http://10.47456/argumentum.v17.2025.49475
Universality
in digital health: digitalisation and datafication in the Unified Health System
(SUS)
A universalidade na saúde
digital: digitalização e dataficação no SUS
Rita de Cássia Cavalcante LIMA
https://orcid.org/0000-0001-9918-7503
Universidade Federal do Rio de
Janeiro, Escola de Serviço Social,
Programa de Pós-Graduação em
Serviço Social, Rio de Janeiro, RJ, Brasil
(Federal
University of Rio de Janeiro, School of Social Service,
Postgraduate
Programme in Social Service, Rio de Janeiro, RJ, Brazil)
e-mail: r.lima@ess.ufrj.br
Vanessa Barreto Corrêa PASSOS
https://orcid.org/0000-0002-2065-9406
Universidade Federal do Rio de
Janeiro, Hospital Universitário Clementino
Fraga Filho, Serviço Social,
Rio de Janeiro, RJ, Brasil
(Federal
University of Rio de Janeiro, University Hospital Clementino Fraga Filho,
Social
Service, Rio de Janeiro, RJ, Brazil)
e-mail: vbcpassos@gmail.com
Priscilla dos Santos Peixoto
Borelli TAVARES
https://orcid.org/0000-0001-6503-3944
Prefeitura do Rio de Janeiro, Secretaria Municipal de
Saúde,
Centro de Atenção
Psicossocial, Rio de Janeiro, RJ, Brasil
(Prefecture
of Rio de Janeiro, Municipal Secretary of Health,
Centre
for Psychosocial Care, Rio de Janeiro, RJ, Brazil)
e-mail: srbpriscilla@gmail.com
Abstract:
This article analyses how
universality is addressed in Brazil’s Digital Health Strategy (ESD28). It starts,
Centre for from the idea that this principle, enshrined in the 1988 Federal
Constitution, emerged as an ethical imperative in modern times but became an adjective
under neoliberalism. Using a qualitative methodology and bibliographic and
documentary sources, it was observed that ESD28 led to the development of
telehealth in remote areas and offered specialties but that it reproduces
technological dependence and the risk to digital sovereignty. Access to
information should not be confused with universal access to comprehensive
healthcare, although it can contribute to this end. The weaknesses of
infrastructure and interoperability in the Unified Health System (SUS) in
Brazil together with digital inequality constrain universality.
Keywords: Universality. Universal health coverage. Digital
Health Strategy. Digitalisation.
Resumo: Este artigo analisa como a
universalidade é tratada na Estratégia de Saúde Digital (ESD28) do Brasil.
Parte da ideia de que este princípio, consagrado na Constituição Federal de
1988, emergiu como imperativo ético na modernidade, mas foi adjetivado no neoliberalismo.
Com metodologia qualitativa e fontes bibliográficas e documentais, observou-se
que a ESD28 desenvolveu telessaúde em áreas remotas e ofertou especialidades,
mas reproduz a dependência tecnológica e o risco à soberania digital. O acesso
à informação não pode ser confundido com o acesso universal à integralidade do
cuidado em saúde, embora possa contribuir para este fim. As fragilidades da
infraestrutura e da interoperabilidade no Sistema Único de Saúde no Brasil e a
desigualdade digital constrangem a universalidade.
Palavras-chave:
Universalidade. Cobertura universal em saúde. Estratégia de Saúde Digital.
Digitalização.
Introduction
This
article results from recent research conducted within the Doctoral Programme in
Social Work at the Federal University of Rio de Janeiro (PPGSS/UFRJ). Both
studies reveal a scarcity of bibliographic output in Social Work regarding the
principle of universality and the Digital Health Strategy (ESD28).
Universality,
associated with human rights, has withstood the test of time. It is a legacy of
Enlightenment values (Rouanet, 1987) and refers
to guaranteeing access for all, without spatial, racial, gender, or other
discrimination.
Based
on a non-systematic bibliographic survey of the SciELO database, the descriptor
universality was found in forty-five article titles. The majority of
these refer to universality in health and universal access,
reflecting the database’s profile, with a predominance of health journals and a
definition of universality as an ethical-political principle of
universal health systems, such as the Unified Health System (SUS). This
principle is linked to the defence of free, comprehensive, universal, and
equitable public health. However, its value content requires updating considering
the advance of conservatism and State responses to the crisis of capital, such
as measures to restrict spending and decouple health revenues (Passos, 2025).
