Visión de futuro
version ISSN 1668-8708
Vis. futuro vol.15 no.2 Miguel Lanus July/Dec. 2011
Organizational Philosophy in the Management of Health in Misiones
Gloria Beatriz, Orzuza
Universidad Nacional de Misiones -
Facultad de Ciencias Económicas
Ruta 12 - Km 7,5 - C.P. 3304 - Miguel Lanús - Misiones - Argentina
The passage of time brings us new knowledge, science advances in all its aspects, which translates to all areas of the organization, of management.
Health care is undergoing marked changes, the welfare model, which serves as a function of demand is gradually adapting to the actions recommended by the sanitary model that acts more intensely with the communities and the environment, promoting health and preventing disease.
The aim of this paper is to reflect the change that occurred in the organizational philosophy of the health system of Misiones. To this end, we first know the concepts of Newtonian and quantum organizations, focused from its philosophical origins. Second, we will refer to the legal framework of the management expenses of the Province government. Third, we analyze the socioeconomic status of the population of Misiones. Fourth, we will refer to the new health paradigm. To finish off highlighting the definitive implementation of a holistic approach, in the health system.
KEYWORDS: Philosophy; Health; Management; Decentralization.
When the World Health Organization (WHO) in its Alma Ata Declaration in 1978, considered the Primary Health Care (PHC) as a key strategy to achieve Health for All by the year 2000: Argentina as a Member State joined together with other countries, the purpose of achieving the stated objective.
APS was defined as "a strategy that comprehensively conceived health problems - disease and care of individuals and society as a whole." [Gateway of the Government of Argentina, 2011, p. 1](1). Acting in a manner that not only provides relevant services to health, "but confronting the root causes (social, economic and political) health absence."[Gateway of the Government of Argentina, 2011, p. 1](2).
In 2003 the Alma Ata completed its 25th anniversary celebration that led to the evaluation "of the values and principles that inspired the Declaration years ago."[Pan American Health Organization, 20073, p.1](3). The purpose was to formulate future strategic and programmatic orientations in PHC, for a new strategy for the renewal of the license that achieves its ambitious goal.
In 2007, in Buenos Aires, the International Conference on Health for Development was held: Rights, facts and realities in the Declaration Towards a strategy for health equity, based on primary care, one analyzed the achievements and difficulties in the implementation of the PHC strategy. Established as the main objective, "to promote the strengthening of already established consensus and generate new proposals aimed, at the consecration of a health strategy for equity, based on primary care." [Pan American Health Organization, 2007, p.1](4).
In this context Misiones implemented a comprehensive health policy, embodied in its Health Law, supplemented by the Decentralization Program for Primary Care Management of Health and in line with the National Federal Health Plan, which corresponds to the Declaration of Alma Ata.
This article aims to reflect the change that occurred in the organizational philosophy of the province health system, focused from the new paradigm assumed. Because it begins to phase out Newtonian management structures and begins to introduce a new approach, the quantum organization. A model that requires the holistic conception of the players involved in the system, where citizen participation acquires a fundamental importance, where the result set by government-population management will result in the transparency of management, institutional strengthening and improving the health indicators over time becoming lines of priority actions to solve the problems of Misiones' citizens.
In order to understand how this, Newtonian need to go back arises. Each new season that starts, is characterized by passing, at first, through a period of criticism of the earlier era. The current dominant theological and philosophical thought was medieval scholasticism, based on a perfect coordination between faith and reason, giving priority to any circumstance to faith rather than reason. Thus, when you start the first time in modern times, the Renaissance, the first question that arises is why in the Middle Ages they referred only to the other world, the world of ideas, beyond their interest in the salvation of man and did not consider another thought, another reality. It focuses then as main subject of criticism, the method of knowledge, which became the dominant theme of the Middle Ages. This is when you decide to look at this world, to the earthly aspect, toward nature and toward the ideal world.
