Submitted by isabela.moljf@hotmail.com (isabela.moljf@hotmail.com) on 2017-04-25T16:00:36Z No. of bitstreams: 1 manuellabarbosafeitosa.pdf: 1557499 bytes, checksum: 9326e5062e067f215575149ce5032dc2 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-04-26T12:22:04Z (GMT) No. of bitstreams: 1 manuellabarbosafeitosa.pdf: 1557499 bytes, checksum: 9326e5062e067f215575149ce5032dc2 (MD5) / Made available in DSpace on 2017-04-26T12:22:04Z (GMT). No. of bitstreams: 1 manuellabarbosafeitosa.pdf: 1557499 bytes, checksum: 9326e5062e067f215575149ce5032dc2 (MD5) Previous issue date: 2011-03-31 / FAPEMIG - Fundação de Amparo à Pesquisa do Estado de Minas Gerais / As desigualdades sociais em saúde podem se manifestar de diversas formas no processo saúde-doença. Isto inclui até mesmo o acesso e a utilização de serviços de saúde. Apesar de inúmeros estudos na literatura nacional apontarem para a existência de iniqüidades analisando a utilização dos serviços de saúde existem limitações na interpretação desse enfoque. Desta forma, visando a avaliação da equidade de forma mais abrangente, proponho a diferenciação da utilização e do acesso. A utilização dos serviços foi analisada sob o enfoque do uso, enquanto o conceito de Acesso adotado foi estruturado em três dimensões: Disponibilidade, Acessibilidade Financeira e Aceitabilidade. Portanto os objetivos do estudo foram: descrever e avaliar a utilização e o acesso aos serviços de saúde materno-infantil nos grupos do ciclo gravídico-puerperal (pré-natal, parto e puericultura), investigar as possíveis associações com as condições de vida e verificar a distribuição geográfica na área de estudo. Realizou-se estudo epidemiológico de corte transversal, na forma de inquérito domiciliar com amostra representativa da população do município de Juiz de Fora (MG), obtendo uma visão mais clara de tais iniqüidades. Os resultados mostraram elevados percentuais de utilização dos serviços de saúde, sendo: 99,5% no pré-natal, 100% parto hospitalar e 90,3% na puericultura, com predomínio da rede assistencial SUS (65,3% no pré-natal, 76,6% no parto e 58,4% na puericultura). O acesso aos serviços, segundo análise fatorial (método dos componentes principais) foi mais influenciado pelas dimensões: Disponibilidade e Acessibilidade Financeira. A representação gráfica da distribuição espacial dos escores, obtidos na análise fatorial, mostraram áreas com persistência na desvantagem na classificação do Acesso e que as áreas em vantagem possuíam cobertura da Atenção Primária em Saúde. Na análise por regressão linear múltipla para o grupo do pré-natal os fatores associados (p<0,05) reforçam que os fatores socioeconômicos e demográficos são determinantes do acesso. Na dimensão Disponibilidade, as variáveis associadas positivamente foram: maior escolaridade materna (ter no mínimo 2° grau completo), pertencer a grupo social mais alto (A ou B), idade do chefe da família e viver com companheiro. As variáveis: número de gestações, distância aos serviços de saúde (quanto mais próximo às instalações de saúde, ou seja, menores distâncias) e o sexo do chefe da família (ser homem) associaram-se negativamente ao desfecho acesso nessa dimensão. Enquanto na dimensão Aceitabilidade os seguintes fatores associaram-se positivamente: chefe da família ter trabalho atual, distância ao serviço de saúde (quanto maior a distância, maior o escore acesso), escolaridade materna (ter no mínimo 2° grau completo) e sexo do chefe de família (ser homem). Na dimensão Aceitabilidade a variável número de moradores esteve associada negativamente ao desfecho acesso, ou seja, quanto menor o número de residentes, maior o escore. Portanto, apesar dos avanços apontados pela utilização dos serviços, na perspectiva do acesso aos serviços, ainda persistem iniqüidades. Espera-se que tais resultados contribuam para a formulação de políticas públicas mais efetivas na implementação da equidade no acesso. / Health inequalities come to being in many different ways in the health-disease process, be it in the form of access or the utilization of health services. Although many studies undertaken in Brazil have highlighted the existence of inequities in the utilization of health services, there are limitations in the interpretation of such approach. This study analyses the utilization of health services with focus on the actual use, while the theoretical concept of Access adopted here is the one which breaks it down into three dimensions: Availability, Affordability and Acceptability. The objectives of the study are, therefore: to describe and evaluate the utilization of and access to infant-maternal health services during three well-defined moments of the