Objective: The promotion of self-management support for people with LTCs is a health policy priority across the UK (LTCAS 2008; DoH 2012). Self-management support is designed to change and improve care for people with LTCs, who form an increasing proportion of the population requiring healthcare and treatment. For health organisations models of care, which support self-management, require greater emphasis on person-focused rather than disease-focused manifestations of health and represents a new model of care delivery requiring changes in practice. Current research demonstrates that health policies are increasingly complex, involve multiple organisations and often fail to translate into effective practice (Noyles et al. 2014). The deficit between what works and what happens in practice is referred to as the “implementation deficit” (Pressman and Wildasky 1984) and traditionally it has been difficult to breakaway from the idea that the policy process is best viewed from the top-down (Barett and Fudge 1981). However, there remains a need to understand the processes of implementation, which takes account of the variation, the multiple layers and interactions which takes place between policy-maker and -implementer as policy becomes practice (Hupe 2011). Implementation of self-management is a contemporary focus in UK health policy and this thesis explains what processes are used to implement self-management policy for people with LTCs into everyday practice in one health board. Methods: A case study approach was used to investigate the policy process with data collected using thirty-one semi-structured interviews with policy-makers and regional and local policy-implementers plus eight hours of observation of national and regional policy meetings. To provide context to the implementation process data also included thirteen policy documents. Data analysis used the retrospective application of NPT as a theoretical framework with which to explore the implementation processes. NPT is an emerging theory that is being promoted as a means of understanding implementation, embedding and integration of new ideas in healthcare (McEvoy et al. 2014). The application of NPT focuses on four mechanisms, termed work (May and Finch 2009: 547), which promote incorporation of new ideas in practice. These areas of work are coherence, cognitive participation, collective action and reflexive monitoring (Mair et al. 2012). Findings: The findings suggest that there are a number of important influences operating behind or as part of the policy implementation process. These included the need for a shared understanding, getting stakeholders involved to drive forward policy, work promoting collaboration and participation was the most detailed and important in the process of policy implementation; the course of policy was affected by factors which facilitated or inhibited stakeholders acceptance of self-management; and NPT fosters key analytical insights. Conclusion: Understanding the process of policy implementation in healthcare and how practice changes as a result of policy is subject to a wide range of influences. What emerges are five key recommendations relating to understanding policy implementation. (1) understanding the concept of self-management is important in promoting policy implementation. This understanding benefits from dialogue between policy-makers and -implementers. (2) stakeholder involvement supports implementation particularly the role of clinical leadership and leadership through existing networks but also value in establishing new organisational structures to create a receptive context. (3) develop participation and collaboration through use of the patient voice which helped simplify the policy message and motivate change. (4) other resources help policy implementation and where these are evident then policy is implemented and where they are absent then implementation is not embedded. Lack of evidence was a particular area of constraint. (5) NPT has shown that social context is important, and provides for this. But in addition there is evidence that historical perspectives and previous experience are also important influence on receptivity to implementation. This research contributes to the development of theory and practice in the area of implementation science. The exploration of the policy implementation has revealed the action and work which policy-makers and -implementers are engaged in while implementing policy. It has tested the utility of NPT in a real-life setting using all four mechanisms.

