A formação e o provimento de profissionais de saúde são parte das estratégias que vêm sendo utilizadas pelos países para aumentar a capacidade de resposta dos seus sistemas de saúde e, assim, melhorar a qualidade de vida das suas populações. Recentemente, o governo brasileiro criou uma lei, instituindo um programa para melhorar a capacidade de resposta para escassez de médicos em áreas remotas, intitulado Programa Mais Médicos. Uma das ações polêmicas desse programa foi a importação de médicos cubanos, através de uma cooperação Cuba-Brasil, mediada pela Organização Pan-americana de Saúde (OPAS). Trata-se de uma iniciativa de grande vulto que envolveu, de 2011 a 2015, um total de 18 mil e 24 mil médicos novos no SUS. Nesse sentido, ganha relevância a análise do Programa Mais Médicos como política recém-implantada em contexto brasileiro, que constitui o objeto deste projeto de pesquisa. Este estudo de caso focaliza o provimento, fundamentalmente na cooperação Cuba-Brasil. Para analisar o programa, adota-se a abordagem do Ciclo de Políticas (Howlett e Ramesh, 2003) que organiza o estudo da política em cinco fases: (a) preparação da agenda, (b) formulação da política, (c) tomada de decisão, (d) implementação e (e) avaliação, adaptado pela análise de contexto de Bowe & Ball, 1992 que defende a análise de políticas a partir do seu campo de prática. Entrevistas com atores chaves, análise documental e estudo de caso foram desenvolvidos. Para o estudo de caso, focalizamos o PMM no Estado do Ceará e visitamos duas cidades no interior do Brasil neste mesmo estado. Os cenários de implementação do programa, as unidades com médicos cubanos e os espaços de supervisão foram os objetos de observação de campo da investigadora. O objetivo do estudo foi analisar os macro e micro efeitos da Cooperação Cuba- Brasil no trabalho médico brasileiro em APS, investigar seu potencial de inovação para o trabalho médico nas Américas e acompanhar todo o ciclo da política em questão, desde a sua entrada na agenda governamental até os mecanismos de avaliação, incluindo a identificação de desdobramentos para as políticas locais dos casos estudados. Ademais, construir novos saberes no campo da análise de políticas, inovações e provimento de profissionais de saúde no mundo. Na dimensão macropolítica, as entrevistas mostram a prática e a educação médica voltada para a atenção especializada, orientada pelo mercado, com um uso exagerado de tecnologias de alta densidade, comparados aos médicos cubanos. Os médicos cubanos trazem uma nova perspectiva para os profissionais de saúde na forma de construir vínculos com os usuários e na maneira de lidar com a pobreza e a iniquidade. Na dimensão micropolítica, ambos, brasileiros e cubanos, se beneficiam de estratégias de educação permanente, supervisão em loco, cursos EAD, rodas de conversa para discussão de problemas, grupos de troca de experiência e compartilhamento de estratégias no planejamento local. Um dos principais problemas apontados no programa é que a estratégia de provisão é temporária, não está bem afinada com a corporação médica brasileira e as supervisões não são bem organizadas pelas Universidades. Demonstra também a fragilidade na articulação entre gestão local e nacional na organização do processo / The education and provision of health professionals are the main strategies to increase capacity and respond to health systems needs among countries worldwide. Recently, the Brazilian government passed a law to create a national program, called the More Doctors Program, to improve the capacity to respond to the demand for doctors in underserved areas. The law was designed with three main axes: provision, education and infrastructure. The first, provision, would increase the provision of medical doctors through monetary and non-monetary incentives to attract national and foreign doctors to work in remote areas. The education axis was related to opening new Courses and Institutions to graduate new doctors in remote areas. The third axis was to improve primary care facilities. However, the most controversial aspect of this Program was the partnership between Cuba and Brazil, through an international cooperation mediated by the Pan-American Health Organization. It involved 18,240 new primary care physicians. Focusing on provision, mainly in the Brazil-Cuba international cooperation, a qualitative study was designed and conducted, analyzing the More Doctors policy cycle, using Howlet & Ramesh, 2003 as well as Ball, 1992 as a reference. This study examined the five stages of the policy cycle: agenda preparation, policy formulation, decision making, implementation and evaluation and context analysis and evaluation on the Ball cycle. Ball argues that policy has to be analyzed in the field. Interviews with stakeholders, document analysis and case studies were developed. As part of the case study, there were visits to three cities in the interior of Brazil; the researchers observed the locally managed education and program. The objective of the study was to investigate the macro and micro effects of Brazilian and Cuban physicians work processes in the Brazilian primary care units served by the program, as well as analyzing the policy as an innovation in health workforce management in the Americas and exploring the whole policy cycle and the implications for medical workforce management in Brazil. On the macro level, the interviews show