Health
is the only Social Security policy to formally incorporate universality, and it
is present in the ethical orientation of ESD28. However, following Law No.
8,080/1990 (Brazil, 1990), disputes over projects have put the meaning of this
principle under tension. Nevertheless, it remains a relevant ethical-political thread
for the generation of knowledge and the struggles in defence of the SUS.
Social
struggles by historically excluded groups, such as Black and Indigenous people,
riverside communities, forest dwellers, quilombola communities, and people with
disabilities, among others, have forced the SUS to recognise their health
demands, and this has increased equity of access.
The
SUS’s commitment to access is consistent with the principles of universality
and equity, but there is a tendency to subordinate these principles to the term
“access”. The quality and quantity of access depend on the degree of ethical
and political priority given to universality. Universality should be understood
as its foundation, access as its descriptive expression, and equity as a
concrete requirement in a country of profound inequalities.
This
article analyses how the principle of universality is addressed in ESD28, which
was formally established in 2020 by Ordinance GM/MS No. 3,632 (Brazil, 2024a).
This took place in the context of the COVID-19 pandemic, a period that
intensified the use of digital technologies. It is organised into two sections.
The first revisits the ethical legacy of the modern Enlightenment as the
foundation of the principle of universality in its opposition to the offensive
of capital. The second discusses old and new contradictions in the
implementation of digital health in the SUS.
From
ethical imperative to universal coverage in the SUS: universality as a legacy
of the modern Enlightenment.
The
term universal is widely used to affirm that human rights are inherent
to all individuals, regardless of nationality, ethnicity, class, or other
social markers. In political science, according to Matta (2009), universality
is a notion originating from the legal field and appropriated by other areas,
as it represents what should be valid for everyone. Bambirra
(2014) points out that universality dates back to
the roots of the formation of Western law in classical Greece, where, even with
imprecisions, it was linked to the ideal of justice and was expressed
politically in democracy, and philosophically in the conception of a cosmos.
This ideal gained strength with the Enlightenment, a movement that linked
reason and criticism as foundations against absolutism and in defence of
natural rights.
According
to Rouanet (1987), these structural elements of the
Enlightenment, criticism and reason, formed an integral part of this
movement, which was not limited to the economic, political, and cultural ideas
that flourished during the 17th and 18th centuries. He proposes that the nature
of the Enlightenment is perennial, and is an antidote to diffuse irrationalism,
using reason to combat myth and power. “In this sense, the Enlightenment is a
trans-epochal tendency that crosses history transversally and that was updated
in the Illustration, but did not begin with it, nor did it end in the 18th
century” (Rouanet, 1987, p. 28). For Rouanet (2003), modernity brings an element of autonomy, formation,
and emancipation of the individual, as heir to the Enlightenment tradition,
which unites the forces of universalism and pluralism. Thus, the “Illustration
appears [...] as a very important historical achievement of the Enlightenment,
certainly the most prestigious, but neither the first nor the last” (Rouanet, 1987, p. 28).
Immanuel Kant (1724-1804) is an exponent of
the Illustration. Rouanet (1987) recognises that Kant’s
“[...] overcoming of minority [...]” (Rouanet, 1987,
p. 30). In other words, “[...] the inability to use one’s own understanding
without external guidance [...]” (Rouanet, 1987, p.
31) – is at the root of the criticism of all teaching that inhibits the use of
reason. Criticism and reason therefore remain the two structural vectors for
the new Enlightenment. “A critique that is not rational or a reason that is not
critical cannot be considered Enlightenment” (Rouanet,
1987, p. 29).
Kantian
ethics propose universality as a moral principle, whose sole criterion is
impartiality: only what can be universalised is morally valid. For Kant (2007),
morality is universal because it cannot be related to individual motives and
particular intentions.
The
moral law of Kantian ethics, expressed by the categorical imperative, is
rational, a priori, and unconditional. This law, which is duty, cannot
be empirically grounded, “[...] the representation of an objective principle,
insofar as it is constitutive for a will, is called a command (of reason), and
the formula of the command is called an ‘imperative’” (Kant, 2004, pp. 43-44).
In the categorical imperative, it is not just any duty that grounds the moral
law, but an unconditional duty.
