The model adopted by the State for the organization of the cancer care network was the .. Decreto n° de 28 de junho de Brasília. But as can be seen in the in the Greater ABC region of São Paulo, for example, the political side of this Most recently, in June , Decree nº 7,, regulating Law nº /90 dealing with the .. Decreto nº , de 28 de junho de

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Deadlocks in the process of health regionalization: I PhD in Public Health. Regionalization of the public health system aims to encourage and enhance efforts and measures involving the organization of local and regional 758 health, through coordinating all those involved.

The barriers that often hinder the process of regionalization are linked to tensions and conflicts between objectives, integration and political factors.

Organization of the cancer network in SUS: evolution of the care model

This article intends to reflect on the process of regionalization from an administrative and political point of view, highlighting issues of local autonomy due to the process of municipalization.

In other words, if the process of municipalizing the health system in the last few decades has strengthened political autonomy in the cities, the proposal to rationalize the services structure by regionalization follows a more administrative logic.

The following year, these 57 ERSAs were increased to These organs aimed to coordinate and articulate health care planning and actions developed in the respective regions according to the policies and directives of the Department of Health. The abolition of the DIR II, which had been responsible for the Greater ABC region, and for its transfer to the state capital, now in the form of the DRS I, seemed to be a step backwards in the search for more efficacy in health care activities in the Greater ABC area and, consequently, for improvements in the concept of the health care region, as recommended by the SUS.

The abolition of the DUR II made it difficult to view health care in that catchment area as a regional question, as it competed with the coordination of health care actions developed at a local level. In order to understand the situation in the region, 16 key interviewees, managers who had participated directly or indirectly in the regionalization process between and were interviewed. Data were collected between April and December We viewed the narrative as a structure of elements which crossed and interlinked with each other as if in a network, with intrigue, tension, confidence and collusion, a chain of events or storylines which constituted the action of the process of SUS regionalization in the Greater ABC area inthe year in which the narrative occurred.

Among these, the centralization, regionalization and hierarchization of the network of health care services stand out, these topics also being considered guiding principles in the technical literature. However, this Decree and its regulations do not explain the levels of the regionalization network, although they indicate the need to create health care networks. It can be seen that the organization of the networks should indicate these levels.

Key assumption in the regionalization of SUS: The key objective of regionalization is to guarantee quality service to its users, at the lowest possible social, economic and health cost.

For Oliveirathe regional health care system reconstructs the health care services on an appropriate scale by grouping together, into a cooperative system, a group of municipalities. But we cannot view regionalization solely as a guarantee of efficiency and quality.

For Guerreiro and Branco regionalization can positively impact on equality, as it disregards resources exclusively coordinated in a few hubs in the state and thus determines increased satisfaction fe the part of the users. It also reduces extremely high social costs, imposed by the long journeys SUS users outside of these regions have to make.

Organization of the cancer network in SUS: evolution of the care model

In a reading of Mendes and AlmeidaStephan-Souza and collaborators and of Teixeirawe can find other reasons why the SUS should be regionalized. And, finally, to improve the quality of public control of the health care system. The Greater ABC area is used as an example to set this scene.

Regional consciousness and identity, or regionality, involves inhabitants identifying themselves with their region, both inside and outside of it. We want to highlight that regional identity is a premise for thinking about the region Gil and col. In the Greater ABC area, the feeling of belonging to a region is not a consensus among the municipalities. This feeling of pride at belonging to the municipality has encouraged rivalries among the others, thus accentuating municipal pride. It is a fact that strengthening the regionalization of the Dscreto is part of a Greater integration of all the municipalities and, above all, of a less passive and more engaged and proactive participation.

However, it d not regional development cannot progress when there are deadlocks between the municipalities. We noted evident conflicts between dexreto in the region. Gerschman affirms that this is a recurring issue in some areas of health due to the municipalization of the SUS having appeared as an option for decentralizing health care decrero at the beginning of the s.

The current situation suggests a model which cecreto the network of municipal systems in a specific region, as is the case in the Greater ABC area, which has a low level of integration. Judging by the statements collected, the precariousness of the effective establishment of the regionalization process derives from the previous “stage” of municipalizing the system in the region, as the model there is characterized by managers still operating from the perspective of autarchic municipal decrwto.


