All governments aim to ensure better health and nutrition to children. The Rajasthan state (India) has implemented a unique frontline coordination model where Accredited Health Social Activist (ASHA) Sahyoginis are expected to support two other frontline workers (FLWs) i.e. the Anganwadi Workers from the Integrated Child Development Services and the Auxiliary Nurse Midwives from the Health department to improve child health. This thesis focuses on examining the existing coordination between the three groups of FLWs in Rajasthan by exploring FLWs' participation in child immunisation and Vitamin A supplementation (two common activities), service coverage and beneficiary's' knowledge (expected outcomes), and the challenges faced and areas that need improvement for better frontline coordination. A mixed methods design was used. Sixteen villages from two blocks (tribal and non-tribal) of Udaipur district (Rajasthan) were selected using multistage purposive sampling. The formative stage included 12 FLWs' in-depth interviews (IDIs) as well as a review of FLWs' job descriptions to understand the process and government expectations on their participation in routine childhood immunisation, polio camps, routine Vitamin A supplementation and Vitamin A campaigns. The next stage included data collection from the 16 selected villages i.e. structured questionnaire survey of FLWs (46), observations of Maternal and Child Health and Nutrition Day (16), review of FLWs' immunisation and Vitamin A registers (32) and a structured questionnaire survey of registered infants' mothers (321)-all to ascertain the actual participation of FLWs in these four activities and the outcomes. IDIs with FLWs (46) and FLWs' line managers (17) were conducted to understand their experience, issues and solutions for better frontline coordination. The participation of FLWs in three of the four activities (except Polio Camps) was found to be limited. The FLWs and their line managers were also dissatisfied with coordination between FLWs. Poor outcomes also indicated unsatisfactory coordination. Overall, frontline participation and outcomes were better in tribal than non-tribal villages. A variety of factors (i.e. personal, professional, organisational, and geo-socio-cultural) appeared to affect coordination between FLWs. Appropriate recruitment, training, monitoring and supervision and rewards to the FLWs along with greater political commitment for coordinated approached and addressing intra-departmental challenges are proposed to improve frontline coordination and child health in Rajasthan.

Contexte. Le paludisme provoque annuellement le décès d’environ 25 000 enfants de moins de cinq ans au Burkina Faso. Afin d’améliorer un accès rapide à des traitements efficaces, les autorités burkinabées ont introduit en 2010 la prise en charge du paludisme par les agents de santé communautaires (ASC). Alors que son efficacité a été démontrée dans des études contrôlées, très peu d’études ont évalué cette stratégie implantée dans des conditions naturelles et à l’échelle nationale. Objectif. L’objectif central de cette thèse est d’évaluer, dans des conditions réelles d’implantation, les effets du programme burkinabé de prise en charge communautaire du paludisme sur le recours aux soins des enfants fébriles. Les objectifs spécifiques sont : (1) de sonder les perceptions des ASC à l’égard du programme et explorer les facteurs contextuels susceptibles d’affecter leur performance ; (2) d’estimer le recours aux ASC par les enfants fébriles et identifier ses déterminants ; (3) de mesurer, auprès des enfants fébriles, le changement des pratiques de recours aux soins induit par l’introduction d’une intervention concomitante – la gratuité des soins dans les centres de santé. Méthodes. L’étude a été conduite dans deux districts sanitaires similaires, Kaya et Zorgho. Le devis d’évaluation combine des volets qualitatifs et quantitatifs. Des entrevues ont été menées avec tous les ASC de la zone à l’étude (N=27). Des enquêtes ont été répétées annuellement entre 2011 et 2013 auprès de 3002 ménages sélectionnés aléatoirement. Les pratiques de recours aux soins de tous les enfants de moins de cinq ans ayant connu un récent épisode de maladie ont été étudiées (N2011=707 ; N2012=787 ; N2013=831). Résultats. Les résultats montrent que le recours aux ASC est très modeste en comparaison de précédentes études réalisées dans des milieux contrôlés. Des obstacles liés à l’implantation du programme de prise en charge communautaire du paludisme ont été identifiés ainsi qu’un défaut de faisabilité dans les milieux urbains. Enfin, l’efficacité du programme communautaire a été négativement affectée par l’introduction de la gratuité dans les centres de santé. Conclusion. La prise en charge communautaire du paludisme rencontre au Burkina Faso des obstacles importants de faisabilité et d’implantation qui compromettent son efficacité potentielle pour réduire la mortalité infantile. Le manque de coordination entre le programme et des interventions locales concomitantes peut générer des effets néfastes et inattendus. / Context. In Burkina Faso, malaria causes approximately 25,000 deaths every year in children under five. In 2010, national health authorities introduced case management of malaria by community health workers (CHWs) as a way to increase prompt access to effective treatments. While this strategy’s efficacy has been demonstrated in controlled studies, very few studies evaluated its effectiveness under real-world and nation-wide conditions of implementation. Objective. The overarching aim of this thesis is to evaluate the effects of the Burkinabè program on treatment-seeking practices in febrile children. The specific objectives are: (1) to examine CHWs’ perceptions and investigate the contextual factors likely to affect their performance; (2) to estimate the use of CHWs in febrile children and its determinants; (3) to evalauate changes in treatment-seeking practices induced by the introduction of a concomitant intervention – the removal of user fees at health centres. Methods. The study was conducted in two similar health districts, Kaya and Zorgho. The evaluation design integrates quantitative and qualitative components. Interviews were carried out with all CHWs in the study area (N=27). Surveys were repeated every year from 2011 to 2013 in 3002 randomly selected households. Treatment-seeking practices of all children with a recent sickness episode (N2011=707; N2012=787; N2013=831) were examined. Results. Results show that the use of CHWs is really low in comparison to previous controlled studies. Feasibility issues in urban areas and barriers to implementation of the community case management of malaria programme were identified. Moreover, its effectiveness in rural areas was challenged by the removal of user fees at health centres. Conclusion. In Burkina Faso, community case management of malaria faces serious challenges of feasibility and implentation. These challenges compromise the programme’s potential to reduce child morbidity and mortality. The lack of integration between the programme and local concomitant interventions can generate unpredicted adverse effects.

Thesis (M.Nurs.)(Hons)--University of Western Sydney, Nepean, 1996. / Title from electronic document (viewed 25/5/10) Includes bibliography.

