Legal gaps and health responsibility in the regionalization of the Unified Health System: From territorial design to thematic networksABSTRACT
The objective of this study was to analyze, from a normative point of view, the regionalization process in the Brazilian health system. This is a documentary study that gathered five legal and ten infra-legal regulations published between 1988 and 2023. As complementary documents, the National Policies for Primary Care, Specialized Care, and Hospital Care were analyzed. The following information was extracted: year, regulation, type of regulation, concept of network, territorial design and organization, making it possible to identify three phases in the regionalization process: The first (1988-2010) is marked by the concept of regionalization as a constitutional and organizational precept of the Brazilian Unified Health System (SUS); the second (2010-2017) is a transition phase, with changes in the concept of regionalization and a lack of mirroring between legal and infra-legal norms; The third phase (2017-2023) is the consolidation of sub-legal norms and the instrumentalization of regionalization, where Integrated Regional Planning becomes merely a formal product without direct consequences in the regionalization process. As a result, a legal and conceptual void is observed in the SUS due to the fragmentation of the territory into thematic networks; the lack of understanding of the health responsibility of hospitals; the separation between regional design and health planning; and the significant increase in the number of planning instruments. It is concluded that there is no mirroring between legal and sub-legal norms, and a review of legal regulations is recommended, aiming at the effective regionalization of the SUS.
KEYWORDS
Unified Health System; Regionalization of health planning; Levels of health care; Integrality in health.
RESUMO
O objetivo do estudo foi analisar do ponto de vista normativo o processo de regionalização no sistema de saúde brasileiro. Trata-se de um estudo documental que reuniu cinco normativas legais e dez infralegais publicadas entre 1988 e 2023. Como docu-mentos complementares, foram analisadas as Políticas Nacionais de Atenção Básica, Especializada e Hospitalar. Buscou-se extrair as seguintes informações: ano, normativa, tipo de normativa, conceito de rede, desenho e organização territorial, sendo possível identificar três fases no processo de regionalização: A primeira (1988-2010) é marcada pelo conceito de regionalização enquanto preceito constitucional e organizativo do Sistema Único de Saúde (SUS); a segunda (2010-2017) é de transição, com mudanças no conceito de regionalização e não espelhamento entre as normas legais e infralegais; a terceira fase (2017-2023) é a consolidação das normas infralegais e de instrumentalização da regionalização, onde o Planejamento Regional Integrado passa a ser apenas um produto formal sem consequências diretas no processo de regionalização. Como resultado, observa-se um vazio legal e conceitual no SUS pela fragmentação do território em redes temáticas; pela não compreensão da responsabilidade sanitária dos hospitais; pela separação entre desenho regional e planejamento em saúde e pelo aumento expressivo do número de instrumentos de planejamento. Conclui-se que não há espelhamento entre as normas legais e infralegais, recomenda-se a revisão das normativas legais, visando a efetiva regionalização do SUS.
PALAVRAS-CHAVE
Sistema Único de Saúde; Regionalização da saúde; Níveis de atenção à; saúde; Integralidade em saúde.
RESUMEN
El objetivo de este estudio fue analizar el proceso de regionalización en el sistema de salud brasileño desde un punto de vista normativo. Este es un estudio documental que reunió cinco regulaciones legales y diez infralegales publicadas entre 1988 y 2023. Como documentos complementarios, se analizaron las Políticas Nacionales de Atención Primaria, Atención Especializada y Atención Hospitalaria. Se extrajo la siguiente información: año, regulación, tipo de regulación, concepto de red, diseño territorial y organización, lo que permitió identificar tres fases en el proceso de regionalización: La primera (1988-2010) está marcada por el concepto de regionalización como un precepto constitucional y organizativo del Sistema Único de Salud de Brasil (SUS); la segunda (2010-2017) es una fase de transición, con cambios en el concepto de regionalización y una falta de reflejo entre las normas legales e infralegales; La tercera fase (2017-2023) se caracteriza por la consolidación de las normas sublegales y la instrumentalización de la regionalización, donde la Planificación Regional Integrada se convierte en un mero producto formal sin consecuencias directas en el proceso regionalizador. Como resultado, se observa un vacío jurídico y conceptual en el SUS debido a la fragmentación del territorio en redes temáticas; la falta de comprensión de la responsa-bilidad sanitaria de los hospitales; la separación entre el diseño regional y la planificación sanitaria; y el aumento significativo del número de instrumentos de planificación. Se concluye que no existe correspondencia entre las normas legales y sublegales, y se recomienda una revisión de la normativa legal con el fin de lograr una regionalización efectiva del SUS.
