The national and international repercussions of the rise in forest fires in the Brazilian Amazon confirm the idea that although such fires occur in specific territories, they are multi-scale and multidetermined phenomena that transcend the local level, making their understanding complex and requiring innovative approaches ¹1. Viana ALd'A, Iozzi FL. Enfrentando desigualdades na saúde: impasses e dilemas do processo de regionalização no Brasil. Cad Saúde Pública 2019; 35 Suppl 2:e00022519.. The example expresses characteristics of the Amazonian territory, with relevant implications for the implementation of the health policies practiced there.

Brazil’s Legal Amazonia, consisting of nine states and 772 municipalities (counties), has 27.5 million inhabitants, of whom 400,000 are indigenous people belonging to 170 distinct ethnic groups. This population as a whole receives an insufficient supply of all kinds of public services, alongside well-known difficulties with infrastructure, particularly communications and transportation ²2. Instituto Brasileiro de Geografia e Estatística. Estimativas da população residente nos municípios brasileiros com data de referência em 1º de julho de 2018. https://www.ibge.gov.br/estatisticasnovoportal/sociais/populacao/9103-estimativas-de-populacao.html?=&t=resultados.
https://www.ibge.gov.br/estatisticasnovo... .

In addition, what we call the Amazon is actually a heterogeneous and multifaceted socioenvironmental scenario where modern large cities coexist with relatively small and isolated towns and villages, in addition to diverse traditional peoples scattered across remote rural areas in practically inexpugnable territories. The social, economic, and health indicators are also highly disparate, combining accelerated demographic and economic growth with massive income concentration and living conditions that are widely unfavorable for the majority of the population. The predominant economic model is characterized by predatory exploitation of natural resources, often explored illegally ³3. Santos D, Mosaner M, Celentano D, Mouta R, Veríssimo A. Índice de Progresso Social na Amazônia brasileira: IPS Amazônia 2018. Belém: Imazon/Social Progress Imperative; 2018..

Recent decades have witnessed the emergence of sustainable economic initiatives that seek to transcend the pilot-project stage and penetrate the green market to produce a scale economy capable of providing income for Amazonian rural producers and offset the depreciated prices practiced in the regional markets. In the absence of such conditions, the Amazonian population groups continue to suffer from low income, limited schooling, and no access to the work market, fully dependent on a public health system (SUS) with a shrinking budget.

The Amazon region’s characteristically long distances are often cited in official speeches and documents, habitually identified as obstacles to economic development and to the extension of public policies to the countryside. Governments of different ideological stripes have responded precariously to this challenge, recommending the opening of highways as a means to solve transportation difficulties. The environmental devastation associated with the opening of highways has been extensively documented, evidencing the “deforestation arc” as the prime material expression of the environmental violence following in the wake of new road construction in the Amazon. Highways are also incapable of generating solutions in spaces where road transportation has not proven to be a feasible alternative to the region’s natural and historical potential for river-borne transportation. Highways have primarily served the interests of major hydroelectric, agribusiness, and mining projects, while contributing little to the marketing of family farm produce or products extracted from the forest.

In the specific case of health, geographic barriers are usually cited as preventing the supply of health services and access to healthcare in the countryside, whether in primary or medium and high-complexity care, with the latter heavily concentrated in the state capitals of the Amazon. Such nominal recognition has not resulted in the provision of services and funding to deal with this irremovable element of the Amazonian landscape. Long distances and transportation difficulties appear to be used more to justify performance shortcomings and adverse health outcomes than for planning purposes to produce innovative strategies in dealing with the Amazonian distances ⁴4. Garnelo L, Sousa ABL, Silva CO. Regionalização em saúde no Amazonas: avanços e desafios. Ciênc Saúde Colet 2017; 22:1225-34..