Esta tese consiste na identificação de contribuições político-pedagógicas dos movimentos sociais populares nas experiências e práticas culturais, integrativas, tradicionais de cuidado e de educação popular em saúde, especialmente do Movimento de Mulheres Camponesas, que poderão compor a caixa de ferramentas pedagógicas dos processos de formação de profissionais/trabalhadores (as) da saúde para sua atuação no Sistema Único de Saúde (SUS) em comunidades do campo, da floresta e das águas. A pesquisa foi realizada junto ao Movimento de Mulheres Camponesas através de análise de observações, registros, documentos, histórias de vida, oficinas e círculos de cultura feitos com mulheres que participam dessa organização, como também as redes de interação com a educação popular e permanente em saúde. A pesquisa articula essas experiências e seus saberes no contexto de produção de vida, saúde e adoecimento das populações que vivem nesses territórios e os desafios para o cuidado integral e a educação em saúde. Territórios marcados pelos interesses do capital transnacional e seus impactos sobre os camponeses (as), onde os determinantes sociais e as desigualdades compõe a complexidade da situação de saúde dessas populações. Traz a ação das mulheres camponesas na produção de cuidado da vida e da saúde na sua trajetória histórica, os eixos estruturantes articulados às relações sociais de gênero, raça/etnia, classe e orientação sexual, ao feminismo e ao projeto popular de agricultura camponesa. Pelo caminho percorrido, foi possível perceber que as políticas públicas de saúde no Brasil, especialmente nos territórios de atuação dessas mulheres camponesas, são recentes e frágeis na garantia do acesso e na atenção integral à saúde. O MMC surge como espaço de luta e valorização das mulheres camponesas na conquista de direitos e a saúde emergem como uma das lutas importantes do movimento. Nele as mulheres se ressignificam, tem o cuidado com vida e a saúde como base central do seu agir e fazem experiências de libertação e emancipação, enquanto sentido profundo de sua práxis portadora de uma dinâmica educativo-terapêutica e uma mística libertadora. Dessa forma, constroem novos significados à integralidade da saúde, fortalecem o sentimento de pertença das mulheres para com o movimento, ao mesmo tempo em que fazem o enfrentamento ao agronegócio, ao neoliberalismo, à cultura machista e às formas de opressão, de exploração, de discriminação e de violência. Das experiências de organização, de cuidado, de luta e de formação que o movimento desenvolve, bem como a interação com os movimentos e práticas de educação popular em saúde e de educação permanente em saúde emergem as contribuições politico-pedagógicas que ajudam a repensar o modo de cuidar a vida e a saúde, bem como as políticas públicas de educação da saúde, tanto para o meio acadêmico, como para os processos de trabalho e educação na saúde junto ao Sistema Único de Saúde e seus atores, principalmente para a atuação no campo, nas florestas e nas águas. / This thesis consists in the identification of the social movements political-pedagogical contributions in the cultural, integrative, traditional experiences and practices of care and the popular education in health, especially in the Rural Women Movement, that would compose the pedagogical toolbox of the workers and health professional formation process to their actuation in the Single Health System in the field, forest and water communities. The search was realized along with the Rural Women Movement, through analysis of observations, records, documents, life stories, workshops and cultural circles made with women that make part of this organization, as well the interaction network with the popular and permanent health education. The search articulate these experiences and its knowledge in the life, health and illness production contest of the population that live in these territories, and the challenges for the comprehensive care and the health education. Territories marked by transnational capital interests and its impacts on farmers, were the social determinants and the inequalities make the complexity of these people health situation. It brings the rural women action in the life and health care in this historical trajectory, the structural axis articulated to social relation of gender, race/ethnicity, class and sexual orientation to the feminism and to the popular design of peasant agriculture. By the path taken, it was possible realize that the public health politics in Brazil, especially on the action territory of these rural women, are recent and frail in the ensuring access and in the comprehensive health care. The Rural Women Movement arises as a fight and valorization space of the rural women in the rights conquers and the health emerges as one of the most important movement fights. In it, women reframe there selves, have care with life, and have the health as a central bases of their action, and make liberation and emancipation experiences, as a deep sense of their praxis carried of a educative-therapeutic dynamics and a liberating mystic. Thereby, they construct new meanings to the health integrality, strengthen the women sense of belonging to the movement, at the same time that make the confronting agribusiness, neoliberalism, machist culture, and the forms of oppression, exploitation, discrimination and violence. From the organization, care, fight and formation experiences that the movement develops, as well as the interaction with the movements and health popular education practices and permanent health education emerges the political-pedagogical contributions that helps to rethink the way of care life and health, as well the health education public policy, both for academic as for the work processes and health education in the Single Health System and its actors, mainly to the field, forests and water action. / Esta tesis es la identificación de las contribuciones políticas y pedagógicas de los movimientos sociales populares en las experiencias y las prácticas culturales, de integración, de cuidado tradicional y un programa de educación para la salud, especialmente el Movimiento de Mujeres Campesinas, que podrán componer la caja de herramientas pedagógicas de procesos de formación de los trabajadores (as) y profesionales de la salud para actuación en el Sistema Único de Salud (SUS ) en comunidades del campo, de los bosques y de las aguas. La encuesta fue realizada junto al Movimiento de Mujeres Rurales a través del análisis de las observaciones, registros, documentos, historias de vida, talleres y círculos culturales realizados con mujeres que participan de esta organización, así como las redes de interacción con la educación popular y permanente en salud. La investigación articula estas experiencias y su sabiduría en el contexto de la producción de vida, salud y enfermedad de las poblaciones que viven en estos territorios y los desafíos para el cuidado integral y la educación en salud. Territorios marcados por los intereses del capital transnacional y su impacto sobre los campesinos (as), donde los determinantes sociales y las desigualdades constituyen la complejidad de la situación de salud de estas poblaciones. Trae la acción de la mujer rural en la producción del cuidado de la vida y la salud en su trayectoria histórica, los ejes estructurales articulados a las relaciones sociales de género, raza/etnia, clase y orientación sexual, al feminismo y proyecto popular de la agricultura campesina En el camino recorrido, se reveló que las políticas de salud pública en Brasil, sobre todo en los territorios de acción de estas mujeres agricultoras, son recientes y frágiles para garantizar el acceso y la atención integral de la salud. El MMC aparece como un espacio de lucha y valoración de las mujeres rurales en la conquista de los derechos y la salud surge como una de las importantes luchas del movimiento. En ella las mujeres se resignifican, tienen el cuidado con la vida y la salud como base central de su actuar y hacen experiencias de liberación y emancipación, mientras sentido profundo de su praxis portadora de una dinámica educativa-terapéutica y una mística liberadora. Por lo tanto, construyen nuevos significados a la integralidad de la salud, fortalecen el sentimiento de pertenencia de las mujeres al movimiento, mientras hacen el enfrentamiento a la agroindustria, al neoliberalismo, la cultura machista e las formas de opresión, de explotación, de discriminación y de violencia. De las experiencias de organización, de cuidado, de lucha y de formación que el movimiento desarrolla, así como la interacción con los movimientos y prácticas de la educación popular e continua en salud emergen las contribuciones políticas y pedagógicas que ayudan a repensar la forma de cuidar la vida y la salud, así como las políticas públicas de educación para la salud, tanto para la comunidad académica como de los procesos de trabajo y educación en la salud por el Sistema Nacional de Salud y sus actores, principalmente para actuar en el campo, bosques y aguas.