pregnancy-puerperal cycle (antenatal, birth and infant care); to investigate the significance of the potential association of such aspects with living conditions and lifestyle and to assess the influence of geographical location on the utilization of and access to health services. A sharper view of observed inequities in health services provision and utilization was enabled by means of a cross-section household sample-survey epidemiological study undertaken in the city of Juiz de Fora, state of Minas Gerais, Brazil. Results show high percentages of health services utilization: 99.5% for antenatal, 100% for hospital births and 90.3% for infant care, the great majority of which provided by the unified public sector – SUS (65.3% for antenatal, 76.6% for births and 58.4% for infant care). Factor analysis (PCA) shows that for the latent variable access, the dimensions Availability and Affordability are predominant. The geographical distributions of the scores obtained from the first factor of PCA for the three moments show persistently disadvantaged areas in terms of access. Multiple linear regression, undertaken for the antenatal moment, shows that the variables kept in the models stress the importance of socioeconomic and demographic factors in the explanation of the observed variance in access. For the Availability dimension of access the significant covariates (p<0.05) associated positively with the scores are: mother´s educational level, mother living with partner, age of partner and belonging to higher social classes. The covariates negatively asso ciated with the scores were: parity, distance to health services and male as head of household. For the Acceptability dimension the following covariates are significant and positively associated with the scores: head of household in full employment, distance to health services, mother´s education and male as head of household; the only covariate negatively associated with the scores is: number of residents in the dwelling. Notwithstanding the advances shown by the levels of utilization, the analyses based on access to health services indicate that inequalities remain. We expect the results presented can contribute to the formulation of more effective public policies targeted at the implementation of equity in terms of Access.

Objetivos. Estimar la prevalencia de insuficiente acceso efectivo a medicamentos (IAEM) y sus factores asociados en usuarios que reciben prescripción médica en la consulta ambulatoria de instituciones prestadoras de servicios de salud (IPRESS) en Perú. Materiales y métodos. Se realizó un análisis secundario de la Encuesta Nacional de Satisfacción de Usuarios en Salud (ENSUSALUD) del año 2014; estudio con muestreo probabilístico bietápico a nivel nacional en IPRESS del Ministerio de Salud y Gobiernos Regionales (MINSA-GR), Seguro Social de Salud, Fuerzas Armadas y Policiales (sanidades), y clínicas del sector privado (CSP). El IAEM se definió como la dispensación incompleta o de ningún medicamento en la farmacia de la IPRESS. Se realizaron modelos lineales generalizados y se estimaron razones de prevalencia (RP) con IC 95% para muestreo complejo. Resultados. De los 13 670 entrevistados, el 80,9% (IC 95%: 79,9-81,8%) recibieron indicación de medicamentos, y de estos el 90,8% (IC 95%: 90,1-91,6%) los solicitaron en la farmacia de la IPRESS, donde el 30,6% (IC 95%:28,8-32,4%) tuvo IAEM. El ser atendido en el MINSA-GR (razón de prevalencia [RP]: 4,8; IC 95%: 3,5-6,54) y en las sanidades (RP: 3,21; IC 95%: 2,3- 4,5), el ser de la tercera edad (RP: 1,17; IC 95%: 1,04-1,34) y el pertenecer al quintil más pobre (RP: 1,21; IC 95%: 1,05-1,41) incrementaron la probabilidad de IAEM. Asimismo, los pacientes atendidos por una enfermedad de menos de 15 días (RP: 1,37; IC 95%: 1,05-1,79) y de 15 días a más (RP: 1,51; IC 95%: 1,16-1,97) tuvieron una mayor prevalencia de IAEM que aquellos atendidos por embarazo u otros controles. Conclusiones. El IAEM está asociado al subsistema de salud, edad, pobreza y tipo de consulta realizada. Se sugieren implementar estrategias para fomentar el acceso a medicamentos en la población peruana. / Objectives. To estimate the prevalence of ineffective access to drugs (IAD) and associated factors in patients receiving a prescription in an outpatient clinic in the Peruvian health system. Materials and Methods. We performed a secondary dataanalysis of the National Survey of Health Users Satisfaction (ENSUSALUD 2014), a two-stage population-based study carried out in health care centers of the Ministry of Health and Regional Governments (MOHRG), Social Security (EsSalud), Armed Forces and Police (AFP) and the Private Sector across