La couverture universelle de santé est aujourd’hui au coeur du financement de la santé. Dans ce contexte, le développement des mécanismes d’assurance et l’amélioration de l’efficience constituent des enjeux majeurs pour garantir l’équité dans l’accès et le financement des services de santé. La transition vers la couverture universelle de santé s’appuie sur la combinaison des fonds d’équité de santé et de l’assurance santé communautaire au Cambodge et sur le développement de l’assurance santé communautaire en Chine avec le Nouveau Système de Coopératives Médicales Rurales. Alors que les modalités du financement de la santé changent, l’utilisation des ressources devient un enjeu central et on doit alors s’interroger sur leur efficience dans le contexte de la couverture universelle de santé. C’est l’objet de cette thèse qui s’articule autour de quatre chapitres. Le chapitre I analyse les enjeux du financement de la santé dans les pays en développement dans le contexte de la couverture universelle de santé, montrant pourquoi la problématique de l’efficience en constitue l’une des interrogations centrales. La thèse se concentre alors sur l’étude de l’efficience des établissements de santé au travers de trois chapitres. Le chapitre II porte sur la mesure de l’efficience technique via l’analyse d’enveloppement des données. Les chapitres III et IV présentent des études de cas portant respectivement sur l’activité et l’efficience des centres de santé de la province de Takéo au Cambodge et des hôpitaux municipaux de la préfecture de Weifang en Chine dans le contexte des réformes orientées vers la couverture universelle de santé. / Universal health coverage is at the heart of health financing. In such context, the development of insurance mechanisms and the improvement of efficiency are major stakes to insure equity in access and financing of health care services. In Cambodia, the transition to universal health coverage relies on a combination of health equity funds and community-based health insurance while in China it relies on the development of community-based health insurance with the New Rural Cooperative Medical Scheme. The composition of health financing evolves and thus, the utilization of resources becomes a central issue. So, as it proposed in this thesis, we have to examine the efficiency in the context of universal health coverage. The chapter I analyses the issues of health financing in developing countries in the context of universal health coverage and underlines why the efficiency is the central issue. The thesis then concentrates on the study of efficiency through three chapters. Chapter II details the data envelopment analysis to estimate technical efficiency. Chapters III and IV respectively study the activity and efficiency of health centers of Takeo province in Cambodia and townships hospitals of Weifang prefecture in China, in the context of reforms oriented to universal health coverage.

Public health nurses (PHNs) are ideally situated to reduce health inequities and based on documents articulating their role, should be working upstream to promote equity, prevent chronic diseases, and improve population health outcomes. In reality however, numerous barriers contribute to lack of role clarity for PHNs, and this goal has not been attainable in practice. A common vision for PHN practice based on discipline specific competencies and full scope of practice has been identified as a priority by Canadian experts. The intention of this study was to develop a model to support PHN practice in an urban Canadian city. This study used a participatory action research approach, grounded in local experience and context. The action was the development of a professional practice model. Data were gathered using semi-structured interview guides during audio-recorded research working group (RWG) meetings from November 2012 to July 2013. A researcher reflexive journal and field notes were kept. The data were analyzed using qualitative methods. A significant feature was full participant involvement throughout the course of the study. A professional practice model was a key organizational tool that provided the framework to develop an autonomous PHN role and the structures necessary to support PHN practice within the health system. The professional practice model fostered full scope of practice and role clarity, with a focus on population health and equity, so that a consistent and evidence-based practice was attainable. The result was that RWG participants reported a shift in their practice, with greater awareness of theory. Participatory action research was essential in developing the framework and common language, and is a research methodology that should continue to be explored with nurses in Canada.

