Acesso à atenção ambulatorial especializada no Brasil: uma análise comparada dos modelos de regulação em cenários brasileiros selecionados

Abstract

Introduction: In Brazil, the Unified Health System promotes the expansion of population access to health services that are appropriate to their needs and delivered in a timely manner through the national regulatory policy. This policy encourages the development of interventions at state and municipal levels through a body known as Regulatory Complexes, which serve as mediators between user demand and the actual provision of care by health services. These interventions influence service delivery processes by modifying or (re)directing their execution by means of inductive, standardizing, regulatory, or restrictive mechanisms. Objectives: To analyze how different subnational governments, based on common national guidelines, develop their own models for regulating access to specialized outpatient care, with varying degrees of innovation, institutionalization, and sustainability; and to examine how telehealth tools have generated incremental innovations in selected contexts and contributed to addressing local challenges related to access, care coordination, and healthcare network organization. Method: This is a comparative study on the implementation of public policies. Data collection was carried out through interviews with key stakeholders, document analysis, and literature review, consolidated into detailed descriptions of each context, which together composed the researchcorpus. The analysis was conducted using the Consolidated Framework for Implementation Research (CFIR). The selected case studies included the states of Ceará, Santa Catarina, the Federal District, and Rio Grande do Sul, as well as the municipalities of Curitiba-PR, Belo Horizonte-MG, Porto Alegre-RS, and São Paulo-SP. Results: The eight Brazilian experiences with outpatient regulation are marked by diversity in organizational models, levels of institutionalization of teleconsultation, and integration across levels of care. The adoption of technologies, clinical protocols, and digital systems varied across locations and was influenced by structural, normative, and contextual factors. When integrated, teleconsultation improved referral quality and increased problem-solving capacity in primary care; however, its implementation remains uneven across the country. Conclusion: Technological advances have significantly contributed to the development of standardized and reproducible processes that facilitate access to health services for the population. Teleconsultation has proven to be an effective strategy for reducing waitlists and organizing demand for specialized care within thepublic health system. Nonetheless, its use is not yet evenly distributed across different regions of the country.