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Resumo: A presente pesquisa consiste na análise do contexto ético expresso por políticas institucionais quanto às mortes tratadas como indigentes em território brasileiro. Buscou-se observar os números e recortes sociais nos dados referentes ao corpo daquele que usualmente é tratado como indesejável. A noção ética aqui se expressa não como um ideal de alcance, mas como constrói-se o juízo de valor moral a partir da noção de indigência, e de como esse elemento naturaliza o descarte daquele que é não propriedade, que pertence, mas não está incluído na sociedade. Abstract: This paper consists on the analysis of the ethical context expressed by institutional policies regarding the deaths treated as indigent in Brazilian territory. One sought to observe the numbers and social cuts in the data referring to the body of the one who is usually treated as undesirable. The ethical notion here is expressed not as an ideal, but how the moral value judgment is constructed from the notion of indigence, and how this element naturalizes the disposal of those who are not property, who belong, but are not included in society.

International audience; The indigents have long been excluded from health policies in sub-Saharan Africa. Despite recent efforts by some countries to allow them free access to health services, they face a multitude of non-financial barriers that prevent them from accessing care. Interventions to address the multiple patient-level barriers to care, such as patient navigation interventions, could help reverse this trend. However, our scoping review showed that no navigation interventions in low-income countries targeted the indigents. The objective of this qualitative study is, therefore, to go beyond the lack of evidence and discuss relevant approaches to act in favor of health care equity. We interviewed 22 public health experts with the objective of finding out which actions related to patient navigation programs (identified in the scoping review for other target groups) could be relevant and/or adapted for the indigents. For each ability to access care described by Levesque and colleagues, we were thus able to list the potential opportunities and challenges of implementing each type of action for the indigents in sub-Saharan Africa. Overall, the experts all felt that patient navigation programs were very relevant to implement for the indigents. They emphasized the need for personalized follow-up and for holistic actions to consider the whole context of the situation of indigence. The recommendations made by the experts are valuable in guiding political decision-making, while leaving room for adaptation of the proposed guidelines according to different contexts.

According to Black’s Law Dictionary, justice is the fair and proper administration of law. Similarly, access to justice is the ability to make use of the courts and other relevant institutions to efficiently protect and enforce rights. Access to justice is imperative in every society. People will access justice only if the proper situation creates. In a bid, to remove this major barrier in accessing justice, the Legal Aid Council of Nigeria was established in 1976. The concept of legal aid means the provision of free legal services to the indigent and underprivileged members of the society. Its importance and cannot be overemphasized particularly considering the level of illiteracy and poverty which are considered on the high side in Nigeria. Hence, in 2011, the Legal Aid Act 2011 was enacted. The birth of the Act repealed the old Act. This article analyses 3ethe provisions of both Acts with emphasis on the innovations of the new Act to promote access to justice and concludes with recommendations. Concerning the Council, it finds that there is a need for better funding and engagement of more salaried lawyers in order to enable it to carry out its functions as the Council is grappling with the challenge of underfunding and recruitment of more hands to work towards the achievement of its set objectives, among others.

Background: Current evidence suggests that mortality is considerably higher in individuals experiencing homelessness. The aim of this study was to analyze the mortality rate and the mortality risk factors in a sample of individuals experiencing homelessness in the city of Girona over a ten-year period. (2) Methods: We retrospectively examined the outcomes of 475 people experiencing homelessness with the available clinical and social data. Our sample was comprised of 84.4% men and 51.8% foreign-born people. Cox's proportional hazard models were used to identify mortality risk factors between origin groups. (3) Results: 60 people died during the ten-year period. The average age of death was 49.1 years. After adjusting for demographic characteristics and the duration of homelessness, the risk factors for mortality were origin (people born in Spain) (HR = 4.34; 95% CI = 1.89-10.0), type 2 diabetes (HR = 2.9; 95% CI = 1.62-5.30), alcohol use disorder (HR = 1.9; 95% CI = 1.12-3.29), and infectious diseases (HR = 1.6; 95% CI = 1.09-2.39). Our results show a high prevalence of infectious and chronic diseases. Type 2 diabetes emerges as an important risk factor in homelessness. The average age of death of individuals experiencing homelessness was significantly lower than the average age of death in the general population (which is greater than 80 years) (4). Conclusions: Foreign-born homeless people were generally younger and healthier than Spanish-born homeless people. Chronic diseases were controlled better in Spanish-born people, but this group showed an increased risk of mortality. DDEUIT

