Spelling suggestions: "subject:"[een] INTERNATIONAL HEALTH"" "subject:"[enn] INTERNATIONAL HEALTH""
31 |
A narrative exploration of policy implementation and change management : conflicting assumptions, narratives and rationalities of policy implementation and change management : the influence of the World Health Organisation, Nigerian organisations and a case study of the Nigerian health insurance schemeKehn-Alafun, Omodele January 2011 (has links)
Purpose: The thesis determined how policy implementation and change management can be improved in Nigeria, with the health insurance scheme as the basis for narrative exploration. It sets out the similarities and differences in assumptions between supra-national organisations such as the World Bank and World Health Organisation on policy implementation and change management and those contained in the Nigerian national health policy; and those of people responsible for implementation in Nigerian organisations at a) the federal or national level and b) at sub-federal service delivery levels of the health insurance scheme. The study provides a framework of the dimensions that should be considered in policy implementation and change management in Nigeria, the nature of structural and infrastructural problems and wider societal context, and the ways in which conceptions of organisations and the variables that impact on organisations' capability to engage in policy implementation and change management differ from those in the West. Design/methodology/approach - A qualitative approach in the form of a case study was used to track the transformation of a policy into practice through examining the assumptions and expectations about policy implementation of the organisations financing the policy's implementation through an examination of relevant documents concerning policy, strategy and guidelines on change management and policy implementation from these global organisations, and the Nigerian national health policy document. The next stages of field visits explored the assumptions, expectations and experiences of a) policy makers, government officials, senior managers and civil servants responsible for implementing policy in federal-level agencies through an interview programme and observations; and b) those of sub-federal or local-level managers responsible for service-level policy implementation of the health insurance scheme through an interview programme. Findings - There are conflicts between the rational linear approaches to change management and policy implementation advocated by supra-nationals, which argue that these processes can be controlled and managed by the rational autonomous individual, and the narratives of those who have personal experience of the quest for 'health for all'. The national health policy document mirrors the ideology of the global organisations that emphasise reform, efficiencies and private enterprise. However, the assumptions of these global organisations have little relevance to a Nigerian societal and organisational context, as experienced by the senior officials and managers interviewed. The very nature of organisations is called into question in a Nigerian context, and the problems of structure and infrastructure and ethnic and religious divisions in society seep into organisations, influencing how organisation is enacted. Understandings of the purpose and function of leadership and the workforce are also brought into question. Additionally, there are religion-based barriers to policy implementation, change management and organisational life which are rarely experienced in the West. Furthermore, in the absence of future re-orientation, the concept of strategy and vision seems redundant, as is the rationale for a health insurance scheme for the majority of the population. The absence of vision and credible information further hinder attempts to make decisions or to define the basis for determining results. Practical implications: The study calls for a revised approach to engaging with Nigerian organisations and an understanding of what specific terms mean in that context. For instance, the definitions and understanding of organisations and capacity are different from those used in the West and, as such, bring into question the relevance and applicability of Western-derived models or approaches to policy implementation and change management. A framework with four dimensions - societal context, external influences, seven organisational variables and infrastructural/structural problems - was devised to capture the particular ambiguities and complexities of Nigerian organisations involved in policy implementation and change management. Originality/value: This study combines concepts in management studies with those in policy studies, with the use of narrative approaches to the understanding of policy implementation and change management in a Nigerian setting. Elements of culture, religion and ethical values are introduced to further the understanding of policy making and implementation in non-Western contexts.
|
32 |
De l'éducation sanitaire à la promotion de la santé : Enjeux et organisation des savoirs au coeur de l'action publique sanitaire (internationale) / From Health Education to Health Promotion at the World Health Organization : intenationalization and transformations in public health action.Vanel, Julia 09 June 2016 (has links)
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.
|
33 |
Le syndrome métabolique et ses associations avec les troubles de la mobilité : différence de genre dans l'étude internationale sur la mobilité des personnes âgées (IMIAS)Toa, Lou Irié Clarisse 06 1900 (has links)
Introduction : Peu d’études internationales ont examiné les différences entre les hommes et
les femmes dans la prévalence du syndrome métabolique (SM).
