Introdução. O Sistema Único de Saúde (SUS) apresentou avanços significativos durante as duas décadas de sua existência. Contudo, a integralidade se destaca como o princípio que, ainda, não foi efetivamente incorporado na organização dos serviços e no cotidiano da atenção. Para realização desta pesquisa, e considerando a polissemia do termo, definiu-se um conceito operacional de integralidade, circunscrito a um de seus múltiplos sentidos, relacionado ao modo de organizar os serviços de saúde. Assim, denominou-se integralidade da assistência à dimensão relacionada com a continuidade do cuidado em saúde, garantida pelo acesso a serviços que incorporam distintas densidades tecnológicas, distribuídos em todos os níveis de complexidade do sistema de saúde. Objetivo. Avaliar a incorporação do princípio da integralidade na gestão e organização dos serviços de saúde em um território selecionado do município de São Paulo, SP. Métodos. A pesquisa foi desenvolvida utilizando a estratégia metodológica do estudo de caso, a partir das seguintes fontes de evidência: (a) documentos de gestão (leis, decretos, portarias, planos, normas técnicas, relatórios de gestão, atas de reunião); b) entrevistas não-estruturadas com informantes-chaves selecionados entre os gestores do SUS no município; c) grupo focal com usuários de uma Unidade Básica de Saúde do território selecionado; d) observação participante, desenvolvida em serviços de saúde e instâncias político-administrativas da Secretaria Municipal de Saúde (SMS-SP). Utilizou-se a técnica da análise temática para analisar o material coletado. Os temas destacados foram: descentralização da gestão municipal; regionalização intramunicipal; e, acesso a ações e serviços de média complexidade. Resultados. Os resultados são apresentados na forma de três artigos, sendo cada um deles correspondente a um dos temas destacados. Os artigos elaborados são: (1) O desafio da descentralização do Sistema Único de Saúde (SUS) em município de grande porte: o caso de São Paulo (SP), Brasil; (2) A regionalização intramunicipal do Sistema Único de Saúde (SUS): um estudo de caso do município de São Paulo (SP), Brasil; e (3) O difícil acesso a serviços de média complexidade do SUS na maior metrópole brasileira, São Paulo (SP), Brasil. Considerações finais. Constatou-se que a política de saúde implementada pela SMS-SP contribuiu para manter e aprofundar a fragmentação do sistema de saúde no município de São Paulo. As estruturas existentes e os mecanismos utilizados pela gestão municipal não tem contribuído para efetivar a integralidade da assistência. O SUS em São Paulo continua distante da imagem objetivo de um sistema de saúde que incorpore o princípio da integralidade como um de seus eixos estruturantes. / Introduction: The Single Health System (Sistema Único de Saúde SUS) presented expressive development during the two decades of its existence. Nevertheless, the issue, which has not been incorporated in the services organization and in the daily basis of the attention, is the global approach. In order to carry out this research and considering the polysemantic word, an operational concept of integrality has been defined, limited to one of its meanings and related so as to organize the health services. Therefore, it has been established the integrality of the health care to the scope related to the permanence of health care, guaranteed by the access to the services, which comprise several levels of technology along all levels of complexity of the health system. Objective: To evaluate the incorporation of the principle of the integrality in the management and organization of health services in a specific area of the city of São Paulo. Methods: The research was performed by utilizing the methodological strategy of case study derived from the following sources of data: (a) management papers (laws, decrees, plans, technical specifications, management reports, minutes of meetings); (b) non-structured interviews with key informers selected among the SUS managers of the city; (c) focal group with users of a Basic Unit of Health of the selected area; (d) active observation, developed in health services and political administrative areas of the City Health Department (SMS-SP). The subject analysis technique has been used for the gathering of the data. The selected subjects were: (1) the decentralization of city management; intercity regionalization, and access to actions and services of medium complexity. Results: Results are presented in the form of 3 articles, being each one related to the selected subjects described. The articles are: (1) The challenge of the decentralization of the Single Health System (SUS in a large city: the instance of the City of São Paulo (SP), Brazil; (2) The intercity regionalization of the Single Health System (SUS): a case study of the City of São Paulo (SP), Brazil; and (3) The complex access to services of medium complexity of SUS in the largest Brazilian metropolis. Final considerations: It has been verified that the Health System applied by the SMS-SP has been a factor to maintain and intensified the fragmentation of the Health System in the City of São Paulo. The present structures and mechanisms used by the City administration have not played the part to produce the integrality of the health care. The SUS in São Paulo is still far from the objective image of a health care system that comprises the principle of global approach as one of its structuring axis.

