Strong health systems are needed to implement clinical and public health interventions. Global evidence-informed health systems guidance, such as that created by the World Health Organization (WHO), has been used to help strengthen health systems. However, global guidance needs to be contextualized or adapted to fit the realities of a particular setting. A workbook for contextualizing health systems guidance was developed to accompany WHO guidance on optimizing health worker roles to increase access to and use of key interventions for improving maternal and newborn health. This dissertation investigates the development and use of the workbook, using qualitative research methods, to help in the planning of future knowledge translation tools, to provide insights for practice and research, and to improve the workbook. First, a single case study explores the development of the workbook, which helped uncover the key features of the process, barriers that arose, and facilitators that helped overcome some of these barriers (chapter 2). Second, a single embedded case study examined the use of the workbook in two real-life settings, Peru and Uganda (chapter 3). Third, a critical interpretive synthesis of the literature was used to better define contextualization and to find what and how contextual factors could be used by policymakers to adapt guidance to their setting (chapter 4). Together, the three studies presented in this dissertation offer substantive, methodological and disciplinary contributions to the field of health systems and policy through a comprehensive examination of the workbook. It presents recommendations for improving the workbook from the perspectives of global guidance developers, users at the national level, and the broader literature on guidance and guideline development, contextualization and implementation. It also supports the continued use of workbooks, or other tools, to contextualize guidance in an effort to strengthen health systems, especially in low- and middle-income countries. / Dissertation / Doctor of Philosophy (PhD) / Strong health systems are needed in order for the right mix of clinical care and public health interventions to get to those who need them. The World Health Organization writes guidance at the global level to help countries strengthen their health systems. This guidance can be used to develop health guidance or policy for the national or subnational (e.g., provincial, state) level, but it first needs to be contextualized or adapted to that particular jurisdiction. It is important to consider what the problem is and what causes it, policy options to help deal with the problem, implementation considerations, as well as factors related to both the health system and the political system that can affect whether or not the intervention will be implemented. A workbook was developed to help contextualize guidance. This dissertation explores the process of developing and evaluating its use to help in the planning of future tools, to provide insights for practice and research, and to improve the workbook.

INTRODUCTION: Non-communicable diseases (NCDs) burden has increased significantly over the past decade in Saudi Arabia (SA). Disparities of NCDs disease prevalence have been documented; however, little is known regarding inequities in NCDs health services access and delivery especially at the primary health care (PHC) level. Moreover, equity considerations have not explicitly been part of allocative financial decision-making criteria. The goal of this study is to assess equity-related challenges in accessing NCDs services as well as the current NCDs priority setting and financial resources allocation process to support the ongoing health system transformation efforts. METHODS: This study used a mixed methods approach. The quantitative data was obtained from existing secondary data of 10,000 households’ surveys, The Kingdom of SA World Health Survey, 2019. The primary collected qualitative data consist of 33 in-depth interviews (IDIs) with public officials from national and regional level using an interview guide supported by documents review. A multiple logistic regression and thematic analysis were used for the analysis. RESULTS: More than 35% of people with diagnosed diabetes, hypertension or dyslipidemia have an unmet need of primary care services. Only 20% of surveyed women had a cervical cancer screening during their last pelvic exam while only 18% of eligible women ever had a mammogram. Significant factors affecting primary care services utilization were region of residence, population density, wealth, income and education. Findings from the interviews revealed that NCDs and PHC are top priorities of the Saudi health reform with strong political commitment and major investments. However, there is no clear strategic direction to improve NCDs services given the highly centralized financial system with suboptimal resources allocation towards PHC and where increasing efficiency focuses mainly on higher level care. Governance-related challenges include accountability and power struggle, partly due to financial and human resources variations across the region. DISCUSSION: Improving budget formulation for primary care and NCDs programs, and harmonizing NCDs programs funding across sectors apart from the health sector while defining what equity and allocative efficiency mean for the Saudi health system transformation are priorities to achieve the health system transformation goals. / 2025-12-11T00:00:00Z

