Looking back to look forward-the history of VAD laws in Australia and future law reform in the Australian territories.

Taking one's own life or attempting to do so has long been decriminalised in Australia. Aiding, counselling, or inciting another person to kill him or herself, however, remains a criminal offence. Yet, all six Australian States have now introduced laws allowing assistance in dying under certain circumstances. This article traces the recent history of Voluntary Assisted Dying (VAD) laws in Australia. It examines the introduction of the world's first assisted dying legislation in the Northern Territory in 1995 followed by the Federal Government's 1997 deprivation of the Territories' power to legislate on assisted dying invalidating said law. It further considers the fifty-seven failed Bills attempting to achieve law reform in this context in Australian jurisdictions between 1993 and 2017 with a view to identifying what factors may have contributed to the continuing lack of success. This article then outlines the rapid introduction of VAD laws in all six Australian States decriminalising VAD over the span of only 5 years. It ponders what may have changed to bring about this law reform. This article closes by contemplating potential future law reform in the Australian Territories, which have been reinstated with jurisdiction to legislate on VAD in December 2022.

Prioritization of research engaged with rare disease stakeholders: a systematic review and thematic analysis.

BACKGROUND: Although rare diseases (RD) are increasingly becoming a priority for healthcare activities and services around the world, developing research policy for investigating RD in public settings proves challenging due to the limited nature of existing evidence. Rare conditions require the involvement of a wide range of stakeholders in order to promote general awareness and garner political support. Consequently, it is critically important to identify trends in the various types of research focusing on rare disease stakeholders, including the specific topics or issues to be included in surveys and studies focused on RD stakeholders. This systematic review and thematic analysis analyses the existing literature based on RD surveys, including the stakeholders involved, and proposes potential research priorities and initiatives for policy-making related to RD. METHODS: Articles were downloaded and analyzed from across five electronic databases (PubMed, EMBASE, Cochrane Central, Web of Science, and CINHAL) and 115 studies were included. RESULTS: Across 115 studies, the main research participants were patients and/or caregivers (n = 77, 67.0%), health professionals (n = 18, 15.7%), and the public (n = 7, 6.1%). The studies discussed RDs in general (n = 46, 40.0%), endocrine, nutritional, and metabolic diseases (n = 20, 17.4%) and other RDs. Experiences with RD were examined by more than half of the selected studies (n = 74, 64.3%), followed by the opinions of stakeholders (n = 24, 20.9%). Most of the studies used surveys in order to collect relevant data (n = 114, 99.1%). Additionally, the majority of the studies were conducted in high-income countries (n = 92, 80.0%) and rarely in middle and low-income countries (n = 12, 13.8%). CONCLUSION: Stakeholder research on RD reveals that there are significant instances of unmet needs and various challenges faced by the medical system in dealing with RDs. Furthermore, public awareness and support is critical to ensuring political feasibility of increasing national-level investments for RDs and development of medical products and treatment.

Creating an Enabling Environment for a Comprehensive Sexuality Education Intervention in Indonesia: Findings From an Implementation Research Study.

PURPOSE: This study examines key factors that facilitated and hindered creating an enabling environment for the implementation of SEmangaT duniA RemajA/Teen's Aspirations (SETARA), a comprehensive sexuality education (CSE) intervention in schools across three sites in Indonesia. METHODS: Data were collected through interviews with teachers, program implementers, and government officials; a review of program documents and monitoring and evaluation data; and a qualitative evaluation with SETARA students. RESULTS: One of the most important factors for creating an enabling environment for CSE relates to how well the program is introduced to government officials for approval. Findings showed that the relationship between the implementing organization and city government officials was important for obtaining approval, support, and formal agreements on collaboration. Framing the curriculum within local policies and priorities made it easier to communicate to schools, community, and parents. Buy-in from school principals was important for creating a supportive environment. Complexity of the materials, lack of time to prepare and implement sessions, and teacher-level factors such as pedagogical skills and misaligned values remain key challenges despite trainings. DISCUSSION: The study suggests that it is possible to implement and create political support for CSE in conservative contexts, especially with a good introduction of the program. Potential solutions for implementation and scaling barriers may lie in the digitalization of the intervention and of capacity strengthening and technical support for teacher. More research is needed to investigate which content and exercises can effectively be delivered digitally and which should best be delivered by teachers to maintain the effect of breaching the taboo around sexuality.

