Essa pesquisa tomou por objeto a explicação de trabalhadores da Secretaria Municipal de Saúde de São Paulo para o aumento da sífilis congênita na região em que trabalham - instâncias administrativas da Coordenadoria de Saúde Norte e da Supervisão Técnica de Saúde Santana-Tucuruvi-Jaçanã-Tremembé. No Brasil, a sífilis congênita, indicador de qualidade da assistência ao pré-natal, tem apresentado nos últimos anos um acentuado crescimento. Em São Paulo, na região Tremembé e Jaçanã, o crescimento se acentuou a partir de 2008, concomitante à adoção pela SMS do modelo de gestão por Organizações Sociais para a maioria das unidades da Atenção Básica. Utilizou-se como marco teórico o Estado, compreendido como instituição inseparável do modo de produção capitalista, que mede a relação de reprodução do capital e as políticas estatais, como instrumentos dessa mediação. O objetivo do estudo foi identificar a explicação de trabalhadores da Secretaria Municipal para o aumento da sífilis congênita a partir da adoção do modelo de gestão por Organizações Sociais, uma vez que a justificativa para a adoção desse modelo foi a promessa de melhor eficiência e eficácia dos serviços. Metodologia. Trata-se de pesquisa qualitativa de caráter descritivo-analítico, que utilizou a técnica de entrevista para obtenção dos dados e o método da análise de conteúdo para a análise dos depoimentos. Os resultados mostraram que os trabalhadores da Administração Direta reconhecem a piora da qualidade na assistência à saúde da região e a associam ao crescimento dos casos de sífilis congênita. Atribuem à piora, tanto da qualidade da atenção quanto do quadro epidemiológico, explicações identificadas com o âmbito institucional e com o âmbito individual. No âmbito institucional, destaca-se a priorização das metas quantitativas e o encerramento contratual das Organizações Sociais gerando insegurança e insatisfação do trabalhador, além de relatos sobre a qualidade da assistência antes da adoção desse modelo de gestão. Já no âmbito individual, aponta-se a 9 mulher no centro do crescimento da sífilis congênita e o homem e o jovem no centro do crescimento da sífilis congênita. Explicação para o crescimento da sífilis congênita recaiu também nas características da própria doença e na redução do Estado. Discute-se que essas explicações para o aumento da sífilis congênita, tanto no âmbito institucional, sem o questionamento do modelo de gestão por Organizações Sociais adotado para o município, como na perspectiva dos indivíduos, particularmente nas suas precárias condições de vida, parecem identificadas com o posicionamento desses trabalhadores que indica que a realidade epidemiológica da doença na região é um fenômeno inevitável e imutável. Considera-se por fim que as explicações dos sujeitos estão coerentes com os argumentos do Plano Diretor de Reforma Administrativa do Estado mostrando que as estratégias de convencimento social utilizadas para implantação do modelo privatizante da gestão alcançou os espaços que foram objeto de politização durante a reforma sanitária. / The object of this research is the explanation of the workers of the Health Department of São Paulo city for the congenital syphilis increase in the area they work administrative instance of the Northern Health Coordination and of the Santana-Tucuruvi-Jaçanã-Tremembé Health Technical Supervision. In Brasil the congenital syphilis is an indicator of prenatal care assistance quality that has been sharply increasing in the last years. In the area of Tremembé and Jaçanã in São Paulo, the sharp increase has been occurring since 2008 concomitant with the adoption of the Health Social Organization administrative model by the Health Department for the majority of the Primary Health Care units. Considering our theoretical framework we advocate that the State is an inseparable institution from the capitalist mode of production that mediates the relation between the capital reproduction and the state policies, which are instruments of this mediation. The objective of the study was to identify the explanation of the Health Department workers for the congenital syphilis increase activated by the Health Social Organization administrative model adoption. The justification of the adoption of this model was the promise of efficiency and efficacy enhancement of the health care services. Methodology: This is a descriptive-analytical qualitative research that used interviews to collect data. The content analysis method was used for the testimonials analysis. The results show that the workers recognized the decrease of the health assistance quality in the area and associated that to the growth of the congenital syphilis cases. Considering the assistance quality and the epidemiology scenario, the subjects attributed explanations identified as belonging to the institutional sphere and to the individual sphere. In the institutional sphere, there is prioritization of quantitative goals, end of Health Social Organization contract generating workers insecurity and dissatisfaction, and reports about the quality of the assistance before the Health Social Organization administrative model. In the individual sphere, women in the center of the congenital syphilis growth, and men and youth in the center of the congenital 11 syphilis growth are highlighted. The characteristics of the congenital syphilis and the State reduction are also taken as explanations for the disease growth. We discuss that these explanations for the increase of congenital syphilis seem to be consistent with the workers positioning, which regards to the inevitability and immutability of the epidemiological scenario, both in the institutional sphere and the individual perspective. They do not question the Health Social Organization administrative model adopted by the city nor the precarious life condition of the individuals. We consider that the subjects explanations are coherent with the State Administrative Reform Plan argument, showing that the social convincing strategies to implant the private administration model have reached the spaces that were object of politicization during the sanitary reform.