In Kantian moral theory, the categorical imperative
does not derive from experience and imposes itself by itself, not by the
purpose that allows one to act. The categorical imperative, whether fulfilled
or not, will always have the character of a practical law, being a proposition
constructed by Kant, which imposes on the subject an imperative (a maxim) that
must be fulfilled by stating a universal law (Hamel, 2011, p. 166).
The
criterion of universality is what absolutely defines the necessity of action
through laws, that is, imperatives. Although Kantian thought is fruitful and a
basis for modern philosophy, it is also the object of criticism from “[...]
wise reason [...]” (Rouanet, 1987, p. 31), that which
is “[...] capable of criticism and self-criticism, apt to expose the true
structures of laws and institutions, armed to unmask supposedly rational
discourses and aware of its vulnerability to the irrational” (Rouanet, 1987, p. 31). So, Kant is a product of the
Eurocentric culture in transformation arising from capitalist social relations,
self-centred, taken as an example of the universal. Furthermore, he disregards
historical inequalities such as those resulting from the Industrial Revolution,
imperialism, and colonisation.
So,
the maxim what applies to me must apply to everyone (not a literal
translation of Kant's work), embodies the categorical imperative and bases its
argument on universality. However, it becomes abstract in bourgeois sociability
if it is not mediated by critical reason.
In
modern times, universality has been actioned in various fields, such as human
rights, science, health, and technology, always referring to the idea that
something belongs to, or applies to, everyone. In the field of social rights,
which is relevant to this article, the debate between targeted and
comprehensive social policies, for example, was common with the advancement of
neoliberalism, beginning in the 1990s (Soares, 2002), when the SUS, was being
implemented.
One of the most widespread neoliberal strategies [...]
is targeting. The idea is that public/state spending and social services
should be directed exclusively towards the poor. [...] As with the privatisation
strategy, restricting access becomes extremely complicated insofar as the poor
constitute the vast majority, if not all, of the demand for basic social
services. [...] The result has been, by avoiding the inclusion of the
‘non-poor’, the exclusion of the poor themselves (Soares, 2002, p. 79).
At the
peripheries of capitalism, the universality of social protection is weakened by
emergency policies and guidelines from international organisations that
condition its scope. Such measures are strongly influenced by the guidelines of
multilateral financial institutions and underpin the commodification of public
services, restricting and conditioning universality in Social Security.
In
Brazil, the offensive of capital also imposes severe limits on social policies,
distorting the radical meaning of the universality of health (Sousa, 2014). Following
social struggles, article 194 of the 1988 Federal Constitution (Brazil, 1988), in
a single paragraph, established the guiding principles of Social Security, with
universal coverage and care being the first of these. This principle is related
to guaranteeing protection against all social risks, breaking with the
meritocratic model of health, and encompassing all residents of the nation.
This universality inspired the creation of the SUS, whose logic broke with the
insurance tradition of social security medicine and recognised access as an
unconditional right similar to the Kantian ethical
imperative.
The
implementation of the SUS, however, occurred in an adverse context, marked by
the rise of neoliberalism in the country and State counter-reforms under the
guise of modernisation. This concept of modernity is prevalent in specialised
literature and in economic and social development policies that link it to
improving the effectiveness of the tax, education, health, transportation,
food, and public administration systems in general. “It is a functional concept
of modernity, in the proper sense of the word: in a modern society,
institutions function better than in an archaic society” (Rouanet,
2003, p. 16). In this sense of modernity, the concept of universality is
qualified by an instrumental rationality that updates everything through a
regression of rights.
This
was reflected in tensions between universal health systems and universal
coverage models, as highlighted by Giovanella (2008),
who denounces segmentation and selectivity as threats to full access. This
focus compromises the principle of universality and the consequent universal
access, as it reduces the scope and quality of health actions to a minimum set
of services. In the consolidation of health systems, the tension between
expanding coverage with only basic care for certain populations and
guaranteeing broad and unrestricted health care is always present. The
direction taken in each conjuncture depends on the political forces in dispute.
In the
current context, despite increased fiscal austerity and capital’s offensive
against social rights, universality remains enshrined in the legislation that
structures health policy, but its formal existence is insufficient. The
principle continues to inspire social movements, such as the Black movement,
which questions: “[...] how to link the pursuit of universal rights with the
demands of specific groups in an unequal society?” (Faustino, 2017, p. 3,831).
