Federalism and SUS Resilience: The new leadership of state governments in facing the COVID-19 pandemic

Abstract

The health emergencies in the last 20 years have highlighted the need to understand the characteristics of health systems that contribute to resilience in the face of extreme shocks. Studies have emphasized organizational aspects of health systems that contribute to resilience. However, this article analyzed the dynamics of intergovernmental relations to investigate how the state governments contributed to SUS resilience during the COVID-19 pandemic. The analytical model proposed by the World Health Organization was adopted to assess the response of health secretaries of state governments to a survey complemented by data from scientific literature. The results show that the leadership of state health secretariats strengthened the four dimensions of resilience: (1) preserving governance and coordination of health policies; (2) managing financial resources and strengthening coverage of health services; (3) securing resources to preserve services and meet new demands; and (4) implementing innovative approaches in health services to address the pandemic challenges. The study concludes that there was asymmetric progress among the four dimensions, with significant advances in governance.

Key words:
Health Systems Resilience; Federalism; Unified Health System; COVID-19

Resumo

As emergências sanitárias dos últimos 20 anos realçaram a necessidade de compreender as características dos sistemas de saúde que contribuem para a resiliência face a choques extremos. Estudos têm enfatizado aspectos organizacionais desses sistemas que contribuem para a resiliência. Este artigo, contudo, analisou a dinâmica das relações intergovernamentais para investigar como os governos estaduais contribuíram para a resiliência do SUS durante a pandemia de COVID-19. O modelo de análise proposto pela Organização Mundial de Saúde foi utilizado para análise das respostas de gestores estaduais do SUS a um questionário, complementado com dados da literatura científica. Os resultados mostram que a liderança das secretarias estaduais de saúde fortaleceu as quatro dimensões da resiliência: (1) manter a governança e a coordenação das políticas de saúde; (2) gerir os recursos financeiros e fortalecer a cobertura dos serviços de saúde; (3) garantir os recursos para manter os serviços e atender às novas demandas; e (4) implantar abordagens inovadoras nos serviços frente aos desafios impostos pela pandemia. Conclui-se que houve evolução assimétrica entre as quatro dimensões, com expressivos avanços na governança.

Palavras-chave:
Resiliência de Sistemas de Saúde; Federalismo; Sistema Único de Saúde; COVID-19

Resumen

Las emergencias sanitarias de los últimos 20 años han resaltado la necesidad de comprender las características de los sistemas de salud que contribuyen a la resiliencia frente a choques extremos. Los estudios han enfatizado aspectos organizacionales de estos sistemas que favorecen la resiliencia. Sin embargo, este artículo analizó la dinámica de las relaciones intergubernamentales para investigar cómo los gobiernos estatales contribuyeron a la resiliencia del SUS durante la pandemia de COVID-19. El modelo de análisis propuesto por la Organización Mundial de la Salud fue utilizado para examinar las respuestas de gestores estatales del SUS a un cuestionario, complementado con datos de la literatura científica. Los resultados muestran que el liderazgo de las secretarías estatales de salud fortaleció las cuatro dimensiones de la resiliencia: (1) mantener la gobernanza y la coordinación de las políticas de salud; (2) gestionar los recursos financieros y fortalecer la cobertura de los servicios de salud; (3) garantizar los recursos para mantener los servicios y atender las nuevas demandas; (4) implementar enfoques innovadores en los servicios ante los desafíos impuestos por la pandemia. Se concluye que hubo una evolución asimétrica entre las cuatro dimensiones, con avances significativos en la gobernanza.

Palabras clave:
Resiliencia de los Sistemas de Salud; Federalismo; Sistema Único de Salud; COVID-19

Introduction

Health emergencies have highlighted the need to understand how to manage health systems in the face of extreme shocks. Events such as Ebola, Zika, and H1N1 outbreaks over the past 20 years indicate that pandemics will become increasingly frequent and that all countries need to be prepared to address them¹.

The COVID-19 pandemic, caused by the SARS-CoV-2 virus identified in late 2019, has reached global proportions, with almost 775 million people infected and more than 7 million deaths recorded by March 2024². National responses have varied during the COVID-19 pandemic, and some countries were more successful than others in containing transmission and preventing deaths.

