Abstract

This study seeks to point out the different configurations of Health Care Networks in primary care (AB) and Hospital Care (AH), dimensioned based on coverage, quality, and resolvability characteristics in health macro-regions. Cross-sectional study used the cluster analysis and segmented 103 macro-regions into different profiles of coverage, quality and resolubility: group 1 (high coverage/AB and medium/AH; low quality AB-AH with high resolubility); group 2 (high coverage/AB and low/AH; low quality AB-AH with medium resolubility) and group 3 (high coverage/AB and medium/AH; high quality AB-AH with high resolubility). Coverage in AB was classified as high for 100% of the Brazilian population and in AH low to 9.70% and medium to 90.29%. Quality/AB-AH is low for 58.54% and high for 41.15%. Resolubility is high for 90.29% and medium for 9.70%. In Brazil, there is expansion of coverage with low quality/AB; shortage of hospital beds and low quality/HA with high resolution. However, in the Southeast and South, high AB-AH quality prevails. The structuring of health networks is still characterized by low resolution, demanding incentives for the governance of inter-federal arrangements.

Key words:
Primary health care; Tertiary health care; Health services coverage; Quality; access; and evaluation of health care; Regionalization of health

Introduction

In Brazil, the universality of the right to health, which since the 1988 Constitution has emerged as a Unified Health System (SUS), constituted of public actions and services that, integrated into a regionalized and hierarchical network, require the combination of different services and professionals. Notwithstanding, epidemiological, and demographic aspects of the population, coinciding with an agenda of State reform, strengthening of neoliberal policies, scientific and technological innovation, and social and regional inequalities, impose challenges for the organization of comprehensive, well-advised, and participatory health care¹1 Viana ALA, Bousquat A, Melo GA, Filho NA, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.

2 Viana ALA, Lima LD, Bonifácio A, Shimizu H, Gimenez B. Relações Federativas e Regionalização no cenário da pandemia de Covid-19: em que e de que forma conseguimos avançar? In: 4º Congresso Brasileiro de Política, Planejamento e Gestão em Saúde. Rio de Janeiro; 2020. p. 1-18.

3 Viana ALA, Iozzi FL. Enfrentando desigualdades na saúde: impasses e dilemas do processo de regionalização no Brasil. Cad Saude Publica 2019; 35(Supl. 2):e00022519.

4 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1481.^-55 Cajueiro JPM. O processo de regionalização do Sistema Único de Saúde no Brasil nos anos 2000: uma contribuição para o debate a partir do estudo da Região Metropolitana de Campinas [tese]. Campinas: Universidade Estadual de Campinas; 2019..

It is known that Primary Health Care (PHC), conceived as a care coordinator and organizer of the Health Care Network (RAS), is one of the requirements of regional dynamics⁶6 Bousquat A, Giovanella L, Fausto MCR, Medina MG, Martins CL, Almeida PF, Campos SEM, Mota PHS. A atenção primária em regiões de saúde: política, estrutura e organização. Cad Saude Publica 2019; 35(Supl. 2):e00099118.. In Hospital Care (AH), hospitals must act in conjunction with PHC and be oriented towards the design of the loco-regional RAS¹1 Viana ALA, Bousquat A, Melo GA, Filho NA, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.^,77 Souza JS, Martins JS, Rosado LB, Santos TBS, Pinto ICM. Gestão hospitalar no SUS: correlações entre rede de atenção e capacidade de gestão dos serviços. Divulg Saude Debate 2018; 58:46-57.^,88 Brasil. Ministério da Saúde (MS). Portaria de Consolidação nº 2, de 28 de setembro de 2017. Consolidação das normas sobre as políticas nacionais de saúde do Sistema Único de Saúde. Diário Oficial da União 2017; 3 out.. However, the need to develop continuing education programs in PHC with institutionalization of monitoring and evaluation practices in local teams draws attention⁹9 Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saude Debate 2018; 42(1):208-223.. In AH, the need to improve contractual instruments stands out, qualifying the role of the hospital in providing services and improving its relationship with the municipality and other levels of care⁷7 Souza JS, Martins JS, Rosado LB, Santos TBS, Pinto ICM. Gestão hospitalar no SUS: correlações entre rede de atenção e capacidade de gestão dos serviços. Divulg Saude Debate 2018; 58:46-57..

In the field of planning and management, regionalization has long been established as an alternative for the design of public policies and, in health, the organization of services in health regions as a strategy to make the system more equitable and efficient has been substantiated²2 Viana ALA, Lima LD, Bonifácio A, Shimizu H, Gimenez B. Relações Federativas e Regionalização no cenário da pandemia de Covid-19: em que e de que forma conseguimos avançar? In: 4º Congresso Brasileiro de Política, Planejamento e Gestão em Saúde. Rio de Janeiro; 2020. p. 1-18.^,33 Viana ALA, Iozzi FL. Enfrentando desigualdades na saúde: impasses e dilemas do processo de regionalização no Brasil. Cad Saude Publica 2019; 35(Supl. 2):e00022519.^,55 Cajueiro JPM. O processo de regionalização do Sistema Único de Saúde no Brasil nos anos 2000: uma contribuição para o debate a partir do estudo da Região Metropolitana de Campinas [tese]. Campinas: Universidade Estadual de Campinas; 2019.^,77 Souza JS, Martins JS, Rosado LB, Santos TBS, Pinto ICM. Gestão hospitalar no SUS: correlações entre rede de atenção e capacidade de gestão dos serviços. Divulg Saude Debate 2018; 58:46-57.^,1010 Brasil. Presidência da República. Decreto 7.508, de 28 de junho 2011. Regulamenta a Lei 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde - SUS, o planejamento da Saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União 2011; 29 jun.. Such a strategy encompasses the intergovernmental relationship 3 and highlights the importance of articulating regional policies, basic and specialized care, regulation, and coordination for the integration of actions¹¹11 Rache B, Rocha R, Nunes L, Spinola P, Malik AM, Massuda A. Necessidades de infraestrutura do SUS em preparo à COVID-19: leitos de UTI, respiradores e ocupação hospitalar. IEPS 2020; Nota Técnica 3:1-5..

