The Brazilian Sistema Único de Saúde (SUS, or Unified Health System) is one of the largest universal health systems in the world. Over its 30-year history, SUS has achieved significant improvements in health outcomes, and is distinguished by its highly decentralised approach to policy implementation at the municipal level.

However, SUS now faces challenges that demand a reimagining of the relationships between the three levels of government in the federation. These issues are particularly relevant in primary care, where municipal management struggles with lack of personnel, inadequate infrastructure, and issues around information technology, among others.

This policy brief outlines a series of recommendations to enhance shared management within SUS's existing institutional framework, in accordance with the constitutional principle of regionalisation of health. Key proposals include increasing resources and professionalising the regional branches of state health secretariats to provide stronger support to municipalities. Additionally, the brief suggests reforming the practices of the regional intergovernmental commissions, which bring together state and municipal managers in each health region, to foster more effective joint decision-making.

This brief is also available in Portuguese.