Dans l’ensemble de la thèse, nous avons appliqué des techniques de ‘mesure des variations spatiales’ pour l'étude des variations géographiques de taux d'hospitalisation en France. La thèse est composée de 4 études :Étude 1 : « Variation géographique des recours aux procédures chirurgicales en France en 2008-2010 et comparaison avec les États-Unis et la Grande-Bretagne ».Étude 2 : « Variation géographique des admissions pour les prothèses du genou, de la hanche et la fracture de la hanche en France : existence d’une demande induite dans le secteur des hôpitaux à but lucratif et dans les hôpitaux public et privés à but non-lucratif »Étude 3 : « Caractéristiques et tendances des admissions non urgentes à but lucratif et sans but lucratif hôpitaux en France en 2009 et 2010 ». Étude 4 : « Taux d'admission pour des ’hospitalisations évitables par le système ambulatoire’ (ACSC) en France en 2009-2010 : tendances, variation géographique, coûts et comparaison internationale ». / For all of this work, we applied ‘small-area variation’ techniques to the study of geographic variations in hospitalization rates in France. We conducted four studies:Study 1: Geographic variation in rates of common surgical procedures in France in 2008-2010 and comparison to the US and BritainStudy 2: Geographic variation in admissions for knee replacement, hip replacement, and hip fracture in France: evidence of supplier-induced demand in for-profit and not-for profit hospitalsStudy 3: Characteristics and patterns of elective admissions to for-profit and not-for-profit hospitals in France in 2009 and 2010Study 4: Rates of admission for ambulatory care sensitive conditions in France in 2009-2010: trends, geographic variation, costs, and an international comparison

Orientador: Silvia Cristina Mangini Bocchi / Resumo: Introdução: A instituição de políticas públicas voltadas ao envelhecimento populacional constitui uma forma efetiva dos países ocidentais lidarem com a transição demográfica. No entanto, poucos países têm programas de saúde pública que possibilitam idosos acessarem cuidados de saúde bucal, por exemplo, sem barreiras financeiras. Apenas em 2004, a política pública de saúde bucal brasileira passou a ofertar cuidados de saúde bucal, de maneira universal e integral, no contexto do Sistema Único de Saúde (SUS). Assim, esta pesquisa pretende analisar a operacionalização da política de saúde bucal por meio das experiências de idosos com o acesso aos cuidados bucais a partir da Atenção Primária à Saúde, bem como dos cirurgiões-dentistas com a oferta deste cuidado e dos gestores com a implantação e consolidação desta política. Desta maneira, questiona-se: — Os idosos brasileiros conseguem acessar cuidados de saúde bucal no SUS? — Como a política nacional de saúde bucal projeta as ações de saúde bucal em nível local? Objetivo geral: Fazer uma análise da operacionalização da política de saúde bucal brasileira a partir da metassíntese das experiências dos cirurgiões-dentistas, idosos e gestores da política de saúde bucal. Objetivos específicos: (a) compreender o processo experiencial de idosos adscritos às Unidades de Saúde da Família (USFs), de cirurgiões-dentistas que os atendem, assim como gestores municipais e federais, envolvidos na operacionalização da política de saúde bucal brasi... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: To proactively enact public policies which address the ageing process is an effective way for Western countries to tackle the demographic transition. However, few countries have public health programs that enable older people to access oral health care, for example, without financial barriers. Only in 2004, the Brazilian oral health public policy started to offer universal and comprehensive oral healthcare in the Unified Health System (SUS). Thus, this research aims to analyze the oral health policy operationalization throughout the elderly’s experiences with oral health care access at the primary health care, the dentists’ experience in providing care, and the managers’ experience with the implementation and consolidation of this policy. Thus, it is questioned: - Can the Brazilian elderly access oral health care in the SUS? - How does the national oral health policy project oral health actions at the local level? General objective: To analyze the operationalization of the Brazilian oral health policy based on the meta-synthesis of the experiences of dentists, elderly and oral health policy managers. Specific objectives: (a) understand the experience of elderly people attended by the Family Health Units (FHUs), the dentists’ experience in assisting them, and the municipal and federal managers’ experience with the Brazilian oral health policy; (b) propose theoretical models of each experience and; (c) elaborate metasynthesis from the theoretical models emerging, ... (Complete abstract click electronic access below) / Doutor

