Dissertations / Theses on the topic 'Public health Financing'

Includes bibliographical references.
Financial risk protection against the cost of unforeseen ill health has become a global concern as expressed in the 2005 World Health Assembly resolution (WHA58.33), which urges its member states to "plan the transition to universal coverage of their citizens". The study (the first of kind in Ghana) measured the relative progressivity of health care financing mechanisms, the catastrophic and impoverishment effect of direct health care payments, as well as evaluating the factors affecting enrolment in the national health insurance scheme (NHIS), which is the intended means for achieving equitable health financing and universal coverage in Ghana. To achieve the purpose of the study, secondary data from the Ghana Living Standard Survey (GLSS) 2005/2006 were used. This was triangulated with data from the Ministry of Finance and other ministries and departments, and further complemented with primary household data collected in six districts. In addition 44 focus group discussions with different groups of people and communities were conducted. In-depth interviews were also conducted with six managers of District NHI schemes as well as the NHIS headquarters. The study found that generally Ghana's health care financing system is progressive. The progressivity of health financing is driven largely by the overall progressivity of taxes which account for over 50% of health care funding. The national health insurance levy is mildly progressive as indicated by a Kakwani index of 0.045. However, informal sector NHI contributions were found to be regressive. Out-of-pocket payments, which account for 45% of funding, are associated with significant catastrophic and impoverishment effects on households. The results also indicate that high premiums, ineffective exemptions, fragmented funding pools and perceived poor quality of care affect the expansion of the NHIS. For Ghana to attain adequate financial protection and ultimately achieve universal coverage, it needs to extend cover to the informal sector, possibly through funding their contributions entirely from tax, and address other issues affecting the expansion of the NHI. Furthermore, the funding pool for health care needs to grow and this can be achieved by improving the efficiency of tax collection and increasing the budgetary allocation to the health sector.

Health systems aim to improve population health. Despite global efforts, millions of children still die every year from vaccine preventable diseases and undernutrition attributed deaths. Moreover, about 293,000 maternal deaths occurred in 2013. The sources of these deaths include various inequalities such as vaccine coverage, nutritional status, and health services utilization. In order to make progress toward mortality reduction, we need to address the sources that are most likely to affect the poorest. One strategy is conditional cash transfers (CCTs), which provides cash payments in exchange for compliance with health-related conditionality. This dissertation explores evidence from two large randomized experiments in Indonesia, PKH (a large-scale household CCT) and Generasi (a large-scale incentivized community block grant). Chapter two investigates whether PKH improves vaccination coverage among poor children. After two years of implementation, the results show that PKH leads to significant increase in vaccination coverage for all vaccine types among children younger than 12 months old. The evidence also suggests that PKH is equity enhancing by reducing the differences in vaccination coverage between children living in more and less supply-ready areas and children of more and less educated mothers. Chapter three investigates the impact of PKH and Generasi on child food intake. The results show that both programs increase child food intake particularly for protein-rich items. They increase milk and fish intake up to 19% and 14% compared to the control group means, respectively. Improving child nutrition outcomes, PKH reduces wasting and severe wasting up to 41% and Generasi reduces the prevalence of severely underweight children up to 47%, compared to the control areas. Chapter four explores how PKH and Generasi help improve determinants of maternal mortality among poor women. Evidence shows different results between the two programs with Generasi produces more positive impact in many aspects of determinants. Both programs, however, are unlikely to have a large effect on maternal mortality due to factors that might significantly reduce the program’s effectiveness. For instance, while the programs improved utilization, they did so at community-based facilities, which are not appropriate for delivery services in the case of obstetric emergency.
Global Health and Population

Bibliography: leaves 302-333.
Health financing reforms, especially those aimed at improving equity, are prone to opposition. Those driving health reforms frequently find themselves pitted against vested interests. The thesis explores how best a reform driver might manage other actors in the reform process to achieve key goals. This involves creating and testing a conceptual framework. A review of the international health care reform literature identifies key gaps in knowledge. Additional bodies of theory, mainly from economics, are selected for review on the basis of their potential insight into relationships between reform drivers and actors. Their findings are compared and contrasted and taken forward into a conceptual framework. This is then tested against four case studies of health financing reform in South Africa: geographic resource allocation, health insurance and the removal of user fees, largely between 1994 and 1999, and the reform of the Conditional Grant for Tertiary hospitals, from 2000 to 2002. Two different approaches are used for testing the conceptual framework. First, key themes about managing actors are drawn from actor interviews in three case studies of health financing reform. With the second, more deductive, approach reform drivers in-- an additional case study were questioned on every element of the conceptual framework to see whether it provided an adequate description and understanding of how reform processes occurred. These two very different approaches acted as a check against each other but produced similar findings. The thesis suggests that an awareness of actor characteristics (such as resources, constraints, reputation and interests) can help a reform driver better manage reform development to achieve desired change. Reform drivers should build up teams of actors that can at the very least bring power, technical skills and specialist knowledge to the reform effort. Team building will also require careful consideration of the different forms of motivation appropriate to each actor. Ideally reform drivers should avoid opposing actors. Yet the prevailing context may indicate this is not possible. In such case reform drivers should limit information exchange, present and discuss reforms at a conceptual level, undermine technically any counter-reform design and choose carefully in which arena to fight.

South Africa possesses a highly fragmented health system with wide disparities in health spending and inequitable distribution of both health care professionals and resources. The national health system (NHI) of South Africa consists of a large public sector and small private sectors which are overused and under resourced and a smaller private sector which is underused and over resourced. In broad terms, the NHI promises a health care system in which everyone, regardless of income level, can access decent health services at a cost that is affordable to them and to the country as a whole. The relevance of this study is to contribute to the NHI debate while simultaneously providing insights from other countries which have implemented national health care systems. As such, the South African government can then appropriately implement as well as finance the new NHI system specific to South Africa’s current socio-economic status. The objective of this study was to examine health care financing models in different countries in order to draw lessons for South Africa when implementing the NHI. A case study was conducted by examining ten countries with a national health insurance system, in order to evaluate the health financing models in each country. The following specific objectives are pursued: firstly, to review the current health management system and the policy proposed for NHI; secondly, to examine health financing models in a selected number of countries around the world and lastly to draw lessons to inform the South African NHI policy debate. The main findings were firstly, wealthier nations tend to have a much healthier population; this is the result of these developed countries investing significantly in their public health sectors. Secondly, the governments in developing nations allocate a smaller percentage of their GDP and government expenditure on health care. Lastly, South Africa is classified as an upper middle income developing country; however, the health status of South Africans mirrors that of countries which perform worse than South Africa on health matters. In other words the health care in South Africa is not operating at the standard it should be given the resources South Africa possesses. The cause of this may be attributed to South Africa being stuck in what is referred to as the “middle income trap” amongst other reasons.

Includes bibliographical references (leaves 73-80).
Drugs are an important factor of production in health care. They constitute a significant proportion of health care expenditure in both developed and developing countries rendering financing of drugs an important health care concern. Previous studies have focused on health care financing in general and less on drug financing specifically and more so in least developed countries. This study therefore aims to provide an overview of the drug-financing situation in Uganda demonstrating the flow of funds for drugs in the health sector. The study further investigates whether the available financial resources could be sustained over time and assesses financial sustainability of resources for drugs in the public sector required to meet the drug component in the National Minimum Health Care Package. Data collection methods involved in-depth interviews with key informants in the relevant institutions and document reviews of financial records and other major relevant publications. The data obtained was analyzed using well-established methodologies. Financing mechanisms were analyzed using a framework consisting of aspects regarding viability, reliability and level of funding. The fund flows for drugs in the health sector were analyzed using the modified National Health Accounts methodology and finally financial sustainability was assessed using projections from the available financial resources. The study findings reveal a mix of financing mechanisms from both the public and the private sector employed to make drugs available to the population. The largest source of drug funding is out-of-pocket expenditure by households followed by central government tax revenue including donor support. There has been a noted increase in drug funding in the public sector though this is not adequate to cover the quantified drug need in the country. The size of the market for drugs increased over the review period (2001-2004) with an estimated total drug expenditure of 210 billion Uganda shillings. The projections show that the available financial resources for drugs will not be able to cover the predicted drug requirement within the National Minimum Health Care Package more so with the introduction of drugs required to treat new diseases like HIV/AIDS and the change to more expensive treatments for endemic diseases like malaria. The study concludes with policy recommendations urging government's commitment to allocate more resources to health and consequently to drugs so that there is less reliance on donor funding. It recommends that more effective means of utilizing available resources by mobilization of domestic resources including out-of-pocket payments through better-designed and well-managed health insurance schemes.

The public sector of all western developed countries has become increasingly involved in financing health care during the past century. Today, thirteen OECD countries have passed landmark legislative reforms that call for compulsory prepayment and universal entitlement to comprehensive services, while most of the others achieve similar coverage through a mixture of public and private voluntary arrangements. This study carried out a detailed analysis of why, how and to what effect governments became involved in health care financing in eight of these countries. During the early phase of this evolution, reliance on direct out-of-pocket payment and an unregulated market mechanism for the financing, production and delivery of health care led to many unsatisfactory outcomes in the allocation of scarce resources, redistribution of the financial burden of illness and stabilisation of health care activities. This forced the state to intervene through regulations, subsidies and direct provision of services. Expansion in prepayment of health care gradually occurred through private insurance, social insurance and general revenues in response to different socio-economic, political and bureaucratic forces. Although improving health may have been the ultimate goal, offering universal access to affordable health care was the way the countries examined achieved this objective. Universal comprehensive coverage was associated with a decade of stable public expenditure on health care compared with GDP, total government expenditure and government consumption expenditure. There were no disproportionate increases in health care expenditure or displacement of public funds away from social programmes that depended on cash transfer payments. Nor do the countries that offer such social protection have higher public debt or poorer economic performance compared with the rest of the OECD. Measures of health status are unfortunately still not sufficiently developed or standardised to permit a detailed analysis of this aspect of outcome through cross-national comparisons. Furthermore, the countries examined may be more vulnerable to political backlash because of the high visibility of their government involvement in health care financing.

The objective of the study was to validate the assumption that respondents who self-identified as white, were more likely to be enrolled in a Medicare Advantage HMO Plan and underutilize health care services when compared to their non-white counterparts.

The results showed that the majority of the respondents in the stratified population of Medicare eligible respondents were categorized as White, 11,271 out of 15,297, and 42% reported being enrolled in a Medicare Advantage HMO Plan. A total of 3,685 of the White respondents on Medicare Advantage HMO Plans indicated they were in "Good" or better health, which was 78% of all White respondents in this population. The mean number of times that White respondents were seen by an MD (Figure 2) fell within the same range of 5-6 times for the majority of the Race/Ethnic groups. The mean number of hospital stays for Whites and the other Race/Ethnic groups ranged from 1.86-1.92 within the same 12 month period, with the exception of Pacific Islanders.

