Abstract:

The article aims to describe the renewed role of regional policies in territorial reconfigurations in the recent and predominantly neoliberal phase of globalization. It further aims to identify some of the impasses that such transformations produce with their multiple scales and dimensions for strengthening public policies focused on confronting health inequalities in Brazil. The article’s discussion begins with a brief review of the characteristics of current territorial reconfigurations in a world in constant transformation, but oriented by neoliberal policy in its multiple dimensions. The article then discusses the changes in local management formats in developed countries. The authors go on to analyze territorial changes in Brazil in recent years, after which the debate addresses the reform agenda in health regionalization and the political cycles in the organization of the Brazilian Unified National Health System (SUS). Finally, the article systematizes some of the impasses in regionalization policy, based on recent studies in which the unit of analysis was Brazilian health regions in the country’s different major geographic regions. The issues identified in the article, also emphasized in the specialized literature, show that the region/networks dyad has not been fully strengthened during the regionalization process in Brazil. A key task for the public policy of regionalization of health in Brazil should be to continue to push forward with the reform agenda in order to mobilize the territory’s diversity and the directive coordination of strategic national policy.

Keywords:
Regional Health Planning; Health Status Disparities; Unified Health System; Health Systems; Health Policy

It is essential to portray the changes in nation states in the current period of globalization and their inseparable and peculiar spatial configurations in order to unveil the impasses in regional policies and their renewed role in this process. Likewise, the context of neoliberalism and the new management model have altered the design of public policies and their field of action, bringing changes to the nature of management on its different scales in various parts of the world.

Meanwhile, health policy has experienced periods of major transformations driven by changes in populations’ epidemiological profile, state reforms, neoliberal macroeconomic policy, and transformations resulting from technological progress and innovations.

Health policy reforms in the early 21st century, unlike those of previous decades, have changed the models for patient care, management, and regulation of health systems, with results that have varied between countries and regions. Even under these impacts, the guidelines of decentralization and regionalization have maintained their force in the reform agenda in various countries, despite variations in depth and adherence, meanings, and degrees of local autonomy in the management of health services and activities ¹1. World Health Organization. Integrated care models: an overview. Geneva: World Health Organization; 2016.^,22. Marchildon GP. Regionalization: what have we learned? Healthc Pap 2016; 16:8-14..

Regional policies can produce a positive impetus capable of substantiating more territorially pertinent and more combative public policies in the face of various inequalities. Still, regional policies need to overcome their role’s impasses and dilemmas, given the recent spatial reconfigurations resulting from the current stage of globalization and its inherent particularities in each place. These actions are also believed to have impacts on health policies by altering the scales (of provision) and flows of health care.

The backdrop for this narrative is built by reviewing the characteristics of this broad movement of changes resulting from Brazil’s current historical moment, with confluences and divergences in its processes. Given this context, identifying the territorial transformations in their multiple scales and dimensions provides a means for strengthening public policies to overcome the inequalities in the neoliberal scenario and the primacy of the financial sphere in the process of capital accumulation, which gains increasingly austere contours in the more peripheral countries and peoples.

Changes in spatial relations in the neoliberal age: the rise of the regional scale and weakening of the national scale

The 1990s witnessed a new cycle of debates on globalization that is far from over. On the contrary, it has gained greater complexity as the global space has reorganized in brand new structures of production, circulation, and communication, indicating a constant need to rethink scales, actors, and ways by which neoliberal ideals have effectively reshaped space and restructured scales and networks. If conceiving of globalization based on its economic, political, and sociocultural components is already a huge task, its spatial dimension adds another complex variable which nevertheless proves fundamental - especially in relation to this article - to reflect on public policies and the need for renewed political-institutional and socio-spatial arrangements.

There is an extensive literature contributing to the debate on aspects linked to globalization’s territoriality. Critical contributions to this arrangement, like those of Milton Santos ³3. Santos M. A natureza do espaço, técnica e tempo, razão e emoção. São Paulo: Editora Hucitec; 1996., Edward Soja ⁴4. Soja EW. Geografias pós-modernas: a reafirmação do espaço na teoria social crítica. Rio de Janeiro: Jorge Zahar Editor; 1993., and David Harvey ⁵5. Harvey D. A produção capitalista do espaço. São Paulo: Annablume; 2005., are but a few examples of the diversity of possible original approaches, with space as the center for analysis of capitalism in its current phase - which is encroaching unequally and combinedly - as contended by Neil Smith ⁶6. Smith N. Desenvolvimento desigual: natureza, capital e a produção de espaço. Rio de Janeiro: Bertrand Brasil; 1988..