L’internationalisation de l’action publique sanitaire est aujourd’hui incontestable, et cette thèse représente une contribution intellectuelle à l’analyse de ce phénomène reconnu mais encore à explorer dans les détails. Partant d’un point très précis voire étroit, la substitution progressive dans le vocabulaire et les pratiques de l’Organisation mondiale de la Santé (OMS) de l’éducation sanitaire par la promotion de la santé, on retrace un parcours autrement considérable qui n’engage rien moins que les représentations historiques et politiques qui ont conduit à la mise en place de politiques publiques dans le domaine sanitaire, et ce à l’international. A la croisée de l’histoire des idées et de l’analyse des politiques publiques internationales, c’est une méthodologie innovante – articulant démarche intellectuelle et recherche empirique, notamment par l’observation participante et la conduite d’entretiens – que nous mobilisons pour retracer l’histoire et le fonctionnement réel de l’OMS.Notre travail se présente comme une histoire d’enchevêtrements de savoir(s), de jeux de pouvoir et de processus d’institutionnalisation dans des contextes changeants. Partant de l’émergence, dès le XVIIIe siècle, de l’éducation sanitaire comme stratégie visant la modification des comportements individuels puis de son inscription au sein de l’OMS, on en arrive à la question du changement de l’action publique (internationale). L’affirmation progressive de la promotion de la santé à partir des années 1980 traduit le travail de sens opéré par des acteurs (de l’OMS) qui, confrontés à des tensions liées à des modifications dans les équilibres jusqu’alors établis, modifient leurs discours et leurs pratiques afin de conserver, ou d’acquérir, une capacité à orienter l’action publique. Surtout, notre recherche montre que l’action publique sanitaire (internationale) se caractérise aujourd’hui par l’effort pour concilier – dans un contexte de complexification des enjeux, d’hétérogénéité croissante des savoirs et de multiplication des acteurs susceptibles d’intervenir au nom de la santé publique – des registres de légitimation (la défense de la liberté individuelle et la nécessité d’une action collective au nom de ce « bien commun » qu’est la santé) et des stratégies d’action (individuelles et collectives) non seulement différentes mais qui souvent même s’opposent. / This doctoral thesis is an intellectual contribution to the analysis of the unquestionable, process of internationalization of public health policies. Starting from a precise and even narrow point—the transition from “health education” to “health promotion” in the discourses and practices put forward by the World Health Organization (WHO)—we retrace the historical and political representations that shape public health-related policies at the international level. This interdisciplinary work, at the crossroad of the history of ideas and the international public policies analysis, is based on an innovating methodology which articulates an intellectual and empirical research to the analysis of the history and the functions of the WHO.This history is one of knowledge intertwining with games of power and institutional processes in shifting contexts. Starting with the emergence as early as the XVIIIth century of health education as a strategy for changing personal behaviors and its inclusion far later in the WHO structure, we move to the question of (international) public (health) policies transformations. The progressive affirmation of health promotion in the 1980’s reflects how WHO instances reframed the meaning of their work, when confronted to the tensions provoked by the shifting balance of well-established conceptions, and how they modified their discourse and their practice in order to keep or acquire a capacity to influence public action.. Above all, our research shows that (international) public health policies are today characterized by a attempt to combine—in a context of complexified issues and increased heterogeneity in knowledge as well as of a greater number of stakeholders in public health (action)—an array of legitimizing discourses ranging from the defense of individual freedom and the need for collective action on behalf of health as a “common good” to (individual and collective) strategies of action that are not only different but often conflicting.

