Abstract

Introduction

The 2030 Agenda, signed in September 2015 by all 193 Member States of the United Nations, is an ambitious global action plan to eradicate poverty and promote a decent life for all. The agreement has 17 Sustainable Development Goals (SDGs) and 169 targets developed to guide the actions of individuals, states, and other institutions towards a sustainable 2030 ¹1. United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. https://sdgs.un.org/2030agenda (acessado em 09/Fev/2022).
https://sdgs.un.org/2030agenda... ^,22. United Nations. Sustainable Development Goals: sustainable development knowledge platform. https://sustainabledevelopment.un.org/index.html (acessado em 27/Nov/2019).
https://sustainabledevelopment.un.org/in... .

The progress of the 2030 Agenda is monitored through a set of 232 internationally defined indicators to allow a comparative assessment from the local to the global level. These indicators seek to provide information to national and subnational governments for the definition of strategies to support the formulation of public policies ³3. Acharya S, Lin V, Dhingra N. The role of health in achieving the sustainable development goals. Bull World Health Organ 2018; 96:591-591A.^,44. Matida A. Por uma agenda global pós-Objetivos de Desenvolvimento do Milênio. Ciênc Saúde Colet 2016; 21:1939-46.^,55. Nunes AR, Lee K, O'Riordan T. The importance of an integrating framework for achieving the Sustainable Development Goals: the example of health and well-being. BMJ Glob Health 2016; 1:e000068..

Institutionalization of monitoring routines based on these indicators is an important path to establish national capacities that can change social and environmental determinants of health ⁶6. Mújica OJ, Moreno CM. De la retórica a la acción: medir desigualdades en salud para "no dejar a nadie atrás". Rev Panam Salud Pública 2019; 43:e12.. Such routines offer important subsidies to public and private agents for more effective and equitable decisions of resource allocation, especially in a context of reduced fiscal space and low systematization in the allocation process, which affects the quality of actions and services provided by the Brazilian Unified National Health System (SUS) ⁷7. Carpanez LR, Malik AM. O efeito da municipalização no sistema hospitalar brasileiro: os hospitais de pequeno porte. Ciênc Saúde Colet 2021; 26:1289-98..

Without more objective criteria, SUS resources, which are shared among the three government levels, expose the system to underfunding, producing inequalities in resource allocation in the territory ⁸8. Oliveira GP, Pinheiro RS, Coeli CM, Barreira D, Codenotti SB. Uso do sistema de informação sobre mortalidade para identificar subnotificação de casos de tuberculose no Brasil. Rev Bras Epidemiol 2012; 15:468-77.. This scenario is aggravated by the tendency to reduce the public budget due to austerity policies. In fact, a reduction in per capita resources in SUS has been observed since 2015, reinforcing the historical underfunding ⁹9. Massuda A, Hone T, Leles FAG, De Castro MC, Atun R. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Glob Health 2018; 3:e000829.^,1010. Rocha R, Atun R, Massuda A, Rache B, Spinola P, Nunes L, et al. Effect of socioeconomic inequalities and vulnerabilities on health-system preparedness and response to COVID-19 in Brazil: a comprehensive analysis. Lancet Glob Health 2021; 9:e782-92.. Massuda et al. ⁹9. Massuda A, Hone T, Leles FAG, De Castro MC, Atun R. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Glob Health 2018; 3:e000829.^,1111. Massuda A, Maria Malik A, Vecina Neto G, Tasca R, Ferreira Junior WC. The resilience of the Brazilian National Health System in the face of the COVID-19 pandemic. Cadernos EBAPE.BR 2021; 19(Special Edition):735-44. discuss the concept of health system resilience and highlight that although SUS shows strong resilience in various crises, adequate funding and resource allocation in strategic areas would expand this capacity, making it less vulnerable to austerity policies. Cavalcanti & Fernandez ¹²12. Cavalcanti P, Fernandez M. A tomada de decisão em políticas públicas de saúde: uma revisão sistêmica a partir de estudos realizados no Brasil. In: Gurgel Junior GD, Pacheco HF, Oliveira SRA, Santos FAS, organizadores. Inovações da gestão pública no SUS: uma abordagem das iniciativas no processo de reforma institucional. Recife: Editora UFPE; 2021. p. 41-72., when analyzing studies related to SUS governance and decisions made by its administrators regarding resource allocation, found the main challenges refer to the use of health information/evidence and proper models to support the process.

