Orientador: Sergio Resende Carvalho / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-22T20:19:23Z (GMT). No. of bitstreams: 1 Souza_TadeudePaula_D.pdf: 1730036 bytes, checksum: ad2e6eaf302e19e0eb38612d993b23d5 (MD5) Previous issue date: 2013 / Resumo: Neste trabalho problematizamos o desafio de cumprimento do direito universal ao acesso em saúde para usuários de álcool e outras drogas no Brasil. Para isso apresentamos alguns vetores que interferem na produção de saúde para esta população. A análise destes vetores (de ordem política, histórica e subjetiva) nos conduziu a composição de um método de pesquisa situado no encontro entre a genealogia e a cartografia. Analisar os desafios do campo da saúde nos conduziu a necessidade de compreender alguns vetores construídos historicamente e ao mesmo tempo nos conduziu a necessidade de avaliar como estes vetores se atualizam no contemporâneo. Assim, o empreendimento de fazer uma genealogia das drogas nos conduziu a diferentes diagramas de saber-poder construídos historicamente. O empreendimento de fazer uma cartografia das drogas nos aproximou ao mesmo tempo dos movimentos atuais das políticas sobre drogas no cenário brasileiro e das experiências concretas vividas nas redes de saúde. Nesse ultimo caso propomos uma aproximação com as metodologias de avaliação participativa e interventiva no intuito de avaliar a rede de atenção a usuário de álcool e outras drogas do município de Campinas - SP. A trajetória de pesquisa de campo partiu das analises dos agentes redutores de danos, profissionais de saúde que acessam usuários de drogas em situação de rua. Além destes aspectos cabe ressaltar o trabalho conceitual que propôs uma análise histórica do conceito de universalidade e dos diferentes sentidos que ele pode assumir / Abstract: In this paper we problematize the challenge of fulfilling the right to universal access to health care services by alcohol and other drugs users in Brazil. To do that, we present some factors that interfere with the health status of these persons. The analysis of these factors (of political, historical and subjective order) led us to compose a research method located in the intersection of genealogy and cartography. Analyzing the challenges in the health field led us to the need to understand how these factors were historically constructed and at the same time how they are contemporary updated. Thus, the endeavor of making a genealogy of drugs led us to different knowledge-power diagrams that were historically constructed. At the same time, the endeavor of mapping the drugs brought us together to the current moves of drug policies in the Brazilian scenario as well as to the concrete experiences performed in mental health services. As to these latter, we propose an approach to participatory and intervention evaluation methodologies in order to evaluate the health care services network offered to alcohol and other drugs users in Campinas - SP. The path of this field research departs from the analysis made by some harm-reduction agents or healthcare workers who approach homeless drug users in street outreach practices, as well as the analytical perspective adopted in this paper derives from their experience. Besides these aspects it is worth noting the conceptual work that proposed a historical analysis of the different meanings that the concept of universality can take on / Doutorado / Política, Planejamento e Gestão em Saúde / Doutor em Saude Coletiva

Magister Public Health - MPH / This is a cross sectional survey study that explored determinant factors contributing to home child delivery and influence of traditional birth attendances on place of delivery in Rungwe District, Tanzania.The study focussed on three main aspects namely factors (socio-economic, cultural and knowledge) that influence women to deliver at health facilities and those who deliver ta home. Reasons/factors associated with the acceptability of health services and influence of traditional birth attendaces on place of delivery and whether accessibility to health services and traditional birth attendants influence women to decide the place of delivery. The study was descriptive cross-sectional in nature where a