CI:4.1%-12.0%) lower respectively in 2030 under the maintenance of BFP and ESF levels of social protection, with 123,549 fewer under-five hospitalisations from all causes over the study period. Reduced coverage of BFP and ESF will also disproportionately affect U5MR in the most vulnerable areas, with the U5MR expected to be in the poorest quintile of municipalities 11.0% (CI: 7.97%-13.83%) lower in 2030 under the maintenance of BFP and ESF levels of social protection, compared to no difference in the richest quintile. Some decreasing trends in health inequalities of the last decade will also halt under a fiscal austerity scenario: the U5MR Concentration Index is expected to remain stable in 2017-2030 compared to a 13.3% (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 employed 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 inequality.
Since 2015, a major economic crisis in Brazil has led to increasing poverty and the implementation of long-term fiscal austerity measures which 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 compared how reduced coverage of BFP and ESF, or an alternative scenario where the level of social protection under these programmes is maintained, may affect the under-five mortality rate (U5MR) and socio-economic 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 was based on the longitudinal dataset and effect estimates from a previously published study which evaluated the effects of poverty, BFP, and 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 U5MR, and compare with scenarios where these programmes maintain the levels of social protection by increasing or decreasing with the size of Brazil's vulnerable populations. 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 BFP and ESF, in the most likely economic scenario the U5MR is expected to be 8.57% (CI: 6.88%- 10.24%) lower in 2030 than under fiscal austerity - a cumulative 19,732(CI: 10,207- 29,285) averted under-five deaths between 2017-2030. U5MRs from diarrhoea, malnutrition and lower respiratory tract infections are projected to be 39.3% (CI: 36.9%- 41.8%), 35.8% (CI:31.5%-39.9%) and 8.5% (CI:4.1%-12.0%) lower respectively in 2030 under the maintenance of BFP and ESF levels of social protection, with 123,549 fewer under-five hospitalisations from all causes over the study period. Reduced coverage of BFP and ESF will also disproportionately affect U5MR in the most vulnerable areas, with the U5MR expected to be in the poorest quintile of municipalities 11.0% (CI: 7.97%-13.83%) lower in 2030 under the maintenance of BFP and ESF levels of social protection, compared to no difference in the richest quintile. Some decreasing trends in health inequalities of the last decade will also halt under a fiscal austerity scenario: the U5MR Concentration Index is expected to remain stable in 2017-2030 compared to a 13.3% (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 employed 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 inequality.
Date Issued
2018-05-22
Date Acceptance
2018-04-20
Citation
PLoS Medicine, 2018, 15 (5)
ISSN
1549-1277
Publisher
Public Library of Science (PLoS)
Journal / Book Title
PLoS Medicine
Volume
15
Issue
5
Sponsor
Medical Research Council (MRC)
Grant Number
MR/R022887/1
Subjects
Science & Technology
Life Sciences & Biomedicine
Medicine, General & Internal
General & Internal Medicine
CASH TRANSFER PROGRAM
INFANT-MORTALITY
HEALTH OUTCOMES
PRIMARY-CARE
IMPACT
AUSTERITY
COUNTRIES
MODELS
Brazil
Child
Child Mortality
Child Welfare
Economic Recession
Economics
Healthcare Financing
Humans
Models, Economic
Morbidity
Poverty
Socioeconomic Factors
Humans
Morbidity
Child Mortality
Models, Economic
Economics
Poverty
Child Welfare
Socioeconomic Factors
Child
Brazil
Economic Recession
Healthcare Financing
11 Medical and Health Sciences
General & Internal Medicine
Publication Status
Published
Article Number
e1002570