Abstract

This study aims to understand the movements of the Urgency and Emergency Care Network production in two health regions. It is characterized as a qualitative multiple case study and was developed through open interviews with managers of the Brazilian Health System, SUS (Sistema Único de Saúde), in two Brazilian states. The empirical material was organized and discussed through identified categories adopting the analytical scheme of the fields of organizational interventions which were: the multiplicity of movements in the production of the RUE, the power of the hospitals; and, the weakness of government regulation. Despite the different times and contexts in these states, both processes emphasized organizational aspects and financing, with low inputs in the production of different modes of health care production. Regional governance is, therefore, produced in the complex relations between national policy and local action. The RUE as a public policy induced nationally by the Ministry of Health becomes a singular production in the field of regional management.

Key words:
Health Care Network; Emergency; Regionalization; Health management; Micropolitics

Introduction

The main organizational reference of the Brazilian Health System (SUS) since 2010 has been the Health Care Networks (RAS)¹1 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; 30 dez.. The model, advocated by the Pan American Health Organization²2 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: OPAS; 2010., has been used in countries in demographic and epidemiological transition where chronic conditions and diseases predominate³3 Mendes EV. As Redes de Atenção à Saúde. Cien Saude Colet 2010; 15(5):2297-2305., presenting itself as an alternative to the fragmentation of health systems⁴4 Organização Panamericana 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 legal regulations that instituted the RAS propose a polyarchic model consisting of different points of care and the links that communicate them to obtain better epidemiological and comprehensive health care results¹1 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; 30 dez..

In this context, the Urgent and Emergency Care Network (RUE) was proposed to articulate and integrate health equipment, expanding and qualifying the access of users in urgencies and emergencies in an agile and timely manner, having as components: health promotion, prevention, and surveillance; primary care; Mobile Emergency Care Service (SAMU); stabilization room; National Health Force; Emergency Care Unit (UPA); hospital and home care⁵5 Brasil. Ministério da Saúde (MS). Portaria nº 1.600, de 7 de julho de 2011. Reformula a Política Nacional de Atenção às Urgências e institui a Rede de Atenção à Urgências no Sistema Único de Saúde. Diário Oficial da União 2011; 7 jul..

The conformation of networks presupposes regionalized planning through the articulation between states and municipalities⁶6 Brasil. Presidência da República. Decreto no 7508/ 2011, de 28 de julho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde, o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União 2011; 28 jul.. While regionalization has guaranteed more access and quality, the mere existence of regional management spaces does not guarantee a live and powerful process⁷7 Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a construção de uma regionalização viva. Cien Saude Colet 2017; 22(4):1045-1054.. Padilha et al.⁸8 Padilha ARS, Amaral MA, Oliveira DC, Campos GWS. Fragilidade na governança regional durante implementação da Rede de Urgência e Emergência em Região Metropolitana. Saúde em Debate 2018; 42(118):579-593. (2018) observed the insufficiency of political instruments and coordination arrangements developed to implement the RUE in the metropolitan region of São Paulo. Even so, advances have been achieved, difficulties need to be overcome, and improvements are needed to engender new management arrangements and care practices⁹9 Jorge AO, Coutinho AAP, Cavalcanti APS, Fagundes AMS, Pequeno CC, Carmo M, Abrahão PTM. Entendendo os desafios para a implementação da Rede de Atenção às Urgências e Emergências no Brasil: uma análise crítica. Divulgação em Saúde para Debate 2014; 52:125-145..

This study is based on the assumption that public policies are redefined in the field of practices. From an epistemological point of view, it is possible to take a public policy as an object of knowledge production, in particular, what happens from its ‘entry’ into the organizational field, constituted by actors who reinvent it based on their intentions, interests, possibilities, limits, desires, and opportunities¹⁰10 Reis AAC, Cecílio LCO. A política de reestruturação dos hospitais de ensino: notas preliminares sobre os seus impactos na micropolítica da organização hospitalar. Saúde em Debate 2009; 33(81):88-97.. The micropolitical performance of managers and other actors in the regional space is understood in this study as the staging described by Ball¹¹11 Mainardes J, Marcondes MI. Entrevista com Stephen J. Ball: um diálogo sobre justiça social, pesquisa e política educacional. Educação & Sociedade 2009; 30(106):303-318.: the conversion of the written word into actions takes place as a play. We have the text, but it only comes to life when someone represents it in an interpretation process invested with local and personal values. This study aims to understand the production movements of the Urgent and Emergency Care Network in two health regions.

