Abstract

Since 2010, the organization of the Brazilian Unified Health System has as its main model the Health Care Networks, based on the Integrated Health Service Networks recommended by the Pan American Health Organization. This study aims to analyze the scientific production on Health Care Networks the integrative literature review method. The research was conducted in databases using the descriptors: Health Care Network and its counterparts in Portuguese and Spanish. A total of 27 articles were selected, including conceptual studies, case reports, implementation analyses and evaluation studies. The analysis of the publications evidenced five cores of meaning: the Health Care Network paradigm; Primary Care as network coordinator; regionalization, networks and regional governance; network care; and challenges for implementation. The results of this review point to two central questions: how to overcome the fragmentation of care, ensuring integrality, composing health care networks from distinct theoretical conceptions? And how can the production of care networks impact inter-federative relations, the financing process, the access to the system and the quality of health care processes?

Key words:
Health Care Networks; Integrated Health Service Networks; Health Systems

Introduction

In Brazil, the Unified Health System (SUS) was conceived and is organized through a regionalized and hierarchical network of services and actions, which aim to ensure that health is a constitutional right. In its construction process, several regulations have induced organizational arrangements based on guidelines such as decentralization, municipalization, regionalization, society participation and inter-federative management, characterizing innovations in the structure of the State and in the public administration of the country¹1 Viana ALA, Machado CV. Descentralização e coordenação federativa: a experiência brasileira na saúde. Cien Saude Colet 2009; 14(3):807-817.. Although the current national political scenario of inflecting public policies and suppressing rights, the materialization of organizational guidelines of decentralization and regionalization was observed, which provided advances and also challenges in the structuring of the health system².

Since 2010, the organization model of SUS has as its main reference the Health Care Networks (in Portuguese Redes de Atenção à Saúde - RAS), which are based on the Integrated Health Service Network recommended by the Pan American Health Organization³3 Organización Panamericana de La Salud (OPAS). Redes integradas de servicios de salud: conceptos, opciones de política e hoja de ruta para sua implementación em las Américas. Washington, D.C.: OPAS; 2010.. This model, which has been used in countries undergoing demographic and epidemiological transition where chronic conditions prevail⁴4 Mendes EV. As Redes de Atenção à Saúde. Brasília: OPAS; 2011., has been shown as an alternative to the fragmentation of health systems⁵5 Organização Pan-Americana de Saúde (OPAS). Organização Mundial de Saúde (OMS). A atenção à saúde coordenada pela APS: construindo as redes de atenção no SUS. Brasília: OPAS, OMS; 2010. and indicates the centrality of primary care in networks⁶6 Tabarquino Muñoz R, Pulgarin Henao D, Giraldo Varón A. Dinámica de una red integral de prestadores de servicios de salud (RIPSS). Gerencia Polit Salud 2018; 17(34):1-12.

7 Almeida PF, Oliveira SC, Giovanella L. Integração de rede e coordenação do cuidado: o caso do sistema de saúde do Chile. Cien Saude Colet 2018; 23(7):2213-2228.^-88 Giovanella L. Redes integradas, programas de gestão clínica e generalista coordenador: análise das reformas recentes do setor ambulatorial na Alemanha. Cien Saude Colet 2011; 16(Supl. 1):1081-1096..

The main justifications to implement RAS are the need to organize systems in order to respond the threefold disease burden - infectious, chronic and external causes - and to obtain better economic, epidemiological and comprehensive health care results⁴4 Mendes EV. As Redes de Atenção à Saúde. Brasília: OPAS; 2011.. To this end, the organization of networks consisting of several points of health care is advocated, with centrality of Primary Care, logistic and support systems⁹9 Mendes EV. As Redes de Atenção à Saúde. Cien Saude Colet 2010; 15(5):2297-2305.. According to Silva e Magalhães Junior¹⁰10 Silva SF, Magalhães Junior HM. Redes de atenção à saúde: conceito, modelo e diretrizes. In: Redes de Atenção à Saúde no SUS. Campinas: IDISA: CONASEMS; 2008., the implementation of RAS is also justified by the need for continued health care for people with chronic conditions, as a strategy to ensure integrality, and by the economy perspective of scale and scope.

Cecílio¹¹11 Cecílio LCO. Modelos Tecno-assistenciais em saúde: da pirâmide ao círculo, uma possibilidade a ser explorada. Cad Saude Publica 1997; 13(3):469-478. proposed a revision of the hierarchical pyramid model, consisting of primary, secondary and tertiary care, pointing out the need for a health system organized from the logic of what would be more important for each patient, and thus offer the right technology in the right space and at the most adequate time. Hartz and Contandriopoulos¹²12 Hartz ZMA, Contandriopoulos AP. Integralidade da atenção e integração de serviços de saúde: desafios para avaliar a implantação de um "sistema sem muros". Cad Saude Publica 2004; 20(2):331-336. also proposed a “system without walls”, in which the barriers of access between the various levels of care would be eliminated, in response to the health needs at local and regional levels. Finally, the legal regulation that instituted RAS in Brazil proposed a polyarchic model of system, consisting of different points of health care and of the links that communicate them, with the aim of obtaining the best results, both epidemiological and of health care integrality¹³13 Brasil. Ministério da Saúde (MS). Portaria nº 4.279, de 30 de dezembro de 2010. Estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2010; dez 31..

