Legal gaps and health responsibility in the regionalization of the Unified Health System: From territorial design to thematic networks

Abstract

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.