multistage random sampling procedure was used to select 8 wards and 16 villages. A systematic sampling was used to determine household interval in each village. Only one woman with at least one child was chosen in a household using a random sampling. In case of the absence of a woman with at least one child in a house falling in the interval, then the next house was considered. A total of 400 women with at least one child were selected at random from household cluster sample from all four divisions in Rungwe district. They were interviewed using semi-structured questionnaire. The participation rate was 100 % in both divisions. The age of the women ranged from 19-49 years with the mean age of 31 years (Std dev 7.5). Data entry and analysis were done using the quantitative statistics with Epi Info 2002 software. Results were presented using descriptive statistics, figures and tables, and analytical statistics, using Student’s t-test and chi-square. A total of 400 women were interviewed, among them, it showed that there were good attendance for antenatal care 395 (98.75%) and only 5 (1.25%) did not attend antenatal care. However, 243 (60.8%) of women interviewed had incidence of home delivery and 157 (39.3%) had incidence of health facility delivery. Home deliveries in a surveyed area are commonly assisted by unskilled persons, and consequently carry increased risks to the mother and to the new-born baby. Improvement of quality and accessibility of health care services by the health facility should involve harmonic balance between health service provider and beneficiaries in order to change the attitude towards minimizing the practice of home child delivery in Rungwe district, in Mbeya region, in Tanzania as awhole and elsewhere in the world.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-01-22T14:50:29Z No. of bitstreams: 1 luanavieiratoledo.pdf: 5557451 bytes, checksum: d6cf6bf176fecb08c54034dccee35705 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-01-25T18:54:57Z (GMT) No. of bitstreams: 1 luanavieiratoledo.pdf: 5557451 bytes, checksum: d6cf6bf176fecb08c54034dccee35705 (MD5) / Made available in DSpace on 2016-01-25T18:54:57Z (GMT). No. of bitstreams: 1 luanavieiratoledo.pdf: 5557451 bytes, checksum: d6cf6bf176fecb08c54034dccee35705 (MD5) Previous issue date: 2014-02-12 / O acesso aos serviços de saúde tem sido objeto de grande interesse na área da saúde coletiva, na qual diversos autores adotam diferentes conceitos para o tema, envolvendo aspectos relacionados aos serviços, aos usuários e a interação entre eles. Nesta pesquisa, com o objetivo de identificar como ocorre o acesso das crianças menores de 2 anos do município de Juiz de Fora aos serviços de urgência e internação hospitalar, utilizou-se como base a reflexão teórica de Mcintyre, Thiede e Birch (2009), que define o acesso sob a perspectiva da disponibilidade, da acessibilidade financeira e da aceitabilidade. Foram analisados os dados das entrevistas de um inquérito domiciliar realizado no referido município no ano de 2010, no qual participaram 325 responsáveis por crianças menores de 2 anos. Para este estudo foram selecionadas, entre essas crianças, aquelas que haviam sido atendidas pelo serviço de urgência e/ou estiveram internadas no período correspondente aos doze meses anteriores à pesquisa, somando-se respectivamente 88 e 54 crianças. As amostras foram divididas em sub-amostras, tendo como critério para a divisão a cobertura ou não de equipes de ESF. Após essa divisão procedeu-se a análise estatística por meio da Análise de Correspondencia (AC) e Análise de Cluster, nas quais foi possível identificar características distintas para as quatro sub-amostras, representando as dimensões de acesso estudadas. Entre os resultados, observa-se que a sub-amostra 1 é caracterizada principalmente pela dimensão de acessibilidade financeira, na qual a variável “presença de gastos com transporte”, é a mais significativa. A sub-amostra 2 também pode ser caracterizada pela dimensão de acessibilidade financeira, entretanto de forma indireta, pois a sua variável mais significativa refere-se ao “tempo de espera maior do que a média”. Em relação à sub-amostra 3, a dimensão de acesso que faz