Revista Panamericana de Salud Públicahttps://scielosp.org/feed/rpsp/2013.v33n2/2018-01-01T00:02:00ZVol. 33 No. 2 - 2013WerkzeugEquity in health systemsS1020-498920130002000012018-01-01T00:02:00Z2018-01-01T00:02:00ZEtienne, Carissa F.
<em>Etienne, Carissa F.</em>;
<br/><br/>
Measuring evolution of income-related inequalities in health and health care utilization in selected Latin American and Caribbean countriesS1020-498920130002000022018-01-01T00:02:00Z2018-01-01T00:02:00ZAlmeida, GiseleSarti, Flavia Mori
<em>Almeida, Gisele</em>;
<em>Sarti, Flavia Mori</em>;
<br/><br/>
OBJECTIVE: To describe the methodology used to measure and explain income-related inequalities in health and health care utilization over time in selected Latin American and Caribbean countries. METHODS: Data from nationally representative household surveys in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru were used to analyze income-related inequalities in health status and health care utilization. Health was measured by self-reported health status, physical limitations, and chronic illness when available. Hospitalization, physician, dentist, preventive, curative, and preventive visits were proxies for health care utilization. Household income was a proxy for socioeconomic status except in Peru, which used household expenditures. Concentration indices were calculated before and after standardization for all dependent variables. Standardized concentration indices are also referred to as horizontal inequity index. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. RESULTS: Results of analysis of the evolution of income-related inequality in health and health care utilization in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru are presented in separate articles in this issue. CONCLUSIONS: The methodology used for analysis of equity in all six country research studies attempts not to determine causality but to describe and explain income-related inequalities in health status and health care utilization over time. While this methodology is robust, it is not free of errors. When possible, errors have been identified and corrected.Analysis of the evolution and determinants of income-related inequalities in the Brazilian health system, 1998 - 2008S1020-498920130002000032018-01-01T00:02:00Z2018-01-01T00:02:00ZAlmeida, GiseleSarti, Flavia MoriFerreira, Fernando FagundesDiaz, Maria Dolores MontoyaCampino, Antonio Carlos Coelho
<em>Almeida, Gisele</em>;
<em>Sarti, Flavia Mori</em>;
<em>Ferreira, Fernando Fagundes</em>;
<em>Diaz, Maria Dolores Montoya</em>;
<em>Campino, Antonio Carlos Coelho</em>;
<br/><br/>
OBJECTIVE: To analyze the evolution and determinants of income-related inequalities in the Brazilian health system between 1998 and 2008. METHODS: Data from the National Household Sampling Surveys of 1998, 2003, and 2008 were used to analyze inequalities in health and health care. Health was measured by self-reported health status, physical limitations, and chronic illness. Hospitalization and physician and dentist visits were proxies for health care utilization. Income was a proxy for socioeconomic status. Concentration indices were calculated before and after standardization for all dependent variables. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. RESULTS: In all three periods analyzed, the poor reported worse health status, while the wealthy reported more chronic diseases; health care utilization was pro-rich for medical and dental services. Yet, income-related inequality in health care utilization has been declining. Private health insurance, education, and income are the major contributors to the inequalities identified. CONCLUSIONS: Income-related inequality in the use of medical and dental health care is gradually declining in Brazil. The decline is associated with implementation of pro-equity policies and programs, such as the Community Health Agents Program and the Family Health Program.Income-related inequality in health and health care utilization in Chile, 2000 - 2009S1020-498920130002000042018-01-01T00:02:00Z2018-01-01T00:02:00ZVásquez, FelipeParaje, GuillermoEstay, Manuel
<em>Vásquez, Felipe</em>;
<em>Paraje, Guillermo</em>;
<em>Estay, Manuel</em>;
<br/><br/>
OBJECTIVE: To measure and explain income-related inequalities in health and health care utilization in the period 2000 - 2009 in Chile, while assessing variations within the country and determinants of inequalities. METHODS: Data from the National Socioeconomic Characterization Survey for 2000, 2003, and 2009 were used to measure inequality in health and health care utilization. Income-related inequality in health care utilization was assessed with standardized concentration indices for the probability and total number of visits to specialized care, generalized care, emergency care, dental care, mental health care, and hospital care. Self-assessed health status and physical limitations were used as proxies for health care need. Standardization was performed with demographic and need