BACKGROUND: Breastfeeding and lactation are cited as sensitive periods in the life course that contribute to the accumulation of risks or opportunities ultimately shaping vulnerability or resilience later in life. As such, breastfeeding and lactation are critical components of health equity. Despite this, Black women in the U.S. initiate and continue to breastfeed at lower rates than White women and other groups. Underlying reasons for racial inequities in breastfeeding rates are poorly understood. Exposure to racism, one manifestation of historical oppression in the U.S. has been cited as a determinant of poor health outcomes for decades but has not been extensively described in the context of breastfeeding. AIMS: To investigate the association between experiences of racism and 1.) breastfeeding initiation 2.) breastfeeding duration 3.) and the association between selected life-course factors and breastfeeding initiation and duration among participants of the Black Women’s Health Study. METHODS: This study was a prospective secondary analysis of the Black Women’s Health Study. The sample included all participants who enrolled in 1995, responded to the racism assessment in 1997 and reported the birth of a first child following the racism assessment resulting in an N=2, 995 for the initiation outcome and N= 2,392 for the duration outcome. In addition to the racism assessment, we also included life-course factors (nativity, neighborhood segregation and social mobility). For each aim, we calculated odds ratios and 95% confidence intervals using binomial and multinomial logistic regression using two models. The first adjusted for age, the second adjusted for age, BMI, education, marital status, geographic region, neighborhood SES and occupation. RESULTS: Associations between daily and institutional summary racism variables and breastfeeding initiation and duration were small and not statistically significant. Experiences of racism in the job setting was associated with lower odds of breastfeeding duration at 3-5 months compared with 3 months 95% CI [0.60, 0.98]. Experiences of racism with the police was associated with higher odds of breastfeeding initiation and duration at 3-5 months [1.01, 1.77] and at 6 months [1.10, 1.82] compared with women who did not report this experience. The participant’s nativity and the nativity of her parents were life-course factors that predicted lower odds of breastfeeding initiation and duration. Neighborhood segregation did not reach statistical significance after adjusting for covariates but results trended toward lower odds of breastfeeding initiation and duration for women who reported living in a predominately Black neighborhood (compared with White) up to age 18 and for women who reported living in a predominately Black neighborhood in 1999. CONCLUSION: Experiences of institutional racism in the job setting was associated with lower odds of breastfeeding duration. In addition to explicit experiences of racism, this study provides preliminary evidence surrounding life-course factors and breastfeeding. Individual level interventions may mitigate harmful effects of racism but structural level interventions are critical to close the gap of racial inequity in breastfeeding rates in the U.S.

Introdução: As condicionalidades de saúde do Programa Bolsa Família (PBF) são consideradas elemento fundamental para melhoria de condições de vida e para a inclusão social sustentável das famílias, promovendo o acesso aos direitos sociais básicos de saúde e de educação. Contudo, este potencial em promover a inclusão depende da organização dos municípios e dos serviços. Objetivo: Avaliar a implementação da atenção à saúde às famílias do PBF, para o cumprimento das condicionalidades da saúde no município do Rio de Janeiro, visando a relacionar o nível e as características de implantação ao cuidado à saúde. Métodos: A tese foi organizada em 4 capítulos escritos em formato de artigo. No primeiro artigo tratamos do processo de formulação das condicionalidades de saúde do PBF. Para isto, o estudo adotou como referencial analítico o modelo de análise de múltiplos fluxos, proposto por Kingdon para quem a mudança na agenda pública acontece com a convergência entre o fluxo dos problemas, o fluxo das soluções e alternativas e o fluxo político. No segundo, apresentamos a sistematização das características municipais do desenho desta ação, por meio da construção de um modelo teórico para avaliação das condicionalidades de saúde do Programa Bolsa Família, que servirá de base para estudo avaliativo apresentado no terceiro artigo. O modelo teórico foi construído a partir da regulamentação e documentos orientadores do Governo Federal e das especificidades da proposta no município. No terceiro artigo avaliamos a adequação da implementação das condicionalidades de saúde do PBF na cidade e suas características. Foram estudadas 128 unidades, sendo realizadas: análise descritiva, análise classificatória multivariada de agrupamento e análise espacial. Por último, no quarto artigo, identificamos, nos discursos dos atores envolvidos, questões referentes à implementação do acompanhamento das condicionalidades de saúde do PBF e suas repercussões, tendo um enfoque sobre equidade e direito à saúde. O desenho metodológico deste estudo foi de pesquisa qualitativa. Foram selecionadas 10 unidades de saúde com diferentes níveis de implantação do acompanhamento das condicionalidades de saúde. Em cada uma das unidades amostradas foram entrevistados 3 grupos de atores: gestores locais, titulares e profissionais de saúde (enfermeiro, médico, assistente social e nutricionista). Resultados: Dentre os principais achados destacamos: 1- Elementos do Modelo teórico tais como: reorganizar e aumentar a oferta qualificada, inserir as famílias nas ações da unidade de saúde, potencializar o programa como oportunidade de cuidado, foco no cuidado integral à família representaram aspectos positivos no desenho das condicionalidades do PBF na cidade do Rio de Janeiro. 