It made the municipalities or states negotiate for resources rather than supplying them based solely on need. Aside from the ambiguity in the meaning of SUS there were other problems during the years of decentralization efforts and some recentralization in Brazil. The speed of reform activities varied between states. It was difficult for the state and municipalities to work together when occasionally they were controlled by different bodies. A final problem was the rigidity of policy across municipalities and states.
States have the potential for running a smaller and more flexible system.
They have better defined goals and expectations. The municipalities also have their strengths. The 700 medium and large municipalities have been responsible for their entire systems including contracts, control and audits. The 3000 or so needy municipalities do only the basics, outpatient immunizations, sanitary vigilance, mosquito control and health education. They have populations between 5,000 and 30,000 and suffer form little management expertise and lack of resources.