Objectifs : Comparer les prévalences du syndrome métabolique chez les femmes et les
hommes et évaluer le rôle du genre dans les associations entre le SM et les troubles de
mobilité (TM).
Méthodes : Nous avons utilisé les données repères de l’étude internationale sur la mobilité des
personnes âgées de 65-74 ans (n=1995), des villes de Kingston (Ontario), Saint-Hyacinthe
(Québec), Tirana (Albanie), Manizales (Colombie), et Natal (Brésil). Parmi les participants,
1728 ont donné un échantillon de sang pour des analyses. Les ratios de prévalence (RP) du
SM et des TM ont été dérivés par la régression de Poisson.
Résultats : Les prévalences du SM étaient significativement plus élevées chez les femmes
dans les villes non canadiennes, cette différence entre sexes n’était pas significative dans les
villes canadiennes. Relativement aux femmes de Kingston, les prévalences du SM étaient plus
élevées chez les femmes de Tirana (RP= 2,66; 95 % IC = 1,98-3,58) et de Natal (RP= 2,21;
95 % IC = 1,52-3,22) et non significatives chez celles de Manizales et de Saint-Hyacinthe.
Chez les hommes, peu de différences significatives étaient observées. Le SM n’était pas
associé à la mobilité dans les villes non canadiennes.
Conclusion : Nos résultats suggèrent que le genre est un facteur de risque pour le SM. Des
recherches sur les relations entre le SM, la mobilité et le genre devraient être entreprises.
Mots-clés : Syndrome métabolique, troubles de la mobilité, genre, santé internationale / Background: Few international studies have examined differences in metabolic syndrome
(MetS) between men and women.
Objectives: To compare the prevalence of MetS in women and men and to assess the role of
gender in the association between MetS and mobility disability.
Methods: We used baseline data from the International Mobility in Aging Study of
community samples aged 65-74 years (n = 1995) of the cities of Kingston (Ontario), Saint-
Hyacinthe (Quebec), Tirana (Albania), Manizales (Colombia), Natal (Brazil). Of these, 1,728
people donated a blood sample. Prevalence ratios of MetS and mobility disability were
estimated by Poisson regression.
Results: In non-Canadian cities the prevalence of MetS was significantly higher in women
while in Canadian cities there was no significant sex difference. Among women, comparing
with Kingston, MetS prevalence was significantly higher for women in Tirana (PR= 2.66;
95%CI = 1.98 to 3.58) and Natal (PR=2.21; 95%CI =1.52 - 3.22), but no significant
differences were observed for women in Manizales and Saint-Hyacinthe. Among men, few
significant differences were observed across cities. In non-Canadian sites, MetS was not
associated with mobility disability.
Conclusion Our results suggest that gender is a risk factor for MetS. Research on the
relationship of MetS, mobility and gender need to be initiated.
Keywords: Metabolic syndrome, mobility disability, gender, international health.
|
34 |
PSO sveikatą stiprinančių iniciatyvų įgyvendinimo galimybių Lietuvos ligoninėse tyrimas / Research on implementation of WHO health promoting (hp) initiatives in Lithuanian hospitalsToleikytė, Lina 08 June 2005 (has links)
Aim of the study - to evaluate the opportunities for implementation of Health Promoting initiatives and International Health Promoting Standards in hospitals of Lithuanian HPH Network.
Objectives: 1. To evaluate managers’ knowledge and attitudes towards implementation of Health Promoting initiatives in hospital. 2. To ascertain structures and personnel which could implement Health Promotion activities at hospital. 3. To compare attitudes towards possibilities of establishment and implementation of Health Promoting initiatives and Health Promoting standards among managers from Kaunas Medical University hospital (KMUH) and hospitals involved in Lithuanian HPH Network.