Whoever who breaks this scholarly tradition is Rene Descartes, who was not only a remarkable philosopher but also a great scientist (just remember discoveries as the laws of refraction and reflection of light, besides being the creator of analytic geometry), which initiated modern philosophy in general and particularly rationalism. The rationalism, which emphasized, the role of reason in knowledge acquisition. Any question starting from a situation that should be absolutely safe, because if it was theoretically inadequate it should be abandoned, we sought to arrive at a knowledge that would be absolutely true. The method employs Cartesian doubt to see if something can resist and that the result is absolutely true. This leads to the doubt being methodical, i.e. it is the tool to get to the truth.
Expression which responded to the issues covered in the four rules of the method.
The precept of Evidence or even of methodical doubt: to admit as truth, knowledge only if it is evident that there is no reason to doubt it. It must meet two characters, clarity and distinction.
The precept of Analysis: Divide the difficulties in as many parts as possible, for the purpose of a better solution. That is, continuing the division until it reaches the obvious.
The precept of Synthesis (also called deduction) or order: Ordering the thought of the simplest to the most complex, always in order to solve more complex problems.
The precept of the enumeration or Control: Ensuring that one has not forgotten to consider any issue or aspect, requires a comprehensive review to ensure that it is not missing any aspect of the reasoning.
Isaac Newton grasped the knowledge and scientific principles of mid-seventeenth century, with the innovations introduced by Galileo, Bacon, Descartes, Kepler. Newton's permanent idea was to find the how instead of the why; concern that allowed him to develop important theories. As Newton's binomial mathematical theorem or Newton's binomial, as the three fundamental laws of motion, Newton's first law or the law of inertia, the second law of interaction and strength, and the third action and reaction; from which the fourth, was deduced, which is best known: the law of gravity. But he not only advanced in mathematics but also in optics, to achieve and explain the composition of white light as a mixture of the colors of the rainbow, he created the first telescope reflector type, worked on topics such as thermodynamics and acoustics. It represented the culmination of the scientific revolution of "the sixteenth and seventeenth centuries, the intellectual transformation that created the modern science and as a representative of this transformation, had an influence on shaping the world of the twentieth century." [Westfall, 2006, p. 9](5)
The seventeenth century gave rise to the mechanistic philosophy that explains nature as a set of mechanical principles, explained by a mathematical system. It said the goal of natural philosophy was to draw conclusions based on a true hypothesis and infer the causes making its effects, allowing to reach by their effects, allowing to reach the origin, the very first cause, which concluded it was not mechanical.
These concepts were transferred to the field of organizations, which reflect in their design characteristics of Newtonian physics, a structured view, hierarchical, mechanistic view of reality. An ordered pattern perfectly assembled, a world which moves precisely similar to how a watch whose particular functions and interrelationships with other mechanisms are unique, sharp and clear.
That is, an organization that has a stable structure, which is characterized by high specialization in the work, which has departmental divisions where there are many rules, it is highly formal, it has a high number of hierarchical levels, there is a great horizontal difference, communication is vertical, the control sections are reduced, centralized decision making and long command chains.
In the same mechanical symphony, respecting the principles and characteristics "in the twentieth century there emerged scientific management from the ideas of great thinkers and doers like Taylor, Fayol, Ford, Weber and Mayo." [García and Morgado Carneiro, 2008, p. 3](6). The principles settled in the work organization, the selection and worker training, cooperation and payment for individual performance, responsibility and expertise of managers in planning the work, tending to specialization and systematization of operations in organizations. In thinking the worker as a machine, they carried out time and motion studies to perform the tasks in the shortest time possible, without repeating movements, demonstrating conclusively that labor was a process tool.