2- No estudo de adequação identificamos boa adesão das unidades às atividades básicas. Outras ações oferecidas para crianças e mulheres apresentaram maior variação nas frequências de unidades que as realizam. Em parte das unidades não é dada prioridade para membros de famílias de PBF, não garantindo a continuidade do cuidado. Foram identificados dois perfis de unidades quanto ao nível de implantação. 3- São pontos positivos das condicionalidades de saúde: permitirem maior entrada nas unidades de famílias de maior vulnerabilidade social; sua sinergia com a agenda da vigilância em saúde e do papel da saúde na agenda da Segurança Alimentar e Nutricional; sua potência como oportunidade de cuidado e estratégia de fortalecimento das famílias como titulares de direito em relação à saúde. Por outro lado, o acesso que proporciona é visto sob a ótica da titularidade provisória; não há rotinas que favoreçam a continuidade do cuidado; as condicionalidades são percebidas por alguns profissionais e diretores como assistencialistas e burocráticas e pelos titulares como obrigações para que mereçam o benefício; os titulares, por vezes, não são vistos e tratados como usuários do SUS, por direito. Conclusão: Os resultados da tese apontam para questões relacionadas ao gerenciamento local, organização do processo de trabalho, além de opiniões dos gestores e trabalhadores, que limitam seu papel na diminuição das iniquidades no acesso aos serviços de saúde. / Introduction: The health conditionalities of the Bolsa Família Program (BFP) are considered fundamental for the improvement of living conditions and sustainable social inclusion of families, promoting access to health and education basic social rights. However, this potential to promote inclusion depends on the organization of municipalities and services. Objective: To evaluate health care implementation for BFP families, to fulfill health conditionalities in Rio de Janeiro city, in order to relate the level and characteristics of health care establishment. Methods: The thesis is organized into four chapters written in paper format. In the first paper we discussed the process of formulating health conditionalities of the BFP. For this, the study adopted the multiple streams model as analytical framework, proposed by Kingdon, for whom the change in the public agenda is in the convergence of the flow of problems, the flow of solutions and alternatives, and the political flow. In the second paper, we present the systematization of municipal features of this action design, through the construction of a theoretical model for assessing the BFP health conditionalities, which will serve as basis for an evaluative study reported in the third paper. The theoretical model was built from the regulations and guidance documents of the Federal Government, and of the specificities of the proposal in the city. In the third paper we evaluate the adequacy of the implementation of BFP health conditionalities in the city and its features. We studied 128 units and conducted descriptive analysis, cluster multivariate classification analysis and spatial analysis. Finally, in the fourth paper we identify, in the speeches of actors involved, issues concerning the implementation of the monitoring of BFP health conditionalities and its repercussions, focusing on equity and right to health. The methodological design of this study was qualitative research. We selected ten health units with different implementation levels of health conditionalities monitoring. In each of the sampled units three groups of actors were interviewed: local managers, holders and health professionals (nurse, doctor, social worker and nutritionist). Results: Among the main findings we highlight: 1) Elements of the theoretical model such as reorganizing and increasing qualified supply, including in the actions of the health unit, enhancing the program as a care opportunity, focusing on integral care for the family these were positive aspects in the design of BFP health conditionalities in Rio de Janeiro city. 2) In the adequacy study we found good compliance of units with basic activities. Other actions offered to children and women had greater variation in the frequencies of units holding them. In some units no priority is given to BFP family members, not ensuring the continuity of care. We identified two profiles of units concerning deployment level. 3) Positive aspects of health conditionalities are: they allow most socially vulnerable families to enter unit; their synergy with the health surveillance agenda and the role of health in the Food and Nutritional Security agenda; its power as a care opportunity and strategy to strengthen families as holders of rights to health. On the other hand, the access they provide is seen from the perspective of temporary ownership; there are no routines to promote continuity of care; conditionalities are perceived by some professionals and directors as welfare and bureaucratic, and by holders as obligations to deserve the benefit; holders sometimes are not seen and treated as SUS users by right. Conclusion: The results of the thesis point to issues related to local management, organization of the work process, besides the opinions of managers and workers, which limit their role in reducing inequities in the access to health care.

