Thèse de doctorat effectuée en cotutelle au Département d’administration de la santé Faculté de médecine, Université de Montréal et à l’École doctorale Biologie-Santé Faculté de médecine, Université de Nantes, France / L’objectif de la thèse est d’approfondir la compréhension des enjeux liés au processus d’introduction du changement dans les organisations. Ce sujet semble important vu les enjeux majeurs auxquels sont actuellement confrontées les organisations pour implanter des changements jugés nécessaires. Notre recherche aborde l’analyse du changement dans les organisations selon une approche systémique. Cette approche a été développée dans le cadre de la thèse et propose de voir l’implantation du changement jugé nécessaire dans les organisations, non comme des initiatives isolées et déconnectées de l’environnement, mais plutôt comme des processus émergents ou programmés permettant autant le changement de l’organisation que le changement et l’évolution de l’environnement dans une perspective de co-évolution des organisations et de leur environnement. Au niveau des organisations, cette approche systémique amène à se pencher sur la question des possibilités réelles des organisations de produire les changements jugés nécessaires. Elle cherche à comprendre pourquoi, malgré les possibilités réelles des organisations de créer des conditions favorables à l’acceptation et à l’implantation du changement et de l’innovation, les organisations ne s’engagent pas à créer de telles conditions et par conséquent ont des difficultés à produire le changement. Dans le cadre de la recherche, nous avons étudié le changement des pratiques professionnelles et managériales dans le contexte hospitalier français suite à l’introduction d’une innovation d’amélioration de la performance hospitalière, et notamment le projet PATH de l’OMS Europe. Il s’agissait pour nous d’analyser la dynamique de l’implantation de PATH dans la production des effets et le degré d’implantation de PATH, tout en faisant ressortir les facteurs contextuels qui permettent d’expliquer les variations dans le degré d’implantation et les effets. Les résultats de notre recherche soutiennent la proposition qu’il est probablement possible de prédire le niveau d’atteinte des objectifs poursuivis par un changement à partir de la connaissance des capacités collectives de l’organisation pour produire le changement et la façon dont elles ont été mobilisées pour atteindre les objectifs poursuivis. Ils envoient un signal fort aux établissements de santé qui voudraient réussir l’implantation des pratiques novatrices d’amélioration de la performance hospitalière qu’ils doivent s’occuper du contexte dans lequel les efforts de l’implantation sont pratiqués et que ces efforts ne sauraient être entrepris tant que des conditions favorables à l’acceptation et à la réalisation du changement ne sont pas mises en place. Les conditions favorables se matérialiseraient dans les établissements par la mise en place de structures favorisant le travail en groupe multi professionnels, de formations relatives à l’implantation de l’innovation, de coordination de l’action collective, d’implication des utilisateurs finals de l’innovation dans tous le processus d’implantation et de soutien du leadership médical et administratif. / The objective of the thesis is to look further into the comprehension of the issues related to the process of introduction of the change into the organizations. This subject seems important in view of the major challenges currently facing the organizations to implement changes considered to be necessary. Our research approaches the analysis of the change in the organizations according to a systemic approach. This approach was developed within the framework of the thesis and proposes to see the introduction of the change considered to be necessary in the organizations, not like isolated and disconnected initiatives from the environment, but rather like emergent or programmed processes allowing the change of the organization as much that the change and the evolution of the environment in a context of co-evolution of the both entities. To the level of the organizations, this systemic approach for analysing the change in the organizations brings to consider the question of the real possibilities of the organizations to produce changes deemed necessary. She seeks to understand why, despite the real possibilities of the organizations to create favourable conditions for the acceptance and to the implementation of the change and of the innovation, the organizations are not committed to create such conditions and consequently have difficulties in produce the change. Within the framework of research, we studied the change of the professional and managerial practices in the French hospital context following the introduction of a hospital performance improvement innovation: the WHO Europe’s project PATH. Our objectives were to analyse the dynamics of the implementation of PATH in the production of effects and the degree of implementation of PATH, and to identify the contextual factors that allow explaining the variations in the degree of implementation and the effects. The results of our research support the proposal which it is probably possible to predict the level of achievement of objectives pursued by the change from the knowledge of the collective capacities of the organization to produce the change and the way in which they were mobilized to achieve the objectives pursued. They send a signal to the hospitals which would like to introduce innovative hospital performance improvement practices that they must deal with the context in which the implementation efforts are practiced and that these efforts could not be undertaken as long as favourable conditions for the acceptance and for the implementation of the change are not put in place. These favourable conditions are materialized in hospitals by structures supporting multidisciplinary group work, by training related to the implementation of the innovation, by a coordination of the collective action, by the end-users of the innovation implication in all the implementation processes and by the medical and management leadership support.