all 25 regions of Peru. IAD was defined as incomplete or no dispensing of any prescribed medication in the health care center pharmacy. Generalized linear models with Poisson distribution for complex survey sampling were fit to estimate prevalence ratios (PR) and 95% confidence intervals (CI). Results. Out of 13,360 participants, 80.9 % (95% CI: 79.9-81.8) had an active prescription, and of those, 90.8 % (95% CI: 90.1-91.6) sought their medications in a health care center pharmacy, where 30.6 % (95% CI 28.8-32.4) had IAD. In the multiple regression model, receiving medical attention in the MOHRG (PR 4.8; 95%CI: 3.5-6.54) or AFP (PR: 3.2; 95%CI: 2.3-4.5), being over 60 years old (PR: 1.17; 95%CI: 1.04-1.34) and being in the poorest income quintile (PR: 1.05; 95%CI: 1.05-1.41) increased IAD. Furthermore, in contrast to seeking care for pregnancy or other routine control, IAD was also more common for medical consultation for diseases diagnosed in the last 15 days (PR: 1.37; 95% CI: 1.05-1.79) or more than 15 days prior (PR: 1.51; 95% CI: 1.16-1.97). Conclusion. In Peru, IAD is associated with the provider institution, older age, poverty and the reason for medical consultation. We suggest strategies to promote access to medicines, especially in the most disadvantaged segments of the Peruvian population. / Revisión por pares

"The thesis of this study is that the flexibility within the exceptions to patent rights protecton under the TRIPS Agreement has not sufficiently been exploited at the national level. The study conceptualises the regimes for the protection of the right to health and IPRs not as mutually exclusive but as potentially reinforcing. The contention is therefore that the obligations in respect to the right to health limit the manner in which states can exercise the flexibilty within the patent regime of the TRIPS Agreement. Eventually the study seeks to answer the question: Where does the guarantee for the right to health lie in light of the TRIPS regime? ... The study is divided into three chapters preceded by an introduction. The introduction lays the background for te discussion. Chapter one deals with the definition of important concepts and provides the context in which the study is set. The chapter also discusses the background to the creation of the TRIPS Agreement, with an emphatic discussion on the involvement or lack thereof of Africn and other least developed and developing countries in this process. Chapter two discusses the patent rights exceptions clause under the TRIPS Agreement. Against this background, compuslory licensing, government use and parallel importing as means of making accessibility to drugs a reality under the TRIPS Agreement will be discussed. Chapter three identifies other means of making drugs more accessible and identifying places where they have worked well. In this chapter, generic substitution, establishemnt of a pricing committee, therapeutic value pricing, pooled procurement, negotiated procurement and planned donations will be discussed. Finally a conclusion will be drawn from the discussion and recommendations will be advanced." -- Chapter 1. / Prepared under the supervision of Riekie Wandrag at the Community Law Centre, University of Western Cape, South Africa / Thesis (LLM (Human Rights and Democratisation in Africa)) -- University of Pretoria, 2002. / http://www.chr.up.ac.za/academic_pro/llm1/dissertations.html / Centre for Human Rights / LLM

No description available.

Olga Davidová - Abstrakt DP - AJ Abstract Diploma thesis "Globalization and Health - access to health care for children of foreigners in the Czech Republic" addresses the issue of availability of health care for children of foreigners in the Czech Republic as development of legal framework in the Czech Republic and human rights issues. The main objective of this work is a critical reflection on the cause of discrimination against children of foreigners from third world countries (non-EU countries) in their access to health care. This is a retrospective case study which is selected by the institutional analysis of the key events of public policy focusing on the development of health insurance legislation. There are different mechanisms of protection of human rights at local, national, and international level in the availability of health care for children of foreign nationals from third world countries; unfortunately national legislation is not fully in line with international requirements in the area of health law. Although international documents are binding for the Czech Republic, they are not sufficiently applied in the Czech constitutional right to prevent violations of human rights.

