Regional Inequalities in Basic Sanitation and Public Health Impacts in Brazil's capitals

Regional inequalities in basic sanitation remain a major public health challenge in Brazil. This study assessed the relationship between sanitation indicators and health outcomes related to Diseases Related to Inadequate Environmental Sanitation (DRSAI) in Brazilian capitals from 2010 to 2019. Mortality and hospitalization data were obtained from DATASUS, and water and sewerage coverage indicators from the National Sanitation Information System (SNIS). Pearson correlations and hierarchical cluster analyses were used to explore spatial patterns and associations. Pronounced regional disparities were observed. Northern and Northeastern capitals, including Macapá, Recife, and Salvador, had the highest DRSAI mortality and hospitalization rates, coinciding with the lowest sewerage coverage (<30%) and limited potable water access (<60%). In contrast, Southern and Southeastern capitals, including Curitiba, Porto Alegre, and São Paulo, showed better sanitation and health indicators. Sewage coverage was significantly and negatively correlated with hospitalization and mortality rates (p<0.05), indicating an inverse association between sanitation coverage and DRSAI outcomes. The findings highlight the central role of sanitation in reducing inequalities in DRSAI-related hospitalizations and mortality. Despite progress, universal access remains distant and requires targeted investments and integrated public policies to improve sanitation and public health outcomes in Brazil, particularly in the country's most socially vulnerable urban areas.