variables. The decomposition method was applied to estimate the contribution of each factor used to calculate the concentration index, including ethnicity, employment status, health insurance, and region of residence. RESULTS: In Chile, people in lower-income quintiles report worse health status and more physical limitations than people in higher quintiles. In terms of health service utilization, pro-rich inequities were found for specialized and dental visits with a slight pro-rich utilization for general practitioners and all physician visits. All pro-rich inequities have decreased over time. Emergency room visits and hospitalizations are concentrated among lower-income quintiles and have increased over time. Higher education and private health insurance contribute to a pro-rich inequity in dentist, general practitioner, specialized, and all physician visits. Income contributes to a pro-rich inequity in specialized and dentist visits, whereas urban residence and economic activity contribute to a pro-poor inequity in emergency room visits. CONCLUSIONS: The pattern of health care utilization in Chile is consistent with policies implemented in the country and in the intended direction. The significant income inequality in the use of specialized and dental services, which favor the rich, deserves policy makers' attention and further investigation related to the quality of these services.Colombian health care system: results on equity for five health dimensions, 2003 - 2008S1020-498920130002000052018-01-01T00:02:00Z2018-01-01T00:02:00ZRuiz Gómez, FernandoZapata Jaramillo, TeanaGaravito Beltrán, Liz
<em>Ruiz Gómez, Fernando</em>;
<em>Zapata Jaramillo, Teana</em>;
<em>Garavito Beltrán, Liz</em>;
<br/><br/>
OBJECTIVE: To assess the change in five health equity dimensions for the Colombian health system: health condition, social health insurance coverage, health services utilization, quality, and health expenditure. METHODS: A common standardization methodology was used to assess equity in countries in the western hemisphere. Data come from the Colombian Life Quality Survey. After indirect standardization, concentration indices and horizontal inequity were estimated. A decomposition analysis was developed. Aggregate household monthly expenditure per equivalent adult was considered as the standard of living. RESULTS: Results show important progress in equity with regard to social health insurance affiliation, access to medicine and curative services, and perception of the quality of health care service. Important gaps persist, which affect poorer populations, especially their perception of having a bad health condition and their access to preventive medical and dental services. CONCLUSIONS: The Colombian model needs to advance in implementing preventive public health strategies to cope with increasing demand concomitant with increased social insurance coverage. The population's access to total services in cases of chronic illness and oral health services must increase and benefit plans must be integrated while preserving the recorded achievements in equity. Decomposition of the concentration index shows that inequities are mostly explained by socioeconomic variables and not by health-related factors.Measuring and explaining health and health care inequalities in Jamaica, 2004 and 2007S1020-498920130002000062018-01-01T00:02:00Z2018-01-01T00:02:00ZScott, EwanTheodore, Karl
<em>Scott, Ewan</em>;
<em>Theodore, Karl</em>;
<br/><br/>
OBJECTIVE: This study addresses the need to measure and explain the inequalities and inequities of Jamaica's health system to generate evidence to support policy development, monitoring, and evaluation. METHODS: The nationally representative Jamaica Survey of Living Conditions data sets for 2004 and 2007 were used to produce concentration curves and concentration indices for three health outcome variables (probability of any illness or injury, duration of latest episode of -illness, and self-assessed health status) and two health care utilization variables (probability of a curative visit to a health practitioner and number of curative visits) to measure income-related inequalities. Their standardized counterparts were used to measure inequities. Decomposition of the concentration index provides a basis for explaining the contributions of socioeconomic and demographic factors to overall inequalities. RESULTS: Probability of illness and duration of illness were concentrated among the poor, while there was a distinct pro-rich inequality with respect to utilization of heath care services. These inequalities and inequities became more pronounced over the period 2004 - 2007. The level of household welfare was found to be the single most significant factor contributing to these inequalities. Other significant contributing factors were unemployment and rural location for health outcomes and insurance coverage for utilization of services. CONCLUSIONS: In spite of measures taken ostensibly to address health equity in Jamaica, income-related inequalities in health outcomes and health care have increased and the population group that needs health services most is using them least. These findings suggest a need for more innovative programs geared toward improving equity in health in Jamaica.Income-related inequalities and inequities in health and health care utilization in Mexico, 2000 - 2006S1020-498920130002000072018-01-01T00:02:00Z2018-01-01T00:02:00ZBarraza-Lloréns, MarianaPanopoulou, GiotaDíaz, Beatriz Yadira
