La coopération portée par les dernières réformes législatives a été préférée à d'autres outils de restructuration. Pourtant, au début des années 2000, il apparait que les coopérations entre établissements publics et privés de santé ne sont pas véritablement satisfaisantes. Avec la loi de santé du 26 janvier 2016 une rupture est faite. Cette loi, en plus d'apporter des modifications au groupement de coopération sanitaire permet la création d'un nouvel outil : le groupement hospitalier de territoire. Tous les établissements publics de santé doivent, sauf exception, être membre d'un groupement hospitalier de territoire. On pense "parcours" et "projet médical partagé" à l'échelle d'un territoire de santé. Pourtant, dans la pratique il est apparu que le groupement hospitalier de territoire n'était pas encore un outil pleinement opérationnel. Il a alors été nécessaire d'adopter une démarche prospective et d'émettre des propositions d'évolution pour que la coopération entre établissements de santé puisse véritablement être considérée comme un levier majeur permettant d’avoir un système de santé plus efficient / The cooperation of recent legislative reforms has been preferred to other restructuring tools. However, in the early 2000s, it appears that cooperation between public and private health facilities is not really satisfactory. With the law of health a break is made. This law, in addition to making changes to the sanitary cooperation grouping tool allows the creation of a new tool: the territorial hospital grouping. All public health establishments must, except in exceptional cases, be members of a regional hospital group. One thinks "course" and "shared medical project" at the scale of a territory of health. However, in practice it became clear that the territorial hospital grouping was not yet a fully convincing tool. It was then necessary to adopt a forward-looking approach and make proposals for changes so that cooperation between health care institutions could truly be considered as a major lever for a more efficient health system

Le service public hospitalier a été institué par la loi du 31 décembre 1970 qui en donne une définition fonctionnelle. Bien que le législateur promeuve un modèle hospitalo-centré, il n’exclut pas les établissements privés associés au service public hospitalier par le biais de modalités de participation qui les défavorisent. Affaibli par les réformes hospitalières successives, le service public hospitalier va s’atrophier jusqu’à la réforme du 21 juillet 2009 qui supprime la notion pour lui substituer celle de missions de service public. Cette conception fonctionnelle est conforme à la théorie du service public et compatible avec la définition du service d’intérêt général défendue par le droit de l’Union européenne, mais elle est en décalage avec les faits. À la définition fonctionnelle théorique défendue par le législateur depuis 1970, se substitue, en pratique, une conception organique résultant de modalités de mise en œuvre du service public hospitalier nettement favorables au secteur public. En effet, les établissements publics de santé bénéficient d’un statut singulier caractérisant leur prépondérance. La loi du 26 janvier 2016 confirme la prégnance de la conception organique en réhabilitant la notion de service public hospitalier, et en maintenant les établissements du secteur public dans leur rôle d’acteurs naturels de ce service public. Des interrogations demeurent, toutefois, concernant la pérennité du système de santé. Celui-ci doit céder la place à un service public de santé, intégrant le service public hospitalier, susceptible de chapeauter l’action de l’ensemble des protagonistes de la santé et de garantir le déroulement d’un parcours de santé accessible, égalitaire et qualitatif. / The public hospital utility has been established by the law of December, 31st, 1970, which gives a functional definition. Although the legislator promotes a hospital-centered model, it doesn’t exclude the private establishments associated to the public hospital utility by means of methods of participation which penalize it. Weakened by successive hospital reforms, the public hospital utility will atrophy until the reform of July, 21st, 2009 which deletes the notion and substitutes it by the concept of public service missions. This functional conception is in accordance with the service public theory and compatible with the definition of general interest service defended by the European Union law, but isn’t in keeping with facts. The theoretical functional definition supported by the lawmaker is replaced, in practice, by an organic conception resulting from details of implementation of public hospital utility decidedly favorable to sector public. Indeed, public health establishments benefit from a singular status characterizing its predominance. The law of January, 26, 2016 confirms the resonance of the organic conception by rehabilitating the notion of public hospital utility, and by maintaining public sector institutions in its role of natural actors of this public utility. Questions remain, nonetheless, concerning the durability of the health system. It must step back for a public health service, integrating the public hospital utility, able to head the action of all health protagonists and to guarantee the progress of an accessible, egalitarian and qualitative fitness trail.

Increased needs for health and social services, along with limits to financial resources, force public sector managers to optimize the allocation of financial resources. In this perspective, this research project is aimed at developing tools to evaluate rehabilitation programs dealing with physical disabilities. More specifically, the objectives are first, to examine relationships between the progression of a physically disabled person's functional profile and the rehabilitation services received, and second, to develop a tool to measure the efficiency of the rehabilitation programs offered. In accordance with the disability creation process conceptual framework, clinical results have been measured by measuring the progression of rehabilitation and efficiency has been defined as the relationship between clinical results obtained and the resources or means employed. A prospective cohort study was done on a sample of 100 users 65 years of age or older enrolled in the visual impairment program. The results of the study tend to show that the hours of service delivery allocated to a user contribute positively to the progress of his or her overall functional profile. They also show that a user's overall functional profile at intake is very strongly related to the consumption of financial resources. This relationship has allowed us to establish a system of classification of homogenous typical functional groups that makes relatively reliable predictions based on a unique measurement. Finally, the efficiency measurement tool developed represents a major innovation in evaluating the performance of rehabilitation programs in that it constitutes a benchmark toward attaining quality objectives for care and services while respecting financial constraints.

