[A history of public health concepts: integrity, coordination, decentralization, regionalization, and universality]. / Uma história de conceitos na saúde pública: integralidade, coordenação, descentralização, regionalização e universalidade.

Brazil's Unified Health System (Sistema Único de Saúde) has highlighted a series of concepts specific to the organization of healthcare systems. Among these, integrity - which shares boundaries with almost all other System principles - has been the object of much academic production in Brazil. Based on an extensive review of primary and secondary sources, the article offers a historical recovery of the concepts of integrity, decentralization, regionalization, and universality - ideas and concepts that in good measure are shaped by and interlinked with the set of ideals of the organization of sanitary services according to the district health centers model.

SUS management in interstate health regions: assessment of the government's capacity. / Gestão do SUS em regiões interestaduais de saúde: análise da capacidade de governo.

This study displays an assessment of SUS management in a Brazilian interstate health region. An evaluative study was conducted with levels of regional analysis and data production, combining interviews with key informants and documentary analysis. Sources and data were compared and linked to analytical categories of the Government Triangle, showing a cutout of the outcomes and the government's capacity assessment. There is a low capacity for government in interstate health regions when managers and co-management spaces are unable to influence regional political decisions, limiting themselves to normative and ratifying government strategies. Disparities in the management capacity among the border states prevent the sustainability of coordinating state decision-making goals, exposing that management strategies are not enough to institutionalize interstate regionalization. There is a predominance of low SUS governance capacity in interstate health regions, and its political pattern becomes an unclear project restricted to the ideological level. The broad documentary appreciation with the use of powerful theoretical referential are methodological contributions of this research for the political analysis of SUS management in spaces that were the least examined, such as interstate borders.

Esta pesquisa apresenta uma análise da gestão do SUS em região interestadual de saúde brasileira. Realizou-se um estudo avaliativo com níveis de análise regional e produção de dados, combinando entrevistas com informantes-chave e análise documental. Cotejaram-se fontes e dados com as categorias analíticas do Triângulo de Governo, apresentando um recorte dos resultados e da análise da capacidade de governo. Há baixa capacidade de governo de regiões interestaduais de saúde quando os gestores e espaços de cogestão têm não conseguem influenciar as decisões políticas regionais, limitando-se a estratégias de governo normativas e homologatórias. Assimetrias na capacidade de gestão entre os estados da fronteira impedem a sustentabilidade de articulação das agendas decisórias estaduais, revelando que as estratégias de gestão são insuficientes para institucionalizar a regionalização interestadual. Predomina baixa capacidade de governo do SUS em regiões interestaduais de saúde, e seu desenho político tende a se tornar projeto incerto e restrito ao plano ideológico. A ampla apreciação documental com uso de potente referencial teórico são contribuições metodológicas deste estudo para análise política da gestão do SUS em espaços pouco investigados, como as fronteiras interestaduais.

Production of knowledge on policy, planning, and management in Journal Ciência & Saúde Coletiva. / Produção de conhecimento em política, planejamento e gestão na Revista Ciência & Saúde Coletiva.

The area of Policy, Planning and Health Management (PPG) express the intersection between research, intervention and political action. The article analyzes the dynamics of knowledge production about PPG in the Journal Ciência & Saúde Coletiva (C&SC) from 1996 to 2019. The study articulates a bibliometric and qualitative approach to explore the profile of articles in three dimensions: thematic, methodological and authorship/institutional partnerships. 1680 PPG manuscripts were identified, corresponding to 28.3% of the total publications. Thematic analysis showed a strong influence of the context and the implementation of Unified Health System (SUS). Qualitative empirical studies predominated, followed by quantitative and quanti-qualitative studies. The combination of methodological procedures was frequent, with bibliographic review and interviews being the most cited. The average number of authors per article and national institutional partnerships increased. As most articles were published in Portuguese, the challenge of internationalization persists. The PPG area stands out in the Journal C&SC and in the production of scientific knowledge relevant to SUS.