Can the use of minipublics backfire? Examining how policy adoption shapes the effect of minipublics on political support among the general public.

Academics and practitioners are increasingly interested in deliberative minipublics and whether these can address widespread dissatisfaction with contemporary politics. While optimism seems to prevail, there is also talk that the use of minipublics may backfire. When the government disregards a minipublic's recommendations, this could lead to more dissatisfaction than not asking for its advice in the first place. Using an online survey experiment in Belgium (n = 3,102), we find that, compared to a representative decision-making process, a minipublic tends to bring about higher political support when its recommendations are fully adopted by the government, whereas it generates lower political support when its recommendations are not adopted. This study presents novel insights into whether and when the use of minipublics may alleviate or aggravate political dissatisfaction among the public at large.

[Perceived Inequality and Political Demand]. / Perzipierte Ungleichheit und politische Nachfrage: Wie beeinflussen Wahrnehmungsbias und mediale Rahmen die Einstellungen zur Vermögensteuer?

According to a recent social science debate, citizens tend to perceive income inequality rather inaccurately, which also influences their acceptance of redistributive policy programmes. The study reported in this article examines whether this can be confirmed using the example of the wealth tax. The wealth tax was suspended in Germany in 1996, but politicians have been debating its reintroduction for several years. Against the background of the debate on biased perceptions in the formation of distributional policy preferences, the article asks, first, how accurately the existing tax burden on wealthy households through the top income tax rate is assessed and whether a bias has consequences for the support of a wealth tax. Second, based on approaches that attribute an important role to mass media in the formation of distributional policy preferences, the influence of media framing on the acceptance of this controversial instrument is examined. According to data from an online survey, the burden of the top income tax tends to be overestimated. The more the tax is overestimated, the lower the political support for a wealth tax. Framing experiments with randomized control and treatment groups have mapped current discourses around the wealth tax and reconstructed positive frames-wealth taxes as an investment promoting tax reform, as a contribution to the reduction of national debt caused by the coronavirus pandemic-as well as negative frames-restriction of investments and loss of jobs if companies are burdened. Exposing potential job losses significantly lowers the support for a wealth tax. Strong support drops to the middle category of "partly/partly," a signal of indecision. The struggle for naming power is thus open. Support for a property tax becomes uncertain the more that political communication activates the framework of threatened jobs.

The rise of COVID-19 cases is associated with support for world leaders.

COVID-19 has emerged as one of the deadliest and most disruptive events in recent human history. Drawing from political science and psychological theories, we examine the effects of daily confirmed cases in a country on citizens' support for the political leader through the first 120 d of 2020. Using three unique datasets which comprise daily approval ratings of head of government (n = 1,411,200) across 11 world leaders (Australia, Brazil, Canada, France, Germany, Hong Kong, India, Japan, Mexico, the United Kingdom, and the United States) and weekly approval ratings of governors across the 50 states in the United States (n = 912,048), we find a strong and significant positive association between new daily confirmed and total confirmed COVID-19 cases in the country and support for the heads of government. These analyses show that political leaders received a boost in approval in the early months of the COVID-19 pandemic. Moreover, these findings suggest that the previously documented "rally 'round the flag" effect applies beyond just intergroup conflict.

A political economy perspective on horizontal FDI in a dynamic Cournot-oligopoly with endogenous entry.