Thus, allocating scarce health resources to meet the growing needs of the population in a context of competitive demands, variable care models, demographic changes, and growing political interference that ignores technical reference is a challenging task. The decision about which services to offer in order to achieve a balance between the demand for goods and services that improve the population health, considering fiscal limitations, involves making choices among various alternatives ¹³13. Seixas BV. The no-destination ship of priority-setting in healthcare: a call for more democracy. Int J Health Policy Manag 2018; 7:345-8., which requires systematic, objective, and transparent methods ¹⁴14. Cromwell I, Peacock SJ, Mitton C. 'Real-world' health care priority setting using explicit decision criteria: a systematic review of the literature. BMC Health Serv Res 2015; 15:164..

Among the most common methods for the rationalization of public policies is the development of synthetic prioritization indexes. The advantages of synthetic prioritization indexes include the fact that they provide objective criteria for decisions of resource allocation. However, synthetic prioritization indexes have important limitations; for instance, lack of methodological clarity in its development stages and the risk of simplistic and unidirectional understandings of more complex realities ¹⁵15. Schumann LRMA, Moura LBA. Índices sintéticos de vulnerabilidade: uma revisão integrativa de literatura. Ciênc Saúde Colet 2015; 20:2105-20.. It suggests that technical solutions and adaptations to these indices are required in order to ensure a more rational alternative for decisions regarding resource allocation.

This article seeks to fill these gaps by developing a synthetic prioritization index to speed up the achievement of national health goals proposed in the 2030 Agenda. The empirical analysis of the study is focused on the Health Regions of Brazil, allowing a portrait of health inequalities in the country and supporting the decision-making process of health management for the allocation of public resources in health issues related to the SDGs and in the territory, thus contributing to a stronger SUS.

Method

This is an ecological study, where the units of analysis are the Health Regions of Brazil. These are continuous geographic spaces, resulting from the combination of neighboring municipalities, according to cultural, social, and economic identities, thus sharing infrastructure and communication networks ¹⁶16. Brasil. Resolução nº 1, de 29 de setembro de 2011. Estabelece diretrizes gerais para a instituição de Regiões de Saúde no âmbito do Sistema Único de Saúde (SUS), nos termos do Decreto nº 7.508, de 28 de junho de 2011. Diário Oficial da União 2011; 30 set..

The analysis at the level of 450 Health Regions allows a study with a higher level of territorial disaggregation when compared to studies conducted at the state level. On the other hand, the analysis at the Health Regions level generates more stable estimates when compared to analyses at the municipal level, which are affected by excessive variability of indicators, especially in municipalities with small populations.

We decided to conduct this study based on a 5-year time frame, from 2015 to 2019 to avoid contamination of results by brief punctual changes in work processes, ensuring estimates with lower spurious variability. The analyses were performed until 2019 to obtain the largest time frame with more homogeneous data, considering the performance of municipalities in 2020 was affected by the COVID-19 pandemic.

The analysis in this time frame under the 2030 Agenda is a challenge for the country, given the postponement of the population census, which interrupted the 10-year periodicity of the survey. As the main source of municipal data, the 2020 Demographic Census was initially postponed because of the pandemic and then because of a reduction in the budget of the Brazilian Institute of Geography and Statistics (IBGE) implemented by the Federal Government.