INTRODUÇÃO: A Avaliação da Tecnologia em Saúde (ATS) tem por objetivo informar aos formuladores de políticas sobre as implicações do desenvolvimento, da difusão e do uso de tecnologias nos sistemas de saúde. A ATS, enquanto produção de conhecimento e política de saúde, disseminou-se nos países desenvolvidos e, mais tardiamente, nos países em desenvolvimento. No contexto brasileiro, foi publicada em 2009 a Política Nacional de Gestão de Tecnologias em Saúde (PNGTS) e, em 2011, foi criada a Comissão de Nacional Incorporação de Tecnologias no SUS (CONITEC). Os estudos realizados sobre a PNGTS têm focado na descrição dos relatórios de recomendação da CONITEC e na análise de aspectos metodológicos, porém, não abordaram a implementação dessa política de saúde. OBJETIVO: Compreender o processo de implementação da Política Nacional de Gestão de Tecnologias em Saúde (PNGTS), utilizando a CONITEC como estudo de caso. MÉTODOS: Trata-se de um estudo de caso único para o aprofundamento da compreensão do processo de implementação da PNGTS. A primeira etapa da pesquisa constituiu-se da análise de documentos formais (arcabouço legal e relatórios de recomendação da CONITEC do período de 2012 a 2016) para elaboração de estatísticas descritivas. Já a segunda etapa compôs-se da realização e da análise qualitativa de entrevistas com atores-chave. Todas as entrevistas foram gravadas, transcritas, inseridas no programa NVivo 12 e analisadas utilizando a abordagem temática. Os quadros teóricos utilizados para a análise qualitativa foram o de formação de agenda de Kingdon e a análise de implementação. Por fim, a terceira etapa objetivou a interpretação das informações quantitativas e qualitativas. RESULTADOS: O arcabouço legal estabeleceu um fluxo estruturado e definiu as evidências científicas exigidas para o processo de incorporação, alteração e exclusão de tecnologias no SUS. Foram analisados 199 relatórios de recomendação da CONITEC. O número anual de relatórios aumentou ao longo do período de estudo, com o pico em 2013 (n=54). Nos anos seguintes observou-se uma leve queda em 2014 (n=41), 2015 (n=44) e 2016 (n=31). O número anual de novas tecnologias incorporadas em 2013 (n=24) foi semelhante ao observado para 2014 (n=24) e 2015 (n=22), diminuindo em 2016 (n=13). O tipo de tecnologia mais frequentemente avaliada foi \"medicamentos\" (68,3%), seguido por \"procedimentos\" (20,1%). Dentre os 101 relatórios em que a tecnologia foi recomendada para incorporação: 83 (82,2%) referiram-se a demandas internas; 13 (12,9%), a demandas externas; 5 (4,9%), a demandas mistas. Desses, 88 (87,1%) não incluíram uma avaliação econômica em saúde completa, nem o cálculo da razão de custo-efetividade incremental. Em relação às 83 demandas internas, apenas 8 (9,6%) apresentaram um relatório completo de ATS; em contrapartida, dentre as 13 demandas externas, 10 (76,9%) apresentaram um relatório completo de ATS. Houve dificuldades relacionadas ao cumprimento das recomendações contidas nas normas da CONITEC, de modo que foram observadas diferenças relevantes entre as demandas internas e as externas quanto ao uso de evidências científicas (avaliação econômica em saúde) e às decisões favoráveis à incorporação da tecnologia no SUS. Na segunda etapa, a análise qualitativa identificou uma série de desafios para a implementação da CONITEC, notadamente: falta de estabilidade político-institucional, dificuldades para o desenvolvimento de estudos de avaliação econômica em saúde (pela indisponibilidade de dados clínicos e econômicos), além de limitações técnicas dos recursos humanos para lidar com os dados econômicos. A diferença entre as demandas internas e externas pode ser explicada pela legitimidade que as demandas internas possuem dentro do governo e pela necessidade de regulação das demandas externas. CONCLUSÃO: O uso de avaliação econômica em saúde na gestão de tecnologias no SUS ainda é incipiente, pois existem dificuldades estruturais e político-institucionais para o desenvolvimento e uso das evidências científicas. Outros critérios, para além dos que constam no arcabouço legal, são utilizados nos processos de incorporação da CONITEC / INTRODUCTION: Health Technology Assessment (HTA) aims to inform policy makers about the implications of the development, diffusion and use of technologies in health systems. HTA, as knowledge production and as health policy, has spread around the developed countries and, later, around developing countries. In the Brazilian context, the National Policy on Health Technology Management (PNGTS, in the Portuguese acronym) was published in 2009 and, in 2011, the National Committee for Health Technology Incorporation into the Brazilian public health system (CONITEC, in the Portuguese acronym) was created. Studies on the PNGTS have been observed to focus on the description of CONITEC\'s recommendation reports and on the analysis of methodological aspects, but have failed to address the