Methodology

The research has a qualitative character, is characterized as a multiple case study and developed through the collection of testimonies with key informants identified among SUS managers in the health region of Campinas (RSC), in the state of São Paulo, and in the health region of Planalto (RSP), in the state of Rio Grande do Sul. The multiple case study method involves more than a single case. It can provide a more robust study by using multiple sources of evidence, being influential in substantiated research in the relationship between depth, the type of experience lived, and their understanding. Its emphasis is not on the potential for generalization but on its understanding, which strongly connects with intentionality and expansion of experience¹²12 Stake RE. Case Studies. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. Thousand Oaks: Sage Publications; 2000. p. 435-454..

In this study, “health regions” result from the inter-managers pact regulated in the Brazilian legal regulations that conceptualize them as continuous geographic spaces constituted by groupings of neighboring municipalities. They are delimited by cultural, economic, and social identities and by communication and infrastructure networks of shared transport, to integrate the organization, planning, and execution of health actions and services⁶6 Brasil. Presidência da República. Decreto no 7508/ 2011, de 28 de julho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde, o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União 2011; 28 jul.. The choice of the two regions was for convenience due to the facilitation of access to the field. Also, the differences by location, population size, socioeconomic characteristics, installed capacity of health services, and the agreement of the RUE carried out in different times and scenarios confer the potential to make the diversity and multiplicity visible in the cases studied. Although the study is not comparative, the two regions have different characteristics, as shown in Chart 1.

Open interviews collected testimonies from regional directors of state secretariats and health managers from municipalities of different sizes about the process of planning, agreement, and implementation of the RUE (Chart 2). The inclusion criterion for the interviewees was their participation in the process of formulating and agreeing on the Regional Action Plan - PAR. The material was recorded and transcribed, encrypting the interviewees’ identification to guarantee confidentiality and anonymity.

After the interviews, narratives elaborated by the researchers who sought to describe the history of the RUE agreement in the studied regions were discussed and reviewed in research group meetings. For Brockmeier and Harré¹⁴14 Brockmeier J, Harré R. Narrativa: problemas e promessas de um paradigma alternativo. Psicol Reflex Crít 2003; 16(3):525-535., the narrative has the sense of organizing experiences and assigning meanings that are of a singular order and, at the same time, cultural and social. Thus, extensive reading of the empirical material enabled us to highlight the micropolitical relationships placed in the implementation of ‘grand politics’ from the understanding that micropolitics is the process of producing subjectivities from power relations, decisive to think about the management, production of care, and training in the health area¹⁵15 Feuerwerker LCM. Micropolítica e saúde: produção do cuidado, gestão e formação. Porto Alegre: Rede Unida; 2014..

The analysis of the material was carried out by identifying the narratives of categories and organizing the results, adopting the analytical scheme of the fields of organizational interventions proposed by Lins and Cecílio¹⁶16 Lins AM, Cecílio LCO. Campos de Intervenções Organizacionais: a contribuição das ciências humanas para uma leitura crítica das propostas de gestão das organizações de saúde. Interface (Botucatu) 2007; 11(23):503-514., in research seminars of the group that developed the investigation. The research had an inducing character, i.e., concepts were researched, and new references were added from the empirical material, considering the theoretical pluralism proposed by Ball¹¹11 Mainardes J, Marcondes MI. Entrevista com Stephen J. Ball: um diálogo sobre justiça social, pesquisa e política educacional. Educação & Sociedade 2009; 30(106):303-318..

Interviewees signed an Informed Consent Form, and the Ethics Committee of the Federal University of São Paulo - UNIFESP approved the project through Opinion No. 2,447,067. The National Council for Scientific and Technological Development - CNPq and Southern College - IMED funded the research.

Results

The following analysis categories were highlighted: the multiplicity of movements in the production of the RUE, the power of hospitals, and the weakness of government regulation. Some of these categories even have potential as analyzers, considered essential devices for the researcher’s displacement¹⁷17 Guizardi FL, Lopes MR, Cunha MLS. Contribuições do movimento institucionalista para o estudo de políticas públicas de saúde. In: Mattos RA, Baptista TW, organizadores. Caminhos para análise das políticas de saúde. Porto Alegre: Rede Unida; 2015. p. 319-346..

