Infrastructure-health nexus in Brazil: a scoping review

Abstract

Background: Health system development requires robust infrastructure systems support, particularly in countries with significant regional and socioeconomic disparities. Brazil's experience with its Unified Health System offers important insights into how the infrastructure and built environment is linked to health outcomes especially in underserved populations. This scoping review examines how different infrastructure systems such as sanitation, transportation, educational facilities, housing, influence population health in Brazil through two key pathways: (1) their role in shaping environmental conditions that affect health, and (2) their impact on healthcare service delivery among vulnerable populations.

Methods: Following PRISMA-ScR checklist, we conducted a systematic search of studies published between 2013-2024 across Scopus, Web of Science, and PubMed databases. Search terms included infrastructure systems (sanitation, transportation, housing, educational facilities), health outcomes (universal health coverage, infectious diseases, maternal health), and population descriptors (vulnerable, indigenous, underserved) combined with Brazil-specific terms. Inclusion criteria focused on studies examining physical infrastructure's impact on health outcomes in underserved Brazilian communities, published in English or Portuguese. After applying exclusion criteria including publication year restrictions, language filters, geographic limitations, duplicate removal, and non-article format exclusions, 68 studies met inclusion criteria following screening and quality assessment using the Critical Appraisal Skills Programme (CASP) checklist. Our analysis applied an infrastructure framework examining institutional, personal, and material infrastructure dimensions. Data extraction captured infrastructure systems, healthcare service tiers (primary, secondary, tertiary), and specific health outcomes. Synthesis involved thematic analysis to identify patterns in infrastructure-health relationships, revealing three interconnected dimensions that form the Infrastructure-Health Nexus framework.

Results: The study revealed three interconnected dimensions of infrastructure impact: Supporting Health & Wellbeing, Service Access and Delivery, and Community Engagement. This framework shows how sanitation, transportation, educational, housing, and waste management systems affect health outcomes, with underserved populations facing particular challenges. Healthcare workforce programs serve as interim solutions, with educational facilities simultaneously functioning as health hubs for service delivery and community engagement. The study highlights misalignment between infrastructure investment and UHC objectives.

Conclusions: The Infrastructure-Health Nexus framework, building on Buhr's complementarity concept, shows how infrastructure shapes health outcomes through pathways requiring integrated planning. While current research focuses predominantly on primary care aspects, Brazil's epidemiological transition calls for broader health system considerations, suggesting reconceptualization of infrastructure systems planning as integral to health system development.

Keywords: Brazil; Health infrastructure; Health system; Healthcare access; Population health; Public health policy; SUS; Scoping review.

Fig. 1

Infrastructure Dimensions and their Relationship with Brazil’s Unified Health System. Legend Framework showing the three interconnected infrastructure dimensions (institutional, personal, and material) that support Brazil’s SUS operations and influence health outcomes. Source Developed by authors

Fig. 2

PRISMA flow diagram of study selection process. Legend Systematic selection process following PRISMA-ScR guidelines, from initial search of 70,425 records across three databases to final inclusion of 68 studies after screening and quality assessment

Fig. 3

Infrastructure-Health Nexus in Brazil. Legend Conceptual framework showing three interconnected dimensions: Supporting Health & Wellbeing, Healthcare Services Access and Delivery, and Community Engagement, and their influence on population health outcomes in Brazil. Source Developed by the authors