Regionalization in the SUS: implementation process, challenges and perspectives in the critical view of system managers

Carvalho, Andre Luis Bonifácio de; Jesus, Washington Luiz Abreu de; Senra, Isabel Maria Vilas Boas

doi:10.1590/1413-81232017224.30252016

Acessibilidade / Reportar erro

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

ARTCILE • Ciênc. saúde colet. 22 (4) • Apr 2017 • https://doi.org/10.1590/1413-81232017224.30252016 copy

Regionalization in the SUS: implementation process, challenges and perspectives in the critical view of system managers

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This article examines the regionalization process in the Brazilian Health System, identifying frameworks and challenges of this process from critical dialogue on the subject, contextualized by the experience of the management system and in the light of an established theoretical debate in the last decade. We used the thematic content analysis of legal and documentary surveys of the regionalization process in SUS, collated by elements of the historical and political context in the period. As evidence, it appears that the regionalization process has been incremental decentralization/deconcentration of management and health actions and services. There are important challenges, particularly in relation to ensuring access and system governance structure, which contributes to critical thinking and construction of new perspectives by those who lead their implementation.

Regionalization; Unified Health System; Management of the SUS; Interfederative articulation; Health policy

Thematic category	Cycle of Debates	Institutional Research
Regionalization as a structuring guideline for the decentralization of actions and services in the SUS	● To ensure the right to health, promoting equity and contributing to the reduction of social inequalities;	● The regionalization is legally based in Law 8.080/1990, developed by means of Operational Norms and Decree 7.508 2011 and its complementary devices;
	● To reduce care gaps; to organize health care actions and services in a care network; to ensure resolving access; to direct investments;	● Regionalization is not yet in the effective agenda management of the system;
	● To allow a solidary, cooperative management, sharing responsibilities; to strengthen the process of decentralization and the role of the state and municipalities and intensify negotiation and agreement among managers.	● It must be considered that some States have advanced in the issue of the regionalization of care, and that there are different movements in the country.
		● The health regionalization model has been constructed in a detached way from the other processes of regionalization;
		● It is only possible to progress in the regionalization process by re-discussing the SUS financing model.
Configuration of the regions and establishment of the regionalized service network	● The aspects taken into account to configure the regions were population; scale and scope; care flows; territorial contiguity; road network (transport network); communication network; accessibility; sufficiency of basic care and accomplishment of part of the medium complexity; socioeconomic and cultural profile; and epidemiological profile.	● The managers’ interest in shaping the regions is not based on users’ needs; its establishment occurred due to administrative rather than health issues;
		● Municipalities with greater capacity have no interest and / or incentives to materialize the principle of solidarity;
		● SUS norms do not consider the regional specificities, which are strictly done for non-existent ideal municipalities;
		● A party-political bias is hampering the process of regionalization.
Structure of “Governance” and the role of managers in the regionalization process of the SUS	● To institutionalize CIR, promoting the creation of technical chambers subsidizing the construction of agreements between regions in the CIB;	● The bureaucracy has defined the actions of the CIR; the spaces of negotiation and decision of the SUS managers in the health regions are fragile; and the lack of technical groups that advise managers in the CIR weaken these decision settings;
	● Ensure greater participation of the state manager, strengthening the continuity of regional projects by CIR members;	● The low technical qualification and the personnel deficit in the municipal and state structures compromise the management of the system;
	● Increase the participation of other actors in the regional governance process (Health Councils, social movements, private initiative, etc.), establishing partnerships between SES, State Regional Administration and COSEMS; to rely on field sponsors; public consortia and ombudsmen in place.	● The normative “fury” of the SUS has disrupted the original functions of negotiation and decision-making spaces of the system; The implementation of the programs ends up becoming unfeasible by party interests and disputes;
		● Political /party issues directly interfere with federative relationships, with negative impacts on the health sector.

Thematic category	Cycle of Debates	Institutional Research
Concerns and challenges before the established process of regionalization	● To develop a solidarity culture among the federated entities, as well as to define the real healthcare responsibilities of each one; to comply with agreements between managers in the health area; to strengthen the CIR;	● The fragmentation of national information systems still persists;
	● To ensure agreement between intra-state and interstate health regions; to overcome the hurdles of access and movement in the territory;	● Instruments / tools are used improperly,
	● To consolidate PHC as coordinator of the health care network; to deconcentrate health services; to increase the decentralization of medium complexity services; to increase installed capacity; ation and control.	● States have no access to municipal information passed on to national databases;
	● To provide adequate financing; to implement a regulatory process; to regulate private providers; to avoid interference of political-partisan factors;	● Bottom-up planning that does not materialize and is not aimed at meeting the health needs of the population, since the economic power of the federal government is what has defined the local priorities;
	● To articulate health and administrative regions of the State; to build interstate health regions; to qualify health managers and servants; to internalize and establish professionals;	● Municipal and state health conferences that still function as stages for the national conference are losing the ability to guide local /regional agendas;
	● To establish monitoring and evaluation processes; to use planning and management tools;	● The deliberations of the conferences, especially those of the national event, are not incorporated into the SUS agenda;
	● To ensure social particip	● The spaces of social control are seized by “corporate” interests, distancing themselves from the interests of the population.

ABRASCO - Associação Brasileira de Saúde Coletiva Av. Brasil, 4036 - sala 700 Manguinhos, 21040-361 Rio de Janeiro RJ - Brazil, Tel.: +55 21 3882-9153 / 3882-9151 - Rio de Janeiro - RJ - Brazil
E-mail: cienciasaudecoletiva@fiocruz.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Collaborations

ALB Carvalho and IMVB Senra participated in the elaboration of this paper, outlining the theme and constructing the text, its rationale and development; WLA Jesus carried out the systematic review and identification of the bibliographic reference, also contributing to its development and the adjustment of the final version.