Research Article: Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis

Date Published: May 30, 2017

Publisher: Public Library of Science

Author(s): Thomas Hone, Davide Rasella, Mauricio L. Barreto, Azeem Majeed, Christopher Millett, Alexander C. Tsai

Abstract: BackgroundUniversal health coverage (UHC) can play an important role in achieving Sustainable Development Goal (SDG) 10, which addresses reducing inequalities, but little supporting evidence is available from low- and middle-income countries. Brazil’s Estratégia de Saúde da Família (ESF) (family health strategy) is a community-based primary healthcare (PHC) programme that has been expanding since the 1990s and is the main platform for delivering UHC in the country. We evaluated whether expansion of the ESF was associated with differential reductions in mortality amenable to PHC between racial groups.Methods and findingsMunicipality-level longitudinal fixed-effects panel regressions were used to examine associations between ESF coverage and mortality from ambulatory-care-sensitive conditions (ACSCs) in black/pardo (mixed race) and white individuals over the period 2000–2013. Models were adjusted for socio-economic development and wider health system variables. Over the period 2000–2013, there were 281,877 and 318,030 ACSC deaths (after age standardisation) in the black/pardo and white groups, respectively, in the 1,622 municipalities studied. Age-standardised ACSC mortality fell from 93.3 to 57.9 per 100,000 population in the black/pardo group and from 75.7 to 49.2 per 100,000 population in the white group. ESF expansion (from 0% to 100%) was associated with a 15.4% (rate ratio [RR]: 0.846; 95% CI: 0.796–0.899) reduction in ACSC mortality in the black/pardo group compared with a 6.8% (RR: 0.932; 95% CI: 0.892–0.974) reduction in the white group (coefficients significantly different, p = 0.012). These differential benefits were driven by greater reductions in mortality from infectious diseases, nutritional deficiencies and anaemia, diabetes, and cardiovascular disease in the black/pardo group. Although the analysis is ecological, sensitivity analyses suggest that over 30% of black/pardo deaths would have to be incorrectly coded for the results to be invalid. This study is limited by the use of municipal-aggregate data, which precludes individual-level inference. Omitted variable bias, where factors associated with ESF expansion are also associated with changes in mortality rates, may have influenced our findings, although sensitivity analyses show the robustness of the findings to pre-ESF trends and the inclusion of other municipal-level factors that could be associated with coverage.ConclusionsPHC expansion is associated with reductions in racial group inequalities in mortality in Brazil. These findings highlight the importance of investment in PHC to achieve the SDGs aimed at improving health and reducing inequalities.

Partial Text: Reducing inequalities within and among countries is the tenth goal of the Sustainable Development Goals (SDGs). This goal includes the target to “adopt policies, especially fiscal, wage and social protection policies” that “progressively achieve greater equality” ( Health systems are essential for social protection and, in addition to their contributions to other SDGs for health, may play a vital role in reducing inequalities [1]. Additionally, promoting equality in access to healthcare is a core principle of universal health coverage (UHC) [2]. Investment in primary healthcare (PHC), as part of efforts to achieve UHC, may be especially important in reducing health inequalities [3–5], but evidence is largely derived from North America and Europe.

Longitudinal (panel data) regression models were employed using routinely collected municipal-level data, which have been widely applied to evaluate the ESF previously [4,20,22,27–30]. These models estimated associations between ESF coverage and mortality from ACSCs among black/pardo and white populations over time, whilst controlling for other confounding factors. The main analysis was restricted to 1,622 municipalities based on previously assessed quality of vital statistics reporting to reduce bias from under-reporting of deaths [31]. Differences in our analytic approach from previous ESF evaluations were necessary to examine associations of ESF expansion and inequalities in mortality between racial groups. These were agreed before compilation and analysis of the data (which commenced in February 2016), and are set out in detail below. In response to reviewers’ suggestions after initial submission, we explored factors associated with ESF uptake, tested for pre-existing trends, tested for biases from ill-defined death adjustments, explored interactions with Bolsa Família, and conducted sensitivity analyses with alternative model specifications and, for comparison with ACSC mortality, on mortality from accidents.

Between 2000 and 2013, there were 281,877 and 318,030 deaths from ACSC causes in the black/pardo and white populations, respectively (after age standardisation). Age-standardised ACSC mortality rates fell 37.9%, from 93.3 to 57.9 per 100,000, in the black/pardo population and by 34.9%, from 75.7 to 49.2 per 100,000, in the white population (Fig 1; S7 Appendix). Mortality from ACSC causes in the black/pardo population was between 17% and 23% higher than in the white population during the study period. There was a sizeable expansion of the ESF over the period, both in terms of the number of municipalities adopting the ESF and the average municipal ESF coverage (Fig 2).

Expansion of the ESF between 2000 and 2013 in Brazil was associated with a 2-fold greater reduction in ACSC mortality in the black/pardo compared to the white population. This differential benefit reduced racial inequalities in mortality and was driven by greater reductions in deaths from infectious diseases, nutritional deficiencies and anaemia, diabetes, and cardiovascular disease in the black/pardo population. This paper provides further evidence of the importance of expanding UHC in low- and middle-income countries.



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