Strengthening health care systems in government meant cost containment and improved equity. Escalating costs and poorly constructed strategies are weakening the efficiency and effectiveness of service delivery in health care. This has a negative impact on value creation and internal processes as critical elements such as human capital, information and organisational capital are not aligned with strategies and roll-out plans for HIV/Aids interventions. This research study therefore questioned the extent to which these strategies have impacted on the roll-out plans for HIV/Aids interventions, and investigated if the utilisation of public-private partnerships (PPP) resulted in applying fiscal reponsible mechanisms in health care reforms (effectively, efficiently, economically and equitably (4Es)). Trends in the new public management (NPM) movement inspired a shift towards business-like reforms and saw PPP as a mechanism that improved efficiency and effectiveness in service delivery as it offered the promise to strengthen the capacity of government policy. The study aimed to put forward value-creating strategies and develop a best practice model that strengthened government’s policy capacity by providing efficient, effective, economical and quitable service in health care and thereby improving strategies that impact on the roll-out plans for HIV/Aids. This comparative study comprised four international case studies (developed and developing countries) which presented benchmarks against which the performance of the national case study was measured. A better understanding of the influence which different ideologies had on the architecture of international and global governance structures was gained as it highlighted and compared the key issues that influenced strategies for HIV/Aids intervention between the developed and developing countries. Results of the study indicated that there are conflicting views between government departments in how to achieve value-for-money outcomes and their application of risk allocation. The conflicting views widened the gap between public and private governance structures and relations. The focus of the PPP definition as applied in the national context of health care is not percieved as being health-specific or effective as it excludes some forms of interactions occurring in the health sector. PPP goals emphasised efficiency, affordability and value-for-money approaches, while health care goals emphasised the interest of the “patient” and public health. / Thesis (PhD (Public Affairs))--University of Pretoria, 2007. / School of Public Management and Administration (SPMA) / unrestricted

The main aim of this thesis is to analyze the history of evolution of American health care system with respect to influence of interest groups. Further, I will try to find reasons, why American health care costs grew enormously during 20th century.

Constata-se que a reforma sanitária brasileira representa um avanço na direção de uma concepção avançada de sistema de saúde. Entretanto o SUS, com toda a materialidade das reformas ao nível macro induzidas a partir dos avanços na legislação, a implantação da regionalização e hierarquização da assistência, e dos instrumentos de gestão, assim como todas as grandes organizações modernas, padece de problemas de coordenação na operação de suas ações. Este trabalho pretende discutir as possibilidades e limites das mudanças organizacionais induzidas pela implementação do SUS na configuração dos sistemas locoregionais de saúde, à luz das experiências internacionais e das contribuições mais recentes das teorias organizacionais, no contexto da transição do fordismo à acumulação flexível. A partir do referencial da teoria dos sistemas, considera-se a contribuição das teorias organizacionais fordistas, pós-fordistas e pós-modernistas na especificidade do campo da saúde coletiva, para discutir a efetividade dos seus subsistemas cibernéticos do SUS: controle, avaliação, regulação, auditoria e vigilância em saúde, no complexo contexto da configuração do poder deste setor. Verifica-se que o SUS, constituído a partir de culturas organizacionais fordistas, do antigo INAMPS e da Saúde Pública tradicional, não tem obtido êxito em configurar estruturas organizacionais competentes, na medida em que reproduz os modelos tradicionais nos seus sistemas de controle. Esta dificuldade em parte deve-se ao momento histórico, que fez coincidir o momento dos avanços na legislação, em direção à ampliação do direito à saúde, com o momento das reestruturações dos aparelhos estatais decorrente da crise global do modo de produção fordista, e com as profundas transformações demográficas, epidemiológicas e da tecnologia da assistência médica. Por outro lado, a disponibilidade de soluções pósfordistas propicia um padrão para a conformação de novas regras e novos modos de regulação do sistema de saúde, que induzam a comportamentos auto-reguladores por parte dos prestadores de serviços de saúde, considerando as metas de equidade e de melhoria da saúde da população. Conclui-se que a necessária reforma do setor saúde demanda o fortalecimento de uma tecno-burocracia protegida contra injunções político-partidárias, que possibilite a incubação uma cultura organizacional profissional em todas as esferas de governo e níveis de gestão, que incentive um trabalho em saúde competente e moralmente comprometido com as finalidades do SUS nesse país. / The Brazilian Health Reform is a step ahead towards an advanced health system concept. However, despite the concrete legal progress achieved through the 1988 Constitution, expressed in reforms at the broader level, aiming to organize the assistance in a hierarchyzed services network, and the promulgation of norms for the decentralized system local management, the Brazilian Unified Health System (SUS), as other large modern organizations, experiences a lack of coordination in its operations. This work aims to discuss the possibilities and limits of the organizational changes induced by this implementation, in the very configuration of regionalized health systems from the viewpoint of international experience with health systems reforms, taking into account the most recent contributions of the organizational theories, considering the transitional context from fordism to post-fordism. From the theoretical perspective of systems, we consider the contribution of organization theories, regarding the specificity of the field of public health, to argue the effectiveness of its regulation subsystems: control and evaluation, regulation, medical audit, health Information and also the surveillance and disease control systems, within the complex configuration of political power in this sector, in Brazil. SUS, characterized by a mix of two fordist organizational patterns the National Institute of Social Security (INAMPS) and traditional Public Health systems fails to build competent organizational structures, since it reproduces traditional models in its controlling systems. These difficulties are due in part to historical determinants, which made the legal advances towards a more comprehensive health right coincide with State reforms arisen from the crisis of fordist regulation patterns, and also with worldwide deep societal transformations, like demographic and epidemiological transitions, and the high costs of medical technology. On the other hand, the availability of post-fordist organizational solutions provides patterns for new rules and ways for health systems regulation, which lead to self-regulated behaviors on the part of health care providers, considering the goals of equity and improvement of populational health. The author conclude that necessary health care reform in Brazil requires the strengthening technobureaucracy protected against political-partisan injunctions, allowing the incubation of a professional organizational culture in all government and managerial levels, fostering the competent health work, committed with SUSs purposes.

