This dissertation examines the paradoxes involved in offering medical aid to undocumented migrants in Berlin, Germany. Coinciding with the end of guestworker programs in the 1970s, undocumented migrants have increasingly filled gaps in the German labor market. Political pressures following reunification, along with border militarization in the wake of European Union expansion, have resulted in restrictions on legal entry. However, neoliberal reforms in the labor market and a rapidly aging population have resulted in high demand for undocumented workers in particular sectors of the economy. At the same time, soaring unemployment and nationalist sentiments have made immigration unpopular, with political parties negatively predisposed to assuring the rights of migrant workers. One such right is access to health care services in a nation with a traditionally universal system of coverage. Undocumented migrants are officially denied "medical citizenship" and must rely upon humanitarian aid provided by nongovernmental organizations (NGOs).This study examines the experiences of multiple stakeholders, particularly physicians and NGOs that provide medical aid. It draws upon the anthropology of health policy, a critical approach within medical anthropology. Fieldwork in Berlin during 2004-2006 included participant observation at an outpatient clinic, which yielded case studies of 204 undocumented patients, along with sixty-one interviews. Results indicate that in Germany, certain minimal rights are technically available to migrants; however, they are not assured access to these rights. This underscores the importance of utilizing legal status as a unifying measure of analysis. I argue that the state absolves itself of responsibility by handing off the provision of services to the NGO sector. While laws criminalize the provision of medical aid, they are only selectively enforced, and organizations are recognized for their volunteer work through awards and commendations. These paradoxes allow the state to square the contradiction of condemning yet relying upon undocumented migration. This dissertation presents an ethnographic portrait of the single largest source of medical aid for undocumented migrants in Germany, providing an analysis of patient characteristics and illnesses. Prenatal care highlights the interplay between race, reproduction, and citizenship, and offers a particularly poignant window into the challenges of nation-building in contemporary Germany.

