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w o r t h wh ile t o h igh ligh t t h e m h e re, sin c e t h e y a re e s se n t ia l fo r p rovid in g le git im a cy fo r p r o-g ram a n d t e ch n o lo o-gic al e va l u a t i o n s, wh e t h e r t h e y a sp ire t o scie n t ific re s e a rch st a t u s o r n o t . Fo r t h e la t t e r, a s we ll e la b o r a t e d b y H a rt z, a l-ways aim to p ro m ot e t h e lin k b e twee n t h ou gh t a n d act io n , o r o p in io n / in t e n tio n / w ill a n d a c -tio n , kn owle d ge a n d t ech n iq u e.
As t h e p a p e r’s d at a a n d d is c u ssio n s h o w, t h e d ifficu lt y lies p a rt icu lar ly in p r o g ra m e va l-u at io n , a lwa ys ve ry b ro a d in it s scop e a n d sl-u fficie n t ly com p le x to en co m p ass an d a d eq u a te -ly id en tify th e com p lex n etwork b etween k n ow l-e d g l-e , va l u l-e s, so c ia l, p o lit ica l, a n d l-e c o n o m ic f a c t o r s, an d te ch n o lo gica l a n d te ch n ical a lt er-n a t i ve s, wh e re e xp licit d isco u rse s o r fo r m u l a te d ra t io n a lte s a rte a n in h te rte n t p a rt o f t h te n te t -w o rk’s co n st ru ctio n (a n d n ot e xt e rn al t o it ).
Fo r t h e Fre n ch “c a s e”, o n e ca n c o n c lu d e t h a t b e gin n in g in t h e 1980s, se rvices we re cre -a t e d -a n d l-a ws -an d -a d m in istr-a t i ve r u lin gs we re d ra ft e d (b o t h ge n e r a l a n d s p e cific for t h e he alth field ) with a view t ow a rd s im p lem en t in g a p u b lic p o licy for p olicy an d p ro g ram e va l u a -t io n , a n d a-t -t e m p -t in g -t o p re s e rve -t h e “Fre n c h wa y of b ein g a n d d oin g” wh ile in ke ep in g with p ro p osals fro m ot h e r We s t e rn d evelop ed cou n -t rie s (b o -t h in -t h e ju s-t ific a-t io n a n d fo r m ). In oth e r wo rd s, a ct io n s we re take n th a t a pp e a r to h a ve b e en b a sed o n th e fo llowin g p rem ises: th e n e e d fo r b et te r ju st ifica t io n o f e xp e n d it u res in th e face o f e con o m ic d ifficu lt ie s; th e search fo r g re at e r e ffect ive n e s s , e q u it y, a n d p u b lic sa t is-fact ion th rou gh pu b lic p ro g ra m s; an d th e a va i l-a b ilit y o f t e c h n icl-al, m l-a n l-a ge ril-a l, l-a n d l-a d m in is-t ra is-t i ve re s o u rce s is-t o ach ie ve is-th e se ob je cis-tive s.
St ill, wh a t a re p ro p e r ju st ific at io n s fo r r e -s o u rce -s e xp e n d e d , a n d wh ic h e ffe ct ive n e -s -s, e q u i t y, a n d sa t isfa c t ion a re d e sire d , a n d b y wh o m ? Th e a n swe rs are n o t clea r. Th e p u rp o se o f th e a r t ic le is n o t t o a n s we r t h e se q u e s t io n , b u t th ey in evita b ly crop u p . On e is le ft with t h e i m p re s sio n t h a t a t le as t fo r th o se in ch ar ge o f p olicies an d p ro g ra m s, wh o m u st h ave h a d suf-ficie n t ly b ro a d p o lit ic a l a n d so c ial su p p o rt t o m ake th e m feasib le, th e p ro p ose d actio n s se ek t o c h a n ge o n ly e n o u gh so a s t o gu a ran t e e t h a t n ot h in g re ally fu n d a m e n t a l a ct u ally ch a n ge s, th a t is, t h e y co u ld b e o n e m ore ep isod e of “p l u s ça chan ge plu s c’est la m êm e ch ose”. In th e ca se o f Fra n c e , w h e n we a n a lyze t h e cou n tr y ’s e p i-d e m io lo gica l a n i-d q u a lity-o f-life in i-d ic a t or s, c o u ld it re a lly b e t h a t n e w p o licie s a n d p ro -g ra m s a re d e s ire d a n d n e e d e d ? Are wh a t a re n ow co n sid ered old , co stly, in d ivid ua list , eliti s t , a n d in e ffe ct ive h e a lth p olicies a n d t e ch n iq u es res p o n sib le fo r t h e Fren ch e co n o m ic c risis (a s m e a s u re d by its h igh u n e m p loym en t ra t e)?
