Unequal treatment

There have been improvements in the accessibility and quality of healthcare services around the world over the last 25 years, but there are still pronounced regional disparities

Ward at the São Mateus General Hospital, in the city of São Paulo

Alexandre Moreira/A2 Photography/Wikimedia

Between 1990 and 2016, public healthcare systems around the world have improved their services, but contrasts in performance between medical institutions in regions of high, medium, and low development have increased. These are the conclusions of an international study produced by 868 researchers who analyzed the accessibility and quality of healthcare systems from 195 countries, including Brazil. The study was published in The Lancet in June 2018. As expected, in general the richer and more developed nations were those with the best healthcare systems. Of the top 20 positions in the ranking, 17 were occupied by European countries. The exceptions were Japan (12th), Canada (14th), and New Zealand (16th). Brazil appears in an intermediate position: number 96.

The study was carried out by a research group coordinated by epidemiologists Nancy Fullman and Rafael Lozano, from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle, United States. Their analysis was predicated on the gigantic Global Burden of Disease (GBD) database. Initially coordinated by the World Health Organization (WHO), since 2007 the GBD has been under the responsibility of the IHME, with support from the Bill and Melinda Gates Foundation. The most recent version of the GBD study gathered some 1,800 experts from 120 countries and examined the mortality rates and impacts of 315 diseases and 79 risk factors in nearly 200 nations.

The team led by Fullman and Lozano used a portion of the GBD data to substantiate the Healthcare Access and Quality index (HAQ), which evaluates the mortality resulting from 32 treatable diseases, including cancer, cardiovascular problems, and infection, in each of the countries analyzed from 1990 to 2016. The closer a country’s HAQ score is to 100 points, the better its healthcare system is deemed to be.

In 2016, the HAQ ranged from 97.1 points in Iceland, which placed first in the survey, to 18.6 in the Central African Republic, which occupies last place. The global average rose from 42.2 in 2000 to 54.4 points in 2016, supported mainly by the improved performance of the poorest countries. The general healthcare situation in Brazil has also improved, according to this survey. The overall average of the country was 46.5 points on the HAQ in 1990 and 55.3 in 2000. In 2016, it reached 63.8 points.

The survey measured, in detail, the actual conditions in particular regions or states of seven countries: Japan, United Kingdom, United States, China, Mexico, Brazil, and India. Pronounced regional disparities have emerged in China, whose performance ranged from 91.5 in Beijing to 48 in Tibet. The same occurred in India, where the state of Goa received 64.8 points and the state of Assam, only 34. Japan had the lowest regional variation, with a difference of only 4.8 points.

Vaccination improves the index
In Brazil, progress was more pronounced between 1990 and 2000 than between 2000 and 2016. “In 1990, the priorities were infectious and pediatric diseases, which can be prevented through vaccination,” says epidemiologist Deborah Carvalho Malta, from the Federal University of Minas Gerais (UFMG), coordinator of the GBD in Brazil and coauthor of the article in The Lancet. “Since 2000, health problems have become more complex, and chronic noncommunicable diseases have become the priority. The reduction in mortality from these diseases depends on several factors, such as long term follow-ups with patients, public health campaigns, and regulatory policies such as the taxation of tobacco, alcohol, and ‘ultra-processed’ foods.” In the most recent study, the treatment in Brazil of four diseases—measles, tetanus, diphtheria, and upper respiratory tract infections—obtained the maximum rating (100 points). Tuberculosis received 67 points, diarrhea 59, diabetes 48, heart attack 41, and leukemia 27.

Although Brazil’s general HAQ score has improved, the regional disparities between the healthcare systems of the Brazilian states have increased during the period covered by the study. The difference between the best performance (the Federal District, with 55.2) and the worst (the state of Alagoas, with 38) was 17.2 points in 1990. In 2016, the distance between the extremes rose to 20.4 points, with the Federal District scoring 75.4 points and Maranhão State only 55 points, just under Alagoas, which reached 56.6 on the index. Second only to the Federal District, the state of São Paulo currently offers the best accessibility and quality of healthcare services, followed by Minas Gerais, Espírito Santo, Rio de Janeiro, and the states of the southern region (see maps). “There are historical, socioeconomic inequalities that explain these results, in addition to the inequality in the distribution of healthcare services and health professionals in the North and Northeast,” explains Dr. Malta.

“The profiles of the North and Northeast have evolved more slowly and didn’t keep up with the standards achieved by the states in the South and Southeast, which have invested more and have more healthcare facilities and specialized professionals, in addition to mature family healthcare programs,” says epidemiologist Maria Paula Curado, a researcher at the A. C. Camargo Cancer Center, in São Paulo, who did not participate in the Lancet study.

Advances in accessibility are not always accompanied by improvement in the quality of healthcare services. “Many times there is a discontinuity in the services, for political or technical reasons, which delays the process of improving treatment and diagnosis,” says Curado. She participated in a study based on the GBD, published in JAMA Oncology in June 2018, which examined 29 types of cancer in 195 countries. Worldwide, the number of cancer cases increased by 28% between 2006 and 2016, with marked disparities between countries.

The two studies indicated that the poorest countries still face major challenges to expanding the accessibility and quality of their healthcare services, especially for noncommunicable diseases. Improving healthcare services, according to the authors of the Lancet study, “requires the adoption of a more comprehensive vision and subsequent provision of quality healthcare for all populations.”

Ewien Van Bergeijk-Kwant/Wikimedia Checking the state of residents’ health in N’Tossoni, south of Mali, in AfricaEwien Van Bergeijk-Kwant/Wikimedia

Global health database 
With this and other recent studies—such as a study on the HIV/AIDS epidemic in 188 countries from 1995 to 2015, also published in The Lancet, in May of 2018—the GBD offers an open database of information on global health, and an alternative to other international surveys, such as those from the WHO, according to epidemiologist Paulo Andrade Lotufo, at the School of Medicine of the University of São Paulo (USP), who participated in the Lancet study.

“The GBD has shown that we need to treat the primary data on healthcare with more rigor,” he says. In his view, limitations also emerge: the data on hospitalizations only include what comes from the public healthcare system, since private healthcare companies, which serve 46 million people in Brazil, are not obligated to provide them. It’s also possible that different results might arise than those obtained utilizing national databases that, for Lotufo, could “generate a healthy debate on methods of analysis of demographic data and make room for advancement in our analyses.”

Infant mortality rate increases

For the first time in 15 years, the infant mortality rate in Brazil showed a slight increase: it rose from 14.3 per thousand live births in 2015 to 14.9 in 2016, the same level observed in 2014, according to a study by the Center for Children and Adolescents of the Abrinq Foundation, based on Brazilian Ministry of Health (MS) data. Although the rate has increased, the total number of deaths, in absolute numbers, decreased from 43,152 in 2015 to 42,581 in 2016. The lower number of births in 2016 (2.85 million live births) in relation to 2015 (3 million) may have had an influence on the mortality rate increase, according to the Information System on Live Births from the Ministry of Health. In 2000, the mortality rate of children from 0 to 5 years in the country was twice the current rate of 30.1 deaths per thousand live births.

Scientific Articles
FULLMAN, N. et al. Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: A systematic analysis from the Global Burden of Disease Study 2016. The Lancet. Vol. 391, no. 10136, pp. 2236–71. June 2, 2018.
FITZMAURICE, C. et al. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 29 cancer groups, 1990 to 2016: A systematic analysis for the Global Burden of Disease Study. JAMA Oncology. Online. June 2, 2018.