referência é a disponibilidade, tendo a variável 1, como representativa, expressando a presença de encaminhamento prévio por algum serviço de saúde. A sub-amostra 4, faz referência à dimensão mais subjetiva de acesso, a aceitabilidade, tendo como a variável mais significativa, a “presença de relatório médico explicativo após a alta hospitalar”. Buscando-se compreender a associação dos dados socioeconômicos com a utilização dos serviços de saúde, procedeu-se a regressão logística binária, na qual foi possível identificar que a idade da criança apresenta relação positiva com a procura pelo serviço de urgência caracterizada por um O.R. de 1,113 com valor p considerado <0,001. No que tange à internação hospitalar, a idade da criança mantém-se como uma variável relacionada, tendo um O.R. de 1,046 e valor p igual a 0,054, associada também à variável referente à presença do companheiro materno, que representa um fator de proteção para as internações, tendo um O.R. de 0,425 e um valor p igual a 0,008. Conclui-se que o acesso deve ser considerado em uma abordagem multidimensional, envolvendo fatores relacionados tanto à disponibilidade quanto aos aspectos socioeconômicos e culturais. Ao se pensar no acesso de crianças, características peculiares a elas devem ser consideradas na avaliação do acesso aos serviços de saúde. / Access to health services has been the subject of great interest in the field of public health, in which different authors adopt different concepts for the theme, including aspects related to services, users and their interaction. In this research, with the aim of identifying how the access of children under 2 years of the city of Juiz de Fora to services of emergency and hospitalization is, we used as a basis for theoretical reflection Mcintyre, Thiede and Birch (2009), defining access from the perspective of availability, affordability and acceptability. The interview data consisting of a household survey conducted in the municipality in 2010, responded by 325 parents of children younger than 2 years were analyzed. For this study we selected those children who had been treated by the emergency department and/or were hospitalized in the twelve months before the study period, amounting to 88 and 54 children respectively. The samples were divided into sub-samples, with the criterion for the division being the coverage or not by ESF (“Estratégia de Saúde da Família” – “Family Health Strategy”). Statistical analysis was performed using correspondence analysis and Cluster Analysis, in which it was possible to identify different characteristics for the four sub-samples, representing the access dimensions studied. Among the results, it is observed that the sub-sample 1 is mainly characterized by the dimension affordability, in which the variable indicating transportation costs is the most significant. The sub-sample 2 can also be characterized by the dimension affordability, however indirectly, because its most significant variable refers to waiting time higher than the average. Regarding the sub-sample 3, the access dimension that refers to availability is represented by the “presence of a previous referral from a health service”. The sub-sample 4, referring to the more subjective dimension of access, acceptability, was represented by the” presence of explanatory medical report after discharge”. Seeking to understand the association of socioeconomic data with the use of health services, we proceeded to binary logistic regression, in which we found that the child's age is positively related to the demand for emergency services characterized by an OR of 1,113 to p < 0.001. Regarding hospitalization, the child's age remains as an associated variable, with an OR of 1.046 (p= 0.054), also associated with the variable referring to the presence of a resident partner who is a protective factor for hospitalizations, with an OR 0.425 (p= 0.008). We conclude that access should be considered in a multidimensional approach, involving factors related both to the availability in terms of socioeconomic and cultural aspects. When one thinks about the access of children, peculiar children´s features should be considered in assessing access to health services.