Thus, induction by the Ministry of Health for implementing the Health Care Networks, from 2011, represented a new stage of SUS organization, aiming at ensuring the integrality of care and changing the modes of health care production through priority thematic networks, which were named as Rede Cegonha, Rede de Urgência e Emergência, Rede de Atenção Psicossocial, Rede de Saúde da Pessoa com Deficiência and Rede de Atenção às Doenças Crônicas¹⁴14 Brasil. Ministério da Saúde (MS). Secretaria de Atenção á Saúde. Implantação das Redes de Atenção à Saúde e outras estratégias da SAS. Brasília: MS; 2014..

Considering the relevance of the Health Care Network Policy, it is essential to conduct studies that may analyze and disseminate the publications that investigated the theme, aiming at increasing the visibility and motivating the realization of new scientific productions on RAS to support the processes of formulation, implementation and evaluation of health policies in SUS. Peiter et al.¹⁵15 Peiter CC, Santos JLG, Lanzoni GMM, Mello ALSF, Costa MFBNA, Andrade SR. Redes de atenção à saúde: tendências da produção de conhecimento no Brasil. Esc Anna Nery Rev Enferm 2019; 23(1):e20180214. analyzed the research trend on RAS in Brazilian theses and dissertations, from the database of the Catalog of Theses and Dissertations of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), however, there is no review study among the published literature on the subject. Given the above, the motivation for the development of this study arose, aiming to describe and analyze the scientific production on Health Care Networks.

Methods

An integrative literature review was performed, regarding the production of knowledge on the Health Care Network public policy. We worked systematically with the research and analysis of the scientific material already produced, allowing the elaboration of syntheses from the several published studies, enabling general conclusions regarding a particular topic under study¹⁶16 Moreira MADM, Lustosa AMDF, Barros EO, Batista JBV, Duarte MCS. Políticas públicas de humanização: revisão integrativa da literatura. Cien Saude Colet 2015; 20(10):3231-3242..

The review was performed in six distinct phases: 1) establishing the topic/review problem and elaborating the guiding question; 2) selecting the articles (establishing descriptors and the inclusion/exclusion criteria for the publications); 3) categorizing the studies and defining the information to be extracted from the reviewed studies; 4) analyzing the selected studies; 5) interpreting and discussing the results; 6) synthesizing the knowledge evidenced in the analyzed articles¹⁷17 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764..

To elaborate this integrative review, first, the central research question was defined: what is the content of the scientific production published in journals regarding the Brazilian public policy of Health Care Networks? To identify the publications that composed the integrative review of this investigation, we surveyed the Virtual Health Library: Latin American and Caribbean Health Sciences Literature (LILACS), the Scientific Electronic Library Online (SciELO) and the Medical Literature Analysis and Retrieval System Online (MEDLINE), in July 2019. To this end, the descriptors used were the expression “Health Care Network” and its counterparts in Portuguese “Rede de Atenção à Saúde” and Spanish “Red Integrada de Servicios de Salud”.

After excluding duplicate articles, we proceeded to assess them by reading the titles and abstracts, having as inclusion criteria the characterization as research article and the thematic approach to RAS, not including studies on specific thematic networks. Through the full reading of the articles, we found the research corpus, excluding articles that did not directly address the topic of RAS, those that addressed experiences in networks of other countries and those that were not fully available.

In order to systematize the data, a pre-categorization was organized and a matrix was prepared containing the following information: title, year of publication, analytical category and objectives of the study. The following were proposed as analytical categories to organize the results: 1) Conceptual Studies; 2) Case Reports; 3) Implementation Analyses and 4) Evaluation Studies, according to the object, objective or methodology of each reviewed study.

The analysis was processed by the authors in meetings of the research group of the project A Rede de Atenção às Urgências e a Produção Viva de Mapas de Cuidados (The Emergency Care Network and the Live Production of Care Maps) financed by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), which uses the RAS and, more specifically, the Urgency and Emergency Network as study object. Key questions were formulated, based on the intensity of the “cores of meanings” identified in the corpus of the review transversely to the analytical pre-categorization. These questions were configured as thematic categories and were aimed to guide the discussion and elaboration of syntheses.

Results

The study allowed the analysis of 27 scientific articles published in national and international journals in the field of Collective Health between 2010 and 2019, on the topic of Health Care Networks. The partial results of each stage of the article selection process are described as shown in Figure 1.

Regarding the year of publication, in 2017, we observed the largest number of studies, seven articles, followed by years 2015 and 2018, with six articles each. In 2010, 2011, 2013 and 2019, only one article published per year was found. Regarding the focus of the publications on RAS, an analytical pre-categorization was proposed to organize the results, described below, and is shown in detail in Charts 1 to 4.

The first category consisted of six articles that address in more depth the concept of RAS (Chart 1). Among these articles, we found an international publication that address the “Integrated Health Service Networks”¹⁸18 Barragán Bechara JC, Riaño Casallas MI, Martínez M. Redes integradas de servicios de salud: hacia La construcción de un concepto. Universidad Salud 2012; 14(2):186-196., the precursor concept of the RAS, and also an article by Mendes⁶6 Tabarquino Muñoz R, Pulgarin Henao D, Giraldo Varón A. Dinámica de una red integral de prestadores de servicios de salud (RIPSS). Gerencia Polit Salud 2018; 17(34):1-12., considered an important theoretical reference for Health Care Networks in Brazil. It is worth mentioning that one of the publications show the concept of Living Networks¹⁹19 Merhy EE, Gomes MPC, Silva E, Santos MFL, Cruz KT, Franco TB. Redes Vivas: multiplicidades girando as existências, sinais da rua. Implicações para a produção do cuidado e a produção do conhecimento em saúde. Divulg Saude Debate 2014; 52:153-164., which emerges in scientific production as another rationality on health networks.

