The aim of this thesis is to map regional variability in the intensity of mortality using methods avoidable mortality and a few selected characteristics of health care. The thesis describes the development of the concept of avoidable mortality, which is then used for the Czech Republic for the period 2006-2010 and to individual districts for the period 2006-2010. Furthermore, this thesis focuses on the relationship between expenditures of General Health Insurance Company and the level of mortality in the regions. For showing regional differences depending on the health care intensity of mortality from ischemic heart disease (both acute and chronic forms) was also selected, depending on the distance of specialized medical care. The last chapter focuses on National screening programs and cancer mortality, which are integrated in a comparison of the percentage of people examine in this program for districts. The relationship between spending per insured and intensity of mortality and outcomes related to the intensity of mortality, depending on the availability of specialized health care has been confirmed by statistical methods - correlation (Pearson correlation coefficient). Relationship between the intensity of mortality in cancer within screening programs and the percentage of people who passed...

This master thesis deals with the field of postgraduate medical education. The main goal of this thesis is deeper understanding of problems in the educational system. By means of a qualitative research the thesis explores the problems and causes of current postgraduate educational system from the perspective of young physicians. The research is based on a series of semi-structured interviews with physicians who are currently passing through a phase of postgraduate medical education. Results of the survey show the most questionable fact, according to participants, is the lack of the educational leadership which is supposed to be secured by the assigned supervisor. Despite the formal rules, this role is often ensured merely formally or is missing at all. Participants also mentioned difficulties related to accomplishing of specialized practical training and required procedures. Both of them are frequently subordinated to informal rules. The main findings are based on revealing the causes of problems mentioned above. The reasons of ascertained discrepancy are introduced with the theoretical help of the theory of informal institutions by G. Helmke and S. Levitsky. Through the lense of chosen theory the issue is that there is insufficient efficiency of formal institutions. Therefore, prospective solution should...

Background: The COVID-19 pandemic calls attention to the importance of sustainable healthcare systems. Frail healthcare systems can become overwhelmed during public health crises, further exacerbating the human, economic, and political toll. Significant work has been done to describe the general attribute of sustainability and resilience in healthcare systems during crises. The next step would be to identify the research domains that has been highlighted during COVID-19 pandemic in order to reflect and achieve further sustainability in healthcare systems.  Methods: A scoping review of the literature was conducted to identify recurring themes, research domains and capacities needed to maintain healthcare systems’ sustainability in COVID-19 outbreak. Until 13 December 2020, six electronic databases were searched using specific keywords such as ‘sustainability,’ ‘resilience,’ and ‘surge capacity’ in ‘healthcare systems.’ Peer-reviewed articles went through a scientometric analysis mapping research fields, domains, study destinations and keywords.  Results: 104 studies met the inclusion criteria – majority (75%) focused on medical research followed by interdisciplinary (12%), social science (5%), and environment studies (5%). Originally identified domains of healthcare systems’ sustainability research included ‘capacity calculation,’ ‘telehealth,’ ‘environment,’ ‘inequity,’ ‘data,’ ‘holistic nexus planning,’ ‘social & environmental risk factor,’ ‘transport connectivity,’ and ‘vulnerability.’  Conclusion: This scoping review represents a systematic assessment of the research domains of healthcare systems’ sustainability during COVID-19 pandemic. Further refined and broadened sustainability framework is required so that healthcare systems can simultaneously achieve sustainable transformations in healthcare practice and health service delivery as well as improve their preparedness for emergencies.

