Miranda et al.

BMC Public Health (2021) 21:1242

https://doi.org/10.1186/s12889-021-11279-6

RESEARCH Open Access

“Inequalities in access to medicines for

diabetes and hypertension across the
capitals in different regions of Brazil: a
population-based study”
Vanessa Iribarrem Avena Miranda1* , Antônio Augusto Schäfer1 , Cristiane Damiani Tomasi1 , Jacks Soratto2 ,
Fernanda de Oliveira Meller1 and Marysabel Pinto Telis Silveira3

Abstract
Background: To guarantee prevention and adequate treatment, as required for the population to have access to
health services and technologies, including medicines. The purpose of this study is to analyse the economic and
regional inequalities in access to medicines for diabetes and hypertension among the adult population in Brazil.
Methods: This was a cross-sectional study with adults aged 18 and over from the VIGITEL study conducted in 2019
in all Brazilian regions. Non-access to antidiabetic and antihypertensive drugs was assessed according to formal
education and housing macro-region. The slope index of inequality (SII) was used to analyse absolute inequalities.
Results: The total number of individuals interviewed was 52,443. Approximately 10.0% of the people with diabetes
and/or hypertension reported not having access to drug treatment. The major means for having access to
antihypertensive drugs, in all regions, was private pharmacies; for antidiabetics, in the North region, people had
greater access through private pharmacies, while in the Northeast, Southeast and South, they had greater access
through the public sector. Inequalities were found in the lack of access to medicines according to the region of
residence, especially in the North region.
Conclusion: The lack of access to medicines showed regional disparities, particularly in the most economically
vulnerable regions.
Keywords: Pharmaceutical services, Pharmacoepidemiology, Health inequalities, Cross-sectional studies, Diabetes,
Hypertension

Background by the emergence of communicable diseases and an in-

Brazil continues in a growing process of epidemiological crease in chronic noncommunicable diseases (NCD) [1,
transition, with an increase in the life expectancy of the 2], especially affecting more vulnerable groups, with a
population in recent decades, and a complex scenario of low level of education and lower income [3].
overlapping health problems. This situation is aggravated In 2015, the United Nations (UN) set 17 Sustainable
Development Goals (SDGs) to be achieved by 2030; one
of them is to reduce premature NCD mortality by one
* Correspondence: vanessairi@unesc.net
1
Postgraduate Program in Public Health, University of Southern Santa third through adequate prevention and treatment [4].
Catarina, Av. Universitária, 1105, Criciúma, Santa Catarina CEP: 88806-000, Model data predictors of mortality for the period 2000
Brazil to 2033 indicate that, among diseases of the circulatory
Full list of author information is available at the end of the article

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data made available in this article, unless otherwise stated in a credit line to the data.
Miranda et al. BMC Public Health (2021) 21:1242 Page 2 of 8

