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.

BackgroundGrip strength, walking speed, chair rising and standing balance time are objective measures of physical capability that characterise current health and predict survival in older populations. Socioeconomic position (SEP) in childhood may influence the peak level of physical capability achieved in early adulthood, thereby affecting levels in later adulthood. We have undertaken a systematic review with meta-analyses to test the hypothesis that adverse childhood SEP is associated with lower levels of objectively measured physical capability in adulthood.Methods and FindingsRelevant studies published by May 2010 were identified through literature searches using EMBASE and MEDLINE. Unpublished results were obtained from study investigators. Results were provided by all study investigators in a standard format and pooled using random-effects meta-analyses. 19 studies were included in the review. Total sample sizes in meta-analyses ranged from N = 17,215 for chair rise time to N = 1,061,855 for grip strength. Although heterogeneity was detected, there was consistent evidence in age adjusted models that lower childhood SEP was associated with modest reductions in physical capability levels in adulthood: comparing the lowest with the highest childhood SEP there was a reduction in grip strength of 0.13 standard deviations (95% CI: 0.06, 0.21), a reduction in mean walking speed of 0.07 m/s (0.05, 0.10), an increase in mean chair rise time of 6% (4%, 8%) and an odds ratio of an inability to balance for 5s of 1.26 (1.02, 1.55). Adjustment for the potential mediating factors, adult SEP and body size attenuated associations greatly. However, despite this attenuation, for walking speed and chair rise time, there was still evidence of moderate associations.ConclusionsPolicies targeting socioeconomic inequalities in childhood may have additional benefits in promoting the maintenance of independence in later life.

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.