Territorial perspective , regionalization and networks : an approach to Federative Republic of Brazil ’ s health policy

Patrícia Tavares Ribeiro Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública. Departamento de Ciências Sociais. Rio de Janeiro, RJ, Brasil. Centro de Estudos Políticas e Informação sobre Determinantes Sociais da Saúde. Rio de Janeiro, RJ, Brasil. E-mail: patriciatr@ensp.fiocruz.br Territorial perspective, regionalization and networks: an approach to Federative Republic of Brazil’s health policy Perspectiva territorial, regionalização e redes: uma abordagem à política de saúde da República Federativa do Brasil


Resumo
O artigo desenvolve o argumento que a regionalização do cuidado à saúde na República Federativa do Brasil requer o aprofundamento da abordagem territorial nas políticas públicas e a contextualização das intervenções governamentais setoriais nas dinâmicas locais de desenvolvimento.A partir da síntese da trajetória dessa estratégia na história recente, em seus objetivos políticos, identifica aspectos da natureza federativa da gestão pública e concepções de território e de redes como processos políticos que podem contribuir para a compreensão do cenário em que vêm se construindo respostas regionais aos problemas locais.A argumentação problematiza a configuração de redes homogêneas de serviços no território nacional em prol de um planejamento territorial, participativo e orientado pelo interesse público que tome como ponto de partida a compreensão do processo saúde-doença e da situação de saúde que se quer alcançar, no futuro de cada lugar.Palavras-chaves: Políticas Públicas; Gestão Pública; Regionalização; Planejamento Territorial; Desenvolvimento Local.This article argues on that an approach to health regionalization in Brazil which deepens the understanding of the federal nature of health policy interventions' field and updates the national and international situation of governments in producing answers to social problems, from a territorial logic, may contribute to a better political direction of propositions and current practices in the Brazilian National Health System (SUS) management.
This argument is based on the assessment that although the political strategies of sectorial regionalization implemented under the induction of national SUS management since 2000, have incorporated in their thematic agenda, categories such as federal, territory, region, networks management and their governance which need to go ahead with interactions with other sectors and overcome the logic of offering services which predominates in system regulation and management of public health's environment.
Based on these assumptions, this study takes as its starting point the "provocation" made by French researcher Philippe Mossé, in a panel occurred in Montreal in 2012, when, presenting an analysis of the health system in France, he characterized the regionalization as " [...] a consensual solution looking for a problem (s) ... to solve [...] ", arguing that the different forms of regionalization, even their necessity, depend on the problems that want to solve and the potential of each situation (Mossé, 2012).
Taking this provocation as a challenge, the question which initially guides the work developed herein is: what problems should be objectively answered towards the health regionalization in Brazil?For such, the procedure is, initially, a brief review of the formulations presented in recent decades to the regionalization of state provision of health care in the country, by identifying the problems intended to solve with this approach.Next, we seek to explore prospects of the federal and the territory context in which the regional answers of the Brazilian National Health Systemare given today.Finally, some considerations are presented towards the development of the proper approach to this issue.Thus, it is expected to contribute with subsidies enhancing 1 Work presented in: MOSSÉ, P. La "régionalisation" du système de santé: enjeux et mise en oeuvre d'un processus.In: GOVERNANÇA, REGIONALIZAÇÃO E PERFORMANCE EM SISTEMAS DE SAÚDE, 2012, Montreal. Quebec, 2012. the sectorial capacity in solving those existing and emerging problems in each locality of the country.
The reflections presented herein are resulting from a research conducted in recent years by Fiocruz-Conass -Conassem Cooperation Project on the Regional Governance in SUS, the Government Research Group and the Public Policy Management Association and, the author's professional experience as a public servant, in the National Health System management at different times in decades.

Regionalize health care state provision in Brazil: why and for what?
The regionalization as a health care state provision decentralization strategy in Brazil is part of the sectorial policy agenda for at least 30 years.Since the early 1980s, when the government strategies formulation for integration of health care services into the democratic transition of the Brazilian state, regionalization makes up the range of innovations for institutionalization of a national health system in the country.
In those early times, regionalization was presented as a strategy for the rational planning of state action in health, aimed at integrating preventive, curative and rehabilitation activities through the interinstitutional coordination of services offered by federal, state and municipal governments, in a second level hierarchical networks of care complexity.
