Mauri Johansson & Timo Partanen

Trade Unions in workplace safety- and health promotion. With focus on cooperation between workers and academics in promoting health

Public Health Partner, Denmark
Finnish Institute of Occupational Health

Mauri Johansson, MD, Denmark

Since the middle of the nineteenth century, workers have organized in unions and parties to strengthen their efforts toward improvement of health and safety at work, job conditions, working hours, wages, job contracts, and safety. During history alliances have, from time to time, been established between workers, their unions and academically trained persons, working in solidarity with the workers and on their premises.

During the last decades there are in the Nordic countries some interesting examples of this type of co-operation between workers and their organizations on the one hand and scientists, practitioners of medical, social, hygienic, and technical occupational health on the other. These coalitions have occasionally been instrumental in improvements in regulation and legislation pertaining workers’ health. They also have been active for a surprisingly long period of time, in spite of ideological changes in the societies in the mean time.

In early 1970s, adverse health effects of organic solvents that were regularly used by construction painters were virtually unknown or alt least unrecognized. In the vivid years following 1968, when joint activities between workers and academics evolved all over Europe and elsewhere, a local painters� union in Aarhus, Denmark, contacted a group of medical students, asking for help to find out about severe central nervous symptoms among their members. Using interviews, short questionnaires and finding relevant scientific documentation it was shown that exposure to organic solvents could explain both acute and chronic symptoms, described by the painters. This led to a joint report , demanding that the working conditions had to be changed and the toxic substances eliminated. The co-operation resulted in a new type of organizations (“Co-operation Worker – Academics” (SAA) in Aarhus and “Action Group Worker Academics” (AAA) in Copenhagen), which still exist. They have produced more than 80 nontechnical reports, pamphlets and other material covering a broad range of industrial and other areas in working life. Most of them were initiated by single workers or shop-stewards, who with help from their local unions followed the problems up with active students and academics. The publications had a wide distribution among workers and were used in training sessions for safety representatives and had positive influence on working conditions throughout the country. AAA has also published a newsletter for distribution among active union representatives. The painter reports were followed by systematic research at university levels, confirming the findings , , . Threshold Limit Values were reduced, and the painting industry was forced to develop and apply water-based paints. Chronic illnesses among painters and others exposed to solvents became compensated as occupational diseases. The number of new cases of chronic solvent syndrome is considerably reduced during the 90’ies. Strong counteractions were taken by the oil industry, hiring scholars to deem the research as false . The public presentation of the oil industry report in 1984 was greeted by red union banners at the University auditorium to mark the protests.

These reports had a considerable impact during 1972 -1975 in Denmark. In a State Committee set up to propose revisions of the 1954 Worker Protection Act, seven of the reports were appreciated by the way they exposed the problems . The committee proposed the main elements to a new Working Environment Law, passed 1975 and enforced since 1977. Workers� influence on their working environment and on occupational health and safety in general was strongly secured. This law in many respects served as inspiration for the European Union Framework Directive as of 1989/391. Also the Danish National Confederation of Trade Unions (LO) was forced to accelerate its working environment programs and demanded influence on university research .

A similar worker-academic coalition (“The Health Front” – Terveysrintama) has been active in Finland since early 1970s. In fact, is has been communicating steadily over the years and occasionally joined forces with the Danish organizations, some times attending each others meetings. So, a report, prepared in Denmark by SAA, covering the questions of psychic working environment, was used as a model for an alike Finnish publication in 1978. The Finnish organization is an NGO, and has published a 8-to-16-page newsletter four times a year, prepared and distributed pamphlets, booklets, and books, and organized various campaigns and training sessions. One of the books presented the laws and formal regulations in a language understandable for ordinary workers. In particular, a set of strict threshold limit values for workplace chemicals and other hazardous exposures , and a draft for a law on occupational health services (OHS) were prepared. Both were printed and distributed among trade unions and unionists, particularly safety representatives, and are likely to have influenced legislation and regulation of workplace chemical exposures and OHS in the country. Annual conferences were held during a long range of years with dozens of participants – both workers and academics, posing statements and resolutions for public debate.

In Sweden, delivery truck drivers employed by a brewery had for years had serious ergonomic problems and accident risks in unloading and delivering cases of beer and mineral water down the steps to basement-placed bars and restaurants. A safety representative and a shop steward contacted the local University Department of Occupational Medicine. The problems were carefully examined, and proposals for a solution were made. After a systematic campaigning, binding regulations were enforced, with a maximum of 5 steps accepted, otherwise no delivery. Mini-elevators were drafted for easier delivery.