Entry in a homogeneous Cournot-oligopoly is excessive if and only if there is business-stealing (Amir et al., 2014). The excessive entry prediction has been derived primarily for closed economies and using a welfarist benchmark. We extend this framework and allow for (1) horizontal FDI in a multi-period setting and (2) interest group-based government behaviour. Opening the market to greenfield investments from abroad tends to aggravate the entry distortion. Moreover, market opening may reduce welfare if a more pronounced entry distortion dominates the gain in consumer surplus. Finally, a government, which places sufficiently little weight on the interests of consumers, will object to market opening, even if welfare rises.

United in Diversity, Divided in Adversity? Support for Right-Wing Eurosceptic Parties in the Face of Threat Differs Across Nations.

This article investigates whether the perceived threat of terrorism explains the support for right-wing Eurosceptic parties and Euroscepticism above and beyond other relevant variables, including perceived economic and immigration threats. We first examined the entire Eurobarometer samples of 2014 and 2015, and then conducted survey experiments in four European Union (EU) countries, that is, United Kingdom (N = 197), France (N = 164), Italy (N = 312), and Romania (N = 144). Our findings suggest that the perceived threat of terrorism has a small effect on the negative attitudes toward the EU above and beyond the effect of immigration and economic threats and other basic control variables. The relationship between these variables varies across countries and it is less linear than we might expect.

Varieties of political support in emerging democracies: A cross-national analysis.

Political support is a multidimensional construct encompassing evaluations of political leaders and institutions (specific support) as well as adherence to basic regime principles (diffuse support). Scholars have traditionally assumed that diffuse and specific support are driven by different forces and evolve largely independently. Prior empirical work, however, has struggled to untangle the two support dimensions and focused predominantly on cross-national differences, ignoring their dynamics. This paper develops an analytical and empirical approach to examine the levels and dynamic interplay of both support dimensions and estimate their determinants, applying it to South American democracies between 1996 and 2015. Contrary to received wisdom, we show that both dimensions are quite volatile and closely linked in this region. In particular, negative economic shocks not only undermine support for government actors, but also fuel democratic disenchantment. Nonetheless, while regime support is rather fickle in South America, it can be ultimately resistant to performance fluctuations.

What are the constraints and opportunities for HIVST scale-up in Africa? Evidence from Kenya, Malawi and South Africa.

INTRODUCTION: HIV self-testing (HIVST) has the potential to increase uptake of HIV testing among untested populations in sub-Saharan Africa and is on the brink of scale-up. However, it is unclear to what extent HIVST would be supported by stakeholders, what policy frameworks are in place and how variations between contexts might influence country-preparedness for scale-up. This qualitative study assessed the perceptions of HIVST among stakeholders in three sub-Saharan countries. METHODS: Fifty-four key informant interviews were conducted in Kenya (n=16), Malawi (n=26) and South Africa (n=12) with government policy makers, academics, activists, donors, procurement specialists, laboratory practitioners and health providers. A thematic analysis was conducted in each country and a common coding framework allowed for inter-country analysis to identify common and divergent themes across contexts. RESULTS: Respondents welcomed the idea of an accurate, easy-to-use, rapid HIV self-test which could increase testing across all populations. High-risk groups, such as men, Men who have sex with men (MSM), couples and young people in particular, could be targeted through a range of health facility and community-based distribution points. HIVST is already endorsed in Kenya, and political support for scale-up exists in South Africa and Malawi. However, several caveats remain. Further research, policy and ensuing guidelines should consider how to regulate, market and distribute HIVST, ensure quality assurance of tests and human rights, and critically, link testing to appropriate support and treatment services. Low literacy levels in some target groups would also need context-specific consideration before scale up. World Health Organization (WHO) policy and regulatory frameworks are needed to guide the process in those areas which are new or specific to self-testing. CONCLUSIONS: Stakeholders in three HIV endemic sub-Saharan countries felt that HIVST will be an important complement to existing community and facility-based testing approaches if accompanied by the same essential components of any HIV testing service, including access to accurate information and linkages to care. While there is an increasingly positive global policy environment regarding HIVST, several implementation and social challenges limit scale-up. There is a need for further research to provide contextual and operational evidence that addresses concerns and contributes to normative WHO guidance.