A área de Políticas, Planejamento e Gestão em Saúde (PPG) é um dos pilares do campo da Saúde Coletiva, expressando a interseção entre pesquisa, intervenção e ação política. O artigo analisa a dinâmica da produção de conhecimento em PPG, na revista Ciência & Saúde Coletiva (C&SC), de 1996 a 2019, articulando abordagem bibliométrica e qualitativa para caracterizar três dimensões: temática, metodológica e autoria/parcerias institucionais. Identificaram-se 1.680 manuscritos, correspondendo a 28,3% do total de publicações da revista no período. A análise temática mostrou influência do contexto e da trajetória de implantação do Sistema Único de Saúde (SUS). Destacaram-se estudos empíricos qualitativos, seguidos dos quantitativos e dos com outros desenhos. A combinação de procedimentos metodológicos foi frequente, sendo mais citadas a revisão bibliográfica e entrevistas/questionários. A maioria dos artigos foi publicada em português e, apesar do aumento das publicações em inglês no final do período, parcerias com autores de outros países foram raras, persistindo o desafio da internacionalização. Conclui-se que a área de PPG se destaca na revista C&SC, periódico que expressa o vigor do campo da Saúde Coletiva na produção de conhecimento científico relevante para o SUS e para a saúde da população.

[Global expansion of clinical trials: innovation and interaction]. / Expansão global dos ensaios clínicos: inovação e interação.

Innovation in health is characterized by strong interaction with the science and technology sector. Growing interest in the internationalization of research and development leads to questions on opportunities as a function of interactions with other countries, as a mechanism for national capacity-building in innovation. As clinical trials cross national borders and achieve global relevance, networks of relations between the actors become increasingly complex and present themselves as a possibility for characterizing interaction of national innovation systems at the global level, particularly from the point of view of producing activities in science, technology, and innovation in health. This study aimed to analyze the global expansion of clinical trials in order to discuss possible factors related to the interaction between national innovation systems in the countries involved. The methods included literature searches and analysis of secondary data. There is a growing interdependence between national innovation systems, requiring new international innovation structures. New opportunities emerge for the production and international dissemination of knowledge. Clinical trials promote and require interaction between companies, universities and government agencies, proving strategic for structuring national innovation systems in health in the global context.

A inovação em saúde é caracterizada por uma forte interação com o setor de ciência e tecnologia. O crescente interesse pela internacionalização das atividades de pesquisa e desenvolvimento conduz ao questionamento sobre as oportunidades em função das interações com outros países, como mecanismo para a construção de capacidades nacionais de inovação. Conforme os ensaios clínicos atravessaram as fronteiras nacionais, alcançando uma expressão global, as redes de relações entre os atores envolvidos tornaram-se cada vez mais complexas e apresentam-se como uma possibilidade para a caracterização da interação dos sistemas nacionais de inovação no plano global, particularmente pelo ponto de vista da produção de atividades de ciência, tecnologia e inovação em saúde. O objetivo deste trabalho foi estudar a expansão global de ensaios clínicos a fim de se discutir possíveis fatores relacionados com a interação dos sistemas nacionais de inovação dos países envolvidos. Os métodos empregados incluíram pesquisa bibliográfica e análise de dados secundários. Constata-se uma crescente interdependência dos sistemas nacionais de inovação, requerendo novas estruturas internacionais de inovação. Surgem novas oportunidades para a produção e a difusão internacional do conhecimento. Os ensaios clínicos promovem e requerem interação entre empresas, universidades e instâncias governamentais, revelando-se como elemento estratégico para a estruturação dos sistemas nacionais de inovação em saúde no contexto global.

La innovación en salud está caracterizada por una fuerte interacción con el sector de ciencia y tecnología. El creciente interés por la internacionalización de las actividades de investigación y desarrollo conduce al cuestionamiento acerca de oportunidades, en función de las interacciones con otros países, como mecanismo para la construcción de capacidades nacionales de innovación. A medida que los ensayos clínicos atravesaron las fronteras nacionales, tuvieron un alcance global, las redes de relaciones entre los actores implicados se hicieron cada vez más complejas y se presentan como una posibilidad para la caracterización de la interacción de los sistemas nacionales de innovación mundialmente, particularmente, desde el punto de vista de la producción de actividades de ciencia, tecnología e innovación en salud. El objetivo de este trabajo fue estudiar la expansión global de ensayos clínicos, a fin de discutir posibles factores relacionados con la interacción de los sistemas nacionales de innovación de los países implicados. Los métodos empleados incluyeron: investigación bibliográfica y el análisis de datos secundarios. Se constata una creciente interdependencia de los sistemas nacionales de innovación, requiriendo nuevas estructuras internacionales de innovación. Surgen nuevas oportunidades para la producción y la difusión internacional del conocimiento. Los ensayos clínicos promueven y requieren la interacción entre empresas, universidades e instancias gubernamentales, revelándose como un elemento estratégico para la estructuración de los sistemas nacionales de innovación en salud dentro del contexto global.