This study investigated the performance of health workers in the decentralised services in Uganda in order to develop a management framework that may be used to improve performance. The study followed a mixed research methodology and was descriptive. The survey design was used to collect quantitative data by means of a structured questionnaire. Qualitative data was collected using a semi-structured interview guide. The study population for the quantitative strand comprised 276 health workers including doctors, clinical officers, and professional nurses working in four districts: Kumi, Mbale, Sironko and Tororo. The health workers were selected using stratified random sampling. The population for qualitative strand was health services managers (N=21) from the same districts. The managers were selected purposively. Quantitative data was analysed using SPSS version 18.0, while qualitative data was coded and analysed manually. The findings revealed that the performance of health workers is generally affected by health systems and work environment related factors. The findings indicated that health workers are skilled, competent, and generally have positive attitudes and behaviours towards their clients. The study uncovered loop holes in performance management in the district health sectors. In most cases there is no target setting, no performance management planning, performance indicators are not clearly defined, and the schedules for performance measurement are not always followed. There is limited career progression and lack of functional performance feedback and rewarding mechanisms. Although health workers are committed, there is widespread political interference and nepotism in the district health sector management. Overall, the researcher is optimistic that if the proposed performance management framework is implemented, the performance of health workers might improve. / Health Studies / D. Litt. et Phil. (Health Studies)

Made available in DSpace on 2011-05-04T12:42:06Z (GMT). No. of bitstreams: 0 Previous issue date: 2010 / A família como foco da atenção é um dos atributos da Atenção Primária em Saúde sendo necessário conhecê-la em sua dinâmica e assisti-la em suas necessidades individuais e de grupo em interação. Reconhece-se o contexto familiar como o espaço primeiro de identificação e explicação do adoecimento de seus membros e onde este adoecimento adquire maior relevância. Tais características tornam a família uma unidade de cuidados, devendo ser compreendida pelos profissionais de saúde em suas interrelações, ao mesmo tempo em que é uma unidade prestadora de cuidados, podendo tornar-se uma parceira dos serviços de saúde no cuidado de seus membros. A Estratégia Saúde da Família tem como proposta estabelecer esta parceria com a família tornando-a mais autônoma, mais independente, contribuindo assim para a construção de sua cidadania. A pesquisa teve como objetivo analisar o atributo centralidade da família no PSF, buscando examinar como o contexto familiar é considerado nas práticas de saúde dos profissionais, e como as famílias percebem estas práticas no PSF de Manaus. Para o desenvolvimento do estudo optou-se pela pesquisa qualitativa. Neste estudo foram informantes as famílias e os profissionais que atuam na Estratégia. Como técnica de levantamento de dados foram realizados grupos focais com enfermeiros, médicos, agentes comunitários de saúde e auxiliares / técnicos de enfermagem; entrevistas semi estruturadas com famílias cadastradas e com coordenadores dos Treinamentos Introdutórios e Cursos de Especialização em Saúde da Família; e observação das práticas dos profissionais das equipes de Saúde da Família nas Unidades Básicas de Saúde da Família (UBSF), e nos domicílios das famílias cadastradas. O trabalho de campo foi realizado no período de dezembro de 2008 a abril de 2009. A análise de dados confrontada com a literatura permitiu identificar que as concepções de família dos profissionais das ESF e das famílias cadastradas corroboram a literatura quando evidencia que o entendimento sobre o que é família é diverso, a depender dos referenciais de quem o manifesta. Deste modo emergiram concepções de família como: família para além da consangüinidade, família como espaço de relações, família como um campo complexo e família como aqueles com quem se pode contar. Como tipologias de família emergiram: família nuclear, família monoparental chefiada por mulher, família trigeracional, família transitória e família satélite. O conhecimento dos profissionais sobre as famílias cadastradas mostrou-se referido às famílias como coletividade, indicando mais um conhecimento sobre a comunidade do que propriamente um conhecimento sobre as famílias. A concepção das famílias cadastradas sobre a abordagem da família pela ESF mostrou o ACS como o membro da equipe que mais lhe conhece. A análise das práticas de saúde dos profissionais das ESF direcionadas às famílias mostrou que a abordagem familiar se fez presente em poucas ações tais como: reunião com a família e visita domiciliar realizadas por ACS, e, atividades desenvolvidas por enfermeiros e médicos na intermediação de conflitos familiares, com repercussões tanto no contexto familiar quanto social. A análise da documentação da família mostrou que os registros sobre o núcleo familiar se dão de forma incompleta e insuficiente, sem interlocução entre os membros da família. O prontuário familiar encontra-se fragmentado com as fichas de Assistência Médico Sanitária dos integrantes da família separadas por programas prioritários e a ficha de cadastro das famílias com dados sócio-econômicos sob a guarda do ACS dificultando sua consulta por parte dos demais membros das ESF. A visita domiciliar é por sua vez uma prática mais direcionada aos indivíduos do que às famílias. Seus objetivos foram referidos como: uma atividade administrativa de coleta de dados, uma atividade assistencial, uma estratégia de informar tanto familiares quanto a equipe, uma forma de estabelecer vínculos, resgatar faltosos e agendar procedimentos na UBSF. A análise destas práticas indica que a abordagem familiar é referida recorrentemente aos indivíduos inscritos nos programas do MS e/ou portadores de limitações físicas que os impeçam de locomoverem-se até às UBSF. Do mesmo modo, as famílias não perceberam receber atenção focada na família, reconhecem a atuação ainda referida ao plano individual do membro da família. A abordagem da família na capacitação dos profissionais das ESF está aquém da proposta do Programa, os conteúdos ministrados sobre abordagem familiar são insuficientes, tanto temáticos como de carga horária. A análise da abordagem da família nas atribuições dos profissionais contida em documentos oficiais aponta o ACS como o maior responsável pelos vínculos com a família devendo munir tanto a ESF quanto as famílias de informações de seu interesse. No entanto, a observação do cotidiano das práticas dos profissionais das ESF indicou baixa utilização pelas ESF das informações trazidas do contexto familiar pelo ACS. Em síntese, a análise da centralidade na família do PSF de Manaus mostrou que a abordagem tem se dado de forma hegemônica sobre o indivíduo, e de forma incipiente sobre a família. Para que as equipes efetivem o atributo da APS centralidade na família são necessárias medidas dos gestores federal, estadual e municipal para uma formação específica e disponibilização de ferramentas e recursos que possibilitem a abordagem familiar. / One feature of Primary Health Care is its focus on the family: understanding family dynamics and providing care to meet the needs of its members, both individually and as an interacting group. The family is recognised as the prime context for identifying and explaining its members' illness and where such illness is most important. These characteristics make the family a unit of care which health workers should understand in terms of its dynamics, at the same time as it is a care-giving unit which can become health services' partner in caring for its members. The purpose of Brazil's Family Health Strategy (Estratégia Saúde da Família) is to establish that partnership with the family in such a way as to make it more autonomous and more independent, thus contributing to building citizenship. The purpose of the present study was to analyse “centrality of the family” as an attribute of the Family Health Strategy (Estratégia Saúde da Familia), examining how health workers contemplate the family context in practice and how family members perceive the practices of the Family Health Strategy in Manaus. It is qualitative study. The study informants were the families and the health professionals working in the Family Health Teams (Equipe Saúde da Família – ESF). The data collection techniques were: focal groups with nurses, doctors, community health workers (CHWs) and nursing auxiliaries; semi-structured interviews of families registered with the Strategy; and observation of the routines of health workers at the family health clinics and at the homes of registered families. Analysis of the data, confronted with the literature, revealed that the conceptions of “family” held by the SF health workers and the registered families corroborate the literature when it shows that the understanding of what family is diverse, depending on the references of whom expresses it. Accordingly, the conceptions of the family that emerged included: family beyond consanguinity, family as a space of relations, family as a complex field and family as the people you can rely on. The typologies of family that emerged were: nuclear family, single-parent family headed by a women, three generational family, transitory family and satellite family. The Strategy health workers' knowledge of the registered families proved to relate to the families as collectivity, indicating more knowledge about the community than properly knowledge about the families. The registered families held a perception of the SF family approach that depicted the CHWs as the team members that knew them best. The analysis of the ESF health workers' dealings with the families showed that the family approach was present in few activities, such as CHWs' home visits and meetings with the family and nurses' and doctors' activities in intermediating family conflicts, which had repercussions in both the family and social contexts. Analysis of family documentation revealed that recordkeeping with regard to the family unit is incomplete and insufficient, with no dialogue among family members. Family health records are fragmented, with individual family members' Medical Care records separated by priority health programme and the family's registration card with social-economical data being held by the CHW, making it more difficult for other ESF workers to consult. Home visits are, in turn, a practice directed more to individuals than to the families. Their purposes were described as: an administrative data-gathering activity, a care activity, a strategy for informing both the family members and the team, and a way of forging links, following up non-attendance and scheduling procedures at the family health clinic. Analysis of these practices indicated that the family approach is recurrently addressed to individuals of priority health programme or with physical disabilities. In the same way, the families did not see themselves as receiving family-focussed care, rather they recognize the activities as still relating to the individual family member level. ESF health worker training falls short of the programme proposal for the family approach: the corresponding course content is insufficient in terms of both subject matter and course hours. Analysis of the family approach in health workers' duties as defined in official documents points to the CHW as the key component responsible for links with the family. The CHW is expected to provide both the ESF and the families with the information they require. Although, observation of ESF workers' day-to-day activities indicated that the ESF made little use of the information on the family context provided by the CHW. In summary, analysis of the family's centrality in the Family Health Strategy in Manaus showed that the approach has been directed predominantly to the individual and only incipiently to the family. In order for the healthcare teams actually to implement “centrality of the family” as an attribute of Primary Health Care measures by federal and municipal managers are necessary to provide specific training, as well as tools and resources to make the family approach possible.

