A systematic review of the process of regionalization of Brazil’s Unified Health System, SUS

Guilherme Arantes Mello Ana Paula Chancharulo de Morais Pereira Liza Yurie Teruya Uchimura Fabíola Lana Iozzi Marcelo Marcos Piva Demarzo Ana Luiza d’Ávila Viana About the authors

Resumo

Nesta revisão foram incluídos apenas estudos específicos sobre o processo de regionalização do SUS, baseados em resultados empíricos e publicados a partir de 2006, já sob o referencial do Pacto pela Saúde. Foi evidenciado que o processo de regionalização é hoje uma realidade em todas as esferas de governo, sujeito a um conjunto de desafios comuns às diversas realidades do país. Entre os principais, os colegiados são valorizados com espaços de inovação, mas ainda em busca da superação da cultura política burocrática e clientelista. A governança regional é ainda prejudicada pela fragmentação do sistema e, em particular, pela histórica deficiência com planejamento, desde o nível local às políticas estratégicas de incorporação tecnológica. As análises permitiram implicar a cultura de amplo privilégio para negociação política em detrimento do planejamento como uma das principais responsáveis por um ciclo vicioso que sustenta a deficiência técnica da gestão.

Regionalização; Descentralização; Reforma dos serviços de saúde; Política de saúde

Abstract

This review focuses only on specific studies into the SUS regionalization process, which were based on empirical results and published since 2006, when the SUS was already under the aegis of the Pact for Health framework. It was found that the regionalization process is now underway in all spheres of government, subject to a set of challenges common to the different realities of the country. These include, primarily, that committee-structured entities are valued as spaces for innovation, yet also strive to overcome the bureaucratic and clientelist political culture. Regional governance is further hampered by the fragmentation of the system and, in particular, by the historical deficiency in planning, from the local level to the strategic policies for technology incorporation. The analyses enabled the identification of a culture of broad privilege for political negotiation, to the detriment of planning, as one of the main factors responsible for a vicious circle that sustains technical deficiency in management.

Regionalization; Decentralization; Health services reform; Health policy

Introduction

The regionalization of health services has, for the last decade, been at the heart of the debate on the reorganization of the SUS. This path has been well documented in the main legal framework of the period, with the NOAS (the Norma Operacional da Assistência à Saúde, or Operational Rules for Healthcare), the Pact for Health and, more recently, Decree 7508 and its Organizing Contracts. This regional vision has been strengthened by the increasing realization of the limited access and equity in a system that is exclusively municipality-based. This difficulty was foreseen in the NOB 96 (1996 Operational Rule – Norma Operacional Básica), the primary instrument that formed the backbone of municipalization policy, which referred to the: “...high risk of disordered atomization of those parts of the SUS, allowing one municipal system to develop to the detriment of another, even threatening the unicity of the SUS”11. Brasil. Ministério da Saúde (MS). Portaria no 2.203, de 5 de novembro de 1996. Norma Operacional Básica do Sistema Único de Saúde (NOB-96). Diário Oficial da União 1996; 6 nov..

The disconnect between decentralization and regionalization in Brazilian health can be initially explained by the long-standing, overwhelming difference of political, historical and conceptual weight in favor of the former – decentralization22. Viana ALA, Lima LD, Ferreira MP. Condicionantes estruturais da regionalização na saúde: tipologia dos Colegiados de Gestão Regional. Cien Saude Colet 2010; 15(5):2317-2326.,33. Mello GA, Viana ALA. Uma história de conceitos na saúde pública: integralidade, coordenação, descentralização, regionalização e universalidade. Hist. cienc. saude-Manguinhos 2012; 19(4):1219-1240. . The model for this municipal-based orientation, in turn, resulted from the set of circumstantial possibilities of each period in time, in which each new set of possibilities defines what how the previously sketched model might be adapted44. Viana ALA. Descentralização e política de saúde: origens, contexto e alcance da descentralização. São Paulo: Hucitec Editora; 2013.,55. Ouverney ALM. Federalismo e descentralização do SUS: a formação de um regime polarizado de relações intergovernamentais na década de 1990. Rio de Janeiro: Fundação Getúlio Vargas; 2015..