Confronting health inequalities: impasses and dilemmas in the regionalization process in Brazil. / Enfrentando desigualdades na saúde: impasses e dilemas do processo de regionalização no Brasil.

The article aims to describe the renewed role of regional policies in territorial reconfigurations in the recent and predominantly neoliberal phase of globalization. It further aims to identify some of the impasses that such transformations produce with their multiple scales and dimensions for strengthening public policies focused on confronting health inequalities in Brazil. The article's discussion begins with a brief review of the characteristics of current territorial reconfigurations in a world in constant transformation, but oriented by neoliberal policy in its multiple dimensions. The article then discusses the changes in local management formats in developed countries. The authors go on to analyze territorial changes in Brazil in recent years, after which the debate addresses the reform agenda in health regionalization and the political cycles in the organization of the Brazilian Unified National Health System (SUS). Finally, the article systematizes some of the impasses in regionalization policy, based on recent studies in which the unit of analysis was Brazilian health regions in the country's different major geographic regions. The issues identified in the article, also emphasized in the specialized literature, show that the region/networks dyad has not been fully strengthened during the regionalization process in Brazil. A key task for the public policy of regionalization of health in Brazil should be to continue to push forward with the reform agenda in order to mobilize the territory's diversity and the directive coordination of strategic national policy.

Este trabalho busca retratar o renovado papel das políticas regionais frente aos processos de reconfigurações territoriais na fase recente da globalização - predominantemente neoliberal. Objetiva, ainda, identificar alguns dos impasses que tais transformações - em suas múltiplas escalas e dimensões - trazem para o fortalecimento das políticas públicas voltadas para o enfrentamento das desigualdades em saúde no Brasil. Para alcançar essa discussão, o artigo traz, inicialmente, uma breve resenha dos traços característicos das reconfigurações territoriais atuais em um mundo em constante transformação, porém, orientado pela política neoliberal em suas múltiplas dimensões. Em seguida, discute as alterações nas formas de gestão local, ocorridas em países desenvolvidos. Mais à frente, o texto aponta mudanças territoriais no Brasil em anos recentes e, logo após, o debate se volta à agenda de reforma da regionalização da saúde e aos ciclos políticos de organização do Sistema Único de Saúde (SUS). Por fim, são sistematizados alguns dos impasses da política de regionalização, com base em pesquisas recentes que tiveram como unidade de análise regiões de saúde brasileiras em diferentes macrorregiões do território nacional. Das questões encontradas, também fortalecidas pela literatura dedicada ao tema, observou-se que o par região e redes não teve seu fortalecimento amadurecido durante o processo de regionalização no Brasil. Continuar avançando em uma agenda de reformas - de modo a acionar a potência da diversidade do território e a coordenação diretiva da política nacional estratégica - deve ser tarefa da política pública de regionalização da saúde no Brasil.

Este trabajo busca retratar el renovado papel de las políticas regionales frente a los procesos de reconfiguraciones territoriales en fase reciente de globalización -predominantemente neoliberal. Tiene como meta, además, identificar algunos de los impasses que tales transformaciones -en sus múltiples escalas y dimensiones- conllevan para el fortalecimiento de las políticas públicas, dirigidas a la lucha contra las desigualdades en salud en Brasil. Para llegar a esta problemática, el artículo plantea, inicialmente, una breve reseña con los trazos característicos de las reconfiguraciones territoriales actuales en un mundo en constante transformación, no obstante, orientado por la política neoliberal en sus múltiples dimensiones. En seguida, discute las alteraciones en las formas de gestión local, que se han producido en países desarrollados. Más adelante, el texto apunta cambios territoriales en Brasil en años recientes y, después, el debate se dirige hacia la agenda de reforma de la regionalización de la salud y a los ciclos políticos de organización del Sistema Único de Salud (SUS). Por fin, se sistematizan algunos de los impasses de la política de regionalización, en base a investigaciones recientes que tuvieron como unidad de análisis regiones de salud brasileñas, en diferentes macrorregiones del territorio nacional. Entre las cuestiones halladas, también reforzadas por la literatura dedicada al tema, se observó que el tándem región y redes no llegó a madurar en su fortalecimiento durante el proceso de regionalización en Brasil. Continuar avanzando en una agenda de reformas -de forma que se active la fuerza de la diversidad del territorio y la coordinación a nivel directivo de la política nacional estratégica- deben ser tareas de la política pública de regionalización de la salud en Brasil.

