[Unmet health care needs in Brazil: an investigation about the reasons for not seeking health care]

Inequalities in unmet need for health care services and medications in Brazil: a decomposition analysis

Background

Unmet need is a metric used to assess the performance of health care systems throughout the world. One of the primary objectives of the Brazilian health care system is to identify ways to improve the health outcomes of all citizens. To accomplish this challenging goal, the health care system in Brazil will need to identify and eliminate barriers and provide timely and adequate access to health care services to all.

Methods

This study assessed the performance of the Brazilian health care system by focusing on the unmet need for health care services and medications. We evaluated the Brazilian National Health Survey data collected in 2013 and 2019 to determine the magnitude of socioeconomic-related inequalities associated with unmet health care needs. Primary contributing factors were identified via decomposition analysis of the calculated concentration indices (CInds).

Findings

Despite the availability of universal health care, 3.8% and 7.5% of the population in Brazil reported unmet needs for health care services and medications, respectively in the 2019 survey. Although the overall unmet need for medications remained unchanged between 2013 and 2019, CInd analysis revealed significant pro-poor inequalities with respect to unmet needs for both health care services and medications. The overall magnitude of these inequalities was higher in the poorer regions of the country. The use of private health insurance as well as individual health and socioeconomic status contributed significantly to the inequalities associated with unmet needs for health care services and medication throughout Brazil.

Interpretations

Policy interventions should focus on improving access to health care services, extending coverage to include pharmaceuticals, and targeting both financial and non-financial barriers to obtaining care, particularly those experienced by the poor and vulnerable populations in Brazil.

Funding

None.

Discontinuation of Health Interventions Among Brazilian Older Adults During the Covid-19 Pandemic: REMOBILIZE Study

The objective of this study was to analyze changes in access to health interventions during the pandemic among Brazilian older adults and to investigate the factors associated with social and health inequalities. We conducted an online survey with Brazilian adults aged 60  +  years between May and June 2020. A multidimensional questionnaire was used to investigate access to health interventions during the pandemic and associated factors. Of 1482 participants, 56.5% reported health care before the pandemic, and 36.4% discontinued it during the pandemic. The discontinuation rate was 64.4% (95% CI 61.1-67.6). Participants with higher educational level (nine or more years of education: OR 0.34; 95% CI 0.17-0.70) and higher income (eight or more times the minimum wage: OR 0.54; 95% CI 0.36-0.81) were associated with less probability of discontinuation. Presenting multimorbidity (OR: 1.42; 95% CI 1.06-1.90) and polypharmacy (OR: 0.61; 95% CI 0.46-0.81) were associated with discontinuity in health interventions. Our study showed that structural health inequities in access to health care shaped the rates of discontinuation in health care interventions during the COVID-19 pandemic. Strategic actions should be set up to actively monitor socially vulnerable older adults and strengthen community-based services to mitigate the discontinuation of health care interventions.

Impact of the Programa Mais médicos (more doctors Programme) on primary care doctor supply and amenable mortality: quasi-experimental study of 5565 Brazilian municipalities

BACKGROUND

Investing in human resources for health (HRH) is vital for achieving universal health care and the Sustainable Development Goals. The Programa Mais Médicos (PMM) (More Doctors Programme) provided 17,000 doctors, predominantly from Cuba, to work in Brazilian primary care. This study assesses whether PMM doctor allocation to municipalities was consistent with programme criteria and associated impacts on amenable mortality.

METHODS

Difference-in-differences regression analysis, exploiting variation in PMM introduction across 5565 municipalities over the period 2008-2017, was employed to examine programme impacts on doctor density and mortality amenable to healthcare. Heterogeneity in effects was explored with respect to doctor allocation criteria and municipal doctor density prior to PMM introduction.

RESULTS

After starting in 2013, PMM was associated with an increase in PMM-contracted primary care doctors of 15.1 per 100,000 population. However, largescale substitution of existing primary care doctors resulting in a net increase of only 5.7 per 100,000. Increases in both PMM and total primary care doctors were lower in priority municipalities due to lower allocation of PMM doctors and greater substitution effects. The PMM led to amenable mortality reductions of - 1.06 per 100,000 (95%CI: - 1.78 to - 0.34) annually - with greater benefits in municipalities prioritised for doctor allocation and where doctor density was low before programme implementation.