In relation to the second category, Case Reports, 8 articles were identified, described in Chart 2. It is worth highlighting that they show approaches ranging from local experiences of health care teams, from municipalities and health regions, and even a comparative study between the cities of Rio de Janeiro and Lisbon.

In the third category, there are nine articles that analyze the implementation of networks (Chart 3), including its challenges and strategies of integration, regionalization, communication, institutional and matrix support.

The fourth category, composed of four articles, deals with HCN evaluation studies (Chart 4), including the formulation of criteria, sanitary conditions of Health Services, the relation between local needs and interests and between the necessary and current organization.

Discussion

The public policy of Health Care Network has been the subject of several studies, in which different methodological approaches and concepts are used. Understanding the concepts that underlie it, as well as the advances, limits and challenges of its implementation process, is imperative as a contribution to the improvement of SUS. In this review, the RAS model is formulated from a specific theoretical referential, but not unique, with influences from other fields of concepts and practices. As presuppositions of the proposed models, the centrality of primary care and the dependence of the health regionalization process are evident. As a practice, the studies indicate competing or integrated actions of two fields that sometimes complement each other, sometimes oppose each other: the organization of networks for health care, with greater emphasis on the structure and definition of flows, and health care as a producer of networks, but more focused on the role of patients and health professionals.

To deepen the discussion, we used the following key questions: 1) the Health Care Network paradigm; 2) Primary health care as RAS coordinator; 3) Regionalization, networks and regional governance; 4) Network care; and 5) Challenges for RAS implementation.

The Health Care Network paradigm

The conceptual RAS model was proposed as paradigm to the SUS organization in Brazil in the last decade and is adopted both by the Ministry of Health and by state and municipal health administrators as a public policy¹³13 Brasil. Ministério da Saúde (MS). Portaria nº 4.279, de 30 de dezembro de 2010. Estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2010; dez 31.. The publication by Mendes⁹9 Mendes EV. As Redes de Atenção à Saúde. Cien Saude Colet 2010; 15(5):2297-2305., author who is an important reference to the topic, criticizes the hierarchical, fragmented systems, oriented to assist acute conditions, and defines the RAS as polyarchic organizations of health services sets, linked together by a single mission, by common objectives and by a cooperative and interdependent action, which allow to offer a continuous and integral care to a certain population, coordinated by primary health care - provided at the right time, place, with a right quality and in a humanized way, and with health and economic responsibilities for this population. This concept was a beacon for RAS and the thematic networks that were subsequently agreed, at the discursive and normative levels, between SUS administrators within the Tripartite Interagency Commission, and subsequently embodied in the respective ordinances¹⁴14 Brasil. Ministério da Saúde (MS). Secretaria de Atenção á Saúde. Implantação das Redes de Atenção à Saúde e outras estratégias da SAS. Brasília: MS; 2014.. Arruda et al.²⁰20 Arruda C, Lopes SGR, Koerich MHAL, Winck DR, Meirelles BHS, Mello ALSF. Redes de atenção à saúde sob a luz da teoria da complexidade. Esc Anna Nery Rev Enferm 2015; 19(1):169-173., when analyzing the concept of RAS in the light of Complexity Theory, identified as its main characteristics: the formation of horizontal relations between the points of care, having a center of communication in primary care; the centrality of the health needs of a population; accountability for continuous and integral care; multi-professional care; and sharing objectives and commitments with health and economic results.

The formulation of the Health Care Network policy in Brazil has an important influence from the Integrated Health Service Networks, recommended by the PAHO, which presuppose care for a specific population, health services or establishment with different levels of care and complexity, and a territorial definition⁵5 Organização Pan-Americana de Saúde (OPAS). Organização Mundial de Saúde (OMS). A atenção à saúde coordenada pela APS: construindo as redes de atenção no SUS. Brasília: OPAS, OMS; 2010.. The central assumption in such definition is that the application of the concept of networks contributes for the articulation, interdependence and coordination of public, private and mixed actors, with the incorporation of specialized technologies expanding the access, also improving the connectivity in the health network and increasing its governance¹⁸18 Barragán Bechara JC, Riaño Casallas MI, Martínez M. Redes integradas de servicios de salud: hacia La construcción de un concepto. Universidad Salud 2012; 14(2):186-196.. Even though, at the discursive level, health regions are considered as a space for planning RAS in the perspective of producing comprehensive care and articulating the set of intersectoral public policies necessary for this, we wonder how such network concept is able to consider, on one hand, the great regional differences, the social-economic heterogeneous structure, and the demographic, nutritional and epidemiologic changes of an overpopulated country with continental dimensions such as Brazil, and, on the other hand, the micropolitical dynamic involved in the production of care, which seems to escape the assumptions that underlie the formulation of the network concept²2 Chioro dos Reis AA, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a Construção de uma Regionalização Viva. Cien Saude Colet 2017; 22(4):1045-1054..