system, diabetes and hypertension will continue to rank The following lines were not eligible for the survey:
among the major health problems [5], and they will they were business telephone lines; they no longer
cause increasing demand for the need to provide access existed or were out of service; in addition, the lines that
to diagnosis and adequate treatment for the population did not respond to six attempts at calls made on differ-
[6]. ent days and times, including Saturdays and Sundays
In low- and middle-income countries, adults face al- and night periods, and which probably corresponded to
most twice as much risk of death from NCDs than those closed households.
from high-income countries [5]. In Brazil, in 2013, 72.6% The applied questions addressed sociodemographic
of deaths were due to NCDs, and cardiovascular diseases characteristics and information on health status and
were the most frequent, accounting for 29.7% of deaths, various risk factors for NCDs. The dependent variables
followed by neoplasms (16.8%), chronic respiratory dis- analysed in this study were the report of diabetes or
eases (5.9%) and diabetes (5.1%). These four diseases hypertension previously diagnosed by a doctor, the use
accounted for 85% of deaths caused by CNCD [6]. of drugs (for those who had these diseases), the source
To guarantee prevention and adequate treatment, the for obtaining the drugs, and lack of access.
population needs to have access to health services and Information on the use of medications was collected
technologies, including medicines. Access to essential through the following questions: “Are you currently tak-
medicines for all individuals is not only a priority in ing any medications to control high blood pressure?”,
current health policies, but also a fundamental right that “In the past 30 days, have you been left without any
has been widely recognized worldwide [7, 8]. medications to control high blood pressure for some
Given the importance of universal access to medicines time?” and “How do you get your medication for high
for the control of NCDs, as well as the identification of blood pressure?”, with the following response options:
disparities in access to this treatment, the aim of this art- Private pharmacy (direct purchase), Brazilian Unified
icle is to analyse the economic and regional inequalities Health System (SUS) – (government health facilities)
in access to medicines for diabetic and hypertensive pa- and People’s Pharmacy Program (PPP). The PPP was
tients among the adult population of Brazil. launched in 2004 by the federal government. This strat-
egy aims to promote the expansion of access to medica-
Methods tion to the entire population. The purpose is to avoid
A cross-sectional population-based study was carried out withdrawal of treatment, especially by individuals with
with Brazilian adults aged 18 years or older. Data were col- low income who use private health services, but have
lected from the Surveillance of Risk and Protection Factors difficulty in buying the required medications in regular
for Chronic Diseases by Telephone Survey (VIGITEL) sur- pharmacies [10, 11]. The same questions were asked
vey, conducted in 2019. VIGITEL is held annually in all Bra- about diabetes medications.
zilian capitals and the Federal District and aims to monitor The independent variables were age in full years, ac-
the frequency and the distribution of the main determinants cording to four categories (18–24; 25–39; 40–59; ≥60),
of chronic noncommunicable diseases (NCDs) [9]. sex (male; female), self-reported skin color (white; black;
For the selection of individuals, probabilistic samples brown), education in years (none; 1–4; 5–8; 9–11; ≥12)
were taken of adults living in households with at least and region of residence (North; Northeast; Midwest;
one landline. For the calculation of risk factor estimates, Southeast; South).
a 95% confidence coefficient and a maximum error of 2 Data analysis was performed using the STATA® statis-
pp. were considered. For specific estimates, according to tical program, version 15.0. The weightings related to
sex, 3 pp. of maximum error was considered. The sample the complex sample design were considered using the
selection was carried out in two stages. In the first one, Rake method [12], which corrects the estimates and pro-
at least 5000 telephone lines per city were selected sys- vides reliable information for the adult population with
tematically and stratified by postal code (CEP). After- landline in each municipality. The reason is that the use
wards, the lines were drawn and divided into replicas of of this weight equates the sociodemographic compos-
200 lines, which had the same proportion of lines per ition estimated from the VIGITEL sample in each town
CEP as the original register. or city to the sociodemographic composition estimated
Initially, 197,600 telephone lines were selected, and to for the total adult population of the same town or city.
reach the minimum number of 2000 interviews per cap- The effect of sample design was considered for all ana-
ital, 36 replicates were used per city, with a range of 30 lyses, using the set of svy commands, specific for the
to 56 replicates, depending on the state. In the second analysis of surveys based on complex samples of the
stage, one of the eligible adults residing in the selected statistical program Stata 15.0. The sample was described
household was selected. More details about the research for the independent variables, and the prevalence of out-
can be found in a previously published report [9]. comes (hypertension and diabetes) was calculated with
Miranda et al. BMC Public Health (2021) 21:1242 Page 3 of 8