In the monitoring and evaluation policy for SUS qualification, two important instruments for planning and structuring health care networks in SUS have been implemented in recent years: the Program for Improving Access and Quality of Primary Care (PMAB-AB)¹²12 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). Manual instrutivo para as Equipes de Atenção Básica [Internet]. 2013. [acessado 2018 jul 16]. Disponível em: http://189.28.128.100/dab/docs/portaldab//publicacoes/manual_instrutivo_PMAQ_AB2013.pdf
http://189.28.128.100/dab/docs/portaldab... and the National Program for Health Services Evaluation (PNASS)¹³13 Brasil. Secretaria-Executiva. Departamento de Regulação, Avaliação e Controle de Sistemas. Programa Nacional de Avaliação de Serviços de Saúde [Internet]. 2015. [acessado 2018 jul 16]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pnass_programa_nacional_avaliacao_servicos.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... , an instrument for evaluating hospital care.

On the other hand, the insufficient resources allocated to SUS; the specificities of Brazilian federalism and the involvement of different agents in the provision of services²2 Viana ALA, Lima LD, Bonifácio A, Shimizu H, Gimenez B. Relações Federativas e Regionalização no cenário da pandemia de Covid-19: em que e de que forma conseguimos avançar? In: 4º Congresso Brasileiro de Política, Planejamento e Gestão em Saúde. Rio de Janeiro; 2020. p. 1-18.^,55 Cajueiro JPM. O processo de regionalização do Sistema Único de Saúde no Brasil nos anos 2000: uma contribuição para o debate a partir do estudo da Região Metropolitana de Campinas [tese]. Campinas: Universidade Estadual de Campinas; 2019.^,1414 Bousquat A, Giovanella L, Campos EMS, Almeida PF, Martins CL, Mota PHS, Mendonça MHM, Medina MG, Viana ALA, Fausto MCR, Paula DF. Atenção primária à saúde e coordenação do cuidado nas regiões de saúde: perspectiva de gestores e usuários. Cien Saude Colet 2017; 22(4):1141-1154. form disjointed municipal systems with low intergovernmental relations¹⁵15 Projeto de Avaliação do Desenvolvimento do Sistema de Saúde (PROADESS). Monitoramento da assistência hospitalar no Brasil (2009-2017) [Internet]. 2019. [acessado 2020 jul 16]. Disponível em: https://www.proadess.icict.fiocruz.br/Boletim_4_PROADESS_Monitoramento%20da%20assistencia%
https://www.proadess.icict.fiocruz.br/Bo... , highlighting in SUS the dynamics between cooperation and competition as one of the main flaws¹⁶16 Ribeiro JM, Moreira MR, Ouverney AM, Silva CMFP. Políticas de saúde e lacunas federativas no Brasil: uma análise da capacidade regional de provisão de serviços. Cien Saude Colet 2017; 22(4):1031-1044.. As a result, PHC and specialized care are characterized by high fragmentation, fragile integration, and communication between services; by deficiency in access regulation processes and lack of effective devices for coordinating user flows and specialist schedules¹⁷17 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Programa de Melhoria do Acesso e da Qualidade. Manual Instrutivo para as Equipes de Atenção Básica e NASF [Internet]. 2017. [acessado 2019 jun18]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/Manual_Instrutivo_3_Ciclo_PMAQ.pdf
http://189.28.128.100/dab/docs/portaldab... .

In studies carried out, Viana and Iozzi³3 Viana ALA, Iozzi FL. Enfrentando desigualdades na saúde: impasses e dilemas do processo de regionalização no Brasil. Cad Saude Publica 2019; 35(Supl. 2):e00022519. draw attention to the fact that both region and networks did not have their strengthening matured during the regionalization process. Bousquat et al.¹⁵15 Projeto de Avaliação do Desenvolvimento do Sistema de Saúde (PROADESS). Monitoramento da assistência hospitalar no Brasil (2009-2017) [Internet]. 2019. [acessado 2020 jul 16]. Disponível em: https://www.proadess.icict.fiocruz.br/Boletim_4_PROADESS_Monitoramento%20da%20assistencia%
https://www.proadess.icict.fiocruz.br/Bo... , in turn, draw attention to the difficulty of consolidating RAS without a robust PHC, capable of coordinating care. At the same time, the PHC cannot perform its role without a solid regional arrangement and coordination between federated entities.

It is clear that federative coordination¹⁸18 Carvalho ALB, Jesus WLA, Senra IMVB. Regionalização no SUS: processo de implementação, desafios e perspectivas na visão crítica de gestores do sistema. Cien Saude Colet 2017; 22(4):1155-1164., involves aspects related to planning and management; regulation; institutionality; financing; the provision of services and the construction of network and care flows¹1 Viana ALA, Bousquat A, Melo GA, Filho NA, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.^,55 Cajueiro JPM. O processo de regionalização do Sistema Único de Saúde no Brasil nos anos 2000: uma contribuição para o debate a partir do estudo da Região Metropolitana de Campinas [tese]. Campinas: Universidade Estadual de Campinas; 2019., demanding integration between providers of the municipal basic and regional specialized networks³3 Viana ALA, Iozzi FL. Enfrentando desigualdades na saúde: impasses e dilemas do processo de regionalização no Brasil. Cad Saude Publica 2019; 35(Supl. 2):e00022519., as well as dialogue on the role of the hospital and its articulation with PHC and other services in the territory⁸8 Brasil. Ministério da Saúde (MS). Portaria de Consolidação nº 2, de 28 de setembro de 2017. Consolidação das normas sobre as políticas nacionais de saúde do Sistema Único de Saúde. Diário Oficial da União 2017; 3 out.^,1313 Brasil. Secretaria-Executiva. Departamento de Regulação, Avaliação e Controle de Sistemas. Programa Nacional de Avaliação de Serviços de Saúde [Internet]. 2015. [acessado 2018 jul 16]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pnass_programa_nacional_avaliacao_servicos.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... .

