Health technology assessment (HTA) frameworks appraise the value of technologies – be they drugs, devices, procedures or services – to inform policy decision-making and resource allocation amongst alternatives within publicly funded health systems. The prevailing principles and metrics by which HTA is conducted were designed with adult health conditions and treatments in mind. The evidentiary and normative dimensions of HTA frameworks may have unique repercussions for drug policy and coverage decisions in children, but their relevance to child health has received almost no critical scrutiny in either academic or policy circles. Approaches to paediatric drug coverage approval and access currently lack child-specific data on social values and priorities, a core component of HTA in most countries with public drug funding programs, including Canada. This thesis presents a mixed methods study of social values relevant to child HTA and drug policymaking in publicly funded health systems, comprised of three original scientific contributions. The first of these is a critical interpretive synthesis (CIS) of the academic literature on the moral dimensions of child health and social policymaking across a range of disciplines and policy domains. The second is a grounded theory analysis of qualitative interviews with diverse health system stakeholders on the social values and health system factors relevant to child HTA and drug funding policy in Canada. The third is a stated preference survey of the general public that assesses societal preferences for health resource allocation to children as compared to adults, to generate evidence for priority setting on health technologies within Canada’s publicly funded health system. Together, these studies yield specific knowledge about the policy landscape for child health technologies in Canada, broad conceptual insights into the normative and methodological dimensions of child HTA, and a foundational understanding of the social values relevant to drug policy decisions for children. / Thesis / Doctor of Philosophy (PhD) / Drug research, development and policy have historically excluded children. One area of persistent neglect is public policy on funding for paediatric medicines. In most publicly funded health systems, including Canada’s, decisions about which drugs to cover are made through a formal process called health technology assessment (HTA). This dissertation examines the role and challenges of HTA as applied to child health technologies, with a focus on the social values that inform drug policy for children. It addresses existing gaps in knowledge through the integration of insights from: 1) a comprehensive review of the academic literature on the moral dimensions of child health and social policymaking; 2) in-depth qualitative analysis of the HTA and drug policy environments for children in Canada, employing Ontario as a case study; and 3) a survey of the Canadian public on health system resource allocation for children. Together, these studies generate a detailed picture of the Canadian policy landscape for child health technologies, insights into the fit of current HTA approaches to the realities of child health and illness, and a foundational understanding of the social values relevant to drug policy decisions for children.

Historically, the federal government has been the institution responsible for setting the nation's drug policy. Since 1996, however, the federal government's authority and legitimacy in this issue area has increasingly been challenged through state ballot measures introduced via the initiative process. While only eight percent of ballot measures historically are approved by voters (Initiative and Referendum Institute 2004), half of the 28 state ballot measures on illegal drugs have been approved by voters over the past decade. The stated goal of those supporting legalization through ballot measures is to "build a political movement to end the war on drugs" (Nadelmann 2004). Nadelmann (2004) suggests that victories in the states show that the "nascent drug policy reform movement" can win in the "big leagues of American politics" and that the successful models presented through the ballot measures will increase "public confidence in the possibilities and virtue" of regulating the non-medical use of illicit drugs. To date there has been no detailed examination of the issue framing strategies in this venue; nor has there been an effort to link the problem definition and direct democracy literatures. This dissertation links the problem definition and direct democracy literatures, using drug policy as the vehicle and applying Stone's (2002) analytic framework of problem definition to make descriptive inferences about the issue framing devices employed in state ballot measures on illegal drugs. The research examines a range of materials related to the state ballot measures on illegal drugs including the language appearing on voter ballots; the full text of the ballot measures, including ballot titles and political preambles; and the voter information statements and their authors. In addition, the dissertation describes the elements of legalization proposed by the ballot measures that were approved by voters and examines three key legal challenges to Proposition 215, one of the first ballot measures on illegal drugs approved by voters in California in 1996, including two U.S. Supreme Court cases. / Ph. D.