Still, it is beyond the scope of this article to provide an overview of the various theoretical currents dealing with the various aspects in the contemporary processes corresponding to capitalism’s spatial dimension. An important part of this effort at undertaking a dialogue between a critical literature (mostly European) and Latin American thinking is the recent publication by Brandão et al. ⁷7. Brandão CA, Fernández VR, Ribeiro LCQ. Escalas espaciais, reescalonamentos e estatalidades: lições e desafios para América Latina. Rio de Janeiro: Letra Capital/Observatório das Metrópoles; 2018., which raises challenges for research oriented by a political economy of scales. However, we do include contributions by some authors to the understanding of globalization as territorial reconfigurations, both socioeconomic and political-institutional. This process unfolds in multiple overlapping geographic scales, promoting (mainly since the 1970s) the decentralization of the national scale and giving way to new territorial configurations in which the subnational and supranational scales acquire increasingly greater centrality ⁸8. Brenner N. A globalização como reterritorialização: o reescalonamento da governança urbana na União Europeia. Cadernos Metrópole 2010; 12:535-64.. This structural backdrop frames the narrower discussion - intended here - concerning the potential role of the regional scale in the Brazilian health system and some of its current impasses.

Proceeding to demarcate this backdrop, one notes that the contemporary phase of globalization encompasses a proliferation of spatial scales, their relative dissociation in intricate hierarchies, and an increasingly complex combination of strategies, since the political and economic forces seek the most favorable conditions to join this constantly changing world order. Although the national scale has lost its postwar predominance, no other scale of economic and political organization (“global” or “local”, “urban” or “triadic”) has achieved similar preeminence ⁹9. Jessop B. El Estado: pasado, presente, futuro. Madrid: Los Libros de la Catarata; 2017..

The multiplicity and density of relations between scales, places, and networks, together with the changes in the national scale given the processes of internationalization and regionalization, point to a decrease in the national scale’s hegemony. Still, this process evidently does not mean a simple transfer of power to other scales, but the identification of new attributions that the nation state assumes in the linkage and coordination between scales and networks within these new dynamics ⁹9. Jessop B. El Estado: pasado, presente, futuro. Madrid: Los Libros de la Catarata; 2017.^,1010. Klink J, Barcellos de Souza M. De uma economia política das escalas espaciais a uma agenda renovada para os estudos críticos espaciais. In: Brandão CA, Fernández VR, Ribeiro LCQ, organizadores. Escalas espaciais, reescalonamentos e estatalidades: lições e desafios para América Latina. Rio de Janeiro: Letra Capital/Observatório das Metrópoles; 2018. p. 361-97..

According to Dente ¹¹11. Dente B. Governare in un contesto federale: qualilezioni per la transizione italiana? In: Dente B, Sharpe JL, Banting KG, Wälti S, Goetz KH, Hooghe L, et al., editors. Governare con il federalismo. Turim: Edizione Fondazione Giovanni Agnelli; 1997. p. 10-47., the attrition in nation states’ power gives them new appearances, and the process of erosion is seen from three angles: upwards, favoring the international dimension; downwards, through decentralization; and sideways, favoring independent administrative authorities. Still, one can argue that the networks and multiple scales coming from the current phase of globalization bring new vectors in directions that transcend this linearity.

Beyond the forms of federal and unitary states, there are other important differences that shape the spatial selectiveness of the state’s forms. Such differences converge in contexts of cooperation and/or competition between local and regional authorities, as well as in relations with the national territorial state and transnational and supranational institutions. Spatial reconfiguration is thus constitutive of the globalization process. If globalization blurs the borders in local spaces, it simultaneously imposes the rise to economic and political power of territorial collectives, when the latter establish close ties with the phenomenon of globalization ¹²12. Lapointe B. La mondialisation et les collectivités territoriales. Paris: Berger-Levrault; 2017..

The notion of territorial collectives (collectivités territoriales), as defined by Lapointe ¹²12. Lapointe B. La mondialisation et les collectivités territoriales. Paris: Berger-Levrault; 2017., includes both those with a Legislative Branch (which the author defines as regionalism or political regionalization, figures in the so-called regional or autonomist European states), as in the case of Italy and Spain, as well as decentralized but unitary states such as France. Thus, territorial collectivity is a political subdivision (political regionalization) or administrative subdivision (decentralization) of a state, with its own attributions, with relative autonomy, or the ability to govern and administer an important share of public business (within the confines of the prevailing legal order) ¹²12. Lapointe B. La mondialisation et les collectivités territoriales. Paris: Berger-Levrault; 2017..

The rise to economic power of territorial collectivities is the result of the economic power of major international corporate groups exposed to an unprecedented degree of entrepreneurial freedom, making recurrent use of the territories as competitive advantages. National borders are not obstacles, but opportunities, and the investments are divided across different territories in different nation states ¹²12. Lapointe B. La mondialisation et les collectivités territoriales. Paris: Berger-Levrault; 2017..

According to Castells ¹³13. Castells M. Ruptura: la crisis de la democracia liberal. Madrid: Alianza Editorial; 2017., the contradictions result from a world of networks that link societies’ structuring activities at all levels, where globalization consists of a global network of global networks that integrates the essential components of finances, the economy, communications, and the power of science and technology on one side, with the other side, where the vast majority of humans survive, lacking institutional capacity to act on programs that govern such networks, and whose reason for living stems from specific cultural systems, built by a common experience: their places, their languages, their cultures, their histories, their ethnic group, their nation, and their religion.

