Overview: A global shortage of over 7.2 million health workers poses a threat to service delivery particularly in sub-Saharan Africa. Sub-Saharan Africa bears a quarter of the global burden of disease; yet, it only has three percent of all health workers. Maldistribution and migration both to urban and international destinations pose persistent challenges to service delivery particularly to rural and remote populations. In Kenya, the health human resources are mostly concentrated in urban areas, and in some cases as high 70% of the health workers are serving only 20% of the population. Literature to date, particularly in the context of Kenya, has focused on doctors and more recently nurses. There has been a gap in analysis in exploring mid-level cadres such as clinical officers, a cadre of non-physician clinicians. Research objectives: The objectives of the research were to: 1) conduct a contextual analysis of human resources for health in Kenya; 2) understand the migration perspectives of Kenyan health professionals including doctors, nurses and clinical officers through an online survey; 3) explore the role of mid-level health worker cadre of clinical officers as a promising practice for Kenya. The thesis is presented in three papers congruent with the three research objectives. I interrogated these areas at a macro, meso and macro level using systems thinking theory. Findings: The first paper found significant developments in the policy context of managing health professionals in Kenya all of which have improved the working conditions for health professionals. International migration was found to have decreased over the past decade and was not deemed be a policy priority by government and development partner stakeholders. Health professional representatives, on the other hand, asserted that they continue to be disgruntled with the current situation and would not hesitate to migrate given the opportunity. The second paper found that the factors that discourage health professionals from staying in Kenya are similar to those available in the literature and include: dissatisfaction with remuneration, governance, working conditions and living conditions. Among health professionals considering migration, few had made short-term plans to leave. Family ties and fear of the unknown were found to be strong factors for continuing to work as health professionals in Kenya. Job security was found to be high in the government while recruitment agencies were not found to play a significant role in migration decisions of health professionals. The third paper found that there was general support for the scale of up clinical officers to enhance the Kenyan health workforce. Barriers to scale-up included resistance from medical doctors, who felt that clinical officers were not competent enough to handle complicated cases, and a lack of employment opportunities given a surplus of about 3,000 unemployed clinical officers in Kenya, who could potentially fill in the health workforce gaps. Conclusion: Overall policy developments have been implemented since 2007 presenting a promising future to the management of human resources for health (HRH) in Kenya. Although few health professionals are making concrete steps to migrate out of Kenya they continue to be dissatisfied with the current living and working conditions. Maldistribution and overall shortages of health professionals continue to hamper service delivery to vulnerable rural populations. Mitigating factors include the potential of scaling up the clinical officer cadre particularly through the surplus of 3000 unemployed clinical officers, a process that requires sufficient political and professional will. A holistic multi-level approach to health system planning is crucial to ensure that any new investments are well coordinated and involve an overall scale-up of health professionals.