More recent versions of the National Policy for Basic Health (PNAB, 2011 and 2017) ⁵5. Ministério da Saúde. Portaria nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União 2011; 22 out.^,66. Ministério da Saúde. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set. recommended the implementation of the Basic Fluvial Mobile Clinics (UBSF in Portuguese), staffed by Fluvial Family Health Teams. The PNAB promoted the official recognition of initiatives already underway in the Amazon and thus provided part of the budget for the activities conducted in the countryside. The habitual induction of actions via funding from the federal government was welcomed by the local health systems, many of which were fully covering the costs of the fluvial mobile clinics already implemented before 2011. However, the insufficiency of funds transferred from the federal to the local levels and the need to adapt the flow of care and the organization of work routines still persists, besides the need to institute evaluation procedures capable of assessing the effectiveness of a mobile healthcare model. Evaluations of the Family Health Basic Care Units could help improve the quality and case-resolution capacity of a healthcare model which has the merit of expanding coverage in unserved areas and mitigating the burden on users in search of healthcare.

Meanwhile, initiatives like the creation of Fluvial Mobile Clinics through the PNAB repeat the pattern of overly generic policies produced by the federal administration that overlook the limited scope of the initiatives they recommend, precisely because they underestimate the profound sociopolitical, economic, geographic, and health differences in the Amazon’s reality. The idea here is not that a nationwide policy can or should cover every local reality’s precise details. However, the ways that the federal power to standardize is currently wielded does not allow the local (i.e., state and municipal) health systems enough room to resize or adapt the national guidelines to their local characteristics and needs.

This scenario of previous difficulties is further complicated by the current cutback in public funds for health, besides changes in the rules for financing primary care and in the use of the enrolled population as the basis for calculating transfers of federal funds to the states and municipalities. Besides disregard for the principle of universal care that originally oriented the creation of the Unified National Health System (SUS), this seriously jeopardizes a region in which population clustering in the largest cities coexists with low healthcare coverage, which is synonymous with fewer people enrolled in the healthcare system, in contrast to the effectively resident population that could not be registered due to the reduced number of active multiprofessional teams.

For rural populations in the Amazon, the harm is even more dramatic, since the low population density (resulting in few users enrolled in the health system) requires high operational expenditures due to the long distances mentioned above. This scenario tends to further deepen the cost of chronically weakened local health systems with difficulty maintaining adequate healthcare coverage.

Fiscal austerity policies like that currently under way exacerbate preexisting inequalities. The latter are further aggravated in populations exclusively dependent on the public healthcare system, hindering the identification of specific territories with such deep inequalities. The cutback in federal funding exacerbate the prevailing unequal distribution of tax revenues, compromising the local governments’ solvency, particularly in small municipalities (counties) and/or those with limited tax bases, even as they have been assigned growing responsibilities in health services provision ⁷7. Louvinson MCP. Regionalização dos sistemas de saúde como resposta às desigualdades territoriais: um debate necessário. Cad Saúde Pública 2019; 35 Suppl 2:e00116019..

The private sector’s growing participation in health also further deepens the concentration of medium and high-complexity services in the largest Amazonian cities, which concentrate the families with the highest income, deepening the limitations in healthcare access, the physical network’s structural insufficiency, and the healthcare’s case-resolution capacity, particularly due to the difficulty in retaining healthcare professionals, specifically physicians ¹1. Viana ALd'A, Iozzi FL. Enfrentando desigualdades na saúde: impasses e dilemas do processo de regionalização no Brasil. Cad Saúde Pública 2019; 35 Suppl 2:e00022519.^,77. Louvinson MCP. Regionalização dos sistemas de saúde como resposta às desigualdades territoriais: um debate necessário. Cad Saúde Pública 2019; 35 Suppl 2:e00116019..

Low income, precarious work conditions, serious labor risks, violence, intense and chronic exposure to infectious agents, lack of access to quality housing and sanitation, and limited access to healthcare are typical health problems afflicting Amazonian populations. The resolution or control of such problems requires complex interventions, sustainable economic alternatives, increased health financing, and a massive improvement in care models and organizational routines that can improve primary care performance in the region ⁸8. 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 Saúde Pública 2019; 35 Suppl 2:e00065218..

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