The multiplicity of movements in rue production

The RUE planning and agreement processes in the two regions took place at different times and dynamics. In RSC, it occurred soon after the publication of the ordinances that regulate the policy, between 2011 and 2012, in a joint action between the state and municipalities, with a solid federal financial induction:

A deficiency in the regional state agency for process coordination appears in the managers’ speeches, having been overcome by the performance of technical teams from some municipalities and services:

However, in the RSP, there was a markedly notarial process, carried out late, only in 2018. Also, in search of funding, planning was carried out centrally by the regional team of the State Secretariat of Health. Municipal managers were absent from the process and were called to ratify the PAR only at the end:

The asymmetry in negotiations between states and municipalities was evidenced in both regions by the different relationships between states and municipalities with different degrees of cooperation or subordination. Added to this are the mobilization capacity and action ways of university hospitals, philanthropic and private service providers.

Among the challenges of the regional management of the RUE, the interviewees express the effect of contingencies on regional governance, such as the discontinuity of administrations and the high turnover of management staff, weakening agreements.

Interviewees also report the non-internalization of the RUE for services and workers who operate it daily:

Users are “blamed” for going to hospital emergency rooms to the detriment of primary care, even though there is recognition of the motivations for these movements:

Some advances were noticed in RSC, such as the implementation of home care, risk classification, and lines of care:

Due to the notary and recent character in RSP, the study points to a fragmented and poorly articulated process, which expresses the network fragility in the territory.

The power of hospitals

Hospitals’ real and symbolic power remains untouched, whether due to their directors’ leading role in the process or the centrality they acquired in planning the RUE, or their role in the network design. In RSP, perceptions were evidenced that the RUE would be the hospital itself as if it were synonymous with emergency hospital care and actions in primary care were not part of the network:

In addition to the understanding that the emergency care coordinates care and the ‘preventive’ function of primary care, there are also reports in RSC that the insertion of primary care in the RUE was not addressed:

The implementation and operation of SAMU in both regions face many difficulties. In RSC, the absence of state participation in funding emerges, making it unfeasible.

In the RSP, although implemented, the SAMU, whose regulation is centralized in Porto Alegre, competes with the actions of firefighters, without articulation actions from them:

The weakness of governmental regulation

In RSP, reports indicate that regulation is fundamentally professional¹⁸18 Cecilio LCO, Carapinheiro G, Andreazza R, Souza ALM, Andrade MGG, Santiago SM et al. O agir leigo e o cuidado em saúde: a produção de mapas de cuidado. Cad Saude Publica 2014; 30(7):1502-1514. and carried out directly between service providers, predominantly private:

In RSC, difficulties are expressed with state regulation, centralized in the Center for Regulation of Offers of Health Services (CROSS):

There are also manifestations of a game of pressure and weaknesses of managers in the process, who are often submissive to the services’ interests:

Thus, despite the different moments and contexts, in both regions, it is evident that there was an emphasis on the organizational aspects and financing of the RUE, influenced by the multiple movements of the actors involved, with low investment in the production of different modes of care and living health networks.

Discussion

Based on the premise that managers, when choosing strategies for conducting organizational change, are influenced by different ways of interpreting reality, Lins and Cecílio¹⁶16 Lins AM, Cecílio LCO. Campos de Intervenções Organizacionais: a contribuição das ciências humanas para uma leitura crítica das propostas de gestão das organizações de saúde. Interface (Botucatu) 2007; 11(23):503-514. formulated an analytical scheme. It is called ‘Fields of Organizational Interventions without Health,’ whose framework

For Lorau¹⁹19 Lorau R. A análise institucional. Petrópolis: Vozes; 1996., the moment of universality has as its content the systems of norms, the values that guide socialization, ideology, in short, the instituted. At the moment of particularity, its content comes down to material and social determinations that deny universality; it is the instituting moment. At the moment of singularity, the concept of the institution has as its content the organizational, legal, or anonymous forms necessary to achieve a particular purpose, institutionalization.

In the Brazilian context of a federative organization, the implementation of networks in the SUS brings unique challenges. Thus, the solid national induction of health policies by the MS, such as the RUE, cannot be characterized as a universalist organizational intervention, as it depends on the inter-federative interaction between managers⁶6 Brasil. Presidência da República. Decreto no 7508/ 2011, de 28 de julho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde, o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União 2011; 28 jul. and local actions in the municipalities.