Globalization should thus not be understood as a binary process - for example, “global-national” or “global-local” -, but seen as a multi-scalar, multitemporal, and multicausal phenomenon in which interaction between places and scales produces processes in multiple directions: top-down, bottom-up, and sideways, rearranging economic, political, cultural, and socio-spatial differences and complementariness, relinking different scales, places, and networks ⁹9. Jessop B. El Estado: pasado, presente, futuro. Madrid: Los Libros de la Catarata; 2017.^,1010. Klink J, Barcellos de Souza M. De uma economia política das escalas espaciais a uma agenda renovada para os estudos críticos espaciais. In: Brandão CA, Fernández VR, Ribeiro LCQ, organizadores. Escalas espaciais, reescalonamentos e estatalidades: lições e desafios para América Latina. Rio de Janeiro: Letra Capital/Observatório das Metrópoles; 2018. p. 361-97..

The multi-scalar dimension of neoliberalism: changes in the management of territorial collectivities

The globalization phenomenon intervenes heavily in the organization of the means of action, in the fields of intervention, in the management formats, and in the financing of territorial collectivities, which produces distinct changes in the public policy area - both spatially and according to sector.

Lapointe ¹²12. Lapointe B. La mondialisation et les collectivités territoriales. Paris: Berger-Levrault; 2017. describes this process at the local level based on an extensive review of official documents and legislation in European countries (France, United Kingdom, Italy, and Nordic countries) and Canada, seeking to establish a frame of reference for the regional policies in the European Union. The author argues that regardless of whether they are active or reactive subjects in globalization, the territorial collectivities of these countries implement public policies - in order to exercise the competencies attributed to them or imposed on them by political regionalization and decentralization. These acts are well-aligned with the ideological aspect of neoliberalism and management-based state reform (emphasis on cost-effectiveness, stimulus for public-private partnerships, reinforcement of regulatory activities, etc.).

The role of principal executive agent in local economic development puts territorial collectivities in a central position in the relationship between state and market, with strategic activity favoring action by private companies. This configuration is a powerful incentive for companies to take over the supply of public services (transportation, a whole range of urban infrastructure services, social activities, and communications, among many others) through legal devices - for example, concessions on public services, contracts, and public-private partnerships, among many other means created to replace public provision with private supply ¹²12. Lapointe B. La mondialisation et les collectivités territoriales. Paris: Berger-Levrault; 2017..

Bischir ¹⁴14. Bischir R. Governança multinível: origem, contornos e limites. Boletim de Análise Político-Institucional 2018; (19):49-55., in dialogue with the European discussion on the concept of multilevel governance in social policies, states that disputes over policies and spaces to be occupied by public and private actors occur mainly at the local scale. However, such disputes also need to be analyzed on the basis of the combination of central regulation and the specific degree of local autonomy. The latter, in tun, is the locus through which one can view the various directions determined by the different disputes playing out there, as well as the dilemmas between different levels of government and diverse actors (state and non-state).

If this scenario unfolds with great force in the developed countries (especially the European nations), poor and developing countries will not be left out of these transformations or exempt from their great disseminating force in the field of public policies.

One can argue that neoliberalization tends to converge in a restructuring of the state in the direction of a multilevel governance in dispute - but mostly pro-market - originating in multiple spaces, scales, and networks ¹⁵15. Souza MB. Reescalonamento espacial do Estado desenvolvimentista no Brasil. Mercator 2016; 15:27-46..

In short, the changes briefly outlined here imply first and foremost a relational conception of places. The only way to approach the scale that best manifests the dynamic under analysis is to identify the combination of different logics - in space and time - and their respective extent.

Brazil in the scenario of neoliberal rescaling: regional scale and institutional impasses

The notion of regional scale has entailed concepts with broad and distinct definitions and uses over the course of history. But for this debate, suffice it to grasp its broad meaning, i.e., a system of acts and objects that manifest inseparably in a given time and given space, and not simply an institutional or organizational system ³3. Santos M. A natureza do espaço, técnica e tempo, razão e emoção. São Paulo: Editora Hucitec; 1996.^,1616. Keating M. The invention of regions: political restructuring and territorial government in Western Europe. In: Brenner N, Jessop B, Jones M, MacLeod G, editors. State/space: a reader. Hoboken: Blackwell Publishing; 2003. p. 256-277^,1717. Silveira ML. Escala geográfica: da ação ao império? Terra Livre 2004; 2:87-96.. The regional scale and its importance can only be understood by appreciating the combination of distinct phenomena in a territory.

Analyzing a region includes examining the most adequate angles for capturing the differentiations in space. To explain the region and the processes that constitute it requires selecting the spaces on the scale at which the phenomena are perceived and best observed, i.e., examining them according to the scales that represent grasping their realities ¹⁸18. Viana ALd'A, Ferreira MP, Cutrim MAB, Fusaro ER, Souza MR, Mourão L, et al. O Processo de Regionalização no Brasil: influência das dimensões Política, Estrutura e Organização. Rev Bras Saúde Mater Infant 2017; 17 Suppl 1:S27-43..