Methods. The study was carried out in KMUH and hospitals of Lithuanian HPH Network. A standard questionnaire was distributed via internet both to managers (n=33) of all departments in KMUH and those from Lithuanian HPH Network (n=11). The questionnaire included two parts: general (created by author of survey) and special (based on WHO experts’ questionnaire, translated into lithuanian). The response rate was 88%.
Results. The majority of respondents define HP initiatives as a very wide spectrum of activities including health education programs both for staff and patients, support in creating healthy and safe workplace, continuous quality improvement plans and efficient management of financial and human resources. According to the survey, level of awareness of HPH’s aims and goals appeared to be rather low among... [to full text]
|
35 |
Tarptautinių sveikatos priežiūros taisyklių įgyvendinimas Lietuvos Respublikoje / Implementation of International Health Regulations in Republic of LithuaniaVaržgalis, Manvydas 06 February 2009 (has links)
Šiame darbe yra analizuojamos Tarptautinės sveikatos priežiūros taisyklės, aptariant jų istoriją, pagrindinius principus bei įtaką šiuolaikiniu globalizacijos periodu. Tarptautinės sveikatos taisyklės yra neatsiejama dalis, siekiant išvengti tarptautinio infekcinių ligų plitimo tarptautiniu mastu, netrukdant tarptautinei prekybai bei susisiekimui. Norint išlikti visaverte partnere tarptautinėje erdvėje vystant ekonominę, socialinę padėtį, privalu taisykles įgyvendinti. Lietuva, būdama Pasaulio sveikatos organizacijos, Europos Sąjungos narė, ratifikavo taisykles bei įsipareigojo jas įgyvendinti Lietuvos Respublikos Vyriausybės nutarime iki 2012 metų. Pagrindiniai uždaviniai – suderinti atitinkamus teisės aktus su Taisyklių reikalavimais, užtikrinti tinkamą pasirengimą ir reagavimą į ekstremalias visuomenės sveikatai situacijas, keliančias tarptautinį susirūpinimą, taip pat efektyviai ir laiku koordinuoti tokias situacijas, sustiprinti administracinius gebėjimus, kurių reikia reaguojant į ekstremalias visuomenės sveikatai situacijas, keliančias tarptautinį susirūpinimą. Teisinė bazė yra rengiama pakeičiant/priderinant jau egzistuojančias bei kuriant naujas teisės normas. Lietuvos Respublikos Vyriausybė įsipareigoja teisinę bazę galutinai parengti 2009 metais. / This work is an analysis of the International Health Regulations, discussing their history, basic principles and the impact of globalization in the contemporary period. International Health Regulations are an integral part, to prevent the international spread of infectious diseases internationally, impeding international trade and travel. To remain full–fledged partner in international space development in economic, social situation, the regulations must be implemented. Lithuania as the member of World Health Organization and European Union has ratified the regulations, and undertook implement by the resolution of the Goverment Republic of Lithuania until 2012. The main tasks of harmonizing the legislation with the regulations, are to ensure adequate preparedness and response to emergency public health situations which pose an international concern, as well as an efficient and timely coordination of such situations, to reinforce the administrative capacity needed to respond to emergency public health situations which pose an international concern. The legal framework is being prepared modyfing / adjusting existing and the developing new legal norms. The Government of the Republic of Lithuania commited to finalise legal framework in 2009.
