Dengue as stress test for the resilience of health systems: An ecological analysis of selected public health functions in Brazil.

OBJECTIVES

Health system resilience is defined as the capacity to maintain essential functions under recurrent or episodic stress. In dengue-endemic settings, seasonal outbreaks represent predictable shocks that simultaneously strain multiple Essential Public Health Functions, providing an empirical lens to assess functional continuity.

STUDY

DESIGN

We conducted an ecological municipality-year study from 2014 to 2024, including 67 Brazilian municipalities with at least 400,000 inhabitants.

METHODS

Functional stress years were defined using extreme deviations in municipality-specific standardized dengue incidence. Functional continuity was measured through z-scores for five services within the Unified Health System: primary health care consultations, antenatal care visits, hospitalizations for diabetes, hospitalizations for hypertension, and elective surgeries. Linear regression and panel data models with fixed and random effects were applied.

RESULTS

Average reductions in functional continuity were observed during stress years, largely within historical municipal variability. Antenatal care showed statistically significant contraction. Hospitalizations for diabetes and hypertension demonstrated relative maintenance, while elective surgeries were positively associated with stress periods. No statistically significant association was observed for primary health care consultations.

CONCLUSION

Dengue outbreaks exert sustained pressure on health services but seldom lead to abrupt systemic disruption. Assessing functional continuity helps distinguish expected adaptation from structural fragility, supporting more policy-relevant evaluations of health system resilience in endemic contexts.