Abstracts

Introduction

In Brazil, the demand for health care is increasing due to its higher life expectancy, changes in its age structure pyramid, and the triple burden of diseases (chronic diseases, infectious diseases, and external causes) ¹1. Politti R. Desigualdade na utilização de serviços de saúde entre adultos: uma análise dos fatores de concentração da demanda. Economia Aplicada 2014; 18:117-37.^,22. Almeida APSC, Nunes BP, Duro SMS, Lima RCD, Facchini LA. Falta de acesso e trajetória de utilização de serviços de saúde por idosos brasileiros. Ciênc Saúde Colet 2020; 25:2213-26.. This growing demand for health care pressures its health system to reorganize supply to meet the needs of its population and address one of the greatest challenges of the Brazilian Unified National Health System (SUS): access to services in the face of social inequities ²2. Almeida APSC, Nunes BP, Duro SMS, Lima RCD, Facchini LA. Falta de acesso e trajetória de utilização de serviços de saúde por idosos brasileiros. Ciênc Saúde Colet 2020; 25:2213-26..

Brazil is the only country with a population of more than 200 million inhabitants that has a universal system covering health care, health surveillance, drug supply, research and development, and free vaccinations, among other services, from primary care to highly complex treatments ³3. Almeida C, Luchmann L, Martelli C. A pandemia e seus impactos no Brasil. Middle Atlantic Review of Latin American Studies 2020; 4:20-5.. In its years of implementation, SUS has struggled with challenges related to its size but it has shown significant results regarding service and professional delivery as well as changing the pattern of health care use ⁴4. Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Ciênc Saúde Colet 2018; 23:1751-62..

Use of health care services and access to them rely on the interplay of factors (geographic, economic, social, racial, and gender) that determine the use of services by different populations ⁵5. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20 Suppl 2:190-8.. These factors (which related to both the perceived need and availability of services) play an important role in demand and are used as elements of analysis to generate evidence on social inequities ⁶6. Travassos C, Castro MSM. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, Escorel S, Lobato LVS, Noronha JC, Carvalho AI, editors. Política e sistemas de saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2008. p. 183-206..

Health care use is an important element of analysis in health surveys because it provides information about demand and factors associated with service use ⁷7. Viacava F. Informações em saúde: a importância dos inquéritos populacionais. Ciênc Saúde Colet 2002; 7:607-21.. Population surveys that have reviewed health care use and its typology in the general population ⁸8. Swart E. The prevalence of medical services use. How comparable are the results of large-scale population surveys in Germany? Psychosoc Med 2012; 9:Doc10.^,99. Park JM. Equity in the use of physician and inpatient hospital services: evidence from Korean health panel survey. Int J Equity Health 2016; 15:159.^,1010. Ypanaqué-Luyo P, Martins M. Uso de los servicios de salud ambulatorios en la población peruana. Rev Peru Med Exp Salud Pública 2015; 32:464-70. or (even in specific populations such as immigrants, women, and seniors ¹¹11. Graetz V, Rechel B, Groot W. Norredam M. Pavlova M. Use of health care services by migrants in Europe - a systematic literature review. Br Med Bull 2017; 121:5-18.^,1212. Bobo FT, Yesuf EA, Woldie M. Inequities in use of reproductive and maternal health care in Ethiopia. Int J Equity Health 2017; 16:105.^,1313. Jiang M, Yang G, Fang L, Wan J, Yang Y, Wang Y, et al. Factors associated with healthcare use among community-dwelling senior in Shanghai, China. PLoS One 2018; 13:e0207646.) have found that socioeconomic, demographic, and demand factors act as predictors of service use. In Brazil, a survey has attempted to examine both changes over time ¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019: informações sobre domicílios. acesso e utilização dos serviços de saúde. Brasil, Grandes Regiões e Unidades da Federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020.^,1515. Viacava F, Porto SM, Carvalho CC, Bellido JG. Desigualdades regionais e sociais em saúde segundo inquéritos domiciliares (Brasil, 1998-2013). Ciênc Saúde Colet 2019; 24:2745-60.^,1616. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira. Pesquisa Nacional de Saúde 2013. Rev Saúde Pública 2017; 51 Suppl 1:3s.^,1717. Malta DC, Gomes CS, Prates EJS, Santos FP, Almeida WS, Stopa SR, et al. Análise da demanda e acesso aos serviços nas duas semanas anteriores à Pesquisa Nacional de Saúde 2013 e 2019. Rev Bras Epidemiol 2021; 24 Suppl 2:E210002.SUPL.2. and social inequities in the population’s use and access to health care. A study that sought to compare the demand and health care use in Brazil from 2013 to 2019, based on data from the Brazilian National Health Survey (PNS), found an increase of about 22% in health care use in the two weeks preceding the survey over the studied period (from 15.3% in 2013 to 18.6% in 2019). Another important finding is that the analysis of all attempts of receiving health care showed a decrease of 11% among those who sought care (from 97% in 2013 to 86.1% in 2019) ¹⁷17. Malta DC, Gomes CS, Prates EJS, Santos FP, Almeida WS, Stopa SR, et al. Análise da demanda e acesso aos serviços nas duas semanas anteriores à Pesquisa Nacional de Saúde 2013 e 2019. Rev Bras Epidemiol 2021; 24 Suppl 2:E210002.SUPL.2..