This thesis deals with the Czech and international ideas applied in the "Strategy of Reform of Psychiatric Care" issued in 2013 by the Ministry of Health of the Czech Republic. The main starting point of this work is the fact that the care of people with mental illness in Czech and international environment is oriented on the biological treatment of the patient with psycho- pharmaceuticals and that there is a deficit in the area of psychosocial treatment. International and Czech mental health policy seeks to promote a bio-psycho-social approach to patient's care. However, current psychiatry continues to be involved in conducting clinical research focused on the efficiency of psycho-pharmaceuticals. These studies are driven and sponsored mainly by the pharmaceutical industry. But international and Czech policies are still not able to adequately reflect this situation within the field of psychiatry. The Czech Republic has not so far paid attention to mental health issues and has lagged behind the other developed countries in this area. The empirical part of this work is divided into two parts. The first part of the research focuses on the Czech and international ideas applied in the "Strategy of Reform of Psychiatric Care" issued in 2013 by Ministry of Health. The methods used here are - content...

Le service des urgences est un important service de soins qui représente le goulot d'étranglement de l'hôpital. Les urgences sont souvent confrontées à des problèmes de tension dans de nombreux pays à travers le monde. L'une des causes de la tension dans les urgences est l'interférence permanente entre trois types de patients : les patients déjà programmés, les patients non programmés et les patients non programmés urgents. Le but de cette thèse est de contribuer à l'étude et au développement d'un système d’aide à la décision pour améliorer la prise en charge des patients aussi bien en mode de fonctionnement normal qu’en mode tension. Deux principaux processus ont été développé. Un processus d’ordonnancement à horizon glissant en utilisant un algorithme mimétique avec l’intégration des opérateurs génétiques contrôlés pour déterminer un calendrier optimal de passage des patients. Le deuxième processus d’orchestration dynamique, à base d’agents communicants, tient compte de la nature dynamique et incertaine de l'environnement des urgences en actualisant continuellement ce calendrier. Cette orchestration pilote en temps réel le workflow du parcours patient, améliore pas à pas les indicateurs de performance durant l'exécution. Grâce aux comportements des agents et aux protocoles de communication, le système proposé a établi un lien direct en temps réel entre les performances requises sur le terrain et les actions afin de diminuer l'impact de la tension. Les résultats expérimentaux, mis en œuvre au CHRU de Lille, indiquent que l’application de nos approches permet d’améliorer les indicateurs de performance grâce aux pilotage par les agents du workflow en cours exécution. / The emergency department is an important care service that represents the hospital's bottleneck. Emergencies often face overcrowding problems in many countries worldwide. One of the causes of the emergency department overcrowding is the permanent interference between three types of arriving patients: already programmed patients, non-programmed patients and urgent non-programmed patients. The aim of this thesis is to contribute to the study and development a decision support system to improve patient management in both normal and overcrowding situation. Two main processes have been developed. A rolling-horizon scheduling process using a memetic algorithm with the integration of controlled genetic operators to determine an optimal schedule for patient. The second dynamic orchestration process, based on communicating agents, takes into account the dynamic and uncertain nature of the emergency environment by continually updating this schedule for patient. This orchestration monitoring in real time the workflow of the patient pathway improves step by step the performance indicators during the execution. Through agent behaviors and communication protocols, the proposed system has established a direct real-time link between the required performances and the effective actions in order to decrease the overcrowding impact. The experimental results in this thesis, implemented at the Regional University Hospital Center (RUHC) of Lille, justify the interest of the application of our approaches to improve the performance indicators thanks to the agents driven patient pathway workflows during their execution.