Antecedentes. Alguns princípios e diretrizes organizativas do Sistema Único de Saúde (SUS) têm sido mais freqüentemente avaliados como a descentralização da gestão, a participação e controle sociais e a extensão de cobertura. A integralidade da atenção à saúde se destaca como um de seus princípios pouco estudado, particularmente no que se refere à sua dimensão sistêmica como a incorporação desse princípio na política e na gestão da saúde no âmbito municipal. Objetivo. Esta pesquisa foi desenvolvida com o objetivo de avaliar se e como a integralidade na assistência à saúde foi incorporada nas políticas de saúde priorizadas e implementadas no processo de (re)construção do SUS no Município de São Paulo (SP), no período de 2001 a 2008. Métodos. A estratégia metodológica utilizada foi a do estudo de caso, utilizando-se como dados e informações coletadas junto a distintas fontes de evidência: (a) atores sociais privilegiados, envolvidos no processo de gestão (informantes-chaves), por meio de entrevistas; (b) documentos de gestão (leis, decretos, portarias, normas técnicas, relatórios de gestão, atas de reunião); e (c) observação participante, desenvolvida em espaços institucionais e instâncias político-administrativas do SUS no município. A análise da incorporação da integralidade da assistência à saúde foi realizada prioritariamente nas dimensões da política de saúde e da gestão do sistema de saúde. Resultados. São apresentados três artigos formatados com recortes temáticos dos resultados da pesquisa e que pudessem ter consistência e densidade suficientes para serem submetidos a periódicos do campo da Saúde Pública/Coletiva. Os artigos elaborados são: (1) Política de saúde e gestão no processo de (re)construção do SUS em município de grande porte: um estudo de caso de São Paulo, Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v.25, 2009 (No prelo); (2) O desafio da direção única no Sistema Único de Saúde (SUS) em município de grande porte: o caso de São Paulo, Brasil. Saúde e Sociedade, São Paulo (encaminhado não avaliado); e (3) AMA (assistência médica ambulatorial): uma inovação assistencial ou uma estratégia para limpar filas de portas de prontos-socorros? (formatado visando a revista Physis ainda não encaminhado). Considerações finais. Espera-se que os resultados e sua divulgação possam contribuir para a análise crítica do SUS no Município de São Paulo e outros município de grande porte, bem como com a identificação de elementos de reflexão, de temas para novas pesquisas, ou fornecer subsídios para a (re)formulação teórico-conceituais sobre política e gestão de sistemas de saúde e o fortalecimento do SUS. / Background. Some principles and organizational guidelines of the Brazilian National Health System (SUS) have been evaluated more frequently such as decentralization of management, the participation and social control and the span of coverage. The integrality of attention to health is one of the issues less analyzed, especially in terms of systemic dimension as the incorporation of such principle in the policy and management in the city scope. Objective. This research was carried out aiming at evaluating if and how the global approach of health care was incorporated in prioritized health policies and executed in the process of (re)construction of the SUS in the City of São Paulo (SP), between 2001 and 2008. Methods. The research was performed by utilizing the methodological strategy of case study derived from the following different sources of evidence: (a) social and institutional actors as privileged performers involved in management process (key-informers) by means of interviews; (b) management documents and papers (laws, decrees, plans, technical specifications, management reports, minutes of meetings); (c) active observation, developed in health services and political administrative areas of the SUS in the city. The analysis of the incorporation of the global approach of health care was made mainly under the aspects of health policy and health system management. Results. Three articles comprising theme excerpts of the research results which can have enough reliability and concentration to be submitted to journals in the field of Public Health. The articles written are: (1) Health policy and management in the (re)construction process of the Brazilian National Health System (SUS) in a large municipality: a case study of