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Les Systèmes de Santé, comme institution essentielle de l’état social, contribuent à la garantie et à l’amélioration du niveau du bien être et de la qualité de vie de la population. Le récepteur de ces politiques est l’ensemble social ou une partie de l’ensemble social. Il est clair, donc, qu’il est aussi important d’étudier les politiques de santé nationales que l’administration publique, puisque celle-ci joue un rôle dominant. Le contenu du Système de Santé, les modèles administratifs et les ressources disponibles caractérisent les politiques des états et se différencient des autres. La combinaison de la politique sociale avec le Système de Santé s’influence par les conditions économiques et sociales de chaque pays. L’évolution diachronique du Système de Santé depuis 1974 jusqu'à aujourd’hui, constitue le pylône principal de notre devoir. L’approche se fera à travers tous les rapports introductifs des lois de l’état grec. Nous allons analyser les sources primaires et utiliser tous les éléments qui ont un rapport avec le contenu du devoir. Les remarques seront illustrées dans les chapitres relatifs durant la progression du devoir. [...] / Health System as a fundamental institution of the welfare state aids in securing and improving the level of welfare and quality of life of the population. The addressees are the members of or the whole community. Therefore, it is made clear that it is important to study the health policies and public administration, whose role is dominant. The content of the Health System, the administration models and the resources available define the policies of the states and are differentiated as opposed to the rest. The combination of welfare policies and the Health System is affected by the economical and social condition of each country. The longitudinal evolution of the Health System from 1974 to 2008 is the main pillar of our study. The subject will be approached through all the explanatory reports of the laws of the Greek republic. The primary sources will be processed and information related to the content of the study will be drawn. [...]

Cette recherche sur les barrières à l’accès pour les pauvres atteints de maladies chroniques en Inde a trois objectifs : 1) évaluer si les buts, les objectifs, les instruments et la population visée, tels qu'ils sont formulés dans les politiques nationales actuelles de santé en Inde, permettent de répondre aux principales barrières à l’accès pour les pauvres atteints de maladies chroniques; 2) évaluer les types de leviers et les instruments identifiés par les politiques nationales de santé en Inde pour éliminer ces barrières à l’accès; 3) et évaluer si ces politiques se sont améliorées avec le temps à l’égard de l’offre de soins à la population pour les maladies chroniques et plus spécifiquement chez les pauvres. En utilisant le Framework Approach de Ritchie et Spencer (1993), une analyse qualitative de contenu a été complétée avec des politiques nationales de santé indiennes. Pour commencer, un cadre conceptuel sur les barrières à l’accès aux soins pour les pauvres atteints de maladies chroniques en Inde a été créé à partir d’une revue de la littérature scientifique. Par la suite, les politiques ont été échantillonnées en Inde en 2009. Un cadre thématique et un index ont été générés afin de construire les outils d’analyse et codifier le contenu. Finalement, les analyses ont été effectuées en utilisant cet index, en plus de chartes, de maps, d'une grille de questions et d'études de cas. L’analyse a tété effectuée en comparant les barrières à l’accès qui avaient été originalement identifiées dans le cadre thématique avec celles identifiées par l’analyse de contenu de chaque politique. Cette recherche met en évidence que les politiques nationales de santé indiennes s’attaquent à un certain nombre de barrières à l’accès pour les pauvres, notamment en ce qui a trait à l’amélioration des services de santé dans le secteur public, l’amélioration des connaissances de la population et l’augmentation de certaines interventions sur les maladies chroniques. D’un autre côté, les barrières à l’accès reliées aux coûts du traitement des maladies chroniques, le fait que les soins de santé primaires ne soient pas abordables pour beaucoup d’individus et la capacité des gens de payer sont, parmi les barrières à l'accès identifiées dans le cadre thématique, celles qui ont reçu le moins d’attention. De plus, lorsque l’on observe le temps de formulation de chaque politique, il semble que les efforts pour augmenter les interventions et l’offre de soins pour les maladies chroniques physiques soient plus récents. De plus, les pauvres ne sont pas ciblés par les actions reliées aux maladies chroniques. Le risque de les marginaliser davantage est important avec la transition économique, démographique et épidémiologique qui transforme actuellement le pays et la demande des services de santé. / This research on the barriers to access chronic disease care for the poor in India has three objectives: 1) to assess whether the goals, objectives, instruments and targeted populations, as formulated in current national health policies in India, address the main barriers to access chronic disease care for the poor; 2) to assess the types of policy levers and instruments identified in current national health policies to address these barriers to access; 3) And to assess whether national health policies in India have improved over time with respect to ensuring chronic disease care to the population and more specifically to the poor. Using Ritchie and Spencer’s framework approach (1993), a qualitative content analysis was completed on selected Indian national health policies. To begin with, a conceptual framework on the barriers to access chronic disease care for the poor in India was generated from a review of the scientific literature. Policy documents were then sampled in India in 2009. A thematic framework and index scheme were generated to build the analysis tools and codify the content. Finally, the analysis was conducted using indexing, charts, maps, questions grids and case studies. It was achieved by comparing the barriers to access identified in the original conceptualization to those identified by the content analysis of each policy. This research highlights that a number of barriers to access for the poor in India are addressed by national health policies as they relate to upgrading services in the public sector, improving the knowledge of the population and scaling up some interventions for chronic disease care. On the other hand, barriers related to the costs of chronic disease care, the affordability of outpatient services and people’s ability to pay for them were the least addressed from the framework that was previously established. Moreover, when looking at the timeline of our sample of policies, it appears that efforts to scale up interventions for physical chronic diseases are more recent. In addition, the poor are not targeted specifically for actions related to chronic disease care. The risk of marginalizing them further is important as economic, demographic and epidemiologic transitions are transforming the country and the demand for health services.