In this sense, in addition to the RAS paradigm, we identify the recent formulation of another conceptual model, that of Living Networks, defined by Merhy et al.¹⁹19 Merhy EE, Gomes MPC, Silva E, Santos MFL, Cruz KT, Franco TB. Redes Vivas: multiplicidades girando as existências, sinais da rua. Implicações para a produção do cuidado e a produção do conhecimento em saúde. Divulg Saude Debate 2014; 52:153-164. as a way of producing existential connections of individuals and collectives, in different contexts of group and social ways of living. In a study with user-guides, Hadad and Jorge²¹21 Hadad ACAC, Jorge AO. Continuidade do cuidado em rede e os movimentos de redes vivas nas trajetórias do usuário-guia. Saude Debate 2018; 42(n. esp. 4):198-210. identified living networks, produced in the act, in the encounter between professionals and patients from health needs, but also the lack of network, which impacted barriers that hinder access. Also, Maximino et al.²²22 Maximino VS, Liberman F, Frutuoso MF, Mendes R. Profissionais como produtores de redes: tramas e conexões no cuidado em saúde. Saude Soc 2017; 26(2):435-447. observed wide care networks, operationalized in several ways and composed of multiple vectors and formal and informal elements, visible and invisible, objective and subjective, that contribute to facilitate or hinder the construction of articulation points between services, people and resources for care. According to Merhy et al.¹⁹19 Merhy EE, Gomes MPC, Silva E, Santos MFL, Cruz KT, Franco TB. Redes Vivas: multiplicidades girando as existências, sinais da rua. Implicações para a produção do cuidado e a produção do conhecimento em saúde. Divulg Saude Debate 2014; 52:153-164., Living Networks are fragmentary and happening, hypertextually, that is, sometimes they are circumstantial, they assemble and disassemble, and sometimes become more stable, but they behave more like logics of digital networks, that may emerge at any point without having to obey a logical arrangement of analog networks, like a hypertext.

Thus, there are different conceptions of health networks that coexist and are interconnected, evidencing the need for studies that analyze and deepen the relation between structure and action, norm and singular production, from the conceptual models of “Non-Network” (fragmentation), “Health Care Network” (systemic organization) and “Living Networks” (singular production), its possibilities and limits in the modeling of health systems and in the production of the way of caring.

Primary health as RAS coordinator

The RAS coordination by primary care emerges as a structuring condition of the model. For Mendes⁹9 Mendes EV. As Redes de Atenção à Saúde. Cien Saude Colet 2010; 15(5):2297-2305., the communication center of health care networks is the interchanging node in which flows and counterflows of the health care system are coordinated, and it is constituted by primary health care.

Chueiria et al.²³23 Chueiri PS, Harzheima E, Takeda SMP. Coordenação do cuidado e ordenação nas redes de atenção pela Atenção Primária à Saúde uma proposta de itens para avaliação destes atributos. Rev Bras Med Fam Comunidade 2017; 12(39):1-18. formulated a proposal for items to assess the coordination of RAS by primary care, composed of the following attributes: 1) primary care that covers the entire population; 2) is organized in multi-professional teams; 3) is the main gateway to the system; 4) is responsible for the coordination of care; 5) is resolutive, being capable of solving the main health problems of its population. In a research developed by Peiter et al.¹⁵15 Peiter CC, Santos JLG, Lanzoni GMM, Mello ALSF, Costa MFBNA, Andrade SR. Redes de atenção à saúde: tendências da produção de conhecimento no Brasil. Esc Anna Nery Rev Enferm 2019; 23(1):e20180214., in which they analyzed the trends of scientific production in postgraduate dissertations and theses in Brazil on RAS, the Primary Health Care (PHC) as coordinator of the network was the most studied among the analyzed categories.

Lapão et al.²⁴24 Lapão LV, Arcêncio RA, Popolin MP, Rodrigues LBB. Atenção Primária à Saúde na coordenação das Redes de Atenção à Saúde no Rio de Janeiro, Brasil, e na região de Lisboa, Portugal. Cien Saude Colet 2017; 22(3):713-724., in a comparative study, observed that historical, cultural, political and legal issues determine differences in PHC as a RAS coordinator in Rio de Janeiro and Lisbon: in Lisbon, the comprehensive PHC model is used, which has enough maturity in the coordination of its system, while Rio de Janeiro suffers historical remnants of a selective PHC. In Brazil, although the perception of administrators that the RAS should be based on the recognition of primary care as the body responsible for system planning and care coordination²⁵25 Shimizu HE. Percepção dos gestores do Sistema Único de Saúde acerca dos desafios da formação das Redes de Atenção à Saúde no Brasil. Physis 2013; 23(4):1101-1122., these attributes still remain one of the main challenges for the organization of regionalized and integrated networks in SUS²⁶26 Silva SF. Organização de redes regionalizadas e integradas de atenção à saúde: desafios do Sistema Único de Saúde (Brasil). Cien Saude Colet 2011; 16(6):2753-2762.. Poorly mentioned in the meetings of the Regional Intergovernmental Commissions (RIC), the goal of setting up Health Care Networks, coordinated by primary care, is still a distant goal in view of the urgency of ensuring access to specialized and urgency/emergency hospital care in the health region, a topic that dominated the RIC discussions, with primary care being limited to municipal discussions²⁷27 Almeida PF, Santos AM, Santos VP, Silveira Filho RM. Integração assistencial em região de saúde: paradoxo entre necessidades regionais e interesses locais. Saude Soc 2016; 25(2):320-335..