Studies have analyzed the strategies health systems use to provide recommendations for better preparation for health crises^3-6. The concept of resilience in these studies encompasses the characteristics of health systems that contribute to addressing increasing demands and maintaining significant performance levels in contexts marked by uncertainties and several pressures, such as natural disasters, climate change, economic depressions, political crises, and constant financial and budgetary constraints⁷. The concept of resilience was inspired by socio-ecological systems analysis approaches^8-12. It emphasizes adaptability and learning capacity as fundamental attributes to sustain dynamics of disrupted equilibrium and stability amid non-linear trajectories characterized by change. Resilience transcends the response to immediate disasters, such as epidemics and natural disasters. It includes the capacity to face chronic and structural challenges, such as underfunding and staffing shortages⁷.

Different studies have used the socio-ecological systems analysis approach to verify the performance of the Unified Health System (SUS) during the COVID-19 pandemic, focusing on preserving health services, such as non-urgent medical and dental appointments, diagnostic tests, surgeries, and transplants, and revealed a declining performance of these procedures against previous years, which characterizes low resilience^13,14. The study by Massuda et al.¹⁵ identified the strengths, weaknesses, and challenges in the SUS structure and organization that influenced its resilience in the face of the pandemic. These approaches follow the trend in international literature, focusing on general or organizational aspects of health systems and the management of hospital care networks¹⁶.

This article presents a federative perspective, focusing on the dynamics of intergovernmental relations in the SUS, showing how the decentralization process over the last three decades has reshaped the scope of possibilities for federative governance, allowing the development of a more horizontal, multipolar leadership. This tripartite dynamic was undermined in the first months of the pandemic due to the autocratic, denialist, and conflictive stance of President Jair Bolsonaro, who provoked confrontation with states and municipalities and militarized the ministry, producing an institutional blockade over the Ministry of Health (MS)¹⁷. Similarly, federative flexibility allowed the construction of emergency and alternative arrangements in other countries as well, especially in those marked by denialist federal governments and significant conflicts between the central and regional/local levels^18,19.

The lack of national coordination and a joint strategy to combat the COVID-19 pandemic forced state governments to take on this role, which led to the implementation of heterogeneous actions in different parts of the country in the first months of the health crisis²⁰. However, it is necessary to understand to what extent the leadership of the National Council of Health Secretaries (CONASS) and the strategies adopted by state governments expanded SUS resilience capacity.

This study investigates how state governments’ actions strengthened SUS resilience during the COVID-19 pandemic. To this end, we shall analyze the convergence of actions among the states with the strategies recommended in the model proposed by Thomas et al.²¹ to identify the role played by state governments in expanding SUS resilience capacity and how the system evolved after the end of this health crisis.

Methods

Analytical model

In partnership with the European Observatory on Health Systems and Policies, WHO has organized a report on policy recommendations with key concepts and strategies to strengthen health system resilience and support policymakers in implementing reforms to reinforce resilience²¹. This document presents a model for analyzing health system resilience based on four stages (preparedness; shock onset and alert; shock impact and management; recovery and learning) and thirteen strategies, classified into four dimensions (governance, financing, resources, and health service delivery), as shown in Figure 1.

Figure 1
Health systems resilience analysis model.

Data collection, systematization, and analysis strategy

This study was conducted using two primary sources: (1) information collected through a structured electronic questionnaire from state health secretariats; and (2) secondary data from official federal government databases and a search in scientific literature.

The study by Fava et al.²² collected information on the actions of state governments in combating the COVID-19 pandemic, highlighting their positions, strategies, agencies involved, instruments, mechanisms, and regulations issued. An electronic questionnaire was sent to the 26 state health secretaries and the health secretary of the Federal District. It was structured and administered through the SurveyMonkey platform from April to December 2022, yielding a total of 19 responses. All respondents reviewed and accepted the Informed Consent Form. Chart 1 shows the states whose responses were considered to support the analysis conducted in this study.

Chart 1
States of questionnaire respondents by principal regions.

Region	State
North	Acre
	Amapá
	Amazonas
	Pará
	Roraima
	Tocantins
Northeast	Bahia
	Ceará
	Maranhão
	Paraíba
	Pernambuco
	Rio Grande do Norte
Midwest	Distrito Federal
	Goiás
	Mato Grosso
	Mato Grosso do Sul
Southeast	Minas Gerais
	Rio de Janeiro
South	Paraná

• Source: Authors, based on Ouverney and Fleury²³.