The synthetic prioritization index proposed in this study was based on 25 indicators with analytical proximity to the official indicators of SDGs and for which data are available from public and official sources at the municipal level for the evaluated period. The basic reference for the development of the indicators was a document published by the Institute for Applied Economic Research (IPEA) with the national indicators and sources agreed by the National Commission for the SDGs (CNODS), which sought alternatives for the subnational evaluation of globally harmonized official indicators by the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (IAEG-SDGs) ¹⁷17. Instituto de Pesquisa Econômica Aplicada. ODS - metas nacionais dos Objetivos do Desenvolvimento Sustentável: proposta de pactuação. https://repositorio.ipea.gov.br/bitstream/11058/8636/1/Agenda%202030%20ODS%20Metas%20Nac%20dos%20Obj%20de%20Desenv%20Susten%202018.pdf (acessado em 15/Dez/2022).
https://repositorio.ipea.gov.br/bitstrea... . Both the numerator and denominator of health indicators also observed the criteria set by the Inter-Agency Health Information Network (RIPSA).

The set of developed indicators allows a broad assessment of health. Table 1 presents the main metadata and sources of indicators based on the thematic areas defined by the World Health Organization (WHO), as follows: (1) reproductive and maternal health; (2) newborn and child health; (3) infectious diseases; (4) noncommunicable diseases; (5) injuries and violence; (6) environmental hazards; and (7) universal health coverage and health systems ¹⁸18. World Health Organization. Global status report on road safety 2018. https://apps.who.int/iris/handle/10665/276462 (acessado em 09/Fev/2022).
https://apps.who.int/iris/handle/10665/2... . In addition to these, for the inclusion of the percentage of the population covered by the Brazilian Income Transfer Program, an important variable for the determination of health inequalities, an additional theme was defined: (8) other health-related indicators.

For the synthetic prioritization index development, partial indices - or subindices - were calculated for each of the 25 indicators. The transformation of data into normalized indices is important to ensure the measurements of the indicators are expressed in the same interval, using a unified and unidirectional criterion when assessing the set of indicators. Then it is possible to avoid indicators with measurement units of larger magnitude from indirectly presenting a higher weight in the final prioritization index.

Algebraically, partial index of high type indicators is better (the higher the indicator, the better the health status of the population) as it consists of the quotient between the difference of the value observed by the minimum value and the difference between the maximum value and the minimum value found in the country. As for low-type indicators, its value is calculated by subtracting from the unit the result obtained in the previous step. The value observed for every Health Region was defined as the average annual indicator of that region, while the minimum and maximum values as the worst and the best performance of the indicator observed in the Health Region, respectively (Table 1). Synthetic indices often use targets instead of the maximum value. However, in our study, this approach was not used because not all SDG monitoring indicators have pre-defined targets to be reached by 2030. Global and national targets agreed by the UN and the CNODS, respectively, offer a higher level of aggregation and are directly associated with the 17 SDGs, while the 232 indicators may refer to methods to achieve the 169 targets or even sub-themes not explicitly addressed in the target ¹⁷17. Instituto de Pesquisa Econômica Aplicada. ODS - metas nacionais dos Objetivos do Desenvolvimento Sustentável: proposta de pactuação. https://repositorio.ipea.gov.br/bitstream/11058/8636/1/Agenda%202030%20ODS%20Metas%20Nac%20dos%20Obj%20de%20Desenv%20Susten%202018.pdf (acessado em 15/Dez/2022).
https://repositorio.ipea.gov.br/bitstrea... .