The
fight for equity, in conjunction with universality, sheds light on concrete
agendas within the SUS to confront prejudices and discrimination related to
racism, ableism, misogyny, LGBTQIAPN+ phobia, among others, whose oppressive forms
impact healthcare. If the critical reason of the modern Enlightenment serves to
updates the radical nature of the ethical principle of universality, then,
“[...] wise reason [...]” (Rouanet, 1987, p. 31)
demands recognition of this historical debt to these populations.
If, however, considering diversity made universalisation
unfeasible, it would be necessary to question whether the set of subjects and
policies already mobilised around health equity—and not only those aimed at
promoting racial equity—risks assuming that the reported discomfort is not the
perspective of equity—nor the risk of neoliberal focusing—but rather the
attempt to achieve racial equity. The Unified Health System itself, in its
notion of an ‘expanded concept of health,’ presents the principle of equity—and also comprehensiveness—alongside the principle of
universality, and not as a counterpoint (Faustino, 2017, p. 3,837).
In
this sense, ESD28, as a recent policy, needs to be analysed from the
perspective of universality, insofar as it commits to guaranteeing equal access
to the benefits of digital health to all citizens, regardless of their location
or socioeconomic status (Brazil, 2020). This is a monumental challenge,
considering the socio-racial inequalities present in the country.
Universality
in Brazilian digital health: old and new challenges.
The Digital Health Strategy for Brazil
(ESD28) was established by the federal government to cover the period 2020 to
2028. It was announced at the end of the first year of the COVID-19 pandemic
and in line with the launch of the Global Strategy on Digital Health 2020-2025
(World Health Organisation, 2021), by the World Health Organisation, which had
already passed three resolutions on the subject since 2005[1].
In
Brazil, the e-SUS medical record, launched by the Ministry of Health in 2012,
was a government initiative to digitise clinical records for the SUS. This is
sensitive data regarding human lives, and its digitalisation into informational
and computational models has become a strategic component for promoting
universal access to healthcare, both by the Brazilian government (Brazil, 2020)
and the World Health Organisation (WHO) (Souza; Maldonato, 2024). Despite the
underlying concept of universality, technocratic optimism obscures the socially
determined nature of technology and the instrumental rationality that guides
proposals for modernising public administration under neoliberalism.
2019
was a milestone in the digital transformation of the federal government, as the
Gov.br platform became the single point of access to public services for
Brazilians. This modernisation of public administration sought to standardise
and automate the provision of public services, reducing public spending and
jobs with repetitive activities (ENAP, 2023). That same year, the Digital Health
Strategy Management Committee (Comitê Gestor da Estratégia de Saúde Digital) was formed to expand the
digital transformation in the SUS, an objective that was accelerated by the
COVID-19 pandemic.
ESD28
reaffirms the constitutional principles of the SUS, among them, the principle
of universality. As we saw in the previous section, the foundations and the
ethical-political direction of this principle have been disputed since the
implementation of the SUS, a period marked by the neoliberal offensive in Brazil
(Soares, 2002; Sousa, 2014). Furthermore, the Ministry of Health, responsible
for the implementation of ESD28, explicitly states its role as a catalyst for
collaborative actions between public and private actors (Brazil, 2020), which
highlights the ownership of digital health as an area of interest
to capital. The same trend is observed internationally.
By mentioning that state and private sectors should
work together to implement a globalised digital health system, the WHO is doing
nothing more than reinforcing the neoliberal precepts of privatising public
services and the State as an agent promoting the interests of capital, while,
in the case of peripheral countries, it also means deepening dependence, since
the implementation of ‘partnerships’ in this area means the contracting by the
State of services, solutions and technologies from multinational private
companies, headquartered in imperialist countries (Souza; Maldonado, 2024, not
paginated).
In
ESD28, there is a need to integrate health data from different systems to
facilitate the secure, agile, and standardised sharing of information,
resulting in the National Health Data Network (Rede Nacional de Dados em Saúde (RNDS)) in 2020. To host
the data for this Network, the federal government contracted the Amazon Web
Services (AWS) data cloud (Rachid et al., 2023).