Contexte : L'Organisation mondiale de la santé (OMS) demande de « promouvoir » l'autonomie des adolescents dans l'accès aux services de santé. Mais la question de l'autonomie des adolescents en matière de soins de santé soulève des questions éthiques complexes (ex. : la nécessité du consentement parental). Il est donc nécessaire d'étudier empiriquement les questions éthiques liées à la promotion de l'autonomie des adolescents dans l'accès aux services de santé sexuelle et reproductive (SSSR). En raison de son contexte particulier (ex. : l'accès légal pour les adolescents aux SSSR), la Colombie a été choisie pour cette étude. Objectifs : 1) comprendre comment les adolescents interprètent le concept d'autonomie ; 2) explorer les préférences et les expériences des adolescents concernant leur autonomie pour accéder aux SSSR ; 3) examiner comment les adolescents souhaitent que leur autonomie soit promue ; 4) identifier et répondre aux questions éthiques reliées à l'appel de l'OMS à promouvoir l'autonomie des adolescents. Méthodologie : Une approche mixte fut utilisée avec des entretiens semi-structurés et des questionnaires. La recherche a eu lieu dans les départements colombiens d'Antioquia et du Valle del Cauca. Les adolescents qui se présentèrent dans deux cliniques Profamilia ont été invités à répondre à un questionnaire. En parallèle, les entretiens ont permis aux participants de présenter et de partager leurs opinions et expériences concernant leur autonomie pour accéder aux SSSR. Résultats : Au total, 812 adolescents de 11 à 24 ans ont répondu au questionnaire et 45 participants (de 14 à 23 ans) ont participé à un entretien individuel. Les entretiens démontrèrent que la compréhension de l'autonomie par les participants dépendait de leurs expériences personnelles, ce qui influence leur capacité d’accès aux SSSR. Selon un cadre de justice reproductive, les résultats soulignent des inégalités en termes d'autonomie pour accéder à des SSSR. Parallèlement, le questionnaire a démontré que les adolescents colombiens ont des préférences diverses en matière d'accès aux SSSR. Les études antérieures rapportent que les adolescents préfèrent la confidentialité et l'indépendance en lien aux SSSR, s’alignant ainsi sur la tendance d’encadrer le principe d'autonomie selon une perspective individualiste et d’autosuffisance. Cependant, la plupart des participants exprimèrent le souhait de pouvoir parler ouvertement avec leurs parents de leur santé sexuelle et reproductive et plusieurs voulaient aussi être accompagnés dans leur accès au SSSR. Conclusions : Les recommandations suivantes sont présentées en faveur d'un accès plus éthique aux SSSR en Colombie : 1) enseigner aux adolescents les fondements de l'autonomie pour que tous disposent des mêmes bases pour exercer leurs droits d'accès aux SSSR ; 2) investir dans la recherche avec les parents pour déterminer si leur fournir une éducation sexuelle aiderait les adolescents à accéder aux SSSR ; 3) adopter une approche « d’autonomie relationnelle » pour respecter les préférences des adolescents colombiens en matière d'accès aux SSSR. Lorsque les adolescents commencent à développer leur autonomie et avoir des relations sexuelles, il est essentiel de leur fournir les outils et les ressources nécessaires pour accéder aux SSSR dont ils ont besoin. / Background: The World Health Organization (WHO) advocates “fostering” the autonomy of adolescents to access health services. But the question of adolescents’ autonomy in healthcare raises complex ethical questions (e.g., necessity of parental consent). Hence, there is a need to investigate empirically the ethical questions around fostering adolescents’ autonomy to access sexual and reproductive health services (SRHS). Because of its particular context (e.g., adolescents’ legal access to SRHS), Colombia was chosen for this study. Objectives: The objectives of this project were to 1) understand how adolescents comprehend the concept of autonomy, 2) explore the preferences and experiences of adolescents regarding their autonomy to access SRHS, 3) examine how adolescents wish for their autonomy to be fostered, and 4) identify the ethical issues and provide ethically informed solutions in line with the WHO’s call to foster adolescents’ autonomy. Methodology: A mixed-method approach was used with semi-structured interviews and surveys for cross-sectional analysis. The research took place in the Colombian departments of Antioquia and Valle del Cauca. Adolescents who presented themselves at two Profamilia clinics were invited to answer a survey. In parallel, the interviews offered an opportunity for participants to present and share their opinions and experiences concerning their autonomy to access SRHS. Results: A total of 812 participants aged 11-24 completed a survey, and 45 participants (aged 14-23) participated in an individual interview. The interviews demonstrated that participants’ understanding of autonomy was highly dependent on personal experiences, which influenced their choice and ability to access SRHS. Seen through the