In this study, micropolitics is observed operating in regional spaces, evidenced by disputes, movements, and interests of managers and actors present or who influenced the planning scenario of the RUE. For Deleuze and Guattari²⁰20 Deleuze G, Guattari F. Mil platôs: capitalismo e esquizofrenia (v. 3). Rio de Janeiro: Editora 34; 1996., micropolitics operates in detail, through flows of intensities, which can be extended to the whole of the social body but have an unpredictable character. Especially in the health area, studies explaining micropolitics through the action of workers with relative autonomy concerning management determinations are common¹⁵15 Feuerwerker LCM. Micropolítica e saúde: produção do cuidado, gestão e formação. Porto Alegre: Rede Unida; 2014.^,2121 Barros LS, Cecílio LCO. Entre a "grande política" e os autogovernos dos Agentes Comunitários de Saúde: desafios da micropolítica da atenção básica. Saúde Debate 2019; 43(6):4-9.^,2222 Merhy EE, Feuerwerker LMC, Santos MLM, Bertussi DC, Baduy RS. Rede Básica, campo de forças e micropolítica: implicações para a gestão e cuidado em saúde. Saúde Debate 2019; 43(6) 70-83., through the relationship between health professionals and users in the production of health care²³23 Feuerwerker LCM, Bertussi DC, Merhy EE, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes - Livro 2. Rio de Janeiro: Hexis; 2016.

24 Mendes PPS, Moebus RLN. A produção do cuidado como micropolítica. Diversitates Int J 2016; 8(1):38-53.

25 Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Júnior H, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes - Livro 1. Rio de Janeiro: Hexis; 2016.^-2626 Melo SM, Cecílio LCO, Andreazza R. Nem sempre sim, nem sempre não: os encontros entre trabalhadores e usuários em uma unidade de saúde. Saúde Debate 2017; 41(112):195-207., or by the actions of users in the production of care maps¹⁸18 Cecilio LCO, Carapinheiro G, Andreazza R, Souza ALM, Andrade MGG, Santiago SM et al. O agir leigo e o cuidado em saúde: a produção de mapas de cuidado. Cad Saude Publica 2014; 30(7):1502-1514. and their therapeutic itineraries²⁷27 Hadad ACAC, Jorge AO. Continuidade do cuidado em rede e os movimentos de redes vivas nas trajetórias do usuário-guia. Saúde Debate 2018; 42(4):198-210..

This research seeks to observe and analyze the micropolitical action in the management space, inter-federative relationship, and regional governance. Based on these assumptions, the discussion of the results will be made through the questions: ‘regional management as a field of interests and disputes’ and ‘the locoregional reconfiguration of national politics.’

Regional management as a field of interest and disputes

In the cases under study, the asymmetric power relations for negotiating the RUE, the heterogeneity between municipalities, the role of hospital service providers, and the state secretariats were present, having a strong influence on the production of PAR.

The Regional Inter-Management Commission (CIR) is defined as an instance of agreement between federative entities to define the rules of shared management of the SUS, its organization, and operation in health care networks⁶6 Brasil. Presidência da República. Decreto no 7508/ 2011, de 28 de julho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde, o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União 2011; 28 jul.. Integration between the three spheres of SUS management is essential for the RUE to be implemented⁹9 Jorge AO, Coutinho AAP, Cavalcanti APS, Fagundes AMS, Pequeno CC, Carmo M, Abrahão PTM. Entendendo os desafios para a implementação da Rede de Atenção às Urgências e Emergências no Brasil: uma análise crítica. Divulgação em Saúde para Debate 2014; 52:125-145.. Co-management takes place by constructing collective spaces and the constitution of subjects with capacity for analysis and intervention, considering that in front of each power nucleus, there are counterpowers with which one has to relate in struggle and negotiation schemes²⁸28 Campos GWS. Um método para análise e co-gestão de coletivos. São Paulo: Hucitec; 2007.. Thus, the CIR is understood not as an idealized space but as a field where conflicts, disputes, and forces become central. As defined by Bourdieu²⁹29 Bourdieu P. Razões práticas: sobre a teoria da ação. Campinas: Papiro; 1996., fields are spaces of practice created or driven by actors with positions defined by greater or lesser power, legitimacy, postures, behaviors, values, and knowledge.

