Author: Prof. Ernesto Pablo Báscolo
Institution: Instituto de la Salud Juan Lazarte
Address: Riobamba 1083, 2000 Rosario, Argentina
E-mail: [email protected]
12th EADI General Conference Global Governance for
Sustainable Development
The Need for Policy Coherence and New Partnerships
Analitical Gobernance on Latin America Health Care Systems
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Abstract
Current policy initiatives in Latin America, aimed at reforming health systems coverage and access, usually focus on the technical components and results, neglecting the importance of the governance patterns that affect the policies' implementation processes. The goal of this study is to contribute to a more comprehensive understanding of health policies' implementation processes at the municipal level in Latin America, with a focus on the linkages between Social Protection in Health policies, Primary Health Care strategies and the access to health care services. Its main objective is to develop and test a methodology aimed at analyzing and assessing the influence of governance patterns on specific health policy implementation processes. This methodology implies the development and field-testing of a new health systems research analytical framework developed by an international research network. It has a focus on the dynamics of relations between stakeholders (social interfaces), the development and implementation of social norms and the institutionalisation process. Its added value lies in its pragmatic ( if focuses on utility and practicality) and realistic (non-normative) features.
The application of the analytical perspective of the governance on these policies will be aimed at answering two central questions:
1) ¿How does the governance of the processes of making and implementing SPH policies affect the results of such policies in terms of accessibility conditions of health services in each case study? The research study includes the use of analytical methods to assess governance patterns and health access in four municipal case studies (two in Argentina and two in Bolivia). In each case study, the relationship between (a) the governance of the processes of implementing policies being studied, considering the policy design and the implementation context, and (b) the results of such policies in terms of their performance (accessibility conditions). This question will have different results in the four cases analyzed. Those answers will be derived from the analysis of context implications, the stakeholder interactions, and the processes of formulation of rules on the conditions of accessibility to health services.
2) From a comparative analysis between cases, is it possible to identify the common characteristics of the governance conditions that act as determiners (positive or negative) of the accessibility to the health services? The question will be answered by a comparative analysis between the four case studies. The goal is to identify "critical" features (common and specific) of the governance based on its weight as a determiner of the effectiveness of the health policies oriented towards the improvement of the conditions of accessibility to health services in the different scenarios being studied in Latin America. This question originates from the need to identify the governance factors which are particular in the Latin American context and which condition the effectiveness of the health policies. This will render answers appropriate to the local context.
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Title: Analitical Gobernance on Latin America Health Care Systems
Date : 30/03/08
Introduction
This work refers to a research protocol which is been developed since 2007 by a research team from the Juan Lazarte Health Institute Department of Health Economic and Management (Rosario, Argentine). The study is supported by the International Development Research Centre (Canada).
In this paper, it is presented a summary methodology propose with the following structure. First, there is a background, with the references of the extension policies of social protection in health. Second, it is developed the Research questions and objectives of the study. The last one part is the methodology design, with the application of the analytical perspective of governance to the extension policies of social protection in health in Latin America.
Background
Extension policies of social protection in health
Different approaches to health reform in Latina America and the Caribbean have been reflected in the literature during the last two decades (Viavaca et al., 2004; Restrepo Zea, 2004). The concept of the “extension of social protection in health” (SPH) has been developed in most countries of the region as new framework making reference to diverse insurance schemes. A set of very different approaches and strategies to social protection in health has been implemented in the recent years in the region. (OPS/OMS, 2002; GTZ, 2004; OIT, 2002, Holzmann & Jørgensen, 2000; Tabor, 2005, Londoño & Frenk, 1997; Frenk, circa 2005, Rosenberg & Andersson, 2000; Echeverri Velasco, 2003). These approaches cover a wide spectrum of policies that range from proposals focused on the population who live under extreme poverty conditions, as it occurs in most Central American countries, initiatives based on financial incentive mechanisms for providers and users of services (e. g. Colombian, Mexican, and Chilean health reforms), to proposals which retake a global view of social policies, as in the cases of Costa Rica and Brazil.
Important differences coexist inside the various conceptualizations of the notion of social protection. These differences are clearly contrasted by the proposal called “social management of risk” (promoted by the World Bank) and by the notion of Extension of Social Protection in Health (SPH), which has been applied by the Pan American Health Organization (PAHO) and then adopted by several Latin American governments with different meanings and scopes.