The aim of this study is to examine the barriers, conditions, and opportunities for harm reduction social work with individuals experiencing drug-related issues in Sweden and Portugal. The study also presents how various forms of harm reduction practices are implemented in the different countries. Additionally, it will investigate how harm reduction is conducted in each country based on the experiences of social workers and how these social workers perceive the significance of harm reduction in terms of risks and opportunities for individuals with drug-related issues. The method used for this study is qualitative. To collect empirical data, qualitative, semi-structured interviews were conducted. The results of the study reveal both similarities and differences in harm reduction practices in Sweden and Portugal. The similarities between the countries' harm reduction approaches are visible in the shared professional perspectives on clients, the organization of services, and the importance of harm reduction. The findings highlight the necessity of considering the local political and societal context when constructing harm reduction programs. The differences in harm reduction between Sweden and Portugal are primarily related to barriers faced by the services and their clients. Sweden has significant barriers for clients and the development of harm reduction efforts, largely due to political control and bureaucracy, which are likely to impact client stigma and access to support. In contrast, Portugal's decriminalization and legal framework for harm reduction have resulted in extensive harm reduction services and a unified, supportive approach towards individuals with drug-related issues. However, the results indicate that there are obstacles to Portuguese harm reduction, such as low fundings and elevated employee turnover.

Cette thèse de doctorat met l’emphase sur les défis rencontrés par les patients atteints de maladies rares. Elle est structurée en trois parties, chacune d’entre elles dédiée aux enjeux d’un acteur au cœur de l’Odyssée diagnostique et thérapeutique des patients atteints de maladies rares. La première partie de la thèse s’intéresse au patient et à son réseau social. Le chapitre 1 considère les sources de délai à l’accès au diagnostic, et explore notamment l’effet du capital social sur le délai d’obtention du diagnostic. Le chapitre 2 évoque les externalités négatives sur la santé maternelle d’un diagnostic d’une maladie chronique chez l’enfant. La seconde partie de la thèse est dédiée à l’industrie pharmaceutique et s’intéresse aux décisions d’investissements de R&D ciblant les maladies rares. Le chapitre 3 évalue l’effet causal de l’Orphan Drug Policy sur l’effort de recherche, et le chapitre 4 envisage les inégalités d’allocation des investissements de R&D entre les maladies rares. La partie 3 est dédiée aux décideurs publics et discute des enjeux d’évaluation des bénéfices de l’innovation thérapeutique et de la définition des conditions d’accès à cette innovation. Le chapitre 5 évalue l’effet causal de l’innovation thérapeutique sur la longévité des patients atteints de maladies rares. Le chapitre 6 est une discussion critique relative à l’utilisation d’outils. / This dissertation emphasizes the challenges raised by the management of rare diseases and is structured around three key actors of the diagnostic and therapeutic “odyssey” of patients with rare diseases. Part I is devoted to patients and their social networks. Chapter 1 considers demand-side sources of delay in receiving a diagnosis; Chapter 2 explores the health spillover effects from patients’ health to their direct support structure. Part II considers pharmaceutical firms and examines how firms’ decisions to allocate R&D investment to rare diseases are impacted by innovation policies in rare arenas. Chapter 3 evaluates the causal impact of the EU Orphan Drug policy on R&D efforts in orphan drugs, while Chapter 4 investigates the inequality in allocation of R&D investment within rare diseases. Part III focuses on policymakers and addresses the issues in measuring pharmaceutical innovation benefits along with costs in rare disease arenas, while considering the opportunity cost of healthcare expenditures. Chapter 5 measures the causal impact of pharmaceutical innovation in rare diseases on longevity, while Chapter 6 is a critical discussion of decision-making tools for rational allocation of healthcare resources, and the use of a cost-effectiveness threshold.