São Paulo city, Brazil. Cadernos de Saúde Pública, Rio de Janeiro, v.25, 2009 (in priting); (2) The challenge of the unified health services management in the Brazilian National Health System (SUS) in a large municipality: the case of São Paulo, Brazil. Saúde e Sociedade, São Paulo (submitted not evaluated); (3) AMA (ambulatorial health care): an innovation in health care or a strategy to empty lines at hospital gates? (written for the magazine Physis not submitted). Final Considerations. It is expected that these results and their presentation may contribute to a significant analysis of SUS in the São Paulo city and other large municipalities, as well as identifying the elements of consideration, of subjects for new researches or provide subsidies for the theoretical and conceptual (re)organization on the policy and management of health systems and the strengthening of SUS.

Introdução. O Sistema Único de Saúde (SUS) apresentou avanços significativos durante as duas décadas de sua existência. Contudo, a integralidade se destaca como o princípio que, ainda, não foi efetivamente incorporado na organização dos serviços e no cotidiano da atenção. Para realização desta pesquisa, e considerando a polissemia do termo, definiu-se um conceito operacional de integralidade, circunscrito a um de seus múltiplos sentidos, relacionado ao modo de organizar os serviços de saúde. Assim, denominou-se integralidade da assistência à dimensão relacionada com a continuidade do cuidado em saúde, garantida pelo acesso a serviços que incorporam distintas densidades tecnológicas, distribuídos em todos os níveis de complexidade do sistema de saúde. Objetivo. Avaliar a incorporação do princípio da integralidade na gestão e organização dos serviços de saúde em um território selecionado do município de São Paulo, SP. Métodos. A pesquisa foi desenvolvida utilizando a estratégia metodológica do estudo de caso, a partir das seguintes fontes de evidência: (a) documentos de gestão (leis, decretos, portarias, planos, normas técnicas, relatórios de gestão, atas de reunião); b) entrevistas não-estruturadas com informantes-chaves selecionados entre os gestores do SUS no município; c) grupo focal com usuários de uma Unidade Básica de Saúde do território selecionado; d) observação participante, desenvolvida em serviços de saúde e instâncias político-administrativas da Secretaria Municipal de Saúde (SMS-SP). Utilizou-se a técnica da análise temática para analisar o material coletado. Os temas destacados foram: descentralização da gestão municipal; regionalização intramunicipal; e, acesso a ações e serviços de média complexidade. Resultados. Os resultados são apresentados na forma de três artigos, sendo cada um deles correspondente a um dos temas destacados. Os artigos elaborados são: (1) O desafio da descentralização do Sistema Único de Saúde (SUS) em município de grande porte: o caso de São Paulo (SP), Brasil; (2) A regionalização intramunicipal do Sistema Único de Saúde (SUS): um estudo de caso do município de São Paulo (SP), Brasil; e (3) O difícil acesso a serviços de média complexidade do SUS na maior metrópole brasileira, São Paulo (SP), Brasil. Considerações finais. Constatou-se que a política de saúde implementada pela SMS-SP contribuiu para manter e aprofundar a fragmentação do sistema de saúde no município de São Paulo. As estruturas existentes e os mecanismos utilizados pela gestão municipal não tem contribuído para efetivar a integralidade da assistência. O SUS em São Paulo continua distante da imagem objetivo de um sistema de saúde que incorpore o princípio da integralidade como um de seus eixos estruturantes. / Introduction: The Single Health System (Sistema Único de Saúde SUS) presented expressive development during the two decades of its existence. Nevertheless, the issue, which has not been incorporated in the services organization and in the daily basis of the attention, is the global approach. In order to carry out this research and considering the polysemantic word, an operational concept of integrality has been defined, limited to one of its meanings and related so as to organize the health services. Therefore, it has been established the integrality of the health care to the scope related to the permanence of health care, guaranteed by the access to the services, which comprise several levels of technology along all levels of complexity of the health