Thesis (D.Phil.)--University of Oxford, 2008. / Supervisors: Dr Rebecca Surender, Professor Robert Walker. Bibliography: leaves 287-300.

Dissertation (D.P.H.)--University of Michigan.

Dissertation (D.P.H.)--University of Michigan.

Thesis--University of California, San Francisco. / Includes bibliographical references (leaves 255-260).

The aim of operations management in health care is to enhance the provision of services to patients and to decrease costs. Overall worldwide health care expenditures represent around 10.5% of the global GDP and are projected to increase at an annual rate of 5.3% from 2015 to 2017 [74]. In order to investigate how to curb health care costs, I study the English NHS, a health care system that provided universal care to around 54 million people in 2014 [243]. The NHS has launched many initiatives to improve the performance of hospital operations such as the "QIPP" program, which has the objective to save £20 billion of costs by 2015 [98]. Given this framework, this research aims to contribute to the theory that is guiding these operational changes, using data on all admissions to hospitals and focussing on the inguinal hernia, one of the most common surgical procedures [86]. In the next chapters, this research describes inguinal hernia care delivery in the English NHS, examines the impact of spillovers and complementarities on costs, and investigates the effects of length of stay reduction on risk of re-admission and risk of death. The findings of this thesis indicate that one of the possible problems in the delivery of inguinal hernia care in the NHS is the decrease in the number of elective operations performed and the increase in readmission rates. They also clarify how decisions on allocation of resources can affect hospital expenditures by showing that loss in focus can increase health care costs and by pointing out that there is little evidence to support the theory of spillovers and complementarities in the surgical context. Finally, the results of this research can be used to suggest the logic of a policy to decrease length of stay that can inform hospital decisions and can decrease hospital costs.

Foram emitidas consideraçoes sobre os indicadores de saúde e a mortalidade por causas evitáveis como instrumentos para a avaliação das condições de saúde da população e ainda analisados os critérios de prioridades e a importância de estabelecer prioridades em saúde em função da limitação dos recursos para o Setor Saúde. O objetivo geral do trabalho foi o de determinar, analisar e comparar as prioridades em saúde de Fortaleza, segundo técnicas de hierarquização, para a mortalidade por grupos de de causas evitáveis 1981-83. O material básico foi Constituído das declarações de óbitos de residentes em Fortaleza referentes ao período 1981-83, obtidas junto à Secretaria de Saúde do Estado do Ceará. As declarações de óbitos, após a seleção da causa básica de morte, foram codificadas e apuradas por causas, ao nível de categorias, segundo sexo e grupo etário, e, em seguida, distribuídas em grupos de causas evitáveis, conforme a classificação proposta por Taucher. Posteriormente, foram redistribuídas nos diversos grupos de causas evitáveis as declarações referentes às causas mal definidas, proporcionalmente à participação por sexo e faixa etária. Para estabelecer as escalas de prioridades dos grupos de causas evitáveis foram utilizadas doze técnicas: ganhos em esperança de vida ao nascer (e0.) e ganhos em esperança de vida ativa (e a.), mediante tábuas de vida de múltiplo decremento; anos de vida ativa potencial -(ea)X - e de um trabalhador-e ax - perdidos, a partir das tábuas de vida ativa; anos potenciais de vida perdidos, com três variantes, limite em 65 anos (APVP 65), limite em 70 anos (APVP 70) e esperança de vida à idade especificada (APVP ex); técnica CENDES/OPS, consoante três modelos diferentes de transcendência (TCl, TC2 e TC3); e perdas econômicas correntes e futuras (PEC e PEF), baseadas nas medianas de renda por sexo e idade. Essas técnicas foram operadas considerando a eliminação total das causas evitáveis e a eliminação parcial, conforme a vulnerabilidade arbitrada a cada grupo de causas evitáveis. A comparação das escalas decrescentes de prioridades foi efetuada por intermédio da correlação por postos de Spearman. Os resultados do trabalho revelaram que 57,55 por cento e 42,46 por cento dos óbitos em homens e mulheres foram por causas evitáveis correspondendo a taxas de 483,77 por 100,000 homens e 295,30 por 100.000 mulheres, respectivamente, e que a mortalidade por causas evitáveis tem um elevado impacto em anos potenciais de vida perdidos e em perdas econômicas. A hierarquização das prioridades segundo as várias têcnicas apontou os Grupo F - mortes produzidas por violências - e C - evitáveis por medidas de saneamento ambiental - como as duas primeiras prioridades saúde em Fortaleza. A comparação entre conjuntos de técnicas demonstrou que a redução e/ou simplificação do número de técnicas adotadas para definir prioridades em saúde podem ser aplicadas sem sacrifício da precisão oferecida pelo modelo completo, que contempla as doze técnicas. Por fim, foi salientada a contribuição dessas técnicas para orientar o processo político que envolve a decisão de eleger as prioridades em saúde. / Considerations were made about the indicators of health and mortality by avoidable causes as instruments for the evaluation of the health conditions of the population and analysed were performed on the criteria of priority and the importance of stablishing priorities in health, taking into account the limitation of resources for the Health Sector. The general objective of the thesis was that of assessing, analysing and comparing health priorities in Fortaleza, Ceará, Brazil, according to techniques of hierarchization for the mortality by groups of preventable causes in 1981-83. The basic material was constituted by the death certificates of residentes in Fortaleza related to the period 1981-83, which were obtained at the Secretary of Health of the State of Ceará. The death certificates, after a selecyion, of underlying cause of death were codified and computed by causes, at the level of categories, in regard to sex and age range, and afterwrds, distributed in groups of preventable causes, according to a classification proposed by Taucher. The certificates referred to illdefined causes were then redistributed, proportionally to the participation by sex and age. Twelve techniques were utilized in distributing the range of priorities of the groups of preventable causes: gains in the life expectancy at birth (eO.), gains in active life expectancy (e a.), through tables of life of multiple decrement; potential active life - (ea)x - and of a worker - e ax - years of life lost from the table of active life; pottentiall years of life lost, with three variants, limit in 65 years (APVP65), limit in 70 years (APVP70) and life expectancy at a specified age (APVPex); CENDES/OPS technique in accordance with three different models of transtendence (TC1, TC2 and TC3): and present and futures economic lesses (PEC and PEF), based in the median of income by sex and age. These techniques were used taking into consideration the total elimination of preventable causes and the partial elimination, as to the ascertained vulnerability to each group\'s of preventable causes. The comparison of the decreasing ranks of priorities was carried out though the correlation by posts of Spearman. The results revealed that 57.55 per cent and 42.46 per cent of deaths in men and women were due to preventable causes, corresponding to rates of 483.77 per 100,000 men and 295.30 per 100,00 women respectively, and that the mortality by preventable causes has and elevated impact on potential life lost and in economic losses. The hierarchization of the priorities according to several techniques pointed to the Groups F- death produced by violence - and C - avoidable by measures of envirorimental sanitation - as the two first priorities of health in Fortaleza; the comparison among sets of techniques demonstrated that the reduction and/or simplification of the number of adopted techniques to define priorities in Health can be applied without sacrificing the precision by the complete model, which comprises the twelve techniques. At last, the contribution of these techniques was stressed to orient the political process that involves the decision of choosing priorities in health.