implementation of this health policy. OBJECTIVE: To understand the process of implementation of the National Policy on Health Technology Management (PNGTS, in the Portuguese acronym), using CONITEC as a case study. METHODS: This is a single-case study to understand the PNGTS implementation process. The first phase of the research consisted in a quantitative analysis of formal documents (legal framework and CONITEC\'s recommendation reports) to produce descriptive statistics. In the second phase, interviews with stakeholders were carried out and qualitatively analyzed. All interviews were recorded, transcribed, uploaded to NVivo 12 and analyzed using the thematic analysis approach. The theoretical frameworks used for the qualitative analysis were Kingdon\'s agenda-setting and implementation analysis. Finally, the third phase aimed to interpret the quantitative and the qualitative information. RESULTS: The legal framework established a structured process and defined the scientific evidence required for the incorporation, alteration or exclusion of health technologies into or from the SUS (the Brazilian health system). A total of 199 CONITEC\'s recommendation reports were analyzed. The annual number of reports increased over the study period, peaking in 2013 (n = 54). In the following years, a slight decrease was observed: 2014 (n = 41), 2015 (n = 44) and 2016 (n = 31). The annual number of new technologies incorporated in 2013 (n = 24) was similar to that observed in 2014 (n = 24) and 2015 (n = 22), decreasing in 2016 (n = 13). The most frequently evaluated type of technology was \"medicines\" (68.3%), followed by \"procedures\" (20.1%). Of the 101 reports in which the technology was recommended for incorporation, 83 (82.2%) referred to internal demands, 13 (12.9%) to external demands, and 5 (4.9%) to mixed demands. Of these, 88 (87.1%) did not include either a full health economic evaluation or the calculation of the incremental cost-effectiveness ratio (ICER). Regarding the 83 internal demands, only 8 (9.6%) presented a full HTA report; on the other hand, among the 13 external demands, 10 (76.9%) presented a complete HTA report. There were difficulties related to compliance with the recommendations contained in CONITEC\'s legal framework, so that relevant differences were observed between internal and external demands regarding the use of scientific evidence (health economic evaluation) and positive recommendations for incorporation into the SUS. In the second stage, the qualitative analysis identified a series of challenges for CONITEC\'s implementation, such as: lack of political-institutional stability, difficulties in the development of health economic evaluation studies, lack of clinical and economic data, and technical limitations for human resources to deal with economic data. The difference between internal and external demands can be explained by the legitimacy that internal demands have within the government and, on the other hand, by the need to regulate external demands. CONCLUSION: The use of health economic evaluation in the management of technologies in the SUS is still incipient, because there are structural and political-institutional difficulties for the development and use of scientific evidence. Other criteria than those contained in the legal framework are used in CONITEC\'s incorporation process

Luo, Weixiang. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 90-105). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts also in Chinese.

殖民時期的香港一直被丛书新自由主義的經典例子。加上香港殖民政府的剝削本質，它一般不會提供廉價醫療服務給予普羅大眾。然而，儘管有「積極不干預主義」這口號，殖民政府仍然於香港留下了龐大公營醫療系統。為什麼龐大公營醫療系統與放任自由主義並存於二次世界大戰後的香港社會？ / 為了解答以上疑問，本研究將從一九六四年醫療改革，探討香港戰後醫療政策。本文認為，香港研究忽視了冷戰對香港公共衛生的影響。文獻回顧後，實證研究分為三部分。第一部分提出「衛生關注」(Sanitary Concern)不足以構成醫療改革的原因。第二部分通過文本分析，發現六十年代的主流報章不重視醫療改革，由此可見改革並非基於公眾的訴求。最後的部分從戰後政府檔案，發現長遠的公營醫療規劃沿於五十年代後期。同時，戰後公營醫療系統的擴張，更可能是因為殖民政府為了確保足夠的戰時緊急醫療服務，及防止左派利用社區診所滲透入基層。 / Hong Kong has been regarded as a textbook example of Neo Liberalism. The exploitative nature of a colonial government makes it unlikely for the colonial state to make commitment for low-cost medical services to the general public. However, the slogan of “positive non-interventionism notwithstanding, the strong public health sector in Hong Kong is also a colonial legacy. Why was such a state-centered medical system established in a laissez-faire society after the Second World War? / This thesis aims at investigating the 1964 hospital reform in Hong Kong to study the colonial governance and arguing that the Cold War factor has been neglected in the analysis of the medical-institutional change. After the literature review, there are three empirical sections to support this explanation. The first part finds that sanitary concern was not a strong reason for the reform. In the second part, a context analysis on newspaper during the 1960s shows that the hospital reform was simply neglected by most newspapers, which implies that the reform was not the direct result of public pressure. The final part looks into the long-term medical planning since the late 1950 and several related medical policies through different archives in order to demonstrate the impacts of Cold War’s politics on Hong Kong’s medical services provision. Evidences suggest that self-sufficiency of military-emergency medical services and control over the growing influence of left-wing community clinics could be a more convincing explanation for the reform. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Tang, Kai Yi. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 156-165). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts also in Chinese. / Thesis/Assessment Committee --- p.i / Abstract --- p.ii / Acknowledgments --- p.iv / List of tables, graphs and figures --- p.v / Acknowledgments --- p.vii / Chapter Chapter One --- Introduction --- p.1 / Chapter 1.1 --- The 1964 medical white paper: the first commitment in the colonial history --- p.2 / Chapter 1.2 --- A state-centred medical system as a colonial legacy --- p.6 / Chapter 1.3 --- The research question --- p.8 / Chapter 1.4 --- Methodology --- p.10 / Chapter 1.5 --- The central argument and outline of the thesis --- p.12 / Chapter Chapter Two --- Literature Review --- p.14 / Chapter 2.1. --- Politics of health in Hong Kong: a sudden change from the voluntary sector to the state? --- p.14 / Chapter 2.2 --- The origin of public health in Britain, India and Singapore --- p.17 / Chapter 2.3 --- Inadequate explanations for the 1964 hospital reform --- p.19 / Chapter 2.4 --- The nature of the Colonial governance: laissez-faire or Interventionist? --- p.21 / Chapter 2.5 --- British Hong Kong: Lacking commitments to local community --- p.24 / Chapter 2.6 --- The partial vision of public health in the colony --- p.25 / Chapter 2.7 --- Financial conservatism, the Pound crisis and social reforms in Hong Kong --- p.29 / Chapter 2.8 --- “1967 riot“ and “MacLehose“ as a explanation for the post-War social reforms --- p.33 / Chapter 2.9 --- An alternative: Cold War, the colonial governance and social service provision --- p.37 / Chapter Chapter Three --- Sanitary concern, diseases and state interventions in Hong Kong: Did the epidemic matter again? --- p.44 / Chapter 3.1 --- The origin of sanitary concern in Victorian Britain --- p.44 / Chapter 3.2 --- Impacts and limitations of sanitary concern in Hong Kong --- p.48 / Chapter 3.3 --- The 1894 Plague as a turning point: the first expansion in the colonial medical system --- p.50 / Chapter 3.4 --- Shadow of sanitary concern after the War --- p.53 / Chapter 3.5 --- Health profile in Hong Kong: a gradual improvement? --- p.56 / Chapter 3.6 --- A epidemiological transition in infectious diseases since 1945 --- p.59 / Chapter 3.7 --- Conclusion: Did diseases really matter? --- p.64 / Chapter Chapter Four --- Public opinion on public health: a driving force to the reform? --- p.65 / Chapter 4.1. --- The political culture in post-war Hong Kong --- p.66 / Chapter 4.2 --- From the rise in telephone fees to a social event in newspapers --- p.69 / Chapter 4.3 --- A content analysis on newspapers in 1964 --- p.72 / Chapter 4.4 --- Most medical news: informative but not critical --- p.73 / Chapter 4.5 --- Hospital reform: simply ignored? --- p.77 / Chapter 4.6 --- Reform: a result of public pressure? --- p.81 / Chapter 4.7 --- A social event: “charity clinics problem“? --- p.84 / Chapter 4.8 --- Conclusion: an ignored reform by an active Chinese community? --- p.88 / Chapter Chapter Five --- Politics of public health in post-war Hong Kong: clinics, hospitals and the Cold War --- p.89 / Chapter 5.1 --- British in Cold War: to defend a valuable but vulnerable port --- p.90 / Chapter 5.2 --- Coincidence: A growing government medical sector since 1957 --- p.97 / Chapter 5.3 --- Planning since 1957: reserved lands, standard clinic design and Executive Council --- p.108 / Chapter 5.4 --- Planning in New Territories: a Heung Yee Kuk’s petition for a new hospital --- p.113 / Chapter 5.5 --- A forgotten alternative in medical financing: medical insurance schemes --- p.117 / Chapter 5.6 --- Politics between Hong Kong and London: Mayo Clinic --- p.120 / Chapter 5.7 --- Incinerators and generators: the role of civil hospitals in defence --- p.123 / Chapter 5.8 --- Civil hospitals in M.D.S.: to defend the indefensible Colony --- p.124 / Chapter 5.9 --- “Inconsistent planning: to defend Hong Kong without military hospitals? --- p.135 / Chapter 5.10 --- Threats from the communist: regulations on refugee doctors and charity clinics --- p.138 / Chapter 5.11 --- Conclusion: 1964, a year of no significance? --- p.144 / Chapter Chapter Six --- Conclusion --- p.145 / Chapter 6.1 --- Summary of arguments --- p.145 / Chapter 6.2 --- A reference point: Cold War’s politics and the medical reform in Singapore --- p.148 / Chapter 6.3 --- Implications on public health and Hong Kong studies --- p.152 / Chapter 6.4 --- Limitations and directions of further study --- p.153 / Reference --- p.156