Introdução: A esterilização cirúrgica foi historicamente considerada como importante problema de Saúde Pública, dada sua alta prevalência em nosso país. Em 2006 (MS), era o método contraceptivo mais utilizado, entre as mulheres de 15 a 49 anos, sendo sua prevalência de 25,9 por cento. Esta prática aconteceu no Brasil em um cenário de clandestinidade, como crime e conduta antiética, salvo em algumas situações de risco de vida, acompanhadas de distorções como a cesárea para fins exclusivos de esterilização. A regulamentação da Lei 9263/96 representou abertura ao direito e ao acesso das mulheres à esterilização cirúrgica. No entanto, seu texto foi considerado ambíguo, induzindo a diferentes interpretações por profissionais, notadamente em relação a sua aplicação a mulheres muito jovens. Objetivos: Identificar como profissionais de saúde conhecem e interpretam a Lei 9263/96; que artigos da Lei apresentam controvérsias na sua interpretação e aplicação; as questões éticas, morais, sociais e clínicas relacionadas com tais controvérsias e que desafios se colocam para cumprimento da mesma como resposta aos direitos das mulheres. Procedimento Metodológico: Pesquisa de natureza qualitativa, com entrevistas de 27 profissionais de saúde da cidade de São Paulo. Na interpretação das narrativas foi utilizada a Análise de Discurso. Resultados: Nos discursos dos vários profissionais há um reconhecimento positivo de que a Lei se apresenta como disciplinadora da prática médica, retirando o procedimento de sua condição de ilegalidade. São identificadas controvérsias em relação ao texto da Lei, sobretudo no que se refere à idade de 25 anos ou dois filhos vivos e, também, à sua realização no momento do parto. Os discursos permitem revelar a complexidade de que se reveste a aplicação da lei, tendo em vista o peso que os critérios sociais assumem no processo de aprovação e execução da esterilização, na medida em que a mesma passa a caracterizar-se, em nível de serviços de saúde, como um procedimento ao mesmo tempo clínico e de intervenção social. Conclusão: Constata-se a importância da esterilização cirúrgica estar inscrita de fato no contexto do planejamento familiar, garantindo previamente o acesso às informações sobre os diferentes métodos, seus benefícios e riscos, colocandose a esterilização como último recurso. As controvérsias e desafios descritos no trabalho apresentam contribuições ao abrirem novas perspectivas para o entendimento do problema e melhor aplicação da Lei / Introduction: Surgical sterilization has historically been regarded as an important public health problem given its high incidence in Brazil; according to the Ministry of Health, in 2006 it was the most widely used contraceptive among women from 15 to 49 years of age, and accounted for 25,9 per cent of the cases. In Brazil this practice was done clandestinely, like a crime or unethical conduct, except in situations involving risk of life, and even in these cases there were distortions - such as cesareans performed for the sole purpose of sterilization. The regulation of Law 9263/96 represented the establishment of the right of women to have access to surgical sterilization. However, its text was considered ambiguous, leading to different interpretations by professionals, especially with respect to its application to very young women. Objectives: To identify how health professionals know and interpret Law 9263/96; which articles of the Law are controversial in their interpretation and application of the Law; the ethical, moral, social and clinical questions related to such controversies and which challenges have to be met to comply with said law to ensure Women\'s Rights are attended. Method: qualitative research, involving interviews with 27 health professionals from São Paulo. Content\'s Analysis was used to interpret the narratives. Results: In their interviews many professionals recognize that the law disciplines this medical practice, removing its illegal stigma. They also identify controversies in relation to the Law, especially as regards the age of 25 or two living children and of the procedure being done at the time of delivery. The discourses reveal the complexity that law enforcement is covered around. The sterilization carries strong social approval criteria to be performed, at the same time that (at the Health Service level) sterilization becomes a clinical and social intervention procedure. Conclusion: The importance of surgical sterilization as a factor to be entered into the context of family planning is shown clearly, thereby ensuring access to advanced information about the different methods, their benefits and risks, and placing sterilization as a last resort. The controversies and challenges described in the paper show contributions to opening new perspectives for the understanding of the problem and improved enforcement of the Law