Approved for public release, distribution is unlimited / The purpose of this thesis was to examine the feasibility of testing hair for illicit drug use in the United States Marines Corps. Specifically, the study determined the hair test's potential for detecting and deterring illicit drug use and abuse among Marines. In addition, the study estimated the potential costs of implementing hair tests and examined fairness concerns with regard to testing hair among ethnically diverse populations. The results indicate that the hair test would be more effective than the urinalysis at detecting a wide variety of illicit drugs, with the exception of marijuana. The increased effectiveness of the hair test is likely to enhance the level of deterrence currently sustained by the Marine Corps' urinalysis program. Costs associated with the implementation of hair test would be offset by the increase in detection of illicit drug use and drug dependence among enlisted recruits and officer candidates pursuing active duty military service. Enhanced deterrence levels among active duty personnel that are a consequence of implementing the hair test would result in additional cost savings. Finally, implementation of the hair test would not result in racial bias, but may amplify the existence of drug preferences among different races. / Major, United States Marine Corps

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Submitted by Jean Medeiros (jeanletras@uepb.edu.br) on 2018-05-11T12:40:13Z No. of bitstreams: 1 PDF - Karla Karolline Barreto Cardins.pdf: 30941373 bytes, checksum: d4b073f99effba1bf984afcb2267d64d (MD5) / Approved for entry into archive by Secta BC (secta.csu.bc@uepb.edu.br) on 2018-05-23T16:58:59Z (GMT) No. of bitstreams: 1 PDF - Karla Karolline Barreto Cardins.pdf: 30941373 bytes, checksum: d4b073f99effba1bf984afcb2267d64d (MD5) / Made available in DSpace on 2018-05-23T16:58:59Z (GMT). No. of bitstreams: 1 PDF - Karla Karolline Barreto Cardins.pdf: 30941373 bytes, checksum: d4b073f99effba1bf984afcb2267d64d (MD5) Previous issue date: 2017-03-29 / Introduction: The implementation of the Unified Health System represented a major advance in the health care policy of the Brazilian population, increasing access to c are networks and consequently to pharmaceutical care. This guarantee also includes the penitentiary system, however, the chronic situation of unhealthy, the higher prevalence of health problems and the difficulty of the population's access to medicines compromise the assistance. Objective: Analyze the pharmaceutical assistance in penitentiaries in the state of Paraíba considering the appropriate prescription and dispensation of essential and strategic medicine. Methodological approach: A descriptive, cross-sectional and qualitative study carried out in seven penitentiaries in the state of Paraíba between February and August of 2016. A survey was carried out in the medical records to verify the prescription of essential and strategic medicines and a local inspection was carried out to evaluate the installations of the places destined to the medicines dispensation. Health professionals and patients were interviewed through a semi-structured and audiograved interview. And the results were categorized and analyzed from a content analysis perspective. Results: Access to the medicine was studied according to their acquisition, as well as the barriers found to guarantee continuous treatment, the rational use was evaluated by means of adequate prescription, supervision of the necessary doses and the storage of medicines and the dispensation was defined by the prescription delivery, the guarantee of the receipt of the medicines within the standards of quality and safety and the guidelines related to the use. It was found that a large part of the penitentiaries have been responsible for providing the medications, however, the prisoners are practically not receiving the revenues, are not guided by suitable professionals and are also not supervised during the taking of the doses. In addition, most penitentiaries do not have a pharmacy and the dispensing process is limited by the prison environment and the lack of trained professionals. Conclusions: It is perceived that the guarantee of pharmaceutical assistance should be a permanent concern of public health policies, since even with a lack of essential and strategic medicines, adequate prescription, dispensing, supervisi on of the doses taken, correct storage and follow-up to ensure continuity of treatment are neglected, in addition to the precarious physical structure and lack of professionals needed and trained for the prison system. Thus, the findings contribute to management gaining insight into the current reality of pharmaceutical care in penitentiaries and for health teams to deepen their knowledge in the area. / Introdução: A implantação do Sistema Único de Saúde representou grande avanço na política de atenção à saúde da população brasileira, ampliando o acesso as redes de assistência e consequentemente à assistência farmacêutica. Essa garantia também inclui o sistema