The quantum theory was installed in 1900 when Max Planck introduced to the German Physical Society his theory of black body radiation, related to the idea of quantum action. Saying that "the light energy can be emitted and absorbed in discrete units called quanta" [Montoya and Montoya, 2002, p. 17] (7) . Tried to "explain a generalissimo phenomenon of the materials employed, independent of the material, the shape of the spectrum of radiant energy in thermal equilibrium, which depends exclusively on its temperature." [Mataix and Rivadulla, 2002, p. 17] (8)
This theory introduced a conceptual revolution in physics, more than "describe properties of bodies or corpuscles, like Newtonian mechanics or vector intensities of the various fields, such as Maxwellian electromagnetism, it describe states of quantum systems." [Mataix and Rivadulla, 2002, p. 18](9)
In 1905, Einstein based on the work of Planck, "one would apply that all forms of electromagnetic radiation can occur not only as a wave, but also how many." [Montoya and Montoya, 2002, p. 17](10). With the discovery of both Planck and Einstein, "was born the first quantum paradox: light and other forms of energy have a split personality and sometimes behave like waves and sometimes like particles." [Montoya and Montoya 2002, p. 17](11).
In 1913 Bohr, following the ideas of Planck and Einstein, and incorporating "the study of the light spectrum of the hydrogen atom, would propose a new model for the atom." [Montoya and Montoya, 2002, p. 17](12).
In 1925, Heisenberg, Bohr and Jordan, introduced matrix mechanics, which involved "use only observable energy concepts and probability. The quantification is interpreted as strong matrix switching. "[Mataix and Rivadulla, 2002, p. 22](13).
In 1926, Schrödinger "founded wave mechanics." [Mataix and Rivadulla, 2002, p.22](14). In the same year, Born "gives the statistical interpretation, a new application to crash." [Mataix and Rivadulla, 2002, p. 22] (15).
In 1927, Dirac formulates "as a complete set of commuting observables and only probabilistic relationships between the measures of two of these sets." [Mataix and Rivadulla, 2002, p. 22](16). Referring to the probabilistic interpretation of the wave function and the total equivalence. As Heisenberg "reasons the inaccuracy relations: indeterminism in the measurement." [Mataix and Rivadulla, 2002, p. 22](17). Affirming, through the uncertainty principle, it is impossible to accurately measure simultaneously the position and momentum of a particle.
In 1928 Bohr gives "his principle of complementarity: definition against observation." [Mataix and Rivadulla, 2002, p. 22](18). To specify that the light and electrons sometimes act like waves and sometimes as particles, but their properties cannot be observed simultaneously with each other but are complementary and necessary for a correct interpretation. The new organizational paradigm is based on quantum physics (1900 and 1925), initiated by Planck and continued by scientists such as [...] "Einstein, Bohr, Heisenberg, Schrödinger. It continues with scientists such as Penrose, Hawking, Glashow. "[Ramos, 2003, p. 147](19), which differ from classical scientists, from Newtonian mechanics, in the manner as phenomena described, that occur in very small systems (atoms, nuclei, electrons).
"Quantum science describes a physical world that is holistic, unpredictable and self-organized. The quantum systems are similar to particles and waves, which have both individual and group properties. "[Inga, 2007, p. 18](20). In this world, absolute uniformity and prediction are impossible. "Living in a quantum world requires us to change habits. We need to stop describing tasks and instead facilitate process. We must become experts at building relationships. "[Wheatley, 1994, p. 70](21). The organization must have the vision and values as central driving force.
Legal framework for management of government expenditure
The Constitution of the Province of Misiones states that the government management costs, are assumed from the economic activities of government and participation in taxes imposed by the Nation as primary sources. To use these resources as a basis the expenditure budget by saying, "any special law, which disposes or authorizes expenses not foreseen in the budget, shall determine the appropriate special use, except to respond to an extreme public need." [House of Representatives, 1958, p. 12](22)
The legal framework of the General Budget is part of the Accounting Law of the Province of Misiones No. 2303, which establishes the general characteristics to be done. The Province Constitution also designates the Court of Auditors as "the competent body to examine the accounts of perception and investment in national income." [House of Representatives, 1974, p. 1](23)
In this context the budget process consists of four successive stages:
First Stage: Preparation. Government priorities are established for the fiscal period, the strategies to address them and the specific resources that will be used for compliance. Each unit does its province budget and submits it to the Ministry of Treasury and Finance, which concentrates all the information and carries out an adjusted analysis to the resources, the incorporation of new programs and the maximum (limit) of expenditure for each jurisdiction. The project, once established, must be submitted to the Legislature Power for discussion and approval before July 31st of each year.