South Africa possesses a highly fragmented health system with wide disparities in health spending and inequitable distribution of both health care professionals and resources. The national health system (NHI) of South Africa consists of a large public sector and small private sectors which are overused and under resourced and a smaller private sector which is underused and over resourced. In broad terms, the NHI promises a health care system in which everyone, regardless of income level, can access decent health services at a cost that is affordable to them and to the country as a whole. The relevance of this study is to contribute to the NHI debate while simultaneously providing insights from other countries which have implemented national health care systems. As such, the South African government can then appropriately implement as well as finance the new NHI system specific to South Africa’s current socio-economic status. The objective of this study was to examine health care financing models in different countries in order to draw lessons for South Africa when implementing the NHI. A case study was conducted by examining ten countries with a national health insurance system, in order to evaluate the health financing models in each country. The following specific objectives are pursued: firstly, to review the current health management system and the policy proposed for NHI; secondly, to examine health financing models in a selected number of countries around the world and lastly to draw lessons to inform the South African NHI policy debate. The main findings were firstly, wealthier nations tend to have a much healthier population; this is the result of these developed countries investing significantly in their public health sectors. Secondly, the governments in developing nations allocate a smaller percentage of their GDP and government expenditure on health care. Lastly, South Africa is classified as an upper middle income developing country; however, the health status of South Africans mirrors that of countries which perform worse than South Africa on health matters. In other words the health care in South Africa is not operating at the standard it should be given the resources South Africa possesses. The cause of this may be attributed to South Africa being stuck in what is referred to as the “middle income trap” amongst other reasons.

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Our federal, state, and local governments are not investing in the design and improvement of strategies for evaluating the costs associated with natural and man-made disasters and events. In this era of fiscal conservatism, one of the biggest challenges in designing and funding public health preparedness is deciding exactly how much to invest and determining the impact of those investments. This thesis developed a rigorous scientific model to evaluate the benefit of using value-based tools to enhance the effectiveness of public health preparedness programs. The key question that framed this research was: Are public health departments that use value-based decision-making more likely to demonstrate and document higher levels of preparedness competencies? Although this research failed to demonstrate a statistically significant relationship between preparedness competency and value-based decision-making, there were some findings to indicate that VBDM may be useful in decisions that determine the financing of public health preparedness. The ability to analytically demonstrate the benefit of public health preparedness might prove beneficial in attracting additional public funding as well as private funding.

This thesis seeks to contribute to the knowledge base about social policy in the United States, using long-term care (LTC) financing policy reform as an illustrative example. Specifically, this thesis explores LTC financing reform efforts during three U.S. Presidential administrations: Bill Clinton (1993-2001), George W. Bush (2001-2009), and Barack Obama (2009-2010). Within this historical framework, the LTC provisions of the Health Security Act of 1993, the development of the Community Living Assistant Services and Supports or 'CLASS' Act during the Bush Administration, and the legislative success of the CLASS Act as a part of the Patient Protection and Affordable Care Act of 2010 provide comparable cases to compare the drivers of social policy. Drawing on the explanatory frameworks of the welfare state such as ideology, historical institutionalism, and an actor-centered approach to policy analysis, this thesis argues that successful path-departing legislation is difficult to achieve due, in part, to the presumed high costs of social programs and the complex institutional framework of the American political system. Policy outcomes result from the interaction between the complex processes and dynamics of the political system through which policy change (or the failure to change) actually occurs. The fact that the CLASS Act was politically successful, yet administratively inoperable as designed, reinforces the argument that social policy outcomes in the United States are reflective of a complex, enduring struggle of competing ideologies. This continual struggle, coupled with a heightened concern over cost control and fiscal austerity, helps to ensure that policies which are legislatively successful within the institutional architecture of the American political system are unlikely to produce major expansions of the welfare state. Social change is therefore highly difficult to achieve, even in the face of significant unmet social needs. Comprehensive reform of U.S. LTC financing arrangements will remain an elusive goal for the foreseeable future. Instead, incremental, highly pro-market solutions are likely to be the types of policies promoted in the years of ahead.

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Constitutional Amendment No. 29 of 2000 (EC No. 29/2000) was approved with the purpose of ensuring adequate financial resources for public health and of involving and committing the three government levels by the funding from the public health sector in the country. The objective of this study is to analyze the allocative decisions of the states and Federal District influenced by EC N ° 29/2000. To carry out this study has been conducted an inferential, explanatory quantitative and qualitative research, addressed using the empirical method to analyze historical data for expenditures allocations to the public health of the States and Federal District in relation to the EC No. 29/2000. The data were analyzed using mathematical methods and statistical techniques used in econometrics. The study has identified that the differences in the fiscal and socioeconomic environments of the states produce different decisions in the public health sector. During the period analyzed, the EC No. 29 and the net income per capita have influenced the variability of the indicator that measures the application rate in the public health sector. However, more financial resources in the sector did not ensure the public health improvement service. Partly managers do not have the appropriate skills to promote the change process with the purpose to improve the effectiveness and efficiency of the sector. This situation is aggravated by the party-political factors that interfere in the sector by means of promoting people without proper qualification and by means of making decisions based on political criteria to the detriment of technical and operational criteria.
A Emenda Constitucional N° 29 de 2000 (EC N° 29/ 2000) foi aprovada com a finalidade de garantir recursos financeiros para a saúde pública e envolver e responsabilizar as três esferas governamentais pelo financiamento do setor público de saúde no país. O objetivo deste estudo é analisar as decisões alocativas dos Estados e Distrito Federal mediante a EC N° 29/ 2000. Para realizar este estudo foi conduzida uma pesquisa inferencial, explicativa, quantitativa e qualitativa, abordada com o uso do método empírico para analisar séries históricas das alocações de gastos destinados à saúde pelos Estados e Distrito Federal em relação à EC N° 29/ 2000. Os dados foram analisados por meio de aplicação de métodos matemáticos e técnicas estatísticas usadas na econometria. Identifica-se que as diferenças dos ambientes socioeconômicos e tributários dos estados produzem decisões diferentes no setor de saúde pública. No período analisado, a EC N° 29 e a receita líquida per capita influenciaram a variabilidade dos percentuais aplicados em saúde. Entretanto, maiores recursos financeiros no setor não garantiu a melhoria dos serviços de saúde pública. Em parte, os gestores não tem a capacitação adequada para promover o processo de mudanças com fins de melhorar a eficácia e a eficiência do setor. Esta situação é agravada pelos fatores político-partidários que interferem no setor promovendo pessoas sem a qualificação adequada e tomando decisões com base em critérios políticos em detrimento dos critérios técnico-operacionais.

In the field of HIV, more than 30 years into the epidemic, the need to ensure that what researchers learn makes its way into tangible actions in the real world is especially poignant. This dissertation addresses the critical divide between research production and its translation into practice. It advances ways to measure the investments of citizens and stakeholders in qualitative studies and offers new perspectives on the losses inadvertently caused by particular investments in health research and services. Unfortunately, many of the problems in how we practice and disseminate research are rampant throughout the health and development research sector. Therefore, while this anthropological dissertation focuses on HIV and Lesotho, several of the findings are applicable in other geographical and topical settings. This dissertation explores how the practice of conducting qualitative research becomes a type of disease prevention intervention itself cutting across systems. Using a large qualitative HIV sexual, social, and behavioral health research project, as a case study, I illuminate how health research knowledge makes its way (or not) to the populations for whom it is intended. Following up four years later, using in-depth semi-structured and structured interviews, I probe practical and theoretical issues involving the original research assistants, a comparison group, and representatives from organizations targeted to be most likely to use the research findings. I pilot a communication diffusion measurement tool that visualizes the researchers’ ability to apply what they learned from the research experience in talking to their families, partners, acquaintances, work colleagues, and students/trainees. The results indicate significant differences between the original team and the comparison group’s communication diagrams, demonstrating the tool’s usefulness in visualizing who is talking to whom, with what magnitude, and the types of life moments that trigger opportunities to have quality conversations about HIV, sex, and Multiple Concurrent Partnerships (MCP). As evidenced in this study, team members are part of the larger social system. They have the potential to influence the formal dissemination of HIV prevention information into policy and programming as well as the informal diffusion into their own life and in the lives of those they encounter in their social network. Nowhere in translation and dissemination research descriptions are the research team members discussed. Based on this research, I argue that, in addition to greater involvement of the public and stakeholders in translational research, there is a need to include the “implementers” of research beyond that of the principal investigators: the research staff. There is a need to further conceptualize the role of the “research team” in the translation of research to practice paradigm. Data have been collected from grey documents, project reports, scientific papers, newspapers, and websites establishing current points of focus for well-funded global entities in context with our understanding of transmission and prevention dynamics and debates. Analysis of these sources reveal strong rhetoric for combined biomedical, social, behavioral and structural approaches but programming and funding reports reflect much more weight and financing to biomedical solutions. The findings from organizational representatives interviewed in this study reveal that the creation of research and diffusion of information will follow the funding. Similar to Lesotho, many researchers and health professionals in developing countries are hired into biomedical or clinical projects for employment. This project explores the HIV response as part of economic, social and health development in Lesotho supported by the aid industry, and presents data on how the investments of money influence the ways in which local leaders and everyday citizens define, communicate, and conceive solutions to the problem of HIV. In the mid-term, translating biomedical findings into real world realities requires qualitative research. Ethically sound and well-trained qualitative researchers are fundamental in the creation and diffusion of knowledge. As the findings in this study indicate, the qualitative experience provides an opportunity to understand the epidemic that leads people to change their own behaviors, influence those around them, and have the desire to facilitate conversations to provoke social action and change. However, this study also demonstrates how people can go years talking, studying, and working in HIV without ever having an “awakening” or deeper understanding of HIV in their local reality. Study results delve into the long-term effects on the local researchers, furthering our understanding of the different ways in which “capacity” is built in the local involvement. The dissertation also explores critical questions about qualitative research methods and ethics within a context of investigating a disease where everyone—researchers and the researched—are either infected or affected. Based on this research, I argue that true education about HIV is a dialogical perpetual process of interrogating what we know, imagining what should be done and trying: Praxis. This heightened awareness of how our daily research practices link to larger systems will help us not to allow our do-gooder attempts to blind us to the harm we may inadvertently do, or to the lost opportunities we squander. Instead, we must capture and maximize our investments in research and people as agents of change and not only as patients, participants, or employees.

