Federalism and SUS Resilience: The new leadership of state governments in facing the COVID-19 pandemic.

The health emergencies in the last 20 years have highlighted the need to understand the characteristics of health systems that contribute to resilience in the face of extreme shocks. Studies have emphasized organizational aspects of health systems that contribute to resilience. However, this article analyzed the dynamics of intergovernmental relations to investigate how the state governments contributed to SUS resilience during the COVID-19 pandemic. The analytical model proposed by the World Health Organization was adopted to assess the response of health secretaries of state governments to a survey complemented by data from scientific literature. The results show that the leadership of state health secretariats strengthened the four dimensions of resilience: (1) preserving governance and coordination of health policies; (2) managing financial resources and strengthening coverage of health services; (3) securing resources to preserve services and meet new demands; and (4) implementing innovative approaches in health services to address the pandemic challenges. The study concludes that there was asymmetric progress among the four dimensions, with significant advances in governance.