Submitted by Nadir Basilio (nadirsb@uninove.br) on 2017-09-19T20:56:23Z No. of bitstreams: 1 Danielle Cristina Campos de Souza.pdf: 1576989 bytes, checksum: da92792bd527aad6147656d031525bac (MD5) / Made available in DSpace on 2017-09-19T20:56:23Z (GMT). No. of bitstreams: 1 Danielle Cristina Campos de Souza.pdf: 1576989 bytes, checksum: da92792bd527aad6147656d031525bac (MD5) Previous issue date: 2017-02-06 / With the objective of analyzing the results of the implantation of electronic systems and tools, used to perform the regulation of high complexity access, that is, consultation schedules and specialized outpatient exams, this research starts from an exploratory descriptive analysis, promoting a greater knowledge on the history of the Regulation of Access to Assistance (Also called regulation of access or care regulation) and the implementation of a computerized system that acts in this practice. With the 1988 Constitution, the Unified Health System was defined as the right of all, and the State should guarantee equal access. At the outset, it found difficulties in broadening access to citizens and decentralize health actions, dividing the responsibility between States and Municipalities. The approach used was qualitative and quantitative, because it intends to describe and interpret the phenomena, besides analyzing the information collected. The regulation of access to care had its mark with publication of NOA / SUS 2001(Health Care Operational Standard), and has intensified over the years, even with the challenges encountered in achieving the quality required by SUS users and meet the needs that vary according to your individual profile. Since its inception in 2008 through ordinance no. 1,559, presented advances related to the improvement of the quality of care flows making this dimension of regulation can be considered the user's access door to public health services. That is why the main objective of the research consists of analyzing the indicators of satisfaction and absenteeism, because, these are the ones that reveal how the image of the institution is and their use in relation to supply and demand. In August 2010, the Central of Regulation of the Health Services Offering - CROSS, and was implanted in the Hospital of this work with its various functions, allowing a more practical and organized flow to promote access to SUS users, so in this work will be evaluated the impact of the schedules made through the CROSS system allowing outpatient access and evaluating the indicators that effectively present the impact of its implementation. The obtained results indicate positive changes and improvements in the quality of care, since it adopts more adequate protocols in the practice of health care regulation. / Com o objetivo de analisar os resultados da implantação de sistemas e ferramentas eletrônicas, utilizados para executar a regulação do acesso de alta complexidade, ou seja, agendamentos de consultas e exames ambulatoriais especializados, esta pesquisa parte de uma análise exploratória descritiva, promovendo um maior conhecimento sobre a história da Regulação do Acesso à Assistência (também denominada regulação do acesso ou regulação assistencial) e a implantação de um sistema informatizado que atua nessa prática. Com a Constituição de 1988, o Sistema Único de Saúde foi definido como sendo direito de todos, devendo o Estado, garantir o acesso igualitário. Em seu início, encontrou dificuldades em ampliar os acessos aos cidadãos e descentralizar as ações de saúde, dividindo a responsabilidade entre Estados e Municípios. A abordagem utilizada foi qualitativa e quantitativa, pois tem a intenção de descrever e interpretar os fenômenos, além de analisar as informações coletadas. A regulação do acesso à assistência teve seu marco com a publicação da NOA/SUS 2001 (Norma Operacional de Assistência à Saúde), e tem se intensificado no decorrer dos anos, mesmo com os desafios encontrados em atingir a qualidade exigida pelos usuários do SUS e atender as necessidades que variam de acordo com seu perfil individual. Desde sua instituição, em 2008 através da portaria nº 1.559, apresentou avanços relacionados à melhoria da qualidade dos fluxos assistenciais, fazendo com que essa dimensão da regulação possa ser considerada a porta de acesso do usuário aos serviços públicos de saúde. Por isso, o objetivo principal da pesquisa consiste em analisar os indicadores de satisfação e absenteísmo, pois, estes são os que revelam como está a imagem da instituição e seu aproveitamento com relação à oferta e demanda. Em agosto de 2010, surgiu a Central de Regulação de Oferta de Serviços de Saúde – CROSS, e foi implantada no Hospital alvo deste trabalho com suas diversas funções, permitindo um fluxo mais prático e organizado de promover o acesso aos usuários do SUS, por isso, neste trabalho será avaliado o impacto dos agendamentos realizados por meio do sistema CROSS, permitindo o acesso ambulatorial e avaliando os indicadores que apresentem efetivamente o impacto de sua implantação. Os resultados obtidos apontam mudanças positivas e melhorias na qualidade assistencial, pois passa a seguir protocolos mais adequados na prática da regulação assistencial.

