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 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.

What happened to health labour markets during COVID-19? Insights from the analysis of cross-sectional survey data on the perceptions of medical doctors in Brazil

“…Finally, we recognise that Maranhão and São Paulo states present very particular configurations of labour market characteristics, organisation of health services, policies and health workforce 32 37 42. Therefore, our findings may not be entirely generalisable to other LMICs.…”

“…By contrast, Maranhão state is home to approximately 7.2 million people, its per capita income is one-third of São Paulo’s and only 1% of the population is covered by private health schemes. In 2022, there were 8743 physicians in Maranhão, that is, 1.22 per 1000—the second lowest rate among Brazilian states 42…”

The Impact of the COVID-19 Pandemic on Physicians’ Working Hours and Earnings in São Paulo and Maranhão States, Brazil

“…As we interviewed a diverse cohort of professionals, it was not possible to identify a common, absolute measure of changes in physicians’ individual workloads and earnings, and perceptions of proportional increases and decreases were used instead. As it is not straightforward to distinguish between private and public providers in Brazil [ 12 ], our categories of public-only and private-only physicians were calculated based on the juridic nature of the employer, irrespective of whether the services were provided in public or private facilities. Therefore, our physician categories may not be directly comparable to those in similar studies elsewhere [ 24 ].…”

“…This matters, as health workers—and physicians in particular—are a scarce and expensive resource for health systems in low- and middle-income countries (LMICs) [ 6 ]. This is especially the case in Brazil, where the health has historically been subsidized, and appears to have shifted some of its elements to adapt to the challenges brought about by the most recent economic crisis [ 12 ], which has had varying consequences for the country’s very unequal states and economic conditions [ 13 ]. Brazil has a dynamic and complex healthcare system, consisting of a variety of public and private organizations established in different historical moments, which presents problems in terms of the supply and distribution of healthcare services and medical professionals [ 14 , 15 ].…”

What happened to health labour markets during COVID-19? Insights from a survey of medical doctors in Brazil

“…By contrast, Maranhão state is home to approximately 7.2M people, its per capita income is one-third of São Paulo's, and only 1% of the population is covered by private health schemes. In 2022, there were 8,743 physicians in Maranhão, that is, 1.22 per 1,000 -the second lowest rate among Brazilian states 39 .…”