Stage Two: Approval and Promulgation. It is the most visible stage of the budget process, the government presented a bill package of income and expenses for legislators to discuss approve or modify such projects. It is sent to the Budget Committee of the Legislature for consideration, later moving on to the members of the Chamber for approval. Once approved by the Budget Act, the Legislature returns it to the Executive for promulgation and publication in the Official Bulletin.
Stage Three: Implementation. The government implements its programs according to the provisions of the Budget Law approved. It is the moment when the executive power, through the use of resources, carries out the public policy defined for each financial year.
Stage Four: Assessment and Control. This stage is crucial because the government is accountable for the amount held and the results obtained. The audit must be issued on the use of resources, efficiency and rationality. In this regard there are two types of controls. One internally, in situ, within the Executive Branch within the field of Accounts of the Province, and one external, ex-post, independent of executive government, supervised by the Court of Auditors.
Within this framework the we have the budget allocated to the health area.
In 2007, the Province Health Act No. 4388, which in its Article 1 states, which aims to ensure "all the inhabitants of the province to have access to better health and life quality, in terms of the Province Constitution, being a public policy provisions. "[Ministry of Public Health, 2010, p. 5](24)
The Executive Power has to define the province health policy. Recognizing the primary responsibility of the State, concerning the health of the community and individual health, as a shared responsibility between the state, the individual and the community.
It sets, as a body for discussion and proposed major health policy guidelines, the creation of Province Health Council. Through the Province Health System which will organize and administrate the public service.
This Act is based on four models: Care, Management, Quality and Finance, engaging "in bringing health to the population through the Primary Health Care."[Ministry of Public Health, 2010, p. 4](25)
Consistent with the new philosophical vision at the beginning of 2008, by Decree 71/08 the Province Government approved the Decentralization Management Program for Primary Health Care, a program which "consists in the gradual decentralization, permanent and total health care of the state health subsector to achieve a more effective primary care, efficiency, effectiveness and equity." [Orzuza, 2008, p. 108] (26). the aim is to strengthen the link between the government and its municipalities in co-management processes and social responsibility for health and particularly in the planning, implementation and evaluation of health services. Action aims to improve final health indicators in municipalities and taking action for preventing health problems.
The socioeconomic status of the population of Misiones
The population of Misiones was 965,522 people, representing 2.7% of the country's population, according to the National Population and Housing 2001 Census, which implied a growth of 22.4% as to 1991; this percentage ranked as the seventh largest province inter-census population growth. Of the total registered population, 70.6% (681,673 people) lived in urban areas and 29.4% (283,849 people) in rural areas, with a male sex ratio of 100.6.
The National Institute of Statistics and Census (INDEC) prepared population estimates for the period between 2001-2015, projecting that the province of Misiones in 2010 would be 1,111,443 inhabitants and that by 2015 it will reach 1,197,823 people. Provisional data published by Population 2010 Census published to date by the Province Institute of Statistics and Censuses (IPEC), indicates that the population of Misiones amounts to 1,097,829 people, a number lower than the projected estimate by the INDEC, a figure that implies a population growth of 13.7% over 2001.
In 2001 the birth rate stood at 24.2 per thousand, higher than the country total which represented 18.2 per thousand. 57.8% of the Misiones population "had no coverage of social work in 2001. The highest percentage corresponds to the age group between 0 to 4, with 66.2%. "[Orzuza, 2010, p. 83](27)
In 2006, the death rate per thousand amounted to 5.5, lower than the national level of 7.5 per thousand.