Abstract The aim of the study was to deepen understanding of the concept of participant steering and to find out what participant steering is like in practical implementation of the social and health care development project. Participant steering refers to the operation of persons involved in the planning organisation of the development project. Participant steering is a new theoretical concept that has been formed during this research process. A qualitative case study approach was used in this study. The social and health care development project related to the Administrative Experiment of the Kainuu Region was chosen as the object of the study. The material of the study consisted of the following: 1. document material, i.e. minutes from meetings of the planning organisation of the Administrative Experiment of the Kainuu Region (n = 86) from 2003–2004, 2. interviews with deliberately selected participants of the social and health care development project planning groups of the Administrative Experiment of the Kainuu region in 2004 (n = 16) and 3. articles published in 2003–2004 in the newspapers Kainuun Sanomat, Kaleva and Ylä-Kainuu concerning the Administrative Experiment of the Kainuu Region (n = 201). The material was analysed using content analysis and text analysis. According to the results of the study, the constructive elements of participant steering were a confidence-building participant-centred approach, focus on interests emphasising cooperation and goal orientation supporting reform. A confidence-building participant-centred approach meant that participants took an active part in the planning and that they had a primary role in the decision-making process associated with the development project. Focus on interests emphasising cooperation referred to participants' efforts to further their own interests and those of the interest groups they represented and to harmonise the two. Goal orientation supporting reform referred to the importance of the goal and objectives of the development project. A marked juxtaposition could be observed in participant steering: insufficient participation vs. trust, competition vs. cooperation and reform vs. change resistance. Development projects seem to be suitable as means of reforming social and health care operation models and culture, as they enable genuine dialogue and meeting of cultures. According to the present study, the launching of productive cooperation between municipalities is promoted by a long planning phase and a planning framework that enables participation. In this process, the needs and goals of cooperation are approached from regional starting points, listening to all parties involved. The information obtained from this study can be utilised in development project planning, steering and evaluation. / Tiivistelmä Tutkimuksen tarkoituksena oli syventää ymmärrystä osallistujaohjauksen käsitteestä sekä selvittää, minkälaista osallistujaohjaus on sosiaali- ja terveydenhuollon kehittämishankkeen käytännössä. Osallistujaohjauksella tarkoitetaan kehittämishankkeen suunnitteluorganisaatioon kuuluvien osallistujien toimintaa. Osallistujaohjaus on uusi teoreettinen käsite, joka muodostettiin tämän tutkimusprosessin aikana. Tutkimuksen lähestymistapana oli laadullinen tapaustutkimus. Tutkimuskohteeksi valittiin Kainuun maakuntakokeiluun liittyvä sosiaali- ja terveydenhuollon kehittämishanke. Tutkimusaineistoina käytettiin 1. dokumenttiaineistoa eli Kainuun maakuntakokeilun suunnitteluorganisaation kokouspöytäkirjoja (n = 86) vuosilta 2003–2004, 2. Kainuun maakuntakokeilun sosiaali- ja terveydenhuollon kehittämishankkeen suunnitteluryhmistä harkinnanvaraisesti valittujen osallistujien haastatteluja vuodelta 2004 (n = 16) ja 3. Kainuun Sanomissa, Kalevassa ja Ylä-Kainuu -sanomalehdissä vuosina 2003–2004 ilmestyneitä Kainuun maakuntakokeilun suunnittelua käsitteleviä sanomalehtiartikkeleita (n = 201). Aineistot analysoitiin sisällönanalyysillä ja tekstianalyysillä. Tutkimustulosten mukaan osallistujaohjaus rakentui luottamusta tuottavasta osallistujalähtöisyydestä, yhteistyötä korostavasta intressipainotteisuudesta ja uudistusta tukevasta tavoitesuuntautuneisuudesta. Luottamusta tuottava osallistujalähtöisyys tarkoitti osallistujien aktiivista osallistumista suunnitteluun ja osallistujien ensisijaisuutta kehittämishankkeen päätöksenteossa. Yhteistyötä korostava intressipainotteisuus tarkoitti osallistujien pyrkimyksiä edistää omia ja edustamiensa sidosryhmien intressejä sekä sovittaa niitä yhteen. Uudistusta tukeva tavoitesuuntautuneisuus tarkoitti kehittämishankkeen päämäärän ja tavoitteiden tärkeyttä. Osallistujaohjauksessa oli nähtävissä voimakas vastakkainasettelu: riittämätön osallisuus versus luottamus, kilpailu versus yhteistyö ja uudistaminen versus muutosvastarinta. Kehittämishankkeet näyttävät soveltuvan sosiaali- ja terveydenhuollon toimintamallien ja kulttuurin uudistamisen keinoiksi, koska aito dialogi ja kulttuurien kohtaaminen ovat niissä mahdollisia. Kuntien välisen tuloksekkaan yhteistyön käynnistämistä edistää tämän tutkimuksen mukaan pitkä suunnitteluvaihe ja osallistumisen mahdollistava suunnittelukehikko. Siinä yhteistyön tarpeita ja tavoitteita lähestytään alueen lähtökohdista kaikkia osapuolia kuunnellen. Tutkimuksen tuottamaa tietoa voidaan hyödyntää kehittämishankkeiden suunnittelussa, ohjauksessa ja arvioinnissa. Erityisesti tietoa voidaan soveltaa kehittämishankkeen suunnitteluun osallistumisen edistämisessä ja uudenlaisen yhteistyön muotoutumisen alkuvaiheessa.