|
36 |
A intersetorialidade no processo de construção da política de saúde brasileiraAbreu, Cassiane Cominoti 22 June 2009 (has links)
Made available in DSpace on 2016-12-23T14:36:45Z (GMT). No. of bitstreams: 1
Cassiane Cominoti Abreu - Parte 1.pdf: 127661 bytes, checksum: 1d193e49438d6eede297963c1ba9c22e (MD5)
Previous issue date: 2009-06-22 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Os objetivos do estudo são analisar como a intersetorialidade foi inserida no processo de construção da política de saúde brasileira, tendo por base o debate construído pelo movimento pela reforma sanitária e Plenária Nacional de Saúde nas décadas de 1970 e 1980, e identificar a intersetorialidade no debate das conferências internacionais de saúde da Organização Mundial de Saúde. A pesquisa se caracteriza por ser qualitativa, orientada pelo método materialista-histórico-dialético. Utilizou-se a pesquisa documental e pesquisa de campo. A primeira envolveu a coleta e a análise de documentos que foram formulados na periodicidade estudada e a pesquisa de campo foi efetuada a partir de 4 entrevistas com participantes da plenária nacional de saúde. Para a análise dos dados foi utilizada a análise de conteúdo. O estudo aponta que no processo de construção da política de saúde brasileira havia dois projetos societais em disputa que congregavam significados diferenciados de intersetorialidade. O projeto neoliberal defende um significado de intersetorialidade baseado na articulação entre os setores em uma perspectiva técnica e racionalizadora que esconde um significado político e ideológico a favor da redução dos recursos financeiros para a política de saúde. Este é o significado de intersetorialidade presente nas conferências internacionais da OMS e manteve forte influência na 7ª Conferência Nacional de Saúde no Brasil. O projeto defendido pela reforma sanitária mantinha um significado de intersetorialidade a favor da articulação entre políticas sociais e da expansão de direitos sociais com a conseqüente consolidação do conceito de saúde defendido pelo movimento sanitário. O estudo conclui que a
intersetorialidade pode ser paradoxalmente restritivo e reafirmador de projetos coletivos estruturados em torno da superação das condições de desigualdade e injustiça social / This study aims at analyzing how the intersectoriality was inserted in the construction process of the Brazilian health policy, having the debate built by the movement and by the
sanitary reform and the National Plenary Health as its basis in the 70 s and 80 s, and identifying the intersectoriality in the debate of international health conferences of the World Health Organization. The research is characterized by being qualitative, oriented by the materialistic-historical-dialectic method. A documental and field research was used.
The first one involved the collection and analysis of documents which were formulated in the studied periodicity and the field research was performed in four interviews with participants of the national plenary health. The content analysis was used for the data analysis. The study indicates that in the construction process of the Brazilian health policy there were two societary projects in dispute that congregated different meanings from
intersectoriality. The neoliberal project defends a meaning of intersectoriality based on the articulation among sectors in a technical and rational perspective which hinders a political
and ideological meaning in favor of the reduction of financial resources for the health policy. This is the meaning for intersectoriality present in the international conferences of
WHO and it had a strong influence in the 7th National Health Conference in Brazil. The project defended by the sanitary reform kept a meaning of intersectoriality in favor of the
articulation among social policies and the expansion of social rights with the consequent consolidation of health concept defended by the sanitary movement. The study concludes
that intersectoriality can be paradoxically restrictive and reasserting of collective projects structured around the overcoming of inequality and social inequity conditions
|
37 |
Le rôle normatif de l'Organisation mondiale de la santé / The normative role of the World Health OrganizationKastler, Florian 09 December 2016 (has links)
