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The Brazilian health system at crossroads: progress, crisis and resilience
  1. Adriano Massuda1,
  2. Thomas Hone2,
  3. Fernando Antonio Gomes Leles3,
  4. Marcia C de Castro1,
  5. Rifat Atun1
  1. 1 Harvard TH Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
  2. 2 Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
  3. 3 Pan-American Health Organization (PAHO)/World Health Organization in Brazil, Brasilia, Brazil
  1. Correspondence to Dr Rifat Atun; ratun{at}


The Unified Health System (Sistema Único de Saúde (SUS)) has enabled substantial progress towards Universal Health Coverage (UHC) in Brazil. However, structural weakness, economic and political crises and austerity policies that have capped public expenditure growth are threatening its sustainability and outcomes. This paper analyses the Brazilian health system progress since 2000 and the current and potential effects of the coalescing economic and political crises and the subsequent austerity policies. We use literature review, policy analysis and secondary data from governmental sources in 2000–2017 to examine changes in political and economic context, health financing, health resources and healthcare service coverage in SUS. We find that, despite a favourable context, which enabled expansion of UHC from 2003 to 2014, structural problems persist in SUS, including gaps in organisation and governance, low public funding and suboptimal resource allocation. Consequently, large regional disparities exist in access to healthcare services and health outcomes, with poorer regions and lower socioeconomic population groups disadvantaged the most. These structural problems and disparities will likely worsen with the austerity measures introduced by the current government, and risk reversing the achievements of SUS in improving population health outcomes. The speed at which adverse effects of the current and political crises are manifested in the Brazilian health system underscores the importance of enhancing health system resilience to counteract external shocks (such as economic and political crises) and internal shocks (such as sector-specific austerity policies and rapid ageing leading to rise in disease burden) to protect hard-achieved progress towards UHC.

  • health systems
  • health systems evaluation
  • health policy

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:©

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  • Handling editor Valery Ridde

  • Contributors RA and AM conceived the study. AM developed the first draft with guidance from RA and input from coauthors. All authors contributed to the final draft.

  • Funding AM was funded by the Pan-American Health Organization/World Health Organization in Brazil.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional unpublished data from the study are available.

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