Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis.
Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis.
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DOI：
10.1371/journal.pmed.1002306
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发表时间：
2017-05
期刊：
影响因子：
15.8
通讯作者：
Millett C
中科院分区：
文献类型：
--
作者：
Hone T;Rasella D;Barreto ML;Majeed A;Millett C
全民健康覆盖（UHC）可以在实现可持续发展目标（SDG）10方面发挥重要作用，该目标旨在减少不平等，但中低收入国家几乎没有支持证据。巴西的家庭保健战略是一个以社区为基础的初级保健方案，自1990年代以来一直在扩大，是在该国提供全民保健的主要平台。我们评估了ESF的扩大是否与种族群体之间适合PHC的死亡率的差异性降低相关。研究人员使用了健康水平纵向固定效应面板回归分析，以检查2000 - 2013年期间黑人/帕尔多人（混合种族）和白色人中ESF覆盖率与非卧床护理敏感性疾病（ACSC）死亡率之间的相关性。模型根据社会经济发展和更广泛的卫生系统变量进行了调整。在2000 - 2013年期间，在所研究的1，622个城市中，黑人/帕尔多人和白色人分别有281，877和318，030例ACSC死亡（年龄标准化后）。在黑人/帕尔多人组中，ACSC标准化死亡率从每10万人93.3例降至57.9例，在白色人组中从每10万人75.7例降至49.2例。ESF扩展（从0%到100%）与15.4%的（率比[RR]：0.846; 95% CI：0.796 - 0.899）黑人/帕尔多人组ACSC死亡率降低，而非白人组为6.8%。（RR：0.932; 95% CI：0.892 - 0.974）白色组的降低（系数显著不同，p = 0.012）。黑人/帕尔多人群体中传染病、营养不良和贫血、糖尿病和心血管疾病的死亡率大幅下降，推动了这些差别效益。虽然分析是生态学的，但敏感性分析表明，超过30%的黑人/帕尔多人死亡的结果是无效的。这项研究是有限的，由于使用的总体数据，这排除了个人层面的推断。省略变量偏差，其中与ESF扩展相关的因素也与死亡率的变化相关，可能影响了我们的研究结果，尽管敏感性分析显示研究结果对ESF前趋势的稳健性，并纳入了可能与覆盖率相关的其他医疗水平因素。在巴西，初级保健的扩大与种族群体死亡率不平等的减少有关。这些发现强调了投资于初级保健以实现旨在改善健康和减少不平等的可持续发展目标的重要性。在一项全国性的纵向研究中，托马斯·霍恩及其同事表明，巴西初级卫生保健的扩大与改善健康结果和减少种族群体之间的健康不平等有关。可持续发展目标包括减少不平等和承诺实现全民健康覆盖（UHC）。几乎没有证据表明扩大初级卫生保健（PHC）-作为对UHC承诺的一部分-与健康不平等，包括种族不平等之间的关系。对于低收入和中等收入国家尤其如此。考虑到巴西和全球存在的巨大差距，种族健康不平等是值得研究的重要不平等。我们研究了2000年至2013年巴西黑人/帕尔多人（混合种族）和白色人的非卧床护理敏感性疾病的死亡率趋势，并评估了死亡率是否与城市PHC的扩张相关。PHC扩张与两个种族群体的死亡率降低有关，但黑人/帕尔多巴西人的死亡率比白色巴西人降低2倍。这些调查结果可能是由于巴西有针对性地向较贫穷和较小的城市推广初级保健，以及在推广之初，巴西黑人/帕尔多人的需求未得到满足。有证据表明，在巴西扩大初级保健与减少保健不平等之间存在联系。优先将初级保健作为全民健康覆盖的一部分扩大到处境更为不利的人群，有可能减少健康不平等。
Universal health coverage (UHC) can play an important role in achieving Sustainable Development Goal (SDG) 10, which addresses reducing inequalities, but little supporting evidence is available from low- and middle-income countries. Brazil’s Estratégia de Saúde da Família (ESF) (family health strategy) is a community-based primary healthcare (PHC) programme that has been expanding since the 1990s and is the main platform for delivering UHC in the country. We evaluated whether expansion of the ESF was associated with differential reductions in mortality amenable to PHC between racial groups. Municipality-level longitudinal fixed-effects panel regressions were used to examine associations between ESF coverage and mortality from ambulatory-care-sensitive conditions (ACSCs) in black/pardo (mixed race) and white individuals over the period 2000–2013. Models were adjusted for socio-economic development and wider health system variables. Over the period 2000–2013, there were 281,877 and 318,030 ACSC deaths (after age standardisation) in the black/pardo and white groups, respectively, in the 1,622 municipalities studied. Age-standardised ACSC mortality fell from 93.3 to 57.9 per 100,000 population in the black/pardo group and from 75.7 to 49.2 per 100,000 population in the white group. ESF expansion (from 0% to 100%) was associated with a 15.4% (rate ratio [RR]: 0.846; 95% CI: 0.796–0.899) reduction in ACSC mortality in the black/pardo group compared with a 6.8% (RR: 0.932; 95% CI: 0.892–0.974) reduction in the white group (coefficients significantly different, p = 0.012). These differential benefits were driven by greater reductions in mortality from infectious diseases, nutritional deficiencies and anaemia, diabetes, and cardiovascular disease in the black/pardo group. Although the analysis is ecological, sensitivity analyses suggest that over 30% of black/pardo deaths would have to be incorrectly coded for the results to be invalid. This study is limited by the use of municipal-aggregate data, which precludes individual-level inference. Omitted variable bias, where factors associated with ESF expansion are also associated with changes in mortality rates, may have influenced our findings, although sensitivity analyses show the robustness of the findings to pre-ESF trends and the inclusion of other municipal-level factors that could be associated with coverage. PHC expansion is associated with reductions in racial group inequalities in mortality in Brazil. These findings highlight the importance of investment in PHC to achieve the SDGs aimed at improving health and reducing inequalities. In a national longitudinal study, Thomas Hone and colleagues show that the expansion of primary healthcare in Brazil was associated with improved health outcomes and reductions in health inequalities between racial groups. The Sustainable Development Goals include reducing inequalities and making commitments to universal health coverage (UHC). There is little evidence about the relationship between expanding primary healthcare (PHC)—as part of the commitment to UHC—and health inequalities, including racial inequalities. This is particularly true for low- and middle-income countries. Racial health inequalities are important inequalities to study given the sharp disparities that exist in Brazil and globally. We examined trends in mortality from ambulatory-care-sensitive conditions for black/pardo (mixed race) and white Brazilians from 2000 to 2013, and evaluated whether there were changes in mortality associated with expansion of PHC in municipalities. PHC expansion was associated with reductions in mortality for both racial groups, but black/pardo Brazilians experienced a 2-fold greater reduction in mortality than white Brazilians. The targeted rollout of PHC in Brazil to poorer and smaller municipalities and the greater unmet needs of black/pardo Brazilians at the start of the rollout are likely to explain these findings. There is evidence of an association between expanded PHC and reductions in health inequalities in Brazil. PHC that is preferentially expanded as part of UHC to more disadvantaged populations has the potential to reduce health inequalities.