Institution spécialisée du système des Nations Unies créée à la sortie de la Seconde guerre mondiale, l'Organisation mondiale de la santé (OMS) s'est vu confiée, par l'article premier de sa Constitution, le but « d'amener tous les peuples au niveau de santé le plus élevé possible ». Pour atteindre cet objectif, les États membres lui ont conféré vingt-deux fonctions dont une normative. Cette dernière lui permet, en théorie, d’adopter à la fois des instruments de santé non contraignants et d'autres contraignants. L'étendue du champ d'application de cette fonction permet à l'OMS d'élaborer des normes au contenu très divers et varié dès lors qu'elle agit dans le cadre de son objectif sanitaire. Parallèlement, en raison de difficultés internes, propres à son organisation régionalisée et à une concurrence externe accrue par la multiplication d'acteurs de santé mondiale, l'OMS est à un tournant de son histoire comme en atteste l'envergure de la réforme qui est toujours en cours depuis 2010. Dans ce contexte, il s'agit de comprendre et d'analyser l'influence du rôle normatif de l'OMS dans les systèmes de santé nationaux. D'abord, une évaluation de son autorité normative, qui apparaît affaiblie, est proposée afin de présenter des évolutions pour la renforcer et ainsi améliorer la protection de la santé mondiale au sein d'un droit international de la santé consolidé. Ensuite, l'étude approfondie de son activité normative est envisagée pour délimiter la conception de la norme de l'OMS par le prisme de son efficacité. L'objectif in fine est de proposer une réflexion sur l'avenir du rôle normatif de l'OMS. / The World health organization (WHO), as a specialized agency, was created, after the Second world war with the objective of, according to article 1 of its Constitution, the "attainment by all peoples of the highest possible level of health”. For that purpose, the WHO was granted twenty two functions by the Member States including a normative one. This normative function allows, in theory, the WHO to adopt both binding and non binding health instruments. The extent of the scope of this function offers a wide and diverse content to theses norms with the only limit that it pursues a health purpose. At the same time, the WHO shows internal difficulties, in part, due to its regional structure and overall lack of financing. Further, the increase number and diversity of actors of global health result in potential external competition with the WHO. The reform initiated in 2010 and still ongoing proves that the WHO is a turning point in its history. In this context, this research seeks to understand and analyze the influence of the normative role of the WHO on national health systems. First, we study the normative authority of the WHO which appears weakened. With the objective of increasing health protection based on a reinforced global health law paradigm, our proposals aim at strengthening the normative authority of WHO. Then, our in-depth analysis of the normative activity of the WHO allows to the define the conception of norm by the WHO using effectiveness as our analytical frame. Finally, this research offers an opportunity to reflect on the future of the normative role of the WHO.
|
38 |
[pt] UNAIDS, GRUPO PELA VIDDA E AIDS UNITED: RELAÇÕES ENTRE AS ORGANIZAÇÕES LOCAIS E INTERNACIONAIS NO COMBATE À PANDEMIA DO HIV/AIDS / [en] UNAIDS, GRUPO PELA VIDDA, AND AIDS UNITED: RELATIONS BETWEEN LOCAL AND INTERNATIONAL ORGANIZATIONS ON THE COMBAT TO THE HIV/AIDS PANDEMICIGOR PEREIRA CARVALHO DE PAULO 26 May 2023 (has links)
[pt] Esta pesquisa trata das relações entre organizações internacionais e locais
na área do combate à AIDS, mais especificamente a relação entre o Programa das
Nações Unidas de HIV/AIDS e as ONGs locais que atuam nesse campo, como o
Grupo pela Vidda (Brasil) e a Aids United (Estados Unidos), voltados para o
esforço do controle epidemiológico do HIV/AIDS. A dissertação apresenta,
primeiramente, o contexto histórico da pandemia e do ativismo nesses países. Em
segundo plano, são analisadas as atividades do UNAIDS e como se estruturam o
Grupo pela Vidda e a AIDS United com o objetivo de compreender a atuação e as
formas de colaboração entre essas organizações. A última seção traz considerações
finais sobre as relações entre tais grupos a fim de compreender como se dá a
participação e colaboração de organizações locais no sistema internacional. / [en] This research deals with the relationship between international and local
organizations around combating AIDS, more specifically the relationship between
the United Nations HIV/AIDS Program and local NGOs that work in this field, such
as Grupo pela Vidda (Brazil) and the Aids United (United States), focused on the
epidemiological control of HIV/AIDS. The dissertation first presents the historical
context of the pandemic and activism in these countries. In the background, the
activities of UNAIDS and how the Grupo pela Vidda and AIDS United are
structured are analyzed with the aim of understanding the performance and forms
of collaboration between these organizations. The last section brings final
considerations on the relationships between such groups to understand how the
participation and collaboration of local organizations in the international system takes place.
