Baggrund: D. 1. januar 2007 trådte kommunalreformen i kraft i Danmark. Regionsdannelsen er den største ændring af den offentlige sektor siden kommunalreformen i 1970. Ansvaret for sundheds-væsenet bliver regionernes hovedopgave. Formål: At beskrive, analysere og diskutere de strukturændringer, der finder sted i sundhedsvæsenet, med hovedvægt på sygehusvæsenet i Danmark. Metode: Opgaven tager afsæt i et litteraturstudie, hvor udgangspunktet er officielle kilder og udredninger samt videnskabelig litteratur. Resultater: Strukturreformen, der er en centralisering, er inspireret af New Public Management-filosofien. Finansieringssystemet på sundhedsområdet er blevet væsentligt forandret med kommunalreformen. Det er en tvivlsom antagelse, at kommunale foranstaltninger er billigere end de regionale sundhedsydelser, og at nettobesparelsen er tilstrækkelig til at drive substitutionsprocessen. En nedsættelse af behandlingsgarantien fra to til en måned må forventes at stimulere markedet for private sundhedsydelser, med en underminering af den integrerede model med offentligt ejerskab og drift af sygehusvæsenet til følge. Konklusion: Den nye finansieringsmodel påvirker aktørernes økonomiske incitamenter, idet de enkelte aktører kun belønnes for de ydelser, de selv leverer til patienten, uden sammenhæng med resten af behandlingsforløbet. Den stigende aktivitetsafhængige finansiering udgør en væsentlig styringsmæssig udfordring. Ventetidsgarantien får med nedsættelsen fra to til en måned karakter af at være et servicemål, frem for at være en garanti for behandling af høj faglig kvalitet. / Background: On 1 January 2007 the Local Government Reform came into force. The formation of regions is the biggest change of the public sector since the Local Government Reform in 1970. The regions’ main task will be the responsibility for health service. Purpose: To describe, analyse and discuss the structural changes taking place in the Danish health service, with emphasis on hospitals. Method: The starting point of the essay is official sources and explanations as well as scientific literature. Results: The structural reform is a centralisation is inspired by the New Public Management philosophy. The financial system in the health care area has been changed significantly through the Local Government Reform. It is dubious to assume that local government measures are cheaper than the regional health services, and that the net saving is sufficient to drive the substitution process. A reduction of the treatment guarantee from two to one month must be expected to stimulate the private health service market, thereby causing undermining of the integrated model with public ownership and operation of health service. Conclusion: The new financing model will affect the financial incentives in the system as the individual players are only rewarded for the services they deliver to the patient with no relation to the remaining treatment. The increasing activity depending financing presents a significant management challenge. With the reduction from two months to one the waiting time guarantee will assume the character of being a service goal instead of a guarantee of treatment of high professional quality. / <p>ISBN 978-91-85721-28-3</p>

O presente trabalho busca discutir o papel político das idéias econômicas em um contexto de transformação estrutural. A Argentina enfrentou, durante os anos 80 e 90, os dilemas próprios de um processo de reformas estruturais. O giro para estas reformas foi produzido sob o impacto da crise da dívida externa. A resposta inicial à emergência econômica, que teve um alcance limitado, não comportou mudanças apreciáveis na organização das instituições econômicas. Este alcance das políticas de ajuste foi correspondido com os diagnósticos do momento que postulavam que os desequilíbrios macroeconômicos eram, fundamentalmente, de curto prazo. O governo lançou, em 1985, um plano de estabilização heterodoxo. Os economistas heterodoxos, chamando a atenção para os componentes inerciais da dinâmica inflacionária, sustentaram que as políticas ortodoxas, eram ineficazes e custosas para resolver o problema inflacionário. Contudo, esse programa não conseguiu estabilizar a economia. O fracasso da experiência heterodoxa abriu as portas para a ortodoxia. A partir do final dos anos 80 a agenda governamental foi dominada por uma onda de reformas estruturais. Em 1989, o governo eleito estabeleceu uma nova orientação em política econômica, a partir da qual levou adiante um profundo processo de ajuste. Para entender a modalidade de mudança estrutural seguida pela Argentina existem alguns elementos fundamentais. Em primeiro lugar, aqueles de caráter econômico relacionados com o impacto da crise. Contudo, embora a crise econômica tenha constituído um estímulo poderoso para o início de um programa de reformas estruturais, por si só não foi suficiente para definir quando, como e em o que medida era necessário fazer o ajuste. A interpretação das causas da crise foi central na direção da inovação política. Assim, o debate de idéias cumpriu um papel chave na entrada das reformas econômicas na agenda pública. Para a direção da inovação política foi central a interpretação das causas dos desequilíbrios econômicos. A controvérsia entre alternativas de políticas, que se levou a cabo tendo como pano de fundo a emergência econômica, constituiu a primeira via de entrada das reformas estruturais na agenda pública. Portanto, o desenlace da disputa de interpretações que se estabeleceu durante esses anos acerca da definição da natureza dos desequilíbrios é o foco central de nosso trabalho. / The present work seeks to discuss the political power of the economic ideas in a context of structural transformation. Argentina faced, during ´80 ´90, the dilemmas characteristic of a process of structural reform. The turn toward the structural