Measuring access to health care systems and services and their use is an important object of study as it indirectly offers the possibility of assessing attributes associated with equity ¹⁸18. Louvison MCP, Lebrão ML, Duarte YAO, Santos JLF, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo. Rev Saúde Pública 2008; 42:733-40.. Thus, we emphasize the need to know the current pattern of social inequities in health and to estimate their magnitude to contribute to the literature on the subject and to the planning and management of community health interventions that prioritize the most vulnerable groups to reduce the found health inequities and discuss the success of the implemented interventions. This study aimed to analyze changes in the prevalence of access and use of health care services for the diseases reported in the two weeks preceding the aforementioned survey, as well as the extent of social inequality in demand, use, and access, resolution of health problems, satisfaction, and use of health care services from SUS, according to levels of education in the population living in the urban area of the Municipality of São Paulo in 2003 and 2015.

Materials and methods

Design

This is a population-based health survey conducted in 2003 and 2015 in the Municipality of São Paulo (ISA-Capital). It was developed by a team of researchers from the School of Public Health and the Medical School of the University of São Paulo (FSP and FM/USP), the School of Medical Sciences from the University of Campinas (FCM/UNICAMP), and the Health Institute of the Department of Health of São Paulo (IS/SES-SP). The main objective of the ISA-Capital survey was to diagnose the population’s living and health conditions and health care use. Methodological details of the ISA-Capital outputs can be found on the ISA-Capital website (https://www.prefeitura.sp.gov.br/cidade/secretarias/saude/epidemiologia_e_informacao/isacapitalsp/) and in the previous publications ¹⁹19. Alves MCGP. Plano de amostragem. In: Cesar CLG, Carandina L, Alves MCGP, Barros MBA, Goldbaum M, editors. Saúde e condição de vida em São Paulo. São Paulo: Faculdade de Saúde Pública, Universidade de São Paulo; 2005. p. 47-63.^,2020. Alves MCGP, Escuder MML. Plano de amostragem ISA Capital 2008. http://www.esp.usp.br/isa-sp/pdf/planoamostral2008.pdf (accessed on 27/Feb/2015).
http://www.esp.usp.br/isa-sp/pdf/planoam... ^,2121. Cesar CLG. Metodologia. In: Cesar CLG . Carandina L, Alves MCGP, Barros MBA, Goldbaum M, editors. Saúde e condição de vida em São Paulo. São Paulo: Faculdade de Saúde Pública, Universidade de São Paulo; 2005. p. 37-47.^,2222. Santos EFS, Monteiro CN, Vale DB, Louvison M, Goldbaum M, Cesar CLG, et al. Social inequalities in access to cancer screening and early detection: a population-based study in the city of São Paulo, Brazil. Clinics 2023; 78:100160..

