Technological arrangements for regulating access to healthcare: experience in the state of São Paulo

Freire, Mariana Prado; Chioro, Arthur; Tofani, Luís Fernando Nogueira; Bigal, André Luiz; Louvison, Marília Cristina Prado

doi:10.11606/s1518-8787.2026060006604

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Original Article • Rev. Saúde Pública 60 • 2026 • https://doi.org/10.11606/s1518-8787.2026060006604 linkcopy

Technological arrangements for regulating access to healthcare: experience in the state of São Paulo

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVE To describe and analyze the regulatory arrangements used to expand access to beds and health services during Covid-19.

METHODS This study, part of the Research for the SUS Program funded by Fundação de Amparo à Pesquisa do Estado de São Paulo (Fapesp) and the Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde do Ministério da Saúde (Sctie-MS) Fapesp/Sctie used mixed methods to investigate the management of network care to face Covid-19 in São Paulo. Data was collected via an electronic questionnaire sent to managers in 645 municipalities between November 2021 and February 2022, with the support of the São Paulo Council of Municipal Health Secretaries (COSEMS-SP). The responses were analyzed quantitatively and qualitatively, with a focus on regulating access to healthcare.

RESULTS 255 valid responses were collected (39.5% of São Paulo municipalities). Most municipalities regulated Covid-19 beds through the state regulation center (58%) and faced difficulties with access (53.7%), insufficient beds and 68.6% difficulties with hospitalization. The creation of new services was reported by 83.1%, and 70.0% implemented specific flows to expand access. In outpatient access, 54.5% used multiple regulation strategies. Financial resources were sufficient for 54.0% of the municipalities and 86.3% faced difficulties in acquiring supplies. Statistically significant associations were observed between municipal size and regulation variables.

CONCLUSION The Covid-19 pandemic has highlighted the importance of bed regulation and the unequal distribution between the public and private sectors. This study identified challenges such as insufficient beds, difficulties in admitting patients, and a reduction in outpatient services. Large municipalities have expanded beds through field hospitals and agreements with private hospitals. Small and medium-sized municipalities adopted regional strategies and multiple protocols. Regional coordination and state regulation were crucial in managing the response, but difficulties with supplies and human resources impacted on access. The incorporation of digital mechanisms and new regulatory strategies was important, despite the structural and political challenges that aggravated the emergency response.

DESCRIPTORS
Effective Access to Health Services; Health Care Coordination and Monitoring; Bed Occupancy; COVID-19

Responding municipalities		n	%
Responding municipalities		255	39.5
Responding municipalities by DRS	DRS 15 São José Rio Preto	37	14.51
	DRS 6 Bauru	35	13.73
	DRS 9 Marilia	28	10.98
	DRS 1 Greater São Paulo	20	7.84
	DRS 11 Presidente Prudente	15	5.88
	DRS 17 Taubaté	15	5.88
	DRS 13 Ribeirão Preto	14	5.49
	DRS 16 Sorocaba	13	5.10
	DRS 2 Araçatuba	13	5.10
	DRS 7 Campinas	12	4.71
	DRS 10 Piracicaba	9	3.53
	DRS 3 Araraquara	9	3.53
	DRS 5 Barretos	8	3.14
	DRS 8 Franca	8	3.14
	DRS 12 Registro	7	2.75
	DRS 4 Baixada Santista	7	2.75
	DRS 14 São João Boa Vista	5	1.96
Respondent	Municipal manager	171	67
Respondent	Representative appointed by the municipal manager	84	33
Size of municipality	Small (up to 20,000 inhabitants)	131	51.37
	Medium (20,001 to 100,000 inhabitants)	83	32.55
	Large (100,001 to 500,000 inhabitants)	35	13.73
	Extra-large (over 500,000 inhabitants)	6	2.35

