Regional Inequalities in Infant Mortality and Primary Health Care in the State of Minas Gerais, Brazil

Espace popula ions socié és Space popula ions socie ies 2014/2-3 | 2014 Popula ionse  e i oi esduB ésil Regional Inequali ies in In an Mo ali y and P ima y Heal h Ca e in he S a e o Minas Ge ais, B azil Les inégali és égionales de la mo ali é in an ile e des Soins de San é P imai es dans l'É a du Minas Ge ais, au B ésil Ri aldoMau odeFa iaandPaulaSan ana Elec onic e sion URL: h ps://jou nals.openedi ion.o g/eps/5852 DOI: 10.4000/eps.5852 ISSN: 2104-3752 Publishe Uni e si é des Sciences e Technologies de Lille B ough o you by Faculdade de Le as da Uni e sidade de Coimb a Elec onic e e ence Ri aldo Mau o de Fa ia and Paula San ana, “Regional Inequali ies in In an Mo ali y and P ima y Heal h Ca e in he S a e o Minas Ge ais, B azil”, Espace popula ions socié és [Online], 2014/2-3 | 2014, Online since 23 Ap il 2015, connec ion on 06 Oc obe 2022. URL: h p://jou nals.openedi ion.o g/eps/ 5852 ; DOI: h ps://doi.o g/10.4000/eps.5852 This ex was au oma ically gene a ed on 3 Ap il 2021. C ea i e Commons - A ibu ion-NonComme cial-NoDe i a i es 4.0 In e na ional - CC BY-NC-ND 4.0 h ps://c ea i ecommons.o g/licenses/by-nc-nd/4.0/ Regional Inequali ies in In an Mo ali y and P ima y Heal h Ca e in he S a e o Minas Ge ais, B azil Les inégali és égionales de la mo ali é in an ile e des Soins de San é P imai es dans l'É a du Minas Ge ais, au B ésil Ri aldoMau odeFa iaandPaulaSan ana 1.In oduc ion 1The decline in in an mo ali y, and he concomi an educ ion in e i o ial inequali ies, is one o he esul s highligh ed by he B azilian go e nmen in he sphe e o he na ional policy o expanding access o P ima y Heal h Ca e (PHC) unde he Family Heal h Teams (FHT) model [B azil, 2012]. In an mo ali y is known o be e y sensi i e o PHC [F ankenbe g, 1995; Shi e al., 1999; S a ield, 1992; San ana, 2005]. Indeed, he main causes o in an mo ali y in he wo ld, such as dia hoea and pneumonia [Lawn, Cousens & Zupan, 2005; Lopez e al., 2006], could in ac be p e en ed wi h app op ia e medical ca e. Howe e , he e is pe haps no o he heal h indica o ha is so dependen upon po e y- ela ed social condi ions, he eby e lec ing social and geog aphic inequali ies [Goldani e al., 2001; Na a o & Shi, 2001; Szwa cwald, And ade & Bas os, 2002; Ma mo , 2005; San ana, 2005]. This explains he spa ial concen a ions o high in an mo ali y a es in egions o he wo ld whe e he popula ions a e poo e and ha e less access o heal hca e [Lopez e al., 2006]. 2PHC is de ined in B azil as a combina ion o ac ions o bo h an indi idual and collec i e na u e, including pa icula ly he p omo ion o heal h and p e en ion o disease [B azil, 2012]. Since he ad en o he Single Heal hca e Sys em (SHS), which was celeb a ed in he B azilian Cons i u ion as ee and uni e sal, he igh o all and du y o he s a e [B azil, 1989], B azil has made g ea e o s o expand access o hese se ices, pa icula ly in iew o i s s a egic ole o he in eg a ion o he heal hca e sys em, and in o de o imp o e heal h indica o s, pa icula ly as ega ds women and RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 1 child en. Hence, he Family Heal h P og amme (FHP) was c ea ed in 1994 in esponse o he need o a heal hca e model ha was less hospi al-o ien ed and mo e decen alized, and also o ake con ol o lows in he PHC. 3The FHP has g adually acqui ed a s a egic dimension o heal h in B azil, pa icula ly in ela ion o basic indica o s such as he educ ion o in an and ma e