Cecílio et al.²⁸28 Cecilio LCO, Andreazza R, Carapinheiro G, Araújo EC, Oliveira LA, Andrade MGG, Meneses CS, Pinto NRS, Reis DO, Santiago S, Souza ALM, Spedo SM. A Atenção Básica à Saúde e a construção das redes temáticas de saúde: qual pode ser o seu papel? Cien Saude Colet 2012; 17(11):2893-2902. describe the following limits for primary care to assume the role of care coordinator: primary network is seen as a place for simple things, there is a powerlessness that is shared between patients and teams when it comes to the primary network functioning as care coordinator, indicating how it does not have material (technological, operational, organizational) and symbolic (values, meanings and representations) conditions to hold the central position in the coordination of thematic health networks. Also, the infrastructure conditions of Primary Healthcare Units, or their sanitary conditions, may interfere in the organization and offer of services provided, in the inefficiency of communication between the levels of care and in failures in the regulation process, generating, thus, problems for the RAS operationalization²⁹29 Barreto LA, Souza MKB, Silva EAL. Rede de atenção e condições sanitárias das unidades de saúde da família: há alguma relação? Rev Enferm UERJ 2016; 24(6):e17440.. In addition, as the system’s preferred gateway, PHC faces a strong competition from hospital outpatient and emergency care services, disconnected from the network³⁰30 Almeida PF, Santos AM. Atenção Primária à Saúde: coordenação do cuidado em redes regionalizadas? Rev Saude Publica 2016; 50:80..

Thus, it is observed that the coordination by primary care is, at the same time, a premise and challenge for RAS, according to the scientific production evidenced in this review.

Regionalization, Networks and Regional Governance

The relation between the process of regionalization, regional governance and production of RAS has been recognized as interdependent, and it is an object of study in Brazil. To Mendes⁹9 Mendes EV. As Redes de Atenção à Saúde. Cien Saude Colet 2010; 15(5):2297-2305., the governance of health care networks, in SUS, should be performed through interfederative arrangements, coherent with the cooperative federalism that is practiced in Brazil. The following inter-management commissions are materialized: at the national level, in the Tripartite Interagency Commission (CIT); in states, in the Bipartite Interagency Commissions (CIB); and in health regions, in the Regional Interagency Commissions (RIC).

Albuquerque and Viana³¹31 Albuquerque MV, Viana ALD. Perspectivas de região e redes na política de saúde brasileira. Saude Debate 2015; 39(n. esp.):28-38. identified three induction phases of the historical process of regionalization and organization of networks in Brazil, guided by different theoretical an political conceptions: normative region with regionalized and hierarchical networks (Health Care Operational Standard - NOAS 2001 and 2002); negotiated region with integrated and regionalized networks (Pact for Health - Ordinance 399/2006); and, region negotiated and contracted with health care networks (Ordinance 4,279/2010 and Decree 7,508/2011). Thus, the recent transition from normative regions to negotiated regions and from hierarchical networks to integrated, regionalized and contractualized networks is evidenced.

The organization of regionalized networks in SUS depends on improving the interfederative administration in health regions in order to qualify the agreement of responsibilities between the government spheres³²32 Silva SF. Contribuição para a análise da implantação de Redes de Atenção à Saúde no SUS. Divulg Saude Debate 2014; 52:165-176.. Thus, strengthening governance and regional planning is subject to a deeper understanding of the context: identifying the causes of problems, the dynamics and power structure of organizations, determinants of patient behavior, as well as local actors, knowledgeable and able to implement the RAS³²32 Silva SF. Contribuição para a análise da implantação de Redes de Atenção à Saúde no SUS. Divulg Saude Debate 2014; 52:165-176.. To Shimizu²⁵25 Shimizu HE. Percepção dos gestores do Sistema Único de Saúde acerca dos desafios da formação das Redes de Atenção à Saúde no Brasil. Physis 2013; 23(4):1101-1122., who investigated the perception of administrators on the challenges for the formation of RAS in Brazil, the operationalization of this process cannot follow prescriptive models, and requires investments that include the improvement of technical and political dimensions.

In the technical dimension, it points to the improvement of contractualization strategies to ensure the provision of health actions and services of different technological densities, as well as logistics to guide the user in the route of network meshes, regulation system, with clear norms and protocols to guide the access to the service network, to define competences and responsibilites²⁵25 Shimizu HE. Percepção dos gestores do Sistema Único de Saúde acerca dos desafios da formação das Redes de Atenção à Saúde no Brasil. Physis 2013; 23(4):1101-1122.. To Leite³³33 Leite JPA, Spatti AC, Campos ML. Redes de Políticas nas Regiões Metropolitanas: O Caso do Sistema de Saúde Brasileiro. Physis 2017; 27(4):1039-1064., the networks are implemented through Care Lines, in agreements with different actors for the construction of a strategic and investment planning, including structural changes, Permanent Education plans and qualification of regulatory processes. Gomes³⁴34 Gomes RM. Redes de Atenção à Saúde do SUS: 25 anos de uma contradição fundamental entre a Organização Necessária e a Organização Atual. Saude Debate 2014; 38(103):938-952., in opposition to the ongoing decentralization process, even proposes the creation, at the federal level and national action, of a new legal entity exclusively focused on SUS, which is as convergent as possible for the necessary network organization, overcoming the political-administrative autonomy of local-regional administrators.

