Cartas al editor / Revisión por pares

In this comparative policy development analysis, I utilize path-dependence theory and presidential records to analyze President Lyndon Johnson's success in passing Medicare and Medicaid and President Bill Clinton's failure to pass national health care reform. Findings support four major themes from the Johnson administration: 1) President Johnson had a keen understanding of the importance of language in framing debate; 2) He placed control of the legislative process in the hands of a small, select group of seasoned political operatives and career policymaking professionals; 3) He paid considerable attention to the details of negotiations and the policy consequences; and 4) He had a highly developed sense of the political and legislative processes involved in passing major legislation. The case study of the Clinton administration reveals five major themes: 1) There is a lack of evidence that President Clinton remained actively engaged throughout the policy development and legislative processes, instead choosing to delegate the process to the First Lady; 2) There was a naiveté on the part of the Clintons and many administration staff members with regard to the legal and political ramifications of their decisions; 3) The Clintons tried to make the plan fully their own, sharing little credit for its development with Congress; 4) Their attempts to incorporate existing corporate health care delivery structures with their vision for universal coverage proved unworkable; and 5) The extended time from task force launch to bill delivery gave opponents ample time to marshal their opposition forces. I conclude that in developing health care legislation, Johnson had the advantages of: 1) a small group of key policymakers; 2) multiple, simultaneous legislative initiatives which diffused the attention of a more limited media; and, 3) national crises which promoted an environment conducive to sweeping policy change. I suggest that major, national health care reform will not occur until: 1) an economic or geopolitical crisis sets the stage for change; 2) business interests and progressive interests find common ground; and, 3) Americans achieve a new cultural understanding of universal health care as both economically just and economically necessary. / text

Since the economic reform in 1978, China’s health system moved from a commune-based system to a market-driven system. This drastic change resulted in various market failures, including cost inflation, perverse incentives for providers and supplier-induced demand for unnecessary care, increasing inequality in access across regions based on economic status, and other problems. Though China attempted to correct its policy mistakes and reform its inadequate and unjust health care system in order to provide basic universal health coverage for all over the past decade, not everyone has equal access to the same quality of affordable health care, especially the non-resident workers, the poor urban residents, and the rural population. This research uses the framework of the five intellectual tasks to assess the history of China’s health policies, the political economy factors that have driven and shaped the reform of China’s health system, the likely projections of policy options, and potential alternatives for policymakers.

People who use illegal drugs all too often experience stigma and discrimination, criminalization and marginalization in Canada. Substance use has both immediate and chronic health consequences that may require healthcare. However, people who use illegal drugs often experience difficulty accessing equitable care, and stigma has been identified as a key barrier to access. This study explores the provision of health care by nurses in an emergency department for people who use illegal drugs, and the impact of hospital policies and procedures on nurses’ capacity to provide care. The study uses data from in-depth interviews with nurses and policy leaders, and analyses policy documents discussed by nurses in the interviews. This study found that neoliberal policies that result in downsizing of social programs means that patients come to emergency departments with a broad set of health and socials needs that extend beyond what nurses can do. The study also uncovered a lack of cultural safety for Aboriginal patients seeking care. Finally, the study discovered the existence of a culture of stigma in the emergency department. The culture of stigma is transmitted and taken up through individual attitudes, relations of power, intake and treatment protocols, critical policy absences and problematic policy. This study concludes with recommendations for policy development and for future research in this area. / Graduate / 0680 / 0573 / 0569 / heyriver@shaw.ca

People who use illegal drugs all too often experience stigma and discrimination, criminalization and marginalization in Canada. Substance use has both immediate and chronic health consequences that may require healthcare. However, people who use illegal drugs often experience difficulty accessing equitable care, and stigma has been identified as a key barrier to access. This study explores the provision of health care by nurses in an emergency department for people who use illegal drugs, and the impact of hospital policies and procedures on nurses’ capacity to provide care. The study uses data from in-depth interviews with nurses and policy leaders, and analyses policy documents discussed by nurses in the interviews. This study found that neoliberal policies that result in downsizing of social programs means that patients come to emergency departments with a broad set of health and socials needs that extend beyond what nurses can do. The study also uncovered a lack of cultural safety for Aboriginal patients seeking care. Finally, the study discovered the existence of a culture of stigma in the emergency department. The culture of stigma is transmitted and taken up through individual attitudes, relations of power, intake and treatment protocols, critical policy absences and problematic policy. This study concludes with recommendations for policy development and for future research in this area. / Graduate / 0680 / 0573 / 0569 / heyriver@shaw.ca

