Orientador: Juliana Luporini do Nascimento / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-25T13:36:47Z (GMT). No. of bitstreams: 1 Leite-Mor_AnaClaudiaMoraesBarros_M.pdf: 1742856 bytes, checksum: 5dd3fede7c6767c9e265b53a373e1cb9 (MD5) Previous issue date: 2014 / Resumo: Nosso trabalho trata de explorar, através da perspectiva teórico e metodológica de Bruno Latour, as perspectivas de democracia e democratização da saúde propostas durante a Assembléia Nacional Constituinte (ANC). A Constituição de 1988 é considerada marco da instituição da Saúde como Direito, da criação e normatização do SUS, bem como de seu postulado de controle social. É o momento no qual o movimento da Reforma Sanitária (RS) alcança seu arcabouço legal com a garantia da saúde como direito de todos e dever do Estado. No entanto, diversas são as dificuldades que o SUS enfrenta ainda hoje, após vinte anos de sua instituição, quanto a garantir a universalidade da atenção a saúde e a eficácia de seus mecanismos de controle social. Diante destas dificuldades, nosso trabalho propõe retornar à ANC, local de produção da Constituição de 88, para abordar as propostas de democracia e democratização da saúde que existiram antes da normatização do SUS, a fim de discuti-las por uma perspectiva política ainda pouco conhecida na Saúde Coletiva: a proposta da Epistemologia Política de Bruno Latour. O sociólogo Bruno Latour reformulou epistemologicamente a noção de política, propondo uma série de conceitos teórico-operacionais que visam renovar as possibilidades de se concretizar a democracia. Tendo partido dos estudos de ciência e tecnologia, este autor produziu uma densa reflexão acerca do pensamento e constituição da modernidade. Latour mostra como a cisão instituída entre Natureza e Sociedade, a concepção do mundo em duas câmaras distintas, a das coisas e a dos humanos, suprime as possibilidades de uma política deliberativa e propriamente democrática. Sua metodologia, eminentemente descritiva-etnográfica, consiste em acompanhar os cursos de ação/mutação das associações entre os atores, desdobrando suas heterogeneidades e controvérsias, até que sejam rastreados os meios de estabilização da rede. A maior inovação de Latour está no reconhecimento da ação política dos não-humanos, que associam-se aos humanos de formas múltiplas. Os objetos, tais como, documentos, legislações, estatísticas, etc. nos fazem fazer coisas a todo momento e, para Latour, são eles que permitem a estabilização das redes de associações. Nosso estudo, assumindo a proposta metodológica de Latour, divide-se em duas partes: 1)A multiplicação das controversas democracias propostas ao longo da Assembleia Nacional Constituinte e 2) A reagregação destas propostas em um coletivo, junto a proposta da Epistemologia Política de Latour. Acreditamos que a perspectiva de Latour pode lançar luzes sobre os atuais embates que a democratização da gestão enfrenta na implementação do SUS. Com isso, pretendemos contribuir com o aprimoramento e fortalecimento dos processos democráticos na saúde coletiva / Abstract: Our project is to explore, through the theoretical and methodological perspective of Bruno Latour, the prospects of democracy and democratization of health care proposals during the National Constituent Assembly. The Constitution of 1988 is considered a landmark of the establishment of Health as a Right, the creation and standardization of SUS as well as its postulate of social control. It is the moment in which the movement of the Sanitary Reform reaches its legal framework with the guarantee of health as a right and duty of the State. However, there are several difficulties still faced by the SUS today, after twenty years of its establishment, as to ensure the universality attention to health care and the effectiveness of its social control mechanisms. Given these difficulties, our project proposes the return to the National Constituent Assembly, the place of production of the 88 Constitution, to address the proposals of democracy and democratization of health that existed before the standardization of SUS in order to discuss them through a political perspective in Public Health which is not yet widely known: the Politics Epistemology proposal of Bruno Latour. The sociologist Bruno Latour epistemologically reformulated the notion of politics, proposing a series of theoretical and operational concepts aimed at reviving the chances of an actual democracy. Based on studies of science and technology, this author has produced a dense reflection about the thought and constitution of modernity. Latour shows how the rupture created between Nature and Society, the conception of the world into two distinct chambers, of the things and of the humans, suppresses the possibilities of deliberative and democratic politics. His methodology, eminently descriptive-ethnographic, consists in following the courses of action / mutation of associations between actors, unfolding their heterogeneity and controversies until the stabilizing means of the network are tracked. The greatest innovation of Latour is in the recognition of the political action of the non- humans, which associate themselves with the humans in multiple forms. The objects, such as documents, laws, statistics, etc., make us do things all the time and, for Latour, they are what allow the stabilization of networks associations. Our study, assuming Latour¿s methodological proposal, is divided into two parts: 1) The multiplication of the controversial democracies proposed along the Constituent National Assembly and 2) The reassembly of these proposals into a collection, together with the proposal of Epistemology Policy from Latour. We believe that Latour¿s prospective can shed light on current debates which the democratization management faces in the implementation of SUS. Thus, we intend to contribute to the improvement and strengthening of democratic processes in public health / Mestrado / Ciências Sociais em Saúde / Mestra em Saúde Coletiva