Mestrado em Economia e Políticas Públicas
Em Portugal, em 2001, foi anunciada a construção de 10 novos hospitais em regime de PPP com a inovação de incluírem a gestão clínica durante 10 anos. Estes hospitais de 1.ª vaga (apenas 3 em funcionamento - Cascais, Braga e Loures - e o de Vila Franca Xira a concluir a sua construção) representam um encargo no ano de 2012 de 300,5 milhões de euros e continuarão a constituir encargos para o Orçamento Estado nos próximos 30 anos em amortizações e juros, pelo que se tem questionado se a contratação tradicional (construção e gestão pública) não será financeiramente mais adequada. No presente trabalho pretende-se estudar uma alternativa, com financiamento público resultante da venda do património dos hospitais substituídos e gestão pública tradicional. O caso em estudo é a construção do Hospital Oriental de Lisboa. Para identificar a necessidade deste novo investimento e, por isso, quais os hospitais a substituir, foi utilizado o Plano Diretor Regional (2002), único instrumento de planeamento regional conhecido. O trabalho valoriza o património daqueles hospitais, atribuí um custo à construção do novo hospital pelo modelo tradicional, considera o seu custo em PPP e compara o orçamento de exploração deste com o dos hospitais substituídos. Ficou assim evidenciada dentro de um conjunto de pressupostos, a vantagem da reorganização da rede hospitalar substituindo 5 antigos hospitais pelo Hospital Oriental de Lisboa e neste caso, a vantagem na substituição do atual modelo PPP pelo modelo de contratação pública tradicional com financiamento público.
In 2001, the Portuguese Government announced the construction of 10 new hospitals under a Public-Private Partnership (PPP) regime with the innovation of including private clinical management for a period of 10 years. This first wave of hospitals represents a financial commitment of 300.5 million Euros in 2012 and it will continue to burden the Portuguese state budget over the next 30 years in amortization and interest payments. This methodology has drawn criticism from opinion-makers from different political and social persuasions - including from those who initially advocated for such a model. The purpose of this study is to present an alternative based on traditional public management financed by public funding resulting from the sale of assets from the replaced hospitals. The case study presented pertains to the construction of the Lisbon Eastern Hospital. The present study evaluates the assets of those hospitals, assigns a cost to the construction of the new hospital using the traditional model, considers its total cost within the PPP logic and compares its operating budget with that of the replaced hospitals. This study aims to show that there is an advantage in the reorganization of the hospital network by replacing the 5 older hospitals with the new Lisbon Eastern Hospital. It also shows that it is more advantageous for the State to replace the current PPP model with the traditional public financing model.

Baggrund: D. 1. januar 2007 trådte kommunalreformen i kraft i Danmark. Regionsdannelsen er den største ændring af den offentlige sektor siden kommunalreformen i 1970. Ansvaret for sundheds-væsenet bliver regionernes hovedopgave. Formål: At beskrive, analysere og diskutere de strukturændringer, der finder sted i sundhedsvæsenet, med hovedvægt på sygehusvæsenet i Danmark. Metode: Opgaven tager afsæt i et litteraturstudie, hvor udgangspunktet er officielle kilder og udredninger samt videnskabelig litteratur. Resultater: Strukturreformen, der er en centralisering, er inspireret af New Public Management-filosofien. Finansieringssystemet på sundhedsområdet er blevet væsentligt forandret med kommunalreformen. Det er en tvivlsom antagelse, at kommunale foranstaltninger er billigere end de regionale sundhedsydelser, og at nettobesparelsen er tilstrækkelig til at drive substitutionsprocessen. En nedsættelse af behandlingsgarantien fra to til en måned må forventes at stimulere markedet for private sundhedsydelser, med en underminering af den integrerede model med offentligt ejerskab og drift af sygehusvæsenet til følge. Konklusion: Den nye finansieringsmodel påvirker aktørernes økonomiske incitamenter, idet de enkelte aktører kun belønnes for de ydelser, de selv leverer til patienten, uden sammenhæng med resten af behandlingsforløbet. Den stigende aktivitetsafhængige finansiering udgør en væsentlig styringsmæssig udfordring. Ventetidsgarantien får med nedsættelsen fra to til en måned karakter af at være et servicemål, frem for at være en garanti for behandling af høj faglig kvalitet.
Background: On 1 January 2007 the Local Government Reform came into force. The formation of regions is the biggest change of the public sector since the Local Government Reform in 1970. The regions’ main task will be the responsibility for health service. Purpose: To describe, analyse and discuss the structural changes taking place in the Danish health service, with emphasis on hospitals. Method: The starting point of the essay is official sources and explanations as well as scientific literature. Results: The structural reform is a centralisation is inspired by the New Public Management philosophy. The financial system in the health care area has been changed significantly through the Local Government Reform. It is dubious to assume that local government measures are cheaper than the regional health services, and that the net saving is sufficient to drive the substitution process. A reduction of the treatment guarantee from two to one month must be expected to stimulate the private health service market, thereby causing undermining of the integrated model with public ownership and operation of health service. Conclusion: The new financing model will affect the financial incentives in the system as the individual players are only rewarded for the services they deliver to the patient with no relation to the remaining treatment. The increasing activity depending financing presents a significant management challenge. With the reduction from two months to one the waiting time guarantee will assume the character of being a service goal instead of a guarantee of treatment of high professional quality.

ISBN 978-91-85721-28-3

The burning of biomass for cooking purposes without proper ventilation and filters poses a massive health and climate risk. Health implications from exposure to household air pollution from this type of fuel impacts women and children in many developing countries, who spend many hours a day cooking and gathering fuel. Climate implications from burning solid biomass results in increased carbon dioxide and black carbon emissions, which contribute to global climate change. This thesis aims to explore the issues associated with biomass cookstoves in terms of both health and climate, and seeks to understand how a new national clean cookstove program could be funded in India. This includes potential partnerships with United States agencies, nonprofit organizations, and other international funding sources. The topic of clean cookstoves has gained traction as a strategy to mitigate emissions and adapt to a changing climate, and with the recent passing of the United Nations Paris Agreement, funding is increasing to support programs that address climate impacts.

Orientador: Eduardo Fagnani
Dissertação (mestrado) - Universidade Estadual de Campinas, Instituto de Economia
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Resumo: A conquista do direito à saúde no Brasil representou um avanço expressivo no campo da proteção social do país. Contudo, apesar da importante vitória associada à construção jurídico-legal do SUS, a implementação do novo sistema encontra uma série de obstáculos, revelando a dificuldade para consolidar um sistema de saúde universal de fato, e não apenas de direito. Esse descompasso está relacionado ao momento histórico da construção do SUS: os avanços na universalidade da cobertura na saúde coincidem com a crise do Estado Nacional Desenvolvimentista no Brasil. Segue-se então uma etapa de crise econômica, baixo crescimento e ênfase na reforma do Estado visando o ajuste fiscal. Este contexto é agravado ainda pela rearticulação das forças conservadoras a partir de 1990 e pelo ressurgimento vigoroso do ideário liberal. Coloca-se assim, um cenário hostil (pós 1988) para a consolidação de um sistema de saúde universal e redistributivo. Heranças do passado redobram seu fôlego. O estreitamento das bases de financiamento e as dificuldades de superar interesses privatistas poderosos, arraigados na política de saúde desde o final dos anos 1960, colocam sérios obstáculos para a consolidação plena do SUS
Abstract: The acquisition of the right to the health in Brazil represented an expressive progress in the field of the social protection of the country. However, in spite of the important victory associated to the juridical-legal construction of Unified National Health System, or SUS, the implementation of the new system finds a series of obstacles, revealing the difficulty in fact to consolidate a system of universal health, and not just of right. That disconnection is related to the historical moment of the construction of SUS: the progresses in the universality of the covering in the health coincide with the crisis of the ¿Brazilian Developmental State¿. Start, then, a stage of crisis economical, low growth and emphasis in the reform of the State seeking the fiscal adjustment. This context is still worsened by the rearticulation of the conservative forces starting from 1990 and for the vigorous resurgence of the liberal thought. Thus, appear a hostile context (starting from 1988) for the consolidation of a universal and redistributive health system. The narrowing of the financing bases and the difficulties of overcoming privates interests, present in the politics of health from the end of the years 1960, they put serious obstacles for the full consolidation of SUS
Mestrado
Economia Social e do Trabalho
Mestre em Desenvolvimento Econômico

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Since the National Health System (SUS) was created by Brazilian 1988 Constitution, one of its goals has been the stability and sufficiency of its financing model. The financing crisis that took place as early as from the years 1990 generated new proposals related to SUS financing. These initiatives led to the approval of Constitutional Ammendment no 29 (EC 29), in september 2000, which established resource ear-marking for the three governmental levels. However, the implementation of this new financing model has been characterized by controversial interpretations of what EC 29 really said. Using the theory from Fiscal Federalism, this thesis aims to study the implementation of resource ear-marking for health, through documental annalysis regarding the National Health Council (CNS) and Audit Offices at the federal, state and municipal levels. Data bases from the National Treasure and Health Public Budget Information Systems (SIOPS), from the Ministry of Health were used to gather data regarding revenues and expenses from federate units. In conclusion, it can be said that EC 29 was an advancement in SUS financing. Nevertheless, some issues are not yet solved. How to treat inequities, how to redistribute resources among different federate units are still unresolved issues, without a strong association with performance goals and responsibility sharing. The forecast of periodical revisions of EC 29´s legal text offers an uncommon opportunity for improving the financing model.
Desde sua criação, pela Constituição de 1988, o Sistema Único de Saúde (SUS) perseguiu a estabilidade e suficiência em seu financiamento. A crise de financiamento que se estabeleceu, já a partir do início dos anos 1990, levou ao surgimento de propostas relativas ao financiamento do SUS. Essas iniciativas culminaram com a aprovação da Emenda Constitucional no 29 (EC 29), em setembro de 2000, estabelecendo a vinculação de recursos para as três esferas de governo. A implantação do novo modelo de financiamento, no entanto, tem sido marcada por controvérsias na interpretação das disposições da EC 29. Este trabalho procurou, utilizando o referencial teórico proporcionado pelos estudos de Federalismo Fiscal, estudar o processo de implantação da vinculação de recursos para a saúde a partir da análise documental desenvolvida a partir, principalmente, do Conselho Nacional de Saúde e dos Tribunais de Contas da União, estados e municípios. Para os dados de receita e despesa das unidades da federação foram utilizadas as bases de dados da Secretaria do Tesouro Nacional e do Sistema de Informações sobre Orçamentos Públicos em Saúde (SIOPS), do Ministério da Saúde. Concluiu-se que a EC 29 constituiu um avanço no financiamento do SUS. Algumas questões, todavia, permaneceram pendentes. O tratamento a ser dado à desigualdades e os mecanismos de redistribuição de recursos, entre as diversas unidades da federação, permaneciam em aberto, sem uma associação mais forte com o estabelecimento de metas de desempenho e divisão de responsabilidades. A previsão de revisão periódica das disposições da EC 29, todavia, oferece uma rara oportunidade de aperfeiçoamento do modelo de financiamento.