This thesis is concerned with the Czech doctor's campaign "Thanks, we are leaving" on the background of the health care system in the Czech Republic. The campaign started in 2010 by the Czech doctors trying to focus on the working conditions, salary conditions, educational system and some failures of the health care system with the aim to improve it. The campaign resulted in February 2011 in a compromise between doctors and Ministry of Health. This thesis focuses especially on media and on the interest group LOK (Medical union trade club) which set the agenda. The perception of the campaign is ambiguous both for the public and for the doctors themselves. The individual milestones of campaign are explained by the theory of punctuated equilibrium from the authors Bryan D. Jones and Frank R. Baumgartner. Using many helpful methods such as content analysis of media messages, semi- structured interviews with particular actors, analysis of secondary sources, stakeholder analysis or analysis of selected events in health policy I explained the core events and actors who participated in this campaign. The theoretical concepts used in this thesis are: public policy in its multidisciplinary meaning, health policy and health care system, punctuated equilibrium theory, theories concerned with interest groups...

The diploma thesis "Czech Healthcare Policy after 2010 in the Context of Heger's Reform", deals with the significant institutional change that was implemented in Czech healthcare law during the right-wing government, which claimed its reforms were necessary in order to balance the budget. The aim of this work is to analyze the development of Czech healthcare policy in the period 2010-2013 with respect to the case of Heger's reform. This thesis uses different methods of analyzing the political process, for example methods of institutional analysis, critical discourse analysis, and other methods. The main theoretical basis of this work consists of a social critique of the neoliberal approach to Czech health care policy, and of a study of healthcare systems, their functions and goals, and a study of health policy and its changes. Attention is paid especially to the context of human rights related to health and the international discourse. This thesis identifies the arguments of neoliberal ideology in the policy-making of Czech healthcare policy makers in the process of justifying reforms. It evaluates the legitimacy of reform changes that don't accept the opinion of the public and don't respond to the international discourse, and investigates how the reform introduces new legal terminology which...