Background While an estimated 70%–75% of the health workforce are women, this is not reflected in the leadership roles of most health organisations— including global decision-making bodies such as the World Health Assembly (WHA). Methods We analysed gender representation in WHA delegations of Member States, Associate Members and Observers (country/territory), using data from 10 944 WHA delegations and 75 815 delegation members over 1948–2021. Delegates’ information was extracted from WHO documentation. Likely gender was inferred based on prefixes, pronouns and other gendered language. A gender-to- name algorithm was used as a last resort (4.6%). Time series of 5-year rolling averages of the percentage of women across WHO region, income group and delegate roles are presented. We estimated (%) change ±SE of inferred women delegation members at the WHA per year, and estimated years±SE until gender parity from 2010 to 2019 across regions, income groups, delegate roles and countries. Correlations with these measures were assessed with countries’ gender inequality index and two Worldwide Governance indicators. Results While upwards trends could be observed in the percentage of women delegates over the past 74 years, men remained over-represented in most WHA delegations. Over 1948–2021, 82.9% of delegations were composed of a majority of men, and no WHA had more than 30% of women Chief Delegates (ranging from 0% to 30%). Wide variation in trends over time could be observed across different geographical regions, income groups and countries. Some countries may take over 100 years to reach gender parity in their WHA delegations, if current estimated trends continue. Conclusion Despite commitments to gender equality in leadership, women remain gravely under-represented in global health governance. An intersectional approach to representation in global health governance, which prioritises equity in participation beyond gender, can enable transformative policymaking that fosters transparent, accountable and just health systems.

BACKGROUND: Globally, 80% of children with cancer live in low- and middle-income countries (LMIC) and 20% or less are expected to survive. Research demonstrates a gap on recording experiences of planners who have successfully established a pediatric cancer unit (PCU), lack of studies on systematic, evidence-based planning of a PCU, and absence of an actionable, practical framework that guides planners. OBJECTIVES: This qualitative study used a case study approach to examine the key elements in the planning process of effectively establishing a new PCU and identify the challenges that need to be addressed. METHODS: Porter’s Value Chain Model served as the theoretical framework to guide the research agenda. Semi-structured in-depth interviews were conducted in 2017 with a purposive sample of 35 key informants reflecting experiences from 30 countries. An interview guide was developed and recruitment continued until saturation. Participants included physicians, nurses, architects, administrators, consultants, and academicians. Data were also employed from three other sources: document review, observation, and pre-dissertation findings. Interviews were recorded, transcribed using REV, and analyzed using NVIVO. Data were analyzed using a thematic analysis and principles of grounded theory method were applied in the interview guide design and analysis. RESULTS: Respondents reported nine strategic elements essential in the process: leadership, mission, planning principles, organizational structure, situation analysis, medical model, financing, stakeholders, and international partnerships. Corruption, distrustful culture, ineffective communication, and lack of data were cited as key barriers. DISCUSSION: Documenting best practices and implementing a data-driven, systems-based planning is essential in advancing local PCU management know-how in LMIC. The modified Porter’s Value Model showed promise as a generalizable model for future public health practitioners and created a framework for systems-based, multidisciplinary approach in strategic planning. / 2020-06-30T00:00:00Z

OBJECTIVE: Immigrants to the United States represent a variety of ethnocultural backgrounds, experiences, and languages. They face stressors unique to migration that may exacerbate or cause mental health concerns. Despite this increased risk, immigrants access treatment at rates far below their native-borne counterparts. Structural and cultural barriers to mental health service utilization expound this disparity. The present thesis proposes a novel system to provide psychosocial support for US immigrants seeking treatment at Massachusetts General Hospital (MGH).  METHODS: Recognizing the need for a new paradigm of care, an Immigrant Mental Health Center prototype was conceptualized using a Human-Centered Design approach. The foundations for this prototype align with the Patient-Centered Medical Home approach to integrated primary and mental healthcare. Narrative reviews informed the theoretical basis of the prototype. A brief review of the existing literature yielded five integrated care themes, forming the basis for prototype evaluation criteria. Communication materials for stakeholder meetings and expert advisory panels were prepared as the next step in the Human-Centered Design approach.  RESULTS: The prototype extended care to a diverse spectrum of US immigrants within the MGH healthcare network. It involved a multidisciplinary team of specialists, whole-patient orientation, a personal practitioner, increased accessibility, and viable internal (MGH) and external (community) linkages.  CONCLUSIONS: The next steps in the Human-Centered Design approach include iteratively designing solutions to co-optimize the prototype for implementation at the MGH Center for Immigrant Health. Recommendations for the iterative refinement stage include clarifying financial metrics and addressing structural barriers to treatment accessibility. A series of feasibility pilot trials and efficacy randomized-controlled trials precede implementation. Future directions include extending the target population to second or third-generation immigrants, attending to severe mental illnesses, and fostering inpatient mental healthcare linkages as a bridge to long-term care.

No description available.