O presente trabalho tem como objetivo investigar a família no contexto da loucura, considerando-se as formas cotidianas da família compreender o que vive neste cenário e as formas de lidar com o sujeito da loucura em sua casa e nos serviços de saúde mental. Para tanto, buscou-se identificar: as representações da família em relação à loucura; as formas da família se relacionar com o sujeito da loucura; as relações estabelecidas entre a família e a rede de atenção em saúde mental; e o espaço social e político destinado às famílias no campo das políticas públicas de saúde mental. Realizou-se um estudo de caso, com base nas entrevistas realizadas com a mãe de um usuário de um CAPS da capital paulista, entendendose que conhecer aspectos de uma realidade familiar, nos fornece subsídios para refletirmos sobre os rumos tomados pela atenção em saúde mental no Brasil, no âmbito da reforma psiquiátrica. Oferece, ainda, a possibilidade de levantar questões pertinentes à sua constante reformulação. A questão da desconstrução da cultura manicomial apresentou-se como um processo que exige novas formas de ver e lidar com a loucura. A família e a rede de serviços de saúde mental expressaram a contradição entre as antigas formas de se relacionar com a loucura institucionalizada e as novas formas propostas pelos ideais da reforma psiquiátrica, que busca a desinstitucionalização da loucura. A discussão tem, por referencial teóricometodológico, a Psicologia Social proposta por Pichon-Rivière. / The aim of this research is to investigate family in insanity context considering the daily ways used to understand what they live and the ways used to deal with the insane at their home and at the mental health services. In order to do that, we intended to identify the following: familys representations towards insanity; the ways the family and the insane interact; the relations set up between family and the mental health services; and the social and political space families have in the mental health policies field. We studied a case based upon interviews with an attendant of CAPS mother, in the capital of the State of São Paulo. We understand that knowing some aspects of the family reality gives us conditions to think about how the mental health attention evolved in Brazil after the psychiatric reform. It also offers us the possibility to make important questions about its constant reformulation. The asylum culture dismantling issue can be faced as a process that demands new ways of seeing and dealing with insanity. In this research, family and mental health services expressed the contradiction between former ways to deal with the institutionalized insanity and new ways proposed by the ideals of psychiatric reform, which pursues the end of institutionalized insanity. The discussion is supported, in theory and methods, by the Social Psychology proposed by Pichon-Rivière.