On European level a cooperation between workers, their local and national unions and academics has existed since the late 80’ies, collecting hundreds of activists every second year for policy planning. Permanent working groups e.g. on OHS are working between the bigger meetings. A very successful e-mail network assists continuously workers and unions with qualified answers to new hazard problems. This network has i.a. been strongly fighting for a total asbestos ban globally. Contacts can be taken on e-mail: editor@hazards.org

What represents research in the above examples might today be called participatory or action research, the research problems being defined by those at risk, and academics providing support with their experience in literature search, systematic documentation, report writing, etc., and the workers contributing with their practical experience and knowledge of what kinds of solutions would be applicable. It must be stressed, that the joint activities between workers and academics during the first years were characterized by some scepticism and the debates were brisk, until differences in the background cultures were mutually understood and accepted. The examples may be considered narrative, since the causal relations between the events were not confirmed in the strict sense.

In conclusion it can be said, that this type of cooperation has been extremely useful and influential on working environment questions. Also broader topics of cultural nature have beet taken up (what do children in schools learn about workers working and living conditions? How can the history of workers struggle for better conditions be presented etc.). The beginning of the co-work was hard both for academics and workers, but as time vent by, it helped mutually.

I can only recommend you to do all your best to establish alike structures to improve the working and living conditions for the working class and others striving under the burdens of the global neoliberalistic experiments.

Marciano S. Bayle, Carlos Ponte, Manuel Martin, Hixinio Beiras and Felix Payo

Social Movements against the privatization policy of the National Health Service in Spain

Federacion de Asociaciones para la Defensa de la Salud Publica, Spain

During the last years several social movements of general people have been produced, inside and outside of the health area, against the initiatives of the Government addressed to the privatization of the public health services. The purpose of this communication is to describe and analyse one of the peculiar structural forms that they have been developed: “The Platforms in defence of the Public Health”, which are playing an important role against the neoliberal measures and with the purpose of defending and improving the Public Health System.

1. What are the Platforms?.

The Platforms are considered as unitary organizations that arise in front of specific health or social problems, as the need of a new hospital or a particular sanitary or medical care service, the improper working of some health service, etc. And also in front of more general problems as governmental political decisions that affect to the whole population. Therefore, its working area is variable. It can be a neighbourhood, a city, a region or all the state.

Its composition is variable: worker unions (CCOO, UGT), or health workers by themselves (SATSE, SAE), Political Parties on the left spectrum (PSOE, IU, Nationalist Parties), Neighbours and Costumer Associations, City hall representatives, Professional Organizations (FADSP, SEMFYC).

Currently, the following platforms are operating:

• In State level with head office in Madrid.
• In several Autonomous Regions (CC.AA): Galicia, Asturias, Andalucia, Madrid, Murcia.
• In several cities: Córdoba, Cádiz, Lugo, León, Valladolid, Burgos, Salamanca, A Coruña, Orense, Valencia, Ciudad Real. Zaragoza.
• In some health areas and neighbourhoods.

2. Activities of the Platforms:

• Discussion, analysis and alternative of the health/social problems object of the platform.
• Diffusion of brochures, information leaflets, public acts, intervention in the media, popular celebrations, demonstrations, legislative initiatives.
• The most outstanding movement:

Medtec (Vigo,1996) against the privatization of a service of hemodynamic and heart surgery.
Protests against a law that decrease the public financiation of drugs prescriptions (1998).
Against the hospitals conversion in Foundations (Trusts): Getáfe and Alcalá (1988), Arriondas (2000).
Claming for the construction of new hospitals: Burgos (1999), Oviedo (2001), Pontevedra (2001).

3. Balance of the Platforms:

The result has been globally positive. In the case of the Foundations, the movement was essential to stop the Government policy. Also they were successful in more specific problems, for example: the maintenance of an old hospital in Santiago and to reconvert in a social clinic…

The Platforms, however, they have some problems:

• * Most of them are of informal character. Only a few of them had an statute or legal personality.
• They use to work in a irregular way. The members joint together only in face to specific problems and without regularity.
• They are influenced in a strong way by the political position of the different organizations that integrate them and by the relationships between them.
• They need an organization, this is the role of our FADSP, to perform the meetings, to propose objectives and to look for agreement and concurrence against the political differences between the organizations that integrate them.

4. Current objectives of the Platforms:

At this time, in the FADSP , the following topics in the Platforms
are outlined

• To make an active follow-up of the decentralization process of the Health Policy from the State to the Autonomous Regions (CC.AA) and Nationalities. This process have to be made with criteria of equity and economic sufficiency, otherwise, it is sure that it will cause an important problem for the immediate future of the public health service. From the FADSP and the state Platform they have been made already proposals in this regard.
• To obtain sufficiency sanitary financing. Our proposal is that the GDP must be increased in 1 point.
• Rejection of the copayment. The Health Ministry already has raised this idea, but the presence of the generalized refusal, it was delayed.

Dorte Gannik

Is General Practice trapped?
Reflections on health care, liberalisation and research priorities

Central Research Unit for General Practice, Panum Institute, Copenhagen

Dorte Gannik, Assoc.Professor, DscSoc

For a while, reforms with a liberal tendency have been discussed with regard to health care in Denmark. Today, health care is largely a public responsibility. 81% of health care costs are financed through personal income taxes. Primary health care consists of general practitioners, practicing specialists, practicing dentists, physiotherapists, nurses etc. Services are available for all, however the general practitioner functions as a “gate-keeper” with regard to hospitals and specialised medical treatment. He/she is paid by regional authorities in a mixed capitation and fee-for-service system. The patient chooses a GP and remains on his/her “list” for a minimum period.

This system is not yet subject to major reforms. However, liberalisation is sneaking in by way of minor administrative changes and individual behavior changes. The development is part of a global liberalisation trend, supported by new economic theory and a postulated pressure of demand.

In this paper I shall discuss first the question of which forces are behind the pressure of demand. Health economists recognise that suppliers have a heavy influence on health care demand by means of informational and organisational de facto monopolies. The explosion of biomedical research, and in turn, the accompanying ultra-specialisation, makes the whole area incalculable and its development obscure.
Given this scenario, suppliers must rely extensively on estimates and judgments in their decision processes, and commercial agents, e.g. pharmaceutical firms, have ample room for choosing and promoting suitable research evidence.

Being the gate-keeper, general practice is obliged to take part in this development. General practice must have a working overview of advances and inventions in a broad medical field. But general practice also holds the inherent qualities of continuity, wholeness and a personal doctor-patient relationship. These qualities may be the very essence of general practice, since general practice works to sort out and coordinate services so that they suit any single patient. Though many commissions and working groups have paid lip-service to these qualities, GP’s today are only partly dedicated to them. They have lain folded into traditional structures of primary health care, handed over by history – the “list” system, the free GP choice, solo praxis and the gate-keeper role.

These GP “core” qualities stand in opposition to liberalisation, and are now threatened by it. The second question I shall discuss in my paper is thus how general practice will face this challenge. We do know something about the merits of the traditional qualities of general practice. They seem to make patients more content, they contribute to shared decisionmaking in the consultation, and they limit economic costs through more coordinated services. However we do not know nearly enough, as this research is scanty, untrendy, non-profitable and tends to be overshadowed in the media. My conclusion would be, that to preserve their trade and to contribute to public health, general practitioners must unite to call for changed public research priorities.

Marciano S. Bayle, Carlos Ponte, Manuel Martin, Hixinio Beiras and Felix Payo

The privatization policy of the National Health Service in Spain

Federacion de Asociaciones para la Defensa de la Salud Publica, Spain

Spain is endowed of a powerful National Health Service with free and universal coverage, with a high degree of equity as the most relevant aspect, and health expenses that are found in 5,8% with respect to the GDP (Gross domestic product) (1,3% the private health). Through the last ten years, in Spain several initiatives clearly addressed to the deregulation and privatization of the parts of their public health services have been developped.
The analysis of these initiatives is the object of the present communication.

The first warning on a new direction of the health policy came from the hand of a parliamentary commission, created in 1991 with the purpose to analyse the economics problems of the Spanish National Health Service with the support of all the parliamentary groups. The conclusions, known as the ” Abril Report” were favourable, between others, to the following points: to the division of the financing and the purchase of the health service, to promote the private management of the public health services, to increase the contracting capacity with the private medicine (particularly the high-tech) and to the extension of the copayment of drugs prescriptions to the retired workers, that already exists for the active workers. It is important to notice that in that year the Socialistic Party was in the Government and that previously it had played a positive role in the development and consolidation of the National Health System.

In spite of the recommendations of the “Abril Report” were not put in effect, it is true that it was an important ideological reference towards a mixed sanitary model, which was significant in the further development of the events. Thus, in the 1993, in the context of a strong restriction of public expenditure, some drugs prescriptions were eliminated from the public financing . (Real Decreto of selective financing of the drugs prescriptions).

After 1995, when the Popular Party obtain the Government, the trend towards the internal market and a mixed model is stressed. The hegemony of the right, in the state and in several Autonomous Regions ( Comumidades Autónomas, CC.AA), permits to be approved the recommendations of a Parliamentary Subcommittee for the Consolidation and Improvement of the National Health Service (1996) giving legal coverage to private management of the public health services and to the insurance.

Political interventions in a neoliberal perspective:

1. To privatize the insurance:

• Law of reform of the Taxes. Permit that the companies contract private health insurances with workers, with tax allowances and other fiscal advantages.
• Greater state subsidies to the private medical services of given collective of workers (public officials, journalists, judges and military professional).

2. To privatize the financing:

• Cutting in financing of drugs prescriptions (a new restrictive decreto of selective financing), proposals of copayment (recent statements of the Health Ministry) and limitation of the health services.

3. To privatize management of the public sector.
The new hospitals are endowed of their own legal personality and with administrative structures of private character (the foundations). Let is take one example like the hospital of Alzira, in Valencia, which has transferred all the specialized assistance to a private company.

Global valuation.

In the last years it has been stressed the trends to the mercantilization and privatization of the health public system. The political opposition on the left political spectrum and several forms of social opposition have made possible, in most cases, that these legislative reforms may have had a limited practical effects. In the last months, the Government seems to give up this initiatives and its health policy has been focused on the devolutions process to the 17 Autonomous Regions (Comunidades Autónomas, CC.AA.) These devolutions have to be made with criteria of equity and economic sufficiency, otherwise, it is sure that they will cause an important problem for the immediate future of the public health service.

Alexis Benos*, Stathis Giannakopoulos**, Theodore Zdoukos***,

The ongoing health services reforms by the greek social-democratic governement: a fast way backwards

*Assistant Prof In Social Medicine,
**General Practitioner, Research Fellow,
***General Practitioner, Secretary of the Union of Physicians working in the NHS
Laboratory of Hygiene & Social Medicine, Medical Dept, Aristotle University of Thessaloniki, Greece

Contact: A. Benos

The Greek National Health System was founded in 1983, by the freshly elected Socialist government. During the eighteen years that followed, minor-scale reforms were attempted but never completed. Immediately after April´s 2000 elections the socialist government announced a major reform of the Greek National Health System.
The main characteristics of the health care system are:

• The complete lack of organized Primary Health Care, especially in urban areas.
• Chronic underfunding of the National Health System, mainly from the Public Insurance Funds, and the lowest per capita public expenses for health in E.U.
• The constantly increasing corruption in the public sector.
• The unrestrained development of the private sector supported by public funds.
• Bureaucratic, medical-centered services, mainly located in big urban centers, developed without reasonable design or unified quality criteria.
• Satisfactory access to the National Health System for all people, at least for urgent health problems.

Though it is a paradox, the same conclusions are included in the report that accompanies the new National Health System�s Reform Act, which proposes answers in not such a «socialistic» direction:

Introduction of the institution of the «personal doctor», a kind of «gate-keeper» based on a capitation system, while there is a dramatically low number of properly trained Primary care workers (GP�s, community nurses, health visitors etc.).

Introduction of an internal market based on the purchaser � provider split. Funds� management is granted to an autonomous, privatized �Fund Allocation Organization�. This organization will manage a closed budget, buying services from public as well as private sector, with main consideration on money saving, regardless the quality of services, the state denying any guaranty for covering the real health care needs of the population.

Creation of a new, bureaucratic corpse of managers in the public hospitals, with increased authorities, focused on profit making and money saving, running the hospitals like private enterprises rather than public institutions.
Privatization of crucial sectors of the hospitals (constructions, catering, cleaning).

Strengthening of the strategic role of the private sector, in favor of the big Health Trusts and against individual private doctors and small firms, with generous funding from public expenses. Expansion of this role to medical education.
A hypocritical effort to control corruption by legalizing it! (Offering private services into the hospitals and creating two uneven categories of patients, depending on their financial capabilities).

Lack of evidence based planning according to the local health care needs.

Last, but most important, equal free access to the system is denied to all non-insured citizens (long-term unemployed, immigrants), estimated to be approximately 10% of total population.

In conclusion, the reform carried out by the Greek social democratic government is an integrated, radical reform, based on the same neo-liberal European trends and rhetoric. These policies, enhancing in a cynical way the reemergence of the �inverse care law�, are imposed with only marginal reactions. The necessity of the emergence of a new social movement defending health as a social right is further discussed.

Eva Bejerot and Hans Hasselbladh

Quality systems in Swedish Health Services: Examination and confession technologies

National Institute for Working Life
School of Economics and Commercial Law
S-112 79 Stockholm Box 610, S- 40530 Gothenburg
Eva Bejerot e-mail
Hans Hasselbladh e-mail

A Swedish law was passed in 1996, which stipulated that appropriate quality systems should be introduced to ensure the quality of the health services. Total Quality Management systems has thus received a governmental sanction which contradicts the idea that it is a passing trend. Instead, quality systems may be seen as a central technology in the transformation of the health services in Sweden. The system has become the instrument that will guarantee quality in the services despite diminished funds and entrpeneurisation. During the 90’s a number of quality models have developed and today there is a whole “tool-box” for quality control in the health services. In this paper we will describe the spread of the quality system in the Swedish health services on the basis of a questionnaire. The quality technologies are also discussed with references to Townely’s work on confession and examination technologies and Power’s work on “The Audit Society”.

The spread of the quality system has been mapped out on the basis of a questionnaire study directed to administrative managers and heads of clinics in the Swedish health services. The investigation shows that 80 per cent of all clinics use at least one quality system and that the Swedish model, which corresponds to the American Malcolm Baldrige Award, is the one most commonly used. Managers and local enthusiasts have been of importance in the local spread of these systems, while trade union representatives have hardly been involved at all. Obviously quality has not been seen as anything that challenges professional autonomy, conditions of work or other important union questions. The replies to the questionnaire suggest, however, that there is a broad span regarding views on how well quality systems such as the Malcolm Baldrige Award function in the health services. Discussion on the advantages and disadvantages of the quality system are, however, absent. Possibly this is because the quality system thrives on rhetoric of common good, value for money and continuous improvement, values which can hardly be questioned.

In the “tool-box” for quality management there are several types of tools, which may be categorised in a few main groups: a diagnosis system for management, pedagogic models for staff members, and various methods for the production of measures and key numbers. At present there is an intensive development of national computer bases for key numbers, data which will be presented on Internet so that citizens, politicians, managers and staff will be able to compare the results obtained by clinics, hospitals etc. This technology is legitimated as being an instrument for customers’ choice, but may also be seen as a technology of examination and shame, where those with the lowest key numbers are pilloried in public. Other technologies in quality systems are techniques that may be characterised as a collective confession-technology, and also standardisation of services, an important part of a comodification process, which enables market solutions, partial privatisation and out-sourcing in health care.

References

Townley B. Foucault, power/knowledge, and it�s relevance for human resource management. Academy of Management Review 1993:18; 3, 518-545.

Power M. The audit society: Rituals of verification. Oxford University Press 1997.

Alicia Stolkiner and research team PT48 UBACyT

Research and Health Policies: including the social actors in research

Institution: Secretariat of Science and Technology of the Buenos Aires University
Address: Conde 665 (cp1426) Buenos Aires, Argentina.
Phone / Fax: (54-11) 4555-7365
E-mail

Introduction

I am grateful for this opportunity to participate in this meeting with you. The question that brings us together � is there any possibility of developing and supporting public health care in a neo-liberal environment? — is central to any research in the field of health and is the heart of any study dealing with the Reform of the sector.

The objective of this presentation is to share with you some thoughts about problems that are inherent to research in the area of health. To do this I will focus on three main questions: the delimitation of the field of research in health, the inclusion of the actors in the investigation process and the reflexivity exercised upon the practice of research in this area.

This proposal arises from a work carried out during six years by an interdisciplinary research team, of which I was the director and which was formed through an agreement between an academic unit (the University of Buenos Aires, Argentina) and a health care service provider (the SAMIC-Eldorado Hospital, in the Province of Misiones). The team included staff members of both institutions .

The group analyzed the impact of the transformation of health care services in the health-disease process in a small border town. The purpose was to assess the unique effects of the reform on small units, without the usual dissociation between a macrosocial and microsocial analysis. The study also included health care workers in order to identify the tools that would facilitate their development as social actors in the transformations in course.

Different levels of analysis were used: firstly, the transformation of the State and the Reform of the Health Care Sector in Argentina to set the contextual framework, then, the particular manner in which the Reform was implemented in the Province of Misiones and finally, a specific assessment of the effects of the transformation in a small border town Municipality. Our aim was to shape and to express the discourse and characteristics of the two key potential actors: workers and users of Health Care Centers.

The methodology combined quantitative and qualitative data production techniques. It included surveys, documentation and interviews. Following research tendencies in health systems and services, the study aims to relate the academic activity to political decisions about sectorial policies. But the core of the methodology was the participation of the health workers included in the research team. The participation of these health workers in the research process favored their empowerment as actors that produced political effects at local level.

The partial results of the research were presented at the last IAHP- Europe meeting in Barcelona ( Stolkiner y otros, 1999) and they show tendencies confirmed in the final field research.

Final results show deep transformations in the uses of the services by poor users and in the performance of the sector workers. These transformations imply changes in practices and social representations. There is a great gap between the statements of the reform, and what happens in the daily lives of the poor. When accessibility barriers increase, poor users develop alternative care strategies, but tend to abandon previously acquired service user habits and in some cases even accept death without medical assistance as the natural destiny of their lives. (Barcala y Stolkiner, 2000). Besides, the practices and ways of participation of the sector workers are also modified ( Contreras A. y Radunski P, 2000).The small unit that was studied shows the effects of an extreme use of mercantile logic in an area that is irrelevant as a market. The attempt to have a financially self-sufficient Hospital and to eliminate Government funding, dismantled all types of primary care, the most necessary one given the population profile in the area.

The last ten years of State reform in Argentina seem to indicate that the development of public health, even just the conservation of public health appears to be impossible within this context. But our experience does not necessarily have to be yours. Inspite of this it is good to remember that , as I said in Barcelona, our experience can be a paradigmatic example for you.

An example of what happens when the forces of civil society are weak and democracy can not limit the voracity of financial power and the national economic power groups related with it. The major interest of the most powerful actors in the Argentine health system reform is not the people�s health. The fundamental principles of the adopted reform are foreign to the health-disease process of the population. It should be noted that some of the main motivators behind all this are based on the needs of the economic model: to ensure an equilibrium in government accounts, making them independent of health care costs, to reduce labour costs and to generate investment opportunities for international investors (Gonzalez García, G. and Tobar F.; 1997).