Populations and sampling process

Sampling was conducted in two stages: census tracts and households. All individuals aged ≥ 20 years were included. The sample in 2003 included 1,667 individuals and in 2015, 3,184 individuals. All respondents were interviewed, informed, and agreed to participate in the study. This study was approved by the Ethics Committee of the FSP/USP (protocol: 719.661/2014).

Variables

The following socioeconomic and demographic variables were selected: gender (male and female), age (20-59 years, 60 years or more), race/color (white, black/mixed-race, and yellow), level of education in full years (0-7, 8 and more), presence of noncommunicable chronic disease (NCD) (yes, no), and self-perceived health (excellent/very good, good, bad/very bad). Socioeconomic and demographic variables were used to characterize the population of this study.

Health problems in the two weeks preceding the survey, demand for health care, access and use of health care services, satisfaction with the care received at the health service, resolution of the health need among those who resorted to health care services, and use of public health care were adopted as the variables of interest in this study. As the 2003 and 2015 ISA-Capital surveys indirectly assessed quality of care, two closely related measures were used to assess quality of care: satisfaction regarding the received treatment and resolution of health problems ²³23. Monteiro CN, Beenackers MA, Goldbaum M, Barros MBA, Gianini RJ, Cesar CLG, et al. Use, access, and equity in health care services in São Paulo, Brazil. Cad Saúde Pública 2017; 33:e00078015..

To assess access and use of health care services, the following questions from the ISA-Capital Questionnaire were considered: “Health problem”, to assess health problems in the two weeks prior to the survey (C101a. Did you have any health problems in the last 2 weeks?); “Demand for health care”, to assess the demand for health services to solve this health problem (C101i. Did you seek help or talk to someone to solve this health problem?); “Access and use of health care”, to assess access to and use of health care services at the sought service (G111. Did you receive care at the service you sought?); “Satisfaction”, to assess satisfaction with the care received at the health service (G134. What did you think of the care you received?); “Resolution”, to assess the resolution of the health need among those who resorted to health care (G137. Has your need been resolved?); and “Use of the public health service”, to assess the use of the public health service in the city of São Paulo (G110. Is this health service public or private/private?).

Health problems in the two weeks prior to the survey considered all illnesses or health problems that the person had in the two weeks, whether acute or chronic diseases. Thus, such diseases or health problems may have emerged in those 14 days prior to the interview or a long time before it. Although people are more likely to mention problems that began in the last two weeks, they can refer to any chronic problems they have to answer this question.

Statistical analysis

First, the individuals in the sample were characterized according to the considered variables, using absolute frequencies and relative percentages in the weighted sample. Prevalence ratios (PR) were estimated by Poisson regression. The prevalence of health care use - outcome variable - was analyzed by demand, access, resolution, satisfaction, use of SUS services, whereas the independent variable consisted of education level in whole years (reference category: eight years or more of schooling) to determine the extent of inequality in health care use for acute conditions. Moreover, the variables gender and age were used as adjustments in the regression models to control for potential confounders. A descriptive level of 0.05 was considered for the Wald test.

All analyses were performed using the survey module of Stata 14.0 (https://www.stata.com), considering the complex effects of our study design and the effect of stratification and embedding the different observation weights.

Results

Table 1 shows the distribution of the population by the following variables: demographic characteristics, socioeconomic characteristics, and health conditions in 2003 and 2015. Regarding demographic characteristics, we found that the proportion of individuals aged 60 years or more tended to grow between the studied years, from 15.99% in 2003 to 18.51% in 2015. Regarding socioeconomic characteristics, we found that between 2003 and 2015, the proportion of individuals who identified themselves as white decreased (67.51% and 52.41%, respectively). We also observed a decrease in the number of individuals with up to three years of schooling (14.16% in 2003 and 6.84% in 2015) and an increase in those who reported 12 and more years of schooling (23.93% in 2003 and 28.75% in 2015).

