Social inequalities in access
and use of healthcare services
in Brazil
Claudia Travassos
DIS/CICT/FIOCRUZ
Brazilian Healthcare System
Constitution of 1988
Unified Health System - SUS
 Health as a citizen right
 Universal access to health services
 Access based on need and not on the ability to pay
Unified Health System – SUS
Public/private mix
The system is composed of three main
sectors
1.
2.
3.
The public sector: publicly provided and financed health
services – Federal, state and municipal.
The private sector (profit and nonprofit) contracted by SUS.
Private insurance schemes (coverage: 25%).
Social inequalities in access and use of
services are large
 Utilization rates increases as income
increases
 For those in need, utilization rate was 50% greater
for the highest quintile of family income when
compared to those in the lowest quintile (PNSN,1989)
Health Status
Percentage distribution of self-assessed health status (bad/very bad) by fam ily incom e . Brazil, 1998
15,0
10,0
1998
6,3
5,3
5,0
4,7
3,4
3,6
2,4
1,9
1,2
0,0
Total
até 1 salário
mínimo
mais de 1 a 2
mais de 2 a 3
mais de 3 a 5
mais de 5 a 10 mais de 10 a 20
mais de 20
salários mínimos salários mínimos salários mínimos salários mínimos salários mínimos salários mínimos
Health care seeking
Percentage distribution of people seeking health care two weeks before the interview by family
income. Brazil, 1998
20,0
18,0
17,2
16,0
14,0
14,8
13,4
13,0
11,8
12,0
11,5
12,1
12,4
1 998
10,0
8,0
6,0
4,0
2,0
0,0
Total
Até 1 salário
mínimo
Mais de 1 a 2
Mais de 2 a 3
Mais de 3 a 5
Mais de 5 a 10 Mais de 10 a 20
Mais de 20
salários mínimos salários mínimos salários mínimos salários mínimos salários mínimos salários mínimos
Inequalities in Dental Care
Percentage distribution of people that have never visited a dentist by family income. Brazil, 1998
40,0
36,5
35,0
30,0
30,0
25,0
20,0
22,5
18,8
1998
16,6
15,0
10,4
10,0
6,4
4,1
5,0
0,0
Total
Até 1 salário
mínimo
Mais de 1 a 2
salários
mínimos
Mais de 2 a 3
salários
mínimos
Mais de 3 a 5 Mais de 5 a 10
salários
salários
mínimos
mínimos
Mais de 10 a
20 salários
mínimos
Mais de 20
salários
mínimos
Utilization by type of service across income groups
- health care markets and income groups Utilization by type of service, PNSN, 1989
Lowest Famile quintile of family income per capita
8%
6%
health center
3%
29%
9%
Inpatient
Pharmacy
Private Practice
Utilization by type of service, PNSN, 1989
Highest quintile of family ncome per capita
Emergency
20%
25%
Health Clinics
Others
health center
3%
11%
3%
8%
16%
Inpatient
Pharmacy
Private Practice
17%
42%
Emergency
Health Clinics
Others
Evidences of factors affecting
inequalities in access and utilization
 Private insurance increases inequalities
 Private insurance coverage is largely concentrated
amongst the rich and the healthy.
 Those with private insurance have more chance of using
health services compared to people not covered, adjusted
by need. In 96/97 this difference was 70%. (Travassos et
al,Ciência e Saúde Coletiva, 2000)
 Place of residence matters
 For the poor, those living in rich areas are
more likely to use services when in need
than those living in poor areas. (Pinheiro et al,
Cadernos de Saúde Pública. 1999).
Probabilidades relativas de internação padronizadas por sexo e
idade – 2000
(Oliveira, Evangelina, tese de doutorado ENSP/FIOCRUZ, 2005)
Procedimentos mais freqüentes
Revascularização do miocárdio
PRIP
PRIP
0.216 0.501 1.001 1.501 2.001 -
0.5
1
1.5
2
2.136
0 - 0.5
0.501 1.001 1.501 2.001 3.001 3.501 -
1
1.5
2
3
3.5
3.75
 Education affects
income
inequalities in
utilization of
services. (Mendonza-
Sassi et al, Revista de Saúde
Pública, 2203)
Trends in inequalities in access and
utilization
 Data from the two last health general
household survey – PNAD (1998 and 2003)
indicate:
 Inequalities in access and utilization have somehow
reduced;
 Heath centers played a major role in these
variations;
 Publicly financed services -SUS - was responsible for
those changes; and
 Private insurance market did not change
The effect health care in reducing
inequalities in health – A Brazilian
example

Since 1996 AIDS patients in Brazil are provided unrestricted
cost-free access to antiretroviral medicines
 In Brazil, despite decrease in incidence, HIV epidemic began
among people with high SES and progressed steadily to the
low SES groups, amongst them women (Goretti et al, 2003).
 On the other hand, a recent study (Antunes at al,
International Journal of Epidemiology, 2005) shows at the
ecological level that reductions in mortality was not correlated
with SES, reducing social inequalities in mortality.
Social policies directed to entire populations can reduce important aspects
of the inequalities in health