Both in RSC’s CIR and RSP’s CIR, although in different times and contexts, actions by actors mobilizing their powers in the field of the RUE agreement were observed. In RSP, there are reports of a centralized notary process, coordinated by the State Secretariat team, with a subordinate role for municipal managers and with influence from hospital services. In RSC, despite a participatory process, there is recognition of the limitations of the state regional agency team, the expressive performance of MS members, the power of the technical teams in some municipalities, the fragility of some managers vis-à-vis service providers, and the active participation of representatives of teaching hospitals.

There was a solid federal induction to implement the RUE, through the expansion of financing, with the release of immediate resources, and to fund new services⁹9 Jorge AO, Coutinho AAP, Cavalcanti APS, Fagundes AMS, Pequeno CC, Carmo M, Abrahão PTM. Entendendo os desafios para a implementação da Rede de Atenção às Urgências e Emergências no Brasil: uma análise crítica. Divulgação em Saúde para Debate 2014; 52:125-145.. Although at different times and different moments due to local contexts, the search for funding emerges as the leading interest for the agreement of the RUE in the two health regions.

Some participants’ knowledge and technical expertise from municipalities, state agencies, and university services contributed to expanding their powers in the negotiations. According to Testa³⁰30 Testa M. Pensar em saúde. Porto Alegre: Artes Médicas; 1992., technical power in health can generate, access, and deal with information with different characteristics, including medical, sanitary, administrative, or theoretical frameworks. In a study on the regional governance of the RUE, Padilha et al.⁸8 Padilha ARS, Amaral MA, Oliveira DC, Campos GWS. Fragilidade na governança regional durante implementação da Rede de Urgência e Emergência em Região Metropolitana. Saúde em Debate 2018; 42(118):579-593. observed the technical power present in the relationships between professionals, between units of the same service, between services, between management structures and health care, between spheres of government, and between all these and the users.

The hospitals’ real and symbolic capital also gave them centrality in the process. The participation of university hospital managers in RSC and the strength of private service providers in RSP led to their hegemony in the RUE. For Focault³¹31 Focault M. Microfísica do poder. Rio de Janeiro: Graal; 1999., power is linked not only to law but the truth, which is produced by the power that demands it and needs it to operate. This truth declared in the interviewees’ speeches about the centrality of hospitals reproduces the idea that the hospital is synonymous with the RUE, making other services in the network invisible. In a study that analyzes the insertion in the RUE of a large hospital in the Central-West region of Brazil, Soares et al.³²32 Soares EP, Scherer MDA, O'Dwyer G. Inserção de um hospital de grande porte na Rede de Urgências e Emergências da região Centro-Oeste. Saúde Debate 2015; 39(106):616-626. conclude that it happens slowly and depends on the articulation of several other services and instances of the SUS. For Jorge et al.⁹9 Jorge AO, Coutinho AAP, Cavalcanti APS, Fagundes AMS, Pequeno CC, Carmo M, Abrahão PTM. Entendendo os desafios para a implementação da Rede de Atenção às Urgências e Emergências no Brasil: uma análise crítica. Divulgação em Saúde para Debate 2014; 52:125-145. (2014), the hospital, historically working in isolation and disconnected from other points of care, is based on curative care dissociated from any articulation with the RAS. Also, there is the incessant search of patients for care and who see them as lifelines for all health problems, guaranteeing its legitimacy and endowing it with even greater power. For Beltrammi and Reis³³33 Beltrammi DGM, Reis AAC. A fragmentação dos sistemas universais de saúde e os hospitais como seus agentes e produtos. Saúde Debate 2020; 43(5):94-103., hospitals are the cause and consequence of the fragmentation of universal health systems. They need to belong to the region as a whole, have it as the object of permanent reflection, regardless of the administrative nature or the federative entity to which they are subordinate. Otherwise, they risk being self-referenced, with a restricted look to the user’s path within themselves and not in the regionalized network⁸8 Padilha ARS, Amaral MA, Oliveira DC, Campos GWS. Fragilidade na governança regional durante implementação da Rede de Urgência e Emergência em Região Metropolitana. Saúde em Debate 2018; 42(118):579-593..