"Although the number of new infections has dramatically decreased during the last ten years, portraying this country [Uganda] as the 'AIDS miracle', the number of people already infected and progressing to AIDS is increasing. Acces to anti-retroviral (ARV) drugs, as well as to medicines for treatment of opportunistic infections (TOI), is essential for people living with HIV/AIDS (PLWHA) to enjoy their right to life and health. Although access to these essentail medicines forms part of the core content of the right to health, which states should be able to provide irrespective of their available resources, slightly more than half of the people in need in Uganda were accessing them in June 2005. Of 63,896 PLWHA accessing ARVs, still 83.5 percent are paying the medicines out of their pockets. This is despite the fact that Uganda receives funds from various sources, among which Global Fund to Fight AIDS, Tuberculosis and Malaria (GF) and the US President's Emergency Plan for AIDS Relief (PEPFAR). Although the cost of ARV treatment in Uganda has dramatically decreased since 1997, the price of treatment remains still unaffordable for most Ugandans. ... This study comprises five chapters. The present chapter exposes the problem, the objectives of the study and the research questions, reviews the literature available on the subject, outlines the study's structure, proposes a methodology and points out the study's limitations and relevance. Chapter two sets out the international legal framework of the study. It oulines the scope of the right of PLWHA to access to essential treatment under different international instruments of relevance for Uganda and its connection with other human rights. The chapter also assesses the implications of this right for state and non-state actors. Chapter three sets out the national legal, policy and judicial framework. It explores the action taken by the various branches of the government in addressing the international obligations with regard to access essential treatment. This chapter will also look at the role played by other relevant stakeholders in the realisation of this right in Uganda. Chapter four analyses the various obstacles that impede the realisation of this right at national level, taking into account the globalisation process, the political situation of Uganda, as well as other socio-economic factors. Chapter five provides the final conclusions and recommends legal, judicial and administrative channels towards the realisation of the right to access essential treatment for OLWHA in Uganda." -- Introduction. / Thesis (LLM (Human Rights and Democratisation in Africa)) -- University of Pretoria, 2005. / [Prepared under the supervision of] Dr. Ben Kiromba Twinomugisha, Makerere University / http://www.chr.up.ac.za/academic_pro/llm1/dissertations.html / Centre for Human Rights / LLM

En mars 2020, l’Organisation mondiale de la santé déclare une pandémie mondiale de SARS-CoV-2. Rapidement, le gouvernement du Québec décrète l’état d’urgence sanitaire alors que la métropole de la province, Montréal, se voit affligée de la plus forte prévalence du virus lors de la première vague. La vulnérabilité et les iniquités antérieurement documentées sont potentialisées parmi les populations migrantes et plus spécifiquement pour celles vivant sans assurance médicale. Selon les données les plus récentes, 50 000 à 70 000 personnes vivent sans couverture médicale au Québec. Déjà, avant la pandémie, les personnes migrantes sans assurance médicale (MSAM) étaient confrontées à des barrières culturelles, linguistiques, économiques lorsqu’elles se présentaient dans le réseau public de santé. Ce mémoire de maîtrise vise à documenter les enjeux sociaux, de santé et d’accès aux soins au Québec, plus spécifiquement à Montréal pour la population MSAM dans le contexte de la COVID-19. Une analyse thématique des entretiens semi-dirigés menés auprès de personnes MSAM (n=19) est supportée par le cadre des déterminants sociaux de santé (Gautier et al.,2020). Quatre thèmes émergents de l’analyse seront présentés: Perceptions et attentes par rapport aux politiques (1), Précarité des conditions de vie et de travail : la position sociale déterminante avant et durant la pandémie (2), Stratégies d’adaptation (et leurs limites) pour prévenir les menaces à la santé (3) intraitables institutions de santé en pandémie de COVID-19 (Ou comment les institutions accentuent-elles les barrières d’accès aux soins?) (4). Les résultats de ce projet de recherche mettent en lumière des difficultés et des défis, potentiellement productrices d’ISS, auxquelles ont dit faire face les personnes MSAM durant les premières vagues de la pandémie. Des recommandations sont adressées aux décideurs et aux institutions de santé afin de favoriser l’inclusion des personnes MSAM dans la société québécoise. Celles-ci touchent notamment des politiques et des programmes pour améliorer leur accessibilité aux soins de santé et aux programmes sociaux en temps de pandémie et même au-delà. / In March 2020, WHO declares a global SARS-CoV-2 pandemic. Quickly, the Quebec government declared a state of health emergency while the metropolis of the province, Montreal, was afflicted with the highest prevalence of the virus during the first wave. Vulnerability and previously documented inequities are growing among migrant populations and more specifically for those living