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

O objetivo deste estudo é analisar a pressão sobre o sistema de saúde no Brasil decorrente da demanda adicional gerada pela COVID-19. Para tanto, foi realizado um conjunto de simulações para estimar a demanda de leitos gerais (microrregiões de saúde), leitos de UTI e equipamentos de ventilação assistida (macrorregiões de saúde) em diferentes cenários, para intensidade (taxas de infecção equivalentes a 0,01, 0,1 e 1 caso por 100 habitantes) e horizontes temporais (1, 3 e 6 meses). Os resultados evidenciam uma situação crítica do sistema para atender essa demanda potencial, uma vez que diversas microrregiões e macrorregiões de saúde operariam além de sua capacidade, comprometendo o atendimento a pacientes principalmente aqueles com sintomas mais severos. O estudo apresenta três mensagens relevantes. Em primeiro lugar, é necessário reduzir a velocidade de propagação da COVID-19 na população brasileira, permitindo um tempo maior para a reorganização da oferta e aliviando a pressão sobre o sistema de saúde. Segundo, é necessário expandir o número de leitos disponíveis. Ainda que o setor privado contribua para amortecer o déficit de demanda, a oferta conjunta dos dois setores não seria suficiente em várias macrorregiões. A construção de hospitais de campanha é importante, tanto em locais onde historicamente há vazios assistenciais como também naqueles onde já se observa uma pressão do lado da demanda. A terceira mensagem diz respeito à organização regionalizada dos serviços de saúde que, apesar de adequada em situações de demanda usual, em momentos de pandemia este desenho implica desafios adicionais, especialmente se a distância que o paciente tiver de percorrer for muito grande.

This study generated significant insight into the Brazilian population's health preferences that can be applied to health technology assessment and economic analyses in Brazil. This information represents an important new tool that can be used in Brazilian health policy creation and evaluation.

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Universal Health Coverage (UHC) is one of the United Nations Sustainable Development Goals (SDGs). Achieving UHC will require strong health systems to promote and deliver equitable and integrated healthcare services through primary healthcare (PHC). In Brazil, the Family Health Strategy (FHS) delivers PHC through the public health system. Created in 1994, the FHS covered almost 123 million individuals (63% of the Brazilian population) by 2015. The FHS has been associated with many health improvements, but gaps in coverage still remain. This article examines factors associated with the implementation and expansion of the FHS across 5419 Brazilian municipalities from 1998 to 2012. The proportion of the municipal population covered by the FHS over time was assessed using a longitudinal multilevel model for change that accounted for variables covering eight domains: economic development, healthcare supply, healthcare needs/access, availability of other sources of healthcare, political context, geographical isolation, regional characteristics and population size. Data were obtained from multiple publicly available sources. During the 15-year study period, national coverage of the FHS increased from 4.4% to 54%, with 58% of the municipalities having population coverage of 95% or more, and municipalities that had not adopted the programme decreased from 86.4% to 4.9%. The increase in FHS uptake and coverage was not homogenous across municipalities, and was positively associated with small population size, low population density, low coverage of private health insurance, low level of economic development, alignment of the political party of the Mayor and the state Governor, and availability of healthcare supply. Efforts to expand the FHS coverage will need to focus on increasing the availability of health personnel, devising financial incentives for municipalities to uptake/expand the FHS and devising new policies that encompass both private and public sectors.

To a certain extent, our results reflect the socioeconomic and demographic characteristics of the countries in which each of the six cities is located. The cities in the countries with the worst social indicators (high income inequality and low human development index) tended to have the greatest inequalities in health and in the utilization of health services.

The primary aim of this study was to analyze the geographic distribution of physicians among the Regions and States of Brazil using a locational choice model. Our individual data analysis showed a positive relationship between the number of physicians per 1,000 inhabitants in a State and the number of places in residency programs. Thus, the concentration of residency programs in some States has contributed to the unequal distribution of physicians in Brazil. There are also significant differences in physicians' income between Regions.

Family Health Strategy, the primary health care program in Brazil, has been scaled up throughout the country, but its expansion has been heterogeneous across municipalities. We investigate if there are unique municipal characteristics that can explain the timing of uptake and the pattern of expansion of the Family Health Strategy from years 1998 to 2012. We categorized municipalities in six groups based on the relative speed of the Family Health Strategy uptake and the pattern of Family Health Strategy coverage expansion. We assembled data for 11 indicators for years 2000 and 2010, for 5,507 municipalities, and assessed differences in indicators across the six groups, which we mapped to examine spatial heterogeneities. Important factors differentiating early and late adopters of the Family Health Strategy were supply of doctors and population density. Sustained coverage expansion was related mainly to population size, marginal benefits of the program and doctors’ supply. The uptake was widespread nationwide with no distinct patterns among regions, but highly heterogeneous at the state and municipal level. The Brazilian experience of expanding primary health care offers three lessons in relation to factors influencing diffusion of primary health care. First, the funding mechanism is critical for program implementation, and must be accompanied by ways to support the supply of primary care physicians in low density areas. Second, in more developed and bigger areas the main challenge is lack of incentives to pursue universal coverage, especially due to the availability of private insurance. Third, population size is a crucial element to guarantee coverage sustainability over time.