In this framework, the present study aims to point out the different configurations of Health Care Networks in Primary Care (AB) and Hospital Care (AH), based on characteristics of coverage, quality, and resolvability in health macro-regions¹⁸18 Carvalho ALB, Jesus WLA, Senra IMVB. Regionalização no SUS: processo de implementação, desafios e perspectivas na visão crítica de gestores do sistema. Cien Saude Colet 2017; 22(4):1155-1164.. Therewith, we seek to identify the prevalent designs of regional organization for the provision of services in SUS.

Method

This is a cross-sectional study²⁰20 Medronho R, Carvalho DM, Bloch KV, Luiz RR, Verneck GL. Epidemiol. São Paulo: Atheneu; 2002. that used as a database the certification score of teams from the 2nd cycle PMAQ-AB¹²12 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). Manual instrutivo para as Equipes de Atenção Básica [Internet]. 2013. [acessado 2018 jul 16]. Disponível em: http://189.28.128.100/dab/docs/portaldab//publicacoes/manual_instrutivo_PMAQ_AB2013.pdf
http://189.28.128.100/dab/docs/portaldab... and the performance score of hospitals evaluated in PNASS¹³13 Brasil. Secretaria-Executiva. Departamento de Regulação, Avaliação e Controle de Sistemas. Programa Nacional de Avaliação de Serviços de Saúde [Internet]. 2015. [acessado 2018 jul 16]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pnass_programa_nacional_avaliacao_servicos.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... , presented in Chaves et al.²¹21 Chaves LA, Malta DC, Jorge AO, Reis IA, Tofoli GB, Machado LF, Santos AF, Andrade EIG. Programa Nacional de Avaliação dos Serviços de Saúde - PNASS 2015-2016: uma análise sobre os hospitais no Brasil. Rev Bras Epidemiol 2020; 24:e210002.; the EqAB population coverage of the e-Gestor Primary Care System; the total number of hospital beds (inpatient and complementary) for the municipalities included in DATASUS, according to the methodology applied by Lima (p. 63)²²22 Lima CP. Comparando a saúde no Brasil com os países da OCDE: explorando dados de saúde pública [dissertação]. Rio de Janeiro: Fundação Getúlio Vargas; 2016. and the Hospital Admission Authorization (AIH) from the Hospital Information System (SIH-RD/SUS) in the year 2016 of DATASUS, according to the methodology applied by Morais (Chart 1)²³23 Morais MM. Regionalização da Assistência à Saúde no Estado de Minas Gerais: capacidade de provisão de serviços hospitalares na média complexidade [dissertação]. Belo Horizonte: Fundação João Pinheiro; 2019.. The choice of the analyzed periods refers to data collection from PMAQ-AB¹³13 Brasil. Secretaria-Executiva. Departamento de Regulação, Avaliação e Controle de Sistemas. Programa Nacional de Avaliação de Serviços de Saúde [Internet]. 2015. [acessado 2018 jul 16]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pnass_programa_nacional_avaliacao_servicos.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... , and application of the questionnaire in PNASS¹³13 Brasil. Secretaria-Executiva. Departamento de Regulação, Avaliação e Controle de Sistemas. Programa Nacional de Avaliação de Serviços de Saúde [Internet]. 2015. [acessado 2018 jul 16]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pnass_programa_nacional_avaliacao_servicos.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... _.

AB and AH are understood as strategic spaces for the organization of the health system and central challenges for the constitution of a Region and RAS in SUS¹1 Viana ALA, Bousquat A, Melo GA, Filho NA, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.. A country with strong orientation towards PHC and expansion of coverage by the Family Health Strategy (ESF) has better and more equitable health results²⁴24 Mackinco J, Starfield B, Erinosho T. The Impact of Primary Healthcare on Population Health in Low- and Middle-Income Countries. J Ambulatory Care Management 2009; 32(2):150-171.. Furthermore, AH, composed of a combination of specialized and complex work processes and an environment in which various institutional arrangements proliferate, constitutes an urgent strategic challenge for SUS¹1 Viana ALA, Bousquat A, Melo GA, Filho NA, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.when it comes to diagnose problems and reorient planning¹³13 Brasil. Secretaria-Executiva. Departamento de Regulação, Avaliação e Controle de Sistemas. Programa Nacional de Avaliação de Serviços de Saúde [Internet]. 2015. [acessado 2018 jul 16]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pnass_programa_nacional_avaliacao_servicos.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . According to Facchini 9, quality is the essential measure to evaluate the completeness and responsiveness of SUS to the country’s health needs. The provision of services must be able to guarantee accessibility for users within the scope of the sanitary territory, promoting the integration of actions in RAS²³23 Morais MM. Regionalização da Assistência à Saúde no Estado de Minas Gerais: capacidade de provisão de serviços hospitalares na média complexidade [dissertação]. Belo Horizonte: Fundação João Pinheiro; 2019..

The level of analysis was the health macro-region, an expanded region that guarantees the resolution of RAS¹⁹19 Brasil. Ministério da Saúde (MS). Resolução nº 37, de 22 de março 2018. Dispõe sobre o processo de Planejamento Regional Integrado e a organização de macrorregiões de saúde. Diário Oficial da União 2018; 23 mar.. The period used to identify the health regions was 2018. Changes in the coverage of the regions in different periods stand out, influencing their quantity. The present analysis covered 103 macro-regions of the 104 established in the Regionalization Master Plan (PDR) in the states, encompassing 5,552 municipalities. The population estimate used data available in e-SUS Primary Care (July/2015).

The technique used was cluster analysis, which allows classifying elements into groups and identifying a “natural” structure of observations based on a multivariate profile²⁵25 Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Análise multivariada de dados. Porto Alegre: Bookman; 2009.^,2626 Mingoti AS. Análise de dados através de métodos de estatística multivariada: uma abordagem aplicada. Belo Horizonte: UFMG; 2017..

