Santos Adriano Maia Dos, Giovanella Lígia, Fausto Márcia Cristina Rodrigues, Cabral Lucas Manoel da Silva, Almeida Patty Fidelis de
Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista, Brasil.
Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
Cad Saude Publica. 2024 Sep 9;40(8):e00194523. doi: 10.1590/0102-311XPT194523. eCollection 2024.
This article analyzed the dynamics of regionalization in municipalities within hinterlands and the possible implications of gaps in care for the marketing of health. This is a multiple case study with a qualitative approach, involving 76 semi-structured interviews with municipal, regional, and state managers. The results show that, particularly in the Northern states, the regional scheme did not reflect the social dynamics of the populations and created inadequate flows and unwanted routes. The municipal political agenda often prioritized interests other than that of regionalization, and rural problems did not mobilize managers to build specific regional planning. Parliamentary amendments were essential for investment in healthcare and the managers pointed to clientelistic relationships to obtain such resources, often conditioned by political-ideological alignment. The scarcity of public services favored dependence on the private sector and the commercialization of health in different situations. The great distances and the lack of public services in municipalities in the hinterland made the local public health system offer eminently dependent on contracts with private providers who negotiated on a retail basis or via service packages. Lastly, in the wake of unmet needs and gaps in care in remote rural municipalities, players in the healthcare market ₋ companies supplying inputs, consultants, healthcare professionals, and transportation services ₋ filled the gaps in public provision, sometimes controlling prices, supply and availability of services.
本文分析了内陆地区各市区域化的动态变化以及医疗服务差距对健康市场的可能影响。这是一项采用定性方法的多案例研究，涉及对市、地区和州管理人员进行的76次半结构化访谈。结果表明，特别是在北部各州，区域方案没有反映人口的社会动态，造成了不适当的流动和不必要的路径。市政治议程往往优先考虑区域化以外的利益，农村问题没有促使管理人员制定具体的区域规划。议会修正案对于医疗保健投资至关重要，管理人员指出通过依附关系来获取此类资源，这往往取决于政治意识形态的一致性。公共服务的匮乏有利于在不同情况下依赖私营部门和医疗商业化。内陆各市距离遥远且缺乏公共服务，使得当地公共卫生系统高度依赖与以零售方式或通过服务包进行谈判的私营供应商签订的合同。最后，由于偏远农村市镇存在未满足的需求和医疗服务差距，医疗市场参与者（提供投入品的公司、顾问、医疗专业人员和运输服务）填补了公共服务的空白，有时还控制着服务的价格、供应和可得性。