Os objetivos do estudo foram correlacionar a razão entre a circunferência abdominal e altura (CA/A) e o índice de massa corpórea (IMC) com as variáveis cardiometabólicas e inflamatórias em escolares de seis a 10 anos; avaliar a frequência de sobrepeso/obesidade e alterações cardiometabólicas e comparar o desempenho dos referenciais de índice de massa corpórea (IMC) do Centers for Disease Control and Prevention 2000 (CDC) e Organização Mundial de Saúde 2007 (OMS) no diagnóstico de sobrepeso/obesidade e alterações cardiometabólicas. Métodos: estudo de corte transversal, que incluiu 175 crianças, provenientes do Centro de Referência para Tratamento da Criança e do Adolescente (CRTCA), em Campos, Rio de Janeiro. As crianças foram divididas segundo os escores z do CDC e OMS em: não obesas (z do IMC <1) e sobrepeso/obesidade (z do IMC > 1). As variáveis cardiometabólicas analisadas foram: pressão arterial sistólica (PAS) e diastólica (PAD), glicose, lipoproteínas de baixa e alta densidades (LDL e HDL, respectivamente), triglicerídeos (TG), HOMA-IR. Como variáveis inflamatórias, analisamos proteína C reativa ultra-sensível (PCR) e leucometria. Resultados: a média da CA/A do grupo sobrepeso/obesidade foi maior que a do não obeso (0,58 ± 0,007 e 0,45 ± 0,004, respectivamente, p< 0,0001). Houve correlação significativa da CA/A com os escores z do IMC (r = 0,88, p < 0,0001), PAS (r= 0,51, p<0,0001), PAD (r= 0,49, p<0,0001), HOMA-IR (r=0,83, p<0,0001), HDL (r = -0,28, p< 0,0002), TG (r= 0,26, p<0,0006), LDL (r= 0,25, p<0,0008) e PCR (r= 0,51, p<0,0001). Contudo, a CA/A não se correlacionou com glicemia nem leucócitos. A sensibilidade da CA/A se equivaleu à do IMC no diagnóstico das alterações cardiometabólicas. A sensibilidade mais elevada da CA/A foi para o diagnóstico de alteração da PAS (80,0 %), PAD (76,6%) e HOMA-IR (92,6%). O ponto de corte superior a 0,47 foi sensível para o diagnóstico de resistência insulínica, mas acima de 0,50, para os demais distúrbios cardiometabólicos. A frequência de sobrepeso/obesidade nos escolares foi igual a 49,7%. Com exceção de hipertrigliceridemia, todas as outras alterações cardiometabólicas foram mais frequentes no grupo sobrepeso/obesidade (aumento de PA, p<0,0001; glicemia de jejum alterada, p < 0,0048; aumento de LDL, p< 0,015 e redução do HDL, p<0,0001). O referencial da OMS 2007 reclassificou 11 crianças a mais como obesas que o CDC, que apresentaram médias de escores z de PAS (1,71 ± 1,54), PAD (2,64 ± 1,83) e HOMA-IR (1,84 ± 0,98) semelhantes às médias das obesas (PAS = 1,25 ± 2,04; PAD = 1,94 ± 1,19 e HOMA-IR = 2,09 ± 1,12), mas superiores às médias das classificadas como sobrepeso (PAS = 0,49 ± 1,34, p < 0,023; PAD = 1,45 ± 0,97, p < 0,04 e HOMA-IR = 1,24 ± 0,67, p < 0,04 ). Conclusões: a razão CA/A foi tão sensível quanto IMC da OMS 2007 no diagnóstico do risco cardiometabólico e inflamatório. O referencial da OMS 2007 foi o mais sensível não só para o rastreamento de sobrepeso/obesidade, como também para pressão arterial elevada e resistência insulínica, em escolares de seis a 10 anos / This study aims to correlate the waist-to-height ratio (WHtR) and the body mass index (BMI) with the cardiometabolic and inflammatory variables in 6-10 year-old school children; to evaluated the frequency of overweight/obesity and cardiometabolic disturbances, and to compare the 2000 Centers for Disease Control and Prevention (CDC) and 2007 World Health Organization (WHO) body mass index (BMI) references in the diagnosis of overweight/obesity and the cardiometabolic disturbances. Methods: a cross-sectional study which included 175 subjects, selected from the Reference Center for the Treatment of Children and Adolescents, in Campos, Rio de Janeiro. The subjects were classified according to the 2000 CDC and 2007 OMS BMI z scores as non obese (BMI < 1) and overweight/obese ones (BMI > 1). The analized cardiometabolic variables were systolic and diastolic blood pressure (SBP and DBP respectively), fasting glycemia, low and high density lipoproteins (LDL and HDL respectively), trigliceride (TG), homeostatic model assessment (HOMA-IR). As inflammatory markers we analized the ultra-sensitive Creactive protein (CRP) and the leucocyte count. Results: the WHtR mean of the overweight/obese group was higher than that of the non obese ones (0,58 ± 0,007 and 0,45 ± 0,004, respectively,p < 0,0001). There was correlation between the WHtR and BMI z score (r = 0,88, p < 0,0001), SBP (r = 0,51, p < 0,0001), DBP (r = 0,49, p < 0,0001), HOMA-IR (r = 0,83, p < 0,0001), HDL (r = -0,28, p < 0,0002, TG (r= 0,26, p < 0,0006), LDL (r = 0,25, p < 0,0008), and CRP (r = 0, 51, p < 0.0001). However, the WHtR was neither correlated with glycemia nor with the leucocyte count. The WHtR sensitivity was equivalent to that of the BMI in the diagnosis of all cardiometabolic variables. The highest WHtR sensitivity was to diagnose the SBP (80,0%), DBP (76,6%) and HOMA-IR (92,6%) alterations. The WHtR cut-off higher than 0,47 pointed out to insulin resistance diagnosis, but higher than 0,5, it did to the other metabolic