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

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  • Thomas Hone
  • Davide Rasella
  • Mauricio L Barreto
  • Azeem Majeed
  • Christopher Millett

Abstract

Background: Universal 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 findings: Municipality-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. Conclusions: PHC 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. In a national longitudinal study, Thomas Hone and colleagues show that the expansion of primary healthcare in Brazil was associated with improved health outcomes and reductions in health inequalities between racial groups.Why was this study done?: What did the researchers do and find?: What do these findings mean?:

Suggested Citation

  • Thomas Hone & Davide Rasella & Mauricio L Barreto & Azeem Majeed & Christopher Millett, 2017. "Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis," PLOS Medicine, Public Library of Science, vol. 14(5), pages 1-19, May.
  • Handle: RePEc:plo:pmed00:1002306
    DOI: 10.1371/journal.pmed.1002306
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    Citations

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    Cited by:

    1. Chen, Taoshan, 2023. "How does Monitoring and Evaluation Affect Racial Health Inequality? Evidence from PMAQ Program in Brazil," Warwick-Monash Economics Student Papers 51, Warwick Monash Economics Student Papers.
    2. Kaio Vinicius Freitas de Andrade & Joilda Silva Nery & Julia Moreira Pescarini & Anna Ramond & Carlos Antônio de Souza Teles Santos & Maria Yury Ichihara & Maria Lucia Fernandes Penna & Elizabeth B. B, 2019. "Geographic and socioeconomic factors associated with leprosy treatment default: An analysis from the 100 Million Brazilian Cohort," PLOS Neglected Tropical Diseases, Public Library of Science, vol. 13(9), pages 1-18, September.
    3. Thomas Hone & Valeria Saraceni & Claudia Medina Coeli & Anete Trajman & Davide Rasella & Christopher Millett & Betina Durovni, 2020. "Primary healthcare expansion and mortality in Brazil’s urban poor: A cohort analysis of 1.2 million adults," PLOS Medicine, Public Library of Science, vol. 17(10), pages 1-20, October.
    4. Gustafsson, Per E. & Fonseca-Rodríguez, Osvaldo & Castel Feced, Sara & San Sebastián, Miguel & Bastos, João Luiz & Mosquera, Paola A., 2024. "A novel application of interrupted time series analysis to identify the impact of a primary health care reform on intersectional inequities in avoidable hospitalizations in the adult Swedish populatio," Social Science & Medicine, Elsevier, vol. 343(C).
    5. Wangnan Cao & Qingping Yun & Chun Chang & Ying Ji, 2022. "Family Support and Social Support Associated with National Essential Public Health Services Utilization among Older Migrants in China: A Gender Perspective," IJERPH, MDPI, vol. 19(3), pages 1-10, January.
    6. López Bóo, Florencia & de la Paz Ferro, Maria & Carneiro, Pedro, 2024. "Impacts of Integrating Early Childhood with Health Services: Experimental Evidence from the Cresça Com Seu Filho Home Visiting Program," IZA Discussion Papers 17130, Institute of Labor Economics (IZA).
    7. Ferreira-Batista, Natalia N. & Postali, Fernando Antonio Slaibe & Diaz, Maria Dolores Montoya & Teixeira, Adriano Dutra & Moreno-Serra, Rodrigo, 2022. "The Brazilian Family Health Strategy and adult health: Evidence from individual and local data for metropolitan areas," Economics & Human Biology, Elsevier, vol. 46(C).

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