Plano Nacional de Saúde nos planos estaduais (2020–2023): análise da difusão da equidade nas 27 Unidades Federativas do Brasil

Abstract

Introduction: Equity is one of the guiding principles of the Brazilian Unified Health System (SUS) and is incorporated into the guidelines of the National Health Plan (PNS) 2020–2023. However, as a polysemic concept, its incorporation into planning instruments may occur in different ways across state contexts. In this scenario, it is important to understand how equity has been interpreted and incorporated into the State Health Plans (PES) of Brazil’s 27 Federative Units. Objective: To critically analyze the presence and definition of the concept of equity in the National Health Plan (2020–2023) and its interpretation in the State Health Plans of Brazil’s 27 Federative Units during the same period. Methods: This qualitative documentary study was based on the policy diffusion through translation approach and on categorical content analysis. The corpus consisted of the National Health Plan (2020–2023) and the 27 State Health Plans in force during the same period. The analysis examined the presence of the term equity, its frequency of occurrence, contexts of use, explicit definitions, related terms, and forms of incorporation into the documents. Data were organized using Microsoft Excel® spreadsheets and analyzed in light of the theoretical framework of policy translation. Results: The term equity was identified in 25 of the 27 State Health Plans analyzed, with considerable variation in frequency across states. Only Mato Grosso and Tocantins did not mention the term. The highest numbers of occurrences were observed in the plans of Rio Grande do Norte (34 citations), Amazonas (31), and Minas Gerais (28). Only ten states provided an explicit definition of equity: Amazonas, Federal District, Espírito Santo, Goiás, Minas Gerais, Paraná, Piauí, Rio de Janeiro, Rio Grande do Sul, and Santa Catarina. The identified definitions were grouped into four categories: equity as distributive justice and differential treatment; equity based on the social determinants of health; equity as the reduction of regional inequalities; and equity as a guideline for access to and organization of the health system. Related terms were also analyzed, particularly inequality, inequity, equality, and social justice, which were frequently employed in situational analyses and institutional guidelines. Discussion: The findings showed that, although equity is widely present in SUS planning instruments, its definition and operationalization vary considerably among states. The diversity of approaches identified reinforces the polysemic nature of the concept and suggests that its incorporation occurs through processes of interpretation, adaptation, and re- signification within state contexts. The differences observed reflect characteristics of the translation processes through which national guidelines are incorporated at subnational levels. Conclusion: Equity is widely present in health planning instruments; however, its incorporation occurs heterogeneously across Brazilian states. The presence of the term is not always accompanied by explicit definitions or consistent operational strategies, highlighting the need to strengthen its conceptual qualification within SUS planning instruments. The findings suggest that the diffusion of equity does not occur through the mere reproduction of national guidelines but rather through translation processes influenced by the territorial, institutional, and political specificities of state contexts.