Nesta investigação analisamos a visão dos gerentes das Unidades Básicas de Saúde (UBS) a cerca da problemática da Tuberculose (TB) em um município do interior do Estado de São Paulo. Participaram do estudo 14 gerentes de UBS, sendo a coleta dos dados realizada por meio de entrevista que enfocava a TB na agenda municipal, foi aplicado um questionário fechado e ao final deste uma questão aberta, que permitiu aos sujeitos manifestarem livremente as dificuldades no controle da TB no âmbito da gerência local. A entrevista se deu após o consentimento livre e esclarecido. Para o tratamento dos dados utilizamos o Programa Statística 8.0 da Statsoft, e, por meio deste, elaboramos tabelas de freqüência simples e para os dados qualitativos, utilizamos a técnica de análise de conteúdo, modalidade temática, surgindo três categorias temáticas: 1) A gerência da UBS no controle da TB: um campo de desafios; 2) Ações gerenciais do controle da TB na Atenção Básica (AB): potencialidades e limites; 3) O Controle da TB na AB: a visão gerencial. Os sujeitos do estudo atuam a mais de cinco anos na função de gerentes e a maioria deles toma a TB como uma doença prioritária no quadro sanitário local, de forma que, 81,3% deles a considera como doença prioritária no quadro sanitário do município, e apenas 12,5% expõem que, às vezes, a consideram prioritária. Quanto à participação deles na discussão e definição de ações para o controle da TB no município mais de 50% participam às vezes ou quase nunca, nos permitindo refletir o quão estes gerentes estão imbuídos desta temática. Observamos que há pontualidade do enfoque da TB na AB, ou seja, nas campanhas e semana da TB. Essa característica de focalização das ações, presente nas falas dos sujeitos remete a cultura presente na organização dos sistemas locais de saúde, refletindo no campo do planejamento. A demora no diagnóstico foi relatada pelos gerentes, fazendo com que o doente retorne várias vezes à unidade de saúde em busca de uma solução para seus sintomas. Somado à demora o estigma é algo aparece na fala dos sujeitos e necessita ser trabalhado, uma vez que ambos implicam diretamente no planejamento e organização das ações do controle da TB na AB. Os dados nos mostram que 50% dos gestores não participam e/ou não sabem em relação à definição de linhas específicas para a TB, no repasse de recursos para o município. A subnotificação é uma preocupação apontada pelos gerentes que possuem pouco conhecimento do Programa de Controle da Tuberculose (PCT), bem como, dos casos de TB de sua área de abrangência. Nos seus depoimentos fica explícito uma gerência técnico-burocrática, com debilidades nas dimensões do planejamento e na organização das atividades da UBS que gerenciam. Assim, os gerentes assistenciais do contexto sanitário estudado necessitam recompor aspectos da gerência, como o planejamento e a organização como formas de viabilizar a política de controle da TB, de acordo com os preceitos jurídico-legais e as normatizações inerentes ao PCT. / In this study we analyzed the view of Basic Health Unit (BHU) managers about the Tuberculosis (TB) issue in a city in the interior of São Paulo state. Fourteen BHU managers participated in the study. Data collection took place through interviews that focused on TB in the municipal agenda. A closed questionnaire was administered, and, at the end, an open question was also applied, which allowed for subjects to freely express the difficulties to control TB in the scope of local management. The interview was carried out after obtaining free and informed consent. Data analysis was performed using the Statsoft software Statística 8.0, which was also used to create simple frequency tables, and thematic content analysis was used for the qualitative data. Thus, three thematic categories emerged: 1) Managing the BHU in TB control: a field of challenges; 2) Managerial actions for TB control in Primary Care (PC); strengths and limits; 3) TB Control in PC: the managerial view. The study subjects have worked as managers for over five years and most consider TB a priority disease in the local health setting. In fact, 81.3% of them consider it a priority disease in the municipal health setting, and only 12.5% state that they sometimes consider it a priority. As to their participation in the discussion and definition oft TB control actions in the city, over 50% sometimes or almost never participate. This shows how deep these managers are imbued with this theme. We observed that TB is strongly focused in PC, i.e., in the campaigns and TB week. This characteristic of focusing on actions, present in the subjects statements, recalls the present culture of the local health system organization, having an effect on the field of planning. Managers reported there is a delay in diagnosis, which implies that the patient comes back several times to the health unit searching for a solution to his or her symptoms. In addition to that delay, subjects also state the stigma, which also needs to be solved since both have a direct effect on the planning and organization of TB control actions in PC. The data show that 50% of the managers do not participate and/or do not know about the definition of specific lines for TB, in terms of transferring resources in the municipality. Underreported cases are a concern pointed out by managers who have little knowledge about the Tuberculosis Control Program (TCP), as well as TB cases in their area. Their statements clearly state a technicalbureaucratic management, deficient in the activity planning and organization dimensions at the BHU they manage. Hence, health care managers in the studied context need to recompose management aspects like planning and organization as ways to make the TB control policy feasible according to the legal precepts and regulations inherent in the TCP.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-03-13T13:42:29Z No. of bitstreams: 1 adebianorobertrodriguespereira.pdf: 2060350 bytes, checksum: 16f8d31efae0439bcc2a12582c5bf3ec (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-03-13T19:28:57Z (GMT) No. of bitstreams: 1 adebianorobertrodriguespereira.pdf: 2060350 bytes, checksum: 16f8d31efae0439bcc2a12582c5bf3ec (MD5) / Made available in DSpace on 2017-03-13T19:28:57Z (GMT). No. of bitstreams: 1 adebianorobertrodriguespereira.pdf: 2060350 bytes, checksum: 16f8d31efae0439bcc2a12582c5bf3ec (MD5) Previous issue date: 2016-11-04 / O trabalho que ora se apresenta, focaliza a atuação dos farmacêuticos argentinos na disputa pela regulação da venda e distribuição de medicamentos. A partir de 1989, o governo Carlos Menem estabelece uma série de medidas liberalizantes, daremos atenção especial ao decreto nº 2.284/91, marco inicial de nossa problemática, pois promove a desregulação econômica no país. O decreto em questão, permitiu a livre importação de medicamentos e a comercialização desses produtos fora de estabelecimentos farmacêuticos. Como resultado da crise do experimento neoliberal, ao final da década de 1990, ganhou espaço coalizões dispostas a reorganizar o arranjo político, fortalecendo a intervenção do Estado em espaços estratégicos por meio de políticas sociais e regulações. Em 2009, com a lei nº 26.567/09, que revoga a desregulação econômica para o comércio de medicamentos, fechamos nosso recorte temporal. / The present work focuses on the performance of Argentine pharmacists in the dispute for the regulation of the sale and distribution of medicines. From 1989, the Carlos Menem government establishes a series of liberalizing measures; we will give special attention to Decree nº 2.284/91, the initial mark of our problematic, as it promotes the economic deregulation in the country. The decree in question allowed for the free importation of medicinal products and the marketing of those products outside pharmacies. Because of the crisis of the neoliberal experiment, in the late 1990s, coalitions were willing to reorganize the political arrangement, strengthening state intervention in strategic spaces through social policies and regulations. In 2009, with Act 26,567/09, which repealed the economic deregulation for the drug trade, we closed our time cut.

