Hospitalization, mortality and public healthcare expenditure in Brazil during the COVID-19 crisis: vulnerabilities in the spotlight

ABSTRACT BACKGROUND: Multiple opinion-based communications have highlighted the actions of the Brazilian government during the pandemic. Nevertheless, none have appraised public data to identify factors associated with worsening of the healthcare system. OBJECTIVE: To analyze and collate data from public health and treasury information systems in order to understand the escalating process of weakening of Brazilian healthcare and welfare since the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. DESIGN AND SETTING: Secondary data study conducted using multiple public databases administered by the Brazilian federal government. METHODS: We processed information from multiple national databases and appraised health and economic-related data. RESULTS: Based on our analyses, there were substantial reductions in inpatient hospital admissions and in the numbers of patients seeking primary care services, along with a decrease in immunization coverage. Moreover, we observed a considerable decline in government transfers to hospital services (reduction of 82.0%) and a diminution of public outlays in several healthcare-related subfunctions (“hospital and outpatient care”, “primary care”, “prophylactic and therapeutic support” and “epidemiological surveillance”). We observed an increase in the overall mortality rate over the period analyzed, especially regarding all group-based diseases. Notably, there were remarkable differences among geographic, racial, gender and other parameters, thus revealing the impact of vulnerabilities on COVID-19 outcomes. CONCLUSION: This assessment of documentation of public expenditure and the shrinkage of investment in sensitive areas of the healthcare system in Brazil emphasized areas that still require collective attention in order to guarantee national welfare.

health and treasury information systems in order to understand the escalating process of weakening of the Brazilian healthcare system and worsening of welfare since the onset of the pandemic.

OBJECTIVE
To analyze and collate data from public health and treasury information systems in order to understand the escalating process of weakening of Brazilian healthcare and welfare since the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

METHODS
We designed and conducted this study through secondary data that originated from the Information Technology Department of the Brazilian National Health System (DATASUS), the health information system for primary healthcare (SISAB) and the Brazilian public expenditure portal (a platform dedicated to making public all expenditures of the federal government). [18][19][20] DATASUS is an online interface governed by the Secretariat for Strategic and Participative Management of the Ministry of Health. 18 It contains multiple information about procedures performed at primary, secondary and tertiary healthcare facilities. 18 Additionally, SISAB is a strategy created by the Department of Family Health that has the aim of expanding information management and process automation, thereby improving conditions and improving work processes. 19 We extracted information about the numbers of hospital admission authorizations, total cost of admissions, mortality rate and amounts of the federal government transfers. The data were stratified according to geographic region, race, type of medical care (elective or emergency), level of complexity and chapter of the International Classification of Diseases, 10 th edition (ICD-10).
We defined four health indicators as relevant primary healthcare performance measurements, in order to monitor the healthcare actions and services offered to society within the primary care level: 1. Mean percentage of diabetic individuals for whom measurements of glycated hemoglobin (HbA1c) were requested; 2. Mean percentage of hypertensive individuals for whom blood pressure levels were measured each semester; 3. Mean proportion of pregnant females who attended at least six prenatal consultations, among which the first consultation occurred no later than the 20 th gestational week; and 4.
Immunization coverage rate. We also examined public healthcare-related expenditure by assessing the overall amounts paid in specific subareas/subfunctions (hospital and outpatient assistance, primary care, therapeutic and prophylactic support, general administrative tasks, epidemiological surveillance and others). Descriptive analysis was performed, and the variance over the period analyzed was calculated. The data were stored and processed using Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States).
All quantitative data from 2020 were compared with baseline data from 2019. All monetary-related variables were deflated in accordance with the Expanded Consumer Price Index (IPCA), based on the 2019 values. 21 One United States (US) dollar was equivalent to 5.32 Brazilian reais on May 25, 2020.