Objetivo: describir las características clínicas, tratamiento y el pronóstico de diferentes casos clínicos revisados durante el Internado Médico en el período junio 2021 a febrero 2022 en los establecimientos de salud: Hospital Nacional Dos de Mayo, Hospital María Auxiliadora, Policlínico Chorrisalud y Centro Médico Fesalud. Metodología: se realizó un estudio descriptivo y analítico de casos clínicos acumulados de diferentes establecimientos de salud y de los que considero obtuve los aprendizajes más significativos. Estos establecimientos fueron el Hospital Nacional Dos de Mayo y el Hospital María Auxiliadora, estos son establecimientos estatales de categoría III-1; también, del Policlínico Chorrisalud y el Centro Médico Fesalud, los cuales pertenecen a establecimientos privados de categoría I-3. Los casos se obtuvieron de las especialidades de Ginecología- Obstetricia, Cirugía - Especialidades, Pediatría – Neonatología y Medicina Interna. Resultados: se describen 30 casos clínicos, de los cuales el 50 % provienen de establecimientos de categoría III-1; mientras que, el otro 50 % han sido recopilados de los establecimientos de categoría I-3. Durante la práctica clínica se pudo observar las fortalezas y limitaciones de cada establecimiento. Además, se pudo prestar atención a los aciertos, fallos y posibilidades que tenía el personal de salud de cada establecimiento. Conclusiones: en conclusión, este trabajo demuestra la preparación de un interno de medicina antes de llegar a ser buen médico bajo tres premisas. Primero, tiene presente que trata personas con enfermedades y no solo enfermedades; segundo, demuestra sus capacidades académicas para tratar y manejar las enfermedades de sus pacientes; y por último desarrolla liderazgo para saber trabajar en grupo en beneficio del paciente. / Objective: to describe the clinical characteristics, treatment and prognosis of different clinical cases reviewed during a Medical Internship between June 2021 to February 2022 in the following health providers: Dos de Mayo National Hospital, María Auxiliadora National Hospital, Chorrisalud Clinic and Fesalud Medical Center. Methodology: a descriptive analysis and study of accumulated clinical cases from different health centers was carried out. Cases were selected based on the author’s criteria according to which were considered to contribute significantly with medical training. These establishments were Dos de Mayo National Hospital and María Auxiliadora National Hospital, categorized as III-1 per state legislation. Chorrisalud Clinic and Fesalud Medical Center, both private establishments, shared I-3 category. The cases will be collected from the specialties of OB-GYM, Surgery (general and specialties), Pediatrics, Neonatology and Internal Medicine. Results: 30 clinical cases were described, from which 50% were retrieved from III-1 category centers and the remaining 50% collected from category I-3 establishments. It was possible to observe the strengths and limitations of each establishment during clinical practice. In addition, it was possible to pay attention to the successes, failures and possibilities that the health personnel of each establishment possessed. Conclusions: in conclusion, this portfolio exemplifies and supports three important arguments for a medical intern to have before graduating. First, keeping in mind to treat the patient as a whole and not just an isolated illness; second, to demonstrate academic ability in treatment and management of said patient’s illness; lastly to establish leadership and knowing how to work as a team for the benefit of the patient. / Trabajo de Suficiencia Profesional

Le Congo a signé bon nombre d'accords internationaux relatifs à la protection du droit à la santé. Cependant, en dépit de la signature et la ratification de ces accords, le droit à la santé n'est pas encore devenu un droit protégé stricto sensu et la population congolaise connait toujours de grands écueils dans l'accès aux soins. D'aucuns affirment que cette notion "d'accès aux soins" n'est qu'un slogan au Congo. Que la santé ne fait pas partie des priorités de politiques publiques et que le manque de volonté des autorités publiques comme en témoigne l'absence d'assurance maladie ne rendent pas possible le recours effectif aux soins. D'autres nuancent par contre ces affirmations et considèrent que même si,des difficultés existent dans l'accès aux soins au Congo, ces difficultés ne sont pas spécifiques à ce pays. Dans bon nombre de pays africains, voire occidentaux, des obstacles existent également dans l'accès aux soins. Par ailleurs, le Congo a essayé tout de même d'entreprendre des actions pour améliorer l'accès aux soins de sa population. Que ces actions menées ont été appuyées par le soutien des Organisations internationales comme l'OMS et aussi par des ONG. / Congo has signed a number of international agreements on the protection of the right to health. Despite the signing and ratification of these agreements, however, the right to health has not yet become a protected right stricto sensu, and the Congolese population still faces great pitfalls in access to care. Some say that this notion of "access to care" is only a slogan in the Congo. That health is not part of public policy priorities and that the lack of will of the public authorities as evidenced by the lack of health insurance do not make effective use of the care possible. Others, on the other hand, qualify these assertions and consider that even if difficulties exist in access to care in the Congo, these difficulties are not specific to this country. In many African and even western countries there are barriers to access to care. On the other hand, Congo has tried to take action to improve access to health care for its population. That these actions were supported by the support of International Organizations such as WHO and also by NGOs. Ac