Das Dissertationsvorhaben greift zu Beginn einen Praxisfall im Krankenhaus auf und verdeutlicht exemplarisch, dass der Krankenhausarzt in einen Konflikt zwischen ökonomischen und ethischen Anforderungen gerät. Um die Frage beantworten zu können, wie die soziale Praxis der Krankenhausärzte gelingen kann, wird das Problem im ersten Schritt rekonstruiert. Nach der Diskussion verschiedener Lösungsansätze für das Problem im zweiten Schritt, werden im dritten Schritt Anregungen für die Praxis abgeleitet.

Development of approaches for early detection of cancer requires a comprehensive understanding of the cellular functions that lead to cancer, as well as implementing strategies for population-wide early detection. Cell functions are supported by proteins that are produced by active or expressed genes. Identifying cancer biomarkers, i.e., the genes that are expressed and the corresponding proteins present only in a cancer state of the cell, can lead to its use for early detection of cancer and for developing drugs. There are approximately 30,000 genes in the human genome producing over 500,000 proteins, thereby posing significant analytical challenges in linking specific genes to proteins and subsequently to cancer. Along with developing diagnostic strategies, effective population-wide implementation of these strategies is dependent on the behavior and interaction between entities that comprise the cancer care system, like patients, physicians, and insurance policies. Hence, obtaining effective early cancer detection requires developing models for a systemic study of cancer care. In this research, we develop models to address some of the analytical challenges in three distinct areas of early cancer detection, namely proteomics, genomics, and disease progression. The specific research topics (and models) are: 1) identification and quantification of proteins for obtaining biomarkers for early cancer detection (mixed integer-nonlinear programming (MINLP) and wavelet-based model), 2) denoising of gene values for use in identification of biomarkers (wavelet-based multiresolution denoising algorithm), and 3) estimation of disease progression time of colorectal cancer for developing early cancer intervention strategies (computational probability model and an agent-based simulation).

Kroniska sjukdomar ökar världen över, i både utvecklings- och industrialiserade länder. Mäniskor som lider av kroniska sjukdomar finner ofta den västerländska medicinen oförmögen att behandla deras sjukdommar, och vänder sig istället till traditionell, komplementär och alternativ medicin [TM/CAM]. TM/CAM har visat sig vara effektiv vid prevention och behandling av kroniska sjukdomar, varför det är av stort intresse att undersöka möjligheten för ökad integration av TM/CAM inom de nationella sjukvårdssystemen. Syftet med denna studie är att undersöka de krafter som främjar respektive förhindrar kommunikation och samarbete mellan utövare av ayurveda, västerländsk och traditionell medicin, samt att se hur detta påverkar integrationen av de medicinska subsystemen på Sri Lanka. Fokus för studien är ett specifikt samarbetsprojekt, “The outcome oriented, evidence informed community health promotion program”, vars mål är att integrera ayurveda och västerländsk medicin inom primärvården. En kvalitativ studie genomfördes under tre månader på Sri Lanka med hjälp av semi-strukturerade intervjuer, deltagande observation samt analys av dokument. Paul Unschulds teori om strukturerad konkurrens, samarbete eller integration användes vid tolkningen av resultaten. Resultaten tyder på att den huvudsakliga formen för samexistens mellan ayurveda och västerländsk medicin på Sri Lanka är strukturerad konkurrens, medan samarbetsprojektet siktar mot att uppnå strukturerat samarbete. Det parallella politiska system som styr samexistenseen mellan ayurveda och västerländsk medicin tycks förhindra integration, medan en ökad professionalisering genom nationella regleringar skapar ökat samarbete och integration. Brist på kunskap om ayurveda bland medicinstudenter förhindrar samarbete. Samtidigt kan inflytandet från västerländsk medicin i den auyurvediska universitetsutbildningen till synes både främja och förhindra samarbete och integration. Genom att höja kompetensen omkring forskningsmetodik och hälsovårdsystem hos ayurvediska läkare kan samarbete främjas. Likaså är forskning utformad med hänsyn till ayurvediska grundprinciper samt närvaro av nyckelpersoner med kompetens inom både ayurveda och västerländsk medicin främjande faktorer för samarbete och integration. / Non-communicable diseases [NCDs] are increasing in both developing and developed countries. Western medicine is not able to offer satisfying solutions and treatments for people suffering from NCDs. TM/CAM have shown promise of effectiveness in the prevention and treatment of NCDs and many people now turn to TM/CAM. Hence it is of great interest to investigate the possibilities of increased integration of TM/CAM in national health care systems. This study was carried out in Sri Lanka, with the aim to investigate the main forces promoting and obstructing cooperation and communication between practitioners of Ayurvedic, Western and traditional medicine, in order to see how this affects integration of the medical subsystems. The focus of this qualitative study was the “Outcome oriented, evidence informed Ayurvedic Community Health Promotion Program”; a collaboration project aiming to integrate Ayurveda and Western medicine in primary health care. Semi-structured interviews, participatory observation and document analysis were carried out during three months in Sri Lanka and the results were analysed using Paul Unschuld’s theory on structured competition, cooperation or integration. The results indicate that the overall coexistence of Ayurveda and Western medicine in Sri Lanka is structured competition, while the collaboration project is aiming for structured cooperation. The results further show that the Sri Lankan parallel political approach to integration can be argued to obstruct integration, while the regulation of Ayurvedic practitioners increases cooperation through professionalization. Education is a main influencing factor for cooperation; lack of CAM-knowledge in medical students obstructs cooperation while westernization of Ayurvedic doctors both promotes and obstructs cooperation and integration. Capacity building, research based on Ayurvedic fundamentals and keypersons with knowledge of both sectors are of importance for increased cooperation and integration to come about.