Este trabalho tem como objetivo analisar o funcionamento do Sistema Único de Saúde (SUS), descrevendo como ocorre a captação dos recursos a serem utilizados no financiamento das ações e serviços de saúde, bem como o fluxo que eles seguem até a sua destinação para a cobertura dos custos de consultas médias, exames diagnósticos, cuidados de enfermagem, entre outros. Além disso, são analisadas as propostas do Ministério da Saúde de melhoria ou transformação do sistema. O trabalho releva que além de se questionar o percentual adequado ao financiamento da saúde no Brasil é preciso que haja um entendimento claro e o cumprimento das determinações legais por todas as esferas de governo.
In this work I analyze the functioning of the Sistema Único de Saúde (SUS, Unified Health System), describing how the fundraising that promotes health actions and services is made. I also describe how these resources get to their destinations to cover costs with consultations, diagnostic tests, nursing care, among others. Furthermore, I analyze the propposals of the Secretary of Health to improve or transform the system. The work highlights that, in addition to questioning the appropriate percentage given to health financing policies in Brazil, is it necessary to promote the clear understanding and the compliance with legal requirements on all spheres of the Government.

The main of objective of this diploma thesis is to define health care as economic goods based on the theoretical definitions. The fact whether health care should be considered as private goods or public goods plays a vital role in this debate. The initial hypothesis presupposes that health care is (based on the basic economic criteria) private goods; however there is objective evidence demonstrating that health care should be understood in terms of public goods. The author defines the necessary terminology and theoretical concepts. According to several expert concepts the author concludes that based on the basic economic definitions health care could be understood as private goods, admitting that in the real world objective limitations exist, which prevent keeping health care exclusively in the economic sphere. The thesis also evaluates the role of individual health care sectors, including their drawbacks. The author demonstrates all concepts on the Czech health care system. In the analytic part of the thesis the author demonstrates discrepancies between theoretical concepts and practice on specific models, including the risks of exclusively private financing of health care. For this purpose three income groups has been defined. The author compares expenditures of these groups on selected medical services with different levels of their savings. The thesis also deals with methods of economical analysis and its limitations in health care system analysis.

Esta tese tem como objeto o estudo do financiamento da saúde pública no Estado de Minas Gerais, no período compreendido entra a promulgação da Constituição mineira, em 21 de setembro de 1989, e o ano de 2005. Seu texto analisa também o financiamento da saúde pública no federalismo trino, em Minas Gerais, e, diferentes momentos de vinculação constitucional: na vigência do ordenamento constitucional determinado pelo 1 do art. 158 da Constituição estadual de 19989 e na vigência da Emenda n 29, de 13 de setembro de 2000, da Constituição da República. A presente tese constrói a série histórica de 1989 a 2005, com os valores do gasto em saúde pelo Estado de Minas Gerais, a partir dos Balanços Gerais do Estado. Através desses dados, comprova-se que a aplicação de recursos em ações e serviços públicos de saúde não se elevou com a vigência da EC-29, ao contrário, constatamos uma diminuição do aporte realizado em 2005 quando comparado ao valor aplicado em 1995 (15,62%). A construção da série histórica de gastos municipais em saúde total despendido pelo conjunto dos 853 municípios mineiros no período 1996-2005, demonstra que Minas Gerais no período analisado o aporte dos governos locais e, na média anual expressa em real de 2005 (13,22%), menor no quinquênio 2000-2005 do que no quadriênio 1996-1999 que antecede a vigência da EC-29. Este estudo pioneiro, já que o Siops disponibiliza dados municipais até o primeiro semestre de 2003, recomenda a necessidade de verificação em outros estados, pois em Minas Gerais a EC-29 se revela ferramenta incapaz de garantir maiores aportes ao financiamento das ações e serviços públicos de saúde. Verificamos, também que, nos últimos quatro anos, há coerência entre as quatro leis que formam o arcabouço do planejamento orçamentário (PMDI, PPAG, LDOs, LOAs) e os respectivos Balanços Gerais do Estado, mas o Fundo Estadual de Saúde FES não é a unidade orçamentária que realiza a maior parte dos gastos na função saúde.
The goal of this paper is the public health financing study in the State of Minas Gerais, within the period comprised between the promulgation of Minas Gerais Constitution, on September 21, 1989 and the year of 2005. The text also analyses the public health financing in the federalism, in Minas Gerais, on different moments of constitutional biding: during the term of the constitutional system established by the state Constitution 1 of art. 158 of 1989, and during the term os the Republic Constitution Amendment nr. 29, of September 13, 2000. The present paper builds the historical series from 1989 to 2005, with the amounts of the expense with health by the State of Minas Gerais, as from the General Balance Sheets of the State. Through these data it is proved that the investment of resources in actions and public health services has not been increased with the enforcement of the EC-29, on the contrary, we verify a reduction to the financial support accomplished in 2005 when compared to the amount invested in 1995 (15,62%). The historical series building on municipalities of Minas Gerais within the period 1996-2005, shows in Minas Gerais, in the period analyzed, that the financial support of the local government and, the yearly average expressed in quadrienium 1996-1999 that antecedes the EC-29 enforcement. This pioneer study, since the Siops makes available the municipal data until the first semester of 2003, recommends the necessity of checking other states, as in Minas Gerais the EC-29 has proved to be a tool incapable of ensuring greater financial supports to the financing of actions and health public services. We also verified that, in the past four years, there is coherence among the four laws that compose the budget planning framework (PMDI, PPAG, LDOs, LOAs) and the respective General Balance Sheets of the State, but the Health State Fund (Fundo Estadual de Saúde FES) is not the budgeting unit that accomplishes the greatest part of the expenses in the health function. Finaççy, due to the results of the analyzed data, we decided for the need of an urgent proceduring of the complementary law project the regulates the EC-29. The external control of the public expenses and the implementation of the National Account in Health, are important strategies to make the private and public expenses with health more effective and efficient, since such financial supports are practically in the Brazilian reality.

O trabalho desenvolvido tem por objeto de estudo a participação do BNDES no processo de centralização de capital na área da saúde brasileira. Por meio da análise da política governamental para o setor produtivo da saúde, com enfoque na intervenção do BNDES, bem como do acompanhamento da dinâmica dos subsistemas que compõe o Complexo Econômico-Industrial da Saúde (CEIS), evidenciou-se a tendência às fusões e aquisições na área. O referido processo foi compreendido no contexto do desenvolvimento econômico brasileiro articulado à consolidação do capitalismo contemporâneo. Dessa forma, nos detivemos à discussão dos pressupostos da acumulação capitalista e à correlação estabelecida com o processo de centralização de capital. Sendo realizada articulação com a mercantilização da saúde. Abordamos, ainda, o debate sobre as características da política de desenvolvimento no país e sua articulação com as requisições do modo de produção capitalista. E, ainda apresentadas as principais políticas governamentais atuais que abrangem o CEIS e análise das mesmas. Compreendemos que o complexo da saúde move-se na direção estabelecida pela dinâmica capitalista atual, que pressupõe a financeirização do capital, articulada à formação de monopólios, com participação do Estado, por meio de abertura econômica, de incentivos e aplicação de recursos do fundo público.
The developed work sets its goal on studying the participation of BNDES in the process of capital centralization in the Brazilian healthcare sector. By analysing the governmental policies for healthcares productive sector, with a focus on the intervention of BNDES, as well as monitoring the dynamics of the subsystems that are part of the Healthcares Economic-Industrial Complex (CEIS), the tendency to fusions and acquisitions in the area were evidenced. The referred process was contained in the Brazilian economic development process articulated with the consolidation of contemporary capitalism. Thereby, we detained ourselves to the discussion around the assumption about the capitalist accumulation and the stabilized correlation with the centralization of capital process, articulating with the commercialisation of healthcare. We also approach the debate about political development characteristics in the country and its articulation with capitalistic production requirements. And yet, the current main governmental policies that embrace CEIS are presented and analysed. We understand the heathcare complex moves itself to the current capitalistic established dynamic, which presupposes a financing of capital, articulated with the formation of monopolies, with the participation of Estate, through economic openness, of incentives and application of resources from the public fund.

During the past decade, the Mexican government launched an ambitious expansion of public health insurance through the Seguro Popular programme (SP). As a result, health care access was legislated as citizens’ entitlement, a generous benefit package was offered, and public health expenditure was significantly increased. In 2011, the programme had reached 52 million affiliates. However, there is limited evidence on its effects on a number of outcomes and their distribution. This thesis analyses three aspects that are key to evaluate health system performance. Specifically, using quasi-experimental methods and recent distributional measures of pure health, it examines the effect of universal insurance coverage on infant mortality, non-medical consumption, and health inequalities. Drawing on municipality-level data, the first article finds that the programme led to a 3.9 per cent decrease in infant and neonatal mortality. These reductions were concentrated in more populated, urban, and less marginalised municipalities, however, probably because this type of municipalities have been traditionally better equipped and are thus better prepared to offer all the interventions from the benefit package. Based on data from the Mexican Family Life Survey (MxFLS), the second article shows that unexpected health events such as accidents and deterioration in physical capacity are associated with large declines in non-medical consumption. Social security seems to provide protection against both types of shocks, but endogeneity-corrected estimates show that the SP only protects consumption against accidents. This suggests that income losses associated with disability shocks for which the programme does not offer protection, are likely larger than medical care expenditures, and poses the question of whether other social security benefits, such as disability insurance, should also be extended. Finally, the third article analyses the distribution of health in the context of the SP implementation. Unlike traditional studies, pure health inequality and mobility are analysed using a recently developed class of indices appropriate for categorical data. If a downward-looking definition of status is employed, the distribution of health appears stable, but if an upward-looking definition is adopted, a significant increase in inequality is observed. Evidence of strong persistence in health was also found. This lack of improvement in the health distribution suggests that factors other than health insurance coverage, such as institutional performance, are more important determinants of health inequalities. Overall, this thesis finds important health effects from extending health insurance coverage but limited effects on economic welfare and the distribution of health status across the entire population.