Esta tese consiste na identificação de contribuições político-pedagógicas dos movimentos sociais populares nas experiências e práticas culturais, integrativas, tradicionais de cuidado e de educação popular em saúde, especialmente do Movimento de Mulheres Camponesas, que poderão compor a caixa de ferramentas pedagógicas dos processos de formação de profissionais/trabalhadores (as) da saúde para sua atuação no Sistema Único de Saúde (SUS) em comunidades do campo, da floresta e das águas. A pesquisa foi realizada junto ao Movimento de Mulheres Camponesas através de análise de observações, registros, documentos, histórias de vida, oficinas e círculos de cultura feitos com mulheres que participam dessa organização, como também as redes de interação com a educação popular e permanente em saúde. A pesquisa articula essas experiências e seus saberes no contexto de produção de vida, saúde e adoecimento das populações que vivem nesses territórios e os desafios para o cuidado integral e a educação em saúde. Territórios marcados pelos interesses do capital transnacional e seus impactos sobre os camponeses (as), onde os determinantes sociais e as desigualdades compõe a complexidade da situação de saúde dessas populações. Traz a ação das mulheres camponesas na produção de cuidado da vida e da saúde na sua trajetória histórica, os eixos estruturantes articulados às relações sociais de gênero, raça/etnia, classe e orientação sexual, ao feminismo e ao projeto popular de agricultura camponesa. Pelo caminho percorrido, foi possível perceber que as políticas públicas de saúde no Brasil, especialmente nos territórios de atuação dessas mulheres camponesas, são recentes e frágeis na garantia do acesso e na atenção integral à saúde. O MMC surge como espaço de luta e valorização das mulheres camponesas na conquista de direitos e a saúde emergem como uma das lutas importantes do movimento. Nele as mulheres se ressignificam, tem o cuidado com vida e a saúde como base central do seu agir e fazem experiências de libertação e emancipação, enquanto sentido profundo de sua práxis portadora de uma dinâmica educativo-terapêutica e uma mística libertadora. Dessa forma, constroem novos significados à integralidade da saúde, fortalecem o sentimento de pertença das mulheres para com o movimento, ao mesmo tempo em que fazem o enfrentamento ao agronegócio, ao neoliberalismo, à cultura machista e às formas de opressão, de exploração, de discriminação e de violência. Das experiências de organização, de cuidado, de luta e de formação que o movimento desenvolve, bem como a interação com os movimentos e práticas de educação popular em saúde e de educação permanente em saúde emergem as contribuições politico-pedagógicas que ajudam a repensar o modo de cuidar a vida e a saúde, bem como as políticas públicas de educação da saúde, tanto para o meio acadêmico, como para os processos de trabalho e educação na saúde junto ao Sistema Único de Saúde e seus atores, principalmente para a atuação no campo, nas florestas e nas águas. / This thesis consists in the identification of the social movements political-pedagogical contributions in the cultural, integrative, traditional experiences and practices of care and the popular education in health, especially in the Rural Women Movement, that would compose the pedagogical toolbox of the workers and health professional formation process to their actuation in the Single Health System in the field, forest and water communities. The search was realized along with the Rural Women Movement, through analysis of observations, records, documents, life stories, workshops and cultural circles made with women that make part of this organization, as well the interaction network with the popular and permanent health education. The search articulate these experiences and its knowledge in the life, health and illness production contest of the population that live in these territories, and the challenges for the comprehensive care and the health education. Territories marked by transnational capital interests and its impacts on farmers, were the social determinants and the inequalities make the complexity of these people health situation. It brings the rural women action in the life and health care in this historical trajectory, the structural axis articulated to social relation of gender, race/ethnicity, class and sexual orientation to the feminism and to the popular design of peasant agriculture. By the path taken, it was possible realize that the public health politics in Brazil, especially on the action territory of these rural women, are recent and frail in the ensuring access and in the comprehensive health care. The Rural Women Movement arises as a fight and valorization space of the rural women in the rights conquers and the health emerges as one of the most important movement fights. In it, women reframe there selves, have care with life, and have the health as a central bases of their action, and make liberation and emancipation experiences, as a deep sense of their praxis carried of a educative-therapeutic dynamics and a liberating mystic. Thereby, they construct new meanings to the health integrality, strengthen the women sense of belonging to the movement, at the same time that make the confronting agribusiness, neoliberalism, machist culture, and the forms of oppression, exploitation, discrimination and violence. From the organization, care, fight and formation experiences that the movement develops, as well as the interaction with the movements and health popular education practices and permanent health education emerges the political-pedagogical contributions that helps to rethink the way of care life and health, as well the health education public policy, both for academic as for the work processes and health education in the Single Health System and its actors, mainly to the field, forests and water action. / Esta tesis es la identificación de las contribuciones políticas y pedagógicas de los movimientos sociales populares en las experiencias y las prácticas culturales, de integración, de cuidado tradicional y un programa de educación para la salud, especialmente el Movimiento de Mujeres Campesinas, que podrán componer la caja de herramientas pedagógicas de procesos de formación de los trabajadores (as) y profesionales de la salud para actuación en el Sistema Único de Salud (SUS ) en comunidades del campo, de los bosques y de las aguas. La encuesta fue realizada junto al Movimiento de Mujeres Rurales a través del análisis de las observaciones, registros, documentos, historias de vida, talleres y círculos culturales realizados con mujeres que participan de esta organización, así como las redes de interacción con la educación popular y permanente en salud. La investigación articula estas experiencias y su sabiduría en el contexto de la producción de vida, salud y enfermedad de las poblaciones que viven en estos territorios y los desafíos para el cuidado integral y la educación en salud. Territorios marcados por los intereses del capital transnacional y su impacto sobre los campesinos (as), donde los determinantes sociales y las desigualdades constituyen la complejidad de la situación de salud de estas poblaciones. Trae la acción de la mujer rural en la producción del cuidado de la vida y la salud en su trayectoria histórica, los ejes estructurales articulados a las relaciones sociales de género, raza/etnia, clase y orientación sexual, al feminismo y proyecto popular de la agricultura campesina En el camino recorrido, se reveló que las políticas de salud pública en Brasil, sobre todo en los territorios de acción de estas mujeres agricultoras, son recientes y frágiles para garantizar el acceso y la atención integral de la salud. El MMC aparece como un espacio de lucha y valoración de las mujeres rurales en la conquista de los derechos y la salud surge como una de las importantes luchas del movimiento. En ella las mujeres se resignifican, tienen el cuidado con la vida y la salud como base central de su actuar y hacen experiencias de liberación y emancipación, mientras sentido profundo de su praxis portadora de una dinámica educativa-terapéutica y una mística liberadora. Por lo tanto, construyen nuevos significados a la integralidad de la salud, fortalecen el sentimiento de pertenencia de las mujeres al movimiento, mientras hacen el enfrentamiento a la agroindustria, al neoliberalismo, la cultura machista e las formas de opresión, de explotación, de discriminación y de violencia. De las experiencias de organización, de cuidado, de lucha y de formación que el movimiento desarrolla, así como la interacción con los movimientos y prácticas de la educación popular e continua en salud emergen las contribuciones políticas y pedagógicas que ayudan a repensar la forma de cuidar la vida y la salud, así como las políticas públicas de educación para la salud, tanto para la comunidad académica como de los procesos de trabajo y educación en la salud por el Sistema Nacional de Salud y sus actores, principalmente para actuar en el campo, bosques y aguas.