disturbances. The frequency of overweight/obesity was 49,7% in these school children. Except for hypertriglyceridemia, all the remaining cardiometabolic disturbances were more frequent in the overweight/obese group. The 2007 WHO BMI reference reclassified 11 children more as obese than the 2000 CDC, who had means of SBP (1,71 ± 1,54) and DBP z scores (2,64 ± 1,83) and HOMA-IR (1,84 ± 0,98) similar to those of the obese ones (SBP = 1,25 ± 20,4; DBP = 1,94 ± 1,1 and HOMA-IR = 2,09 ± 1,12), but higher than those of the classified as overweight (SBP= 0,49 ± 1,34, p<0,023; DBP= 1,45 ± 0,97, p<0,04 and HOMA-IR= 1,24 ± 0,67, p<0,04). Conclusions: the WHtR was so sensitive as the 2007 WHO BMI z score in diagnosing the cardiometabolic and inflammatory risk. The 2007 WHO reference was the most sensitive not only to screen obesity, but also the high blood pressure and insulin resistance, in 6-10-year-old children

Os objetivos do estudo foram correlacionar a razão entre a circunferência abdominal e altura (CA/A) e o índice de massa corpórea (IMC) com as variáveis cardiometabólicas e inflamatórias em escolares de seis a 10 anos; avaliar a frequência de sobrepeso/obesidade e alterações cardiometabólicas e comparar o desempenho dos referenciais de índice de massa corpórea (IMC) do Centers for Disease Control and Prevention 2000 (CDC) e Organização Mundial de Saúde 2007 (OMS) no diagnóstico de sobrepeso/obesidade e alterações cardiometabólicas. Métodos: estudo de corte transversal, que incluiu 175 crianças, provenientes do Centro de Referência para Tratamento da Criança e do Adolescente (CRTCA), em Campos, Rio de Janeiro. As crianças foram divididas segundo os escores z do CDC e OMS em: não obesas (z do IMC <1) e sobrepeso/obesidade (z do IMC > 1). As variáveis cardiometabólicas analisadas foram: pressão arterial sistólica (PAS) e diastólica (PAD), glicose, lipoproteínas de baixa e alta densidades (LDL e HDL, respectivamente), triglicerídeos (TG), HOMA-IR. Como variáveis inflamatórias, analisamos proteína C reativa ultra-sensível (PCR) e leucometria. Resultados: a média da CA/A do grupo sobrepeso/obesidade foi maior que a do não obeso (0,58 ± 0,007 e 0,45 ± 0,004, respectivamente, p< 0,0001). Houve correlação significativa da CA/A com os escores z do IMC (r = 0,88, p < 0,0001), PAS (r= 0,51, p<0,0001), PAD (r= 0,49, p<0,0001), HOMA-IR (r=0,83, p<0,0001), HDL (r = -0,28, p< 0,0002), TG (r= 0,26, p<0,0006), LDL (r= 0,25, p<0,0008) e PCR (r= 0,51, p<0,0001). Contudo, a CA/A não se correlacionou com glicemia nem leucócitos. A sensibilidade da CA/A se equivaleu à do IMC no diagnóstico das alterações cardiometabólicas. A sensibilidade mais elevada da CA/A foi para o diagnóstico de alteração da PAS (80,0 %), PAD (76,6%) e HOMA-IR (92,6%). O ponto de corte superior a 0,47 foi sensível para o diagnóstico de resistência insulínica, mas acima de 0,50, para os demais distúrbios cardiometabólicos. A frequência de sobrepeso/obesidade nos escolares foi igual a 49,7%. Com exceção de hipertrigliceridemia, todas as outras alterações cardiometabólicas foram mais frequentes no grupo sobrepeso/obesidade (aumento de PA, p<0,0001; glicemia de jejum alterada, p < 0,0048; aumento de LDL, p< 0,015 e redução do HDL, p<0,0001). O referencial da OMS 2007 reclassificou 11 crianças a mais como obesas que o CDC, que apresentaram médias de escores z de PAS (1,71 ± 1,54), PAD (2,64 ± 1,83) e HOMA-IR (1,84 ± 0,98) semelhantes às médias das obesas (PAS = 1,25 ± 2,04; PAD = 1,94 ± 1,19 e HOMA-IR = 2,09 ± 1,12), mas superiores às médias das classificadas como sobrepeso (PAS = 0,49 ± 1,34, p < 0,023; PAD = 1,45 ± 0,97, p < 0,04 e HOMA-IR = 1,24 ± 0,67, p < 0,04 ). Conclusões: a razão CA/A foi tão sensível quanto IMC da OMS 2007 no diagnóstico do risco cardiometabólico e inflamatório. O referencial da OMS 2007 foi o mais sensível não só para o rastreamento de sobrepeso/obesidade, como também para pressão arterial elevada e resistência insulínica, em escolares de seis a 10 anos / This study aims to correlate the waist-to-height ratio (WHtR) and the body mass index (BMI) with the cardiometabolic and inflammatory variables in 6-10 year-old school children; to evaluated the frequency of overweight/obesity and cardiometabolic disturbances, and to compare the 2000 Centers for Disease Control and Prevention (CDC) and 2007 World Health Organization (WHO) body mass index (BMI) references in the diagnosis of overweight/obesity and the cardiometabolic disturbances. Methods: a cross-sectional study which included 175 subjects, selected from the Reference Center for the Treatment of Children and Adolescents, in Campos, Rio de Janeiro. The subjects were classified according to the 2000 CDC and 2007 OMS BMI z scores as non obese (BMI < 1) and overweight/obese ones (BMI > 1). The analized cardiometabolic variables were systolic and diastolic blood pressure (SBP and DBP respectively), fasting glycemia, low and high density lipoproteins (LDL and HDL respectively), trigliceride (TG), homeostatic model assessment (HOMA-IR). As inflammatory markers we analized the ultra-sensitive