For the articulation of regional networks, the operation of the CIRs is vital, as their performance allows the constitution of a permanent political arena for the dispute of projects, where the construction of new power relations that imposes itself as power can take place⁷7 Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a construção de uma regionalização viva. Cien Saude Colet 2017; 22(4):1045-1054.. For Furtado³⁴34 Furtado LAC. O desafio da construção do comum nas máquinas de governo: o estado em disputa [tese]. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2016., the current spaces of regional management are essential but not sufficient to guarantee shared and qualified management in the regions, as macrostructures are produced all the time in the space of micropolitics. Diving into the micropolitical field of power relations is required to understand how strategies are constructed and redesigned and influence the power of institutional arrangements, showing that it is in this relational field, and not in the normative one, that the actual CIR is produced⁷7 Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a construção de uma regionalização viva. Cien Saude Colet 2017; 22(4):1045-1054..

The locoregional reconfiguration of national policy

The processes of implementing national health policies in Brazil are complex. For Viana et al.³⁵35 Viana ALA, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalização e redes de saúde. Cien Saude Colet 2018; 23(6):1791-1798., the political cycles to organize SUS comprise two periods in which decentralization to subnational entities prevailed. The municipal sphere played a leading role in the first (1988 to 2000) and the regionalization and construction of RAS in the second (2000 onwards). In this context, there are immense challenges, such as the heterogeneity between regions and the plurality of their territorial arrangements, to guarantee a universal, comprehensive, equitable system with quality and social legitimacy⁷7 Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a construção de uma regionalização viva. Cien Saude Colet 2017; 22(4):1045-1054..

While the constitution of inter-federative management instances at the federal, state, municipal, and regional levels has given voice to states and municipalities, it has not yet replaced the inducing and regulatory activities of the Ministry of Health. The maintenance of a centralized practice and the use of instruments of political and financial induction submit other entities to the system’s rules, not always with policies agreed upon and sustained in the different realities of the country³⁶36 Baptista TWF. Análise das portarias ministeriais da saúde e reflexões sobre a condução nacional da política de saúde. Cad Saude Pública 2007; 23(3):615-626.. The transfer of resources pre-defined by the federal government may suggest a reduction in autonomy and limitation of locoregional solutions³⁷37 Moreira LMC, Ferré F, Andrade EIG. Financiamento, descentralização e regionalização: transferências federais e as redes de atenção em Minas Gerais, Brasil. Cien Saude Colet 2017; 22(4):1245-1256.. For Reis et al.⁷7 Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a construção de uma regionalização viva. Cien Saude Colet 2017; 22(4):1045-1054., the production of comprehensive care in regional networks requires facing the inheritance of vertical programs and the logic of specific standardized incentives for a country of continental and heterogeneous dimensions.

The federal inducing action does not nullify the autonomy of states and municipalities for the development of local policies, nor the acceptance or not to the offers of the MS. Also, centrally defined policies, which can only be carried out in conjunction with other actors and other institutional spaces, tend to be redesigned at the regional level peculiarly. They are implemented with different levels of dialogue by managers in each reality, interacting with other social actors and assuming new intentions and conformations¹⁰10 Reis AAC, Cecílio LCO. A política de reestruturação dos hospitais de ensino: notas preliminares sobre os seus impactos na micropolítica da organização hospitalar. Saúde em Debate 2009; 33(81):88-97.. The simple financial induction of policies such as the RUE is not enough for the immediate implementation of its model, objectives, and guidelines, nor the recommended devices and arrangements.

In the RUE, which is already operationalized in daily life regardless of the pact or tutelage of regional governance, the mere reproduction of the policy formulated at the federal level seems to be very far from being achieved. The investigation makes visible the multiplicity of factors that operate in the micro-political construction of the RUE in each space beyond the intended induction of a national policy. Thus, it is not possible to think of this process as a universalist intervention. The organization is seen as a system that tends to homeostasis by determining a rational/legal axis¹⁶16 Lins AM, Cecílio LCO. Campos de Intervenções Organizacionais: a contribuição das ciências humanas para uma leitura crítica das propostas de gestão das organizações de saúde. Interface (Botucatu) 2007; 11(23):503-514..