			n	%
Regulation of Covid-19 beds through a central regulation center	Management axis	State / CROSS	148	58.0
		Regulated by more than one center	76	29.8
		Regional	11	4.3
		Not regulated by central regulators	10	3.9
		Municipal	7	2.7
		Don’t know	3	1.2
Difficulty admitting patients	Network Assistance	Had difficulties with both	175	70.3
		Difficulties with surgeries and non-Covid-19 cases	32	12.9
		No difficulties	23	9.2
		Had difficulties with hospitalization of Covid-19 cases in ward or ICU	19	7.6
Regulation of Covid beds - difficulties in accessing beds	Management	Insufficient ward, ventilator, or ICU beds	137	53 .7
		Insufficient beds associated with other factors	60	23.5
		No difficulties encountered in accessing Covid-19 beds	38	14.9
		Don’t know	11	4.3
		Problems other than insufficient beds	9	3.5
Situations faced by the private sector	Axis Ges so	Various situations faced with the private sector - beds and other resources	107	42.0
		None	77	30.2
		Situations faced with the private sector not involving hospitalization beds	56	22.0
		Situations with the private sector exclusively involving inpatient beds	15	5.9
Covid bed regulation - protocols used	Management axis	More than one protocol	109	42.7
		State protocol	91	35.7
		Regional protocol	28	11.0
		Municipal protocol	19	7.5
		Can’t answer	4	1.6
		Did not use protocols	2	0.8
		National protocol	2	0.8
Creation of new services in the care network	Network Assistance	Yes	212	83.1
Creation of new services in the care network	Network Assistance	No	39	15.2
Strategies adopted in urgent and emergency services	Networked Care	Specific areas/flows for Covid care in existing services	179	70.2
		Services created or adapted for Covid care	131	51.3
		Specific emergency services set up for Covid care	43	16.8
		Municipality does not have an emergency service	29	11.3
		There has been no change in the emergency network	25	9.8
		Specific Samu units have been assigned to Covid-19 care	17	6.6
		Telehealth for emergency services implemented	14	5.4
		Don’t know	3	1.1

			n	%
Regulation strategies adopted	Management axis	Multiple strategies	139	54.5
		Other outpatient regulation strategies	39	15.3
		Qualification / monitoring of waiting lines,	28	11.0
		No action was taken,	18	7.1
		Implementation of risk classification protocols	14	5.5
		Don’t know	12	4.7
		Teleregulation	3	1.2
		Matrix Support	2	0.8
Change in the supply of specialized consultations	Network Assistance	Decreased	187	73.3
		Increased	36	14.1
		Remained stable	29	11.4
		Don’t know	3	1.2
Change in the supply of diagnostic support tests	Network Assistance	Decreased	163	63.9
		Increased	58	22.7
		Remained stable	31	12.2
		Don’t know	3	1.2
Change in the offer of therapeutic procedures	Network Assistance	Decreased	172	67.5
		Increased	47	18.4
		Remained stable	28	11.0
		Don’t know	8	3.1
Change in the supply of surgeries	Network Assistance	Decreased	210	82.4
		Increased	3 1	12.2
		Don’t know	8	3.1
		Remained stable	6	2.4
Change in teleservice offer	Network Assistance	Increased	93	36.5
		Don’t know	72	28.2
		Decreased	54	21.2
		Remained stable	36	14.1
Were the financial resources sufficient?	Management axis	Yes	138	54.1
		No	100	39.2
		Don’t know	17	6.7
Changes in the workforce - emergency services and SAMU	Management	There was an increase in staff	116	45.5
		No change	80	31.4
		Don’t know how to answer	30	11.8
		There has been a reduction in staff, including departures and resignations	29	11.4
Changes in the workforce - hospital	Management	There was an increase in staff	125	49.0
		No change	57	22.4
		Don’t know how to answer	47	18.4
		There has been a reduction in staff, including departures and resignations	26	10.2
Changes in the workforce - specialized care	Management	No change	134	52.5
		There was a reduction in staff, including leaves of absence and resignations	45	17.6
		There was an increase in staff	40	15.7
		Can’t answer	34	13.3
		There has been a reduction in staff	2	0.8
Difficulties in acquiring materials/inputs	Management	Multiple difficulties	220	86.3
		Lack of products on the market	14	5.5
		No difficulties	8	3.1
		Abusive prices	6	2.4
		Administrative / legal obstacles to purchase	4	1.6
		Insufficient municipal finances / budget	2	0.8
		Don’t know how to answer	1	0.4

