Background The COVID-19 pandemic exposed vulnerabilities in global health systems, highlighting the need for resilience in governance, leadership, and response mechanisms. Brazil's Unified Health System (SUS) is one of the largest health systems in the world and due to its decentralised and fragmented model could provide learnings to other health systems. Objective This research explores governance for health system resilience to the COVID-19 pandemic in Brazil’s Unified Health System (SUS), focusing on leadership and governance structure, legislation and regulation, information and intelligence, and accountability, integrity and trust. Methods A qualitative approach was employed, including document analysis, focus groups and interviews with 35 national, state and local health experts. Data were analysed by the inductive approach to examine the system’s response, and recovery, and learning phases. Results In the absence of strong federal leadership, state and municipal governments played pivotal roles in managing the crisis. This decentralisation enabled more flexible and region-specific responses. Furthermore, legislative flexibility, as demonstrated by the rapid vaccine approval processes and local production efforts, underpinned timely public health interventions. Information and intelligence systems were also crucial in providing reliable health data, particularly from independent consortia, which countered misinformation and helped maintain public trust. Accountability mechanisms, supported by national health councils, were instrumental in ensuring the implementation of public health measures, despite political and structural challenges. Conclusions Decentralised governance, adaptable legal frameworks, transparent communication, and robust accountability are essential for building resilient health systems capable of responding to future global health crises.

Background:Cardiovascular disease (CVD) and cancer are the first and second leading causes of death in Brazil and worldwide. However, an ongoing epidemiological transition in which cancer surpasses CVD has been observed in many high and middle-income countries. In this study, we provided a nationwide analysis of the transition towards cancer mortality predominance over CVD mortality in Brazil. Methods:We leveraged data from 5570 municipalities using the Mortality Information System and classified the causes of death using ICD-10 codes. Age-standardized CVD and cancer mortality rates were calculated annually between 2000 and 2019. Mortality rate ratios (MRRs = CVD rates divided by cancer rates) described the predominance of cancer or CVD mortality across municipalities and states. Choropleth maps displayed state-specific MRRs and the transition in the predominant cause of death over time. Findings:From 2000 to 2019, CVD mortality rates declined in 25 out of 27 states, whereas cancer mortality increased in 15 states, indicating a shift towards cancer predominance. While in 2000 cancer mortality was lower than CVD in all states and only exceeded the latter in 7% of the municipalities, by 2019 the gap narrowed considerably, with 13% of municipalities displaying higher cancer mortality rates vs CVD mortality rates. Additionally, higher household income correlated with higher mortality from cancer vs CVD. Interpretation:An ongoing epidemiological transition in which cancer mortality surpasses CVD mortality is occurring in Brazil, particularly in municipalities with higher household incomes. Our findings may provide important information for policymakers and public health practitioners in Brazil. Funding:National Council for Scientific and Technological Development (CNPq).

CASE REPORTSa middle-aged man with acute intestinal obstruction due to an ileo-ileal intussusception of inverted Meckel's diverticulum with a lipoma that was managed by laparoscopy.Worthy of note is the very scarce number of case reports on this exceeding uncommon association.

Resumo Introdução: A pandemia de COVID-19 exigiu a ampliação da capacidade dos serviços de saúde nos estados e municípios do Brasil. Este estudo analisou a distribuição geográfica da provisão de recursos de saúde no país no período que antecede essa crise sanitária. Objetivo: Descrever a provisão de recursos de saúde segundo o índice de desenvolvimento humano (IDH) das 133 regiões geográficas intermediárias do Brasil, em 2018. Método: Dados sobre cobertura populacional da Estratégia Saúde da Família, número de consultas ambulatoriais e hospitalizações, investimento público em saúde, leitos hospitalares, leitos mantidos pelo SUS, leitos de UTI e leitos de UTI mantidos pelo SUS foram obtidos junto ao Ministério da Saúde e IBGE. A associação das variáveis com o IDH das regiões intermediárias foi avaliada pela correlação de Pearson. Resultados: A provisão de recursos de saúde foi mais elevada nas regiões intermediárias do Sul e Sudeste, enquanto as regiões do Centro-Oeste tiveram valores intermediários. O IDH correlacionou positivamente com os recursos em saúde. O inverso ocorreu para a cobertura da Estratégia Saúde da Família, que foi maior nas regiões Norte e Nordeste. Conclusões: Monitorar geograficamente a provisão de recursos de saúde pode instruir estratégias para reduzir desigualdades no país. Em 2018, as regiões intermediárias estavam desigualmente preparadas para atender às necessidades em saúde de suas populações e refletiam a lei do cuidado inverso. Foi este o cenário de partida para a resposta à pandemia por COVID-19 em 2020.