Information available in the academic literature on the sector was gathered throughout the research’s development and was used to complement the questionnaire’s data. Scientific articles were searched in the SciELO Brazil and Google Scholar databases using keywords that referred to the selected topics, enabling an analysis of the trends in the health system’s specific indicators, comparing the period before and after the COVID-19 pandemic. The questionnaire data and the information available in scientific literature were analyzed following the four dimensions proposed in the guiding model of this work²¹, as shown in Chart 2.

Chart 2
Topics analyzed per dimensions proposed in the guiding model.

Dimension	Topics for analysis
Governance	(1) Governance structures and coordination of health services available (2) Adequate epidemiological surveillance systems, with mechanisms for collecting and sharing data available
Financing	(3) Monetary resources available (4) Health coverage
Resources	(5) Adapted availability of health professionals (6) Strategies to improve resource use efficiency
Service delivery	(7) Preserving existing health services (8) Meeting new demands

• Source: Authors, 2024.

Results and discussion

This section presents and discusses the results, organized by dimension. The analyses revealed advances in nearly all dimensions, expanding the SUS resilience capacity. However, such advances did not follow a symmetrical pattern across the dimensions, nor were they unidirectional. In other words, there were significant setbacks in the post-pandemic period, with a return to the previous situation, particularly in financing.

Governance

The governance dimension of the health system refers to effective leadership with communication skills, which ensures collaboration between different sectors, levels of government, and governmental and non-governmental stakeholders. It also promotes the efficient flow of information to generate knowledge in health surveillance and decision-making in service management²¹.

Health policy governance and coordination structures

National coordination capacity was undermined in the pre-pandemic years following political changes such as the impeachment of President Dilma Rousseff in 2016 and the enactment of Constitutional Amendment No. 95 by her successor, Michel Temer²⁴. This led to a reduction of R$ 20 billion in the health budget in 2019 alone²⁵. This context created conditions for the emergence of an ultra-right-wing government led by Jair Bolsonaro, who adopted a denialist discourse regarding the pandemic’s severity, diverging from WHO guidelines and scientific evidence on the prevention and treatment of COVID-19^26,27. This resulted in the federal government’s failure to coordinate a strategy to confront the pandemic and significant federal clashes with governors^28-30.

Most governors opposed the President of the Republic’s stance, recognizing the pandemic’s critical nature, which polarized federal relations. Their position, aligned with the recommendations of the WHO, as well as national universities and research centers, led the states to adopt immediate measures as soon as the first cases were identified. State decrees established states of emergency and public calamity, with the first measures restricting movement and operation of commerce, services, and transportation. These decrees also established the main institutional mechanisms to coordinate actions and mobilize public administration and organized civil society. These mechanisms involved state managers, scientists, business representatives from several sectors, and municipal managers. The principal subsequent actions were conducted based on these arrangements and on the state health secretariats’ analyses.

Thus, governors and mayors became the dynamic core of this federalism, emerging as a leadership that confronted President Bolsonaro. Another element was the horizontal coordination of state governments, particularly strengthened by the action of the Governors’ Forum and the interstate development consortia, especially the Northeast Consortium.

The role of CONASS should also be highlighted as an institution that coordinated the core of state health secretariats in partnership with the National Council of Municipal Health Secretariats (CONASEMS). CONASS played a key role in disseminating institutional and managerial innovations, encouraging learning and the exchange of expertise, enhancing organicity of actions, and coordinating the dissemination of information to the media and civil society.

This horizontal coordination is unprecedented and was not even observed during the 1980s when governors spearheaded the re-democratization process and bridged the coordination gap created by the Ministry of Health’s militarization. Its presence results from a long political-institutional construction that began with the democratizing and decentralizing project of the Brazilian Health Reform, enshrined in the 1988 Constitution and the Organic Health Laws.

Therefore, a bipartite pact was established to manage the SUS, with national expression and extension in the states, around the Interagency Committees (CIBs), articulating state secretariats and COSEMS. A crisis governance framework was developed around this state pact, covering several other areas of government, universities, research centers, business entities, and social movements. This arrangement is expected to be maintained after the pandemic, strengthened by the gradual return of the MoH to national coordination.