|
39 |
The Power of Mobile Health: The Girl With the Gadgets in UgandaOnweni, Chidinma L., Venegas-Borsellino, Carla P., Treece, Jennifer, Turnbull, Marion T., Ritchie, Charles, Freeman, William D. 01 April 2021 (has links)
Medical-grade ultrasound devices are now pocket sized and can be easily transported to underserved parts of the world, allowing health care providers to have the tools to optimize diagnoses, inform management plans, and improve patient outcomes in remote locations. Other great advances in technology have recently occurred, such as artificial intelligence applied to mobile health devices and cloud computing, as augmented reality instructions make these devices more user friendly and readily applicable across health care encounters. However, broader awareness of the impact of these mobile health technologies is needed among health care providers, along with training on how to use them in valid and reproducible environments, for accurate diagnosis and treatment. This article provides a summary of a Mayo International Health Program journey to Bwindi, Uganda, with a portable mobile health unit. This article shows how point-of-care ultrasonography and other technologies can benefit remote clinical diagnosis and management in underserved areas around the world.
|
40 |
Le dilemme de la promotion de la santé en Amérique latine : les cas de l’Argentine et du BrésilRuiz, Gabriela 03 1900 (has links)
À partir des années 1980, la théorisation de la promotion de la santé et sa mise en place font partie de l’agenda des organisations internationales de santé et de plusieurs gouvernements. Cependant, une certaine tension est observable dans la compréhension de la promotion de la santé, et ce, dès ses débuts. En effet, elle est conçue en général selon une approche comportementale comme stratégie pour le changement de comportements individuels ou collectifs qui met l’accent sur les facteurs de risque et très peu fréquemment conçue selon une approche structurelle, incluant une action sur les déterminants structurels des sociétés responsables de l’état de santé des populations dans une mesure plus importante que les systèmes de soins.
Cette recherche qualitative –étude de cas multiples- menée en Argentine et au Brésil, vise à analyser la place et la compréhension de la promotion de la santé dans les politiques nationales de santé de deux pays à travers l’analyse du processus d’élaboration des politiques publiques. Nous viserons à distinguer la promotion de la santé en tant que comportementale ou structurelle et à expliquer les raisons pour lesquelles elle est comprise de telle ou telle autre façon. Finalement, nous essayerons d’identifier les opportunités pour qu’une approche structurelle de la promotion de la santé soit adoptée dans la politique nationale de santé.
Les données analysées proviennent d’entrevues semi-structurées (n=28) et de documents divers : sites gouvernementaux sur Internet, documents remis par les interviewés, documents officiels, soit gouvernementaux, soit des organismes de coopération et de financement. Notre cadre conceptuel s’est inspiré des trois modèles : celui du changement des politiques publiques de Sabatier et Jenkins-Smith (1999 ; 2009), celui des courants politiques de Kingdon (1984) et le cadre conceptuel proposé par Walt (1994) pour l’analyse du rôle des organisations internationales. Nous avons identifié deux niveaux d’analyse : l’organisation de l’État et le sous-système de santé. Nous avons aussi tenu compte de l’influence des événements externes et des organisations internationales de coopération technique et de financement. Notre démarche vise à observer, à analyser et à comprendre la façon dont ces niveaux influencent la place et la compréhension de la promotion de la santé dans la politique nationale de santé. La perspective temporelle de plus de douze années nous a permis de mener une analyse sur plusieurs années et de mieux comprendre le changement de la politique de santé à différents moments de son histoire ainsi que l’identification des acteurs et des coalitions les plus importants depuis l’origine des champs de la santé publique dans les deux pays.