Esta tese consiste na identificação de contribuições político-pedagógicas dos movimentos sociais populares nas experiências e práticas culturais, integrativas, tradicionais de cuidado e de educação popular em saúde, especialmente do Movimento de Mulheres Camponesas, que poderão compor a caixa de ferramentas pedagógicas dos processos de formação de profissionais/trabalhadores (as) da saúde para sua atuação no Sistema Único de Saúde (SUS) em comunidades do campo, da floresta e das águas. A pesquisa foi realizada junto ao Movimento de Mulheres Camponesas através de análise de observações, registros, documentos, histórias de vida, oficinas e círculos de cultura feitos com mulheres que participam dessa organização, como também as redes de interação com a educação popular e permanente em saúde. A pesquisa articula essas experiências e seus saberes no contexto de produção de vida, saúde e adoecimento das populações que vivem nesses territórios e os desafios para o cuidado integral e a educação em saúde. Territórios marcados pelos interesses do capital transnacional e seus impactos sobre os camponeses (as), onde os determinantes sociais e as desigualdades compõe a complexidade da situação de saúde dessas populações. Traz a ação das mulheres camponesas na produção de cuidado da vida e da saúde na sua trajetória histórica, os eixos estruturantes articulados às relações sociais de gênero, raça/etnia, classe e orientação sexual, ao feminismo e ao projeto popular de agricultura camponesa. Pelo caminho percorrido, foi possível perceber que as políticas públicas de saúde no Brasil, especialmente nos territórios de atuação dessas mulheres camponesas, são recentes e frágeis na garantia do acesso e na atenção integral à saúde. O MMC surge como espaço de luta e valorização das mulheres camponesas na conquista de direitos e a saúde emergem como uma das lutas importantes do movimento. Nele as mulheres se ressignificam, tem o cuidado com vida e a saúde como base central do seu agir e fazem experiências de libertação e emancipação, enquanto sentido profundo de sua práxis portadora de uma dinâmica educativo-terapêutica e uma mística libertadora. Dessa forma, constroem novos significados à integralidade da saúde, fortalecem o sentimento de pertença das mulheres para com o movimento, ao mesmo tempo em que fazem o enfrentamento ao agronegócio, ao neoliberalismo, à cultura machista e às formas de opressão, de exploração, de discriminação e de violência. Das experiências de organização, de cuidado, de luta e de formação que o movimento desenvolve, bem como a interação com os movimentos e práticas de educação popular em saúde e de educação permanente em saúde emergem as contribuições politico-pedagógicas que ajudam a repensar o modo de cuidar a vida e a saúde, bem como as políticas públicas de educação da saúde, tanto para o meio acadêmico, como para os processos de trabalho e educação na saúde junto ao Sistema Único de Saúde e seus atores, principalmente para a atuação no campo, nas florestas e nas águas. / This thesis consists in the identification of the social movements political-pedagogical contributions in the cultural, integrative, traditional experiences and practices of care and the popular education in health, especially in the Rural Women Movement, that would compose the pedagogical toolbox of the workers and health professional formation process to their actuation in the Single Health System in the field, forest and water communities. The search was realized along with the Rural Women Movement, through analysis of observations, records, documents, life stories, workshops and cultural circles made with women that make part of this organization, as well the interaction network with the popular and permanent health education. The search articulate these experiences and its knowledge in the life, health and illness production contest of the population that live in these territories, and the challenges for the comprehensive care and the health education. Territories marked by transnational capital interests and its impacts on farmers, were the social determinants and the inequalities make the complexity of these people health situation. It brings the rural women action in the life and health care in this historical trajectory, the structural axis articulated to social relation of gender, race/ethnicity, class and sexual orientation to the feminism and to the popular design of peasant agriculture. By the path taken, it was possible realize that the public health politics in Brazil, especially on the action territory of these rural women, are recent and frail in the ensuring access and in the comprehensive health care. The Rural Women Movement arises as a fight and valorization space of the rural women in the rights conquers and the health emerges as one of the most important movement fights. In it, women reframe there selves, have care with life, and have the health as a central bases of their action, and make liberation and emancipation experiences, as a deep sense of their praxis carried of a educative-therapeutic dynamics and a liberating mystic. Thereby, they construct new meanings to the health integrality, strengthen the women sense of belonging to the movement, at the same time that make the confronting agribusiness, neoliberalism, machist culture, and the forms of oppression, exploitation, discrimination and violence. From the organization, care, fight and formation experiences that the movement develops, as well as the interaction with the movements and health popular education practices and permanent health education emerges the political-pedagogical contributions that helps to rethink the way of care life and health, as well the health education public policy, both for academic as for the work processes and health education in the Single Health System and its actors, mainly to the field, forests and water action. / Esta tesis es la identificación de las contribuciones políticas y pedagógicas de los movimientos sociales populares en las experiencias y las prácticas culturales, de integración, de cuidado tradicional y un programa de educación para la salud, especialmente el Movimiento de Mujeres Campesinas, que podrán componer la caja de herramientas pedagógicas de procesos de formación de los trabajadores (as) y profesionales de la salud para actuación en el Sistema Único de Salud (SUS ) en comunidades del campo, de los bosques y de las aguas. La encuesta fue realizada junto al Movimiento de Mujeres Rurales a través del análisis de las observaciones, registros, documentos, historias de vida, talleres y círculos culturales realizados con mujeres que participan de esta organización, así como las redes de interacción con la educación popular y permanente en salud. La investigación articula estas experiencias y su sabiduría en el contexto de la producción de vida, salud y enfermedad de las poblaciones que viven en estos territorios y los desafíos para el cuidado integral y la educación en salud. Territorios marcados por los intereses del capital transnacional y su impacto sobre los campesinos (as), donde los determinantes sociales y las desigualdades constituyen la complejidad de la situación de salud de estas poblaciones. Trae la acción de la mujer rural en la producción del cuidado de la vida y la salud en su trayectoria histórica, los ejes estructurales articulados a las relaciones sociales de género, raza/etnia, clase y orientación sexual, al feminismo y proyecto popular de la agricultura campesina En el camino recorrido, se reveló que las políticas de salud pública en Brasil, sobre todo en los territorios de acción de estas mujeres agricultoras, son recientes y frágiles para garantizar el acceso y la atención integral de la salud. El MMC aparece como un espacio de lucha y valoración de las mujeres rurales en la conquista de los derechos y la salud surge como una de las importantes luchas del movimiento. En ella las mujeres se resignifican, tienen el cuidado con la vida y la salud como base central de su actuar y hacen experiencias de liberación y emancipación, mientras sentido profundo de su praxis portadora de una dinámica educativa-terapéutica y una mística liberadora. Por lo tanto, construyen nuevos significados a la integralidad de la salud, fortalecen el sentimiento de pertenencia de las mujeres al movimiento, mientras hacen el enfrentamiento a la agroindustria, al neoliberalismo, la cultura machista e las formas de opresión, de explotación, de discriminación y de violencia. De las experiencias de organización, de cuidado, de lucha y de formación que el movimiento desarrolla, así como la interacción con los movimientos y prácticas de la educación popular e continua en salud emergen las contribuciones políticas y pedagógicas que ayudan a repensar la forma de cuidar la vida y la salud, así como las políticas públicas de educación para la salud, tanto para la comunidad académica como de los procesos de trabajo y educación en la salud por el Sistema Nacional de Salud y sus actores, principalmente para actuar en el campo, bosques y aguas.