In this context, it is expected that the use of different scales will incorporate the density and diversity of social, economic, and political processes, as well as tendencies in transformation, flows, and networks promoted by the state, society, and private agents, among others. Hence the importance of knowing the networks and flows in a world in movement ¹⁸18. Viana ALd'A, Ferreira MP, Cutrim MAB, Fusaro ER, Souza MR, Mourão L, et al. O Processo de Regionalização no Brasil: influência das dimensões Política, Estrutura e Organização. Rev Bras Saúde Mater Infant 2017; 17 Suppl 1:S27-43.^,1919. Iozzi FL, Albuquerque MV. Saúde e desenvolvimento na formação socioespacial brasileira. In: Viana ALd'A, Ibañez N, Elias P, organizadores. Saúde, desenvolvimento e território. São Paulo: Editora Hucitec; 2009. p. 60-96..

The proposal by Monteiro Neto et al. ²⁰20. Monteiro Neto A, Brandão CA, Castro CN. Desenvolvimento regional brasileiro: dilemas e perspectivas neste início de século XXI. In: Monteiro Neto A, Castro CN, Brandão CA, organizadores. Desenvolvimento regional no Brasil: políticas, estratégias e perspectivas. Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada; 2017. p. 429-70. is apparently consistent with this direction when the authors argue that regional analyses have still not grasped the various types of transformations that Brazil has experienced recently. These authors also ask “whether the public policies under discussion or in implementation are based on conceptions that are more or less consistent with the regional specificities of the changing territorial framework” ²⁰20. Monteiro Neto A, Brandão CA, Castro CN. Desenvolvimento regional brasileiro: dilemas e perspectivas neste início de século XXI. In: Monteiro Neto A, Castro CN, Brandão CA, organizadores. Desenvolvimento regional no Brasil: políticas, estratégias e perspectivas. Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada; 2017. p. 429-70. (p. 454).

Despite recent efforts by the Brazilian government, a broad and lasting link has not been achieved between economic and social development. Neither has the country consolidated effective regional policies to decrease its socio-spatial inequality. As the specialized literature has shown extensively, implicit regional policies have been much more successful then explicit ones ²¹21. Araújo TB. Dinâmica regional brasileira nos anos noventa: rumo à desintegração competitiva? In: Castro IE, Miranda M, Egler CAG, organizadores. Redescobrindo o Brasil 500 anos depois. 2ª Ed. Rio de Janeiro: Bertrand Brasil; 2000. p. 70-92.^,2222. Brandão C, Siqueira H, organizadores. Pacto federativo, integração nacional e desenvolvimento regional. São Paulo: Editora Fundação Perseu Abramo; 2013.^,2323. Resende GM. Avaliação de políticas públicas no Brasil: uma análise da Política Nacional de Desenvolvimento Regional (PNDR). Brasília: Instituto de Pesquisa Econômica Aplicada; 2017..

Given the above, it is possible that a strategy for comprehensive territorial development that allows intra- and inter-regional integration will allow “a dynamic with multi-scalar linkage, founded on a social and territorially alternative coalition. In this dynamic, the development of regional connectivity and the parts that consolidate the invigorating forms of the bottom-up territorial logic should be complemented with the anti-fragmentary forms of coordination, ordering, and strength proper to the top-down nationally-based logic” ²⁴24. Fernández VR. Desenvolvimento regional sob transformações transescalares: por que e como recuperar a escala nacional? In: Brandão CA, Fernández VR, Ribeiro LCQ, organizadores. Escalas espaciais, reescalonamentos e estatalidades: lições e desafios para América Latina. Rio de Janeiro: Letra Capital/Observatório das Metrópoles; 2018. p. 276-325. (p. 318).

Social policies, and health policy in particular, also deal with the challenge of lack of scalar and institutional integration. The next section is intended to discuss this issue in light of recent studies that have dwelt on the regionalization process in health.

The territorial dimension of health policy: new challenges in the organizational cycles of Brazilian Unified National Health System

The political, economic, and social contexts differed in the two organizational cycles of Brazilian Unified National Health System (SUS). The first cycle featured decentralization of services, professionals, and some administrative and regulatory functions to the local level, Brazil’s municipalities (counties). The second cycle emphasized the building of health care regions and networks. The political context in the first cycle was inaugurated by a new Federal Constitution (1988) from which stemmed the new system’s principles and guidelines and the beginning of democratic governments, with a leading role for neoliberal policies in command of the economy and a social policy agenda focused on decentralization in the 1990s. The second cycle had hybrid characteristics, with the continuation of neoliberal orders in the economy and the return of the regional issue to the economic and social agendas (first and second decades of the 21st century) ²⁵25. Machado CV, Lima LD, Baptista TWF. Políticas de saúde no Brasil em tempos contraditórios: caminhos e tropeços na construção de um sistema universal. Cad Saúde Pública 2017; 33 Suppl 2:e00129616.^,2626. Viana ALd'A, Silva HP. Desenvolvimento e institucionalidade da política social no Brasil. In: Machado CV, Baptista TWF, Lima LD, organizadores. Políticas de saúde no Brasil: continuidades e mudanças. Rio de Janeiro: Editora Fiocruz; 2012. p. 31-60..