Adequate epidemiological surveillance systems

In Brazilian legislation, an epidemiological surveillance system is defined as the systematic collection, consolidation, analysis, and dissemination of data on health-related events to plan and implement public policy measures to protect people’s health, with risk, illness, and disease prevention and control and health promotion³¹. The first efforts to organize a national surveillance system occurred in 1975. However, an epidemiological intelligence area was defined only in the 1990s. Its organization was based on coordination with CONASS and CONASEMS, and it was operationalized by implementing decentralized information systems, namely, the Live Birth Information System (SINASC), the Notifiable Diseases Information System (SINAN), and the Mortality Information System (SIM)³².

The universal surveillance component for severe acute respiratory syndrome (SARS) was structured in 2009 through the SINAN Influenza Web to identify cases and deaths from influenza following the Declaration of a Public Health Emergency of International Concern, due to human cases of influenza A (H1N1)³³. Therefore, we can conclude that, regarding the organization and structuring of the epidemiological surveillance system, the SUS appeared to be potentially well-prepared for a health shock (Stage 1), leading the MoH to monitor suspected COVID-19 cases as early as late January 2020.

Following the declaration of a Public Health Emergency of National Concern (ESPIN) due to human infection by the novel coronavirus, the Influenza Epidemiological Surveillance Information System (SIVEP-Gripe) was adapted to include the registration of COVID-19 cases and deaths. However, this system initially aimed to report hospitalized SARS cases or deaths through sentinel surveillance units or hospitals. As the number of disease cases grew, the e-SUS Epidemiological Surveillance system was established to collect notifications by Primary Care and emergency care units, and private units. This system also became an online management tool, allowing municipal and state health secretariats to manage the data within their scope, while ensuring information reliability, integrity, and security at the national level³⁴. This swift adaptation of systems for reporting cases and deaths from the disease demonstates rapid government action in Stage 2 to account for real-time numbers and consolidate and update information about the pandemic daily.

The structuring of this system for reporting COVID-19 cases and deaths, with an already established flow of information, was essential for CONASS to assume responsibility for recording data on cases and deaths from the disease with the state health secretariats starting in June 2020. This allowed for daily updates, with the data being made available to the public through the COVID-19 Dashboard. This response from state governments followed changes in the MoH’s publication of COVID-19 figures, which excluded the total number of deaths and confirmed cases³⁵, ensuring that health information remained available for state and municipal governments’ decision-making in the pandemic during Stage 3.

The structured epidemiological surveillance system, organized through collaboration between all federated entities, along with an organizational culture of compulsory notification of cases and deaths from various diseases, contributed to all state health secretariats that responded to the questionnaire (19 respondents) stating that they had implemented a risk classification system by region within the state. This system considered indicators such as the rate of confirmed cases and deaths from COVID-19, as well as the percentage of occupancy of clinical beds and intensive care units (ICU) for risk assessment. Other indicators used by 16 respondents included the total number of cases, total number of deaths, fatality rate from COVID-19, and the distribution of deaths by age group.

The culture of surveillance also helped respondents evaluate some epidemiological indicators as important for decision-making regarding the adoption of restrictive and social distancing measures during the pandemic. Confirming cases and deaths from COVID-19 and monitoring suspected cases of the disease are among the principal factors influencing the implementation of social restriction strategies, together with the percentage increase in hospital bed occupancy and WHO guidelines. Similarly, the two most important factors highlighted in the decision-making process to relax social protection measures were the guidelines from the Scientific Committees, which were supported by epidemiological information, and the WHO guidelines.

In epidemiological surveillance, the experience with the COVID-19 pandemic encouraged the creation and implementation of territorialized panels to monitor disease cases, an innovation highlighted by 12 state health secretariats (of the 19 respondents) in health policy and network organization. This instrument could support monitoring cases of other diseases that may become pandemic, evidencing organizational learning (Stage 4).

Financing

The financing dimension refers to guaranteeing sufficient financial resources for the health system through countercyclical mechanisms and reserves that are immune to the effects of shocks and allow for purchasing and reallocation flexibility based on demand changes. This dimension also includes the previous existence of a broad health service structure with universal or somewhat comprehensive coverage, which can be quickly adapted in health emergencies²¹.

Guarantee of monetary resources and their allocative flexibility

SUS financing in the immediate pre-pandemic period was marked by extensive underfunding, resulting from the spending cap policy implemented during Michel Temer’s government, and by the persistence of two other trends built throughout the 1990s and 2000s.