reform took place under the impact of the crisis of the foreign debt. The initial answer to the economic emergency that had a limited reach, didn\'t behave appreciable changes in the organization of the economic institutions. This limited reach of the adjustment belonged together with the diagnoses of the moment that postulated that the macroeconomic imbalances, were fundamentally imbalances of short term. The government rushed, in 1985, a heterodox stabilization plan. The heterodox economists, getting the attention on the inertial components of the inflationary dynamics, they sustained that the politicians of orthodox, were ineffective and expensive to solve the inflationary problem. However the program was not able to stabilize the economy. The failure of the heterodox experience opened the doors for the orthodoxy. From ends of the years eighty, the government agenda was dominated by a wave of political of structural reforms. In 1989, the elect government established a new orientation in economic politics, starting from which took a deep adjustment process ahead. To understand the modality of structural change continued by the Argentina, some fundamental elements exist. In the first place, those of economic character related with the impact of the crisis. But, although the economic crisis constituted a powerful stimulus for the setting in march of a program of structural reform, by itself it was not enough to define when, how and in what measure it must make the adjustment. The interpretation of the causes of the crisis was central in the address of the political innovation. The debate of ideas completed a key role in the entrance of the economic reform in the public calendar. For the address of the political innovation it was central the interpretation of the causes of the economic imbalances. The controversy among alternative of political that was taken to end on the backdrop of the economic emergency, it constituted the first road of entrance from the structural reform to the public agenda. Therefore, the outcome of the bid of interpretations that was begun in those years about the definition of the nature of the imbalances is the central focus for our work.

O Brasil tem visto um forte processo de judicialização de sua vida pública. Hoje, a Justiça exerce um papel político importante no país, mas é marcada pela ineficiência na solução de disputas e cobrança de créditos. Críticas à expansão desse papel político são, pois, abundantes. Diz-se que (i) geraria instabilidade institucional e um ambiente hostil ao desenvolvimento (crítica institucional); (ii) produziria resultados ilegítimos (preferências judiciais substituiriam decisões majoritárias - crítica de legitimidade) e (iii) resultaria em ações inefetivas, pois o aparato das cortes não é adequado a resolver conflitos policêntricos e prospectivos (crítica instrumental). Este trabalho analisa o processo brasileiro de judicialização e os argumentos centrais da crítica instrumental. Sugere que ela refere-se a um modelo de direito e justiça que está em transformação. No modelo emergente, a justiça distributiva é reintroduzida na dinâmica legal e a administração de interesses sobrepuja, aos poucos, a tutela de direitos. Essas mudanças, mais a judicialização, levam a alterações importantes no processo judicial. Reconhecendo os problemas daí decorrentes, a tese sugere um caráter virtuoso desse novo contencioso de direito público emergente. Ele parece forjar um mecanismo de reforço de participação política que pode avançar a democracia e melhorar condições de igualdade política. / From democratization in the mid 80? on, Brazilian public life has been forced into an increasingly intense process of judicialization. Lack of confidence in representative institutions, a very open-texted charter of social and economic rights, an important political use of the Judiciary by the oppositions, and other related factors seem to be implicated in this. Brazilian justice holds today a considerable political power, but that is just part of a story. It is also astonishingly inefficient as a services provider, and fails to respond to most of its dispute-solving and credit-enforcement functions. Criticism about the expansion of the political role of the Judiciary in this context is profuse. First, it is said to generate institutional instability, which in turn would bring out a hostile environment for economic growth. Second, it is said to be illegitimate, as far as politicized judges may often replace majoritarian decisions by their own. Third, it is said that litigation involving political issues and social reform tend to be erratic and ineffective, because the institutional designs of both courts and their processes are not adequate to regulate polycentric and prospective conflicts. This work puts Brazilian judicialization into context, and analyses the main arguments of the institutional capacity critique (which is called in here the instrumental critique). The author suggests that the instrumental critique refers to a certain model of law and justice that has been changing (both globally and in Brazil) since the end of the last century. In the emergent model, distributive justice is reintroduced into the dynamics of law, and the administration of diffuse interests slowly replaces the adjudication of individual rights as the paradigmatic activity of the Judiciary. Those changes in both law and justice, along with judicialization, are argued to have lead to other important changes in the design of the judicial process in Brazil. Despite the many problems related to those changes, the ending notes of this work point to a possible virtuous character of the new Brazilian public law litigation. As stated herein, this litigation seems to be creating a participation-reinforcing device that in the long run may foster democracy and political equality.