Health authority administrators were interviewed for their perspectives on what makes a good health care system; on tailored population-specific services as a way to address health inequities; and on how they perceive themselves to be making good funding decisions on the public’s behalf. The qualitative descriptive research dataset includes 24 hour-and-a-half long interviews with administrators from four BC health authorities, health region documents, memos, and field notes. Participants support the continuation of a public health care system and all participants acknowledge using tailored services as a route towards reducing health inequities. However, these identified services have not been evaluated for their overall effectiveness. When it comes to decision-making, participants describe using a series of governance and bioethical principles that help them frame what and how issues can be considered. Decision situations are framed in a way that informs them whether they need to use formal or informal processes. In both cases participants collect information that allows others to understand that they have made wise decisions. The Recognition-Primed Decision Model accurately reflects the intuitive processes that participants describe using during informal decision-making and portions of formal decision-making. However, in relation to formal decision situations, there is less alignment with existing Decision-Analysis literature. Seven practice and future research recommendations are provided: 1. Increase health authority participation in intersectoral partnerships that address non-medical determinants of health. 2. Develop new strategies for addressing health inequities. 3. Evaluate the efficacy of using tailored services beyond their ability to remove barriers to access. In addition, increase focus on testing new strategies for reducing the inequities gap. 4. Enhance existing decision-making processes by including the explicit review of decision tradeoffs, value weighting, and mechanisms for requesting revisions. 5. Focus future research on developing and evaluating the usefulness of formal decision-making tools in health authority structures and their relation to decision latitude. 6. Launch a longitudinal research study that examines how health authority expert decision-makers use judgmental heuristics and how they avoid the negative effects of bias. 7. Commission public dialogue on shifting the current illness-based system to one that is wellness based. / Graduate and Postdoctoral Studies / Graduate