The overall synthetic prioritization index was defined as the geometric mean for the 25 subindices in the Health Region. The geometric mean is commonly used in the literature as a method to ensure the index is not so influenced by outliers, as seen with the arithmetic mean. Likewise, the geometric mean establishes that all targets must progress together ¹⁹19. Chen S, Guo L, Wang Z, Mao W, Ge Y, Ying X, et al. Current situation and progress toward the 2030 health-related Sustainable Development Goals in China: a systematic analysis. PLoS Med 2019; 16:e1002975.^,2020. Hogan DR, Stevens GA, Hosseinpoor AR, Boerma T. Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services. Lancet Glob Health 2018; 6:e152-68.^,2121. GBD 2015 SDG Collaborators. Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015. Lancet 2016; 388:1813-50.^,2222. GBD 2017 SDG Collaborators. Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392:2091-38.^,2323. Machado DB, Pescarini JM, Ramos D, Teixeira R, Lozano R, Pereira VOM, et al. Monitoring the progress of health-related sustainable development goals (SDGs) in Brazilian states using the Global Burden of Disease indicators. Popul Health Metr 2020; 18(Suppl 1):7.. That is, the indicators have the same weights in the synthetic prioritization index, an implicit hypothesis in the use of the unweighted arithmetic mean. Then, each of the 450 Health Regions in the country has a single synthetic prioritization index. The lower the synthetic prioritization index of a region, the higher the prioritization for public investment. On the other hand, regions with high synthetic prioritization indexes can teach important lessons and provide parameters to speed up the development in other regions.

To facilitate the analysis, three prioritization intervals were defined: (I) 0.00 to 0.40: regions with insufficient performance; that is, priority regions for health resource allocation; (II) 0.41 to 0.69: regions with medium performance - to be improved; and (III) 0.70 to 1.00: regions with adequate performance - an example to be followed by other territories ²⁴24. Battesini M, Fischmann A, Weise AD. Identificação de prioridades em saúde: uma alternativa técnica de apoio à tomada de decisão. Ciênc Saúde Colet 2013; 18:3673-82..

The analyses were performed using R 4.0.2 (http://www.r-project.org), packages rgdal, tidyverse, ggplot2, and factoextra.

Results

Table 2 summarizes basic statistics of the distribution of Health Regions in the synthetic prioritization index intervals for each Brazilian state. The best performance was found for the Northeast Region, where only 2 of the 129 regions were classified as insufficient and 2 as adequate. The Southeast and Central-West regions had the second best performance with 5 and 1 Health Regions, respectively, presenting synthetic prioritization index classification as insufficient and 11.5% and 20.5% of Health Regions as medium. The South and North regions presented the worst performance, with adequate synthetic prioritization index for only 30 of 68 (44%) and 20 of 45 (44%) Health Regions, respectively.

Figure 1 shows the geographic distribution of Health Regions by synthetic prioritization index classification, with a high concentration of Health Regions presenting medium and insufficient synthetic prioritization index in the North and South regions. Also, the regions with the worst performance are not isolated in the territory, as they generally border other low-performance regions as well.

The spatial representation of subindices (Figure 1) illustrates the greatest challenges of the country: maternal and reproductive health, newborn and child health, and non-communicable diseases. In all these cases, the number of Health Regions with insufficient level is much higher than the general index. In addition, different patterns can be observed in the country, defying the higher homogeneity indicated by the synthetic prioritization index. While the North Region has Health Regions with the worst performance in aspects such as maternal and reproductive health and health system coverage, the Health Regions with the worst performance in non-communicable diseases are distributed throughout the national territory. On a small scale, infectious diseases and injuries and violence are also well distributed in the territory. Newborn and child health is more problematic in the Northeast Region (besides the North Region).

Figure 2 illustrates the distribution of subindices by theme and macro-region of the country, showing the number of outliers by macro-region under each theme and the important inequalities observed in the national territory. The number of outlier municipalities in the Health Region with inadequate performance in the Southeast Region is a highlight, although this region has the highest average in partial indices and high homogeneity of its Health Regions (expressed as the shortest inter-quartile distance) - which is seen in most of the themes evaluated.

Also, in reproductive and maternal health and newborn and child health, the North and Northeast regions present lower performance when compared to the Southeast Region and, particularly, the South, which presents the best results in the country in these themes. The figure shows that, to a large extent, the second worst performance of the South Region in the general index is due to its worst condition in noncommunicable diseases and Brazilian Income Transfer Program coverage (other indicators). The region also presents low performance in infectious diseases, environmental hazards, and injuries and violence.