[pt] A gamificação de sistemas visa engajar usuários com as principais funcionalidades de sistemas. Tal engajamento é alcançado via um modelo conceitual de gamificação que associa elementos do jogo (pontos, etc.) e regras (políticas de classificação, etc.) às funcionalidades. Vários sistemas existentes, isto é, que não foram originalmente projetados com gamificação em mente, precisam ser gamificados. Porém, o apoio prático às atividades de desenvolvimento necessárias para gamificar sistemas existentes é precário. Gamificar um sistema existente requer: (i) a definição do modelo de gamificação que guia a incorporação de elementos de jogos e regras ao sistema; e (ii) um conhecimento das atividades necessárias à gamificação desse sistema. Infelizmente, há poucos modelos de gamificação bem definidos, menos ainda focados no apoio à saúde pública, especialmente na prevenção de doenças transmitidas por mosquitos. Também não há método sistemático que guie as atividades específicas da gamificação de sistemas existentes. Esta dissertação de mestrado endereça as limitações mencionadas acima com base na experiência prática de se gamificar o sistema VazaZika. VazaZika é um sistema que encoraja a prevenção a doenças transmitidas por mosquito como Zika e Dengue. Primeiro, nós refinamos um método da literatura para lidar com a gamificação de sistemas existentes. Segundo, nós introduzimos um modelo de gamificação com 12 elementos e 16 regras de jogos para gamificar sistemas de prevenção das doenças acima. O nosso modelo foi avaliado com 20 usuários em termos de facilidade de uso, interface, diversão, motivação, potencial de uso constante e potencial de disseminação do sistema. Nossos resultados são promissores: (i) após refinamentos baseados em experiência, o método foi aplicado com sucesso na gamificação do VazaZika; (ii) identificamos 22 atividades de desenvolvimento que se tornaram desafiadoras para os desenvolvedores durante a gamificação; e (iii) nosso modelo de gamificação apoiou a construção de um sistema fácil de usar e capaz de engajar usuários em funcionalidades essenciais à saúde, como o relato de criadouros de mosquito. Esta dissertação provê guias adicionais à gamificação de sistemas existentes e realça oportunidades para trabalhos futuros. / [en] Software gamification aims to leverage the user engagement with key features of software systems. Engagement is promoted by a conceptual gamification model that associates game elements (e.g., points) and rules (e.g., ranking policy) with features. It is quite common to gamify existing systems that were not originally designed with gamification in mind. Unfortunately, the development activities required to gamify a system are barely supported in practice. Gamifying an existing system requires: (i) the definition of a gamification model for guiding the incorporation of game elements and rules into an existing system; and (ii) the knowledge about key development activities to gamify this existing system. However, there are only a few models aimed to support the gamification of existing systems, and none is specific to software domains such as the prevention of mosquito-borne diseases. More critically, there is no systematic method aimed to guide the activities of gamifying existing systems. This Master s dissertation addressed the aforementioned limitations based on our experience with gamifying the VazaZika system. VazaZika is a system that encourages the prevention of mosquitoborne diseases such as Zika, Dengue, and Chikungunya. We introduce a gamification method that supports key activities during the gamification of existing systems, plus a gamification model composed of 12 game elements and 16 rules. Second, we evaluate our model with 20 users by means of ease of use, user interface, user fun, user motivation, and the potential for both constant system use and system dissemination. Our results are promising: (i) after some experience-based refinements, our method was successfully applied in the VazaZika gamification; (ii) we have identified 22 development activities that became challenging for developers to perform along the VazaZika gamification; these activities helped us to shape our method; and (iii) our gamification model has resulted in an easy-to-use system that is able to improve user engagement with critical healthcare-related features, such as the report of mosquito breeding sites. In summary, this dissertation contributed with additional guidance for supporting gamification of existing systems while shedding light on opportunities for future work.

