While health outcome indicators are fairly consistent across countries and the literature on determinants of health is large, there have been no unified efforts at measuring “equal access for equal need, equal utilization for equal need, or equal quality for all.” To tell us whether policies are equity-enhancing, we need indicators of actual policy implementation, rather than party platforms or legislation passed. To this end I have collected data on central primary care reform coverage rates.
While the Spanish government has never published formal statistics on coverage rates, the most prominent health policy experts in the country used the govern- ment health maps to construct population coverage rates for the reform for each AC (Gonz´alez and Urbanos 2004; L´opez-Casasnovas, et al 2001). A government report on health care in 1991, the Informe Abril assesses primary reform coverage rates in that year, which match up precisely with scholarly estimates. Variation in coverage has been high and early decentralizers have had much higher variation and overall lower levels of implementation than those ACs that remained within direct central government health provision (INSALUD) until 2001. Figures A.5 and A.6 show the differing trends for the seven early decentralizing ACs and the 10 late decentralizing ACs. It was not until 2004, a full two decades later, that reform was considered complete in all ACs.
In Brazil, there is a Primary Care Division within the National Ministry of Health (DAB-MS, Departamento da Aten¸c˜ao B´asica) that keeps tabs on coverage rates for the primary reform, called the Programa Sa´ude da Fam´ılia (PSF, Family Health Program). The PSF is not a state level program, but is implemented with state support in the municipalities and the center publishes aggregate data on rates of population coverage in each state. The reform began in 1994 country-wide and shows similar variation to the Spanish case. Figure A.4 shows the average trajectory of
the PSF in Brazil. After 15 years, coverage has been nearly 100 per cent in many states for some time, while remaining very low in others. I interpolate the years 1994- 1998, as central figures were not kept until this year but in all states it is much more accurate to assume a trend from 1994 to the level achieved in 1998, than to omit the first four years of the program.
There were quite a few state and municipal programs for primary care before the PSF began and the vast majority of these were folded into the PSF in order to take advantage of federal incentives for implementation. These processes are captured by high early levels of PSF in places like Bras´ılia or Cear´a, which had their own programs earlier. A handful of municipalities chose to forgo federal subsidies for primary care in order to maintain their own programs. Sometimes these were less generous, less efficient programs that were eventually scrapped (S´ao Paulo city) and in some cases they are more generous programs (Porto Alegre). Regardless, even Porto Alegre has PSF operating alongside its municipal program. Determing the coverage levels of the handful of municipal programs that accompany the PSF is unfeasible, so these programs are not captured in the variable.
This indicator is not without problems, but its meaning is clear and the mea- sure is comparable across regions and in both countries. The main drawback is that the composition of primary care teams has varied regionally and over time in both countries, though fairly consistently in the direction of more complete teams (incor- porating dentists and pediatricians in addition to nurses and General Practitioners (GPs), for example), with better training and more resources. However, the current economic crisis has begun to erode the resources of the primary care network in Spain, while in Brazil it is still in an expansionary phase, having been implemented over a decade later. The Spanish data are somewhat less reliable because of higher regional
authority over program design, which means that there have not been uniform ti- tles and terminology used for all ACs, making assessment of reform somewhat more difficult (Lamata 2012).
Assessing primary care also allows me to avoid using health spending as an indica- tor of equity-enhancing policy effort, which can be particularly problematic in health care. Uncommitted actors are often quite happy to spend public money on health when their electoral supporters include private medical and pharmaceutical interests and the construction industry. Because both countries still have under-funded health systems overall, I do consider health spending in the case studies.
The extent of equity-enhancing health policy should depend on the level of com- mitment to equity among governing actors at all relevant levels of government, the level of capacity in the region, and the territorial distribution of authority, while con- trolling for the legacy of democracy, income inequality, economic development levels, poverty, and growth. In Spain, conflict over the territorial scope of the reference com- munity means that left and right parties that defend minority nationalisms should be considered independently. While in Brazil the territorial scope of the reference com- munity is not politically contested, the legacy of slavery is territorially concentrated. One should control for the racial composition of the states—capturing the dominant dimension of ethnic heterogeneity in the country.