Th e Fre n c h h e a lt h sys t e m , a cc or d in g t o a s u rve y fro m t h e e a rly 1990s q u o t e d in t h e p a -p e r (No va e s, 1992), h a d a lre a d y b e e n id e n t i-fie d a s q u it e d iffe re n t fr o m w h a t t h e Bra z i l i a n He alth Re f o r m m ovem en t co n sid ered ad eq u a te for a go o d h e a lt h sys t e m , ye t it a p p e a re d t o p le a se t h e va st m ajor it y o f t h e Fre n c h p op u la -t io n , w h ich d isp la ye d e xc e lle n -t h e a l-t h co n d i-t ion s as m e a su re d b y i-t h e u su a l in d ic ai-t o rs an d in co m p arison t o o t h er d eve lo p e d cou n tr i e s. A p a ra d o x? I t h in k n o t . Th e d isc u ssio n r a i s e d h e re u n d e r sc o re s t h e n e e d for a n a ll e n c o m -p a s s in g a n a lys is o f h e a lt h -p o licie s a n d -p r o-g ra m s, w h ich sh o u ld b e s e e n a s s o c ia lly a n d t ech n ica lly con st ru ct ed a lte rn a t i ve s fo r sp e cif-ic c o n t e xt s, an d n o t a s u n ive r sa l m o d e ls o r a o n e -a n d -o n ly p a th w ay t o h a p p in e ss.
N OVAES, H. M. D., 1992. Processu s de Déve l o p p e m e n t Scien tifiqu e et Te c h n o l o g i q u e : Tech n ologies Méd i-cales en Fra n c e ,1 9 7 0 - 1 9 9 0. Re l a t ó rio d e p ó sd o u -t o ra do a o CN Pq. Bra sília : CNPq . (m im e o. )
Se c re t a ry for H ealth Po l i c y, Brazilian Mi n i s t ry of He a l t h , Bra s í l i a , Bra z i l .
João Yu n e s Fir st o f a ll, a n an a lys is o f t h e t it le a n d su b se -q u e n t re a d in g o f t h e a rt icle a llows o n e t o h a ve a con te xtu al u n d erst an d in g o f t he Fren ch e xpe-rien ce with evalu ation a s com p are d t o p ra c t i c e s u se d in o t h e r cou n t ri e s. Th e a rticle fo cu se s on t h e e valu a tio n p ro cess th a t b ega n in 1970 with t h e p e rin at a l ca re se ct o r in Fran ce in 1970 an d w it h t h e co u n t r y ’s st at e p o lic ie s as a wh o le in 1993, t h ro u gh t h e “Office Pa rl e m e n t a i re d ’ É
va-lu a tion d es Choix Scien tifiqu es et Te c h n o l o-g i q u e s”.
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A se n t e n ce t h a t s u m s u p t h is id e a is b y a Fre n ch a u t h or (Bio n , 1994): “ Evalu ation n
eces-sarily brin gs ou t con tra d i c t i o n , en tailin g m u lti-p le lti-poin t s of v iew a n d ad d in g a t ri b u n i c i e n n e
f u n c t i o n .”
Th e a rt ic le m a ke s fo r p ar t icu la rly in t e re s t -in g re a d -in g a t t h is m o m e n t -in Bra z i l’s h ist o r y, wh e n t h e c o u n t ry h a s ju st in st it u t ion a lized it s e va lu a t io n p ro c e s s, in 1998, b y fo u n d in g t h e De p a rt m en t o f H ealth Po licy Evalu a tio n u n d er t h e He a lt h Po licy Se c re t a r ia t o f t h e Mi n i s t r y o f He a lt h . Th is b r in gs u p t h e firs t p ra c t ica l c h al-l e n g e, in kee pin g wit h on e of th e au t h o rs q u o t-e d in t h t-e ar t iclt-e : “on n e p eu t pa s être ju ge p
ar-t i e”. If a n e valu a t io n is n o t gove r n m e n t a l (i.e. , co n d u ct ed by a De p a rt m en t), h ow cou ld it b e a s t a t e e va lu a tio n ? An d t h is is a lwa ys d e s ir a b l e a n d n ecessa ry.
Th e au th or h erself sa ys t h at e va lu at io n can -n ot d o wit h ou t a u d it i-n g (of e ffe ct ive-n ess), a-n d if it is n ot gove rn m e n t a l, h ow d o e s o n e c o m -b in e th e t wo ?
In a n o th e r p ar t o f t h e a r t i c l e, e va l u a t i o n e m e rges as a m e d iat or b et wee n kn owled ge (in -f o r m a tio n ) an d d e cision -m a kin g. Is th is n ot th e o ld IPDA c ircu it (in fo rm a t io n , p la n n in g, d e ci-sion -m akin g, a ction ) in a n ew gu ise (sin ce e va l-u a t io n ca n o n ly b e va ll-u e d a s a co m p o n e n t o f p l a n n i n g ) ?