the respective confidence intervals using Pearson’s Chi- trend of increasing prevalence with advancing age. For
square test, using the significance level of 0.05. the education variable, there was an inversely propor-
Formal analyses of economic and regional inequalities tional trend. In addition, there were differences in the
in access to medicines for diabetic and hypertensive pa- prevalence of diabetes among regions, with the South-
tients were carried out considering, respectively, formal east being the one with the highest proportion (data not
education and macro-region of residence of the individ- shown in the table).
uals. To identify possible inequalities, the slope index When assessing the main source of access to medi-
(SII) was used [13]. The SII is a measure of absolute in- cines according to the three study sources (SUS, Popular
equality, based on the difference in the values of a given pharmacies or Private pharmacies), the main means of
outcome between the extremes of the distribution, obtaining antihypertensive drugs in all regions was pri-
through a logistic regression for binary outcomes. It is vate pharmacies, whereas for antidiabetics, the main
expressed in percentage points ranging from 100 and source of obtaining varied according the region of the
100, where zero represents no inequality, and negative country, with a predominance of SUS in all regions ex-
values are translated as the poorest group having high cept for the Midwest.
prevalence of the outcome [13]. A significance level of Table 2 and Fig. 1 shows the inequalities in the lack of
0.05 was considered. To better illustrate these differ- access to medicines for hypertension and diabetes
ences between the subgroups, equiplot graphics were among adults over 18 years old according to Region of
used (Fig. 1). residence and formal education.
The VIGITEL research project was approved by the Regarding the source of access to medicines for hyper-
National Commission for Ethics in Research for Human tension and diabetes according to the region of resi-
Beings of the Ministry of Health (CAAE: dence, it was found that the main means of obtaining
65610017.1.0000.0008). A Free and Informed Consent antihypertensive drugs in all regions was through pur-
was obtained verbally at the time of the telephone call chase in private pharmacies; the rate was higher in the
that was carried out by a central office and had all the Midwest (52.1%) and North (51.2%) regions. For antidia-
interviews recorded for the purpose of data quality betic drugs, no standard of achievement was found. The
control. North region had greater access through private phar-
macies (41.3%), while the Northeast, Southeast and
Results South regions had greater access through SUS (34.7,
Of the total sample of 52,443 individuals, 7.5% (95% CI 48.3 and 41.7%, respectively) (Fig. 2).
7.0; 7.8) reported having diabetes; of these, 84.0% were According to the inequality index, inequalities were
using oral diabetes medications, and 20.4% were using found when assessing the lack of access to medicines ac-
insulin. Of the 24.5% (95% CI 23.8; 25.3) who reported cording to region of residence. The result indicates that
having hypertension, 83.4% reported being on medica- the lack of access to anti-hypertensive and anti-diabetic
tion. Total access to medicines was 90% of the popula- drugs occurs in greater magnitude in the residents of the
tion. On the other hand, approximately 10.0% of people North region. For medicines for hypertension and dia-
with diabetes and/or hypertension reported a lack of ac- betes, residents in the Northeast have less access than
cess to these drugs. residents in the South (Table 2).
Table 1 shows the description of the interviewed sam- About formal education, the indices suggest that indi-
ple and the prevalence of lack of access to medicines for viduals with a low level of education have, on average,
diabetes and hypertension according to sociodemo- less access to antihypertensive drugs when compared to
graphic characteristics. It was found that the lack of ac- those with a higher level of education; however, the esti-
cess decreases with increasing age for both drugs. mates were not significant.
Furthermore, the lack of access to antihypertensive
drugs was greater in those individuals with less educa- Discussion
tion (1–4 and 9–11 years). Access to medicines is part of the right to health, which
Regarding the characteristics of individuals according in turn must be promoted through the adoption of pub-
to chronic diseases, there was a higher prevalence of lic policies and, in some cases, legislative mechanisms to
hypertension among female individuals, with a positive ensure them [14, 15]. Nevertheless, there is an inequity
trend with age. On the other hand, the prevalence in this guarantee, which reinforces the need to
tended to decrease with the increase in schooling. The strengthen the Unified Health System for free supply of
region with the highest prevalence of hypertensive pa- medicines with a view to reducing inequalities [16].
tients was the Midwest, followed by the Southeast. Re- Among the respondents, 84.0% of diabetic patients
garding individuals with diabetes, there were no and 83.4% of hypertensive patients were using drug
differences between males and females, and there was a treatment. It is known that the control of both chronic
Miranda et al. BMC Public Health (2021) 21:1242 Page 4 of 8

Fig. 1 Inequalities in the lack of access to medicines for hypertension and diabetes among adults over 18 years old according to Region of
residence and formal education Vigitel. 2019

diseases is based on a series of precautions, which in- A study conducted with data from the 2011 VIGITEL
volve nutritional changes, physical activity and control of survey showed a lower prevalence of medication use
some risk factors [17, 18]. However, drug treatment be- among diabetic and hypertensive patients, with 78.2 and
comes the most effective way to control and prevent 71.0%, respectively, compared to findings of the present
complications of these morbidities, as adherence to life- article [21]. The National Health Survey (2013) showed
style changes is always lower than adherence to treat- that 80.2 and 81.4% used drugs to control diabetes and
ment [19]. However, for this treatment to be effective, hypertension, respectively [22]. These results suggest a
users must have access to it [20]. progression in the use of medications for these two
Miranda et al. BMC Public Health (2021) 21:1242 Page 5 of 8