that in Brazil medical education and practice are market oriented and focused on specialized care, with an overuse of high-technology resources, compared to Cuban doctors. All the Cuban physicians in Brazil were educated as General Practitioners. In addition, there could be an influence of the Cuban socialist model. The Cuban doctors bring a new perspective to Brazilian health professionals on how to build linkages with the users and how to deal with poverty and inequity. On the micro level, both groups benefited from ongoing learning strategies, supervisions in locus, distance learning courses, round tables on the main health problems, group practice sharing, and the interchange on health local planning. The main problems involve the temporary nature of the provision strategy, which is not well resolved with the Brazilian medical corporations and professional bodies. Furthermore, the supervisions are not always well organized by the Universities. The study also shows the fragilities of federative integration regarding policy implementation and management

A formação e o provimento de profissionais de saúde são parte das estratégias que vêm sendo utilizadas pelos países para aumentar a capacidade de resposta dos seus sistemas de saúde e, assim, melhorar a qualidade de vida das suas populações. Recentemente, o governo brasileiro criou uma lei, instituindo um programa para melhorar a capacidade de resposta para escassez de médicos em áreas remotas, intitulado Programa Mais Médicos. Uma das ações polêmicas desse programa foi a importação de médicos cubanos, através de uma cooperação Cuba-Brasil, mediada pela Organização Pan-americana de Saúde (OPAS). Trata-se de uma iniciativa de grande vulto que envolveu, de 2011 a 2015, um total de 18 mil e 24 mil médicos novos no SUS. Nesse sentido, ganha relevância a análise do Programa Mais Médicos como política recém-implantada em contexto brasileiro, que constitui o objeto deste projeto de pesquisa. Este estudo de caso focaliza o provimento, fundamentalmente na cooperação Cuba-Brasil. Para analisar o programa, adota-se a abordagem do Ciclo de Políticas (Howlett e Ramesh, 2003) que organiza o estudo da política em cinco fases: (a) preparação da agenda, (b) formulação da política, (c) tomada de decisão, (d) implementação e (e) avaliação, adaptado pela análise de contexto de Bowe & Ball, 1992 que defende a análise de políticas a partir do seu campo de prática. Entrevistas com atores chaves, análise documental e estudo de caso foram desenvolvidos. Para o estudo de caso, focalizamos o PMM no Estado do Ceará e visitamos duas cidades no interior do Brasil neste mesmo estado. Os cenários de implementação do programa, as unidades com médicos cubanos e os espaços de supervisão foram os objetos de observação de campo da investigadora. O objetivo do estudo foi analisar os macro e micro efeitos da Cooperação Cuba- Brasil no trabalho médico brasileiro em APS, investigar seu potencial de inovação para o trabalho médico nas Américas e acompanhar todo o ciclo da política em questão, desde a sua entrada na agenda governamental até os mecanismos de avaliação, incluindo a identificação de desdobramentos para as políticas locais dos casos estudados. Ademais, construir novos saberes no campo da análise de políticas, inovações e provimento de profissionais de saúde no mundo. Na dimensão macropolítica, as entrevistas mostram a prática e a educação médica voltada para a atenção especializada, orientada pelo mercado, com um uso exagerado de tecnologias de alta densidade, comparados aos médicos cubanos. Os médicos cubanos trazem uma nova perspectiva para os profissionais de saúde na forma de construir vínculos com os usuários e na maneira de lidar com a pobreza e a iniquidade. Na dimensão micropolítica, ambos, brasileiros e cubanos, se beneficiam de estratégias de educação permanente, supervisão em loco, cursos EAD, rodas de conversa para discussão de problemas, grupos de troca de experiência e compartilhamento de estratégias no planejamento local. Um dos principais problemas apontados no programa é que a estratégia de provisão é temporária, não está bem afinada com a corporação médica brasileira e as supervisões não são bem organizadas pelas Universidades. Demonstra também a fragilidade na articulação entre gestão local e nacional na organização do processo / The education and provision of health professionals are the main strategies to increase capacity and respond to health systems needs among countries worldwide. Recently, the Brazilian government passed a law to create a national program, called the More Doctors Program, to improve the capacity to respond to the demand for doctors in underserved areas. The law was designed with three main axes: provision, education and infrastructure. The first, provision, would increase the provision of medical doctors through monetary and non-monetary incentives to attract national and foreign doctors to work in remote areas. The education axis was related to opening new Courses and Institutions to graduate new doctors in remote areas. The third axis was to improve primary care facilities. However, the most controversial aspect of this Program was the partnership between Cuba and Brazil, through an international cooperation mediated by the Pan-American Health Organization. It involved 18,240 new primary care physicians. Focusing on provision, mainly in the Brazil-Cuba international cooperation, a