Previously, the variables were standardized using the mean values and standard deviation (Z-Score). Once the proximity measurement (similarity) was chosen and the Euclidean distance similarity was adopted, the partition procedure chosen was the hierarchical method²⁵25 Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Análise multivariada de dados. Porto Alegre: Bookman; 2009.. In the hierarchical partition procedure, it is necessary to define the clustering algorithm to determine how similarity is defined between multi-member clusters in the process. The complete linkage method was used to define the similarity between two clusters. The process of creating clusters generated a tree diagram (dendrogram)²⁵25 Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Análise multivariada de dados. Porto Alegre: Bookman; 2009.^,2626 Mingoti AS. Análise de dados através de métodos de estatística multivariada: uma abordagem aplicada. Belo Horizonte: UFMG; 2017.. Finally, the NbClust function was used (available at NbClust library: https://CRAN.R-project.org/package=NbClust) to evaluate the optimal number of groups.

The average scores for the variables were measured and the authors defined a scale for classifying the groups based on the percentile, as follows: low (below P₅₀); medium (between P₅₀ and P₇₀) and high (above P₇₀). For variables that did not present a normal distribution, the scale was considered low (below 50.0); medium (between 50.0 and 70.0) and high (above 70.0). Thus, the groupings were classified for the variables as follows:

AB quality: low (below 52.59), medium (52.60 to 55.51), high (above 55.52).

Coverage/Family Health Team: low (below 50.0), medium (between 50.0 and 70.0) and high (above 70,0).

Quality in AH (Risk component and quality of hospitals /PNASS): low (below 64.64), medium (64.65 to 71.52), high (above 71.53).

Coverage/hospital bed: low (below 1.65), medium (1.66 to 1.89), high (above 1.9).

Resolvability rate: low (below 50.0), medium (between 50.0 and 70.0) and high (above 70.0).

Subsequently, the description of the groupings compared the average score obtained in each variable with the constructed classification scale. Thereby, in the interpretation stage, it was possible to examine the characteristics of the clusters and identify substantial differences between them.

Finally, the Shapiro-Wilk test was applied to assess whether the distribution resembles the normal distribution and the Kruskal-Wallis test was applied to compare variables by region, grouped into profiles related to coverage, quality and resolvability. All statistical analyses were performed using R software (R Core Team, 2018).

To use PMAQ-AB data, the project obtained approval from the Research Ethics Committee of the Federal University of Minas Gerais (UFMG) under number 1,275,911. For other data, a public domain secondary database was used, without nominal identification, in accordance with Federal Government Decree No. 7,724, May 16, 2012²⁷27 Brasil. Presidência da República. Decreto 7.724, de 16 de maio 2012. Regulamenta a Lei nº 12.527, de 18 de novembro de 2011, que dispõe sobre o acesso a informações previsto no inciso XXXIII do caput do art. 5º, no inciso II do § 3º do art. 37 e no § 2º do art. 216 da Constituição. Diário Oficial da União 2012; 16 maio., and Resolution No. 510, April 7, 2016²⁸28 Brasil. Presidência da República. Resolução nº 510, de 7 de abril de 2016. Dispõe sobre as normas aplicáveis a pesquisas em Ciências Humanas e Sociais cujos procedimentos metodológicos envolvam a utilização de dados diretamente obtidos com os participantes ou de informações identificáveis ou que possam acarretar riscos maiores do que os existentes na vida cotidiana, na forma definida nesta Resolução. Diário Oficial da União 2016; 24 maio..

Results

The descriptive statistic for Brazil (Table 1) presents 2-variable equations (population coverage estimated by EqAB) and the 3-variable one (Risk component and quality of hospitals/PNASS) with the greatest variability in the set of elements. The distribution is normal for 1 (AB quality component), 3 (Risk component and quality of hospitals/PNASS) and four variables (beds per thousand inhabitants - SUS).

Table 2 shows the average per state for the AB and AH variables, and in the comparison between regions there is evidence that at least one indicator belonging to a region differs from the others: 1) “AB quality component” - the South with the highest and the North with the lowest average indicator, showing differences between the regions: Southeast and Northeast, Southeast and North, South and Central-West, South and Northeast, in addition to South and North; 2) “Population coverage estimated by EqAB” - Northeast presented the highest and Central-West the lowest average indicator, with a difference between the Northeast and Central-West, in addition to the Southeast and Northeast; 3) “Risk component and quality of hospitals evaluated in PNASS” - Southeast the highest and the North the lowest average indicator, with differences between North and Northeast, Southeast and Northeast, Southeast and North, South and Northeast, in addition to South and North; 4) “SUS Beds per thousand inhabitants” - South and Southeast presented the highest and lowest average indicators, respectively, presenting difference between South and Southeast and 5) “Resolvability rate” - South with the highest average indicator and Northeast with the lowest, indicating differences between Southeast and Northeast and, ultimately, South and Northeast (Kruskal-Wallis test, p < 0.05).

Characteristics and spatial distribution of the clusters are presented in Table 3 and Figure 1. Group 1 (High Coverage/AB and Medium/AH; Low quality/AB-AH with High resolvability) - compiles 47 health macro-regions. It has higher population percentage (49.13%) and municipalities (48.23%), in addition to affecting all geographic regions. It has the highest average score for coverage and lowest for quality/AB-AH. Altogether, it indicates an intermediate scenario for coverage, quality, and resolvability.

Group 2 (High Coverage/AB and Low/AH; Low quality/AB-AH with Medium resolvability) - consists of a smaller number of macro-regions (8), distributed in the Central-West and Northeast, illustrating lower population percentage (9.7%) and municipalities (7.31%). It presents the lowest average score for coverage/AB-AH and resolvability. When comparing groups, it indicates the worst-case scenario.

Group 3 (High Coverage/AB and Medium/AH; High quality/AB-AH with High resolution) - covering 48 macro-regions located in the Northeast, Center-West, Southeast and South, represents 44.45% of the Brazilian population and has 2468 municipalities. It presents the highest average score for quality/AB-AH and resolvability. It also indicates the best scenario for coverage, quality, and resolvability.

Overall, groups 1 and 2, showing the worst results for quality/AB-AH, represent 58.54% of the Brazilian population and group 3, with the best results, 41.15%. Coverage was classified as high for 100% of the population (groups 1, 2 and 3) in AB and, in AH, it is average for 90.29% of the population (groups 1 and 3) and low for 9.7% (group 2). Resolvability is high for 90.29% of the population (groups 1 and 3) and average for 9.7% (group 2).

