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Techinical Note • Dados rev. ciênc. sociais 68 (3) • Jan 2025 • https://doi.org/10.1590/dados.2025.68.3.004x linkcopy

Open-access Health Policies of Brazilian States During the COVID-19 Pandemic: A Dataset of the Regulations Issued*

AuthorshipSCIMAGO INSTITUTIONS RANKINGS

    ABSTRACT

    This database provides a comprehensive overview of the health regulations issued by the state governments of Brazil over the COVID-19 pandemic. For this compilation, we gathered and analyzed the regulatory frameworks of health policies developed by Brazil’s 27 states from February 2020 to October 2021, covering the first three waves of COVID-19 in the country. As a result, we have an original dataset of Subnational Regulation data, comprising over 4,000 norms related to COVID-19 in the field of health. This database aims to contribute to the understanding of state responses to the pandemic, considering the federative configuration and the autonomy of local authorities.

    Resumo

    Este banco de dados apresenta um amplo panorama das normativas de saúde elaboradas pelos governos estaduais do Brasil durante a evolução da pandemia de Covid-19. Para sua consolidação, reunimos e analisamos os marcos regulatórios de políticas de saúde desenvolvidas pelos 27 estados do Brasil no período de fevereiro de 2020 a outubro de 2021, abrangendo as três primeiras ondas da Covid-19 no país. Temos como resultado um conjunto original de dados de Regulação Subnacional, compreendendo mais de 4 mil normas relacionadas à Covid-19 no campo da saúde. Esse banco de dados visa contribuir para o entendimento das respostas estaduais à pandemia, considerando o contexto federativo e a autonomia das autoridades locais.

    governos estaduais; federalismo; Covid-19; políticas de saúde; políticas públicas

    Résumé

    Cette base de données offre un vaste panorama des réglementations sanitaires élaborées par les gouvernements des états du Brésil durant l’évolution de la pandémie de COVID-19. Pour sa consolidation, nous avons rassemblé et analysé les cadres réglementaires des politiques de santé mises en place par les 27 états du Brésil entre février 2020 et octobre 2021, couvrant ainsi les trois premières vagues de COVID-19 dans le pays. Nous avons constitué un ensemble de données original sur la réglementation infranationale, comprenant plus de 4000 normes liées à la gestion du COVID-19 dans le domaine de la santé. Cette base de données a pour objectif de contribuer à une meilleure compréhension des réponses étatiques à la pandémie, en tenant compte du contexte fédéral et de l’autonomie des autorités locales.

    gouvernements des états; fédéralisme; COVID-19; politiques de santé; politiques publiques

    Resumen

    Este banco de datos presenta un amplio panorama de las normativas de salud elaboradas por los gobiernos estatales de Brasil durante la evolución de la pandemia de Covid-19. Para su consolidación, reunimos y analizamos los hitos regulatorios de políticas de salud desarrolladas por los 27 estados de Brasil en el período de febrero de 2020 a octubre de 2021, abarcando las tres primeras olas de Covid-19 en el país. Tenemos como resultado un conjunto original de datos de Regulación Subnacional, que comprende más de 4 mil normas relacionadas con el Covid-19 en el campo de la salud. Este banco de datos tiene como objetivo contribuir a la comprensión de las respuestas estatales a la pandemia, considerando el contexto federativo y la autonomía de las autoridades locales.

    gobiernos estatales; federalismo; Covid-19; políticas de salud; políticas públicas

    Introduction

    As the COVID-19 pandemic spread globally, multiple governmental responses to the health emergency emerged, despite experts and international agencies’ recommendations. Some explanations for this multitude of solutions point to state capacity, governance structures, and the national political environment (Allin et al., 2020; Mazzucato, Kattel, 2020). Others emphasized economic and social variables, which posed greater challenges for dealing with the economic impacts of the pandemic (Atkeson, 2020; Baker et al., 2020) or highlighted how democracies and autocracies differed in their responses (Stasavage, 2020).

    In Brazil, government reaction became a point of interest for researchers and political actors, due to (i) the denialist stance of the then-President of the Republic and his inner circle in the executive branch (Ferigato et al., 2020; Fernandez, Dantas, 2020; Casarões, Magalhães, 2021; Bertholini, 2022), including the establishment of a parallel cabinet within the Ministry of Health (Dias et al., 2021; Miskolci, 2023); (ii) the severity of the public health emergency in the country (Bastos et al., 2020; Castro et al., 2021); and (iii) the lack of intergovernmental coordination in response actions (Abrucio et al., 2020). Managing the pandemic halted Brazilian federalism’s cooperative model, giving way to a lack of coordination and highlighting the conflicting actions among the federation entities, especially regarding the management of the country’s Unified Health System (SUS) adopted from the Federal Constitution of 1988 (Arretche, 2021; Viana, Machado, 2009; Abrucio et al., 2020; Fernandez, Pinto, 2020; Fleury, Fava, 2022).