penitenciário, porém, a situação crônica de insalubridade, a maior prevalência de agravos à saúde e a dificuldade de acesso da população aos medicamentos comprometem a assistência. Objetivo: Analisar a assistência farmacêutica nas penitenciárias do estado da Paraíba considerando estratégicos. Caminho metodológico: Estudo descritivo, de corte transversal e natureza a adequada prescrição e dispensação dos medicamentos essenciais e qualitativa, realizado em sete penitenciárias do estado da Paraíba entre os meses de fevereiro a agosto de 2016. Foi empreendido um levantamento nos prontuários para verificar a prescrição de medicamentos essenciais e estratégicos e realizada uma inspeção local para avaliar as instalações dos locais destinados a dispensação de medicamentos. Foram entrevistados profissionais de saúde e apenados, através de uma entrevista semiestruturada e a udiogravada. E os resultados foram categorizados e analisados na perspectiva da análise de conteúdo. Resultados: O acesso aos medicamentos foi estudado de acordo com a forma de aquisição dos mesmos, bem como as barreiras encontradas para garantir o tratamento contínuo, o uso racional foi avaliado mediante prescrição adequada, supervisão das doses necessárias e o armazenamento dos medicamentos e a dispensação foi definida pela entrega mediante receita, da garantia do recebimento dos medicamentos dentro dos padrões de qualidade e segurança e das orientações relacionadas ao uso. Verificou-se que grande parte das penitenciárias têm se responsabilizado em prover as medicações, porém, os apenados praticamente não recebem as receitas, não são orientados por profissionais adequados e também não são supervisionados durante a tomada das doses. Além disso, a maioria das penitenciárias não possui farmácia e o processo de dispensação é limitado pelo ambiente prisional e pela falta de profissionais capacitados. Conclusões: Percebe-se que a garantia da assistência farmacêutica deve ser uma preocupação permanente das políticas públicas voltadas para a saúde, pois mesmo com pouca falta de medicamentos essenciais e estratégicos, a prescrição adequada, a dispensação, a supervisão das doses tomadas, o armazenamento correto e o acompanhamento para garantir a continuidade do tratamento são negligenciados, além da estrutura física precária e da falta de profissionais necessários e capacitados para o sistema prisional. Desta forma, os achados contribuem para que a gestão obtenha conhecimentos sobre a realidade atual da assistência farmacêutica nas penitenciárias e para que as equipes de saúde aprofundem seus conhecimentos na área.

Submitted by Luciana Ferreira (lucgeral@gmail.com) on 2016-10-03T13:23:24Z No. of bitstreams: 2 Dissertação - Sâmia Cristina Rodrigues Borges Aragão - 2015.pdf: 3374814 bytes, checksum: f4bc7c58a16e041e8274c3529234f038 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2016-10-03T13:24:52Z (GMT) No. of bitstreams: 2 Dissertação - Sâmia Cristina Rodrigues Borges Aragão - 2015.pdf: 3374814 bytes, checksum: f4bc7c58a16e041e8274c3529234f038 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2016-10-03T13:24:52Z (GMT). No. of bitstreams: 2 Dissertação - Sâmia Cristina Rodrigues Borges Aragão - 2015.pdf: 3374814 bytes, checksum: f4bc7c58a16e041e8274c3529234f038 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2015-10-21 / Medications readily available for the Brazilian population in the Unified Health System (SUS) is one of the health policies and programmes that meet the constitutional right of every Brazilian citizen. Lots of regulations have been created for medication distribution through Pharmaceutical Assistance (PA), however the user of the medication sometimes is confused and how obtain it. Describe the pathway and regulations for medication distribution through the public health policies in a city. Qualitative research held from December 2014 to January 2015, which focused on normative and explanatory documents for the public health system in Brazil in the city of Goiania in Goias state. An extensive bibliographic research has been carried out on this topic to fundament the analysis of the documents. The medication right is defined in the Brazilian’s constitution, legislation and regulatory acts for the private labour sector and public through co-payment as a means for medication access. In Goiania establishes the Pharmaceutical Assistance (PA) as it is for the Pharmacy and Therapeutics Committee (CFT), SMS Pharmacies, publicizing information related to drugs, health programmes such as “Farmácia Popular“ and the administrative access road through the Division of Assets Evaluation and non-Standardized Services (DABSNP) as a way to meet the demands of those users who have failed treatment through public policies. The medications available through the public policies are organized by REMUNE and the list of medications with high costs of Juarez Barbosa. The public health programmes “Farmácia Popular” and “Saúde Não Tem Preço“ are the ways of co-payment and free of charge. Medications not listed on REMUNE or unavailable to the user are available via administrative