The concept of the regionalization of the Sistema Único de Saúde and its historical time. / O conceito de regionalização do Sistema Único de Saúde e seu tempo histórico.

This essay assumes that from a simple administrative guideline, regionalization has become the main concept for enabling the doctrine of equitable and universal coverage behind the Brazilian Sistema Único de Saúde. At the interface between studies of the historicity of the concepts and extensive fieldwork, it is argued that the traditional concept of the regionalization of the Sistema Único de Saúde has reached the historical limits of its productive capacity. However, updating this term challenges novel perspectives for a clinical system integrated in networks within a broader intersectoral strategy of regional production clusters.

Este ensaio assume que, de simples diretriz administrativa, a regionalização se tornou hoje o principal conceito de viabilização doutrinária da universalidade equitativa e integral do Sistema Único de Saúde. Na interface de estudos sobre a historicidade dos conceitos com extensas experiências de campo, argumenta-se que o conceito de regionalização tradicional do Sistema Único de Saúde alcançou limites históricos de capacidade produtiva. Sua atualização, entretanto, desafia perspectivas inovadoras para um sistema clínico integrado em redes, inserido numa estratégia intersetorial de complexos produtivos regionais.

Evaluation of the quality of Primary Health Care services for children: reflections on the feasibility of using the Brazilian version of the Primary Care Assessment Tool as a routine assessment tool.

OBJECTIVE: To assess the quality of the Primary Health Care services provided to children and the feasibility of using the Brazilian version of Primary Care Assessment Tool (PCAT-Brazil) as a routine quality assessment tool. METHODS: A cross-sectional study was carried out in Joanópolis, a small rural town in the State of São Paulo (SP), Brazil. Seven health professionals and 502 caretakers of children using the public health center were interviewed using the PCAT-Brazil, collecting data on the core and related attributes of Primary Health Care provided to children. The score of each attribute was calculated. RESULTS: Caretakers rated as good the following attributes; "degree of affiliation", "first contact care - use of services", "coordinated care", and "comprehensive care - available services". The attributes of "first contact accessibility", "long term person care", "comprehensive care - offered services" and "family- and community-oriented care" were scored as poor. The health professionals only rated the attribute of "first contact accessibility" as satisfactory, and considered that all other Primary Health Care attributes needed improvement. To conduct this study, at least 1,241 working hours were invested, and the estimated budget was R$12.900,00 (or U$3,953.00). CONCLUSION: The use of the PCAT-Brazil as a routine assessment and planning tool seemed to be not feasible in the given setting due to high costs, lack of trained personnel and the huge workload. To overcome the encountered obstacles, advices are given based on field experience.

Neoliberal meritocracy and financial capitalism: consequences for social protection and health. / Meritocracia neoliberal e capitalismo financeiro: implicações para a proteção social e a saúde.

There is inherent tension between the idea of health as a social right and of health as a private good. From the latter perspective, healthcare provision is brought closer to the logic of ownership, where access depends on ability to pay. The prioritization of markets (over governments), economic incentives (over social or cultural norms), and entrepreneurship (over collective or community action), one of the hallmarks of neoliberalism, constitutes a project to dismantle the welfare state, defined as a set of policy mechanisms designed to meet collective needs. This article examines the above process and its consequences for social protection and health by reflecting upon two phenomena that threaten the principle of health as a social right: neoliberal ideas and policies; and financial capitalism. We argue that the common good must be defended or insulated from the negative effects of financial capitalism and from the erosion and fragmentation of public institutions and social protection systems caused by neoliberalism.

Existe uma tensão inerente à ideia de saúde como direito social e de saúde como bem econômico e individual, na medida em que esta ultima aproxima a prestação de serviços de saúde da lógica proprietária, cujo acesso depende da capacidade de pagamento de cada indivíduo ou família. A preferência por mercados (sobre os governos), incentivos econômicos (sobre normas sociais ou culturais) e empreendedorismo individual (sobre a ação coletiva ou comunitária) é uma característica marcante do neoliberalismo e, por isso mesmo, um projeto de desmonte do estado social, definido como um conjunto de dispositivos que visam atender às necessidades coletivas. O objetivo do artigo é examinar esse processo e suas implicações para a proteção social e a saúde, mediante algumas reflexões sobre dois fenômenos que ameaçam a saúde como direito social: as ideias e as políticas neoliberais, de um lado, e a financeirização da riqueza, de outro. Argumentamos que o bem comum precisa ser defendido ou insulado tanto da devassa provocada pelo capital financeiro quanto pela erosão e fragmentação provocada pelo neoliberalismo nas instituições públicas e nos sistemas de proteção social.

