“Dos Brasis que se faz um país”: desafios para a regionalização da saúde no Brasil

Abstract

This doctoral thesis explores the intricate dynamics of federalism, decentralization, and healthcare regionalization in Brazil, with a special focus on municipalization and its challenges. The research reveals that over the decades, decentralization, often interpreted as municipalization, has established a complex political and institutional framework that impacts the effective organization and management of the healthcare service network in the country. Two recurring assumptions in this process are identified: the belief that all municipalities could efficiently integrate their healthcare actions and services, regardless of local dynamics and power differences, and the expectation that states would have the capacity to coordinate this integration, even if legislation did not grant them specific tools and powers for it. These challenges raise the central question of this research: after more than three decades of building the Unified Health System (SUS), what are the challenges posed by municipalization for the effective regionalization of healthcare in Brazil? And, more importantly, how can we navigate the paths to materialize this process? We conclude that the thesis, although comprehensive, does not exhaust all the answers, underscoring the complexity of the subject and pointing to the need to address the intricate network of challenges associated with decentralization and regionalization, considering political dynamics, local disparities, and the pursuit of a more effective state-level role in coordinating this integration. The study also highlights the importance of the health authority at the state level as a fundamental actor in coordinating and integrating healthcare services. Furthermore, it emphasizes the need for a new federal pact that balances powers, roles, and responsibilities among government spheres and includes intergovernmental transfers to reduce regional disparities. The transformation of this new management model into practical actions will require the commitment of all levels of government, as well as active participation from civil society and healthcare professionals. Nevertheless, this effort is essential to build a more integrated, equitable healthcare system capable of providing quality care to all Brazilian citizens.