Magister Public Health - MPH / Introduction: Health Sector Reform was initiated as a component of the Structural Adjustment Policies that were imposed on the developing countries by the international monetary organizations such as the International Monetary Fund and the World Bank during the 1980s and the 1990s. It included three main components, that is, financing reforms, decentralization and introducing competition to the health sector. Changes to the Egyptian health system were introduced in the 1980s through the cost recovery projects, while the Health Sector Reform Program was announced in 1997. This culminated in a change from a Primary Health Care model to a Family Health Model as regards the Primary Health Care sector of the Egyptian health system. Changes in the health systems have profound effects on people, so that it is essential to study the ongoing transformation of the Egyptian health system and its implications. Aim: The aim of the current study was to determine the acceptability of the Family Health Model, which replaces Primary Health Care, as currently implemented in Wardan Village, Giza, Egypt. Methodology: The study was a cross sectional survey utilizing a structured questionnaire that was used to determine the awareness and perception/satisfaction of the community members in an Egyptian rural area (Wardan village, Giza Governorate) towards the transformation from primary health care to family health model. 357 subjects participated in this study. Results: Awareness of the study participants towards the transformation process was 15.6%. The overall satisfaction with the family health unit by the participants was 80.5% compared with 35.7% for the old PHC one. Higher satisfaction was associated with older age (p=0.02), less education (p<0.001), being married in the past or present (p=0.02), working status (p=0.007), and more years of using the unit (p<0.001). Acceptability of the family health model among the participants of the current study was high at 88.3%. Higher score of acceptability were associated with less education (p<0.001), being or have been married (p=0.048), and with working status (p=0.005). 93.8% of the participants think that family health unit services are accessible and 79.9% of the participants think that the family health unit provides quality services. Conclusion: The Family Health Model has achieved successes when implemented but encountered some difficulties that have limited the gains and interfered with some of its aspects. The current study has shown that the Family Health Unit has gained a high score of satisfaction and acceptability by the study participants, although the awareness of the study participants about the transformation of the Primary Health Care Model to a Family Health Model was low.

The National Health Insurance Policy Paper (NHI) that was promulgated in 2011, marks the beginning of the South African Department of Health’s journey into delivering a health system that offers universal coverage to all it’s citizens, that is free at the point of contact. (NHI, 2011) The implementation of this new health system faces many challenges such as the impact of HIV/AIDS. This research was conducted to ascertain what this impact would be according to subject matter experts in the field.Twenty interviews with experts from the different stakeholder groups were undertaken.The findings revealed that there is dire a need for a new health system to offer financial risk protection and universal coverage to all South African residents. Health Systems strengthening will form a significant part of the reformation that is needed to get the health system to work efficiently. HIV/AIDS must be monitored and managed carefully to avoid multi-drug resistant strains from emerging. An existing model has been adapted for the purposes of this study that allows focus on the various components of the health system. Each component or building block will need attention and strategic direction to ensure that the entire system can function holistically, seamlessly and efficiently. / Dissertation (MBA)--University of Pretoria, 2013. / Gordon Institute of Business Science (GIBS) / unrestricted

Background. Developing countries are undergoing a process of epidemiological transition from infectious to non-communicable diseases, described by the United Nations Secretary General Ban Ki-Moon as “a public health emergency in slow motion”. One of the most prevalent of these diseases, in sub-Saharan Africa, is hypertension, which is a complex chronic condition often referred to as the “silent killer” and a key contributor to the development of cardiovascular and cerebrovascular diseases. Hypertensive patients in this setting are estimated to increase from 74.7 million in 2008 to 125.5 million in 2025, a 68% increase. There is however an important gap between emerging high-level policies and recommendations, and the near-absence of practical guidance and experience delivering long-term medical care for non-communicable diseases within resources-limited health systems. To address this gap, our study consisted of field investigations to determine the minimum health systems requirements necessary to ensure successful delivery of anti-hypertensive medications when scaling-up interventions. Methods/Design. A cross-sectional analytic study was conducted in the Western Cape Province of South Africa using a mixed method approach with two sets of semi-structured interviews and simulation modeling. One set of interviews was conducted with health professionals involved in the care of hypertensive patients within nine community health centers (five urban and four rural) to understand the challenges associated with their care. The other set was used to map and assess the current supply chain management system of antihypertensive medications and involved key informants at different levels of the process. Finally, modeling and simulation tools with ARENA Software were used to estimate minimum numbers of health workers required to ensure successful delivery of medications when scaling up interventions. Results. The study found numerous challenges affecting the care of hypertensive patients in primary health care facilities and categorized these into five interconnected dimensions: Management of the visits within the PHC facility, Adequacy of human resources, Standardization of patients’ care, Infrastructure limitations, and Patients’ responsibilities. Potential solutions to overcome these challenges were explored in order to improve the care of the hypertensive patients in the PHC facilities. Mapping of the drug supply chain management system highlighted the complexity of the system. In fact many of the issues reported fell outside of the control of the provincial health department. The need for a more single comprehensive computer system to handle most of the functions of the drug supply management system was heavily emphasized. The modeling and simulation tool with ARENA Software estimated the type and number of health care professionals needed to provide appropriate services to a certain patient population based on the set targets. The sample data used showed how one can test the impact of various changes in the processes and staffing levels to minimize waiting times while increasing the daily patients’ intake at the facility. We found that with few additional nursing staff, that are more affordable and quicker to train than medical doctors and pharmacists, one can considerably improve the performance of the facilities in the care of hypertensive patients. Discussion. This investigation has highlighted the detailed processes in place for the care of hypertensive patients in primary health care facilities, identifying the challenges in providing such care. The potential solutions suggested by the study results, if implemented, should help improve services offered and ensure that the system remains sustainable when patients’ intake increases exponentially as a result of scaled up interventions. The weaknesses of the drug supply chain management system demand immediate action. The modeling and simulation tools used in this study, if used on an ongoing basis, could create more effective planning of needed resources, although their proper utilization will require extra training for managers. Whether there is sufficient political support to ensure the resources necessary to reach the provincial health department’s hypertension target remains to be seen, and would benefit with further economic studies to estimate the cost associated with tackling the hypertension epidemic.

