Mortality associated with alternative policy options for primary care and the Mais Médicos (More Doctors) Program in Brazil: forecasting future scenarios.

OBJECTIVE: To forecast the impact of alternative scenarios of coverage changes in Brazil's Family Health Strategy (Estratégia Saúde da Família) (ESF)-due to fiscal austerity measures and to the end of the Mais Médicos (More Doctors) Program (PMM)-on overall under-5 mortality rates (U5MRs) and under-70 mortality rates (U70MRs) from ambulatory care sensitive conditions (ACSCs) up through 2030. METHODS: A synthetic cohort of 5 507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data. Reductions in ESF coverage, and its effects on U5MRs and U70MRs from ACSCs, were forecast based on two probable austerity scenarios, as compared to the maintenance of current ESF coverage. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, variables related to health care, and program duration effects. RESULTS: In comparison to maintaining stable ESF coverage, with the decrease in ESF coverage due to austerity measures and PMM termination, the mean U5MR and U70MR would be 13.2% and 8.6% higher, respectively, in 2030. The end of PMM would be responsible for a mean U5MR from ACSCs that is 4.3% higher and a U70MR from ACSCs that is 2.8% higher in 2030. The reduction of PMM coverage due only to the withdrawal of Cuban doctors who have been working in PMM would alone be responsible for a U5MR that is 3.2% higher, and a U70MR that is 2.0% higher in 2030. CONCLUSIONS: Reductions in primary health care coverage due to austerity measures and the end of the PMM could be responsible for many avoidable adult and child deaths in coming years in Brazil.