No abstract

Brazilian Ministry of Health, Pan American Health Organization, and Wellcome Trust.

In 1988, Brazilian Constitution definedhealth as a universal right and state responsibility. Progress towards universal health coverage (UHC) has been achieved through a Unified Health System (Sistema Único de Saúde, SUS) which was created in 1990. With successes and setbacks in the implementation of health programmes and organization of its health system, Brazil has achieved nearly-universal access to health services for her citizens. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale UHC in a health system in a highly-unequal country and relatively low resources. The analysis of the 30 years since the inception of SUS shows that innovations in the Brazilian health system extend beyond the development of new models of care and highlights the importance of establishing political, legal, organizational and management-related structures, and the role of the federal and local governments in the governance, planning, financing, and provision of health services. The expansion of SUS has allowed Brazil to rapidly address the changing health needs, with dramatic scaling up health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographic inequalities, insufficient funding, and the suboptimal private-public collaboration. Recent fiscal policies that ushered austerity measures, environmental, educational and health policies of the new administraion introduced in Brazil could reverse the hard-earned achievements of the SUS and threaten its sustainability and its ability to fulfil its constitutional mandate of providing 'health for all'. 2000 2010 2015 Births attended by skilled health staff (% of total) 87•6 98•6 98•9 99•1 Immunization, BCG (% of one-year-old children) 79 99 99 99 Immunization, measles (% of children ages 12-23 months) 78 99 99 96 Immunization, DPT (% of children ages 12-23 months) 66 98 99 96 Immunization, Hib3 (% of children ages 12-23 months) 90 99 96 Immunization, Pol3 (% of one-year-old children) 58 99 99 98 Immunization, HepB3 (% of one-year-old children) 94 96 96 Antiretroviral therapy coverage (% people living with HIV) 27 38 57

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread rapidly in Manaus, the capital of Amazonas state in northern Brazil. The attack rate there is an estimate of the final size of the largely unmitigated epidemic that occurred in Manaus. We use a convenience sample of blood donors to show that by June 2020, 1 month after the epidemic peak in Manaus, 44% of the population had detectable immunoglobulin G (IgG) antibodies. Correcting for cases without a detectable antibody response and for antibody waning, we estimate a 66% attack rate in June, rising to 76% in October. This is higher than in São Paulo, in southeastern Brazil, where the estimated attack rate in October was 29%. These results confirm that when poorly controlled, COVID-19 can infect a large proportion of the population, causing high mortality.

Background: As the population of Africa rapidly urbanizes, large populations could be protected from malaria by controlling aquatic stages of mosquitoes if cost-effective and scalable implementation systems can be designed.

The Unified Health System (Sistema Único de Saúde (SUS)) has enabled substantial progress towards Universal Health Coverage (UHC) in Brazil. However, structural weakness, economic and political crises and austerity policies that have capped public expenditure growth are threatening its sustainability and outcomes. This paper analyses the Brazilian health system progress since 2000 and the current and potential effects of the coalescing economic and political crises and the subsequent austerity policies. We use literature review, policy analysis and secondary data from governmental sources in 2000–2017 to examine changes in political and economic context, health financing, health resources and healthcare service coverage in SUS. We find that, despite a favourable context, which enabled expansion of UHC from 2003 to 2014, structural problems persist in SUS, including gaps in organisation and governance, low public funding and suboptimal resource allocation. Consequently, large regional disparities exist in access to healthcare services and health outcomes, with poorer regions and lower socioeconomic population groups disadvantaged the most. These structural problems and disparities will likely worsen with the austerity measures introduced by the current government, and risk reversing the achievements of SUS in improving population health outcomes. The speed at which adverse effects of the current and political crises are manifested in the Brazilian health system underscores the importance of enhancing health system resilience to counteract external shocks (such as economic and political crises) and internal shocks (such as sector-specific austerity policies and rapid ageing leading to rise in disease burden) to protect hard-achieved progress towards UHC.