Through a case study about the impact of IT adoption in a residential aged care organisation, this thesis examines the increasing pressure for service integration as mainstreamed through reform policies. Specifically, the research investigates the role of IT in facilitating the 1997 aged care reform agenda of 'ageing in place' focusing on the levels of transformation from the policy context to the organisational/management context, and to the context of service provision by care staff. A single embedded case study (Yin, 1993) is used in order to meet the general objective to capture the dynamics of the impact of ageing in place in the three social contexts. The research is informed by social constructionism, a theoretical framework that emphasises the significance and effects of language in shaping social realities (Ainsworth, 2001; Hosking, 1999). The framework, therefore, justifies the qualitative analysis of both written (i.e., policy documents) and spoken (i.e., interviews with staff) texts to address meaning in relation to context. Changing technologies can result in altered societal structures (Betz, 2003) at all levels, from the very complex to the very basic. As such, it is important to understand a few basic premises of technology. First, technology is a human invention to improve the well-being of society (Ayres, 1996). Consequently, technological inventions that improve the quality of life are seen by people as a necessity for modern living. In the case of ageing, modernisation and technological advances effectively resulted in people becoming healthier and living longer (Department of Health and Aged Care [DHAC], 2000). Second, technology is a human means to control nature (Betz, 2003). As such, technological advances can be seen as a modernising process of predicting and regulating the effects of the trends existing in the environment, such as ageing. Ageing in the twenty first century presents a challenge to government's development policies because ageing is depicted as a steady force with a long-term economic impact (Johnson, 1999). Third, a technology becomes powerful when it is sponsored by the market (Betz, 2003; Hughes, 1983). Unless a technology is backed by business, it lacks the influence on a large scale. Fourth, technology is used to enable change. By using IT, governments, business and the community are co-operating through a paradigm similar to the business sector. As a result, the service environment is shifting towards more business-like approaches. To sustain the changes brought by a different paradigm and modes of operation, the rhetoric of technology is employed. Therefore, the purpose of the study is to investigate the use of IT in processes of organisational adaptations to reform, which requires the examination of: a) specific meaning of IT as used in long-term care policies for older people since the last structural reform, b) the rationale behind the introduction of a new IT system into a residential care organisation, and c) the meaning of IT as articulated by care staff who have experienced a change in technology. The first paper represents a rhetorical analysis at the macro or policy level. There is a significant influence of a global political actor in developing proactive strategies on ageing, which results in a new, multi-organisational approach in delivering government-subsidised services, such as residential care. Three key institutional texts were selected to represent international to local policy development since the time ageing became a global concern. Since then, ageing is also viewed as a human rights issue. Using Burke's pentad, an analytic framework to analyse rhetoric in texts (Stillar, 1998), these institutional texts are seen to employ the rhetoric of 'technology for sustainability' to justify changes to policy approaches that seek long-term viability. Technology, in the name of sustainable development ensures support for economic growth, which balances the long-term effects of population ageing. The existence of a global force, such as population ageing, allows the intervening powers of the UN in mainstreaming ageing into development policies. Accordingly, it initiates corresponding actions at national (Australian Commonwealth Government) and state (Queensland Government) levels. IT is a medium of communication, knowledge transfer, and standard practice at these levels of actions. The second paper represents a qualitative analysis at the meso or organisational level. This paper explores the cogent rationale in the introduction of a computer-based, care documentation system in a large residential aged care organisation. Twenty two staff, from every level of the organisation, were interviewed to get an insight into the role of IT in substantive changes to organisational structure and modes of service provision. Responses from staff indicate external and internal influence that pressured the organisation to change. In the bid to sustain the future of aged care, the industry is changing through the introduction of new structure of service delivery. The Aged Care Structural Reform instigated a shift towards sustainable service provision that is consumer-driven, with a fixed cost compliance mechanism and performance criteria that are tied to funding. Facing the requirement for evidence to corroborate funding, a residential care organisation changed its structure of service delivery by introducing a new strategic direction. IT is part of this new strategic direction, planning, and operations of a changed service environment. The third paper represents a qualitative analysis at the micro or individual level to examine the