Thesis (MBA (Business Management))--University of Stellenbosch, 2007. / ENGLISH ABSTRACT: The democratic government of South Africa inherited a healthcare system that was fragmented and inequitable. The Department of Health was mandated by the Constitution and the Bill of Rights to implement a system whereby quality, affordable healthcare could become available to all citizens of the country within the constraints of the available resources. The objective of government, through reform legislation, is to establish a social health insurance (SHI) system for the country which will ultimately lead to the implementation of a national health insurance (NHI) system in order to achieve universal coverage. Medical schemes have been identified as an important component of this transformation process. The private healthcare industry, represented largely by medical schemes, acknowledges that SHI is the ideal pathway chosen by government to achieve universal coverage, but is concerned with the process being used to achieve this aim, the pace at which transformation is occurring, and the effect of this on medical schemes. The movement towards an equitable healthcare system required the introduction of reform legislation necessary for the establishment of an enabling environment. The implementation of community rating, open enrolment and prescribed minimum benefits (PMBs) reforms, succeeded in ending the risk-rating of those medical schemes that were excluding members who were considered vulnerable. However, these legislations were not followed by a risk equalisation mechanism in the form of a proposed risk equalisation fund (REF) for the South African environment. The main purpose of this fund is to ensure that equity within the medical schemes industry is maintained through the equalisation of the risks that had resulted from the implementation of the first components of reform legislation. The research into the experiences of other countries shows that South Africa is the only country in the world that has implemented the above legislation without a system of risk equalisation. All indications are that the proposed implementation of the REF has been delayed to beyond 2009. In addition, the reform legislation regarding the statutory solvency ratio requires medical schemes to maintain this ratio at 25 percent. This, together with the delay in REF is placing financial pressure on medical schemes. Low income medical schemes (LIMS) legislation is pending implementation. Its purpose is to provide basic medical cover to the lower income market until such time that the components of SHI have been fully negotiated; it is thus an interim measure, but no indication to implement LIMS has yet been given. The average number of years for a country to implement SHI is 70. The South African situation is only 13 years old and though some success has been achieved during this relatively short period, much more still needs to be accomplished. The research shows that, the approximate timelines and intended sequence of implementing the reform legislation were perhaps too ambitious. This has caused the industry stakeholders to be disillusioned about the current state of affairs. Given the time that has elapsed, and considering the progress that has been made thus far, it is recommended that the existing plan be revised or even replaced with a more realistically timed one. This will restore some of the confidence into the “future healthcare vision of universal coverage” for South Africa intended by the government, through a system of social health insurance. / AFRIKAANSE OPSOMMING: Die demokratiese regering van Suid-Afrika het ‘n gesondheidsorgstelsel geërf wat gefragmenteerd en onregverdig was. Die Departement van Gesondheid het in die Grondwet en die Handves van Menseregte die mandaat gekry om ‘n stelsel te implementeer waarvolgens bekostigbare gesondheidsorg van goeie gehalte vir alle landsburgers beskikbaar kon word binne die beperkinge van die beskikbare hulpbronne. Die regering se doelwit met hervormingswetgewing is om ‘n maatskaplike gesondheidsversekeringstelsel (SHI) vir die land daar te stel wat uiteindelik sal lei tot die implementering van ‘n nasionale gesondheidstelsel (NHI) met die oog op universele dekking. Mediese skemas is geïdentifiseer as ‘n sleutelkomponent van hierdie transformasieproses. Die privategesondheidsorgindustrie, wat grotendeels deur mediese skemas verteenwoordig word, erken dat SHI die ideale weg is wat deur die regering gekies is om universele dekking te bereik, maar is besorg oor die proses wat gebruik word om hierdie doelwit te bereik, die pas waarteen transformasie geskied, en die uitwerking hiervan op mediese skemas. Die beweging na ‘n regverdige gesondheidsorgstelstel het vereis dat hervormingsgswetgewing ingestel word soos nodig vir