As for the political dimension, there are power disputes and conflicts at the regional level, including those formed by the private health service that requires strong regulatory mechanisms²⁵25 Shimizu HE. Percepção dos gestores do Sistema Único de Saúde acerca dos desafios da formação das Redes de Atenção à Saúde no Brasil. Physis 2013; 23(4):1101-1122.. To Mendes et al.³⁵35 Mendes A, Louvison MCP, Ianni AMZ, Leite MG, Feuerwerker LCM, Tanaka OY, Duarte L, Weiller JAB, Lara NCC, Botelho LAM, Almeida CAL. O processo de construção da gestão regional da saúde no estado de São Paulo: subsídios para análise. Saude Soc 2015; 24(2):423-436., regionalization, more than a process of organizing the health actions and services of the territory, aiming at ensuring the integrality of care, is a political construction that must favor the dialogue between local actors and federated administrators in order to recognize and face the health needs of specific territories.

A study performed in the Amazon health regions, from the implementation of the QUALISUS-Rede project, observed that governance and integration were strengthened differently between the regions, depending on the capacity of direction and consensus among actors, making it difficult to overcome regional inequalities³⁶36 Casanova AO, Cruz MM, Giovanella L, Alves GR, Cardoso GCP. A implementação de redes de atenção e os desafios da governança regional em saúde na Amazônia Legal. Cien Saude Colet 2017; 22(4):1209-1224.. Chioro dos Reis et al.²2 Chioro dos Reis AA, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a Construção de uma Regionalização Viva. Cien Saude Colet 2017; 22(4):1045-1054., when proposing the construction of a Living Regionalization, indicated that this requires a strong investment of administrators so that the regional space may become a living and potent space of shared management. Without this, it will be reduced to a formal space, instituted by the standards and without power to implement a quality SUS in each region, capable of producing more life for all Brazilians.

Therefore, it is noticed that an intense process of co-administration and regional planning in essential for the implementation of the RAS, being the regional governance also constituted as a challenge, and its technical and political aspects should be observed beyond the Brazilian federative context.

Network Care

The networks formed in the health care process value the professional-patient encounter as producer of plots and connections, since they cause the construction of networks in greater or lesser power. These moments directly impact the outcome of care for cases²¹21 Hadad ACAC, Jorge AO. Continuidade do cuidado em rede e os movimentos de redes vivas nas trajetórias do usuário-guia. Saude Debate 2018; 42(n. esp. 4):198-210.. Cecílio et al.²⁸28 Cecilio LCO, Andreazza R, Carapinheiro G, Araújo EC, Oliveira LA, Andrade MGG, Meneses CS, Pinto NRS, Reis DO, Santiago S, Souza ALM, Spedo SM. A Atenção Básica à Saúde e a construção das redes temáticas de saúde: qual pode ser o seu papel? Cien Saude Colet 2012; 17(11):2893-2902., in a study on the role of primary care in thematic networks, reflect in the conclusion on the false image of harmony between care and a complex plot drawn by individuals in the singular composition of their care network.

To Maximino et al.²²22 Maximino VS, Liberman F, Frutuoso MF, Mendes R. Profissionais como produtores de redes: tramas e conexões no cuidado em saúde. Saude Soc 2017; 26(2):435-447., formal networks coexist with informal ones, sometimes not recognized by professionals, pointing to the need to value the patient and their networks as protagonists seeking for support. According to Merhy et al.¹⁹19 Merhy EE, Gomes MPC, Silva E, Santos MFL, Cruz KT, Franco TB. Redes Vivas: multiplicidades girando as existências, sinais da rua. Implicações para a produção do cuidado e a produção do conhecimento em saúde. Divulg Saude Debate 2014; 52:153-164., patients are Living Networks of themselves; they are all the time producing movements, elaborating knowledge, building and sharing care. Patients, most of the time, are the ones who ask for the networks, and the network is not given as a framework to be filled in a protocol way, because they are being woven in events. As for Arruda et al.²⁰20 Arruda C, Lopes SGR, Koerich MHAL, Winck DR, Meirelles BHS, Mello ALSF. Redes de atenção à saúde sob a luz da teoria da complexidade. Esc Anna Nery Rev Enferm 2015; 19(1):169-173., networks woven by patients are understood as an undesirable and dysfunctional situation: as an orchestra in which each instrument plays a different song, disharmony is installed, patients enter the system through all the doors and a labyrinth is formed with different paths to be taken and which often are not understood by them or by the professionals that are part of this complex process.

The need for investment to train workers for integral health practices that consider the patient as the protagonist of their care is highlighted by Hadad and Jorge²¹21 Hadad ACAC, Jorge AO. Continuidade do cuidado em rede e os movimentos de redes vivas nas trajetórias do usuário-guia. Saude Debate 2018; 42(n. esp. 4):198-210.. To Nobre et al.³⁷37 Nobre CLC, Oliveira A, Joia JH, Cruz LS, Franco L, Oliveira KRF, Eleuterio J, Rezende ML, Rocha SR. O trabalho em rede nos casos de alta complexidade e de alta vulnerabilidade: a experiência de uma UBS. Disturb Comun 2017; 29(2):377-384., the formation of a network brings professionals closer to the territory, explores the potential of assistance and enables a more integrated approach, providing a more humanized service. In addition to a Permanent Health Education, other management arrangements may introduce these practices. The Institutional Support is a possibility of co-management, in an attempt to reduce noises, know the limits, respect the place of the other, to understand oneself, understand the others and build a work and care environment in a healthier and more pleasurable way³⁸38 Machado SS, Moreira LCH, Nascimento MAA, Casotti E. Apoio Institucional na ótica de gestores, apoiadores e trabalhadores: uma aproximação da realidade a partir de diferentes lugares. Interface (Botucatu) 2018; 22(66):813-825.. According to Medeiros³⁹39 Medeiros RHA. Uma noção de matriciamento que merece ser resgatada para o encontro colaborativo entre equipes de saúde e serviços no SUS. Physis 2015; 25(4):1165-1184., the Matrix Support may contribute to the integrality of care, and one must reject the rule producing models and crystallized positions to the detriment of the law liberating the elements and systems equated in the matrix team: a law that cannot be inscribed in a manual, since it must be written in each case to which the matrix is called, so that it fulfills its originally intended role.