The non-adherence to the model defined by the national policy does not necessarily mean the disqualification of the RUE, as the singular processes of construction of policies in the territories can produce more powerful arrangements that are coherent with the needs. On the other hand, we cannot understand the RUE as a particularist intervention either. The field of particularist interventions is defined by the action/freedom of subjects to redefine the structure of the organization¹⁶16 Lins AM, Cecílio LCO. Campos de Intervenções Organizacionais: a contribuição das ciências humanas para uma leitura crítica das propostas de gestão das organizações de saúde. Interface (Botucatu) 2007; 11(23):503-514.. Even though planned, agreed upon, and executed in the locoregional space by actors with formal autonomy and crossed by many disputes, the RUE is a policy that comes from a solid central induction. Thus, practices already instituted and operating in regional and municipal management spaces and the services themselves are observed to tend to be maintained or transformed through possible instituting actions triggered by local actors. The implementation of a new public policy presupposes transformations. In a study analyzing the implementation of the British health system, Klein³⁸38 Klein R. Britain's National Health Service Revisited. N Engl J Med 2004; 350(9):937-942. described it as a model of “exhortation and hope,” where the central government exhorted and hoped that measures would be taken at the local level. Health policies implemented in Brazil seem to be based on this model.

A central element is a perception that there was not necessarily the formation of integrated networks, but a more significant investment in the hospital component and emergency care services to the detriment of other points of care, always guided by the search for more funding in a brutally unfinanced system³³33 Beltrammi DGM, Reis AAC. A fragmentação dos sistemas universais de saúde e os hospitais como seus agentes e produtos. Saúde Debate 2020; 43(5):94-103.. The SAMU, conceived as an element of network articulation, presents itself as a critical node in the two studied regions. Primary care, with the attribute of horizontality of care, was separated and neglected in both regions.

Another issue that highlights the instituted operating in the RUE is regulation, especially the weakness of government regulation. Cecílio et al.¹⁸18 Cecilio LCO, Carapinheiro G, Andreazza R, Souza ALM, Andrade MGG, Santiago SM et al. O agir leigo e o cuidado em saúde: a produção de mapas de cuidado. Cad Saude Publica 2014; 30(7):1502-1514. identify different regulatory regimes - governmental, professional, clientelistic, and lay - indicating that this is a field in permanent dispute, a social production. In the cases under study, a government regulation centralized by the state is observed in RSC. In RSP, regulation is even more incipient, centered on services, markedly professional, and carried out informally through applications. For Jorge et al.⁹9 Jorge AO, Coutinho AAP, Cavalcanti APS, Fagundes AMS, Pequeno CC, Carmo M, Abrahão PTM. Entendendo os desafios para a implementação da Rede de Atenção às Urgências e Emergências no Brasil: uma análise crítica. Divulgação em Saúde para Debate 2014; 52:125-145., there is a lack of political decision to regulate in most managers, and the operation of networks without regulation has been the rule.

An important observation in implementing the RUE in the regions, which express the relationship between universal, particular, and singular, was the little emphasis given to the proposed changes in health care practices. For Reis et al.⁷7 Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a construção de uma regionalização viva. Cien Saude Colet 2017; 22(4):1045-1054., the construction of living care networks, which connect the various services existing in the territories, is one of the central objectives of regional governance. The agreement made ‘from above’ was not internalized for the services, managers, and workers who operate the ‘de facto’ policy daily. This perception is supported by studies that identify that implementing the set of components of the RUE was not accompanied by modifying the care model towards comprehensive, resolute, qualified, and user-centered care⁸8 Padilha ARS, Amaral MA, Oliveira DC, Campos GWS. Fragilidade na governança regional durante implementação da Rede de Urgência e Emergência em Região Metropolitana. Saúde em Debate 2018; 42(118):579-593.^,99 Jorge AO, Coutinho AAP, Cavalcanti APS, Fagundes AMS, Pequeno CC, Carmo M, Abrahão PTM. Entendendo os desafios para a implementação da Rede de Atenção às Urgências e Emergências no Brasil: uma análise crítica. Divulgação em Saúde para Debate 2014; 52:125-145.^,3232 Soares EP, Scherer MDA, O'Dwyer G. Inserção de um hospital de grande porte na Rede de Urgências e Emergências da região Centro-Oeste. Saúde Debate 2015; 39(106):616-626.. Such occurrence would require bringing together and encourage the protagonism of worker³²32 Soares EP, Scherer MDA, O'Dwyer G. Inserção de um hospital de grande porte na Rede de Urgências e Emergências da região Centro-Oeste. Saúde Debate 2015; 39(106):616-626., reinvent the internal arrangements in the production of care⁸8 Padilha ARS, Amaral MA, Oliveira DC, Campos GWS. Fragilidade na governança regional durante implementação da Rede de Urgência e Emergência em Região Metropolitana. Saúde em Debate 2018; 42(118):579-593., and evaluate the implementation of the predicted qualification devices⁹9 Jorge AO, Coutinho AAP, Cavalcanti APS, Fagundes AMS, Pequeno CC, Carmo M, Abrahão PTM. Entendendo os desafios para a implementação da Rede de Atenção às Urgências e Emergências no Brasil: uma análise crítica. Divulgação em Saúde para Debate 2014; 52:125-145..