qualitative study was designed and conducted, analyzing the More Doctors policy cycle, using Howlet & Ramesh, 2003 as well as Ball, 1992 as a reference. This study examined the five stages of the policy cycle: agenda preparation, policy formulation, decision making, implementation and evaluation and context analysis and evaluation on the Ball cycle. Ball argues that policy has to be analyzed in the field. Interviews with stakeholders, document analysis and case studies were developed. As part of the case study, there were visits to three cities in the interior of Brazil; the researchers observed the locally managed education and program. The objective of the study was to investigate the macro and micro effects of Brazilian and Cuban physicians work processes in the Brazilian primary care units served by the program, as well as analyzing the policy as an innovation in health workforce management in the Americas and exploring the whole policy cycle and the implications for medical workforce management in Brazil. On the macro level, the interviews show that in Brazil medical education and practice are market oriented and focused on specialized care, with an overuse of high-technology resources, compared to Cuban doctors. All the Cuban physicians in Brazil were educated as General Practitioners. In addition, there could be an influence of the Cuban socialist model. The Cuban doctors bring a new perspective to Brazilian health professionals on how to build linkages with the users and how to deal with poverty and inequity. On the micro level, both groups benefited from ongoing learning strategies, supervisions in locus, distance learning courses, round tables on the main health problems, group practice sharing, and the interchange on health local planning. The main problems involve the temporary nature of the provision strategy, which is not well resolved with the Brazilian medical corporations and professional bodies. Furthermore, the supervisions are not always well organized by the Universities. The study also shows the fragilities of federative integration regarding policy implementation and management

Mémoire de fin d'études de maitrise réalisé par l'étudiante Clerveau Vanessa, sous la direction du professeur Denis Jean-Louis et Johri Mira pour l'obtention de la maitrise en administration des services de santé, option santé mondiale / La pénurie de main-d’œuvre en santé représente une problématique de santé mondiale et sa gestion par les pays de destination pourrait entraîner de graves conséquences sur les systèmes de santé des pays d’origine. Afin d’en atténuer certaines, l’Organisation mondiale de la santé (OMS) a créé le Code de pratique mondiale. Nous avons exploré le potentiel des accords bilatéraux proposés par ce Code dans le processus de migration des infirmiers haïtiens au Québec. Une analyse qualitative exploratoire a été menée avec des données de la littérature grise, scientifique et du grand public, ainsi que des entrevues semi-dirigées d’experts d’Haïti et de Québec selon un échantillon raisonné, au moyen d’un guide d’entrevue. Elles ont été transcrites manuellement, enregistrées sur Teams et analysées sur Nvivo. La formation des infirmiers haïtiens nécessaire au renouvellement de la main-d’œuvre, le renforcement des capacités du système de santé haïtien, le transfert de connaissances et de compétences, et l’intégration du personnel infirmier haïtien font partie des éléments clés évoqués par les experts en vue d’explorer le potentiel des accords bilatéraux. Haïti et le Québec devraient désigner des éléments nécessaires définissant clairement les besoins respectifs de leur système de santé. Cependant, la mise en œuvre pourrait être compromise par les enjeux d’équité, de dynamique, de pouvoir et d’instabilité en Haïti. Les accords bilatéraux dans le processus de migration des infirmiers haïtiens pourraient servir de levier d’amélioration des politiques de santé publique et de la coopération internationale entre Haïti et le Québec. / The shortage of healthcare workers is a global health issue, and its management by destination countries could impact healthcare systems in countries of origin. The World Health Organization (WHO) has taken steps to mitigate some of these issues by implementing the Global Code of Practice. We explored the potential of the bilateral agreements proposed by this Code in the migration process of Haitian nurses to Quebec. An exploratory qualitative analysis was conducted using data from the grey, scientific, and public literature, as well as semi-structured interviews with experts from Haiti and Quebec based on a purposive sample, using an interview guide. They were manually transcribed, recorded on Teams, and analyzed on Nvivo. The training of Haitian nurses needed to renew the workforce, capacity building of the Haitian healthcare system, transfer of knowledge and skills, and integration of Haitian nurses were among the key elements raised by experts to explore the potential of bilateral agreements. Haiti and Quebec should identify the necessary elements that clearly define the respective needs of their healthcare systems. However, implementation could be compromised by issues of equity, dynamics, power, and instability in Haiti. Bilateral agreements in the Haitian nurse migration process could serve as a lever for improving public health policies and international cooperation between Haiti and Quebec.