By region, the distribution of the clusters shows that the macro-regions of North were classified in group 1. Northeast, with macro-regions in the three groups, concentrates (66.66%) in group 1; (16.66%) in group 2 and (16.66%) in group 3. A scenario of high resolvability and low AB-AH quality stands out for 83.33% of the macro-regions. Central-West classifies (62.5%) of macro-regions in group 1. Southeast, displaying macro-regions in groups 1 (18.75%) and 3 (81.25%), divergent for AB-AH quality, with Minas Gerais corresponding of 84.61% of the macro-regions in group 3 (best scenario) and São Paulo 88.23%. South classifies 75% of the macro-regions in group 3, Santa Catarina displays 100% of the macro-regions in this group.

In Brazil, it is noteworthy that, in AB, the average score for quality is low in 77% of the states and, for coverage, it is high in 85%. There is a prevalence in Southeast and South of macro-regions classified in group 3 (best scenario). Additionally, even though the average score for coverage/AH was classified as high in some states, there was no classification of groups with high coverage/AH, with Southeast presenting the lowest average among the regions.

Across the country, no macro-region was identified that combined high quality and AB-AH coverage with high resolvability, but group 3 is the closest to this scenario.

Discussion

The study allowed a regional examination, based on the classification of health macro-regions into groups constructed by similarity (coverage, quality and resolvability in AB-AH), and by the difference between macro-regions.

The analysis showed that in AB, for 100% of the Brazilian population, coverage is high, according to the classification scale constructed in the study, with the average coverage variable being approximately 80% in the national territory. Also in AB, three-fifths of the population, 58.54%, access low-quality services and two-fifths, 41.15%, high-quality services. The results demonstrate a scenario of expansion of ESF coverage, in agreement with other studies⁹9 Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saude Debate 2018; 42(1):208-223.^,2424 Mackinco J, Starfield B, Erinosho T. The Impact of Primary Healthcare on Population Health in Low- and Middle-Income Countries. J Ambulatory Care Management 2009; 32(2):150-171.^,2929 Giovanella L, Bousquat A, Schenkman S, Sardinha LMV, Vieira MLFP. Cobertura da Estratégia Saúde da Família no Brasil: o que nos mostram as Pesquisas Nacionais de Saúde 2013 e 2019. Cien Saude Colet 2021; 26(Supl.1):2543-2556.. Notwithstanding, if access to basic care services has increased, due to federal resources transfers, there has not yet been an equalization in the supply patterns between municipalities³⁰30 Marques E, Arretche M. Condicionantes locais da descentralização das políticas de saúde. Cad CRH 2003; 39:55-81., (Table 2).

In AH, coverage is low at 9.70% and average at 90.29%. Comparable to AB, 58.54% access low quality services and 41.15% high quality. Resolvability is high for 90.29% of the population and average for 9.70%. In AH, low quality and average coverage are observed with high resolution. Although the study indicates average coverage for AH, with an average of 1.7 in the country (Table 2), there is an insufficiency of beds when compared to the average number of beds in OECD countries 31. Another issue refers to resolvability, which indicates accessibility of users for medium complexity hospital admission.

On the above facts, there is an inequality of access in AB to the level considered of high quality, suggesting fragility in the centrality of AB coordination in the organization of systems and networks⁷7 Souza JS, Martins JS, Rosado LB, Santos TBS, Pinto ICM. Gestão hospitalar no SUS: correlações entre rede de atenção e capacidade de gestão dos serviços. Divulg Saude Debate 2018; 58:46-57.^,1414 Bousquat A, Giovanella L, Campos EMS, Almeida PF, Martins CL, Mota PHS, Mendonça MHM, Medina MG, Viana ALA, Fausto MCR, Paula DF. Atenção primária à saúde e coordenação do cuidado nas regiões de saúde: perspectiva de gestores e usuários. Cien Saude Colet 2017; 22(4):1141-1154.. For HA, there is a need for evaluation of its systemic effectiveness¹1 Viana ALA, Bousquat A, Melo GA, Filho NA, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.^,1515 Projeto de Avaliação do Desenvolvimento do Sistema de Saúde (PROADESS). Monitoramento da assistência hospitalar no Brasil (2009-2017) [Internet]. 2019. [acessado 2020 jul 16]. Disponível em: https://www.proadess.icict.fiocruz.br/Boletim_4_PROADESS_Monitoramento%20da%20assistencia%
https://www.proadess.icict.fiocruz.br/Bo... . A recent study has presented a critical situation in the Brazilian health system to meet hospital demands generated by COVID-19 pandemic³²32 Noronha NVMS, Guedes GR, Turra CM, Andrade MV, Botega L, Nogueira D, Calazans JÁ, Carvalho L, Servo L, Ferreira MF. Pandemia por COVID-19 no Brasil: análise da demanda e da oferta de leitos hospitalares e equipamentos de ventilação assistida segundo diferentes cenários. Cad Saude Publica 2020; 36(6):e00115320.. Another study highlights that, particularly in low- and middle-income countries, there is a need to improve access to high-quality care for critically ill patients in hospital³³33 Razani OT, Bastos LSL, Gelli JGM, Marchesi JF, Baião F, Hamacher S, Bozza FA. Characterisation of the first 250.000 hospital admissions for COVID-19 in Brazil: a retrospective analysis of nationwide data. Lancet Respir Med 2021; 9(4):407-418.. However, what draws attention is the percentage of the population with high quality/AB-AH (41.15%), indicating the potential of the Brazilian system for the development of actions that encourage a systemic improvement in the quality of care provided by SUS.