Table 1 Sample characteristics and prevalence of lack of access to medicines for diabetes and hypertension
Variable Total sample Lack of access to diabetes medications Lack of access to medicines for hypertension
% % 95% CI P value % 95% CI P value
Gender 0.177 0.601
Male 46.0 11.0 8.3; 14.3 10.0 8.0; 12.3
Female 54.0 8.7 7.1; 10.7 10.6 9.4; 11.9
Age (years) 0.025a < 0.001a
18–24 13.7 19.3 6.8; 43.9 17.7 5.9; 42.3
25–39 33.4 16.1 9.3; 26.2 12.3 8.7; 17.0
40–59 34.6 10.5 7.8; 13.9 12.8 10.8; 15.2
60 or more 18.3 7.8 6.2; 9.7 7.6 6.7; 8.6
Ethnicity 0.115 0.357
White 43.8 8.7 6.4; 11.6 9.7 8.1; 11.7
Black 11.4 15.2 9.6; 23.3 9.9 7.4; 13.0
Brown 44.8 10.3 7.9; 13.4 11.4 9.7; 13.4
Education (years) 0.279 0.037
none 2.1 12.5 5.1; 27.3 8.1 5.7; 11.5
1–4 10.7 9.4 6.8; 12.8 11.3 8.7; 14.5
5–8 16.0 7.2 4.9; 10.3 12.0 9.6; 14.7
9–11 38.4 12.2 9.1; 16.1 10.7 8.9; 12.6
12 or more 32.8 8.7 6.0; 12.4 7.2 5.8; 9.0
Region of residence 0.188 0.060
North 10.4 13.4 9.6; 18.3 12.5 10.2; 15.3
Northeast 25.2 11.0 9.0; 13.3 12.1 10.7; 13.5
Midwest 11.8 9.2 5.3; 15.4 10.2 7.9; 13.1
Southeast 44.6 9.3 6.7; 12.6 9.7 7.8; 11.9
South 8.0 5.6 3.5; 8.6 7.7 5.9; 9.9
P-value: chi-square test for heterogeneity
a
p-value of the linear trend test

chronic conditions. The increase in the use of medicines the PNAUM study (21) [23], collected between Septem-
for these diseases may also reflect a less healthy behav- ber 2013 and February 2014, indicated greater access to
ior, which leads to an increase in the prevalence of medicines to treat hypertension (94.6%); when compared
hypertension and diabetes, and increases the number of by region, such access was higher in the South and lower
people who need these medicines. However, data from in the Midwest and Northeast, confirming the regional

Table 2 Absolute inequality (Slope Index-SII) in the lack of access to medicines for hypertension and diabetes in relation to the
education and region of residence of the studied Brazilians. Vigitel. 2019
Prevalence of lack of access according to schooling
none 1a4 5a8 9 a 11 12 or more P valuea SII P valueb
Antihypertensive 8.2 11.3 12.0 10.7 7.2 0.037 −3.6 0.056
Antidiabetic 12.5 9.4 7.2 12.2 8.7 0.279 0.7 0.825
Prevalence of lack of access by region of residence
North Northeast Midwest Southeast South P valuea SII P valueb
Antihypertensive 12.5 12.1 10.2 9.7 7.7 0.065 −4.7 0.004
Antidiabetic 13.5 11.0 9.2 9.3 5.6 0.188 −5.4 0.020
a
p-value of the Chi-square test for linear trend
b
p value from Wald test
Miranda et al. BMC Public Health (2021) 21:1242 Page 6 of 8

Fig. 2 Source of access to medicines for hypertension and diabetes according to the region of residence of the Brazilians studied. Vigitel. 2019

inequality found in this analysis, as for both hyperten- Unified Health System (SUS) [25]. PFP emerged with the
sion and diabetes, access was greater in the South and aim of expanding access to medicines to the entire
lesser in the North and Northeast. population, aiming to prevent withdrawal of treatment,
The general lack of access to medicines for diabetes especially in low-income individuals who cannot afford
and/or hypertension was approximately 10.0%. Although to buy the medicines they need in private pharmacies
the findings indicate that the constitutional right of [26]. In 2011, the program was redesigned to further in-
health may be compromised by a portion of the investi- crease the coverage of access to medicines and promote
gated participants, it should be noted that there is a con- comprehensive health care, changing its name to “Health
siderable level of access to antihypertensives and is priceless”, in which medicines for the treatment of
antidiabetics in Brazil, and this is due to a series of pub- diabetes, hypertension and asthma began to be provided
lic policies that have been adopted to guarantee univer- free of charge [11].
sal and free access to medicines [24]. After a separate analysis of the three sources of access
In 1998, Brazil instituted the National Medicines Pol- to medicines, it was found that the main means of
icy [8] and adopted, among other guidelines, the Na- obtaining antihypertensive drugs in the North, Northeast
tional List of Essential Medicines [14]. Subsequently, the and Midwest regions was the private pharmacy. This re-
generic medicine policy was also implemented, whose sult is similar to the one reported in the VIGITEL 2011
objective was to expand access to medicines with guar- study [21]. This finding may reflect a series of barriers
anteed quality and at a more affordable price for the that still exist, e.g., difficulty in scheduling a medical
population. In 2004, the Popular Pharmacy Program consultation to renew the prescription to be to obtain
(PFP) was created within the scope of the System the medications, lack of knowledge about the list of
Miranda et al. BMC Public Health (2021) 21:1242 Page 7 of 8