Índice de Dependência Regional e Macrorregional: uma contribuição ao processo de regionalização do SUS / Regional and Macro-regional Dependency Index: A contribution to the SUS regionalization process

RESUMO O estudo aborda a interdependência das regiões e macrorregiões de saúde no Brasil nas internações de média e alta complexidade, no ano de 2019. Foi realizada a análise dos fluxos estabelecidos, utilizando o Índice de Dependência Regional e Macrorregional, a partir de dados secundários do Sistema Único de Saúde (SUS) obtidos no Sistema de Informação Hospitalar. Os resultados demonstram que grande parte das regiões e macrorregiões de saúde absorvem em seus territórios as internações de média complexidade, com variações entre as especialidades. Nas internações de alta complexidade, a maioria das regiões de saúde apresenta grande dependência, sendo que a assistência está concentrada em 15% delas. Entre as macrorregiões de saúde, o cenário é significativamente heterogêneo, com dependência expressiva nas regiões Norte, Nordeste e Centro-Oeste, e alta resolutividade na região Sul. Em todas as análises, o porte populacional das regiões e macrorregiões de saúde apresenta relação inversa à dependência regional e macrorregional. O aprimoramento da regionalização pressupõe a organização de uma rede de atenção à saúde que considere as desigualdades e as diversidades territoriais, a interdependência e a autonomia entre os territórios e os atores implicados, e a coordenação entre as unidades federativas, de modo a garantir cuidado integral e equânime.

ABSTRACT The study addresses the interdependency between health regions and macro-regions in Brazil in 2019, concerning both medium and high complexity hospitalizations. The analysis of the flows established was carried out using the Regional and Macro-regional Dependency Index, based on secondary data provided by the Hospital Information System of the Unified Health System (SUS). The results show that a significant number of health regions and macro-regions absorb medium-complexity hospitalizations in their territories, varying according to specialties. In high-complexity hospitalizations, most health regions are highly dependent, assistance concentrated in 15% of these. Among health macro-regions, the scenario is significantly heterogeneous: highly dependent on the North, Northeast and Midwest Regions, and highly resolutive in the South Region. Analyses show that the population size of health regions and macro-regions is inversely related to the regional and macro-regional dependency. The improvement of regionalization requires an organized health care network, one that takes into account territorial inequalities and diversities, interdependency and autonomy among the territories and actors involved, and inter-federative coordination, so as to provide care that is both comprehensive and equitable.

Regionalization and Health Networks. / Regionalização e Redes de Saúde.

The aim of this article was to reflect on the challenges faced in building the Health Regions and Networks in Brazil. These reflections result from studies conducted in several health regions. The central challenges for the constitution of the Health Regions and Networks are as follows: the Care Model, Primary Health Care, Care for Users with Chronic Diseases, and Hospital Care. In order to consolidate the regions and networks the organization needs to incorporate an ethical sense: focusing on social, public and individual needs, derived from comprehensive care, human and social rights, in broad, multi-scale and inter-sectorial interactions, with the constitution of a systemic, regionalized innovation. Of prime importance is the capacity to devise which general principles are responsible for maintaining the unity(mode of care), seeking to outline the coherence of the different provision models that the system might develop according to the social needs in regional settings. Without that, users will continue to seek and create ways of accessing health services that challenge the rationale of those very services. Hospital reform is also required to integrate and reorient the hospital networks. These reflections are important for the SUS to uphold its solidarity project, expressed in the trinity of universality-comprehensiveness-equality.