Recent Brazilian studies on the theme of regionalization, such as the projects Region and Networks (http://www.resbr.net.br), Health Tomorrow (http://www.saudeamanha.fiocruz.br), Proadess (http://proadess.icict.fiocruz.br), and Regional Management and Networks in São Paulo ²⁷27. Ibañez N, Tardelli R, Viana ALd'A, Iozzi FL. Gestão regional e redes: estratégias para a saúde em São Paulo. São Paulo: Edições Manole/Secretaria de Estado de Saúde de São Paulo; no prelo., show the importance of developing new elements, variables, and criteria for shaping territorial planning in health. These studies signal a heavy concentration of services and resources in hub-municipalities and that Brazil’s Atlantic territorial configuration (the coastal strip of the South, Southeast, and Northeast) still concentrates most of the services and technologies.

Some policies stood out in responding to structural problems, including the construction of new infrastructure, such as the Emergency Care Units (UPAs) ²⁸28. Ibañez N. Rede de atenção às urgências e emergências: implantação e desempenho das unidades de pronto atendimento (UPAs). Brasília: Conselho Nacional de Secretários de Saúde; 2015. (CONASS Documenta, 28)., the More Doctors program, aimed at supplying more physicians, especially in underserved territories, alongside the expansion of medical schools ²⁹29. Pierantoni CR, Magnagob C, Girardic SN, Carvalho CL, Vieira SP, Ney MS, et al. Formação médica em nível de graduação: análise do período 2000-2013. Novos Caminhos 2015; (4)., the National Program to Improve Access and Quality of Basic Care (PMAQ-AB) ³⁰30. Bousquat A, Giovanella L, Fausto MCR, Fusaro ER, Mendonça MHM, Gagno J, et al. Tipologia da estrutura das unidades básicas de saúde brasileiras: os 5 R. Cad Saúde Pública 2017; 33:e00037316.^,3131. Lima JG, Giovanella L, Fausto MCR, Bousquat A, Silva EV. Atributos essenciais da Atenção Primária à Saúde: resultados nacionais do PMAQ-AB. Saúde Debate 2018; 42:52-66., and even expansion in the supply of essential medicines, such as the Popular Pharmacy Program, to cite a few examples. Still, these initiatives have typically specific characteristics rather than adopting rigorous territorial planning to build comprehensive, systemic heath care in the country.

Therefore, the regionalization process in health in Brazil differs from that implemented in the developed countries, heavily oriented to building integrated, comprehensive networks and systems of care. International studies on the theme of regionalization ²2. Marchildon GP. Regionalization: what have we learned? Healthc Pap 2016; 16:8-14.^,3232. Marchildon G, Bossert TJ. Federalism and decentralization in health care: a decision space approach. Toronto: University of Toronto Press; 2018. indicate that the developed countries stimulate patient-centered forms of health systems’ organization capable of responding to the epidemiological challenge and improving services’ performance. In Brazil, structural problems overlap with an incomplete structure of equipment and specialties (human and technological resources) across the territory, bringing to the forefront the issue of territorial equity as the greatest challenge for achieving the guideline of comprehensive care in the SUS.

Another issue that overloads the regionalization agenda is the profitization of health services’ supply, typical of recent years. This juridical format for equipment management contracts has spread across the country, encompassing different levels of care. The weight of institutional segments under the aegis of private law experienced its greatest growth in recent years (2005 to 2013), attesting that local management in Brazil is also characterized by a greater presence of private actors in the management of certain policies, similar to the international experience described in this article’s first section ³³33. Viana ALd'A, Miranda AS, Silva HP. Segmentos institucionais de gestão em saúde: descrição, tendências e cenários prospectivos. In: Noronha JC, Lima LD, Chorny AH, Dal Poz MR, Gadelha P, organizadores. Brasil Saúde Amanhã: dimensões para o planejamento da atenção à saúde. Rio de Janeiro: Editora Fiocruz; 2017. p. 151-88..