process to prevent lawsuit. Conclusion: The medication right is defined in the Brazilian’s constitution, and public policies with little or no influence of local city government. However, how to obtain it, the list of available medication, and the requirements is a local governmental duty. Therefore, the policies defined for such programmes can facilitate the understanding of the network comprising the Pharmaceutical Assistance (PA) in the Brazil’s Unified Health System (SUS). / O acesso a medicamentos no Sistema Único de Saúde (SUS) integra as ações de atenção à saúde como um direito dos brasileiros. As vias institucionalizadas de acesso ao medicamento surgem mediante uma diversidade de regulamentações relacionadas à operacionalização da Assistência Farmacêutica (AF) que muitas vezes incorre em “confusão” junto ao usuário, na busca pela efetivação deste direito. Esta dissertação objetiva descrever as vias institucionalizadas de acesso ao medicamento em uma cidade brasileira. A pesquisa documental constituiu-se de natureza descritiva realizada nos meses de dezembro/2014 a janeiro/ 2015. O objeto de estudo foram documentos de caráter legal, normativo e explicativo capazes de descrever as vias de acesso institucionalizadas pelas políticas públicas de saúde vigentes no Brasil, em nível de assistência ambulatorial, no município de GoiâniaGO. Destaca-se que o direito ao acesso ao medicamento foi positivado no texto constitucional, na legislação infraconstitucional e em atos regulatórios que definem as vias pública, privada e através de co-pagamento como formas de acesso aos medicamentos. Em Goiânia a AF se encontra normatizada a respeito da Comissão de Farmácia e Terapêutica (CFT), funcionamento das farmácias da Secretaria Municipal de Saúde (SMS), publicização de informações relacionadas a medicamentos, implementação da Farmácia Popular (FP) e a via administrativa de acesso através da Divisão de Avaliação de Bens e Serviços Não-Padronizados (DABSNP), como forma de atender a demanda daqueles usuários que não conseguiram tratamento através das políticas públicas. O fluxo de acesso em Goiânia indica que os medicamentos disponíveis no sistema público estão organizados por meio da Relação Municipal de Medicamentos Esssenciais (REMUME) e da Lista de medicamentos de Alto Custo-Juarez Barbosa (Componente Especializado). As vias por co-pagamento e gratuitos são disponibilizadas pelos programas FP e “Saúde Não Tem Preço” (SNTP) e suas respectivas listas. A via administrativa de acesso, para medicamentos não constantes na REMUME ou indisponível para o usuário, cumpre papel de evitar que a demanda gere processo judicial. Conclusão: O direito ao medicamento é basicamente definido pelas políticas nacionais sofrendo pouca influência local. Já o itinerário que cada cidadão terá que percorrer e os medicamentos disponíveis são definidos em nível municipal. Portanto, o fluxo de acesso elaborado pode facilitar a compreensão da intrincada rede que constitui a Assistência Farmacêutica no Brasil.

The theoretical part of this diploma thesis defines basic terms related to the marketing and gives a general overview of marketing strategies. It also evaluates the importance of marketing in public health services and describes possibilities of internet health technologies that patients use for the contact with health professionals and getting information about health. The practical part analyzes patients' opinion on pharmacy marketing practice and importance of internet communication. Data were collected via the questionnaire survey among the users of internet and Facebook and customers in one independent community pharmacy in Beroun. Practical part also refers about the experimental marketing campaign that was performed in the pharmacy in Beroun and that focused on the creating promotion materials and technologies of internet communication. According to results, many patients appreciate marketing activities of community pharmacies. There is also noticeable a positive trend of using the web sites and social media to connect with the community pharmacy. Key words: marketing, healthcare, community pharmacy, internet, social media, the Czech Republic

Thesis is focused on drug system development in Czech Republic during years 2000 to 2008, on study of present circumstances and on key features comparison with its development in selected European countries. Author has described drug system functioning, its participants and relations among them set to Czech Republic. Attention is paid especially to sources of rise in prices of drugs and to growth in consumption, then to safety and awareness of current medication. Factors effecting total expenses on drugs are investigated and participation of total expenses on drugs on total health expenses is analyzed. Due to the international comparison there is pronounced conviction that the increase in drug expenses has become a global phenomenon of todays which is to be solved. Great emphasis is placed on questionable segments of drug policy in Czech Republic and on potentials of its improvements in this performance, too.