Made available in DSpace on 2016-04-29T14:16:00Z (GMT). No. of bitstreams: 1 Solange Conceicao Albuquerque de Cristo.pdf: 3324541 bytes, checksum: a7b8c5bdc0a23c4025bbce1dead7450c (MD5) Previous issue date: 2011-05-27 / Conselho Nacional de Desenvolvimento Científico e Tecnológico / This thesis aims to develop a reflection on the possibility of exercising social control, cooperating effectively to the parallel democratization of the state and society. Aiming to contribute to a more detailed examination of the experiences of social control, specifically in the area of health in the state of Pará, it was necessary to rescue the trajectories of people‟s struggles in Pará, its history, its uniqueness and diversity we have sought with this thesis: a) clarify the real difficulties that the segment of users have had to mobilize and organize at this juncture; b) identify the leaders and present interests in Municipal Health Councils in the State of Pará, c) identify the need for government investment in the health sector in the State of Pará. The model of research combined quantitative and qualitative approaches. It shows the profile of the Health Councils in Brazil and in the State of Pará. We sought evidence to delineate the ability to allocate investments in health facilities in cities. The collection of data on coverage of attendance and health services occurred in Pará from the Survey of Medical Care and 2009. It also had connection to the entries of each Health Council in each city in Pará, through Internet in the period of 2007/2008 on the National Health Council website. According to the Register of the Municipal Councils of Health, nearly one third of the presidency of the State Health Council of Pará is occupied by representatives of the segment of users. Among these, we chose two city councils, Belém and Melgaço, for interviews with the presidents. In choosing these two cities, we took into account the specific characteristics of each one. As a result, it was clear that the State Health Department has strong influence on the decisions of the municipal councils. In the Health Councils, according to the study, supervision as a means of controlling the implementation of health policy prioritized the operation of services. According to the research and analysis developed in this thesis, it is understood that the Municipal Health Councils in Pará, especially in Belém and in Melgaço, have not yet been able to fulfill the task of participating in strategy development of health policies, on the other side, they seek to understand the Municipal Health Plan, questioning the reason for certain actions and not others / Esta tese pretende desenvolver uma reflexão sobre as possibilidades do exercício do controle social, cooperando, efetivamente, para a democratização paralela do Estado e da Sociedade. Com o objetivo de contribuir para um exame mais circunstanciado das experiências de controle social, especificamente na área da saúde no Estado do Pará, foi preciso resgatar as trajetórias de lutas do povo paraense, sua história, sua singularidade e diversidade - procurou-se com esta tese: a) explicitar as reais dificuldades que o segmento dos usuários têm tido de mobilização e organização na atual conjuntura; b) identificar as lideranças e interesses presentes nos Conselhos Municipais de Saúde no Estado do Pará; c) identificar as necessidades de investimentos governamentais no setor de saúde no Estado do Pará. O modelo de pesquisa combinou abordagens quantitativas e qualitativas. Mostra o perfil dos Conselhos de Saúde no Brasil e no Estado do Pará. Buscou evidências para delinear a capacidade de alocação de investimentos nas estruturas de saúde nos municípios. A coleta de dados sobre a cobertura de atendimento e de serviços de saúde no Pará ocorreu a partir da Pesquisa de Assistência Médico-Sanitária 2009. Teve-se contato também com os cadastros de cada Conselho de Saúde de cada município paraense, preenchidos pela internet no período de 2007/2008 junto ao site do Conselho Nacional de Saúde. De acordo com o Cadastro dos Conselhos Municipais de Saúde, quase um terço da presidência dos Conselhos de Saúde do Pará é ocupada por representantes do segmento dos usuários. Dentre estes, escolheu-se dois Conselhos de municípios, Belém e Melgaço para as entrevistas junto aos presidentes. Na escolha desses 02 municípios, levou-se em conta especificidades características de cada um. Como resultado, percebe-se que a Secretaria de Saúde exerce forte influência nas decisões dos Conselhos. Nos Conselhos de Saúde, de acordo com o estudo, a fiscalização enquanto instrumento de controle da execução da política de saúde priorizou o funcionamento dos serviços. De acordo com a pesquisa e análises desenvolvidas nesta tese, entende-se que os Conselhos de Saúde no Pará, especialmente em Belém e em Melgaço, não conseguiram ainda cumprir a função de participar na formulação de estratégias da política de saúde, por outro lado, buscam entender o Plano Municipal de Saúde, indagando o porquê de determinadas ações e não de outras

This research study examines the influence of two major forces, competition and regulation, on the strategic orientation of hospitals. This is a particularly relevant subject, as the effectiveness of competition versus the effectiveness of regulation in the health care market has been called one of the Bellwether issues in health care policy, and the most controversial and far reaching philosophical battle facing the health care industry. Even after three decades of research and debate, there is still no consensus on how the hospital industry responds to either a competitive environment or a regulated environment. There continues to be significant variation across the country on which model provides the environmental context for hospitals, and there is no resolution of the issue on the horizon. It is clear that the dichotomy of a competitive environment or a regulated environment and the wide variation from market to market will continue to be significant factors influencing the development of hospital strategies. Developing strategies that provide an appropriate fit with the particular environmental context is a critical aspect of the success of an organization.This study provides a unique perspective on the subject, with an examination of the relationship between the level of competition in the market and the level of regulation in the market, and whether these dimensions influence hospital strategic orientation. Porter's strategic orientation typology is used as the model for hospital strategy, and the theoretical framework combines the legitimacy seeking elements of institutional theory and the resource and cost control elements of resource dependency theory.The findings of this study indicate an association between a competitive environment and a differentiation orientation. As competition decreases, there is a greater likelihood of association with cost inefficiency. The results also indicate that in the absence of CON or as CON decreases, there is a greater likelihood of cost inefficiency. Although this study provides a timely analysis of a very controversial topic, it is clear that additional research efforts are needed on this critical issue that impacts every hospital in the country.