But, given the primacy now enjoyed by regionalization, international knowledge makes it clear that it would be a mistake to view the decentralization of Brazilian health as an immutable and defined situation. Experience shows that the established order is subject to the constant movement of correlations of political forces66. Saltman RB, Bankauskaite V, Vrangbæk K, editors. Decentralization in health care: strategies and outcomes. Maidenhead: Open Univ. Press; 2007. (European observatory an health systems and policies series).,77. Pisco L. Centralizar ou descentralizar a gestão da saúde? [Entrevista]. [acessado 2016 maio 15]. Disponível em: http://www.resbr.net.br/centralizar-ou-descentralizar-a-gestao-da-saude/
http://www.resbr.net.br/centralizar-ou-d...
: There can be severe ideological rearrangements88. Greer SL, Jarman H, Azorsky A. A reorganisation you can see from space. The architecture of power in the new NHS [Internet]. Center for Health and the Public Interest; 2014 [acessado 2016 fev 21]. Disponível em: http://chpi.org.uk/wp-content/uploads/2014/01/The-architecture-of-power-in-the-NHS-Scott-Greer-Jan-2014.pdf
http://chpi.org.uk/wp-content/uploads/20...
,99. Marchildon GP. The crisis of regionalization. Health Manage Forum 2015; 28(6):236-238. – while there are also some aspects related to new technologies and healthcare that are “relatively independent of the political structures”1010. Jakubowski E, Saltman RB, European Observatory on Health Systems and Policies, editors. The changing national role in health system governance: a case-based study of 11 European countries and Australia. Copenhagen: European Observatory on Health Systems and Policies; 2013. Observatory studies series..

Equitable access is recognized as a major driving force by both the policy of decentralization in Brazilian health, and, more accentuatedly, by the discourse on regionalization. Great ambitions, great challenges. Unequal distribution of health equipment is an old and common reality in the most varied contexts – an issue that is admitted to be a difficult one1111. Hart JT. The inverse care law. Lancet 1971; 297(7696):405-412.,1212. Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health 2006; 4:12.. The specifics of Brazil – “...the only country with more than 100 million inhabitants that has a universal health system. And [...] political, administrative and financial decentralization to the local power”1313. Monteiro O. Integralidade truncada [Entrevista]. [acessado 2016 maio 15]. Disponível em: http://www.resbr.net.br/integralidade-truncada/
http://www.resbr.net.br/integralidade-tr...
, and its tradition of allowing political criteria in the adoption of technology, are additional elements in Brazil’s case. But on the technical side, one problem is that the direct relationship between decentralization/regionalization and equity is not something simple to demonstrate – beginning with the difficulty in defining dependent and independent variables1414. European Union. Committee of the Regions. The management of health systems in the EU Member States the role of local and regional authorities. Luxembourg: Publications Office; 2012.. Furthermore, there is the complexity of how to read the data and factors related to the municipality1515. Roux AVD. Health in cities: is a systems approach needed? Cad Saude Publica 2015; 31(Supl. 1):9-13..

As a contribution to analyses of the process of healthcare regionalization, this article presents a systematic review of the recent experiences of regional organization of Brazil’s SUS, in search of the main factors conditioning this process in Brazil.

Methodology

The initial spark for this study was a reading of Vargas et al.1616. Vargas I, Mogollón-Pérez AS, Unger J-P, da-Silva MRF, De Paepe P, Vázquez M-L. Regional-based Integrated Healthcare Network policy in Brazil: from formulation to practice. Health Policy Plan 2015; 30(6):705-717., the references in which provided six initial articles as lines to pursue. For the review a systematized search was carried out in the databases of the Virtual Health Library – which include Lilacs and SciELO; and in Medline/PubMed. The descriptors “regionalization/regional health planning” AND “Brasil/Brazil” were used in the title, abstract or subject fields, with the inclusion of original articles, theses and dissertations in Portuguese, English and Spanish. Complementary sources included the references of the articles selected, and indications of the authors’ knowledge. The criteria for inclusion were: studies with a specific subject related to regionalization of the SUS; with empirical results, published since 2006 – so as to include only research already referenced to the ‘Pact for Health’ and so on. Criteria for exclusion were: revisions; opinion essays; and research focused on policies prior to the Pact for Health, or in which regionalization emerges as a context and not as a primary object. In the interests of an exhaustive review, all research studies covered by the review, without considering the importance of the publication or the methodology chosen, were included.

The selection was performed by two researchers independently, and cases in doubt were judged by a third researcher. Initially, texts were excluded by reading of the metadata. At this point a search was made for possible texts not included in the scientific databases through ‘Google Scholar’ – the ‘gray literature’ – without success. Then the abstracts of the texts included in the first screening were read. All texts selected after reading the abstracts were read in full and the data extracted independently by at least two of the authors, and subsequently organized into groups. Figure 1 systematizes the process of search and identification of the works.

Figure 1
Research and selection of papers.

Results

The methodological criteria enabled the inclusion of 26 studies on the process of Brazilian regionalization (Chart 1). Two studies were included as exceptions: One essay, because it considered the discourse of a group of municipal health secretaries as analogous to the empirical interviews with these players1717. Assis E, Cruz VS, Trentin EF, Lucio HM, Meira A, Monteiro JCK, Cria SM, Focesi MR, Cielo CA, Guerra LM, Farias RMS. Regionalização e novos rumos para o SUS: a experiência de um colegiado regional. Saúde Soc. 2009; 18(Supl. 1):17-21., and the other, ostentatiously addressing healthcare networks, but which after reading was considered to deal primarily with the question of regional organization in health1818. Medeiros CRG, Gerhardt TE. Avaliação da Rede de Atenção à Saúde de pequenos municípios na ótica das equipes gestoras. Saúde Debate 2015; 39(n.spe):160-170.. One study was excluded due to duplicated subject matter and inconsistency.