nal mo ali y, inc ease in accina ion co e and educ ion o hospi aliza ions. To gi e an idea o i s signi icance, 6.5% o he B azilian popula ion we e co e ed by he p og amme in 1998, bu his igu e had gone up o 40% by 2004 and o a ound 60% by 2012 (SIAB, 2012). The e o e, he Na ional Basic Heal hca e Policy (NBHP), which is he documen ha de e mines he way PHC is o ganized in B azil, no longe conside ed o be a p og amme (because a p og amme is unde s ood as a package o sho - e m solu ions), bu a he as a s a egy o he consolida ion o PHC h ough he implan a ion o Family Heal h Teams (FHT) [B azil, 2012]. 4The e o e, he amily is he smalles geog aphical uni wi h which PHC acili ies wo k in B azil. Bu each eam, gene ally consis ing o a doc o (gene al p ac i ione ), nu se, echnicians, ancilla ies and communi y heal h agen s, ha e o be esponsible o he heal h o a geog aphically de ined g oup o amilies. P oblem-sol ing is one o i s mos impo an p inciples [B azil, 2012]. Thus, acco ding o Mendes (2009), hese eams should be equipped o a end o and o e come mos o he popula ion’s heal h p oblems. 5Reducing egional inequali ies in in an mo ali y was one o he B azilian go e nmen ’s main objec i es in de eloping FHTs [B azil, 2012]. This is e y impo an because, despi e he ac ha he in an mo ali y a e has been dec easing o e he las wen y yea s in B azil ( om 33.9‰ in 1994 o 13.6‰ in 2011) [SIAB, 2012], he e a e s ill eno mous egional inequali ies in his indica o , wi h e y high le els in he mo e dep i ed a eas o he No h and No heas o he coun y [Vic o a e al., 2011; Fa ia, 2013). Bu also on he in e egional and e en in au ban scales, he e a e conside able a ia ions in he in an mo ali y a es. Tha is he case wi h he s a e o Minas Ge ais, whose loca ion a he in e sec ion be ween he No heas , Sou heas and Cen e-Wes egions o he coun y, combined wi h his o ical p ocesses o occupa ion and he di e en o ms o economic and p oduc i e li e, has eno mous social and egional inequali ies and consequen ly eno mous a ia ions in in an mo ali y a es. 6The s a e o Minas Ge ais is he ou h la ges in B azil in e i o ial e ms, wi h almos wen y million inhabi an s, dis ibu ed ac oss 853 municipali ies and 66 adminis a i e mic o egions [IBGE, 2010]. This s a e also has some speci ic public heal h policies, including in he domain o PHC. In ac , he go e nmen o Minas Ge ais, h ough he S a e Sec e a y o Heal h, and in associa ion wi h policies al eady c ea ed by he Minis y o Heal h, has gi en b oad echnical and inancial suppo o he expansion o FHT co e age h oughou he s a e. Th ough i s s uc u ing p ojec “Heal h a Home” [SESMG, 2005], which cu s ac oss o he public heal h policies, he go e nmen achie ed an FHT co e age o almos 72% o he popula ion in 2012, which is abo e he a e age o he coun y as a whole. 7Howe e , he e ha e been e y ew s udies ha assess he impac o his inc eased PHC co e age on popula ion heal h indica o s, pa icula ly on in an mo ali y. I is wo h men ioning he wo k o Raselha e al. (2013), speci ically as ega ds he ela ionship be ween he inc eased PHC co e and he educ ion in in an mo ali y. Al hough i s main heme is en ans e p og ammes, he au ho s show how hose p og ammes, RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 2 associa ed o g ea e public heal h co e , a e impo an o imp o e popula ion heal h indica o s. F om a di e en pe spec i e, hough no less impo an , Lou enço e al. (2014) also show signi ican posi i e co ela ions be ween he inc ease in PHC and he educ ion in in an mo ali