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vol.35 suppl.2Confronting health inequalities: impasses and dilemmas in the regionalization process in Brazil author indexsubject indexarticles search
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Cadernos de Saúde Pública

Print version ISSN 0102-311XOn-line version ISSN 1678-4464

Cad. Saúde Pública vol.35  supl.2 Rio de Janeiro  2019  Epub June 13, 2019 


Contributions to the debate on regionalization and health

Ana Luiza d’Ávila Viana1

Luciana Dias de Lima2

Hudson Pacifico da Silva3

João Henrique Gurtler Scatena4

1Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil.

2Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.

3École de Santé Publique, Université de Montréal, Montréal, Canada.

4Instituto de Saúde Coletiva, Universidade Federal do Mato Grosso, Cuiabá, Brasil.

Transformations in the territory are one of the watersheds of change in the contemporary capitalist world. They represent alterations in the various dimensions of the relationship between the state, economy, and society, featuring: structures and forms of production; social relations, including labor relations, and rules of political representation and participation 1,2. They also reflect changes in the composition and actions of stakeholders (public, private, and corporative) and in the modes of public policymaking, including the reconfiguration of institutions and decision-making networks and flows at multiple levels and territorial scales of governance (transnational, national, regional, and local) 3,4,5.

Recent studies have attempted to deepen the understanding of the meaning and implications of such changes 6,7,8,9,10,11. Various interpretations and proposals have emerged in this context, based on values of equality and solidarity 6.

Social scientists such as Pierre Rosanvallon 12 propose the formulation of a positive project for society with a focus on democratic construction and solidarity in the social field, beyond a reductionist view of the relationship between the economy and the social state, which aims to dissociate itself from a policy based on a call to resistance or a mere restoration of past historical forms. According to the author, the current transformations are characterized by a “capitalism of innovation”, associated with the emergence of an “individualism of singularities” and the decline of representative democracy in the international context.

In this sense, the search for equality no longer finds echo in abstract universal proposals or those strongly centered on community identities within national states. Another construction of the social is necessary, taking into account the problems arising from globalization, from diverse living conditions and situations, and the existence of individual singularities, and that uses politics as a way to expand forms of social participation. The horizon indicated by Rosanvallon at the end of his work is to understand the tensions and crises that mark the history of the development of modernity and the ways they manifest in the present, in order to redefine a project for human emancipation 12.

Other authors emphasize views of territory that integrate economic, social, and environmental perspectives 13 in order to build more democratic spaces (less unequal and more favorable to values of respect for life and the construction of plural societies). An important proposition is the expansion of the role of the current Social Welfare States, conceived at a time when little was known of environmental problems and the interaction between the social and the environmental. In this new “Social-Ecological Welfare State”, the risks and threats from the negative effects of human activity on various global ecosystems have also led to protective measures 14,15.

This Supplement emerges from these concerns. We believe that the challenge for building the social (the bridge between the individual and the collective, between civil society and citizens) and a culture of solidarity in Brazil, marked by profound inequalities, political cleavages, and economic performance depending on international circuits of accumulation, is found in the dynamic recognition of what is both universal and specific. For this to happen, it is necessary to consider the multiscale determinations of the territory, its various dimensions, and the way they relate to the variety of living conditions and situations.

The Supplement combines a set of theoretical and empirical analyses by authors from various academic institutions and fields of knowledge, expanding the approach to a specific policy, namely the process of regionalization of Brazilian Unified National Health System (SUS), acknowledging the complexity of its conditioning factors its actual experiences.

The Debate article analyzes the relevance of the regional focus in relation to the processes of territorial reconfiguration of the recent phase of globalization, with predominantly liberal orientation. Based on an extensive literature review and research results, the authors identify the impasses in the current transformations for regionalization and for addressing health inequalities in Brazil.

The Thematic Section features three articles that explore the experiences of Canada, Portugal, and Argentina on important themes for the process of regionalization and health, namely: integration and coordination of care; reorientation of primary care; and programs to promote social participation. The next section, Essay, has two articles that systematize the theoretical contributions from the network approach and research on federalism for studies on public policies and health.