“Why do immigrants and refugees need community health workers/lay health workers (CHWs) if Canada already has a universal health care system?” Abundant evidence demonstrates that despite the universality of our health care system marginalized populations, including immigrants and refugees, experience barriers to accessing the health system. Evidence on the role of CHWs facilitating access is both lacking and urgently needed. This dissertation contributes to this evidence by providing a thick description and thorough analytical exploration of a CHW model, in Edmonton, Canada. Specifically, I examine the activities of the Multicultural Health Brokers Co-operative (MCHB Co-op) and its Multicultural Health Brokers from 1992 to 2011 as well as the relationship they have with Alberta Health Services (AHS) Edmonton Zone Public Health. The research for this study is based on an instrumental and embedded qualitative case study design. The case is the MCHB Co-op, an independently-run multicultural health worker co-operative, which contracts with health and social services providers in Edmonton to offer linguistically- and culturally-appropriate services to marginalized immigrant and refugee women and their families. The two embedded mini-cases are two programs of the MCHB Co-op: Perinatal Outreach and Health for Two, which are the raison d’être for a sustained partnership between the MCHB Co-op and AHS. The phenomenon under study is the Multicultural Health Brokers’ practice. I triangulate multiple methods (research strategies and data sources), including 46 days of participant and direct observation, 44 in-depth interviews (with Multicultural Health Brokers, mentors, women using the programs, health professionals and outsiders who knew of the work of the MCHB Co-op and Multicultural Health Brokers), and document review and analysis of policy documents, yearly reports, training manuals, educational materials as well as quantitative analysis of the Health Brokers’ 3,442 client caseload database. In addition, data include my field notes of both descriptive and analytical reflections taken throughout the onsite research. I also triangulate various theoretical frameworks to explore how historically specific social structures, economic relationships, and ideological assumptions serve to create and reinforce the conditions that give rise to the need for CHWs, and the factors that aid or hinder their ability to facilitate marginalized populations’ access to health and social services. Findings reveal that Multicultural Health Brokers facilitate access to health and social services as well as foster community capacity building in order to address settlement, adaptation, and integration of immigrant and refugee women and their families into Canadian society. Findings also demonstrate that the Multicultural Health Broker model is an example of collaboration between community-based organizations and local systems in targeting health equity for marginalized populations; in particular, in perinatal health and violence against women. A major problem these workers face is they provide important services as part of Canada’s health human resources workforce, but their contributions are often not recognized as such. The triangulation of methods and theory provides empirical and theoretical understanding of the Multicultural Health Brokers’ contribution to immigrant and refugee women and their families’ feminist urban citizenship.