<em>Barraza-Lloréns, Mariana</em>;
<em>Panopoulou, Giota</em>;
<em>Díaz, Beatriz Yadira</em>;
<br/><br/>
OBJECTIVE: To measure income-related inequalities and inequities in the distribution of health and health care utilization in Mexico. METHODS: The National Health Survey (NHS) 2000 and the National Health and Nutrition Survey (NHNS) 2006 were used to estimate concentration indices for health outcomes and health care utilization variables before and after standardization. The study analyzed 110 460 individuals 18 years or older for NHS 2000 and 124 149 individuals for NHNS 2006. Health status variables were self-assessed health, physical limitations, and chronic illness. Health care utilization included curative visits and dental, hospital, and preventive care. Individuals were ranked by three standard-of-living measures: household income, wealth, and expenditure. Other independent variables were area of residence, geographic region, education, employment, ethnicity, and health insurance. Decomposition analysis allowed for assessing the contributions of independent variables to the distribution of health care among individuals. RESULTS: The worse-off population reports less good self-assessed health and more physical limitations, whereas better-off individuals report more chronic illnesses. Utilization of curative visits and hospitalization is more concentrated among the better-off population. No significant changes in these results can be established between 2000 and 2006. According to available evidence, standard of living, health insurance, and education largely contribute to the inequitable distribution of health care. CONCLUSIONS: Despite improvements in health care utilization patterns, income-related health and health care inequities prevail. Equity remains a challenge for Mexico.Equity in health and health care in Peru, 2004 - 2008S1020-498920130002000082018-01-01T00:02:00Z2018-01-01T00:02:00ZPetrera, MargaritaValdivia, MartínJimenez, EduardoAlmeida, Gisele
<em>Petrera, Margarita</em>;
<em>Valdivia, Martín</em>;
<em>Jimenez, Eduardo</em>;
<em>Almeida, Gisele</em>;
<br/><br/>
OBJECTIVE: This study evaluates whether recent positive economic trends and pro-poor health policies have resulted in more health equity and explores key factors that explain such change. METHODS: This study focuses on the evolution of measures of health status (self-reported morbidity) and use of health care services obtained from the 2004 and 2008 rounds of the Peruvian National Household Survey (Encuesta Nacional de Hogares). It concentrates on health inequalities associated with socioeconomic status and uses interquintile differences (gradient), concentration indices with and without needs-based adjustments, and decomposition analysis. RESULTS: Findings show a low level of inequality in measures of health status, with a slightly pro-poor inequality in self-reported health problems and a slightly pro-rich inequality in self-reported chronic illness. Inequity in the use of curative services declined significantly between 2004 and 2008, while inequity in the use of preventive services increased slightly. Use of hospital and dental services remained unchanged during the same period. CONCLUSIONS: Limitations of self-reported morbidity measures probably underestimate the results of health inequalities across socioeconomic groups. Improved equity in the use of curative health services can be explained by a number of positive factors that occurred concurrently during the analysis-namely, increased mean household income, reduced economic inequality, the Juntos conditional cash transfer program, and gradual expansion of public health insurance, Seguro Integral de Salud (SIS). Given that SIS expansion is the main public policy for promoting health equity in Peru, it is crucial that future steps in expansion come with a strategy to isolate its contribution to health equity improvements from that of other positive socioeconomic trends.Retraso en el diagnóstico de lepra como factor pronóstico de discapacidad en una cohorte de pacientes en Colombia, 2000 - 2010S1020-498920130002000092018-01-01T00:02:00Z2018-01-01T00:02:00ZGuerrero, Martha IníridaMuvdi, SandraLeón, Clara Inés
<em>Guerrero, Martha Inírida</em>;
<em>Muvdi, Sandra</em>;
<em>León, Clara Inés</em>;
<br/><br/>