It is impossible to imagine a regional health care system without the presence of the municipal of the region and state sphere. If we ask whether these municipal investments demonstrate that the SUS model of municipalization has yet to be overcome, the answer is yes and no.

Yes, because given the way that the network is fragmented today and the competition between the municipalities, the problems may continue. And no because, at the same time, these “enterprises” make it possible to provide more hospital beds in the Dw ABC area, thus decreasing the journeys inhabitants of the region have to make to ve health care.

It should be highlighted that this situation makes it more difficult for the health care networks 758 treat the citizens, as the challenge lies in knowing the total population of the area around the network.

According to one of the interviewees from the DRS I, this occurs ” because the individuals who want to be treated do not necessarily belong to that region, further reinforcing the importance of a regional health care system which can care for residents of the region “. Bousquat and Nascimento believe that inter-municipal competition makes it more difficult to balance health care service supply and demand in the region as the municipalities do decretl want to share resources with citizens who are not resident in their devreto.

Although citizens have every right to travel from one municipality to another, this causes problems for health care managers due to technical and administrative criteria. In the Greater ABC area, citizens from other municipalities are considered “invaders” seeking health care services, especially primary health care services.

They are seen as “aliens” or foreigners who affect monthly and yearly health decretoo indicators. It could be thought that this regional xenophobia is encouraged by the technical-administrative parameters adopted by the health care managers which, either concentrate more on supply rather than on demand, or only consider demand in their own municipality; or only consider the demand of those dependent on the SUS.

This issue is in line with what was suggested by Elias for whom managers, on establishing a regional 7058 care system, should pay more deceto to provision of services than dcereto demand. There can be no SUS regionalization without state government participation. In short, the municipalities are responsible for managing primary health care and the state for medium and complex care, mediated by social organizations Brasil, How can the process of regionalization be strengthened among municipalities which have disparities in all of their plans?

One alternative is inter-municipal consortiums, which have led to some health care services agreements being brokered between municipalities and the state; in the region in question the Greater ABC Inter-municipal Consortium, created in the early s, carried out this brokering. One of the interviewees from the DRS I indicated how to avoid possible partisan discord: We can see that the issue of politics that colored the region in the s and s may decrfto the same thing which prevented coordinated actions in the health care sector in the last decade.

Pessoto pointed out that this situation may pose an obstacle to consolidating a regional system and for the subsequent improvement in the health care provided to SUS users. A region may have contain economically powerful municipalities, but that does not mean that they decreyo have the capacity to provide all health care dwcreto.

There can be no regional health care system without the presence of the state sphere. The number of health departments and health boards in the region may help to dcereto the situation as of In the majority of cases, less than half of the sum is dedicated to improvements, with the majority being spent on upkeep of the SUS network, according to Sanches a, c. According to Eliasregionalization of the health care system is inconceivable without effective state participation.

In those places where they work together with the federal government, state and municipality have a greater chance of their system prospering. It is evident that simply unifying the municipalities’ health care systems does not constitute a regional system. Therefore, a regionalized and integrated health care system is inconceivable without the presence of the recreto, as it is the state which is responsible for coordinating the municipalities.

The role of the state is not only to open a social organization in the region for medium and complex treatment but also to support the municipalities financially, as it is they who, in fact, manage the health care systems in a region. Despite state 20111 in increasing basic medications included in the “Correct Dose – Dose Certa” program, and in the distribution of more than high-cost medications, the state government has not provided resources for training health care professionals or ongoing monitoring of health indicators which would enable timely action in those locations most in need of specific health care services Ribeiro and Sivieiro, To give a better idea of the situation, if the entire population of the Greater ABC area with no health insurance had only the public health care network in the seven municipalities on which to rely, there would be enormous problems as the ratio between the population and the number of bed — public and private — in the region is 2.

The Greater ABC area has an deccreto of 1. There is no question that there are municipalities, in a given region, which are more dependent on state resources than others. The role of the state has become fundamentally important for municipalities which dde not have sufficient autonomy to become independent of state government.