This proposal is based on a universal perspective of health rights. Under this perspective, the universal definition of “health care policies” is taken as part of a social and political construction process of citizenship. The definition of “health rights” is engraved in political strategies that recognize the conflicts of the “political economy”, which assumes the contradiction and overcoming of competitive interests between the stakeholders in the health system (Acuña & Levcovitz, 2003). In this sense, the analysis of poverty, exclusion, and inequity in health, together with the mapping of strategic stakeholders linked to this situation, are basic elements for setting up the components, the scope, and the strategies of “extension policies of social protection in
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health”. These elements bear the capacity to overcome these social problems through adapting the formulation of these extension policies and implementing them according to the local conditions.
In brief, this proposal promotes the elaboration of a global model of social inclusion of the population as a whole as beneficiaries of an integrated system that guarantees health coverage conditions and accessibility to the services according to the needs, without restriction of payment capacities, or social or occupational categories.
Research on policies
The diversity of approaches in the field of research in health policies comprises at least three different analytical lines. First of all, there is an analysis that relies on policy design and component characterization as determiners of the health systems operation. The characteristics of the coverage, the focus, or the universality of the population defined as beneficiary represent central aspects of these studies (Fleury, 2001).
In the second approach, the results of such policies or programs are revalued as dimensions on the health status of the population or on the performance of the health services. In this way, the most remarkable aspects are those referring to evaluate the improvements in accessibility conditions, quality and epidemiological situation of the population (Donabedian, 1984; Starfield, 2002).
Finally, the third approach refers to the analysis of the political processes of the reform initiatives in the health services system. In this context, several aspects related to the following are revalued: i) the change dynamics of the institutional models introduced in the last decade in the relations among organizations in charge of the financing and provision of health services, ii) the economic policy problems such changes generate in the interests’ dispute among affected stakeholders, and iii) the technical feasibility of the implementation of their measures and instruments (Prats, 2003). In this perspective, it is necessary to integrate an analysis comprising the characteristics of its political processes of implementation and the results of such SPH initiatives.
The research proposal developed in this document in framed mainly within the third analytical line previously described.
Research on policies and governance in health systems
The elaboration of an analytical and methodological framework capable of recognizing and analyzing the relation between the implementation processes of the SPH schemes and their effects on the equity conditions to accessibility, represents an outstanding need and challenge.
In this frame, the use of the concept of governance represents a new contribution of social sciences to the analysis of processes of social and health policies implementation. However, there is still a conceptual and theoretical confusion in its use, in the social sciences and public health academic bibliography, in international organizations and in policymakers and service managers (Hufty, et al. 2006).
It is possible to distinguish mainly two conceptual approaches related to governance, one corresponding to a regulatory vision and the other to an analytical approach.
The approach promoted by different international organisms, such as the World Bank and the Iinter-American Development Bank, corresponds to the regulatory and prescriptive approach of “good governance”. This approach seeks to identify and measure different dimensions that define the degree of "governance" of a country, based on the application of the evaluation framework built on "ideal" institutional parameters. One aspect identified as a weakness in this perspective is that the identification of “good governance” criteria should depend on the values, cultural rules and institutional idiosyncrasy of each society, as well as the definition of the desired
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scopes. This aspect reveals the limitations of this approach in the articulation of the analysis of the specificities of institutional and political change “processes” in the different scenarios. Therefore, such “solutions” tend to present greater difficulties to adapt the recommendations to the real needs of the decision makers involved in the processes of making and implementing policies for social extension in health (IDRC, 2006).
Alternatively, the analytical and inductive approach enables the recognition of diversity in various ways of governance of the processes of making and implementing policies, characterized according to the specificities of the constituents and their ability to respond to the inequity in health conditions. In this perspective, governance involves the interactions among the processes that determine how power is executed, how decisions are made and how stakeholders participate. Governance constitutes the social fact itself and can be analyzed from a non-regulatory and non-prescriptive approach. The existence of several ways of governance can be recognized, as an expression and result of the social, political and institutional specificities of each object of analysis. These different ways can be subject to analysis and interpretation.
Therefore, the analysis of political and institutional processes for the implementation of SPH strategies is based on the acknowledgement of enjeux such policies or sub-problems acknowledged through the application of the governance analytical framework. The characterization of those processes’ specificities is carried out through their observable constituents (interaction among stakeholders, generation and application of rules and norms, and node points), explaining the factors of "governance" that influence the problem of accessibility to health, and acknowledging the effectiveness of the models or forms of governance of the intervention strategies (places where it is possible to intervene in order to improve the conditions of inequity in health).