Design of CIAO, a research program to support the development of an integrated approach to prevent overweight and obesity in the Netherlands.

BACKGROUND: The aim of this paper is to describe the research aims, concepts and methods of the research Consortium Integrated Approach of Overweight (CIAO). CIAO is a concerted action of five Academic Collaborative Centres, local collaborations between academic institutions, regional public health services, local authorities and other relevant sectors in the Netherlands. Prior research revealed lacunas in knowledge of and skills related to five elements of the integrated approach of overweight prevention in children (based upon the French EPODE approach), namely political support, parental education, implementation, social marketing and evaluation. CIAO aims to gain theoretical and practical insight of these elements through five sub-studies and to develop, based on these data, a framework for monitoring and evaluation. METHODS/DESIGN: For this research program, mixed methods are used in all the five sub-studies. First, problem specification through literature research and consultation of stakeholders, experts, health promotion specialists, parents and policy makers will be carried out. Based on this information, models, theoretical frameworks and practical instruments will be developed, tested and evaluated in the communities that implement the integrated approach to prevent overweight in children. Knowledge obtained from these studies and insights from experts and stakeholders will be combined to create an evaluation framework to evaluate the integrated approach at central, local and individual levels that will be applicable to daily practice. DISCUSSION: This innovative research program stimulates sub-studies to collaborate with local stakeholders and to share and integrate their knowledge, methodology and results. Therefore, the output of this program (both knowledge and practical tools) will be matched and form building blocks of a blueprint for a local evidence- and practice-based integrated approach towards prevention of overweight in children. The output will then support various communities to further optimize the implementation and subsequently the effects of this approach.

Preaching to the converted? An analysis of the UK public for space exploration.

This article presents the results of a survey carried out at two space outreach events in the UK aimed at characterising "the public for space exploration" and measuring public support for space exploration. Attitude towards space exploration and policy preferences were used as measures of public support. The sample involved 744 respondents and was mainly composed of adults between 25 and 45 years old, with men slightly over-represented compared with women. Findings revealed that males appeared to be stronger supporters than females - men had a more positive attitude towards space exploration and stronger space policy preferences. Because mixed groups tend to come together to such events we argue that male respondents would be more likely to be part of the "attentive" and "interested" public who come to outreach activities and bring a less interested public with them.

Legitimidad y percepciones generales de justicia de las autoridades legales de Córdoba (Argentina): Un abordaje desde las valoraciones de justicia procedimental / Legitimacy and general perceptions of judicial authorities from Córdoba (Argentina): An approach from procedural justice perceptions

La justicia es uno de los principios básicos que se aplica a individuos e instituciones, siendo un facilitador social que posibilita la interacción entre personas y grupos (Tyler, 2000). Por esta razón, se ha convertido en un tema de gran interés para la investigación en Psicología Social. Distintos autores han examinado el impacto de las experiencias en las percepciones de legitimidad de las autoridades (Baird, 2001; De Cremer & Tyler, 2007; Hinds, 2007), así como la influencia de estas valoraciones de legitimidad, en el comportamiento de obediencia de normas (Murphy, 2005; Tyler, 1990). En el estudio que se informa se examinaron las percepciones de legitimidad de autoridades legales de Córdoba (Argentina), por parte de los ciudadanos. Asimismo, se estudió el impacto de las valoraciones de justicia procedimental sobre las valoraciones de legitimidad y justicia de las autoridades. Finalmente, se controló la influencia de variables socio-demográficas y situacionales. Para ello, se tomó una muestra no probabilística, cuotificada por edad, género y nivel socio-económico, de 300 personas de la ciudad de Córdoba que hubieran tenido contacto reciente con alguna de las autoridades en estudio (Policía, Policía Caminera, juzgados e inspectores municipales). Los resultados mostraron que las valoraciones de las autoridades locales son, en general, negativas. Además, las valoraciones de justicia procedimental realizaron un aporte significativo a la explicación de las valoraciones de legitimidad y justicia de las autoridades en general. Las variables de control no mostraron una influencia significativa.