CONCLUSIONS

PMM potential health benefits were undermined due to widespread allocation of doctors to non-priority areas and local substitution effects. Policies seeking to strengthen HRH should develop and implement needs-based criteria for resource allocation.

Leveraging household survey data to measure barriers to health services access in the Americas

OBJECTIVE

To identify advantages and challenges of using household survey data to measure access barriers to health services in the Americas and to report findings from most recent surveys.

METHODS

Descriptive cross-sectional study using data retrieved from publicly available nationally representative household surveys carried out in 27 countries of the Americas. Values for indicators of access barriers for forgone care were generated using available datasets and reports from the countries. Results were disaggregated by wealth quintiles according to income or asset-based wealth levels.

RESULTS

Most surveys were similar in general approach and in the categories of their content. However, country-specific questionnaires varied by country, which hindered cross-country comparisons. On average, about one-third of people experienced multiple barriers to forgone appropriate care. There was great variability between countries in the experience of these barriers, although disparities were relatively consistent across countries. People in the poorest wealth quintile were more likely to experience barriers related to acceptability issues, financial and geographic access, and availability of resources.

CONCLUSIONS

The analysis indicates major inequalities by wealth status and uneven progress in multiple access barriers that hinder progress towards the goals of equity as part of the Sustainable Development Goals and universal health in the Americas. Access barriers were multiple, which highlights the need for integrated and multisectoral approaches to tackle them. Given the variability between instruments across countries, future efforts are needed to standardize questionnaires and improve data quality and availability for regional monitoring of access barriers.

An evaluation of non-adherence to pharmacotherapy for chronic diseases and socioeconomic inequalities in Brazil

OBJECTIVE

To evaluate non-adherence to pharmacotherapy for chronic diseases and to investigate the existence of socioeconomic inequalities related to this outcome in Brazil.

METHODS

This was a cross-sectional study based on data from the National Survey on Access, Use and Promotion of the Rational Use of Medicines (PNAUM). The study population corresponded to individuals aged 18 years or older with a medical diagnosis of at least one chronic disease and an indication for pharmacological treatment. The dependent variable was non-adherence to chronic disease pharmacotherapy measured by less than 80% adherence to drug therapy. Socioeconomic inequality related to non-adherence was assessed by absolute (SII) and relative (RII) inequality indices, calculated by logistic regression analyses.

RESULTS

The prevalence of non-adherence to pharmacotherapy in Brazil was 20.2%, ranging from 17.0 to 27.8% between regions. Furthermore, this study revealed absolute and relative socioeconomic inequalities in non-adherence to pharmacotherapy of chronic diseases in Brazil (SII = -7.4; RII = 0.69) and the Northeast (SII = -14.0; RII = 0.59) and Center West (SII = -20.8; RII = 0.38) regions. The probability of non-adherence to pharmacotherapy in Brazil was higher among individuals with worse socioeconomic status.

CONCLUSION

The findings of the present study indicate the need for the restructuring and strengthening of public policies aimed at reducing socioeconomic inequalities, in order to promote equity in adherence to the pharmacotherapy associated with chronic diseases.

Constructing social identity through multiple "us and them": a grounded theory study of how contextual factors are manifested in the lives of residents of a vulnerable district in Brazil

The association between contextual factors and health inequalities is well documented, also in Brazil. However, questions about how contextual factors actually affect health and well-being persist. The aim of this qualitative study was to explore how contextual factors—i.e., social stratification and neighborhood opportunity structures—are manifested in the lives of the residents of a vulnerable district in Brazil. We used a Constructivist Grounded Theory approach based on 12 in-depth interviews. The core category constructing social identity through multiple “us and them” is supported by eight main categories that characterize different pairs of “us and them”, based on internal and external aspects of the social processes involved. Our findings strengthen and support the links between contextual factors and health inequalities, highlighting the relevance of downward social comparison, territorial segregation and stigmatization and erosion of social capital in the construction of social identities and the manifestation of social hierarchies and neighborhood structures in the Brazilian context. Ultimately, these create shame and stress but also pride and empowerment, which are recognized determinants of health inequities.