PURPOSE: To evaluate Canada’s most comprehensive outdoor smoke-free ordinance, in Woodstock, Ontario, using both quantitative (longitudinal cohort survey) and qualitative methods (key informant interviews with policy makers). Measures include levels of support for outdoor smoking restrictions, smoking behaviour in outdoor environments, measures of the social denormalization of smoking, measures of concern about litter or fires caused by discarded cigarette butts, and reported changes in use of services, facilities or businesses that were regulated by the by-law. This study also sought to understand aspects of the policy development process and determine to how relevant the findings may be to other communities across Canada, and the world. BACKGROUND: The City of Woodstock, Ontario created a comprehensive outdoor smoke-free ordinance (OSFO) that came into effect on September 1, 2008. This by-law restricted or banned smoking in 5 different outdoor environments owned or regulated by the city including patios on downtown sidewalk cafés, parks and recreational fields, areas around transit stops and shelters, and doorways of city run facilities such as city hall. The by-law also created two schedules to further regulate smoking in other outdoor environments if elected by citizens in the community; one for non-city-owned properties such as private business to regulate smoking in their doorway environments and a second schedule for outdoor events organized by groups in the community. The schedules allowed council to pass a by-law that could easily regulate and enforce additional smoke-free environments, as requested by citizens, without the need for council approval. METHODS: Qualitative and quantitative methods were used to address the research objectives. Quantitative measures were collected using a pre-post survey design, interviewing smokers and non-smokers, in the City of Woodstock, and a neighbouring community (Ingersoll) in the same county (Oxford County). Before the by-law was enacted, two surveys were conducted. The telephone survey (August 13-28, 2008) was a random digit dialled (RDD) general adult population survey of non-smokers (n=373) and smokers (n=234). A face-to-face survey (August 13-19, 2008) was conducted among a targeted sample of smokers who were observed smoking in one of the outdoor areas that was to become smoke-free in accordance with the by-law (n=176). Face-to-face interviewers used handheld Palm III devices to assist in the interviewing of these respondents. Surveying both samples ensured the beliefs, attitudes, and behaviour of those smokers who, given circumstances of their recruitment, would be more likely to be affected by the by-law, would be measured in this evaluation study. Using a longitudinal cohort design, respondents from both Wave 1 surveys were re-contacted by telephone in approximately one year after the ban was implemented (August 18-September 15, 2009), to measure changes in the key outcome variables. The Wave 2 survey was conducted entirely by telephone with no replenishment. The Wave 2 survey included respondents that were successfully re-contacted from the general population sample (non-smokers n=299, smokers n=182), and respondents from the targeted sample (n=61). This qualitative study sought to identify any specific lessons or findings from the process undertaken that would be applicable or helpful to other communities. The qualitative study involved 6 key informant interviews with identified public health and city staff and an elected official who were involved in different aspects of the by-law, from development to enforcement. The data collected from the key informant interviews was analysed using an inductive qualitative method called the ‘framework approach’. RESULTS: After the Woodstock outdoor smoking restrictions had been in place for approximately 1 year, most respondents from the general population survey, smokers, (71%), and non-smokers (93%), supported or strongly supported the by-law. Most smokers (82%) and non-smokers (96%) agreed or strongly agreed that the by-law had been good for the health of the children of Woodstock. The by-law was also associated with increased quit intentions; 15% of the smokers from the general population sample reported that the smoke-free by-law made them more likely to quit, and approximately 26% of the smokers from the targeted sample reported the by-law made them more likely to quit. Smokers from both the general population (30%) and the targeted sample (42%) reported that the smoke-free outdoor by-law had helped them cut down on the number of cigarettes they smoke. There were 30 respondents in the Wave 1 survey that were smokers, who had successfully quit at the time of the Wave 2 survey. Of these ‘quitters’, 33% reported that they outdoor smoke-free by-law had helped them to quit smoking, and approximately half (48%) reported that they by-law had helped them to stay a non-smoker. The overwhelming majority of smokers reported that the by-law did not impact their use of facilities or businesses that had been regulated by the by-law. The key informant interviews revealed that the outdoor smoke-free ordinance was developed by following a standard public health policy development process that involved community (public) participation, exploration of policy options, and a political decision made by the city’s elected officials. It was identified that the implementation of two schedules in the by-law, which allows for expansion of the environments regulated and enforced by the city, was an effective strategy to gradually increase smoke-free spaces without burdening the City Council with regular needs to amend or update a by-law. Appropriate public relations were engaged including disseminating information about the by-law, and publicizing it through established networks in the community. Signage in the regulated environments, and enforcement were considered critical by the implementation team. City staff members recommended that other communities should consider passing similar by-laws and dedicate more effort to implementing and enforcing restrictions, rather than discussing or debating whether or not to enact a by-law. An analysis of the key informant interviews revealed that there were no unique features or circumstances specific to Woodstock that would suggest this by-law could not be developed or passed in another area municipality provided the community already has established smoke-free policies in indoor or enclosed public spaces. If Woodstock is unique in any way, it was in the presence of conditions such as high smoking prevalence and close proximity to tobacco growing regions that make it less likely to have successfully enacted an outdoor smoke-free ordinance. CONCLUSION: Support for the Woodstock comprehensive outdoor smoking by-law is high among smokers and non-smokers. The overwhelming majority of residents interviewed supported the by-law and felt that the by-law was good for the health of the children of Woodstock. The by-law has not had negative impacts on use of facilities including parks and recreational fields. Further, a third of smokers reported that the outdoor by-law has helped them to cut down how much they smoke and almost a fifth of smokers reported that the by-law has made them more likely to quit smoking. Approximately half of the quitters in the sample also reported the by-law helped them to stay quit. These findings suggest that expanding smoke-free ordinances to include a range of outdoor environments will be supported by citizens, and will help smokers to reduce how much they smoke, encourage quitting and help those that quit, remain abstinent. The findings from the key informant interviews suggest that other jurisdictions should explore expanding their smoke-free ordinances to include outdoor environments, particularly environments frequented by children.

BACKGROUND: Parents of children with juvenile idiopathic arthritis (JIA) are often forced to make trade-offs between the effectiveness, convenience, safety, and cost of drug treatments for their child. METHODS: A discrete choice experiment was administered to parents of children with JIA to determine their preferences for drug treatments. Multinomial logit regression was used to estimate part-worth utilities and willingness-to-pay. RESULTS: Participation in daily activities was the most important attribute, followed by child reported pain. Child age, gender, years with JIA, and household income had the greatest impact on preferences. Parents’ were willing to pay $2,080 to switch from a drug representing methotrexate to etanercept (95% CI $698, $4,065). CONCLUSIONS: Parents of children with JIA have the highest maximum willingness-to-pay for drug treatments that improve daily functioning and reduce pain. Cost is a significant factor in the decisions that parents make surrounding the best treatment for a child.

