The atlas of variation in healthcare Brazil: remarkable findings from a middle-income country

BACKGROUND: Brazil’s Universal Health System is the world’s largest and covers every citizen without out-of-pocket costs. Nonetheless, healthcare inequities across regions have never been systematically evaluated. METHODS: We used government databases to compare healthcare resource utilization, outcomes, expenditure, and years of life lost between 2016 and 2019. The maps used patients’ residences as reference and adjusted for age and private health insurance coverage. RESULTS: The Atlas shows that for several comparisons, there were no procedures in some regions, including primary coronary angioplasty, thrombolysis for stroke, bariatric surgery, and kidney transplant. Colonoscopy varied 1481.2-fold, asthma hospitalizations varied 257.5-fold, and mammograms varied 133.9-fold. Cesarean births ranged from 19.5% to 84.0%, and myocardial infarction and stroke case-fatalities were 1.1% to 33.7% and 5.0% to 39.0%, respectively. Higher private health insurance coverage in each region was associated with increased resource utilization in the public system in most comparisons. CONCLUSION: These findings demonstrate that the SUS does not fulfill the Brazilian constitutional rights due to underutilization, overutilization, and access disparities. The Atlas outlines multiple opportunities to generate value in the SUS.