O discurso da Comissão de Determinantes Sociais da Saúde (CSDH) instituída pela Organização Mundial de Saúde (OMS) constitui-se como objeto desde estudo. O contexto econômico-social, resultado das políticas neoliberais, aprofundou em âmbito mundial as desigualdades sociais. Em 2003, a CSDH foi instituída pela OMS, assumindo como objetivos a documentação de evidências das ações e políticas para promover a equidade em saúde, e articular um movimento global para que esta seja alcançada. As publicações da CSDH tornaram-se referência mundial no tema das desigualdades em saúde. Autores do campo da Saúde Coletiva identificaram importantes limitações e contradições na sua formulação teórico-metodológica, apesar de alguns reconhecerem uma possibilidade de avanço nesta iniciativa. A Saúde Coletiva constituiu-se como campo de teorias e práticas que superam a naturalização do processo de saúde. O marco teórico deste estudo é a teoria da determinação social da saúde, que afirma que a sociedade de classes, fundada na exploração da força de trabalho, produz diferentes desgastes e fortalecimentos advindos das formas de trabalhar, que determinam as formas de viver dos diferentes grupos sociais. Os perfis epidemiológicos são o objeto de ação da Saúde Coletiva, constituídos pelos perfis de reprodução social e pelos perfis de saúde-doença, definidos por meio de estudos da epidemiologia crítica. Objetivo geral: analisar o discurso da CSDH. Objetivos específicos: identificar e analisar os conceitos utilizados pela CSDH; identificar e analisar as diretrizes de ação propostas pela Comissão; comparar os conceitos de determinação social e determinantes sociais. Método: pesquisa qualitativa, que utiliza dados de fonte secundária - o documento da CSDH A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion. Publicado em 2010, o documento oferece a construção teórica e as diretrizes das ações de enfrentamento aos determinantes sociais da saúde propostas pela Comissão. Os resultados foram analisados pela metodologia da análise de discurso, para apreender a estrutura do discurso, o posicionamento da CSDH. Resultados: o construto teórico da Comissão não considera as contradições advindas da exploração do trabalho como fonte da riqueza e da desigualdade social, mas incorpora termos que remetem à estrutura social, como estratificação social e posição sócio-econômica. A dimensão histórica está ausente na teoria dos determinantes sociais da saúde, que retoma conceitos e formato originais do campo da Saúde Pública, como a multicausalidade, a circularidade entre doença e pobreza e o risco. O uso recorrente de termos relacionados à hegemonia ideológica neoliberal é necessário para estabelecer mediações que mantêm encobertas as contradições próprias do capitalismo. Baseando-se em um conceito impreciso de equidade, as ações propostas são focalizadas, tomam como objeto a vulnerabilidade e o risco individuais e têm como finalidade a responsabilização individual pela saúde e a liberdade de escolha, como o empowerment. As diretrizes de ação propostas aproximam-se ao ideário da promoção da saúde. Considerações finais: entende-se que a opção teórica da Comissão é intencional e alinhada com o atual regime de acumulação capitalista - dependente da organização flexível do trabalho - não constituindo uma mudança de perspectiva em relação ao objeto, representa uma inovação apenas no plano retórico. O referencial teórico-prático dos determinantes sociais da saúde é insuficiente para subsidiar o enfrentamento das desigualdades sociais e seus resultados no processo de saúde. Compreende-se que as práticas da Saúde Coletiva, como o monitoramento crítico e práticas emancipatórias, a partir da uma perspectiva de luta de classes, podem contribuir para responder à desigualdade nos perfis epidemiológicos. / Introduction: The discourse of the Comission on Social Determinants of Health (CSDH), established by the World Health Organization (WHO), is the object of study of this paper. The socio-economic context, result of neoliberal policies, has deepen worldwide social inequality, resulting from the capitalist accumulation regime. In 2003, CSDH, instituted by the WHO, assumed as goal the documentation of evidences of actions and policies to promote equity in health and articulate a global movement for it to be reached. CSDH publishes have become a worldwide reference on health equality. Writers of the Collective Health field indentified important limitations and contradictions in its theoretical-methodological formulation, although some perceive an advance in this initiative. The Collective Health has established itself as the field theories and practices that overcome the naturalization of the health process. The theoretical goal of this study is the social determination of health theory, which affirms that the classes society, founded on the exploitation of labor, produces different body distress and strengths arisen from the specificities of labor, which determines the different ways of living of different social groups. Epidemological