Creactive protein (CRP) and the leucocyte count. Results: the WHtR mean of the overweight/obese group was higher than that of the non obese ones (0,58 ± 0,007 and 0,45 ± 0,004, respectively,p < 0,0001). There was correlation between the WHtR and BMI z score (r = 0,88, p < 0,0001), SBP (r = 0,51, p < 0,0001), DBP (r = 0,49, p < 0,0001), HOMA-IR (r = 0,83, p < 0,0001), HDL (r = -0,28, p < 0,0002, TG (r= 0,26, p < 0,0006), LDL (r = 0,25, p < 0,0008), and CRP (r = 0, 51, p < 0.0001). However, the WHtR was neither correlated with glycemia nor with the leucocyte count. The WHtR sensitivity was equivalent to that of the BMI in the diagnosis of all cardiometabolic variables. The highest WHtR sensitivity was to diagnose the SBP (80,0%), DBP (76,6%) and HOMA-IR (92,6%) alterations. The WHtR cut-off higher than 0,47 pointed out to insulin resistance diagnosis, but higher than 0,5, it did to the other metabolic disturbances. The frequency of overweight/obesity was 49,7% in these school children. Except for hypertriglyceridemia, all the remaining cardiometabolic disturbances were more frequent in the overweight/obese group. The 2007 WHO BMI reference reclassified 11 children more as obese than the 2000 CDC, who had means of SBP (1,71 ± 1,54) and DBP z scores (2,64 ± 1,83) and HOMA-IR (1,84 ± 0,98) similar to those of the obese ones (SBP = 1,25 ± 20,4; DBP = 1,94 ± 1,1 and HOMA-IR = 2,09 ± 1,12), but higher than those of the classified as overweight (SBP= 0,49 ± 1,34, p<0,023; DBP= 1,45 ± 0,97, p<0,04 and HOMA-IR= 1,24 ± 0,67, p<0,04). Conclusions: the WHtR was so sensitive as the 2007 WHO BMI z score in diagnosing the cardiometabolic and inflammatory risk. The 2007 WHO reference was the most sensitive not only to screen obesity, but also the high blood pressure and insulin resistance, in 6-10-year-old children

Sob o referencial da história das idéias, este estudo revisa o pensamento sanitarista brasileiro, norteado pela figura do Centro de Saúde. A reforma do Serviço Sanitário paulista de 1925 e a instituição das Unidades de Saúde da Família em 1994 definem os limites gerais da revisão. Considera-se a possibilidade de que o discurso sobre o Centro de Saúde inaugurou uma nova era epistemológica na saúde pública, definida pela dimensão individual da educação sanitária, em detrimento da medicina das cidades ou era bacteriana. As novas concepções surgiram, sustentaram e foram sustentadas pelo deslocamento da influência política e intelectual francesa para os Estados Unidos, materializada nas ações da Fundação Rockefeller, tendo por base a Universidade Johns Hopkins. São Paulo foi uma das cidades escolhidas para investimento maciço, como efeito demonstração do novo ideário. Embora a atuação institucional da Fundação tenha tido escala planetária, a apropriação discursiva e adaptação local se mostrou mais precoce e coesa na América Latina, dando ensejo a criação e fortalecimento de um verdadeiro pan-americanismo na saúde pública, com a participação do Brasil. No país, o discurso da era sanitária e seus corolários medicina preventiva, medicina integral, medicina comunitária e atenção básica/primária, foi clivado por três grandes matrizes políticas, que se sucederam e predominaram em momentos distintos: pensamento clássico, de matriz liberal e que dá significação cultural local às idéias que prevalecem no debate internacional a partir dos anos 1920; o pensamento radical, de matriz marxista, que aflora na segunda metade dos anos 1970, principalmente no seio da intelectualidade acadêmica; e o pensamento comunitário em saúde pública, de raízes no pensamento político da assistência social, estimulado pela estratégia da Saúde da Família nos anos 1990. O pensamento radical em saúde pública nasce sob incisiva oposição ao regime militar e ao pensamento clássico. Em sua matriz discursiva a saúde coletiva substitui as expressões anteriores e se concentra no determinantes sociais da saúde, relegando o debate setorial ao segundo plano. Embora sem a devida clareza, o pensamento comunitário recupera e busca atualizar muitas das concepções clássicas, sem fugir da composição com o discurso radical. Alguns conceitos originalmente ligados ao ideário dos Centros de Saúde se destacam ao longo do período analisado: integração (integralidade); descentralização (desconcentração); e socialização (universalidade). Num plano histórico mais abrangente, reconhece-se atualmente que a saúde pública brasileira esteve na essência de um projeto de construção nacional iniciado na Primeira República, mas efetivamente posto em ação na era Vargas. Os Centros de Saúde, hoje representados no ideário da Atenção Básica, não só participaram desta história, como, na realidade, lhe foram em grande parte seus protagonistas / This study reviews the history of ideas in the public health of Brazil. The reform of the Health Service of Sao Paulo in 1925 and the establishment of the Family Health Program in 1994 set the general limits of the review. It considers the possibility that the discourse on the Health Centre inaugurated a new epistemological era in public health, defined