Master of Public Health - MPH
Background: Hospital pharmacy practice is an important aspect of healthcare, as drugs are a key component of patient treatment in hospitals. In Lagos state, Nigeria, provision of healthcare services, including drugs, was at one time entirely free but in the face of ever dwindling resources and increasing government responsibility, the health sector has to compete with other sectors for scarce public funds. Therefore, in 2002, a private sector initiative (PSI) in hospital pharmacy was implemented in seven hospitals in Lagos state as an alternative financing system for managing drug procurement and supply to fee-paying patients. Each of these seven hospitals now has two pharmacies, one providing free drugs to certain categories of patients entitled to this service and the second providing services to all other patients. Aim: This study aimed to explore and describe the impact of this private sector initiative on the job satisfaction of the pharmacists working in these hospitals from the viewpoint of the hospital pharmacists and relevant stakeholders, and to suggest ways of improving the job satisfaction of hospital pharmacists in Lagos state. Study Design: The study utilized a qualitative research design to explore the perceptions and experiences of government-employed pharmacists and key stakeholders on the impact of the private sector initiative. Study Population and Sampling: Individual interviews were conducted with three key informants and two focus group discussions were carried out, one with hospital pharmacists from the fee-paying pharmacies and the second with pharmacists from the free pharmacies from the seven hospitals in Lagos state where the private sector initiative was in operation. Data Collection and Analysis: The audio-taped interviews and focus group discussions were transcribed and analysed to identify the key categories and themes raised by the participants. Results: The study found that most pharmacists felt that the PSI has met the main objective for which it was set up, that is, improving availability of drugs in the hospital but there were some attendant factors like inadequate funding of the free health unit, increased workload of the fee-paying unit and poor working conditions, which affect the job satisfaction of pharmacists. The study however showed that the introduction of the PSI has led to improved performance of roles and recognition of the pharmacists and better working relationships between pharmacists and other healthcare workers which have impacted positively on the job satisfaction of pharmacists. Recommendations: The study recommended that the working conditions should be improved and issues of staffing and workloads should be addressed. Also, alternative but effective means of drug financing should be sought to ensure availability of drugs to all categories of patients.

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Coordenação de Aperfeiçoamento de Pessoal de Nível Superior
Part of the Reform Plan of the State's strategy was to transfer at the end of the 90s, to the non public sector producing services such as health, education and culture, seeking to promote greater efficiency and quality services. A key strategy was the creation of social organizations (OS). Since 1998, the State Health Department of São Paulo (SES) transferred the management of hospitals to these organizations through management contracts that discriminated objectives and targets to be achieved for the production of health services. Due to the fact that it was the management of public money, the corporate governance issue was relevant to public administration. The research evaluates the governance in the social organization of health SPDM - Association for the Development of Medicine as the criteria for accountability (account responsibility) and transparency through the analysis of existing, contracts and reports that regulate OSS legislation. The research results show that the criteria for accountability and transparency - important to ensure good governance in the public sector elements - according to the literature examined were not achieved considering that: the government of Sao Paulo is the main buyer, payer and performance controller of these organizations; in compliance with the time limits due to law enforcement for accountability; the quality of information of the S.E.S. to the departments of external control and the difficulty of access to information for stakeholders
Parte da estratégia do Plano Diretor da Reforma do Estado foi transferir, no final da década de 90, para o setor público não estatal a produção de serviços tais como saúde, educação e cultura, procurando promover maior eficiência e qualidade dos serviços. Uma das principais estratégias foi a criação das organizações sociais de saúde (OSS). A partir de 1998, a Secretaria de Estado de Saúde de São Paulo (SES) tem repassado a gestão de hospitais para essas organizações mediante contrato de gestão que discrimina objetivos e metas para a produção de serviços de saúde. Por se tratar da gestão do dinheiro público, o tema governança corporativa é relevante para a administração pública. A pesquisa avalia a governança na organização social de saúde SPDM - Associação para o Desenvolvimento da Medicina - quanto aos critérios de accountability (responsabilidade em prestar conta) e transparência por meio da análise da legislação vigente, contratos e relatórios que regulam as OSS. Os resultados da pesquisa demonstram que os critérios de accountability e transparência - elementos importantes para garantir uma boa governança no setor público , de acordo com a literatura examinada, ainda não foram alcançados tendo em vista que o governo de São Paulo é o principal comprador, pagador e controlador do desempenho dessas organizações; que há necessidade do cumprimento dos prazos previstos na lei para prestação de contas; que a qualidade das informações pela S.E.S. junto aos órgãos de controle externo é primordial, e que há dificuldade de acesso às informações para os stakeholders

Efforts to encourage healthy behaviour often fail to bring about sustained changes in people’s lifestyles. New approaches to tackling chronic disease include the use of financial incentives: rewards paid to individuals conditional upon their achieving some pre-specified target, such as losing weight or quitting smoking. Incentives may provide an extra motivation to adopt healthy lifestyles, and structure behaviour change efforts in ways more conducive to success. Health incentives have, however, provoked controversy, attracting accusations of ‘bribing people to be healthy,’ ‘rewarding bad behaviour,’ and ‘wasting taxpayers’ money.’ It remains unclear how viable health incentives could be as a tool for health promotion; but, even if effective, their contentious nature may still give reason for hesitancy. Here, I explore whether such ethical concerns present us with convincing reasons not to use health incentives. I begin by looking at the nature of the criticisms of incentives in the media, and grouping these arguments into more general themes for discussion. I then proceed to consider each of these in turn, beginning first with debates about the requirements for the state to act efficiently without overstepping its legitimate sphere of influence. I then move on to concerns relating to the potential for incentives to undermine liberty and autonomy. Next, I discuss whether health incentives are unjust insofar as they are undeserved, and how this relates to agent freedom and responsibility for adopting healthy lifestyles. Finally, I consider the worry that using money as a healthcare intervention could corrupt certain values that we care about. In concluding, I seek to give an overall idea as to the ethical permissibility of health incentives, and identify some key features that are likely to render incentives more or less acceptable as a means of improving health.

Includes bibliographical references (leaves 58-60).
Absenteeism is a problem affecting the Public and the Private sector institutions alike. Anecdotal evidence from monthly absenteeism statistics and managers' comments suggest that it is also a problem for Red Cross Children's Hospital (RCCH). This dissertation describes the investigation into absenteeism among nurses at RCCH that was conducted by the writer in the year 2004. The writer reviewed attendance records for the year 2003. The main findings from the investigation and recommendations on management of absenteeism are then presented. The overall objective of the study was to establish the determinants of absenteeism among nursing personnel of RCCH and financial implications thereof. This involved establishing the extent of absenteeism among the nursing personnel, identifying major causes, estimating the financial burden and making recommendations on how to manage this problem. The study followed a descriptive as well as analytic methodology in presentation and discussion of results. The methodology included a review of the literature on absenteeism, motivation and migration of health personnel. The study has a qualitative and a quantitative aspect. Focus groups and in-depth interviews were conducted for collection of primary data from nurses. Two questionnaires were used as interview guides. Secondary data was collected from PERSAL database using the data capture sheet. Attendance records of all nurses were reviewed for the quantitative aspect of the study. A major finding of the study was that absenteeism among nursing personnel at RCCH was above what most writers on the subject regard as acceptable level. Staff turnover was found to be high in the nursing department with staff leaving the service and posts remaining vacant. It was felt that there is difficulty in recruiting nurses especially from the outskirts of the Western Cape and other provinces because of lack of accommodation. It was suggested that Staff Residence policy be enforced to address this problem since it confers power of granting or refusing accommodation to management. Stress was identified as the major cause of absenteeism by all interviewees. The source of stress was identified as both personal and work related problems. The financial burden of nurses' absenteeism was estimated at more than one million rands for the year 2003. Important recommendations that emerged from the study were that absenteeism control should be included in the job descriptions of supervisory positions. Development of institutional absenteeism policy was also recommended. it was also recommended that mechanisms be developed to recognize staff members with good attendance records.

Heart failure readmissions place a significant financial burden on the healthcare system. Stakeholders of this system have utilized many approaches to reduce the number and costs of heart failure readmissions, without significant improvement. The purpose of this practice improvement project was to determine whether education on the financial impact associated with readmissions improved a patient’s measured quality of life, encouraged adherence to a therapeutic regimen, and thereby reduced readmission rates in Medicare and Medicaid patients diagnosed with heart failure. Theoretical support is derived from the theory of self-care of chronic illness, which recognizes the complex self-care processes a patient with chronic illness negotiates. The project used a quantitative methodology with a pre-test/post-test design. A convenience sample was enrolled of 10 Medicare and Medicaid patients who had recurrent heart failure readmissions. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used to collect pre/ post-intervention data which was then analyzed by two-tailed paired t-test. There was no statistically significant difference from the intervention to determine any impact on the participant’s measured quality of life (p = .953; α = .05). However, none of the participants were readmitted during the 30 day period of this project. The findings indicate heart failure patients acknowledge their financial constraints but quality of life is not as impacted by finances as anticipated. Polypharmacy and uncertainty with managing daily regimens during symptom exacerbation were the greatest concerns. It is recommended that heart failure patient education should be persistent and individualized to address the patient’s unique needs.

This research report examines the factors associated with facilitating and constraining the implimentation of financial management and budget reforms in the public sector using the Health Sector (National and Provincial Departments of Health) as a case study. The main findings of this report are that there are factors that are both facilitating and constraining the implementation of financial management and budget reform in South Africa. The primary constraining factor in this regard is that there is limited capacity in the country with regard to financial management.