The purpose of this study was to investigate and describe the experience of infertility of African women, men and family member. It is hoped that this description will contribute to a deeper understanding of the psychosocial difficulties involved in the area of infertility and ofthe ways in which people respond to the situation of infertility. A qualitative research approach was used, and in particular social constructivist-interpretive research and feminist research approaches. The sample consisted of39 participants: 19 women, 10 men, and 10 family members faced with infertility. The research orientation was field-based, concerned with collecting data using the technique of in-depth semi-structured interviews. Each participant was interviewed individually. The interviews were recorded on tape, transcribed in their full length and translated into English. Data were analysed on the basis of the interpretive feminist approach. Analysis of individual cases and crosscase analysis were employed. The findings suggested a contextual definition of infertility, for example, for some, having had an ectopic pregnancy or a miscarriage meant that they did not fit into the definition of infertility. The findings revealed that for many African women and men, blood ties still defined the family and the persona. Thus, failure to have a blood child resulted in courtship and marital break up, extramarital relationships, polygamy, and divorce and remarriage. Infertility had serious psychosocial consequences for both the infertile individuals and their families. Participants experienced repeated periods of existential crisis, which began at different points for different participants. Analysis of gender differences indicated similarities in the experience of the crisis, but differences in terms of expression and ways of responding to the crisis. Family dynamics within the context of infertility were coloured by ambivalent feelings, resentment, insensitivity, and miscommunication, but also affection, and social support. Traditional and modern medical health systems offered the possibility of finding explanations and treatment, but there was further strain from the negative experiences with the health care system. The findings in this study suggested the need for policy reformulation, for psychosocial intervention as part of the treatment plan, and for future research on the outcome of using various coping strategies. / Psychology / D. Phil. (Psychology)

Thesis (MPhil (Sociology and Social Anthropology))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: This study gives us insight into the daily lives and battles for survival of poor women in an age of HIV/AIDS in rural areas of the Western Cape, South Africa. I set out to get an understanding of the shortcomings of the current interventions aimed at combating HIV and AIDS. Soon after I commenced my fieldwork I realised that it is the socio-economic circumstances of the people I encountered that was mostly responsible for their HIV positive status or the reason why they are living with HIV/AIDS rather than the choices they make. However, most of the interventions aimed at combating the global HIV/AIDS epidemic focuses on behavioural interventions or the provision of medical care. By entering the spheres in which women living with HIV/AIDS live their daily lives I aimed to get a better comprehension of the challenges they encounter and why the interventions that focus on behaviour and medical treatment fail to address the needs of these women. In doing so I learned about their struggles to merely stay alive and that protecting yourself against a disease like HIV/AIDS can appear as a luxury. A luxury you cannot afford when your only means of an income is your body which you need to barter in exchange for money or food and shelter. I learned about their powerlessness in protecting themselves against the disease and the loneliness they have to endure once they learn they are infected with the virus. In addition to this, it also came to my attention that their conditions of poverty are of such an extent that even ‘free’ medical treatment can sometimes be too expensive for them to afford because of hidden costs such as transport. At the end of my study it was my conclusion that we need to pay more attention to the root causes of the spread of the HIV/AIDS epidemic in order to combat it successfully, also at the entry levels of the healthcare system. / AFRIKAANSE OPSOMMING: Die studie bied insig in die daaglikese lewens en stryd om oorlewing van arm vroue in ‘n tyd van MIV/VIGS in die landelike gebiede van die Wes-Kaap, Suid-Afrika. Ek het die studie begin met ‘n poging om die tekortkominge van die huidige intervensies om MIV/VIGS te bekamp beter te verstaan. Kort nadat ek met my veldwerk begin het het ek reeds tot die besef gekom dat die die sosio-ekonomiese omstandigehede die oorsaak is dat die vroue met die virus leef, eerder as die keuses wat hulle vrywilliglik maak. Ten spyte van my bevinding fokus meeste intervensies tans op gedragsveranderinge en mediese behandeling. Ek het die lewensruimtes van hierdie vroue binnegegaan in ‘n poging om die daaglikse uitdagings te verstaan, asook