The Telehealth Network of Minas Gerais, Brazil: two decades of scaling and sustainability.

Improving healthcare access in underserved areas remains a major challenge worldwide, particularly in low-income and middle-income countries. In Brazil, the Telehealth Network of Minas Gerais (TNMG) was created to address this gap by integrating digital health strategies into the public health system. This study describes TNMG's implementation framework, key projects, effectiveness, cost-benefit and actual coverage, while also identifying success factors and challenges over its 20-year trajectory. A retrospective analysis of operational data was conducted, including historical landmarks and project outcomes. TNMG's strategy is based on a structured and adaptive framework encompassing needs assessment, research and development, pilot testing and integration into routine care. The model aligns with national health policies and involves in-house software development, workforce training, performance monitoring and regular audits. Over two decades, TNMG has demonstrated the capacity for scale and sustainability. Its tele-ECG service spans 1374 municipalities in 14 states, with over 11.9 million ECGs interpreted remotely from June 2006 to October 2025, reducing diagnostic delays. Teleconsultations, which were initially associated with the prevention of 80% of unnecessary referrals, were expanded during COVID-19 to include risk stratification, direct consultations and telemonitoring. The tele-acute myocardial infarction project was associated with lower in-hospital mortality, from 17.2% to 11.6%, and scaled nationally in 2024 to 450 prehospital ambulances. A national telespirometry service has completed over 43 000 tests from December 2021 to October 2025, contributing to improved access to respiratory care. TNMG's success is linked to its cyclical process of implementation and innovation, alignment with public policies, cost-benefit and strong partnerships across sectors. However, challenges such as infrastructure limitations, digital literacy gaps and regulatory barriers persist. In conclusion, TNMG offers a scalable and sustainable model to reduce health inequities through digital health. Its experience provides actionable insights for other regions and countries aiming to strengthen health systems and expand access through telehealth.