by the individual dimension of \"health education\", to the detriment of the \"medicine of the cities\" or \"bacterial era\". New concepts emerged, sustained and were sustained by the displacement of French intellectual and political influence for the United States, embodied in the actions of the Rockefeller Foundation, based on the Johns Hopkins University. São Paulo was one of the cities chosen for massive investment, as \"demonstration effect\" of those new ideas. Although the institutional performance of the Foundation has had a planetary scale, the discursive appropriation and local adaptation was earlier and more cohesive in Latin America, giving rise to creation and strengthening of a true Pan-Americanism in public health, with the participation of Brazil. Nationwide, the \"health education\" ideas and its corollaries \"preventive medicine\", \"comprehensive medicine\", \"community medicine and primary care, was cleaved by three major political perspectives that ensued and prevailed at different times. The \"classical thought\", in a liberal perspective, gave local significance to the ideas present in the international debate since the 1920s. The \"radical thought\", under a Marxist matrix, arouse in the second half of the 1970s, especially within academic intellectuals, and \"community thought\" in public health, stimulated by the Family Health Program in the 1990s. The radical thought in public health movement was strengthened in opposition to the military regime and the classical thought. \"Collective health\" replaced the previous expressions and focuses on social determinants of health, relegating the services organization in the background. Although lacking the necessary clarity, community thought recovers and seeks to update many of the classical concepts, in composition with the radical discourse. Some concepts originally linked to the ideals of the Health Centers are highlighted throughout the studied period: integration (comprehensiveness), decentralization and socialization (universality). In a broader historical view, it is current recognized the role of the Brazilian public health in the national identity construction started in the First Republic, but actually put into action in the Vargas era. Health Centres, today represented in the ideas of primary care, not only participated in this history, as indeed they were largely its protagonists

This dissertation investigates the mutual life project of Signe (1896-1988) and Axel Höjer (1890-1974), a married couple who were key actors in the construction of the Swedish welfare state. It emphasises the ways in which they went about asserting a special public health expertise in different contexts. As starting points I take the malleability of the concept folkhälsa (people’s health or population health) and the centrality of expertise in the governance of modern societies. Theoretical concepts such as gender, policy transfer, biopower and governmentality are central to the analysis. The dissertation includes three parts. The first part investigates how the Höjers agreed to coordinate their work and how they, with reference to ideas picked up in France and England at the end of World War I, attempted to reform mother and child health care in Sweden. Their strategies where rhetorical but also practical, using Hagalund outside Stockholm as their experimental ground. The second part investigates, firstly, how Axel Höjer, as General-Director of the Medical Board of Sweden (1935-52) asserted a sociomedical expertise, integrating the emerging social sciences and universalist views on the organisation of the welfare state into the realm of medicine, in order to launch ideas of a thorough reorganisation and expansion of the Swedish health care system. His focus was on preventive medicine and health care, with the complete physical, mental and social health of the whole population as an explicit goal. Secondly, it explores how Signe Höjer at the same time tried to launch ideas on health and wellbeing as a social politician and a public committee member. She also tried to define family policy as a specific policy area. However, despite her training as a nurse and a social worker, she was largely confined to asserting a particularly ”female” expertise, which made her position rather ambiguous in terms of authority. The third part investigates how the Höjers, in the 1950s and 60s, worked with international health, Axel mainly for the WHO in India and Ghana, Signe as a policy entrepreneur, primarily in the fields of childcare and family planning. My findings partly confirm theories that see development aid as an extension of domestic social policy, but they challenge the view of aid as a simple one-way process. I demonstrate how the Höjers at least tried to adapt their projects abroad to meet local circumstances, and also show how they brought lessons from the third world to a domestic public. In the latter case they did not primarily act as experts of Swedish-style social policy, but as experts on the developing countries and on development aid.

