This qualitative study examines the healthcare provision for gender dysphoria patients by the National Health Service (NHS) in England. The thesis takes as its starting point the experiences of those providing and receiving care following the A, D & G vs North West Lancashire Health Authority court decision in 1999. The aims of the research are threefold: To examine what trans narratives tell us about individual understandings of gender, to explore what practitioner narratives tell us about the understandings of gender utilised in NHS treatment, and to determine what issues are important to consider when providing gender services. It undertakes an empirical thematic analysis through a triangulation of data sources - a literature review, qualitative interviews with specialists and focus groups with trans patients. The research is underpinned by three central questions: Do differences exist between the ways in which trans people and their doctors understand gender identity? Can the ways in which trans people formulate and express their gender identity map onto the notions of gender that practitioners employ? What are the wider implications for healthcare policymaking? The research questions were intended to investigate how trans people formulate and express their gender, whether and how those understandings differ from those that practitioners employ, whether trans narratives can map onto medicalised notions, and the implications for healthcare policymaking.

Este é um estudo das relações intergovernamentais entre as três esferas de governo que ocorrem na implantação e implementação da política de saúde no estado do Acre, com o foco na função de coordenação da esfera estadual do SUS na condução dessa política. A investigação buscou identificar como ocorre essa coordenação que envolve transferências de recursos financeiros entre as esferas de governo que são negociados no âmbito do sistema de saúde. A investigação foi centrada na Secretaria Estadual de Saúde e na Secretaria Municipal de Saúde de Rio Branco. Os demais 21 municípios do estado foram estudados nas suas relações com a esfera estadual no seu papel de gestora do sistema de saúde. Foi adotada a estratégia do estudo de caso para caracterizar, descrever e analisar o Sistema Único de Saúde do Acre no período do início da década de 1990 até o final de 2008. Para contextualizar as especificidades do Acre foram estudados os serviços de saúde antecedentes ao SUS. Realizou-se investigação documental, observação sistemática e entrevistas com os principais atores envolvidos com essa política. A implantação do SUS no Acre foi um processo lento com divergências entre as esferas de governo quanto à descentralização dos serviços. Essas divergências eram maiores e retardavam mais o processo nos municípios onde os gestores locais tinham identificações partidárias diferentes do gestor estadual. O processo de implantação da política de saúde no Acre aconteceu em cenários de escassez de recursos financeiros sendo que em alguns momentos os poucos recursos e falhas administrativas causaram graves crises nos serviços. Em 1999, a receita fiscal do Estado do Acre foi de 81,83 milhões de Reais e os gastos com a saúde foram de 97,37 milhões de Reais. Em 2008, a receita fiscal foi de 555,33 milhões de Reais e os gastos com a saúde foram de 373,48 milhões de Reais. Embora pareça um significativo aumento da receita, nesse período houve a descentralização de serviços de saúde para os municípios e os mesmos passaram a receber recursos financeiros da União para sustentarem seus serviços. Tanto na esfera estadual como nos municípios, a sustentação da política de saúde depende dos recursos da União. As relações da esfera estadual do SUS com os municípios passaram por sucessivos conflitos para a descentralização de serviços e no período recente persiste um tratamento desigual da esfera estadual em relação aos municípios / This is a study of intergovernmental relations between the three spheres of government that occur in the deployment and implementation of health policy in the state of Acre, with the focus on the coordinating role of the state sphere of SUS in the conduct of that policy. The investigation sought to identify how this coordination occurs which involves transfers of funds between the spheres of government that are traded within the health system. The investigation was centered on the State Health Department and the Municipal Health Secretariat of Rio Branco. The remaining 21 counties in the state were studied in their relations with the state level in his role as manager of the health system. We adopted the strategy of case study to characterize, describe and analyze the National Health System of Acre during the beginning of the 1990s until the end of 2008. To contextualize the particularities of Acre were studied health services background to SUS. We carried out documentary research, systematic observation and interviews with key actors involved with this policy. The implementation of the NHS in Acre was a slow process with divergent levels of government regarding the decentralization of services. These differences were larger and more retarded the process in the municipalities where local managers had different party identifications of the state administrator. The implementation process of health policy happened in Acre on scenarios of scarcity of financial resources and in some instances the few resources and administrative failures caused serious crises in services. In 1999, tax revenue of Acre was 81.83 million Reais and health spending were 97.37 million Reais. In 2008, tax revenue was 555.33 million Reais and health care expenditures were 373.48 million Reais. Although it seems a significant increase in revenues during this period was the decentralization of health services to municipalities and they began to receive Union funds to sustain their services. Both at the state level as in the municipalities, the support of health policy depends on the resources of the Union\'s relations with the state level SUS municipalities have gone through successive conflicts for the decentralization of services and in the recent period there remains an unequal treatment of state level in relation to municipalities