BACKGROUND: Parents of children with juvenile idiopathic arthritis (JIA) are often forced to make trade-offs between the effectiveness, convenience, safety, and cost of drug treatments for their child. METHODS: A discrete choice experiment was administered to parents of children with JIA to determine their preferences for drug treatments. Multinomial logit regression was used to estimate part-worth utilities and willingness-to-pay. RESULTS: Participation in daily activities was the most important attribute, followed by child reported pain. Child age, gender, years with JIA, and household income had the greatest impact on preferences. Parents’ were willing to pay $2,080 to switch from a drug representing methotrexate to etanercept (95% CI $698, $4,065). CONCLUSIONS: Parents of children with JIA have the highest maximum willingness-to-pay for drug treatments that improve daily functioning and reduce pain. Cost is a significant factor in the decisions that parents make surrounding the best treatment for a child.

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Both national equity in healthcare and the county councils’ local autonomy are important values supported by Swedish law. Politically it is a balancing act; how much freedom should the county councils have and to what extent should healthcare be equal throughout the country? The general aim of this dissertation, concerning political governance in Swedish healthcare, is to investigate the tensional values of national equity and local autonomy in the light of current trends in healthcare governance in Sweden. How is this tension manifested? Four studies are included in the dissertation. These studies show that the Swedish state is becoming more active in governing and regulating healthcare, for example by the use of informative governance and legislation, which increasingly rely on monitoring and evaluation of results that are made public. The findings show that the tension between national equity and local autonomy is manifested in increasing emphasis on national equity – or rather national equivalence – which is interpreted in terms of Swedish healthcare being recentralized. Delivery and financing of healthcare are still the responsibilities of the county councils. Planning and arranging – the setting of the regulatory framework – is increasingly taken over by the central state. Although power seems to be transferred from local level to central level, the county councils’ autonomy is only partially restricted, which means Swedish healthcare is still decentralized. However, if the recentralization process proceeds further, the county councils´ autonomy may be seriously challenged. Another challenge is to maintain or strengthen the procedures for democratic legitimacy through citizen participation at the local level. When local autonomy looses ground, it becomes more difficult to tailor healthcare according to local needs and conditions in the county councils, and decisions are taken at greater distance from the citizens.

Since the 1990s rates of prescription drug abuse and overdose have skyrocketed to unprecedented levels. As a result states have enacted and implemented new drug control policies in hopes of slowing and reversing this health epidemic. The goals of this study were to (a) determine the impact these state-based drug control policies have on prescription drug abuse and overdose and (b) deduce what leads some states to pass stricter policies than others. Results indicated that the prevalence of prescription drug overdose in 2008 largely impacted the future strength of a state’s drug control policy. States with higher rates of drug overdose and abuse in earlier years tended to develop tougher policy by 2013. In addition, states’ Prescription Drug Monitoring Programs (PDMPs) were found to be strongly related to the growth rate of prescription drug abuse in states. While not significantly differing from national trends at first, after about five years of PDMP operation, states began to see a slow or decrease in their rates of prescription drug abuse. Though much more can be done to combat prescription drug abuse and overdose, PDMPs that provide unsolicited reports to users and are accessible to law enforcement and are an effective step to begin to curb the problem.

Purpose: This study aimsto analyze managerial aspects of governance within Icelandic healthcare institutions, particularly regarding job descriptions and policy-making plans. Method: We used a qualitative research method and content analysis to examinedata collected from semi-structured interviews Ten participants (5 malesand 5 females) who worked as senior managers, middle-management executives in the healthcare service, and Ministry of Welfare officials. The participants reflected a breadth of experience and education across the spectrum of age, length of service, and work experience in both hospitals and primary care. Results: Data analysis revealed three main categories including policy-making plans in healthcare, which identified a considerable gap between managers and executives on one side and the Ministry of Welfareon the other, especially regarding strategy. Incidental control and effect of politicians on healthcare operation. Second, inrelation to the Ministry of Welfareand healthcare institutions we observed unstructured, onerous, and remote communications and organization that focused too little on professional issues. The Ministry of Welfare tended to interfere with managers’ responsibilities and scope of work. Third, we observeds trengths and weaknesses in management. Strengths includedad ministrators’ enthusiasm, ideas of empowerment, short lines of communications, and often straightfor ward interactions, compared withweaknesses in the workprocesses within healthcare institutions and toward the Ministryo f Welfare, and also in job descriptions and vague definitions of the institutions’role. Conclusion: The indications reported here suggestun clear policy-making plansfor healthcare institutions. Although managers and executives maintained that visions for the futureare vague, the Ministry of Welfare stated that the strategy was clear. The study identified a need of strengthening and restructuring the way of communications, as well as clarifying managers’ role toward the Ministry of Welfare / <p>ISBN 978-91-982282-7-4</p>

