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We conducted a comparative case study of Maranh\u00e3o and S\u00e3o Paulo, two unevenly developed states in Brazil, to explore the health financing and system performance changes brought in by its 2014\u20132015 economic recession.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>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\u2019s health spending over the 2010\u20132018 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 S\u00e3o Paulo and Maranh\u00e3o.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Our analysis shows that Brazil\u2019s macroeconomic conditions deteriorated across the board after 2015\u20132016, with S\u00e3o Paulo\u2019s economy experiencing a wider setback than Maranh\u00e3o\u2019s. 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 Maranh\u00e3o 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 Maranh\u00e3o were not affected by the crisis, a decrease in public physicians was observed in S\u00e3o Paulo.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>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.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjgh-2019-002122","type":"journal-article","created":{"date-parts":[[2020,2,28]],"date-time":"2020-02-28T14:25:15Z","timestamp":1582899915000},"page":"e002122","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":15,"title":["The differential impact of economic recessions on health systems in middle-income settings: a comparative case study of unequal states in Brazil"],"prefix":"10.1136","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5848-611X","authenticated-orcid":false,"given":"Lucas Salvador","family":"Andrietta","sequence":"first","affiliation":[{"name":"Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, S\u00e3o Paulo, Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2298-4162","authenticated-orcid":false,"given":"Maria Luiza","family":"Levi","sequence":"additional","affiliation":[{"name":"Centro de Engenharia, Modelagem e Ci\u00eancias Sociais Aplicadas, Universidade Federal do ABC, Santo Andre, S\u00e3o Paulo, Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8931-6471","authenticated-orcid":false,"given":"M\u00e1rio C","family":"Scheffer","sequence":"additional","affiliation":[{"name":"Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, S\u00e3o Paulo, Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4806-7752","authenticated-orcid":false,"given":"Maria Teresa Seabra Soares de Britt","family":"Alves","sequence":"additional","affiliation":[{"name":"Departamento de Sa\u00fade P\u00fablica, Universidade Federal do Maranh\u00e3o, Sao Luis, Maranh\u00e3o, Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8053-7972","authenticated-orcid":false,"given":"Bruno Luciano","family":"Carneiro Alves de Oliveira","sequence":"additional","affiliation":[{"name":"Departamento de Sa\u00fade P\u00fablica, Universidade Federal do Maranh\u00e3o, Sao Luis, Maranh\u00e3o, Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2716-369X","authenticated-orcid":false,"given":"Giuliano","family":"Russo","sequence":"additional","affiliation":[{"name":"Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom"}]}],"member":"239","published-online":{"date-parts":[[2020,2,28]]},"reference":[{"key":"2025072914070178000_5.2.e002122.1","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0193165","article-title":"Welfare states, the great recession and health: trends in educational inequalities in self-reported health in 26 European countries","volume":"13","author":"Le\u00e3o","year":"2018","journal-title":"PLoS 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