Highlights from HFACT research activities
Structural Breaks in Public Health Expenditure in India and their Implications
Government health spending in India has been static at around 1% since the mid-1990s, and both central and state budgets have yet to see a sizeable jump in the share of health spending out of GDP and Gross State Domestic Product (GSDP) respectively. The increase post-COVID-19 pandemic has also been very marginal.
There have been three health policies released formally in India, and the health sector has seen many programmes and interventions over the years. An important question, therefore, is whether these programmes and policies have led to a sustainable increase in health spending of the government? In other words, has government health spending been “responsive and pro-active” or “reactive and passive” in India. Raising resources sustainably is crucial for all states but especially for states that are deemed vulnerable – the Empowered Action Group (EAG) states – that have relatively poor health indicators compared to the non-EAG states.
This analysis brings to the fore issues of health sector prioritization in government finances and sustainability of health spending. The current discourse around Universal Health Coverage (UHC) and the need to raise health spending for faster progress towards UHC makes this issue even more critical to understand, especially for policymakers.
This research project looks at government health spending in India and specifically aims to address the following areas:
- Estimate the structural breaks in government health spending in India since 1980
- Analyse whether these structural breaks correspond to major health programmes or policies in India
- Assess the implications of the estimated structural breaks
Sources:
- Economic Political Weekly Research Foundation (EPWRF)
- Ministry of Health and Family Welfare (MoHFW), Union Budget
- National Statistical Office, Ministry of Statistics and Programme Implementation
Methods: Multiple Structural Break Analysis
Policy theme: Raising resources for health
Doctor Turnover and Health Outcomes: Evidence from the Exit of Cuban Doctors in Brazil
Brazil has long suffered from a highly unequal provision of primary care doctors. Especially remote and poor regions were severely under-served, restricting the populations’ access to primary care. Making an effort to increase the supply of doctors in those regions, in 2013 the Brazilian government introduced the More Doctors Program. The program was designed to pay competitive wages and provide additional benefits to doctors who agreed to work in eligible areas. As low numbers of Brazilian doctors applied to participate in the program, it was opened to doctors trained abroad. Through an international agreement, a substantial number of Cuban doctors were sent to Brazil: Out of around 18,000 doctors that enrolled in the program between 2013 and 2018, roughly half came from Cuba.
But Cuba’s participation in the More Doctors Program was highly politicized. Following the election of Brazil’s former right-wing President Jair Bolsanaro – a fierce opponent of the More Doctors Program – in October 2018, the Cuban government unilaterally and unexpectedly decided to withdraw all of its 8,316 primary care doctors from the More Doctors Program. The Cuban exit affected many municipalities, leaving some without a single primary care doctor. The Brazilian government put great effort and expenses into replacing the missing primary care doctors as fast as possible and managed to fill almost all resulting vacancies after a few months.
We study how the Cuban exit and the resulting turnover of primary care doctors affected health care utilization, health outcomes and health system adaptation. We compare municipalities that lost some (or all) of their doctors to those who did not lose any. We find that the large-scale turnover persistently decreased primary care utilization related to chronic and ongoing care, even after vacancies have been filled again. Curative and urgen care, however, remained largely unaffected. Surprisingly, the reduction in primary health care utilization did not translate into any systematic changes in health outcomes even throughout the end of the following year after the Cuban exit. We do not observe any effects on hospital admissions nor on mortality, neither on aggregate levels nor from specific causes.
Adaptation of local health systems and demand diversion seem to have helped mitigate turnover effects without major adverse repercussions for the affected populations. We explore different adaption mechanisms that could explain the overall pattern. We find evidence for (i) a priotization of primary care services towards urgent and curative needs, and (ii) a partial substitution of primarcy care by emergency care. This could entail fragmentation and decreased efficiency in health care, which potential negative long-term consequences for tackling the increasing burden of chronic diseases.
The findings can be found in the IEPS working paper series no 18, on the IEPS website.