Thus, the micropolitical dimension of work and health care is observed as a possibility for networks, another rationality to be considered, in which the role of the patient and the autonomy of health professionals can produce their own networks and maps of singular care based on health needs.

Challenges for the implementation of Health Care Networks

The challenges for implementing RAS were object of study of several investigations in the reviewed literature, evidencing several orders of challenges, including structural, functional and political.

An analysis of the health care systems, made from an international perspective, shows that they are fragmented, focused on the careof acute conditions and the acutization of chronic conditions⁹9 Mendes EV. As Redes de Atenção à Saúde. Cien Saude Colet 2010; 15(5):2297-2305.. In Brazil, the coordination capacity of networks is affected by fragmentation²⁷27 Almeida PF, Santos AM, Santos VP, Silveira Filho RM. Integração assistencial em região de saúde: paradoxo entre necessidades regionais e interesses locais. Saude Soc 2016; 25(2):320-335. and hinders the promotion of health as a social right by SUS²⁵25 Shimizu HE. Percepção dos gestores do Sistema Único de Saúde acerca dos desafios da formação das Redes de Atenção à Saúde no Brasil. Physis 2013; 23(4):1101-1122.. According to Arruda et al.²⁰20 Arruda C, Lopes SGR, Koerich MHAL, Winck DR, Meirelles BHS, Mello ALSF. Redes de atenção à saúde sob a luz da teoria da complexidade. Esc Anna Nery Rev Enferm 2015; 19(1):169-173., RAS, theoretically, are organized in increasing degrees of complexity, where the population should enjoy the various levels through coherent flows. However, in practice, this flow runs into a truncated, bureaucratic and disjointed functioning that does not consider the needs and real movements of people within the system, which makes it slow and, in many cases, with unsatisfactory results.

The insufficiency of resources resulting from the low public investment in health is a structural problem for SUS and hinders the regional planning for organizing RAS²⁰20 Arruda C, Lopes SGR, Koerich MHAL, Winck DR, Meirelles BHS, Mello ALSF. Redes de atenção à saúde sob a luz da teoria da complexidade. Esc Anna Nery Rev Enferm 2015; 19(1):169-173.^,2626 Silva SF. Organização de redes regionalizadas e integradas de atenção à saúde: desafios do Sistema Único de Saúde (Brasil). Cien Saude Colet 2011; 16(6):2753-2762.^,3333 Leite JPA, Spatti AC, Campos ML. Redes de Políticas nas Regiões Metropolitanas: O Caso do Sistema de Saúde Brasileiro. Physis 2017; 27(4):1039-1064.^,3535 Mendes A, Louvison MCP, Ianni AMZ, Leite MG, Feuerwerker LCM, Tanaka OY, Duarte L, Weiller JAB, Lara NCC, Botelho LAM, Almeida CAL. O processo de construção da gestão regional da saúde no estado de São Paulo: subsídios para análise. Saude Soc 2015; 24(2):423-436.. For Chioro dos Reis et al.²2 Chioro dos Reis AA, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a Construção de uma Regionalização Viva. Cien Saude Colet 2017; 22(4):1045-1054., the commitment of the municipal budget with health beyond the mandatory minimum (15%) is harmful to the balanced management of cities. Low participation of states in financing is still observed, and the state resources in many scenarios have not been agreed with municipal administrators. Recent initiatives froze the federal public spending for two decades, pointing to the definitive infeasibility of SUS. Without the prospect of new resources, regional planning and programming become unfeasible.

Another structural challenge in Brazil is the policy for training health professionals. To Arruda et al.²⁰20 Arruda C, Lopes SGR, Koerich MHAL, Winck DR, Meirelles BHS, Mello ALSF. Redes de atenção à saúde sob a luz da teoria da complexidade. Esc Anna Nery Rev Enferm 2015; 19(1):169-173., there is an insufficient personal training policy for SUS, including quantitative and qualitative aspects. There is a need for training and education, with consequent availability of professionals for the public system²⁶26 Silva SF. Organização de redes regionalizadas e integradas de atenção à saúde: desafios do Sistema Único de Saúde (Brasil). Cien Saude Colet 2011; 16(6):2753-2762. and the need to engage health workers and, specifically, doctors, as agents of change for the constitution of health regions and neworks⁴⁰40 Viana ALD, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798..

