In December 2019, the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was identified as the causative agent of coronavirus 2019 (COVID-19) (1). The WHO declared COVID-19 a pandemic disease by the end of January 2020 (1). As of July 6, 2021, COVID-19 infected more than 183 million people and resulted in almost 4 million deaths globally (2). However, Brazil, where the virus reached much later than other countries, is one of the most affected countries with 19.1 million confirmed cases and 533,000 deaths reported so far (2). This case burden put the Brazilian health service at risk of total collapse (3).

To provide necessary health system resources to adequately overcome COVID-19, a strong coordinated emergency response with adequate facilities, personnel, and equipment is required (4). Resource constraints, including a lack of intensive care, inequitable distribution of hospital beds, and inadequate numbers of ventilators, compromise the capacity of the health system to care for patients with COVID-19 (5). In addition, the Brazilian government has faced several challenges while seeking the funds for the public Unified Health System (SUS) over the last decade (6). The lack of funds to support the public health system has led to a deterioration of health capacity among smaller municipalities and exacerbating inequalities (6).

The Unified Health System (Sistema Único de Saúde, SUS) of Brazil is the Brazil Health System. Brazil is the only country with a population of more than 200 million people to have a universal health care system, where almost 75% of the population rely on the service (7). SUS is maintained by public power, with supplementary participation of private initiatives, which guarantees free health care for all citizens, which is based primarily on equity, universality, and integrality (7, 8). However, as Brazil is a country of continental dimensions (8), geographic distribution of hospitals and physicians does not necessarily reach all Brazilians, turning healthcare accessibility into a severe problem. Many studies have recently used the Geographic Information System (GIS) to verify the accessibility to healthcare or to identify poorly served areas (9–11). The two-step floating catchment area (2SFCA) is, by far, the most used GIS technique to verify the accessibility to care, calculating the ratio of suppliers to the population within a service area centered at the location of a supplier (12). Such a method provides useful information on resources management by addressing the necessary support to the most deprived location of the country.

Globally, healthcare systems have collapsed due to COVID-19 (13). Hospital administrators, governments, policy-makers, and researchers must prepare for an immense surge of patients overloading the healthcare system. Thus, to verify the Brazilian healthcare preparedness in pandemic times, this study aims to analyze the geospatial distribution of healthcare resources (intensive care units and hospital beds, ventilators, and hospitals) and the access to establishments with intensive care units (ICU).

Our study showed that Brazil has significant regional disparities in infrastructure and professional resources that affect health outcomes during COVID-19 pandemic. In general, our findings demonstrated a health care system suffering from geographical inequalities (6). However, the North region was the most affected by the pandemic due to the dispersion of cases of COVID-19, as demonstrated by Castro et al. (24), and corroborated with our study showing the lack of access to hospital resources.

The oxygen crisis in Manaus can be considered as an example of the consequences of the inequity distribution of emergency resources (25). During the first wave of COVID-19, around May 2020, Amazonas also experienced an exponential increase of deaths at home that led to a collapse of both the health care and funerary systems (25). Despite the consequences associated with the first wave, Manaus decided to relax social-distancing measures. When the second COVID-19 wave struck, oxygen shortages led to the deaths of up to 40 COVID-19 ICU patients in Manaus, in January 2021 (25). Key failures at the local and national levels contributed to these tragedies.

In Brazil, health professionals are not evenly distributed geographically to accomplish the Collegiate Board Recommendations Resolution, especially those who work in ICU. In terms of nursing and physicians in ICU, many regions have few critical care workers. These professionals care for more beds than recommended, potentially putting patients at risk of adverse outcomes (26). Kerlin et al. (27) verified that overworked professionals in critical care are more likely to experience burnout and provide unsatisfactory quality of care, which may have significant consequences for patient care and the healthcare system. In addition, the intense and emotionally charged work drains healthcare providers physically and emotionally to the point where they may get sick, further limiting their ability to treat patients and reducing the available workforce (28). Therefore, Brazilian regions with overworked professionals may face a more significant challenge against COVID-19.