O artigo teve como objetivo refletir sobre os desafios da construção das Regiões e Redes de Saúde no Brasil. São elencados como desafios centrais para a constituição das Regiões e Redes de Saúde: o Modelo de Atenção, a Atenção Primária à Saúde, o Cuidado aos Usuários com Doenças Crônicas e a Assistência Hospitalar. Para a consolidação das Regiões e Redes é necessária a incorporação de um sentido ético da organização: a centralidade nas necessidades sociais, populacionais e individuais, derivadas da integralidade, dos direitos humanos e sociais, em amplas interações multiescalares e intersetoriais; com a constituição de uma inovação sistêmica regionalizada. É central a capacidade de divisar quais são os princípios gerais responsáveis por manter a unidade (o modo de atenção), buscando balizar a coerência dos diferentes modelos de provisão que o sistema pode desenvolver segundo as necessidades sociais em contextos regionais. Sem isso, os usuários continuarão a buscar e a criar maneiras de acessar os serviços de saúde que desafiam a racionalidade dos próprios serviços. É também necessária uma reforma hospitalar que integre e reoriente as redes. Essas ponderações são importantes para que o SUS mantenha seu projeto de solidariedade, expresso na tríade da universalidade-integralidade-equidade.

Integration between Primary Health Care and Emergency Services in Brazil: Barriers and Facilitators.

INTRODUCTION: Characteristics of primary health care and emergency services may hamper their integration and, therefore, reduce the quality of care and the effectiveness of health systems. This study aims to identify and analyse policy, structural and organizational aspects of healthcare services that may affect the integration between primary health and emergency care networks. THEORY AND METHODS: We conducted a qualitative research study based on grounded theory that included: (1) interviews with 30 health care leaders; and (2) documental analysis of the summaries of Regional Interagency Committee meetings from two regions in the state of Sao Paulo, Brazil. RESULTS: The integration between primary health and emergency care network is inefficient. The barriers that contributed to this situation are as follows: (1) policy: the municipal health department is responsible for providing primary health care and the regional health department provides emergency care, but there is a lack of space for the integration of services; (2) structural: distinct criteria for planning mechanisms; and (3) organizational: ineffective point of interaction between different levels of the health system. CONCLUSIONS AND DISCUSSION: Our findings have implications for health management and planning in low-and middle-income countries (LMICs) with suggestions for interventions for overcoming the aforementioned barriers.

Gestão regional no enfrentamento à pandemia da Covid-19: estudo de casos em São Paulo / Regional management in the face of the COVID-19 pandemic: case study in São Paulo

RESUMO Ao final do ano de 2019 o mundo foi surpreendido pela Covid-19, que chegou ao Brasil no início de 2020, fazendo com que o Sistema Único de Saúde (SUS) adotasse estratégias imediatas para atender as necessidades de saúde da população, colocando em evidência todos os obstáculos que o sistema de saúde vinha enfrentando nos últimos anos. O estado de São Paulo não foi diferente do restante do País em relação ao enfrentamento. Este estudo objetivou identificar as principais estratégias adotadas em 5 regiões de saúde de São Paulo, com foco na gestão regional, analisando os processos e práticas adotados para o enfrentamento à pandemia da Covid-19. Tratou-se de um estudo qualitativo, realizado através de estudo de casos múltiplos, com abordagem exploratória, a partir de pesquisa de campo e realização de oficinas regionais. As regiões de saúde deste estudo puderam comprovar a importância da intersetorialidade nas ações de saúde como um todo. Notou-se o grande papel dos municípios nestas ações e a união destes, fortalecendo o papel da regionalização e ampliando a importância da governança em saúde. Ademais, as regiões de saúde saíram fortalecidas porque exerceram seu papel de liderança e organizaram ações junto aos municípios.

ABSTRACT At the end of 2019 the world was surprised by COVID-19, which arrived in Brazil at the beginning of 2020, causing the Unified Health System (SUS) to adopt immediate strategies to meet health needs, as well as putting in check all the obstacles that the health system has been facing in recent years. In the state of São Paulo it was not different from the rest of the country in relation to the confrontation. This study aimed to identify the main strategies adopted in 5 health regions of São Paulo, focusing on regional management, analyzing the processes and practices adopted to face the COVID-19 pandemic. It was a qualitative study, carried out through a multiple case study, with an exploratory approach, based on field research and regional workshops. In this study, the health regions were able to prove the importance of intersectoral actions in the health system. It was noted the great role of municipalities in these actions and their union, strengthening the role of regionalization and expanding the importance of governance in health. In addition, the health regions were strengthened because they exercised their leadership role and organized actions with the municipalities.

[Universal health systems and territory: challenges for a regional policy in the Brazilian Legal Amazon]. / Sistema de saúde universal e território: desafios de uma política regional para a Amazônia Legal.