The ConecteSUS Programme, in the form of a website and cell
phone application, was part of ESD28 and became known for issuing the Digital
National Vaccination Card (Carteira Nacional de Vacinação Digital) and the National Vaccination Certificate
against COVID-19 (Certificado Nacional de Vacinação contra COVID-19) – in this case, in multilingual
versions. In January 2024, it became My SUS Digital (Meu SUS Digital), integrating
and making health information available to every Brazilian and to health
professionals. The information that flows through this system and that of the National
Health Data Network require an informational and computational infrastructure
for interoperability. Although using the infrastructure of the Brazilian
company Serpro[2] MultiCloud, it nevertheless has partnerships with multinational
technology giants, namely: AWS, Azure Stack (Microsoft), Google Cloud, Huawei
Cloud, IBM Cloud, and Oracle. “In practice, this means that the storage of RNDS
data remains on AWS infrastructure and can also be allocated to other
international corporations under Serpro’s management”
(Souza; Maldonado, 2024, not paginated).
Under
Lula’s (President Luiz Inácio Lula da Silva) government,
which took power in 2023, there is interest in attracting international
investment in the construction of data centres based in Brazil. In May 2025,
the Minister of Finance met with the three leading digital technology companies
– Nvidia, Google, and Amazon – and announced that the Brazilian government,
through the National Bank for Economic and Social Development (Banco Nacional
de Desenvolvimento Econômico
e Social (BNDES)), will finance a credit line of R$ 2 Billion with lower
interest rates for data centres installed in the North and Northeast regions
(Queiroz, 2025).
Because
of this, researchers concerned with digital sovereignty have warned of the
risks of handing, over not only the health data of citizens and professionals
in the field, but also “[...] strategic information aimed at the development
and advancement of Brazilian health science” (Souza; Maldonado, 2024, not
paginated).
We know that the central countries, where these
companies are concentrated, have become strongly involved in technological
development and patent registration in the 21st century, so the more data they
obtain, the more economic and political advantages they will have over other
countries, such as Brazil (Souza; Maldonado, 2024, not paginated).
The
Brazilian State is, therefore, reproducing technological dependence and
actively participating in the datafication sought by big tech
companies, whose objective is to strengthen their geoeconomic and geopolitical
power, turning the processing of health data into a means for producing
information and a relevant information vantage point concerning the morbidity
and mortality profile of Brazilians.
This
type of asymmetrical power relationship does not align with the ethical
imperative underlying the principle of universality. According to Souza and
Maldonado (2024), the implementation of health services through digital means
without concessions to the neoliberal agenda requires a solid strategy of
digital sovereignty and autonomy over health data. Furthermore, as healthcare
and its corresponding record-keeping depends on living labour, that is, on
workers in direct contact with users who use their knowledge for intervention
and recording. Digital technologies can mediate the encounter between
healthcare professionals and the population, expanding access to certain
procedures, but their use must be preceded by a technical and ethical evaluation.
Regarding
the computerisation of the large mass of health data, there remain challenges
regarding the integration projected in the RNDS (in primary, secondary and
tertiary health care), and its objective of improving care for the population
by; minimizing the effort of data collection; guaranteeing the privacy and
security of shared information; avoiding errors in retyping information and
strengthening care based on referral and counter-referral (Brazil, 2020).
Gradually,
the RNDS and the My Digital SUS (Meu SUS Digital) will allow users and
healthcare professionals to access information through a longitudinal health
history, including situations of violence, health problems, and other relevant
data. The implementation of the RNDS, which requires the interoperability of
different health systems, also allows for the monitoring of indicators and
social determinants of health in the population. Access to information should
not, however, be confused with universal access to comprehensive healthcare,
although it may contribute to this end.
There
are challenges for the RNDS, including expanding the technological
infrastructure of municipal health units, expressed by increasing the number of
available computers and the digital skills of professionals, as well as
guaranteeing the confidentiality of user information. This challenge is
amplified by a country of continental size, with regional disparities,
especially for territories that are not in urban centres, such as Indigenous,
quilombola, rural, and Amazonian populations. The scarcity of infrastructure
for cable and fibre optic technologies in the “Northern Region makes internet
access expensive and inaccessible [...], causing the use of mobile internet to
be the preferred option among the population” (Soares; Azevedo, 2023, p. 6).