Justice is a desirable principle in social interactions. At the same time, in the case of institutions, justice is a virtue that is manifested in its role of distributing goods and costs or rights and duties (distributive justice) and its corrective function topunish actions that violate social norms (justice sanctioning) (Garzón, 2004). The role of justice as the main regulator of social relations has become a topic of great interest to Social Psychology. The majority of recent studies in this perspective of justice have investigated perceptions of procedural justice, this is, justice based on the process used by an authority to make a decision. Most researchers found that procedural justice evaluations are an important predictor of the legitimacy of the authorities. However, these studies have been conducted mainly in the United States, and in our local area there is no previous research centered in this perspective of justice. Although there are some previous studies that recognize the problem of legitimacy in Latin America (Latinobarometro Corporation, 2010; Salles, 2010; Turner & Carballo, 2010), we have no knowledge of local research, conducted in the field of Social Psychology, that examines the origins of this lack of confidence in legal authorities. For this reason, the present study evaluates not only perceptions of legitimacy of legal authorities, but also their relationship with procedural justice values. According to that, we study the impact of citizens’ procedural justice perceptions of a particular experience with a legal authority on perceptions of legitimacy and fairness of the authorities in general. In addition, we control for the influence of various socio-demographic variables (gender, age, educational level and socioeconomic status) and status (presence of a conflict, the voluntariness of the experience, the favorability of outcomes and the relevance of results and treatment) on this relationship. We used a retrospective ex post facto design in a nonrandom sample of 300 citizens (54.7% male) from the city of Córdoba (Argentina). We interviewed only those who had a personal experience with at least one of the authorities under study (police, traffic police, courts, and municipal inspectors) during the last year. Most of the situations involved contact with the police (52.9%) or traffic police (30.4%), whereas only 10% were with municipal inspectors, and the remaining 6.7% were situations related to court issues. Moreover, the vast majority of situations with the authorities involved a non-voluntary contact (71.7%) and only 9% included a dispute with another person. The descriptive results of the perceived legitimacy of the authorities were consistent with previous research: Most people did not have a positive valuation of legal authorities, and courts were the institutions worst valued, while the traffic police were among the best valued. It was also found that procedural justice is a significant predictor of perceptions of legitimacy (r = 52) and General Valuation of Justice (r = 61) of the legal authorities. Regarding the control variables, we found that the socio-demographic and situational variables have no significant effect on these two dependent variables, when procedural justice is taken into account. These results are important because they expose the relevance of authorities’ performance during their contacts with citizens: those who believed that authorities had not acted in a fair way during their personal encounter, were more likely to assign less legitimacy to authorities in general. This results are relevant in Social Psychology field, taking into account that previous research has emphasized the relevance of legitimacy and justice perceptions for the support of the authorities and their effectiveness, that is, the maintenance of the social order.

Legitimidad y percepciones generales de justicia de las autoridades legales de Córdoba (Argentina): Un abordaje desde las valoraciones de justicia procedimental / Legitimacy and general perceptions of judicial authorities from Córdoba (Argentina): An approach from procedural justice perceptions

