The article by Ana Luiza d’Ávila Viana & Fabíola Lana Iozzi addresses an extremely relevant theme in the current political context in health, making contributions to the conceptual debate and historical analysis of the regionalization process of the SUS. The article reveals an effort at summarizing the problem of territoriality in the context of the crisis of globalized capitalism and the adoption of neoliberal economic policies by most Western countries, including Brazil, processes that impact health and generate changes in the healthcare model, management, and health systems regulation. In this scenario, according to the authors, “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” (p. 2).

Based on the above, the article provides a theoretical update on the topic, contributing to a more comprehensive understanding of the complexity involved in territorial reconfiguration in the context of globalization, which “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” (p. 3). This highlights the emergence of new territorial configurations, defined by the combination of economic, political, administrative, and sociocultural criteria, such as the formation of supranational blocs of countries and new divisions of national territories in regions, which come to play the “role of principal executive agent in local economic development” (p. 4), occupying “a central position in the relationship between state and market, with strategic activity favoring action by private companies” (p. 4).

Based on this frame of reference, the authors proceed to retrieve studies on the regionalization of the Brazilian health system, seeking to identify the difficulties and potentialities, considering “territorial equity” “as the greatest challenge for achieving the guideline of comprehensive care in the SUS” (p. 6). The authors thus identify issues with great impact on the implementation of the region-networks combination, which covers structural differences between Brazil’s major geographic regions and political and administrative difficulties in the functioning of the complex institutional engineering built in the 30 years of implementation of the SUS, among others.

Considering the nature and diversity of these problems, which can be viewed as either obstacles or challenges, we believe that the main critical nodes result from the dispute between distinct political projects in relation to the SUS. The huge structural differences between Brazil’s major geographic regions are a fact. These differences are related to the distinct demographic profiles, epidemiological specificities, socioeconomic inequality, and insufficiency (gaps in care) and poor distribution of physical, financial, and human resources. In other words, a set of factors that impact the population’s access to health services and require adjustments to the organization and supply of actions and services. Such adjustments assume investments in infrastructure and hiring and training personnel, obviously in keeping with the intended model of care for implementation and consolidation. In this sense, by defending a political project referenced on the so-called “constitutional SUS”, the expansion and organization of integrated health services networks gain meaning in the pursuit of universal and comprehensive care, as proposed and defended by various actors and levels of representation of the SUS policymakers.

However, in the restrictive scenario emerging from the 2008 economic crisis, made more acute by recent measures to contain public expenditures (Constitutional Amendment n. 95), this project (“constitutional SUS”) has been increasingly supplanted by the mercantilist project, expressed in the scope of the SUS by the expansion of contracting-out and private business management of complex units (Social Organizations - OS, Public-Private Partnerships - PPP, etc.), a tendency identified by the authors as one of the impasses faced by the regionalization policy, to the extent that the transfer of responsibility for the management of public health units to these new management modalities hinders the integration of services. Having said this, I believe that it would be worthwhile to reflect further on the effects of this process on the relations between the “basic network” (predominantly public, under public management) and the medium- and high-complexity services (predominantly private or under “alternative” modalities of public management), which in my view go beyond obstacles to the organization of networks on a defined territorial base, with emphasis on primary care, strengthening (on the contrary) a form of organization subordinated to specialized and hospital-centered care.

Thus, two models for the organization of services production in the scope of the SUS are at stake, linked to two distinct political projects: one that defends the “constitutional SUS” and prioritizes strategies that guarantee universal and comprehensive care for the entire population and therefore defends the regionalization and organization of integrated healthcare networks, and the other, mercantilist, subordinated to the market, or rather to the health industrial complex, which links (under financial dominance ¹1. Sestelo JAF. Dominância financeira na assistência à saúde: a ação política do capital sem limites no século XXI. Ciênc Saúde Colet 2018; 23:2027-33.) the production of inputs and health services, a space that ensures the multinational and domestic health sector companies’ profitably and that of financial institutions offering health plans.

The principal impasse is thus political, expressed in the tensions and conflicts reverberating in the levels of inter-federative linkage in the SUS (Tripartite Inter-managerial Commissions - CIT, Bipartite Inter-managerial Commissions - CIBs) and in other public institutional spaces (Ministry of Health, National Congress, National Health Council, etc.) with the diversity of conceptions and interests of the system’s administrators and representatives of corporate and business bodies, associations, and social movements in the field of health. Therefore, I agree with the authors that one of the impasses in the regionalization process results from “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” (p. 8). In fact, Brazil’s current political scenario does not appear favorable for this movement. Particularly worrisome are the intentions materializing in “capital’s assault on health” ²2. Teixeira CF, Paim JS. A crise mundial de 2008 e o golpe do capital na política de saúde no Brasil. Saúde Debate 2018; 42(n.spe 2):11-21., currently aggravated by the federal government’s composition and modus operandi. The resistance to the “dismantlement” of the SUS (clashing head-on with the principles and guidelines set out by Brazil’s Federal Constitution of 1988) has gained momentum with the movement to organize the 16th National Health Conference. In reference to the historic 8th National Health Conference (1986), the motto now is “8th + 8”, reclaiming the driving spirit in the struggle for Brazil’s Health Reform more than 30 years ago. It is thus appropriate for this debate to include the precious contribution by researchers Viana & Iozzi.

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