Chart 1
Studies included in the review.

As expected, most of the studies focus on the regional scope (state, macro, and region)1616. Vargas I, Mogollón-Pérez AS, Unger J-P, da-Silva MRF, De Paepe P, Vázquez M-L. Regional-based Integrated Healthcare Network policy in Brazil: from formulation to practice. Health Policy Plan 2015; 30(6):705-717.

17. Assis E, Cruz VS, Trentin EF, Lucio HM, Meira A, Monteiro JCK, Cria SM, Focesi MR, Cielo CA, Guerra LM, Farias RMS. Regionalização e novos rumos para o SUS: a experiência de um colegiado regional. Saúde Soc. 2009; 18(Supl. 1):17-21.

18. Medeiros CRG, Gerhardt TE. Avaliação da Rede de Atenção à Saúde de pequenos municípios na ótica das equipes gestoras. Saúde Debate 2015; 39(n.spe):160-170.

19. Souto Junior JV. O papel da CIB/MG no processo de regionalização do SUS em Minas Gerais [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2010.

20. Brandão ICA, Martiniano CS, Monteiro AI, Marcolino EC, Brasil SKD, Sampaio J. Análise da organização da rede de saúde da Paraíba a partir do modelo de regionalização. R bras ci Saúde 2012; 16(3):347-352.

21. Bretas Junior N, Shimizu HE. Planejamento regional compartilhado em Minas Gerais: avanços e desafios. Saúde Debate 2015; 39(107):962-971.

22. Guerra DM. Descentralização e regionalização da assistência à saúde no sstado de São Paulo: uma análise do índice de dependência. São Paulo: Universidade de São Paulo; 2015.

23. Stephan-Souza A, Chebli ICF, Jacometti EJM, Paiva MG. Regionalização sob a ótica dos gestores: uma abordagem dialética. Rev APS 2010; 13(Supl. 1):S35-45.

24. Pereira AMM. Dilemas federativos e regionalização na saúde: o papel do gestor estadual do SUS em Minas Gerais [dissertação]. Rio de Janeiro: Fiocruz; 2009.

25. Coelho APS. O público e o privado na regionalização da Saúde: processo decisório e condução da política no estado do Espírito Santo. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2011.

26. Mesquita RMS. Consensos da comissão intergestores regional para a organização do sistema regional de Saúde [dissertação]. Fortaleza: Universidade de Fortaleza; 2011.

27. Venancio SI, Nascimento PR, Rosa TE, Morais MLS, Martins PN, Voloschko A. Referenciamento regional em saúde: estudo comparado de cinco casos no Estado de São Paulo, Brasil. Cien Saude Colet 2011; 16(9):3951-3964.

28. Silva EC, Gomes MHA. Impasses no processo de regionalização do SUS: tramas locais. Saúde Soc. 2013; 22(4):1106-1116.

29. Silva EC da, Gomes MH de A. Regionalização da saúde na região do Grande ABC: os interesses em disputa. Saúde Soc. 2014; 23(4):1383-1396.

30. Silva MJV. Regionalização da saúde no oeste de Mato Grosso: um estudo de caso do Colegiado de Gestão Regional [dissertação]. Cuiabá: Universidade Federal de Mato Grosso; 2014.

31. Santos AM, Giovanella L. Governança regional: estratégias e disputas para gestão em saúde. Rev Saude Publica 2014; 48(4):622-631.

32. Martinelli NL. A regionalização da saúde no Estado de Mato Grosso: o processo de implementação e a relação público-privada na região de saúde do Médio Norte Mato grossense [tese]. São Paulo: Universidade de São Paulo; 2014.

33. Mendes A, Louvison MCP, Ianni AMZ, Leite MG, Feuerwerker LCM, Tanaka OY, Duarte L, Weiller JAB, Lara NCC, Botelho LAM, Almeida CALO. O processo da gestão regional da saúde no Estado de São Paulo: subsídios para a análise. Saúde Soc. 2015; 24(2):423-437.
-3434. Kehrig RT, Souza ES, Scatena JHG. Institucionalidade e governança da regionalização da saúde: o caso da região Sul Mato-Grossense à luz das atas do colegiado de gestão. Saúde Debate 2015; 39(107):948-961.. Four present a national dimension22. Viana ALA, Lima LD, Ferreira MP. Condicionantes estruturais da regionalização na saúde: tipologia dos Colegiados de Gestão Regional. Cien Saude Colet 2010; 15(5):2317-2326.,3535. Lima LD, Viana AL d’Ávila, Machado CV, Albuquerque MV, Oliveira RG, Iozzi FL, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Cien Saude Colet 2012; 17(11):2881-2892.