The elaboration of this methodological approach bridges the gap between the interpretative framework and the empirical observation, producing an analytical tool effective for describing and understanding the processes of governance of the SPH strategies. Besides, the results of the governance analytical framework will be used and applied by decision makers/stakeholders of the SPH policies, improving their implementation capacity and their performance of such policies.
The governance of the implementation of SPH initiatives and policies tries to recognize the dynamics of social interfaces which explain the decision making process and the elaboration of new rules (formal and informal) on different scenarios and institutional levels (Long, 1999).
Research questions and objectives
The application of the analytical perspective of the governance on these policies will be aimed at answering two central questions:
1. ¿How does the governance of the processes of making and implementing SPH policies affect the results of such policies in terms of accessibility conditions of health services in each case study?
In each case study, the relationship between (a) the governance of the processes of implementing policies being studied, considering the policy design and the implementation context, and (b) the results of such policies in terms of their performance (accessibility conditions). This question will have different results in the four cases analyzed. Those answers will be derived from the analysis of context implications, the stakeholder interactions, and the processes of formulation of rules on the conditions of accessibility to health services.
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2. From a comparative analysis between cases, is it possible to identify the common characteristics of the governance conditions that act as determiners (positive or negative) of the accessibility to the health services?
The question will be answered by a comparative analysis between the four case studies. The goal is to identify “critical” features (common and specific) of the governance based on its weight as a determiner of the effectiveness of the health policies oriented towards the improvement of the conditions of accessibility to health services in the different scenarios being studied in Latin America. This question originates from the need to identify the governance factors which are particular in the Latin American context and which condition the effectiveness of the health policies. This will render answers appropriate to the local context.
General objective:
Develop and test a Governance Analytical Framework (GAF) contributing to a better understanding and improvement of the effectiveness of health policies in Latin America, with a focus on the linkages between the governance of Social Protection in Health Schemes (SPHS), implementation processes based on Primary Health Care (PHC) strategies and health care access at the municipal level in Argentina and Bolivia.
Specific objectives:
1) Develop the GAF conceptual and methodological framework and implement a pilot study in the municipality of Rosario, Argentina in order to test and strengthen the methodological tools that will be used to analyze the implementation of SPH policies and PHC strategies at the municipal level in Argentina and Bolivia.
1) Conduct four case studies -two in Argentina and two in Bolivia- that will use the GAF methodology to analyze the implementation of SPH policies and PCH strategies and its impact upon the access to health care services at the municipal level.
2.1) Identify and analyze the specific governance patterns affecting SPH policies, PHC strategies and having an impact upon the access to health care services in each one of the four case studies.
2.2) Compare the results of the case studies and identify the common “critical governance patterns” that influence access to health care services in the four municipalities.
2.3) Implement a capacity building strategy and involve decision makers and other relevant stakeholders in order to strengthen the health policy implementation process at the municipal level and promote new pathways to improve health care access.
METHODOLOGY
Conceptual and theoretical framework
In the light of the difficulties to implement policies that are usually presented as logical and agreed interventions, but whose implementation is extremely difficult, it is necessary to have a methodology applicable in the field of health systems that facilitates the analysis of the social processes involved in such processes. The technical solutions should be analyzed in the framework of the complex social and political processes and in the context where they take place. The concept of
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governance and development as an analytical tool was adopted, in the framework of a strict methodology for the understanding of such decision-making processes.
To accomplish this objective, it was necessary to overcome two obstacles; one is the great confusion that exists around the term itself (Hufty et al., 2006), which hinders the development of a collaborative research agenda between the academic area and the decision-makers involved; and the other is the normative-prescriptive use of the concept by the international agencies of cooperation for development (World Bank, UNDP), which has caused rejection or difficulty of use in many sectors and political areas (however, this obstacle is not so noticeable in the Spanish language, given that the word most frequently used by the international organizations is «governability» to the detriment of the term «governance» (Hufty 2001).