Regarding health conditions, we observed an increasing trend in those affected by NCDs, from 59.89% in 2003 to 64.58% in 2015. We should highlight that health self-perception among individuals also changed during the studied period. The proportion of individuals who rated their health as excellent or very good (36.78% in 2003 and 27.11% in 2015) and bad or very bad (8.74% in 2003 and 4.77% in 2015) decreased, whereas we found an increase in those who described it as good (54.49% in 2003 and 68.12% in 2015) (Table 1).

Table 2 and Figure 1 provide information on the frequency of access and use of health care services due to health disorders in the two weeks preceding the survey. We found that the demand for health care in the two weeks preceding the survey increased from 53.77% in 2003 to 64.79% in 2015. Health care use on-demand also increased between 2003 and 2015, from 73.65% to 94.86%. When analyzing health care use by type of service, we found an increasing trend in the use of public services (from 91.25% in 2003 to 95.90% in 2015) and in the use of private services (from 61.85% in 2013 to 93.17% in 2015) as well.

Satisfaction with received health care tended to decrease, from 77.62% in 2003 to 71.91% in 2015. When we analyzed satisfaction, we found (regarding type of service) a decreasing tendency in public services (from 71.91% in 2003 to 64.37% in 2015) and a stable tendency in private services (83.28% in 2003 to 84.45% in 2015). Regarding the resolution of health problems, we observed an increase in the studied period (32.36% in 2003 and 53.75% in 2015), and this resolution tended to increase in public (36.05% in 2003 and 50.9% in 2015) and private services (28.71% in 2003 and 58.54% in 2015) (Table 2). Regarding the use of public health care, we found an increasing trend in use of services from SUS, from 49.73% to 62.5% between 2003 and 2015 (Figure 1).

Table 3 shows our analyses of the estimated PR regarding access and use of health care services for health disorders in the two weeks preceding the survey according to levels of education. We managed to review the changes in inequities related to the use of public health care between 2003 and 2015.

In 2003, the use of public health care services was 148% (PR = 2.48; 95% confidence interval - 95%CI: 1.61-3.81) higher among individuals with lower levels of education, whereas, in 2015, analysis found that the use of public health care services was 44% (PR = 1.44; 95%CI: 1.23-1.68) higher among individuals with a lower level of education than among those with higher levels of education. Analysis showed that inequities in the use to public health care services suffered the influence of levels of education in which we observed a strong positive association between these two variables (p < 0.001). Despite this association, the magnitude of disparities in the use to public health care services between individuals with different levels of education decreased in the studied period (Table 3).

Discussion

The demographic and socioeconomic characteristics observed in this study correspond to changes found in surveys of the Brazilian population ¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019: informações sobre domicílios. acesso e utilização dos serviços de saúde. Brasil, Grandes Regiões e Unidades da Federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020.^,1515. Viacava F, Porto SM, Carvalho CC, Bellido JG. Desigualdades regionais e sociais em saúde segundo inquéritos domiciliares (Brasil, 1998-2013). Ciênc Saúde Colet 2019; 24:2745-60.^,1616. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira. Pesquisa Nacional de Saúde 2013. Rev Saúde Pública 2017; 51 Suppl 1:3s.^,2424. Instituto Brasileiro de Geografia e Estatística. Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2019.. A higher proportion of older adults and the increase in the number of people who identified themselves as black and mixed-race confirm the results observed in Brazil since the 1980s due to its aging population and the changes in its socially constructed ethnic-racial identification ²⁵25. Instituto Brasileiro de Geografia e Estatística. Panorama nacional e internacional da produção de indicadores sociais: grupos populacionais específicos e uso do tempo. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2018.. The increase in the level of education follows the national trend confirmed by the Continuous Brazilian National Household Sample Survey (Continuous PNAD), which found a significant increase in the level of education of the population from 2012 to 2018 ²²22. Santos EFS, Monteiro CN, Vale DB, Louvison M, Goldbaum M, Cesar CLG, et al. Social inequalities in access to cancer screening and early detection: a population-based study in the city of São Paulo, Brazil. Clinics 2023; 78:100160..

