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Brazil is a populous middle-income country, characterized by deep economic and social inequalities. Like most Latin American nations, Brazil historically constructed a health system that included, on the one hand, public health programs and, on the other, social insurance healthcare, which only covered formal workers. This study analyzes the implementation of a universal health system from the mid-1980s to the present, focusing on the context, political agendas, government orientations, and actors. Research techniques included a literature review, interviews with national health authorities, analysis of documents and selected health indicators. In the 1980s, against the backdrop of democratization, Brazil's health reform movement proposed a Unified Health System (SUS), which was incorporated into the 1988 Constitution. The combination of a democratic system with opportunities for interaction between various developmental and social agendas and actors has played a key role in shaping health policy since then. However, the expansion of public services has been hampered by insufficient public funding and by the strengthening of the private sector, subsidized by the state. Private enterprises have expanded their markets and political influence, in a process that has accelerated in recent years. Despite these obstacles, SUS has produced significant health-status improvements and some reductions in Brazil's health inequalities. A combination of long-term structural and contingent factors, international agendas and interests, and domestic political struggles, explains the advances and obstacles to building a universal system in an economically important yet unequal peripheral country. Further consolidation of SUS and reduction of health inequalities hinge on the uncertain prospects for democracy and national development, on enlarging the political coalition to support a public and universal health system, and on strengthening the state's ability to regulate the private sector. Key messages The implementation of a universal health system in Brazil has favored health improvements but has been hampered by insufficient funding and by state subsidies to the expansion of the private sector. A combination of structural and institutional factors, international and domestic political agendas and interests explains the advances and obstacles to building a universal system in Brazil.

Struggles for a universal health system in Brazil: successes, obstacles and setbacks