For her MPH thesis research, Alex Kent conducted secondary analysis of data from the Equity Lens in Public Health (ELPH) research program to explore whether and how Indigenous health equity is prioritized within one regional health authority [HA100] in British Columbia’s public health system. Her thesis addresses the question: How has Indigenous health equity been identified and prioritized within HA100 as reflected in core documents and plans as well as interviews with key decision makers in the health authority? Using the Xpey’ Relational Environments Framework, a theoretical framework designed by Drs. Charlotte Loppie and Jeannine Carriere, Alex identifies and discusses the physical and theoretical settings where Indigenous health equity is and is not manifested in the public health system. Her findings highlight a number of examples of how HA100 has implemented successful strategies aimed at enhancing Indigenous health equity as well as several areas for improvement across the relational environments. Alex concludes that improving Indigenous health equity through human, non-human and symbolic interactions in institution, system and community settings appears to be a current priority for HA100; whereas reconciling historical relationships and creating equitable social, cultural and political conditions that promote optimal health and wellbeing for Indigenous peoples is positioned as a long-term and indirect goal. / Graduate

Magister Public Health - MPH / This secondary data study, framed in social constructionism theory, descibes and analyses the "pull" factors influencing migration of health professionals developing to developed countries. The literature review sets the context withing which international migration takes place and explores relevant aspects of the G8, globalisation, and the General Agreement on Trade in Services. The research demonstrates that temporary or permanent international migration occurs for employment or study purposes. It further confirms that, despite the lack of accurate data from African counties, the number of health professionals leaving the continent has increased significantly during the 1990's. / South Africa

To tackle one of the world’s worst maternal, neonatal and child health outcomes and a chronic shortage of human resources for health, the Afghan Ministry of Public Health deployed volunteer Community Health Workers (CHW) in rural areas of Afghanistan in 2003. This thesis documents the Afghan CHW program, exploring organizational and community contexts. The research design in this study is a mixed methods case study. The actual Afghan CHW program was situated with an Afghan complex adapative health system, mainly guided by the policy of the health system but was also largely influenced by the power and gender dynamics of the community context in which it was implemented. The tasks of CHWs were numerous but CHWs role was more than just the sum of their tasks; they occupied a unique location juxtaposed between formal and informal HRH systems. It is important to acknowledge the assembly of so many national and international organizations in achieving a shared goal of providing health services to a large population in an unstable and partially insecure environment. The shared goal in the Afghan context may have been interpreted only in terms availability of services, though the goal carries with it, either explicitly or implicitly, the values of effectiveness, efficiency, timeliness, and costliness – known as quality by some participants of this study. The community component was another layer of the complex adaptive system that made up the Afghan CHW program. Political-ethnic power in the community and legal-rational authority of the health system influenced the way communities were mapped in an inequitable manner, in turn, contributed to the unfair distribution of resources to the populations. Finally, the intersection of the gender equity approach and the gendered nature of the work as a cross-cutting layer added to the complexity of the Afghan health system.

