The intention of this thesis is to explore and discuss the experiences of consumers and carers with psychiatric disability support services. In particular their participation in service development and delivery and the degree to which their relationship with services and providers has influenced this participation, is explored and discussed. These relationships are particularly relevant in the context of the dynamics that determine power and the strategies that consumers have adopted so that they become more empowered and have control over their own lives. / Consumers and their carers are placing greater demands on the mental health service system within Victoria. Reforms to mental health and psychiatric disability support service delivery and practice have resulted in deinstitutionalisation, recognition of fundamental human rights and changes to mental health legislation. Participation by consumers and carers in service development and delivery has been viewed by governments as necessary and important in contributing to care, treatment and support systems. / The National Mental Health Policy developed by the Australian Health Ministers paid substantial attention to the need to include consumers and carers in decisions that shape mental health services. These are underpinned by the World Health Organisation’s doctrine that people have the right and duty to participate individually and collectively in the planning and implementation of their health care. (WHO 1990, p. 14). In Victoria, the National Mental Health Policy lead to the development of a framework for mental health services that reinforced consumer and carer participation in service development and delivery. / A qualitative methodology was used for this investigation. In-depth interviews were conducted with consumers and carers to gain a thorough understanding of their experiences and perceptions of the current mental health system. A review of available literature on the developing mental health consumer movement and on the concepts and practices of empowering strategies was undertaken. The opportunities for participation in the design, development and delivery of services in the context of actual experiences, are discussed with consumers and carers with particular emphasis on consumers’ perceptions of power and empowerment. / The transition from institution to community, known as deinstitutionalisation, has not been an easy one to accept by consumers and carers alike. The changes to service design and delivery with a greater focus on community and out reach services, and the necessary changes in attitudes by providers toward consumers as a result of these changes, have established major challenges for the mental health and psychiatric disability support services sector. Consumers and carers argue that the rhetoric inherent in the decision to implement deinstitutionalisation policies and practices that have lead to a shift to services primarily delivered outside of institutions, needs to be taken to another level. They want to ensure that they are recognised and accepted as bringing essential knowledge and experience to a service system that should be designed to support consumers and carers who face life altering circumstances as a result of a mental illness. / The information provided by consumer participants suggests that the reforms to some degree have provided them with more opportunities to take control over their own lives particularly in relation to their involvement in community based psychiatric disability support services. However, they describe the attitudes of providers as remaining the greatest barrier to advancing consumer participation. Carers on the other hand describe their experiences with psychiatric disability support services as disempowering. Their disillusionment with the mental health system is attributed to the lack of support and their perceived lack of recognition in their role as carers.

This thesis examines the implementation of mental health reforms in Britain and Italy since the 1950s from a geographical perspective. Both countries have experienced the policies of deinstitutionalisation and community care, yet the timing, methods and outcomes of implementation have varied considerably, both between the countries and within them. This situation suggests that underlying social, political, economic and cultural differences have been important influences on the implementation of the respective mental health reforms, and this is a theme that is considered throughout the thesis. The research was conducted at three levels of enquiry: firstly by comparing the implementation of mental health reforms at the national scale in Britain and Italy, looking in particular at the influence of politics and place; secondly by focusing upon the implementation of the reforms in two cities, for which Sheffield and Verona were selected; thirdly a case study approach was adopted in order to study in greater detail one community-based mental health service in each city. It was at this level of enquiry that the more intensive research was carried out, in the form of two local resident questionnaire surveys, one in each city, and semi-structured interviews with mental health professionals from the two case study services. This research illustrates that the implementation of mental health reforms in Britain and Italy has led to a geographical unevenness in the distribution of community-based services at all spatial scales. However, the social, cultural and political contexts in which the reforms have occurred in the two countries have been quite different and therefore when contemplating direct comparisons between mental health reforms in Britain and Italy, the argument that 'place matters' is highly pertinent.

abstract: This work is driven by two facts. First, the majority of households in the U.S. obtain health insurance through their employer. Second, around 20% of working age households choose not to purchase health insurance. The link between employment and health insurance has potentially large implications for household selection into employment and participation in public health insurance programs. In these two essays, I address the role of public and private provisions of health insurance on household employment and insurance decisions, the distribution of welfare, and the aggregate economy. In the first essay, I quantify the effects of key parts of the 2010 health care reform legislation. I construct a lifecycle incomplete markets model with an endogenous choice of health insurance coverage and calibrate it to U.S. data. I find that the reform decreases the fraction of uninsured households by 94% and increases ex-ante household welfare by 2.3% in consumption equivalence. The main driving force behind the reduction in the uninsured population is the health insurance mandate, although I find no significant welfare loss associated with the elimination of the mandatory health insurance provision. In the second essay, I provide a quantitative analysis of the role of medical expenditure risk in the employment and insurance decisions of households approaching retirement. I construct a dynamic general equilibrium model of the household that allows for self-selection into employment and health insurance coverage. I find that the welfare cost of medical expenditure risk is large at 5% of lifetime consumption equivalence for the non-institutionalized population. In addition, the provision of health insurance through the employer accounts for 20% of hours worked for households ages 60-64. Finally, I provide an quantitative analysis of changes in Medicare minimum eligibility age in a series of policy experiments. / Dissertation/Thesis / Ph.D. Economics 2011

No description available.