Depuis janvier 2001, nous travaillons au Programme national de Lutte contre la tuberculose du Burkina Faso en tant que son coordonnateur. Nous avons jugé utile d’analyser la détection des cas de tuberculose et leurs résultats de traitement après quelques années de mise en œuvre de ce Programme. Le constat de la faiblesse de nos résultats et la recherche de solution de leur amélioration nous a conduits à mettre en œuvre une recherche sur la base de l’hypothèse suivante.<p><p>Hypothèse<p>Le présent travail repose sur l’hypothèse qu’une organisation de la lutte contre la tuberculose prenant en compte les préoccupations et les propositions des acteurs (tuberculeux, membres de leurs familles, professionnels de santé, guérisseurs traditionnels, et membres des comité de gestion des services de santé) peut contribuer à améliorer les résultats du programme National Tuberculose (Détection des cas ;Taux de succès au traitement) et (Meilleure adhésion des professionnels de santé, des patients et de leur proches aux stratégies de prise en charge des malades tuberculeux). <p><p>Éléments de méthodologie <p>Figure 1 :Schématisation de notre travail<p>Les travaux ont été réalisés au Burkina Faso. La pauvreté et les conditions de vies difficiles (logement, nutrition, climat chaux et sec) favorisent l’installation de la tuberculose.<p>Dans le cadre de l’analyse de base de la lutte antituberculeuse avant l’intervention nous avons réalisé deux études:<p>• Une enquête rétrospective dans six districts sur la période du 1er janvier au 31 décembre 2001. Cette étude visait à identifier les difficultés du système de santé à diagnostiquer et mettre sous traitement les malades atteints de tuberculose.<p>• Une étude rétrospective de cohortes. Elle a couvert la période 1995- 2003. Cette étude a porté sur le suivi du traitement des tuberculeux pendant 9 ans de mise en œuvre du Programme National de lutte contre la Tuberculose au Burkina Faso.<p>Dans le cadre de notre intervention nous avons réalisé quatre études :<p>• Une étude qualitative :vingt-huit groupes focalisés et 68 entrevues approfondies avec (des patients tuberculeux, des représentants de la communauté, des membres du comité de gestion du centre de santé, des guérisseurs traditionnels et des professionnels de la santé) pour savoir leurs perceptions de la stratégie de prise en charge des cas de tuberculose appliquée par le Programme National de lutte contre la Tuberculose.<p>• Trois études descriptives à visée analytique en vue d’évaluer les résultats de deux ans d’intervention (Les résultats de la décentralisation de la prise en charge des tuberculeux de l’hôpital de district vers le centre de santé périphérique. Les effets de l’intervention sur les étapes de la détection des cas de tuberculose. Et la contribution des guérisseurs traditionnels au contrôle de la tuberculose au Burkina Faso).<p>• Nous avons fait une analyse de situation deux ans après la fin de l’intervention pour voir ce qu’il reste du processus et des résultats dans les districts d’intervention et aussi ce qui se passait dans les districts témoins.<p><p>Principaux résultats de ces études :<p>Avant intervention<p>• La première étude dans le cadre de l’analyse de base de la lutte antituberculeuse au Burkina Faso a montré que le niveau de dépistage des cas de tuberculose pulmonaire à microscopie positive est faible, du fait de la déperdition des cas dans chacune des étapes qui conduisent au diagnostic de la tuberculose. Le dépistage est dépendant de l’efficacité opérationnelle des personnels des services de santé, ainsi que du recourt au CDT (centre de diagnostic et de traitement de la tuberculose) par les patients suspects référés.<p>• La deuxième étude a analysé neuf ans de suivi des tuberculeux par le programme national de lutte contre la tuberculose et a trouvé que le taux de négativation des examens de crachats de contrôle du deuxième mois de traitement a baissé de façon régulière depuis 1997. Cela pourrait être du à certaines caractéristiques des patients telles que des affections associées ou surtout à un traitement incorrect (irrégularité dans la prise des médicaments, doses insuffisantes, apparition de résistances ?)<p><p>Les résultats de l’intervention<p>• L’intervention a commencé par l’étude de l’accessibilité et de l’adhésion au traitement de la tuberculose. Elle révèle que les patients tuberculeux expérimentent trois groupes interdépendants de difficultés pour terminer avec succès leur traitement (difficultés pour arriver au centre de santé, difficultés pour aller régulièrement au centre de traitement, difficultés à l’intérieur du centre de santé). Ces difficultés sont compliquées par des facteurs d’accessibilité géographique, de pauvreté et de genre.<p>La mise en œuvre pendant deux ans du paquet d’activités défini de façon consensuel par les acteurs (Patients tuberculeux, professionnels de santé, guérisseurs traditionnels, membres de la communauté) a apporté plusieurs résultats :<p>• Pendant les premiers ateliers qui réunissaient les représentants des malades, des professionnels de santé et des guérisseurs traditionnels, les échanges étaient quasiment impossibles. Les malades ne voulaient pas s’exprimer devant les professionnels de santé, les guérisseurs traditionnels se méfiaient des professionnels de santé et ceux-ci monopolisaient la parole comme s'ils étaient les détenteurs de tout le savoir. A partir du quatrième atelier, les échanges sont devenus vraiment interactifs et chaque type de participant disait vraiment ce qu’il pensait et abordait tous les sujets de la réunion sans se faire d’auto censure). <p>• L’identification des tousseurs et des tousseurs chroniques parmi les patients adultes de la consultation générale s’est améliorée (respectivement de 10,6% à 14% et de 1,1% à 1,8%). La référence des patients suspects de tuberculose vers le laboratoire pour les examens de crachats s’est aussi améliorée (de 66% à 78,3%). Cependant notre étude a mis en exergue un problème important et à résoudre qui est la faible accessibilité du laboratoire pour les patients suspects de tuberculose). <p>• En milieu rural plus de 46% des patients suspects ont opté pour la collecte de crachats sur place plutôt que de se rendre au laboratoire de l’hôpital pour les examens de crachats. La détection des cas de tuberculose a augmenté de (14 cas pour 100.000 habitants à 15) dans les districts témoins contre une augmentation de (14 cas pour 100.000 habitants à 26) pour les districts d’intervention. Nous n’avons pas noté de différence significative entre les taux de succès de traitement en comparant les districts d’intervention avec les districts témoins. <p>• Les associations des guérisseurs traditionnels ont identifié 248 patients suspects de tuberculose dont 44 (17,74%) ont été confirmés positifs. Ils ont ramené 87 malades absents au traitement. Justifiant ainsi de l’utilité de leur implication).