Health resources in Brazil are majorly accessible to the people living in urban areas, with abundant access focused in larger centers in the southeast and south regions such as São Paulo, Rio de Janeiro, Paraná, and Santa Catarina States. On the other hand, underdeveloped, rural, and sparsely populated regions did not receive the same attention in comparison to the developed areas. The uneven distribution of health resources led to a disproportionate number of cases and mortality of COVID-19.

Here we analyzed the distribution of ICU beds in February, before the arrival of COVID-19 in Brazil, to verify the preparation for health resources management. Initially, few hospital beds were relocated to serve only patients with COVID-19, which reduced the number of beds available for patients with other pathologies. This maneuver affected negatively densely populated regions where they usually have a greater availability of beds. However, the impact was even worse in regions with few beds. Therefore, to circumvent this situation, new ICU beds were created to serve patients with COVID-19, apart from preexisting ones. But when the first wave hit Brazil by June, we verified that new beds were mainly added in the south and southeast regions, where there were already higher numbers of beds in comparison to other regions. Thus, those regions with few beds faced a disproportional challenge to overcome COVID-19.

In Brazil, existing socioeconomic inequalities have affected the course of COVID-19, with a disproportionate adverse burden on states and municipalities with high socioeconomic vulnerability (29). The results we got are aligned with other studies in the literature, emphasizing that the distribution of emergency resources dedicated to tackle COVID-19 followed the patterns of inequalities present in the country before the pandemic (29). Part of this outcome was due to a lack of central coordination to better drive the opening of new ICU beds, distribution of ventilators, as well as the other resources to support emergency care. The political context posed a major challenge to the response. The risk of the virus has been downplayed by the current political leadership in Brazil, and messages from the federal government have been mixed with regard to physical distancing restrictions, use of face masks, and reopening plans, among other aspects (29).

The surge of critical supply shortages affected all countries and led to a worldwide race for ventilators (30). The availability of ventilators in Brazil was not satisfactory in several regions, especially in the north and northeast regions. Therefore, the most severe cases of COVID-19 may be more overwhelming in these regions (31). This situation predicted and stated that Brazil faced a double crisis: COVID-19 and internal political conflicts. The federal government went against the Ministry of Health and WHO's technical recommendations when COVID-19 reached Brazil (32). Thus, each administrative level implemented isolated responses to prepare for COVID-19 with limited country-level coordination. The effective absence of a Brazilian government response to COVID-19 made the country particularly susceptible to outcome inequities (33). Furthermore, healthcare has been overlooked by the government, delaying and promoting insufficient resources to aid the most vulnerable population (34).

This study presents its strengths. First, all data are publicly available. In addition, this is one of the first studies to perform spatial analysis to verify the uneven distribution of ICU beds in Brazil. However, the study also presents some limitations. Biases are commonly found in observational studies based on secondary data and cannot be ruled out, especially here since the data were obtained from the government. The accessibility index to ICU beds was performed, taking into consideration that everyone within the radius of 120 km from HCC had the same chance to be treated. However, the geography in Brazil is highly diverse, and the population in the Amazon region probably had higher challenges since their transportation frequently relies on rivers. Furthermore, we could be overestimating the accessibility of large centers because patients deliberately travel great distances to larger centers to have a greater chance of being assisted, overloading this center as it would be serving a population outside the scope stipulated by the analysis.

In conclusion, Brazil has a myriad of infrastructure challenges limiting its ability to treat critically ill patients. We have demonstrated an insufficient number of ICU beds and ventilators, and a severely limited number and inequitable healthcare professional distribution. Additionally, the allocation of new beds did not address areas with known gaps in care and health infrastructure accessibility. Therefore, the SARS-CoV-2 epidemic in Brazil may be devastating, especially in areas with limited health infrastructure. Lastly, this study suggests that strong leadership is needed to coordinate the response efforts against COVID-19.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

LS contributed to the investigation, software, formal analysis, and writing—original draft. AC, PI, and GR made substantial contributions to the data curation and formal analysis. LA, IP, JC, PV, and TH performed the methodology, formal analysis, validation, and visualization. CS contributed to the supervision and writing—review and editing. JN and RF contributed equally to the conceptualization, project administration, and contributed to the supervision and writing—review and editing. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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