Inequalities in Access to Health and the Role of the Unified Health System in Brazil: Evidence from administrative hospital records and survey data

1990年颁布的立法在巴西建立了公共卫生系统，保证免费、全面和普遍的覆盖，包括平等获得医疗和药品服务（Bustreo和Hunt，2013年）。在这方面，巴西是一个先行者，是其他社会的潜在模式（Harris 2014）。在现实中，获得服务是一个严重的问题，服务的配给是通过漫长的等待时间来实现的，这在程序和地区之间各不相同，这导致了私营卫生部门的出现。因此，尽管在过去二十年中，大部分贫困人口获得基本保健的机会有所增加，但对获得保健机会不平等的关切是巴西的首要政策关切。这些不平等的程度目前尚不清楚，因为它们不能从通常用于公共辩论的轶事和汇总数据中正确推断出来。按社会经济地位、性别和地区查明和评估在获得保健方面的不平等现象。我们将按发病率类型分析趋势，因此也就隐含地按年龄分析。为了评估国家提供的初级卫生保健服务的扩展对这些不平等的演变的影响，重点是获得医院治疗，并在获得条件下，治疗费用和恢复outcomes.There是大量的文献健康不平等，但这通常着眼于结果的不平等。相反，我们关注的是获得机会的不平等，这是没有实际意义的，因为巴西（像英国一样）承诺平等获得公共卫生。即使有平等的机会，涉及家庭历史和个人行为的结果不平等也可能持续存在。例如，贫穷与传染病密切相关，抑郁倾向往往因性别而异。家庭健康计划（PSF）是SUS内最重要的创新，它在当地社区部署了专业团队，重点关注预防和早期发现。我们将解决我们的第二个目标，这是评估如何扩展的PSF跨州与不断变化的配置文件的健康不平等的状态使用的PSF覆盖趋势的行政数据。利用这一点，我们将跟踪该计划最近的一个主要扩展，以询问：PSF如何影响传染病？它在多大程度上影响了慢性病，可能是通过行为改变？PSF是否通过足够早地解决问题，降低了住院率，从而减少了拥挤并改善了住院数据的结果[质量]？PSF是如何影响住院的人的，它又是如何影响健康不平等的？为了实现第一个目标，即记录获得保健服务方面的不平等现象，我们建议使用统一卫生系统和巴西家庭调查的行政住院记录。医院数据提供了自20世纪90年代中期以来的个人信息，包括入院、主要诊断、住院时间、手术、支出、死亡率结果和特征，包括年龄、性别、教育和状态。获得住院情况普查的机会很少，这使得分析在巴西以外的情况下可能有用。我们将结合联合收割机调查和医院数据来描述医疗保健的可及性。

Legislation enacted in 1990 established a public health system in Brazil (SUS) that guarantees free, comprehensive and universal coverage, including equal access to medical and pharmaceutical services (Bustreo and Hunt 2013). In this regard, Brazil is a forerunner, a potential model to other societies (Harris 2014). In reality, access is a serious problem and rationing of services takes place through long waiting times, which vary across procedures and regions, and this has led to emergence of a private health sector. So, despite increased access to basic health care for a major part of the poorer population over the last two decades, concerns about inequalities in access to health are a first order policy concern in Brazil. The extent of these inequalities in access is currently unknown, since they cannot be correctly inferred from the anecdotal and aggregate data that are typically used in public debate.Our proposal contains the following core elements-1. To identify and assess inequalities in access to health care by socio-economic position gender and region. We will analyse trends by type of morbidity and, hence, implicitly by age.2. To assess the impact of the expansion of state-provided primary health care services on the evolution of these inequalities, with a focus on access to hospital treatment and, conditional upon access, on treatment expenditures and recovery outcomes.There is a vast literature on health inequalities but this typically looks at inequalities in outcomes. We focus instead on inequalities in access which is moot because Brazil (like the UK) has a commitment to equality in access to public health. Even with equal access, inequalities in outcomes, which involve family histories and individual behaviours, may persist. For instance, poverty is closely linked to infectious disease and the tendency towards depression tends to vary by gender. The Family Health Program (PSF), the most significant innovation within SUS, placed professional teams in local communities, focusing upon prevention and early detection. We will address our second objective, which is to evaluate how expansion of the PSF across states was associated with the changing profile of health inequalities across states using administrative data on trends in PSF-coverage. Using this we will track a major recent expansion of the program to ask: How did PSF impact infectious disease? To what extent did it influence chronic disease, possibly through behavioural change? Did the PSF, by addressing problems early enough, lower hospital admission rates and did this, in turn, reduce crowding and improve outcomes [quality] in hospitalization data? How did the PSF influence who gets admitted to hospital, and how did it thereby influence health inequalities?To address the first objective of documenting inequalities in access to health, we propose to use administrative hospitalization records from SUS and the Brazilian Household Survey. The hospital data provide individual-level information since the mid-1990s on admissions, main diagnosis, length of stay, procedures, expenditures, mortality outcomes, and characteristics, including age, gender, education and state. Access to a census of hospitalization is rare, permitting analyses potentially useful outside the Brazilian-context. We will combine survey and hospital data to profile access to healthcare.