Among the operating challenges of the RAS, the need to overcome the limitations of some strategies is observed. For Leite et al.³³33 Leite JPA, Spatti AC, Campos ML. Redes de Políticas nas Regiões Metropolitanas: O Caso do Sistema de Saúde Brasileiro. Physis 2017; 27(4):1039-1064. there is a need for improving the information systems and failures in network monitoring and evaluation processes. As for Velho et al.⁴¹41 Velho APM, Vermelho SCSD, Lucena TFR, Bortolozzi F, Bennemann RM. Estratégias de comunicação das Secretarias Municipais de Saúde: desafios para as Redes de Atenção à Saúde. Saude Pesqui 2018; 11(3):505-515., they highlight the fragilities of the processes of communication: networks are weakly grounded and, despite the promotion programs and campaigns, there is still no process that provide measures capable of bringing information to the citizen, so that they assume the co-responsibility in the construction and conduct of SUS. For Chioro dos Reis et al.²2 Chioro dos Reis AA, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a Construção de uma Regionalização Viva. Cien Saude Colet 2017; 22(4):1045-1054. the main challenges are planning and dimensioning the service network, the production of living networks of care, the regulation and the coordination capacity of the regional system. Viana et al.⁴⁰40 Viana ALD, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798. indicate the need for an institutional leadership to be exercised by the states of the federation. For Mendes et al.³⁵35 Mendes A, Louvison MCP, Ianni AMZ, Leite MG, Feuerwerker LCM, Tanaka OY, Duarte L, Weiller JAB, Lara NCC, Botelho LAM, Almeida CAL. O processo de construção da gestão regional da saúde no estado de São Paulo: subsídios para análise. Saude Soc 2015; 24(2):423-436., the state sphere of power still shows difficulties to assume the effective coordination of this process, restricting itself to the role of administrating the provision of its own services.

In the political dimension, the main challenges are in the relations between several actors that compose the territories were the RAS are built. To Albuquerque and Viana³¹31 Albuquerque MV, Viana ALD. Perspectivas de região e redes na política de saúde brasileira. Saude Debate 2015; 39(n. esp.):28-38., the models of territorial organization of the health system and its combinations, in constant dispute within the federation, are conditioned by spatial dynamics and relations between state, market and society in the conduction of politics and health networks. Also, the electoral cycles, the inter-federative relations and the regional agreements are political processes that impact RAS²2 Chioro dos Reis AA, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a Construção de uma Regionalização Viva. Cien Saude Colet 2017; 22(4):1045-1054.. Mendes et al.³⁵35 Mendes A, Louvison MCP, Ianni AMZ, Leite MG, Feuerwerker LCM, Tanaka OY, Duarte L, Weiller JAB, Lara NCC, Botelho LAM, Almeida CAL. O processo de construção da gestão regional da saúde no estado de São Paulo: subsídios para análise. Saude Soc 2015; 24(2):423-436. highlight the need for agreements to include several municipalities with greater socioeconomic, epidemiological, demographic and service offer difficulties, in order to strengthen the set of municipal administrators and to allow a greater coping of regional challenges; in addition, they emphasize that the weaknesses of the political-administrative construction of a Regional Management Collegiate make them more vulnerable to private interests at the expense of collective ones.

Final considerations

The scientific production on RAS is dense and includes conceptual researches, case reports, analyses of implementation strategies, addresses proposals of evaluation methods, and discusses the production of care in the network. There are also investigations on the challenges of RAS implementation, addressing different conceptions and thematic cutouts.

The conceptual model of Health Care Networks is shown as a new paradigm of organization for SUS, and seeks to reorient the system in order to ensure integrality and better health results. It is evident how the conceptual model impacts the perspective of shaping networks. In this model, primary care assumes a central role as coordinator of care and organizer of the system, which is both a premise and a challenge. There is a question here regarding how much this premise has helped in the actual shaping of the networks. Also, the regionalization and regional governance bring the interfederative relation as a bet and limitation, and its technical, political aspects and the way they are produced must be observed, including by the particularities of the federative structure in the Brazilian context. On the other hand, another conceptual and practical production is identified, the Living Network, in which the micropolitical dimension of work and health care are shown as a possibility for the networks. This is another rationality, showing a less functionalist network conception. Such conception brings to the scenario the protagonist role of the patient and their relationship with the health worker, which may produce their own networks, based on health needs, forming rhizomatic networks.

In addition to the challenges of the regional governance, the underfunding, transformed now into a di-funding of SUS, to the established powers, the hegemonic care model and to the powers and limitations of primary care, the organizational modeling of SUS transitions between a fragmented system (chaos), polyarchic networks (organization) and the plots and connections produced in the care space (creativity). The differences between the various possibilities shown here do not seem to be a mere conceptual question or random choice by each actor. They indicate different paths.

Some limitations need to be mentioned at the end of this research. First, most of the reviewed studies was mostly based on qualitative methods, which, although they bring insights, concepts and theoretical-practical elaborations, expose little evidence production through numerical data and health indicators. In another direction, the focus on the investigation of a Brazilian public health policy, even if influenced by international experiences and models, establishes challenges regarding the comparison between national reality and the experiences of other countries. Consequently, the reviewed results should be interpreted with caution, considering the limitations of generalization and synthesis.

Finally, this integrative review point to two central questions, and not to a conclusion.

The first regards a theoretical-practical problem, since this question arises: how to overcome the fragmentation of care, ensuring integrality, composing the health care networks from distinct theoretical conceptions? That is, how to produce a SUS in a non-chaotic manner, which, when structuring formal networks, necessary for the management of the system and services, includes the living production of health care, based on the creative practices performed daily in face of the multiple and singular encounters between patients and health workers?

The second question, systemic and political, is: how can the production of care networks impact the inter-federative relations, the SUS financing process, the conformation of several types of health services, the population’s access to the system and, centrally, the quality and power of health care processes?

References

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