profiles are the object of work of Collective Health, composed by the social reproduction profiles and the health-disease profiles, defined trought critical epidemiology researches. Objeticve: to analyze the CSDH discourse. Specific objectives: to identify and analize the concepts used by CSDH; to identify and analyze the action guidelines proposed by the Comission; to compare the concepts of social determination and social determinants. Methodological Procedures: qualitative research, using secondary source data - CSDH document A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion. Published in 2010, this document offers the theoretical construction and guidelines of coping actions toward the social determinants of health proposed by the Comission. The results have been analyzed through the discourse analyses method, to seize the structure of the discourse, the CSDH positioning. Results: the Comission\'s theoretical construct does not consider the contradictions from labor exploitation as the wealth and social inequality source, but it incorporates terms that refers to the social structure, as social stratification and socio-economical position. The historic dimension is absent on the social determinants of health theory, which recaptures original concepts and form from the Public Health field, as multicausality, the circularity between health and poverty, and the risk. The recurrent usage of terms related with hegemonic neoliberal ideology is necessary to establish mediations capable of covering the inherent capitalism contradictions. Based on a imprecise concept of equity, the actions proposed are focused, take the vulnerability and individual risks as an object, and perceive the individual accountability for its health and the freedom of choice as a goal, such as empowerment. The proposed action guidelines approach the Health Promotion ideals. Final considerations: understanding that the Commission\'s theoretical choice is intentional and aligned with the current capital accumulation regime - depending on the flexible organization of labor - without changing the perspective toward the object, its innovation is only at the rhetorical frame. The practical and theoretical referential of the social determinants of health is scarce to subsidize the confront of social inequality and its results on the health process. The understanding of how Collective Health practices, and critical monitoring and emancipatory practices, through a class struggle perspective, can contribute to a response toward the inequality on epidemiological profiles.

Trata-se de análise a respeito do Consultório na Rua, estratégia de atenção básica às pessoas em situação de rua. Foram utilizados três métodos para compreender este serviço: análise comparada das propostas legais das unidades móveis de Portugal, Estados Unidos da América e Brasil; estudo sócio-histórico, por meio da sociogênese proposta por Pierre Bourdieu, com base em documentos oficiais, literatura indexada e entrevistas de agentes; e avaliação de implantação de uma equipe de Consultório na Rua da cidade de São Paulo, utilizando-se de observação participante, informações oriundas de relatórios e prontuários, entrevistas com trabalhadores e usuários do serviço, e apoiando-se em modelo lógico e matriz de avaliação de grau de implantação. A proposta brasileira de unidade móvel apresentou semelhanças no uso de equipes multiprofissionais e oferecimento de ações de redução de danos entre as demais analisadas, elementos que contribuem para o alcance da equidade. Sua gênese foi possível em contexto político favorável ao investimento de políticas sobre drogas e expansão da Política Nacional de Atenção Básica. Porém sofreu influências de conflitos entre agentes de diferentes polos do espaço social. A análise de implantação revelou adaptações da proposta federal oriundas de programas anteriores do município de São Paulo, de limitações da rede de serviços, e influências de conflitos identificados na gênese / This is an analysis of the Clinic on the Street, a strategy of basic care for people in homelessness. Three methods were used to understand this service: comparative analysis of the legal proposals of the mobile units of Portugal, the United States of America and Brazil; socio-historical study, through the sociogenesis proposed by Pierre Bourdieu, based on official documents, indexed literature and interviews of agents; and evaluation of the implantation of a \'Clinic on the Street\' team from São Paulo, using participant observation, information from reports and records, interviews with workers and users of the service, and based on a logistic model and evaluation matrix of degree of implantation. The Brazilian proposal of mobile unit showed similarities in the use of multiprofessional teams and offering harm reduction actions among the others analyzed, elements that contribute to equity. Its genesis was possible in a political context favorable to the investment of policies on drugs and expansion of the National Policy of Basic Attention. However, it was influenced by conflicts between agents from different poles of the social space. The implementation analysis revealed adaptations of the federal proposal from previous programs in the city of São Paulo, limitations of the service network, and influences of conflicts identified in the genesis