Intensive care inequity in Rio de Janeiro: the effect of spatial distribution of health services on severe acute respiratory infection

OBJECTIVE

To analyze the distribution of adult intensive care units according to geographic region and health sector in Rio de Janeiro and to investigate severe acute respiratory infection mortality in the public sector and its association with critical care capacity in the public sector.

METHODS

We evaluated the variation in intensive care availability and severe acute respiratory infection mortality in the public sector across different areas of the city in 2014. We utilized databases from the National Registry of Health Establishments, the Brazilian Institute of Geography and Statistics, the National Mortality Information System and the Hospital Admission Information System.

RESULTS

There is a wide range of intensive care unit beds per capita (from 4.0 intensive care unit beds per 100,000 people in public hospitals in the West Zone to 133.6 intensive care unit beds per 100,000 people in private hospitals in the Center Zone) in the city of Rio de Janeiro. The private sector accounts for almost 75% of the intensive care unit bed supply. The more developed areas of the city concentrate most of the intensive care unit services. Map-based spatial analysis shows a lack of intensive care unit beds in vast territorial extensions in the less developed regions of the city. There is an inverse correlation (r = -0.829; 95%CI -0.946 to -0.675) between public intensive care unit beds per capita in different health planning areas of the city and severe acute respiratory infection mortality in public hospitals.

CONCLUSION

Our results show a disproportionate intensive care unit bed provision across the city of Rio de Janeiro and the need for a rational distribution of intensive care.

Changes in health care inequity in Brazil between 2008 and 2013

Background

Brazil has made progress towards a more equitable distribution of health care, but gains may be threatened by economic instability resulting from the 2008 global financial crisis. This study measured predictors of health care utilization and changes in horizontal inequity between 2008 and 2013.

Method

Data were from two nationally representative surveys that measured a variety of sociodemographic, health behaviors and health care indicators. We used Poisson regression models to estimate adjusted prevalence ratios and the Horizontal Equity Index (HEI) standardized by health needs to measure inequity in the utilization of doctor and dentist visits, hospitalizations and reporting of a usual source of care (USC) for those 18 and older. To estimate the HEI, we ranked the population from the poorest to the richest using a wealth index. We also decomposed the HEI into its different components and assessed changes from 2008 to 2013.

Results

The population proportion with doctor and dentist visits in the past year and a USC increased between 2008 and 2013, while hospitalizations declined. In 2013, pro-rich inequity in doctor visits increased significantly while the distribution of hospitalizations shifted from pro-rich in 2008 to neutral in 2013. Dentist visits were highly pro-rich and USC was slightly pro-rich; the distribution of dentist visits and USC did not change over time. Health need was a strong predictor of health care utilization regardless of the type of coverage (public or private). Education, wealth, and private health plans were associated with the pro-rich orientation of doctor and dentist visits. Private health plans contributed to the pro-rich orientation of all outcomes, while the Family Health Strategy contributed to the pro-poor orientation of all outcomes.

Conclusion

The results of this study support the claim that Brazil’s population continued to see absolute gains in access to care despite recent economic crises. However, gains in equity have slowed and may even decline if investments are not maintained as the country enters deeper financial and political crises.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-016-0431-8) contains supplementary material, which is available to authorized users.

[The social value of teeth and access to dental health services]

Oral healthcare provided by the Unified Health System (SUS) faces the challenge of attending the epidemiological profile of Brazil's adult population. Qualitative research using semi-structured interviews was conducted to understand the experiences, expectations and perception of SUS users to services in Diamantina, State of Minas Gerais, and content analysis was used to assess the data. Discussion of the results was based on dialogue between the symbolic interactionism of Goffman and Bourdieu's concept of habitus. The results show that the users did not give importance to dental care during childhood and adolescence because care was unknown to them. There was no offer of treatment besides dental extraction. Today, they value teeth and suffer the embarrassment caused by rotten teeth. However, access to dental restoration via SUS is not possible. For their children, they perceive better access to information and care, but for specialized procedures there are barriers. They express resignation both in relation to the poor state of the teeth and the difficulties of access to dental care, which can be understood by the constant exclusion experienced by them in the past, shaping their actions in the present. It was concluded that oral health in SUS should incorporate the social value and the aesthetic dimension of teeth as a social right.