PALABRAS CLAVE
Sistema Unificado de Salud; Regionalización de la salud; Niveles de atención sanitaria; Integralidad en salud.
Introduction
Regionalization, as an organizing principle of the Unified Health System (SUS), is a practice of regional territorialization involving the territorial reorganization in ‘health areas’, by grouping municipalities based on geographic proximity, population size, health service infrastructure, and cultural, economic, and political characteristics. The rational organization of health territorialization within the SUS must provide access and care aligned with the complexity of health issues, following a logic wherein the greater the reliance on ‘hard technologies’, the more these services are concentrated regionally, whereas the greater the need for ‘light technologies’, the more they are concentrated locally. Both the local and regional levels constitute the totality of the ‘Health Region’ and its capacity to foster quality and comprehensive care1.
The regionalization of the SUS stems from European health models based on the territorial organization outlined in the 1920 Dawson Report, which was adopted as the model for the English system following World War I. That report remains relevant today due to its clarity and significance, particularly regarding the need for coordination between preventive and curative care within a structure organized into primary, secondary, and tertiary levels. The initial definition of a ‘Health Region’ - or health area - as set forth in the Dawson Report, is still used in the European model and must encompass: home care services, primary health centers, secondary health centers, hospitals, and supplementary services (specifically mental health services, orthopedic centers, hospitals for certain infectious diseases, and rehabilitation centers), as well as the requirement for a teaching hospital affiliated with a medical school to serve a population of approximately two million people1.
The Dawson Report finds that the “organization of medicine has proven inadequate and fails to make the benefits of medical knowledge properly accessible to the population”, addressing an “organizational deficiency” that had become “more evident with the expansion of knowledge and the growing conviction that the best means to maintain health and cure diseases must be made available to all citizens”1(2). This implies a strong link between levels of care: hospitals have their referral health centers, and health centers have their reference populations; thus, the organization of primary, secondary, and tertiary levels constitutes a health area.
In Brazil, the decentralization of health services following the creation of the SUS by the 1988 Federal Constitution occurred detached from the process of regionalization and the construction of health areas based on territorialized hospitals. Whether university-affiliated or not, hospitals are not territorialized based on a specific number of Basic Health Units (UBS) - as in the European model; instead, Brazil opted for a regional organization via thematic networks rather than structuring a single, organic, SUS network. It was only in the 2000s that the Operational Norm for Health Care (NOAS) 01/2001 defined regionalization as a process that “must incorporate an integrated planning logic, encompassing notions of territoriality to identify intervention priorities and shape functional health systems, not necessarily restricted to municipal boundaries”9(2), while respecting municipalities as indivisible units. This approach aims to guarantee citizens’ access to all actions and services needed to resolve their health issues, thereby optimizing available resources. However, the notion of territoriality, ranging from the micro-region to the macro-region, as introduced by NOAS, shifts during the publication of subsequent legal and infra-legal regulations3.
Thus, in Brazil, the decentralization/municipalization process of the 1990s did not proceed pari passu with the regionalization of the SUS starting in the 2000s. This situation was exacerbated by the staggered release of the national structural policies that underpin the SUS’s unified/organic network-namely, the National Policies for Primary Care (PNAB), Specialized Care (PNAE), and Hospital Care (PNHOSP), thereby intensifying the challenges of combating regional inequalities and addressing the fragmentation of health actions.
This article aims to analyze the regionalization process within the Brazilian health system from a normative perspective. To this end, it examines the practice of regionalization in Brazil and the regional configurations developed based on the principle of territorial health responsibility. It also reflects on regionalization and its various phases throughout the three decades of the SUS’s development, drawing on a timeline extending from the 1988 Federal Constitution to Resolution No. 01/2021 of the Tripartite Interagency Commission (CIT).