The analysis of subindices by indicator identified those with the worst performance in each theme and region. More significant fragilities are related to the themes of noncommunicable diseases and health of newborns and children. The five indicators with the worst national performance are: premature mortality from chronic diseases (especially in the South Region), mortality due to traffic accidents (especially in the Central-West Region), maternal mortality (especially in the North and Northeast regions), prevalence of malnutrition (especially in the North and Northeast regions), and suicide mortality (mainly in the South Region) (Table 3).

Discussion

Resource allocation in health is a topic that has not been fully explored in the public health literature. Silva et al. ²⁵25. Silva KR, Souza FG, Roquete FF, Faria SMC, Peixoto BCF, Vieira A. Alocação de recursos para assistência à saúde em tempos da pandemia de COVID-19: revisão integrativa. Rev Bras Enferm 2020; 73 Suppl 2:e20200244. highlight the need for more research investments in public health management and policies, especially regarding the ethical, financial, and cost aspects, in order to support difficult decisions regarding resource allocation. When investigating resource allocation in health during the COVID-19 pandemic in Brazil, we found a lack of theoretical frameworks, indicating that resource allocation decisions promote ethical and moral conflicts for decision makers, who do not always feel prepared to make such decisions - a situation that may lead to physical and/or mental disorders in these individuals ²⁵25. Silva KR, Souza FG, Roquete FF, Faria SMC, Peixoto BCF, Vieira A. Alocação de recursos para assistência à saúde em tempos da pandemia de COVID-19: revisão integrativa. Rev Bras Enferm 2020; 73 Suppl 2:e20200244..

Indeed, factors such as population size, population density, and geographic proximity to capitals are more important than epidemiological characteristics and care capacity/demand when allocating SUS resources ²⁶26. Fernandes GAAL, Pereira BLS. Os desafios do financiamento da ação de enfrentamento ao COVID-19 no SUS dentro do pacto federativo. Rev Adm Pública 2020; 54:595-613.. More recently, discretionary resource allocation has gained relevance through parliamentary amendments, contributing to unequal non-evidence-based distribution of health resources.

Then, effective management processes and continuous assessments must be adopted in health systems for an efficient distribution of resources at the local level ²⁷27. Heredia-Martínez HL, Artmann E. Criterios para la (re)distribución equitativa de los equipos básicos de salud en el nivel local en Venezuela. Cad Saúde Pública 2018; 34:e00171117.. After all, decision makers in health are constantly faced with the challenge to define priorities in their territory as a natural consequence of the imbalance between demands and available provisions, whether physical, material, or human resources. The definition of priorities should take into account different types of knowledge and actors in order to prevent the use of health planning and evaluation tools as instruments for different forms of domination ²⁸28. Furtado JP, Campos GWS, Oda WY, Onocko-Campos R. Planejamento e avaliação em saúde: entre antagonismo e colaboração. Cad Saúde Pública 2018; 34:e00087917..

The inclusion of different actors in the decision-making process requires simplifying language to express the health situation of population, allowing it to be understood by non-experts. The synthetic prioritization index used in this study, by incorporating indicators recommended in the 2030 Agenda, offers an important assessment of the health conditions of population and it is easy to replicate and understand, expanding its use at the local level to answer questions such as: what are the priority health problems in the various territories? In which territories should investments be prioritized?

The results of this study also show that more investments are required in health in the North Region of Brazil, in agreement with prior studies reporting the lowest rates of health service use by the population in this region ²⁹29. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saúde Pública 2017; 51 Suppl 1:3s., and presenting an availability of medical professionals (1/1,000 inhabitants) that is seven times lower than the ratios found in the capitals of the South Region (7.1/1,000) and the worst assessments of primary care services ³⁰30. Pinto LF, Quesada LA, D'Avila OP, Hauser L, Gonçalves MR, Harzheim E. Primary Care Asssement Tool: diferenças regionais a partir da Pesquisa Nacional de Saúde do Instituto Brasileiro de Geografia e Estatística. Ciênc Saúde Colet 2021; 26:3965-79..