die redes hoekom die huidige intervensies nie hierdie vroue se behoeftes aanspreek nie. Deur dit te doen het ek geleer hoe dit as ‘n luuksheid beskou kan word om jouself teen infeksie met die virus te beskerm. ‘n Luuksheid wat jy nie kan bekostig indien jou lyf jou enigste bron van inkomste is wat jy moet gebruik om geld mee in te win of kos en woonplek te verseker nie. Vroue is dikwels magteloos om hulself teen infeksie met MIV/VIGS te beskerm en die eensaamheid waarmee hul moet saamleef wanneer hul wel met die virus ge-infekteer is. Dit het ook onder my aandag gekom dat die armoede van so ‘n aard is dat selfs ‘gratis’ mediese behandeling soms onbekostigbaar is as gevolg van versteekte kostes, soos vervoer. Aan die einde van my studie was dit my gevolgtrekking dat daar meer aandag geskenk moet word aan die oorsake wat aanleiding gee tot die verspreiding van die MIV/VIGS epidemie indien ons dit suksesvol wil bekamp, ook op die intreevlakke van die gesondheidstelsel.

La thèse a pour objectif d’étudier l’influence du financement des soins de santé sur la performance des systèmes de soins compte tenu des caractéristiques organisationnelles sanitaires des systèmes. Elle s’articule autour des trois objectifs suivants : 1) caractériser le financement des soins de santé à travers les différents modèles émergeant des pays à revenu élevé ; 2) apprécier la performance des systèmes de soins en établissant les divers profils apparaissant dans ces mêmes pays ; 3) examiner le lien entre le financement et la performance en tenant compte du pouvoir modérateur du contexte organisationnel des soins. Inspirée du processus de circulation de l’argent dans le système de soins, l’approche a d’abord consisté à classer les pays étudiés – par une analyse configurationnelle opérationnalisée par les analyses de correspondance multiples (ACM) et de classification hiérarchique ascendante (CHA) – dans des modèles types, chacun représentant une configuration particulière de processus de financement des soins de santé (article 1). Appliquée aux données recueillies auprès des 27 pays de l’OCDE à revenu élevé via les rapports Health Care in Transition des systèmes de santé des pays produits par le bureau Européen de l’OMS, la banque de données Eco-Santé OCDE 2007 et les statistiques de l’OMS 2008, les analyses ont révélé cinq modèles de financement. Ils se distinguent selon les fonctions de collecte de l’argent dans le système (prélèvement), de mise en commun de l’argent collecté (stockage), de la répartition de l’argent collecté et stocké (allocation) et du processus de paiement des professionnels et des établissements de santé (paiement). Les modèles ainsi développés, qui vont au-delà du processus unique de collecte de l’argent, donnent un portrait plus complet du processus de financement des soins de santé. Ils permettent ainsi une compréhension de la cohérence interne existant entre les fonctions du financement lors d’un éventuel changement de mode de financement dans un pays. Dans un deuxième temps, nous appuyant sur une conception multidimensionnelle de la performance des systèmes, nous avons classé les pays : premièrement, selon leur niveau en termes de ressources mobilisées, de services produits et de résultats de santé atteints (définissant la performance absolue) ; deuxièmement, selon les efforts qu’ils fournissent pour atteindre un niveau élevé de résultats de santé proportionnellement aux ressources mobilisées et aux services produits en termes d’efficience, d’efficacité et de productivité (définissant ainsi la performance relative) ; et troisièmement, selon les profils types de performance globale émergeant en tenant compte simultanément des niveaux de performance absolue et relative (article 2). Les analyses effectuées sur les données collectées auprès des mêmes 27 pays précédents ont dégagé quatre profils de performance qui se différencient selon leur niveau de performance multidimensionnelle et globale. Les résultats ainsi obtenus permettent d’effectuer une comparaison entre les niveaux globaux de performance des systèmes de soins. Pour terminer, afin de répondre à la question de savoir quel mode – ou quels modes – de financement générerait de meilleurs résultats de performance, et ce, dans quel contexte organisationnel de soins, une analyse plus fine des relations entre le financement et la performance (tous définis comme précédemment) compte tenu des caractéristiques organisationnelles sanitaires a été réalisée (article 3). Les résultats montrent qu’il n’existe presque aucune relation directe entre le financement et la performance. Toutefois, lorsque le financement interagit avec le contexte organisationnel sanitaire pour appréhender le niveau de performance des systèmes, des relations pertinentes et révélatrices apparaissent. Ainsi, certains modes de financement semblent plus attrayants que d’autres en termes de performance dans des contextes organisationnels sanitaires différents. Les résultats permettent ainsi à tous les acteurs du système de comprendre qu’il n’existe qu’une influence indirecte du financement de la santé sur la performance des systèmes de soins due à l’interaction du financement avec le contexte