without medical insurance. According to the most recent data, 50,000 to 70,000 people live without medical coverage in Quebec. Already before the pandemic, uninsured migrants faced cultural, linguistic and economic barriers when they entered the public health network. This master's thesis aims to document the health and social challenges that they are facing in the context of COVID-19, in Quebec Province, specifically in Montreal. A thematic analysis of the semi-structured interviews conducted with uninsured migrants (n = 19) is supported by the social determinants of health framework (Gautier et al., 2020). Three emerging themes of the analysis will be presented: Precarious living and working conditions: Four emerging themes of the analysis will be presented: Perceptions and expectations in relation to policies (1), precarious living and working conditions: the decisive social position before and during the pandemic (2), adaptation strategies (and its limits) to prevent threats to health (3) Intractable health structures in the COVID-19 pandemic (or how to accentuate the barriers to access to care?) (4). The results of this research project shed light on the difficulties and challenges, potentially producing ISS, that uninsured migrants said they faced during the first waves of the pandemic. Recommendations are addressed to decision-makers and health institutions in order to promote the inclusion of uninsured migrants in Quebec. These relate to policies and programs to improve their accessibility to health care and social programs in times of pandemic and even beyond.

[pt] O presente estudo tem por objetivo geral analisar a relação dos profissionais em formação nas residências multiprofissionais em saúde no que tange ao atendimento de pessoas trans em um hospital universitário do município Rio de Janeiro. Evidenciar o tema da transexualidade a partir do olhar das profissionais de saúde é fundamental para a construção de uma formação profissional e de uma educação permanente em saúde de qualidade que contribua para a criação de espaços de diálogos entre as profissionais de saúde e a população atendida. Para isto, este trabalho teve como objetivos específicos: 1) Identificar a percepção das profissionais de saúde em formação acerca das demandas das pessoas transexuais que comparecem aos serviços de saúde, 2) Analisar a interação entre profissionais de saúde e as pessoas trans no atendimento de suas demandas e 3) Analisar a incorporação e reificação da dimensão de gênero na formação da residência em saúde pública a partir do olhar das profissionais. Os episódios de atitudes discriminatórias contra as sexualidades consideradas desviantes da norma são recorrentes nos ambientes de saúde. Foram realizadas oito entrevistas individuais com profissionais de saúde residentes do segundo ano de formação dos programas de residência multiprofissionais. Na análise dos dados coletados, utilizamos a análise de conteúdo das narrativas das profissionais de saúde entrevistadas, a partir de três categorias: Noções sobre transexualidade e demandas em saúde, atendimento às pessoas trans e interação com as profissionais de saúde e gênero e formação profissional. Observamos que as dificuldades de lidar com as questões relativas ao gênero e à sexualidade, especialmente à sexualidade feminina, faz com que as profissionais de saúde reduzam o impacto de suas ações. Os resultados apontam que a maneira como esses profissionais entendem e constroem as noções de gênero e sexualidade, torna-se uma das principais barreiras de acesso das pessoas trans aos serviços. / [en] This study aims to evaluate healthcare professionals (HCP) during their multiprofessional postgraduate training - residency - and their perceptions of the care dispensed to transgender people in a university hospital in Rio de Janeiro city. It is highly important to value the transexuality subject from the HCP perspective in order to build proper professional education and permanent health education that allows experience exchange spaces between those professionals and the population. This work has as specific goals: 1) To identify the in-training HCP perception about the demands of transgender people who attend to the health facility, 2) To evaluate the intercommunication between HCPs and trans people regarding the resolution of their needs and 3) To evaluate the internalization and reification of gender dimension in the public health education during residency from the professionals perception. Gender discrimination episodes against people whose sexuality is considered deviating is recurrent in health care institutions.. For this work, we conducted 8 interviews with 2nd-year health care students during their multiprofessional residency. To perform data analysis the content analysis method was used to evaluate the narratives of the interviewees, using three categories: basic knowledge on transexuality and health needs, health care to trans people and interactions with HCP and gender and professional training. We observed that the difficulties in dealing with gender and sexuality topics, specially those regarding female sexuality, reduce the impact of the action of those health professionals. Our results evidentiate that the manner the HCPs deal with gender and sexuality and how they understand those subjects are barriers to transgender people on their access to health care services.