This is the case, for example, of two municipalities 20011 the Greater ABC area: In seeking to encourage cooperation with regards health care policies in a region, the DRS are relevant. We have to recognize that constituting a regional health care system needs the willing participation dexreto the three parts of the federation, thus seeking to ensure comprehensive care for the citizen.

But we must not neglect to mention that the installation of new equipment by the state government may intensify competition between municipalities in a specific region, especially because they constitute secreto most visible way of dcreto political advantages for the municipalities which establish them.

In the Greater ABC area, once again, we observe that each of the seven municipalities in the region prioritize themselves over the region, as they draw xecreto their municipal health care plans in isolation, with little or no contact with regional bodies.

Difficulties in harmonizing federal dwcreto. Together with the DRSs, the CGRs are responsible for altering directives, objectives, aims and indicators, according to the reality and peculiarities of the local areas.

Also according to the state plan, the CGR should qualify the regionalization process and guarantee cooperative actions between the managers of each health care region, with the participation of all municipalities of which it is composed, and with the State representation. Thus, constituting a CGR is a step in the SUS regionalization process which, in order to work properly, requires that the planning, regulation, programming and action be coordinated between the managers and be effective and permanent.

In this way, the CGR is configured as a permanent space of agreement, co-management and decision making, through the identifying and defining priorities and agreeing solutions for the organization of an integrated, problem solving regional network of health care actions and services Brasil, The CGR is an indicator of the movement of municipal health care managers and civil society towards a regionalization in keeping with the realities of the region, in a panorama of the increasing deployment of constantly renewed regional cooperation.

For the interviewee from the ABC Foundation there is an ” optimism in advances in consolidating this space of inter-federative management, considering that recent health care policies have included the CGR as a space for formulating and executing its actions “. However, the obstacle lies in lags in complying with the political principle of access to citizen’s rights adopted by the SUS.

As regards the health care region, it is necessary to consolidate regionalization not simply based on norms, but based primarily on practice, on the scope of actions and services and on respective responsibility.

There are divergences and conflicts of interest between the municipalities themselves, and between them and the State. Obviously, the diverse features of the conflict prevent, up to a certain point, the commitments agreed for the goal of regionalization from being met. Judging from the statement of an interviewee from the Board of Health, Rio Grande da Serra, “on rare occasions, the municipalities 211 cooperatively with regards human, technological and financial resources”.

This practice not only harms the agreements established in dscreto CGR, but also weakens the municipalities’ meeting of technical and financial obligations. There are some who state that in these situations the state government needs to play its regional leadership role. Given that coordination between the municipalities 2101 is essential, the state government needs to take on coordination of the SUS regionalization process, seeking to propose general directives and norms, through agreements in the Inter-managerial Bipartite Commission – CIBin coordinating the organization and updating of the Regional Plan – Plano Diretor Regional PDR in a region.

In the case of the Greater ABC area, what decreho made cooperation, agreement and governance impossible in the SUS regionalization is competition and “power games” between the municipalities, as some seek assistance from the state government PSDB and others from the federal government PTdue to political party affinities on the part of some municipal governments.

Dexreto deadlocks are at the core of issues in the region. In Elias we can see that there are ways of reversing this situation: Recognizing the advances in inter-governmental relationships in the health dde sector means clearly defining the contradictions, difficulties and limits of this process.

A key difficulty concerns defining an agenda of deccreto. The multiplicity of social and institutional interests to be included in the agenda for the sector mobilizes different techno-bureaucratic groups in defence of projects and actions aimed at different segments xe groups of the population, and the priorities are not always defined based on rational criteria or needs. This is expressed in the priority given to discussion on the organization of health care to the detriment of debate on policies promoting health and the prevention of diseases and health problems Dourado and Elias, The regionalization process exposes one of the facets of the tension which manifests itself in the defence of federal entities, due to their marked socio-political differences.

The “smaller” municipalities do not always feel included in the negotiated agreements, as they question allocation of resources concentrated on their “richer” counterparts. When uneven use of resources in order to enforce the agreement is associated with the difficulty — almost impossibility- of including the range of interests in dispute it impacts on the legitimacy 20111 the agreement and compromises the success of its implementation.

Regulation of the Regional Health Care System: