H A RTZ, Z. M . A. 2 5 0
Cad. Saúd e Públic a, Rio d e Jane iro , 15(2):229-259, abr-jun, 1999
Th e a rt icle b y Zu l m i ra Ha r t z d e scr ib es t h e in i-t i a i-t i ve s, a i-t le a s i-t a s p ro p o s a l s, ch a r a c i-t e ri z i n g th e im p le m e n t atio n o f a n ove rall p ub lic p olicy a n d a s p ecific p u b lic p o lic y fo r t h e h e a lt h sec-t o r fo r e va lu a sec-t io n o f p olicie s a n d p ro g ra m s ( w h e re “p o l i c i e s” an d “p ro g ra m s” ca n a ls o b e se e n a s pro g ram s an d te ch n ologies, b ut d o n ot in c lu d e p o licie s in t h e s e n s e o f “p o l i t i c s”) in Fra n c e b e gin n in g in t h e 1980s. In o rd e r t o d e -ve lop so m e co m p arison s an d estab lish a n alyti-ca l alyti-ca t egories for eva lu a t io n p olicie s th e au t h o r d e s c rib e s sp e cific a sp e cts of p olicy im p le m en tation in cou n t rie s like t h e Un ited St a t e s, Ca n a -d a, an -d Au s t ra l i a .
Th e ove ra ll ju st ifica t io n fo r d e ve lo p in g h e r re s e a rch a s p re se n t e d in t h e p a p e r is b a sed o n t h e p re m ise t h a t kn o wle d ge o f t h e r e alit y o f o t h e rs fo st e rs a b e t t e r u n d e rst a n d in g o f o u r own , a n d m o re s p e cifica lly t h at a c o u n t r y ’s p u b lic p olicie s a n d p ro g ra m s ca n b e im p rove d ( i . e., b e m a d e m o re a p p ro p r ia t e t o t h e ir o b je c-t i ve s, m o re e ffe c c-t ive , m o re d e m o c ra c-t ic, e c-t c. ) u s in g o t h e r c o u n t ri e s’ e xp e r i e n c e s. In o t h e r w o rd s, n o t o n ly is t h e re n o t a h ist o ric a l d e t e rm in isrm o r “ i n e xo ra b ilit y” (a t le a s t n o t a n ab -so lu t e o n e ); ra t h e r, ra t i o n a l i ze d co lle ct ive a c-tion s are p ossib le, an d th ey a re stren gth en ed to a ce rt a in ext e n t wh e n b a se d o n kn owled ge ac -cep t ed a s t ru e.
Th e s e p re m is e s a re o b vio u sly a re f e re n c e fo r a m ajo r p o rtio n o f re s e a rch a ct ivity, p a r t i c-u la rly in t h e fie ld o f Co l l e c t i ve He a lt h , b c-u t it is H . Ma ria Du t i l h
Nova e s
De p a rtam en to d e Med icin a Pre ve n t i va , Fa cu ld ad e d e Me d i c i n a , Un i versid ad e d e Sã o Pa u l o, Sã o Pa u l o, Bra s i l .
Ha r t z m e n t io n s a n o t h e r im p or t a n t a sp e ct o f e va lu a t io n , t h at it is a n e ve r-e n d in g p ro c e s s. Eva lu at io n s a lwa ys co m e e it h e r t o o so o n (t h e p ro g ra m d o e s n o t a p p e a r t o h a ve b e e n fu lly im p le m e n t e d a n d s t ab ilize d ) o r t o o la t e (ir re -versib ility h a s b ee n cre ate d ). Bu t th is ju d gm e n t is b ased o n an erro n eo u s p erce p t io n of eva l u a -t io n , co n ce ive d o f a s a o n e - sh o -t ju d gm e n -t a -t o n e given m om e n t in t im e , a llowin g for a st op -o r- g-o d e cis i-o n . Ra t h e r, e va lu a t i-o n s h -o u ld b e se e n a s a le ar n in g p ro c e s s , e ach st e p id e n t ify-in g wh at is a lre ad y kn own a n d wh at rem aify-in s t o b e le arn e d .
Fi n a l l y, if o n e se e s e valu a t io n a s a p ro c e s s t o im p ro ve co n d it io n s fo r d e m o cra t ic d e b at e in ou r p a r liam e n t a r y s yst e m s, t h e n on e m u s t ra ise t h e issu e o f e q u a l a cce ss t o t h e e xp e rt i s e re q u i re d fo r e va lu at io n . Eq u a l a c ce ss h a s t w o m a in d im e n s io n s. Th e first re lat e s t o p u b lic d i s c l o s u re o f e va lu a t io n s co n d u ct e d b y p u b lic s e r vic e s o r p a rlia m e n t a r y o ffice s, i.e ., r e s u l t s th at sh ou ld b e p u b licized as wid ely a s p o ssib le. I a m aw are t h at m a n y sh a re a p e ssim istic vie w o f h u m a n n a t u re a s t o wh e th e r a cce ss to in fo r-m a t io n a n d q u a lit y kn o wle d ge ir-m p r ove s o u r societ ies (Re vel, 1988). A Ma c h i a ve llian vie w o f g ove r n a n c e a ls o t e n d s t o a rgu e ove r la Raison d ’ É t a t. Bu t a n o rga n izat io n se ld o m h a s th e ca -p a city to a d a -p t itse lf fro m th e in sid e, a n d it of-te n n e e d s “e xo ge n o u s sh o c ks” t o im p rove. Mo re ove r, in t h e c as e o f p u b lic se r v i c e s, c it i-ze n s a re o ft e n ca p t ive c u st o m e rs. Eva l u a t i o n m a ke s p u b lic services m o re a ccou n ta b le to th e p e o p le th e y a re su p p ose d t o se r ve. My se co n d p o in t is m o re u t o p ia n . In d e m o c ra t ic n at io n s, a cc e s s t o fr e e le ga l c o u n se l is gu a ra n t e e d for t h ose wh o ca n n ot afford t o h ire a lawyer t o d e-fe n d th e m in cou r t . T h e re is n o gu a ran t ee t h at t h is la wye r will d o t h e b e s t wo rk in t h e wo rld , b u t a t lea st fre e le ga l aid is p rovid e d . Access t o e va lu a t ion is ce r t ain ly n o t d ist r ib u t e d e q u a lly a m on g socioe con om ic cate go ri e s. So m e act ors h a ve t h e re s o u rce s t o b u ild t h e ir ow n e va l u a -t io n o f p u b lic se rvice s a n d u se -t h is -t o lo b b y, p ro m o t e, o r p r ot e c t t h e ir in t e re s t s. Is it p o ssib le t o im a gin e t h a t p o lit ic a lly w e a ke r co n st it u e n cies cou ld h o p e t o co u n t e rb a la n ce eco n o m ic power a n d b e su p po rt ed b y p u b lic m on -ey to d e velo p th eir own eva l u a t i o n ?
Ha ve we re a lly m e t t h e s e re q u i re m e n t s in Fra n c e, a s t h e re c o rd o f ach ie vem en ts list ed b y H a rt z m igh t s u gge st ? Ac t u a l l y, w e a re s t ill fa r s h o r t o f m a n y o b je c t ive s , in b o t h t h e h e a lt h s e c t or a n d o t h e rs. Th e ro le o f p a rlia m e n t a ry e va lu a t io n is m o d e s t b e ca u s e o f t h e m o d e s t l e ve l o f re s o u rc e s in ve st e d , e va lu a t io n is fa r f ro m b ein g acce p te d a s a n orm al m a n a ge m en t p ra ct ic e in p u b lic se r v i c e s, a n d e va l u a t i ve re
-s e a rch la ck-s le git im acy. Bu t it m a y w ell b e th a t h e alt h will b e a m od el fo r ot h e r se ct o rs of p u b -lic in t e r ve n t io n , b e c a u se o f se ve re e xo g e n o u s s h o c k s, n o t o n ly fin a n c ia l, b u t a lso s cie n t ific, a n d t h ro u gh t h e e m e rge n c e o f m a jo r p u b lic h e a lt h issu e s su ch a s “n e w p ove rt y ”, AIDS, p ri-o n s, p ri-o p ulatiri-o n a gin g, a n d ri-o th e rs.
H IRSCH MAN , A. O., 1970. Ex i t , Voice an d Loy a l t y. Bo sto n : Ha rva rd Un i ve rsit y Pre s s.
AVALIAÇÃO DE PRO GRAMAS E PO LÍTICAS DE SAÚDE NA FRANÇA 2 5 1
Cad . Saúde Púb lic a, Rio d e Jane iro , 15(2):229-259, ab r-jun, 1999 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”.