Regarding health conditions, the increase in the prevalence of adults with chronic diseases has also been confirmed by the Global Burden of Diseases²⁶26. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories. 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396:1204-22. and PNS ¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019: informações sobre domicílios. acesso e utilização dos serviços de saúde. Brasil, Grandes Regiões e Unidades da Federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020. and requires attention due to its impact on individuals’ lives and the health care network given the greater need for access and use of health care services ²⁷27. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Doenças crônicas não transmissíveis e a utilização de serviços de saúde: análise da Pesquisa Nacional de Saúde no Brasil. Rev Saúde Pública 2017; 51 Suppl 1:4s.. The decline in the prevalence of excellent or good self-assessments confirms the results found in the PNAD analysis from 1998 to 2013. We found a decrease in positive health self-assessment, especially among populations with lower levels of education. Such a decrease could relate to a better knowledge of each individual’s health status as a result of greater use and access to health care ¹⁵15. Viacava F, Porto SM, Carvalho CC, Bellido JG. Desigualdades regionais e sociais em saúde segundo inquéritos domiciliares (Brasil, 1998-2013). Ciênc Saúde Colet 2019; 24:2745-60..

Health system performance characteristics - access, cost, effectiveness, and satisfaction - are increasingly interrelated ²⁸28. Gold M. Beyond coverage and supply: measuring access to healthcare in today's market. Health Serv Res 1998; 33:625-52.. Thus, the analysis of the elements of the use of health systems and services becomes an important object of study.

Analyses of access and use of health care services in 2003 and 2015 found an increase in the demand for services due to health disorders in the two weeks preceding the survey. These results agree with the findings of the PNS ¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019: informações sobre domicílios. acesso e utilização dos serviços de saúde. Brasil, Grandes Regiões e Unidades da Federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020., which also observed an increase in demand for health care in the country, higher among populations with higher levels of education. We should emphasize that health care use partially depend on the morbidity, severity, and urgency of health disorder ⁵5. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20 Suppl 2:190-8.. We should consider that the increase in the prevalence of chronic diseases we observed could also explain the increased demand for health care, considering how the progression of acute health disorders affects demand.

Another point worth highlighting is the increase in access and use of health care services among individuals who reported having a demand in the two weeks preceding the survey. A study that used PNAD data from 1998 to 2013 and PNS data confirmed the trend of increased use of health services over the years by all individuals. However, we should stress that despite the increase in access and use of health care services, we also find an increase in inequalities regarding dental services ²⁹29. Pilotto LM, Celeste RK. Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998-2013. Cad Saúde Pública 2018; 34:e00052017..

Regarding satisfaction with the care received for health problems in the two weeks preceding the survey (a proxy of health care service quality), this study found that satisfaction remained stably high, with a downward trend regarding public services and stability regarding private services. A study conducted by the PNS in 2013 in the five regions of Brazil found that its Southeast, which has the highest Human Development Index (HDI), had a better evaluation of the care received in hospital services than the other regions of the country ¹⁶16. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira. Pesquisa Nacional de Saúde 2013. Rev Saúde Pública 2017; 51 Suppl 1:3s..

We should stress that determinants of potential access are unable to explain effective access because its effects on health and satisfaction (effective access) go beyond the determinants of service use. As mentioned, service use depends on predisposing factors, health needs, and contextual factors, and effective and efficient use depends on individual factors and factors within the health care system that affect the quality of the provided services ⁵5. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20 Suppl 2:190-8..