In 2007, the 21,639 births in Misiones, 21.8% were to mothers under 20, exceeding the 15.8 Country total. That same year, infant mortality was 14.6 per thousand, higher than the national 13.3. And the maternal mortality rate was 8.3 per 10,000 live births above the national figure of 4.4.
The unemployment rate reached in the fourth quarter of 2010, 3.7% in Posadas, lower than that estimated for the 31 urban areas considered at country level, 7.3%.
New Health Paradigm
The genesis of the paradigm shift is reflected in the priority set by government authorities when they committed their action to achieve the full term of the right to health for the population, stating that primary care is the way to carry out the overall health.
To achieve the goal they set four paradigms:
"1. Talk about health instead of disease.
2. State Health Policy, rather than party politics and government.
3. State Regulatory role rather than active role.
4. Subside demand rather than supply. "[Ministry of Public Health, 2010, p. 1] (28)
Basing its action on four pillars.
"The Attention Model is based on the APS as an organizing principle of the province system with criteria of equity, efficiency, effectiveness, solidarity. The Management Model is based on decentralization and self-management of hospital services. The Model of Health Care Quality and Health Services is based on regular and continuous application of quality assurance standards. The quality through the other three models and is defined as the user satisfaction and the unimpeded exercise of their right to health. Financing Model leads to self-managed hospitals not only as a concept of cost-recovery tuition but also an equitable application of these funds. "[Ministry of Public Health, 2010, p. 1] (29)
This model aims at the Province Health Insurance whose ultimate goal is to end social exclusion, health, of its vulnerable population.
Province Health Act
This policy is framed in Law 4388, which to realize the objectives, establishing the Province Health Board as a body of debate and proposals of the major health policy guidelines (advisory status). Province Institutes of Health System formed by the institutions of public administration and private sector to provide health services. In the health sectors and subsectors there are three care levels. The first level addresses the actions and services for prevention, diagnosis, treatment and rehabilitation services in basic specialties, family medicine, for outpatient care. The second consists of all the services that involve specialized outpatient care or require hospitalization of any type. So one should prioritize the strengthening of the Health Centers, Hospitals Departmental inpatient capacity of basic specialties. And the third, which is made up of all actions and services of high medical and technological complexity, which by their particular nature are found on the top step of the network of medical benefits.
This model aims at administrative decentralization of the respective use of effectors of the second and third levels of care, to strengthen and consolidate their skills definitive institutional management and functional integration for networks of health care system.
Decentralization Management Program for Primary Health Care
With the approval of the program begins the process of gradual decentralization. This action will strengthen the link between the Province government with the municipalities in the process of co-management and social responsibility of health, aimed at improving health indicators in municipalities. Coordinating Unit and Operational Coordination structures will help achieve the objective set by public health policy. Its implementation will be through the signing of an agreement between the Province of Misiones and the municipality, which will enable the transfer of Province resources to the latter to meet the expenses arising from the Primary Health Care. The resources consist of a monthly per capita payment. It is worth clarifying that the Province Health Law specifies that the annual budget of the Organization Ministerial Unit of Public Health shall not be less than 10% of the annual General Budget of the Province, also, the Law of Public Administration of Province Budget, for Fiscal Year 2008, No. 4397, authorizing the Executive to allocate the sum of one dollar per month per person for the purpose of ensuring primary health care.
Distribution Zones and Territorial Health Program Areas
In early January 2008 by Decree 97/08 there was approved the restructuring of the health zones and program areas under the Ministry of Public Health.
According to this decree, the public health system is structured in Misiones in six areas of health, XIX Program Areas, 32 Level I Hospital Care for Low Risk; 8 Level II, Medium Risk; 4 Level III, high risk and 314 Primary Care Health Centers geographically located throughout Misiones, covering the 75 municipalities that comprise it.