“Why do immigrants and refugees need community health workers/lay health workers (CHWs) if Canada already has a universal health care system?” Abundant evidence demonstrates that despite the universality of our health care system marginalized populations, including immigrants and refugees, experience barriers to accessing the health system. Evidence on the role of CHWs facilitating access is both lacking and urgently needed. This dissertation contributes to this evidence by providing a thick description and thorough analytical exploration of a CHW model, in Edmonton, Canada. Specifically, I examine the activities of the Multicultural Health Brokers Co-operative (MCHB Co-op) and its Multicultural Health Brokers from 1992 to 2011 as well as the relationship they have with Alberta Health Services (AHS) Edmonton Zone Public Health. The research for this study is based on an instrumental and embedded qualitative case study design. The case is the MCHB Co-op, an independently-run multicultural health worker co-operative, which contracts with health and social services providers in Edmonton to offer linguistically- and culturally-appropriate services to marginalized immigrant and refugee women and their families. The two embedded mini-cases are two programs of the MCHB Co-op: Perinatal Outreach and Health for Two, which are the raison d’être for a sustained partnership between the MCHB Co-op and AHS. The phenomenon under study is the Multicultural Health Brokers’ practice. I triangulate multiple methods (research strategies and data sources), including 46 days of participant and direct observation, 44 in-depth interviews (with Multicultural Health Brokers, mentors, women using the programs, health professionals and outsiders who knew of the work of the MCHB Co-op and Multicultural Health Brokers), and document review and analysis of policy documents, yearly reports, training manuals, educational materials as well as quantitative analysis of the Health Brokers’ 3,442 client caseload database. In addition, data include my field notes of both descriptive and analytical reflections taken throughout the onsite research. I also triangulate various theoretical frameworks to explore how historically specific social structures, economic relationships, and ideological assumptions serve to create and reinforce the conditions that give rise to the need for CHWs, and the factors that aid or hinder their ability to facilitate marginalized populations’ access to health and social services. Findings reveal that Multicultural Health Brokers facilitate access to health and social services as well as foster community capacity building in order to address settlement, adaptation, and integration of immigrant and refugee women and their families into Canadian society. Findings also demonstrate that the Multicultural Health Broker model is an example of collaboration between community-based organizations and local systems in targeting health equity for marginalized populations; in particular, in perinatal health and violence against women. A major problem these workers face is they provide important services as part of Canada’s health human resources workforce, but their contributions are often not recognized as such. The triangulation of methods and theory provides empirical and theoretical understanding of the Multicultural Health Brokers’ contribution to immigrant and refugee women and their families’ feminist urban citizenship.

“Why do immigrants and refugees need community health workers/lay health workers (CHWs) if Canada already has a universal health care system?” Abundant evidence demonstrates that despite the universality of our health care system marginalized populations, including immigrants and refugees, experience barriers to accessing the health system. Evidence on the role of CHWs facilitating access is both lacking and urgently needed. This dissertation contributes to this evidence by providing a thick description and thorough analytical exploration of a CHW model, in Edmonton, Canada. Specifically, I examine the activities of the Multicultural Health Brokers Co-operative (MCHB Co-op) and its Multicultural Health Brokers from 1992 to 2011 as well as the relationship they have with Alberta Health Services (AHS) Edmonton Zone Public Health. The research for this study is based on an instrumental and embedded qualitative case study design. The case is the MCHB Co-op, an independently-run multicultural health worker co-operative, which contracts with health and social services providers in Edmonton to offer linguistically- and culturally-appropriate services to marginalized immigrant and refugee women and their families. The two embedded mini-cases are two programs of the MCHB Co-op: Perinatal Outreach and Health for Two, which are the raison d’être for a sustained partnership between the MCHB Co-op and AHS. The phenomenon under study is the Multicultural Health Brokers’ practice. I triangulate multiple methods (research strategies and data sources), including 46 days of participant and direct observation, 44 in-depth interviews (with Multicultural Health Brokers, mentors, women using the programs, health professionals and outsiders who knew of the work of the MCHB Co-op and Multicultural Health Brokers), and document review and analysis of policy documents, yearly reports, training manuals, educational materials as well as quantitative analysis of the Health Brokers’ 3,442 client caseload database. In addition, data include my field notes of both descriptive and analytical reflections taken throughout the onsite research. I also triangulate various theoretical frameworks to explore how historically specific social structures, economic relationships, and ideological assumptions serve to create and reinforce the conditions that give rise to the need for CHWs, and the factors that aid or hinder their ability to facilitate marginalized populations’ access to health and social services. Findings reveal that Multicultural Health Brokers facilitate access to health and social services as well as foster community capacity building in order to address settlement, adaptation, and integration of immigrant and refugee women and their families into Canadian society. Findings also demonstrate that the Multicultural Health Broker model is an example of collaboration between community-based organizations and local systems in targeting health equity for marginalized populations; in particular, in perinatal health and violence against women. A major problem these workers face is they provide important services as part of Canada’s health human resources workforce, but their contributions are often not recognized as such. The triangulation of methods and theory provides empirical and theoretical understanding of the Multicultural Health Brokers’ contribution to immigrant and refugee women and their families’ feminist urban citizenship.