Less-than-optimal reliability of mortality information systems regarding the underlying cause of death can mask the reality of oral (OC) and oropharyngeal cancer (OPC) mortality. This study aimed to assess the impact on the magnitude and temporal trends of OC and OPC mortality in Brazil of two statistical approaches to redistribute deaths with ill-defined underlying causes. We analyzed deaths with ill-defined causes in Brazil by macro-region, between 1996-2018. The Mortality Information System provided official information on deaths. Two correction methods were applied: the EF method, which proportionally reallocates deaths classified as R00-R99 in the ICD-10 to the remaining specific causes of death according to the proportion of deaths with certified causes; and the GBD method, which considers the concept of garbage codes, redistributing deaths from several ICD-10 chapters according to previously established coefficients. For the trend analysis of mortality (certified and redistributed), the Prais-Winsten method was carried out. The OC and OPC death rates had an evident increase after the redistribution by the two techniques in all regions of the country; the increase was higher using the GBD method. In the Northeast and North regions, this method more than doubled the certified death rates. The redistribution methods also changed time series trends. In epidemiological studies of mortality from OC and OPC, it is necessary to redistribute deaths from ill-defined causes when analyzing data from less-than-optimal information systems. The choice of the correction method is critical; epidemiological studies must manage it as a methodological decision that has significant impacts on results.

A Covid-19 evidenciou a necessidade de fortalecer a atenção primária à saúde com a reorientação de financiamento, de governança e de alocação de recursos humanos e tecnológicos.

RESUMO Este é um estudo observacional, exploratório, que utilizou metodologia qualitativa, com apoio de dados quantitativos, para analisar a resposta do Sistema Único de Saúde (SUS) à Covid-19 em três municípios brasileiros. Utilizaram-se entrevistas semiestruturadas para escuta e diálogo com gestores das cidades analisadas, que foram orientadas por roteiro para explorar a percepção dos gestores durante o processo de resposta à pandemia, compreender as motivações que orientaram suas escolhas estraté- gicas e visualizar as fragilidades e potencialidades do sistema municipal em uma emergência de saúde pública. Realizou-se análise qualitativa considerando pontos-chave da resposta do SUS à pandemia, entre eles, coordenação e governança, vigilância e prevenção, e rede de serviços de saúde. Nos resultados, apresentam-se e discutem-se as principais características dos municípios, o curso da pandemia em 2020, ações de resposta adotadas; e exibe-se uma análise do padrão de resposta dos gestores do SUS municipal na pandemia.

ABSTRACT This qualitative, observational, and exploratory study was supported by quantitative data to analyze the Brazilian Unified Health System (SUS) response to Covid-19 in three Brazilian municipalities. We used semi-structured interviews to listen to and dialogue with managers of the cities analyzed, guided by a roadmap to explore the managers’ perception during the response to the pandemic, understand the motivations that guided their strategic choices, and visualize the weaknesses and potentials of the municipal system in a public health emergency. We conducted a qualitative analysis considering the critical points of the SUS response to the pandemic, including coordination and governance, surveillance and prevention, and the health services network. In the results, we present and discuss the main characteristics of the municipalities, the 2020 pandemic course, the response actions adopted, and submit an analysis of the response pattern of municipal SUS managers in the pandemic.

Background As of December 31, 2020, Brazil had the second-highest burden of COVID-19 worldwide. Given the absence of federal government coordination, it was up to the local governments to maintain healthcare provision for non-COVID health issues. In this descriptive study, we aimed to discuss the SUS functionality and resilience, describing the impact of the pandemic on non-COVID health services delivery while considering the regional inequalities of the allocation of financing health system, health infrastructure and health workforce. Methods We used input-output framework based on the World Health Organization (WHO) Health System Building Blocks to estimate health system functionality and resilience. An ecological assessment was designed to calculated mean relative changes to compare the first year of the pandemic in Brazil with the previous one. All data used in this study were anonymized and made available by the Brazilian Ministry of Health. Input indicators were categorized in health system financing (federal funding received as well as expenditure of both state and city governments), health system's infrastructure (hospital beds) and health workforce (healthcare workers positions). Output indicators were categorized into nine different groups of service delivery procedures. To explore the relationship between the variation in procedures with socioeconomic conditions, we used the Socioeconomic Vulnerability Index (SVI). Findings State governments had a 38 center dot 6% increase in federal transfers, while municipal governments had a 33 center dot 9% increase. The increase of ICU beds reached its peak in the third quarter of 2020, averaging 72 center dot 1% by the end of the year. The country also saw an increase in jobs for registered nurses (13 center dot 6%), nurse assistants (8 center dot 5%), physiotherapists (7 center dot 9%), and medical doctors (4 center dot 9%). All procedures underwent expressive reduction: Screenings (-42 center dot 6%); Diagnostic procedures (-28 center dot 9%); Physician appointments (-42 center dot 5%); Low and medium complexity surgeries (-59 center dot 7%); High complexity surgeries (-27 center dot 9%); Transplants (-44 center dot 7%); Treatments and clinical procedures due to injuries of external causes (-19 center dot 1%); Irrepressible procedures (-8 center dot 5%); and Childbirths (-12 center dot 6%). The most significant drop in procedures happened in the first quarter of the pandemic, followed by progressive increase; most regions had not yet recovered by the end of 2020. State-level changes in numbers of procedures point towards a negative trend with SVI. Interpretation The Brazilian Government did not consider that socioeconomically vulnerable states were at a higher risk of being impacted by the overburden of the health system caused by the COVID-19, which resulted in poorer health system functionality for those vulnerable states. The lack of proper planning to improve health system resilience resulted in the decrease of a quarter of the amount of healthcare procedures increasing the already existing health disparities in the country. Copyright (c) 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