Regarding the resolution of the health problem by the care received in the two weeks preceding the survey, we observed an increase in private services from 2003 to 2015. Health problem resolution has been studied in other works and consists of health problem resolution and patients and healthcare providers’ satisfaction ³⁰30. Turrini RNT, Lebrão ML, Cesar CLG. Resolutividade dos serviços de saúde por inquérito domiciliar: percepção do usuário. Cad Saúde Pública 2008; 24:663-74.. Our results differ from a study conducted in six basic health units (UBS) in a large municipality in the State of São Paulo, which found that users complain about delays in care services and, consequently, in the resolution of their health problems ³¹31. Campos RTO, Ferrer AL, Gama CAP, Campos GWS, Trapé TL, Dantas DV. Avaliação da qualidade do acesso na atenção primária de uma grande cidade brasileira na perspectiva dos usuários. Saúde Debate 2014; 38 n.spe:252-64..

We found a rise in the prevalence of the use of public services from 2003 to 2015. The rise in the use of public services could relate to the significant expansion in the offer of private health insurance with limited coverage during this period, as shown by Bahia et al. ³²32. Bahia L, Scheffer M, Dal Poz M, Travassos C. Planos privados de saúde com coberturas restritas: atualização da agenda privatizante no contexto de crise política e econômica no Brasil. Cad Saúde Pública 2016; 32:e00184516., who found that health insurance companies included public facilities in their network of authorized partners.

The population who used SUS the most was the population with the lowest socioeconomic status in all the studied years. SUS use failed to differ between adults and older adults, confirming a universal system that follows the principle of longitudinal care, in which patients receive care from primary health care (PHC) professionals over time, which is considered a central feature of this level of care and essential to the effectiveness of SUS ³³33. Cunha EM, Giovanella L. Longitudinalidade/continuidade do cuidado: identificando dimensões e variáveis para a avaliação da atenção primária no contexto do sistema público de saúde brasileiro. Ciênc Saúde Colet 2011; 16 Suppl 1:1029-42..

We observed no inequalities according to education in the prevalence of use of services due to health problems in two weeks prior to the survey, demand for health services to solve this health problem, satisfaction with the care received at the health service, and resolution of health needs among those who resorted to health care. This result may be linked to the structural, operational, and relational dimensions that influence access to health services ³⁴34. Viegas APB, Carmo RF, Luz ZMP. Fatores que influenciam o acesso aos serviços de saúde na visão de profissionais e usuários de uma unidade básica de referência. Saúde Soc 2015; 24:100-12.. The Municipality of São Paulo, as a structural dimension, shows a unique socioeconomic context that impacts the living conditions of its resident population; as an operational dimension, it has a complex network of organized services that permeate all levels of health care; and as a relational dimension, it shows a diversity of perceptions, beliefs, and values, which may imply the understanding of health-disease and the search for services.

Another important point we should highlight based on the absence of inequalities for these analyzed factors is the success of the SUS as a social inclusion policy. Results show that health services in São Paulo are more equitable and guarantee access despite its population size and social diversity.

The analysis of the prevalence of access to and use of health care services by level of education, only showed a statistically significant association with the use of public services. We found that individuals with less than eight years of schooling had greater access and use of public services than those with more than eight years of schooling. This result resembles other studies, which found a greater use of public services in less educated individuals ²³23. Monteiro CN, Beenackers MA, Goldbaum M, Barros MBA, Gianini RJ, Cesar CLG, et al. Use, access, and equity in health care services in São Paulo, Brazil. Cad Saúde Pública 2017; 33:e00078015.^,3535. Quadra MR, Shafer AA, Meller FO. Desigualdades no uso dos serviços de saúde em um município no Sul do Brasil em 2019: estudo transversal. Epidemiol Serv Saúde 2023; 32:e2022437., a situation that may relate to their lower ability to pay for health services privates or by achieving equity in health.

Comparing 2003 and 2015, we found a reduction in inequalities in the use of public health services according to levels of education. The role of SUS in reducing inequities and its equity factor stands out. Despite its problems, especially in the depletion of the system over the years, SUS has ensured health care for all the Brazilian population, especially in São Paulo, during the three decades of its history, as per our results. However, it faces challenges to solve the population’s health problems.