Constata-se que a reforma sanitária brasileira representa um avanço na direção de uma concepção avançada de sistema de saúde. Entretanto o SUS, com toda a materialidade das reformas ao nível macro induzidas a partir dos avanços na legislação, a implantação da regionalização e hierarquização da assistência, e dos instrumentos de gestão, assim como todas as grandes organizações modernas, padece de problemas de coordenação na operação de suas ações. Este trabalho pretende discutir as possibilidades e limites das mudanças organizacionais induzidas pela implementação do SUS na configuração dos sistemas locoregionais de saúde, à luz das experiências internacionais e das contribuições mais recentes das teorias organizacionais, no contexto da transição do fordismo à acumulação flexível. A partir do referencial da teoria dos sistemas, considera-se a contribuição das teorias organizacionais fordistas, pós-fordistas e pós-modernistas na especificidade do campo da saúde coletiva, para discutir a efetividade dos seus subsistemas cibernéticos do SUS: controle, avaliação, regulação, auditoria e vigilância em saúde, no complexo contexto da configuração do poder deste setor. Verifica-se que o SUS, constituído a partir de culturas organizacionais fordistas, do antigo INAMPS e da Saúde Pública tradicional, não tem obtido êxito em configurar estruturas organizacionais competentes, na medida em que reproduz os modelos tradicionais nos seus sistemas de controle. Esta dificuldade em parte deve-se ao momento histórico, que fez coincidir o momento dos avanços na legislação, em direção à ampliação do direito à saúde, com o momento das reestruturações dos aparelhos estatais decorrente da crise global do modo de produção fordista, e com as profundas transformações demográficas, epidemiológicas e da tecnologia da assistência médica. Por outro lado, a disponibilidade de soluções pósfordistas propicia um padrão para a conformação de novas regras e novos modos de regulação do sistema de saúde, que induzam a comportamentos auto-reguladores por parte dos prestadores de serviços de saúde, considerando as metas de equidade e de melhoria da saúde da população. Conclui-se que a necessária reforma do setor saúde demanda o fortalecimento de uma tecno-burocracia protegida contra injunções político-partidárias, que possibilite a incubação uma cultura organizacional profissional em todas as esferas de governo e níveis de gestão, que incentive um trabalho em saúde competente e moralmente comprometido com as finalidades do SUS nesse país. / The Brazilian Health Reform is a step ahead towards an advanced health system concept. However, despite the concrete legal progress achieved through the 1988 Constitution, expressed in reforms at the broader level, aiming to organize the assistance in a hierarchyzed services network, and the promulgation of norms for the decentralized system local management, the Brazilian Unified Health System (SUS), as other large modern organizations, experiences a lack of coordination in its operations. This work aims to discuss the possibilities and limits of the organizational changes induced by this implementation, in the very configuration of regionalized health systems from the viewpoint of international experience with health systems reforms, taking into account the most recent contributions of the organizational theories, considering the transitional context from fordism to post-fordism. From the theoretical perspective of systems, we consider the contribution of organization theories, regarding the specificity of the field of public health, to argue the effectiveness of its regulation subsystems: control and evaluation, regulation, medical audit, health Information and also the surveillance and disease control systems, within the complex configuration of political power in this sector, in Brazil. SUS, characterized by a mix of two fordist organizational patterns the National Institute of Social Security (INAMPS) and traditional Public Health systems fails to build competent organizational structures, since it reproduces traditional models in its controlling systems. These difficulties are due in part to historical determinants, which made the legal advances towards a more comprehensive health right coincide with State reforms arisen from the crisis of fordist regulation patterns, and also with worldwide deep societal transformations, like demographic and epidemiological transitions, and the high costs of medical technology. On the other hand, the availability of post-fordist organizational solutions provides patterns for new rules and ways for health systems regulation, which lead to self-regulated behaviors on the part of health care providers, considering the goals of equity and improvement of populational health. The author conclude that necessary health care reform in Brazil requires the strengthening technobureaucracy protected against political-partisan injunctions, allowing the incubation of a professional organizational culture in all government and managerial levels, fostering the competent health work, committed with SUSs purposes.