Free universal healthcare reduces health inequality in Brazil

Expanding access to primary healthcare has helped to reduce health inequalities between racial groups in Brazil.

Researchers from Imperial College London and Fiocruz in Brazil have highlighted the importance of expanding universal health coverage to reduce “avoidable” deaths among Brazil’s black and mixed race populations.

The Brazilian government began rolling out free primary healthcare in the 1990s under the family health strategy (FHS), focusing on poorer areas with reduced access to healthcare. Today, around 70% of the Brazilian population is covered by the FHS, which has become the main platform for achieving universal health coverage (1) in the country.

Previous research has shown that expansion of FHS is associated with lower infant mortality, avoidable hospitalizations, and deaths from cardiovascular and respiratory diseases. However, to date no studies have evaluated how the FHS affects mortality rates among different racial groups.

Now, Dr Thomas Hone and Professor Christopher Millett from Imperial College London and their colleagues from Fiocruz in Brazil, have analysed mortality data from 2000-2013 to determine the effect of the FHS on avoidable deaths in black and mixed race Brazilians compared to white Brazilians. They found rates of avoidable deaths were between 17 and 23% higher in black and mixed race populations than in the white population during 2000-2013.

The researchers looked at mortality data for 281,877 black or mixed race individuals and 318,030 white individuals, and examined causes of death that should be treated in primary care settings such as family health clinics or GP surgeries. This included conditions such as vaccine-preventable infections, gastrointestinal infections, diabetes, hypertension, heart disease, and asthma.

The study, published in PLOS Medicine, found that between 2000 and 2013 the mortality rate from avoidable diseases in the black/mixed race population fell by twice as much as in the white population (15.4% compared to 6.8%) with expanded FHS coverage. Increased coverage from the FHS was therefore associated with a disproportionate benefit for black/mixed race Brazilians when compared to white Brazilians.

Brazil is an important setting for this study because of the stark inequalities in education, income and health outcomes between racial groups. Black and mixed race populations in Brazil have, on average, lower life expectancy, higher mortality rates, and are more likely to be affected by anaemia, malnutrition, and infectious diseases such as tuberculosis and leprosy.

The authors, who included researchers from the Center for Data Integration and Knowledge for Health (Cidacs), says the study shows that the positive effect of expanded healthcare on mortality for the black/mixed Brazilians was driven by fewer deaths from infectious diseases, nutritional deficiencies and anaemia, diabetes and cardiovascular disease.

Dr Thomas Hone, lead author of the paper from Imperial’s School of Public Health, said: “The lower levels of access to healthcare experienced by black and mixed race Brazilians at the beginning of this study are likely to explain the greater falls in mortality rates associated with FHS expansion compared to the white population. This is strong evidence that rolling out primary healthcare to more vulnerable populations with higher disease burdens and lower levels of access is extremely important in reducing deaths and health inequalities.”

Prioritising populations

The authors argue that the FHS should continue to be prioritised, especially in Brazil’s current political and economic climate. Expansion and consolidation should continue in areas with vulnerable populations in order to further reduce health inequalities.

Dr Hone added: “Our findings reinforce the importance of investing in strong universal primary healthcare systems to improve population health – especially among the poorest and most vulnerable. This is valuable evidence for the global community to inform how to achieve the United Nations’ tenth Sustainable Development Goal, which focuses on reducing inequality.”

1. Universal health coverage - The United Nations Sustainable Development Goals that all UN Member States have agreed to try to achieve Universal Health Coverage by 2030. This includes financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all. 

"Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: the national longitudinal analysis" by Thomas Hone, Davide Rasella, Mauricio L. Barreto, Azeem Majeed, Christopher Millett, published on the 30th May, PLoS Medicine.

See the press release of this article