Among regions, intra- and inter-regional asymmetries in health care were observed, in agreement with other studies³⁴34 Malta DC, Santos MAS, Stopa SR, Vieira JEB, Melo EA, Reis AAC. A cobertura da estratégia de Saúde da Família (eSF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Cien Saude Colet 2016; 21(2):327-338.^,3535 Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Cien Saude Colet 2018; 23(6):1751-1762.. The North region, with the lowest average indicators for quality/AB-AH; Northeast, with highest average for coverage/AB, corroborating data from Giovanella et al.²⁹29 Giovanella L, Bousquat A, Schenkman S, Sardinha LMV, Vieira MLFP. Cobertura da Estratégia Saúde da Família no Brasil: o que nos mostram as Pesquisas Nacionais de Saúde 2013 e 2019. Cien Saude Colet 2021; 26(Supl.1):2543-2556., and lowest for resolvability; Central-West had the lowest average for coverage/AB; South had the highest average for quality/AB; coverage/AH and resolvability and Southeast, lowest average indicator for coverage and highest for quality in AH. Viana and Iozzi³3 Viana ALA, Iozzi FL. Enfrentando desigualdades na saúde: impasses e dilemas do processo de regionalização no Brasil. Cad Saude Publica 2019; 35(Supl. 2):e00022519. highlight territorial equity as one of the biggest challenges in achieving comprehensiveness in SUS, and it is important to highlight the fragile role assumed by the states; inequalities in the distribution of resources; concentration of services in large cities; little integration between services and the fragility of planning.

Viana et al.³⁶36 Viana ALA, Machado CV, Baptista TWF, Lima LD, Mendonça MHM, Heimann LS, Albuquerque MV, Iozzi FL, David VC, Ibañez P, Frederico S. Sistema de saúde universal e território: desafios de uma política regional para a Amazônia Legal. Cad Saude Publica 2007; 23(Supl. 2):s117-s131. discuss the territorial dimension and point out that it has not been strongly incorporated into the formulation of health policies. They add that regionalization has been directed more towards aspects of the organization of the service network at the intra-state level. Nonetheless, differences were also found in the classification of macro-regions within the same state, which refers to the difficulty in regional articulation. Ribeiro et al.³⁷37 Ribeiro JM, Moreira MR, Ouverney AM, Pinto LF, Silva CMFP. Federalismo e políticas de saúde no Brasil: características institucionais e desigualdades regionais. Cien Saude Colet 2018; 23(6):1777-1789. concluded that centralized Brazilian federalism does not produce strong local coordination of health policy, due to its competitive aspects at the subnational level and socioeconomic factors, representing important obstacles to redistributive policies. There is a weakness in regional planning³⁸38 Albuquerque AC, Cesse EAP, Felisberto E, Samico IC, Frias PG. Avaliação de desempenho da regionalização da vigilância em saúde em seis Regiões de Saúde brasileiras. Cad Saude Publica 2019; 35(Supl. 2):e00065218. and the need to develop a solid institutional capacity that considers planning in tackling structural inequalities in health regions³⁹39 Arretche M. Democracia, federalismo e centralização no Brasil. Rio de Janeiro: FGV; 2012., a fact recognized since the promulgation of Decree 7508/2011¹⁰10 Brasil. Presidência da República. Decreto 7.508, de 28 de junho 2011. Regulamenta a Lei 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde - SUS, o planejamento da Saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União 2011; 29 jun..

Almost three-fifths of the population access low-quality services and two-fifths access high-quality services. One of the main guidelines of the Ministry of Health, in the development of the Monitoring and Evaluation Policy for SUS Qualification, aims to evaluate the performance of the health system in strategic dimensions of access and quality³⁶36 Viana ALA, Machado CV, Baptista TWF, Lima LD, Mendonça MHM, Heimann LS, Albuquerque MV, Iozzi FL, David VC, Ibañez P, Frederico S. Sistema de saúde universal e território: desafios de uma política regional para a Amazônia Legal. Cad Saude Publica 2007; 23(Supl. 2):s117-s131.. Despite the investments, the results indicate the persistence of problems in the quality of primary care⁹9 Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saude Debate 2018; 42(1):208-223. as found in other studies. Tomasi et al.⁴⁰40 Tomasi E, Fernandes PAA, Fischer T, Siqueira FCV, Silveira DS, Thumé E, Duro SMS, Saes MO, Nunes BP, Fassa AG, Facchini LA. Qualidade da atenção pré-natal na rede básica de saúde do Brasil: indicadores e desigualdades sociais. Cad Saude Publica 2017; 33(3):e00195815., evaluating, for instance, aspects of the quality of prenatal care in the basic health network in Brazil, concluded that only 15% of the women interviewed received quality care.

In the present study, coverage/AB has been classified as high for 100% of the Brazilian population. There is a consensus among scholars on the equitable expansion of access and use of family health services and actions⁴⁰40 Tomasi E, Fernandes PAA, Fischer T, Siqueira FCV, Silveira DS, Thumé E, Duro SMS, Saes MO, Nunes BP, Fassa AG, Facchini LA. Qualidade da atenção pré-natal na rede básica de saúde do Brasil: indicadores e desigualdades sociais. Cad Saude Publica 2017; 33(3):e00195815., with a progressive increase in the ESF, reaching 42,784 teams in 2019⁴¹41 Brasil. Ministério da Saúde (MS). Sala de Apoio à Gestão Estratégica [Internet]. 2020. [acessado 2021 maio 20]. Disponível em: https://sage.saude.gov.br/#>
https://sage.saude.gov.br... . Other data⁴²42 Instituto Sulamaricano Gobierno En Saluda (ISAGS). Mapeamento e análise dos modelos de atenção primária à saúde nos países da América do Sul - Atenção Primária à Saúde no Brasil. Rio de Janeiro: UNASUR; 2014. demonstrate that, from 1998 to 2006, the ESF coverage of approximately 7 % reached 46% of the population. Neves et al.⁴³43 Neves RG, Flores TR, Duro SMS, Nunes BP, Tomasi E. Tendência temporal da cobertura Estratégia de Saúde da Família no Brasil, regiões e unidades da federação, 2006-2016. Epidemiol Serv Saude 2018; 27(3):e2017170. corroborate this by indicating that, between 2006 and 2016, coverage was 45.3% and 64%, respectively, with an increasing tendency. Almeida et al.⁴⁴44 Almeida ER, Sousa ANA, Brandão CC, Carvalho FFB, Tavaresi G, Silva KC. Política Nacional de Atenção Básica no Brasil: uma análise do processo de revisão (2015-2017). Rev Panam Salud Publica 2018; 42:e180. indicate an increase from 2007 to 2017, ranging from 48% to 64%. In another study⁴⁵45 Organização Pan-Americana de Saúde (OPAS). Relatório 30 anos de SUS, que SUS para 2030? Brasília: OPAS; 2018., coverage in PHC (ESF and other care models), between 2008 and 2013, varied from 75.8% to 80.6%%.