The first trend was the deconcentration of federal health spending through the transfer of significant amounts of resources from the direct execution modality of the MoH to that of transfers to states and municipalities. This process began during Itamar Franco’s government, with the publication of NOB 93 and the implementation of the fund-to-fund mechanism, boosting, on the one hand, the MoH role as an inducer and, on the other, the trajectory toward greater financial autonomy for states and municipalities to organize their service networks and hire providers³⁶. Initially, in the Itamar and FHC governments, still with a pattern expressively regulated by the MoH, through fragmented ordinances and incentives, states and municipalities were acquiring greater allocative autonomy in federal transfers as the decentralization process advanced, in particular, with the publication of financing blocks, within the Pact for Life, in 2006, and with Ordinance GM No. 3,992/2017.

The second trend was the change in the federative proportion of the SUS financing base, based on Constitutional Amendment N°29/2000 and ratified by Complementary Law No. 141/2012, which established the allocation of subnational entities’ resources to health. Establishing a gradual rule of annual percentage increases changed the level of contribution from the spheres of the federation, increasing the joint participation of states and municipalities from 40.2% in 2000 to 55.3% in 2011. In 2019, the year before the pandemic, this contribution reached 57.8%^37,38.

These two trends established the sectoral financial federative dynamics, characterized, on the one hand, by the gradual reduction of the Federal Government’s role in sectoral financing and its diminished capacity to influence policies, especially after the dismantling during Michel Temer´s government, and on the other hand, by the expanded municipal contributions. The states remained stable throughout this process and were the entity with the smallest participation, which means that their position in sectoral financing, due to historical reasons such as the fiscal distribution of the 1988 Federal Constitution and the indebtedness of state governments, did not favor an insertion as a leader in sectoral financial governance³⁹.

The financial basis of the national coordination of the SUS was highly affected by the enactment of EC 95/2016, which exacerbated sectoral underfunding. Historically, total public health spending was 3.9% of GDP, a percentage below the standards of the European Welfare State, which stood at 9%. Establishing the spending cap caused Brazil’s declining public share of total health spending from 44.8% (2015) to 42.2% (2019)⁴⁰.

The emergence of the pandemic in 2020 increased the risks of a worsening national social and political crisis, especially given the federal government’s denialist stance and the MoH’s militarization. Given this situation, the coalition led by state governments with the several parliamentary groups in Congress established a special public finance regime based on Art. 65 of the Fiscal Responsibility Law, based on five strategies to increase the volume of resources available to support the actions of states and municipalities in combating the pandemic: 1) Relaxing fiscal targets and spending limits established by the LRF; 2) Suspending contractual obligations to pay debts to the Federal Government and creditor institutions; 3) Directly transferring resources to states and municipalities to offset losses in revenue; 4) Relaxing the rules for the use of financial resources transferred before the pandemic and not yet spent; and 5) Transferring resources to SUS strategic partners, such as the philanthropic hospital sector²³.

These strategies temporarily halted the SUS financing base deterioration, especially in 2020 and 2021, the official period of validity of the state of public calamity. The expanded Congress role in managing the federal budget allowed, failing the MoH’s coordination, the use of monetary and fiscal policy instruments available to the Federal Government to expand crude federal debt and direct resources so that states and municipalities could implement actions to combat the pandemic.

In MoH’s specific case, in 2020, R$67.46 billion was added to the initial budget allocation of the LOA of R$ 138.96 billion under an extrabudgetary regime through provisional measures. This made the Federal Government responsible for 76% of the resources committed this year to confront COVID since states and municipalities have few fiscal instruments for significant increases in their budgets⁴¹.

However, given the SUS decentralized nature and the lack of MoH coordination, the state governments managed most of the funds and spearheaded the actions. Adopting provisional measures also fragmented the budgetary supplementation and allowed the federal government to carry out transfers slowly, hindering the action of state and municipal health secretariats. The MoH’s budget expansion strategy for 2021 was similar but less based on issuing public bonds, focusing on the diversification of sources without breaking with the logic of an extraordinary fiscal regime, preserving the current spending cap. Therefore, from a financing perspective, the pandemic did not produce a permanent rupture in the federative SUS financing dynamics due to the adopted spending exception regimen, which returned to previous trends after the official end of the state of public calamity⁴².

Health coverage

In a crisis, a well-organized and well-resourceful financial, physical, and human health system is crucial to maintain care activities and increase scale to meet new demands²¹. Universal health coverage includes access by all people to a comprehensive set of quality health services, ranging from health promotion and prevention to treatment, rehabilitation, and palliative care. The most effective and economical way to achieve universal health coverage is through primary care, as investments at this level of care ensure the identification, prioritization, and integrated management of the population’s health needs in coordination with the community⁴³.