Thus, the RUE becomes a singular production when it enters the organizational field of regional management, being crossed by the micropolitical action of actors that shape it according to the relationship of interests and powers they operate. For institutionalists, at the singular moment, society works because universal norms, admitted as such, are not directly incarnated in individuals but go through the mediation of singular social forms, adapted modes of organization¹⁹19 Lorau R. A análise institucional. Petrópolis: Vozes; 1996.. In the cases under study, a complex relationship can be seen between the policy in action - the process - and the official policy - the model - producing a singular policy in the context of practices.

For Lorau¹⁹19 Lorau R. A análise institucional. Petrópolis: Vozes; 1996., the action of particular subjects concerning the universal is triggered mediated and organized by the singular dimension. According to Lins and Cecílio¹⁶16 Lins AM, Cecílio LCO. Campos de Intervenções Organizacionais: a contribuição das ciências humanas para uma leitura crítica das propostas de gestão das organizações de saúde. Interface (Botucatu) 2007; 11(23):503-514., in singular organizational interventions, the organization’s official project embodies the institution’s discourse to which it is linked. It represents the tremendous normalizing axis, ‘cross-cut’ by several other projects disputed by protagonist groups skilled in handling resources for its autonomy.

Deuleze and Guattari²⁰20 Deleuze G, Guattari F. Mil platôs: capitalismo e esquizofrenia (v. 3). Rio de Janeiro: Editora 34; 1996. use the concept of segmentarity to explain this relationship. For the authors, every society and individual is crossed by two segmentarities: a molar and a molecular one. They are distinguished but inseparable, always presupposing the other. Every policy is both macro and micropolitics. There is, then, a hard segmentarity (molar) and a flexible segmentarity (molecular), which mix and coexist. For Merhy et al.²⁵25 Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Júnior H, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes - Livro 1. Rio de Janeiro: Hexis; 2016., understanding how these lines are intertwined all the time and mutually constituting, in movements of escape and construction of change and processes of resistance and confirmation of the instituted, helps to understand the daily life of the SUS.

An important question then emerges: the singular production, in the relationship between the formulated policy and the policy in action, is not necessarily good or bad¹⁹19 Lorau R. A análise institucional. Petrópolis: Vozes; 1996.. What can be an innovative action or a necessary adaptation to the local reality in the RUE policy can also be an act of resistance and maintenance of the instituted against proposals and objectives formulated at the federal level. However, a health policy that could enable transformations to build a more inclusive system committed to the defense of life can, however, strengthen powers, institutions, and processes that do not necessarily contribute to the common interest. Thus, the study findings regarding micropolitical action, disputes, powers, and singularities in the field of inter-federative regional management should be considered by the formulators and conductors of health policies. It is essential to build singular management projects⁷7 Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Reflexões para a construção de uma regionalização viva. Cien Saude Colet 2017; 22(4):1045-1054. for each region, considering each territory’s specificities.

Final considerations

Health policies induced nationally by the MS become singular productions in health regions, municipalities, and health services. The planning, agreement, and implementation process of the RUE in the two studied health regions can be understood as organizational interventions in the field of singularity since they were produced or reproduced in a different way from what was predicted in the formulated policy. Public policies aimed at organizing the health system into networks are reprocessed in particularity and singularity fields, acquiring other unplanned designs.

Considering the micropolitical action of actors inherent to the regional management scenario using their knowledge, powers, and actions was central in making the RUE construction process visible in each region. Despite the macro-determinations of national policy, the regional governance field and the micro-political relationships of the actors involved produce singular processes. Therefore, regional governance is produced in the complex relationships between national politics and local action, understood not as dichotomous or deterministic but as immanent. The construction process of the RUE in the two health regions, based on a normalizing axis, was noted to be cross cut by different powers and projects in dispute between the local actors, producing in each territory the possible synthesis between a national policy and the locoregional realities.

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