Une composante de l'intervention de financement basée sur la performance appliquée au Burkina Faso était de fournir un accès gratuit aux soins de santé par la distribution de cartes d'exemption des paiements directs à des personnes indigentes préalablement identifiées. La présente étude examine les facteurs qui ont conduit à l'obtention de cartes d'exemption par des indigent-e-s et l'effet de la possession de la carte sur l'utilisation des services de santé. Un ensemble de données de panel de 1 652 individus indigent-es sélectionné-e-s au hasard a été utilisé. Parmi les personnes indigentes interrogées en 2017, 75,51/100 ont reçu des cartes d'exemption. L'alphabétisation de base, vivre à moins de 5 km d'un centre de santé et résider à Diébougou ou Gourcy étaient positivement associés à la possession d'une carte. La possession d'une carte n'a pas augmenté l'utilisation des services de santé pour les indigent-e-s. Une meilleure conception et mise en oeuvre des interventions, accompagnées de stratégies complémentaires comme la mise en place de navigateurs patients et de navigatrices patientes, pourraient aider les personnes indigentes à surmonter tous les obstacles d'accès et d'utilisation des services de santé.

Contexte : La mauvaise qualité et la faible utilisation des services de santé contribuent aux taux élevés de morbidité et de mortalité dans plusieurs pays à faible et à moyen revenu. Face à cette situation, le gouvernement du Burkina Faso a testé une intervention novatrice qui combine le financement basé sur la performance (FBP) à des mesures d'équité en santé. Les formations sanitaires ont reçu des prix unitaires pour des services de santé fournis ainsi que des bonus conditionnels à la qualité des soins. Des comités communautaires ont sélectionné les indigents pour leur octroyer des exemptions de paiements des soins. Malgré le peu d’études sur le sujet, des acteurs en santé mondiale craignent que l’intervention puisse avoir des conséquences non intentionnelles importantes. Objectif : Cette thèse vise à accroître les connaissances scientifiques sur les conséquences non intentionnelles du FBP combiné à des mesures d'équité en santé dans un environnement à faible revenu. Méthodes : Nous avons développé un cadre conceptuel basé sur la théorie de la diffusion des innovations. Une étude de cas multiples a été réalisée avec neuf formations sanitaires au Burkina Faso. Cinq mois sur le terrain ont permis d’effectuer 104 entrevues semi-structurées, 266 séances d'observation et des conversations informelles avec un large éventail d'acteurs incluant les prestataires de soins, les patients et les vérificateurs. Les données qualitatives ont été codées avec QDA miner pour faciliter l’analyse thématique. Nous avons également utilisé des données quantitatives du système de gestion pour décrire l'évolution des services et trianguler les résultats. Résultats : La nature et la mise en œuvre de l'intervention ont interagi avec le système social et les caractéristiques de ses membres pour engendrer des conséquences non intentionnelles importantes, dont la plupart étaient indésirables. Les prestataires de soins ont démontré une fixation sur les mesures de rendement, ont falsifié les registres médicaux et ont enseigné de mauvaises pratiques aux stagiaires pour augmenter leurs subsides et bonus. Comme conséquence non intentionnelle désirable, certaines formations sanitaires ont limité la vente de médicaments sans prescriptions pour encourager les consultations. Les vérifications communautaires, durant lesquelles les patients sont retrouvés pour vérifier les services déclarés, ont entraîné la falsification des données de vérification, la perte de la confidentialité des patients et certaines craintes chez les patients, bien que certains étaient heureux de partager leurs opinions. Enfin, les prestataires de soins ont limité les services offerts gratuitement aux indigents, ce qui a déclenché des conflits. Discussion : Cette thèse contribue au développement des connaissances scientifiques sur la façon dont le FBP, combiné à des mesures d'équité, peut