As Mario Borini (1996) wrote, the key objective of the process is to legitimize the appropriation of the surplus that the health care funds could generate. The goal is to have less expenditure than financing as a means to legitimize the profits of the banks and insurance companies. It is the author’s opinion that the ultimate goal is an extreme financial logic (at the expense of private hospitals and mainly professional medical fees) to legitimize the appropriation phenomenon. The competition, in which all the subsectors would be involved, including state-owned hospitals would be a function of the goal to reduce costs and allow a surplus production.

In spite of this situation, at decision levels and in the academic world, the discussion tends to focus on technical and administrative issues. The adoption of innovative management and marketing techniques, quality control standards, etc., have replaced the profound analysis and a realistic assessment of the future for the health care system. Inasmuch as the goals of the transformation are external to the system, a double discourse is generated. It seems that researchers must serve this logic without being critical of it or they will be accused of being �ideologists� without any practical proposals.

We are therefore obliged as researchers to ask ourselves, first of all, what is and what should be our role in this process and the definition of this role will necessarily determine the choice of research strategies. As Alvesson and Sköldberg (2000) wrote �it is not methods but ontology and epistemology which are the determinants of good social science�.

1 The Field of Research in Health. Some Reflections on its Configuration.

As Bourdieu says the incorporation of the concept of field means thinking in relational terms. A field can be defined as a network of objective relations among positions. These positions define themselves objectively by their existence, by both the decisions they impose upon the occupants � the agents or institutions � because of their current and potential location (situs) within the distribution structure of the different kinds of power or capital, the possession of which implies access to the specific earnings that are at stake within the field and finally by their objective relations with the rest of the positions. (Bourdieu P. and Wacquant L. , 1995, pg. 64).

The field of health research appears at an intersection between the specifics of the field of health and the field of science and technology production . This point of intersection implies that its actors and institutions bring together determinations inherent to the health sector on one hand and to the domain of scientific and technological production on the other. Both areas have undergone major transformations directly related to the transformations that have taken place in the relations among State, Market and Society within the framework of the neo-liberal models.

A characteristic of this field of research is that it does not depend heavily on the traditional academic world. Industries, international agencies and organizations, governments and academic entities all participate in it.

Considered globally, the field of biomedicine and technology is the one that probably receives the largest amount of funding, being highly dependent on the interests of the industries involved . During the last decades the chemical-pharmaceutical industry�s needs to increase their competitiveness have led it to invest heavily in research and on some occasions to break ethical codes. It is estimated that laboratories must launch two o three products a year capable of generating sales of over one billion dollars just to stay in the world markets (Bouguerra, M.L. , 2001). The recent legal battles between the South African government and the important laboratories over the cost of AIDS medication is an emerging sign of the times and perhaps even a political one to be kept in mind. They clearly demonstrate the antagonism that exists between the interests in profits and the right to life.

Research into health systems and services or into health policy does not have such a direct link to the market. Its origin is more tied to health policies within the framework of the so-called Social States and to the Latin American developmentalist proposals. The fact that it is linked to states makes it vulnerable to the vicissitudes suffered by these. Although international organizations have been insisting on the need for the development and promotion of this kind of studies for the last two decades, the gap between what is investigated and the need to develop and improve the people�s health is not closing.

A document published by the Council for Health Research makes a quick situational diagnosis and states: ” No more than ten percent of global spending on Health research is devoted to solving the main health problems of the poor… even in countries with a disproportionately high burden of disease the national research effort may not be directed at pressing problems but may be driven by the profit motives of the private sector, the curiosity of researchers or the particular agendas of donor agencies” ( COHRED, 2000- p.2).

What seems to worry those in charge of developing this area is how to make research directly influence the taking of both decisions and action in health, that is to say, the policy making. The debate revolves around the question of how to develop the capacity of effective research (capacity building) and how to involve the policy makers in the results.

I will not stop to discuss this question now but rather to consider what it omits: the determinations that operate in this field of the production of knowledge and its agents. Given the struggle to obtain funding for research, the existence of hegemonic languages and methodological models in the area of health policy research determines the production of knowledge. These, in turn, determine the investigator�s position in this complex institutional world.

The agencies and institutions upon which research depends are also subjected to the same transformations as those that affect the field of health. In analyzing the Brazilian scientific – technological production agencies, Mario Hamilton declares: ” The logic that precedes the realization of scientific activities is influenced by both the widest macro ” institutional context in which they are immersed and by the way the changes in this environment affect the “values” that precede the realization of such scientific activities. Among the principle stimuli affecting this process, the following factors can be highlighted:

1. changes in public policies that tend to stimulate both the commercialization of the generated technologies and the practical application of knowledge that has been developed
2. demands from the macro – environment requiring an adaptation in the orientation of scientific activities towards more intense competition
3. the growing need for scientific institutions to search for alternative sources of research funding due to the decline from traditional public sources”.(Hamilton, M., 2000).