The present thesis investigates the possible effects of limiting the compensations victims can obtain in medical malpractice cases through schedules of noneconomic damages. While economic damages are rather simple to calculate, problems arise with respect to the assessment of noneconomic damages. To reduce both the variability in the compensations granted to victims and the perception of a high level of arbitrariness in determining noneconomic losses, many countries have adopted different types of ceilings to limit the nonmonetary component of malpractice compensations. While flat and tiered caps have been widely studied in the related literature, the effects of schedules are still debated due to the scarce available evidence. Using Italy as a case study, I investigated the likely impact of schedules on noneconomic damages on a number of key outcomes showing that this policy can affect patients´ behavior and the filing of malpractice claims. Schedules are associated to a lower number of claims as well as of claims not decided on the merit. These results seem to be due to a drop in the number of frivolous claims. In addition, under schedules, average compensation and trial duration results to be higher. This is consistent with the expectation that under schedules there is a higher frequency of claims involving serious injuries. Hence, results could be further explored and used also in Czech Republic policy.

The health system in Abu Dhabi has undergone a series of far reaching reforms during the past six years, yet in spite of the structural transformations, public confidence in the performance of this vital sector is still skeptical at best and employee engagement is still low. The thesis was underpinned by the aim to reveal the challenges in public health system reform outside the context of western administration. This thesis is an attempt to analyse the intricate, multidimensional concept of organisational culture within the complex structure of public healthcare sector in a fast growing economy like Abu Dhabi. Managing organisational culture is increasingly viewed as an essential part of health system reform. Organisational culture in health care organisations has gained increased consideration as an important factor that affects health systems reform and influences the quality of health care. The research project aims to explore the context of health system reform in Abu Dhabi and to understand the organisational culture of the different constituents of its public healthcare sector. Using a multi-method investigation combining both qualitative and quantitative approaches using the Competing Values Framework as conceptual framework, this research aims to provide a critical assessment of organisational culture in healthcare sector in Abu Dhabi. Semi-structured interviews were conducted in the regulator, operator, and three public hospitals prior to the use of a survey instrument based on the Organisational Culture Assessment Instrument (OCAI). The data analysis revealed that the prevailing cultural model of the Abu Dhabi public sector organisations was concurrently governed by hierarchy and market cultures while the presence of clan and adhocracy models was relatively limited. Interesting variations in assessment of clan culture were found between UAE nationals and other nationality clusters. The findings also revealed a desired cultural shift manifested by a higher emphasis on clan and adhocracy cultures and a lower emphasis on hierarchy and market culture. Those results confirm the presence of two opposing or competing cultural dimensions clan/adhocracy vs. hierarchy/market. This research makes a considerable contribution to the sparse empirical studies in health system reforms and organisational culture in the Arab Gulf states, and proposes important explanations and possible solutions to the salient challenges facing the health system in Abu Dhabi.