36. Albuquerque MV. O enfoque regional na política de saúde brasileira (2001-2011):diretrizes nacionais e o processo de regionalização nos estados brasileiros [tese]. São Paulo: Universidade de São Paulo; 2013.
-3737. Duarte CMR, Pedroso MM, Bellido JG, Moreira RS, Viacava F. Regionalização e desenvolvimento humano: uma proposta de tipologia de Regiões de Saúde no Brasil. Cad Saude Publica 2015; 31(6):1163-1174.; two deal with metropolitan regions3838. Spedo SM, Pinto NRS, Tanaka OY. A regionalização intramunicipal do Sistema Único de Saúde (SUS):um estudo de caso do município de São Paulo-SP, Brasil. Saúde Soc. 2010; 19(3):533-546.,3939. Ianni AMZ, Monteiro PHN, Alves OSF, Morais MLS, Barboza R. Metrópole e região: dilemas da pactuação da saúde. O caso da Região Metropolitana da Baixada Santista, São Paulo, Brasil. Cad Saude Publica 2012; 28(5):925-934.; and only one focuses on a border region4040. Preuss LT, Nogueira VMR. O pacto pela saúde nas cidades gêmeas da fronteira do Rio Grande do Sul com a Argentina e o Uruguai. Texto e Contexto 2012; 11(2):320-332.. In general, case studies with a qualitative method, phenomenological approach and low power of analytical generalization stand out. However, several studies can be highlighted for their originality, methodological consistency and analytical depth22. Viana ALA, Lima LD, Ferreira MP. Condicionantes estruturais da regionalização na saúde: tipologia dos Colegiados de Gestão Regional. Cien Saude Colet 2010; 15(5):2317-2326.,1616. Vargas I, Mogollón-Pérez AS, Unger J-P, da-Silva MRF, De Paepe P, Vázquez M-L. Regional-based Integrated Healthcare Network policy in Brazil: from formulation to practice. Health Policy Plan 2015; 30(6):705-717.,2222. Guerra DM. Descentralização e regionalização da assistência à saúde no sstado de São Paulo: uma análise do índice de dependência. São Paulo: Universidade de São Paulo; 2015.,2525. Coelho APS. O público e o privado na regionalização da Saúde: processo decisório e condução da política no estado do Espírito Santo. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2011.,2727. Venancio SI, Nascimento PR, Rosa TE, Morais MLS, Martins PN, Voloschko A. Referenciamento regional em saúde: estudo comparado de cinco casos no Estado de São Paulo, Brasil. Cien Saude Colet 2011; 16(9):3951-3964.,3535. Lima LD, Viana AL d’Ávila, Machado CV, Albuquerque MV, Oliveira RG, Iozzi FL, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Cien Saude Colet 2012; 17(11):2881-2892.

36. Albuquerque MV. O enfoque regional na política de saúde brasileira (2001-2011):diretrizes nacionais e o processo de regionalização nos estados brasileiros [tese]. São Paulo: Universidade de São Paulo; 2013.
-3737. Duarte CMR, Pedroso MM, Bellido JG, Moreira RS, Viacava F. Regionalização e desenvolvimento humano: uma proposta de tipologia de Regiões de Saúde no Brasil. Cad Saude Publica 2015; 31(6):1163-1174.,4141. Lima JC, Rivera FJU. Gestão de sistemas regionais de saúde: um estudo de caso no Rio Grande do Sul, Brasil. Cad Saude Publica 2006; 22(10):2179-2189.. With the exception of the proposal for a regional typology3737. Duarte CMR, Pedroso MM, Bellido JG, Moreira RS, Viacava F. Regionalização e desenvolvimento humano: uma proposta de tipologia de Regiões de Saúde no Brasil. Cad Saude Publica 2015; 31(6):1163-1174., the other studies represent the discursive universe of professionals related to health management. Although almost tangentially, three studies add points of view of the provider2323. Stephan-Souza A, Chebli ICF, Jacometti EJM, Paiva MG. Regionalização sob a ótica dos gestores: uma abordagem dialética. Rev APS 2010; 13(Supl. 1):S35-45.,2525. Coelho APS. O público e o privado na regionalização da Saúde: processo decisório e condução da política no estado do Espírito Santo. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2011.,3232. Martinelli NL. A regionalização da saúde no Estado de Mato Grosso: o processo de implementação e a relação público-privada na região de saúde do Médio Norte Mato grossense [tese]. São Paulo: Universidade de São Paulo; 2014.. Chart 2 lists the main categories of analysis employed in these studies. Below are brief comments on the overall dimensions of these categories.