The collapse of the barriers separating private interests and the State, in terms of research, necessarily produces modifications in the values and representations that are the foundation of scientific activity.

For example, the elaboration of indicators and tools for evaluation and management carries an undeniable ideological and political load. A recent article by Vicente Navarro in which he analyses the WHO World Health Report is an excellent exercise in deconstruction, which criticizes suppositions and ideological values used to support the construction of the tool which was, in turn used to produce the same report that assessed the world�s health � care systems based on an overall index of performance (Navarro, 2000).

Although it may be obvious, we must remember that the researchers depend on these vicissitudes for their subsistence and for their recognition . In a recent debate about Health Systems and Services Research Susana Belmartino wrote: ��researchers must be aware that it is a scientific � technical function being exercised within the context of a strong political struggle among social organization models in conflict, and intensified by a demand for financial resources which thoroughly exceeds available supply�� (Belmartino,S., 2001). I do not agree with the definition of �scientific � technical� function for research but I do agree with the statement that �researcher must be aware�. This then, takes us into the subject of reflexivity in the research process.

Reflexivity and critical research

Given the fact that health research is strongly related to practices and their applications, it paradoxically requires a greater epistemological vigilance. This implies always being aware of the determinations and forces that act upon the process of the production of knowledge.

For Alvesson and Skoldberg (2000) a reflective approach means that…�due attention is paid to interpretive, political and rhetorical nature of empirical research. This in turn calls for an awareness among researchers of a broad range of insights : into interpretive acts, into the political, ideological and ethical issues of the social sciences and into their own construction of the �data� or empirical material� . A reflexive approximation implies recognizing oneself in the place one occupies within a specific field. This place is not neutral, is not external and does not stop producing effects.

For example, the fact that the institutional mainstay for our research was a Public University gave us some freedom in the choice of theoretical frameworks and strategies. We are aware of the fact that this freedom tends to diminish when the place of universities is questioned and attacked.

We also decided to include primary level of attention workers as team researchers because we considered that within this reform process they remained objectively linked to the health requirements of the most needy populations. There was a very strong relation between their necessities and demands and those of the population although there continue to be some differences. With their incorporation as participants and valid speakers, we counterbalanced the academic tendency and transferred tools for action into their hands. In fact, we also questioned the traditional concept of scientific objectivity.

This, in turn, was the result of an adopted ideological position; that the investigation had to place two silent actors of the reform process on the stage of events: the primary level workers and the poor users of the sector. Special consideration was also given to the organizations within civilian society that act in the area of health.

Regarding the inclusion of the users, we decided to select a particular group � the poor � and to recuperate as part of the study�s micro and psychosocial dimension their experiences, discourses and strategies. This level of analysis turned out to be indispensable for the emergence of some unexpected results.

It would seem that the weak voice of the users in the reform process is not just a local characteristic. A recent text by Richard Saltmann (2000) states that …� The reform of the Health Sector in Europe during the 90�s has made a great variety of subjects and actors appear. The institutions that provide services, the health sector professionals, the public and private payers and the public authorities, all of them have witnessed the important changes in their roles and responsibilities. The actor whose relation with the health system has least changed, as strange as it may seem, has been the patient.� He concludes by saying that patients are still more objects than subjects with respect to the health service systems.

But this quality and characteristic of being an object is precisely how the patients are represented in the logic of the service providers and is many times adopted acritically by researchers in their methodologies. In the micro and psychosocial dimension of our research the users showed themselves as subjects of great vitality but having a low capacity of impact upon the decision � taking level. This poor population that had had access to free state health services and that had actively participated in a successful primary attention health program � later dismantled by the reform � developed health care strategies which are basic in all rational use of health services. They had a spontaneous tendency towards preventive practices if they were offered the adequate information, they did not practice self-medication with industrial drugs (a frequent habit among Argentine middle class sectors) and within the process of attention they especially valued the doctor�patient relationship very highly, far more than the use of devices and medication. They also established informal community health care networks. The downside of the matter is that when they were prevented from using the services they acted with resignation : the idea of social rights was not installed among them (Barcala and Stolkiner, 2001).

Just like the term `population´, the category of �user�, which is created by the service sector, is an amorphous unit that quickly breaks down into different groups and associations as soon as it is analyzed. �Macro� research tends to consider the users as a unit and passes directly from this undifferentiated collective grouping to the individuals themselves and their behavior. They are frequently omitted as possible actors except to consider their individual behaviors. The opposite of this would be to��overcome the interpretation of the user as an individual-patient-carrier requiring attention and build a new relational perspective that would link the service organization with the needs, expectations and demands of the population under its charge. This would imply incorporating the dimension of groups or social units and refers to ways of organizing demand that could incorporate a political dimension.� (Belmartino, 2001-pg40).

