Racial inequalities in access to healthcare services in Brazil (2019): a decomposition analysis

Abstract Background Racial and ethnic inequalities in access to healthcare services pose a significant challenge for many countries, with ethnic minorities and Afro-descendants frequently experiencing poorer access to services and health outcomes. However, little is known about the factors that drive racial inequalities in access to healthcare, especially in low- and middle-income countries. Methods This is a cross-sectional, observational study that uses data from the National Health Survey (2019) in Brazil and assesses the contribution of predisposing, facilitating, and need-for-care factors to inequalities in healthcare access between White, Black and Pardo (Brown) Brazilians. The Oaxaca-Blinder method was used to separate differences between racial groups into explained and unexplained determinants. Variables included in the models were age, sex, marital status, family size and composition, access to sanitation, health insurance, primary care coverage, income quintile, employment status, education, and self-rated health status. Results The responses from 204,918 individuals were analysed. White Brazilians reported better access to healthcare and medications than Black or Pardo Brazilians, with the largest racial inequalities in unmet needs for healthcare services and access to medication. Racial inequalities are mostly explained by observable factors (between 35% and 87%), most notably the access to financial resources (income and access to private health insurance). Being covered by the Family Health Program and higher levels of education were associated with reduced inequalities between racial groups. The unexplained portion of inequalities was the greatest when comparing Black and White individuals, implying that factors beyond socioeconomic status likely drive these inequalities including community, cultural or behavioural factors, and inequalities and bias in healthcare services. Conclusions While investments in universal healthcare and education may be important for reducing racial inequalities in access to healthcare, better understanding of cultural and contextual factors and targeted public policies and services interventions for addressing racial inequalities are needed.