L’objectif de la thèse est d’approfondir la compréhension des enjeux liés au processus d’introduction du changement dans les organisations. Ce sujet semble important vu les enjeux majeurs auxquels sont actuellement confrontées les organisations pour implanter des changements jugés nécessaires. Notre recherche aborde l’analyse du changement dans les organisations selon une approche systémique. Cette approche a été développée dans le cadre de la thèse et propose de voir l’implantation du changement jugé nécessaire dans les organisations, non comme des initiatives isolées et déconnectées de l’environnement, mais plutôt comme des processus émergents ou programmés permettant autant le changement de l’organisation que le changement et l’évolution de l’environnement dans une perspective de co-évolution des organisations et de leur environnement. Au niveau des organisations, cette approche systémique amène à se pencher sur la question des possibilités réelles des organisations de produire les changements jugés nécessaires. Elle cherche à comprendre pourquoi, malgré les possibilités réelles des organisations de créer des conditions favorables à l’acceptation et à l’implantation du changement et de l’innovation, les organisations ne s’engagent pas à créer de telles conditions et par conséquent ont des difficultés à produire le changement. Dans le cadre de la recherche, nous avons étudié le changement des pratiques professionnelles et managériales dans le contexte hospitalier français suite à l’introduction d’une innovation d’amélioration de la performance hospitalière, et notamment le projet PATH de l’OMS Europe. Il s’agissait pour nous d’analyser la dynamique de l’implantation de PATH dans la production des effets et le degré d’implantation de PATH, tout en faisant ressortir les facteurs contextuels qui permettent d’expliquer les variations dans le degré d’implantation et les effets. Les résultats de notre recherche soutiennent la proposition qu’il est probablement possible de prédire le niveau d’atteinte des objectifs poursuivis par un changement à partir de la connaissance des capacités collectives de l’organisation pour produire le changement et la façon dont elles ont été mobilisées pour atteindre les objectifs poursuivis. Ils envoient un signal fort aux établissements de santé qui voudraient réussir l’implantation des pratiques novatrices d’amélioration de la performance hospitalière qu’ils doivent s’occuper du contexte dans lequel les efforts de l’implantation sont pratiqués et que ces efforts ne sauraient être entrepris tant que des conditions favorables à l’acceptation et à la réalisation du changement ne sont pas mises en place. Les conditions favorables se matérialiseraient dans les établissements par la mise en place de structures favorisant le travail en groupe multi professionnels, de formations relatives à l’implantation de l’innovation, de coordination de l’action collective, d’implication des utilisateurs finals de l’innovation dans tous le processus d’implantation et de soutien du leadership médical et administratif. / The objective of the thesis is to look further into the comprehension of the issues related to the process of introduction of the change into the organizations. This subject seems important in view of the major challenges currently facing the organizations to implement changes considered to be necessary. Our research approaches the analysis of the change in the organizations according to a systemic approach. This approach was developed within the framework of the thesis and proposes to see the introduction of the change considered to be necessary in the organizations, not like isolated and disconnected initiatives from the environment, but rather like emergent or programmed processes allowing the change of the organization as much that the change and the evolution of the environment in a context of co-evolution of the both entities. To the level of the organizations, this systemic approach for analysing the change in the organizations brings to consider the question of the real possibilities of the organizations to produce changes deemed necessary. She seeks to understand why, despite the real possibilities of the organizations to create favourable conditions for the acceptance and to the implementation of the change and of the innovation, the organizations are not committed to create such conditions and consequently have difficulties in produce the change. Within the framework of research, we studied the change of the professional and managerial practices in the French hospital context following the introduction of a hospital performance improvement innovation: the WHO Europe’s project PATH. Our objectives were to analyse the dynamics of the implementation of PATH in the production of effects and the degree of implementation of PATH, and to identify the contextual factors that allow explaining the variations in the degree of implementation and the effects. The results of our research support the proposal which it is probably possible to predict the level of achievement of objectives pursued by the change from the knowledge of the collective capacities of the organization to produce the change and the way in which they were mobilized to achieve the objectives pursued. They send a signal to the hospitals which would like to introduce innovative hospital performance improvement practices that they must deal with the context in which the implementation efforts are practiced and that these efforts could not be undertaken as long as favourable conditions for the acceptance and for the implementation of the change are not put in place. These favourable conditions are materialized in hospitals by structures supporting multidisciplinary group work, by training related to the implementation of the innovation, by a coordination of the collective action, by the end-users of the innovation implication in all the implementation processes and by the medical and management leadership support. / Thèse de doctorat effectuée en cotutelle au Département d’administration de la santé Faculté de médecine, Université de Montréal et à l’École doctorale Biologie-Santé Faculté de médecine, Université de Nantes, France

OBJECTIVE/ METHOD The study examined implementation challenges faced by primary health care workers within the Ekurhuleni Metropolitan Municipality in Gauteng South Africa. Data collection was based on semi-structured interviews carried out on a purposive sample (n=19) of frontline clinicians working within the district as primary health care practitioners. RESULTS Participants confirmed that work within the primary health care service disproportionately focussed on curative and rehabilitative functions of their roles with little prioritisation of preventive and promotive interventions. Primary identified reasons included, institutional culture that prioritised short-term curative approaches. Clinicians also cited a range of other organisational barriers, such as – poor strategic planning, and a lack of understanding of health promotion and illness prevention. CONCLUSIONS Although the challenges that exist in implementing primary health care are clearly understood, clinicians perceive the solutions for these as being within the control of policy makers and those with power within the organisation. / Health Studies / M.A. (Public Health)

