Governance for health system resilience: Lessons from Brazil’s decentralized health system

• Decentralized governance enabled region-specific responses to the COVID-19 crisis. • Legislative flexibility supported rapid vaccine approval and local production. • Reliable health data from independent consortia countered misinformation. • State and local authorities led the pandemic responses, due to federal absence. • Social Accountability mechanisms ensured effective public health interventions. ; The COVID-19 pandemic exposed vulnerabilities in global health systems, highlighting the need for resilience in governance, leadership, and response mechanisms. Brazil's Unified Health System (SUS) is one of the largest health systems in the world and due to its decentralised and fragmented model could provide learnings to other health systems. This research explores governance for health system resilience to the COVID-19 pandemic in Brazil’s Unified Health System (SUS), focusing on leadership and governance structure, legislation and regulation, information and intelligence, and accountability, integrity and trust. A qualitative approach was employed, including document analysis, focus groups and interviews with 35 national, state and local health experts. Data were analysed by the inductive approach to examine the system’s response, and recovery, and learning phases. In the absence of strong federal leadership, state and municipal governments played pivotal roles in managing the crisis. This decentralisation enabled more flexible and region-specific responses. Furthermore, legislative flexibility, as demonstrated by the rapid vaccine approval processes and local production efforts, underpinned timely public health interventions. Information and intelligence systems were also crucial in providing reliable health data, particularly from independent consortia, which countered misinformation and helped maintain public trust. Accountability mechanisms, supported by national health councils, were instrumental in ensuring the implementation of public health measures, despite political and structural challenges. Decentralised governance, adaptable legal frameworks, transparent communication, and robust accountability are essential for building resilient health systems capable of responding to future global health crises.