die daarstelling van ‘n omgewing wat dit moontlik maak. Die implementering van gemeenskapsevaluering, oop lidmaatskap en hervorming van voorgeskrewe minimum voordele (PMB’s) was suksesvol vir die beëindiging van die risikoevaluering van daardie skemas wat lede uitgesluit het wat as kwesbaar beskou is. Maar hierdie wetgewing is nie opgevolg deur ‘n risikogelykstellingsmeganisme in die vorm van ‘n voorgestelde risikogelykstellingsfonds (REF) vir die Suid-Afrikaanse omgewing nie. Die hoofdoelwit van hierdie fonds is om te verseker dat gelykheid binne die mediesefondsindustrie gehandhaaf word deur die gelykstelling van risiko’s wat die gevolg was van die implementering van die aanvanklike hervormingswetgewing. Navorsing oor die ondervinding in ander lande toon dat Suid-Afrika die enigste land in die wêreld is wat sodanige wetgewing geïmplementeer het sonder ‘n stelsel van risikogelykstelling. Alle tekens dui daarop dat die voorgestelde implementering van die REF uitgestel is tot na 2009. Daarbenewens vereis die hervormingswetgewing ten opsigte van die statutêre solvensieverhouding dat mediese skemas hierdie verhouding op 25% handhaaf. Tesame met die vertraging in REF plaas dit finansiële druk op mediese skemas. Lae-inkomstemedieseskemas (LIMS) is verdere hervormingswetgewing wat wag op implementering. Die doel daarvan is om basiese mediese dekking te voorsien aan die laer-inkomstemark totdat die komponente van SHI ten volle onderhandel is. Dit is dus ‘n oorgangsmaatreël, maar daar is nog geen aanduiding gegee van die implementering van LIMS nie. Die gemiddelde tyd wat dit neem vir ‘n land om SHI te implementeer, is 70 jaar. Die Suid-Afrikaanse situasie is net 13 jaar oud, en hoewel daar heelwat sukses behaal is in hierdie relatief kort tydperk, moet daar nog baie meer bereik word. Navorsing toon dat die geskatte tydperk en voorgenome opeenvolging van die implementering van die hervormingswetgewing dalk te ambisieus was. Dit het veroorsaak dat die belanghebbers in die industrie ontnugter is oor die huidige stand van sake. Met inagneming van die tyd wat verloop het en die vordering wat tot dusver gemaak is, word daar aanbeveel dat die bestaande plan hersien word of selfs vervang word deur een met ‘n meer realistiese tydsbeperking. Dit sal ‘n mate van vertroue herstel in die Suid-Afrikaanse Regering se “toekomsvisie van universele gesondheidsdekking” deur ‘n stelsel van maatskaplike gesondheidsversekering.

This research on healthcare strategies of home-based, low-wage, immigrant careworkers contributes to the ways medical anthropology, migration studies and social science understand human-economy-family care relationships and health and carework as commodities in today's global economy. It reveals the consequences for workers as they defray the costs of care for the Italian government and contribute to their home economies. This research was conducted in Genoa, Italy, which has the largest percentage of people over the age of 70 in any city of its size in the world and a tradition of sending and receiving immigrant workers. The main question was: Under the circumstances of providing labor-intensive, in-home supportive services, how do immigrant workers respond to their own health needs? The researcher collected data from interviews with 50 careworkers, 25 professionals who provide services to the careworkers, and 23 administrators in the health system, government agencies, labor unions, and the Catholic Church. The careworkers interviewed were women from South America, as they do most of the carework jobs in this city. Long-term participant observation and interview data were analyzed to: 1) produce empirical data on health concerns of and healthcare resource use by migrant careworkers; and 2) investigate the relationships between health concerns, living/working conditions, and healthcare resource use of transnational immigrants in the informal economy. The data showed that the Catholic Church promoted immigrants as able workers, aided their elderly parishioners, and provided necessary mental health support to careworkers who experienced stress. The data also revealed that the health care system of Italy functioned well to address the physical health concerns of immigrant careworkers. The relationship between the client and the worker was important for the general well-being of the worker and her ability to maintain her general health, have time for medical appointments, socialize outside of the workplace, and attend community events. This study examined: strategies for using health resources; responses of the Italian medical system personnel to anti-immigrant legislation; use of non-State resources to meet health needs; the health consequences of caring for an elderly person in the private home; and ways to address these health consequences.