Methodology
The study employed a documentary research method involving an analysis of the legislation underpinning the SUS, covering all regulations regarding regionalization published between 1988 and 2025. Documents were selected based on criteria involving legal and infralegal regulations related to SUS management and regionalization from 1988 to 2023. Once the criteria were established, searches were conducted on various websites: the Virtual Health Library (BVS), the Health Legislation System (SLEGIS), and the Planalto Legislation Portal. Each regulation was examined for concepts regarding health networks, their respective planning instruments, and the proposed regionalization design. The analysis covered five legal regulations and ten infralegal regulations, which constitute the core of SUS regulatory frameworks. Additionally, the study analyzed key SUS structural policies-specifically those defining primary, secondary, and tertiary care levels: the National Primary Care Policy (2006, 2011, and 2017), the Specialized Care Policy (2023), and the Hospital Care Policy (2013). Data extraction focused on the following elements: year, type of regulation, network concept, territorial design, and territorial organization. As the documents analyzed are publicly accessible, submission to a human research ethics committee was not required. Table 1 lists the legal and infralegal regulations analyzed.
Legal and sub-legal regulations according to year of publication and type of regulation. Brazil, 2025
Results and discussion
When examining the period from the 1988 Federal Constitution to CIT’s Consolidation Resolution No. 01/2021 - specifically analyzing the core regulations governing the SUS and regionalization as an organizational principle of the system - a divergence becomes apparent between the actual practice and the constitutional understanding of the SUS’s regionalized and hierarchical network. The definition of regionalization as a unified, organic, regionalized, and hierarchical network is established in the 1988 Federal Constitution, Law No. 8.080/1990, NOAS (2002), the Health Pact (2006), Presidential Decree No. 7.508/2011, and Law No. 141/2012. However, in the Network Consolidation Ordinance No. 03/2017 and CIT Consolidation Resolution No. 01/2021, the current sub-legislative norms guiding regionalization - although based on the understanding of a regionalized and hierarchical network, the concept shifts to Health Care Networks, in reference to the various thematic networks proposed by the Ministry of Health (MS). Regionalization is no longer conceived and implemented based on levels of complexity (primary, secondary, and tertiary) aligned with their respective structuring national policies (PNAB, PNAES, and PNHOSP); instead, it is operationalized through thematic care networks involving Regional Action Plans (PAR) and macro-regional health plans2-21. Table 2 highlights the key aspects of the analyzed regulations.
Organization and territorial design in the legal and sub-legal regulations of the SUS and conceptual changes over time. Brazil, 2025
Understanding the concept is the first challenge in the regionalization of the SUS. There is a gap between Article 198 of the Federal Constitution - which states that “public health actions and services form part of a regionalized and hierarchical network and constitute a unified system”2 based on territory, and the shift toward regionalization based on thematic networks starting in 2010, with the publication of the infralegal regulation Ordinance No. 4,279 of December 30, 2010, which establishes guidelines for the organization of the Health Care Network within the scope of the SUS, subsequently incorporated into Consolidation Ordinance No. 03/201721. Amidst this process of conceptual shifts, changing regionalization models, and evolving planning and management tools, it was possible to identify three phases of the regionalization process in Brazil (table 3).
Subsequently, each of these phases is discussed, highlighting their timeframes and the normative acts that underpinned them.
Legal phase of regional territorial design
The first phase spans from 1988 to 2010 and encompasses the following regulations: the 1988 Federal Constitution, Law No. 8.080/1990, the Basic Operational Norms (NOB 91, 92, 93, and 96), the Operational Norm for Health Assistance (NOAS 2001 and 2002), and the Health Pact (2006), aligned with the publication of the first PNAB (2006). This phase is characterized by an understanding of regionalization based on its constitutional concept of a unified/organic network, specifically, a network that is regionalized and hierarchical according to legal regulations. It follows the European model of regional design regarding territory-based health service responsibilities (as proposed in the Dawson Report), although in Brazil, this mandate was focused solely on Primary Health Care (PHC).