However, we agreed with Ouverney et al.⁴⁶46 Ouverney AM, Noronha JC. Modelos de organização e gestão da atenção à saúde: redes locais, regionais e nacionais. In: Fundação Oswaldo Cruz. A saúde no Brasil em 2030 - prospecção estratégica do sistema de saúde brasileiro: organização e gestão do sistema de saúde [online]. Rio de Janeiro: Fiocruz/Ipea/Ministério da Saúde/Secretaria de Assuntos Estratégicos da Presidência da República, 2013., because, even given the expansion scenario, it is not possible to conclude that coverage/AB is uniform across the national territory. A study that evaluates socioeconomic inequalities in the performance of ESFs based on the PMAQ suggests that municipal factors are important determinants of their performance⁴⁷47 Kovacs R, Barreto JOM, Silva EN, Borghi J, Kristensen SR, Costa DRT, Gomes LB, Junior GDG, Sampaio J, Jackson TP. Socioeconomic inequalities in the quality of primary care under Brazil's national pay-for-performance programme: a longitudinal study of family health teams. Lancet 2021; 9(3):331-339.. Another study, analyzing the implementation of the Basic Care Standard (PAB), concluded that there was an increase in access to AB services, but inequality between municipalities did not decrease³⁰30 Marques E, Arretche M. Condicionantes locais da descentralização das políticas de saúde. Cad CRH 2003; 39:55-81.. PAHO also considers that the low availability of doctors to work in remote areas of the country is a limiting factor in the expansion of ESF coverage⁴⁵45 Organização Pan-Americana de Saúde (OPAS). Relatório 30 anos de SUS, que SUS para 2030? Brasília: OPAS; 2018.. This set of findings corroborates the quality and coverage data found in the present study, highlighting the need to carry out new analyzes that deepen the coverage-quality relationship in SUS.

Throughout the national territory, a macro-region with high coverage/AH (above 1.9 beds/thousand inhabitants) was not classified, characterizing a huge difference compared to the number of beds in universal systems. In 2017, in OECD countries, the average number of beds was estimated at 4.7 beds/thousand inhabitants³¹31 Organization for Economic Co-operation and Development (OECD). Health at a glance 2019: OECD indicators. Paris: OECD; 2019.. Brazilian results demonstrated average coverage for 90.29% of the population and low coverage for 9.70%, suggesting regional differences in access. A study that investigates the networks established for different types of demand for health services, including basic hospital care, demonstrated inequalities in access, which is even more striking in relation to more complex services⁴⁸48 Oliveira EXG, Carvalho MS, Travassos C. Territórios do Sistema Único de Saúde - mapeamento das redes de atenção hospitalar. Cad Saude Publica 2004; 20(2):386-402.. Another study, working with the mapping of the number of ICU beds (adults in SUS) and ventilators and respirators existing in the country, found enormous regional heterogeneity and scarcity of resources in most regions of the country, indicating that it is essential to identify the most vulnerable regions to strengthen the response capacity of the health system at regional and local levels¹¹11 Rache B, Rocha R, Nunes L, Spinola P, Malik AM, Massuda A. Necessidades de infraestrutura do SUS em preparo à COVID-19: leitos de UTI, respiradores e ocupação hospitalar. IEPS 2020; Nota Técnica 3:1-5.. Data from PROADES¹⁶16 Ribeiro JM, Moreira MR, Ouverney AM, Silva CMFP. Políticas de saúde e lacunas federativas no Brasil: uma análise da capacidade regional de provisão de serviços. Cien Saude Colet 2017; 22(4):1031-1044. indicate, between 2007 and 2019, a decrease in the number of curative beds available to SUS in all major regions apart from the North region.

The situation is worsened by the concentration of hospitals in large and medium-sized cities¹1 Viana ALA, Bousquat A, Melo GA, Filho NA, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798. and in the Southeast, South and coastal regions²¹21 Chaves LA, Malta DC, Jorge AO, Reis IA, Tofoli GB, Machado LF, Santos AF, Andrade EIG. Programa Nacional de Avaliação dos Serviços de Saúde - PNASS 2015-2016: uma análise sobre os hospitais no Brasil. Rev Bras Epidemiol 2020; 24:e210002. and, due to the way they are socially distributed throughout the national territory, concentrated in the richest areas of the capitals⁴⁹49 Negri Filho AA. Bases para um debate sobre a reforma hospitalar do SUS: as necessidades sociais e o dimensionamento e tipologia de leitos hospitalares em um contexto de crise de acesso e qualidade [tese]. São Paulo: Universidade de São Paulo; 2016.. A recent study highlights that 30% of health regions (microregions) in the country are particularly vulnerable, due to a combination of ICU bed infrastructure below the minimum, and mortality from conditions similar to COVID-19, above the national median, highlighting the Southeast and Northeast regions¹¹11 Rache B, Rocha R, Nunes L, Spinola P, Malik AM, Massuda A. Necessidades de infraestrutura do SUS em preparo à COVID-19: leitos de UTI, respiradores e ocupação hospitalar. IEPS 2020; Nota Técnica 3:1-5..