ethical lens of a reproductive justice framework, the results highlight the unequal opportunities of adolescents in terms of autonomy to access SRHS. In parallel, the survey showed that Colombian adolescents have a variety of preferences regarding how to access SRHS. Previous research has shown that adolescents prefer privacy and independence where SRHS are concerned, findings that align with the longstanding tendency to frame the ethical principle of autonomy from the perspective of individuality and self-reliance. However, most participants in this study expressed a strong wish to be able to talk openly with their parents about sexual and reproductive health, and many also wanted to be accompanied when they access SRHS. Conclusions: Based on the study findings, the following recommendations are put forward in support of a more ethical access to SRHS in Colombia: 1) teach adolescents the basis of autonomy, so they can equally benefit from the necessary knowledge and skills to exercise their rights to access SRHS; 2) invest in research with parents to determine if providing them with comprehensive sex education could help adolescents access SRHS; 3) adopt a nuanced “relational autonomy” approach to respect the myriad of preferences that Colombian adolescents have regarding access to SRHS. As adolescents start developing their autonomy and engaging in sexual relations, it is critical to provide them with the necessary tools and resources to access needed SRHS. / Contexto: La Organización Mundial de la Salud (OMS) llama a "fomentar" la autonomía de los adolescentes en el acceso a los servicios de salud. Sin embargo, la cuestión de la autonomía de los adolescentes en la atención de salud plantea complejas cuestiones éticas (por ejemplo, la necesidad del consentimiento de los padres). Por lo tanto, es necesario estudiar empíricamente las cuestiones éticas relacionadas con la promoción de la autonomía de los adolescentes en el acceso a los servicios de salud sexual y reproductiva (SSSR). Debido a su contexto particular (por ejemplo, el acceso legal de los adolescentes a los SSSR), se eligió a Colombia para este estudio. Objetivos: (1) entender cómo los adolescentes comprenden el concepto de autonomía; (2) explorar las preferencias y experiencias de los adolescentes con respecto a su autonomía para acceder a los SSSR; (3) examinar cómo los adolescentes desean que se fomente su autonomía para acceder a los SSSR; (4) identificar las cuestiones éticas y proponer soluciones éticamente informadas en línea con el llamamiento de la OMS para fomentar la autonomía de los adolescentes. Métodos: Se utilizó un enfoque de método mixto: entrevistas semiestructuradas y encuestas. La investigación tuvo lugar en los departamentos colombianos de Antioquia y Valle del Cauca. Los adolescentes que se presentaron en dos clínicas de Profamilia fueron invitados a responder una encuesta. Paralelamente, las entrevistas permitieron a los participantes presentar y compartir sus puntos de vista y experiencias sobre su autonomía en el acceso a la salud sexual y reproductiva. Resultados: Un total de 45 participantes de 14 a 23 años participaron en una entrevista, y 812 participantes de 11 a 24 años completaron una encuesta. Las entrevistas demostraron que la comprensión de la autonomía de los participantes dependía en gran medida de sus experiencias personales, lo que influyó en su elección y capacidad para acceder a los SSSR. Visto a través de la lente ética de un marco teórico de justicia reproductiva, los resultados ponen de manifiesto la desigualdad de oportunidades de los adolescentes en términos de autonomía para acceder a los SSSR. Paralelamente, las encuestas mostraron que los participantes tienen una variedad de preferencias para acceder a los SSSR. Las investigaciones anteriores muestran que los adolescentes prefieren la privacidad y la independencia en lo que respecta a los SSSR. Dichos hallazgos se alinean con la tendencia a enmarcar el principio ético de la autonomía sobre la base de una perspectiva individualista y de autosuficiencia. Sin embargo, la mayoría de los participantes expresaron su deseo de poder hablar abiertamente con sus padres sobre su salud sexual y reproductiva y muchos también querían recibir apoyo para acceder a los SSSR. Conclusión: Según los resultados de la investigación, se proponen las siguientes recomendaciones: (1) enseñar a los adolescentes las bases de la autonomía, con el objetivo de que todos los adolescentes tengan las mismas bases para ejercer sus derechos de acceso a los SSSR; (2) invertir en estudios con los padres para determinar si proporcionarles una educación sexual integral ayuda a los adolescentes a acceder a los SSSR; (3) adoptar un enfoque de “autonomía relacional” para respetar la miríada de preferencias que tienen los adolescentes colombianos para acceder a los SSSR. A medida que los adolescentes comienzan a desarrollar su autonomía y a tener relaciones sexuales, es fundamental proporcionarles las herramientas y los recursos necesarios para acceder a los SSSR que necesitan.

