Print version ISSN 0102-311X
Cad. Saúde Pública vol.15 n.2 Rio de Janeiro Apr. 1999
H. Maria Dutilh Novaes
Debate sobre o artigo de Zulmira M. A. Hartz
Debate on the paper by Zulmira M. A. Hartz
|Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil.|| |
The article by Zulmira Hartz describes the initiatives, at least as proposals, characterizing the implementation of an overall public policy and a specific public policy for the health sector for evaluation of policies and programs (where "policies" and "programs" can also be seen as programs and technologies, but do not include policies in the sense of "politics") in France beginning in the 1980s. In order to develop some comparisons and establish analytical categories for evaluation policies the author describes specific aspects of policy implementation in countries like the United States, Canada, and Australia.
The overall justification for developing her research as presented in the paper is based on the premise that knowledge of the reality of others fosters a better understanding of our own, and more specifically that a country's public policies and programs can be improved (i.e., be made more appropriate to their objectives, more effective, more democratic, etc.) using other countries' experiences. In other words, not only is there not a historical determinism or "inexorability" (at least not an absolute one); rather, rationalized collective actions are possible, and they are strengthened to a certain extent when based on knowledge accepted as true.
These premises are obviously a reference for a major portion of research activity, particularly in the field of Collective Health, but it is worthwhile to highlight them here, since they are essential for providing legitimacy for program and technological evaluations, whether they aspire to scientific research status or not. For the latter, as well elaborated by Hartz, always aim to promote the link between thought and action, or opinion/intention/will and action, knowledge and technique.
As the paper's data and discussion show, the difficulty lies particularly in program evaluation, always very broad in its scope and sufficiently complex to encompass and adequately identify the complex network between knowledge, values, social, political, and economic factors, and technological and technical alternatives, where explicit discourses or formulated rationales are an inherent part of the network's construction (and not external to it).
For the French "case", one can conclude that beginning in the 1980s, services were created and laws and administrative rulings were drafted (both general and specific for the health field) with a view towards implementing a public policy for policy and program evaluation, and attempting to preserve the "French way of being and doing" while in keeping with proposals from other Western developed countries (both in the justification and form). In other words, actions were taken that appear to have been based on the following premises: the need for better justification of expenditures in the face of economic difficulties; the search for greater effectiveness, equity, and public satisfaction through public programs; and the availability of technical, managerial, and administrative resources to achieve these objectives.
Still, what are proper justifications for resources expended, and which effectiveness, equity, and satisfaction are desired, and by whom? The answers are not clear. The purpose of the article is not to answer these question, but they inevitably crop up. One is left with the impression that at least for those in charge of policies and programs, who must have had sufficiently broad political and social support to make them feasible, the proposed actions seek to change only enough so as to guarantee that nothing really fundamental actually changes, that is, they could be one more episode of "plus ça change plus c'est la même chose". In the case of France, when we analyze the country's epidemiological and quality-of-life indicators, could it really be that new policies and programs are desired and needed? Are what are now considered old, costly, individualist, elitist, and ineffective health policies and techniques responsible for the French economic crisis (as measured by its high unemployment rate)?
The French health system, according to a survey from the early 1990s quoted in the paper (Novaes, 1992), had already been identified as quite different from what the Brazilian Health Reform movement considered adequate for a good health system, yet it appeared to please the vast majority of the French population, which displayed excellent health conditions as measured by the usual indicators and in comparison to other developed countries. A paradox? I think not. The discussion raised here underscores the need for an all-encompassing analysis of health policies and programs, which should be seen as socially and technically constructed alternatives for specific contexts, and not as universal models or a one-and-only pathway to happiness.
NOVAES, H. M. D., 1992. Processus de Développement Scientifique et Technologique: Technologies Médicales en France, 1970-1990. Relatório de pós-doutorado ao CNPq. Brasília: CNPq. (mimeo.)