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

Abstract

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 38·6% increase in federal transfers, while municipal governments had a 33·9% increase. The increase of ICU beds reached its peak in the third quarter of 2020, averaging 72·1% by the end of the year. The country also saw an increase in jobs for registered nurses (13·6%), nurse assistants (8·5%), physiotherapists (7·9%), and medical doctors (4·9%). All procedures underwent expressive reduction: Screenings (-42·6%); Diagnostic procedures (-28·9%); Physician appointments (-42·5%); Low and medium complexity surgeries (-59·7%); High complexity surgeries (-27·9%); Transplants (-44·7%); Treatments and clinical procedures due to injuries of external causes (-19·1%); Irrepressible procedures (-8·5%); and Childbirths (-12·6%). 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.

Funding: MCTIC/CNPQ/FNDCT/MS/SCTIE/DECIT N^o 07/2020.

Figure 1

Correlations between Socioeconomic Vulnerability Index and relative change of federal transfers and expenditure with own resource by UF. *Significant at the 5% level.

Figure 2

Relative change distribution of hospital beds rates in health regions by major region and quarter.

Figure 3

Trendlines of total of contracts signed divided by the total of workers and the rate per 1000 habitants of a given health profession group.

Figure 4

Relative change distribution of procedures rates in health regions by procedure group, major region, and quarter. *Significant at the 5% level.

Figure 5

Correlations between Socioeconomic Vulnerability Index and relative change of healthcare production by procedure group and UF. *Significant at the 5% level.

Figure 6

Relative change distribution of procedures rates in health regions by major region and quarter and correlation between Socioeconomic Vulnerability Index and relative change of healthcare production by UF. *Significant at the 5% level.