Testing Resilience: The COVID-19 Pandemic and the Brazilian Health System
The COVID-19 pandemic posed an unprecedented resilience challenge for healthcare systems worldwide. In Brazil, the consequences were particularly dramatic: by December 2023, the country had reported approximately 700,000 deaths, equating to around 3,200 deaths per million people—significantly higher than the global average of 873 deaths per million. There is evidence that the number of diagnostic procedures carried out in the Brazilian public health system (SUS) fell by 20% in 2020 during the pandemic, possibly due to the postponement of routine exams caused by isolation and the temporary suspension of elective/non-urgent care by health units overwhelmed by the demand for COVID-19 cases. The delay in conducting some tests is alarming, as it may lead to later diagnoses of diseases for which early detection is crucial to increasing the chances of a cure. This situation prompts us to consider whether the pandemic has caused a permanent shift in the profile of medical actions, postponing procedures and triggering other second-order effects.
The consequences of the pandemic on health systems worldwide are still under study, and Brazil, due to its unique characteristics and the non-uniform restraining measures across the country during the pandemic crises, stands out as a noteworthy case study. Firstly, its public Unified Health System (SUS) is among the largest globally and aims to achieve universal coverage as mandated by the Constitution. Secondly, primary health care, with the Family Health Strategy (ESF) program as its flagship, serves as the main gateway for access.
Established in 1994 and gradually expanded across various Brazilian localities, the Family Health Strategy (ESF) follows federal guidelines but is implemented by municipalities. It comprises Family Health Teams, consisting of community health workers, physicians, nurses, and other professionals. These teams conduct home visits to individuals and households, emphasizing preventive measures, health promotion, and the early detection of health issues. Previous evidence suggests that the ESF has been effective in improving various health outcomes over the years, but its role in the COVID-19 pandemic still needs to be understood.
This research project aims to investigate the impact of the COVID-19 pandemic on the Brazilian health system. More specifically, we aim to address the following questions:
- What is the effect of the COVID-19 pandemic on services for other non-respiratory diseases in the short and long term?
- Has there been a change in priorities regarding the types, complexity, and funding of medical procedures performed due to the pandemic?
- Has the pandemic contributed to intensifying inequalities in access to medical procedures?
- To what extent has primary care, especially the ESF, contributed to mitigating the impacts of COVID-19, in terms of mortality, across the Brazilian regions? What are the channels?
The development of this research project aims to work in collaboration with representatives from state and municipal health secretariats across Brazil, health policymakers, and health economics researchers.
Sources:
- WHO Coronavirus Dashboard
- Ministry of Health’s Outpatient Information System (SIASUS)
Methods: Empirical policy impact evaluation, Equity Analysis
Policy Themes: Advancing effectiveness and equity in resource allocation, Ensuring and funding access to health care for left-behind groups
Establishing the cost-effectiveness and budget impact of providing antenatal HIV care to non-nationals living in South Africa
In South Africa, there is widespread legal access to healthcare, guaranteed by South Africa’s constitution under section 27, for all who live within its borders. The National Health Act and various South African department of health policies provide for not only expansive free primary care but also free maternal health and care for children under the age of six. This access is guaranteed to citizens and non-citizens (including undocumented individuals) alike. Access to health care for migrants however is often subject to debate.
The public hearings on South Africa’s proposed National Health Insurance law, which promises a major overhaul of how the country’s primary care services are to be delivered and accessed, were dominated by the question of how South Africa ought to cater for the migrant population. Policymakers lamented the lack of extant examples of other countries addressing a large migrant population’s health needs in a cost-effective manner. They also wanted to understand what it costs to provide free care to non-nationals in public facilities, how it benefits South Africa (and South Africans) and how it can be contained within existing budget constraints.
This study aims to examine this question through the lens of South Africa’s vastly successful antenatal prevention of mother to child transmission (PMTCT) program aimed at reducing the vertical transmission of HIV from a pregnant mother to her unborn child. The antenatal care program to which all who live within SA’s borders are entitled, is often the first contact point for migrant mothers’ entry into the PMTCT program.
Working with a large maternal and child hospital in central Johannesburg with a significant migrant patient population, we will analyse the HIV outcomes among nationals and non-nationals of South Africa and the costs associated with each (from a SA government perspective). We will additionally determine what the cost per HIV neonatal infection averted is, what the total budget impact of free services provided to migrants is, and what the health and financial consequences of not providing such care would be.
To implement the project we will be working with:
- Representatives from Rahima Moosa Hospital
- Lead from Empilweni Research Centre
- Head of pediatrics department
- Experts in migration and human rights within Southern Africa (working at the African Center for Migration Studies)
- Migrant populations
Methods: Economic evaluation & decision analysis
Policy themes: Ensuring and funding access to health care for left-behind groups