Current studies also display a certain consensus on low adherence to the issue by some important actors, as well as the paralysis of initiatives to foment this public policy at the federal and state levels in recent years. One possible explanation is the difficulty in reaching consensuses in this specific public policy, given its high degree of complexity, involving such conditioning factors as: inequality in the spatial distribution of equipment, inputs, and technologies, and limited availability of human and financial resources; difficulties with regional integration of public policies and state action in various fields of health care; and the diversity of agents (government and nongovernmental, public and private) participating in the management and provision of services in the territory ¹⁸18. Viana ALd'A, Ferreira MP, Cutrim MAB, Fusaro ER, Souza MR, Mourão L, et al. O Processo de Regionalização no Brasil: influência das dimensões Política, Estrutura e Organização. Rev Bras Saúde Mater Infant 2017; 17 Suppl 1:S27-43.^,3434. Noronha JC, Lima LD, Chorny AH, Dal Poz MR, Gadelha P, organizadores. Brasil Saúde Amanhã: dimensões para o planejamento da atenção à saúde. Rio de Janeiro: Editora Fiocruz; 2017.^,3535. Lima LD. Condicionantes da regionalização da saúde no Brasil: recomendações para o planejamento e gestão territorial do SUS no horizonte dos próximos 20 anos. Rio de Janeiro: Fundação Oswaldo Cruz; 2015. (Textos para Discussão, 15)..

The context of political, institutional, and economic crisis in Brazil’s recent period (post-2015) has created barriers to dialogue between actors in sectorial and inter-sectorial policy, hindering the creation of joint proposals to achieve the founding principles of the SUS. Some initiatives have survived, led by state or municipal management (in hub municipalities) in favor of greater density of regional designs and partnerships to better define patient flows and their regulation in the regional territories. Still, such initiatives are few and temporary (not permanent, and irregular).

Recent federal and state policies in favor of a system operated in network format put Brazil in the position of a certain contemporary consistency with the international profile, by determining that the organization of care within health systems should be operated by networks (http://www.resbr.net.br), aimed at building integrated health systems ³⁶36. Mendes EV. As redes de atenção à saúde. Brasília: Organização Pan-Americana da Saúde. 2011.^,3737. Albuquerque MV, Viana ALd'A. Perspectivas de região e redes na política de saúde brasileira. Saúde Debate 2015; 39:28-38.^,3838. Viana ALd'A, Bouquat AE, Mello GA, Negri Filho AA, Medina G. Regionalização e redes de saúde. Ciênc Saúde Colet 2018; 23:1791-8..

Networks began to entail a new logic for the management and organization of health services, potentially facilitating the territorial point of view or further fragmenting the system in the region. At least two interconnected factors drive this misalignment: a disconnect between the thematic networks (failing to function systemically) and lack of public leadership in this integration ²⁷27. Ibañez N, Tardelli R, Viana ALd'A, Iozzi FL. Gestão regional e redes: estratégias para a saúde em São Paulo. São Paulo: Edições Manole/Secretaria de Estado de Saúde de São Paulo; no prelo..

A new policy cycle in the organization of the SUS requires new tools that were not part of the theoretical framework for the proposals in the preceding cycle. For example, greater understanding of the networks and Brazil’s urban complexity, based on multi-scalar analyses, given the great interdependence between the country’s urban, peri-urban, and rural areas. Other elements that also need to be included are: (a) an integrated vision of health systems and socio-spatial determinants, with different types of inter-sector interventions operated by a multiplicity of agents and institutions; (b) definition of standards for public-public and public-private contracts, given the accelerated process of profitization of health care in the public sector; (c) introduction of a new technological paradigm, since connectivity, integration, and regulation assume the intensive use of new devices and platforms, such as telemedicine, related to territorial inequalities in technologies and professional staffing; (d) new and complex formats in regulation, not only classic regulation of access, but regulation of professionals and providers (services), regulation of treatment or care, and new tools that occupy the regulation of quality of care and patient safety ³⁸38. Viana ALd'A, Bouquat AE, Mello GA, Negri Filho AA, Medina G. Regionalização e redes de saúde. Ciênc Saúde Colet 2018; 23:1791-8..

Conceiving a reform agenda for a new cycle of regionalization in the SUS

The obstacles and challenges for regionalization policy in health in Brazil are of different orders and types, with extreme complexity. Recent studies ²⁷27. Ibañez N, Tardelli R, Viana ALd'A, Iozzi FL. Gestão regional e redes: estratégias para a saúde em São Paulo. São Paulo: Edições Manole/Secretaria de Estado de Saúde de São Paulo; no prelo. (http://www.resbr.net.br) with health regions as the analytical units have identified five issues with great impact on the implementation of the region-networks dyad. Such impasses may definitely unfold in others, as can the respective paths to mitigate them. Still, the objectives here are to discuss the main results of these studies and to continue the urgent debate that such issues raise for confronting inequalities in Brazil.

Added to these issues is a crosscutting and structural challenge related to the urgency of expanded regional planning, capable of convening strategic agents to confront historic territorial inequalities in different aspects of Brazil’s formation. This impasse entails conjunctural specificities that take on adverse shapes for achieving a radical reformism, equity, and universal access to essential public goods.