In Brazil, large-scale expansion of access to health through primary care began in the 1990s, mainly through financial incentives to municipal governments, conditioned on the implementation of Family Health teams, established by the SUS Basic Operational Standard 96, and later improved in subsequent legislation⁴⁴. In 2019, the Previne Brasil Program was established by Ordinance MS/GM No. 2,979/2019, which also incorporated incentives for primary care teams outside the Family Health Strategy, promoting the implementation of this team type. Data available on the MoH website reveal that the number of Family Health teams grew from 2,054 in July 1998 to 51,369 in December 2023, and the number of Primary Care teams increased from 1,104 in January 2020 to 5,708 in December 2023⁴⁵.

In December 2019, population coverage by primary healthcare already indicated, in general, that the health system was well prepared for shocks (Stage 1), with 74.8% population coverage. However, the distribution of these teams was unequal across the country. The Federal District had the lowest coverage (53.4%), along with São Paulo and Rio de Janeiro (around 60%). In contrast, three states in the Northeast (Piauí, Pernambuco, and Sergipe), together with Tocantins and Santa Catarina, had coverage above 90%, which may have weakened the SUS resilience during the COVID-19 pandemic.

During the pandemic (Stages 2 and 3), PHC population coverage grew slowly and systematically, reaching 79.7% of the Brazilian population in December 2023, though with significant regional differences. Therefore, inequities must be reduced to better prepare the health system for a new health shock (Stage 4).

Although municipal governments are responsible for managing primary care services, nine state secretariats (out of the 19 questionnaire respondents) reported strengthening primary care as a strategy to address bottlenecks in public health services caused by the health emergency. However, it is necessary to specify the actions implemented by state governments to support municipalities in improving PHC during the pandemic (Stage 3) and whether there is any continuity in this process (Stage 4).

Resources

The resource dimension encompasses the adequate level and distribution of human and physical resources, and the capacity to increase their availability in response to new demands. This dimension also includes the workforce motivation levels²¹.

Understanding the challenges faced by policymakers and managers is essential to ensuring the availability and accessibility of doctors in the SUS. According to a study on medical demographics in Brazil⁴⁶, the number of doctors has grown yearly, and the number of doctors per population increased from 1.63 in 2010 to 2.60 in 2020. However, the uneven distribution of doctors and specialists remains a cause for concern.

The study indicates that the Southeast, Midwest, and South have a ratio of around three doctors per thousand inhabitants, while the Northeast has a ratio of 1.93 doctors per thousand inhabitants. The North had the lowest ratio among the regions, with 1.45 per thousand inhabitants. The concentration of health professionals in large urban centers and the scarce availability especially in rural areas, pose political and social challenges, reducing the population’s access to quality and timely healthcare⁴⁷. Thus, in terms of the adequate distribution of human resources, the SUS was not well prepared for the shock (Stage 1).

Survey results indicate that state governments identified the lack of trained health professionals (11 of 19 respondents), tests to confirm the diagnosis (10), and beds with adequate equipment for hospitalization (9) as the three main hurdles in the early months of the COVID-19 pandemic in the SUS. After the initial shock, challenges shifted to low adherence of the population to isolation measures (12) and the spread of fake news (11), suggesting that the initial difficulties in organizing and offering health services had been overcome.

The COVID-19 pandemic was only possible in Brazil due to the increased availability of resources in the SUS. Survey data showed that, to meet the increased demand for health services, state health secretariats primarily invested in recruiting health professionals (14 of 19 respondents), expanding the public network through field hospitals or additional beds (12), and contracting the private sector for beds and services (9). These measures allowed states to address the sudden demand surge (Stage 3).

However, state managers highlighted several obstacles to implementing these measures, including the exorbitant price increases and shortages of equipment, supplies, and medicines (15 of 19 respondents), delays in the release of ordinary and extraordinary federal financial resources (9), and logistical difficulties faced by the Federal Government in distributing supplies (8).

Health service delivery

This dimension focuses on Stages 3 (Impact and shock management) and 4 (Recovery and learning). It involves implementing alternative and flexible approaches to ensure healthcare during the health emergency and identifying which of these strategies can be sustainably incorporated into the system’s evolution²¹.