y in he s a e o São Paulo. Al hough hese s udies ha e made an eno mous con ibu ion, he e a e s ill nume ous ques ions o be discussed on he subjec , as ega ds bo h se ices and social inequali ies. Hence, his s udy aims o analyse he egional impac s o PHC on he in an mo ali y a es (IMRs) in he s a e o Minas Ge ais, aking in o accoun speci ic socioeconomic con ex s. In an mo ali y was analysed o he pe iods 2002-2006 and 2007-2011 in he 66 mic o egions o he s a e, wi h ela ion o h ee ope a i e dimensions: he indices o amilies ecei ing PHC assis ance; indexes o p ena al ca e; he Index o Socioma e ial Dep i a ion (ISD). 2.Ma e ialsandme hods 8The s udy was implemen ed on he le el o he 66 adminis a i e mic o egions o Minas Ge ais o he yea s 2002 o 2011, g ouped in o wo pe iods (2002-2006 and 2007-2011) in he case o in an mo ali y and p ena al ca e, and a in e als in he case o he FHT co e age and social dep i a ion indica o s (2002 and 2011). The da a we e collec ed om seconda y o icial sou ces, namely he B azilian Ins i u e o Geog aphy and S a is ics (IBGE), Li e Bi hs In o ma ion Sys em (SINASC), he Mo ali y In o ma ion Sys em (SIM) and he Basic Heal hca e In o ma ion Sys em (SIAB). The ollowing indica o s we e cons uc ed om he da abase in he ligh o he desi ed aims: in an mo ali y a e (IMR), clus e ed o he yea s 2002-2006 and 2007-2011; index o popula ion egis e ed wi h he FHTs, calcula ed o he yea s 2002, 2006 and 2011; index o women ha did no ha e p ena al ca e du ing p egnancy; Index o Socioma e ial Dep i a ion (ISD) in 2002 and 2011. 9The ISD was cons uc ed in acco dance wi h he me hodology sugges ed by Ca a s & Mo is (1991) (ci ed by San ana, 2005), in ol ing he s a egic selec ion o h ee social indica o s: illi e acy amongs women o ep oduc i e age; domiciles wi hou indoo ba h ooms; low-wage amilies (i.e. hose ea ning less han hal he minimum wage). 10Following San ana (2005), hose a iables we e s anda dized using he z-sco e me hod so each would ha e he same in luence on he inal esul o he index. The ISD hus ep esen s he sum o hose s anda dized a iables. 11Pea son’s co ela ion coe icien was also used o calcula e he in e dependence o he a iables o he s udy and hei a ios, pa icula ly as ega ds egional dynamics. 12A e he cons uc ion and modelling o he indica o s in acco dance wi h he p e iously de ined spa ial and empo al scales, a hema ic ca og aphy was cons uc ed using he Geog aphic In o ma ion Sys em (GIS). Fo his, he IBGE ca og aphic base was used a a scale o 1:50,000, and he A cGis P og amme om he company Es i. i. ii. iii. i. ii. iii. i . i. ii. iii. RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 3 3.Resul s 3.1.In an mo ali y: empo al a ia ionandspa ialdis ibu ion 13As in he es o he B azil, he s a e o Minas Ge ais, in luenced by he policies o he coun y, has seen a educ ion in in an mo ali y. In 2002-2006 he a e was 18.0‰ which declined o 13.1‰ in 2007-2011. I is, he e o e, lowe han he B azilian a e age (13.6‰ in 2011). The e was also a d op in in an mo ali y in he mic o egions gene ally (Figu e 1) o e he pe iod, hough his did no occu in all mic o egions. The e a e s ill eno mous spa ial inequali ies in in an mo ali y in Minas Ge ais, as some mic o egions ha e low a es while o he s a e highe han he Millennium De elopmen Goal o in an heal h [WHO, 2005] ( he 4 h MDG de e mines he educ ion o he IMR in B azil o 15.7‰ by 2015). 