La justicia es uno de los principios básicos que se aplica a individuos e instituciones, siendo un facilitador social que posibilita la interacción entre personas y grupos (Tyler, 2000). Por esta razón, se ha convertido en un tema de gran interés para la investigación en Psicología Social. Distintos autores han examinado el impacto de las experiencias en las percepciones de legitimidad de las autoridades (Baird, 2001; De Cremer & Tyler, 2007; Hinds, 2007), así como la influencia de estas valoraciones de legitimidad, en el comportamiento de obediencia de normas (Murphy, 2005; Tyler, 1990). En el estudio que se informa se examinaron las percepciones de legitimidad de autoridades legales de Córdoba (Argentina), por parte de los ciudadanos. Asimismo, se estudió el impacto de las valoraciones de justicia procedimental sobre las valoraciones de legitimidad y justicia de las autoridades. Finalmente, se controló la influencia de variables socio-demográficas y situacionales. Para ello, se tomó una muestra no probabilística, cuotificada por edad, género y nivel socio-económico, de 300 personas de la ciudad de Córdoba que hubieran tenido contacto reciente con alguna de las autoridades en estudio (Policía, Policía Caminera, juzgados e inspectores municipales). Los resultados mostraron que las valoraciones de las autoridades locales son, en general, negativas. Además, las valoraciones de justicia procedimental realizaron un aporte significativo a la explicación de las valoraciones de legitimidad y justicia de las autoridades en general. Las variables de control no mostraron una influencia significativa.(AU)

Justice is a desirable principle in social interactions. At the same time, in the case of institutions, justice is a virtue that is manifested in its role of distributing goods and costs or rights and duties (distributive justice) and its corrective function topunish actions that violate social norms (justice sanctioning) (Garzón, 2004). The role of justice as the main regulator of social relations has become a topic of great interest to Social Psychology. The majority of recent studies in this perspective of justice have investigated perceptions of procedural justice, this is, justice based on the process used by an authority to make a decision. Most researchers found that procedural justice evaluations are an important predictor of the legitimacy of the authorities. However, these studies have been conducted mainly in the United States, and in our local area there is no previous research centered in this perspective of justice. Although there are some previous studies that recognize the problem of legitimacy in Latin America (Latinobarometro Corporation, 2010; Salles, 2010; Turner & Carballo, 2010), we have no knowledge of local research, conducted in the field of Social Psychology, that examines the origins of this lack of confidence in legal authorities. For this reason, the present study evaluates not only perceptions of legitimacy of legal authorities, but also their relationship with procedural justice values. According to that, we study the impact of citizens’ procedural justice perceptions of a particular experience with a legal authority on perceptions of legitimacy and fairness of the authorities in general. In addition, we control for the influence of various socio-demographic variables (gender, age, educational level and socioeconomic status) and status (presence of a conflict, the voluntariness of the experience, the favorability of outcomes and the relevance of results and treatment) on this relationship. We used a retrospective ex post facto design in a nonrandom sample of 300 citizens (54.7% male) from the city of Córdoba (Argentina). We interviewed only those who had a personal experience with at least one of the authorities under study (police, traffic police, courts, and municipal inspectors) during the last year. Most of the situations involved contact with the police (52.9%) or traffic police (30.4%), whereas only 10% were with municipal inspectors, and the remaining 6.7% were situations related to court issues. Moreover, the vast majority of situations with the authorities involved a non-voluntary contact (71.7%) and only 9% included a dispute with another person. The descriptive results of the perceived legitimacy of the authorities were consistent with previous research: Most people did not have a positive valuation of legal authorities, and courts were the institutions worst valued, while the traffic police were among the best valued. It was also found that procedural justice is a significant predictor of perceptions of legitimacy (r = 52) and General Valuation of Justice (r = 61) of the legal authorities. Regarding the control variables, we found that the socio-demographic and situational variables have no significant effect on these two dependent variables, when procedural justice is taken into account. These results are important because they expose the relevance of authorities’ performance during their contacts with citizens: those who believed that authorities had not acted in a fair way during their personal encounter, were more likely to assign less legitimacy to authorities in general. This results are relevant in Social Psychology field, taking into account that previous research has emphasized the relevance of legitimacy and justice perceptions for the support of the authorities and their effectiveness, that is, the maintenance of the social order.(AU)