Because of evidence of regional variation in health and healthcare use, this thesis used health equity and access to care theory to examine regional differences in access to primary care, using survey- as well as secondary data in four empirical studies. First, a systematic literature review was used to categorize forms and reasons for regional healthcare shortages and access barriers, with a particular focus on rural areas. After information extraction from the selected studies and a thematic content analysis, the forms and causes identified in the literature were grouped and discussed. Following the literature-based review of these thematic foundations, a study was then designed to evaluate patient-reported access to primary care in exemplary German regions and assess empirical differences in rural vs. urban populations. This allowed the importance to patients of different access dimensions to be evaluated. For a subgroup of study participants with multidisciplinary care needs, care coordination failures and the supportive role of the general practitioner as a primary point of access was investigated. Finally, regional factors that are associated with variations in need, health, and utilisation beyond individual health determinants were identified, and placed on different regional framework conditions. These health-related factors were summarised in a regional deprivation measure and small-scale regions in Germany were differentiated by their regional deprivation by the main dimensions (material, social, ecological). Finally, their association to regional health outcomes were cross-sectionally estimated. To reduce unwarranted access variation, while also taking the patient perspective (by region) into account, the thesis concludes with a chapter on implications. Here, concepts for regional and multidimensional access monitoring, as well as further regulatory measures in capacity and distribution planning of primary care, are discussed.:Content Tables ........................................................................................................................... V Figures ....................................................................................................................... VI Abbreviations ........................................................................................................... VII 1. Background and research objectives .................................................................. 9 1.1. Health equity and access to health care ........................................................ 10 1.2. Regional variation as a contradiction to the equity principle ....................... 16 1.3. Reducing unwarranted regional variation in health care .............................. 20 1.4. Research objectives and thesis structure ...................................................... 24 References ............................................................................................................... 28 Legal sources .......................................................................................................... 33 2. Rural health care shortages and access barriers ............................................. 34 3. Regional access and satisfaction with primary care........................................ 35 Appendix 3 .............................................................................................................. 36 4. Access to primary care and outpatient care coordination .............................. 48 4.1. Introduction .................................................................................................. 49 4.2. Background ................................................................................................... 51 4.2.1. The patient perspective of care coordination ......................................... 51 4.2.2. Coordinating mechanisms ..................................................................... 52 4.3. Methods ........................................................................................................ 55 4.3.1. Data collection and sample .................................................................... 55 4.3.2. Measures ................................................................................................ 55 4.3.3. Data analysis .......................................................................................... 58 4.4. Results .......................................................................................................... 59 4.5. Discussion and limitations ............................................................................ 62 4.6. Implications .................................................................................................. 65 References ............................................................................................................... 69 Appendix 4 .............................................................................................................. 73 5. Area deprivation and its impact on health ....................................................... 76 6. Summary of implications ................................................................................... 77 6.1. Establishing a framework to assess primary care access and performance .. 77 6.2. Strengthening patient involvement in health care structure planning .......... 81 6.3. Strengthening access to GPs as outpatient care coordinators ....................... 84 6.4. Including regional deprivation factors in health care structure planning ..... 86 References ............................................................................................................... 90