Nevertheless, this analytical framework was developed to describe and understand the interactions among stakeholders, processes and rules in connection with the behavior and decision-making of the society (Hufty et al., 2006). This methodology offers an analytical perspective focused on intervention. It is based on: (1) The analysis of the main characters that are involved in an specific area, their characteristics (perception of what is at risk, resources, power and influence, objectives and visions and operative methods); (2) the synchronic and diachronic analysis of the interaction processes among these main characters; (3) the analysis of the results and consequences of the processes (decisions, explicit and implicit regulations, social rules, institutions); (4) the observations of the nodal points, the physical places (organizations, decision-making organisms) or virtual places (networks) of interaction (Hufty, 2004; Hufty et al., 2006). The objective is to be able to describe accurately the mechanisms of establishment and the functioning of the development programs in the accessibility and equity conditions to public health services, identify the malfunctions in terms of governance, as well as the places where they are produced, with the aim of promoting effective interventions.
Analytical development
We refer to governance as the processes of collective action that are organized by the stakeholders and the social rules dynamics, with which a society determines its behavior. The behavior of a society is considered as the way of taking and executing decisions related to the society as a whole.
In this vision, it is recognized the existence of several ways of governance in the application processes of health policies, considered from the disintegration of its observable constituents. Likewise, it is intended to characterize the interactions produced between the different types of governance with the factors considered as determiners or independent variables and the consequences of the interventions on the selected dependent variables.
In the prospect of an interaction chain, the governance is considered as an intermediate variable. On one hand, it causes certain effects on a dependent variable (for example; the problem of accessibility to health services), and on the other hand, it depends on independent variables by which it is determined (for example; the institutional organization of the health system). Also, governance may comprise just one factor among others, that may contribute to explain the problem under consideration (“multi-causality”).
Figure 1: Governance as intermediate variable
Independent variables Intermediate variable Dependent variables
Independent ∂ Socio-economic
Institutional Organizational
SPH characteristics
Intermediate ∂ Governance
Actors Nodal points Regulations Processes
Dependent ∂ Access / equity
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The analytical categories or observable dimensions of governance are a central feature of the methodology: the stakeholders, the social rules, the nodal points, and the processes. The stakeholders are individuals or groups. Their collective action (agreements or decisions) leads to the formulation of rules (or regulations, or decisions) that conduct the stakeholders’ behavior and are modified by the collective action. Collective action comes from the interaction/transaction among the stakeholders, whether conflictive or cooperative, the agreements or the decisions that are made, and their application.
For the purposes of the analysis, for a given dependent variable (health budget allocation), we can identify “nodal points”, physical and virtual places (for example; a negotiation table, the federal or state health council, etc.), where it is found a convergence of several processes, stakeholders and regulations, that cause effects, separately or in interaction with others, on the studied dependent variable.
The processes are sequences of stages through which the interrelation among stakeholders, regulations and nodal points occur. The processes, the stakeholders and the regulations may be formal, that is to say, recognized by the stakeholders having the authority over the observed society (this recognition is “legal” to the level of the societies provided with a positive right), or informal; defined by the practice of the stakeholders.
From the use of the analysis categories, the methodology aims at identifying the way the governance influences on the selected dependent variables. It intends to identify those favorable or unfavorable social interfaces to a change in the problem under consideration.
In Table 2 there is a simplified example that assumes governance as an intermediate variable. It is understood that, through the analysis of the social interfaces and the processes of interaction (in this case, the interaction on nodal points), it is possible to identify the specific place of intervention (nodal point B) to accomplish a change in the problem under consideration (the inequity).
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Figure 2: Intervention methodology
Methodological criteria of the governance analytical approach
The methodological criteria that lead the GAF are: realism, transdisciplinarity and reflexivity. The realism criterion, referred to the descriptive more than the normative nature, exists on the analysis of the characteristics of the health services system and on its dynamic of change. The transdisciplinarity involves the construction of knowledge through interfaces built among disciplines, researchers and political and civil society stakeholders. This process begins from the moment of sensitization, problematization and development of the research project, to the moments of collection, analysis and interpretation of the results. The reflexive nature of research implies the recognition of the transformation produced on the interfaces where the stakeholders in charge of the management of the health care policies are integrated (responsible politicians or local health care authorities, stakeholders in charge of primary health care management, professionals in charge of services management and provision). Researchers participate as stakeholders involved in the analysis of the problem and the change strategies of the health system organization.
The collection, the analysis and the contextualization of data in participative areas with the stakeholders involved in management, seek to produce changes in the behaviors and relationship stories between the stakeholders involved in the processes under consideration and such research.
