Brazil's health system functionality amidst of the COVID-19 pandemic: An analysis of resilience

Background As of December 31, 2020, Brazil had the second-highest burden of COVID-19 worldwide. Given the absence of federal government coordination, it was up to the local governments to maintain healthcare provision for non-COVID health issues. In this descriptive study, we aimed to discuss the SUS functionality and resilience, describing the impact of the pandemic on non-COVID health services delivery while considering the regional inequalities of the allocation of financing health system, health infrastructure and health workforce. Methods We used input-output framework based on the World Health Organization (WHO) Health System Building Blocks to estimate health system functionality and resilience. An ecological assessment was designed to calculated mean relative changes to compare the first year of the pandemic in Brazil with the previous one. All data used in this study were anonymized and made available by the Brazilian Ministry of Health. Input indicators were categorized in health system financing (federal funding received as well as expenditure of both state and city governments), health system's infrastructure (hospital beds) and health workforce (healthcare workers positions). Output indicators were categorized into nine different groups of service delivery procedures. To explore the relationship between the variation in procedures with socioeconomic conditions, we used the Socioeconomic Vulnerability Index (SVI). Findings State governments had a 38 center dot 6% increase in federal transfers, while municipal governments had a 33 center dot 9% increase. The increase of ICU beds reached its peak in the third quarter of 2020, averaging 72 center dot 1% by the end of the year. The country also saw an increase in jobs for registered nurses (13 center dot 6%), nurse assistants (8 center dot 5%), physiotherapists (7 center dot 9%), and medical doctors (4 center dot 9%). All procedures underwent expressive reduction: Screenings (-42 center dot 6%); Diagnostic procedures (-28 center dot 9%); Physician appointments (-42 center dot 5%); Low and medium complexity surgeries (-59 center dot 7%); High complexity surgeries (-27 center dot 9%); Transplants (-44 center dot 7%); Treatments and clinical procedures due to injuries of external causes (-19 center dot 1%); Irrepressible procedures (-8 center dot 5%); and Childbirths (-12 center dot 6%). The most significant drop in procedures happened in the first quarter of the pandemic, followed by progressive increase; most regions had not yet recovered by the end of 2020. State-level changes in numbers of procedures point towards a negative trend with SVI. Interpretation The Brazilian Government did not consider that socioeconomically vulnerable states were at a higher risk of being impacted by the overburden of the health system caused by the COVID-19, which resulted in poorer health system functionality for those vulnerable states. The lack of proper planning to improve health system resilience resulted in the decrease of a quarter of the amount of healthcare procedures increasing the already existing health disparities in the country. Copyright (c) 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)