system. Objective: To evaluate the incorporation of the principle of the integrality in the management and organization of health services in a specific area of the city of São Paulo. Methods: The research was performed by utilizing the methodological strategy of case study derived from the following sources of data: (a) management papers (laws, decrees, plans, technical specifications, management reports, minutes of meetings); (b) non-structured interviews with key informers selected among the SUS managers of the city; (c) focal group with users of a Basic Unit of Health of the selected area; (d) active observation, developed in health services and political administrative areas of the City Health Department (SMS-SP). The subject analysis technique has been used for the gathering of the data. The selected subjects were: (1) the decentralization of city management; intercity regionalization, and access to actions and services of medium complexity. Results: Results are presented in the form of 3 articles, being each one related to the selected subjects described. The articles are: (1) The challenge of the decentralization of the Single Health System (SUS in a large city: the instance of the City of São Paulo (SP), Brazil; (2) The intercity regionalization of the Single Health System (SUS): a case study of the City of São Paulo (SP), Brazil; and (3) The complex access to services of medium complexity of SUS in the largest Brazilian metropolis. Final considerations: It has been verified that the Health System applied by the SMS-SP has been a factor to maintain and intensified the fragmentation of the Health System in the City of São Paulo. The present structures and mechanisms used by the City administration have not played the part to produce the integrality of the health care. The SUS in São Paulo is still far from the objective image of a health care system that comprises the principle of global approach as one of its structuring axis.

Business process analysis and integration are key endeavours for today's enterprises. Recently, Web services have been widely adopted for the implementation and integration of business processes within and across enterprises. In this dissertation, we investigate the problem of enabling the analysis of service interactions, in today's enterprises, in the context of business process executions, and that of service integration. Our study shows that only fraction of interactions in the enterprise are supported by process-aware systems. However, enabling above-mentioned analyses requires: (i) a model of the underlying business process to be used as a reference for the analysis, and (ii) the ability to correlate events generated during service interactions into process instances. We refer to a process model and the corresponding process instances as a "process view". We propose the concept of process space to refer to all process related information sources in the enterprise, over which various process views are defined. We propose the design and development of a system called "process space discovery system" (PSDS) for discovering process views in a process space. We introduce novel approaches for the correlation of events into process instances, focusing on the public processes of Web services (business protocols), and also for the discovery of the business protocol models from the process instances of a process view. Analysis of service integration approaches shows that while standardisation in Web services simplifies the integration in the communication level, at the higher levels of abstractions (e.g., services interfaces and protocol models) services are still open to heterogeneities. We characterise the mismatches between service interfaces and protocol specifications and introduce "mismatch patterns" to represent them. A mismatch pattern also includes an adapter template that aims at the resolution of the captured mismatch. We also propose semi-automated approaches for identifying the mismatches between interface and protocol specifications of two services. The proposed approaches have been implemented in prototype tools, and experimentally validated on synthetic and real-world datasets. The discovered process views, using PSDS, can be used to perform various analyses in an enterprise, and the proposed adaptation approach facilitates the adoption of Web services in business process integration.