Les changements qui ont marqué le monde industriel pendant les dernières décennies ont eu un impact significatif sur la réorganisation du travail. La fragmentation de l'organisation à intégration verticale ne peut plus être contestée. L’organisation en réseau se profile désormais comme un modèle capable de répondre au nouveau contexte socio-économique. Avec une structure à frontières irrégulières, à l'intérieur desquelles les organisations et les actions apparaissent moins ordonnées, cette nouvelle forme organisationnelle demeure toutefois objet à exploration, afin d'identifier notamment les règles qui déterminent autant sa structure que les comportements des acteurs qui ont un impact direct sur son fonctionnement. Bien que le secteur privé ait été le premier à subir les effets de ces changements, le secteur public n'en fait pas exception. Le domaine de la santé s'inscrit aujourd'hui dans le paradigme de l'organisation en réseau. L’objectif de cette recherche est de comprendre les mécanismes qui assurent le maintien de cette structure organisationnelle et favorisent sa régulation et son institutionnalisation. Il s’agit plus précisément d’étudier les facteurs qui permettent son fonctionnement interne, soit les mécanismes qui assurent une coordination des services et la collaboration des acteurs. À cette fin, nous avons réalisé une étude de cas qui porte sur un programme de santé, le programme cible santé – maladies chroniques, au sein d’un CISSS du Québec, un réseau local de services de santé. Notre recherche nous a permis d’analyser en profondeur la nature de ce CISSS qui se profile comme un réseau fortement régulé et institutionnalisé et de mettre en évidence l’importance qu’occupent les acteurs dans son fonctionnement réel. Si la définition de l’objectif commun, aligné à la stratégie organisationnelle, permet la planification de l’intégration des ressources et l’adaptabilité aux besoins des usagers, c’est l’équilibre entre ces facteurs qui assure la performance du réseau. La collaboration entre les acteurs, fondée sur la confiance, favorise un tel équilibre et permet la naissance de solutions qui répondent à l’objectif commun, par l’innovation fondée sur le partage ouvert des connaissances. Cela assure une coordination efficace des services de santé. Par ailleurs, si la structure cadre l’action des acteurs, par la définition de règles, ces derniers, par leur implication volontaire au fonctionnement du système, le redéfinissent également. / The changes that have shaped the industry over the past decades had a significant impact on work reorganisation. The break-up of the vertically integrated organisation cannot be questioned any more. The network organisation currently stands out as the model that addresses the new socioeconomic context. With irregular borders, inside which departments and actions appear less orderly, this new organisation structure remains an area of exploration aimed to identify the rules that determine both its design and the behaviours of the players that have direct impact on its operations. Although the private sector was the first to carry the effects of these changes, the public sector was impacted as well. Health care is governed today by the network organisation structure paradigm. The objective of this research is to understand the mechanisms that support this organizational structure, favouring its regulation and its establishment. More precisely it is focused on the analysis of the factors that allow its internal functioning, the coordination of services and the collaboration between different players. To this aim we performed a case study on the chronic disease healthcare target program within a Quebec medical services network (CISSS). Our inquiry allowed us to deep dive into the functioning of this CISSS that stands out as a strongly regulated and institutionalised network and to bring into the spotlight the importance of different players to its operations. The definition of the common objective, aligned with the organizational strategy, allows for the resource integration planning and adaptability to customer needs but it is the harmonisation of these factors that ensures the network’s performance. The stakeholders collaboration based on mutual confidence favours such harmonisation and allows for the identification of solutions that address the common objective, through innovation based on a wide information sharing. This ensures an efficient coordination of the healthcare services. Otherwise, while the structure frames the stakeholders’ actions by defining rules, the stakeholders also reshape the system through their deliberate involvement.