organisationnel sanitaire. L’une des originalités de cette thèse tient au fait que très peu de travaux ont tenté d’opérationnaliser de façon multidimensionnelle les concepts de financement et de performance avant d’analyser les associations susceptibles d’exister entre eux. En outre, alors que la pertinence de la prise en compte des caractéristiques du contexte organisationnel dans la mise en place des réformes des systèmes de soins est au coeur des préoccupations, ce travail est l’un des premiers à analyser l’influence de l’interaction entre le financement et le contexte organisationnel sanitaire sur la performance des systèmes de soins. / The aim of this thesis is to investigate the influence of health care financing on the performance of health care systems when organizational characteristics of health care system contexts are taken into consideration. It focuses on the following three objectives: 1) to characterize health care financing across the various models emerging in high-income countries; 2) to assess the performance of these health care systems by identifying the different profiles seen in these countries; and 3) to examine the relationship between health care financing and system performance, taking into account the moderating influence of the organizational context of health care. Inspired by the revenue flow process in health care systems, the approach adopted consisted in first classifying the countries studied – using configurational analysis operationalized through multiple components analysis (MCA) and ascending hierarchical classification (AHC) – into typical models, each representing a particular configuration of health care financing processes (article 1). Analysis of data collected on 27 high-income OECD countries from the Health Care in Transition reports produced by the WHO Regional Office for Europe, the 2007 Éco-Santé OCDE database and the 2008 WHO statistics revealed five financing models. These models differ among themselves in terms of the functions of collecting money (collection), pooling the collected funds (pooling), distributing the collected and pooled funds (allocation) and paying the professionals and health care establishments (payment). The models thus developed, which extend beyond the simple process of collecting money, provide a more complete picture of the health care financing process. As such, they enable a better understanding of the internal coherence that exists among the four health care financing functions that will impact any change in a country’s health care financing system. Next, based on a multidimensional conception of health care system performance, we classified the same 27 countries according to three parameters: (1) their levels of resources mobilized, health care services provided and health outcomes achieved (absolute performance); (2) the efforts they invested to achieve higher levels of health outcomes in proportion to resources mobilized and health care services provided, in terms of efficiency, efficacy and productivity (relative performance); and (3) the overall performance profiles that emerged when absolute performance and relative performance were combined (article 2). The analyses we carried out on the data collected for these 27 countries produced four profiles that were differentiated in their multidimensional and overall performance. The results thus obtained allow us to compare overall health care system performance among high-income countries. Finally, to answer the question of what financing modalities would generate the best performance, and in what types of health care organizational contexts, we carried out an in-depth analysis of the relations between health care financing and health care system performance (as defined above), taking into account the organizational characteristics of the health care contexts (article 3). The analysis revealed almost no direct relations between health care financing and health care performance. However, when we looked at interactions between financing and health care organizational contexts to capture the level of system performance, some relevant relations emerged. Thus, in terms of performance, some health care financing modalities would appear to be more appealing than others, depending on the organizational characteristics of the health care context. These results can help health care system stakeholders to understand that there is only an indirect relationship between financing and system performance, due to the interaction between health care financing and the organizational characteristics of health care contexts. One original aspect of this thesis lies in the fact that very few studies have attempted to operationalize the concepts of health care system financing and performance using multidimensional approaches before analyzing any relationships that might exist between them. Furthermore, despite the relevance of taking into account the organizational characteristics of health care contexts in health system reforms, this thesis is the one of the first to analyze the impact of the interaction between health care financing and organizational contexts on health care system performance.