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-06-15T11:29:29Z No. of bitstreams: 1 alessandramontezanodepaulacarvalho.pdf: 2760755 bytes, checksum: 552e32c16aa35470c41f406f3720a03d (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-07-13T14:08:31Z (GMT) No. of bitstreams: 1 alessandramontezanodepaulacarvalho.pdf: 2760755 bytes, checksum: 552e32c16aa35470c41f406f3720a03d (MD5) / Made available in DSpace on 2016-07-13T14:08:31Z (GMT). No. of bitstreams: 1 alessandramontezanodepaulacarvalho.pdf: 2760755 bytes, checksum: 552e32c16aa35470c41f406f3720a03d (MD5) Previous issue date: 2016-02-25 / Ao princípio da equidade são atribuídos diversos significados, que ancorados em diferentes valores éticos, podem influenciar o modo de se fazer a assistência em saúde. As doenças sexualmente transmissíveis (DST) têm-se apresentado como situações que culturalmente trazem estigma, preconceito e discriminação ao seu portador. Esse cenário constitui-se como campo fértil para que velhas e novas representações sejam elaboradas. Assim, visando contribuir para a problematização do discurso das estratégias dos profissionais para o cuidado em saúde ao portador de DST sob o prisma da equidade, este estudo teve como objetivos: analisar as representações sociais sobre o princípio da equidade para os trabalhadores da Estratégia de Saúde da Família (ESF) no cuidado em saúde aos portadores de DST e discutir a relação existente entre as representações sociais desses trabalhadores sobre a equidade e o cuidado em saúde aos portadores de DST. De abordagem qualitativa, o trabalho teve como pressuposto teórico-filosófico a Teoria das Representações Sociais. Foram entrevistados vinte profissionais de saúde de nível universitário dentre enfermeiros, médicos e cirurgiões-dentistas, que trabalham na rede de atenção básica em saúde de unidades com ESF do município de Viçosa – MG. Os discursos foram organizados por meio do software OpenLogos e analisados conforme a análise de conteúdo temática proposta por Bardin. Da análise dos depoimentos emergiram quatro categorias: os princípios do SUS nas representações dos trabalhadores da ESF; representações sobre a equidade no SUS e no trabalho cotidiano em saúde; necessidades de saúde e a equidade no cuidado ao portador de DST; conexões e fluxos da rede de cuidado em saúde ao portador de DST. Os achados deste estudo demonstram que não existe um entendimento único para o princípio da equidade entre os profissionais entrevistados. No entanto, eles reconhecem que a equidade é fundamentada na defesa de uma situação de justiça a ser instaurada mediante as diferentes necessidades de saúde das pessoas. Nas “maneiras de se fazer” o princípio da equidade no cuidado ao portador de DST, identificou-se a desconstrução de uma visão curativista, biológica e fragmentada diante da valorização das tecnologias relacionais para uma atenção mais equânime e adequada. As representações também apontam os entraves existentes, do próprio sistema de saúde, para conformação estrutural e organizativa dos serviços de saúde nos moldes de um modelo assistencial usuário-centrado. Espera-se que os resultados deste estudo possibilitem uma contribuição para proferir reestruturações importantes no processo de trabalho dos profissionais da atenção primária e na organização da rede de serviços ao portador de DST, que remodele as práticas profissionais no sistema de saúde numa lógica inclusiva do conceito da diversidade. / To the principle of equity many meanings are attributed, which when anchored to different ethical values may influence the way to perform health assistance. Sexually Transmittable Diseases (STD) have been showed as situations that culturally bring stigma, prejudice and discrimination to their carrier. This scenario is a fertile ground for old and new representations to be elaborated. Thus, aiming to contribute to the problematisation of discourse of professionals’ strategies to the Health Care of an STD carrier under the equity perspective, this study had as objectives: to analyse the social representations about the equity principle for the workers of Health Family Strategy (ESF) in the Health Care of STD carriers and to discuss the existent relationship between the social representations of these workers over the equity and the Health Care of STD carriers. The qualitative approach was based on the theoretical-philosophical Social Representation Theory. Twenty healthcare professionals of Bachelor level, among which nurses, medical doctors and dentists, who work in Primary Healthcare of ESF units of City of Viçosa – MG were interviewed. Discourses were organised with OpenLogos software and analysed according to the thematic content analysis proposed by Bardin. Four categories emerged from