The maternal mortality rate in the USA is the highest in the industrialized world. Black women in the USA are three times more likely to die due to pregnancy and childbirth-related health issues than their white counterparts. According to 2017–2019 data from the CDC, 80% of these deaths are preventable.The purpose of this thesis is to understand how women’s bodily autonomy is both racialized and politicized. Key questions here are: What is the relationship between access to healthcare and reproductive rights? How are reproductive rights racialized? How is bodily autonomy racialized and politicized?This research is based on a literature review and a case study of the documentary Aftershock, released in July 2022. Aftershock charts the deaths of two young Black American women after they gave birth and shows how their partners and families stood together and became effective activists determined to fight the Black maternal mortality epidemic in the US, and thereby increase awareness and bring about change in society.

Introduction: Vulnerable European Union citizens (vulnerable EU citizens) are those who come to Sweden from EU member states. In Sweden the term “vulnerable EU citizens” is associated with the word “beggars”, which in turn is associated with Roma people. By November 2015 the number of vulnerable EU citizens in Sweden was estimated to be 4 700. The majority of these were from Romania. Roma as citizens of an EU member state have the right to reside in EU countries in accordance with the EU’s freedom of movement rights concept for up to but no longer than three months. However, to obtain the right for residence after three months, proof of financial resources and health insurance are required. Lacking these resources, vulnerable EU citizens have subsequently lost their right for residence and therefore became undocumented. They often find themselves in the same situation as undocumented migrants from outside the EU, having poor health outcomes and limited access to health care. In my study I aim to explore access to health care for vulnerable EU citizens in Umeå, a city in eastern Sweden. Methods: A qualitative design methodology has been applied in this thesis. Those contacted for this study were; Doctors of the World, Health on Equal Terms, Staff for planning and control Västerbotten Region, University Hospital of Umeå and representatives of vulnerable EU citizens’ community from Romania in Umeå. Seven in-depth interviews were collected with professionals and volunteers from these organisation/institutions and members of vulnerable EU citizens’ community. Questions were asked about their experience and knowledge regarding access to health care for vulnerable EU citizens. Data was analyzed using qualitative content analysis. Results: Three main categories and one final theme were developed during data analysis. The first category “Difficult to access health care for vulnerable EU citizens in Sweden without European Health Insurance” elaborates the dependence of vulnerable EU citizens’ access to health care on having health insurance, specifically European Health Insurance and National Health Insurance. It also describes what kind of access to health care vulnerable EU citizens have in Sweden. The second category “Decision about how much access to health care provide for vulnerable EU citizens lies on medical personnel” discusses the situation of health care personnel when they treat vulnerable EU citizens in hospitals. The third category “Organisations, Doctors of the World and Health on Equal Terms, mediate connection between vulnerable EU citizens and hospitals, so they can have their right to health fulfilled” elaborates about the role the organisation plays when vulnerable EU citizens are in need of health care. After grouping categories and looking at the data from more interpretive, abstracted higher level, the final theme was created “Lack of attention from the national and international levels to the situation of vulnerable EU citizens’ access to health care”. Conclusion: This study highlights the difficulty for vulnerable EU citizens to access health care in Umeå if they do not have European Health Insurance. Being treated as undocumented migrants is the only way they have access to emergency services. Health care personnel feel insecure when treating vulnerable EU citizens, because there are no clear guidelines when vulnerable EU citizens can be treated as undocumented migrants as well as what is included in the clause “the care that cannot wait”. Because of this situation, vulnerable EU citizens sometimes are not able to receive the medical help they need. Organisations, Doctors of the World and Health on Equal Terms, help to mediate the connection between vulnerable EU citizens and hospitals which helps them to access the health care and fulfille their right to health. Lack of attention from the national as well as international governments to this situation is found to be important factor influencing vulneralbe EU citizens’ access to health care