Le processus menant à la stérilisation irréversible chez les femmes nullipares comporte plusieurs enjeux sur le plan individuel et social. L’objectif de cette recherche est de comprendre de quelle façon est vécue cette expérience par ces femmes au sein du système de santé québécois en portant attention aux difficultés administratives et émotionnelles du processus et aux moyens utilisés pour surmonter ces difficultés et parvenir à réaliser l’opération de stérilisation. Cette recherche a été concrétisée grâce à la participation de treize femmes qui n’ont pas d’enfant et qui souhaitent se faire ligaturer les trompes de Fallope. Les entrevues semi-dirigées réalisées auprès de ces participantes qui composent le corpus de données de cette recherche ont été effectuées sur les plateformes de visioconférence Zoom et Facetime. L’analyse des résultats de l’étude a permis de démontrer qu’une identité liée à la biosocialité émerge au fil du processus, que l’expérience de ces femmes témoigne d’une forme d’agentivité à la fois active et passive et enfin que la relation que ses femmes établissent avec les médecins au sein du système de santé peut être problématisée en termes de biopouvoir. Cette recherche permet d’une part d’offrir un regard anthropologique sur l’expérience des femmes sans enfant par choix tout au long du processus menant à la ligature des trompes de Fallope. D’autre part, elle contribue à cerner les enjeux qui sont en lien avec la reproduction et ceux qui concernent l’hégémonie de la biomédecine au sein du système de santé québécois. / The process leading to irreversible sterilization for nulliparous women involves several individual and social issues. The objective of this research is to understand how this experience is lived by these women within the Quebec healthcare system by paying attention to the administrative and emotional difficulties of the process and to the means used to overcome these difficulties and achieve the sterilization operation. This research was carried out by the participation of thirteen women who do not have children and who wish to undergo tubal ligation. The semi-structured interviews conducted with these participants make up the corpus of datas for this research. They were conducted on Zoom videoconferencing platforms as well as on Facetime. The analysis of the results of the study allowed to demonstrate that an identity linked to biosociality emerges throughout the process, that the experience of these women testifies to a form of agency that is both active and passive, and finally that a form of biopower emerges from their relationship with the physicians within the health system. On the one hand, this research provides an anthropological look at the experience of women who are childfree by choice throughout the process leading to tubal ligation. On the other hand, it contributes to identify issues related to reproduction and those concerning the hegemony of biomedicine within the Quebec health system.

Mental illness that affects an accused’s fitness to stand trial is an ill-explored topic in the South African criminal justice system. The necessity to explore this topic is motivated by the increasing number of persons with mental illness moving into the criminal justice systems in South Africa, Canada, and the United States of America. An accused’s fitness to stand trial is assessed once concern about his ability to follow the proceedings, or give proper instructions to his legal representative, is in doubt. The assessment is conducted in the forensic system where the vastly different fields of law and psychiatry meet. The South African forensic system is plagued with resources and skills shortages. These inadequacies cause delays in resolving pre-trial issues for an accused in respect of whom fitness is at issue. The accused is oftentimes detained in a correctional facility awaiting fitness assessment for anything between three months to two years. Generally, detention in a correctional facility has a negative effect on the mental state of a person with a mental illness. The logistics of fitness assessments differ between the three jurisdictions referred to above. However, the threshold for fitness in these jurisdictions is relatively low, with the result that the majority of accused persons sent for fitness assessments are found fit to stand trial. Such a finding does not imply that the accused is not mentally ill; it simply means that the illness does not affect his understanding of the court proceedings and that it does not influence his ability to communicate with his legal representative. An accused with a serious mental illness such as schizophrenia or major depression can, for example, be found fit to stand trial. After a fitness assessment, a court may either find an accused fit to stand trial or unfit to stand trial. The fact that many persons found fit to stand trial have a mental illness suggests that there is a third category on the fitness continuum that must be