Introduction: There are many factors to be identified and flows to be established in the interface between primary care and the emergency care network. Comparing different health systems with processes of health policies based on regionalization can result in new health planning instruments. In this sense, understanding the regional arrangements and dynamics of the Canadian health system in a comparative study with the Brazilian reality enabled the implementation of strategies for the development of innovations and health management planning in Brazil. Objective: To identify the factors that interfere in the establishment of primary care and emergency care network interfaces in different socio-spatial realities (regions) and in different health systems. Methods: Two case studies: in Brazil, using mixed methods and in Canada, qualitative methods. The study in the North-Barretos and South-Barretos regions (São Paulo, Brazil) consists of interviews with key informants and analysis of secondary data. In the Mississauga Halton Local Health Integration Network and Toronto Central Local Health Integration Network (LHIN) (Ontario, Canada) interviews were conducted with key informants. The data from the structured questionnaires were tabulated using the PHP Line Survey - Open Source software. Statistical calculations were performed using SPSS Statistics for Windows, Version 22.0. Thematic analysis of the qualitative data (interviews with open-ended questions, meeting minutes and documents) was carried out in Atlas-ti software. The results of the case studies were analyzed independently and, finally, compared to identify their differences and similarities. The study was approved by the Ethics Committee of the University of São Paulo Faculty of Medicine, under process number 045/16. Results: Aspects of policy, structure and organization interfere at different levels between primary care and the emergency care network in the regions selected for this study. Regionalization as a dimension of health policy has presented satisfactory results for planning, decision making, and resource management focused on health needs, but has been insufficient for the integration of primary care and the emergency care network. Barriers and facilitators, at policy, structural and organizational levels, were identified for the integration of primary care and the emergency services in the studied regions. Conclusion: Health managers should recognize the interfaces and integrate the different health services and share knowledge and population health diagnoses. Fragmented health management is reflected in fragmented health care. To achieve effective integration among health services, stakeholders and policy makers should prioritize better management performance, effective teamwork forums, leadership training, and monitoring programs for each dimension of integrated care / Introdução: Há muitos fatores a serem identificados e fluxos a serem estabelecidos nas interfaces entre a atenção primária e a rede de urgência e emergência. A comparação de diferentes sistemas de saúde com processos de políticas de saúde baseados na regionalização pode resultar em novos instrumentos de planejamento de saúde. Nesse sentido, compreender os arranjos e dinâmicas regionais do sistema de saúde canadense em um estudo comparativo com a realidade brasileira possibilitou a implementação de estratégias para o desenvolvimento de inovações e o planejamento da gestão em saúde no Brasil. Objetivo: Identificar os fatores que interferem no estabelecimento das interfaces da atenção primária e a rede de urgência e emergência em diferentes realidades socioespaciais (regiões) e nos diferentes sistemas de saúde. Métodos: Trata-se de dois estudos de caso: no Brasil, utilizando métodos mistos e no Canadá, métodos qualitativos. O estudo nas regiões Norte-Barretos e Sul-Barretos (São Paulo, Brasil) consiste em entrevistas com informantes-chave e análise de dados secundários. Na Mississauga Halton Local Health Integration Network e na Toronto Central Local Health Integration Network (LHIN) (Ontário, Canadá) foram realizadas entrevistas com informantes-chave. Os dados dos questionários estruturados foram tabulados usando o software PHP Line Survey - Open Source. Os cálculos estatísticos foram realizados no SPSS Statistics for Windows, versão 22.0. A análise temática dos dados qualitativos (entrevistas com questões abertas, atas de reuniões e documentos) foi realizada no software Atlas-ti. Os resultados dos estudos de caso foram analisados de forma independente e, finalmente, comparados para identificar suas diferenças e semelhanças. O estudo foi aprovado pelo Comitê de Ética em Pesquisa da Faculdade de Medicina da Universidade de São Paulo sob o número de processo 045/16. Resultados: Aspectos políticos, estruturais e organizacionais interferem em diferentes níveis entre a atenção primária e a rede de urgência e emergência nas regiões selecionadas para este estudo. A regionalização como dimensão da política de saúde tem apresentado resultados satisfatórios para o planejamento, a tomada de decisão e a gestão de recursos com foco nas necessidades de saúde, mas tem sido insuficiente para a integração da atenção primária e da rede de urgência e emergência. Barreiras e facilitadores, nos níveis político, estrutural e organizacional, foram identificados para a integração da atenção primária com os serviços de emergência nas regiões estudadas. Conclusão: Os gestores de saúde devem reconhecer as interfaces e integrar os diferentes serviços de saúde e compartilhar conhecimentos e diagnósticos de saúde da população. A gestão fragmentada da saúde reflete-se em cuidados de saúde fragmentados. Para alcançar uma integração eficaz entre os serviços de saúde, as partes interessadas e formuladores de políticas devem priorizar um melhor desempenho gerencial, fóruns eficazes de trabalho em equipe, treinamento de liderança e programas de monitoramento para cada dimensão do cuidado integrado

A formação e o provimento de profissionais de saúde são parte das estratégias que vêm sendo utilizadas pelos países para aumentar a capacidade de resposta dos seus sistemas de saúde e, assim, melhorar a qualidade de vida das suas populações. Recentemente, o governo brasileiro criou uma lei, instituindo um programa para melhorar a capacidade de resposta para escassez de médicos em áreas remotas, intitulado Programa Mais Médicos. Uma das ações polêmicas desse programa foi a importação de médicos cubanos, através de uma cooperação Cuba-Brasil, mediada pela Organização Pan-americana de Saúde (OPAS). Trata-se de uma iniciativa de grande vulto que envolveu, de 2011 a 2015, um total de 18 mil e 24 mil médicos novos no SUS. Nesse sentido, ganha relevância a análise do Programa Mais Médicos como política recém-implantada em contexto brasileiro, que constitui o objeto deste projeto de pesquisa. Este estudo de caso focaliza o provimento, fundamentalmente na cooperação Cuba-Brasil. Para analisar o programa, adota-se a abordagem do Ciclo de Políticas (Howlett e Ramesh, 2003) que organiza o estudo da política em cinco fases: (a) preparação da agenda, (b) formulação da política, (c) tomada de decisão, (d) implementação e (e) avaliação, adaptado pela análise de contexto de Bowe & Ball, 1992 que defende a análise de políticas a partir do seu campo de prática. Entrevistas com atores chaves, análise documental e estudo de caso foram desenvolvidos. Para o estudo de caso, focalizamos o PMM no Estado do Ceará e visitamos duas cidades no interior do Brasil neste mesmo estado. Os cenários de implementação do programa, as unidades com médicos cubanos e os espaços de supervisão foram os objetos de observação de campo da investigadora. O objetivo do estudo foi analisar os macro e micro efeitos da Cooperação Cuba- Brasil no trabalho médico brasileiro em APS, investigar seu potencial de inovação para o trabalho médico nas Américas e acompanhar todo o ciclo da política em questão, desde a sua entrada na agenda governamental até os mecanismos de avaliação, incluindo a identificação de desdobramentos para as políticas locais dos casos estudados. Ademais, construir novos saberes no campo da análise de políticas, inovações e provimento de profissionais de saúde no mundo. Na dimensão macropolítica, as entrevistas mostram a prática e a educação médica voltada para a atenção especializada, orientada pelo mercado, com um uso exagerado de tecnologias de alta densidade, comparados aos médicos cubanos. Os médicos cubanos trazem uma nova perspectiva para os profissionais de saúde na forma de construir vínculos com os usuários e na maneira de lidar com a pobreza e a iniquidade. Na dimensão micropolítica, ambos, brasileiros e cubanos, se beneficiam de estratégias de educação permanente, supervisão em loco, cursos EAD, rodas de conversa para discussão de problemas, grupos de troca de experiência e compartilhamento de estratégias no planejamento local. Um dos principais problemas apontados no programa é que a estratégia de provisão é temporária, não está bem afinada com a corporação médica brasileira e as supervisões não são bem organizadas pelas Universidades. Demonstra também a fragilidade na articulação entre gestão local e nacional na organização do processo / The education and provision of health professionals are the main strategies to increase capacity and respond to health systems needs among countries worldwide. Recently, the Brazilian government passed a law to create a national program, called the More Doctors Program, to improve the capacity to respond to the demand for doctors in underserved areas. The law was designed with three main axes: provision, education and infrastructure. The first, provision, would increase the provision of medical doctors through monetary and non-monetary incentives to attract national and foreign doctors to work in remote areas. The education axis was related to opening new Courses and Institutions to graduate new doctors in remote areas. The third axis was to improve primary care facilities. However, the most controversial aspect of this Program was the partnership between Cuba and Brazil, through an international cooperation mediated by the Pan-American Health Organization. It involved 18,240 new primary care physicians. Focusing on provision, mainly in the Brazil-Cuba international cooperation, a qualitative study was designed and conducted, analyzing the More Doctors policy cycle, using Howlet & Ramesh, 2003 as well as Ball, 1992 as a reference. This study examined the five stages of the policy cycle: agenda preparation, policy formulation, decision making, implementation and evaluation and context analysis and evaluation on the Ball cycle. Ball argues that policy has to be analyzed in the field. Interviews with stakeholders, document analysis and case studies were developed. As part of the case study, there were visits to three cities in the interior of Brazil; the researchers observed the locally managed education and program. The objective of the study was to investigate the macro and micro effects of Brazilian and Cuban physicians work processes in the Brazilian primary care units served by the program, as well as analyzing the policy as an innovation in health workforce management in the Americas and exploring the whole policy cycle and the implications for medical workforce management in Brazil. On the macro level, the interviews show that in Brazil medical education and practice are market oriented and focused on specialized care, with an overuse of high-technology resources, compared to Cuban doctors. All the Cuban physicians in Brazil were educated as General Practitioners. In addition, there could be an influence of the Cuban socialist model. The Cuban doctors bring a new perspective to Brazilian health professionals on how to build linkages with the users and how to deal with poverty and inequity. On the micro level, both groups benefited from ongoing learning strategies, supervisions in locus, distance learning courses, round tables on the main health problems, group practice sharing, and the interchange on health local planning. The main problems involve the temporary nature of the provision strategy, which is not well resolved with the Brazilian medical corporations and professional bodies. Furthermore, the supervisions are not always well organized by the Universities. The study also shows the fragilities of federative integration regarding policy implementation and management

A formação e o provimento de profissionais de saúde são parte das estratégias que vêm sendo utilizadas pelos países para aumentar a capacidade de resposta dos seus sistemas de saúde e, assim, melhorar a qualidade de vida das suas populações. Recentemente, o governo brasileiro criou uma lei, instituindo um programa para melhorar a capacidade de resposta para escassez de médicos em áreas remotas, intitulado Programa Mais Médicos. Uma das ações polêmicas desse programa foi a importação de médicos cubanos, através de uma cooperação Cuba-Brasil, mediada pela Organização Pan-americana de Saúde (OPAS). Trata-se de uma iniciativa de grande vulto que envolveu, de 2011 a 2015, um total de 18 mil e 24 mil médicos novos no SUS. Nesse sentido, ganha relevância a análise do Programa Mais Médicos como política recém-implantada em contexto brasileiro, que constitui o objeto deste projeto de pesquisa. Este estudo de caso focaliza o provimento, fundamentalmente na cooperação Cuba-Brasil. Para analisar o programa, adota-se a abordagem do Ciclo de Políticas (Howlett e Ramesh, 2003) que organiza o estudo da política em cinco fases: (a) preparação da agenda, (b) formulação da política, (c) tomada de decisão, (d) implementação e (e) avaliação, adaptado pela análise de contexto de Bowe & Ball, 1992 que defende a análise de políticas a partir do seu campo de prática. Entrevistas com atores chaves, análise documental e estudo de caso foram desenvolvidos. Para o estudo de caso, focalizamos o PMM no Estado do Ceará e visitamos duas cidades no interior do Brasil neste mesmo estado. Os cenários de implementação do programa, as unidades com médicos cubanos e os espaços de supervisão foram os objetos de observação de campo da investigadora. O objetivo do estudo foi analisar os macro e micro efeitos da Cooperação Cuba- Brasil no trabalho médico brasileiro em APS, investigar seu potencial de inovação para o trabalho médico nas Américas e acompanhar todo o ciclo da política em questão, desde a sua entrada na agenda governamental até os mecanismos de avaliação, incluindo a identificação de desdobramentos para as políticas locais dos casos estudados. Ademais, construir novos saberes no campo da análise de políticas, inovações e provimento de profissionais de saúde no mundo. Na dimensão macropolítica, as entrevistas mostram a prática e a educação médica voltada para a atenção especializada, orientada pelo mercado, com um uso exagerado de tecnologias de alta densidade, comparados aos médicos cubanos. Os médicos cubanos trazem uma nova perspectiva para os profissionais de saúde na forma de construir vínculos com os usuários e na maneira de lidar com a pobreza e a iniquidade. Na dimensão micropolítica, ambos, brasileiros e cubanos, se beneficiam de estratégias de educação permanente, supervisão em loco, cursos EAD, rodas de conversa para discussão de problemas, grupos de troca de experiência e compartilhamento de estratégias no planejamento local. Um dos principais problemas apontados no programa é que a estratégia de provisão é temporária, não está bem afinada com a corporação médica brasileira e as supervisões não são bem organizadas pelas Universidades. Demonstra também a fragilidade na articulação entre gestão local e nacional na organização do processo / The education and provision of health professionals are the main strategies to increase capacity and respond to health systems needs among countries worldwide. Recently, the Brazilian government passed a law to create a national program, called the More Doctors Program, to improve the capacity to respond to the demand for doctors in underserved areas. The law was designed with three main axes: provision, education and infrastructure. The first, provision, would increase the provision of medical doctors through monetary and non-monetary incentives to attract national and foreign doctors to work in remote areas. The education axis was related to opening new Courses and Institutions to graduate new doctors in remote areas. The third axis was to improve primary care facilities. However, the most controversial aspect of this Program was the partnership between Cuba and Brazil, through an international cooperation mediated by the Pan-American Health Organization. It involved 18,240 new primary care physicians. Focusing on provision, mainly in the Brazil-Cuba international cooperation, a qualitative study was designed and conducted, analyzing the More Doctors policy cycle, using Howlet & Ramesh, 2003 as well as Ball, 1992 as a reference. This study examined the five stages of the policy cycle: agenda preparation, policy formulation, decision making, implementation and evaluation and context analysis and evaluation on the Ball cycle. Ball argues that policy has to be analyzed in the field. Interviews with stakeholders, document analysis and case studies were developed. As part of the case study, there were visits to three cities in the interior of Brazil; the researchers observed the locally managed education and program. The objective of the study was to investigate the macro and micro effects of Brazilian and Cuban physicians work processes in the Brazilian primary care units served by the program, as well as analyzing the policy as an innovation in health workforce management in the Americas and exploring the whole policy cycle and the implications for medical workforce management in Brazil. On the macro level, the interviews show that in Brazil medical education and practice are market oriented and focused on specialized care, with an overuse of high-technology resources, compared to Cuban doctors. All the Cuban physicians in Brazil were educated as General Practitioners. In addition, there could be an influence of the Cuban socialist model. The Cuban doctors bring a new perspective to Brazilian health professionals on how to build linkages with the users and how to deal with poverty and inequity. On the micro level, both groups benefited from ongoing learning strategies, supervisions in locus, distance learning courses, round tables on the main health problems, group practice sharing, and the interchange on health local planning. The main problems involve the temporary nature of the provision strategy, which is not well resolved with the Brazilian medical corporations and professional bodies. Furthermore, the supervisions are not always well organized by the Universities. The study also shows the fragilities of federative integration regarding policy implementation and management

Dans la gestion des systèmes de soins, la maîtrise des flux hospitaliers et l’anticipation des tensions sont des enjeux majeurs. Le but de cette thèse est de contribuer à l’étude et au développement d’un Système Collaboratif d’Aide à l’Ordonnancement et à l’Orchestration (SysCAOO) des tâches de soins à compétences multiples pour gérer les tensions dans les Services d’Urgences Pédiatriques (SUP) afin d’améliorer la qualité de prise en charge des patients. Le SysCAOO intègre une approche Workflow collaboratif pour modéliser le parcours patient afin d’identifier les dysfonctionnements et les pics d’activités du personnel médical dans le SUP. L’aspect dynamique et incertain du problème nous a conduits à adopter une alliance entre les Systèmes Multi-Agent (SMA) et les Algorithmes Evolutionnaires (AE) pour le traitement et l’ordonnancement des tâches de soins en tenant compte du niveau d’expérience des acteurs du SUP et leurs disponibilités. En cas d’aléas dans le SUP, une coalition d’agents se forme pour collaborer et négocier afin de proposer des décisions d’orchestration du Workflow et minimiser le temps d’attente des patients en cours de leur prise en charge. Les résultats expérimentaux présentés dans cette thèse justifient l’intérêt de l’alliance entre les SMA et les Métaheuristiques afin de gérer les tensions dans le SUP. Les travaux de recherche présentés dans cette thèse s’intègrent dans le cadre du projet HOST (Hôpital : Optimisation, Simulation et évitement des tensions) (http://www.agence-nationale-recherche.fr/?Projet=ANR-11-TECS-0010). / Health care systems management and the avoidance of overcrowding phenomena are major issues. The aim of this thesis is to implement a Collaborative Support System for Scheduling and Orchestration (CSSystSO) of multi-skill health care tasks in order to avoid areas bottlenecks in the Pediatric Emergency Department (PED) and improve health care quality for patients. The CSSystSO integrates a collaborative Workflow approach to model patient journey in order to identify dysfunctions and peaks of activities of medical staff in the PED. The dynamic and uncertain aspect of the problem has led us to adopt an alliance between Multi-Agent Systems (MAS) and Evolutionary Algorithms (EA) for health care tasks treatment and scheduling taking into account the level of experience of the PED actors and their availabilities. In case of perturbations in the PED, a coalition of agents is formed to collaborate and negotiate in order to provide orchestration Workflow decisions to minimize the waiting time of patients during their treatment. The experimental results presented in this thesis justify the interest of the alliance between MAS and Metaheuristics to manage overcrowding phenomena in the PED. This work belongs to the project HOST (Hôpital: Optimisation, Simulation et évitement des tensions). (http://www.agence-nationale-recherche.fr/?Projet=ANR-11-TECS-0010).