Business process analysis and integration are key endeavours for today's enterprises. Recently, Web services have been widely adopted for the implementation and integration of business processes within and across enterprises. In this dissertation, we investigate the problem of enabling the analysis of service interactions, in today's enterprises, in the context of business process executions, and that of service integration. Our study shows that only fraction of interactions in the enterprise are supported by process-aware systems. However, enabling above-mentioned analyses requires: (i) a model of the underlying business process to be used as a reference for the analysis, and (ii) the ability to correlate events generated during service interactions into process instances. We refer to a process model and the corresponding process instances as a "process view". We propose the concept of process space to refer to all process related information sources in the enterprise, over which various process views are defined. We propose the design and development of a system called "process space discovery system" (PSDS) for discovering process views in a process space. We introduce novel approaches for the correlation of events into process instances, focusing on the public processes of Web services (business protocols), and also for the discovery of the business protocol models from the process instances of a process view. Analysis of service integration approaches shows that while standardisation in Web services simplifies the integration in the communication level, at the higher levels of abstractions (e.g., services interfaces and protocol models) services are still open to heterogeneities. We characterise the mismatches between service interfaces and protocol specifications and introduce "mismatch patterns" to represent them. A mismatch pattern also includes an adapter template that aims at the resolution of the captured mismatch. We also propose semi-automated approaches for identifying the mismatches between interface and protocol specifications of two services. The proposed approaches have been implemented in prototype tools, and experimentally validated on synthetic and real-world datasets. The discovered process views, using PSDS, can be used to perform various analyses in an enterprise, and the proposed adaptation approach facilitates the adoption of Web services in business process integration.

The success of Web services comes from the benefits that it brings in reducing the cost and the time needed to develop data and applications by reusing them, and simplifying their integrations through standardization. However, standardization in Web services does not remove the need for adapters due to possible heterogeneity among service interface and protocol definitions. Moreover, the current service APIs are targeted toward professional programmers, but not accessible to a wider class of users without programming expertise, but would never the less like to build their own integrated applications. In this dissertation, we propose methods and tools to support both service developers and non-expert users in their data and application integration tasks. To support service developers, we propose a framework that enables rapid development of Web service adapters. We investigate particularly the problem of service adaptation focusing on business interface and protocol layers. Our study shows that many differences between business interfaces and protocols are recurring. We introduce mismatch patterns to capture these recurring differences and provide solutions to resolve them. We present the notion of adaptation aspects, which is based on the aspect-oriented programming paradigm, to enable rapid development and deployment of service adapters. We also present a comparative study between standalone and aspect-oriented adapters development. The study shows that the aspect-oriented approach is preferable in many cases, especially when adapters need to access internal states of services. The proposed approach is implemented in a prototype tool, which is used to illustrate how it simplifies adapters development through a case study. To support users without programming expertise, we propose a spreadsheet-based Web mashups development framework, which enables users to develop mashups in the popular spreadsheet environment. First, we provide a mechanism that makes structured data first class values of spreadsheet cells. Second, we propose a new component model that can be used to develop fairly sophisticated mashups, involving joining data sources and keeping spreadsheet data up to date. Third, to simplify mashup development, we provide a collection of spreadsheet-based mashup patterns that captures common Web data access and spreadsheet presentation functionalities. Users can reuse and customize these patterns to build spreadsheet-based Web mashups instead of developing them from scratch. Fourth, we enable users to manipulate structured data presented on spreadsheet in a drag-and-drop fashion. Finally, we have developed and tested a prototype tool to demonstrate the utility of the proposed framework.

