This paper makes two contributions in understanding how government health spending shapes health outcomes by exploiting unique top-down variation generated by Brazil's 29th Constitutional Amendment, which mandated minimum thresholds for municipal health spending. Firstly, we track downstream effects from increases in spending, documenting increases in available resources and access to health, with resulting declines in infant mortality. Secondly, we uncover non-linearities and input complementarities in production functions of public healthcare, mapping margins of spending effectiveness and constraints, including institutional factors. In particular, we find that effects are eroded in high corruption areas but substantially enhanced where strong management capabilities exist.

Won the Prize of Best Applied Microeconomics Article of the 44th Meeting of the Brazilian Econometric Society

Background

Remote Brazilian municipalities face persistent specialist shortages, causing delayed care and heavy reliance on Out-of-Home Treatment (TFD) for long-distance travel. Teleinterconsultation—synchronous provider-to-provider telemedicine—aims to bridge this gap. We evaluated TeleAmes, a large-scale program in Northern Brazil, where geographic barriers severely constrain physician access and patient mobility.

Methods

This quasi-experimental study used a staggered difference-in-differences estimator and administrative data from TeleAmes and the national outpatient system (SIA). We analyzed quarterly municipal-level outcomes, including teleinterconsultations and TFD procedures. Secondary outcomes covered TFD expenditures and travel distances. Results represent average treatment effects on the treated with municipality-clustered standard errors.

Findings

TeleAmes significantly expanded access: quarterly teleinterconsultations rose by 3.9–4.2 per 1,000 inhabitants, while SIA-recorded teleconsultations increased by 0.203 per 1,000. Rising in-person consultations suggested complementarity between remote and face-to-face care. TFD procedures decreased, primarily through a reduction of ~2.3 land-based transfers per 1,000 inhabitants. Effects on river and air transfers were minimal. While teleconsultations can substitute for travel, improved diagnostics for complex conditions may increase referrals; consequently, TFD expenditures and distances showed modest, heterogeneous, or imprecise changes.

Interpretation

Substantial improvements in specialist access and reduced land-based patient transfers indicate that TeleAmes strengthened primary care in remote Amazonian municipalities. Despite some statistical imprecision, the effect sizes reflect operationally relevant declines in patient mobility. Teleinterconsultation is a strategic tool for reducing geographic inequities and improving specialist access in remote regions of Brazil and similar settings.

Recent increases in mortality have brought life expectancy back to the forefront of the public health debate in the US. Though unprecedented, this trend comes after an equally striking phenomenon: a decades long deterioration in the relative position of the US in the world’s life expectancy distribution, culminating in the late 2010s in a gap of close to 3 years to the OECD average. This paper takes a comparative approach and documents the relative performance of life expectancy in the US from an international perspective. We characterize the changes in this relative performance over time, its age and cause of death profiles, and estimate its welfare implications. We show that this phenomenon is not recent, is not restricted to very particular causes of death, but is mostly driven by adult and old age mortality. We calculate that welfare gains in the US over the last few decades could have been between 19% and 28% higher had the US been able to reproduce the average health performance of OECD countries at their typical health expenditures.

IZA Discussion Paper Series

In this paper we assess trends in health expenditures and equity in health financing across Brazilian municipalities over the period 1998-2018. We document improvements in equity occurred in tandem with the introduction of the Piso da Atenção Básica (PAB) and the 29th Constitutional Amendment of 2000. Yet, the reduction in inequality faded by the beginning of the 2010s. Moreover, we observe that inequalities persist among municipalities with high and low fiscal capacity. We also document that the reduction in inequality fades despite the equalizing efforts of the PNAB reform that redefined the PAB fixo. Redistribution of resources introduced via PAB fixo was not sufficiently effective for relevant changes in equity.

This paper documents trends in life expectancy inequality across Brazilian states. We apply demographic methods to estimate the main determinants of the slowdown of the convergence process. Our analysis suggests that young adult and mid-aged mortality and mortality due to external causes are the main drivers of that process, with elderly mortality gaining importance in the last years.

LAPP, “Laboratório de Políticas Públicas e Programas Sociais” [Public Policy and Social Programs Lab], is a platform that seeks to gather, organize and provide in a straightforward fashion, information (causal evidence) on the impacts of public policy and social programs that went under rigorous evaluation worldwide (discontinued).

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