In 2011, an estimated 3 million children died in their first four weeks of life. The majority of these neonatal deaths are avoidable if effective low-cost interventions, such as clean delivery practices, exclusive breastfeeding, and newborn resuscitation are available. However, these interventions are clearly not reaching many of the women and newborns who need them most. A major challenge is how best to expand access to essential obstetric and newborn interventions, particularly among disadvantaged populations and in areas with poor access to health services. This requires an understanding of the social and geographical patterning of neonatal mortality rates (NMR) as well as evidence about which policies can reduce inequalities in access to essential maternal and newborn care. The three objectives of my thesis addressed these issues directly.First, we described socioeconomic inequalities in NMR across low- and middle-income countries (LMIC) and assessed changes in inequalities over the past decade. Using Demographic and Health Survey (DHS) data from 24 countries, we estimated absolute and relative socioeconomic inequalities using the Slope Index of Inequality and the Relative Index of Inequality, respectively. In most countries, absolute and relative inequality in NMR declined over the approximate 10-year period. There was, however, considerable heterogeneity both in the magnitude of NMR inequalities between countries and in how inequalities changed over time. Furthermore, there remained a substantial survival advantage for newborns born into wealthier and more educated households, which should be considered in global efforts to further reduce NMR. Next, we evaluated the impact of a policy that removes user fees for facility-based deliveries on health service utilization, neonatal mortality, and socioeconomic inequalities. Using DHS data from ten countries in sub-Saharan Africa, we employed a difference-in-differences regression approach to control for underlying secular trends in the outcomes that are common across countries and for time invariant differences between countries. Reducing fees for delivery services was associated with an increase in facility-based deliveries and a possible reduction in NMR. Furthermore, increases in facility-based deliveries occurred across all socioeconomic groups, with no indication that richer or more educated women benefited more from the policy change.Finally, we assessed the effect of distance to emergency obstetric and newborn care (EmONC) services on early neonatal mortality and examined whether proximity to services contributed to socioeconomic inequalities in early neonatal mortality. Using geographical coordinates collected in both surveys, we linked data from the 2011 Ethiopian DHS with comprehensive facility census data from the 2008 Ethiopian EmONC Needs Assessment. Closer proximity to delivery services and higher level of care were associated with lower early NMR. Distance to EmONC services was a main determinant of total inequality in NMR, although it did not make a significant contribution to socioeconomic inequality. In this thesis, we have identified several barriers that contribute to large and persistent inequalities in neonatal mortality and in the utilization of essential obstetric and newborn care in LMIC. The findings highlight the importance of a multipronged policy approach that addresses geographic accessibility and quality of obstetric and newborn services, affordability barriers, and socioeconomic inequalities to significantly reduce neonatal mortality. Further research examining the relative importance of various access barriers in different settings will help policy makers and planners adopt locally relevant approaches to improve newborn survival.
En 2011, environ 3 millions d'enfants sont morts au cours des quatre premières semaines de leurs vies. La majorité de ces morts néonatales peuvent être évitées si des interventions abordables, telles que des accouchements sanitaires, l'allaitement exclusif et la réanimation des nourrissons sont disponibles. Cependant, ces interventions ne sont pas accessibles aux femmes et aux nouveaux nés qui en ont le plus besoin. Un des défis majeurs à relever est de formuler la meilleure stratégie pour étendre l'accès des interventions obstétriques et des interventions aux nouveaux nés aux populations désavantagées et dans les zones qui manquent des services de santé. Cela nécessite une connaissance des dynamiques sociales et géographiques des taux de mortalité néonatale (TMN) et des données concernant les politiques pouvant réduire les inégalités d'accès aux soins essentiels aux mères et aux nouveaux nés. Les trois objectifs de ma thèse explorent directement ces sujets. D'abord, nous décrivons les inégalités socioéconomiques du TMN à travers les pays à bas et moyens revenus (PBMR). Basée sur les données du Demographic and Health Surveys (DHS) sur 24 pays, nous calculons les inégalités absolues et relatives. Dans la plupart des pays, les inégalités absolues et relatives du TMN ont diminué sur une période approximative de 10 ans. Il y a toutefois une hétérogénéité considérable quant à la magnitude des inégalités du TMN entre les pays et quant à leur fluctuation dans le temps. De plus, un avantage de survie substantiel pour les nouveaux nés des ménages riches et éduqués subsiste encore. Ensuite, nous évaluons l'impact des politiques supprimant les coûts des accouchements qui ont lieu dans des établissements de santé sur l'utilisation des services de santé, la mortalité néonatale et sur les inégalités socioéconomiques. Avec les données du DHS de dix pays sub-sahariens, nous utilisons l'approche de différence-en-différences dans des modèles de régression pour réguler les tendances séculaires des indicateurs communs à tous les pays ainsi que pour contrôler toute différence fixe dans le temps qui pourrait exister entre les pays. La réduction des coûts liés aux services d'accouchement est associée à une augmentation du nombre d'accouchements dans les établissements de santé et à une réduction potentielle du TMN. De plus, l'augmentation des accouchements en établissements de santé a eu lieu dans tous les groupes socioéconomiques.Enfin, nous évaluons l'effet de la distance entre le domicile et les centres des services obstétricaux et néonataux d'urgence (SONU) sur la mortalité néonatale. Dans ce projet, nous lions les données géographiques du DHS 2011 sur l'Éthiopie avec celles du recensement exhaustif des établissements de santé de 2008 sur l'Éthiopie. La proximité des services d'accouchement et un niveau élevé de soins sont associés à un plus faible taux de mortalité néonatale. La distance des services SONU est un déterminant principal des inégalités totales dans le taux de mortalité néonatale, malgré le fait qu'elle ne contribue pas significativement aux inégalités socioéconomiques. Dans cette thèse, nous identifions plusieurs obstacles qui contribuent aux inégalités larges et persistantes dans le taux de mortalité néonatale et de l'utilisation des soins obstétrique et néonataux essentiels dans les PBMR. Les résultats démontrent l'importance d'une approche politique multidimensionnelle qui prend en considération l'accessibilité géographique, la qualité des services obstétriques et néonataux, et l'accessibilité des coûts et des inégalités socioéconomiques afin de réduire sensiblement la moralité néonatale. D'autres recherches portant sur l'importance relative des obstacles à l'accessibilité dans différents contextes aideront les décideurs politiques et les administrateurs à adopter des approches locales appropriées pour améliorer la survie des nouveaux nés.

The purpose of this thesis is to examine the impact of financial incentives to promote health behaviour change. Financial incentives include tangible rewards as cash, vouchers and lotteries that are offered to individuals conditional to the fulfilment of health guidelines. Despite the growing use of such patient incentives in practice, some fundamental questions are yet to be answered: (1) Are financial incentives effective? (2) What type and size of incentive is more effective? (3) Do patient income and past health behaviour moderate the impact of incentives? These questions are analysed in the context of (a) blood donation and (b) compliance with health care including adherence to treatment, disease screening, immunisation and appointment keeping. Behavioural economics, in particular prospect theory, provide the theoretical foundations for this work and substantiate my hypotheses about the effect of financial incentives. I perform the first meta-analyses in the literature to quantify the impact of patient financial incentives to promote blood donation (chapter 3) and compliance (chapter 4). These results show that financial incentives do not promote blood donation but increase compliance with health care, particularly for low income patients. Two large field studies were developed to further examine the effect of incentives in compliance - testing pioneer incentive schemes. I test the impact of a certain (£5 voucher) versus uncertain (£200 lottery) incentive framed either as a gain or loss to promote Chlamydia screening (chapter 5). I also develop the first study ever testing preferences for sequences of events in the field – using the naturalistic setting of colorectal cancer. This study compared the effect of a €10 incentive offered at the end of screening versus two €5 incentives offered at the beginning and end of screening (chapter 6). The former showed the voucher framed as a gain was the most effective incentive and the latter showed that smaller two €5 incentives increase screening more than a single €10 incentive (which had a detrimental effect compared to no incentive). I fundamentally contribute to the literature by showing that (i) patient financial incentives do not increase the quantity of blood donations and may have an adverse effect on quality, providing empirical evidence to a long-standing policy debate. Furthermore (ii) small certain rewards around £5 are likely to be the optimal incentive for compliance with health care, (iii) higher incentives may be more effective if offered as smaller segregated incentives of the same amount and (iv) incentives have over twice the impact on low income patients than on more affluent patients.

Objectives: Mothers of low socioeconomic status (SES) and of non-Hispanic black race deliver prematurely more often. The goal of my dissertation was to improve understanding of the mechanism of disproportionate premature birth in low SES women. I tested a psychological and physiological stress explanation of prematurity risk, estimated the effect of the Affordable Care Act (ACA) Medicaid expansion on gestational age (GA), and estimated how the ACA Medicaid expansion effect was influenced by race. Data and Methods: I developed a conceptual framework of how psychological and physiological stress increase premature birth risk utilizing Appraisal and pathophysiology theory. I generated hypotheses about how financial risk removal would impact GA and tested them utilizing variation in expansions in Medicaid eligibility for pregnant women in three matched state pairs and distribution of the Earned Income Tax Credit (EITC). I utilized data from the Pregnancy Risk Assessment Monitoring System and performed multivariate ordinal regressions. I also used national birth record data and exploited state variation in ACA Medicaid expansion status to estimate the impact on GA in non-Hispanic black and all other mothers using multivariate linear regressions and linear probability models.

Results: Hypothesis testing based on two of the three Medicaid expansion for pregnant women state pairs and the EITC analyses resulted in significant evidence (one-sided p-values < 0.05) for a direct pathway between psychological stress concerning financial risk, physiological stress, and GA. The ACA Medicaid expansion was associated with an increase in GA for non-Hispanic black mothers (+34 hours), a decrease for all other mothers (–6 hours), and a 3% decrease (95% CI = –5% to –2%) in the incidence of early term or shorter gestation births for non-Hispanic black mothers.

Conclusions: Decreasing financial risk for low SES women with Medicaid or the EITC is associated with increased GA. The higher premature birth risk in this population is likely the result of a direct pathway involving psychological and physiological stress. Other financial risk removal strategies should be investigated. The ACA Medicaid expansion did not meaningfully influence GA on a weekly scale but did moderately decrease overall preterm birth risk in non-Hispanic black mothers.

Includes bibliographical references (leaves 57-59).
[Background] Selective non-operative management (SNOM) of abdominal gunshot wounds is a practice that is becoming more common in major urban trauma centres. With increasing levels of violence, SNOM offers a useful method for managing injured patients. Historically, operative management of blunt and penetrating wounds to the abdomen has been the standard of care. This has changed over the past several decades with the advancement of imaging techniques and the realization that many penetrating wounds do not require surgical intervention. However, reticence towards SNOM for the management of abdominal gunshot wounds has remained because of the high probability of visceral organ damage. This study contributes to the growing field of violence prevention and trauma systems management by examining the use ofSNOM for abdominal gunshot wounds. We examined the hypothesis that SNOM does not increase morbidity or mortality in patients and decreases total hospital costs. [Methods] A retrospective cohort study of257 consecutive patients admitted to a level I trauma centre in South Africa for the management of abdominal gunshot wounds over a one year period from I April 2004 to 31 March 2005 was performed. [Results] Ninety-three of257 (36%) of abdominal gunshot wound victims were nonoperatively managed. Of these 93 patients, 5 (5%) later required surgery and were converted to a delayed laparotomy. Of the 164 patients who were treated. with immediate laparotomy, 10 (6%) underwent non-therapeutic laparotomies. There were no deaths within the cohort of patients that were managed non-operatively during the hospital stay compared to 9 deaths in the group of surgically managed patients (p=0.03). On multivariate analysis, there was no statistically significant difference in overall complication rate during the hospital stay between patients who were treated non-operatively compared to those who were treated operatively after adjusting for injury severity (HR 1.25, 95% CI 0.61-2.55). There was also no statistically significant difference in total hospital cost between the two groups (HR 0.40, 95% CI 0.15-1.08). [Conclusion] This study has policy implications for violence prevention and health systems management. It suggests that SNOM can be successfully used in less severely injured abdominal gunshot wounds. The use of SNOM does not increase morbidity or mortality rates during the hospital stay. Thus, it can also be used effectively as a part of cost-containment policies geared towards the redistribution of human and financial resources in the trauma centre.