This article presents the results of a study on Federal health policy in the Brazilian Legal Amazon (BLA) from 2003 to 2005, aimed at backing the development of regional health policies. The region has peculiar dynamics, an extensive border area, and adverse social indicators. The methodology included documental and financial analysis, participatory observation, interviews with heads of various Federal Ministries and State and Municipal health secretaries from the BLA; characterization of geographic situations in the BLA; and field studies in 15 municipalities. Institutional consolidation of health policy proved to be low in the Amazon during the study period, due to structural, institutional, and political difficulties. The identification of six geographic situations was useful for systematizing land use differences with repercussions on health, and which should be considered when implementing public policies. There is a certain gap between Federal actions and territorial dynamics, expressed as a mismatch between the current policy and its recognition by local administrators. In addition to establishing a regional policy for the Amazon, there is an evident need for differentiated policies within the region.

Policies for fostering health science, technology and innovation in Brazil and the role of clinical research. / Políticas de fomento à ciência, tecnologia e inovação em saúde no Brasil e o lugar da pesquisa clínica.

The purpose of this article is to highlight a number of underlying issues that may be useful for a comprehensive review of the management of Health-Related Science, Technology and Innovation policies (ST&I/H), and its strategies and priorities. It is an analytical study supported by an extensive review of the technical and journalistic literature, clippings, legislation and federal government directives. The results show that the Healthcare Production Complex undeniably and increasingly needs science to maintain itself. One may infer that a framework of institutional milestones is being built in Brazil, to strengthen, guide and encourage Research and Development, and that clinical research creates scientific knowledge to address public healthcare issues by generating new inputs or enhancing existing techniques, processes and technologies that will be produced, marketed and used in the different segments, thus feeding the Healthcare Productive Complex.

[Social protection in Latin America and the Caribbean: changes, contradictions, and limits]. / Proteção social na América Latina e Caribe: mudanças, contradições e limites.

Recent studies suggest that governments in the majority of Latin American and Caribbean countries were able to expand social investments and introduce innovations in social protection policies in the last two decades with positive results in the actions' coverage and impact. However, the restrictions imposed by the current fiscal crisis and the rise of governments more ideologically aligned with the neoliberal discourse in various countries in the region point to a new retreat of the state from the social area, thereby compromising recent advances. The article aims to discuss the changes, contradictions, and limits of recent social protection standards in Latin America and the Caribbean. The discussion includes three items: a description of the history of social protection in the region, seeking to identify its principal historical periods and characteristics (benefits, target public, and financing); the social protection models that have been implemented in the region; and the specific case of health. We argue that although countries have adopted different solutions in the field of social protection, the policies' hybrid nature (with extensive private sector participation in the financing, supply, and management of services) and the prevalence of segmented models (with differential access according to individuals' social status) have been predominant traits in social protection in Latin America and the Caribbean, thus limiting the possibilities for greater equity and social justice.

Gestão do SUS em regiões interestaduais de saúde: análise da capacidade de governo / SUS management in interstate health regions: assessment of the government's capacity

Resumo Esta pesquisa apresenta uma análise da gestão do SUS em região interestadual de saúde brasileira. Realizou-se um estudo avaliativo com níveis de análise regional e produção de dados, combinando entrevistas com informantes-chave e análise documental. Cotejaram-se fontes e dados com as categorias analíticas do Triângulo de Governo, apresentando um recorte dos resultados e da análise da capacidade de governo. Há baixa capacidade de governo de regiões interestaduais de saúde quando os gestores e espaços de cogestão têm não conseguem influenciar as decisões políticas regionais, limitando-se a estratégias de governo normativas e homologatórias. Assimetrias na capacidade de gestão entre os estados da fronteira impedem a sustentabilidade de articulação das agendas decisórias estaduais, revelando que as estratégias de gestão são insuficientes para institucionalizar a regionalização interestadual. Predomina baixa capacidade de governo do SUS em regiões interestaduais de saúde, e seu desenho político tende a se tornar projeto incerto e restrito ao plano ideológico. A ampla apreciação documental com uso de potente referencial teórico são contribuições metodológicas deste estudo para análise política da gestão do SUS em espaços pouco investigados, como as fronteiras interestaduais.

