Print version ISSN 0102-311X
Cad. Saúde Pública vol.15 n.2 Rio de Janeiro Apr. 1999
Debate sobre o artigo de Zulmira M. A. Hartz
Debate on the paper by Zulmira M. A. Hartz
|Secretary for Health Policy, Brazilian Ministry of Health, Brasília, Brazil.|| |
First of all, an analysis of the title and subsequent reading of the article allows one to have a contextual understanding of the French experience with evaluation as compared to practices used in other countries. The article focuses on the evaluation process that began in 1970 with the perinatal care sector in France in 1970 and with the country's state policies as a whole in 1993, through the "Office Parlementaire d'Évaluation des Choix Scientifiques et Technologiques".
Cuisine internationale is a culinary process, just as sur mesure is a sophisticated clothing design process, much more sophisticated than prêt-à-porter or ready-made. In the latter, as in fast food, what counts is the product. The author thus begins with a distinction between the French model, centering on the process and discussion (allowing it to employ a specific model for each program or policy) and that of other countries (especially Anglo-Saxon ones) who conduct their evaluations in a more standardized and less specific way.
A sentence that sums up this idea is by a French author (Bion, 1994): "Evaluation necessarily brings out contradiction, entailing multiple points of view and adding a tribunicienne function."
The article makes for particularly interesting reading at this moment in Brazil's history, when the country has just institutionalized its evaluation process, in 1998, by founding the Department of Health Policy Evaluation under the Health Policy Secretariat of the Ministry of Health. This brings up the first practical challenge, in keeping with one of the authors quoted in the article: "on ne peut pas être juge partie". If an evaluation is not governmental (i.e., conducted by a Department), how could it be a state evaluation? And this is always desirable and necessary.
The author herself says that evaluation cannot do without auditing (of effectiveness), and if it is not governmental, how does one combine the two?
In another part of the article, evaluation emerges as a mediator between knowledge (information) and decision-making. Is this not the old IPDA circuit (information, planning, decision-making, action) in a new guise (since evaluation can only be valued as a component of planning)?
The French experience in the health sector connotes an emphasis on health care policy and program evaluation, focusing on hospital care (including out-patient care), the physician's role, and the technology employed.
It appears that the practice of evaluation gained impulse when it increased participation by local actors through the creation of regional evaluation committees for physician and hospital care. Expanding on this view, what is Hartz' opinion concerning a sphere for health policy and program evaluation in Brazil's Municipal Health Councils, based on minimum standards for the country as a whole?
In addition, under the National and State Health Councils, wouldn't it be possible to incorporate technical chambers not only to perform evaluation of health policies and national and State health programs, but also to outline methodologies and evaluation techniques of a less episodic and more permanent nature?
In the Policy Secretariat there are technical and scientific committees in charge of advising the Ministry's technical boards in drafting and conducting its specific programs and policies. How does Hartz view the use of this sphere to back specific evaluation of given issues?
I believe that her study could be extended to compare ideas as to the applicability of the French experience in Brazil. To begin with, it would be interesting to learn about the methods and indicators for results as used in France to determine whether they are similar to those in Brazil.
Thus, several issues might be discussed, including the following:
Which of the operational concepts of process used in France might be useful for the Brazilian process?
Could (and should) some of the phases described in the French process be reproduced in Brazil?
Is it possible to evaluate the result of a set of public policies, or is it more advisable to proceed to sectorial evaluations? In the latter case, how could they be reconciled and consolidated?
With regard to the evaluation process currently under way in the world, the issue is not what purpose it serves (which can be answered easily), but whose purpose it serves. That of governments, governors, the population, social sectors, evaluators themselves and their associations?
Based on the article, evaluation processes emerge at times of economic difficulty or transitions from one model to another (which is the same thing, since new models are meant to replace old ones which no longer meet the people's demands or those of government programs with the same resources). Is this the appropriate moment to institutionalize evaluation, or is it merely a moment of which to take advantage?
With regard to the resources needed to institutionalize evaluation, what is the best alternative? The American, which devotes 1% of the programs' funds for evaluation, or the Canadian, which sets a percentage to invest in the process?