medications available for free, prejudice against free and hypertension present in health centers and pharma-
medications provided by the government, and geograph- cies affiliated with PFP. On the other hand, the results
ical limitations, among others [3, 10]. For diabetes medi- also point out that there is still a portion of the popula-
cations (oral and insulin), it was found that the main tion without access to these essential medicines, espe-
means of obtaining them in the North was private phar- cially in the most economically vulnerable regions. This
macies, suggesting regional disparities in access. result is evidence that there are regional disparities and,
The problems with access to medicines were also re- in this way, it contributes insights to the management of
ported in the National Survey on Access, Use and Pro- existing public health policies.
motion of Rational Use of Medicines (PNAUM-
Acknowledgements
Services) [27], which pointed to statistically significant Not applicable.
differences in access to essential medicines among re-
gions of the country, as well as according to type of Accordance with relevant guidelines and regulations
medicine. A study carried out on the basis of the VIGI The authors confirm that all methods were carried out in accordance with
relevant guidelines and regulations.
TEL survey (2011) showed that it is precisely in the capi-
tals of Brazilian regions with less economic development Informed consent
and a greater number of socially vulnerable people that Informed consent was obtained from all individual participants included in
the study.
patients most needed to make direct disbursements to
access treatment for hypertension and diabetes [21]. Authors’ contributions
This finding points out how unequal health care is in a V. I. A. Miranda, F. O. Meller and A. A. Schäfer participated in the analysis and
interpretation of the data. F. O. Meller, A. A. Schäfer, M. P. T. Silveira, C. D.
country with continental dimensions such as Brazil. Tomasi, J. Soratto wrote the article, critically reviewed the intellectual content
This study highlights the difficulties of obtaining medi- and approved the final version to be published. All authors are responsible
cation in the North region, which clearly demonstrates for all aspects of the work in ensuring the accuracy and integrity of any part
of the work.
geographical inequalities in the field of health, when
compared with the South region. Access to medicines in Funding
that region is a challenge for patients and for the man- There was no funding for the research.
agement of health services; in addition, the medicines
Availability of data and materials
are financed per capita, which is a disadvantage for the All data are public and can be found on the official website of the study
North region, where costs are higher [23, 28]. https://saude.gov.br/saude-de-a-z/vigitel
The idea of inequality caused by geographical difficulty
in accessing medicines is further strengthened by analys- Declarations
ing some of the different spaces for health care and ac- Ethics approval and consent to participate
cess to medication prescriptions, such as the Family Vigitel 2019 were approved by the National Research Ethics Commission
Health Strategies (FHS) [29]. While the North region from Brazil through CAAE: 65610017.1.0000.0008. The data used in this
manuscript were collected from the online and open access database from
has family health coverage of more than 63.0%, the VIGITEL (http://svs.aids.gov.br/download/Vigitel/), which justifies the absence
Southeast region has less than 54.0% [30]. This finding of the permission of the Research Ethics Committee.
converges with the hypothesis that it is not enough to
Consent for publication
guarantee access to health, if the ability of users or pa- Not applicable.
tients to obtain them is not considered. Also, another
point to be considered is the hypothesis that the distri- Competing interests
The authors declare that they have no conflict of interest.
bution of health services is not proportional to the dis-
tribution of demands [29]. Author details
1
Major limitations of this study, since it contains self- Postgraduate Program in Public Health, University of Southern Santa
Catarina, Av. Universitária, 1105, Criciúma, Santa Catarina CEP: 88806-000,
reported information, are the memory bias of the inter- Brazil. 2Postgraduate Program in Public Health, University of Southern Santa
viewees, possible differences in the understanding of Catarina, Criciúma, Santa Catarina, Brazil. 3Postgraduate Program in
some issues and the selection bias, since the survey did Epidemiology, University Federal of Pelotas, Pelotas, Rio Grande do Sul, Brazil.
not include individuals living in households without a Received: 30 November 2020 Accepted: 27 May 2021
landline. In addition, it should be noted that the results
are valid and comparable only capitals.
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