It focused on the economies of scale aimed on providing the national health care system; the establishment of referral and counter mechanisms between units and levels of complexity; and the institution of planning and management collegiate institutions, with the participation of society.
It can be said that regionalization, in that political scenario, consisted mainly of a managerial perspective to rationalize the chaotic range of services and public spending on health in the context of interinstitutional coordination, integration expectations which guided the state action reorganization, conducted by the Ministry of Social Security.
However, regionalization was also part of the set of propositions for debate in society in favor of a sectorial reform that would overcome the inequali-ties of all kinds generated by the Brazilian historical pattern of state intervention, consolidated during the authoritarian regime.In view of the political reform movement, regionalization was defended as an essential tool for comprehensive care and equity in access to programs and services in achieving the universal right to health.
The Federal Constitution of 1988 established the regionalization and the hierarchy as guidelines for organization of the decentralized network of activities and services of the National Health System, to ensure equal access of the population to care provided by the State to protect, promote and restore health to its citizens.Given the expansion and strengthening of federalism promoted by the Constitution, the SUS emerged with the task of harmonizing the activities of federal entities in achieving health equity in the national territory of the federation.
Until the late 1990s, the federal government strategies prioritized the institutionalization and strengthening of decentralized management system in the states and municipalities, especially in the latter.Locally, regional reach answers in health care organization resulted from inter-partnership initiatives for the establishment of health consortia, encouraged at the time by the national leadership of the SUS (Brazil, 1993) or at the option of state governments to promote such regionalization of state action in their jurisdiction.
From the 2000s, the regulation of health care regionalization gained the political agenda of the SUS national management, particularly from the second mandate of Fernando Henrique Cardoso.Initially guided by a systemic view, limited to the health sector, regionalization was directed by ranking strategies of health services and search for greater equity in access through the organization of functional and resolving system regional scale, technically designed by federal rules .The ministerial standards explained the purpose of avoiding the SUS atomization into an inefficient, unfair and not resolving systems' environment.In this initial direction, regional planning instruments were valued by reference to the intergovernmental agreement, under which the health regions in the states is defined.
The ministerial directive was revised at the be-ginning of Luiz Inacio Lula da Silva's government, in the light of the evolution of sectorial policy process intergovernmental agreement reached with the growing strength of the SUS decentralized management in the new federal environment.The regionalization, supportive and cooperative, started to be referred in the context of qualification, improvement and better definition of health responsibilities and management of all federal entities in the health regions, around the impact of priorities in the local health situation.
Health regionalization, at this juncture, was based on a sectorial national pact -the Pact for Health, which officially formalizes commitments among federal, state and municipal managers for solving difficulties accumulated as they were evaluated at that time, as excessive national induction of local processes through general rules insensitive to a country of continental dimensions and with high inequality, and by the complex and detailed technical and procedural content which characterized the previous regulation.
Since the publication of this pact in a specific order issued by the Ministry of Health (Brazil, 2006), the normative has updated guidelines for the formulation of regional responses which seek to include: i) the federal nature of intergovernmental relations involved in the health regions political management; ii) the existing diversity of situations in the states and municipalities and the respect to the autonomy of subnational entities in the election of priorities and the design of health regions; iii) the decentralization of decisions about resources allocation to regional management boards; iv) the tripartite financing of necessary changes; v) accountability of each federal entity for decisions taken in the national sectorial concentration federal, state and regional arenas; and vi) intergovernmental contracting mechanisms for defining, monitoring and evaluating regional goals.
Along the way, the integrated planning logic, comprising notions of territoriality, is reinforced and reiterates the objectives of ensuring the access of all and every citizen to actions and services neces-sary to solve their health problems, with optimization of available resources and partnership among federal agencies towards the care provision.
These general guidelines for regionalization comprise the content of Decree 7508/2011, recently enacted by Dilma Rousseff's Government, which analyzes the regionalization in all the contents provided for SUS regulation, organization, health planning, health care, and joint inter-federal articulation (Brazil, 2011).