engendrer des conséquences non intentionnelles. Les résultats sont utiles pour affiner ce type d’intervention et éclairer une mise en œuvre efficace dans le secteur du financement de la santé. Plus largement, cette thèse démontre la faisabilité et la valeur ajoutée d'utiliser un cadre conceptuel pour étudier les conséquences non intentionnelles. Elle pourra guider les chercheurs à élargir leur angle d’analyse afin de rendre compte des conséquences intentionnelles et non intentionnelles des interventions complexes en santé., Background: Poor quality and low utilization of healthcare services contribute to high levels of morbidity and mortality in many low- and middle-income countries (LMICs). In response, the government of Burkina Faso tested an innovative intervention that combines performance-based financing (PBF) with health equity measures. Healthcare facilities received unit fees for targeted services and bonuses conditional upon the quality of care. To reduce inequities in access to care, community-based committees selected indigents, i.e., the poorest segment of the population, to offer them user fee exemptions. Facilities were also paid more for services delivered to indigents. Despite the potential of this type of intervention, many global health actors argue that it could lead to important unintended consequences that influence its overall impact. Yet, little attention has been given to studying the unintended consequences of this complex intervention. Objective: This thesis aims to increase the scientific knowledge on the unintended consequences of PBF combined with health equity measures in a low-income setting. Methods: We developed a conceptual framework based on the diffusion of innovations theory. Using a multiple case study design, we selected nine healthcare facilities in Burkina Faso. Over five months of fieldwork, we collected multiple sources of qualitative data including 104 semi-structured interviews, 266 recorded observation sessions, informal conversations and documentation. Participants included a wide range of stakeholders, such as providers, patients, and PBF verifiers. Data were coded using QDA miner to conduct a thematic analysis. We also used secondary data from the PBF routine management system to describe the evolution of services and triangulate results. Results: Interactions between the nature and implementation of the intervention, the nature of the social system, and its members’ characteristics led to important unintended consequences, most of which were undesirable. Providers were fixated on performance measures rather than on underlying objectives, falsified medical registers, and taught trainees improper practices to increase subsidies and bonuses. As a desirable unintended consequence, we found that some facilities limited the sale of non-prescribed medication to encourage patients to consult. Community verifications, in which patients are traced to verify the authenticity of reported services and patient satisfaction, also led to unintended consequences, such as the falsification of verification data, the loss of patient confidentiality, and fears among patients, although some were pleased to share their views. Lastly, health equity measures also triggered changes that were not intended by program planners. For example, providers limited the free services and medication delivered to indigents, which led to conflicts between parties. Discussion: This thesis contributes to the development of scientific knowledge on how PBF interventions, combined with equity measures, can trigger unintended consequences in a low-income setting. The results are useful to inform effective implementation and refine interventions, particularly in the health financing sector. More broadly, this thesis demonstrates the feasibility and added value of using a conceptual framework to study the unintended consequences of complex health interventions. This thesis can inspire and guide future researchers to broaden their analytical horizons to capture both intended and unintended consequences of health interventions.