<p><p>Nous avons fait une sortie de collecte de données et d’analyse de la situation dans les districts sites d’intervention en août 2008, soit plus de deux ans après la fin de l’intervention pour savoir ce qu’il en restait :<p><p>• La décentralisation de la prise en charge des cas de tuberculose de l’hôpital de district vers les centres de santé périphériques est reprise dans les plans d’action des districts concernés. <p>• Nous avons constaté que les outils de gestions des cas (fiche et carte de traitement du CSPS du tuberculeux, bulletin d’examen de crachats, fiche de rapport d’activités tuberculose du CSPS, registre transitoire de la tuberculose du CSPS) sont toujours là et utilisés par les professionnels de santé. <p>• Les associations d’anciens malades sont encore là. Elles tiennent leurs réunions périodiques même si elles sont irrégulières. <p>• Les associations de guérisseurs traditionnels mènent encore des activités de référence de patients suspects de tuberculose aux centres de santé dans le district de Gorom. <p>• La supervision croisée ne se fait plus entre les trois districts d’intervention. Elle a été jugée difficile à organiser par insuffisance de ressources humaines et matérielles selon les médecins chefs de district. <p>• Au Burkina Faso les directions régionales de la santé et les districts ont une certaine autonomie pour le choix des activités à inclure dans les plans d’action annuels. Dès 2006 les districts témoins ont planifié les activités suivantes (décentralisation de la collecte des crachats et du traitement des tuberculeux, implication des associations à base communautaire, utilisation des outils de gestion de la tuberculose dans les centres de santé périphériques. Ils ont aussi utilisé le module de formations des professionnels de santé de l’intervention dès 2006). La détection des cas de tuberculose était de 26 cas pour 100.000 habitants dans les districts sites de l’intervention contre 15 cas pour 100.000 habitants pour les témoins en fin de l’intervention. Deux ans environ après l’intervention, la détection est devenue 24,5 cas pour 100.000 habitants dans les districts d’intervention contre 23,9 cas pour 100.000 habitants dans les districts témoins pour une moyenne nationale de 20,5 cas. Le taux de succès au traitement était de 75% dans les districts témoins et de 74,3% dans les districts d’intervention pour une moyenne nationale de 72,8%.<p><p>Conclusion générale<p>Pour finir on peut dire que les éléments du paquet d’activités qui sont restés deux ans après la fin de l’intervention méritent d’être repris, organisés et intégrés dans la démarche de prise en charge des malades tuberculeux dans le Programme National de Lutte contre la Tuberculose. <p>Ce qui a manqué le plus, deux ans après l’intervention c’est la supervision des acteurs par une équipe de santé technique compétente et à effectif suffisant.<p>La tuberculose est une maladie et la prise en charge des cas est une activité d’abord médicale. Les activités peuvent être renforcées et les résultats améliorés par une collaboration de divers acteurs autour de l’équipe de santé. Le registre de la tuberculose du centre de santé qui se situe à l’hôpital de district doit rester la pièce principale du processus de prise en charge des malades tuberculeux. C’est dans ce registre que toutes les données de tous les tuberculeux pris en charge dans le district doivent figurer. L’équipe médicale responsable de ce registre est responsable du devenir de tous les patients tuberculeux dans le district. La décentralisation de la prise en charge des cas de l’hôpital de district vers le centre de santé périphérique implique des devoirs de l’équipe médicale du CDT à l’endroit des prestataires de soins des CSPS. A ce titre l’équipe médicale du CDT doit superviser et aider les CSPS dans une mise en œuvre efficace des taches qui leurs sont confiées. <p>Les membres organisés de la communauté peuvent apporter beaucoup dans l’information de la population sur la tuberculose, à condition que les contenus des messages soient élaborés sur une base d’informations techniques médicales vraies. La visite à domicile et l’accompagnement des malades graves par les associations seront utiles quand ils seront faits dans une synergie et une complémentarité de l’équipe médicale responsable du registre de la tuberculose. L’identification de plus de patients suspects de tuberculose et leur orientation vers les centres de santé par les associations n’aura de résultats que quand il existera un dispositif efficace de réponse dans le centre de santé ( laboratoires équipés animés par des techniciens de laboratoires motivés, compétents, en nombre suffisant et régulièrement supervisés par des superviseurs eux même compétents) ;(prestataires de soins formés à l’écoute des patients, motivés et supervisés régulièrement par des superviseurs compétents).<p>Notre étude nous enseigne qu’il est utile de prendre le temps nécessaire d’avoir les propositions des acteurs pour élaborer des stratégies qui rencontreront le plus possible leur adhésion. Notre étude nous enseigne aussi que plus il y a d’acteurs plus nous devons mettre en place des efforts de suivi, de supervision et d’accompagnement. <p>Le renforcement du système de santé (agents de santé compétents, motivés, équipés, supervisés et en nombre suffisant) est nécessaire pour la pérennisation de toute initiative et résultats de santé.<p><p>Since January in 2001, I am the National Tuberculosis Programme Manager in Burkina Faso. I thought it would be helpful to analyze TB cases detection and the outcomes of their treatment after a few years of tuberculosis control. Because of low results and looking how to improve them we made a research with the following hypothesis.<p><p>Hypothesis<p>This research is based on the hypothesis that organizing tuberculosis control buy taking into consideration the concerns and the propositions of the stakeholders (TB patients, members of their family, health workers, traditional healers, and members of the health centre Management committee) we can contribute to improving the results of the National Tuberculosis Control Programme (TB cases detection, treatment success) and (good adherence of health workers ,TB patients and their relatives to the strategies of health care to tuberculosis patients). <p><p>Figure 1 :Our work plan<p>The research was conducted in Burkina Faso. Poverty and difficult living conditions (accommodation, nutrition, hot and dry climate) are favorable for the spread of tuberculosis<p>As part of the basic analysis of tuberculosis control before the intervention, we carried out two researches:<p>• A retrospective research in six districts between 1st January and 31st December 2001. This research was aimed at analyzing the health system capacity to diagnose and to put patients infected with tuberculosis on treatment.<p>• A retrospective study of groups. It covered the period 1995- 2003. This study bordered on monitoring the treatment during the 9 years of implementation of the National Tuberculosis Control Programme in Burkina Faso.<p><p>As part of our intervention we carried out four studies:<p>• A qualitative study :twenty eight focused groups and 68 detailed discussions sessions with (tuberculosis patients, representatives of the community, members of the Health Centre Management Committee, traditional healers and health professionals) to sample their views on the tuberculosis treatment strategy applied by the National Tuberculosis Control Programme.<p>• Three analytic and descriptive studies, to evaluate the results of the two years of intervention. (Results of decentralisation of tuberculosis care, from district hospital to peripheral health centre’s. The effects of the intervention on the stages of detection of tuberculosis cases. And the contribution of traditional healers to tuberculosis control in Burkina Faso).<p>• We also looked for what was remaining from the process and the results of the intervention two years after the end of the intervention in the intervention district and what was happing in the witness districts.<p><p>Principal results of these studies <p>Before intervention<p>• The first study into the basic analysis of tuberculosis control in Burkina Faso showed that there is a low rate of positive microscopic pulmonary tuberculosis, because of losses in cases in each of the stages leading to the diagnosis of tuberculosis. Cases detection is dependent on the operational efficiency of health services staff, as well as the using of the CDT (Tuberculosis diagnosis and treatment centre’s) by the suspected tuberculosis patients.<p>• The second study before intervention which analyzed nine years of tuberculosis control by the National Tuberculosis Control Programme, discovered that the rate of negativation at the 2 month follow- up sputum examination has fallen steadily since 1997. This could be due to certain characteristics of patients due to an incorrect treatment (irregularity in taking medicines, insufficient dosages, and appearance of resistance?).