Variables		Size				Cramer value	p-value
Variables		Extra large	Large	Medium	Small	Cramer value	p-value
Were the financial resources sufficient?	No	4	25^a	44^a	27^a	0.309	< 0.001
	Don’t know	0	2	8	7
	Yes	2	8^a	31^a	97^a
Is regulation of Covid-19 beds done through a regulation center?	State/CROSS	1^a	15	52	80	0.315	< 0.001
	Municipal	3^a	4^a	0	0^a
	Not regulated by central regulators	0	1	3	6
	Don’t know	0	0	0	3
	Regional	0	0	4	7
	Regulated by more than one central office	2	15	24	35
Covid bed regulation - protocols used	More than one protocol	1	20	34	54	0.312	< 0.001
	Don’t know how to answer	0	1	0	3
	Did not use protocols	0	0	1	1
	State protocol	0	7^a	36	48
	Municipal protocol	5^a	6^a	5	3^a
	National protocol	0	0	1	1
	Regional protocol	0	1	6	21^a
Covid bed regulation - difficulties in accessing beds	Insufficient beds associated with other factors	0	12	26^a	22^a	0.241	< 0.001
	Insufficient ward beds, ventilator support or ICU beds	1	14	48	74
	No difficulties encountered in accessing Covid-19 beds	3^a	2	6^a	27^a
	Don’t know	1	2	3	5
	Problems other than insufficient beds	1	5^a	0^a	3
Outpatient regulation - non-Covid access	Implementation of risk classification protocols	2^a	1	7	4	0.191	0.146
	Matrix Support	0	0	1	1
	Multiple strategies	4	25^a	42	68
	No action was taken.	0	1	2^a	15^a
	Don’t know	0	1	5	6
	Other outpatient regulation strategies	0	3	13	23
	Qualification / monitoring of waiting lines	0	4	12	12
	Tele-regulation	0	0	1	2
Situations faced with the private sector	None	0	1^a	26	50^a	0.224	< 0.001
	Situations faced with the private sector not involving hospitalization beds	0	6	12^a	38^a
	Situations with the private sector - involving inpatient beds	1	3	5	6
	Situations with the private sector involving beds among others	5^a	25^a	40	37^a
Difficulty admitting patients	Don’t know	1	1	1	3	0.180	0.017
	No difficulty	0	2	3^a	18^a
	Had difficulty with both	3	24	69^a	79^a
	Had difficulties with surgeries and non-Covid-19 cases	2	6	7	17
	Had difficulties with hospitalization of Covid-19 cases in ward or ICU	0	2	3	14^a
Changes in the workforce - emergency services and Samu	There has been an increase in staff	5	22^a	45^a	44^a	0.195	0.001
	There has been a reduction in staff, including departures and refusals	0	7	10	12
	No change	1	4^a	23	52^a
	Don’t know how to answer	0	2	5^a	23^a
Changes in the workforce - hospital	There was an increase in staff	5	25^a	53^a	42^a	0.259	0.000
	There was a reduction in staff, including departures and resignations	0	6	10	10
	No change	0	1^a	7^a	49^a
	Don’t know how to answer	1	3	13	30^a
Changes in the workforce - specialized care	There was an increase in staff	1	3	20^a	16	0.194	0.004
	There was a reduction in staff	0	1	1	0
	There was a reduction in staff, including leaves of absence and resignations	1	13^a	15	16^a
	No change	3	17	41	73
	Don’t know how to answer	1	1	6	26^a
Difficulties in acquiring materials/inputs	Administrative/legal obstacles to acquisition	0	0	2	2	0.203	0.026
	Lack of products on the market	1	0	3	10
	Insufficient municipal finances/budget	0	1	0	1
	multiple difficulties	4	33	78^a	105^a
	No difficulties	0	1^a	0^a	7^a
	abusive prices	0	0	0	6
Change in the supply of specialized consultations	Increased	0	4	15	17	0.076	0.882
	Decreased	5	26	59	97
	Remained stable	1	4	9	15
	Don’t know	0	1	0	2
Change in the offer of diagnostic support tests	Increased	1	5	27^a	25	0.171	0.008
	Decreased	4	25	49	85
	Remained stable	0	5	7	19
	Don’t know	1^a	0	0	2
Change in the offer of therapeutic procedures	Increased	1	4	19	23	0.073	0.903
	Decreased	5	25	53	89
	Remained stable	0	4	9	15
	Don’t know	0	2	2	4
Change in the supply of surgeries	Increased	1	3	13	14	0.108	0.443
	Decreased	4	30	68	108
	Remained stable	0	1	2	3
	Don’t know	1	1	0	6
Change in customer service	Increased	5^a	18^a	28	42	0.140	0.094
	Decreased	0	4	16	34
	Remained stable	1	5	10	20
	Don’t know	0	8	29	35

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[TFN1] DRS: regional health departments.