During this first phase, regionalization emerges as an organizational principle of the SUS, involving regionalization by territorial areas - ranging from care modules (micro-regions) to health regions and macro-regions - with health territorialization serving as the foundation for system organization and management. The same logic of municipal territorialization applies at the regional level; that is, areas of health responsibility with assigned populations are organized according to a unified territorial design logic that must be reflected in health planning2-11,21. This period saw a major expansion of primary care in the country with the creation of the Family Health Strategy (ESF) in 1994. During this time, the municipalization of the SUS advanced alongside the growing power of service providers and public-private organizational structures, yet there was no definition of territories of health responsibility or assigned populations for Specialized Care (SC) in Brazil. The management tools to be employed encompass planning instruments linked to financial resources, such as the Agreed and Integrated Programming (PPI) and the Master Investment Plan (PDI), while the regional coordination forum, known as the Regional Management Board (CGR), is still in the process of being organized9-11.
Transition phase involving changes in the understanding of regionalization
The second phase, from 2010 to 2017, is marked by the publication of the Networks Ordinance No. 4279/2010, later incorporated into Consolidation Ordinance No. 03/2017. During this period, in addition to Ordinance No. 4279/2010, there is the publication of Decree No. 7508/2011, Complementary Law No. 141/2011, the PNAB 2017, and CIT Resolution No. 23/2017 (included in CIT Consolidation Resolution No. 01/2021)13,20-22. It is a phase of transition of concepts and non-mirroring of legal and infra-legal regulations, with a distancing from the constitutional conception of a single/organic regionalized and hierarchical network in legal norms towards a conception of thematic networks in infra-legal norms.
At this stage, two logics of territorial design and organization emerge: territorialization of the municipality into areas and micro-areas, and regional organization into thematic networks, abandoning regional territorialization into health areas or micro-regions. New planning instruments emerge at the regional level, such as the PARs for each thematic network. Thus, there are two regional designs: one of territorialization into areas for municipalities, and another for the region and macro-region in thematic networks. These are two logics of territorial organization with distinct management instruments: first, the Municipal Health Plans (PMS) linked to the Annual Budget Law (LOA), the Budget Guidelines Law (LDO), and Multi-Year Plans (PPA) in the budgetary cycle; and second, for the region/macro-region, thematic PARs aimed at enabling services at the federal level.
There is no unity in the reasoning behind the bottom-up planning of the SUS, and in practice, this complicates communication between existing planning instruments. Within each plan, there are different logics for understanding the territory, which are not yet aligned. In other words, at this stage there is a separation from what is fundamental to regionalization: the synergy between regional design and health planning, given that plans are produced from territorial design and not the other way around. The separation between regional design and health planning results in increased complexity in the way regionalization is carried out in Brazil, due to the existence of distinct logics of territorial organization, bureaucratizing the regionalization of the SUS and diverting the focus of SUS actors from the essential aspects of organizing the unified/organic network, through the strengthening of its levels of care in its respective structuring health policies (PNAB - PNAE - PNHOSP and a possible National Policy for Emergency Care - PNAU)13,22,23.
In this logic of creating thematic networks and not organizing areas within the regional territory, the microregional territorial space present in the NOAS 2001 and 2002 was lost, in a country where more than 70% of municipalities have fewer than 20,000 inhabitants. Added to the difficulties of autonomous municipalization, this increases the difficulties faced by small municipalities in organizing themselves and joining together in health areas of a minimum scale and scope in Hospital Care (HC). The discussion shifts to the macroregional space, where thematic networks should ‘be closed’, without discussing the microregional level, the ascending structure in organized health areas with defined territories of health responsibility for services, both in PHC and SC and HC9,10. As an example, since 2012, municipalities in Paraná have been trying to reorganize themselves into health microregions, by joining 5 to 6 municipalities with fewer than 10,000 inhabitants, and provide more access and quality to users with a reorganization of Small Hospitals into Medium Hospitals, and they face numerous problems given that the 2013 PNHOSP was neither implemented nor updated, the PNAES does not address the organization of AH, and the health microregion is not included in current regulations27.
Even within the scope of thematic networks, there is confusion between the concepts of thematic network and Care Production Lines (LPC)28, which further hinders the discussion of the budgetary programming of thematic networks. The LPC is the user’s itinerary within the healthcare network, articulating resources and practices of health services through clinical, care, and flow guidelines throughout the life cycle. It organizes health at different points of care and, therefore, the LPC will always be specific to a particular condition. In a fundamental design of a universal healthcare system, with a hierarchy of care between PHC, SC, HC, and Emergency Care, the LPCs should be thematic, such as the care production lines for maternal and child health, mental health, hypertension, diabetes, etc. The LPCs provide better healthcare because they define care flows, care protocols, and the scheduling of necessary examinations for the specific needs of the health condition being analyzed. These lines are agreed upon by managers and permeate the entire unified/organic network. The problem arises in the practice of regionalizing the SUS when the opposite occurs in this process: instead of the LPCs permeating the unified/organic network, based on their structuring policies (PNAB, PNAES, PNHOSP), it is the organic network that permeates the thematic networks. In other words, points of care for maternal and child health, points of care for mental health, and points of care for urgent and emergency care are organized without defining the points of care for outpatient and hospital care and their connection to their respective UBS.
Added to the challenges of the temporal mismatch between municipalization (1990) and regionalization in the SUS (2000), there is the temporal mismatch in the publication of structuring policies, with seventeen years between the first PNAB of 2006 and the first PNAES of 2023 and numerous intermunicipal arrangements in the interim to respond to the demands of medium and high complexity. Not regionalizing via the single/organic network of the SUS and opting for regionalization via thematic networks is a significant cause of the fragmentation of care in the SUS.
During this period, the spaces for agreement: Regional Inter-managerial Commission (CIR), State Bipartite Inter-managerial Commission (CIB) and National Tripartite Inter-managerial Commission are strengthened by Decree No. 7,508 and Law 12,446, both of 2011, and the CGR is legally identified as CIR13,14. The Organizational Contract for Public Action (COAP) was created and died during this same period, and only the states of Ceará and Mato Grosso do Sul formalized the document29.
Still, the year 2017 deserves a closer look: the revision of Complementary Law 141/2012, which should occur every five years, as cited by the law itself, did not take place in 2017 and, instead of revising it, publications began via CIT Resolution, revoking the COAP and inserting the Integrated Regional Planning (PRI), thus, the sub-legal regulations gained more space for discussion in the deliberative spaces of the SUS than the legal regulations. In this year, the new PNAB and Consolidation Ordinances were published (Consolidation Ordinance GM/MS No. 1, 2, 3, 4, 5 and 6/2017), the latter in an effort by the MS to consolidate the sub-legal regulations of the SUS.
Also in 2017, the Conasems-Cosems Network began, along with institutional support from the Councils of Municipal Health Secretariats (COSEMS) as strong arms of the National Council of Municipal Health Secretariats (CONASEMS) in regional territories throughout the country30. This second phase is marked by a period of defining regionalization in a regionalized and hierarchical network based on legal norms and the practical organization of the regional territory through thematic networks in sub-legal norms, where the dimension of microregions and macroregions already established in NOAS 200212 is lost. In the same year, CIT Resolution No. 23/2017 of August 17 initiated the discussion of Interstate Health Regions as a “regional space” that guarantees accessibility and operational sustainability22.
The management instruments to be employed become planning tools detached from financial resources, as if the availability of financial resources were not essential for any planning that one wishes to implement. The discussion about the PPI and the Regionalization Master Plan (PDR) loses momentum, and the PARs of each thematic network become a source of regional financial resources via MS authorizations. In parallel, the regional agreement spaces are consolidated and are named CIR, CIB and CIT, according to Decree No. 7,508/2011 and Law No. 12,466/201113,14,21,31.
Phase of consolidation of sub-legal regulations and legal vacuum in the SUS
The third phase, beginning in 2017 and continuing to the present day, starts with CIT Resolution No. 23/2017 and expands upon CIT Resolution No. 37/2018, Resolution No. 44/2019, and Consolidation Resolution No. 01/2021, establishing guidelines and criteria for regionalization and the PRI, aiming at the organization of Thematic Networks of Health Care28. This phase is marked by a period in which sub-legal regulations override legal regulations, and there is an instrumentalization of regionalization; that is, there are changes not only in the concept of regionalization but also in the hierarchical normative structure, which hinders necessary revisions and guarantees of legal updates. From 2017 onwards, regionalization is conducted via sub-legal regulations through CIT resolutions and consolidated by Thematic Networks, with a return to the macro-regional territory of NOAS/2002, but still without discussion of the micro-regional space. The PRI becomes a method for regionalization in six stages and a product to be delivered by the states to the Ministry of Health, with the process being conducted via the Program to Support the Institutional Development of the SUS (PROADI-SUS). According to the document ‘Tripartite Guidelines for Integrated Regional Planning’, the stages of the PRI would be:
a) Development of the health situation analysis: Identification of health needs, Identification of installed capacity and care gaps, and Identification of access flows; b) Definition of health priorities: guidelines, objectives, goals, indicators and deadlines for execution; c) Organization of the points of care in the RAS; d) Development of the General Program of Health Actions and Services; e) Definition of the necessary investments31(8-9).
It is important to emphasize that the stages of the PRI have sparked important debates in the territories, but the disconnect between regional design and health planning deepens, and local health needs are rendered invisible by the need to choose a priority thematic network to be followed by the states during the stages. At this stage, the time required to organize a regional territory becomes immeasurable because, by organizing the regional territory through a priority thematic network each time, as is the guideline for a specific population, it prevents the analysis of the entire territory and the population assigned by levels of care (primary, secondary, and tertiary), and actions are significantly fragmented.
The PRI has fostered discussions on planning methodology and has been creating organized processes for analyzing the health situation and collectively constructing guidelines, objectives, goals, and health indicators, but it has made little progress because it lacks the power of bed and service authorizations from the PAR and is essentially organized by Priority Thematic Networks without clarity regarding financial programming in health, even for these specific populations already defined. The PRI is geared towards planning health macro-regions, anchored in the CIT Consolidation Resolution No. 01/2021, but it conflicts with, first, the definition of territory in the current legal norm (Complementary Law No. 141/2021) and, second, with the concept of regional planning and not macro-regional planning22,31,32.
The PRI is born fragile because it lacks funding and does not stem from the territorialization of the health region/macro-region. It is considered a planning instrument for agreements between entities, but not a management instrument, even though it should be included in Municipal and State Plans and be part of their construction. The PARs, organized for the request for service accreditation at the federal level, are constructed according to each thematic network in a regional or macro-regional manner. The Alyne Network, the Emergency and Urgent Care Network, and the Network for People with Disabilities are organized through macro-regional action plans, and the Mental Health Network, via regional action plans. The sum of the PARs should be synthesized in the PRI and this in the State Health Plan (PES), but the PAR and PRI are not part of the management instruments of the budgetary cycle (Health Plans, Annual Health Programming - PAS and Annual Management Reports - RAG).
As mentioned above, Complementary Law No. 141/2012, the last published legal norm, should be in its 3rd revision, if reviewed every five years as the law itself states, having regionalization as a way to reduce regional inequalities, the basis of the regionalization of universal health systems2,16. In case of conflict between norms, the superior norm prevails and, in this case, Complementary Law No. 141/2012 is valid, even if not revised33. With this data, the SUS has been in a legal vacuum since the publication of Complementary Law No. 141/2012 and the lack of mirroring between legal and infra-legal norms, added to the lack of interconnection of its structuring policies.
The regional design is once again being discussed in terms of how it will compose the management instruments (PMS, PES and PNS), their respective PAS and RAG, and there is immense difficulty for state and municipal managers in associating regional design and health planning due to the displacement between the two in the last decade. There is a disconnect between planning and programming/budgeting, financing and management, with a PRI lacking financial resources and not integrated with the instruments of public administration: Multi-Year Plan, LOA, LDO.
It is, therefore, a phase of consolidating the separation between regional design and planning, with new instruments agreed upon without defined financial resources, with a strengthening of the CIT in the publication of Resolutions that does not translate into the strengthening of the legal norms of the system; with two logics of territorial organization, one municipal and the other regional/macro-regional and, therefore, two logics of regionalization: territorial areas and thematic networks; with an excess of management and planning instruments that do not produce defined health responsibility and competences for either the federated entities or the medium-complexity health services.
The definition of health areas of responsibility, as well as the competences of the federated entities and territorial competences of primary, secondary and tertiary health services, is a basic condition for the organization of a universal health system. In this phase, an inversion is observed: it is not the territory and its regional/macro-regional territorial design that is the basis of planning, but the planning instrument itself, the PRI, and its application method as the basis of planning. This inversion makes it difficult to reconcile management instruments and to effectively build health planning in a country that uses different logics for its health territories. Even though the health region and macro-region are not federated entities, the definition of health areas and the health responsibility of all levels of health, from primary to tertiary care, is essential for regionalization1,2,34,35.
As a synthesis of these phases, there are significant changes in the construction of the territorial design and its organization since 2010. These different conceptions generate different ways of understanding the regionalization of the SUS. That is, there is a lack of conceptual alignment and mirroring between legal and infra-legal norms, with a change in the concept of territorial regionalization to thematic networks; discussion of the macro-region without discussion of the micro-region and ascending territorial design; conflict between the concepts of region in legal norms (Law No. 141/2012) and macro-region in infra-legal norms (Consolidation Resolution CIT 01/2021); creation of new management instruments such as the PARs for each thematic network with resources tied to accreditations via the MS and PRI, without provision for financing like the PDI or the Regionalization and Investment Master Plan (PDRI) of the NOAS (2001/2002). As a result, there is a fragmentation of health services, the management of the SUS by sub-legal norms, and a lack of conceptual alignment on regionalization among the federative entities.
There has been a clear distancing, over the years, from the constitutional concept of regionalization by territorialization in areas of health responsibility to regionalization by thematic networks, without the necessary discussion between ascending regional design, health planning with budgetary forecasting, and the health responsibility of the AH, as postulated by the Dawson Report, in linking Hospitals to their respective Health Centers (1920). The AH must have direct responsibility for the PHC, understanding that the concept of hierarchization is within the scope of different technological densities, the hierarchical organization of the complexity of care, and not a greater or lesser valuation between levels1,35-40, where the health responsibility of hospitals would expand the ordering of the network and coordination of care by the PHC.
Final considerations
What is the hierarchical structure of the 1988 Constitution and what is the problem with regionalizing through thematic networks? Is the problem the thematic networks themselves; have they disorganized regionalization? The thematic networks, important for increasing the number of health services in the country, are also the result of a regionalization without sanitary responsibility on the part of hospitals, without due discussion of AE and AH in Brazil.
Understanding the concept of a network is the first challenge of regionalization at this time, because the constitution deals with a single/organic, regionalized, and hierarchical network composed of services in PHC, SC, AH, and emergency and urgent care, permeated by health surveillance and pharmaceutical assistance actions.
Like other countries with universal health systems, the regionalized and hierarchical network proposed by the Dawson Report in Brazil refers to structuring policies of the network: the National Primary Care Policy (PNAB 2006, PNAB 2011, PNAB 2017), the National Specialized Care Policy (PNAES 2023), the National Hospital Care Policy (PNHOSP 2013), and a necessary recovery of the National Emergency Care Policy (PNAU 2003), with clarity in the points of care and emergency/urgent sanitary transport and integration with the other policies. The PNAU, published by Ordinance No. 1863/2003 of September 29, was revoked by Ordinance 1600/2011 of July 7, which, according to the ordinance itself, reformulates the PNAU and establishes the Emergency Care Network in the SUS37. This fact aligns with the findings of the article, which points out that there has been a change in the concept of network definition since 2010, with the publication of Ordinance No. 4279/2010 of December 30. It was observed that there are significant changes in the concept, forms, and instruments of regionalization during this period.
The Dawson Report proposal did not refer to thematic care networks as its initial design, such as the Maternal and Child Network, Chronic Disease Network, Disability Network, Mental Health Network, and Emergency and Urgent Care Network, citing the main thematic networks discussed in Brazil, because this produces duplication of services and fragmentation of health care. It is noteworthy that the mismatch in the publication of policies for the unified/organic network of the SUS - with a decade’s gap between the PNHOSP and the PNAE, or the publication of three PNABs for one PNAE with seventeen years between them, or even the publication of national policies without concrete implementation, financial resources, monitoring, evaluation, and revision of the policy itself, such as the 2013 PNHOSP - encourages a fragmented regionalization through thematic networks and the failure to construct health areas with the competencies of the levels of care defined and structured.
The 2013 PNHOSP does not clarify hospital typologies in Brazil and does not organize the hospital network with the necessary medium-sized hospitals; it does not promote discussion about the public-private relationship in hospital care and, mainly, it does not address health responsibility in hospital care in assigned and ascribed territories, leaving this responsibility exclusively to the PNAB. Although it should organize the network and coordinate care, the PNAB needs an integrated, planned and financed PNAE and PNHOSP, where care lines with specific programs permeate, and not via articulated Thematic Networks, because this process complicates and ties up regionalization, which is essentially simple.
The American model analyzed by Kuschnir & Chorny35, where health responsibility does not derive from a territorial basis, but from voluntary affiliation to a market-regulated service in an attempt to organize “integrated care”, makes sense based on specific care lines or a thematic network. However, this logic does not work in universal health systems, where the organization of a regionalized and hierarchical network is the most cost-effective and, primarily, rational form of organization for expanding access and reducing inequalities. The reproduction of the American model of system organization through integrated care pathways in Brazil, without defining and interconnecting micro-level spaces (defined and forgotten in NOAS 2002) to macro-level spaces (defined in CIT Consolidation Resolution No. 01/2021), coupled with the lack of definition of territorial health responsibility with assigned and unassigned populations at all levels of care, generates more obstacles to the regionalization process than the desired production of integrated care.
By not establishing health areas that include services of PHC, AE and AH, guided by the single/organic network of the SUS and permeated by thematic care lines, it is not possible to clearly understand regional territorialization and the demand for intermediate services, such as Medium-Sized Hospitals, resulting from the union of smaller municipalities in ascending intermediate health areas/microregions that connect from the micro to the macro. In a country where more than 70% of municipalities have fewer than 20,000 inhabitants, the discussion of the health responsibility of hospitals for the construction of intermediate health areas is one of the paths to improving care and territorial reorganization of municipalization processes disconnected from regionalization. This involves balancing the autonomy of municipal entities and the regional health responsibility to be built in Brazil.
Like the COAP, the PRI has so far been finalized in only a few states and without a defined financial program. The discontinuity of legal processes demonstrates the need for a National Regionalization Policy aligned with long-term legal norms, with regional plans associated with long-term Investment Plans, based on projections of the population over 65 years of age. It is considered that the PNAB, the PNAE, the PNHOSP and a possible PNAU need to be articulated in each Health Region in a logic of ascending construction of assigned and restricted health responsibility areas for both PHC, AE and AH, systematized in territorial designs: microregion, region and macroregion of health for the ascending and intermediate construction of services.
We lack the intermediary, the filter, the unified/organic network of the SUS, the construction of health areas with sanitary responsibility for services in their respective territorial designs for all levels of care and not only for primary care, along with corresponding legislation that is revised as knowledge expands, as the Dawson Report of 1920 already warned us.
Acknowledgments
We thank the Department of Federal and Participatory Management (DGIP) of the Ministry of Health for its contributions to the debates on the PRI in the country.
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Financial support:
Non-existent
Data availability:
The research data are contained in the manuscript itself
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Edited by
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Editor in charge:
Leonardo Vidal Mattos, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro (Rio de Janeiro/RJ), Brasil. Lattes: http://lattes.cnpq.br/0343170437330734, Orcid: https://orcid.org/0000-0003-4800-0010, e-mail: leonardomattos@iesc.ufrj.br