Background: This thesis presents three research papers that evaluate the current tools and methods used to assess the availability of health resources and services during humanitarian emergencies. Methods: A systematic review of peer-reviewed and grey literature was conducted to locate all known health facilities assessment tools currently in use in low- and middle-income countries. The results of this review were used to generate a framework of essential health facilities assessment domains, representative of seven health systems building blocks. Using this framework, a field-based evaluation of tools used to assess the availability of health resources and services in emergencies in Haiti and the Darfur states of Sudan was conducted. The collected assessment tools from these countries were compared against the framework from the systematic review, as well as the Minimum Standards for Health Action in the Sphere Humanitarian Charter and Minimum Standards in Humanitarian Response, and the Global Health Cluster’s Set of Core Indicators and Benchmarks by Category. A coding system was developed using all of these frameworks that enabled the comparison of the assessments collected in both countries. Field-based interviews were conducted with key informants using a convergent interviewing methodology, to gain perspectives on data collection and the use of evidence in formulating health systems interventions in emergencies. Results: 10 health facility assessments were located in the systematic review of the literature, generating an assessment framework comprised of 41 assessment domains. Of the included assessments, none contained assessment criteria corresponding to all 41 domains, suggesting a need to standardize these assessments based on a structured health systems framework. In Haiti and Sudan, a total of 9 (Haiti, n=8; Sudan, n=1) different assessment tools were located that corresponded to assessments of the availability of health resources and services. Of these, few collected data that could reasonably have corresponded to the different assessment domains of the health facilities assessment framework or the Sphere Standards, nor could many have provided the necessary inputs for calculating the Global Health Cluster’s indicators or benchmarks. The exception to this was the one tool located in Sudan, which fared reasonably well against these criteria. The interviews with participants revealed that while evidence was viewed as important, systematically-collected data were not routinely being integrated into program planning in emergency settings. This was, in part, due to the absence of reliable information or the perceived weaknesses of the data available, but also due uncertainty as to how to best integrate large amounts of health system data into programs. Conclusions: Greater emphasis is needed to ensure that data on the availability and functionality of health services during major emergencies is collected using methodologically-sound approaches, by field staff with expertise in health systems. There is a need to ensure that baseline data on the health system is available at the outside of emergency response, and that humanitarian health interventions are based on reliable evidence of needs and capacities from within the health system.

Philosophiae Doctor - PhD / Health system in Sub-Saharan in Africa face multifaceted capacity challenges to fulfil their mandates of service provision and governance of their resources. Wide-ranging capacity development interventions exist to address these limitations. however, failure to take into account complexity into planning and implementation in the practice and research of these capacity development intervention predominate , hindering understanding and learning, and resulting in poor implementation or lack of sustainability of the capacity gains.

Master of Public Health - MPH / Non-communicable diseases (NCDs) are the leading cause of death globally, affecting a significant proportion of the economically active population, the majority of these occurring in low- and middle-income countries (LMICs). In South Africa, over 40% of deaths are attributable to NCDs. The use of healthcare services by individuals who have NCDs is putatively high but has yet, not been adequately quantified. Furthermore, there is a paucity of research data on factors that influence healthcare services use among those experiencing NCDs in South Africa.

Magister Public Health - MPH / Health systems require effective leadership and management in order to provide quality services especially in resource constrained low- and middle-income countries (LMICs). As in higher income countries (HICs), clinicians in LMICs often transition from a purely clinical to a hybrid role, which includes managerial responsibilities, without any management training. There are both challenges and opportunities in the hybrid manager role. This study explores clinicians’ experiences of the opportunities and challenges of being a hybrid manager in a tertiary academic hospital setting in the Western Cape, South Africa.