Abstract
This study describes the behavior of health inequalities in Brazil between 1980 and 2010 and revisit theoretical and methodological difficulties on researching this topic. The behavior of infant mortality and life expectancy in Brazil’s municipalities was investigated, attempting to identify the relationship between these indicators, on the one hand, and income, income inequality, supply of public health services and basic sanitation, and education, on the other. Over the course of that period, considerable improvements were recorded in both infant mortality rates and life expectancy at birth as well as in reducing the inequalities in these indicators among Brazil’s regions, states, and municipalities. A robust and statistically significant association was found between health indicators and mean income in the municipalities. That association was also positive for women’s level of education. Contrary to expectations, no association was found between expansion of public health care service supply and improvement in health indicators. An exercise to deepen the analysis, considering health inequalities between socioeconomic and racial groups, was made by calculating mortality rates directly, which yielded unsubstantial results. Improvement in Brazil’s vital statistics recording systems will make it possible – beyond the reach of this study – to examine the contribution made by the Brazilian public health system, the SUS, to improving health conditions and reducing health inequalities.
We are grateful to Patrick Silva, who organized the material presented in this chapter, for his thorough, painstaking work, and to Rogério Barbosa, for his invaluable contribution to processing and analyzing the data. We thank Elza Berquó, Jane Greve, Marta Arretche, Argelina Figueiredo, José Marcos P. da Cunha, Estela M. G. P. Da Cunha, Carlos Eugenio de C. Ferreira, and Cristina Guimarães for their careful reading of preliminary versions and their valuable suggestions. The chapter presents results of FAPESP projects 2013/07616-7 and 2011/20641-5.
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Notes
- 1.
Health inequalities are the differences, in descriptive terms, in levels of health among population groups identified on the basis of socioeconomic, gender, race, color, and ethnic characteristics.
- 2.
As municipal-level mortality data are available only from 1979 onward, our study period starts in 1980.
- 3.
There are no definitive conclusions, however, on the direction of the causal association: do socioeconomic conditions impact health or vice versa?
- 4.
Kondo et al. (2009) concluded that each 0.05 increment in the Gini coefficient is associated with a 7.8% higher mortality hazard, even though there is no consensus as to the geographical areas where this relationship holds. They suggest that, if the relationship between inequality and mortality is in fact causal, 1.5 million deaths (9.6% of adult mortality) could be prevented in 30 OECD countries by reducing the Gini coefficient to below the 0.3 threshold.
- 5.
Duarte (2007) identified more than 60 original studies of infant mortality published between 1998 and 2006. These studies examined the relations between infant mortality rates and the following factors: (i) total fertility and birth rate, (ii) unemployment, (iii) illiteracy, (iv) per capita GDP, (iv) Gini coefficient, (v) connection to public drinking water supply and sewage system, (vi) health facilities, and (vii) vaccination coverage.
- 6.
In each period, municipalities were ranked by mean per capita household income and divided into quartiles. This chapter describes only the first (the poorest municipalities) and last quartiles (the wealthiest municipalities). The makeup of these quartiles changes over time, not just because new municipalities have been created but also because municipalities may change position in the ranking from 1 year to the next.
- 7.
The Theil index, which measures inequality in income distribution among individuals, is calculated on the basis of per capita household income. The calculation does not include those with null per capita household income. The index is null when there is no income inequality among individuals and increases as the inequality among them increases.
- 8.
For more in-depth analysis, see the accompanying chapters by Marta Arretche, Naercio Menezes Filho, and Charles Kirschbaum and Carlos Antonio Costa Ribeiro and Rogerio Schlegel.
- 9.
For items (a) and (b), census data were used; for item (c), the data used were provided, respectively, by the Medical Assistance Research, IBGE, and the Ministry of Health.
- 10.
Infant mortality and life expectancy do not fit a normal distribution among municipalities –they are right-skewed – and the convention is to observe heteroscedasticity in distribution of the regression residuals. Least squares regression analysis presents non-skewed values for the point estimates, even given asymmetry and heteroscedasticity; accordingly, preference was given to use of the log of the dependent variables (in line with models widely used in the literature on the subject). In order to obtain non-skewed estimates of the coefficient distribution statistics, robust errors were calculated (Huber-White).
- 11.
The control exerted by the fixed effects is similar to what is obtained when including indicator variables for each state, except for the fact that the implicit fixed effects are not taken into account in calculating the coefficient of determination (R2).
- 12.
Here too, these effects did not enter into the calculation of R2.
- 13.
These rates were calculated using, as numerator, data from the Ministry of Health Mortality Information System (SIM/MS) for each group and, as denominator, the population reported by the census for each group. This procedure is necessary because in order to proceed with the analysis proposed, there needs to be information on individual deaths, which are available in the SIM, but are not provided by the databases used in the previous section, which provide corrected mortality rates.
- 14.
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Coelho, V.S.P., Dias, M. (2019). Health and Inequalities. In: Arretche, M. (eds) Paths of Inequality in Brazil. Springer, Cham. https://doi.org/10.1007/978-3-319-78184-6_9
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