    In light of this, state governments emerged as leaders during the pandemic response (Bertholini, 2022; Carvalho et al., 2022). They began to develop measures to combat the public health emergency locally. This sort of state action raises some questions: are there differences in health policies to deal with the coronavirus at the subnational level? Did these actions intensify as the pandemic progressed?

    These questions guide the construction of this database, which aims to provide an overview of the health regulations produced by state governments throughout the COVID-19 pandemic in Brazil. Despite the importance of subnational actions in this context, there are no datasets addressing state regulations, only data on federal regulations (Ventura, Reis, 2021) and isolation measures (Hale et al., 2021). The creation of this database seeks to contribute to the understanding of the influence of federal dynamics on public policymaking and to investigate how state governments act in contexts of crises.

    Data collection and coding

    We identified and analyzed health regulations developed by the 27 Brazilian federative entities from February 2020 to October 2021. This period corresponds to the first three waves of COVID-19 in Brazil. We produced an original dataset of subnational regulations, with 4,837 norms related to combating COVID-19.

    The regulations used were produced by the state executive power and made available for consultation on the official websites of the states and their respective Official Gazettes. The information was collected daily, during the period described above, manually, for the 26 states and the Federal District. There was an additional verification process for the collection and classification of the regulations, conducted independently, with double-checking for each state.

    To search for regulations in the Official Gazettes of the states, 12 keywords were used: “COE-”1; “covid”; “public calamity”; “public emergency”; “health emergency”; “pandemic”; “corona”; “coronavirus”; “quarantine”; “SARS”; “covid19”. After selecting the regulations by keyword, we excluded those addressing social isolation, as we were mapping the actions of the state executive linked to health actions.

    The database was organized so that each regulation corresponds to an observation. Additionally, it identified the federative unit that originated the regulation, its main objective (when available), the analyzed document, and its type.

    Regulations were coded based on the data collection. For this, analytical categories were defined based on international discussions on the necessary measures to address public health emergencies (WHO, 2020). Five main categories and nineteen subcategories were established. For coding, the regulations were read and analyzed individually by one of the group’s researchers. Cases that raised doubts were discussed in weekly meetings by all group researchers to standardize classification. After this stage, a second researcher reviewed all the abstracts and classifications, grouped monthly, and a third reviewed gaps and inconsistencies in the final material.

    The database was then constructed by indicating the presence (1) or absence (0) of each subcategory (Table 1) in all the analyzed regulations. Thus, the same regulation may belong to different subcategories, referring to each of the possible health actions its text addresses. A total of 2,171 regulations were identified as coded in more than one category.

    Thumbnail
    Table 1
    : Health regulations analysis matrix (“health actions”)

    In addition to the listed categories, the regulations were also classified by type. This typology is related to the objectives of each document, described in Table 2.

    Thumbnail
    Table 2
    : Types of regulations

    Through a descriptive analysis of data, we present below an overview of Brazilian states’ actions throughout the pandemic in the country regarding issuing regulations related to health policies. The data were analyzed using RStudio version 4.3.1.

    Brazilian states and the COVID-19 pandemic

    In this section, we describe the database and highlight possible paths of analysis provided by this dataset. The 4,837 regulations were classified into five major categories of health actions. These categories present an overview of the regulations produced by state governments on health-related topics during the given period.

    Figure 1
    : Classification of regulations based on analysis categories

    In these broader categories, we observe that most of the regulations fall under “Expenses” (37.77%), followed by “Infrastructure” (19.21%). “Human Resources” and “Health Service Processes” are the least prominent categories, representing 10.60% and 14.60% of the classified actions, respectively. Epidemiological surveillance actions account for 17.79% of the total actions.

    In Brazil, pre-existing disparities in state capacities2 at different levels of government affect the implementation of effective measures in response to the pandemic crisis (Abrucio et al., 2020; Lima, Pereira, Machado, 2020). Thus, classifying regulations into broad categories allows for the analysis of, for example, how these disparities influenced the actions taken by different federative entities, or how investments were used to mitigate these disparities, enabling case studies or comparisons between them.

    In Figure 2, we present an overview of the distribution of state regulations across the 19 subcategories.