The thesis is primarily oriented on economic aspects of health systems. It contains the analysis and description of health risks, health-insurance systems (models) and current status of Czech health system. Czech health system is described and scarified. Analysis of weak points, status of reforms and also a design of possible solutions are integral parts of this thesis. Both public and commercial approaches to health and insurance systems are involved, including current commercial insurance products which are available on Czech market.

The diploma thesis is focused on comparison of emergence of welfare states in Great Britain during the government of Labor party in the years 1945-1951 and in Czechoslovakia during the first five-year plan during the government of the Communist party in the years 1948-1953. By degrees there are different elements of the areas of social security, health services, education and housing policy examined. In all these areas the two compared countries faced up to similar problems solved by government interventions; however also significant differences can be found in particular selected solutions. This analysis is focused primarily on the impact on individuals, but also illustrates the difficulty of application of the reforms from the perspective of the government.

L’une des principales sources de changement dans le système de santé est actuellement la numérisation et la mise en réseau technique, se traduisant par le développement de la télémédecine. Si cette « médecine à distance », utilisant les TIC, a pu se résumer en quelques expérimentations menées essentiellement dans le cadre hospitalier, le gouvernement entend lui donné une nouvelle impulsion. Elle doit constituer un facteur clé d’amélioration de la performance du système de santé. Son usage dans les territoires doit incarner une réponse organisationnelle et technique aux nombreux défis épidémiologiques, démographiques et économiques auxquels fait face le système de santé aujourd’hui. Cette recherche apour but de contribuer à établir le sens social et politique du développement de la télémédecine. Il s’agit de cerner de façon systématique et dans leur ensemble les dynamiques qui conduisent ce changement, tout en mettant en avant les conséquences dans la démarche de soin classique au niveau des usagers. Analyse des politiques publiques et étude du changement technologique se fondent dans l’approche choisie de la sociologie politique des usages. Ancrée au confluent du modèle des politiques publiques et de la sociologie de l’innovation, la recherche a permis d’identifier et d’expliquer les principales dynamiques conditionnant le processus de développement de la télémédecine, en partant des politiques publiques jusqu’à la mise en place des technologies. La télémédecine est la fois le moteur et le résultat de la réformede la modernisation du système de santé. Son référentiel est fortement imprégné par les exigences de rationalisation et de gestion du réseau socio-sanitaire et demeure principalement légitimé par des critères de rentabilité et de performance qui sont probablement incompatibles avec l’efficience clinique et thérapeutique des services de soins. La télémédecine pourrait rendre de nombreux services dans la gestion des activités humaines et professionnelles, par une gestion davantage réfléchie, concertée et planifiée du changement technologique / One the main source of change in the health service system is the digitization and Networking technique wich can be seen in the development of telemedicine. If this « medicine at distance », using ITC, could be summed up in a few experiments in the hospital field, the government wants to give it a new impulse. It must be the key to improve the health service system. Its use in the territories must embody an organizational and technical answer epidemiological, demographic and economic numerous challenges, to wich the health system has to face nowadays. This investigation is aimed at contributing to settle the social and political meaning of telemedicine development. One has to identify systematically and in the whole the forces which lead to this change, while at the same time highlighting the consequences in users the classical approach. The analysis of the public politics and the study of the technological change convey in the political sociology uses. Anchored between the public politic model and the sociological innovation, the investigation has allowed to identify and explain the main dynamics which influence the telemedicine development process, starting by the public policies to the implémentation of technologies. The telemedicine is both the impulse and the result of the health service system modernization reform. Itsrepository is strongly influenced by the rationalizing of the requirements and the management of the health and social network and remains mainly legitimized by profitability and performance criterias which are probably incompatible with clinical and therapeutic efficiency of health services. The telemedicine could make many services in the management of human and Professional activities, thank to a management more thought, concerted, planed of the technologic change