Horizontal equity in health care utilization in Brazil, 1998-2008.
BACKGROUND
This study assesses trends in horizontal equity in the utilization of healthcare services from 1998 to 2008--a period of major economic and social change in Brazil.


METHODS
Data are from nationally representative surveys repeated in 1998, 2003, and 2008. We apply established methods for assessing horizontal inequity in healthcare access (the principle that people with the same healthcare needs should have similar access to healthcare services). Horizontal inequity is calculated as the difference between observed healthcare utilization and utilization predicted by healthcare needs. Outcomes examined include the probability of a medical, dental, or hospital visit during the past 12 months; any health service use in the past two weeks; and having a usual source of healthcare. We use monthly family income to measure differences in socioeconomic position. Healthcare needs include age, sex, self-rated health, and chronic conditions. Non-need factors include income, education, geography, health insurance, and Family Health Strategy coverage.


RESULTS
The probability of having at least one doctor visit in the past 12 months became substantially more equitable over time, ending with a slightly pro-rich orientation in 2008. Any hospitalization in the past 12 months was found to be pro-poor in all periods but became slightly less so in 2008. Dental visits showed the largest absolute decrease in horizontal inequity, although they were still the most inequitably (pro-rich) distributed outcome in 2008. Service use in the past two weeks showed decreased inequity in 2003 but exhibited no significant change between 2003 and 2008. Having a usual source of care became less pro-rich over time and was nearly income-neutral by 2008. Factors associated with greater inequities include income, having a private health plan, and geographic location. Factors associated with greater equity included health needs, schooling, and enrolment in the Family Health Strategy.


CONCLUSIONS
Healthcare utilization in Brazil appears to have become increasingly equitable over the past 10 years. Although this does not imply that equity in health outcomes has improved correspondingly, it does suggest that government policies aimed at increasing access, especially to primary care, have helped to make healthcare utilization in Brazil fairer over time.
Department of Nutrition, Food Studies & Public Health, New York University, 411 Lafayette Street, 5th Floor, New York, NY 10003, USA. jmj5@nyu.edu
James
J
Macinko
Maria Fernanda
MF
Lima-Costa
D000293:Adolescent; D000328:Adult; D000368:Aged; D001938:Brazil / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000706:statistics & numerical data* / Q000639:trends; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000706:statistics & numerical data / Q000639:trends; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data / Q000639:trends; D054625:Healthcare Disparities / Q000706:statistics & numerical data* / Q000639:trends; D006801:Humans; D007182:Income / Q000706:statistics & numerical data; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D012959:Socioeconomic Factors; D055815:Young Adult