Abstract
Introduction (with objective): Introduction: Methodologically robust, transparent, and implementable guidelines are fundamental to guiding health decisions in the Brazilian Unified Health System (SUS). However, guidelines aimed at health systems (Health Systems Guidance, HSG) present variability in quality and limited standardization, which compromises their applicability and impact on public policies. In this context, AGREE-HS is a structured instrument to evaluate the methodological quality of these guidelines through domains that encompass problem definition, stakeholder participation, methodological rigor, recommendations, and implementability, including structural and contextual dimensions not addressed by AGREE II. In Brazil, its use is not yet institutionalized, representing a significant gap for Health Technology Assessment (HTA) and for strengthening governance in the SUS. Objective: To map and critically analyze the use of the AGREE-HS tool in the international literature and discuss its implications for strengthening guidelines and governance in the SUS. Material and Method: A scoping review was conducted according to the recommendations of the Joanna Briggs Institute and reported according to PRISMA-ScR (Protocol: 10.17605/OSF.IO/BMERX). Searches were performed in September 2025 in the PubMed, Web of Science, Scopus, and Dimensions.ai databases, including studies that fully applied AGREE-HS in the assessment of HSG. Data were synthesized descriptively, complemented by non-parametric inferential analysis (Friedman and Kruskal-Wallis tests; 95% CI). Results: Seven studies were included (2021–2025), totaling 186 guidelines, mostly produced by the WHO, CDC, and ECDC. Superior performance was observed in the Topic and Recommendations domains, and weaknesses in Participants, Methods, and Implementability (p<0.001). Heterogeneity was identified in the application of the tool, with variations in the number of evaluators, methods of consolidating scores, and the way results were presented, compromising comparability and reproducibility. Discussion: The findings highlight structural gaps that compromise the applicability of HSG, especially in the operationalization of recommendations and stakeholder participation. For the implementation of AGREE-HS in the SUS (Brazilian Unified Health System), structural measures are highlighted, including its incorporation into the Methodological Guidelines of the Ministry of Health and the processes of CONITEC (National Commission for the Incorporation of Technologies in the Unified Health System), training of evaluators in the Health Technology Assessment Centers (NATS), national standardization of scoring and interpretation criteria, integration with frameworks such as GRADE/EtD, and strengthening of mechanisms for transparency and social participation. The expansion of the use of AGREE-HS converges with the principles and guidelines of the SUS by promoting transparency, social participation, and evidence-based decisions, strengthening equity, comprehensiveness, and efficiency in the organization of health services. Conclusions: AGREE-HS shows significant potential for improving health system guidelines and strengthening evidence-based governance in the Brazilian Unified Health System (SUS), contributing to more consistent, equitable, and sustainable decisions.