Master of Public Health - MPH / The aim of this thesis was to conduct a situational assessment of human resources planning at one local health authority, in order to determine how decentralisation has impacted the effectiveness of human resources planning. / South Africa

South Africa possesses a highly fragmented health system with wide disparities in health spending and inequitable distribution of both health care professionals and resources. The national health system (NHI) of South Africa consists of a large public sector and small private sectors which are overused and under resourced and a smaller private sector which is underused and over resourced. In broad terms, the NHI promises a health care system in which everyone, regardless of income level, can access decent health services at a cost that is affordable to them and to the country as a whole. The relevance of this study is to contribute to the NHI debate while simultaneously providing insights from other countries which have implemented national health care systems. As such, the South African government can then appropriately implement as well as finance the new NHI system specific to South Africa’s current socio-economic status. The objective of this study was to examine health care financing models in different countries in order to draw lessons for South Africa when implementing the NHI. A case study was conducted by examining ten countries with a national health insurance system, in order to evaluate the health financing models in each country. The following specific objectives are pursued: firstly, to review the current health management system and the policy proposed for NHI; secondly, to examine health financing models in a selected number of countries around the world and lastly to draw lessons to inform the South African NHI policy debate. The main findings were firstly, wealthier nations tend to have a much healthier population; this is the result of these developed countries investing significantly in their public health sectors. Secondly, the governments in developing nations allocate a smaller percentage of their GDP and government expenditure on health care. Lastly, South Africa is classified as an upper middle income developing country; however, the health status of South Africans mirrors that of countries which perform worse than South Africa on health matters. In other words the health care in South Africa is not operating at the standard it should be given the resources South Africa possesses. The cause of this may be attributed to South Africa being stuck in what is referred to as the “middle income trap” amongst other reasons.

Masters in Public Administration - MPA / The research explored the new health care service vehicle of South African with special reference to health service providers in Western Cape Department of health for the period 1995-2001. A study was made of the District Health System and the shift of emphasis from tertiary and secondary level of health care to the more cost effective Primary Health Care Service rendered at District level. / South Africa