Decentralization and regionalization: dynamics and conditioning factors for the implementation of the Health Pact in Brazil

Decentralization and regionalization represent constitutional guidelines for the organization of the Unified Health System, which in the last 20 years has required the adoption of mechanisms to coordinate and accommodate federative tensions in Brazil's healthcare sector. This paper analyzes the national implementation of the Health Pact between 2006 and 2010 involving a strategy that reconfigures intergovernmental relations in the sector. The study involved the analysis of documents, official data and interviews with federal, state and municipal managers in the Brazilian states. The content of the national proposal is initially discussed, including its implications for health policy. The different rhythms and degrees of implementation of the Health Pact are then reviewed, with respect to adherence by states and municipalities and the formation of Regional Management Boards. Lastly, the conditioning factors for the multiplicity of experiences observed in the country are identified and the challenges facing progress toward a decentralized and regionalized health system in Brazil are discussed.

Regionalization and access to healthcare in Brazilian states: historical and political-institutional conditioning factors

This article examines the healthcare regionalization process in the Brazilian states in the period from 2007 to 2010, seeking to identify the conditions that favor or impede this process. Referential analysis of public policies and especially of historical institutionalism was used. Three dimensions sum up the conditioning factors of regionalization: context (historical-structural, political-institutional and conjunctural), directionality (ideology, object, actors, strategies and instruments) and regionalization features (institutionality and governance). The empirical research relied mainly on the analysis of official documents and interviews with key actors in 24 states. Distinct patterns of influence in the states were observed, with regionalization being marked by important gains in institutionality and governance in the period. Nevertheless, inherent difficulties of the contexts prejudice greater advances. There is a pressing need to broaden the territorial focus in government planning and to integrate sectorial policies for medium and long-term regional development in order to empower regionalization and to overcome obstacles to the access to healthcare services in Brazil.

Landscape and soil regionalization in southern Brazilian Amazon and contiguous areas: methodology and relevance for ecological studies

Soils of a large tropical area with differentiated landscapes cannot be treated uniformly for ecological applications. We intend to develop a framework based on physiography that can be used in regional applications. The study region occupies more than 1.1 million km² and is located at the junction of the savanna region of Central Brazil and the Amazon forest. It includes a portion of the high sedimentary Central Brazil plateau and large areas of mostly peneplained crystalline shield on the border of the wide inner-Amazon low sedimentary plain. A first broad subdivision was made into landscape regions followed by a more detailed subdivision into soil regions. Mapping information was extracted from soil survey maps at scales of 1:250000-1:500000. Soil units were integrated within a homogenized legend using a set of selected attributes such as taxonomic term, the texture of the B horizon and the associated vegetation. For each region, a detailed inventory of the soil units with their area distribution was elaborated. Ten landscape regions and twenty-four soil regions were recognized and delineated. Soil cover of a region is normally characterized by a cluster composed of many soil units. Soil diversity is comparable in the landscape and the soil regions. Composition of the soil cover is quantitatively expressed in terms of area extension of the soil units. Such geographic divisions characterized by grouping soil units and their spatial estimates must be used for regional ecological applications.

Chorioallantoic and yolk sac placentation in Thrichomys laurentinus (Echimyidae) and the evolution of hystricognath rodents

The evolutionary history of Hystricognathi is associated with major transformations in their placental system. Data so far indicate that key characters are independent from size dimensions in medium to very large species. To better understand the situation in smaller species, we analyzed placental development in a spiny rat, Thrichomys laurentinus. Fourteen individuals ranging from early implantation to near term were investigated by histology, immunohistochemistry, proliferation activity and electron microscopy. Placentation in Thrichomys revealed major parallels to the guinea pig and other hystricognath rodents with respect to the early and invasive implantation, the process of trophoblast invasion, the internal organization of the labyrinth and the trophospongium as well as the establishment of the complete inverted yolk sac placenta. In contrast to systematically related small-sized species, the placental regionalization in Thrichomys was characterized by a remarkable lobulated structure and associated growing processes. Reverse to former perspectives, these conditions represented ancient character states of hystricognaths. The subplacenta was temporarily supplied by both the maternal and fetal blood systems, a rare condition among hystricognaths. The extraplacental trophoblast originating from the subplacenta was partly proliferative in mid gestation. In conclusion, the presented results indicated that only minor variations occurred in small-sized hystricognath species, independent of their systematic interrelationships. Previous views were supported that placentation in hystricognaths followed an extraordinary stable pattern, although the group had distinct habitats in South America and Africa that were separated 30-40 million years ago. J. Exp. Zool. (Mol. Dev. Evol.) 318:13-25, 2012. (C) 2011 Wiley Periodicals, Inc.

Metropolitan and regional health planning: dilemmas of the Pact for Health in the Baixada Santista Metropolitan Area, Sao Paulo State, Brazil

This paper focuses on the relationship between metropolitan and regional health planning based on the processes of regionalization and the Pact for Health in the Baixada Santista Metropolitan Area, Sao Paulo State, Brazil. The method used was a case study in two stages, namely during initial implementation of the Pact for Health (2007) and the Regional Administration Committees (CGR) and in 2010. Municipal and regional health systems managers and the director of the Metropolitan Agency were interviewed, and records were analyzed from ten years of meetings of the Regional Inter-Administration Committee and the Regional Development Council. Four issues emerged: financing and infrastructure; health services utilization; inefficiency of the Regional Health Administration's instruments and decision-making levels; and the relationship between different levels in the Administration. Metropolitan health management remained as an underlying issue, appearing only incidentally or tangentially to regional management. Despite some limitations, the CGR has been legitimized as a space for regional health management.

Uma história de conceitos na saúde pública: integralidade, coordenação, descentralização, regionalização e universalidade

O Sistema Único de Saúde conferiu visibilidade a uma série de conceitos próprios da organização de sistemas de saúde. Entre eles a integralidade, que delimita fronteiras comuns com quase todos os demais princípios do Sistema, tem sido objeto de ampla literatura no Brasil. Com base em extensa revisão de fontes primárias e secundárias, este artigo apresenta uma recuperação histórica dos conceitos de integralidade, descentralização, regionalização e universalidade - ideias e conceitos que em grande parte se conformam e se interligam no ideário da organização dos serviços sanitários pelo modelo dos Centros de Saúde distritais.

As instituições administrativas e o planejamento territorial paulista: 1938-1967

O objetivo é analisar o papel das instituições administrativas no planejamento urbano e regional do Estado de São Paulo. Nosso objeto de estudo são as leis e decretos estaduais e federais e as ações do Estado que definiram os padrões de organização territorial das cidades. Entendemos que a partir deles as ações administrativas atribuíram às cidades um modelo de planejamento setorizado e polarizado. Entre as décadas de 1930 e 1960, esse modelo formou a base para a aplicação de uma divisão funcional urbana fundada nas características produtivas e responsável pela provisão de recursos. A partir da década de 1960, a organização territorial paulista foi padronizada pelo conceito de polo urbano e o planejamento urbano e regional ficou submetido às condicionantes econômicas.