acknowledged, namely, fit but mentally ill accused persons. No alternatives to traditional prosecution currently exist in South Africa for this third group of accused persons despite the fact that their situation in the criminal justice system calls for a therapeutic response. The South African legislative framework that regulates fitness assessments and the processes associated therewith are not without challenges. The assessment practices have recently been under scrutiny by the Constitutional court, which judgment changed the position for the accused found unfit to stand trial. The position of the fit but mentally ill accused remains unregulated. The Canadian and American criminal justice systems have implemented diversion programmes for fit but mentally ill accused persons in the form of Mental Health Courts. The underlying principle of a Mental Health Court is therapeutic jurisprudence. Therapeutic jurisprudence evaluates the impact of the law on those in conflict with it. It promotes the inclusion of expertise from other disciplines to improve the effectiveness of the law in a particular set of circumstances. Many South African scholars acknowledge the need for mental health expertise in the criminal justice system, and suggestions have been made for the diversion of mentally ill accused persons charged with minor offences. Those above notwithstanding, no formal diversion programmes exist in South Africa for the fit but mentally ill accused. This research investigates the Mental Health Court as a therapeutic response to the mentally ill accused in the South African criminal justice system. The Mental Health Court models as employed in Canada and the United States of America are studied to identify elements thereof that can be employed in the South African context to provide an effective alternative to traditional prosecution for the mentally ill accused. The Toronto Mental Health Court is studied in the Canadian context as a court that is not a diversion programme as such but has a diversion component attached to it. Diversion in Canada is reserved for those charged with less serious offences, and only these accused persons are allowed into the diversion component of the Mental Health Court. However, the Canadian Mental Health Court assists those who do not qualify for diversion but who need the specialised skills of the Mental Health Court for purposes of, for example, a bail application. The Brooklyn Mental Health Court in the United States of America is investigated as a model that constitutes a complete diversion programme and considers diversion of accused persons charged with more serious offences. The unique structure and procedure of each of these Mental Health Courts are investigated with due consideration to the eligibility criteria of each and the sanctions employed for non-compliance of the court-monitored treatment programmes. Further, the successes and challenges of each model are highlighted. Finally, a proposal is made for a Mental Health Court model mindful of the uniquely South African factors that have to be taken into account when building such a model. Amendments to the existing legislative framework are proposed to incorporate a Mental Health Court as a therapeutic response to mentally ill accused persons in the South African criminal justice system. / Criminal and Procedural Law

Det svenska vårdsystemet står inför en rad utmaningar relaterade till de journalsystem som används idag. Sjukvårdspersonalen upplever svårigheter med systemen vilket påverkar det dagliga arbetet inom vården. Undersökningar visar att personal behöver använda sig av flera olika system för att få en helhetsbild över en patients situation, vilket försvårar en fungerande vårdkedja. Kommunikationen mellan utvecklare och sjukvården är komplex eftersom de inte är insatta i varandras arbetssätt och det saknas även enheter som ansvarar för att föra samman sjukvårdspersonalens behov på ett strukturerat sätt. Denna rapport syftar till att undersöka om och i så fall hur sjukvårdspersonalens behov och upplevelser integreras vid utveckling av journalsystem samt om detta har resulterat i att systemet uppfyller användarnas behov. Fokus för studien har varit på journalsystemet TakeCare vilket är det dominerande journalsystemet inom Region Stockholm. Arbetet som denna rapport består av utgörs delvis av en litteraturstudie för att bygga en teoretisk bakgrund om användarcentrerade produktutvecklingsprocesser, analysmetoder för behovsidentifiering, hur användarinvolvering kan bedrivas och svårigheter som kan finnas. Rapporten utgörs även av en empirisk studie bestående av semistrukturerade intervjuer där totalt sex respondenter har medverkat. Dessa respondenter utgörs av en produktägare för ett utvecklingsteam, en chef på ett förvaltningsföretag, en vårdadministrativ chef på ett akutsjukhus samt sjukvårdspersonal. Vidare så genomfördes en analys, jämförelse och diskussion gällande den information som erhållits från teorin och den