OBJETIVO: Evaluar los factores pronósticos de la presencia de discapacidad al momento del diagnóstico de lepra en una cohorte de pacientes colombianos de 2000 a 2010. MÉTODOS: Estudio analítico y observacional descriptivo de una cohorte retrospectiva de pacientes ingresados con diagnóstico de lepra en el Centro Dermatológico Federico Lleras Acosta, de Bogotá, Colombia, entre 2000 y 2010. Se realizó el análisis descriptivo de las variables y se identificaron factores pronósticos de la presencia de discapacidad al momento del diagnóstico mediante análisis simple y multifactorial (modelo de riesgos proporcionales de Cox); se calcularon las razones de riesgo (hazard ratio) para cada uno de los factores incluidos en el modelo. RESULTADOS: El tiempo entre los primeros síntomas y el diagnóstico en los 333 pacientes de la cohorte fue en promedio 2,9 años; 32,3% de ellos tenían algún grado de discapacidad, especialmente en los pies. Hubo una mayor proporción de retraso en el diagnóstico y discapacidad en hombres que en mujeres y en pacientes con lepra multibacilar que con paucibacilar. La discapacidad se asoció significativamente con demoras ≥ 1 año en el diagnóstico, edad ≥ 30 años, índice baciloscópico inicial ≥ 2, lepra multibacilar y proceder de Cundinamarca o Santander. Los factores protectores fueron ser del sexo femenino, tener algún grado de escolaridad y residir en Boyacá. CONCLUSIONES: El tiempo entre los primeros síntomas y el diagnóstico constituye el factor pronóstico clave de la discapacidad al momento del diagnóstico de lepra. Se recomienda reforzar la búsqueda activa de personas infectadas y promover el diagnóstico precoz.Política de segurança alimentar e nutricional no Brasil: uma análise da alocação de recursosS1020-498920130002000102018-01-01T00:02:00Z2018-01-01T00:02:00ZCustódio, Marta BattagliaYuba, Tânia YukaCyrillo, Denise Cavallini
<em>Custódio, Marta Battaglia</em>;
<em>Yuba, Tânia Yuka</em>;
<em>Cyrillo, Denise Cavallini</em>;
<br/><br/>
OBJETIVO: Descrever a evolução e a distribuição dos recursos da União para programas e ações que se inserem nas diretrizes brasileiras da Política Nacional de Segurança Alimentar e Nutricional (PNSAN) no período de 2004 a 2010. MÉTODOS: Este estudo descritivo utilizou dados do Portal da Transparência mantido pela Controladoria Geral da União, que gera planilhas de Excel para cada pesquisa realizada. Para o levantamento dos recursos alocados, foi organizada uma base de dados contendo todas as ações executadas pelo governo federal entre 2004 e 2010. Essa base foi revisada e as ações que não eram relativas à PNSAN foram descartadas. Os montantes anuais obtidos tiveram os valores corrigidos pelo Índice de Preços ao Consumidor e atualizados para o ano de 2010. Como as ações são parte de programas específicos, a soma dos recursos destinados a todas as ações de um programa equivaleu aos recursos destinados ao programa como um todo. Os programas foram então hierarquizados de acordo com o volume de recursos recebidos em 2010. RESULTADOS: Das 5 014 ações que receberam recursos da União no período, 814 foram relacionadas à PNSAN (229 programas). Houve crescimento dos recursos alocados para os programas da PNSAN, alcançando, em 2010, US$ 15 bilhões (82% superior ao gasto no ano de 2004). A maior proporção dos recursos foi absorvida pelo Programa Bolsa Família. Dez programas receberam 90% dos recursos, sendo cinco ligados aos processos de produção alimentar. CONCLUSÕES: A PNSAN vem recebendo aporte crescente de recursos concentrados em ações e programas que favorecem a segurança alimentar e nutricional.Agenda Nacional de Investigación en Tuberculosis en Perú, 2011 - 2014S1020-498920130002000112018-01-01T00:02:00Z2018-01-01T00:02:00ZYagui Moscoso, MartínJave, Héctor OswaldoCurisinche Rojas, MaricelaGutiérrez, CésarRomaní Romaní, Franco
<em>Yagui Moscoso, Martín</em>;
<em>Jave, Héctor Oswaldo</em>;
<em>Curisinche Rojas, Maricela</em>;
<em>Gutiérrez, César</em>;
<em>Romaní Romaní, Franco</em>;
<br/><br/>
La selección de los temas prioritarios de investigación sobre tuberculosis (TB) en Perú se desarrolló en tres etapas: la revisión bibliográfica de los resultados de investigación y de la información sobre TB en Perú; la propuesta de los temas de mayor importancia mediante la consulta a 31 investigadores clave (identificados a partir de 233 artículos publicados entre 1981 y 2011), 16 (48,5%) de los 33 coordinadores regionales de la Estrategia Sanitaria Nacional de Prevención y Control de Tuberculosis y 16 académicos y funcionarios líderes de opinión en el tema de la TB; y un taller participativo con 103 profesionales y funcionarios invitados, distribuidos en 10 mesas temáticas de discusión. De los 49 temas de investigación identificados en la segunda etapa del proceso, en el taller participativo se seleccionaron y ordenaron según su prioridad los 30 temas de investigación más importantes para Perú. Estos temas, seleccionados mediante esta metodología inclusiva, transparente y participativa, pasaron a conformar la Agenda Nacional de Investigación en Tuberculosis en Perú para los años 2011 - 2014. Estos resultados deben contribuir a mejorar las estrategias de control de la TB en el país y optimizar el uso de los recursos financieros y humanos.