Can primary health care mitigate the effects of economic crises on child health in Latin America? An integrated multicountry evaluation and forecasting analysis

Background Latin American and Caribbean countries are dealing with the combined challenges of pandemic-induced socicoeconomic stress and increasing public debt, potentially leading to reductions in welfare and health-care services, including primary care. We aimed to evaluate the impact of primary health-care coverage on child mortality in Latin America over the past two decades and to forecast the potential effects of primary health-care mitigation during the current economic crisis. Methods This multicountry study integrated retrospective impact evaluations in Brazil, Colombia, Ecuador, and Mexico from 2000 to 2019 with forecasting models covering up to 2030. We estimated the impact of coverage of primary health care on mortality rates in children younger than 5 years (hereafter referred to as under-5 mortality) across different age groups and causes of death, adjusting for all relevant demographic, socioeconomic, and healthcare factors, with fixed-effects multivariable negative binomial models in 5647 municipalities with an adequate quality of vital statistics. We also performed several sensitivity and triangulation analyses. We integrated previous longitudinal datasets with validated dynamic microsimulation models and projected trends in under-5 mortality rates under alternative policy response scenarios until 2030. Findings High primary health-care coverage was associated with substantial reductions in post-neonatal mortality rates (rate ratio [RR] 0 center dot 72, 95% CI 0 center dot 71-0 center dot 74), toddler (ie, aged between 1 year and <5 years) mortality rates (0 center dot 75, 0 center dot 73-0 center dot 76), and under-5 mortality rates (0 center dot 81, 0 center dot 80-0 center dot 82), preventing 305 890 (95% CI 251 826-360 517) deaths of children younger than 5 years over the period 2000-19. High primary health-care coverage was also associated with lower under-5 mortality rates from nutritional deficiencies (RR 0 center dot 55, 95% CI 0 center dot 52-0 center dot 58), anaemia (0 center dot 64, 0 center dot 57-0 center dot 72), vaccine-preventable and vaccine-sensitive conditions (0 center dot 70, 0 center dot 68-0 center dot 72), and infectious gastroenteritis (0 center dot 78, 0 center dot 73-0 center dot 84). Considering a scenario of moderate economic crisis, a mitigation response strategy implemented in the period 2020-30 that increases primary health-care coverage could reduce the under-5 mortality rate by up to 23% (RR 0 center dot 77, 95% CI 0 center dot 72-0 center dot 84) when compared with a fiscal austerity response, and this strategy would avoid 142 285 (95% CI 120 217-164 378) child deaths by 2030 in Brazil, Colombia, Ecuador, and Mexico. Interpretation The improvement in primary health-care coverage in Brazil, Colombia, Ecuador, and Mexico over the past two decades has substantially contributed to improving child survival. Expansion of primary health-care coverage should be considered an effective strategy to mitigate the health effects of the current economic crisis and to achieve Sustainable Development Goals related to child health. Copyright (c) The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.