Abstract This study displays an assessment of SUS management in a Brazilian interstate health region. An evaluative study was conducted with levels of regional analysis and data production, combining interviews with key informants and documentary analysis. Sources and data were compared and linked to analytical categories of the Government Triangle, showing a cutout of the outcomes and the government's capacity assessment. There is a low capacity for government in interstate health regions when managers and co-management spaces are unable to influence regional political decisions, limiting themselves to normative and ratifying government strategies. Disparities in the management capacity among the border states prevent the sustainability of coordinating state decision-making goals, exposing that management strategies are not enough to institutionalize interstate regionalization. There is a predominance of low SUS governance capacity in interstate health regions, and its political pattern becomes an unclear project restricted to the ideological level. The broad documentary appreciation with the use of powerful theoretical referential are methodological contributions of this research for the political analysis of SUS management in spaces that were the least examined, such as interstate borders.

[Structural typology of Brazilian primary healthcare units: the 5 Rs]. / Tipologia da estrutura das unidades básicas de saúde brasileiras: os 5 R.

The structural typology of Brazil's 38,812 primary healthcare units (UBS) was elaborated on the basis of the results from a survey in cycle 1 of the National Program for Improvement in Access and Quality of Primary Care. Type of team, range of professionals, shifts open to the public, available services, and installations and inputs were the sub-dimensions used. For each sub-dimension, a reference standard was defined and a standardized score was calculated, with 1 as the best. The final score was calculated by factor analysis. The final mean score of Brazilian UBS was 0.732. The sub-dimension with the worst score was "installations and inputs" and the best was "shifts open to the public". The primary healthcare units were classified according to their final score in five groups, from best to worst: A, B, C, D, and E. Only 4.8% of the Brazilian UBS attained the maximum score. The typology showed specific characteristics and a regional distribution pattern: units D and/or E accounted for nearly one-third of the units in the North, and two-thirds of units A were situated in the South and Southeast of Brazil. Based on the typology, primary healthcare units were classified according to their infrastructure conditions and possible strategies for intervention, as follows: failed, rudimentary, limited, fair, and reference (benchmark). The lack of equipment and inputs in all the units except for type A limits their scope of action and case-resolution capacity, thus restricting their ability to respond to health problems. The typology presented here can be a useful tool for temporal and spatial monitoring of the quality of infrastructure in UBS in Brazil.

Regional health inequalities: changes observed in Brazil from 2000-2016. / Desigualdades regionais na saúde: mudanças observadas no Brasil de 2000 a 2016.

Advances in reducing poverty and inequalities in the 2000s had a paradoxical effect in Brazil. This article examines how socioeconomic transformations, and the complexity of health services, are expressed in the regions established for planning purposes and the inter-governmental management of the Brazilian Unified Health System. An effort was made to identify and explain differences in the compositions of the 438 existing health regions and their spatial distribution by comparing situations observed in 2016 with those in 2000. Factor analysis and grouping techniques were used to construct a typology in the two years of the series, which was based on a diverse set of secondary data sources. It was found that there was an evolution in terms of income levels and service provision within the health regions, with a significant improvement in the socioeconomic conditions of the population. These results suggest that there was a positive impact from the combination of strategies related to social, economic and regional policies for the promotion of development, which generated more widespread well-being within the affected areas. However, limitations remain regarding the policies implemented for the universalization of the health system.

A systematic review of the process of regionalization of Brazil's Unified Health System, SUS. / O processo de regionalização do SUS: revisão sistemática.

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.

Primary health care and the coordination of care in health regions: managers' and users' perspective. / Atenção primária à saúde e coordenação do cuidado nas regiões de saúde: perspectiva de gestores e usuários.

This paper aims to analyze the healthcare coordination by Primary Health Care (PHC), with the backdrop of building a Health Care Network (RAS) in a region in the state of São Paulo, Brazil. We conducted a case study with qualitative and quantitative approaches, proceeding to the triangulation of data between the perception of managers and experience of users. We drew analysis realms and variables from the three pillars of healthcare coordination - informational, clinical and administrative/organizational. Stroke was the tracer event chosen and therapeutic itineraries were conducted with users and questionnaires applied to the managers. The central feature of the construction of the Health Care Network in the studied area is the prominence of a philanthropic organization. The results suggest fragility of PHC in healthcare coordination in all analyzed realms. Furthermore, we identified a public-private mix, in addition to services contracted from the Unified Health System (SUS), with out-of-pocket payments for specialist consultation, tests and rehabilitation. Much in the same way that there is no RAS without a robust PHC capable of coordinating care, PHC is unable to play its role without a solid regional arrangement and a virtuous articulation between the three federative levels.