O presente trabalho tem como objetivo investigar a família no contexto da loucura, considerando-se as formas cotidianas da família compreender o que vive neste cenário e as formas de lidar com o sujeito da loucura em sua casa e nos serviços de saúde mental. Para tanto, buscou-se identificar: as representações da família em relação à loucura; as formas da família se relacionar com o sujeito da loucura; as relações estabelecidas entre a família e a rede de atenção em saúde mental; e o espaço social e político destinado às famílias no campo das políticas públicas de saúde mental. Realizou-se um estudo de caso, com base nas entrevistas realizadas com a mãe de um usuário de um CAPS da capital paulista, entendendose que conhecer aspectos de uma realidade familiar, nos fornece subsídios para refletirmos sobre os rumos tomados pela atenção em saúde mental no Brasil, no âmbito da reforma psiquiátrica. Oferece, ainda, a possibilidade de levantar questões pertinentes à sua constante reformulação. A questão da desconstrução da cultura manicomial apresentou-se como um processo que exige novas formas de ver e lidar com a loucura. A família e a rede de serviços de saúde mental expressaram a contradição entre as antigas formas de se relacionar com a loucura institucionalizada e as novas formas propostas pelos ideais da reforma psiquiátrica, que busca a desinstitucionalização da loucura. A discussão tem, por referencial teóricometodológico, a Psicologia Social proposta por Pichon-Rivière. / The aim of this research is to investigate family in insanity context considering the daily ways used to understand what they live and the ways used to deal with the insane at their home and at the mental health services. In order to do that, we intended to identify the following: familys representations towards insanity; the ways the family and the insane interact; the relations set up between family and the mental health services; and the social and political space families have in the mental health policies field. We studied a case based upon interviews with an attendant of CAPS mother, in the capital of the State of São Paulo. We understand that knowing some aspects of the family reality gives us conditions to think about how the mental health attention evolved in Brazil after the psychiatric reform. It also offers us the possibility to make important questions about its constant reformulation. The asylum culture dismantling issue can be faced as a process that demands new ways of seeing and dealing with insanity. In this research, family and mental health services expressed the contradiction between former ways to deal with the institutionalized insanity and new ways proposed by the ideals of psychiatric reform, which pursues the end of institutionalized insanity. The discussion is supported, in theory and methods, by the Social Psychology proposed by Pichon-Rivière.