At the federal level, strategies were stablished to increase funding flexibility and ensure resource availability in health units. Moreover, the MoH released several publications with guidelines on preserving primary care (care for people with chronic diseases, assistance for pregnant and postpartum women, and dental care) and for organizing services to meet pandemic-related demand (protocols for COVID-19 response centers, hospital response plan, and implementation of field hospitals)⁴⁸. Progress was made in implementing digital technologies based on the Digital Health Strategy for Brazil 2020-2028⁴⁹. However, these strategies were insufficient to maintain the production of essential services, including non-urgent medical and dental appointments, diagnostic tests, surgeries, and transplants^13,14.

Survey data indicate that state governments sought alternatives to address bottlenecks in public health services during the pandemic (Stage 3) to ensure health facilities functioning. In addition to the strategies to increase the availability of resources mentioned in the previous section, the implementation of specific criteria for COVID-19 in the Bed Regulation Center (14), the creation of a room for crisis management (9), and communication campaigns on prevention and social isolation (8) were highlighted. Strategies involving greater governmental intervention in the private sector, such as temporary public management of private hospitals (2) and an unified queue for public and private healthcare services (2), were mentioned infrequently.

Among the innovations introduced in the health policy that indicated system evolution (Stage 4), the most frequently mentioned were the recruitment of new professionals for inpatient care (15 of 19 respondents), the improved policy for enabling ICU beds (14), the creation of a territorialized panel for monitoring COVID-19 cases (13), and enhancements in laboratory diagnostic procedures (11). However, actions aimed at advancing digital health technologies, such as implementing telemedicine (7) and digitizing medical records (2), were mentioned infrequently.

Conclusion

In partnership with the municipalities, the new leadership of the state health secretariats played a significant role in strengthening SUS resilience and expanding its capacity to confront the pandemic, considering the four dimensions highlighted by the model proposed by Thomas et al.²¹.

First, it’s important to highlight that the shift in the pattern of federative relations under the new SES leadership steams from a long process of building the SUS as a decentralized, cooperative, and tripartite system. In this sense, the development of leadership, coordination capacity, and a culture of learning, central aspects of governance, results from nearly four decades of joint federative efforts, starting with the inclusion of the Health Reform Movement project in the Eighth National Health Conference and its incorporation in the 1988 Constitution and SUS Organic Laws, which contributed to strengthening governance.

Therefore, the ability to develop alternative political arrangements, especially at the level of federative coordination, is a key attribute of SUS resilience capacity in responding to the pandemic. This institutional characteristic requires long and successive learning stages, a typical path-dependence process that ensures the sustainability to social protection systems^50,51. Thus, resilience in health systems is a long-term institutional attribute built with the constant reaffirmation of the central role of the State in social policies^7,15.

Furthermore, the WHO framework emphasizes that resilience is a multidimensional attribute of a public policy, and our research support this claim. Throughout the SUS trajectory, the same level of institutional development observed in governance was not identified in the other three dimensions, particularly in financing.

A long history of health policy underfunding was observed before the pandemic, followed by an extraordinary fiscal execution regime during the crisis. This was due to the declaration of a state of public calamity, which suspended the limits imposed by the Responsibility Law and led to the implementation of a financial support package for states and municipalities (Complementary Law No. 173/2020). In the post-pandemic period, the same restrictions as before remain and may constitute an obstacle to SUS resilience.

Consequently, this change is also expected to impact performance in two other dimensions analyzed here - resources and service delivery. During the pandemic, the exceptional fiscal regime enabled large-scale expansion in hiring and training professionals, setting up field hospitals, purchasing new beds from the private and philanthropic sectors, and acquiring additional equipment. However, it is unlikely that all this additional capacity will be maintained, an outcome that could significantly enhance SUS resilience in future adverse scenarios.

It’s important to note that some strategies in the model were not included in this analysis due to difficulties in obtaining SUS-related data on these actions, which is a limitation of this study. In this sense, strategies aimed to motivate and support the workforce (resources dimension).

Therefore, a health system’s resilience is a multidimensional condition, dependent on structural variables that cannot be fully restored through immediate emergency efforts if neglected throughout its trajectory. In other words, it must be continuously sustained over long institutional trajectories.

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Edited by

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  20 June 2025
• Date of issue
  June 2025

History

• Received
  30 Mar 2024
• Accepted
  25 Feb 2025
• Published
  27 Feb 2025