Inequalities in Access to Health and the Role of the Unified Health System in Brazil: Evidence from administrative hospital records and survey data

Legislation enacted in 1990 established a public health system in Brazil (SUS) that guarantees free, comprehensive and universal coverage, including equal access to medical and pharmaceutical services (Bustreo and Hunt 2013). In this regard, Brazil is a forerunner, a potential model to other societies (Harris 2014). In reality, access is a serious problem and rationing of services takes place through long waiting times, which vary across procedures and regions, and this has led to emergence of a private health sector. So, despite increased access to basic health care for a major part of the poorer population over the last two decades, concerns about inequalities in access to health are a first order policy concern in Brazil. The extent of these inequalities in access is currently unknown, since they cannot be correctly inferred from the anecdotal and aggregate data that are typically used in public debate.
Our proposal contains the following core elements-
1. To identify and assess inequalities in access to health care by socio-economic position gender and region. We will analyse trends by type of morbidity and, hence, implicitly by age.
2. To assess the impact of the expansion of state-provided primary health care services on the evolution of these inequalities, with a focus on access to hospital treatment and, conditional upon access, on treatment expenditures and recovery outcomes.

There is a vast literature on health inequalities but this typically looks at inequalities in outcomes. We focus instead on inequalities in access which is moot because Brazil (like the UK) has a commitment to equality in access to public health. Even with equal access, inequalities in outcomes, which involve family histories and individual behaviours, may persist. For instance, poverty is closely linked to infectious disease and the tendency towards depression tends to vary by gender.

The Family Health Program (PSF), the most significant innovation within SUS, placed professional teams in local communities, focusing upon prevention and early detection. We will address our second objective, which is to evaluate how expansion of the PSF across states was associated with the changing profile of health inequalities across states using administrative data on trends in PSF-coverage. Using this we will track a major recent expansion of the program to ask: How did PSF impact infectious disease? To what extent did it influence chronic disease, possibly through behavioural change? Did the PSF, by addressing problems early enough, lower hospital admission rates and did this, in turn, reduce crowding and improve outcomes [quality] in hospitalization data? How did the PSF influence who gets admitted to hospital, and how did it thereby influence health inequalities?

To address the first objective of documenting inequalities in access to health, we propose to use administrative hospitalization records from SUS and the Brazilian Household Survey. The hospital data provide individual-level information since the mid-1990s on admissions, main diagnosis, length of stay, procedures, expenditures, mortality outcomes, and characteristics, including age, gender, education and state. Access to a census of hospitalization is rare, permitting analyses potentially useful outside the Brazilian-context. We will combine survey and hospital data to profile access to healthcare.

ODA Compliance
This project assesses poverty and economic development issues including population health and trends in the relative position of the poor. In principle Brazil is a model for public health provision. In practice it is plagued by inequalities in other domains that interfere with its objective to provide universal health coverage. Brazil's Family Health Program shifted health-care provision from a centralized model structured around public hospitals in urban areas to a decentralized one involving local communities. This has led to increased inclusion of the poor and improvements in infectious disease but less is known about inequality in chronic disease and access to more complex care.

We will conduct the research effectively, using non-parametric techniques to describe inequality and econometric methods of policy evaluation (Sonia's skills, well-represented in ISER, the UK host institution). We will use rich, fairly unique data sources. All three applicants have publication records of internationally excellent standards. Rudi Rocha from Brazil is a junior colleague who will spend several weeks at a stretch in the UK, working with Sonia, attending seminars and workshops in Essex and London.

Beneficiaries
The project is expected to yield evidence relevant to poverty, inequality and public health provision in Brazil with wider relevance to other developing countries and in fact also to richer countries insofar as it assesses performance of a state-funded universal health coverage plan. In addition to producing evidence for policy, it will advance an academic literature in the domains of poverty and public health.

Benefits of the Research Partnership
The benefit of the proposed collaboration to UK research is multi-fold. Research on health and health provision in Brazil stands to inform UK health policy. The data sources for Brazil are better at least insofar as they have administrative hospital records. The issues at the forefront of our research in Brazil viz non-communicable disease management, hospital crowding and waiting times, and inequalities in health are at the forefront of discussions pertaining to health in the UK. Like the UK and in contrast to many developing nations, Brazil offers free universal health coverage but, like the UK, it faces quality issues. Rodrigo has an established reputation for his work on health and Rudi is a rising star in the area, so Sonia will enjoy direct scholarly benefits from this collaboration. It is likely to have spillovers. A junior colleague in Essex has already exhibited an interest in following our research agenda using UK data, and we will explore this when Rudi visits. Sonia Bhalotra has considerable experience of research in health, development and gender and she brings a fresh external perspective to meld with that of her Brazilian colleagues.

As regards relevance to current Research Council funding, Sonia is co-investigator on MiSoc, the ESRC research centre at Essex. Her MiSoc-research investigates health innovations and health inequalities using a combination of historical and contemporary data on the US, Sweden and Norway. The proposed analysis set in Brazil will complement and enhance this agenda, with positive knowledge externalities in both directions.

The need for international collaboration runs in both directions. Sonia benefits directly from access to Brazilian data (even where public, this in documented in Portugese) and from the intricate knowledge of current policy debates that her Brazilian colleagues have. Rudi and Rodrigo benefit from Sonia's knowledge of health in several other countries. The team have complementary skills in economics and econometrics. Rodrigo and Sonia already have an international network of co-authors but neither, at present, has a UK-Brazil link and this is something we are all enthusiastic about developing and taking forward.