Studies addressing Health Regions in the Legal Amazon show that health policies from the Federal Government have low institutionality, discontinuity, and limited sensitivity to regional specificities ³¹31. Garnelo L, Sousa ABL, Silva CO. Health regionalization in Amazonas: progress and challenges. Ciênc Saúde Colet 2017; 22:1225-34.. According to the authors, the region also receives less resources than the national average, in addition to limited management capacity at the municipal level.

The findings also point to important inequalities among the regions regarding the thematic areas and the evaluated indicators that must be considered in decisions about resource allocation. Even if they are influenced by a higher reporting capacity of a Health Region due to several factors, this difference in the capacity indicates that more investments are required in the Health Region.

Regarding health problems that should be prioritized, premature mortality from chronic diseases is highlighted in the South Region of the country. Despite studies reporting reduction of some chronic diseases in Brazil in recent years ³²32. Cardoso LSM, Teixeira RA, Ribeiro ALP, Malta DC. Mortalidade prematura por doenças crônicas não transmissíveis nos municípios brasileiros, nos triênios de 2010 a 2012 e 2015 a 2017. Rev Bras Epidemiol 2021; 24:E210005.SUPL.1.^,3333. Confortin SC, Andrade SR, Draeger VM, Meneghini V, Schneider IJC, Barbosa AR. Mortalidade prematura pelas principais doenças crônicas não transmissíveis nos estados do Brasil. Rev Bras Enferm 2019; 72:1588-94.^,3434. Malta DC, Andrade SSCA, Oliveira TP, Moura L, Prado RR, Souza MFM. Probabilidade de morte prematura por doenças crônicas não transmissíveis, Brasil e regiões, projeções para 2025. Rev Bras Epidemiol 2019; 22:E190030. and good perspectives regarding the achievement of the global target of 25% reduction by 2025, as established in the Global Action Plan for Chronic Noncommunicable Diseases ³⁴34. Malta DC, Andrade SSCA, Oliveira TP, Moura L, Prado RR, Souza MFM. Probabilidade de morte prematura por doenças crônicas não transmissíveis, Brasil e regiões, projeções para 2025. Rev Bras Epidemiol 2019; 22:E190030., this is still an important challenge for the country.

Addressing chronic noncommunicable diseases (CNCDs) involves the development of policies and programs, especially in primary health care, for health promotion strategies, reduction of risk factors (smoking, inadequate diet, obesity, physical inactivity, and excessive alcohol use) and support for disease treatment ³⁵35. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil: 2011-2022. Brasília: Ministério da Saúde; 2011.. For Ribeiro et al. ³⁶36. Ribeiro ALP, Duncan BB, Brant LCC, Lotufo PA, Mill JG, Barreto SM. Cardiovascular health in Brazil: trends and perspectives. Circulation 2016; 133:422-33., successful strategies that have led to reduced mortality from CNCDs include expansion of primary care, improvements in the provision of health services, and distribution of medication to the population at risk (such as cardiovascular diseases). Then, resource allocation to this area is essential in Health Regions with poor performance indicator in this theme.

Mortality from traffic accidents was the main health problem found in the Central-West Region. In addition to leading to the death of a significant part of the economically active population, traffic accidents have a significant impact on the economy due to the high costs of patient care and hospitalization ³⁷37. Cover DP, Nunes EAB, Carvalho KM. Mortalidade por acidentes de trânsito no Piauí: caracterização dos casos no biênio 2012-2013. Revista Uningá 2016; 49:12-9.. Such impacts emphasize the importance of allocating resources to intersectoral actions involving traffic education, as well as inspection of the drink-driving law in force in Brazil since 2008, which has promoted a significant reduction in mortality from traffic accidents, as reported in studies conducted in the state of Santa Catarina and the Federal District ³⁸38. Nunes HRC, Murta-Nascimento C, Lima MCP. Impacto da Lei Seca sobre a mortalidade no trânsito nas Unidades Federativas do Brasil: uma análise de série temporal interrompida. Rev Bras Epidemiol 2021; 24:e210045..

