We wish to acknowledge the highly welcome commentary from the researchers convened by CSP - Carmen Fontes Teixeira, Elizabeth Artmann, Marilia Cristina Prado Louvison, Telma Maria Gonçalves Menicucci, Carlos Antonio Brandão, and Eduardo Fagnani - a group with diverse backgrounds and institutional affiliations, who have collaborated generously for readers to enjoy a set of texts with in-depth reflections on the theme of transformations in the territory and their implications for health policy and the context of socio-spatial inequalities in Brazil. The theme is dear to the principles of Brazil’s 1988 National Constitution, which determines that the fight against regional inequalities, based on regional development, is a commitment for the Brazilian state.

The commentators have made numerous contributions to dealing with the issues faced in the implementation of a policy to decrease health inequalities and that backs the consolidation of a system that simultaneously responds to the requirements of universal coverage and regional and local specificities. The researchers also analyze the long-term reasons (and alarming immediate reasons in the current context) for the lack of commitment to more comprehensive implementation of systemic, universal, coordinated, and cooperative public policies, notably in the Brazilian Unified National Health System (SUS).

For this very reason, it is impossible to debate all the questions suggested by the commentators, which would mean not only producing at least one more article, but also conducting further studies for a new series of reflections. We thus believe it will be more reasonable to focus on the discussion as a whole, referring to the crosscutting issues in all the commentary (although from various perspectives) that are pertinent to the underlying arguments in our original debate article.

The regional phenomenon involves a broad process involving the combination of various dimensions: political, institutional, economic, cultural, and natural. Since this phenomenon is influenced by the complexity of old and renewed international and national flows, it creates a mosaic with a broad spectrum and territorial differentiation. An analysis of the regional scale thus requires identifying globalization’s inherent processes. Given the current period of accelerated transformations, the region, when viewed on a more local scale, still requires a guarantee of continuity. Currently, however, the region’s heavy fragmentation and the discontinuity of its extensions require an analysis according to differentiated territorial scales in order to capture the respective phenomena in a given time period ¹1. Viana AL'A, Ferreira MP, Cutrim MA, 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-S43..

This broad understanding of the regional phenomenon is important for addressing the Brazilian scenario, given the processes of territorial reconfigurations in the recent phase of predominantly neoliberal globalization.

Some brief and focused observations can be made on the process of neoliberal rescaling in Brazil, which does not differ from the historical pattern of strong territorial concentration and the creation of new types subordinated to the logic of globalization (or strictly induced by it).

In Brazil’s recent spatial configuration, explored in studies by the Brazilian Institute of Geography and Statistics (IBGE) ²2. Instituto Brasileiro de Geografia e Estatística. Regiões de influência das cidades 2007. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2008., the 14 Expanded Regions and 171 Intermediate Regions located in the Southeast, South, and Northeast of Brazil have the most urban hubs and large cities. Their territory is thus more diversified, exhibits more complex urban-regional arrangements, and concentrates the highest supply of specialized services (health and general) ³3. Viana AL'A. População, território, saúde e governança setorial: horizontes para os próximos 20 anos. 2019. (Novos Caminhos, 17). http://www.resbr.net.br/novos-caminhos/#.XXfQHvd7lCU.
http://www.resbr.net.br/novos-caminhos/#... . This generates medium and long-term flows and constant and regular risks (clinical and others) for people, besides different types of high costs (transportation, administration, regulation, etc.) for social services systems, resulting from these movements across the territory in search of specialized services.

Mapping of expanded and intermediate regions signals the heavy socio-spatial disparity of Brazil’s territory, including the population’s distribution, social and health indicators, and economic activities in general: heavy concentration of the population in the expanded regions of São Paulo, Rio de Janeiro, Belo Horizonte, and other coastal urban areas. This configuration results from the historically consolidated occupation of these regions and the direct relationship with the availability of services, productive activities, and infrastructures in these urban networks. On the other hand, these consolidated regions exhibit lower population growth than the Brazilian national average ³3. Viana AL'A. População, território, saúde e governança setorial: horizontes para os próximos 20 anos. 2019. (Novos Caminhos, 17). http://www.resbr.net.br/novos-caminhos/#.XXfQHvd7lCU.
http://www.resbr.net.br/novos-caminhos/#... .

Meanwhile, new dynamic regions have displayed a different scenario, and one of population growth. The small and medium-sized cities in the intermediate and immediate regions of the states of Amazonas, Pará, Roraima, and Mato Grosso concentrate a smaller population contingent, but they are the areas with the highest growth and highest birth rates and the largest proportion of the young population, particularly those under 15 years of age. This situation is strongly related to the migratory movements associated with the expansion of the agricultural frontier and other economic activities in these regions, especially those associated with the use of natural resources, spearheaded by the country’s large hydroelectric and mining projects, induced by the recent globalization process, among other factors ³3. Viana AL'A. População, território, saúde e governança setorial: horizontes para os próximos 20 anos. 2019. (Novos Caminhos, 17). http://www.resbr.net.br/novos-caminhos/#.XXfQHvd7lCU.
http://www.resbr.net.br/novos-caminhos/#... .

The Brazilian scenario points to the fact that the health system also reflects the consequences of the lack of integration between social and economic policies and is conditioned by the logics of selective and concentrated modernization in the territory, incentivized by globalization - the more a place sits on the fringes of these processes, the greater the challenges for the universal right to health ⁴4. Iozzi FL, Albuquerque MV. Saúde e desenvolvimento na formação socioespacial brasileira. In: Viana AL'A, Ibañez N, Elias P, organizadores. Saúde, desenvolvimento e território. São Paulo: Editora Hucitec; 2009. p. 60-96.. It is thus not possible to understand inequalities in the field of health without grasping globalization’s impacts on places in the territory. It is necessary to analyze the circulation of capital, people, technologies, knowledge, goods, and services. That is, the actions and material expressions in the field of health are developed in relation to the intensity, quality, and direction of these flows.

The countless institutional arrangements built over the course of recent decades have also failed to respond effectively with integrated regional planning - between the social and economic spheres and between different policies in the social field - in order for the federative design to lead (coordinate) and assist (cooperate with) the production of public policies focused on decreasing inequalities.

As for the argument of the current political and economic context’s influence - that of a fiscal and monetary policy that fails to recuperate income, while deepening the recession - there is already clear evidence, according to any parameter or indicator for measuring social and regional inequalities, of the profound abyss that current austerity policies are consolidating.

However, in an outburst of optimism, we believe that the commentators’ contributions to the debate offers news suggestions for research and avenues for reflection - necessary for building a new fit between development and the construction of less unequal and more democratic societies - and also for the emergence of a medium-term agenda focusing on some essential formulations such as the fight against inequalities in Brazil.

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