Th e Fre n ch exp e r ie n ce in t h e h e a lt h se cto r c o n n o t e s a n e m p h a sis o n h e a lt h c a re p o licy a n d p ro g ra m e va lu a t io n , fo cu sin g o n h osp it al c a re (in c lu d in g o u t -p a t ie n t ca re ), t h e p h ys i-c i a n’s ro l e, a n d t h e te i-ch n ology em p loye d .
It a p p e a rs t h a t t h e p ra ct ic e o f e va l u a t i o n ga in ed im p u lse wh e n it in cre ased p a rt i c i p a t i o n b y lo ca l a ct o rs th r ou gh th e cre a t ion o f re g i o n -a l e v-alu -a t io n c o m m it t e e s fo r p h ys ici-a n -a n d h o sp it a l ca re. Exp an d in g o n t h is vie w, wh a t is Ha rt z’ o p in io n co n ce rn in g a sp h e re fo r h e alt h p o licy a n d p ro g r am e va lu a t io n in Bra z i l’s Mu -n icip a l He a lt h Co u -n c i l s, b a se d o -n m i n i m u m s t a n d a rd s fo r t h e co un try as a wh o le ?
In a d d it io n , u n d e r t h e Na t io n a l an d St a t e He a lt h Co u n c i l s, wo u ld n’t it b e p o ssib le t o in -c o r p o rat e t e-ch n i-ca l -ch a m b e rs n ot on ly to p e r-f o rm eva lu at ion or-f h e alth p o licies an d n a tion a l a n d St a t e h e a lt h p r o g ra m s, b u t a lso t o o u t lin e m e t h od o logie s a n d e valu a t io n t ech n iq u e s o f a less e p iso d ic an d m o re p e rm an e n t n at u re ?
In t h e Policy Se c re t a riat t h ere are t ech n ica l a n d scien tific co m m itte es in ch arge o f a d visin g t h e Mi n i s t ry ’s t e ch n ica l b o a rd s in d ra ft in g a n d co n d u ctin g it s sp e cific p ro g ra m s a n d p o licie s. Ho w d o e s Ha rt z vie w t h e u s e o f t h is sp h e re t o b a ck sp ecific evalu a t io n of give n issu es?
I b e lie ve t h a t h e r st u d y co u ld b e e xt e n d e d t o c o m p a re id e a s a s t o t h e ap p lica b ilit y of t h e
Fre n ch e xp e r ie n ce in Br az il. To b e gin wit h , it wou ld b e in t e re st in g t o le ar n a b o u t t h e m e t h -od s a n d in d icat o rs fo r resu lts as u sed in Fra n c e to d e t er m in e wh et h er t h ey a re sim ila r t o t h ose in Bra z i l .
T h u s, se ve ral issu es m igh t b e d iscu ssed , in -clu d in g th e fo llow i n g :
• Wh ich of th e op eration al con cepts of p ro c e s s u sed in Fran ce m igh t b e u seful for t h e Bra z i l i a n p ro c e s s ?
• Cou ld (an d sh o u ld ) so m e o f t h e p h a se s d e -s c rib e d in t h e Fre n ch p roce -s-s b e re p rod u ced in Bra z i l ?
• Is it p o ss ib le t o e va lu a t e t h e re su lt o f a se t o f p u b lic p o lic ie s, o r is it m o re a d vis a b le t o p ro ce e d t o se ct o ria l e valu a t io n s ? In t h e la t t e r c a s e, h ow cou ld th ey b e re con ciled an d con sol-i d a t e d ?
• Wit h re g a rd t o t h e e va lu a t io n p ro ce ss cu r -re n t ly u n d e r wa y in t h e wo rld , t h e issu e is n o t
w h a tp u rp o se it ser ves (wh ich ca n b e a n swe re d e a sily), b u t w h o s ep u r p o s e it se rve s. Th a t o f g ove rn m e n t s, gove rn o r s, th e p o p u la tion , so cial s e c t o r s, e va lu a t or s t h e m se lve s an d t h e ir a ss o -c i a t i o n s ?
• Ba se d on t h e a r t i c l e, e va lu a t ion p ro c e s s e s e m e rge at t im e s o f e con om ic d ifficu lt y or t ra n -sitio n s fr o m o n e m o d e l t o an o t h e r (wh ic h is th e sa m e th in g, sin ce n e w m o d els are m ea n t to re p la c e o ld o n e s wh ic h n o lo n ge r m e e t t h e p e o p l e’s d em a n d s o r th ose of gove rn m e n t p ro g ra m s wit h th e sa m e re s o u rce s). Is t h is t h e ap p ro p r iat e m o m e n t t o in s t it u t io n aliz e e va l u a -tio n , o r is it m ere ly a m om e n t of w h ich t o t ake a d va n t a g e ?
