25 de outubro de 2021
atualizado em 24 de agosto de 2023
INTRODUCTION – Brazil is an important setting for evaluating the evolution of and inequalities in depression prevalence and the treatment gap. On the one hand, socio-economic inequalities are large, and it is one of the most unequal countries in the world with a GINI index of 53.4 in 2019 (World Bank, 2021). Racial inequalities are also stark. In 2018, 32.9% of black or brown/mixed individuals had incomes below the US$5.5/day poverty line and 8.8% below the US$1.9/poverty line. Among white individuals, those shares were 15.4% and 3.6%, respectively. Racial inequalities are pervasive –for example, illiteracy and homicide rates are significantly larger among black or brown/mixed individuals than among whites (IBGE, 2019). Additionally, the period of our analysis coincides with major economic recession in Brazil, signed by a fall in GDP per capita and increased unemployment rate. During this period, increases unemployment rates were associated with higher mortality among black or brown/mixed race individuals, but not among white individuals (Hone et al., 2019).
On the other hand, Brazil has a national health service that provides publicly funded and free at the point of care services at all levels of care. A central piece of Brazil’s national health service are primary healthcare programs, which have been expanded nationally through the deployment of Family Health Teams since the mid-1990s. FHTs currently cover over 60% of the population and have been shown to be related to improved population health (Bastos et al., 2017; Bhalotra et al., 2020; Hone et al., 2020; Rocha & Soares, 2010) and reduced health inequalities (Hone et al., 2017). While in the 2000s there have been initiatives to expand services provided by the national health service, including mental healthcare (Athié et al., 2016; Soares & de Oliveira, 2016), access to specialized care remains a major challenge in the public sector, with long waiting lines (Castro et al., 2019). There is also a sizable private healthcare sector in Brazil, where approximately one quarter of the population, mostly higher-income and formally employed individuals in urban centers, are covered by private health insurance schemes (Paim et al., 2011).
This study contributes to the literature on socioeconomic and racial inequalities in health and healthcare access in Brazil. Existing evidence suggest they exist in different areas: infant mortality (Garcia & Santana, 2011), obesity (Triaca et al., 2020), multimorbidity and associated healthcare (Hone et al., 2021), catastrophic health expenditure (Boing et al., 2014), reproductive and maternal health interventions (França et al., 2016), and healthcare utilization (Barbosa & Cookson, 2019; Mullachery et al., 2016).