So,
WhatsApp, as a free communication platform, has been used by healthcare
professionals to communicate with each other and to interact with the
population. A recent initiative is in Amazonas, where the State Government, in
the municipality of Anamã, is using WhatsApp in its
functionality to increase universal access to telehealth. In June 2025, two
telehealth rooms were implemented at the Luzia Nunes de Melo Basic Health Unit,
offering care in twelve medical specialties, enabling remote consultations and
diagnoses through the Saúde AM Digital programme. Patients are notified via
WhatsApp regarding appointments and exams, scheduled through Sisreg. The aim is to reduce non-attendance for scheduled
procedures, which reaches approximately 60%, and to bring specialised medical
care, especially to the interior and remote regions of Amazonas (Santos, 2025).
Telehealth
is a digital tool that enhances access for populations in remote areas and
others marked by violence, where people have limited options for traveling for
healthcare services or where professionals cannot reach or provide home care.
Since
2015, to mitigate the infrastructure limitations in the Northern Region, a
series of programmes have been implementing information highways via riverbed fibre
optic cables along the Amazon Basin, aiming to offer “[...] a series of quality
data network services, such as high-speed internet, telemedicine, distance
learning, public safety monitoring and tourism” (Soares; Azevedo, 2023, p. 8). This
intention contrasts, however, with the reality of 2024, when health
establishments in the state of Amazonas still had only partial connection to
the RNDS due to “[...] insufficient financial resources for the purchase of
equipment and good quality connectivity to support the network’s needs”
(Brazil, 2024b, unpaginated). To expand connectivity, the Ministry of Health
plans to connect 12,000 primary health care units by 2026, including those in Indigenous
communities, and to contract satellite internet services to serve 1,191 primary
health care units in remote areas by 2025 (Mais..., 2025).
This
projection stemmed from the creation of the SUS Digital Programme, in which the
guidelines of “[...] universality and equity in access to digital health
products and services, at all levels of health care” (Brazil, 2024a,
unpaginated) were ratified and included the following,
[...] digital health encompasses, among others,
interoperable information systems, electronic health data records, application
of data science, artificial intelligence, telehealth, mobile health
applications, wearable devices, applied robotics, personalised medicine, and
the internet of things, among others, aimed at the health sector (Brazil,
2024a, unpaginated).
According to the Monitoring of Adherence and
Situational Diagnosis Panel (Painel do Monitoramento da Adesão e do Diagnóstico Situacional) of this
Programme, adherence included all 27 Brazilian states and 5,570 municipalities.
In the first stage of adherence, the Ministry transferred R$232 million to
resource digital health (Brazil, 2024b) and obtained data collected from the Federal
entities that conducted a self-diagnosis. The most cited challenge identified in
the implementation of the Digital Health Programme relates to infrastructure
and connectivity, followed by training and continuing education, and finally,
the interoperability and integration of state and municipal systems with the
RNDS.
Expanding
connectivity is essential to increasing the availability of telehealth services.
In 2024 this covered only 39% in primary health care units nationwide (Mais,
2025). Despite 77.9% of primary health care units having telematic resources,
only slightly more than half offer telehealth, identifying obstacles that need
to be investigated.
It is
worth remembering that telehealth was driven by the need to prevent the spread
of the COVID-19 virus. Regulated by Law No. 13.989/2020 and the Federal Council
of Medicine, it allowed medical consultations to be conducted through digital
platforms. However, telehealth is not limited to telemedicine and has come to
be used by other professions, post the COVID-19 pandemic this continued as
telecare.
So,
telehealth and RNDS are the main strategies for universal access. ESD28
foresees the need to,
[...] identify the data and Information and
Communication Technologies in Health (ICTs) essential for remote care to be
integrated into continuous care, at various levels of complexity within the
SUS, focusing on addressing inequalities in access to and use of health
services in the SUS (Brazil, 2020, p. 58).
Most
actions set out in ESD28 for expanding universal access to healthcare
presuppose that users possess smartphones, internet connectivity, and the
skills to operate them. According to the 2024 ICT Households Survey (CGI.br,
2025), profound inequalities in internet access persist in Brazil. While 99% of
households in class A (with a monthly family income above R$ 25,200) have
internet access, this percentage drops to 67% in classes D/E (D: with income
between R$ 1,250 and R$ 3,400; and E: up to R$ 1,249), revealing a strong class
divide. Inequality is also expressed regionally: 28% of the rural population
remain disconnected, compared to 21% in urban areas. Furthermore, 15% of urban
households and 26% of rural households do not have fixed broadband. Only 22% of
the Brazilian population lives in households with significant connectivity – a
criterion that considers speed, connection stability, and diversity of
connected devices – which compromises equitable participation in access to
public services remotely, such as telehealth and My Digital SUS (Meu SUS
Digital).