Reducing maternal mortality has been a UN commitment since the Millennium Development Goals (MDGs) and is an old challenge for Brazil, particularly in the most vulnerable regions. Understanding the dynamics of this indicator involves complex aspects, such as social and economic inequalities in the country’s regions; quality of information available; development of policies, programs, and actions to address this issue; care related to the pregnancy-puerperal cycle and illegal abortion ³⁹39. Motta CT, Moreira MR. O Brasil cumprirá o ODS 3.1 da Agenda 2030? Uma análise sobre a mortalidade materna, de 1996 a 2018. Ciênc Saúde Colet 2021; 26:4397-409..

Then, the results suggest more investments should be made in Health Regions presenting lower performance in this indicator, focusing on qualification and evaluation of prenatal services, with emphasis on the prevention of hypertensive complications, better adequacy of prenatal care in women between 10 and 29 years old, policy adaptation to prevent deaths among young mothers, legalization of abortion, reduction of the cesarean section rate, reduction of the gestational risk associated with late pregnancy, and improvements in the quality of information about maternal deaths ³⁹39. Motta CT, Moreira MR. O Brasil cumprirá o ODS 3.1 da Agenda 2030? Uma análise sobre a mortalidade materna, de 1996 a 2018. Ciênc Saúde Colet 2021; 26:4397-409.. The prevalence of malnutrition among children under 5 years of age is also a concern in the North and Northeast regions, which reinforces the fact that investments are required in interventions for maternal and child health.

The fifth and most important health problem, according to the ranking of this study, is the suicide mortality rate, particularly in Health Regions in the South Region of the country. Suicide is one of the major causes of preventable violent death in modern society. The state of Rio Grande do Sul has historically been among the Brazilian states with the highest suicide rates ⁴⁰40. Rodrigues CD, Souza DS, Rodrigues HM, Konstantyner TCRO. Trends in suicide rates in Brazil from 1997 to 2015. Braz J Psychiatry 2019; 41:380-8.. Addressing this problem involves investments in public health strategies and specific social policies ⁴¹41. Leenaars A. Effective public health strategies in suicide prevention are possible: a selective review of recent studies. Clin Neuropsychiatry 2005; 2:21-31..

The synthetic prioritization index proposed in our study is a tool with high potential to help Brazilian municipalities in the process of fulfilling the targets of the 2030 Agenda and its commitment to leaving no one behind. Many national initiatives have been identified, from governments and the private sector, that support municipalities in the implementation and monitoring of SDGs. These initiatives present important indicators for that purpose at the local level, using tools that include interactive maps, panels, infographics, among others.