Methodological design
� Objective Nº: 1
The conceptual and methodological analysis around the GAF will involve a job that is continuous and parallel to the empiric objective. This process will start from the development of a pilot test of the GAF application in the Municipality of Rosario, during the first year of the research and will continue with the reflection derived from its application to four case studies (two in Argentina and two in Bolivia). The heterogeneity of the policies under consideration and their geopolitical contexts, as well as the
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characteristics of the researchers (origin and multidisciplinary education) are enriching elements of the discussion.
� Objective Nº: 2
The analysis of local scenarios requires recognizing different initiatives of SPH policies, formulated and implemented from the political management of the municipalities considered. The diversity of social, economical and political conditions of the scenarios requires distinguishing different situations and answer modalities of the policies implemented to the social issues in middle- and low- income countries. Argentina and Bolivia offer these characteristics respectively. Likewise, they offer scenarios of advanced decentralization processes. In the case of Argentina, two provincial states (Buenos Aires and Santa Fe) have municipalities with a wide experience in the primary health care management from the municipal level. In the case of Bolivia, with the Popular Participation (1994) and Administrative Decentralization (1995) acts, the creation of an additional level of self government in the municipalities of all the national territory, with responsibilities associated with the provision of certain assets and local services takes place.
The selection criteria of the municipalities to be included in the analysis of the GAF application respond to: (1) The size of the municipalities (middle size: between 100,000 to 1,000,000 inhabitants), (2) development of health services systems in primary health care, (3) experience in primary health care management processes, (4) existence of policies or development initiatives of the primary health care as a SPH policy addressed to the population in vulnerable conditions in socioeconomic terms, (5) sharing and accepting the application of the methodological proposal, (6) commitment to considering the process results and due to this investigation as consumable in the implementation of their policies, (7) availability of a management team with the ability to provide and make the development of the project activities viable, and (8) disposition to the creation and integration of research teams and decision makers, (9) availability and quality of the information concerning health conditions and characteristics of the health service network at the municipal level.
The methodological design integrates the design of case studies, and the development of comparison among cases (Seiler, 2004) in different local scenarios. The starting point is the local level, from where an upward analytical process of each governance stage takes place. The research performs a case analysis of SPH policies, and their formulating and implementing processes in different local scenarios, which will enable the recognition and comparison of governance models and their implications in the conditions of accessibility of services. It is expected that the governance models with causalities associated to certain generalizable features of the health policies may be identified through the analysis of the governance models of the researched cases. The GAF process will be followed from the local to the provincial level, and through every decision making level.
First stage
In a first stage, people will work on a pilot test in Rosario, testing the methodology of the research.
Second stage
In the second stage of the project, the corresponding case studies will be developed in two municipalities from Argentina and two from Bolivia.
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Work stages for cases:
1. Characterization of the economic, social and demographic conditions of the population and of the structure of the network of health services of each municipality.
2. Identification and characterization of the SPH schemes that tend to reinforce the primary health care in the different municipalities, from the methodology developed by the PAHO (Levcovitz & Acuña, 2003; Acuña & Levcovitz, 2003).
3. Description of the accessibility conditions to public health services of the most vulnerable population of each municipality.
4. Reconstruction of the social problem (problem of inequity in the accessibility to health services) for the construction of the sociological problem.
5. Analysis of the process of implementation of the SPH schemes, from the GAF prospect.
6. Analysis of the relationship among the characteristics (design) of the SPH policies, the political process of formulation and implementation of such policies and their results in terms of the accessibility conditions to health services.
7. Comparison of cases.
8. Identify, as a result of the analysis, intervention strategies that enable the improvement of equity in the accessibility to health services.
The aim in each case will be to describe the relationship among the variables that make up the GAF (independent, intermediate and dependent variables).
Independent variables
The following will be considered as independent variables: life conditions and epidemiological characteristics of the population and characteristics of the network of health services in every one of the scenarios under consideration. Their description in each one of the scenarios under consideration will be performed using secondary sources.
The table below summarizes the dimensions, indicators and data sources that will be used.
Dimensions Indicators Data sources
Life conditions of the population
Literacy, average of children per woman, violent deaths/100,000 inhabitants, percentage of population with UBN, poverty and indigence level, housing precariousness and sanitation conditions, employment conditions, percentage of population without health coverage.
National censuses of population.