Table 2
Prevalent categories on regionalization in discourse connected with public health management in Brazil

Policies and politics

In the politics, the municipal autonomy that results from the process of decentralization – with consequent fragmentation of the system – is seen as the main obstacle to the regional organization of services. The solution to this problem has to be associated with the very challenge that the federative legal framework imposes. The political culture of negotiation at the expense of planning, and of a tendency toward clientelism, is a matter of common observation in Brazil. In terms of policies, the influence of inductive federal rule-making is clear – and responsible for guiding regional policy in most states on the basis of the principle of equity – in particular in terms of access to and inequalities in funding – and an increased existing capacity is also visible. However, this influence weakens over time, for a variety of reasons: it is difficult to continuously increase the stimulus, in proportion to new needs to strengthen the regional process – there is a consensus that there is a shortfall in funding; fragmented areas of responsibility involved in the Health Ministry; imprecise laws, rules and regulations; and initiatives with low prospects of being adopted throughout the whole system.

The Municipal Health Secretariat (SMS)

Municipal Health Secretariats (Secretarias Municipais de Saúde, or SMSs) are omnipresent, and are the main candidate for assuming the roles of management with solidarity, cooperativeness and regional interdependence. They are seen as bureaucratic structures with a profile tending to centralization. Their performance is further hampered by the political discontinuity resulting from the turnover of appointees as municipal health secretary. Moreover, perhaps their greatest point of vulnerability is technical weakness. CONASEMS is cited as an important supporter in the regional process.

State Health Departments (SES)

The government of the individual State is most often seen as the absent partner. There is a certain call for the State Health Departments (Secretarias Estaduais de Saúde, or SESs) to assume a greater leadership role in coordinating the regional process, with an effective presence in regulation, mediation and negotiation. However, their structural and technical fragility for taking on such central roles is recognized.

The Regional Inter-Management Committee (CIR or CGR)

Regional bodies are widely valued as a space for innovative policy and regional governance. But, naturally shaped by the breadth of a consolidating democracy and its historical mindsets, they suffer from a difficulty of overcoming simple reproduction of the municipal political culture with its marked electoral, clientelist, and corporate interests. From this it can be inferred that the regionalization of health suffers more influence from the comprehensive political and social dynamics and their historical accumulation than from health policy per se.

The concept of the public-private (state-market) mix

In Brazil, it is not so much that there is coexistence between the market and the state – throughout the country, the relationship can perhaps be better described as interdependence. In some regions the interdependence is more predominant; in others less so – there is no definable pattern. There is a consensus that managers are not successful in regulating the contracted private sector, whose strong influence is due to its existing operational capacity, its participation in decision processes, and its multiple professional links.

Instruments

Another strong consensus is that there lacks a culture of planning; and planning is further hampered by the weakness of the available instruments: the Health Plan is worked in a formal and symbolic manner; the RDP (Regional Development Plan) is contaminated by considerations of lower-level policy; and the PPI (Public-Private Initiative) partnership projects are stalled by underfunding and inter-municipal disputes. The legal instruments available to guarantee agreements are weak, and practically absent at metropolitan and inter-state levels and in border regions. It becomes clear that one of the key challenges to regional governance is the development of effective tools for coordination, regulation and planning.

Regulation

Although this is such a commonly-used expression, the truth is there is a lack of clarity about the broader meaning of the term ‘regulation’. In pragmatic terms, there is a generally agreed difficulty in regulating regional flows – insofar as they are commonly referred to by the more structured municipalities as ‘invasions’.

Discussion

Homogeneity of discourse

Even if it is because they are describing the exercise of similar functions, the homogeneity and regularity of the body of discourse found in this review – across time, size and region – is remarkable, and even extends to similarity with studies prior to the Health Pact3333. Mendes A, Louvison MCP, Ianni AMZ, Leite MG, Feuerwerker LCM, Tanaka OY, Duarte L, Weiller JAB, Lara NCC, Botelho LAM, Almeida CALO. O processo da gestão regional da saúde no Estado de São Paulo: subsídios para a análise. Saúde Soc. 2015; 24(2):423-437.,4242. Albuquerque MV, Viana ALA. Perspectivas de região e redes na política de saúde brasileira. Saúde Debate 2015; 39(n.spe):28-38.. This was to some extent expected, if only because the influence of federal rules will tend to result in a certain cohesion between the activity of different entities, revealing common technical difficulties. National forums and representative bodies, such as CONASS and CONASEMS, also participate in this correspondence. But it is as if a major summary of the literature that is the subject of this review had been commissioned in the essay produced by a meeting of Municipal Health Secretaries1717. Assis E, Cruz VS, Trentin EF, Lucio HM, Meira A, Monteiro JCK, Cria SM, Focesi MR, Cielo CA, Guerra LM, Farias RMS. Regionalização e novos rumos para o SUS: a experiência de um colegiado regional. Saúde Soc. 2009; 18(Supl. 1):17-21. – in the sense of the idea of ‘organizational isomorphism’4343. Almeida APSC, Lima LD. O público e o privado no processo de regionalização da saúde no Espírito Santo. Saúde Debate 2015; 39(n.spe):51-63., although we do not want here to address the institutionalist approach.

A first reason could be that the geographic and temporal cohesion of the set of studies reveals substantial external validity of the categories reviewed – so that this body of discourse is assumed as a common representation of the managerial discourse in the process of regionalization of the SUS nationwide. The most immediate consequence is to reinforce a statement that the phenomena mentioned are indeed undeniable and important to the regional process, throughout Brazil.