With this brief background on the sectorial approach, the regional solutions to local problems in the management of the Unified Health System, particularly the federal rules which regulated this process in recent history, it seems fair to say that regionalization seeks to answer the following needs: i) expansion and equalization of access to adequate care for Brazilian citizens health protection, promotion and restoration, wherever they reside; ii) institutions integration, units and health services with different technological densities in shaping a hierarchical network of universal access with decentralized and shared management between state agencies; iii) rationalization / optimization of resources in the provision of programs and services, oriented equity gains; and iv) SUS answers adequacy to the huge differentiation of existing health institutions in the country.
In this study, I argue that the sectorial government action reordering experiences in this direction can move forward in the production of territorialized policies and contribute to regional planning, from a greater understanding: i) of the federal context which conditions the dynamic sector policy and the participation of each federal entity into the Brazilian National Health Systemmanagement in each place; and ii) of the territory which contextualizes the healthdisease process and where there is an encounter with the policies towards the society, whatever the scale of intervention.
Thus, in my view, one can enhance the sectorial responses to the existing and emerging problems in each country locality.In the following sessions, I justify this argument.

SUS federal management in constructing regional response to local problems
The federal context of government action in Brazil brings to public policy production processes -and their management -important challenges, especially if we consider that our triune federation, with decentralized management, is young -it is around 26 years, and this period had to accommodate more than five thousand political actors incorporated into the Union with the elevation of the city to the federal entity condition.
These challenges, it is worth noting, are even more complex if we consider the significant changes in government, the market and society as well, derived from the globalization processes, and the relationships between them, which were directly levied on public management and pressed for reconfiguration of state action.
In this context, any public policy, of regional, state or federal coverage, is facing the challenges of finding the balance between regulation, accountability and autonomy in the distribution of powers between the federal entities for its operation and the best intergovernmental arrangement for its financing.
The division of responsibilities between federal, state and municipalities in the implementation of such regional health system action, anywhere in the country, requires, as in other policies of the Brazilian federation, understanding among the entities involved that resources and services corresponding to the region should be planned, organized and managed in a collaborative scheme (Saviani, 2011).
It requires, and perhaps there is the greatest difficulty, the political ability to identify the regional territory as a field of responsibility and common investment, which is critical to the collective effort of construction, with society, of a shared vision for the future action of regional governments, not always compatible with the partisan composition of local governments.
The identification and funding of regional priorities in the SUS require action, on the other hand, overcoming efforts in the traditional position of dependence on funds from the federal government, even if it is a material reality.The funding must be shared between the federal entities involved, subject to the peculiarities, expertise and financial capacity of each, based on solidarity and aimed at the loco-regional development (Ribeiro;Barros, 2010).Consequently it is important to evaluate the existing financial conditions for health care reorganization in regions where regional SUS action becomes necessary, considering: i) the sectorial action financing structure in the national federal arrangement; ii) the share of each entity in the distribution of functions and expenses necessary for the priority actions implementation; iii) the ability of each entity to participate with its own resources to finance the necessary changes; iv) the need for additional support from the Union; and v) the need to provide or give greater autonomy to regional authorities for management and financial implementation.
This provision is affected not only by the party configuration of sub-national governments which make up the region, but also the technical skills of managers and technical policy and local bureaucracies to analyze their financial situation and determine the best regional arrangement for financing innovations -which it is worth remembering, also requires extensive dialogue with other governmental sectors of each one and the continuous monitoring of governors and mayors.
Dealing with this Brazilian complexity on the federal, state public policies is a sine qua non condition to identify, at the moment of sectorial innovations, sustainable alternatives to reduce inequalities in access to health services expected as a result of SUS regional action.

The territory used as subject and object of the regional public policies production
Also relevant to the formulation of strategies and programs of regional scope, is the deep healthdisease knowledge in its differentiation in the country and specificity that takes place in each site.
For this, in my view, it is essential to understand the region as part of a larger territory than the health territory -this, often identified as mere support of an insufficient installed service offering.
The political geography has made a huge contribution to the understanding of territorial scales on which there are government interventions in the contemporary world, in providing approaches for analysis of public policies, updated with the new dynamics found in multi-scale scenarios, rapidly changing, which characterize the public space.Central in these approaches is the recovery of the conception of space as a power, in the multidimensionality acquired by power in recent history; and notions of territory and territoriality in their new uses.
Once this environment is recognized, according to Rückert (2010), any public policy today is territorial and, accordingly, expressive from the power exercised by various actors in the production of space, whether through the practice of powers, policies, strategic programs, either by sense of new uses of such territory.