empiriska studien. Resultatet av studien visar att det sker användarinvolvering under produktutvecklingen av TakeCare men inte i den omfattning som behövs för att uppfylla användarnas behov. Det framgår att detta inte beror på en ovilja till involvering, utan främst på att det finns en avsaknad av struktur i processen och kommunikation mellan utvecklare och användare. Det behov som återkommande uttrycks av användarna och som inte uppfylls är avsaknaden av tillräcklig kompatibilitet mellan journalsystemet och andra system inom vården. Avsaknad av kompatibilitet gör att användarna måste utföra dubbelt arbete vilket både har en inverkan på patientsäkerheten och tar tid från att vårda patienter. / The swedish healthcare system is facing some challenges related to the electronic medical records that are being used. The healthcare personnel are experiencing some difficulties with the systems, which affects their daily work in a negative aspect. Studies have shown that the personnel actively must use different systems in parallel to get a complete understanding of a patient's status. Furthermore, this makes the care system as a whole more complicated and inadequate.The communication between developers and healthcare can be seen as a complex process since they do not have an complete understanding of each others ways of working. Also, units for bringing together user needs in a structured manner does not exist. This study aims to examine if, and if so, how the needs of healthcare personnel are being involved in the development process of electronic medical records and if this has resulted in a more user adaptive system. The study will focus on the electronic medical record named TakeCare, which is the most used electronic medical record system inside Region Stockholm. This report partly consists of a literature study that aims to establish a theoretical background focusing on user-centered processes of product development, methods for analysing user needs, how user involvement can be conducted and what kind of difficulties that can be identified. The report also consists of an empirical study with focus on semi structured interviews with six different respondents. These respondents are both healthcare personnel, a product owner for a development team, a chief from a company that specializes in managing the electronic medical record TakeCare and a chief specialized in administrative healthcare. Furthermore, an analysis, a comparison and a discussion were followed out concerning the information gained from the theory and empirical study. The results from the study shows that user involvement during the product development process of TakeCare exists, but not to an enough extent that fulfills the user needs. This is not caused by unwillingness to adapt user involvement in the process, but a lack of structure and inadequate communication between developers and users. One particular user need that repeatedly has been expressed by the healthcare personnel, but not been fulfilled, is the lack of software compatibility between the electronic medical record and other electronic systems within the healthcare sector. The lack of software compatibility have resulted in that the users having to perform the same task repetitively, which has an impact on patient safety but also results in reduced time spent on the patients.

Résumé Introduction Depuis une quinzaine d'années en Afrique, cercles de qualité, audits cliniques, cycles de résolution de problèmes et autres 'projets qualité' ont été mis en oeuvre dans les services publics de santé pour améliorer la qualité des soins. Ces projets ont souvent mis l'accent sur des approches participatives, la résolution locale de problèmes et le changement, bousculant les pratiques managériales traditionnelles. A court terme, les évaluations montrent l'amélioration des résultats de programmes ou d'activités. Mais la pérennité de la dynamique reste largement à prouver. Le véritable aboutissement d'un programme d'assurance qualité devrait être apprécié à l'aune de sa capacité à mettre la préoccupation pour la qualité au cœur du management et du fonctionnement du système, et ce de façon continue. C'est en effet la vision moderne de l'assurance qualité déclinée dans les approches du management de la qualité totale, de l'amélioration continue de la qualité ou de l'organisation apprenante. Méthode La définition, la mesure et le management de la qualité en santé se révèlent être beaucoup plus qu'une simple procédure technique: c'est un processus social dans un système complexe dont l'étude requiert une approche méthodologique appropriée (Chapitre 1). Notre objectif est d'explorer dans quelle mesure les projets qualité ont permis aux systèmes de santé d'adopter les principes du management de la qualité. Nous proposons de conduire une 'évaluation réaliste' de projets qualité en Afrique (Chapitre 2). Conceptualisée par Pawson et Tilley (1997) dans le domaine des sciences sociales, l'évaluation réaliste ('realistic