What questions about the future of SUS should candidates discuss in elections?

It is clear that the Universal Health System (SUS) needs increased resources, but the complexity of this topic goes beyond simple financing. Discussions during elections often focus on isolated aspects of SUS, starting or concentrating on the wrong issue—the lack of money. Although it is obvious that SUS requires more funds, the problem lies in the assumption that solving all of Brazil's health problems is merely a matter of increasing budgetary allocations, whereas the topic is much more multifaceted.

From a practical standpoint, in the coming years, there is unlikely to be a significant increase in funding. Based on this reality, the central question may be different: can the existing funding model meet the needs of the Brazilian healthcare system? The current model played an important role in the implementation and expansion of SUS, but it no longer meets the demands of an aging population living with chronic diseases and needing a coordinated care network. Today, a large part of the funds continues to be allocated to paying for procedures and hospitalizations, but expanding the range of services is one thing, and organizing the healthcare system is quite another; the network organizes management.

Beyond Financing

Consider the example of a small hospital. It solves some of the population's problems, but it does not perform cardiac surgeries, treat cancer, or carry out high-tech procedures. Nevertheless, it continues to consume resources because it is included in the fee-for-service funding model. If a mayor decides that it is more profitable to purchase these services elsewhere and close this hospital, a serious conflict arises. Another key question to ask is: in such cases, do the funds follow the patient or remain tied to the municipality's structure? Most often, they remain where they always were.

This is where the discussion often reaches a deadlock and does not move forward. Instead of discussing how to reorganize the network, only how much money should be invested in it is discussed. The question should be phrased differently: how to finance care for the population, not just existing services? To achieve this, regional health centers must be strengthened. Instead of scattering funds among thousands of municipalities, funding should follow the regional network capable of jointly deciding where it is appropriate to keep hospitals, expand outpatient clinics, hire specialized services, or invest in primary healthcare. The citizen already uses this regional network, but the management is organized as if each municipality can independently solve its population's problems.

Therefore, the mayor often states that certain care is the state's responsibility, while the state points to another manager. Strictly speaking, neither is wrong. The problem is that each manages only their part of the system. The citizen, however, goes through the entire network.

Divided System, Single Patient

Queues follow the same logic. We often view them as a consequence of lack of money, but this is not always the main reason. They often arise in a system where each manager organizes only their part. The municipality creates one queue, and the State creates another. The patient enters both. If they receive care in one place, they continue to wait in another because the systems do not interact. It is easy to understand why this happens, but it is difficult to continue viewing this problem as solely a resource shortage.

One need only look at the São Paulo subway. There is an excellent state network and an excellent municipal network. The problem is not the quality of the services. The problem is that they function as two autonomous networks. Each regulates its patients, sets its own flows, and manages its own resources. The person who needs help does not see this division; they simply want to solve their problem. But the administrative logic is organized by boundaries that make sense to the managers, but not necessarily to those who use the system.

There is a discussion that, in my opinion, receives far less attention than it should: regionalization. A citizen does not get sick within one municipality. They go through a network of services. Today, they have an analysis in one city, consult a specialist in another, and if they need high-tech examinations and treatment, they will most likely be served in a third municipality. The system already works at the regional level. The management does not. Each body administers its part. The citizen goes through the entire system; the management remains fragmented.

The same logic appears in discussions about doctor shortages. It is always said that more specialists need to be trained. Of course, the country needs to expand its capacity for training personnel. But is it enough just to open vacancies? That is not enough. A doctor works where they find a functioning hospital, residency opportunities, structured teams, and prospects for professional development. This is true in Brazil and in any other country.

We also face deep demographic changes. The Brazilian population is aging rapidly, and this completely changes the demand for medical services. Care ceases to be a one-time service and turns into continuous monitoring of people with chronic diseases, multiple medications, and needs affecting various specialists. It is known that such care is not organized from municipality to municipality; it depends on an integrated network.

The introduction of new technologies will undoubtedly take a significant place in healthcare proposals. Artificial intelligence, telemedicine, electronic health records, and information systems can significantly improve the quality of care. But again, the question is different. What does technology solve? If it is implemented in a disorganized system, it will continue to yield limited results. I will give a simple example. A patient undergoes an examination at a facility in the Morumbi neighborhood, and a few days later seeks help in Ponte Pequena. The tests already exist, but the doctor cannot access them. Often, everything has to be repeated. It is not a lack of technology. It is that the systems were designed to interact within one organization, not between different services. Solving the interoperability problem may bring more benefit to the citizen than simply computerizing isolated medical facilities.

The Challenge of Reorganization

There is another discussion that gained momentum after the pandemic: the country's ability to produce medicines, vaccines, equipment, and other healthcare consumables. For a long time, we viewed this almost exclusively as industrial policy. The pandemic showed how necessary industrial policy in healthcare is. When all countries had to simultaneously purchase the same products, it became clear that having resources was not enough. Production capacity is needed. A universal system like SUS depends on this security.

The same principle applies to the relationship between SUS and supplementary health insurance. We often present these two as independent systems. This is not the case. The same citizen moves between them throughout life. The person with health insurance uses SUS for vaccination, transplantation, epidemiological surveillance, expensive drugs, and high-tech procedures. At the same time, SUS users turn to the private sector when they can afford a consultation or examination.

Perhaps the confusion is even greater than the belief that these systems operate separately. In fact, healthcare is much more than just access to a private service network. It depends on prevention, health promotion, continuous monitoring, primary healthcare, specialized care when necessary, and integration between all these levels of care. No system—state or private—works properly if these parts do not interact with each other.

The choice in elections should look not at isolated problems, but at how the system functions. Financing, queues, doctors, drug production, technological innovations, and supplementary health insurance are indispensable topics for discussion. However, none of them will be fully solved if we continue to manage a system where each manager is responsible only for their part, while the citizen depends on a network that must work as a whole.

SUS was created almost four decades ago. Since then, Brazil has been aging, the disease profile has changed, medicine has introduced new technologies, and the demand for care has become much more complex. The system must adapt to this transformation. Therefore, the discussion of healthcare during elections should not be limited to the question of how much to spend. The central question is different: how to reorganize the universal system to meet the needs of modern society. This, in my opinion, is a conversation the country still needs to have.