Les résultats de notre analyse montrent que la promotion de la santé – conçue selon une approche structurelle – ne fait pas encore partie du courant principal de la politique nationale de santé dans aucun des deux pays. Cependant, les explications diffèrent : En Argentine, on observe un sous-système de santé fragmenté avec prédominance du modèle médical ; les actions menées renforcent ce fonctionnement en ne permettant pas la discussion à propos des valeurs sous-jacentes à l’organisation du système de santé ni sur son changement en fonction des besoins de santé du pays. Au Brésil, la réforme sanitaire questionne le modèle préexistant et arrive à instaurer la santé comme droit au niveau de l’État. L’accent mis sur l’organisation des services réduit la compréhension de la promotion de la santé à une « politique nationale de promotion de la santé » qui vise le changement des comportements. L’analyse du rôle des organisations internationales montre deux situations différentes dans les deux pays : pour l’Argentine, il existe une dépendance majeure autant à l’agenda qu’au financement de ces organisations. Le manque d’un agenda national en matière de promotion de la santé fait que le pays adopte l’agenda international avec très peu des questionnements. Dans le cas du Brésil, la situation est bien différente et on observe une capacité importante à négocier avec la coopération internationale. Cela se fait aussi avec un intérêt du pays pour l’adoption de l’agenda des organisations internationales dans le but d’une reconnaissance et de sa participation à des instances internationales. Alors, pour des raisons différentes, les deux pays adoptent l’agenda international de la promotion de la santé avec une approche comportementale.
À partir de notre recherche, nous considérons que cinq réflexions doivent guider l’analyse de la promotion de la santé en Amérique latine : 1) Les processus de réforme de l’État des années 1990 et ses conséquences actuelles (type de réforme, valeurs sociétales, arrangements constitutionnels) ; 2) Les processus de réforme des systèmes de santé avec un regard sur la composante de décentralisation (réforme sanitaire ou administrative ?, quel modèle prédomine dans le champ de la santé publique ?) ; 3) La revalorisation des soins primaires de santé de la fin des années 1990 (quel impact dans le pays ?) ; 4) La tendance à la réduction des propositions élargies autant des politiques que des programmes ; et 5) Les défis actuels des systèmes de santé (travailler avec d’autres secteurs pour produire de la santé, pour incorporer et pour mieux maîtriser les déterminants sociaux et structuraux de santé).
Les résultats de notre analyse nous permettent d’identifier l’importance du rôle du gouvernement national par rapport au développement et à la compréhension de la promotion de la santé. De plus, cette recherche montre que même s’il existe une influence du contexte et de l’idéologie du gouvernement sur la compréhension de la promotion et l’inclusion des déterminants sociaux de santé, c’est l’organisation de l’État avec ces valeurs de base qui sera déterminante dans la création des conditions pour le développement d’une promotion de la santé structurelle. Alors que la littérature sur la promotion de la santé accorde encore très peu de place au rôle du niveau national et de l’État dans son développement, il est clair que ces derniers ont un impact fondamental sur la place de la promotion de la santé dans la politique et sur la façon de la comprendre et de la mettre en place.
Les théories utilisées pour cette recherche nous ont aidée à modéliser notre cadre conceptuel et à mener une démarche d’analyse des politiques publiques. Cette démarche permet d’améliorer les connaissances sur le changement de la politique nationale de santé par rapport à la promotion de la santé en tenant compte des dynamiques gouvernementales, champ peu exploré encore. Ce cadre conceptuel, à la fois souple et rigoureux, pourrait s’avérer approprié pour mener d’autres recherches similaires portant sur la place et la compréhension de la promotion de la santé dans les politiques nationales de santé dans d’autres pays de l’Amérique latine. / From the 1980's, the theorization of health promotion and its implementation are part of the agenda of international health organizations and governments. However, from the beginning, there is a tension in its understanding. Indeed, health promotion in general is conceived from a behavioral approach as a strategy for changing individual or group behaviors, with emphasis on risk factors. It is rarely conceived from a structural approach that includes action on the social structural determinants of the societies.