evaluation') est une approche méthodologique de la famille des theory based evaluations. Au-delà du constat d'un effet produit par une intervention, l'évaluation réaliste cherche à comprendre ce qui marche, pour qui, dans quelles circonstances et comment. Alors que les résultats issus de la 'grounded theory', de la recherche action et d'autres méthodes de recherche sur les systèmes de santé restent très liés à un contexte, l'évaluation réaliste génère des théories intermédiaires ('middle range theories') qui permettent d'étendre la validité des interprétations au-delà d'un contexte particulier. Construite autour d'études de cas menées dans des contextes multiples et variés, l'évaluation réaliste met en effet l'accent sur l'interaction entre le contexte et la logique d'une intervention. Résultats Afin de construire une théorie initiale, nous comparons les systèmes de santé Européens et Africains à l'aide des configurations organisationnelles de Mintzberg (chapitre 3). Nous mettons ainsi en évidence le rôle joué par la nature bureaucratique ou professionnelle de la configuration des organisations de santé dans les résistances à l'introduction des principes du management de la qualité. Nous menons ensuite une série d'études de cas au Niger, en Guinée, au Maroc et au Zimbabwe pour étudier cette interaction. Dans une première série comparative de trois études de cas (Chapitre 4), nous mettons en évidence la tension qui existe entre la logique de commande et de contrôle des organisations bureaucratiques et la logique de l'assurance qualité valorisant la prise d'initiative de changement par des équipes non hiérarchisées. Nous explorons ensuite cette tension dans trois études de cas distinctes au Zimbabwe et au Maroc. Laissées à la merci des contraintes bureaucratiques, les initiatives locales pour améliorer la qualité apparaissent dépendantes de la capacité des acteurs à développer des stratégies de contournement (Chapitre 6). Faute de quoi elles doivent réduire fortement leurs ambitions à moins qu'elles ne bénéficient d'un soutien émanant d'une institution située hors de la ligne hiérarchique mais reconnue légitime (Chapitre 5). Les systèmes publics de santé de ces pays, conçus comme des organisations bureaucratiques structurées autour de relations hiérarchiques de commande et de contrôle tolèrent une démarche qualité, valorisant l'innovation, la créativité, la prise d'initiative locale et le travail en équipes non hiérarchisées, à la condition qu'elle se déroule à l'abri d'un projet. Force est de constater que ces dimensions clé de la culture qualité n'ont pas fondamentalement ni durablement imprégné des pratiques de management restées bureaucratiques. L'émergence d'une véritable 'culture qualité', un produit attendu de l'introduction de projets qualité, ne semble pas s'être produite au niveau organisationnel (Chapitre 7). Nous procédons ensuite à la synthèse 'réaliste' de l'ensemble de nos études de cas (Chapitre 8). Nous en tirons les leçons sous la forme d'un enrichissement progressif de notre théorie initiale. Nous pouvons alors formuler une théorie améliorée, toujours intermédiaire et provisoire, dérivée de nos théories intermédiaires successives. Discussion Notre discussion s'organise autour de deux thèmes (chapitre 9). Dans une première partie, nous discutons le potentiel et les limites de nos résultats et de l'approche réaliste de l'évaluation. Nous montrons que nos résultats sont des théories provisoires et incomplètes, deux caractéristiques d'une middle range theory. En dépit de ces limites, l'approche réaliste est potentiellement très riche pour interpréter les effets d'interventions dans des systèmes complexes. Elle se situe dans une perspective d'aide à la décision pour orienter l'action sur le terrain plutôt que dans une perspective de genèse de lois universelles. Elle représente une avancée méthodologique particulièrement pertinente pour la recherche sur les systèmes de santé dans un monde turbulent où de multiples initiatives se télescopent. Dans une deuxième partie, nous discutons les conséquences de nos résultats pour le futur de l'assurance qualité dans les systèmes de santé. Les projets qualité étudiés ne parviennent pas à changer une culture organisationnelle bureaucratique qui compromet pourtant leur pérennisation. Nous envisageons alors les stratégies susceptibles de permettre à la culture qualité de s'épanouir et au contexte organisationnel d'évoluer en conséquence. Décentralisation et nouveau management public, en vogue hier et aujourd'hui, montrent leurs limites. Il faut probablement trouver un équilibre entre trois idéaux-types décrits par Freidson: l'idéal-type bureaucratique, malmené par les stratégies de débrouille locale, l'idéal-type du marché, valorisant l'initiative, et l'idéal-type professionnel, émergent mais encore embryonnaire en Afrique. Finalement, à côté des mécanismes du contrôle et de la compétition, un troisième mécanisme régulateur devrait prendre toute sa place: la confiance. Abstract Introduction For nearly two decades in Africa, quality circles, clinical audits, problem solving cycles and other quality projects have been implemented in public health services to improve quality of care. Challenging traditional managerial practices, these projects usually emphasized participatory approaches, local problem solving and change. At short term, evaluation shows improvement in programs and activities output. However the capacity to put quality at the heart of system's management should be considered as the genuine achievement of a quality assurance program. Did quality projects contribute to the adoption of quality management principles by health systems ? This is the question addressed in the present thesis. Method Our methodology belongs to the realistic evaluation paradigm conceptualized by Pawson and Tilley and focuses on the interaction between an intervention mechanism and its context in order to understand what works, for whom, in what circumstances and how ? Based on case studies in various contexts in Niger, Guinea, Morocco and Zimbabwe, we build a middle range theory, that explains organizational behavior towards quality management. Results Based on Mintzberg's models, we show the role of health care organizational configuration in resisting to quality management principles. We then explore the tension between the bureaucratic organization's command and control approach and the quality assurance approach promoting initiative and change through team work. Local initiative had to develop coping strategies to overcome bureaucratic constraints. Failing to do so, ambitions had to be reduced unless there was support from an external, yet legitimate institution. Public health systems of these countries, structured as command and control hierarchical organizations, allowed innovation, creativity, local initiative and non hierarchical relationships as long as they developed within the boundaries of a project. However, these key characteristics of a quality culture did not permeate routine management. The quality culture shift expected from quality projects does not seem to have happened at organizational level. Discussion We first discuss the potential and limitation of realistic evaluation which appear particularly relevant for complex health systems research. We then discuss consequences of our results on the future of quality assurance in health systems. Since quality projects fail to transform a bureaucratic organizational culture, which in turn undermines their sustainability, alternative strategies must be sought to promote quality culture and relevant organizational change. Decentralization and new public management show their limitations. We suggest a balance between three ideal-types described by Freidson: The bureaucratic ideal-type, challenged by local coping strategies, the market ideal-type, which is fashionable today and promote initiative, and the professional ideal-type, emerging and promising, yet still embryonic in Africa.

Politikwissenschaftliche Studien der vergangenen Jahre stellen fest, dass das deutsche und österreichische Gesundheitswesen eher reformresistent sind. Anhand der Einführung der elektronischen Kartensysteme im deutschen und österreichischen Gesundheitswesen zeigt diese Dissertation, dass gesundheitspolitische Reformschritte möglich sind. Durch ein vergleichendes Forschungsdesign werden anhand der zwei relativ ähnlich strukturierten Staaten Deutschland und Österreich mit dennoch relevanten Unterschieden im Politikfeld Gesundheit Theorien aus der vergleichenden Policy-Forschung und der Staatstätigkeitsforschung auf ihre Erklärungskraft hin untersucht. Durch eine qualitative Inhaltsanalyse nach Mayring und die Auswertung von Experteninterviews werden die Bestimmungsfaktoren für den gesundheitspolitischen Wandel analysiert. Auf Grund der Abweichung dieser Dissertation (Reformmöglichkeit) von bisherigen empirischen Ergebnissen (Reformresistenz) aus dem Bereich der Gesundheitspolitologie, leistet die in dieser Arbeit vorgenommene Erklärung von politischem Wandel einen Beitrag zur politikwissenschaftlichen Forschung. Die Dissertation zeigt, dass eine Kombination von Theoriemodulen aus der vergleichenden Staatstätigkeitsforschung und der Policy-Forschung die Einführung der elektronischen Kartensysteme im deutschen und österreichischen Gesundheitswesen sinnvoll erklären kann. Die Arbeit stellt dar, dass der politische Wandel vor allem bis zur Phase der Implementation im Politikzyklus in beiden Staaten zügig möglich war. Geänderte Machtverhältnisse, die Verteilung von Machtressourcen zwischen den Interessengruppen im Politikfeld, vormals getroffene politische Entscheidungen und selbstverstärkende Mechanismen, das Engagement "neuer" Akteure im Subsystem, sowie gebundene Rationalitäten der politischen Entscheider sind die maßgeblichen Gründe, welche die Einführung des elektronischen Kartensystems im deutschen und im österreichischen Gesundheitswesen veranlassten.