The difficulties in the materialization of healthcare regionalization in Brazil are widely known and are the object of scattered studies with different perspectives. Despite these difficulties, a consensus remains on the importance of regionalization, which presupposes, among other things, cooperation between federated entities, network integration, regional infrastructure provision, regulation, etc., to guarantee the constitutional principles of universal and comprehensive care. Although there have been a series of attempts since the 2000s to develop an institutional framework to encourage and favor the creation of regionalized systems based on self-sufficient territories, regionalization has proven difficult in practice. An ongoing challenge is to understand this process and its determinants, based on which to conceive possible solutions to remove the obstacles.

The article by Viana & Iozzi thus has the intrinsic merit of taking new looks and corroborating other studies on a pending issue within the broader theme of implementing healthcare in the SUS. The article’s title itself evokes the core issue by highlighting inequalities, suggesting the role of regionalization to tackle this huge challenge, in keeping with the constitutional provisions that declare the universal and egalitarian nature of healthcare. Beyond intending to identify the “impasses and dilemmas of regionalization”, the authors take a purposive stance by proposing solutions or necessary measures to solve them, pointing to “a new reform agenda”. These two elements confirm the essay’s great merit.

The article’s analytical approach starts consistently with the idea of the regional scale’s potential in the Brazilian health system, emphasizing the role of territorially focused regional policies to combat inequalities, highlighting that such policies alter the scales in the provision of services and healthcare flows with probable effects on inequality. From this perspective, I would underscore that the regionalization process is justified by the nature of healthcare itself, which requires the management of a network of diversified services distributed across different levels of complexity, generally territorially dispersed and acting on various scales as a function of the degree of complexity and the demand. Considering Brazil’s federative context, management of the services network requires combining the federal, state, and municipal levels’ autonomy with cooperation between them in order to guarantee the constitutional principles of universal and comprehensive care, with compatibility between people’s territorial localization and the healthcare network under the responsibility of diverse administrators ¹1. Menicucci T, Marques AMF. Cooperação e coordenação na implementação de políticas públicas: o caso da saúde. Dados Rev Ciênc Soc 2016; 58:823-65.. After all, the comprehensive healthcare proposal puts pressure on regional policies. In this sense, the association with the notion of multilevel governance identified by the authors is quite pertinent, although not elaborated in the essay, and which in the case at hand refers to the three levels of government in the Brazilian federation, which are jointly responsible for the country’s healthcare. On the one hand, multilevel management allows comprehensive healthcare, while such management results in a major share of the difficulties in making regional care effective on a scale transcending municipal boundaries and produces tension for an institutional construction not founded on the prevailing formal structures in the Brazilian federation. As the authors cite, disputes at the local level need to be analyzed according to the combination of regulation at the central level and the specific degree of local autonomy. Even if the central level (the Federal Government in Brazil’s case) has powerful institutional resources to coordinate health policy, such as the power to standardize and regulate, in addition to greater availability of financial resources, the subnational levels (states and municipalities) are politically and administratively autonomous. Therefore, to build regions and regional policies based on autonomous local entities is a task that requires negotiation, agreements, bargaining, and incentives that favor cooperation. In other words, I contend that it is not possible to discuss regionalization without considering the characteristics of the Brazilian federative arrangement.

The reform agenda suggested by the authors for what they call “a new cycle of regionalization in the SUS” (to allow overcoming the current impasses) appears to derive from the difficulties and inefficacy of the institutional framework operated so far for the country’s health regionalization. This agenda features: (a) the need for expanded regional planning that convenes strategic actors to deal with the territorial inequalities; (b) changes in the healthcare model given the population’s new epidemiological profile, characterized by the juxtaposition of health problems with distinct determinants and important regional variations, requiring the consolidation of networks of care focused on chronic conditions, as well as inter-sector actions; (c) financing aligned with the regionalization policy to confront deficiencies in supply, infrastructure, and resources; (d) strengthening of the states and respective regional bodies for planning/negotiation/deliberation (CIRs) with a view towards building an effective regional governance arrangement for the SUS; (e) training managers to regulate and manage contracts with the “Social Organizations”, allowing to adjust the demand for services to the supply; and (f) the need to build a solid political base to promote what the authors call “radical reformism” in the organization and management of the SUS.

Although the agenda’s points are presented sequentially and cumulatively, I would emphasize the need to discriminate the place and meaning of each, mainly underscoring that point (f) in the proposed agenda is a precondition for any reform, as something that is not built in technical spheres, but politically, which is apparently not on the current horizon in Brazil. Meanwhile, items (c) and (d) touch on nerve points in building regional governance. I agree with the authors’ emphasis on territorial federative cooperation and the promotion of subnational government capacities to ensure the presence of territorial interests in cooperative policymaking. A study I performed1 in a sample of seven states with 65 health regions proved statistically that implementation of cooperative relations between municipalities in a specific territorial space is significantly affected both by state government action (in charge of coordination) and by structural factors related to the resources that affect the capacity for health services provision at the regional level and that are a precondition for cooperation between municipalities.

The essay’s main weakness is the attempt (failed, in my view) to refer the discussion of regional health policies to the processes of territorial reconfigurations in the recent phase of globalization. If multilevel governance appears to be an adequate concept for understanding the needs and impasses of health regionalization, it is not obvious in the article how this approaches the territorial configurations linked to globalization. Along the same line, the final conclusion does not appear to have been demonstrated in the article, that is, that confronting health inequalities pushes the country towards confronting the particular challenges of globalization. A point that merits elucidation is the extent to which national changes in the current period of globalization help unveil the impasses in regional health policy in Brazil.

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