But this does not exclude the possibility that the angle taken by the survey is mostly aimed in one direction only, ignoring possible variations of the scenario (the choice of key actors and script, for example, is a choice by the researcher – and the questioner not only knows only part of the response, but also influences the direction of discourse). As an example, only two papers mention the prospect of inter-sector regionalization, but without going at all deeply into the merits2525. Coelho APS. O público e o privado na regionalização da Saúde: processo decisório e condução da política no estado do Espírito Santo. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2011.,3535. Lima LD, Viana AL d’Ávila, Machado CV, Albuquerque MV, Oliveira RG, Iozzi FL, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Cien Saude Colet 2012; 17(11):2881-2892.. The role of providers – especially of hospitals – and, for example, issues of technology and innovation, are largely hidden.

This low degree of variation in discourse in recent years also strengthens indications that, following the inflection promoted by the NOAS, and more forcefully by the Pact for Health, the regional process has for some time reached a kind of political plateau. One of the easiest causes to propose would be the insufficiency of new stimuli – that is to say funds – to overcome the stages reached. The ubiquity of the complaint of underfunding is self-explanatory.

The sphere of the state, meanwhile, adds little to the overall calculation: it is most often regarded as amiss, and sometimes as an obstacle. In reality, however, the technical fragility of the municipal entity – and also of the individual State – is one of the most categorical obstacles to the process of regionalization in the country; and this is undoubtedly as a result of the perceived vulnerability and bureaucratization of CGRs/CIRs.

In general, the resulting thematic categories can be understood at once – there is no need for any specific discussions about each one – but the scale and continuity of this group of statements, in dialog with the historical-structural context of the country, makes it possible for us to deepen the discussion using more robust analytical categories, as follows.

Regionalization, decentralization and re-centralization

There is a reluctant criticism of the participation of the State Health Departments (SESs) in the regional process. Although it probably originated from the context of regionalization, the problem actually comes from an earlier stage, and refers to the process of decentralization44. Viana ALA. Descentralização e política de saúde: origens, contexto e alcance da descentralização. São Paulo: Hucitec Editora; 2013.,55. Ouverney ALM. Federalismo e descentralização do SUS: a formação de um regime polarizado de relações intergovernamentais na década de 1990. Rio de Janeiro: Fundação Getúlio Vargas; 2015. – and indeed probably from broader and older influences, since the polarization between municipalities and federation had already been characterized in policies from the era of dictator-president Vargas4444. Martinelli NL, Viana ALA, Scatena JHG. O Pacto pela Saúde e o processo de regionalização no estado de Mato Grosso. Saúde Debate 2015; 39(n.esp):76-90.. It could therefore be asked: to what extent does the regional process also depend on updating the questions of Brazil’s federal structure?

It is known that municipalization has resulted in a more democratic pattern of local governance4545. Lotufo M, Miranda AS. Sistemas de direção e práticas de gestão governamental em secretarias estaduais de Saúde. Rev. Adm. Pública 2007; 41(6):1143-63.,4646. Cecilio LCDO, Andreazza R, Souza ALM, Lacaz FADC, Pinto NRS, Spedo SM, Lacaz FAC, Sato WNS, Bestetti LMA. O gestor municipal na atual etapa de implantação do SUS: características e desafios. R Eletr de Com Inf Inov Saúde [Internet]. 2007; 1(2). [acessado 2015 out 15]. Disponível em: http://www.reciis.cict.fiocruz.br/index.php/reciis/article/view/84/79
http://www.reciis.cict.fiocruz.br/index....
. But at the same time the problem of decentralization, with its regional inequities, bureaucratization and politicization at local level, at the same time making it difficult to regulate the central level66. Saltman RB, Bankauskaite V, Vrangbæk K, editors. Decentralization in health care: strategies and outcomes. Maidenhead: Open Univ. Press; 2007. (European observatory an health systems and policies series)., provides motivation to strengthen the regional issue in the country.

Brazilian states have achieved differentiated stages of decentralization in health, which translates in particular to the degree of control over medium and high complexity (MHC) treatments, affording a privileged position to the reference hospital in the organization of the system. The role that this hospital plays in regional governance is still poorly understood within the regionalization process1414. European Union. Committee of the Regions. The management of health systems in the EU Member States the role of local and regional authorities. Luxembourg: Publications Office; 2012.. There is a certain perception that the states that have made the most progress in the decentralization of their health systems nowadays experience more difficulty in regulating the regional process, which would raise the possibility that some degree of recentralization could be beneficial in some cases (though this is certainly not applicable in all cases – São Paulo has a considerable MHC component and is also seen as a fragile link in the process). This is a balance in which structural and non-structural measures are continually weighed in the search for a dynamic equilibrium1010. Jakubowski E, Saltman RB, European Observatory on Health Systems and Policies, editors. The changing national role in health system governance: a case-based study of 11 European countries and Australia. Copenhagen: European Observatory on Health Systems and Policies; 2013. Observatory studies series..