L’évaluation de l’action humanitaire (ÉAH) est un outil valorisé pour soutenir l’imputabilité, la transparence et l’efficience de programmes humanitaires contribuant à diminuer les inéquités et à promouvoir la santé mondiale. L’EAH est incontournable pour les parties prenantes de programme, les bailleurs de fonds, décideurs et intervenants souhaitant intégrer les données probantes aux pratiques et à la prise de décisions. Cependant, l’utilisation de l’évaluation (UÉ) reste incertaine, l’ÉAH étant fréquemment menée, mais inutilisé. Aussi, les conditions influençant l’UÉ varient selon les contextes et leur présence et applicabilité au sein d’organisations non-gouvernementales (ONG) humanitaires restent peu documentées. Les évaluateurs, parties prenantes et décideurs en contexte humanitaire souhaitant assurer l’UÉ pérenne détiennent peu de repères puisque rares sont les études examinant l’UÉ et ses conditions à long terme. La présente thèse tend à clarifier ces enjeux en documentant sur une période de deux ans l’UÉ et les conditions qui la détermine, au sein d’une stratégie d’évaluation intégrée au programme d’exemption de paiement des soins de santé d’une ONG humanitaire. L’objectif de ce programme est de faciliter l’accès à la santé aux mères, aux enfants de moins de cinq ans et aux indigents de districts sanitaires au Niger et au Burkina Faso, régions du Sahel où des crises alimentaires et économiques ont engendré des taux élevés de malnutrition, de morbidité et de mortalité. Une première évaluation du programme d’exemption au Niger a mené au développement de la stratégie d’évaluation intégrée à ce même programme au Burkina Faso. La thèse se compose de trois articles. Le premier présente une étude d’évaluabilité, étape préliminaire à la thèse et permettant de juger de sa faisabilité. Les résultats démontrent une logique cohérente et plausible de la stratégie d’évaluation, l’accessibilité de données et l’utilité d’étudier l’UÉ par l’ONG. Le second article documente l’UÉ des parties prenantes de la stratégie et comment celle-ci servit le programme d’exemption. L’utilisation des résultats fut instrumentale, conceptuelle et persuasive, alors que l’utilisation des processus ne fut qu’instrumentale et conceptuelle. Le troisième article documente les conditions qui, selon les parties prenantes, ont progressivement influencé l’UÉ. L’attitude des utilisateurs, les relations et communications interpersonnelles et l’habileté des évaluateurs à mener et à partager les connaissances adaptées aux besoins des utilisateurs furent les conditions clés liées à l’UÉ. La thèse contribue à l’avancement des connaissances sur l’UÉ en milieu humanitaire et apporte des recommandations aux parties prenantes de l’ONG. / Evaluation of humanitarian action (EHA) is increasingly deployed as a means to enhance accountability, transparency, and efficiency of humanitarian programs aimed at reducing health inequities and promoting global health. EHA has become a vital tool for program stakeholders, funding agencies, and policy-makers seeking to render practice and decision-making more evidence-based. However, considerable uncertainty remains about evaluation use (EU), as EHA is frequently conducted without being used. Moreover, conditions that influence EU vary across contexts and their applicability in humanitarian non-governmental organizations (NGOs) remains unclear. Program evaluators, stakeholders, and policy-makers in humanitarian contexts have little guidance to support long-term EU, given that few studies have documented EU and its conditions over time. The aim of the present qualitative thesis is to shed light on these issues by documenting EU and the conditions influencing it over a 29-month period within an evaluation strategy embedded into a humanitarian NGO’s health care user fee exemption program. To facilitate access to care, the exemption program subsidized the health service fees of mothers, children under five, and indigents in health districts of Niger and Burkina Faso—West African Sahel regions where food crises and poverty have engendered high rates of malnutrition, morbidity, and mortality. Initial evaluation of the exemption program in Niger led to development of the evaluation strategy subsequently integrated into the same program developed in 2008 in Burkina Faso. The thesis consists of three articles. The first presents an evaluability assessment (EA), a preliminary step undertaken to determine whether an EU evaluation was feasible. Results showed the evaluation strategy’s logic was coherent and plausible, data was accessible, and evaluation strategy stakeholders deemed an EU study to be useful. The second article documents how stakeholders engaged in EU and how it served them and advanced the NGO’s mission. Results showed that stakeholders used findings instrumentally, conceptually, and persuasively, but used evaluation processes only instrumentally and conceptually. The third article identifies the conditions stakeholders saw as influencing EU over time. Key influential conditions were users’ attitudes toward evaluation, stakeholders’ interactions and communications, and evaluators’ skill in producing and sharing evaluation-based knowledge tailored to users’ needs. This thesis furthers knowledge on EU in the humanitarian action context and provides practical recommendations for stakeholders of NGOs.