impact of IT at frontline service delivery. This study is also based on interviews with twenty-two staff, across the organisational structure; however, this time the focus is more on staff who are involved in providing direct care to older residents at the organisation. The reason behind this is that IT has always been a management tool which handles management priorities such as financial planning and performance monitoring. The themes arising from the interviews indicate discord at the level of service delivery from the introduction of a new technical system. It also points to the idea that staff generally refer to ethical ideas and future promise of the new system. In summary, these three papers attached to this thesis support the notion that the meaning of technology is socially constructed. First, technology in the aged care sector has particular reference to improving or enhancing the well-being of older people, and in this case, the provision of high quality services that fulfil the needs of older people. Second, IT has an important role in meeting the evidence-based requirement, such as in the use of information in manipulating the use of resources required for the ageing population. Third, the meaning of IT is conceived from the context requiring its use such as the need to use resource efficiently to ensure long-term sustainability, which were emphasised in the last reform. Fourth, IT is used to enable structural changes in organisations to implement generic practices originated from the business sector, requiring the use of strong rhetoric such as balance and future. The limit of this case study is that these dimensions of technology can only be applied to the specific context of aged care and is not generalisable to other political contexts. However, the strength of the study rests on the macro-, meso- and micro-analysis of the meaning of technology. Therefore, future studies should investigate and compare the dimensions of technology in other contexts.

O Brasil tem visto um forte processo de judicialização de sua vida pública. Hoje, a Justiça exerce um papel político importante no país, mas é marcada pela ineficiência na solução de disputas e cobrança de créditos. Críticas à expansão desse papel político são, pois, abundantes. Diz-se que (i) geraria instabilidade institucional e um ambiente hostil ao desenvolvimento (crítica institucional); (ii) produziria resultados ilegítimos (preferências judiciais substituiriam decisões majoritárias - crítica de legitimidade) e (iii) resultaria em ações inefetivas, pois o aparato das cortes não é adequado a resolver conflitos policêntricos e prospectivos (crítica instrumental). Este trabalho analisa o processo brasileiro de judicialização e os argumentos centrais da crítica instrumental. Sugere que ela refere-se a um modelo de direito e justiça que está em transformação. No modelo emergente, a justiça distributiva é reintroduzida na dinâmica legal e a administração de interesses sobrepuja, aos poucos, a tutela de direitos. Essas mudanças, mais a judicialização, levam a alterações importantes no processo judicial. Reconhecendo os problemas daí decorrentes, a tese sugere um caráter virtuoso desse novo contencioso de direito público emergente. Ele parece forjar um mecanismo de reforço de participação política que pode avançar a democracia e melhorar condições de igualdade política. / From democratization in the mid 80? on, Brazilian public life has been forced into an increasingly intense process of judicialization. Lack of confidence in representative institutions, a very open-texted charter of social and economic rights, an important political use of the Judiciary by the oppositions, and other related factors seem to be implicated in this. Brazilian justice holds today a considerable political power, but that is just part of a story. It is also astonishingly inefficient as a services provider, and fails to respond to most of its dispute-solving and credit-enforcement functions. Criticism about the expansion of the political role of the Judiciary in this context is profuse. First, it is said to generate institutional instability, which in turn would bring out a hostile environment for economic growth. Second, it is said to be illegitimate, as far as politicized judges may often replace majoritarian decisions by their own. Third, it is said that litigation involving political issues and social reform tend to be erratic and ineffective, because the institutional designs of both courts and their processes are not adequate to regulate polycentric and prospective conflicts. This work puts Brazilian judicialization into context, and analyses the main arguments of the institutional capacity critique (which is called in here the instrumental critique). The author suggests that the instrumental critique refers to a certain model of law and justice that has been changing (both globally and in Brazil) since the end of the last century. In the emergent model, distributive justice is reintroduced into the dynamics of law, and the administration of diffuse interests slowly replaces the adjudication of individual rights as the paradigmatic activity of the Judiciary. Those changes in both law and justice, along with judicialization, are argued to have lead to other important changes in the design of the judicial process in Brazil. Despite the many problems related to those changes, the ending notes of this work point to a possible virtuous character of the new Brazilian public law litigation. As stated herein, this litigation seems to be creating a participation-reinforcing device that in the long run may foster democracy and political equality.