Many studies have examined the association between corporate social responsibility (CSR) and corporate financial performance, but scholars argue that the exact relationship between CSR and corporate financial performance remains unclear. This quantitative study examines the impact of CSR on corporate financial performance in the pharmaceutical industry. The study addresses the research question: What is the financial performance in the pharmaceutical industry among companies that have embraced CSR? The alternative hypothesis predicted positive correlations between financial performance and CSR. The related null hypotheses predicted that there would be no correlations between any of 8 dimensions of CSR and corporate financial performance. Archival data from 18 leading global pharmaceutical companies ranked by Access to Medicine Index were used to answer the research question.

In 4 of the 8 hypotheses tested, the results show partial support for a positive effect of CSR on corporate financial performance in the pharmaceutical industry based on significant correlations in 2014. Specifically, significant 2014 relationships with corporate financial performance were observed for CSR general access to medicine management, CSR capacity advancement in product development and distribution, CSR product donations and philanthropic activities, and overall CSR. However, no significant 2014 relationships with corporate financial performance were observed for CSR public policy and market influence, CSR research and development, CSR pricing, manufacturing, and distribution, and CSR patents and licensing. In the 8 hypotheses tested, the findings in 2012 did not show any effect of CSR on corporate financial performance in the pharmaceutical industry. The results of this study suggest at the minimum, that CSR does not negatively impact corporate financial performance in the pharmaceutical industry. This study does not support arguments against product donations and philanthropic activities. The partial support for a positive effect of CSR on corporate financial performance and no negative impact of CSR on financial performance in the pharmaceutical industry, could encourage corporate leaders to pay attention to, not only their corporate financial profits, but also ethical, environmental, and social issues such as improving the access to medicines; and contributing to improving society.

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The Brazilian Public Health System (Sistema Único de Saúde - SUS), defined by the Constitution of 1988, is almost 20 years old and is a landmark for health public policies. In these 20 years, the law was altered several times with the objective of prioritizing the investment of public money in such a needy area as health. Among these changes, it is important to single out the Constitutional Amendment number 29, issued on 13th September 2000, which determined the minimum investment in health. According to this amendment, as from the year 2000, the municipalities should invest in health services a minimum of 7% of the revenue from taxes and transferences from the Federal and State governments. This value was to rise gradually to 15% by 2004. Since every public policy should be systematically evaluated and considering the assumption that, according to the incrementalist theory, more money invested in health would tend to solve the crisis in the health system, this dissertation consists of a study of a set of health indicators in some municipalities of the State of Pernambuco after the Amendment 29. The evaluation period spanned 4 years, from 2002 to 2005 and the area chosen for the study was located in southern agreste region of the state. Ten health indicators were selected, all of which included in the Administrative Rule no 493, of the Health Ministry. It was found that in the chosen period the average investment in health was greater than 15% of the municipalities¿ revenue since 2002. However, the value of the investment per capita, considering the municipality's share of it, which was half of the total investment, decreased from 2002 to 2004 and increased in 2005. It was also found that the municipalities with the lowest per capita income were the ones with the highest investment per capita in health. As regards children mortality in the region, it was on average 33 for every 1000 children born, which is classified as ¿medium¿ according to the above mentioned Administrative Rule no 493. No statistically significative correlation was found between the amount of money invested in health and children mortality.
O Sistema Único de Saúde - SUS, definido pela Constituição de 1988, está prestes a completar vinte anos, constituindo-se em um marco para as políticas públicas no setor da saúde. Ao longo destes anos, diversas foram as alterações na legislação, no sentido de dar prioridade à aplicação de recursos públicos em um setor tão carente como é o da saúde e, em especial, chama-se atenção para a Emenda Constitucional nº 29, de 13 de setembro de 2000, que estabeleceu vinculação mínima de aplicação de recursos de impostos em ações e serviços de saúde. De acordo com esta Emenda, a partir do ano 2000, os municípios deveriam aplicar em ações e serviços de saúde o percentual mínimo de 7% de suas receitas originadas de impostos e transferências da União e dos Estados, devendo este percentual ser elevado gradualmente até atingir 15% em 2004. Como toda política pública deve ser sistematicamente avaliada, e partindo da premissa de que, de acordo com a teoria incrementalista, mais recursos aplicados em saúde tenderiam a resolver a crise na saúde, esta dissertação apresenta como resultado um estudo do comportamento de um conjunto de indicadores relacionados com a saúde, em municípios do Estado de Pernambuco após a Emenda Constitucional nº 29. O período da avaliação compreende os anos de 2002 a 2005 e a região avaliada está localizada no agreste meridional do Estado de Pernambuco. Foram selecionados 10 indicadores relacionados com a saúde que integram a Portaria nº 493 do Ministério da Saúde. Como resultado, constatou-se que, no período, o percentual médio aplicado em saúde era superior a 15% desde o ano de 2002. Todavia, o valor per capita relativo à parcela municipal foi reduzido no período 2002 a 2004, sendo elevado no ano de 2005, devendo ser destacado que os municípios arcaram com a metade dos gastos em saúde. Constatou-se, ainda, que os municípios com menor renda per capita foram os que tiveram os maiores valores per capita aplicados em saúde. No que diz respeito ao coeficiente de mortalidade infantil para a região, constatou-se que o valor da média do período, trinta e três para cada grupo de mil crianças nascidas vivas, é classificado como ¿médio¿, de acordo com o padrão definido pela Portaria n¿ 493. Não foi constatada correlação estatisticamente significativa entre valores aplicados em saúde e coeficiente de mortalidade infantil.

This study explores the practical and ideological implications of the New Public Management (NPM) paradigm as introduced in Greece by the so-called “Troika”, a sobriquet referring to a triumvirate comprising representatives of the IMF, the European Union, and the European Central Bank. In the past, attempts had been made by Greek officials to implement managerial practices within the Greek National Health Service (NHS) and the hospital sector in particular, albeit at a more leisurely pace than that of other countries’. On arrival to Greece the Troika imposed a number of changes to improve the country’s public services; and set a brisk pace to accelerate their implementation. The present doctoral thesis seeks to critically evaluate the issue of whether those reforms, especially those salient to the Greek NHS system, are true manifestations of a shift in the NPM paradigm or whether they represent yet another archetypal Greek public sector restructuring. It will also evaluate responses to and outcomes of the successive reforms in the Greece’s NHS system, ascertain the factors contributing to and/or impeding the adoption of those reforms, and identify new opportunities for growth. In order to gain access to a more profound insight into the Greek context, the collection of secondary data provides, among other things, an historical background of Greece’s public healthcare system; reviews the system’s characteristics in terms of healthcare policies, and probes into the state of working conditions within public hospitals. The heightened managerial spirit prevalent in Greece at the moment and brought about by the Troika’s tenure, has made it necessary for the literature review of the present work to focus on the ways that managerial practices and ideologies are imposed on other countries so that their public sector dysfunctionalities may be rectified. Drawing on the literature reviewed, the study develops an integrated analytical framework anchored in NPM, so as to test it in the Greek case and contribute to understanding the Greek NHS organisational realities as well as to evaluating how the new changes have been evolving and faring within Greece’s healthcare organisations. The framework is comprised of a review of the NPM paradigm so as to contextualise the Greek reforms in terms of ideology and practices; a review of Principal-Agent Theory (PAT) for illuminating the interrelationships and involvement of the key actors with the reforms; and a review of Critical Realism (CR) for assisting to reveal the underlying mechanisms and structures that bind the actors with the organisations and their development. Apart from providing the conceptual basis of the thesis, the framework also serves in informing its methodological design (i.e., generating the interview schedule), analysing the findings, and steering the discussion. The study adopts an in-depth, qualitative research approach that views social life within organisations in terms of processes, events, actions, and activities between key actors as factors unfolding over time. To that purpose, semi-structured interviews were conducted with the key stakeholders of the Greek NHS system: State hospital doctors, hospital managers, and policymakers. The contribution of the study is an in-depth analysis of reform implementation as carried out in Greece’s medical system which now stands, within a turbulent economic and political context. By means of that analytical framework, it is shown that Greece is a sui generis case whose context and historical background are altogether different than those of other countries’. Moreover, the framework demonstrates that, despite the fact that NPM is firmly ensconced, as far as practice and ideology go, it is too soon to be drawing any conclusions: NPM is still in its infancy and reforms to the Greek NHS system have yet to be finalised as they continuously stumble on the inefficiencies and blunders of the past which hinder them from functioning properly. Last, the thesis does possess one more unique feature: it delves into the thinking, manoeuvres, and behaviour of the Greek healthcare professionals as a group, a world rarely if ever explored by empirical studies.

In strengthening health systems, the World Health Report 2000 indicates that health system improvement strategies must also cover private (for-profit and non-profit) health care provision and financing if progress towards Universal Health Coverage is to be achieved. Yet very little is known about the financing of non-profit providers in Africa - especially not faith-based health providers, who have often historically remained elusive in terms of financial transparency. This thesis reports on a multiple case study conducted with two non-profit faith-based health providers in Kenya, namely the Africa Inland Church Kijabe Hospital; and Nyumbani-Children of God Relief Institute in Nairobi (Nyumbani) - and situates these within the broader context of health systems financing and public-private partnership in Kenya. Data was collected from multiples sources including: secondary literature; secondary analysis of existing data (such as the Kenya Health Information System); financial data on projects and annual reports; routine facility and service data; previous research on both organizations; archival data; and supplemented by 6 in-depth interviews with key stakeholders. The study reveals a highly complex funding environment for non-profit (and faith-based) health providers in Kenya, which is a result of historic health system configurations, and current funding policy and focus (such as the influx of HIV-related funding). The HIV program in AIC Kijabe Hospital is solely funded by USAID; while Nyumbani is also funded by USAID (70%), but has other private sources. In both cases, funding from various sources is structured differently with varied financial flows and requirements. Faith-based health providers in Kenya are highly dependent on complex donor-funding arrangements, and lack financial resilience as a result. Donors need to better understand the nuance of engagement with such providers.