<p><p>Results of the Intervention <p>• The intervention began with a study of accessibility and adherence to treatment of tuberculosis. It reveals that Tuberculosis patients experiment with three interdependent groups of difficulties for a successful treatment (difficulty in arriving at health centre’s, difficulties in regularly visiting treatment centre’s, difficulties within the health centre). These difficulties are further compounded by geographical accessibility factors, poverty and gender. <p>The two years of implementation of the packet of activities collectively defined by stakeholders (Tuberculosis patients, health services providers, and community members) has yield a lot of results: <p>• During the earlier workshops which brought together representatives of the patients, health services providers and traditional healers, deliberations were almost impossible. Patients did not want to talk in front of health service providers, traditional healer’s mistrusted health services providers and the latter monopolised all discussions, as if they were the only repository of all knowledge. From the fourth workshop however, discussions became really interactive and each type of participant expressed his thought and tackled all topics at the meeting without any ill-feeling. <p>• Identification of coughers and chronic coughers among adult patients of general consultation improved (respectively from 10.6% to 14% and from 1.1% to 1.8%). Reference of suspected tuberculosis patients to laboratories for sputum smear examination also improved (from 66% to 78.3%). However, our study highlighted an important problem which needs immediate solution. This problem is the low utilization of laboratories by suspected tuberculosis patients. <p>• In the rural areas more than 46% of suspected patients opted for the collection of sputum samples on the spot instead of going to the hospital laboratory for the sputum smear examination. Detection of tuberculosis cases increased from (14 cases per 100 000 inhabitants to 15) in pilot districts and it increase from (14 cases per 100 000 inhabitants to 26) in intervention districts. There was no significant difference between the two successful treatment rates, when we compared the intervention districts with the pilot districts. <p>• Traditional healers associations identified 248 suspected tuberculosis patients, out of whom 44 (17. 74%) were confirmed positive. They brought 87 absentee patients for treatment, thereby justifying the usefulness of their involvement.<p>We made the analysis of the situation in the intervention districts in august 2008, two years after the end of the intervention in order to know what was remaining:<p>• The decentralization of taking care of TB cases from the district hospital to the peripheral health center was written in the concerned districts year planning.<p>• We have noticed that the tools of cases management (CSPS therapy form and card of the TB patients, expectorations exams bulletin, CSPS TB activities report form, transitory register of the CSPS TB) are still there and used by the health care providers of this level.<p>• Associations of TB patients still exist. They hold their periodic meeting even if it is not regular.<p>• Associations of traditional healers are still holding activities to send patients suspected of TB to health center in the district of Gorom.<p>• Crossed supervision is not more done between the three districts of intervention. It has been judged difficult to organize because of insufficient human resources and material according to the chief’s doctors of the district.<p>• At the end of the intervention detection of TB cases was of 26 cases for 100 000 inhabitants in the districts of intervention against 15 cases for 100 000 inhabitants for the witnesses. Almost two years after the intervention the detection became 24, 5 cases for 100 000 inhabitants in the intervention district against 23, 9 case for 100 000 inhabitants in the witness districts. The significant difference that was existing between witnesses and intervention districts disappeared two years after the intervention. <p><p>General conclusion<p>As conclusion we can say that elements of activities that remained two years after the end of intervention are good to be taken, organized and integrated in the National Tuberculosis Program approach of taking care of TB Patients.<p>What lacked the most, two years after the intervention is the supervision of the stakeholders’ by a competent health technical team.<p>TB is a disease and taking care of the cases is first a medical activity. Activities can be reinforced and the results improved by a collaboration of various stakeholders around the health team. TB register of the health center that is located at the district hospital must remain the key piece of the TB patients managing process. It is in this register that all the data of all the TB patients cared in the district must be. The medical team responsible of this register is responsible of the becoming of all the TB patients in the district. The decentralization of taking care of TB cases from the district hospital to the peripheral health centers implies duties of the CDT medical team towards CSPS’ health care providers. Because of that the CDT medical team must monitor and help CSPS in the efficient implementation of the tasks assigned to them.<p>Members of organized community can bring a lot in the information of the population on TB, at the condition that the contents of messages are elaborated on a base of true technical medical information. Home visit and support to the patient seriously sick by the association will be useful when they will be done in a synergy and complementarily of the medical team responsible for the TB register. Identification of more patients suspected of TB and their orientation to health centers by the associations will only have results when there will be an efficient response in the health system (equipped laboratories animated by motivated, competent, and regularly monitored laboratories technicians by monitors who are also competent); (health care providers trained to listen to the patients, motivated and regularly monitored by competent monitors).<p>Our study teaches us how useful it is to take necessary time to have stakeholders’ proposals in order to elaborate strategies that will meet the most their adhesion. Our study teaches us also that the more there are players the more we must put in place follow up, monitoring and support efforts,<p>The building of a strong health system (competent, motivated, equipped, monitored health staffs) is necessary for the durability of all health initiative and results. / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

Public demands have forced countries to explore new ways of rendering primary health care to reach the poor who are not within reach of the modern health care systems. New categories of health care personnel, like lay health workers emerged. There are vast differences in the roles of these lay health workers as was revealed with an extensive literature search. The phenomenology qualitative research method was used to investigate perceptions of farm lay health workers regarding their roles in rural areas. A convenience, non-random sample (N=5) was used for focus group discussions and in-depth interviews to collect data. The latter revealed five main themes associated with the role of farm lay health workers: (1) community link; (2) carer; (3) community developer; (4) counsellor and (5) role model. Guidelines were formulated to enhance the role of lay health workers in the rural Western Cape Province and to improve the quality of care to rural communities / Health Studies / M.A. (Health Studies)