The differential impact of economic recessions on health systems in middle-income settings: a comparative case study of unequal states in Brazil.

Introduction: Although economic crises are common in low/middle-income countries (LMICs), the evidence of their impact on health systems is still scant. We conducted a comparative case study of Maranhão and São Paulo, two unevenly developed states in Brazil, to explore the health financing and system performance changes brought in by its 2014-2015 economic recession. Methods: Drawing from economic and health system research literature, we designed a conceptual framework exploring the links between macroeconomic factors, labour markets, demand and supply of health services and system performance. We used data from the National Health Accounts and National Household Sample Survey to examine changes in Brazil's health spending over the 2010-2018 period. Data from the National Agency of Supplementary Health database and the public health budget information system were employed to compare and contrast health financing and system performance of São Paulo and Maranhão. Results: Our analysis shows that Brazil's macroeconomic conditions deteriorated across the board after 2015-2016, with São Paulo's economy experiencing a wider setback than Maranhão's. We showed how public health expenditures flattened, while private health insurance expenditures increased due to the recession. Public financing patterns differed across the two states, as health funding in Maranhão continued to grow after the crisis years, as it was propped up by transfers to local governments. While public sector staff and beds per capita in Maranhão were not affected by the crisis, a decrease in public physicians was observed in São Paulo. Conclusion: Our case study suggests that in a complex heterogeneous system, economic recessions reverberate unequally across its parts, as the effects are mediated by private spending, structure of the market and adjustments in public financing. Policies aimed at mitigating the effects of recessions in LMICs will need to take such differences into account.