Malaria not only remains a leading cause of morbidity and mortality, but it also impedes socioeconomic development, particularly in sub-Saharan Africa. Rapid and unprecedented urbanization, going hand-in-hand with often declining economies, might have profound implications for the epidemiology and control of malaria, as the relative disease burden increases among urban dwellers. Reviewing the literature and using a modeling approach, we find that entomologic inoculation rates in cities range from 0 to 54 per year, depending on the degree of urbanization, the spatial location within a city, and overall living conditions. Using the latest United Nations figures on urbanization prospects, nighttime light remotely sensed images, and the "Mapping Malaria Risk in Africa" results on climate suitability for stable malaria transmission, we estimate that 200 million people (24.6% of the total African population) currently live in urban settings where they are at risk of contracting the disease. Importantly, the estimated total surface area covered by these urban settings is only approximately 1.1-1.6% of the total African surface. Considering different plausible scenarios, we estimate an annual incidence of 24.8-103.2 million cases of clinical malaria attacks among urban dwellers in Africa. These figures translate to 6-28% of the estimated global annual disease incidence. Against this background, basic health care delivery systems providing early diagnosis and early treatment and preventive actions through mother and child health programs and the promotion of insecticide-treated bed nets for the rapidly growing numbers of the urban poor must be improved alongside well-tailored and integrated malaria control strategies. We propose environmental management and larviciding within well-specified productive sites as a main feature for such an integrated control approach. Mitigation of the current burden of malaria in urban African settings, in turn, is a necessity for stimulating environmentally and socially sustainable development.

Frontier malaria is a biological, ecological, and sociodemographic phenomenon operating over time at three spatial scales (micro͞ individual, community, and state and national). We explicate these linkages by integrating data from remote sensing surveys, groundlevel surveys and ethnographic appraisal, focusing on the Machadinho settlement project in Rondô nia, Brazil. Spatially explicit analyses reveal that the early stages of frontier settlement are dominated by environmental risks, consequential to ecosystem transformations that promote larval habitats of Anopheles darlingi. With the advance of forest clearance and the establishment of agriculture, ranching, and urban development, malaria transmission is substantially reduced, and risks of new infection are largely driven by human behavioral factors. Malaria mitigation strategies for frontier settlements require a combination of preventive and curative methods and close collaboration between the health and agricultural sectors. Of fundamental importance is matching the agricultural potential of specific plots to the economic and technical capacities of new migrants. Equally important is providing an effective agricultural extension service.Brazilian Amazon ͉ frontier malaria E conomically and politically driven human migration in the Amazon basin of Brazil over the past century has been accompanied by substantial ecosystem transformation and the promotion of malaria transmission (1-3). Research programs in parasitology, entomology, and epidemiology of vector-borne diseases were established in Brazil in the 1890s (4-6) followed, almost immediately, by translation into malaria mitigation strategies (3, 7). Major eradication and control campaigns in Amazonia, initiated in the 1950s and persisting until 1970 (1), succeeded in reducing the number of malaria cases in the region to Ϸ30,000 (in 1970) (roughly 60% of all cases reported in the country).The modern era of Amazon frontier expansion began during the military government with the introduction of large scale colonization projects focused on agriculture, mineral extraction, and wide-ranging human settlement (8-13). The human population of the Amazon grew from 7.2 million in 1970 to 11 million in 1980 and then to 18.7 million by 1996, accompanied by a dramatic increase in malaria cases (14, 15). As of 1999, there were Ϸ600,000 malaria cases in Brazil, 99.7% of which were concentrated in the legal Amazon. The spatial distribution of these cases was very irregular, and a lack of spatially targeted mitigation strategies resulted in inefficient allocation of resources. In 1986, 60% of all malaria cases in the Amazon were concentrated in 58% of the municipalities, but 70% of the budget for malaria control was spent in municipalities with only 3% of the cases (16).Characterizing malaria risk in the rapidly transforming Amazon ecosystems requires considering biological and ecological phenomena acting at multiple spatial scales, juxtaposed with behavioral and economic conditions. In this regard, we adapt and add precis...