With the advent of the new National Health Act, health care in South Africa is at a critical point as this will be the first time in history that a National Health Insurance is being implemented in this country. Globally National Health Insurance has been around for more than a hundred years, however some countries with long established national health schemes are currently grappling with funding issues surrounding their health systems. South Africa should take note of these issues as it embarks on this journey. The objective of this study was to perform a literature review on how South Africa’s National Health Insurance can be funded taking cognisance of the history of the country and experiences of other countries. It is imperative for each country to achieve optimal health care funding to ensure the success and long-term sustainability of National Health Insurance. The analysis of the problems experienced by other countries revealed that balancing the three main funding options namely, allocated from the national revenue fund, user charges and or donations or grants from international organisations, is critical as the funds needed in a system to achieve coverage at an affordable cost is dependent on the current state of health care in a country. Considering South Africa’s history and current inequality in society and health care it is clear that the majority of funding for the National Health Insurance should be supplied by the national revenue fund. The required funds can either be raised by increasing existing taxes or introducing a new tax specifically aimed at financing the National Health Insurance. The use of user charges is important however, although not purely for a revenue collection point, but from a cost control point of view as well. Some studies have revealed that the lack of user charges results in a misuse of the system. / Financial Accounting / M. Phil. (Accounting Science)

Submitted by Erika Demachki (erikademachki@gmail.com) on 2015-05-14T18:52:31Z No. of bitstreams: 2 Dissertação - Soraya Bianca Reis Duarte - 2011.pdf: 8127329 bytes, checksum: f18b3d5216f1c83a464e9bc3acd9a309 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Erika Demachki (erikademachki@gmail.com) on 2015-05-14T18:55:18Z (GMT) No. of bitstreams: 2 Dissertação - Soraya Bianca Reis Duarte - 2011.pdf: 8127329 bytes, checksum: f18b3d5216f1c83a464e9bc3acd9a309 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-05-14T18:55:18Z (GMT). No. of bitstreams: 2 Dissertação - Soraya Bianca Reis Duarte - 2011.pdf: 8127329 bytes, checksum: f18b3d5216f1c83a464e9bc3acd9a309 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2011-11-28 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / INTRODUCTION: there are several forms of expression, understanding and interpretation of the concept of disability, as well as a multitude of indicators that interfere significantly to the conceptual composition of the theme. In recent decades, the biological view of disability has been expanded due to the inclusion of socio-anthropological aspects. In the case of the deaf, the need to have their story considered through this approach is relevant to the appropriate care by the Health Professionals. OBJECTIVE: to analyze the Brazilian Sign Language (Libras) version of the WHOQOL-BREF instrument for assessing quality of life in focal groups. METHODS: transversal type descriptive and exploratory qualitative research using the technique of focal groups in three groups distributed as follows: 1) deaf people; 2) deaf people families; and 3) Libras interpreters. Two meetings were held with three focal groups. The first aimed to explain all the details of the research, delivery of a DVD, signing of the Term of Free and Informed Consent and application of a sociodemographic questionnaire. The second aimed to discuss and analyze the Libras version of the WHOQOL-BREF. Data were analyzed based on the technique of analysis of categorial and thematic content proposed by Bardin. RESULTS:100% of the participants of the three Focal Groups (GFs) understood and considered the questions relevant to the QOL of the deaf. In the category of suggestion, GF1 came with 76.94%, GF2 presented 65.39% and GF3 came with 73.08% of the questions that needed changes. CONCLUSIONS: the scarcity of scientific research on the use of focal groups with deaf people was considered a challenging factor. This study showed that the technique of focal groups with deaf people will have better success if it consists of a maximum of six members per group. / INTRODUÇÃO: há diversas formas de manifestação, compreensão e interpretação do conceito de deficiência, assim como uma multiplicidade de indicadores que interferem significativamente para a composição conceitual do tema. Nas últimas décadas, a visão biológica da deficiência vem sofrendo ampliações devido à inclusão dos aspectos socioantropológicos. No caso dos surdos, a necessidade de ter sua história analisada neste enfoque é relevante para o atendimento adequado por parte dos profissionais de Saúde. OBJETIVO: analisar a versão em Língua Brasileira de Sinais (Libras) do instrumento de avaliação de qualidade de vida WHOQOL-BREF em grupos focais. MÉTODOS: pesquisa qualitativa de tipologia transversal descritivo-exploratória utilizando a técnica de grupo focal em três grupos assim distribuídos: 1) pessoas surdas; 2) familiares de surdos; 3) intérpretes da Libras. Foram realizadas duas reuniões com três grupos focais. A primeira teve o objetivo de explicar todos os detalhes da pesquisa, entregar um DVD, obter assinatura do Termo de Livre Consentimento e aplicação do questionário sociodemográfico. A segunda objetivou discutir e analisar a versão em Libras do WHOQOL-BREF. Os dados foram analisados com fundamentação na técnica de análise de conteúdo categorial temática proposta por Bardin. RESULTADOS: 100% dos participantes dos três grupos focais compreenderam e consideraram as questões relevantes para a qualidade de vida dos surdos. Na categoria de sugestão, o GF1 apresentou sugestões em 76,94% das questões, o GF2 apresentou 65,39% e o GF3 apresentou 73,08% de sugestões para as questões que precisavam de alterações. CONCLUSÕES: a escassez de produção científica sobre a utilização de grupos focais com pessoas surdas foi considerada fator desafiador. Este estudo evidenciou que a técnica de grupos focais com pessoas surdas terá maior êxito se composta por, no máximo, seis integrantes por grupo.