A forma atual da organização local dos serviços de saúde motiva o desenvolvimento de estudos que explicitem a busca de cuidados terapêuticos, permitindo, assim, pensar a organização e funcionamento da rede de serviços de saúde com mais dinamismo, à qual as pessoas possam optar, ou outras formas de cuidado, que melhor resolvam seus problemas de saúde. A temática do presente estudo visa a estabelecer relações entre a rede de serviços de saúde disponíveis e as práticas e trajetórias terapêuticas de pacientes portadores de câncer,em um Município da região Noroeste do Estado do Rio Grande do Sul. O presente estudo tem por objetivo conhecer e caracterizar essa rede, bem como a utilização de serviços e as trajetórias e práticas terapêuticas dos usuários portadores de câncer, no Município referido. É um estudo exploratório, descritivo, de abordagem qualitativa, com uso de entrevistas a 13 sujeitos cadastrados na Liga Feminina de Combate ao Câncer do Município. As entrevistas identificaram problemas em relação ao modelo de atenção e de gestão da saúde, revelados pelas dificuldades que os sujeitos apresentam em suas trajetórias terapêuticas, com vários caminhos traçados para encontrar o tratamento adequado. Desta forma, também foram muitas as práticas terapêuticas procuradas pelos sujeitos, devido às dificuldades de atendimento na rede de assistência à saúde do Município. Os resultados apontaram para a necessidade de problematizar junto aos gestores, trabalhadores de saúde, prestadores de serviço e instâncias de controle social do Sistema Único de Saúde, a oferta de serviços de saúde tanto no âmbito municipal, quanto regional. Para a efetivação de um atendimento integral, é importante que os serviços de saúde se organizem para atender às necessidades definidas pelos sujeitos, no sentido de minimizar as assimetrias no atendimento à atenção oncológica, como também a outras especialidades. / The current configuration of the health services organization, is reason for the development of studies that specify the search for therapeutic care, thus allowing thinking over the organization and operation of the health services network in a more dynamic way so that people may choose health services or other care alternatives that best solve their health problems. The theme of this study aims at establishing a relationship between the available network of health services and the therapy practices and trajectories of patients with cancer in the municipality, state of Rio Grande do Sul. This study has therefore the objective of learning and characterizing the available network of health services, the utilization of services and the therapy trajectories and practices of users with cancer in the studied municipality. It is an exploratory, descriptive study of qualitative approach with the application of interviews with 13 subjects enrolled in the Feminine League for Coping Cancer in the municipality. The interviews demonstrate problems regarding the model of health care and management, revealed by the difficulties that the subjects present over their therapy trajectories with several ways to be traced in order to find the proper treatment. The subjects also searched for several therapy practices due to the care difficulties in the local health care network. The results point out to the need of raising the problem of the offer of health services both in the municipal and in the regional range with the management staff, health workers, services professionals and sectors of social control of the SUS. In order to perform an integral care, it is important that the health services get organized in order to meet the health needs as defined by the subjects in the sense of minimizing the asymmetries in the attendance of oncological care as well as of other specialties. / La forma actual de la organización de los servicios de salud, motiva el desarrollo de estudios que expliciten la búsqueda de cuidados terapéuticos, permitiendo así pensar la organización y el funcionamiento de la red de servicios de salud con más dinamismo, en la cual las personas puedan optar por servicios de salud o otras formas de cuidado, que mejor resuelvan sus problemas de salud. La temática del presente estudio visa, establecer una relación entre la red de servicios de salud disponibles y las prácticas y trayectorias terapéuticas de pacientes portadores de cáncer en la municipalidad, provincia de Rio Grande do Sul. El presente estudio tiene, el objetivo de conocer y caracterizar la red de servicios de salud disponible, la utilización de servicios y las trayectorias y prácticas terapéuticas de usuarios portadores de cáncer en aquella municipalidad. Es un estudio exploratorio, descriptivo de abordaje cualitativo, con aplicación de entrevistas a 13 sujetos registrados en la Liga Femenina de Combate al Cáncer de la Municipalidad. Las entrevistas demuestran problemas con relación al modelo de atención y de gestión de la salud, revelados por las dificultades que los sujetos presentan en sus trayectorias terapéuticas con varios caminos trazados para encontrar el tratamiento adecuado. De esta forma, también fueron varias las prácticas terapéuticas buscadas por los sujetos debido a las dificultades de atención en la red de asistencia a la salud de la municipalidad. Los resultados apuntan para la necesidad de tratar el problema junto a los gestores, trabajadores de salud, prestadores de servicio e instancias de control social del SUS, la oferta de servicios de salud tanto en el ámbito municipal como en el regional. Para los efectos de una atención integral, es importante que los servicios de salud se organicen para atender las necesidades en salud definidas por los sujetos en el sentido de minimizar las asimetrías en la atención oncológica, como también en otras especialidades.