Horizontal equity in health care utilization in Brazil, 1998–2008

James Macinko,Maria Lima-Costa

doi:10.1186/1475-9276-11-33

Abstract

IntroductionThis study assesses trends in horizontal equity in the utilization of healthcare services from 1998 to 2008--a period of major economic and social change in Brazil.MethodsData are from nationally representative surveys repeated in 1998, 2003, and 2008. We apply established methods for assessing horizontal inequity in healthcare access (the principle that people with the same healthcare needs should have similar access to healthcare services). Horizontal inequity is calculated as the difference between observed healthcare utilization and utilization predicted by healthcare needs. Outcomes examined include the probability of a medical, dental, or hospital visit during the past 12 months; any health service use in the past two weeks; and having a usual source of healthcare. We use monthly family income to measure differences in socioeconomic position. Healthcare needs include age, sex, self-rated health, and chronic conditions. Non-need factors include income, education, geography, health insurance, and Family Health Strategy coverage.ResultsThe probability of having at least one doctor visit in the past 12 months became substantially more equitable over time, ending with a slightly pro-rich orientation in 2008. Any hospitalization in the past 12 months was found to be pro-poor in all periods but became slightly less so in 2008. Dental visits showed the largest absolute decrease in horizontal inequity, although they were still the most inequitably (pro-rich) distributed outcome in 2008. Service use in the past two weeks showed decreased inequity in 2003 but exhibited no significant change between 2003 and 2008. Having a usual source of care became less pro-rich over time and was nearly income-neutral by 2008. Factors associated with greater inequities include income, having a private health plan, and geographic location. Factors associated with greater equity included health needs, schooling, and enrolment in the Family Health Strategy.ConclusionsHealthcare utilization in Brazil appears to have become increasingly equitable over the past 10 years. Although this does not imply that equity in health outcomes has improved correspondingly, it does suggest that government policies aimed at increasing access, especially to primary care, have helped to make healthcare utilization in Brazil fairer over time.

Highlights

This study assesses trends in horizontal equity in the utilization of healthcare services from 1998 to 2008--a period of major economic and social change in Brazil
Inequities in healthcare utilization are generally decreasing in Brazil
In 1998, they were already pro-poor for hospitalization, which represents the most costly and perhaps most urgent form of healthcare need

Summary

Introduction

This study assesses trends in horizontal equity in the utilization of healthcare services from 1998 to 2008--a period of major economic and social change in Brazil. Health disparities are relevant as Brazil continues to develop its national health system Created in 1988, the SUS was conceived of as a national health service designed to provide comprehensive and universal care through decentralized management and provision of health services that are free of charge at the point of delivery. As of 2010 the SUS contained over 41,000 health posts and centers, 30,000 specialized outpatient services, nearly 2,000 public hospitals, and 236,000 community health agents [4]. In 2009 the SUS financed nearly 12 million hospitalizations and delivered about 100 million ambulatory care procedures per month [4].

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