    Figure 2
    : Classification of regulations based on subcategories of analysis

    Subcategories demonstrate that most actions are related to the acquisition of supplies, followed by the increase in hospitalization capacity and other actions linked to health and epidemiological surveillance. The fewest actions speak to the training of health professionals.

    The various health actions promoted by the states can support several debates about managing the pandemic in the country. Among these debate topics could be the effectiveness of the policies adopted compared to the number of infections and deaths from the disease; the strategies used to reduce the spread of the virus; and/or the best care methods for those affected by COVID-19. Additionally, it is also possible to contrast the decision-making of subnational governments with the scientific evidence presented in international documents. The theme of evidence-based policy arises in response to denialist practices during the pandemic, such as promoting early treatment and disregarding non-pharmaceutical intervention measures (Fernandez, 2022; Langlois et al., 2016). Considering this, some relevant research questions emerge: how do Brazilian subnational governments respond to scientific evidence? Does decision-making at this level adhere to the best international practices? How do the science and state actions differ and align? Were these practices coordinated with the federal government actions?

    Analyzing subcategories allows for a deeper understanding of how managers allocated their attention. For example, the low prevalence of regulations related to the training and protection of health professionals contrasts with international evidence and recommendations that highlight the importance of enabling health professional protection during a crisis through support for using personal protective equipment and proper training (WHO, 2020). Brazilian studies also pointed to the importance of political authorities supporting healthcare professionals (Fernandez, Lotta, 2020) and the pandemic’s impacts on their lives and work routines (Lotta et al., 2021; Fernandez et al., 2023). Therefore, it would be important to understand the states’ stance on health professionals throughout the health emergency.

    Most types of regulation refer to contract terms, resolutions, and ordinances. Figure 3 presents the main types of regulations. Analyzing their types can be a valuable tool to explore more specific themes, such as public procurement by state executives (Sousa, 2021). The waiver of bidding in an emergency is also a point of debate brought up by authors like Vargas et al. (2021), Rodrigues (2020), and Augusto et al. (2021), highlighting the controversies of this waiver in situations of emergency or public calamity. The dataset’s data can help understand the issue comparatively, quantitatively, and qualitatively.

    Figure 3
    : Classification of regulations by document types

    There is a significant disparity between states regarding the issuing of health regulations during the given period, as shown in Figure 4. The governments of Ceará (CE), Pernambuco (PE), and Rio Grande do Norte (RN) have the highest number of regulations presented -- 547, 340, and 319, respectively. The state with the fewest regulations produced was Santa Catarina (SC), with 52 regulations, followed by Goiás (GO) and Roraima (RR), with 67 regulations each. According to the thematic scenario of health regulations by state, most regulations are related to public spending, as previously mentioned. Most states followed this pattern.

    Figure 4
    : Number of regulations by state and category

    The data allows questions already explored in the literature to be further examined, such as the role of regional initiatives like the Northeast Consortium, a political arrangement that sought to strengthen the role of state executives in this region in facing the COVID-19 pandemic (Fernandez, Pinto, 2020). The volume of regulations per state could also raise discussions about the motivations for the intense production of regulations by a particular state executive. In this sense, what is behind the large production of regulations by a specific state? Were these regulations effectively translated into actions?

    Government behavior changes as COVID-19 progresses. As noted by Brasil (2020), time is an important variable to consider in times of crisis, especially as it significantly alters the decision-making process and impacts how public decision-makers process information. In light of this, this database can help demonstrate how this process changes during the health emergency, bringing up issues such as learning and political change in times of crisis (Dunlop, Radaelli, 2015; Kamkhaji, Radaelli, 2016) and the effects of policy diffusion in times of crisis (Mistur, 2022).

    Thus, a possible application of the database would combine the categorization of regulations with the waves of COVID-19 in Brazil to try to understand and contextualize the states’ actions. Policies and responses to COVID-19 evolved over time, and analyses of this nature allow for understanding how changes occurred in laws and initiatives by state governments, providing a chronological understanding of actions and policy changes. This analysis presents time in epidemiological weeks of the COVID-19 pandemic.

    With this information, we can observe the distribution of regulations presented by the states during the pandemic. In an initial approach to this analysis, Figure 5 demonstrates the number of regulations per epidemiological week. We observe that week 27 of 2020 (between 6/28/2020 and 7/4/2020) concentrates the highest number of health regulations during the observed period. The first peak of regulations presents itself at the beginning of the first wave, between weeks 10 (03/01/2020 to 03/07/2020) and 15 (04/05/2020 to 04/11/2020) of 2020. A new spike in regulations can be seen at the beginning of the second wave, in epidemiological week 50 of 2020 (12/06/2020 to 12/12/2020).

