More than 20 years have passed since the Brazilian Sistema Único de Saúde (Unified Health System or SUS) was formally established by the 1988 Constitution. The SUS reforms established health as a fundamental right and duty of the state and started a process of fundamentally transforming Brazil"s health system to achieve this goal. Twenty Years of Health System Reform in Brazil asks what has been achieved and what challenges remain in accomplishing the goals that were established in 1988. Specifically, it assesses whether the SUS reforms have transformed the health system as envisaged and whether they have improved access to services, financial protection, and health outcomes. The report finds that the health system reforms provided the foundation for the improved health system that Brazil has today. These improvements include an impressive expansion of utilization and access to primary care, a profound restructuring of the health system, the steady decentralization of responsibilities to municipalities, and a growth in government health care spending.