This perspective complicates the territorial context of public policies implementation, which now encompasses nature and society, objects and actions, spatial forms and power relations, environmental resources and infrastructure, economic, social and environmental, political and cultural interactions, processes, continuities and discontinuities, new scales, materiality and immateriality.The territory becomes one and multiple, singular and plural -and singular to plural, live space, and concomitantly abstract and concrete.(Saquet, 2007 apud Knopp;Alcoforado, 2010).
In other words, the territory as a public policy object, can be understood as content, means and process of social relations; bearer of the history of different places; and support of multi-scale territorial dynamics, in which several territoriality can be socially constructed, in their different cuts.
The region as territorial cut for production of public policies, in relativism times of the national scale and global rescheduling, constitutes, therefore, as: i) a field of internal and external practices, standards, and of social, marketing, cultural and political values, seeded by contradictions between global and national institutional processes which affect it and the relationships between individuals and social actors living, circulating and interacting there; and, ii) employed territory, which takes a new operation in the globalized present, resulting from uprights and horizontalities happening simultaneously as networks and as a space for all (Santos, 2005).
It expands importance as functional cut to the dynamics of cooperation between actors such as policy coordination level and as a priority area for intersectorial cooperation, government action restructuring processes, under which, depending on the density of existing social and institutional relations, becomes more or less possible to mobilize collaborative efforts and deepen democratic organization.
From this perspective, the regions can no longer be seen as spaces for administrative intervention, restricted to multi-sectorial and multi-level government actions that unfold there, but as the product of a territory where there are distinct, and often in conflict, economic, social, political, institutional and individual expectations building a new territoriality.
In Brazil, any learner who is engaged to analyze the changes engendered by the State democratization and the power decentralization to states and municipalities will discover the emergency power practices with a territorial approach in multiple scales of power and management, and territorial policies in supranational, national, regional and meso-regional scale.There are countless examples of public policies on territorial approach in phase of implementation towards the federal units.One will also be faced with the challenge of reducing regional imbalances placed for governments and society in different places.
Just to name some examples, in recent decades, the federal government established the National Policy for Regional Development and programs such as Borders Development Program, the Sustainable Development of Rural Areas National Program, and the Territories of Citizenship Program.
This scenario requires for governments the need to territorialize their approaches to national, regional and local problems in the formulation of public policies and to establish in the governanceas a strategic practice -managing territories, noting the territorial reality socially constructed on a plot of space trimming to organize the state action.For public health policies, recovery and deepening of the territorial approach to the health-disease process and the planning of sectorial responses is required.
Regionalize, therefore may correspond, in this context, to the production of a political cup in a given territory (employed), for construction of answers, socially and institutionally articulated to the problems whose solution requires collaborative and coordinated efforts of every governmental and non-governmental actors, involved in local actions in such a region.
In my view, networks, understood as political processes anchored inside the territory, should be considered in the construction of regional responses.

Networks and political processes integrating the production of regional responses
From the perspective which guides the arguments development presented herein, networks are thought of as political processes of support / sustaining the production of regional responses.
The concept of network, as rightly pointed out by Enne (2004) and Acioli (2007), took commonplace in current analyzes of society to define new forms of socialization and information flow, which have been analyzed in different ways within the social sciences and communication.
As a social interaction system, it applies to contemporary social contexts in which the articulation and re-articulation between individuals is permanent.Field of interactions, it is a social construction of relationships which composes and recomposes multiple possibilities for arrangements and negotiations, depending on the potential contacts and borders that involved social actors can establish.
Whatever the approach, the concept of networks assumes management of information flows, which are materialized, made public and distributed according to the demands of such social interactions (Hannerz, 1992).In this first degree abstraction in which the network is a reality, the social actors define the social boundaries and the indemnificatory criteria of such a network.Therefore, the network concept also relates to a process of communication that takes place from normative standards for behavior and identifying patterns of those who compose it.
This conceptual reference, besides needing further development for application to the problems placed by the government action seems to me as useful for an approach to the materiality assumed by public policies as networks in the territory.With this understanding, the network that, in my opinion, better embodies and epitomizes the political processes which drive the dynamics of technological, social rearticulations of economic enterprises and government production, with direct impact on the results of public policies, is the urban network.Its density and its flows may vary significantly in different regions of the country and influences the local development and life in the cities.It is therefore necessary to incorporate the dimension of such urban network in all policies.