    Figure 5
    : Number of regulations per epidemiological week

    Figure 6 allows for a more specific observation of the number of regulations, showing how state governments dealt with the pandemic at different times, according to each epidemiological week. We observe that the highest point of spending actions occurs at the peak of the pandemic in 2020, specifically in epidemiological week 28 of 2020 (from 7/5/2020 to 7/11/2020), with other peaks over the analyzed period. Infrastructure actions peak at the beginning of the pandemic’s first wave and when the highest number of cases was recorded in 2020, in epidemiological week 28 of 2020 (from 7/5/2020 to 7/11/2020), and a similar pattern can be seen for epidemiological surveillance actions. Human resources actions did not show significant changes throughout the health emergency, while health service process actions had a peak at the beginning of the first wave, in weeks 11 and 14 of 2020 (from 3/8/2020 to 3/14/2020 and from 3/29/2020 to 4/4/2020) and remained unchanged for the rest of the observed period.

    Figure 6
    : Type of regulation by epidemiological week

    Another possible use of the dataset is to analyze it in conjunction with other databases. To illustrate this potential, we examined the interactions between the number of state regulations and the incidence of Severe Acute Respiratory Syndrome (SARS) in the country in 2020. Using data from the Ministry of Health, available on Open DataSus, we gathered the number of SARS cases from the Epidemiological Week recorded in the SARS notification form, which includes information on COVID-19. The results are shown in Figure 7.

    Figure 7
    : Total regulations and total Severe Acute Respiratory Syndrome by epidemiological week, 2020

    In the graph, the left y-axis refers to state regulations, while the right y-axis refers to the total number of reported SARS cases. Generally, we observe a coincidence in the number of SARS cases and the number of regulations. The exception is the period of the twentieth epidemiological week when there is a peak in SARS cases. This peak is followed by the peak in the total number of regulations, indicating a relationship between the increase in cases and the increase in states issuing regulations in the following period.

    Final considerations

    The COVID-19 pandemic highlighted the importance of the actions of different levels of government (federal, state, and municipal) in decision-making and the implementation of measures during the health emergency. By building this database, we aim to contribute to discussions about the dynamics of subnational actions in federalist contexts and intergovernmental relations, including cooperation, conflict, and coordination between these levels of government.

    In various fields of Social, Human, and Biomedical Sciences, the interest in the COVID-19 pandemic and its consequences has led to the emergence of diverse research agendas (Fernandez et al., 2022; Brasil, 2020). In this sense, this dataset can be used to expand research that attempts to understand the period of the COVID-19 pandemic in Brazil, especially the actions of states throughout the crisis. The analysis of regulations allows to identify patterns in the strategies adopted by different states to deal with the pandemic, highlighting issues such as efficiency and effectiveness, resource allocation, and the unique dynamics of each state. These are potential research agendas that can be explored using this database.

    Thus, the comparative analysis of regulations would allow for a deeper understanding of decision-making differences between states, including the analysis of political party, socioeconomic, and administrative capacity factors. Additionally, the selection of policy alternatives and the differences and similarities in decision-making processes is an agenda to be explored. In the lens of comparative politics, the actions taken by subnational entities can also be studied considering other federalist countries, understanding contrasts and parallels in how the pandemic altered these dynamics and the different responses of the federated entities. The regulations also offer insights into the dynamics of cooperation, conflict, and coordination between different levels of government, contributing to a better understanding of intergovernmental relations during the pandemic.

    Therefore, by collecting and organizing data, and examining and classifying regulations, we aim to contribute comprehensively to advances in research agendas and to inform policies, practices, and strategies for dealing with future public health crises such as COVID-19.

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    Notes

    • 1
      . COE = emergency operations center
    • 2
      . According to Gomide and Pires (2014), state capacities relate to the technical-administrative, bureaucratic and political capacities of the state to act in the public policy process.
    • *
      The research was supported by the Fundação de Apoio à Pesquisa do Distrito Federal (FAPDF) No. 476/2022. We thank Rebeca de Carvalho, Letícia Macário, Letícia Pereira, Guilherme Ribeiro, and Stelle Rocio for their support in building the database between 2020 and 2021.

    Publication Dates

    • Publication in this collection
      17 Feb 2025
    • Date of issue
      Jan 2025

    History

    • Received
      12 Sept 2023
    • Reviewed
      6 Feb 2024
    • Accepted
      22 Mar 2024
    Creative Common - by 4.0
    This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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