The Articles section consists of seven empirical studies that jointly provide evidence for a more in-depth analysis of the progress, problems, and challenges in the regionalization of the SUS. The articles as a whole present the previously unpublished results of the research project Policy, Planning, and Management of Healthcare Regions and Networks in Brazil, consisting of an interinstitutional and interdisciplinary network of researchers ( With different approaches and methods, the research efforts address the following themes: regional governance arrangements; policy, structure, and organization of primary care; spatial configuration of the use of hospitalization services; supply and institutional strategies in undergraduate health training; patterns and intervening factors in physician turnover; performance assessment of the regionalization of health surveillance; and incorporation of technologies in health systems.

Through the different approaches in this Supplement, we hope to contribute to the debate on regionalization and health, which is not limited to valuing the regional dimension of management organization of policies and services in the relations between the different levels of Brazil’s federal system, although these issues are relevant. To regionalize means to identify the changes underway in the various life spaces historically constructed in the territory, seeking new explanations, orders, and ethical meanings for political action that promote the reduction of social inequalities, the enjoyment of collective goods, and improvement of the population’s health. In short, a debate that reinforces the commitment by Public Health to democratic practices, with the notion of health as a universal right, which should be guaranteed according to people’s needs and respect for all types of diversity while overcoming unjust inequalities.


1. Jessop R. El Estado: passado, presente, futuro. Madrid: Los Libros de La Catarata; 2017. [ Links ]

2. Streeck W. Tempo comprado. A crise adiada do capitalismo democrático. São Paulo: Boitempo Editorial; 2018. [ Links ]

3. Pierre J, Peters BG. Governance, politics and the State. London: Macmillan; 2000. [ Links ]

4. Cox KR. "Globalization", the "regulation approach" and the politics of scale. In: Harod A, Wright M, editors. Geographies of power: placing scale. Oxford: Blackwell; 2002. p. 85-114. [ Links ]

5. Kazepov Y. Rescaling social policies: towards multilevel governance in Europe. Vienna: Ashgate; 2010. [ Links ]

6. Touraine A. La fin des sociétés. Paris: Éditions du Seuil; 2013. [ Links ]

7. Berardi FB. And: phenomenology of the end. Cambridge: MIT Press; 2015. [ Links ]

8. Levitsky S, Ziblatt D. Como as democracias morrem. São Paulo: Zahar; 2018. [ Links ]

9. Runciman D. Como a democracia chega ao fim. São Paulo: Todavia; 2018. [ Links ]

10. Castells M. Ruptura: a crise da democracia liberal. São Paulo: Zahar; 2018. [ Links ]

11. Guilluy C. No society: la fin de la classe moyenne occidentale. Paris: Flammarion; 2018. [ Links ]

12. Rosanvallon P. Notre histoire intellectuelle et politique 1968-2018. Paris: Éditions du Seuil; 2018. [ Links ]

13. Laurent E. La social-écologie: une perspective théorique et empirique. Rev Fr Aff Soc 2015; 1-2:125-43. [ Links ]

14. Laurent E. Measuring tomorrow: accounting for well-being, resilience, and sustainability in the twenty-first century. Princeton: Princeton University Press; 2018. [ Links ]

15. Mersch M. Well-being for everyone in a sustainable Europe. Report of the Independent Commission for Sustainable Equality | 2019-2024. Brussels: Group of the Progressive Alliance of Socialists & Democrats; 2018. [ Links ]


A. L. d’A. Viana, L. D. Lima, H. P. Silva and J. H. G. Scatena contributed in the study conception and writing of the manuscript.

Additional informations

ORCID: Ana Luiza d’Ávila Viana (0000-0003-4498-899X); Luciana Dias de Lima (0000-0002-0640-8387); Hudson Pacifico da Silva (0000-0001-7507-0917); João Henrique Gurtler Scatena (0000-0002-7660-3479).

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