Governance for health system resilience

Lessons from Brazil’s decentralized health system

Bibliographic Data

ID21467786
AuthorsMarco Antonio Catussi Paschoalotto (0000-0003-2276-8531, Fundação Getulio Vargas, corresponding author), Alessandro Bigoni (0000-0002-2483-3299, Fundação Getulio Vargas), Andreza Carolina Davidian (Fundação Getulio Vargas), Kelerson Semerene Costa (0000-0002-2218-6024, Fundação Getulio Vargas), Karen Sarmento Costa, Ana Maria Malik (0000-0002-0813-8886, Fundação Getulio Vargas), Mariana Carrera (0000-0002-8785-7730), Wanderson Kleber De Oliveira (0000-0002-9662-1930, Armed Forces Hospital), Leandro Safatle, Leandro Pinheiro Safatle (Federal Government of Brazil), Adriano Massuda (0000-0002-3928-136X, Fundação Getulio Vargas)
Year2026
Volume167
Pages105586
Publication date2026-05-01
Peer ReviewedYes
Open AccessYes
TypeARTICLE
VenueHealth Policy (JOURNAL)
Journal identifiersISSN: 0168-8510 • E-ISSN: 1872-6054
PublisherElsevier BV (PUBLISHER)
DOI10.1016/j.healthpol.2026.105586
PMID41759438
OpenAlexW7130556005
LanguageEN
Citations received1
References cited28

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

Accountability · Corporate governance · Global health · Healthcare system · Public health · COVID-19 Digital Contact Tracing · Data-Driven Disease Surveillance · Viral Infections and Outbreaks Research · Health Policy