Findings suggest that: (1) Public hospitals are turned into state-owned enterprises as they are encouraged to grow into larger size by management autonomy and financial regulatory reform, and the abandonment of the government on the control over management and hospital assets; (2) government abandons its financial responsibility towards public hospital workers and the latter need to use market mechanism to earn their income by cross-reimbursement of price and that devalues professionalism of these workers; (3) government abandons the subsidy to public hospitals through the reform of public hospital financial system; (4) the large higher-tiered public hospitals obtain their preferential rights through political advantageous position; (5) the reform of public hospitals is not at all one dimensional: public hospitals respond by active actions, aggregate breaking of rules and regulations, individual break-through, and no response. In summary, marketization, de-professionalization, diswelfare and market diversification contribute to the reverse triangle model of China's public healthcare system. / Key words: social policy, public hospital, marketization, de-professionalization, discriminated market. / Reform of China's public healthcare system is an extension of China's reform of its social welfare provision system. The above findings provide evidences on the economic rules, social relationships, and government actions in social welfare services as illustrated in the provision of health care by public hospitals in China. It is important reference for decision-makers in the new round of public service reform in the coming future. / Service providers are indispensable components of a social welfare system. Their performance is influenced by government policies and how service providers are active agents. Therefore, attaining the goals of social welfare services needs to consider the institutional arrangements for service providers. / Taking public health service in China as an example, this research answers why the public healthcare provision system in China turns out to be a reverse triangle structure, which is an anti-welfare model suggested by the World Health Organization. With a new institutionalism perspective, policy documents are used to study the effect of government intervention on public hospitals, and the interaction of government and public hospitals. / 馮文. / Submitted: 2010年12月. / Submitted: 2010 nian 12 yue. / Adviser: Chack-kie Wong. / Source: Dissertation Abstracts International, Volume: 73-04, Section: A, page: . / Thesis (Ph.D.)--Chinese University of Hong Kong, 2011. / Includes bibliographical references (p. 272-329). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [201-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in Chinese and English. / Feng Wen.

A substantial gap exists between those who are considered experts on mental health (e.g., academics, mental health professionals) and those in charge of constructing mental health policies (e.g., legislators, Senators). This gap is in areas of both knowledge and professional relations. Mental health professionals are not adequately trained to engage in policy advocacy and reform efforts and have little to no policy advocacy training (Smith, Reynolds, & Rovnak, 2009). Policymakers lack necessary knowledge related to mental health for effective mental health policy construction (Corrigan, Druss, & Perlick, 2014; Lee, Smith, & Henry, 2013). As a result of this gap, mental health policies are ineffective, and many mental health professionals lack understanding and experience in the area of policy advocacy (Smith et al., 2009; Tanenbaum, 2005). This qualitative study aimed to contribute to filling this gap by exploring the perspectives of policymakers with the purpose of gaining a better understanding of the mental health policy construction and reform process. The purpose of this qualitative study was to explore the perspectives and lived experiences of state-level, practicing policymakers regarding their decision-making processes related to mental health policy construction in efforts to reveal a clearer understanding of how to participate in effective policy reform.A phenomenological qualitative research design and Interpretative Phenomenological Analysis (IPA) approach was used to explore the lived experiences and perspectives of a total of eight state-level practicing policymakers surrounding the mental health policy construction process. After securing IRB approval, all eight participants participated in face-to-face individual, semi-structured interviews. The interviews were audio recorded and ranged from 45 to 90 minutes. Data was then analyzed using IPA data analysis methods. The final data analysis product included three super ordinate themes and related themes and subthemes.

