Telehealth as a Strategy to Expand Access in Brazil’s Unified Health System: Analysis of São Paulo State’s Experience Across the Three Levels of Health Care

Key findings from this study

• The study found that 19,053 teleconsultations were conducted in primary health units with a Net Promoter Score of 97, demonstrating high patient satisfaction at the foundational care level.
• The researchers demonstrate that telehealth implementation across 52 facilities in 47 municipalities achieved operational feasibility at primary, secondary, and tertiary care levels despite limited scale deployment.
• The authors report that intensive care unit case discussions at tertiary facilities numbered 4,178 with a Net Promoter Score of 86, indicating strong acceptance of telehealth for complex clinical collaboration.

Overview

This descriptive study examines the implementation of telehealth services across primary, secondary, and tertiary levels of care within São Paulo State's public health system during 2024. The research addresses the challenge of expanding access to health services in Brazil's Unified Health System (Sistema Único de Saúde, SUS), which serves approximately 60% of São Paulo State's population of over 44 million inhabitants. The initiative represents a response to accelerated digital health adoption following the COVID-19 pandemic and addresses persistent barriers to telehealth implementation in Brazil's public sector, including technological inequalities, economic constraints, and workforce limitations.

The study was conducted in the context of São Paulo State's position as Brazil's most populous state with significant economic capacity yet substantial challenges in ensuring equitable health care access. The implementation model involved coordination between the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo and the State Health Secretariat to deploy telehealth services across multiple municipalities. The research contributes to understanding how telehealth can function as a strategy for expanding service coverage in resource-constrained public health systems, particularly in settings where the majority of the population depends on publicly funded care and where private sector telehealth adoption has outpaced public implementation.

Methods and approach

The implementation involved 52 health care facilities distributed across 47 municipalities in São Paulo State, selected based on technical, health care, and infrastructure criteria by participating institutions. The facilities comprised 30 primary health units, 4 specialty care outpatient clinics, and 18 hospitals, representing all three levels of health care organization. Teleconsultations were conducted using an institutional teleconferencing platform designed to ensure data security and privacy compliance with Brazilian data protection regulations. All participating facilities executed formal terms of adherence and data sharing agreements with the proposing institution.

Data collection occurred between April and December 2024 through REDCap (Research Electronic Data Capture), capturing operational metrics and patient satisfaction measured via Net Promoter Score (NPS). Patient participation required informed consent through a formal telehealth adherence and consent document that specified care provisions, patient rights and responsibilities, and medical professional credentials. The study received approval from the Research Ethics Committee for Human Subjects of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo and complied with Brazilian data protection legislation. The proof-of-concept design allowed assessment of telehealth feasibility when implemented at limited scale across differentiated care levels within a large, diverse state health system.

Results

The implementation generated 19,053 teleconsultations at primary health units, achieving a Net Promoter Score of 97, indicating high patient satisfaction at the foundational level of care. At the secondary care level, 218 teleconsultations were completed in specialty care outpatient clinics with an NPS of 74. Tertiary care facilities conducted 4,178 intensive care unit case discussions, registering an NPS of 86. These metrics demonstrate operational feasibility and acceptance across the three-tiered health care structure, with satisfaction scores consistently indicating positive reception among users at each level.

The distribution of services across 52 facilities in 47 municipalities demonstrates geographic reach within São Paulo State's complex health network. The variation in consultation volumes reflects the different roles and scales of operation characteristic of each care level, with primary care units handling the largest volume of direct patient interactions, specialty clinics addressing more focused case loads, and tertiary facilities engaging in collaborative case discussions for complex intensive care scenarios. The consistently high satisfaction scores across all three levels suggest that the telehealth model was well-received by patients and health care professionals despite implementation at limited scale, supporting the conclusion that telehealth represents a viable expansion strategy even under resource constraints typical of public health systems in middle-income contexts.

Implications

The findings provide evidence that telehealth implementation in Brazil's public health system is operationally feasible across all levels of care organization, even when deployed at limited scale. This has particular relevance for São Paulo State, where approximately 28 million residents depend on SUS for medical services, and suggests that digital health strategies can contribute meaningfully to expanding access and service coverage in resource-constrained settings. The high satisfaction scores recorded at each care level indicate acceptance among both patients and providers, addressing concerns about cultural and organizational barriers that have historically impeded telehealth adoption in Brazilian public health contexts. The successful coordination across primary, secondary, and tertiary facilities demonstrates that integrated telehealth networks can function within Brazil's hierarchical health system structure.

The study's proof-of-concept approach offers a scalable model for other Brazilian states and similar middle-income health systems facing challenges of geographic coverage, workforce distribution, and equitable access. The implementation framework, involving formal adherence agreements, standardized consent procedures, ethics oversight, and data protection compliance, provides a replicable administrative structure for telehealth expansion. Given that telehealth adoption has been more prevalent in Brazil's private sector while the majority of the population depends on public services, these results suggest pathways for reducing health care inequities through strategic digital transformation. The findings support telehealth as a priority intervention for strengthening health care delivery networks, particularly in contexts where population size, geographic dispersion, and economic constraints limit traditional in-person service expansion. Future efforts may build on this limited-scale implementation to achieve broader coverage across São Paulo State's 645 municipalities and inform national policy development for telehealth integration in SUS.

Scope and limitations

This summary is based on the study abstract and available metadata. It does not include a full analysis of the complete paper, supplementary materials, or underlying datasets unless explicitly stated. Findings should be interpreted in the context of the original publication.