Infectious diseases attract a lot of mediatic, cultural and political attention. But are those diseases like Ebola, or ‘disease x’ actually what kills us? Since 1946, the WHO is the most authoritative figure in the fights against infectious disease outbreaks. So how does the WHO maintain this power and authority after tremendous budget cuts, competition for authority, and a shift to non-communicable disease epidemiology? This thesis uses a mixed-methods approach of quantitative analysis of ‘Disease Outbreak News’ reports, and qualitative analysis of key WHO literature, to develop the alternative narrative answering those questions. This thesis found that the WHO activities surrounding the collection and distribution of data create a political and institutional environment in which the WHO seems to be the only logical solution to prevent them. Additionally, the narrative put forth by the WHO prioritizes the ‘alert and response’ and operational capabilities of the organization to further expand authority in outbreak response. This study concludes that the WHO, through the collection and distribution of knowledge, and efforts to increase operational capability as seen through the Global Outbreak Alert and Response Network (GOARN), seeks to maintain normative authority and power as an international organization. / M.A. / Globalization of trade and travel has only increased the fear of infectious disease transmission. There is a great demand for a global health security system that is alert and capable. Based on this ‘threat’ the WHO justifies their role as global health leader. The Global Outbreak Alert and Response Network (GOARN) is the system that currently acts as the operational arm of the WHO, monitoring and coordinating response to infectious disease outbreaks globally. Despite the critical role of GOARN, its day-to-day endeavors remain unexplored by the public health field. This thesis analyzes how the WHO uses GOARN and its surveillance capabilities to collect and transform data as a method to maintain normative authority, and projects a powerful narrative as the leader of ‘alert and response’. In a competitive environment with limited financial resources, the WHO has adapted in terms of surveillance and operational capability to maintain its leadership and authority in the global public health field.

The study explored the cultural care beliefs, values and attitudes among Shangaans relating to hypertension. The study aimed to describe the cultural values, beliefs and practices such as taboos, rituals and religion within the world view of the Shangaan. The study was undertaken in the Mopani region of the Greater Giyani area, with the purpose of making recommendations on patient care. Data collection was done by conducting focus group and individual interviews. The five themes that emerged were: + Hypertension + The traditional healer: the instrumental role + Traditional medicine versus Western medicine + Magico-religious healings + Experiences of hypertensive patients with regard to traditional healers and hypertension / Health Studies / M. A. (Health Studies)

This thesis aims to fill the gaps in the literature of the theory of constraints (TOC) in publicly funded health systems. While TOC seems to be a natural fit for this resource-constrained environment, there are still no reported application of TOC’s drum-buffer-rope tool and inadequate customizations with regards to defining system-wide goal and performance measures. The “Drum-Buffer-Rope for an Outpatient Cancer Facility” chapter is a real world case study exploring the usefulness of TOC’s drum-buffer-rope scheduling technique in a publicly funded outpatient cancer facility. With the use of a discrete event simulation model populated with historical data, the drum-buffer-rope scheduling policy is compared against “high constraint utilization” and “low wait time” scenarios. Drum-buffer-rope proved to be an effective mechanism in balancing the inherent tradeoff between the two performance measures of instances of delayed treatment and average patient wait time. To find the appropriate level of compromise in one performance measure in favor of the other, the linkage of these measures to system-wide performance measures are proposed. In the “Theory of Constraints’ Performance Measures for Publicly Funded Health Systems” chapter, a system dynamics representation of the classical TOC’s system-wide goal and performance measures for publicly traded for-profit companies is developed, which forms the basis for developing a similar model for publicly funded health systems. The model is then expanded to include some of the factors that affect system performance, providing a framework to apply TOC’s process of ongoing improvement in publicly funded health systems. The “Connecting Low-Level Performance Measures to the Goal” chapter attempts to provide a framework to link the low-level performance measures with system-wide performance measures. It is claimed that until such a linkage is adequately established, TOC has not been fully transferred to publicly funded health systems.