In 1963, President John F. Kennedy signed the Mental Retardation and Community Mental Health Centers Construction Act, establishing the beginnings of deinstitutionalization in the United States. By some counts, this Act was a stupendous policy success—by others, a dismal failure. 50 years later, no cohesive national mental health care policy has emerged to deal with increased rates of mental illness among the homeless and the incarcerated. However, California has made enormous strides to create a state policy which provides adequate services to the mildly, moderately, and severely mentally ill as well as adequate funding for those services through Proposition 63, the Mental Health Services Act, passed in 2004. This paper reviews mental health policy history from Colonial America to the present, paying special attention to JFK's deinstitutionalization in 1963 and the discontents that followed. It takes a special look at California's mental health care policy history and the strides the state has made to better serve the mentally ill.

Ethiopia has two stories to tell: a fast progress and unfair distribution of the gains in child health care. Despite Ethiopia’s achievement in meeting MDG4, wealth-related mortality inequality increased by 1.5 for every 1,000 live births between 2000 and 2011. Two major dividing lines contribute to child health inequality in Ethiopia: place of residence and wealth status. Lack of proper studies on health inequality policy making is affecting the comprehensiveness and quality of inequality reduction in Ethiopia. This study wished to assess child health inequality and policy factors that affect progress in inequality reduction. Accordingly, the study explored policy-makers’ attitude and interest; policy contents, and institutions to make recommendations that promote child health equity in Ethiopia. The research is mainly a qualitative policy research. Conducted between 2013 and 2017, it was design based on health policy researching and health inequality theories. The researcher conducted semi-structured interviews among health policy makers; policy analysis; and a review of the literature. Twenty policy-makers, 15 policy documents, over 350 literatures were selected through purposing and theoretical open sampling methods. Data was synthesised and analysed with ATLAS.ti 7.1.4 through applying the tools of critical interpretive synthesis and ground theory. The study found that Ethiopia is in an early state of recognizing and intervening against health inequalities. The quality and level of knowledge is mixed and gets reduced as one goes far from the centre. Consensus is still growing on the major underlying causes of child health inequalities in Ethiopia. Most of the policy makers focus on down-stream factors than broader determinants of health. Wealth inequality is less discussed and intervened than geographical inequalities. The production of a new Plan of Action can helped to resolve the challenges of lack of detailed approaches that can help reduce the gap in Ethiopia. However, the content of the health policy documents is not comprehensive and based on global lessons. Policy makers from the central government in Ethiopia tend to reject the use of redistribute justice intervention as policy options. There were multiple reasons including: fear of sustainability, ethics and effectiveness were used to reject these interventions. However, leaders from DRS and DPs broadly support the proper adaption of these interventions. The recent surge of interest to address health inequalities is mainly led by small groups from the top leaders. The engagement of the middle level leaders, Developing Regional States (DRSs), civil society and development partners has been limited. The relation between different institutes is very important in the Ethiopian federal state to reduce inequality. Without an improved level of awareness; change in attitude; broader engagement of citizens; use of independent data source and review of resource distribution Ethiopia’s progress towards Universal Health Coverage in 2030 could get delayed. Finally, this research provided a list of recommend interventions that Ethiopia might take in its plan, to narrow down health inequalities among children by 2030. / Health Studies / D. Litt. et Phil. (Health Studies)

This study explores the practical and ideological implications of the New Public Management (NPM) paradigm as introduced in Greece by the so-called “Troika”, a sobriquet referring to a triumvirate comprising representatives of the IMF, the European Union, and the European Central Bank. In the past, attempts had been made by Greek officials to implement managerial practices within the Greek National Health Service (NHS) and the hospital sector in particular, albeit at a more leisurely pace than that of other countries’. On arrival to Greece the Troika imposed a number of changes to improve the country’s public services; and set a brisk pace to accelerate their implementation. The present doctoral thesis seeks to critically evaluate the issue of whether those reforms, especially those salient to the Greek NHS system, are true manifestations of a shift in the NPM paradigm or whether they