14Figu e 1 shows he spa ial concen a ions o high IMR in he mic o egions in he No heas , and also, hough wi h lowe alues, in he mic o egions o he “Fo es Zone” and Cen e. In con as , he mic o egions loca ed be ween he No hwes and he “Mining T iangle”, and be ween Belo Ho izon e and Sou h ha e lowe IMRs in he wo pe iods, hough mo e ma kedly be ween 2007-2011. Special a en ion should be gi en o he mic o egions loca ed in he ex eme No heas : ou mic o egions had a e y high IMR, and o hose, wo ac ually wo sened, while he o he wo expe ienced only a e y sligh educ ion. 15As Table 1 shows, he e was spa ial a ia ion in IMRs be ween mic o egions in acco dance wi h popula ion size. The en mos popula ed mic o egions, whe e almos hal he popula ion o he s a e is concen a ed and whe e he la ges ci ies a e loca ed, including he capi al Belo Ho izon e, a e hose wi h he lowes IMR. On he o he hand, he en leas popula ed egions, which accoun o only 3.7% o he popula ion o he s a e and which ha e only small ci ies, ha e highe IMRs on a e age, loca ed mos ly in he No heas o he s a e. I should be poin ed ou ha he IMRs indica ed in he Table 1 a e he a e age calcula ed be ween he en mos popula ed and he en leas popula ed mic o egions. The o he s a e g ouped sepa a ely. I can be seen ha he en mos popula ed mic o egions ha e IMRs ha a e close o he s a e a e age, accompanying he gene al end owa ds educ ion seen no only in Minas Ge ais bu also in B azil as a whole. The same canno be said o he en leas popula ed mic o egions. RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 4 Figu e 1. In an mo ali y a e (IMR) by egions o he S a e o Minas Ge ais, B azil, o he yea s 2002-2006 and 2007-2012. Table1.Compa isono IMR,li ebi hswi hou p ena alca e,ISD,andFHTco e age o  he en mos andleas popula edmic o egionsando he sin hes a eo MinasGe ais,B azil IMR (‰)* LBWPC (‰)** ISD*** FHTs (%)*** Popula ion (%)*** U baniza ion Index*** 10 + popula ed 13.6 10.4 -1.7 63.0 48.9 89.9 10 – popula ed 16.6 10.6 2.4 93.9 3.7 65.6 O he s 15.01 9.96 -0.16 80.4 47.4 77.9 *Re e ing o he agg ega e pe iod 2007-2011 ** Li e bi hs wi hou an ena al ca e in he agg ega e pe iod 2007-2011 ***Re e ing o he yea 2011 Sou ce: Da asus, Minis y o Heal h, 2013 (cons uc ed and adap ed by he au ho s). 16Table 1 also shows a ia ions in IMR in acco dance wi h he u baniza ion a e in he mos and leas popula ed mic o egions. The o me a e he mos u banized as hey include he bigges ci ies o Minas Ge ais (as men ioned abo e), including i s capi al, Belo Ho izon e. The opposi e occu s wi h he leas popula ed mic o egions. The highes IMRs we e ound in he leas u banized mic o egions and diminished as he u baniza ion index inc eased. In ac , he en mos popula ed and mos u banized mic o egions ha e IMRs simila o he s a e a e age, and some a e e en lowe han ha a e age. Fo example, he wo mos popula ed mic o egions in he s a e, Belo Ho izon e and Ube lândia (Mining T iangle), ha e IMRs o 11.6‰ and 11.8‰ espec i ely. The e o e, wi h ega d o he agg ega ed pe iod o 2007-2011, hei a es a e lowe han he s a e a e age. On he o he hand, he leas popula ed and leas u banized mic o egions ha e IMRs well abo e he s a e a e age. RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 5 17Ne e heless, i is ele an o analyse hese a es in ela ion o o he indica o s, pa icula ly he indica o s o PHC co e and usage. This is also impo an o cla i y a discou se ha has al eady been p esen ed by some au ho s [e.g. Sas y, 1997; Souza e al., 1999] acco ding o which u baniza ion is associa ed o a educ ion in in an mo ali y. 3.2.Expansiono p ima yheal hca ep o isionuse oan ena alca e 18Wi h