This dissertation consists of three essays. The first essay, or Chapter 2, advances the literature by examining the conditional effects of lobbying on the relationship between policy learning and policy reinvention. Scholars have consistently shown that learning of successful policies in other states leads to higher likelihood of policy adoption. This essay extends this finding two ways. First, policy learning can also lead to more comprehensive adoption of successful policies. Second, the effect of policy learning on policy comprehensiveness is conditional on lobbying by interest groups, an alternative source of information about policy success. To test these hypotheses, I conduct a directed dyad-year analysis using a dataset on American state drunk driving regulations from 1983 to 2000. The results show that more comprehensive policy adoption by states is positively related to policy success in other states when lobbying by Mothers Against Drunk Driving (MADD) is relatively low. Moreover, lobbying by MADD increases policy comprehensiveness when policy success is relatively low. The second essay, or Chapter 3, examines the effects of GASB 45 on local government borrowing costs. Government financial disclosure is a key instrument to improve fiscal transparency and accountability. In 2004, the Governmental Accounting Standards Board (GASB) issued Statement No. 45 to require state and local governments to disclose information about other postemployment benefits (OPEB) for the first time. The theoretical framework incorporates both direct and indirect effects of disclosure on borrowing costs. The empirical tests use a panel of counties across states and the bonds they issued in the primary market between 1999 and 2012. To account for the impact of GASB 45 on county governments’ decisions to issue bonds, a Heckman selection model is estimated. GASB 45 increases borrowing costs of county governments, with the effects decreasing over time. GASB 45 has a larger effect on borrowing costs of county governments issuing bonds of lower credit quality and adopting the generally accepted accounting standards (GAAP). The third essay, or Chapter 4, examines the impact of information about funding of OPEB plans on borrowing costs of local governments. Local governments have disclosed information about other postemployment benefits (OPEB) plans under the Governmental Accounting Standards Board Statement No. 45 issued in 2004. Funding status is measured by percentage of annual required contribution (ARC) contributed and funded ratios. Two panels of counties and cities with comprehensive annual financial reports available from the Government Financial Officers Association are matched with the bonds they issued between 2008 and 2014. The results show that higher percentage of ARC contributed of OPEB plans are associated with lower borrowing costs for counties; and higher OPEB funded ratios are correlated with lower borrowing costs for cities. Higher percentage of ARC contributed and funded ratios of pension plans are associated with lower borrowing costs for both counties and cities. This essay demonstrates that information about OPEB and pension plans is incorporated in municipal bond pricing.

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Nas últimas décadas o custeio da saúde tem sido crescente em todo o mundo. Este aumento dos custos é explicado pela transição demográfica e epidemiológica: maior sobrevida com aumento de pessoas idosas e das doenças crônicas e pelo aumento de tecnologias mais complexas aplicadas à saúde. No Brasil, a Constituição de 1988 reconhece a saúde como direito do cidadão e dever do Estado e o Sistema Único de Saúde Brasileiro tem, entre seus princípios, o da universalidade. Entretanto, é reconhecida a escassez dos recursos para a área saúde no País, aumentando a responsabilidade dos gestores de bem administra-los, através do planejamento dos gastos e investimentos. O presente trabalho teve como objetivo analisar a gestão dos recursos financeiros da saúde dos municípios da DRS VI – Bauru, analisando o conhecimento dos gestores sobre a administração dos recursos financeiros. foi elaborada amostra de conveniência de 22 municípios, representativa do total de 68 do DRS-VI, segundo agrupamento dos mesmos por tamanho populacional. Foi elaborado questionário específico, aplicado pelo pesquisador aos 22 secretários municipais de saúde. Foram utilizados dados secundários relativos ao custeio da saúde dos municípios e anos estudados. os percentuais do orçamento municipal e das transferências dos governos estadual e federal para os gastos com saúde em 2005-2006, não mostraram relacionamento com a densidade populacional dos municípios. O índice de desenvolvimento humano foi maior nos municípios mais populosos. Os gestores tinham conhecimento das fontes dos recursos financeiros para a saúde e referiram sua insuficiência. Em todas as outras respostas sobre os procedimentos financeiros mostraram desconhecimento ou concentração das decisões na esfera das prefeituras. a gestão exercida pelos secretários de saúde pareceu restrita à área técnica dos serviços...
Over the last decades health funding has increased throughout the world. This fund increase is explained by the demographic and epidemiological transition: higher survival with an increase of elderly people and chronic diseases and by the increase of complex health applied technologies. In Brazil, the Constitution of 1988 recognizes health as a citizen right and a State obligation and the Brazilian Health Care System has universality as one of its principles. Therefore, shortage of resources in the health area is generally accepted in the country, making resources managers more responsible to well administer them through investments and planning expenses. The present work aimed to analyze the administration of health financial resources of cities from DRS VI - Bauru, evaluating manager’s knowledge about the administration of financial resources. a convenience sample of 22 cities was made representing a total of 68 from DRS-VI, according to their assemblage by population size. A specific questionnaire was done and applied by the researchers on 22 health officials of the cities. Secondary data about health funding of the cities and their respective studied years were used. the percentages of the budgets of the cities and of state and federal transferences for health expenses in 2005-2006, did not show any relation to the population density of the cities. Human development index was higher in crowed cities. The managers knew about health financial resources origin and mentioned its insufficiency. In every other answer about financial procedures they showed ignorance or decision concentration on their respective city halls. the administration performed by health officials seemed to be restricted to the technical area of services and financial administration concentrated on the city halls. One verifies that health officials need to receive education about economy and financial administration... (Complete abstract click electronic access below)

Using the Health and Retirement Study Panel core files from 1996 to 2014, I analyze how Medicare Part D impacted access to prescription drug coverage by various demographic factors such as race, gender, and income. In Chapter 1, I find the highest take-up rates for those who were white, female, and with higher incomes. However, increases in coverage were high across the board, such that Medicare Part D also improved drug insurance coverage for those who were black, male, and with lower income. Thus, although Medicare Part D did increase prescription drug insurance coverage for seniors across the board, I also find potential for improvement in enrollment for difficult-to-reach groups. Next, Chapter 2 examines the impact of Medicare Part D on mortality. Although I do not find an impact on the life expectancy of respondents as a whole, I do find a significant positive effect for black respondents, indicating that Medicare Part D may have mattered more for disadvantaged groups. The largest impact is for black men, who have an additional 9 percentage point chance of living to age 73 for an additional 8 years of coverage (significant at the 5% level). When looking only at cardiovascular mortality, which is more likely to be influenced by drug coverage, I find improvements in life expectancy for the total population, with stronger effects for minorities and men. Overall, my findings suggest that Medicare Part D did move the needle on its goal: to improve the health of those who, without government intervention, had the most difficulty paying for prescription drugs. Chapter 3 looks at the impact of Medicare Part D prescription drug coverage on cost-related medication adherence, food insecurity, and finances among seniors. It would be reasonable to assume that Medicare Part D, which led to near-universal drug coverage among senior citizens, could allow seniors to shift money previously spent on drug expenditures to other areas. The strongest effect of Medicare Part D is on cost-related medication nonadherence, leading to a 21% decrease for an additional 8 years of Medicare Part D coverage. The impact is even stronger for the black male population (30%). I fail to reject the null hypothesis that Medicare Part D did not reduce food insecurity or household debt. Overall, Medicare Part D appears to have improved the financial stability of seniors.

This thesis focus on the growing problem of elder mistreatment in the United States and related risk factors. In particular, focus is given to the problem of elder financial exploitation using survey analysis of an urban adult sample in the United States.

This research investigates the changes in the operations of CHSs (Christian health services) in developing countries, particularly their funding bases, relationships with their respective governments, and the extent to which these have resulted in changes to the socioeconomic characteristics of their users. Three main areas of study are woven together: the history of medical mission, health service management and its response to the pressures of the last half-century, and the role of non-state providers in a comprehensive health care system. Evidence was assembled from interviews with officials of twelve UK based mission organisations, a survey of CHSs in thirteen countries, and case studies of CHS provision in Malawi and India based mainly on extensive interviews with selected stakeholders. The research confirmed that funds received by CHSs from mission organisations have declined and are now more often in the form of project funding. CHSs have, for the most part, continued to provide services for the poor in a variety of ways: first, by providing low cost services; second, by developing hi-tech tertiary services, the profits from which subsidise services for the poor; and third, by working more collaboratively with governments, for which they receive varying degrees of financial and other support.

Diskussioner kring kostnader inom hälso- och sjukvårdsverksamhets kan betraktas som ett omtvistat ämne. Avvägningen mellan kostnad och kvalitet är kanske mer komplext på detta område än på många andra. Moraliska aspekter, liksom värdighet och diskretion är exempel på avseenden som är svåra att mäta i ekonomiska termer men som är nödvändiga för att kvaliteten på vården skall betraktas som hög. Det kan således anses finnas en inbyggd konflikt mellan vissa kvalitetsaspekter och kostnaden för vården.

Denna uppsats har sin utgångspunkt i vårdverksamhetens ökade ekonomiska styrning, vilket är en följd av de rationaliseringar och omstruktureringar som sedan 1980-talet uppmärksammats inom den offentliga sektorn och som går under benämningen New Public Management. Syftet är att utifrån relevant teori genomföra intervjuer för att samla information om hur de förändringar som kommit att ta plats inom hälso- och sjukvården märks av och hur de bemöts av vårdpersonalen, samt konsekvenser av styrningens villkor och effekter.

Slutsatserna har landat i att det inte råder något tvivel om att New Public Management kommit att förändra organisation och styrning inom hälso- och sjukvården. Privata inslag, som målstyrning, uppföljning och utvärdering, lokalt verksamhetsansvar förenat med central kontroll, präglar numera verksamheten i syfte mot ökad effektivitet och produktivitet. Detta märks bland annat genom att verksamheten har utvecklats till att bli betydligt mer kostnadsmedveten. Det existerar en bred tillämpning av olika metoder och modeller för styrning av verksamheten, vilket lett till att det administrativa arbetet ökat - en utveckling som upplevs negativ inom verksamheten eftersom den strider mot vårdpersonalens intressen. Politikernas inflytande, vilket kommit att öka, betraktas främst som negativ, dels beroende på politikernas bristande kunskap inom ämnesområdet, dels på grund av att professionens auktoritet minskat.

Discussions on costs in health care activities can be regarded as a questionable substance. The balance between cost and quality is perhaps more complex in this area than in many others. Moral aspects, as well as dignity and discretion are examples of ways that are difficult to measure in monetary terms but which are necessary for quality of care should be regarded as high. It can therefore be considered to be a built-in conflict between certain aspects of quality and cost of care.

This paper has its starting point in care activities increased financial control, which is a result of the rationalization and restructuring since the 1980s, attention in the public sector and termed New Public Management. The aim is that based on relevant theory conduct interviews to gather information about the changes that have come to take place in health care organizations and how they are treated by health professionals, as well as the consequences of it.

The findings have landed in that there is no doubt that the New Public Management has changed the organization and management in health care. Private elements, as management by objectives, monitoring and evaluation, local business responsibilities associated with central control, now characterizes the activity in order to increase efficiency and productivity. This is shown inter alia by the business has evolved to be much more cost conscious. There is an extensive use of various methods and models for control of the operation, which have led to an increased degree of administrative work - a development that is perceived negatively in the activity since it is contrary to the interests of health professionals. The politicians’ influence, which reached to increase, mainly regarded as negative, partly due to politicians’ lack of knowledge in the subject, partly because of the profession's authority diminished.