Internet of Things is expanding to the areas such as healthcare, home management, industrial, agriculture, and becoming pervasive in our life, resulting in improved efficiency, accuracy and economic benefits. Smart sensors with embedded interfacing integrated circuits (ICs) are important enablers, hence, variety of smart sensors are required. However, each type of sensor requires specific interfacing chips, which divides the huge market of sensors’ interface chips into lots of niche markets, resulting in high develop cost and long time-to-market period for each type. Software defined sensor is regarded as a promising solution, which is expected to use a flexible interface platform to cover different sensors, deliver specificity through software programming, and integrate easily into the Internet of Things. In this work, research is carried out on the design and implementations of ultra low power analog interface circuits toward software defined sensors for healthcare services based on Internet of Things.    This thesis first explores architectures and circuit techniques for energy-efficient and flexible analog to digital conversion. A time-spreading digital calibration, to calibrate the errors due to finite gain and capacitor mismatch in multi-bit/stage pipelined converters, is developed with short convergence time. The effectiveness of the proposed technique is demonstrated with intensive simulations. Two novel circuit level techniques, which can be combined with digital calibration techniques to further improve the energy efficiency of the converters, are also presented. One is the Common-Mode-Sensing-and-Input-Interchanging (CSII) operational-transconductance-amplifier (OTA) sharing technique to enable eliminating potential memory effects. The other is a workload-balanced multiplying digital-to-analog converter (MDAC) architecture to improve the settling efficiency of a high linear multi-bit stage. Two prototype converters have been designed and fabricated in 0.13 μm CMOS technology. The first one is a 14 bit 50 MS/s digital calibrated pipelined analog to digital converter that employs the workload-balanced MDAC architecture and time-spreading digital calibration technique to achieve improved power-linearity tradeoff. The second one is a 1.2 V 12 bit 5~45 MS/s speed and power-scalable ADC incorporating the CSII OTA-sharing technique, sample-and-hold-amplifier-free topology and adjustable current bias of the building blocks to minimize the power consumption. The detailed measurement results of both converters are reported and deliver the experimental verification of the proposed techniques.     Secondly, this research investigates ultra-low-power analog front-end circuits providing programmability and being suitable for different types of sensors. A pulse-width- -modulation-based architecture with a folded reference is proposed and proven in a 0.18 μm technology to achieve high sensitivity and enlarged dynamic range when sensing the weak current signals. A 8-channel bio-electric sensing front-end, fabricated in a 0.35 μm CMOS technology is also presented that achieves an input impedance of 1 GΩ, input referred noise of 0.97 Vrms and common mode rejection ratio of 114 dB. With the programmable gain and cut-off frequency, the front-end can be configured to monitor for long-term a variety of bio-electric signals, such as electrooculogram (EOG), electromyogram (EMG), electroencephalogram (EEG) and electrocardiogram (ECG) signals. The proposed front-end is integrated with dry electrodes, a microprocessor and wireless link to build a battery powered E-patch for long-term and continuous monitoring. In-vivo test results with dry electrodes in the field trials of sitting, standing, walking and running slowly, show that the quality of ECG signal sensed by the E-patch satisfies the requirements for preventive cardiac care.    Finally, a wireless multimodal bio-electric sensor system is presented. Enabled by a customized flexible mixed-signal system on chip (SoC), this bio-electric sensor system is able to be configured for ECG/EMG/EEG recording, bio-impedance sensing, weak current stimulation, and other promising functions with biofeedback. The customized SoC, fabricated in a 0.18 μm CMOS technology, integrates a tunable analog front-end, a 10 bit ADC, a 14 bit sigma-delta digital to current converter, a 12 bit digital to voltage converter, a digital accelerator for wavelet transformation and data compression, and a serial communication protocol. Measurement results indicate that the SoC could support the versatile bio-electric sensor to operate in various applications according to specific requirements. / <p>QC 20151221</p>

La reconnaissance du pluralisme du système de santé, et donc des interdépendances unissant l’État aux acteurs participant à l’offre des services de santé, pose non seulement la question de la capacité de l’État à gouverner selon ses objectifs, mais aussi celle de la forme des interventions entreprises à cette fin. Cette thèse vise à comprendre comment se développe la participation de l’État à la gouverne d’un secteur de services de santé, et plus particulièrement comment ses interactions avec les acteurs impliqués dans l’offre des services affectent, au fil du temps, les possibilités d’actions étatiques sous-jacentes à la sélection d’instruments de gouverne spécifiques. Elle propose pour ce faire un modèle théorique qui s’inspire de la littérature traitant des instruments de gouverne ainsi que de la théorie de la pratique (Bourdieu). La participation de l’État à la gouverne y est conçue comme le résultat d’un processus historique évolutif, marqué alternativement par des périodes de stabilité et de changement en regard des instruments mobilisés, qui se succèdent selon l’articulation des interactions