La respuesta al COVID-19 en Argentina, Brasil y México: los desafíos a la coordinación federativa de las políticas de salud

Machado, Cristiani Vieira; Pereira, Adelyne Maria Mendes; Freitas, Carlos Machado de; Souza, Michele Souza e; Tobar, Sebastián; Oliveira, Suelen Carlos de

doi:10.1590/0102-311XEN055023

Cristiani Vieira Machado

contributed with the study conception, analysis

writing, and review

approved the final version

Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.

https://orcid.org/0000-0002-9577-0301

Adelyne Maria Mendes Pereira

contributed with the study conception, analysis

writing, and review

approved the final version

Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.

https://orcid.org/0000-0002-2497-9861

Carlos Machado de Freitas

contributed with the study conception, analysis

writing, and review

approved the final version

Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.

https://orcid.org/0000-0001-6626-9908

Michele Souza e Souza

contributed with the study conception

writing, and review

approved the final version

Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brasil.

https://orcid.org/0000-0002-8014-8528

Sebastián Tobar

contributed with the study conception

writing, and review

approved the final version

Centro de Relações Internacionais em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.

https://orcid.org/0000-0002-2966-0219

Suelen Carlos de Oliveira

contributed with the analysis and review

approved the final version

Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.

Universidade do Grande Rio, Mesquita, Brasil.

https://orcid.org/0000-0002-0090-2341

Correspondence C. V. Machado Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz. Rua Leopoldo Bulhões 1480, 7º andar, Rio de Janeiro, RJ 21041-210, Brasil. cristiani.machado@fiocruz.br

Additional information

ORCID: Cristiani Vieira Machado (0000-0002-9577-0301); Adelyne Maria Mendes Pereira (0000-0002-2497-9861); Carlos Machado de Freitas (0000-0001-6626-9908); Michele Souza e Souza (0000-0002-8014-8528); Sebastián Tobar (0000-0002-2966-0219); Suelen Carlos de Oliveira (0000-0002-0090-2341).

Characteristics	Argentina	Brazil	Mexico
Demographic
Total population (in million) (2019) *	44,938	211,782	125,085
Population aged 65 and over (% of total population) (2019) *	11.6	9.0	7.9
Socioeconomic
GDP per capita (USD) (2019) *	9,963.67	8,845.32	10,145.15
Poverty (% of population) (2019) **	11.2	26.2	31.1
Ratio of average family income per capita (quintile 5/quintile 1) (2019) **	8.5	19.1	11.9
Gini index (2019) **	0.429	0.535	0.467
Vulnerable jobs (% of total jobs) (2019) *	22.7	28.3	27.2
Health
Life expectancy (years) (2019) ***	76.6	75.9	76.0
Standardized mortality rate from noncommunicable diseases (per 100,000 inhabitants) (2019) ***	435.2	424.5	464.8
Probability of death between 30-70 years due to CVD, cancer, diabetes, or CKD (2019) **	15.7	15.5	15.6
Prevalence of obesity among adults (BMI ≥ 30, % estimate) (2016) ***	28.5	22.3	28.4
Prevalence of diabetes (% of population aged 20-79) (2019) **	5.4	8.8	16.9
Health system structure
Physicians (per 10,000 inhabitants) (2019) ***	39.8	23.0	24.7
Nurses (per 10,000 inhabitants) (2019) ***	25.9	73.7	28.8
Beds (per 10,000 inhabitants) (2017) ***	49.9	20.9	9.9
Intensive care beds (per 100,000 inhabitants) ^#	19.0	21.6	3.3
Health system financing
Health expenditure (% of GDP) (2019) ***	10.0	9.6	5.4
Government health expenditure (% of GDP) (2019) ***	6.1	3.9	2.7
Government health expenditure (% of general government expenditure) (2019) ***	1.399	599	542
Public health expenditure (% of total public expenditure) (2019) ***	16.1	9.2	10.3
Private health expenditure (% of health expenditure) (2019) ***	39.2	59.1	50.8
Out-of-pocket expenditure (% of health expenditure) (2019) ***	23.9	24.9	42.3
System coverage (per type)
Public system (noncontributory and free access through state or contracted services) ^##	100.0/34.8	100.0	36.5
Social security (contributory, for workers) ^##	62.7	NA	61.1
Private sector of health plans and insurance/“prepaid” medicine ^##	13.6	24.2	2.8

Country	Cumulative incidence *	Cumulative mortality **	Excess mortality (%) ***	Lethality (%) ^#			Tests (per 1,000 inhabitants) ^##	Vaccination coverage (%) ^###	Booster doses (per 100 inhabitants) ^§
Country	Cumulative incidence *	Cumulative mortality **	Excess mortality (%) ***	2020	2021	2022
Argentina	217,338.36	2,859.22	19.24	2.92	2.12	1.32	773.09	76.10	60.45
Brazil	167,775.53	3,217.37	20.44	2.56	2.78	1.92	330.91	78.29	48.22
Mexico	56,826.32	2,598.52	29.53	9.90	7.58	4.57	117.38	62.70	41.69
Canada	116,407.83	1,259.18	6.31	2.73	1.52	1.08	1,538.60	81.77	57.16
United States	292,706.07	3,192.46	14.04	1.81	1.57	1.09	2,483.63	67.28	37.64
Germany	446,707.54	1,987.98	6.32	2.83	1.68	0.45	1,357.56	76.03	68.33
South Africa	67,590.07	1,712.49	17.97	2.67	2.66	2.53	393.41	31.76	5.71
India	31,525.51	374.47	NA	1.45	1.38	1.19	551.94	64.19	2.95
Russia	150,395.92	2,718.36	24.29	1.80	2.93	1.81	1,928.73	51.36	10.09
Australia	408,521.74	680.59	4.45	3.25	0.65	0.17	2,487.17	82.68	61.53