In this context, Viana et al.¹1 Viana ALA, Bousquat A, Melo GA, Filho NA, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.draw attention to the integration of the hospital into the RAS and the leadership of state governments in the regional and state organization of specialized and hospital provision. It is clear, as discussed in Chaves et al.²¹21 Chaves LA, Malta DC, Jorge AO, Reis IA, Tofoli GB, Machado LF, Santos AF, Andrade EIG. Programa Nacional de Avaliação dos Serviços de Saúde - PNASS 2015-2016: uma análise sobre os hospitais no Brasil. Rev Bras Epidemiol 2020; 24:e210002., that the distribution of the supply of beds needs to be based on the formation of regional arrangements that can implement¹1 Viana ALA, Bousquat A, Melo GA, Filho NA, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798. the proper inclusion of hospital services in a systemic network design. Negri Filho⁴⁹49 Negri Filho AA. Bases para um debate sobre a reforma hospitalar do SUS: as necessidades sociais e o dimensionamento e tipologia de leitos hospitalares em um contexto de crise de acesso e qualidade [tese]. São Paulo: Universidade de São Paulo; 2016., when addressing the scarcity of beds, concluded that the hospital access crisis constitutes a reason for a strategic agenda of Brazilian hospital reform, covering⁵⁰50 Brasil. Ministério da Saú de (MS). Reforma do Sistema de Atenção Hospitalar Brasileira [Internet]. 2004. [acessado 2018]. Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/1518.pdf
https://www.nescon.medicina.ufmg.br/bibl... the dimensions of the social, financial, political, organizational, assistance and Teaching and Research crisis.

Resolvability is high for 90.29% of the population and average for 9.7%, suggesting accessibility to medium complexity procedures during hospital admission. Still, coverage/AH (classified as average for 90.29% of the population) indicates insufficient beds to meet the population’s demands, referring, on the one hand, to the need to investigate AH¹1 Viana ALA, Bousquat A, Melo GA, Filho NA, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.^,2121 Chaves LA, Malta DC, Jorge AO, Reis IA, Tofoli GB, Machado LF, Santos AF, Andrade EIG. Programa Nacional de Avaliação dos Serviços de Saúde - PNASS 2015-2016: uma análise sobre os hospitais no Brasil. Rev Bras Epidemiol 2020; 24:e210002.^,5050 Brasil. Ministério da Saú de (MS). Reforma do Sistema de Atenção Hospitalar Brasileira [Internet]. 2004. [acessado 2018]. Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/1518.pdf
https://www.nescon.medicina.ufmg.br/bibl... , an extremely complex and challenging issue and on the other, the impacts of this scarcity of beds on hospital quality, corroborated by data from the present study, when 58.54% of the population access low-quality services, and 41.15% are discharged.

As limitations of the study, it is important to highlight that cluster analysis will always create groups, and finding them does not validate their existence, making it necessary to reconcile the interpretation of quantitative data with conceptual contextualization²⁵25 Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Análise multivariada de dados. Porto Alegre: Bookman; 2009.. Finally, local, and micro-regional specificities were not highlighted or data for non-hospital specialized outpatient care were included, which is recognized as an important bottleneck in assistance when it comes to SUS.

Final considerations

The advances implemented in the field of public health since the creation of SUS in 1988 are undeniable. It stands out the contribution to access to health services and the expansion of the ESF with positive impacts on child health and the reduction of the mortality rate and hospitalization for cardiovascular diseases and stroke⁴⁵45 Organização Pan-Americana de Saúde (OPAS). Relatório 30 anos de SUS, que SUS para 2030? Brasília: OPAS; 2018.. Also, the institution of the National Hospital Care Policy (PNHOSP), which established the guidelines for the organization of the hospital component in RAS, and the National Policy for Small Hospitals⁸8 Brasil. Ministério da Saúde (MS). Portaria de Consolidação nº 2, de 28 de setembro de 2017. Consolidação das normas sobre as políticas nacionais de saúde do Sistema Único de Saúde. Diário Oficial da União 2017; 3 out., considered important in the configuration of loco-regional assistance, to guarantee access to hospital admission and reduce regional inequalities⁵¹51 Conselho Nacional de Secretários de Saúde (CONASS). Política Nacional de Atenção Hospitalar: diretrizes para a reorganização dos hospitais de pequeno porte - HPP. Brasília: CONASS; 2014..

Nonetheless, whether due to the recognized crisis of the federative pact, the challenges of the decentralization process, the discussion of the role of municipalities, the role of the private health sector and its relationship with the public sector, or the need to improve social participation mechanisms⁴⁵45 Organização Pan-Americana de Saúde (OPAS). Relatório 30 anos de SUS, que SUS para 2030? Brasília: OPAS; 2018., major challenges are posed to the management of the system. It is understood that, without adequate financing, regulation, and public participation in the provision of services, it is not possible to guarantee universal access in accordance with the health needs of the population⁵²52 Rede de Pesquisa em Atenção Primária à Saúde da Abrasco. Contribuição para uma agenda política estratégica para a Atenção Primária à Saúde no SUS. Saude Debate 2018; 42(Esp. 1):406-430..

The study also demonstrated the expansion of ESF coverage, yet, with low quality of health actions and services. Despite that, even though no grouping was found that would add high coverage, quality and resolvability, it is noteworthy that, for two-fifths of the population, a scenario of high coverage/AB and average/AH prevails; high quality/AB-AH with high resolvability; situation that accentuates the urgency of investments in the monitoring and qualification of SUS, with the development of studies that deepen the relationship between coverage and quality and that can also offer comparative parameters with other standards of organization of international health systems.

It is known that the interfederative relationship represents a major challenge in the design of public policies⁴4 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1481.^,3939 Arretche M. Democracia, federalismo e centralização no Brasil. Rio de Janeiro: FGV; 2012.^,5353 Albuquerque MV. O enfoque regional na política de saúde brasileira (2001-2011): diretrizes nacionais e o processo de regionalização nos estados brasileiros [tese]. São Paulo: Universidade de São Paulo; 2013.. In view of what is presented in the study, it appears that the institutionalization of SUS⁵⁵55 Instituto de Estudos para Políticas de Saúde (IEPS). A regionalização da saúde no Brasil. São Paulo: IEPS; 2022. management still has low resolution in the national territory. There is a lag in intergovernmental relations, which is reflected in the regional functioning of health networks and makes cooperation between the federation entities difficult⁵⁵55 Instituto de Estudos para Políticas de Saúde (IEPS). A regionalização da saúde no Brasil. São Paulo: IEPS; 2022..

Thus, looking to the future, we understand the importance of a planning that addresses the management of the relationship between the federation entities to consolidate the system, drawing attention to the implementation of regional governance that incorporates articulation with the APS and strengthening its resolution capacity. For this, unquestionably, there is a need for adequate public financing, consideration of territorial dimensions, as well as the interdependence and political-administrative role of federated entities.

References

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