the interview analyses: SUS’s principles in the representations of ESF workers; representations about the equity in SUS and in daily healthcare work; healthcare needs and the equity in Health Care of STD carriers; connections and flows in the Health Care network of STD carriers. The findings of this study show there is not a unified understanding of the principle of equity among the interviewed professionals. However, they recognize that equity is based on the defence of a justice situation to be established in view of people’s different healthcare needs. In “ways to perform” the principle of equity in the Health Care of the STD carrier, it was identified the deconstruction of a curative, biological and fragmented view, given the valuing of relational technologies to a more equanimous and adequate care. The representations also point the existent barriers of the own healthcare system to a structural and organisational conformation of healthcare services in the form of a user-centred care model. It is expected that results from this study may allow a contribution to deliver important restructuring of the work process of primary healthcare professionals and in the organisation of the service network for STD carries that remodel professional practices in the healthcare system through an inclusive logic of the concept of diversity.

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The 2015 global adoption of the United Nations 2030 Agenda for Sustainable Development places the achievement of health equity as a global priority for health and development. Due to the normative nature of the concept of health equity and the multi-level, multi-sectoral approaches required to advance it, interdisciplinary investigations are warranted to demonstrate how health equity as a policy objective is understood and operationalized. This dissertation is a case study of health equity in maternal, newborn and child health (MNCH) in Ethiopia, using qualitative methods to explore how health equity is conceptualized and pursued by stakeholders across levels of the health system. Ethiopia, a low-income country in East Africa, reported improvements in MNCH during the Millennium Development Goal period (1990-2015), largely attributed to the expansion of health services into rural areas; however, achievements were not realized across all geographies and population groups. Health equity is a stated policy objective for the country. Through a series of four articles, this dissertation addresses: community members’ perceptions and experiences related to health inequity and MNCH; barriers and enablers encountered by community-level health workers in implementing an equity-oriented MNCH intervention; subnational health managers’ understandings of health equity, and their roles in promoting it; and the characterization of health equity as a policy problem in national-level health discourses. This work deconstructs health equity into three components (health, distribution of health and characterization of the distribution of health) and compares how stakeholders across levels of the health system attribute meaning to each component and imply responsibility and accountability for health equity. The findings detail how diverse experiences related to health equity in MNCH across community, subnational and national contexts are driven by high-level technocratic framings of health equity, which tend to emphasize the delivery of a narrow package of health services to under-served geographical areas. Providing support and recognition for the role of subnational stakeholders in mediating the adaption of national health equity policies to local contexts, and making prominent the social justice underpinnings of health equity in the implementation of national policies are opportunities to strengthen the advancement of health equity in Ethiopia.

The introduction of welfare markets in publicly financed healthcare system has together with digital innovation of healthcare delivery led to a rapid growth of direct-to-consumer telemedicine services. In Sweden, the rise of such digital doctors has sparked a debate and there are indications that these developments might affect the overreaching goals of Swedish healthcare delivery on equal terms and according to need. This thesis examines the emergence of the new digital healthcare market and the political debate surrounding these developments, in order to answer the overreaching question of what these developments mean for equity in health in the Swedish healthcare system. This is done by describing developments on the digital healthcare market in Sweden and by conducting an idea analysis of the political parties’ views on these developments. Findings indicate that healthcare providers have great influence on the digital healthcare market in Sweden at the expense of public actors. Results from the idea analysis shows that political parties mainly discuss health equity in relation to the digital healthcare market in line with social or liberal egalitarian ideas of health equity.