he FHT model, he e was an inc ease in PHC co e age h oughou all he mic o egions o Minas Ge ais (Figu e 2). The s a e a e age, which was 50% in 2002, wen up o 64% in 2006 and 71% in 2011. The mic o egions loca ed in he No h, No heas , Cen e and “Fo es Zone” p esen ed highe le els o co e age in he h ee yea s analysed, while he opposi e happened in he mic o egions loca ed in he Sou h, “Mining T iangle”, Belo Ho izon e and No hwes , whe e he FHT co e age was lowe . In ac , he i s g oup had le els o co e age ha we e highe han he s a e a e age, while he second was gene ally lowe han he s a e a e age, despi e he inc ease in he supply in he pe iod analysed. 19In any case, he da a indica e he eno mous ad ances in FHT co e age in Minas Ge ais. Fo many mic o egions, pa icula ly hose o he No h and No heas o he s a e, p o ision was uni e sal by 2011. Conside ing only he mic o egions wi h a p o ision o o e 80%, he e is a o al o 35 mic o egions, which ep esen s o e hal . I can also be seen ha he mos popula ed and u banized mic o egions (Table 1), whe e he majo ci ies in Minas Ge ais a e loca ed such as Ube lândia (“Mining T iangle”), Juiz de Fo a (“Fo es Zone”), Belo Ho izon e (Me opoli an Region), Poços de Caldas, Pouso Aleg e and Va ginha (Sou h) and Mon es Cla os (No h), a e hose wi h he lowes le els o co e age, a e aging 63% o he popula ion. In con as , in he less popula ed and u banized mic o egions, whe e he small ci ies a e loca ed, he le el o co e age exceeds 93%. I should be men ioned ha he expansion o se ices in he less popula ed mic o egions was one o he goals o he Na ional Basic Heal hca e Policy [B azil, 2012]. Thus, in acco dance wi h he p inciple o equi y, he mic o egions ha a e less dense in public heal h se ices and consequen ly ha e g ea e heal h needs should ha e a g ea e supply o se ices pe inhabi an . RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 6 Figu e 2. Co e age o Family Heal h Teams (in pe cen age o popula ion) by egions o he S a e o Minas Ge ais, B azil, in 2002 (A), 2006 (B) and 2011 (C) 20Howe e , i we compa e he way se ices a e dis ibu ed (pe cen ages pe popula ion), as in Figu e 2, he e is clea ly a endency o a homogeniza ion o supply; by 2011, he e was a p edominance o mic o egions wi h o e 61% p o ision, and a educ ion o mic o egions wi h less han his. In ac , in 2002, he e we e 44 mic o egions (accoun ing o 66.9% o s a e’s popula ion) wi h less han 60% p o ision, while in 2011 his igu e had d opped o 9 mic o egions (19.9% o he popula ion). Simila ly, in 2002 he e was 80% co e age in only 5 mic o egions (5.3% o he popula ion) and by 2011, i exis ed in 35 mic o egions (o e 28%). 21Thus, i can be concluded ha he policy o expanding PHC h ough he es ablishmen o FHTs has yielded nume ically impo an esul s, in keeping wi h he policies p oduced o he sec o . This is despi e he ac ha he Na ional Basic Heal hca e Policy [B azil, 2012] does no s ipula e he igu e o be achie ed, bu me ely aims o an expansion o co e age in he leas popula ed/mos dep i ed a eas. 22I should be added, howe e , ha he exis ence o se ices, o a he he expansion o p o ision, does no mean ha hese heal h se ices a e p ope ly accessed and used, no does i au oma ically p oduce good heal h ou comes. I is necessa y o analyse he impac o he se ices upon he popula ion’s li ing condi ions and heal h. In his case, i is wo h e lec ing on he popula ion’s access o and use o se ices, and on heal h ou comes, pa icula ly o in an mo ali y. The e a e nume ous indica o s o access/ use o p ima y heal h se ices by he popula ion. In ela ion o child heal h and impac s upon in an mo ali y a es, p ena al ca e is impo an , gi en i s po en ial o he p e en ion o disease and in an mo ali y h ough he p omo ion o ma e nal heal h. The e o e i is o be hoped ha he inc eased FHT co e age in Minas Ge ais will ha e had a posi i e impac by p o iding g ea e access o p ena al ca e, and consequen ly helping educe in an mo ali y. RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 7 23In acco dance wi h he Wo ld Heal h O ganiza ion [WHO, 2002], he e should be a leas six p ena al consul a ions du ing p egnancy. The B azilian Minis y o Heal h has ecommended ha hese should ake place e e y ou weeks, and e e y 15 days a e he 36 h week o p egnancy [B azil, 2006] As his is an impo an indica o o ma e nal and child heal h, he Minis y o Heal h i sel moni o s he numbe o p ena al consul a ions ha ha e aken place du ing p egnancy in ela ion o he numbe s o li e bi hs. Howe e , he o icial da a do no dis inguish be ween consul a ions ha ha e aken place in he public and p i a e heal hca e sys ems. Thus, only da a ela i e o li e bi hs wi hou any p ena al ca e du ing p egnancy ha e been collec ed. In o he wo ds, wha is assessed is he ulne abili y o women and oe uses when p ena al consul a ions do no ake place. This is shown in Figu e 3 o he yea s 2002-2006 and 2007-2011. Figu e 3. Li e bi hs wi hou p ena al ca e (in ‰) be ween he yea s 2002-2006 and 2007-2012 by egions o he S a e o Minas Ge ais, B azil 24Figu e 3 shows ha he e was a educ ion in he numbe o li e bi hs wi hou p ena al ca e in almos all he mic o egions o Minas Ge ais. The s a e a e age, which was 14.4‰ in 2002-2006, d opped o 10.1‰ in 2007-2012, a educ ion o almos 30%. These alues a e below he na ional a e age o 36.7‰ in 2002-2006 and 26.9‰ in 2007-2012 (a educ ion o 26.5%). The e o e, no only is he a e age in he s a e o Minas Ge ais be e han he coun y as a whole, i s pe o mance was also be e in his indica o . Howe e , he indexes o li e bi hs wi hou p ena al ca e a e s ill high in some mic o egions, compa ed wi h he s a e and na ional a e ages. Mo eo e , he spa ial concen a ion o hese indices is isible in mic o egions loca ed be ween he Cen e and No heas o he s a e. In ac , hough he e has been a educ ion, he e con inue o be spa ial concen a ions o highe a es o li e bi hs wi hou p ena al ca e o e he wo pe iods. RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 8 NAVARRO V., SHI L. (2001), The poli ical con ex o social inequali ies and heal h, Social Science & Medicine, ol. 52, nº 3, pp. 481-491. RASELLA D. e al (2013), E ec o a condi ional cash ans e p og amme on childhood mo ali y: a na ionwide analysis o B azilian municipali ies, The Lance , ol. 382, nº 9886, pp. 57-64. RAVALLION M. (2009), Compa a i e Pe spec i e on Po e y Reduc ion in B azil, China and India, Washing on, DC, Wo ld Bank. SANTANA P. (1995), Acessibilidade e U ilização dos Cuidados de Saúde. Ensaio Me odológico em Geog a ia da Saúde, Lisboa, ARSC/CCDRC. SANTANA P. (2005), Geog a ia da Saúde e do Desen ol imen o: E olução e Tendências em Po ugal, Lisboa, Almedina,. SASTRY N. (1997), Wha explains u al-u ban di e en ials in child mo ali y in B azil? Social Science & Medicine, Vol. 44, n° 7, pp. 989–1002. SESMG – Sec e a ia de Es ado da Saúde de Minas Ge ais. (2005), Resolução SES Nº 661, de 22 de ma ço de 2005, disponí el em: www.saude.mg.go .b , acessado em: dezemb o de 2012. SHI L. e al. (1999), Income inequali y, p ima y ca e, and