The overall purpose of this study was to examine the relevance of policy factors identified by Mulvale and Bourgeault (2007) on interprofessional collaboration in PHC, by soliciting stakeholders’ perspectives. / ABSTRACT Background: Interprofessional team-based approaches to primary health care (PHC) delivery have gained support in the literature. Interprofessional primary health care (IPC) models of service delivery allow for different professionals to work together to address patients’ needs. Family Health Teams (FHTs) are a newly introduced model of IPC delivery in Ontario. A variety of factors can influence collaboration between professionals in IPC teams. Purpose/Research Objectives: The purpose of this study was to examine stakeholders’ perspectives about policy factors that influence IPC team collaboration, using the example of FHTs in Ontario. Methods: This descriptive study employs semi-structured interviews with key informants from select Ontario FHTs. Directed content analysis was used to examine the Mulvale and Bourgeault (2007) framework. Interviews were conducted with FHT professionals to describe their perspectives on the influence of policy factors in shaping collaboration within their teams and whether identified policy factors acted to enhance or hinder collaboration. Findings: Key informants cited, with highest agreement, economic and regulatory factors as influencing collaboration. Factors agreed upon unanimously by all key informants included funding, provider payment/remuneration, and practice scope. Key informants identified a range of policy factors that hinder collaboration. These included provider payment/remuneration, legal accountability, and the existence of multiple governing bodies. Implications/Conclusion: A number of policy factors were reported to influence collaboration in FHTs in Ontario. Although the findings suggest that incremental reform is possible, widespread policy reform of physician incentives, a key barrier to collaboration, is unlikely. Prospects for reform of this factor may be more promising at an organizational level. / Thesis / Master of Science (MSc)

During the last decade, there has been growing international interest in generating new knowledge regarding understanding, developing and evaluating mechanisms that support the use of research evidence by policymakers as a strategy to strengthen health systems in low-and middle-income countries (LMICs). This thesis contributes to this knowledge through three original scientific contributions that employ a mixed methods approach, with the goal of supporting the use of research evidence in the Colombian health system. Specifically, in the chapters I present: 1) the development of an analytical schema that explains the conceptualization of the Colombian government, research funder and universities of an evidence-informed health system; 2) two case studies that explain whether and how political factors influenced the role of research evidence in the agenda-setting and policy-development stages of two past health policy decisions in Colombia; and 3) a protocol for a randomized controlled trial evaluating the effectiveness of a multifaceted intervention in increasing the utilization of an evidence service and the intention to use synthesized research evidence by policy advisors and analysts at the Colombian Ministry of Health. As a whole, the chapters presented in this thesis provide substantive, methodological and disciplinary contributions to the field of health systems research and particularly to the study of efforts that aim to support evidence-informed policy in LMICs. They also help to provide insights that can be utilized to support a more nuanced approach to the use of research evidence in LMICs that takes into account the many factors that can influence health system policymaking. Ideally, this will help those engaged in developing mechanisms to support the use of research evidence in the policy process, and contribute to stronger health systems across the world. / Thesis / Candidate in Philosophy

Background: Refugees and refugee claimants experience health needs upon arrival in Canada. Retrenchments to the Interim Federal Health program (IFHP) in 2012 greatly reduced healthcare access for refugee claimants, generating concerns among healthcare providers and other stakeholders affected by the reforms. In 2014 a new IFH program temporarily reinstated access to some health services however, little is known about the reforms and more information is needed to map its impact on key stakeholders. This study aims to examine the perception of key stakeholders regarding the impact of the 2014 reforms on the policy’s intermediary goals: access and provision of healthcare. Methodology: Data was collected using semi-structured key informant interviews with refugee health policy stakeholders (n=23), refugees and refugee claimants (n=6), policy makers and government officials (n=5), civil society organizations (n=6) and professionals and practitioners (n=6). Data was analysed using a constant comparative approach with NVivo 10 (QSR International). A stakeholder analysis was used to map out key stakeholder perceptions, interests and influences in refugee health policy and a content analysis was further employed to abstract themes associated with barriers and facilitators to access and provision of healthcare in the current situation. Results: The findings provide information for management of stakeholder engagement revealing the perceptions of key stakeholders on the 2014 reforms: eight were opposed to the reforms, eight held mixed positions, four supported the reforms and one did not comment. Five facilitators to accessing healthcare were identified. Eighteen themes emerged under four health care access and provision barrier categories: cognitive, socio-political, structural and financial. There were four common themes perceived among all stakeholder groups: lack of communication and awareness of refugee and provider, lack of care provider training leading to unfamiliarity with IFHP, lack of continuity and comprehensive care and the political discourse leading to refugee and claimant social exclusion. Other common barrier themes included healthcare affordability for refugees and the healthcare system, fear of the healthcare system, and interaction with the Ontario Temporary Health Program. Conclusion: The study highlights that reforms to the IFHP in 2014 have transferred refugee health responsibility to provincial authorities and healthcare institutions resulting in bureaucratic strains, inefficiencies, overburdened administration and increased health outcome disparities as refugees and claimants choose to delay seeking healthcare due to existing barriers. There are some benefits to the reforms, but the lack of support and mixed opinions among the majority of stakeholders emphasize the need for reformulation of policy with stakeholder engagement. This study recommends future refugee health reform strategies incorporate stakeholder leadership, cooperation and perspectives, as revealed in this research, to successfully move healthcare policy from theory to practice. / Thesis / Master of Science (MSc)