This corrects the article: 10.11606/s1518-8787.2021055003319

This study aims to assess the magnitude and trend of mortality rates due to oral (OC) and oropharyngeal cancer (OPC) in the 133 Intermediate Geographic Regions (IGR) of Brazil between 1996 and 2018 and to analyze its association with sociodemographic variables and provision of health services. It also aims to compare the trend of mortality from neoplasms that have been reported as associated with HPV (OPC) with the trend of neoplasms that have been reported as not associated with HPV (OC). We obtained mortality data from the Mortality Information System in Brazil and analyzed the trends using the Prais-Winsten method. Then, we assessed the relationship between mortality trends and socioeconomic, health spending, and health services provision variables. The median of the annual percent change of the country's mortality rates was 0.63% for OC and 0.83% for OPC. Trends in mortality in the IGRs correlated significantly with the Human Development Index and government expenditure on ambulatory health care and hospitalizations. Mortality from both types of cancer decreased in those IGR in which the government spent more on health and in the more socioeconomically developed ones. This study found no epidemiological indication that HPV plays the leading etiological factor in OPC in Brazil.

charon redistributes deaths by ill-defined causes and garbage codes according to different methodologies. The command allows applying four different methods, facilitating the comparison of methodologies, and helping to choose the best option.

Background In Brazil, 211 thousand (16.14%) of all death certificates in 2016 identified cancer as the underlying cause of death, and it is expected that around 320 thousand will receive a cancer diagnosis in 2019. We aimed to describe trends of cancer mortality from 1996 to 2016, in 133 intermediate regions of Brazil, and to discuss macro-regional differences of trends by human development and healthcare provision. Methods This ecological study assessed georeferenced official data on population and mortality, health spending, and healthcare provision from Brazilian governmental agencies. The regional office of the United Nations Development Program provided data on the Human Development Index in Brazil. Deaths by misclassified or unspecified causes (garbage codes) were redistributed proportionally to known causes. Age-standardized mortality rates used the world population as reference. Prais-Winsten autoregression allowed calculating trends for each region, sex and cancer type. Results Trends were predominantly on the increase in the North and Northeast, whereas they were mainly decreasing or stationary in the South, Southeast, and Center-West. Also, the variation of trends within intermediate regions was more pronounced in the North and Northeast. Intermediate regions with higher human development, government health spending, and hospital beds had more favorable trends for all cancers and many specific cancer types. Conclusions Patterns of cancer trends in the country reflect differences in human development and the provision of health resources across the regions. Increasing trends of cancer mortality in low-income Brazilian regions can overburden their already fragile health infrastructure. Improving the healthcare provision and reducing socioeconomic disparities can prevent increasing trends of mortality by all cancers and specific cancer types in Brazilian more impoverished regions.

The intrauterine period of growth is extremely important for lifelong health as growth and development of fetal tissues and organ systems occur at a very rapid pace. Any perturbation to this process, either through nutritional insufficiency or exposure to endocrine disruptors or toxins, not only interrupts or delays the growth process, but in some cases results in metabolic abnormalities that challenge adult health. In terms of early childhood nutrition and growth, a number of studies have reported that stunting is a risk factor for obesity and central adiposity. However, other studies have reported divergent findings. Regardless, it is well accepted that nutrition during early childhood through adolescence has a profound effect on healthy growth and deficits in energy or specific micronutrients have a negative impact of adult height and growth. More important, the growth pattern, such as slow or rapid growth, is now considered to be a primary factor in terms of body composition and health. This chapter will describe the relationship between poor growth in utero and early childhood as a risk factor for adult chronic diseases based on epidemiologic and clinical studies. As well, the influence of poor growth during childhood on metabolism and body composition will be explored as potential areas in which mechanisms may explain epidemiological studies.

ABSTRACT The objective of this study was to characterize and analyze the different existing methods for the evaluation of food and nutrition programs and services in Brazil, through a systematic review of the literature focused on complete articles published in national indexed journals. We searched the PubMed, MedLine and LILACS databases using the following search terms and Boolean operators: “evaluation and program”; “project”; “intervention”; “servisse”; “actions and nutrition”; “nutritional”. The research was restricted to articles written in Portuguese, English and Spanish and published between 2001 and 2015. Twenty-two studies were selected and the analysis indicates; most were carried out through quantitative approaches and external evaluations based on epidemiological theory; participatory evaluation strategies are still uncommon; Impact assessments and implementation were predominant; there is little diversity in terms of references to the theoretical framework in the field of evaluation of health care programs in the planning and execution of the evaluation processes analyzed. The results of this study indicate the need for a more comprehensive evaluation considering the complexity of the interventions evaluated using the theoretical-methodological apparatus available in the literature to understand the importance of the different perspectives of the agents involved in the evaluation processes.