One of the effects that our research work had was to promote a demand for primary health action within the community and this proposal was inevitably taken up by some possibly influential actors. It also strengthened the political strategies of the health worker sector.

CONCLUSIONS

The first step that must be taken to assure that research has an influence on policies and decisions would be to recognize the political nature of all research processes. This implies that the investigators must firstly reflect upon their own position as actors, both in the field in which they do their research and in the field of research itself.

Within the field of research itself, it is a matter of finding collective and social ways of defending the autonomy in the production of learning and knowledge. Nowadays ,research institutions are obliged to submit to market logic as must the health sector. This determines both the possible limits for thought and the influence upon its values.

We must recognize ourselves as actors of our institutions (universities, agencies, etc.) so as to build and defend spaces for counter-hegemonic thought. In Latin America there are extreme cases of social movements made up of people excluded from the system that create or develop their own knowledge producing institutions and centers. This is the case of the Universidad de los Sin Tierra (University of the Landless Ones) in Brazil or of the recent founding of their own university by a faction of the Madres de Plaza de Mayo (The Mothers of May Square).

This is one more emerging factor in the configuration of a globalized pole of groups that defend rights � among them the right to health and to live � and that do not accept being subordinated to the needs of financial capitals. In our countries this antagonism is more evident but in essence it is universal.

Furthermore, any research done in the area of health policies and services requires adopting a position with respect to the actors in that field. We must formulate the questions and the problems from the point of view and understanding the logic of those actors whose interests are objectively bound to the health of the general populations and to the defense of the right to life. The establishment of a knowledge production alliance with these actors fortifies the research processes and simultaneously strengthens their actions. To do this, the research process must necessarily conserve their nature as subjects methodologically intact, that is to say, they must not be objectivized.

All of this does not mean forsaking technical and methodological rigor in research. It simply means abandoning the idea of research done from a neutral site because it is carried out in fields that are basically built upon antagonism and conflict. The question is to favor the redistribution of the symbolic capital, in contrast to the growing tendency towards the concentration of capital and wealth.
Meetings such as these can be part of the fulfillment of this objective.

Bibliography

Alvesson M.& Sköldberg (2000) : �Reflexive methodology- New Vistas for Qualitative Research� SAGE Publications, London.

Borini, M.(1996): “Reforma Sanitaria Argentina: ¿ Cómo se crea un nuevo excedente para una apropiación legalizada?”. Revista Salud Problema y Debate, año VIII, Número 14, Buenos Aires.

Bouguerra M. L.(2001) : En la jungla Farmacéutica Le Monde Diplomatique, año II, No 21, Marzo de 2001.Buenos Aires.

Barcala A. y Stolkiner A. (2001) : “Accesibilidad a Servicios de Salud de Familias con necesidades Básicas Insatisfechas: estudio de caso” VII Anuario de Investigaciones de la Facultad de Psicología- Universidad de Buenos Aires (en edición)

Belmartino S. (2001) : “Redefiniciones posibles en la investigación en sistemas y servicios de salud” Cuadernos para discusión No 1- Red de Investigación en Sistemas Y servicios de Salud del Cono Sud. Rio de Janeiro.2001

Council of Health Research and Development-COHRED (2000) : “The ENHR Handbook- a guide to Essential National Health Researh” , Switzerland.

Contreras A. y Radunski P.(2000) : “Reforma en Salud y Subjetividad de los trabajadores de primer nivel de atención en Eldorado, Misiones” VII Anuario de Investigaciones de la Facultad de Psicología- Universidad de Buenos Aires (en edición).

Cuadernos para La Discusión No 1 – Red de Investigación en Sistemas y Servicios de Salud del Cono Sur. Marzo de 2001. ( in internet:www.bireme.br./bvs/equidad/cuadernos1.pdf)

González García, G y Tobar, F (1997): Más salud por el mismo dinero. La reforma del Sistema de Salud en Argentina, ISALUD, Buenos Aires.

Hamilton, M (2000) : “Análisis Estratégico de Instituciones de Ciencia y Tecnología en Salud: una propuesta metodológica” Cuadernos Médico Sociales No 78. Noviembre de 2000, Rosario

Navarro V. (2000) : “Assessment of the World Health Report 2000” Lancet 2000; 356: 1598-601

Saltman Richard B (2000): “Dimensiones de la Participación Ciudadana en la Atención en Salud” ,Escuela de Salud Pública de la Universidad Emory. Informando & Reformando, Boletín trimestral del NAADIR. Octubre/Diciembre 2000

Stolkiner A. y otros (1999) : “Neoliberalism and Health Services in Argentina: a case study” Barcelona, España, Mayo de 1999. 11 INTERNATIONAL CONFERENCE – International Association of Health Policy- EUROPE