The complexity and breadth of the system pose challenges to health services in São Paulo. A system that still faces unresolved basic and primary problems, such as a lack of basic sanitation. As in most Brazilian cities, the inhabitants of the most diverse and distant outlying districts are forced to commute daily in a low-quality transportation system. We are unable to deny the contribution of territory and segregation processes to the production and reproduction of vulnerabilities and inequalities affecting most urban areas, especially in the periphery of metropolitan areas such as São Paulo, in which intra-urban inequalities and the effects of segregation have tended to worsen as a result of social transformations, the pandemic crisis, and the reorientation of urban policies ³⁶36. Carvalho IMM. Segregação, vulnerabilidade e desigualdades sociais e urbanas. Civitas: Revista de Ciências Sociais 2020; 20:270-86..

According to Esposti et al. ³⁷37. Esposti CDD, Santos-Neto ET, Oliveira AE, Travassos C, Pinheiro RS. Desigualdades sociais e geográficas no desempenho da assistência pré-natal de uma Região Metropolitana do Brasil. Ciênc Saúde Colet 2020; 25:1735-50. since access to health care alone is unable to contribute to the reduction of health inequalities, it is necessary to set intersectoral partnerships to promote better living conditions for populations.

This study shows the role of SUS in the last 15 years in São Paulo, one of the most socially unequal cities in the world ³⁸38. Marques E. Notes on social conditions, rights and violence in Brazilian Cities. Journal of Iberian and Latin American Research 2021; 27:21-36., with a complex health care network.

The inequalities in São Paulo became even more evident in the COVID-19 pandemic, highlighting the importance of SUS in playing a leading role in caring for the victims of the disease ³3. Almeida C, Luchmann L, Martelli C. A pandemia e seus impactos no Brasil. Middle Atlantic Review of Latin American Studies 2020; 4:20-5. and in vaccinating the population. SUS has provided the best responses to this crisis, ranging from direct assistance to health care users to the combined operation of public laboratories and the epidemiological surveillance by the Brazilian Ministry of Health ³⁹39. Dantas AV. Coronavírus, o pedagogo da catástrofe: lições sobre o SUS e a relação entre público e privado. Trab Educ Saúde 2020; 18:e00281113.. The points discussed above should guide a public agenda to restructure the São Paulo municipal government after the pandemic.

We should point out that the answers to the ISA-Capital survey are self-reported and may contain errors in the classification of participants’ answers. Moreover, we conducted our analyses up to 2015, the most recent period with available data.

However, we should emphasize that these data come from a population-based survey, contributing to information that represents the extent of the problem in the most populous Brazilian megalopolis and one of the most socially unequal municipalities in the world. Moreover, ISA-Capital can measure information on all health care services used by the population, including different types of public and private services, thus serving to monitor inequalities.

Conclusions

We observed no social inequities in health care use among those who reported health disorders in the two weeks preceding the survey in the Municipality of São Paulo for issues related to demand, access, satisfaction, and resolution according to levels of education. Results show important progress in the use and resolution of health problems, as well as in the increase of the prevalence of public services use in 2003 and 2015. The population who most frequently used SUS was that with the lowest socioeconomic status in all studied years. The role of SUS is to reduce inequalities, and we found that the equity factor stands out. The higher prevalence of public health care use individuals with lower levels of education evince the work of the SUS in the Municipality of São Paulo. We should also consider that despite the increase in the resolution of health problems, we found a trend toward a reduction in satisfaction with the care received in public health services (although not statistically significant), indicating the importance of further studies to further develop and monitor the analysis of the quality of provided services.

Acknowledgments

Supported by the São Paulo Research Foundation (FAPESP) which funded the postdoctoral fellowship grant of Edige Felipe de Sousa Santos (grant #2020/03013-0); FAPESP and Thematic Project Social Inequalities in Health in the Headquarter Municipalities of two Metropolises in São Paulo: Measurement, Monitoring and Analysis (grant #2017/23995-9); and Brazilian National Research Council (CNPq) which funded the research productivity grant of Marilisa Berti de Azevedo Barros (grant #303241/2019-5).

References

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