Municipal needs and regionalization

Municipal management is widely interpreted as a fragile and obstructive link in the regional process – this question naturally embodies the idea that technical improvement of the municipal situation would impact regional capacity. Of this there is no doubt. But the studies make no progress on a vital central question: why does this fragility show no signs of improvement over time? It does not seem to be just a ‘how-to’ problem, something for which someone would soon suggest technical, specialization, and related courses, or perhaps a problem related to staff turnover.

Looking from another angle, it can be put forward that the focus of these analyses is too concentrated on the regional content of the reform, the formation of networks and on the care given, to the detriment of stakeholders4747. Melo MABC. Municipalismo, nation-building e a modernização do Estado no Brasil. Rev. Bras. Ci. Soc. 1993; 6(23):85-99. – thinking of reversing the perspective of the municipality as a main actor interested in regionalization and its own needs (and not in the special-interest ‘regionalization’ within the municipality). From this new, seemingly paradoxical point of view, the need to support, reinforce and invest in municipal management seems to emerge as an inherent part of the regionalization policies themselves. This issue also highlights the discussion of the role of COSEMS, an actor not widely referred to in the studies, but always in a positive way.

The successful induction of municipal technical capacity is a concrete historical possibility4848. Viana AL d’Ávila, Machado CV. Descentralização e coordenação federativa: a experiência brasileira na saúde. Cien Saude Colet 2009; 14(3):807-817.. The challenge is to think of an induction model that technically strengthens the municipality and the region in parallel, and within an acceptable period of time. It is as if there is a need – and indeed there is – to enter a post-industrial society without first experiencing industrialization; or enter into a modern public administration, without first experiencing efficient bureaucratic administration.

In a serene and reflexive position, Gilles Dussault4949. Fleury S, Ouverney ALM, Kronemberger TS, Zani FB. Governança local no sistema descentralizado de saúde no Brasil. Rev. Panam. Salud Públ 2010; 28(6):446-445. points out what seems to him to be the greatest managerial difference between Anglo-Saxon and Latin cultures: “the degree of professionalization and corresponding de-politicization of the management of health services and, in general, of public services”; a tradition of management training, and favor for meritocratic appointment, especially “for management positions where the latter results from competencies and experiences that correspond to the specific requirements of the function.”

But if the need for greater focus on municipal needs, favoring management careers, and more appropriate managerial choices provide part of the answer, another particular feature of Brazilian politics, discussed below, also helps perpetuate the broad front of municipal incapacity revealed in the surveys.

Planning: linking the parts

The argument developed here benefits from the analysis of Vargas et al.1616. Vargas I, Mogollón-Pérez AS, Unger J-P, da-Silva MRF, De Paepe P, Vázquez M-L. Regional-based Integrated Healthcare Network policy in Brazil: from formulation to practice. Health Policy Plan 2015; 30(6):705-717., in which they observe that the challenges of health regionalization in Brazil bring together four major categories of analysis:

  1. Implementation based on negotiation instead of planning

  2. Great responsibility of municipalities with low technical capacity

  3. Failures in planning and coordination of the competencies involved

  4. Lack of clarity on the political rules of implementation

The point is not to re-discuss these points here, but to refer those interested to the original discussion. But it should be noted that these categories are not arranged in the same historical plane of analysis; hence it is possible to specify a hierarchy of cause and effect among them. The political culture of consensus mediated by negotiation comes historically before its conceptual opposite, politics based on planning – as exemplified in the tradition of the political negotiation (bargain) model in the country, pointed our extensively since Oliveira Viana5050. Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan 1994; 9(4):353-370., Victor Nunes Leal5151. Arretche M, Marques E. Municipalização da saúde no Brasil: diferenças regionais, poder do voto e estratégias de governo. Cien Saude Colet 2002; 7(3):455-479., or Rodolfo Mascarenhas5252. Entrevista com o professor Gilles Dussault: desafios dos sistemas de saúde contemporâneos, por Eleonor Minho Conill, Ligia Giovanella e José-Manuel Freire. Cien Saude Colet 2011; 16(6):2889-2892., the latter relating to public health in São Paulo.

Vargas et al.1616. Vargas I, Mogollón-Pérez AS, Unger J-P, da-Silva MRF, De Paepe P, Vázquez M-L. Regional-based Integrated Healthcare Network policy in Brazil: from formulation to practice. Health Policy Plan 2015; 30(6):705-717. provide an essential element to the debate. In the pragmatism of the U.S., for example, it has long been clear that metropolitan and regional issues related to public health are primarily in planning and not in political bargaining5353. Viana O. Instituições políticas brasileiras. Brasília: Conselho Editorial do Senado Federal; 1999..