COUNTRY	MAIN CHARACTERISTICS OF COUNTRIES’ RESPONSE
Argentina	Governance and national coordination: suprasectoral governance efforts between government areas and dialogue with experts; agreed mechanisms of federative coordination in health, but with fragile institutionality; Containment and mitigation measures: initially, border closure strategies (with difficulties), mandatory distancing strategies, and economic and social protection measures. Then, “social fatigue” and resistance to measures - new waves; Health system response: segmented health system with robust hospital provision. Federal Government investments (increase in ICU beds, respirators, hiring). Innovations and search for coordination between sectors. Limited role of primary health care. Vaccination began in December 2020, and good availability of vaccines through purchase from various suppliers. Relevance of achieving high vaccination coverage from 2021 to contain serious cases and mortality.
Brazil	Governance and national coordination: limits in national leadership and federative and intersectoral coordination; scant consideration of scientific evidence and societal participation; Containment and mitigation measures: initially, border closure strategies (with difficulties), tensions between the Federal Government and experts, states and municipalities created their own regulation regarding distancing measures, and insufficient economic and social protection measures; Health system response: relevance of the SUS, but difficulties due to inequalities and low investments; emphasis on hospital care (expansion of beds), limited coordination between public and private sectors, little appreciation of primary health care in the response; in 2020, little testing, difficulties in importing inputs and equipment. Relevance of national production of tests and vaccines (responsible for more than half of the doses administered until 2022) with technology transfer. Decisive role of vaccination from mid-2021, with good vaccination coverage of adults with the primary initial schedule. However, there are difficulties in high coverage of booster doses among children.
Mexico	Governance and national coordination: effort on national guidelines, especially for surveillance, but difficulties in federal coordination with the states; Containment and mitigation measures: initial delay in adopting physical distancing measures; then national program, limited scope. Insufficiency and low coordination of measures to protect the economy, employment, and social protection; Health system response: segmented and fragmented health system (under reform), with infrastructure inequalities, limits on public financing, and availability of equipment and supplies. Surveillance strategies based on previous experience with health emergencies. Emphasis on hospital care and testing restricted to serious cases. Dependence on purchasing vaccines from different suppliers. Initial slowness in the pace of vaccination and difficulties in achieving high vaccination coverage.

DIMENSION	FAVORABLE	UNFAVORABLE
Structural	Upper-middle-income countries State participation in shaping health systems and policies	Social inequalities Global asymmetries in resources and STI
Historical-institutional	Public health systems - SUS (in Brazil), existence of public providers, tradition, and previous experiences in public health and surveillance actions (in the three countries) Role of universities and public research institutions Some national capacity for the production of inputs and vaccines	Limits on investments in public systems; fragmentation/segmentation Little appreciation of primary health care; difficulties in integrating between primary health care and surveillance; low testing Limits in STI and dependence on imports
Political-conjunctural	National leadership efforts, with intergovernmental dialogue (Argentina) Subnational government initiatives (Brazil)	Difficulties in federative and intersectoral coordination and conflicts within and between governments Political decisions not based on scientific evidence and social dialogue (Brazil) Resistance from governments to the adoption of restrictive measures on economic and social activities
Societal	Commitment from public health organizations, scientific societies, and experts Mobilization of communities in some areas High adherence to adult vaccination	Low adherence to social distancing measures and the use of masks “Fake news” and, in some groups, hesitation to vaccinate children

[TFN1] BMI: body mass index; CKD: chronic kidney disease; CVD: cardiovascular disease; GDP: gross domestic product; NA: not applicable; PPP: purchasing power parity.

[TFN2] Source: prepared by the authors, with data available in the databases:

[TFN3] * World Bank 15;

[TFN4] ** Economic Commission for Latin America and the Caribbean 2. Argentina’s poverty, income ratio, and Gini data are only for the urban population, and those from Mexico refer to 2018;

[TFN5] *** World Health Organziation 16. Data from Argentina regarding nurses are from 2017;

[TFN6] ^# For Argentina, 2019 data from the Argentine Health Information Integrated System, obtained from Gilardino et al. 18; for Brazil, data from January 2020 from the Brazilian Critical Care Association 19; for Mexico, 2017 data from Organization for Economic Cooperation and Development/World Bank 17;

[TFN7] ^## For Argentina, 2019 data from the Argentine Ministryof Health, available in Tobar 20; the entire population can access public services (100%), and 34.8% only have access to them. For Brazil, whose system is public and universal (the Brazilian Unified National Health System), data on health plans and insurance from the Brazilian National Supplementary Health Agency 21, referring to 2019. For Mexico, the 2020 “derechohabiencia” data was used, from the Mexican National Institute of Statistics and Geography 22.

La respuesta al COVID-19 en Argentina, Brasil y México: los desafíos a la coordinación federativa de las políticas de salud

Resumen: