Regional governance arrangements of the Brazilian Unified National Health System: provider diversity and spacial inequality in service provision

• Published in: Cadernos de saúde pública 2019-06, Vol.35Suppl 2 (Suppl 2), p.e00094618-e00094618
• Main Authors: Lima, Luciana Dias de, Albuquerque, Mariana Vercesi de, Scatena, João Henrique Gurtler, Melo, Enirtes Caetano Prates de, Oliveira, Evangelina Xavier Gouveia de, Carvalho, Marilia Sá, Pereira, Adelyne Maria Mendes, Oliveira, Ricardo Antunes Dantas de, Martinelli, Nereide Lucia, Oliveira, Clarice Furtado de
• Format: Article
• Language: eng ; por
• Subjects: Brazil; Delivery of Health Care - organization & administration; Health Policy; Health Services Administration - statistics & numerical data; Health Status Disparities; Humans; National Health Programs - organization & administration; National Health Programs - statistics & numerical data; Private Sector; Public Sector; Regional Health Planning - organization & administration; Regional Health Planning - statistics & numerical data; Residence Characteristics
• ISSN: 1678-4464
• DOI: 10.1590/0102-311X00094618

The study analyzes regional Brazilian Unified National Health System (SUS, in Portuguese) governance arrangements according to providers' legal sphere and the spacial provision of middle and high-complexity services. These arrangements express the way in which State and health system reforms promoted the redistribution of functions between governmental and private entities in the territory. We carried out an exploratory study based on national-scope secondary data from 2015-2016. Using cluster analysis based on the composition of the provision percentages of the main providers, we classified 438 health regions. In middle-complexity health care, municipal public providers (outpatient) and private philanthropic providers (hospital) predominate. In high complexity provision, philanthropic and for-profit providers (outpatient and hospital) predominate. Middle-complexity provision was recorded in all health regions. However, in 12 states, more than half of the provision is concentrated in only one health region. High-complexity provision is concentrated in state capital regions. Governance arrangements may be more or less diverse and unequal, if different segments and regional concentration levels of middle and high-complexity provision are considered. The study suggests that the convergence between decentralization and mercantilization favored re-scaling of service provision, with increase in the scale of participation of private providers and strengthening of reference municipalities. Governance arrangement characteristics challenge SUS regionalization guided by the collective needs of the population.