Equity in universal health systems: hip arthroplasties as a proxy measure for access to healthcare in the public sectors of Brazil and Scotland
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The central tenets of both the National Health Services of Scotland (NHS) and the Unified Health System of Brazil (SUS) are universality and equity of access to services on the basis of need, free at the point of delivery. Redistribution is designed into the Scottish system. This study uses a mixed methods approach to analyse access to health care and the influence of socioeconomic factors using hip arthroplasty as a proxy measure for equity in the public health care systems of Brazil and Scotland. Methods Three studies were conducted to establish the extent to which equity is achieved in each system and the extent to which inequalities in socioeconomic status and health service supply affect equity. First, an ecological study using routine data of hip arthroplasty rates in the public sector by country and geographic region (2009/10 to 2012/13) complemented by an analysis of supply, specifically per capita distribution of beds and staff nationally and by area. Second, inequalities in access due to socioeconomic status were analysed for Scotland using the Scottish Index of Multideprivation (SIMD) in association with standardised rates; in Brazil two socioeconomic indicators (Gini and Human Development Index - HDI) were modelled (Zero Inflated Poisson - ZIP) with standardised municipal rates of arthroplasties (5,565 municipalities); and a Pearson’s correlation. Finally, qualitative interviews were undertaken in both countries with civil servants, health workers and policy makers who were invited to comment on the quantitative results from stages I and II based on a script of open ended questions. Results There is an almost eight fold difference in treatment rates between Brazil (7.8-8.3/100,000) and Scotland between 2009/10 to 2012/13 (57.7-61.1/100,000). There are geographic differences within both countries. The health board areas with the lowest and highest regional rates in Scotland were Glasgow & Clyde with rates of 29.2-40.2/100,000 and Ayrshire & Arran with a rate of 60.2-88.5/100,000 respectively; in Brazil the lowest and highest regions were the North Region (2.3-4/100,000) and South Region (15.4-17.9/100,000) respectively. The two least deprived quintiles (4 and 5) in the Scottish population had both a higher utilisation (42.6%) and proportional growth in number of procedures than the two more deprived (1 and 2); quintile 3 had no consistent changes. In Brazil municipal rates showed a negative correlation with Gini (r=- .226) and a positive correlation with HDI (r=.396); the ZIP model demonstrated that for every standard deviation (SD) change in Gini, rates would be 23% higher or lower, for HDI each SD would lower or increase rates by 56%. Three major areas were identified by interviewees as explanatory factors for these quantitative results: equity of access, health systems, evidence based actions/policies. Crucially the interviewees identified GDP spend on public health care, the ability of governments to redistribute and reallocate resources on the basis of need and the distorting effect of the market and private providers including physicians as key factors; and the need for better data collection from the private sector. Conclusion Although both countries aspire to universal health care, Brazil is very far from reaching that goal due to the widespread socioeconomic differences and that the health system does not redistribute resources, staff and beds according to need. Scotland appears to be achieving universal access on the basis of need, nevertheless there are geographic and socioeconomic differences in access that need to be carefully monitored and understood. In Brazil there should be better planning and resource allocation so that public resources are redirected towards those most in need of the North and Northeast regions.
AuthorsFilippon, Jonathan G
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