Absence of routine medical consultation among hypertensive and/or diabetic elders: an epidemiological study based on the Brazilian National Household Survey 2008

OBJECTIVE: This exploratory study aimed to investigate the predisposing, enabling and health need characteristics associated with lack of medical visits in the last 12 months, among 23,620 elderly hypertensive and/or diabetic individuals. METHODS: In this research, we used the theoretical behavioral model of Andersen and Newman for use of health services. The data analyzed were produced by the health supplement of the Brazilian National Household Survey (PNAD) 2008, nationwide. To identify the associations, we used the Poisson regression model, which estimates the prevalence ratios and confidence intervals of 95%, considering the significance level of 5%. RESULTS: The results showed that 10.6% of the study population did not consult the doctor in the period considered, and the prevalence was higher among hypertensive subjects (10.5%) than among diabetic ones (7.1%). The lack of medical consultation was negatively associated with female sex and increasing age (predisposing characteristics), with health insurance coverage (enabling characteristic), worse self-rated health, chronic health conditions selected and the presence of hypertension associated with diabetes (health needs), while the fact of living in the Northeast, North and Midwest appeared positively associated with the event under investigation. CONCLUSION: These results corroborate those observed in national and international studies and show evidence of inequality and inequity in the use of medical consultation for this population, based on the findings related to health plan coverage and geographic region.

Hipertensão arterial referida e utilização de medicamentos de uso contínuo no Brasil: um estudo de base populacional

O objetivo do presente estudo foi estimar a prevalência e fatores associados à não utilização de algum medicamento de uso contínuo nos indivíduos de 30-79 anos que referiram hipertensão arterial na Pesquisa Nacional por Amostra de Domicílios (PNAD-2008), Brasil. Razões de prevalência (RP) e respectivos intervalos de 95% de confiança (IC95%) foram obtidos por meio de regressão de Poisson. A proporção de indivíduos que não utilizava medicamentos de uso contínuo foi de 17%. Características positivamente associadas à não utilização foram: sexo masculino, residência nas regiões Norte, Nordeste, Centro-oeste e hábito de fumar. O não uso desses medicamentos diminuiu com a idade, renda domiciliar per capita, número de doenças crônicas e de consulta médica nos últimos 12 meses; foi menor entre os que tinham 11 anos e mais de estudo (RP = 0,92; IC95%: 0,86-0,98), nos que não trabalhavam nem estavam desempregados e nos que não realizavam atividade física. A adesão à terapia medicamentosa no controle de hipertensão arterial é necessária e requer investimento na atenção primária, na melhoria no acesso aos serviços de saúde e no enfretamento das desigualdades regionais, sociais e de gênero.

Barriers in access to healthcare in countries with different health systems. A cross-sectional study in municipalities of central Colombia and north-eastern Brazil

There are few comprehensive studies available on barriers encountered from the initial seeking of healthcare through to the resolution of the health problem; in other words, on access in its broad domain. For Colombia and Brazil, countries with different healthcare systems but common stated principles, there have been no such analyses to date. This paper compares factors that influence access in its broad domain in two municipalities of each country, by means of a cross-sectional study based on a survey of a multistage probability sample of people who had had at least one health problem within the last three months (2163 in Colombia and 2155 in Brazil). The results reveal important barriers to healthcare access in both samples, with notable differences between and within countries, once differences in sociodemographic characteristics and health needs are accounted for. In the Colombian study areas, the greatest barriers were encountered in initial access to healthcare and in resolving the problem, and similarly when entering the health service in the Brazilian study areas. Differences can also be detected in the use of services: in Colombia greater geographical and economic barriers and the need for authorization from insurers are more relevant, whereas in Brazil, it is the limited availability of health centres, doctors and drugs that leads to longer waiting times. There are also differences according to enrolment status and insurance scheme in Colombia, and between areas in Brazil. The barriers appear to be related to the Colombian system's segmented, non-universal nature, and to the involvement of insurance companies, and to chronic underfunding of the public system in Brazil. Further research is required, but the results obtained reveal critical points to be tackled by health policies in both countries.