Some of these initiatives propose indices comprised of different indicators from the 2030 Agenda, such as the Atlas of Human Development in Brazil ⁴²42. Programa das Nações Unidas para o Desenvolvimento; Fundação João Pinheiro; Instituto de Pesquisa Econômica Aplicada. Atlas do desenvolvimento humano no Brasil. http://www.atlasbrasil.org.br (acessado em 10/Set/2022).
http://www.atlasbrasil.org.br... , an initiative that collects information about the Municipal Human Development Index (M-HDI) of all Brazilian municipalities; the Sustainable Cities Project ⁴³43. Programa Cidades Sustentáveis. Índice de desenvolvimento sustentável das cidades. https://www.cidadessustentaveis.org.br/paginas/idsc-br (acessado em 22/Out/2022).
https://www.cidadessustentaveis.org.br/p... , which presents the City Sustainable Development Index and the Social Progress Index (SPI), a direct measurement of human development based on indicators selected from three dimensions: basic human needs, foundations of human wellbeing, and opportunities ⁴⁴. However, experiences like these are rarely reported in the scientific literature, which justifies the development of studies that assess the situation and evolution of health in the national territory and support decisions about resource allocation, promoting reflection on possible ways to support municipalities in the implementation of the SDGs, especially considering the perspective that Brazil may not fulfill any of the 17 goals proposed in the 2030 Agenda ⁴⁵45. Moreira MR, Kastrup E, Ribeiro JM, Carvalho AI, Braga AP. O Brasil rumo a 2030? Percepções de especialistas brasileiros(as) em saúde sobre o potencial de o país cumprir os ODS. Saúde Debate 2019; 43:22-35.^,4646. Vieira FS. O financiamento da saúde no Brasil e as metas da Agenda 2030: alto risco de insucesso. Rev Saúde Pública 2020; 54:127..

This study has limitations which are inherent to ecological studies, particularly regarding the use of secondary data in comparisons between HRs, which does not take into account the weaknesses of information systems. Studies indicate significant underreporting differences in information systems regarding the structure of health networks when comparing the regions of the country ⁴⁷47. Drumond EF, Machado CJ, França E. Subnotificação de nascidos vivos: procedimentos de mensuração a partir do Sistema de Informação Hospitalar. Rev Saúde Pública 2008; 42:55-63.^,4848. Oliveira VHFP, Oliveira MB, Blumenberg C, Herval AM, Paranhos LR. Analysis of financial resources for public health in Brazilian capitals: a time trend ecological study. Cad Saúde Pública 2022; 38:e00311620.^,4949. Muzy JM, Campos MR, Emmerick I, Silva RS, Schramm JMA. Prevalência de diabetes mellitus e suas complicações e caracterização das lacunas na atenção à saúde a partir da triangulação de pesquisas. Cad Saúde Pública 2021; 37:e00076120.. This is particularly relevant in the North Region, with the highest number of underreported diseases, for example, diabetes mellitus and tuberculosis ⁴⁷47. Drumond EF, Machado CJ, França E. Subnotificação de nascidos vivos: procedimentos de mensuração a partir do Sistema de Informação Hospitalar. Rev Saúde Pública 2008; 42:55-63.. Small municipalities also have higher numbers of underreported diseases. Then, the synthetic prioritization index results, especially in Health Regions with a higher number of small municipalities and which are distant from large national centers, may marginally reflect this pattern of Brazilian health information systems. However, this reality is different for the various indicators, so that its effects are quite diluted in the partial and general indices. Also, the results obtained in this study reflect the best picture of the Health Region based on available data (without adjustments that require deep knowledge of local reporting dynamics), and using such health information for planning purposes can even be a good strategy to reduce underreporting.

Final considerations

The synthetic prioritization index proposed in our study was considered a powerful method to support health management decisions. Its results helped identify that Health Regions with less favorable social characteristics, particularly in the North Region of the country, are the most vulnerable and, therefore, should be priority regions for resource allocation. In addition, the analysis of subindices highlighted local health bottlenecks, reinforcing that municipalities in each region should establish their own priorities in health resource decisions.

The findings of this study, when identifying Health Regions and priority themes for more investments, show paths that can support the implementation of the 2030 Agenda at local or national levels, and provide elements through which policy makers can minimize the effects of social inequalities on health, prioritizing territories with lower indices.

The synthetic prioritization index proposed in this study is a step forward in supporting decisions based on care and epidemiological characteristics, particularly for highlighting major inequalities in the country and the themes and regions with stronger demands. However, the notion of prioritization indicated by the index must be limited to understanding the different realities found in the country and should not be used as a notion of inter-regional competition for scarce resources. The index does consider the existence of sufficient resources for public health policy. In this sense, SUS underfunding is the most pressing issue in the current Brazilian context.

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