This qualitative research, a multiple case study conducted in Argentina and Brazil, aims to analyze the location and the understanding of health promotion in the national health policies of both countries through the analysis of the public policy development process. We aim to distinguish the approaches to health promotion, behavioral or structural, and explain the reasons why is understood in one way or the other. Finally, we try to identify opportunities for a structured approach to health promotion to be adopted in national health policy.
The data analyzed come from semi-structured interviews (n = 28) and from the following sources: government websites, documents provided by the interviewees, and official documents from governments, cooperation agencies and funding organizations. Our conceptual framework was inspired by three models: the Model of Policy Change of Sabatier & Jenkins-Smith (1999, 2009), the Multiple Streams Model of policy-making defined by JW Kingdon (1984) and the conceptual framework proposed by Walt (1994) for analyzing the role of international organizations.
We identified two levels of analysis: the organization of the State and the subsystem of health. We have also taken into account the influence of external events and of international organizations for technical cooperation and financing. We propose to observe, analyze and understand how these levels influence the place and the understanding of health promotion in national health policy. A time horizon of more than a decade allowed us to conduct a comprehensive analysis and get a better understanding of the health policy change in different historical moments of the countries studied, as well as identifying the most important actors and coalitions in the public health field.
The results of our analysis show that health promotion, conceived according to a structural approach, is not yet part of the mainstream of national health policy in any of the two countries. However, the explanations are different; in Argentina we see a fragmented subsystem of health with predominance of the medical model, where the actions taken reinforce this functioning and do not allow for discussion, neither on the values underlying the organization of the health system, nor concerning their change according to the country's health needs.
In Brazil, the health care reform of the 1980’s challenged the pre-existing model and achieved instituting health as a right at the State level. By putting emphasis on the organization of health services it reduced the understanding of health promotion to a "National Policy for Health Promotion" aimed at behavioral change. The analysis of the role of international organizations shows different situations in both countries: Argentina has a very strong dependence on both the agenda and the funding of these organizations; the lack of a national agenda on health promotion facilitates the adoption of the international agenda, almost without questioning.
In the case of Brazil the situation is different and a strong capacity to negotiate with international cooperation is observable. The interest of this country to adopt the agenda of international organizations has the objective, among others, to gain recognition and participation in international bodies. Thus, for different reasons, we observe that the two countries adopt the international agenda of health promotion from a behavioral approach.
In our research, we considered five considerations that should guide the analysis of health promotion in Latin America: 1) The processes of state reform of the 1990’s and the current consequences (type of reform, social values, constitutional arrangements), 2) the reforms of health systems with particular attention to the decentralization component (health or administrative reform?), which model dominates the field of public health?, 3) the revaluation of the APS of the late 1990’s (what impact did it have on the country?), 4) the tendency to reduce both the scope of policy and program proposals and, 5) current challenges facing health systems (collaboration with other sectors to improve health, incorporate and enhance the understanding of social and structural determinants of health).
The results of our analysis allow us to identify an important role for the national government in regards to the development and understanding of health promotion. Our research shows that the organization of the State, with its basic values, will be crucial in creating the conditions for developing a structural health promotion, even when there is influence of context and government ideology on the understanding of promotion of health and the inclusion of its social determinants. While the literature on health promotion still dedicates very little attention to the role of national level and State for their development, our research shows that these two levels have a fundamental impact on the place of health promotion in national policy and on how to understand and implement it.
The theories used for this research allowed us to build our conceptual framework and carry out a process of public policy analysis. This process improves the knowledge about the change in national health policy with regard to health promotion taking into account the relatively unexplored field of government dynamics. This conceptual framework is both flexible and rigorous, and may be appropriate to carry out similar research on the promotion of health in national health policies of other countries in Latin America.
|
Page generated in 0.0328 seconds