RESULTS
Overall, there was a reduction in the number of inpatient hospital authorizations in 2020, compared with 2019 (mean decrease of 13.7%, ranging from 11.4% to 15.6%; Table 1 and Figure 1).
The reduction was more pronounced in the northeastern and southern regions (-15.6% and -15.1%, respectively) and among white and indigenous individuals (-15.1% and -16.1%, respectively).
Interestingly, black individuals were a racial group with a disproportionately large decrease in inpatient hospital authorizations (-3.4%), compared with other racial groups. Additionally, elective medical hospitalizations showed a substantial decline from 2019 to 2020 (-34.3%) with increases in the total cost of hospitalizations (+3.4%) and the all-cause mortality rate (+30.6%).
Considering each chapter of the ICD-10, most groups showed a decrease in the number of inpatient hospital authorizations, except with regard to chapter I (infectious and parasitic diseases) and chapter XVI (disorders of the perinatal period). Nevertheless, as can be seen in Figure 1, the decrease in hospital admissions was not followed by any reduction in the specific-cause mortality rate (except with regard to chapters XVI, VII and XV). Additionally, there was an increase in deaths due to infectious and parasitic diseases (approximately 40.0%).
Regarding monetary variables, general hospitalization costs increased in most Brazilian macroregions, except in the southern region (-1.1%). In addition, hospitalization costs declined among individuals of indigenous origin (-0.8%), elective medical hospitalizations (-21.9%) and high-complexity care procedures (-12.5%). Regarding the general value of the federal complement of hospital services approved over the period analyzed, a substantial decrease in the amount transferred was noticed from 2019 to 2020 (-82.0%). Based on the public expenditure analysis ( Table 2), the federal government spent nearly R$ 114 billion (9.5% of total federal expenditure) on healthcare in 2019.
Of that, the subfunction "hospital and outpatient care" accounted for nearly R$ 57 billion, "primary care" about R$ 26 billion, "prophylactic and therapeutic support" about R$ 10 billion and "general administration" about R$ 7 billion. The full-year federal expenditure report for the fiscal year 2020 showed that there was an increase in the federal government's direct outlays on healthcare (approximately R$ 150 billion, corresponding to 9.4% of total federal expenditure), particularly for the subfunction "general administration" (relative increase of 24.2%). Nevertheless, significant reductions in public expenditure in several healthcare-related subfunctions were noticed, including for "hospital and outpatient care" (relative reduction of 13.6%), "primary care" (relative reduction of 5.9%), "prophylactic and therapeutic support" (relative reduction of 2.0%) and "epidemiological surveillance" (relative reduction of 1.1%).
The all-cause mortality rate increased among all the major parameters analyzed (Figure 1). The greatest differences in allcause mortality rate were observed in the northern region (+44.6%), among indigenous and male individuals (+49.7% and +32.5%, respectively), in elective medical procedures (+83.6%) and in medium-complexity care (+45.9%).
Among primary care performance variables, four main parameters were analyzed. Overall, the mean percentage of diabetic individuals for whom glycated hemoglobin (HbA1c) measurements were    [26][27][28][29] For instance, in the United States, cardiac catheterization due to laboratory ST-segment elevation myocardial infarction activation was reduced by 38.0%, and this was similar to results found in Spain (40.0% reduction).
Regarding oncology services, a recent systematic review showed that interruption of cancer treatment at any stage was reported by up to 77.5% of the patients enrolled at the services included in the surveys, and that this was usually associated with reduced service availability. 30 In general, the reasons for this reduction in services may involve interruption of clinical and surgical procedures, including those with diagnostic purposes, and a representative decrease in transplantation activities. This ultimately implies an increasing accumulation of patients with chronic conditions but without care, which would be in addition to the historical repressed demand for elective surgeries. This situation may be exceedingly harmful, and is aggravated by the reduction of 81.9% in federal complementation of resources destined for hospitalizations. Thus, we reiterate and advocate that there is a need to maintain access to healthcare, particularly for patients with comorbidities, in order to decrease morbidity and mortality among this considerable proportion of the whole population.
We found that there had been considerable reductions in public