The door is open, but not everyone may enter: racial inequities in healthcare access across three Brazilian surveys

Constante, Helena Mendes; Marinho, Gerson Luiz; Bastos, João Luiz

doi:10.1590/1413-81232021269.47412020

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ARTICLE • Ciênc. saúde coletiva 26 (09) • Sept 2021 • https://doi.org/10.1590/1413-81232021269.47412020 copy

The door is open, but not everyone may enter: racial inequities in healthcare access across three Brazilian surveys

A porta está aberta, mas nem todos podem entrar: iniquidades raciais no acesso à saúde em três inquéritos brasileiros

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Health policies in Brazil have sought to expand healthcare access and mitigate inequities, but recent revisions of their content have weakened the Brazilian Unified Health System. This study estimates three healthcare indicators across three national surveys conducted in 2008, 2013, and 2019 to assess the impact of changes to the National Primary Care Policy on racial inequities in healthcare. Considering the survey design and sampling weights, we estimated the prevalence of each outcome among both whites and Blacks for the whole country, and according to the Brazilian regions. We test the following hypotheses: compared to whites, Blacks showed higher frequency of coverage by the Family Health Strategy, lower frequency of health insurance coverage, and higher frequency of perceived difficulty accessing health services (H1); Racial inequities decreased in the ten-year period but remained constant between 2013-2019 (H2); Racial gaps have widened among regions with lower proportions of Blacks (H3). Our findings fully support H1, but not H2 and H3. Racial inequities either remained constant or decreased in the 2013-2019 period. By downplaying the importance of the universality and equity principles, the latest revision of the National Primary Care Policy has contributed to the persistence of racial inequities in healthcare.

Key words:
Race factors; Healthcare disparities; Brazil; Racism

Race and indicators of healthcare access	2008 PNAD		2013 PNS		2019 PNS
Race and indicators of healthcare access	%	95%CI	%	95%CI	%	95%CI
Race
Whites	50.4	49.6;51.2	48.2	47.4;49.0	44.0	43.2;44.6
Blacks	49.6	48.8;50.4	51.8	51.0;52.6	56.0	55.3;56.7
Coverage by the FHS	48.9	47.7;50.1	60.8	59.5;62.0	68.8	67.7;69.9
Coverage by health insurance	28.1	27.5;28.8	30.2	29.3;31.1	29.6	28.8;30.4
Difficulty accessing health services in the last two weeks	3.1	2.9;3.3	2.9	2.7;3.2	3.2	3.0;3.4

Indicators of healthcare access according to race	2008 PNAD		2013 PNS		2019 PNS
Indicators of healthcare access according to race	%	95%CI	%	95%CI	%	95%CI
Coverage by the FHS
Whites	42.5	41.1;43.9	54.7	52.9;56.5	63.4	61.6;65.1
Blacks	55.6	54.3;56.9	66.4	65.1;67.7	73.0	71.9;74.1
Coverage by health insurance
Whites	36.9	36.2;37.7	39.8	38.4;41.2	39.9	38.7;41.1
Blacks	18.9	18.3;19.5	21.1	20.2;21.9	21.6	20.9;22.3
Difficulty accessing health services in the last two weeks
Whites	2.2	2.0;2.3	2.1	1.8;2.4	2.5	2.2;2.8
Blacks	4.0	3.8;4.3	3.7	3.4;4.1	3.8	3.5;4.1

Indicators of healthcare access according to Brazilian geographic regions	2008 PNAD				2013 PNS				2019 PNS
	whites		Blacks		whites		Blacks		whites		Blacks
	%	95%CI	%	95%CI	%	95%CI	%	95%CI	%	95%CI	%	95%CI
Coverage by the FHS
North	48.8	44.9;52.6	53.3	49.1;57.4	55.3	51.3;59.1	61.2	58.4;64.0	63.9	60.7;66.9	69.7	67.5;71.7
Northeast	63.6	61.0;66.1	67.2	65.1;69.2	69.3	66.8;71.6	75.7	74.3;77.0	76.2	74.3;78.0	80.9	79.8;81.9
Southeast	31.3	29.3;33.3	45.1	43.0;47.1	47.1	44.0;50.2	59.4	56.5;62.2	54.1	51.0;57.2	66.1	63.6;68.6
South	50.7	47.9;53.5	56.4	52.6;60.1	61.3	57.9;64.6	68.7	62.9;73.9	74.4	72.6;76.6	80.3	77.3;83.0
Center-West	47.2	44.0;50.4	50.7	47.7;53.6	56.9	53.9;59.8	61.5	58.9;64.1	64.0	60.9;67.0	69.4	66.9;71.8
Coverage by health insurance
North	21.0	19.0;23.2	12.9	11.8;14.1	21.9	19.3;24.6	13.3	11.9;14.8	24.1	21.4;26.9	14.8	13.5;16.1
Northeast	21.5	20.1;23.0	12.1	11.3;12.9	24.7	22.4;27.0	14.2	13.1;15.3	24.7	22.9;26.6	14.7	13.8;15.5
Southeast	44.2	43.0;45.3	27.0	26.1;28.0	46.2	43.9;48.5	28.7	26.9;30.5	46.7	44.6;48.8	29.0	27.4;30.6
South	34.6	32.9;36.3	20.6	18.9;22.3	37.9	35.4;40.4	23.9	20.2;28.0	37.4	35.6;39.2	22.9	20.6;25.4
Center-West	33.7	31.7;35.7	21.1	19.6;22.5	40.4	37.9;42.8	26.7	24.7;28.8	39.1	36.5;41.7	25.8	24.1;27.7
Difficulty accessing health services in the last two weeks
North	3.9	3.2;4.7	5.4	4.6;6.3	3.2	2.1;4.9	4.7	3.8;5.8	4.4	3.0;6.4	4.1	3.5;4.7
Northeast	4.0	3.4;4.6	5.2	4.6;5.8	3.8	3.1;4.6	4.5	4.0;5.1	4.1	3.4;4.9	4.9	4.4;5.4
Southeast	1.7	1.5;1.8	2.6	2.4;2.9	1.6	1.2;2.1	2.5	2.0;3.1	2.2	1.8;2.7	3.2	2.7;3.7
South	1.7	1.5;1.9	2.8	2.3;3.4	1.7	1.3;2.3	2.8	1.7;4.6	1.5	1.2;1.9	1.9	1.3;2.8
Center-West	2.6	2.2;3.0	4.0	3.5;4.5	2.9	2.2;3.8	4.5	3.7;5.6	3.5	2.5;4.9	2.8	2.3;3.6

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[1] Collaborations

HM Constante contributed to the study conception and planning, performed the analyses, and was responsible for drafting the first version of this article, including revising its final version. GL Marinho participated in the study conception and planning, data interpretation, writing-up of elements of the article, and critically revising its final version. JL Bastos contributed to the study conception, planning, and design, reviewing the analyses and data interpretation, and writing the final version of the discussion, including revising the final version of this article.