The success of Web services comes from the benefits that it brings in reducing the cost and the time needed to develop data and applications by reusing them, and simplifying their integrations through standardization. However, standardization in Web services does not remove the need for adapters due to possible heterogeneity among service interface and protocol definitions. Moreover, the current service APIs are targeted toward professional programmers, but not accessible to a wider class of users without programming expertise, but would never the less like to build their own integrated applications. In this dissertation, we propose methods and tools to support both service developers and non-expert users in their data and application integration tasks. To support service developers, we propose a framework that enables rapid development of Web service adapters. We investigate particularly the problem of service adaptation focusing on business interface and protocol layers. Our study shows that many differences between business interfaces and protocols are recurring. We introduce mismatch patterns to capture these recurring differences and provide solutions to resolve them. We present the notion of adaptation aspects, which is based on the aspect-oriented programming paradigm, to enable rapid development and deployment of service adapters. We also present a comparative study between standalone and aspect-oriented adapters development. The study shows that the aspect-oriented approach is preferable in many cases, especially when adapters need to access internal states of services. The proposed approach is implemented in a prototype tool, which is used to illustrate how it simplifies adapters development through a case study. To support users without programming expertise, we propose a spreadsheet-based Web mashups development framework, which enables users to develop mashups in the popular spreadsheet environment. First, we provide a mechanism that makes structured data first class values of spreadsheet cells. Second, we propose a new component model that can be used to develop fairly sophisticated mashups, involving joining data sources and keeping spreadsheet data up to date. Third, to simplify mashup development, we provide a collection of spreadsheet-based mashup patterns that captures common Web data access and spreadsheet presentation functionalities. Users can reuse and customize these patterns to build spreadsheet-based Web mashups instead of developing them from scratch. Fourth, we enable users to manipulate structured data presented on spreadsheet in a drag-and-drop fashion. Finally, we have developed and tested a prototype tool to demonstrate the utility of the proposed framework.

Research has indicated that offering support and services for people who experience mental health problems and their families is a complex and contested area. Despite the controversies surrounding therapeutic interventions with families, it has now been recognised that relatives and other supporters of people with mental health problems should be included in their care. Whole- family interventions and partnership working with carers and families is now central to secondary care UK mental health policies and clinical practice guidelines. However, for many families/ carers this remains an aspiration rather than a reality. The way in which we successfully developed family focused mental health practice, as well as specialist family interventions (FI) for people who have been given a diagnosis of psychosis, has therefore aroused considerable interest. The Somerset Partnership NHS Foundation Trust has adopted a Strategy to Enhance Working Partnerships with Carers and Families, developed best practice guidance and has established two complementary workforce development projects - the development of specialist family intervention services and the widespread training of mental health staff to create a ‘triangle of care’ with service users and their families. This has resulted in widespread adoption of systemically informed, ‘whole-family’ practice. In response to the widespread difficulties experienced following other staff- training initiatives we developed specialist family interventions (FI) services by means of an innovative one-year course delivered in partnership with Plymouth University. This training initiative has been widely acknowledged for its novel integration of psycho-educational and systemic approaches and the effective in-situ, multi-disciplinary service development model. An advantage of this approach is that by the end of the course a local FI Service has been established and staff experience fewer difficulties in applying their new skills than people trained in other programmes. We then ensure the continued development of clinical skills by means of a service structure that emphasises on-going supervision. Regular audits of the service and in-depth research studies clearly indicate that the service is effective and highly valued by users. Our ‘cognitive-interactional’ approach, which integrates systemic therapy with psychosocial interventions (individual- and family-CBT) within a collaborative therapeutic relationship, enables us to meet the needs of families in a flexible, tailored manner. The FI teams are able to deliver early interventions for people with first episode psychosis, as well as meeting the NICE guidelines for people with longstanding symptoms. Recognising that many families do not require formal family interventions/ therapy, we also have been designing ‘stepped-care’ family intervention services. We have developed, and extensively evaluated, short training packages to enhance working partnerships with families throughout our mental health services. We have used this three-day package to train a range of community and inpatient teams. We have also encouraged family- inclusive practice with the establishment of a trustwide steering group, practice guidelines and the establishment of ‘family liaison’ posts to facilitate family meetings on inpatient units, as part of the assessment process. Both training initiatives explicitly focus on developing systemic thinking, by integrating CBT and systemic therapy. The involvement of families/ carers in the design and delivery of both training initiatives is also crucial.