Trata-se de pesquisa quali-quantitativa que envolve observação participante, análise de documentos e realização de entrevistas com usuários de um hospital do SUS e um particular. O foco da investigação é o consentimento informado na assistência à saúde, entendido como o processo decisório compartilhado no qual há troca de informações, impressões e valores entre os usuários do serviço e os profissionais de saúde. Objetivou-se verificar sua prática no sistema de saúde brasileiro, com recorte para a área da oncologia. Para a análise estatística, as variáveis categóricas foram avaliadas por meio do teste exato de Fisher e, as variáveis numéricas, comparadas utilizando o teste t, com nível de significância de 5 por cento . Quanto aos termos de consentimento, os testes de Flesch e Flesch-Kincaid apontaram legibilidade inadequada segundo padrões internacionais, bem como diante dos níveis educacionais de fato encontrados nos hospitais. Mais de 70 por cento dos entrevistados do SUS não tinham escolaridade compatível com a exigida para a leitura dos documentos. Apesar de a quase totalidade dos usuários dos hospitais ter relatado satisfação com as informações recebidas sobre o procedimento que iria realizar, apenas 58 por cento souberam elencar ao menos um risco relacionado ao mesmo. Conforme o esperado, houve associação entre nível educacional e renda dos usuários com a compreensão de riscos dos procedimentos. Mesmo que não se tenha notícia da variável renda ter sido considerada em estudos anteriores, por meio de regressão logística múltipla, observou-se que teve peso muito maior do que a escolaridade em predizer a chance de a pessoa citar um dos riscos do procedimento, embora ambos os fatores sejam preditores independentes. Não houve relação entre a compreensão de riscos e se o hospital era SUS ou particular, e nem em relação ao tempo de tratamento. Diferentemente de pesquisas em outros países, tampouco houve associação entre nível educacional e leitura do termo de consentimento. Entretanto, quando foi o médico, dentre os profissionais de saúde, quem entregou o termo, este foi mais lido pelos usuários. Houve associação entre o usuário estar no hospital particular e acreditar que o termo de consentimento serve para proteger os médicos, em contraposição a servir à sua própria garantia. Pela análise qualitativa, os usuários do SUS tiveram maior habilidade que o esperado na compreensão do diagnóstico e histórico da doença. Acredita-se que o bom acolhimento conseguiu superar em parte o nível educacional e de renda que foram detectados como barreiras ao entendimento das informações, de forma que a humanização da saúde parece impactar positivamente na compreensão das informações pelos usuários. Contudo, em ambos os hospitais, apesar de conseguirem relatar bem os procedimentos pretéritos e futuros, muitos usuários pareciam não saber se contextualizar em seus tratamentos e nem entender os motivos e objetivos dos procedimentos realizados. Em geral, tanto usuários como profissionais mostraram não entender o que é o consentimento informado e a diferença deste para os termos de consentimento, comumente tratados como mera burocracia jurídica. Tudo isso pode estar prejudicando os objetivos do consentimento informado e são questões que necessitam ser repensadas no sistema de saúde / This qualitative-quantitative research includes participant observation, document analysis, and interviews with users from both SUS and private hospitals. It focuses the informed consent in the health care, understood as the shared decisionmaking process in which information, opinions, and values are exchanged between the service users and their health professionals. The goal is to analyze the practice of the informed consent within the Brazilian Health Systems oncology field. The evaluations of categorical variables associations used the Fisher\'s exact test, while the numerical variables were compared through a t-test, at the 5 per cent significance level. Through Flesch and Flesch-Kincaid methods, it was found that the hospitals informed consent terms are of inadequate readability according to international standards, and also inappropriate compared to the actual users literacy level: more than 70 per cent of the SUS interviewees do not match the required literacy standard for comprehending the documents. In addition, although almost all users reported satisfaction with the information they received about their procedure, only 58 per cent were able to name at least one related risk. As expected, there was an association between the educational and income levels of the participants and their ability to understand the risks of a medical procedure. It is noteworthy that previous studies, both national and foreign, do not seem to have considered income level as a variable. Although both factors were independent predictors, multiple logistic regressions showed that income level had a greater weight than educational level in predicting a person\'s chance of citing one of the procedural risks. Additionally, no matter the timing of the treatment, there was no relation between knowledge of risks and whether the hospital is SUS or private. Unlike results found in other countries, there appears to be no association between educational level and the reading of consent terms. Nevertheless, when the doctor is the health professional who applies the term, it is read more often by the users. The research demonstrated that there was an association between the user being in the private hospital and believing that the consent term exists to protect the rights of the doctor instead of their rights as health service users. Through qualitative analysis, this study found that the SUS hospital users had greater ability than expected to understand disease diagnosis and history. The hospitals effective patient care appears to have partly overcome the educational barrier that often prevents patients from understanding diagnostic and medical procedures information, so that humanization of healthcare seems to have a positive impact on users understanding of information. Despite of both hospitals users satisfactorily report past and future procedures, several of them appear not to contextualize their treatments either understand the performed procedures reasons and objectives. In general, users and health professionals in both hospitals do not seem to understand the informed consent concept, neither the difference between informed consent and informed consent terms, generally seen as mere legal bureaucracy. All of these issues may jeopardize the goals of informed consent, if they are not addressed properly at the health care