Epidemiological context

A change in the health care model is imperative given the Brazilian population’s current epidemiological profile, alongside accelerated aging, intense urbanization, and growing inequality in access to goods and services in recent years. The transition from acute to chronic health conditions is not a linear process and presents a scenario of juxtaposition of health problems with different determinants ³⁹39. Silva Júnior JB, Ramalho WM. Cenário epidemiológico do Brasil em 2033: uma prospecção sobre as próximas duas décadas Rio de Janeiro: Fundação Oswaldo Cruz; 2015. (Textos para Discussão, 17)..

Brazil’s epidemiological context features important differences between the country’s major geographic regions, related to distinct demographic profiles, socioeconomic conditions, access to health services, and prevalence of risk factors for chronic noncommunicable diseases (NCDs) ³⁹39. Silva Júnior JB, Ramalho WM. Cenário epidemiológico do Brasil em 2033: uma prospecção sobre as próximas duas décadas Rio de Janeiro: Fundação Oswaldo Cruz; 2015. (Textos para Discussão, 17). (https://saudeamanha.fiocruz.br). In this context of inequality, a large share of Brazil’s health regions suffer a shortage of services and difficulties in linking to referral services for chronic conditions. Thus, the consolidation of networks of care for chronic diseases is a preponderant and urgent factor for providing health care to a growing number of citizens. In addition, the need to link various points in distinct thematic networks underscores the importance of inter-sector action to guarantee comprehensive and effective care ²⁷ (http://www.resbr.net.br).

Structure

A second impasse relates to the obstacles raised by the insufficient structure of resources of various orders (physical, financial, and human), a situation aggravated by the size of gaps in health care in the country.

The establishment of health regions and networks is jeopardized by the deficient capacity in infrastructure supply and availability of resources (physical, financial, and human), services, and actions. An analysis of the availability of resources in the country’s basic health units (UBS) shows that a huge share of them suffers from structural shortage of equipment, inputs, and professionals, thus hindering the response to the population’s health problems ³⁰30. Bousquat A, Giovanella L, Fausto MCR, Fusaro ER, Mendonça MHM, Gagno J, et al. Tipologia da estrutura das unidades básicas de saúde brasileiras: os 5 R. Cad Saúde Pública 2017; 33:e00037316..

The health regions analyzed showed low rates of physicians residing locally in many of the regions, and the circulation of physicians between health regions shows similar patterns, with dependency on physicians from other regions varying from 30% to 40% ²⁷27. Ibañez N, Tardelli R, Viana ALd'A, Iozzi FL. Gestão regional e redes: estratégias para a saúde em São Paulo. São Paulo: Edições Manole/Secretaria de Estado de Saúde de São Paulo; no prelo. (http://www.resbr.net.br). This situation highlights the relevance of conceiving different strategies to retain physicians in health regions.

Financing that is more aligned with regionalization policy is imperative, given the exhaustion of municipal budget funds, the limited systemic and equitable rationality in state spending, and underfinancing at the federal level ⁴⁰40. Ocke-Reis CO. Sustentabilidade do SUS e renúncia de arrecadação fiscal em saúde. Ciênc Saúde Coleti 2018; 23:2035-42.^,4141. Duarte LS, Mendes AN, Louvison MCP. O processo de regionalização do SUS e a autonomia municipal no uso dos recursos financeiros: uma análise do Estado de São Paulo (2009-2014). Saúde Debate 2018; 42:25-37..

Federative asymmetries

Another impasse, this one institutional, involves Brazil’s federative asymmetries and low development of intergovernmental relations between spheres of planning, negotiation, and decision-making, an obstacle that has existed since the implementation of the SUS. Although various channels have been created for these relations, they have still not overcome the various conflicts arising from attempts to strengthen an integrated system ⁴²42. Viana ALd'A, Machado CV. Descentralização e coordenação federativa: a experiência brasileira na saúde. Ciênc Saúde Colet 2009; 14:807-17.^,4343. Grin EJ, Abrucio F. O comitê de articulação federativa no governo Lula: os percalços da cooperação territorial. Rev Bras Ciênc Soc 2018; 33:e339703..

Studies have shown a lack of regional leadership in linking services from the basic municipal networks to the regional networks of specialized care, resulting in weakness of the Regional Inter-Managers Commission (CIR). These studies have also shown that strengthening the states and respective regional levels, alongside the involvement of municipalities through a combination of mechanisms, attributions, and obligations, can favor a regional governance arrangement for the SUS ²⁷27. Ibañez N, Tardelli R, Viana ALd'A, Iozzi FL. Gestão regional e redes: estratégias para a saúde em São Paulo. São Paulo: Edições Manole/Secretaria de Estado de Saúde de São Paulo; no prelo.^,4444. Albuquerque MV, Lima LD, Oliveira RAD, Scatena JHG, Martinelli NL, Pereira AMM. Governança regional do sistema de saúde no Brasil: configurações de atores e papel das Comissões Intergovernamentais. Ciênc Saúde Colet 2018; 23:3151-61. (http://www.resbr.net.br).

In this sense, territorial federative cooperation with the promotion of state-level subnational capacities can build institutional policy tools that ensure the presence of territorial interests in cooperative policy-making.