The Characteristics of Healthy City Project in Korea / 農村醫學 地域保健

OBJECTIVES: The purpose of this study was to investigate healthy city project related characteristics to members of the Korea Healthy Cities Partnership(KHCP). METHODS: This study analyzed general characteristics of healthy city, characteristics of healthy city(political support, collaboration & citizen participation, healthy city project, infrastructure development, capacity building), self-evaluation of healthy city and etc by self-questionnaires from February to December, 2007, which were distributed to government workers who were in charged in health city project of 23 membership cities of KHCP. RESULTS: The number of urban city was 11(47.8%) and that of rural municipality was 12(52.5%). Public health center was almost in charge of healthy city project(73.9%). As for the characteristics of healthy city, healthy city municipal budget(91.3%), city health profile(91.3%), technical support of cooperative university(82.6%), healthy city regulation(78.3%), citizen participation(78.3%), committee(73.9%), setting approach(69.9%) and healthy city network(69.6%) were good. But intersectoral collaboration(34.8%), long-term healthy city plan(39.1%), administrative policy or campaign promise(43.5%), programs to the vulnerable population(47.8%), department in charge(47.8%) and seminar(47.8%) were not good. Especially, characteristics of healthy city according to the existence of department in charge were significantly different in intersectoral collaboration, citizen participation, setting approach and healthy city network. CONCLUSIONS: In spite of rapid expansion in healthy cities, there were great difficulty in political support, collaboration, department in charge and programs of health equity. So we need to go a long way to achieve the vision of healthy cites by its principles and characteristics.

Implementação da reforma sanitária: a formação de uma política / Health reform implementation and policy formation

Este artigo procura interpretar o processo de implementação da reforma do sistema de saúde ocorrida na década de 1990. A implantação de uma política é dotada de autonomia e envolve decisões, além de ser um processo de adaptação em função das mudanças do contexto, portanto, sua implementação exige decisão e iniciativa governamental, e instrumentos para efetivá-la, entre os quais a disponibilidade de recursos financeiros e o suporte político organizado, particularmente, por parte dos grupos sociais afetados positivamente. O processo de implementação da reforma da política de saúde não é simplesmente a tradução concreta de decisões, mas um processo ainda de formulação da política de saúde. Durante esse processo, tiveram grande importância não apenas os efeitos do contexto político-econômico de ajustes e a reconfiguração da agenda pública, mas principalmente os efeitos de feedback das políticas de saúde anteriores, que se traduziram na ausência de suporte político, no subfinanciamento e na incapacidade de publicização da rede de serviços, os quais funcionaram como constrangimentos à implementação completa da reforma nos termos de seus formuladores. Dentro desses limites, foram tomadas decisões cruciais que redefiniram a reforma, sendo as mais significativas o estabelecimento do marco regulatório da assistência privada, que explicita a segmentação e derruba formalmente as pretensões universalistas, e as relacionada ao financiamento, que ainda configurava objeto de disputa. O resultado foi a consolidação de um sistema de saúde dual - público e privado.

This paper analyses the process of implementation of the health system reform in the 1990s. The starting point is the proposition that policy implementation is endowed with autonomy and involves decisions, apart from being a process of adaptation to changes in context; implementation requires governmental decision and initiative and tools to make it effective, among them the availability of financial resources and organized political support, especially from those groups that benefit more directly. The process of implementation of the health system reform was not simply a concrete translation of decisions, but also a process of health policy design. In it, the effects not only of adjustments in the political and economic contexts and of the reconfiguration of the public agenda, but mainly the feedback effects of previous health policies could be felt. The latter translated themselves into the absence of political support, underfinancing and the incapacity to create a public network of services. They acted as constraints to the full implementation of the reform, as it was conceived by its formulators. Within these limits, crucial decisions were made, which redefined the reform, the most important being, on the one hand, the creation of a regulatory framework for private assistance that made the segmentation explicit, formally abandoning any universalistic intent, and, on the other hand, those related to financing, which still are an object of dispute. The result is the consolidation of a dualistic health system - public and private.