In this study it was analysed the perception of different professionals working with persons experiencing homeless, specifically about the situation of homelessness institutions during the first weeks of the state of alarm as a consequence of the COVID-19 pandemic. The method employed was a qualitative analysis of thematic content. An ad hoc online questionary was designed including open questions about the perception of professionals about the management of the COVID-19 crisis in the services addressed to homeless people. A sample of 202 participants of almost all the autonomic communities of Spain was recruited (professionals of social education, social work, social integration and psychology). Main conclusions indicated that homelessness services had a lot of difficulties to adapt their circumstances to the confinement requirements. These circumstances influenced in the mental health of the professionals specially. Persons experiencing homelessness with mental health or addictions problems were persons that suffered more difficulties (highlighting situations of sheltering in temporary macro institutions as pavilions). Residential resources that limited the access of people and confine them, had less difficulties to manage the situation. A recapitulation of recommendations of the participants was included at the end of the paper just in case future epidemic situations could influence in these population En el presente estudio se analiza la percepción de distintos profesionales especialistas en el fenómeno del sinhogarismo, sobre la situación en las instituciones especializadas, durante las primeras semanas del estado de alarma consecuencia de la pandemia del COVID-19. El método empleado fue el análisis cualitativo de contenido temático. Se creó un cuestionario en línea ad hoc, con preguntas abiertas sobre la percepción de la gestión de la crisis del COVID-19 en los dispositivos dirigidos a personas en situación de sin-hogar. Se reclutó una muestra de 202 participantes, profesionales de la educación social, el trabajo social, la integración social y la psicología, de prácticamente todas las comunidades autónomas del estado español. Las principales conclusiones indican que los servicios tuvieron muchas dificultades para adaptarse a la situación de confinamiento, las cuales repercutieron especialmente en la salud mental de los y las profesionales. Las personas sin-hogar con problemas de salud mental y/o adicciones, especialmente aquellas que fueron confinadas en macroinstalaciones temporales, fueron las que sufrieron más dificultades. Los recursos residenciales de tamaño reducido, que limitaron su acceso y se confinaron, tuvieron más facilidad para gestionar la situación. El manuscrito finaliza con una recopilación de recomendaciones de las personas participantes, a tener en cuenta en caso de futuros rebrotes o epidemias que influyan en esta población

Treball de Fi de Grau en Ciències Polítiques i de l'Administració. Curs 2019-2020 Tutor: Jordi Pascual Saüc El present treball posa de manifest la invisibilitat que pateixen les dones en situació de sense llar amb l’objectiu de mostrar que el sensellarisme femení i el sensellarisme masculí són fenòmens diferents, amb diferents característiques i per tant s’han d’abordar de manera diferent. A partir d’entrevistes i una recerca bibliogràfica s’ha arribat a la conclusió que, efectivament, hi ha diferencia entre aquests fenòmens i s’ha intentat entendre la invisibilitat que pateixen les dones en aquesta situació davant la dominació masculina tenint en compte que una persona sense llar no és només aquella que dorm al carrer, sinó que, basant-nos en la categoria ETHOS (European Typology of Homelessness and Housing Exclusion), hi ha moltes més persones que formen aquest col·lectiu. Hem de destacar que una part important d’aquest grup està format principalment per dones que viuen sota un sostre però en una situació d’exclusió i sense una llar estable i segura. En ser un fenomen que no sempre és manifesta als carrers, sinó molts cops de portes endins, hi ha dificultat a l’hora d’aconseguir dades i poder fer estudis. Aquest treball posa en relleu la necessitat de fer més investigacions sobre el tema i expressa la importància que té aquest fenomen per poder abordar l’exclusió residencial. The present work presents the invisibility that suffer the women in a homeless situation with the aim to show that female homelessness and male homelessness are different phenomenons, with distinct characteristics and, therefore, have to be approached in diferent ways. From interviews and bibliographic enquiry I have reached the conclusion that there is, indeed, a difference between these phenomenons; I have noticed the invisibility that the women in this situation suffer in front of the masculine dominance, taking into account that a homeless person is not only the one that sleeps in the street, but that, according to the cathegory ETHOS (European Typology of Homelessness and Housing Exclusion), there are a lot more persons that form this community. We must highlight that a part of this community consists predominately of women that live under a ceiling but in a situation of exclusion and without a stable and safe home. As it is a phenomenon that is not always self-evident in the streets, since most of the cases are found indoors, it is difficult to gather data and make surveys. This work emphasizes the necessity to make more inquests on the issue and stresses the importance that this phenomenon has in order to be able to understand the topic of home exclusion.