Background: Public deliberation can be used in a number of decision-making processes to make the health system more responsive to public values, and to help inform and refine health system policy decisions. This study evaluates how the McMaster Health Forum implements the key elements of public deliberation and identifies both areas of strength and potential areas for improvement. Methods: An evaluative case study approach was used. Data were collected from three sources: quantitative and open-ended responses to questionnaires from 19 panels (200 respondents); panel summaries from 13 panels; and transcripts of 2 panel deliberations. Thematic analysis was used to assess four key elements of deliberation: the representativeness of participants, the information supports provided to them, the procedural criteria used, and the focus on explicit reasoning in coming to conclusions. Results: Participants felt that the McMaster Health Forum recruited a representative sample of participants based on gender and diversity of opinion. However, participants noted that the panels could be improved by striving for more age and ethnocultural diversity while also including health professionals or policymakers. Participants mostly occupied the role of a ‘consumer’ of health services. They viewed the information presented in citizen briefs as credible but had questions about the brief-development process. Procedurally, the panels fostered openness without impeding consensus and facilitators fostered mutual respect among participants. Finally, the groups incorporated values, showed an ability to come to a deeper understanding of policy options and harnessed the diverse experiences of their fellow participants as they reasoned. Discussion: This case study is part of a larger evaluation process that assesses all of the McMaster Health Forum citizen panels which aim to elicit citizens’ values and preferences about health system issues in Canada. The framework used to assess the public deliberation process can be used to evaluate other processes in the future. / Thesis / Master of Science (MSc)

Background and aim: Lung cancer is the leading cause of cancer incidence and mortality in Canada. Population-based screening programs using low dose computed tomography are being more widely used. Screening reduces lung cancer mortality. It also introduces potential ethical issues that need to be elucidated to inform the ethical, equitable, and effective implementation of screening programs. This aim of this research was to begin developing an understanding of what the ethical issues are and how they are being, and should be, approached in health policy. Methods: Using empirical ethics inquiry, this research produced descriptive evidence via three independent studies: a systematic literature review and mixed methods integrative synthesis of public perspectives on screening benefits and harms, and two qualitative description studies about public and key informants’ ethical and social values on ethical issues in screening. Results: The major finding of this research was the preponderance of ethical issues located within health and social systems and structures, including equity of screening access, stigma against people who currently smoke commercial tobacco, commercialization of tobacco, and the need for increased investment in primary prevention of lung cancer. These ethical issues reflect the social, economic, and political determinants of lung cancer and the means available to reduce the burden of lung cancer in Canada, including but not limited to screening. In health policy, there was a lack of ethical frameworks or principles currently being used to address these ethical issues and the sometimes-conflicting perspectives found between the public and key informants. Discussion: Future empirical and normative research is needed to understand ethical and social values related to screening by populations with high lung cancer incidence and mortality, and to integrate empirical evidence with appropriate ethical theories to make recommendations for ethical, equitable, and effective population-based LDCT lung cancer screening policy in Canada. / Thesis / Candidate in Philosophy / Lung cancer is the top cause of cancer in Canada. An estimated 30,000 people were diagnosed with lung cancer and 20,700 people died from lung cancer in 2022. Screening is being more widely used to find and treat lung cancer in earlier stages. There are some ethical questions to consider, like how to ensure that screening programs are fair and effective. This research focused on understanding what the ethical issues are and how they could be solved in health policy. Perspectives on ethical issues were collected and analyzed from the public and lung cancer screening leaders. The two major ethical issues were fair access to screening and stigma against people who currently smoke commercial tobacco. There was a lack of ethical guidance to address these issues in health policy. Ethical concepts about justice and individual choice, and ethics research with key communities, may help navigate ethical issues in health policy.

There's frequent discourse regarding the rising cost of insulin in the US. Insulin is a drug that over 7 million people rely on for survival, and it has tripled in cost over the last decade. The pricing regulation of the drug is dependent on multiple stakeholders, including wholesalers, pharmacy benefit managers, and manufacturing companies. Due to the lack of governmental intervention in the process of pharmaceutical cost regulation in the US, data on the price negotiations and the rebate system between these entities is unavailable in public records, making it difficult to determine a primary cause as the root of the issue of insulin costs. This paper attempts to understand the policies in place that impact the nature of insulin affordability and assesses the Canadian regulation of the cost of insulin to understand the discrepancy between the affordability in Canada in comparison to the affordability of insulin in US. A literature review was conducted to examine the policies and congressional discourse in order to analyze the current insulin market and the policies currently in discussion. Ultimately the discrepancy between the nature of health care in Canada and in the US is characterized by the underlying social principles that govern each country in terms of health policy. The Canadian health care system is built on the foundation that health care is a human right, whereas in the United States, health care is a commodity. The effect of this ideology is observed in the costs and regulation of pharmaceutical insulin.

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This dissertation examines the formation of health policy as a cultural process in a large federal bureaucracy in the United States, namely the Department of Veterans Affairs (VA). The everyday experience of bureaucrats working in the VA is used to answer the question: why does the VA fail to meet veterans’ needs in the face of a sacred trust, available political will, and robust resources? To answer the question, this project employs ethnographic methods that draw on participant observation at the headquarters office of the VA in Washington DC, archival research, and interviews with current and former VA employees during the Obama administration. I argue that care of veterans during post-war periods are critical moments of intervention that not only improved the population health of veterans but also impacted the ways in which America conceives and responds to health challenges. I also argue that when the VA operates at its best, it is often the leading edge of health reform, setting new standards for care and effectively establishing alternative models of care. Finally, my findings show that institutional factors play an important role in the process of health policy formation in ways that contribute to new understanding about causal conceptions of health. I conclude with a framework that draws on the lessons the VA affords, for health reform and advancing just health for all. / Anthropology