According
to Veloso (2011), the advancement of technology in bourgeois society has been
characterised by its non-universality, since a large portion of the population
does not possess, or faces difficulties in accessing, telematic means –
internet access, devices, and digital skills. For him, this can be considered
one of the contemporary expressions of the social question, as it presents the
restrictions faced by the working class in accessing socially produced wealth.
Digital health, therefore, is conditioned by historical social inequalities,
including race, ethnicity, gender, disabilities, which challenge the
universality of the SUS.
Final
considerations
This
article highlights the tensions and contradictions surrounding the principle of
universality in its modern philosophical dimension, and as a guiding principle
of the SUS and digital health in Brazil, including its milestones such as
ESD28.
Although
universality is present in the 1988 Constitution and Law No. 8,080/1990
(Brazil, 1990), there is a significant gap between what is legal and what is
real. Neoliberalism did not eliminate the principle, but rather qualified it in
its defence of universal health coverage, as opposed to a universal health
system.
The
digitalisation of the SUS, embodied in the ESD28 and, more recently, in the
Digital Health Programme, reveals an intrinsic tension within the system. While
its implementation can be interpreted as a response to the neoliberal agenda,
by potentially containing social spending and increasing dependence on external
technologies, it also presents a contradiction, as it enables responses to the
demand for access to certain services and improves the dissemination of
strategic information on health indicators to the population.
Achieving
the potential of digital health is, however, profoundly conditioned by Brazil’s
continental size, which, paradoxically, also justify it. The persistence of
chronic operational challenges, including deficiencies in infrastructure and
connectivity, the complex interoperability of public health systems, and the
need for continuing education and the availability of the health workforce are
factors that demonstrate marked regional particularities. Despite these
obstacles, ongoing digital health experiences in the Northern Region
demonstrate that regional inequalities can be mitigated and increase the effectiveness
of the SUS.
The
effects of these telehealth experiences require further empirical
investigation, and health information systems and the staging of RNDS data in
big tech clouds demand an urgent political debate, lest the digitalisation of
the Brazilian state fundamentally serves the datafication interests of
these companies.
Digital
health aims to both expand access to healthcare and to recognise the demands of
underserved population groups and territories. In both cases, comparing any
assessments with the ethical imperative of universality will be fundamental,
especially when it involves geopolitical and geoeconomic interests related to
digital sovereignty.
We
observe that ESD28 expresses the limits placed on social policies by the
expanded reproduction of capital, running the risk of being employed as a
technological solution capable of concealing the structural underfunding of the
SUS, while in-person services remain dilapidated and, at times, not even
implemented.
It is essential
that universal digital health guarantees digital infrastructure as a universal
right, ensures the country's sovereignty regarding technological innovation,
and secures public funding for the SUS. These
are battlegrounds guided by universality.
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________________________________________________________________________________________________
Rita
de Cássia Cavalcante LIMA Worked
on the conception and design, writing of the article, critical review, and
approval of the version to be published.
Holds
a PhD in Social Work from the Postgraduate Program in Social Work at the
Federal University of Rio de Janeiro (PPGSS/UFRJ) and is a Professor in the
Social Work Course and the Postgraduate Program in Social Work at the Federal
University of Rio de Janeiro.
Vanessa
Barreto Corrêa PASSOS Worked
on the conception and design, writing of the article, and approval of the published
version.
Holds
a PhD in Social Work (PPGSS/UFRJ) is a Social Worker, and Technical Head of
Social Service at the Clementino Fraga Filho University Hospital of the Federal
University of Rio de Janeiro.
Priscilla
dos Santos Peixoto Borelli TAVARES Worked on the conception and design, writing of the
article, and approval of the published version.
Master's degree in Social Work (PPGSS/UFRJ), Director of the Psychosocial Care Centre
of the Municipal Health Department of Rio de Janeiro, and Substitute Professor
at the Faculty of Social Work of the State University of Rio de Janeiro.
________________________________________________________________________________________________
Editors
Silvia Neves Salazar – Editor in Chief
Maria Lúcia Teixeira Garcia –
Editor
Submitted 0n: 24/7/2025. Revised on:
15/10/2025. Accepted on: 1/12/2025.
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