Expressions of inequalities in access to health services in Latin America: a scoping review

Oliveira, Thaís de Souza; Pereira, Adelyne Maria Mendes

doi:10.1590/1413-81232024297.04932024EN

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ARTICLE REVIEW • Ciênc. saúde coletiva 29 (7) • July 2024 • https://doi.org/10.1590/1413-81232024297.04932024EN copy

Expressions of inequalities in access to health services in Latin America: a scoping review

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Abstract

Latin America is one of the most unequal regions in the world. Due to colonization and occupation of the territory, structural inequalities mark people’s living and health conditions. In health, we can observe how different dimensions of inequalities condition access and user experience in the service. This scoping review aimed to map and analyze the expressions of inequalities in access to health services in Latin American countries from the scientific production of the last ten years, from which 272 articles were selected. The categorical analysis classified articles into five dimensions, which characterize the expressions of inequalities in access to health services: socioeconomic, geospatial, ethnic/racial, gender, and people with disabilities. The most frequent access barriers were socioeconomic or ability to pay, geographic or transportation difficulty, availability of services, cultural/ethnic, communication, and architecture. The main conditioning factors of health inequalities were income, schooling, transportation, and living conditions. Combating health inequalities requires proposing structuring and sectorial policies.

Key words:
Inequalities; Health inequities; Access to health services

Scoping review question	Population	Concept	Context
What are the expressions of inequalities in the access to health services in Latin American countries?	Health service systems	Access inequalities	20 Latin American countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Dominican Republic, Uruguay, and Venezuela
Key concepts for the scoping review question
Key concepts	Descriptors	Definitions
Disparities	Disparidades nos Níveis de Saúde Health Status Disparities Disparidades en el Estado de Salud	Health inequalities can be defined as differences in health status or the distribution of its determinants among different population groups. Some differences are attributable to biological variations or free choice and others are attributable to the external environment and conditions generally beyond the control of the individuals in question. In the latter case, unequal distribution may be unnecessary, avoidable, and unfair, such that health disparities lead to health inequality⁶6 Barata RB. Como e por que as desigualdades sociais fazem mal à saúde. Rio de Janeiro: Editora Fiocruz; 2009.^,⁷7 Barreto ML. Desigualdades em saúde uma perspectiva global. Cien Saude Colet 2017; 22(7):2097-2108..
Inequalities	Iniquidades em Saúde Health Inequalities Inequidades en Salud	Differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work, and age⁸8 Whitehead M. The Concepts and Principles of Equity and Health. Int J Health Serv 1992; 22(3):429-445.^,⁹9 Braveman P. Health disparities and health equity: concepts and measurement. Ann Rev Public Health 2006; 27(1):167-194..
Access to health		Individuals accessing and using healthcare services to solve problems that affect their health. Factors that influence this possibility include geographic, architectural, transportation, and financial considerations¹³13 Vieira-da-Silva LM, Almeida Filho N. Equidade em saúde: uma análise crítica de conceitos. Cad Saude Publica 2009; 25(Suppl. 2):s217-s226.^,¹⁴14 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20(Suppl. 2):s190-s198..

