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Background: As health systems struggle to tackle the spread of Covid-19, resilience becomes an especially relevant attribute and research topic. More than strength or preparedness, to perform resiliently to emerging shocks, health systems must develop specific abilities that aim to increase their potential to adapt to extraordinary situations while maintaining their regular functioning. Brazil has been one of the most affected countries during the pandemic. In January 2021, the Amazonas state's health system collapsed, especially in the city of Manaus, where acute Covid-19 patients died due to scarcity of medical supplies for respiratory therapy. Methods: This paper explores the case of the health system's collapse in Manaus to uncover the elements that prevented the system from performing resiliently to the pandemic, by carrying out a grounded-based systems analysis of the performance of health authorities in Brazil using the Functional Resonance Analysis Method. The major source of information for this study was the reports from the congressional investigation carried out to unveil the Brazilian response to the pandemic. Results: Poor cohesion between the different levels of government disrupted essential functions for managing the pandemic. Moreover, the political agenda interfered in the abilities of the system to monitor, respond, anticipate, and learn, essential aspects of resilient performance. Conclusions: Through a systems analysis approach, this study describes the implicit strategy of "living with Covid-19", and an in-depth view of the measures that hampered the resilience of the Brazilian health system to the spread of Covid-19. [ABSTRACT FROM AUTHOR]

This paper contributes to discussions about subnational responses to the coronavirus disease (COVID-19) pandemic in federal countries. In the scholarship on federalism and public policy, few studies seek to understand the factors that shape subnational differences in welfare levels. This article seeks to better understand this issue in Brazil by exploring how, in a context with little national-level coordination, subnational governments tackle the inequalities exacerbated by the COVID-19 pandemic. This study analyzes two social policy areas with distinct national-level coordination mechanisms and federal responsibilities: social assistance and education. Two multi-level cases are examined: the states of Amazonas and São Paulo and the cities of Manaus and São Paulo. This analysis relies on quantitative data, mainly social indicators, and qualitative data collected through documents and in-depth interviews. Social assistance and education policy actors in Amazonas and São Paulo faced at times significant obstacles adapting and/or creating policies to tackle inequalities, resulting in a fend-foryourself federalism and fragmented subnational policies. Differences in subnational responses can be explained by distinct policy legacies and previous capacity, which were key in organizing a useful response to the pandemic. However, to fully explain subnational responses, the role of actors within institutional contexts must also be taken into account. In social assistance, shared responsibilities among different levels of government led to competition and credit claiming dynamics, reinforcing fragmented and uncoordinated responses. In education, decentralization and more stable funding allowed political leadership to activate and mobilize subnational capacities and other actors at the subnational level, producing more sustainable responses. [ABSTRACT FROM AUTHOR]

Objective: To study the profile of hospitalizations due to COVID-19 in the Unified Health System (SUS) in Brazil and to identify factors associated with in-hospital mortality related to the disease. Methods: Cross-sectional study, based on secondary data on COVID-19 hospitalizations that occurred in the SUS between late February through June. Patients aged 18 years or older with primary or secondary diagnoses indicative of COVID-19 were included. Bivariate analyses were performed and generalized linear mixed models (GLMM) were estimated with random effects intercept. The modeling followed three steps, including: attributes of the patients; elements of the care process; and characteristics of the hospital and place of hospitalization. Results: 89,405 hospitalizations were observed, of which 24.4% resulted in death. COVID-19 patients hospitalized in the SUS were predominantly male (56.5%) with a mean age of 58.9 years. The length of stay ranged from less than 24 hours to 114 days, with a mean of 6.9 (±6.5) days. Of the total number of hospitalizations, 22.6% reported ICU use. The odds on in-hospital death were 16.8% higher among men than among women and increased with age. Black individuals had a higher likelihood of death. The behavior of the Charlson and Elixhauser indices was consistent with the hypothesis of a higher risk of death among patients with comorbidities, and obesity had an independent effect on increasing this risk. Some states, such as Amazonas and Rio de Janeiro, had a higher risk of in-hospital death from COVID-19. The odds on in-hospital death were 72.1% higher in municipalities with at least 100,000 inhabitants, though being hospitalized in the municipality of residence was a protective factor. Conclusion: There was broad variation in COVID-19 in-hospital mortality in the SUS, associated with demographic and clinical factors, social inequality, and differences in the structure of services and quality of health care. [ABSTRACT FROM AUTHOR]