Brazilian experiences with public consortia in health have shown some capability to decrease inequalities in access and to produce more democratic decisions and interventions. Still, these experiences have received relatively little attention, and their conditioning factors and operational formats still lack more in-depth studies.

Contracting and profitization

Contracting and profitization raise the challenge of how to involve other highly relevant agents for consolidating health regions and networks of care in public-private relations. There is an incremental trend towards the migration of state-owned establishments with Indirect Administration under Private Law to the new modalities of establishments mediated by so-called Social Organizations (OS) ³³33. Viana ALd'A, Miranda AS, Silva HP. Segmentos institucionais de gestão em saúde: descrição, tendências e cenários prospectivos. In: Noronha JC, Lima LD, Chorny AH, Dal Poz MR, Gadelha P, organizadores. Brasil Saúde Amanhã: dimensões para o planejamento da atenção à saúde. Rio de Janeiro: Editora Fiocruz; 2017. p. 151-88.^,4545. Coelho VSP. Contratação de serviços e regionalização. Novos Caminhos 2017; (13)..

The State of São Paulo uses contracting of primary care services mainly to increase the number of health professionals. Deficient regulation has been diagnosed, with the juxtaposition of instruments (municipal vs. state), outdated processes (manuals, non-standardized systems), and the lack of specialized human resources (regulating physicians). However, contracting is still rare in health, placing the implementation of targets, indicators, and sanctions at risk ²⁷27. Ibañez N, Tardelli R, Viana ALd'A, Iozzi FL. Gestão regional e redes: estratégias para a saúde em São Paulo. São Paulo: Edições Manole/Secretaria de Estado de Saúde de São Paulo; no prelo.. In these cases, to better regulate contracting in the municipalities, it is important to train municipal managers in the implementation of their own legislation to regulate and manage the contracts with the OS, potentially serving as another instrument for adjusting the demand to the regional supply of services ²⁷27. Ibañez N, Tardelli R, Viana ALd'A, Iozzi FL. Gestão regional e redes: estratégias para a saúde em São Paulo. São Paulo: Edições Manole/Secretaria de Estado de Saúde de São Paulo; no prelo.^,4545. Coelho VSP. Contratação de serviços e regionalização. Novos Caminhos 2017; (13)..

Political base

A fifth impasse is the lack of a solid political base capable of fomenting the creation of an agenda that promotes radical reformism in the organization and management of the SUS, or capable of collectively defining the agenda for the public power/governments to alter the nature of the reforms now under way and more democratically expand social participation in health policy. Among the actors, physicians have political strength, but it has been associated with a certain displacement in systemic action in the regionalization process and in shaping the networks of care.

There is thus an emerging need to create a convergent agenda aimed at institutional leadership, to be exercised by the states, but with greater involvement by physicians, other health professionals, and citizens at large in the process of creating and operating regions and networks.

Final remarks

Our discussion concludes with some issues that have also been identified in the literature on regionalization. The first is that solving the federative issue must involve the federal, state, and municipal entities in a shared governance arrangement. The main task will be the integration of providers in the municipal basic network and the regional specialized network, through management built on planning the health needs and the specificities of the other regional networks. This underscores the urgency of strengthening the states and other regional/subnational levels as inducers and leaders of regionalization.

The studies consulted here have also shown that the region-networks dyad has not been sufficiently strengthened during the regionalization process. The health regions were not reinforced by the networks’ creation, nor could the latter count on support from the regions and their decision-making spheres, such as the CIR. The two have not reinforced each other, because the networks still do not operate as networks, nor do the regions operate as regions. This merely produces an agglutination of services or of municipalities.

As key task for improving public policy in the regionalization of health in Brazil is to continue to build a reform agenda, moving forward in the search for better accommodation between bottom-up and top-down logics and events in order to mobilize the former’s power of diversity and the latter’s directive coordination, reassuming here the national scale’s strategic role ⁷7. Brandão CA, Fernández VR, Ribeiro LCQ. Escalas espaciais, reescalonamentos e estatalidades: lições e desafios para América Latina. Rio de Janeiro: Letra Capital/Observatório das Metrópoles; 2018..

The multi-scalar and trans-scalar approach can be useful for supporting this task, revealing the imperative of conceiving regions not hermetically, but considering the diverse events permeating them, also raising challenges originating outside of them, constantly reshaping them ⁹9. Jessop B. El Estado: pasado, presente, futuro. Madrid: Los Libros de la Catarata; 2017.. Confronting health inequalities thus demands confronting the particular challenges of globalization (predominantly neoliberal) with particular and multi-scalar strategies in each place and in each time period.

Acknowledgments

A. L. d’A. Viana holds a research scholarship from the Brazilian National Research Council (CNPq). The studies providing the basis for the article were funded by the Call for Projects MCTI/CNPq/CT-Saúde/MS/SCTIE/Decit n. 41/2013 and the Project for Strengthening State-Level Health Management (Inter-American Development Bank and São Paulo State Health Department - IDB/SES-SP).

References

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