heal h indica o s, Jou nal Family P ac ice, ol. 48, nº 4, pp. 275-284. SIAB - Sis ema de In o mação da A enção Básica. (2012), Cadas amen o Familia , B asília. SOUZA A. C. Te a de (1999), Va ia ions in in an mo ali y a es among municipali ies in he s a e o Cea á, No heas B azil: an ecological analysis. In e na ional Jou nal o Epidemiology, ol. 28, nº 2, pp. 267-275. STARFIELD B. (2004), The Medical Home, Access o Ca e, and Insu ance: A Re iew o E idence, Pedia ics, ol. 113, nº 4, pp. 1493-1498. STARFIELD B. (1992), P ima y ca e: concep , e alua ion, and policy, New Yo k, Ox o d Uni e si y P ess. SZWARCWALD C. L., ANDRADE C. L. T., BASTOS F. I. (2002), Income inequali y, esiden ial po e y clus e ing and in an mo ali y: a s udy in Rio de Janei o, B azil, Social Science Medicine h p:// www.sciencedi ec .com/science/jou nal/02779536, ol. 55, nº 12, pp. 2083-2092. VERDOM J., CAO H. (2011), Heal h Ca e Access and Regional Dispa i ies in China, Espace popula ions Socié és, ol. 2011, n° 1, pp. 63-78. VICTORA C. G, e al. (2011), Saúde de mães e c ianças no B azil: p og essos e desa ios, The Lance , ol. 377, nº 977, pp.32-46. WHO - Wo ld Heal h O ganiza ion (2002), WHO an ena al ca e andomized ial: manual o he implemen a ion o he new model, Gene a, WHO. WHO - Wo ld Heal h O ganiza ion (2005), Heal h and he Millennium De elopmen Goals, Gene a, WHO. WONG C. (2006), Indica o s o u ban and egional planning, London, Rou ledge. ABSTRACTS In an mo ali y has declined in B azil in ecen yea s, pa ly as a esul o inc eased P ima y Heal h Ca e (PHC) co e age and be e access o i . Howe e , he e a e s ill eno mous egional RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 15 inequali ies in hese indica o s, and he e o e spa ial a ia ions in in an mo ali y. In a coun y like B azil ha is o con inen al p opo ions, i is impo an o analyse/assess heal h policies in he con ex o egional inequali ies in o de o ensu e equi y. This s udy hus aims o analyse he egional impac s o PHC and assess he impo ance o socioeconomic con ex s upon in an mo ali y a es (IMRs) in he s a e o Minas Ge ais. This is he ou h bigges s a e in B azil, wi h a popula ion o almos 20 million, dis ibu ed o e 66 mic o egions. The IMR was assessed o he pe iods 2002-2006 and 2007-2011 in he 66 mic o egions, conside ing h ee ope a i e dimensions: i. indexes o amilies aided by PHC; ii. indexes o p ena al ca e; iii. and he Index o Socioma e ial Dep i a ion (ISD). The da a we e collec ed om seconda y o icial sou ces, and modelled on empo al and spa ial scales de ined and wo ked in a Geog aphical In o ma ion Sys em. The ISD, which is a composi e indica o used o exp ess social and egional inequali ies, was cons uc ed on he basis o h ee indica o s: i) illi e acy; ii) wages; and iii) homes wi hou indoo ba h ooms. The esul s showed a educ ion in IMR in almos all he mic o egions o Minas Ge ais be ween 2002-2006 and 2007-2011. Howe e , he e we e inequali ies in his dec ease, wi h a con inuing concen a ion o mo ali y in mic o egions wi h highe ISD. The expansion o PHC is mo e ma ked in he mic o egions wi h highe ISD, which is a posi i e sign om he B azilian Heal h Sys em. Howe e , he expansion o hese se ices as an isola ed sec o ial policy, hough impo an , has no on i s own been able o educe he geog aphical inequali ies in in an mo ali y in Minas Ge ais. Hence, i is necessa y o conside he social and economic con ex s o amilies when a emp ing o imp o e indica o s ha go beyond me e heal hca e in e en ion. In o he wo ds, in