The purpose of this study was to explain how public health renewal has shaped public health nursing practice, how public health nurses have managed these changes, and the perceived impact of such changes on health outcomes. I used the grounded theory method to develop a theoretical explanation of how public health nurses navigated the changing organizational milieu in British Columbia. I interviewed 29 public health nurses and three public health nursing managers in three health authorities to explicate the impact of healthcare reform initiatives on public health nurses and public health nursing practice. Over the last few decades, there have been several organizational and policy changes in British Columbia, intended to strengthen the health system and health service delivery. These changes have eroded the nature of the public health nurse role and negatively influenced public health nursing practice, undermining the ability of public health nurses to improve population health and health equity. Many participants were concerned about changes in their practice and reported that leaders restricted their role, particularly in their broad health promotion and community development efforts. Nurses in this study highlighted specific organizational and policy changes that have undermined their effectiveness. For example, nurses talked about cuts to the public health budget, the disbanding of health unit structures, the appointment of leaders who lacked public health or public health nursing knowledge and experience, and the increase in mandated targeted public health nursing programs with a corresponding decrease in universal programs. As a result, participants engaged in the process of managing the eroding of the public health nurse role, which comprises five strategies. In standing tall, a number of nurses in this study advocated for their practice and pushed back against decisions that jeopardized the quality of public health nursing programs and services with varying degrees of force. Public health nurse participants also worked within organizational expectations and constraints in the process of getting by. In going underground, several public health nurses engaged in various activities in secret by harnessing their community connections and attended to community issues they believed went unaddressed. A number of nurses, dissatisfied by the state of their role, were contemplating getting out and considered other employment possibilities. Throughout the process of navigating external changes affecting practice, many nurses restored their dedication to the public health nurse role in reaffirming commitment. Given the limited research exploring the impact of healthcare reform and public health renewal on public health nursing practice, this research helps to provide an initial glimpse into the effects of such change on public health nurses in British Columbia. / Graduate

No description available.

Proponents of Canadian health reform in the 1990s argued for regional structures, which enables budget silos to be broken down and integrated budgets to be formed. Although regionalization has been justified on the basis of its potential to increase home care resources, political science draws upon the scope of conflict theory, which instead suggests marginalized actors, such as home care, may be at risk of being cannibalized in order to safeguard the interests of more powerful actors, such as hospitals. Prince Edward Island, Nova Scotia, and New Brunswick, constitute a natural policy experiment. Each has made different decisions about the regionalization model implemented to restructure health care delivery. The policy question underpinning this research is: What are the implications of the different regional models chosen on the allocation of resources to home care? Provincial governments are at liberty to fund home care within the limits of their fiscal capacity and there are no federal terms and conditions which must be complied with. This policy analysis used a case comparison research design with mixed methods to collect quantitative and qualitative data. Two financial outcomes were measured: 1) per capita provincial government home care expenditures and 2) the home care share of provincial government health expenditures. Hospital data was used as a comparator. Qualitative data collected from face-to-face, semi-structured interviews with regional elite key informants supplemented the expenditure data. The findings align with the scope of conflict theory. The trade-off between central control and local autonomy has implications for these findings: 1) home care in Prince Edward Island increased it share from 1.6% to 2.2% of provincial government health spending; 2) maintaining central control over home care in Nova Scotia resulted in an increase in its share from 1.4% to 5.4%, and 3) in New Brunswick, home care share grew from 4.1% to 7.6%. Inertia and entrenchment of spending patterns was strong. Health regions did not appear to undertake resource reallocation to any great extent in either Prince Edward Island or New Brunswick. Resource reallocation did occur in Nova Scotia where the hospital share of government spending went down and was reallocated to home care and nursing homes. But, Nova Scotia is the only province of the three in which home care was not regionalized. Regional interests in maintaining existing levels of in-patient hospital beds was clearly a source of tension between the overarching policy goals formulated for health reform by the provincial governments and the local health regions.

In this master thesis, I resume basic principles of health systems in some developed countries and also in the Czech Republic. Further, I describe changes in Czech health system and main bases of health reform with emphasis on incentive fees. Following sociological survey indicates, that factors influence behaviour of consumer in health care services. Some proposals created with regard to sociological survey are found as the conclusions of this thesis.