represent yet another archetypal Greek public sector restructuring. It will also evaluate responses to and outcomes of the successive reforms in the Greece’s NHS system, ascertain the factors contributing to and/or impeding the adoption of those reforms, and identify new opportunities for growth. In order to gain access to a more profound insight into the Greek context, the collection of secondary data provides, among other things, an historical background of Greece’s public healthcare system; reviews the system’s characteristics in terms of healthcare policies, and probes into the state of working conditions within public hospitals. The heightened managerial spirit prevalent in Greece at the moment and brought about by the Troika’s tenure, has made it necessary for the literature review of the present work to focus on the ways that managerial practices and ideologies are imposed on other countries so that their public sector dysfunctionalities may be rectified. Drawing on the literature reviewed, the study develops an integrated analytical framework anchored in NPM, so as to test it in the Greek case and contribute to understanding the Greek NHS organisational realities as well as to evaluating how the new changes have been evolving and faring within Greece’s healthcare organisations. The framework is comprised of a review of the NPM paradigm so as to contextualise the Greek reforms in terms of ideology and practices; a review of Principal-Agent Theory (PAT) for illuminating the interrelationships and involvement of the key actors with the reforms; and a review of Critical Realism (CR) for assisting to reveal the underlying mechanisms and structures that bind the actors with the organisations and their development. Apart from providing the conceptual basis of the thesis, the framework also serves in informing its methodological design (i.e., generating the interview schedule), analysing the findings, and steering the discussion. The study adopts an in-depth, qualitative research approach that views social life within organisations in terms of processes, events, actions, and activities between key actors as factors unfolding over time. To that purpose, semi-structured interviews were conducted with the key stakeholders of the Greek NHS system: State hospital doctors, hospital managers, and policymakers. The contribution of the study is an in-depth analysis of reform implementation as carried out in Greece’s medical system which now stands, within a turbulent economic and political context. By means of that analytical framework, it is shown that Greece is a sui generis case whose context and historical background are altogether different than those of other countries’. Moreover, the framework demonstrates that, despite the fact that NPM is firmly ensconced, as far as practice and ideology go, it is too soon to be drawing any conclusions: NPM is still in its infancy and reforms to the Greek NHS system have yet to be finalised as they continuously stumble on the inefficiencies and blunders of the past which hinder them from functioning properly. Last, the thesis does possess one more unique feature: it delves into the thinking, manoeuvres, and behaviour of the Greek healthcare professionals as a group, a world rarely if ever explored by empirical studies.

Healthcare resources in Sweden are limited, and not everyone that wants care can receive it. Restrictions on access to care are therefore necessary. The restrictions can be implemented in various ways, but in Sweden, waiting lists are used. Waiting lists are often considered a more equitable way to distribute healthcare compared to using prices. Research has however shown that these waiting lists sometimes lead to inequalities, where, for example, higher income is associated with shorter waiting times. We study the relationship between socioeconomic status and waiting times for elective care in Region Östergötland during the period 2018-2023. Linear regression analysis is used to study this link. The overall delivery of care appears equal, but the specialty of Ophthalmology shows disparities in waiting times related to socioeconomic factors. A more detailed analysis also shows that the relationship varies depending on the length of the waiting time within Ophthalmology / Hälso- och sjukvårdens resurser i Sverige är knappa och alla som vill ha vård kan inte få det. Begränsningar i tillgången till vård är således ett måste. Det kan ske på flera olika sätt men i Sverige används vårdköer för detta. Köer anses ofta vara ett mer jämlikt sätt att fördela vård än att använda priser. Det finns dock studier som visar att dessa vårdköer ibland leder till ojämlikheter, där exempelvis högre inkomst är kopplat till kortare väntetider. Vi studerar sambandet mellan socioekonomisk status och väntetid till elektiv kirurgi i Region Östergötland under 2018-2023. Linjär regressionsanalys används för att analysera sambandet. Resultaten visar att vården i stor utsträckning levereras på ett jämlikt sätt. Det existerar dock ojämlikheter inom specialistområdet Ögonsjukvård kopplat till socioekonomisk status. En mer detaljerad analys visar även att sambandet varierar beroende på väntetidens längd inom Ögonsjukvård.