an heal h is he esul o in eg a ed public policies (eg. housing, employmen /wages, educa ion/ aining) and mul i-le el decisions and ac ions (local, municipal, egional, ede al). La mo ali é in an ile a diminué au B ésil au cou s des de niè es années, g âce, en e au es, à l'ex ension de la cou e u e e l'accès aux soins de san é p imai es (SSP). Cependan , d'éno mes inégali és égionales pe sis en en ce qui conce ne ces deux de nie s indica eu s qui on un impac su les a ia ions spa iales de la mo ali é in an ile. Dans les pays de la aille d’un con inen comme le B ésil, il es pe inen d'analyse / d’é alue les poli iques de san é dans le con ex e des inégali és égionales, dans le bu d’assu e plus d’équi é. Ceci a mo i é la p ésen e é ude, don l'objec i es d'analyse les impac s égionaux du SSP, en incluan égalemen l'analyse des con ex es socio-économiques, su le aux de mo ali é in an ile (TMI) dans l'É a du Minas Ge ais, au B ésil. Ce é a es le qua ième plus g and É a du B ésil, sa popula ion s’élè e à p ès de 20 millions d'habi an s, épa is en 66 mic o égions. L'analyse de TMI a é é éalisée pou les pé iodes 2002-2006 e 2007-2011 dans chacune de ces mic o égions, en ela ion a ec ois dimensions opé a ionnelles de l'analyse: i. le aux de amilles assis ées pa SSP, ii. les aux de cou e u e des soins p éna aux iii. e l’indice de dé a o isa ion ma é ielle e sociale (IDMS). Les données on é é ecueillies à pa i de sou ces secondai es o icielles, adap ées à des échelles spa iales e empo elles dé inies e a aillées a ec un Sys ème d’In o ma ion Géog aphique. L’indice de dé a o isa ion ma é ielle e sociale, indica eu composi e u ilisé pou exp ime les inégali és sociales e égionales, a é é cons ui su la base de ois indica eu s i) l'analphabé isme, ii) les e enus e iii) le nomb e de ménages sans ins alla ions sani ai es au sein de leu oye . Les ésul a s on mon é une baisse du aux de mo ali é in an ile dans p esque ou es les mic o égions du Minas Ge ais, en e 2002-2006 e 2007-2011. Tou e ois, on cons a e des inégali és dans ce e baisse a ec une mo ali é plus o e dans les égions ayan un IDMS plus éle é. L’expansion des SSP es plus impo an e dans les égions qui possèden un IDMS plus éle é, ce qui es un signal posi i pou le Sys ème de San é b ésilien. Cependan , l’expansion des SSP en RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 16 an que poli ique sec o ielle isolée, malg é son impo ance, n’es pas su isan e pou édui e les inégali és spa iales de la mo ali é in an ile à l’in é ieu du Minas Ge ais. Pou cela, il es nécessai e de p end e en comp e le con ex e social e économique des amilles quand l’objec i es d’amélio e les indica eu s au-delà d’une simple in e en ion sani ai e. Pou le di e au emen , la san é de l’en an es la ésul an e des poli iques publiques in ég ées (exemples : logemen , emploi/ e enu, éduca ion/ins uc ion,) e des décisions e ac ions à di é en s ni eaux (local, municipal, égional, édé al). INDEX Keywo ds: p ima y heal hca e, egional inequali y, in an mo ali y Mo s-clés: soin de san é p imai e, inégali é égionale, mo ali é in an ile AUTHORS RIVALDOMAURODEFARIA Ins i u e o Geosciences S a e Uni e si y o Campinas Unicamp, B azil Uni e si y Fede al o San a Ma ia, B azil [email p o ec ed]. PAULASANTANA Cen e o S udies in o Geog aphy and Te i o ial Planning Depa men o Geog aphy Uni e si y o Coimb a, Po ugal paulasan ana.coimb [email protected]. RegionalInequali iesinIn an Mo ali yandP ima yHeal hCa ein heS a ... Espacepopula ionssocié és,2014/2-3|2014 17