Sob o referencial da história das idéias, este estudo revisa o pensamento sanitarista brasileiro, norteado pela figura do Centro de Saúde. A reforma do Serviço Sanitário paulista de 1925 e a instituição das Unidades de Saúde da Família em 1994 definem os limites gerais da revisão. Considera-se a possibilidade de que o discurso sobre o Centro de Saúde inaugurou uma nova era epistemológica na saúde pública, definida pela dimensão individual da educação sanitária, em detrimento da medicina das cidades ou era bacteriana. As novas concepções surgiram, sustentaram e foram sustentadas pelo deslocamento da influência política e intelectual francesa para os Estados Unidos, materializada nas ações da Fundação Rockefeller, tendo por base a Universidade Johns Hopkins. São Paulo foi uma das cidades escolhidas para investimento maciço, como efeito demonstração do novo ideário. Embora a atuação institucional da Fundação tenha tido escala planetária, a apropriação discursiva e adaptação local se mostrou mais precoce e coesa na América Latina, dando ensejo a criação e fortalecimento de um verdadeiro pan-americanismo na saúde pública, com a participação do Brasil. No país, o discurso da era sanitária e seus corolários medicina preventiva, medicina integral, medicina comunitária e atenção básica/primária, foi clivado por três grandes matrizes políticas, que se sucederam e predominaram em momentos distintos: pensamento clássico, de matriz liberal e que dá significação cultural local às idéias que prevalecem no debate internacional a partir dos anos 1920; o pensamento radical, de matriz marxista, que aflora na segunda metade dos anos 1970, principalmente no seio da intelectualidade acadêmica; e o pensamento comunitário em saúde pública, de raízes no pensamento político da assistência social, estimulado pela estratégia da Saúde da Família nos anos 1990. O pensamento radical em saúde pública nasce sob incisiva oposição ao regime militar e ao pensamento clássico. Em sua matriz discursiva a saúde coletiva substitui as expressões anteriores e se concentra no determinantes sociais da saúde, relegando o debate setorial ao segundo plano. Embora sem a devida clareza, o pensamento comunitário recupera e busca atualizar muitas das concepções clássicas, sem fugir da composição com o discurso radical. Alguns conceitos originalmente ligados ao ideário dos Centros de Saúde se destacam ao longo do período analisado: integração (integralidade); descentralização (desconcentração); e socialização (universalidade). Num plano histórico mais abrangente, reconhece-se atualmente que a saúde pública brasileira esteve na essência de um projeto de construção nacional iniciado na Primeira República, mas efetivamente posto em ação na era Vargas. Os Centros de Saúde, hoje representados no ideário da Atenção Básica, não só participaram desta história, como, na realidade, lhe foram em grande parte seus protagonistas / This study reviews the history of ideas in the public health of Brazil. The reform of the Health Service of Sao Paulo in 1925 and the establishment of the Family Health Program in 1994 set the general limits of the review. It considers the possibility that the discourse on the Health Centre inaugurated a new epistemological era in public health, defined by the individual dimension of \"health education\", to the detriment of the \"medicine of the cities\" or \"bacterial era\". New concepts emerged, sustained and were sustained by the displacement of French intellectual and political influence for the United States, embodied in the actions of the Rockefeller Foundation, based on the Johns Hopkins University. São Paulo was one of the cities chosen for massive investment, as \"demonstration effect\" of those new ideas. Although the institutional performance of the Foundation has had a planetary scale, the discursive appropriation and local adaptation was earlier and more cohesive in Latin America, giving rise to creation and strengthening of a true Pan-Americanism in public health, with the participation of Brazil. Nationwide, the \"health education\" ideas and its corollaries \"preventive medicine\", \"comprehensive medicine\", \"community medicine and primary care, was cleaved by three major political perspectives that ensued and prevailed at different times. The \"classical thought\", in a liberal perspective, gave local significance to the ideas present in the international debate since the 1920s. The \"radical thought\", under a Marxist matrix, arouse in the second half of the 1970s, especially within academic intellectuals, and \"community thought\" in public health, stimulated by the Family Health Program in the 1990s. The radical thought in public health movement was strengthened in opposition to the military regime and the classical thought. \"Collective health\" replaced the previous expressions and focuses on social determinants of health, relegating the services organization in the background. Although lacking the necessary clarity, community thought recovers and seeks to update many of the classical concepts, in composition with the radical discourse. Some concepts originally linked to the ideals of the Health Centers are highlighted throughout the studied period: integration (comprehensiveness), decentralization and socialization (universality). In a broader historical view, it is current recognized the role of the Brazilian public health in the national identity construction started in the First Republic, but actually put into action in the Vargas era. Health Centres, today represented in the ideas of primary care, not only participated in this history, as indeed they were largely its protagonists