Este estudo faz uma análise dos discursos da Organização Pan-Americana da Saúde (OPAS) sobre políticas de saúde para a América Latina e Caribe, no período compreendido entre os anos de 1986 a 1994. A análise é realizada tendo como contraposição os discursos do Banco Mundial, no mesmo período. Procura-se demonstrar que os dois discursos se construíram, se realizaram e se atualizaram em relação de heterogeneidade constitutiva. Para a realização desta tarefa apoia-se na corrente denominada de 'escola francesa de análise do discurso' (AD). Após a manutenção de uma longa polêmica discursiva, foi possível chegar à conclusão que a OPAS atualizou seu discurso a partir dos temas apresentados pelo Banco Mundial: financiamento, eficácia e eficiência. Houve um desequilíbrio associativo semântico entre universalidade, integralidade e gratuidade da atenção à saúde defendida pela OPAS. A defesa do principio da não-exclusividade, pelo Banco, foi decisiva para aquele desequilíbrio. / This study analyses the Pan American Health Organization (PAHO) discourses about Health Policies to Latin America and Caribbean Islands, from 1986 to 1994. The analysis was based on the World Bank discourses, as a counterpoint, during the same period. The objective is to demonstrate that both discourses were built, turn into reality and became up to date in heterogeneity constitutive relationship. The 'French school of speech analysis' (SA) is the technique used to support the analysis. After a long and controversial discoursive dispute, it was possible to conclude that the PAHO updated its discourse using as starting point the themes presented by the World Bank: financing, efficacy and efficiency. There was a semantic associative lack of balance between universality, integrality and gratuitousness for the health care defended by the PAHO. The defense of the principle of non-exclusivity, by the World Bank, was decisive for that lack of balance.

Made available in DSpace on 2016-04-26T20:48:39Z (GMT). No. of bitstreams: 1 Natalia Carolina Cairo Lara.pdf: 1602596 bytes, checksum: 3ec8e016919d150b6ba802a06622ad89 (MD5) Previous issue date: 2013-12-11 / The regionalization of the Unified Health System (SUS), is one of the guidelines that should guide the organization of the NHS, according to the 1988 Constitution. The process of decentralization of health is a movement that started its structure over the 80 and defined the Constitution and the subsequent constitutional legislation (Law 8080, Law 8142, rules, regulations and decrees regulated). Since its construction, we observe policies of decentralization and regionalization of SUS, which start with NOBs, passing through NOAS, Covenant Health, and recently the Organisational Agreement and Public Health Action (COAP). To discuss and understand the process of regionalization of SUS, was studied the Metropolitan Health Region of Santos in the light of its financing capacity and analysis of your spending. Thus, we look at how this region is organized in a financially effective regional management / A regionalização do Sistema Único de Saúde (SUS) constitui uma das diretrizes que devem orientar a organização do SUS, de acordo com a Constituição de 1988. O processo de descentralização da saúde é um movimento que inicia a sua estruturação ao longo da década de 80 e ganha contornos mais definidos na Constituição e na legislação infraconstitucional subsequente (Lei 8.080, Lei 8.142, normas, portarias regulamentadas e decretos). Desde a sua construção, observam-se políticas de descentralização e regionalização do SUS, que se iniciam com as NOBs, passando pelas NOAS, Pacto da Saúde e, recentemente, o Contrato Organizativo da Ação Pública e da Saúde (COAP). Para debater e compreender o processo de regionalização do SUS foi estudado a Região de Saúde Metropolitana da Baixada Santista à luz da sua capacidade de financiamento e análise dos seus gastos. Dessa forma, analisa-se como essa região se organiza financeiramente em uma gestão regional eficaz