Periodic official surveys.
Publications of the national or provincial crime organisms.
Epidemiological characteristics of the population
Infant, neonatal, post neonatal and maternal mortality rate, percentage of avoidable deaths, main causes of deaths by age stratum and gender, morbidity indicators.
National Ministries of Health publications and municipal information system.
Characteristics of Quantity and level of complexity of health National Ministries of Health
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the network of health services
facilities, dependency and organizational model.
publications and municipal information system.
Dependent variable:
The dependent variable is given by the “social problem”, considered on this project as the inequity on the accessibility to health services. On this project, the concept of accessibility defined as those aspects of the service supply related to the ability to provide services and to respond to the health needs of a certain area will be used, that is to say, the characteristics of the services and health resources that provide or limit their use by potential users. Accessibility is an important factor in the organization of the service supply to explain the variations in the use of health services by population groups and it represents a relevant dimension for equity research (Travassos & Martins, 2004; Donabedian, 1973).
The accessibility problem will consist of the identification and characterization of the economic, cultural, geographic and organizational barriers present in the relationship between the needs, culture and social organization of the community and the service supply, and the provision and management model of health services.
The study of the accessibility conditions will include the assessment of structure, processes and results, using secondary and primary sources of information, with qualitative and quantitative techniques of data collection. Below, the information sources and the indicators or dimensions to be considered for each component are described.
Component Indicators, categories or dimensions
Information sources, according to the type of source (Secondary -S- Primary -P-)
Collection and data analysis techniques
Structure assessment
Number of health centers by km2 and by population density and population without coverage, number of hours of professionals according to their specialty by number of population without coverage, composition of health teams, days and business hours of health centers, existence of on call services and possibility of performing diagnostic studies, provision of free medicine.
Municipal information systems -S-
National Ministries of Health publications –S-
National censuses of population -S-.
Review of secondary sources and statistical analysis
Process assessment
Coordinating mechanisms between levels of assistance, production of planned services and directed toward the population needs and a sense of responsibility to the population.
Interviews to decision makers and health workers -P-
Official documents -S-
Partly structured interviews (between 4 and 6 according to the case specificity and the level of saturation)
Documentation review
Result assessment
Accessibility conditions with information from regular source of health care, access barriers to
Group interviews to potential health services users and
Interviews to focal groups (between two and four per case
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medicines, lab, spontaneous and scheduled visits, from the users’ point of view and use of health services.
health care providers -P-
Home surveys among the population with higher social vulnerability corresponding to the reference area of health services.
Municipal information systems (organization and performance of the services) -S-
according to the population).
Surveys: Samples of n=400 per each municipal case.
Statistical analysis
Intermediate variable
The intermediate variable is given by the governance conditions of the SPH under consideration. Its description implies to initially perform a characterization of the SPH, which will be carried out according to the dimensions suggested by Acuña (2005:29), referred to in the chart below:
Dimensions Categories Sources of Information
Type of scheme Social Security, Maternal & Child Insurance, Species Transfer Program, Money Transfer Program, Provision schemes of primary health care, Social Security Extension to informal workers, free health care to Maternal & Child population
Services provision mode
Vertical, Horizontal
Population covered Focused, Universal
Holder of the right to coverage
Individual, Familiar, Community
Access condition Citizenship, payment capacity, place of residence, employment contract, specific attribute (gender, age, income, ethnic origin)
Territorial scope National, Sub-National, Local
Resource management level
Centralized, Decentralized
Financing Public financing, beneficiaries contributions, extra budgetary resources
Intervention focus Supply focused, Demand focused
Official documents.
Interviews to decision makers who are responsible for the management of the Secretary of Public Health and the primary health care management (between 4 and 6 according to the specificity of each case and saturation of information)
After this first characterization of the SPH schemes, the research continues with the governance conditions analysis. This research has two stages.
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The first stage consists of turning the social problem (the problem presented by the researchers according their knowledge and budgets) into a sociological problem by means of the deconstruction of the initial problem and its reconstruction as sociological or governance problem.
The deconstruction of the social problem (the dependent variable of the research) derives from contrasting the problematization of the dependent variable by the stakeholders (actors directly linked to or affected by the management of the SPH schemes aimed at improving the population accessibility conditions). The reconstruction of the social problem consists of the review of the initial challenge according to the analysis of the perceptions of the social problem, the risks and the stakeholders’ motivations.