This task is made easier, in Brazil, because we can count on relevant initiatives of the federal government, including two that I will highlight: i) the IBGE line research Regiões de Influencia das Cidades (REGIC), which periodically publishes frameworks of such Brazilian urban network, enabling monitoring its evolution in the period of 1972/2007; ii) and the research Análise de Mapeamento e das Políticas para Arranjos Produtivos Locais no Brasil, carried out by the BNDES in partnership with universities in 22 states in the period of 2009/2010.
The data and maps provided by REGIC allow the location of production economic activities, private and collective consumption in the country, as well as provide important contributions to the understanding of current social relations and spatial patterns emerging from them.With regard to basic social services, including health, they provide relevant information on the population accessibility conditions to places where they are installed, and supporting rational decisions on new plants addressed for the care of population in certain regions.
The research on the local clusters, with its mapping, seeks to identify clusters of firms located in the same territory, which present productive specialization and maintain joint linkages, interaction, cooperation and learning among themselves and with other stakeholders, such as: government, business associations, credit, teaching and research institutions.
In addition, through characterization of public and private policy actions in support of these arrangements in such 22 States, in terms of support structure, beneficiaries, adhesion, penetration, effectiveness of implemented policies, municipal location on maps, it provides important information on economic dynamics and contributes to the formulation of new regional development policies.
On the other hand, it is known that in the recent history of local governments, the configuration of actors and entities networks which mobilize around one or more issues of public interest, forming partnerships between various public and private institutions has been multiplying.And in this way, expanding the public space and the break with the centralized uni-organizational state provision model (Farah, 2010).
So, if indeed we adopt a territorial approach in the production of sectorial responses to local problems in a given regional level, we should also consider the situation of such urban network in the region, in its potential and its limits for the strategies formulation process, for the sectorial response organization; the potential for region economic development; and articulated actors networks or in conjunction within the local and / or regional governments.

Final considerations
To complete the arguments presented herein, I go back to the question that gave rise to this study, namely, what problems should be objectively answered towards the health regionalization in the Federative Republic of Brazil?Perhaps the most likely answer in the social consensus is to be: problems relating to restrictions on access to services which impact the conditions and opportunities of federal entities to meet the local needs, those of collective and individual protection and health care, producing inequities in the application of the universal right to health.
In this sense, it seems reasonable to conceptualize the regionalization in the SUS management spaces as to be political processes, organized to seek regional answers to health problems, territorially contextualized.Problems identified from locally defined needs on which these responses must relate to obtain effective improvements in living conditions and health, in each place.
Regional answers therefore will hardly confined to the health sector field, but will result from the combination of actions in various sectors, governmental or not, aimed to keep complementary to each other or have synergistic effects for local development in the different regions.
For this, I finally argument, it is necessary to overcome the access to health care equalization logic by setting the homogeneous service networks in the country, ideally and hierarchically regionalized, which is leading the SUS since its inception.A territorial, participatory planning, taking as its starting point the health situation that one wants to achieve in the future of each place, city, state, region and country, from the recognition of the specificity assumed by the health-disease process in each locality will find different settings for governmental responses in the different impact of public policies scales.
If it is intended that the SUS, in fact, has its operations regulated by territorialized policies, coordinated within territories management, it is necessary to know the territorial dynamics which characterize and influence the health-disease process and the responsiveness of federal entities to the epidemiological profile and the priorities which should be socially identified and politically agreed.
Such knowledge is not achieved only through the technical and scientific contributions of government bureaucracies, without essential and relevant questions.It emerges from urban interactions, from interactions between the different social actors, in the network or in cities' daily life, and in the reconfiguration of political action and of public space.
The knowledge collective construction can give to these social relations a role of relevance in the sector dynamics, balancing particular political and social interests in the public interest.And so, inform and enhance the participatory planning which is already being practiced in several states and municipalities, in order to better distinguish between local and regional responses answers, as defined based on the federal nature of state action.
From this scenario, different modalities of regionalization can arise, spontaneous or induced, according to the potential of each situation, as pointed out by Contel (2014).Or even other arrangements, above infra-municipals, not necessarily regional as pointed out by Mossé (2012).