et des contextes affectant les possibilités d’action que les acteurs perçoivent avoir. Ce modèle a été appliqué dans le cadre d’une étude de cas portant sur le secteur génétique québécois (1969-2010). Cette étude a impliqué l’analyse processuelle et interprétative de données provenant de sources documentaires et d’entrevues réalisées auprès de représentants du ministère de la Santé et des Services sociaux ainsi que de médecins et chercheurs œuvrant dans le secteur de la génétique. Ces analyses font émerger quatre périodes de stabilité en regard des instruments de gouverne mobilisés, entrecoupées de périodes de transition au cours desquelles le Ministère opère une hybridation entre les instruments jusque là employés et les nouvelles modalités d’intervention envisagées. Ces résultats révèlent également que l’efficacité de ces instruments - c’est-à-dire la convergence entre les résultats attendus et produits par ceux-ci - perçue par le Ministère constitue un facteur de première importance au regard de la stabilisation et du changement des modalités de sa participation à la gouverne de ce secteur. En effet, lorsque les instruments mobilisés conduisent les médecins et chercheurs composant le secteur de la génétique à agir et interagir de manière à répondre aux attentes du Ministère, les interventions ministérielles tendent à se stabiliser autour de certains patterns de gouverne. À l’inverse, le Ministère tend à modifier ses modes d’intervention lorsque ses interactions avec ces médecins et chercheurs le conduisent à remettre en cause l’efficacité de ces patterns. On note cependant que ces changements sont étroitement liés à une évolution particulière du contexte, amenant une modification des possibilités d’action dont disposent les acteurs. Ces résultats révèlent enfin certaines conditions permettant au Ministère de rencontrer ses objectifs concernant la gouverne du secteur de la génétique. Les instruments qui impliquent fortement les médecins et chercheurs et qui s’appuient sur des expertises qu’ils considèrent légitimes semblent plus susceptibles d’amener ces derniers à agir dans le sens des objectifs ministériels. L’utilisation de tels instruments suppose néanmoins que le Ministère reconnaisse sa propre dépendance vis-à-vis de ces médecins et chercheurs. / The recognition of a pluralistic healthcare system based on the interdependency between the State and other healthcare providers raises the question on how the State can manage according its own goals and what are the necessary actions to achieve those. The current thesis aims at understanding how can the State participate in governing the healthcare sector. More precisely, it intends to accurately look at how the State’s interaction with several health care providers impacts over time its action capacities to select specific governance instruments. To achieve these objectives, the thesis uses a theoretical framework based on literature about governance instruments as well as Bourdieu’s practice theory. The State’s participation in governance is conceived as an evolving historical process with periods of stability and change over instruments in use. They alternate according the interaction dynamic and the context influencing an actor’s perception of action possibilities. This framework is applied on a case study: Quebec’s genetic sector (1969-2010). This study involves processes and interpretative analysis of data originating from bibliographical sources and interviews conducted amongst representatives of the Ministère de la Santé et des Services Sociaux (hereafter: the ministry), as well as physicians and researchers working in genetics. The analysis outlines four periods of stability in regards to the mobilization of governance instruments, intertwined by periods of transition during which the ministry operates hybridization between instruments used and new intervention modes considered. These results show that the efficiency of these instruments – meaning the convergence between expected results and actual outcomes – perceived by the ministry is a prime factor in terms of stabilization and change in its participation in the governance of the field. Thus, when used instruments lead physicians and researchers in genetics to act and interact in a way responding to the ministry expectations, its interventions tend to gravitate towards a certain governance pattern. On the other hand, the ministry tends to modify its methods of intervention when its interactions with the physicians and researchers shed doubts on the efficiency of those patterns. It was noticed that these changes are closely linked to a particular evolution of the context, bringing a modification to possible actions available to actors. Finally, results show certain factors allowing the ministry to achieve its objectives in regards to the governance of the genetics sector. The instruments strongly involving physicians and researchers and based on expertise considered to be legitimate appear more likely to bring a favorable action from those specialists in the view of the ministry’s objectives. Nevertheless, using such instruments supposes that the ministry recognizes its own dependence towards these physicians and researchers.