This analysis will be carried out with a round of interviews to the stakeholders involved, with a "snow ball" methodology, exploring the identification of the map of stakeholders, from the group of stakeholders with higher visibility and formality in the implementation of the SPH policies, to completing a chart of greater scope and integrality.
The characterization of the affected, involved and strategic stakeholders related to the analyzed problem will be carried out from the following categories:
• Their identity and category (provincial, municipal or local level in the production or direct relation to the services) Their core of responsibilities or formal and real functions covered
• Their beliefs or ideologies and mental maps concerning the problem of accessibility to health services.
• Their ways of expressing and acting.
• Their organizational capacity and the resources that they handle or put into practice: it includes resources of different types: symbolic (professional power), financial (budget, resources allocated to fees or payment of benefits or consumables), of social asset (integration to social and political relationships) or cultural asset (representations).
• Their intervention area in health system.
• Their positioning (opponent or facilitator) before the program or policy being studied, and sensitivity and consideration regarding the problem of the accessibility to services.
Next, the second stage on the research of governance conditions will take place. The identification of the critical social interfaces, the risks and the analysis of the interaction of stakeholders, nodal points, regulations (formal and informal) and the processes of change of the SPH policies will be carried out.
The analysis of the interaction among stakeholders implies a situational analysis of the relative power of the stakeholders and their relational situation. The aim is to analyze the density of the reciprocal relationships established and the nature of the committed transactions (negotiation, direction, distribution or reciprocity) among the stakeholders related to the organization and provision of services, the management areas of the primary health care policies, other community, social and political areas, and the population as a user or beneficiary of the coverage system of the municipal public sector.
The “nodal points” will be used as observation areas of the interrelationship of the stakeholders, the formulation of rules and the process of change. The selection of theses areas (physical or virtual) for a characterization of their processes of change will be performed according to:
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• The relevance of the density of the interrelationships between the stakeholders involved in the implementation process of the SPH policies.
• The type of regulations and decisions at risk, and their importance for the implementation of SPH policies.
• Their capacity to facilitate the process of change of the implementation of the policies under analysis.
The identification of the nodal points implies recognition of the process and dynamics of the interrelationships among stakeholders, and the formulation of rules capable of conditioning the same social interfaces and the social issue under analysis. The aim will be to identify different nodal points that enable the integration of the complexity of the different social interfaces involved in the process of policy implementation, at different levels and with the capacity of conditioning the problem of accessibility to services.
The research on governance conditions requires the performance of interviews and workshops with the stakeholders and the collection of official documents. The information processing will be made through the technique of potential text content analysis (transcription of interviews, workshops and official documents registration). For each case, the number of these interviews is estimated between 10 to 15 ones, varying according the type and number of identified stakeholders and approach to the saturation point of the information. It is estimated the need of two participating workshops with the stakeholders for each case.
Stages of the research on governance conditions
Sources of information, according to the type of source (Secondary - S- Primary - P-
Collection and data analysis techniques
Construction of the sociological problem Interviews to identified stakeholders through the “snow ball” technique” -P-
Deconstruction of the social problem by contrasting the stakeholders’ perceptions.
Stakeholders’ characterization
Identification of the social interfaces and risks.
Analysis of actors’ interaction and identification and characterization of regulations.
Identification of nodal points
Interviews and workshops -P- and official documents (public documents, work documents, management reports) -S-
Analysis of the potential content of the interviews, records of the workshops and official documents.
Relations among variables
In each case, those mechanisms derived from the governance conditions that strengthen and/or weaken the capacity of SPH local policies to improve the equity conditions in the services accessibility will be identified and described. On this analysis, the contextual variables that contribute to the accomplishment of the expected results will be taken into account.
Comparison of case studies
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The results of the cases will be compared using the analysis of the relation among: i) the identification of the accessibility problems, ii) the characteristics of the context (socioeconomic and cultural characteristics of the population and structure and organization of the health services supply), iii) the design of the SPH policies, and iv) the governance characteristics of their implementation processes. The aim will be to recognize those “critical” features of the governance, in terms of stakeholders’ interaction models and ways of creating regulations with capacity of influencing on the organization and the accessibility conditions to health services.
The analysis should distinguish critical features of governance: a) common to every case, as facilitators of better accessibility conditions, and b) specific, conditioned by particular context characteristics and the design of the SPH policies of each scenario.
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