This thesis examines some social policies and public health measures in the small county of Bedford, within the national context, 1904-38. No other such study exists which covers these aspects; it will, therefore, fill a gap in the body of knowledge. At this time, national and imperial needs for a healthy British race were paramount in the minds of politicians and social reformers, particularly in the face of competition for industrial and military supremacy from other powers, including Germany and the United States of America. Certain key themes permeated this era: the changing functions of local and central government, the role of the state and voluntary sectors, and a medical profession divided between those employed in preventive medicine, and those in private practice. However, war, the preparation for war and its after effects have been found to be the most significant factors. George Newman (1870-1948), figures large, because he played a major part in public health initiatives, firstly, as part-time County Medical Officer of Health to Bedfordshire County Council (1900-07), and then at central government level, as Chief Medical Officer of the Board of Education (1907-35), and of the Ministry of Health (1919-35). Two methodological tools were used in this thesis. Historical research was carried out using, mainly, primary source material, and an empirical study was undertaken using a descriptive case study approach. These methods enabled the collection of quantitative and qualitative data and helped to determine both the final content, and the form in which the research was presented. Chapter 1, the Introduction, provides a background to the key figures and themes discussed and describes the intra-county differences in Bedfordshire. Chapter 2 concerns infant mortality, as it is an indicator of the health ofthe whole community. Chapter 3 describes the health of school children, because the Government was particularly anxious about their condition, as they would be needed for industrial and imperial expansion, and in the event of war. Chapter 4 concerns the welfare of children. It provides examples of how the state and voluntary sectors strove to preserve child life, despite problems such as orphanhood and cruelty, and yet still attempted to meet the needs of the British Empire for labour. Chapter 5 discusses women's health, as it was relatively neglected by central government in this period. It takes the form of a case study and makes use of oral testimony from a cohort of 84 women who lived in Bedfordshire in the inter-war years. Chapter 6, the conclusion, examines the effect of war, the role played by the voluntary and state sectors, and the divided medical profession. It also considers the extent to which Bedfordshire led, or lagged behind national social policies and public health measures, and the progress made towards a healthier nation until 1938, the last full year of peace in Europe before the outbreak of World War II.

This research seeks to identify what accountability frameworks were in place for the home and community care sector in the Canadian province of Ontario, how home and community care agencies in Ontario responded to accountability demands attached to government service funding (specifically through Community Care Access Centre (CCAC) contracts and Local Health Integration Network (LHIN) Multi-Service Accountability Agreements (MSAAs) and what, if any, effect accountability frameworks had on service delivery. This study uses a multi-phase parallel mixed methods approach. First, an environmental scan and document analysis was conducted to identify accountability frameworks and identify key characteristics of accountability demands. Next, 114 home and community care agencies in Ontario were surveyed and 20 key informant interviews were conducted with executives from 13 home and community care agencies, two CCACs and two LHINs. Data from these different methods were combined in the analysis phase. Home and community care agencies face multiple accountability requirements from a variety of stakeholders. We found that government agencies relied most heavily on regulatory and expenditure policy instruments to hold home and community care organizations to account. Organizational size and financial dependence were significantly related to organizational compliance to accountability demands attached to CCAC contracts and MSAAs. In addition to the theorized potential organizational responses to external demands (compliance, compromise, avoidance and defiance), this study found that organizations engaged in internal modification where internal practices are changed to meet accountability requirements. Smaller, more poorly resourced organizations that were highly dependent on LHINs or CCACs were more likely to internally modify organizational practice to meet accountability demands. Although MSAAs and CCAC contracts supported a quality culture amongst organizations, internal organizational changes, such as redirecting time towards reporting requirements and away from care, and cutting innovative practices and programs, were reported to have a negative impact on the quality of service delivery. Government reliance on contract-based accountability for funded home and community care services, while politically advantageous, has the potential to seriously and negatively affect the quality of home and community services delivered. Policy makers need to carefully consider the potential impact on quality of service delivery when developing and implementing accountability policy.