The article by Viana & Iozzi is instigating, providing an excellent systematization of the current debate on health inequality and regionalization, besides presenting an agenda for future research on reform.

The historical and structural determinations that have profoundly transformed the geopolitics, geoeconomics, and geoculture of contemporary capitalism pose political, social, and analytical challenges, including their spatial dimension and the resulting territorial reconfigurations. The weakening (or lack thereof) of the national scale and the role of public policies in this context are crucial controversies in the debate.

Changes on the global scale and their spinoffs on the national scale are analyzed quite well in the aforementioned article.

In relation to the national scale, the article points correctly to the various political cycles and crises and the impasses in the regionalization of public policies, especially those focused on health inequalities. The article also presents various research results in the health area concerning issues of regions and networks.

The article highlights the role of the regional scale, emphasizing the need to create regional bases and platforms that are better structured for health. The authors contend that health regions should be conceived that can grasp and properly link the current and future regional reconfigurations in Brazil. They call attention to the pressing need to be aware of the renewed (and old) processes that unequally structure the national space and that can adequately mobilize the social-regional diversity of Brazil’s heterogeneous and local spaces. In other words, a better linkage of health regions and networks should link public actions that are more consistent with the regional specificities of the continental-sized mosaic that is Brazil.

After discussing the processes of globalization and neoliberalization and the resulting changes in spatial relations, the authors address international experiences, highlighting the territorial collectivities. I may be mistaken, but I believe that this concept of territorial collectivities is permeated by an excessive neo-institutionalist content, centered inordinately on regional identities, and perhaps insufficiently inclined to question the powers and interests embedded in each territory.

The discussion appears interesting. However, the authors, well-versed in the constraints on Brazil’s federative pact in health, could dwell further in future studies on the links between the spatial scales and specificities at the three levels of government and difficulties in adequately offering public goods. How to characterize Brazil’s territorial collectivities subject to such a peculiar federalism?

How to advance more concertedly in the supply of public and collective services, if Brazilian federalism proves to be debilitated and with limited capacity, strength, and power to organize and socially and politically regulate (on multiple scales in a given territory) more systemic, inclusive, structuring, lasting, and crosscutting processes in expanding the horizons for possibilities of a certain society that lives and reproduces socially in this territory? And how to promote these dynamics in a context which undoubtedly witnessed the loss of functions of coordination between the federative levels, especially at the state level?

In an institutional and political context so hostile to concerted, systemic, and coordinated action, it is necessary to verify the technical, institutional, governance, and public administrative capacities, attempting to understand the difficulties in resizing the state ¹1. Kazepov Y. Rescaling social policies: towards multilevel governance in Europe. Burlington: Ashgate; 2010.. The more articulated and less targeted public policies have encountered nearly insurmountable difficulties in conducting movements with adequate upscaling and downscaling logics in order to advance concerted strategies in the provision of citizens’ services which simultaneously and efficiently raise (bottom-up) and lower (top-down) the spatial scales of public action.

What is highly peculiar in the Brazilian federative game and its spatiality is that it has not succeeded in constituting the following spatial scales of intermediation (as an articulative prism of public action). It has not succeeded in shaping (through upscaling of action and decisions by crucial agents and subjects) horizontal cooperative games hacia arriba in each of the following bottom-up scalar movements. No progress has been made in a scalar movement starting from the municipal level to forge a supralocal scale. No area has been agglutinated and consolidated around the regional hubs, that is, a hinterland, to structure a microregional scale. Much less has a scalar movement been linked in order to organically engender the mid-regional scale. Finally, no scale has been linked that corresponds to the state government level, which ends up having little substance to objectively implement structural policies and consistent development strategies in keeping with the national scale.

There is a lack of capability and training to lead socio-spatial pacts and agreements at the national and subnational levels, engendering structured and systemic coherences that can promote a radical reformism in the organization and administration of the SUS, led by states and micro-regions inducing regionalization that can structure and operate regions and networks, integrating the municipal basic network provider and the regional specialized network ²2. Lima LD, Albuquerque MV, Scatena JHG, Melo ECP, Oliveira EXG, Carvalho MS, et al. Arranjos regionais de governança do Sistema Único de Saúde: diversidade de prestadores e desigualdade espacial na provisão de serviços. Cad Saúde Pública 2019; 35:e00094618.. The authors question the existence of the necessary political base to advance this radical reformism. It would be interesting for the authors to comment further on what has changed since 2016. From my point of view, there have already been three years of increasingly serious setbacks on these issues, with destructive effects on some activities that were being developed or consolidated, in terms of new regional networks and dynamics.

It would be necessary to conceive of a provision of public and collective goods and services in a strategically planned way, based on the hierarchies of services observed in the urban network’s complexity. As the authors point out, this view, I would say, of the network of cities and rural communities, should respect and value the particularities and strategies of regionalization focused on the establishment of comprehensive, coherent, and systemic healthcare in the country.

Half of the Brazilian population is excluded in various ways from the fruits and recent gains in the country’s development. Placing public services at the service of the Brazilian people, as a counterpart to the machine that produces inequalities and deprivations, seeking to guarantee a country for people and human life and not for private profit, is essential for a daring civilizational undertaking. It is also necessary to overcome the frequent submission of the public sector to the dictates of private “planning” that inhibits planned coordination that otherwise lends meaning to (and reinforces) the federative pact.

I believe that this debate should also be contained in a comprehensive vision, backed by a concept of systems of provision of collective public utility goods, equipment, services, and infrastructures that enter people’s daily lives, at the ground level of immediate practices, in the specific locus of social reproduction of “flesh-and-blood people”, pedagogically and politically demonstrating what a state means with the capacity and quality in its concrete transformative action in realities where services and rights are denied.

In short, it would be interesting to expand the debate on public policies in health regionalization in Brazil, focusing on the country’s highly peculiar regional scales, levels of government, and very specific spheres of power and interests. In addition, it would be crucial to insert this debate in the country’s current and medium-term conjuncture: how to consolidate a correlation of political forces capable of advancing such a project of radical reformism in health, when even democracy is in jeopardy?

Acknowledgments

I wish to thank Brazilian National Research Council (CNPq) for supporting the research on social infrastructure in Brazil.

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