La reconnaissance du pluralisme du système de santé, et donc des interdépendances unissant l’État aux acteurs participant à l’offre des services de santé, pose non seulement la question de la capacité de l’État à gouverner selon ses objectifs, mais aussi celle de la forme des interventions entreprises à cette fin. Cette thèse vise à comprendre comment se développe la participation de l’État à la gouverne d’un secteur de services de santé, et plus particulièrement comment ses interactions avec les acteurs impliqués dans l’offre des services affectent, au fil du temps, les possibilités d’actions étatiques sous-jacentes à la sélection d’instruments de gouverne spécifiques. Elle propose pour ce faire un modèle théorique qui s’inspire de la littérature traitant des instruments de gouverne ainsi que de la théorie de la pratique (Bourdieu). La participation de l’État à la gouverne y est conçue comme le résultat d’un processus historique évolutif, marqué alternativement par des périodes de stabilité et de changement en regard des instruments mobilisés, qui se succèdent selon l’articulation des interactions et des contextes affectant les possibilités d’action que les acteurs perçoivent avoir. Ce modèle a été appliqué dans le cadre d’une étude de cas portant sur le secteur génétique québécois (1969-2010). Cette étude a impliqué l’analyse processuelle et interprétative de données provenant de sources documentaires et d’entrevues réalisées auprès de représentants du ministère de la Santé et des Services sociaux ainsi que de médecins et chercheurs œuvrant dans le secteur de la génétique. Ces analyses font émerger quatre périodes de stabilité en regard des instruments de gouverne mobilisés, entrecoupées de périodes de transition au cours desquelles le Ministère opère une hybridation entre les instruments jusque là employés et les nouvelles modalités d’intervention envisagées. Ces résultats révèlent également que l’efficacité de ces instruments - c’est-à-dire la convergence entre les résultats attendus et produits par ceux-ci - perçue par le Ministère constitue un facteur de première importance au regard de la stabilisation et du changement des modalités de sa participation à la gouverne de ce secteur. En effet, lorsque les instruments mobilisés conduisent les médecins et chercheurs composant le secteur de la génétique à agir et interagir de manière à répondre aux attentes du Ministère, les interventions ministérielles tendent à se stabiliser autour de certains patterns de gouverne. À l’inverse, le Ministère tend à modifier ses modes d’intervention lorsque ses interactions avec ces médecins et chercheurs le conduisent à remettre en cause l’efficacité de ces patterns. On note cependant que ces changements sont étroitement liés à une évolution particulière du contexte, amenant une modification des possibilités d’action dont disposent les acteurs. Ces résultats révèlent enfin certaines conditions permettant au Ministère de rencontrer ses objectifs concernant la gouverne du secteur de la génétique. Les instruments qui impliquent fortement les médecins et chercheurs et qui s’appuient sur des expertises qu’ils considèrent légitimes semblent plus susceptibles d’amener ces derniers à agir dans le sens des objectifs ministériels. L’utilisation de tels instruments suppose néanmoins que le Ministère reconnaisse sa propre dépendance vis-à-vis de ces médecins et chercheurs. / The recognition of a pluralistic healthcare system based on the interdependency between the State and other healthcare providers raises the question on how the State can manage according its own goals and what are the necessary actions to achieve those. The current thesis aims at understanding how can the State participate in governing the healthcare sector. More precisely, it intends to accurately look at how the State’s interaction with several health care providers impacts over time its action capacities to select specific governance instruments. To achieve these objectives, the thesis uses a theoretical framework based on literature about governance instruments as well as Bourdieu’s practice theory. The State’s participation in governance is conceived as an evolving historical process with periods of stability and change over instruments in use. They alternate according the interaction dynamic and the context influencing an actor’s perception of action possibilities. This framework is applied on a case study: Quebec’s genetic sector (1969-2010). This study involves processes and interpretative analysis of data originating from bibliographical sources and interviews conducted amongst representatives of the Ministère de la Santé et des Services Sociaux (hereafter: the ministry), as well as physicians and researchers working in genetics. The analysis outlines four periods of stability in regards to the mobilization of governance instruments, intertwined by periods of transition during which the ministry operates hybridization between instruments used and new intervention modes considered. These results show that the efficiency of these instruments – meaning the convergence between expected results and actual outcomes – perceived by the ministry is a prime factor in terms of stabilization and change in its participation in the governance of the field. Thus, when used instruments lead physicians and researchers in genetics to act and interact in a way responding to the ministry expectations, its interventions tend to gravitate towards a certain governance pattern. On the other hand, the ministry tends to modify its methods of intervention when its interactions with the physicians and researchers shed doubts on the efficiency of those patterns. It was noticed that these changes are closely linked to a particular evolution of the context, bringing a modification to possible actions available to actors. Finally, results show certain factors allowing the ministry to achieve its objectives in regards to the governance of the genetics sector. The instruments strongly involving physicians and researchers and based on expertise considered to be legitimate appear more likely to bring a favorable action from those specialists in the view of the ministry’s objectives. Nevertheless, using such instruments supposes that the ministry recognizes its own dependence towards these physicians and researchers.