Orientador: Maria Elizabete Sampaio Prado Xavier / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Educação / Made available in DSpace on 2018-08-06T07:52:15Z (GMT). No. of bitstreams: 1 Figueiredo_IreniMarileneZago_D.pdf: 1190071 bytes, checksum: 10bfbcc3c3789d47a31c8080784f1637 (MD5) Previous issue date: 2006 / Resumo: As políticas de educação e saúde são produtos de relações complexas entre as dimensões econômico-social e político-ideológica de um determinado contexto histórico de desenvolvimento do capitalismo. Tendo essa relação como pressuposto e as características peculiares do processo de desenvolvimento capitalista brasileiro como referência, analisamos, neste trabalho, as políticas de educação e de saúde como determinadas, em última instância, pelas condições econômico-sociais e político-ideológicas vigentes. Nesse movimento, buscamos compreender as categorias do desenvolvimentismo e da globalização e as relações estabelecidas com a educação e a saúde, ultrapassando a análise interna das instituições públicas, visto que o estudo crítico das políticas de educação e saúde, através da apreensão da sua relação com a base econômica e a superestrutura ideológica, só é possível pela análise do modo de produção capitalista e seus modos de desenvolvimento. Nesta perspectiva, partimos da compreensão de que as políticas de educação e saúde básicas integram o conjunto das reformas econômicas e, portanto, estão circunscritas ao processo de reforma e modernização do Estado e seus objetivos políticos e econômicos. Sustentamos que, no contexto da ideologia da globalização, a educação e a saúde básicas são consideradas variáveis fundamentais para administrar a pobreza, contribuindo para a estabilidade política e social e, ao mesmo tempo, criando as condições favoráveis mínimas para o implemento das políticas de ajuste econômico, pois no processo de implementação dessas políticas existe um consenso entre o BID e o BIRD de que o Estado deve oferecer os serviços essenciais básicos, de educação e de saúde, para dar resposta às demandas imediatas, visando à proteção dos grupos vulneráveis. Verificamos que as reformas de educação e saúde estão inscritas no contexto mais amplo do processo de reestruturação econômica do país e, desse modo, os objetivos definidos pelo BIRD e pelo BID, nos empréstimos de ajuste estrutural e setorial e as estratégias definidas por essas instituições, sustentam o processo de reforma e modernização do Estado, a partir da definição e de implementação de políticas nacionais submetidas às condicionalidades expressas nos seus contratos de empréstimos. A articulação e a convergência das orientações e das propostas nos projetos financiados pelo BIRD e pelo BID para as reformas da Educação Básica (Ensino Fundamental) e da saúde modificaram as formas de financiamento e administração dessas áreas, mediante as estratégias de descentralização (através da privatização, da participação das ONGs na prestação desses serviços, da realização de parcerias com a comunidade e da municipalização do ensino e da saúde), baseadas na construção de critérios gerenciais para promover a concorrência, a qualidade, a produtividade (eficiência interna e externa, eficácia) e a racionalidade econômica (relação custo-benefício) no processo de distribuição e utilização dos recursos públicos. Procuramos demonstrar, dessa forma, o como as políticas de educação e de saúde básicas incorporaram e consolidaram esses conceitos, viabilizando os objetivos econômicos das políticas de ajuste estrutural e setorial e, ao mesmo tempo, contribuindo para o processo de reforma e modernização do Estado brasileiro e de suas instituições públicas de educação e saúde / Abstract: Education and health care policies are products from complex relationships between the economic-social and political-ideological dimensions from a certain historical context of capitalism development. Having this relationship as presupposed and the particular characteristics of the Brazilian capitalist development process as a reference, we analyzed, in this paper, the educational and health care policies as determined, in the last instance, by the current economic-social and political-ideological conditions. In this movement, we tried to understand the globalization and development systems categories and the relationships established with education and health care, going beyond the inner analysis of public institutions, because the critical study of education and health care policies, through the understanding of its relationship with the economical base and the ideological superstructure, it's only possible by the analysis of the way of capitalist production and its development ways. In this perspective, we started from the comprehension that the basic educational and health care policies integrate the economical reform conjoint and, therefore, are circumscribed to the reform and modernization process of the State and its political and economical objectives. We affirm that, in the globalization ideology context, basic education and heath care are considered essential variables to administrate the poverty, contributing to the social and political stability and , at the same time, creating minimal favorable conditions for the implement of economical adjustment policies, because the implementation process of these policies there is an agreement between BID and BIRD in which the State must offer the basic supply, in education and health care, to provide answers to immediate demands, seeking the protection of vulnerable groups. We checked that the educational and health care reforms are enrolled in the more ample context of the economical reorganization of the country and, this way, the objectives determined by BIRD and BID, in the loans of sectoral and structural adjustment and the strategies determined by these institutions, support the modernization and reform process of the State, from the definition and implementation of national policies submitted to conditions expressed in their loan contracts. The articulation and convergence of orientations and the proposals in the projects financed by BIRD and BID for the Basic Educational reforms (Elementary school) and health care modified the administration and financing forms of these areas, by means of decentralization strategies (through privatization, participation of NGOs in the performing of theses services, the realization of partnerships with the community and the education and health care municipalization), based on the construction of managing criteria to promote the competition, quality, productivity (internal and external efficiency, efficacy) and the economical rationality (cost-benefit relationship) in the distribution and usage process of public resource. We tried to demonstrate, this way, how the basic education and health care policies incorporated and consolidated these concepts, enabling the economical objectives of sectoral and structural adjustment policies and, at the same time, contributing to the reform and modernization process of the Brazilian State and the education and health care public institutions / Doutorado / Historia, Filosofia e Educação / Doutor em Educação