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This work provides cultural and political explanations on how and why cigarette smoking has increasingly become an object of intolerance and control in Hong Kong. Since the 1980s, the smoking population has been falling. Smoking behavior, sales and promotion of cigarette products have been under close surveillance by the government, medical experts and society at large. Cigarette smoking, as well as smokers, has increasingly been rejected and demonized in the public discourse. What are the conditions that make the growing intolerant discourses and practices against cigarette smoking possible and dominant? Why and how has the tobacco control campaign become prevalent as a governmentalist project, which is strong enough to tear down the alliance of tobacco industry giants? Why is tobacco singled out from other legal but harmful substances, such as alcohol, as an imperative object of intolerance and control? This work tackles these questions by adopting a Foucauldian discursive approach and the theory of articulation developed in cultural studies. By considering tobacco control as a historical and contextual practice, it traces the specific trajectory of tobacco control in Hong Kong, maps the cultural and political contexts that make it possible, and considers its consequence regarding the complex relationship among control, construction of risk, identity and freedom in society.

Objective: To examine spillovers from a federal policy, managed care market, and community perspective. Data Sources/Study Setting: We studied spillovers from a federal policy and managed care market perspective using the Health Care Utilization Project’s (HCUP) State Inpatient Database (SID). American Hospital Association (AHA) data, Interstudy Commercial Managed Care, and Area Health Resource File (AHRF). Medicare Advantage county-level payment schedules originate from CMS. We examined community uninsurance spillovers using 2011-2015 Medical Expenditure Panel Survey (MEPS), the Area Health Resource File (AHRF), and the Small Area Health Insurance Estimator (SAHIE). Study Design: Ordinary Least Squares (OLS) and difference-in-difference regression analyses were used to examine a federal policy spillover on hospital readmissions. We used OLS and instrumental variable (IV) estimation to examined Medicare Advantage (MA) spillovers on Medicare fee-for-service (FFS) hospital readmissions. We used logistic regression to examine community uninsurance spillovers on the privately insured. Principal Findings: After the HRRP, Medicare FFS saw a decrease in 30-day preventable condition- and all-cause readmissions. Medicare Advantage saw a positive spillover after the HRRP. MA market penetration has no effect on Medicare FFS hospital readmissions. High community uninsurance rates are associated with less access to behavioral health related outpatient/office-based and prescription utilization. Conclusions: HRRP had a positive spillover on MA hospital all-cause readmissions. MA market penetration has no effect on Medicare FFS readmissions. High levels of community uninsurance are associated with poorer access to outpatient/office-based and prescription behavioral related services.

Only three states have enacted informed consent laws aimed at providing more information concerning any alternative treatments for women who undergo hysterectomy. This study attempted to fill the research gap regarding consent laws and perceptions of women who underwent hysterectomy in a state with no informed consent laws. Supported by the health belief model (HBM), the research questions focused on the perceptions of women and their lived experiences. The purpose of this qualitative study was to examine the beliefs and attitudes of women in a state with no informed consent laws. Interviews were the main data collection technique. The participants were 10 women who underwent a hysterectomy and were between 20 and 40 years of age at the time of the research. The interview data were analyzed using thematic analysis. The findings demonstrated that the women who underwent hysterectomies in the absence of comprehensive informed consent law could be subjected to the procedure without sufficient information. Participants negatively described their physiological, psychological, and emotional consequences of undergoing hysterectomies without sufficient information; many of them reported feeling deceived by their doctors. Overall, the women expressed the belief that care providers should be required to offer all the pertinent information about hysterectomies and alternative treatments prior to the procedure. The results of this research can be used to advocate for the introduction of comprehensive informed consent laws, promoting the positive social change that would benefit the women of the U.S.