Esta pesquisa analisa o processo recente de reforma da política pública de saúde para a população não-assegurada, no México (1982-2000) e no Brasil (1985-1998), como um processo de legitimação política, em construção nas esferas políticas macro (nacional) e micro (estadual no México e municipal no Brasil), e em articulação com as esferas da sociedade civil e econômica. Enfocaremos as estratégias de descentralização, construídas em distintos contextos de dupla transição a fim de integrar a população não-assegurada na política. O problema da legitimação da nova política pública - legalizada e reivindicada como legítima pela autoridade macro, porém dificilmente reconhecida durante a decisão e implementação nas esferas políticas micro -, será relacionado à problemática da identidade, isto é: ao fato do novo ser construído não apenas por novos atores e instituições, mas também por atores e instituições ainda identificados com a velha concepção de público que se pretende substituir/reformar. Estabeleceremos conexões entre os processos políticos macro e micro, verificando as formas distintas como as legalidades reivindicadas pelo poder macro nacional, em cada fase da reforma e país, foram realizadas no nível micro sub-nacional. A análise demonstra que um padrão mais amplo de participação direta na decisão macro, como é o caso do Brasil, resulta em níveis mais altos de identificação (política, administrativa e social) na política micro. Níveis de identificação serão posicionados no contínuo obediência-rejeição e interpretados como coeficientes de legitimidade da política pública de saúde em construção em nos dois países. / This research studies the recent processes of public health care reform directed at the uninsured population in Mexico (1982-2000) and Brazil (1985-1998). Reforms will be studied as a new process of political legitimacy, which is under construction at the macro (federal Government) and micro (state level in Mexico, and mainly the municipality level in Brazil) political spheres, implying different forms of articulation with the social and economic spheres. I will focus on the strategy of decentralisation, adopted in different sequences of double political transitions in order to integrate the non-insured part of the population in politics. The problem of political legitimacy will be understood as a matter of identification (values and interests); as reforms are not only constructed by new actors and institutions, but also by actors and institutions still identified with the old concept of the public. I will stress the relationships existent between the macro and micro processes, verifying if and in which terms the legalities constructed at the macro level, in each phase of the reform and country, were realized in the policy process in the micro political spheres. The analysis shows that a broader pattern of direct participation in policy-making decision, as happened in Brazil, generates higher levels of (political, administrative and social) identification. Levels of identification will be linked to positions in the obedience-rejection continuum and, thus, understood as coefficients of legitimacy in the process of constructing a new public policy in both countries.

Esta pesquisa analisa o processo recente de reforma da política pública de saúde para a população não-assegurada, no México (1982-2000) e no Brasil (1985-1998), como um processo de legitimação política, em construção nas esferas políticas macro (nacional) e micro (estadual no México e municipal no Brasil), e em articulação com as esferas da sociedade civil e econômica. Enfocaremos as estratégias de descentralização, construídas em distintos contextos de dupla transição a fim de integrar a população não-assegurada na política. O problema da legitimação da nova política pública - legalizada e reivindicada como legítima pela autoridade macro, porém dificilmente reconhecida durante a decisão e implementação nas esferas políticas micro -, será relacionado à problemática da identidade, isto é: ao fato do novo ser construído não apenas por novos atores e instituições, mas também por atores e instituições ainda identificados com a velha concepção de público que se pretende substituir/reformar. Estabeleceremos conexões entre os processos políticos macro e micro, verificando as formas distintas como as legalidades reivindicadas pelo poder macro nacional, em cada fase da reforma e país, foram realizadas no nível micro sub-nacional. A análise demonstra que um padrão mais amplo de participação direta na decisão macro, como é o caso do Brasil, resulta em níveis mais altos de identificação (política, administrativa e social) na política micro. Níveis de identificação serão posicionados no contínuo obediência-rejeição e interpretados como coeficientes de legitimidade da política pública de saúde em construção em nos dois países. / This research studies the recent processes of public health care reform directed at the uninsured population in Mexico (1982-2000) and Brazil (1985-1998). Reforms will be studied as a new process of political legitimacy, which is under construction at the macro (federal Government) and micro (state level in Mexico, and mainly the municipality level in Brazil) political spheres, implying different forms of articulation with the social and economic spheres. I will focus on the strategy of decentralisation, adopted in different sequences of double political transitions in order to integrate the non-insured part of the population in politics. The problem of political legitimacy will be understood as a matter of identification (values and interests); as reforms are not only constructed by new actors and institutions, but also by actors and institutions still identified with the old concept of the public. I will stress the relationships existent between the macro and micro processes, verifying if and in which terms the legalities constructed at the macro level, in each phase of the reform and country, were realized in the policy process in the micro political spheres. The analysis shows that a broader pattern of direct participation in policy-making decision, as happened in Brazil, generates higher levels of (political, administrative and social) identification. Levels of identification will be linked to positions in the obedience-rejection continuum and, thus, understood as coefficients of legitimacy in the process of constructing a new public policy in both countries.