In our own public health history, which is something of an offshoot from that pragmatic historical approach in the US, Barros Barreto, the main person responsible for shaping Brazilian healthcare in the first half of the 20th century, already pointed to the need to plan the distribution of health services in the interior of the country – he was aware of what was later to be called inter-sector integration5454. Leal VN. Coronelismo, enxada e voto: o município e o regime representativo no Brasil. São Paulo: Companhia das Letras; 2012.. In the institutional culture, the SESP Foundation, which had a strong American influence, was the entity that insisted most on the need for rational organization, planning and integration of health services among us33. Mello GA, Viana ALA. Uma história de conceitos na saúde pública: integralidade, coordenação, descentralização, regionalização e universalidade. Hist. cienc. saude-Manguinhos 2012; 19(4):1219-1240.,5555. Mascarenhas RS. Problemas de saúde pública no estado de São Paulo. Arquivos da Faculdade de Higiene e Saúde Pública da Universidade de São Paulo 1954; 8(1):1-13. – this was a school that was strongly opposed to the rise of the critical political thinking that would culminate in Collective Health. One of the main reasons was precisely the opposition to that which was seen as an eminently technical culture that disregarded the strategic importance of political intentionality in planning. In any event, although one can think of the specific implications of this schism in the formation of a public health system, the results reviewed in this study suggest that the regional dynamic is more about the social culture and open policy than the sectoral health issue per se1616. Vargas I, Mogollón-Pérez AS, Unger J-P, da-Silva MRF, De Paepe P, Vázquez M-L. Regional-based Integrated Healthcare Network policy in Brazil: from formulation to practice. Health Policy Plan 2015; 30(6):705-717.,3535. Lima LD, Viana AL d’Ávila, Machado CV, Albuquerque MV, Oliveira RG, Iozzi FL, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Cien Saude Colet 2012; 17(11):2881-2892.; notably, a political-administrative culture with difficulties in creating virtuous long-range planning22. Viana ALA, Lima LD, Ferreira MP. Condicionantes estruturais da regionalização na saúde: tipologia dos Colegiados de Gestão Regional. Cien Saude Colet 2010; 15(5):2317-2326..

But how can one interpret the perennial character of this deficiency in planning? A central point is that ultimately the logic of bargaining keeps the concept of health planning very much subordinated to the remaining possibilities of political negotiation – of unequal conditions between municipalities. This is an imbalance that annihilates the very notion of planning (how does one improve a mutilated concept?). Thus a vicious circle is completed – of low technical and managerial qualification, high professional turnover and simple removal of the sense and purpose of planning: in other words, a reaffirmation that the primacy of political negotiation over planning ends up subordinating all other approaches. This is a context that is certainly unfavorable to the development of effective and innovative tools for regional planning and, thus, to overcoming the limitations affecting the innovative creation of new regional instances. It also helps in understanding the low possibility of the planning model replacing the current model based on supply – obviously a priority when negotiation comes first – with another based on demand, able to lead the complementary private sector to adhere to the primary objectives of the SUS.

Final considerations

This review has shown that the process of regionalization is now a vivid reality in health management in Brazil, in all spheres of government, but that it faces a set of challenges common to the various situations throughout the country. Value is given to the regional committee organizations as important spaces for innovation, but they are seen as still looking for ways of overcoming a bureaucratic and clientelist political culture. Regional governance needs to addressing the system fragmentation, and the historical deficiency in planning, all the way from local issues to strategic policies such as the adoption of technology. The analyses that were reviewed delivered an incisive implication of a culture giving dominant priority to political negotiation, in a vicious cycle that simply maintains the technical deficiency of the management.

The clearly maturing output of studies emphasizes the potential behind the present tension between the political priorities established in the health sector and the capacity for the reaction of academics to provide sets of evidence and indicators of the process. The gap between academic and political priorities seems to be well represented by the fact that there is a significant presence of universities in the regional process in only three states3535. Lima LD, Viana AL d’Ávila, Machado CV, Albuquerque MV, Oliveira RG, Iozzi FL, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Cien Saude Colet 2012; 17(11):2881-2892. – this is in addition to the historical difficulty of inserting university hospitals into healthcare planning2323. Stephan-Souza A, Chebli ICF, Jacometti EJM, Paiva MG. Regionalização sob a ótica dos gestores: uma abordagem dialética. Rev APS 2010; 13(Supl. 1):S35-45.. The mismatch between the implementation of social policies and academic research has indeed been described in the international literature as a common challenge5656. Adams T. Regional Planning in relation to public health. Am J Public Health 1926; 16(11):1114-1121.. According to reports, an important factor in the low reflexivity of the recent dismantling of regional health processes in Canada was precisely the lack of scientific evidence about implemented policies99. Marchildon GP. The crisis of regionalization. Health Manage Forum 2015; 28(6):236-238..

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Publication Dates

  • Publication in this collection
    Apr 2017

History

  • Received
    11 May 2016
  • Reviewed
    04 Aug 2016
  • Accepted
    23 Sept 2016
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