Ana Luiza d’Ávila Viana e Fabíola Lana Iozzi propose to identify the challenges posed by globalization and the impacts on different scales and dimensions for dealing with health inequalities in Brazil through public policies and regionalization.

The article addresses the global territorial reconfigurations oriented by neoliberal policy according to the authors. Changes in forms of local management and territorial changes in Brazil shape the backdrop for resuming the health regionalization agenda related to various organizational and policy cycles in the SUS and for updating the agenda to tackle the huge challenge in Brazil’s public policy for health regionalization.

One should begin by acknowledging globalization’s influence on regionalization and the pertinence of adding the spatial dimension to this analysis, already translated to the health field by various authors. The territory-process understood in its relational dimensions includes multiple interests and actors. This issue is fundamental for understanding a political economy of scales and the revaluation of the regional dimension’s role, without failing to assign the proper value to the national state and the new roles it has played.

The article shows how the complexity of local-regional levels increases as globalization (viewed as a multi-scalar/multicausal phenomenon) interferes in their dynamics, producing new governance arrangements, management forms, financing, and impacts on public policies, especially in health.

The entry of new regional actors vying in the space for power and influence could be positive and help balance interests at the local and central levels. But this would depend on the correlation of forces and the actual scenario. In a scenario of health services supply characterized by a public-private mix, partnerships are expected between private companies and the state. Still, agreeing with the authors, there is always the risk of favoring the market ¹1. Rivera FJU, Artmann E. Planejamento e gestão em saúde: conceitos, história e propostas. Rio de Janeiro: Editora Fiocruz; 2014. to the detriment of meeting the population’s health needs, especially for poorer citizens, whose income does not allow purchasing these services, which requires greater regulation. Contradictions and conflicts between the regional level and the central and local levels (municipalities) would require a permanent model of political negotiation, which extrapolates any forms of application of a normative/technocratic logic. This model would not dispense legislation, levels of control/regulation, and actual spaces capable of guaranteeing less unequal access and which would include the right to health as expressed in the country’s 1988 Federal Constitution.

In the current scenario in Brazil, in order to confront the huge intra- and interregional differences and inequalities, it is essential to acknowledge the influence of domestic and multinational interests contrary (or indifferent) to recognition of the people’s right to health. The system’s force, ruled by money and power, becomes autonomous, disconnected from the actor’s lifeworld, ruled by solidarity ²2. Habermas J. Teoria do agir comunicativo. São Paulo: Editora Martins Fontes; 2012..

Progress is not linear, but made of historical gains that often take time to produce positive impacts that can be lost quickly. While we used to be in a position of criticizing the lack of integration, the limited progress with some policies capable of giving answers (albeit partial) to structural problems and confronting inequalities, such as the Emergency Care Units (UPAs), the More Doctors Program, the expansion of medical schools, the National Program for Improvement of Access and Quality in Basic Care (PMAQ-AB), and the Popular Pharmacy Program, among others, our position today should be to denounce the abandonment of these strategies. It is also necessary to value initiatives in other sectors, but which have strong synergies with health, such as Brazilian Income Transfer Program and Zero Hunger, which led to a reduction in maternal and child mortality ³3. Rasella D, Aquino R, Santos CAT, Paes-Sousa R, Barreto ML. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet 2013; 382:57-64..

In search of minimum consensuses based on solidarity and ethics concerning the best solutions for society (without skirting the ever-present economic issue), I wish to retrieve the discussion on the virtuous potential of the Health Economic-Industrial Complex (HEIC). As a Keynesian approach, one of the instruments of the HEIC is Partnerships for Productive Development (PDP), designed to meet the demands of the SUS, decreasing its vulnerability while generating investments, income, and employment ⁴4. Gadelha CAG, Temporão JG. Desenvolvimento, Inovação e Saúde: a perspectiva teórica e política do Complexo Econômico-Industrial da Saúde. Ciênc Saúde Colet 2018; 23:1891-902.. It is essential to discuss Brazil’s economic development model and the type of model Brazilians want in order to avoid more setbacks and to confront health problems from the perspective of combatting inequalities.

The health field’s huge complexity requires inter-sector action, the linkage of different dimensions1 that are expressed in the territories and in the relationship between local, regional, and central actors. Health planning requires focusing on the centralization/decentralization dyad that calls on the actors, including the state as one of the protagonists, to confront each of the challenges, linking the macro and micro levels of action. Complex problems depend on the scenario, in a context marked by difficult-to-govern variables and that links diverse dimensions of reality. Prediction of the behavior of these variables, in the scenarios that condition both the problems and the ways to deal with them, is part of the effort at strategic prospecting and has an interdisciplinary and inter-sector nature. A scenario with more health and less inequality depends on the capacity for negotiation between different actors that control critical resources involved in dealing with the challenges named by the authors for the reform agenda for a new cycle of regionalization in the SUS.

Considering technological scenarios, telemedicine has the potential to overcome current barriers to services in time and space, helping implement new organizational/professional forms beyond a simple telecommunications network. A broader technical system is needed to allows access to other service structures, a technical network consisting of diagnostic and therapeutic equipment needed by patients, and a human system of physicians, technicians, and administrative personnel with online communication.

Networks represent the organizational form that replaces the traditional structure, to the extent that connections are needed to implement distance medical coordination. This new organizational form places a check on current planning and resource distribution models based on traditional regional schemes. That is, a network of conversations that connects the various points in the system, the professionals, and users is crucial ¹1. Rivera FJU, Artmann E. Planejamento e gestão em saúde: conceitos, história e propostas. Rio de Janeiro: Editora Fiocruz; 2014..

Concerning the cynical and scarcely optimistic scenario Brazilians face today, the wager is on the communicative capacity of language in the negotiation between actors to guarantee health for the population and a more egalitarian supply. The opposite would be to believe in violence, in insistence on actors’ unrelenting positions, on the incapacity of civil society to voice its demands and make them heard ²2. Habermas J. Teoria do agir comunicativo. São Paulo: Editora Martins Fontes; 2012..

The plan for building public policies is through struggle, as shown by history. Fundamental rights like the vote, recognition, health, dignity, and emancipation have never been given, but hard-won at each turn in history.

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