Danielle Monteiro (ENSP Report)
COVID-19 has exposed socio-economic and healthcare inequalities in Brazil, as well as the importance and weaknesses of the SUS, pointing to the need to reverse divestment in the universal public health system, a fundamental policy for reducing inequalities in the country. This is the conclusion of the article COVID-19 inpatient mortality in Brazil from 2020 to 2022: a cross-sectional overview study based on secondary data, authored by researchers from the National School of Public Health (Ensp/Ficrcuz) Margareth Portela, Mônica Martins, Sheyla Lemos, Carla Andrade and Claudia Pereira. Published in the International Journal for Equity in Health, the study shows that variations in the mortality of patients hospitalized for the disease were associated not only with the age group and severity of the case, but also with social and regional inequalities and in access to good quality care.
The study used data from the Influenza Epidemiological Surveillance Information System (Sivep-Gripe), the National Register of Health Establishments (CNES), the SUS Hospital Information System (SIH-SUS) and the Brazilian Institute of Geography and Statistics (IBGE). Adult hospitalizations for COVID-19 in inpatient units with at least 100 cases between 2020 and 2022 were considered.
The study investigated the occurrence of hospitalizations and mortality from the disease over time and among groups of hospitals defined by their legal form and participation in the SUS. The effects of factors relating to patient profile, healthcare processes, hospital units and municipalities of residence and location of hospital units on inpatient mortality were also identified.
The results showed that more than 70% of hospitalizations for COVID-19 in Brazil were covered by SUS. The Unified Health System served the most vulnerable population groups, but had worse adjusted hospital mortality. In general, private and philanthropic hospitals not belonging to the SUS, most of which are reimbursed by private healthcare plans accessible to the more privileged socio-economic classes, had the best results.
The South of Brazil had the best performance among the macro-regions, and the North had the worst. Black and indigenous people living in municipalities with a lower HDI and hospitalized outside their city of residence had a higher chance of hospital mortality. Moreover, adjusted hospital mortality rates were higher at the peak of the
pandemic and significantly reduced after vaccination against COVID-19 reached reasonable coverage, starting in July 2021.
According to the researchers, the findings demonstrate the key role of the SUS in the provision of healthcare, as most hospitalizations for COVID-19 were covered by the Brazilian public health system. On the other hand, the results also indicate weaknesses in the performance of SUS hospital units compared to the private sector or even, in some regions, to public hospital units that do not provide services for the SUS, reflecting accumulated structural and funding problems.
The findings also point to higher hospital mortality from COVID-19 among black people in all regions of Brazil, and indigenous people in the North and Midwest regions. According to the researchers, the Sivep-Gripe data, with a high rate of non-completion of the race/color variable, did not allow the identification of a higher occurrence of deaths among browns compared to whites, except in the South. The authors warn of the complexity of processing this variable: "In addition to the high frequency of unrecorded information on this variable, in the country, it is measured based on phenotype (physical appearance) and not based on ancestry (origin), further being recommended to consider self-declared color, which may lead to a subjective judgment, affected by contextual aspects".
The researchers understand that the brown race/color includes a particularly heterogeneous group and point out that, although the data did not allow differentiation of the risk of death between brown and white people hospitalized for COVID-19, differences may exist. "Analyses by macro-region or according to regional differences are important for assessing the effects of this variable, since macro-regions are very diverse in their population composition and reflect very different socio-economic conditions and access to health services", they point out.
The study also indicated higher hospital mortality in the first (April to August 2020) and second (December 2020 to May 2021) waves of the pandemic, becoming lower in 2022, even during the third wave (January to February). Deaths peaked in March 2021, when hospitals across the country were at or above capacity, leading to a shortage of critical resources such as ventilators, oxygen and ICU beds. "As lessons learned, improvements need to be made to better prepare the health system for future pandemics or other large-scale health emergencies. This includes investing in more health infrastructure, increasing the number of health workers, offering better training and support for these workers, as well as better salaries and working conditions, including protective devices," the researchers suggest.
For the authors of the article, despite its challenges, the SUS has several strengths that make it essential, unique and valuable to Brazilians. According to them, the results warn of the need to invest in and improve the Unified Health System, with a particular focus on the causes of inequalities in the supply, access and results of care, further providing elements for the debate, in crisis scenarios, on the role and performance of each type of hospital care provider (private and public) in the Brazilian health system.
"Changes, investments and monitoring are necessary to avoid the risks of compromising universal access to health services and widening inequalities between SUS and non-SUS users. In summary, the study highlighted the need for continued efforts to improve the quality and equity of health for all," they conclude.