Reperes pour une modélisation systemique des programmes de sante : Approach for a systemic modelling of health programmes

The aim of this paper is to achieve a systemic model to describe a health programme taking into account the influence of the actors. The data were collected via interviews with 15 people collaborating on two programmes: screening of colorectal cancer using the Hémoccult II® test in France, and restructuring health services in a district in Guinea. The results stress that a public and community health programme can be described as a self-organizing, dynamic, observing and observed system. With a systemic approach, a programme can be modelled according to three steps. First, preliminaries: although initially motivated by the wish to improve the system, the intervention on it meets with resistance to any change. This stage proposes to open an "intervention space" including the definition of an appropriate framework, and the modelling of the problematic situation. Second, change: this stage brings new standards in the system. The more useful, the more suited to the mind of the collaborators and the more integrated into the existing social networks, the more easily the changes are welcomed. Finally, autonomization: the regulations of the system contribute to maintain the new standards, and thus to strengthen the changes. In conclusion, in the initial purpose to improve its operational capabilities, an intervention on a local part of the social and health system may, on the contrary, cause troubles. The systemic approach proposes a scenario in order to deal with this complexity. It also gives new insights for planning, implementing, and assessing health programmes.