<p>This thesis comprises three essays that empirically investigate important issues in two areas of health economics: physician labour supply and health insurance policy interventions.</p> <p>In the first essay, gendered associations between family status and physician labour supply are explored in the Canadian labour market, where physicians are paid according to a common fee schedule and have substantial discretion in setting their hours of work. Data from 1991 to 2006 show no gender difference in physician labour supply after controlling for family status. Male and female physicians have statistically indistinguishable hours of work when never married and without children. Married male physicians, however, have higher market hours than unmarried male physicians and parenthood either increases their hours or leaves them unchanged. In contrast, married female physicians have lower market hours than unmarried physicians and parenthood substantially lowers market hours. Little change over time in these patterns is observed for males, but for females two offsetting trends are observed: the magnitude of the marriage-hours effect declined, whereas that for motherhood increased. Preferences and/or social norms induce substantially different labour market outcome across the sexes. In terms of work at home, the presence of children is associated with higher hours for male physicians, but for females the hours increase is at least twice as large. A male physician’s spouse is much less likely to be employed in the presence of children, and if employed, has lower market hours in the presence of children. In contrast, a female physician’s spouse is more likely to be employed in the presence of children, and if employed, has slightly lower market hours in the presence of children. Both male and female physicians have lower hours of work when married to another physician.</p> <p>This second essay examines the impacts of a mandatory, universal prescription drug insurance program on health care utilization and health outcomes in a public health care system with free physician and hospital services. Beginning in 1997, all residents of the province of Quebec, Canada, were required by law to have drug insurance coverage. Under this program, all persons under age 65 who are eligible for a private plan are required to join that plan, while the public prescription drug insurance plan covers all Quebecers who are not eligible for a private plan. Using the National Population Health Survey from 1994 to 2003, we find that the mandatory program substantially increased drug coverage among the general population. The program also increased medication use and general practitioner visits but had little effect on specialist visits and hospitalization. Findings from quantile regressions suggest that there was a large improvement in the health status of less healthy individuals. Further analysis by pre-policy drug insurance status and the presence of chronic conditions reveals a marked increase in the probability of taking medication and visiting a general practitioner among the previously uninsured and those with a chronic condition. We also find evidence of positive health gains among the chronically ill.</p> <p>The third essay examines the impact of delisting routine eye exam services on patient eye care utilization and on providers’ labour market outcomes in a public health care system. Beginning in the early 1990s, provincial governments in Canada started to de-insure routine eye examinations from the basket of publicly funded health care services. We exploit delisting policy changes across Canadian provinces to estimate the impact of delisting from the supply- and demand-sides. Demand side analysis using the National Population Health Survey and Canadian Community Health Survey data suggests that the delisting of eye exams for the working age population decreased the probability of using eye care among this population group. However, the number of visits among those who continued to use eye care services was not affected. We also find suggestive evidence that the delisting policies targeted at the working age population were associated with increased eye care utilization among the elderly patients. Using the optometrist sample from the Canadian census data we find that the delisting of eye exams decreased optometrists’ weekly work hours while raised their annual work weeks. There was no statistically significant effect on optometrists’ income.</p> / Doctor of Philosophy (PhD)

Cervical cancer rates among Vietnamese American women are the highest when compared to other women of color and white women. In an article by Taylor, Nguyen, and McPhee, a majority of Vietnamese Americans immigrated to the United States over the last three decades; and the President's Advisory Commission on Asian Americans identified cervical cancer among Vietnamese women as one of the most important health disparities experienced by the Asian American population. HPV vaccination, according to the CDC, helps prevent cervical cancer and it is recommended that female and male preteens, ages 11 or 12, receive the vaccination. My research aims to better understand what second generation Vietnamese American women know about the HPV vaccination, their relationship to healthcare, and their overall health. By interviewing second generation Vietnamese American women, I hope they become more empowered to ask their doctors about health disparities that affect their communities. In looking at preventative measures to cervical cancer and trying to better understand a vulnerable population's relationship to healthcare, I hope that the rates of cervical cancer will go down in Vietnamese American women. Furthermore, I hope to push for greater disaggregation of data collection among Asian American populations to better understand the health disparities that affect the various ethnicities that fall under the umbrella term, Asian American.