Organized medicine is a uniquely powerful political force in Canada, with physician colleges and associations exerting extensive influence over healthcare provision. Their influence has contributed to what social scientists describe as medical dominance, or the exceptional power of the medical profession within the healthcare system and wider society. However, Canadian medical organizations do not consistently defend this dominance; rather, they have occasionally lent support to policy changes that, on their face, would appear incompatible with traditional conceptions of medical power and authority. Typically, these instances are explained as a simple matter of strategic retreat: medicine conceding defeat on a particular issue in an effort to save face or conserve resources, without any change in underlying beliefs. This dissertation questions that assumption, asking if at times organized medicine’s support for threats to medical dominance is instead a function of more fundamental shifts in core policy beliefs. Through a series of interviews exploring how organized medicine responded to the re-emergence of midwifery and expansions of pharmacy scope in four provinces (Alberta, Ontario, Quebec and Nova Scotia), the analysis determines that, while medicine only supported expanded pharmacy scope out of strategic retreat, there are signs of more substantive shifts in belief with respect to midwifery. This suggests that the relationship between organized medicine and traditional medical dominance is more flexible and dynamic than has been assumed.

This thesis extends and refines a growing body of literature that has highlighted the impact of Catholic social principles on the development of welfare state provision. It suggests that Catholic social teaching is intent on preserving the role of the traditional family, and keeping power out of the hands of the state. Much of this literature, however, is concerned with European experience (Esping-Andersen, 1990; Castles, 1993; van Kersbergen, 1995). More recently Smyth (2003) has augmented this research through an examination of the influence of Catholic social thought on Australian welfare policy. He concludes that the Australian Church, at least up to the 1970s, preferred a �welfare society� over a �welfare state�, an outlook shared by the wider Australian community. Following the lead of Smyth, this thesis extends the insights of the European research through an examination of Catholic Church resistance to ALP proposals to introduce national health schemes in the 1940s and the 1970s. These appeared to satisfy the Church�s commitment to the poorest and most marginalised groups in the community. Why, then, did the Australian Church resist the proposals? The thesis concludes that there are at least two possible ways of interpreting Catholic social teaching � a preconciliar interpretation that minimises the role of the state, and a postconciliar interpretation that allows for an active, albeit limited, state. The adoption of either is informed by socio-political factors. The thesis, then, concludes that the response of the Church in the 1940s and the 1970s was conditioned by socio-political and historical factors that inclined the Australian Catholic Church towards a conservative view of welfare.

Health policy making is fraught with difficult decisions that result from conflicts between people’s values. Citizens are important stakeholders in this process, and it is through methods of public engagement that they can be involved in developing health policy. Deliberative forms, in particular, have the ability to improve decision quality and promote greater acceptance of decisions. This study used the Toronto Health Policy Citizens Council to examine citizens’ values on 7 specific health policy questions asked over a two-year period. A thematic analysis was performed on the transcript content derived from the audiotaped deliberations from Council meetings. Nineteen values were identified. The results suggest that it may be a combination of factors of the health policy topic discussed that shapes the values elicitation seen in this kind of public engagement. In conclusion, citizens councils appear effective at eliciting citizens’ values, and are a good way to actively educate participants about health care.

Objective: To determine the dental treatment needs of Canadians and how they are distributed. Methods: A secondary analysis of data from the Canadian Health Measures Survey was undertaken. Weights were applied to make the data nationally representative. Bivariate and multivariate regressions were used to identify predictors of need. Sensitivity, specificity, positive and negative predictive values were calculated to compare self-reported and clinically determined needs. Results: Of the 34.2% who required dental treatment, most needed restorative (20.4%) and preventive (13.7%) care. The strongest predictors of need were having poor oral health, reporting a self-perceived need for treatment and visiting the dentist infrequently. A discrepancy was found between clinical and self-reported needs. Conclusions: Roughly 12 million Canadians have unmet dental needs. A number of factors are predictive of having unmet dental conditions. Program and policymakers now have information by which to assess if their programs match the dental needs of Canadians.