The Comprehensive Health Impact of Cash Transfers, Social Pensions and Primary Care in Brazil: An Integrated Evaluation and Forecasting Analysis to Mitigate the Effects of the COVID19-Related Economic Crisis

Background: In the past few years, Brazil has implemented some of the world`s largest Conditional Cash Transfers(Bolsa Familia Program -BFP), Social Pensions(Benefício de Prestação Continuada -BPC), and Primary Health Care(Family Health Strategy –FHS). We evaluated their comprehensive impact on morbidity and mortality indicators over the last two decades. We then forecasted their mitigation effects on the adverse health impact of the economic crisis due to the COVID-19 pandemic.Methods: In the retrospective impact evaluation, we used fixed-effects negative binomial models with a cohort of Brazilian municipalities from 2004-19 to estimate the impact of BFP, BPC, and FHS coverage on hospitalizations and mortality, adjusted for all relevant demographic, social, and economic factors. Subsequently, we integrated the longitudinal dataset and parameters with validated dynamic microsimulation models, projecting hospitalization and mortality trends up to 2030 according to different intensities and durations of the economic crisis, and alternative policy responses.Findings: Consolidated coverages of BFP, FHS, and BPC were associated with a statistically significant reduction of overall age-standardized mortality rates, with Rate Ratios(RR) of 0.94(95%CI:0.94-0.96), 0.93(95%CI:0.93-0.94), and 0.92(95%CI:0.91-0.92), respectively. Stronger effects were found for under-five mortality, with RR of 0.87(95%CI:0.85-0.90), 0.90(95%CI:0.88-0.93),and 0.84(95%CI:0.82-0.86), respectively. A significant impact was also found on over-70 mortality and hospitalizations. Considering a scenario of moderate economic crisis, a mitigation strategy that will increase the coverage of BFP, FHS, and BPC proportionally to the increase of poverty will avert 778,845 (95%CI:665,074-893,674) deaths and 10,780,108 (95%CI:8,003,123-13,523,359) hospitalizations by 2030, if compared with the current coverage trends, and 1,424,624 (95%CI:1,264,552–1,587,859) deaths and 15,656,283 (95%CI:11,963,641-19,358,468) hospitalizations, if compared with scenarios of fiscal austerity.Interpretation: Cash transfers, social pensions, and primary health care could strongly reduce morbidity and mortality in LMICs, and their expansion should be considered an effective mitigation strategy for the adverse health impact of the current global economic crisis.Funding Information: This study was supported by the Medical Research Council (MRC), United Kindom Research Institute (UKRI), Grant_Number: MC_PC_MR/T023678/1.Declaration of Interests: We declare no competing interests.