A partisan pandemic: state government public health policies to combat COVID-19 in Brazil

Abstract

Introduction: To present an analysis of the Brazilian health system and subnational (state) variation in response to the COVID-19 pandemic, based on 10 non-pharmaceutical interventions (NPIs).

Materials and methods: We collected daily information on implementation of 10 NPI designed to inform the public of health risks and promote distancing and mask use at the national level for eight countries across the Americas. We then analyse the adoption of the 10 policies across Brazil's 27 states over time, individually and using a composite index. We draw on this index to assess the timeliness and rigour of NPI implementation across the country, from the date of the first case, 26 February 2020. We also compile Google data on population mobility by state to describe changes in mobility throughout the COVID-19 pandemic.

Results: Brazil's national NPI response was the least stringent among countries analysed. In the absence of a unified federal response to the pandemic, Brazilian state policy implementation was neither homogenous nor synchronised. The median NPI was no stay-at-home order, a recommendation to wear masks in public space but not a requirement, a full school closure and partial restrictions on businesses, public transportation, intrastate travel, interstate travel and international travel. These restrictions were implemented 45 days after the first case in each state, on average. Rondônia implemented the earliest and most rigorous policies, with school closures, business closures, information campaigns and restrictions on movement 24 days after the first case; Mato Grosso do Sul had the fewest, least stringent restrictions on movement, business operations and no mask recommendation.

Conclusions: The study identifies wide variation in national-level NPI responses to the COVID-19 pandemic. Our focus on Brazil identifies subsequent variability in how and when states implemented NPI to contain COVID-19. States' NPIs and their scores on the composite policy index both align with the governors' political affiliations: opposition governors implemented earlier, more stringent sanitary measures than those supporting the Bolsonaro administration. A strong, unified national response to a pandemic is essential for keeping the population safe and disease-free, both at the outset of an outbreak and as communities begin to reopen. This national response should be aligned with state and municipal implementation of NPI, which we show is not the case in Brazil.

Keywords: COVID-19; descriptive study; health policy; qualitative study.

Figure 1

This shows Brazil as the country with the least stringent national response over the course of the COVID-19 pandemic.

Figure 2

This provides an illustrative description of the timing and rigour in the adoption of policies at the state level in Brazil during the pandemic. The graph reflects great heterogeneity in the timing of policy implementation to mitigate the spread of COVID-19. Some states such as Rondônia, the federal district, Pernambuco and Tocantins were the first to introduce policies for the containment of the virus. Other states such as Mato Grosso do Sul, Acre, Mato Grosso and Paraíba acted later, although the differences in the timing of implementation are much smaller than the differences in the number of policies adopted and the intensity of implementation.

Figure 3

This presents data on population mobility by state, beginning 2 weeks prior to the first reported case in the country as a baseline. Mobility fell sharply as states implemented measures restricting movement but rose steadily beginning in April as governments relaxed restrictions, even as cases and deaths spiked. as of 15 September, the population of Amazonas was 25% more mobile than 2 weeks prior to the first case in the country. The national average for mobility has returned to exactly the same level of mobility as prior to the pandemic. Once again, population mobility reflects two distinct phases of the pandemic: phase 1, in March, April, and May, when population mobility fell well below normal, and phase 2, where some states’ mobility had returned to prepandemic levels as early as July.

Figure 4

Public Policy Index, population mobility and governors’ political ideology