Expressions of inequalities in access to health services
Dimensions of inequalities	Definition	Characteristics recurrent in the articles reviewed	Barriers and factors that conditioned access inequalities
Socioeconomic Inequality	Refers to the way and intensity with which socioeconomic inequalities influence access to health services. Income concentration and poverty are key factors for understanding the dynamics of health inequalities in this dimension¹⁸18 Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: supply, access to and use of health services over the last 30 years. Cien Saude Colet 2018; 23(6):1751-1762.^,²⁴24 Comissão Econômica para a América Latina e o Caribe (CEPAL). Panorama Social da América Latina e do Caribe [Internet]. 2022. [acessado 2023 fev 7]. Disponível em: https://repositorio.cepal.org/bitstream/handle/11362/48609/S2200949_pt.pdf?sequence=5&isAllowed=y https://repositorio.cepal.org/bitstream/... ^,²⁶26 Monteiro CA, Benicio MHD, Conde WL, Konno SC, Lima ALL, Barros AJD, Victora CG. Desigualdades socioeconômicas na baixa estatura infantil: a experiência brasileira, 1974-2007. Estud Av 2013; 27(78):35-49..	Cross-sectional to other dimensions of inequalities. Associations between socioeconomic inequality and difficulty in accessing PHC, oral health, and women’s health services stand out - notably more deficient among vulnerable populations. Several articles address restricted access to healthcare for immigrants, Black, riverine, and Indigenous populations.	Main access barriers identified: socioeconomic, geographic, services’ availability, and cultural. Main conditioning factors: income and schooling, showing the relationship between lower education and worse socioeconomic status.
Geospatial Inequality	It concerns the way and frequency in which geospatial inequalities influence access to health services. Aspects such as inequalities in the distribution of health services in the territory stand out²⁷27 De Pietri D, Dietrich P, Mayo P, Carcagno A, De Titto E. Indicadores de accesibilidad geográfica a los centros de atención primaria para la gestión de inequidades. Rev Panam Salud Publica 2013; 34(6):452-460.^,²⁸28 Aguilera SL, França BH, Moysés ST, Moysés SJ. Intermunicipal inequities in access and use of secondary health services in the metropolitan area of Curitiba. Rev Bras Epidemiol 2014; 17(3):654-667..	Strong association between geospatial and socioeconomic inequalities and moderate association with ethnic/racial and gender inequality. The inequalities in access to health between urban and remote/rural areas and the travel time to access health units stand out. Some articles focus on specific health actions and services, such as specialized care.	Main access barriers identified: geographic, socioeconomic, and services’ availability. Main conditioning factors: Transportation and housing, with significant expression of income and schooling.
Gender Inequality	Related to the way and intensity with which gender inequalities influence access to health services¹⁹19 Comissão Econômica Para a América Latina (CEPAL). Panorama Social da América Latina [Internet]. 2018. [acessado 2022 jan 14]. Disponível em: https://repositorio.cepal.org/bitstream/handle/11362/44412/1/S1801085_pt.pdf https://repositorio.cepal.org/bitstream/... ^,²⁹29 Aqui estão os nomes organizados de acordo com a norma Vancouver e separados por vírgulas:.	Strong association between gender and socioeconomic inequalities in most of the articles reviewed. Significant association between this dimension and ethnic/racial and geospatial inequalities. The inequalities in access between men and women, among women living in urban and rural areas, and the barriers faced by immigrant, Indigenous, and women deprived of liberty stand out.	Main access barriers identified: socioeconomic cultural, services’ availability, and geographic. Main conditioning factors: income and schooling.
Ethnic/racial Inequality	It expresses how race/ethnicity issues influence access to health services³⁰30 Martínez HLH, Artmann E, Nascimento M. Desvendando barreiras de gênero no acesso de adolescentes à informação sobre saúde sexual e reprodutiva na Venezuela. Cad Saude Publica 2020; 36(4):e00193918..	Strong association between ethnic/racial and socioeconomic inequalities. Moderate association with geospatial and gender inequality. Studies that address access difficulties for original and racialized populations in Latin America and immigrants stand out. Some articles focus on how communication problems and cultural issues prevent access to health services.	Main access barriers identified: socioeconomic de services’ availability, and cultural. Highlighting the cultural barrier, rarely mentioned in other dimensions. Main conditioning factors: income and schooling.
Inequalities in People with Disabilities	Gathers studies that address the inequalities faced by people with disabilities in accessing health services³³33 Lages RB, Oliveira GP, Simeão Filho VM, Nogueira FM, Teles JBM, Vieira SC. Desigualdades associadas à não realização de mamografia na zona urbana de Teresina-Piauí-Brasil, 2010-2011. Rev Bras Epidemiol 2012; 15(4):737-747. 34 World Health Organization (WHO). Global report on health equity for persons with disabilities [Internet]. 2022. [cited 2023 fev 5]. Available from: https://apps.who.int/iris/handle/10665/364834 https://apps.who.int/iris/handle/10665/3... ^-³⁵35 Banco Mundial. Inclusão das pessoas com deficiência na américa latina e no Caribe: um caminho para o desenvolvimento sustentável [Internet]. 2021. [acessado 2023 fev 26. Disponível em: https://documents1.worldbank.org/curated/en/099140012012113013/pdf/P1753830ce0fdc022096580be345ee9f027.pdf https://documents1.worldbank.org/curated... .	Strong association with socioeconomic inequalities and moderate association with geospatial and gender inequalities. Articles focusing on the difficulties in accessing mental health care, oral health, cervical-uterine cancer prevention and child care stand out for people with disabilities.	Main access barriers identified: socioeconomic, services’ availability, architectural, acceptability and cultural barriers. Main conditioning factors: income and schooling, highlighting the importance of improving accessibility in schools.

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[1] Chief editors:

Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva