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Background: Ethical medical practice requires managing health services to promote professionalism and secure accessibility to care. Commercially financed and industrially managed services strain the physicians’ clinical autonomy and ethics because the industry’s profitability depends on commercial, clinical standardisation. Private insurance companies also reduce access to care whilst fragmenting and segmenting health systems. Against this background, given the powerful, symbolic significance of their common voice, physicians’ and patients’ organisations could effectively leverage together political parties and employers’ organisations to promote policies favouring access to professional care. Main text: To provide a foundation for negotiations between physicians’ and patients’ organisations, we propose policy principles derived from an analysis of rights-holders and duty-bearers’ stakes, i.e. patients, physicians and health professionals, and taxpayers. Their concerns are scrutinised from the standpoints of public health and right to health. Illustrated with post-WWII European policies, these principles are formulated as inputs for tentative action-research. The paper also identifies potential stumbling blocks for collective doctor/patient negotiations based on the authors’ personal experience. The patients’ concerns are care accessibility, quality, and price. Those of physicians and other professionals are problem-solving capacity, autonomy, intellectual progress, ethics, work environment, and revenue. The majority of taxpayers have an interest in taxes being progressive and public spending on health regressive. Mutual aid associations tend to under-estimate the physician’s role in delivering care. Physicians’ organisations often disregard the mission of financing care and its impact on healthcare quality. Conclusion: The proposed physicians-patients’ alliance could promote policies in tune with professional ethics, prevent European policies’ putting industrial co, SCOPUS: no.j, info:eu-repo/semantics/published

Background: Since some form of dual clinical/public health practice is desirable, this paper explains why their ethics should be combined to influence medical practice and explores a way to achieve that. Main text: In our attempt to merge clinical and public health ethics, we empirically compared the individual and collective health consequences of two illustrative lists of medical and public health ethical tenets and discussed their reciprocal relevance to praxis. The studied codes share four principles, namely, 1. respect for individual/collective rights and the patient’s autonomy; 2. cultural respect and treatment that upholds the patient’s dignity; 3. honestly informed consent; and 4. confidentiality of information. However, they also shed light on the strengths and deficiencies of each other’s tenets. Designing a combined clinical and public health code requiresfleshing out three similar principles, namely, beneficence, medical and public health engagement in favour of health equality, and community and individual participation; andadopting three stand-alone principles, namely, professional excellence, non-maleficence, and scientific excellence. Finally, we suggest that eco-biopsychosocial and patient-centred care delivery and dual clinical/public health practice should become a doctor’s moral obligation. We propose to call ethics based on non-maleficence, beneficence, autonomy, and justice – the values upon which, according to Pellegrino and Thomasma, the others are grounded and that physicians and ethicists use to resolve ethical dilemmas – “neo-Hippocratic”. The neo- prefix is justified by the adjunct of a distributive dimension (justice) to traditional Hippocratic ethics. Conclusion: Ethical codes ought to be constantly updated. The above values do not escape the rule. We have formulated them to feed discussions in health services and medical associations. Not only are these values fragmentary and in progress, but they have no universal ambition: they are a, SCOPUS: no.j, info:eu-repo/semantics/published

Background: Revisiting professionalism, both as a medical ideal and educational topic, this paper asks whether, in the rise of artificial intelligence, healthcare commoditisation and environmental challenges, a rationale exists for merging clinical and public health practices. To optimize doctors’ impact on community health, clinicians should introduce public health thinking and action into clinical practice, above and beyond controlling nosocomial infections and iatrogenesis. However, in the interest of effectiveness they should do everything possible to personalise care delivery. To solve this paradox, we explore why it is necessary for the boundaries between medicine and public health to be blurred. Main body: Proceeding sequentially, we derive standards for medical professionalism from care quality criteria, neo-Hippocratic ethics, public health concepts, and policy outcomes. Thereby, we formulate benchmarks for health care management and apply them to policy evaluation. During this process we justify the social, professional - and by implication, non-commercial, non-industrial - mission of healthcare financing and policies. The complexity of ethical, person-centred, biopsychosocial practice requires a human interface between suffering, health risks and their therapeutic solution – and thus legitimises the medical profession’s existence. Consequently, the universal human right to healthcare is a right to access professionally delivered care. Its enforcement requires significant updating of the existing medical culture, and not just in respect of the man/machine interface. This will allow physicians to focus on what artificial intelligence cannot do, or not do well. These duties should become the touchstone of their practice, knowledge and ethics. Artificial intelligence must support medical professionalism, not determine it. Because physicians need sufficient autonomy to exercise professional judgement, medical ethics will conflict with attempts to introduce cli, SCOPUS: no.j, info:eu-repo/semantics/published

Background: Strong relations between medicine and public health have long been advocated. Today, professional medical practice assumes joint clinical/public health objectives:GPs are expected to practice community medicine;Hospital specialists can be involved in disease control and health service organisation;Doctors can teach, coach, evaluate, and coordinate care;Clinicians should interpret protocols with reference to clinical epidemiology.Public health physicians should tailor preventive medicine to individual health risks. This paper is targeted at those practitioners and academics responsible for their teams’ professionalism and the accessibility of care, where the authors argue in favour of the epistemological integration of clinical medicine and public health. Main text: Based on empirical evidence the authors revisit the epistemological border of clinical and public health knowledge to support joint practice. From action-research and cognitive psychology, we derive clinical/public health knowledge categories that require different transmission and discovery techniques. The knowledge needed to support the universal human right to access professional care bridges both clinical and public health concepts, and summons professional ethics to validate medical decisions. To provide a rational framework for teaching and research, we propose the following categories:‘Know-how/practice techniques’, corresponding a.o. to behavioural, communication, and manual skills;‘Procedural knowledge’ to choose and apply procedures that meet explicit quality criteria;‘Practical knowledge’ to design new procedures and inform the design of established procedures in new contexts; andTheoretical knowledge teaches the reasoning and theory of knowledge and the laws of existence and functioning of reality to validate clinical and public health procedures. Even though medical interventions benefit from science, they are, in essence, professional: science cannot standardise eco-biopsychosoci, SCOPUS: no.j, info:eu-repo/semantics/published

SCOPUS: ed.j, info:eu-repo/semantics/published

In an attempt to produce recommendations, this thesis aimed to study the impact of international (WB and USAID) aid to Bolivia on health system fragmentation and segmentation, on sustainability of promoted reforms and the reasons for these. We thus explored whether the objectives (e.g. disease control and MCH) and activities of these agencies contributed to mending pre-existing fractures in the (individual) health (care) system, or instead strained access to care and contributed unwittingly to the worsening of avoidable mortality and suffering. The methodology relied on 1. An historiographical insight into system development, assessing structure and performance across time and examining whether observed changes were linked to the cooperation’s stated / ‘undeclared’ (non-health) objectives, activities and undesired effects. 2. A comparison of USAID / WB projects, exploring their (in-) consistency and complementarity in order to delineate a possible joint strategy 3. The study of their socio-political strategy to promote health system reform (HSR) while comparing the attempts of Bolivian and Ecuadoran socialist governments to reverse it. The WB / USAID comparison revealed that the aid-promoted HSR reshuffled the Bolivian health system, although with disappointing effects on their own health objectives. Besides, aid deepened the pre-existing system fragmentation and segmentation, thereby maintaining access to care at quite a low level. Costs to high-income countries taxpayers increased significantly but were limited to less than 10 years. The Bolivia / Ecuador comparison revealed an obstacle to socially motivated health policies in Andean countries: a powerful social and political alliance (of physicians and middle classes). This was built by the studied aid agencies (amidst political instability) to support care delivery and financing commoditization and to consequently open health markets to international economic actors. This aid rationale is visible in the similari, Con ánimo de emitir recomendaciones, esta tesis estudia en Bolivia el impacto de la cooperación internacional (Banco Mundial y la USAID, la agencias más importantes) sobre la fragmentación y segmentación del sistema de salud, así como la sostenibilidad de las reformas promovidas y sus razones. Se examina si los objetivos (Control de Enfermedades y Salud Materno-Infantil) y las actividades de estos organismos habrían atenuado las fracturas pre-existentes del sistema de salud o, por el contario, redujeron el acceso a la atención en salud e inconscientemente empeoraron la mortalidad y morbilidad evitables. La metodología se basa en: 1. Un estudio historiográfico de la evolución del sistema de salud, incluyendo • la evolución de su estructura y su rendimiento en el tiempo, y • la relación entre estos cambios y los objetivos declarados, los "implícitos" (no relacionados a la salud) y las actividades del Banco Mundial y USAID. 2. Una comparación de los proyectos del BM y de USAID buscando identificar su (di)convergencia y complementariedad - para revelar una posible estrategia conjunta. 3. Un estudio de las estrategias socio-políticas de promoción de la reforma sectorial de salud (RSS) mediante comparación de los intentos de los gobiernos socialistas boliviano y ecuatoriano de revertir la reforma. La comparación BM / USAID demostró que la RSS promovida cambió profúndame el sistema de salud, aunque con resultados desalentadores en cuanto a sus propios objetivos del estado de salud. Especialmente, profundizando la segmentación y fragmentación del sistema, la RSS contribuyó al estancamiento del acceso a una atención médica de calidad en un nivel inaceptable. La comparación Bolivia / Ecuador revela que una coalición político-social entre los médicos y las clases medias y altas es un escollo mayor para las políticas de salud con fines sociales en la región andina. Por iniciativa de las agencias de cooperación, en un clima político muy inestable, esta coalición fue formada para, (MED 3) -- UCL, 2012

The present article proposes an analysis of the USA-Bolivia relationships in the health sector between 1971 and 2010 based on a grey and scientific literature review and on interviews. We examined United States Agency for International Development (USAID) interventions, objectives, consistency with Bolivian needs, and impact on health system integration. USAID operational objectives-decentralization, fertility and disease control, and maternal and child health-may have worked against each other while competing for limited Ministry of Health resources. They largely contributed to the segmentation and fragmentation of the Bolivian health system. US cooperation in health did not significantly improve health status while the USAID failed to properly tackle anti-drugs, political, and economic US interests in Bolivia. Copyright © 2012 John Wiley & Sons, Ltd.

This article analyses the influence of the World Bank on reforms of the health sector in Bolivia during the period 1986–2006, and assesses their impact on the health care delivery system to date. The article examines the transformation of health services undertaken by the current socialist government since 2006. A literature review and interviews with decision-makers critically examine the outcome of reforms on criteria linked to health system integration. The study illustrates that Bolivia applied quite comprehensively the WB recommendations. Among others these included indirect privatization through public health services’ restriction of access to a basic package of care and decentralization with devolution. In consequence, the segmentation and fragmentation of the health system was exacerbated, accessibility and quality of care suffered and health status barely improved. The article attempts to locate the relationship between policy, health care delivery and health systems functioning.

In 1987, district health care policies were officially adopted by a majority of developing countries. Many operational problems constraining implementation of such policies have subsequently been identified, most of which are attributable to well-known characteristics of less developed countries. However, the policy of operational and administrative decentralization has often been critically obstructed by inappropriate organizational structures in ministries of health. By applying Mintzberg's analytical framework to several ministries of health, we identify structural deficiencies that make systems unfit to match their policy environment and yield the expected outcomes of functional and decentralized services. We propose a typology likely to elicit strategies for decentralizing health care administration. Our analysis is based on the following steps: a description of Mintzberg's concepts of organizational structure, generic components (strategic apex, technostructure, supporting structure, middle line, operational core) and functions (horizontal and vertical integration, liaison devices, vertical and horizontal decentralization) applied to health systems; a discussion of divisionalized adhocracy as a suitable configuration for health organizations with a need for a high degree of regional autonomy, community participation, medical staff initiative, action research and operational research, and continuous evaluation; a discussion of the organizational features of a number of health ministry systems and a consideration of strategies for transforming configurations towards divisionalized adhocracy.

In 1987, district health care policies were officially adopted by a majority of developing countries. Many operational problems constraining implementation of such policies have subsequently been identified, most of which are attributable to well-known characteristics of less developed countries. However, the policy of operational and administrative decentralization has often been critically obstructed by inappropriate organizational structures in ministries of health. By applying Mintzberg's analytical framework to several ministries of health,we identify structural deficiencies that make systems unfit to match their policy environment and yield the expected outcomes of functional and decentralized services. We propose a typology likely to elicit strategies for decentralizing health care administration. Our analysis is based on the following steps: - a description of Mintzberg's concepts of organizational structure, generic components (strategic apex, technostructure, supporting structure, middle line, operational core) and functions (horizontal and vertical integration, liaison devices, vertical and horizontal decentralization) applied to health systems; - a discussion of divisionalized adhocracy as a suitable configuration for health organizations with a need for a high degree of regional autonomy, community participation, medical staff initiative, action research and operational research, and continuous evaluation; - a discussion of the organizational features of a number of health ministry systems and a consideration of strategies for transforming configurations towards divisionalized adhocracy., SCOPUS: re.j, info:eu-repo/semantics/published

In 1987, district health care policies were officially adopted by a majority of developing countries. Many operational problems constraining implementation of such policies have subsequently been identified, most of which are attributable to well-known characteristics of less developed countries. However, the policy of operational and administrative decentralization has often been critically obstructed by inappropriate organizational structures in ministries of health. By applying Mintzberg's analytical framework to several ministries of health,we identify structural deficiencies that make systems unfit to match their policy environment and yield the expected outcomes of functional and decentralized services. We propose a typology likely to elicit strategies for decentralizing health care administration. Our analysis is based on the following steps: - a description of Mintzberg's concepts of organizational structure, generic components (strategic apex, technostructure, supporting structure, middle line, operational core) and functions (horizontal and vertical integration, liaison devices, vertical and horizontal decentralization) applied to health systems; - a discussion of divisionalized adhocracy as a suitable configuration for health organizations with a need for a high degree of regional autonomy, community participation, medical staff initiative, action research and operational research, and continuous evaluation; - a discussion of the organizational features of a number of health ministry systems and a consideration of strategies for transforming configurations towards divisionalized adhocracy., SCOPUS: re.j, info:eu-repo/semantics/published

Doctorat en sciences médicales, info:eu-repo/semantics/nonPublished

Doctorat en sciences médicales, info:eu-repo/semantics/nonPublished