Characteristics of the Newtonian organization mechanical system is reflected in the field of Province public health, identifying primarily with the budget process for the allocation of resources. A process that has a stable organizational environment that is embedded in a legal framework, which sets limits on each stage, which defines the sequence in which the institutions involved, the dates that each sector should submit information to its superior, that respects the vertical chain of command of the hierarchical pyramid, which has well-defined control systems. Each agency that is part of the budget process knows when to act on the system. In each sequence, each actor knows that he has a role to play, hence the interest in each task specialization, which are clearly defined and delimited and are constantly the same.
Thus, the organizational structure of the health sector acts waiting for the sick, watching what was the symptom present to determine the type of disease to be attended to by creating health programs that address this theme, it is total welfare.
In quantum organizations one observes horizontal structures, employees contribute to the common tasks of the departments, collaborating in the vertical and horizontal functions which are adaptable, tasks are set and defined through the employee's work team, there is little formalism, the hierarchy of authority is less, controls and rules are minor, the knowledge and control tasks are located anywhere within the organization, communication is horizontal, the deciding authority is decentralized.
This situation implies increasing internal integration and improving organizational capacity to respond quickly to sudden changes in an uncertain environment. In a moving environment, the work must be constantly redefined to meet the ever changing world. Members of the organization must have ability to solve various problems.
Features of this quantum system, holistic, is reflected in the Province health policy defined for Misiones, where it provides that the guarantor of comprehensive health care is the primary care. Proclaiming the beginning of an arduous task of changing paradigms, old due to years being in practice, have not adapted to other trends, including international ones, which indicated the need for a change of direction for the health of the population. It expresses, as one of the actions to be executed, the health planning with social participation, through the democratization of the actions that help eliminate inequities.
Before the 90s health care focused toward healing aspects, at present directed to prevention and health promotion.
There begins, then a long road ahead of changing patterns of decentralization. A system which sets off from the Province Ministry of Public Health, incorporates the municipality and reaches the citizen, to diminish the risk of becoming ill, through sustained sanitary promotion, prevention, and health protection actions. Executing a decentralization process, defined through the Decentralization Management of the Primary Health Attention. Decentralization which will allow decision taking, in the highest level of the organization.
In the province public policies, defined for the public health sector, there meet two kinds of management structures, two different philosophies to face the same subject. On one hand the system which contains the budget process, is frame worked in a Newtonian - mechanist organization, where all the process answers to a pyramidal structure, perfectly frame worked within the juridical environment, where the control systems are perfectly frame worked, where each part integrating the complex of the process, has got its functions perfectly defined, and acts accordingly, representing perfect gears in a machine. On the other hand we have a new health system, which is beginning to be implemented, which was defined in a new paradigm, which is backed by a recently sanctioned health law, which establishes the decentralization of management of primary attention, which incorporates new actors to the system, (municipal and citizen), which was projected in harmony with The National Federal Health Plan, which had its origin in the Alma Ata Declaration, defined by the WHO. This responds to a holistic system, quantum, to a change in thought and execution model, where one pretends to establish that the energy flow from the Province responsible authorities, towards the citizen and once again flows towards the central government with new demands, with new needs, evidencing mistakes, reaching a dynamic connectivity between government and those governed.
One observes that there coexist two organizational philosophies, mechanist and quantum, that both are executed without any problem. But one knows that new organizations have to be created, more open, participative and with greater adaption capacity. It is important to highlight that the quantum emphasizes the participation role, the citizen must incorporate this concept to his mental scheme, he must understand that there is a relation, between the individual's action and the whole. The present task is complex, but not impossible. Health is a universal right, as instituted by the Conference on International Primary Health Attention, called Alma-Ata Declaration (1978), health is the state of total welfare, physical, mental and social, and not only the absence of infections or illnesses.
One should stop looking and applying the theories of the XVII Century, one should begin to explore what is known in the XXI Century, one should expand the search in the organizational principles, which include what is known of the universe.
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