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.

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.

<b>Background</b>: In order to protect the poor from health shocks, the Government of India launched Rashtriya Swasthya Bima Yojna (RSBY) in 2008. The objectives of this study are: a) to assess the changes in the financial burden of health care on the poor population; b) to estimate the effects of RSBY in reducing the financial burden on the poor; and c) to examine the impact of RSBY on the labour supply of the poor. <b>Methods</b>: The study is based on data from the National Sample Survey Organisation (NSSO). The sample size is between 100-125 thousand households at the all-India level. The study uses pooled cross-section regression analysis to assess the changing pattern of out-of-pocket (OOP) payments on healthcare. The impact of RSBY on financial risk protection and labour force participation rate in India were estimated using the difference-in-differences (DID) method. <b>Findings</b>: My thesis consists of three papers. The findings in the first paper, changing pattern of out-of-pocket payments, reflect that the poorest 20% of households, compared to the richest 20%, realised a slower increase in out-of-pocket as a share of the household’s total expenditure (-0.5%) and catastrophic payments (-2%) during the period of 2000-2012. However, during the same period, Scheduled caste/tribe and Muslim households reported an increased burden of out-of-pocket. The second paper finds reduction in the probability of incurring ‘any inpatient expenditure’ and ‘catastrophic inpatient expenditure’ after RSBY intervention but marginal increase in the ‘per person monthly inpatient expenditure’ and insignificant change in ‘inpatient expenditure as a share of households’ total expenditure’. The effects of the scheme on the total out-of-pocket payment are negligible and non-drug expenditure reflected significant increase. The third paper finds that women’s labour supply increased (3% per annum) but the elderly labour supply declined (1.5%). Further, men switched from self-employment to casual work while women moved to wage-paid regular and casual jobs at the cost of being self-employed. <b>Discussion and conclusion</b>: The poor and other less advantaged population groups realised an increasing OOP burden mainly on account of two factors: i) outpatient care is not covered under RSBY; and ii) the benefit package under the scheme is very modest. Women’s labour supply increased and the elderly labour supply declined in favour of leisure because of possible improvements in health. However, the overall labour supply did not change. The Indian government needs to consider broadening the benefit package and including outpatient coverage under RSBY.

Health is deemed central to a nation’s development. Accordingly, health care reform and expansion are key policy priorities in developing countries. Many such nations are now testing various methods of funding and delivering health care to local disadvantaged populations. Similarly, India launched the Rashtriya Swasthya Bima Yojana (RSBY) national health insurance programme for low-income groups in 2008. The RSBY intends preventing catastrophic health-related expenditure by improving recipients’ access to hospital-based care. This thesis is an in-depth qualitative evaluation of the RSBY in Delhi state. It examines the RSBY’s effectiveness in fulfilling its goals and meeting local health care needs. Walt and Gilson’s (1994) actors-content-process-context model informs the research design and an actor-centred “responsive” (Stake 1975) or “constructivist” approach guides data analysis. Three research questions are examined: (i). Why was a health insurance programme launched and why now? Why was this model favoured over alternate methods of service expansion? (ii). Is the RSBY delivered as intended? If not, why? (iii) How does the RSBY affect patients’ access to services? The findings are based on documentary sources, observation of implementation sites and activities and 164 semi-structured interviews with RSBY policymakers, insurers, NGOs, doctors, and patients. The results show improved access to curative and surgical care for RSBY patients. However, RSBY’s focus on hospitalisation and omission of primary and outpatient services had undesired negative effects. The lack of ambulatory facilities led RSBY patients to self-medicate or use dubious quality informal providers. By only allowing inpatient care, the RSBY also seemingly encouraged the substitution of outpatient care with costlier hospitalisations. In effect, the RSBY’s design contributed to cost increases and poor patient outcomes. While more funds and human resources were needed to improve RSBY implementation, the performance of frontline agencies could potentially improve through more stable, longer-term contracts. Similarly, modifying RSBY’s monetary incentives for doctors may lead to better service delivery by them. By evaluating the RSBY’s strong points and shortcomings, this thesis provides key lessons on strengthening policy design and health service delivery in developing countries. Thereby, it makes a broader contribution to understanding the determinants of successful policymaking.

LIMA, M. M. P. Avaliação da Política Nacional de Transplantes no Ceará: atuação da Central Estadual e das Comissões Intra-Hospitalares. 2011. 120f. Dissertação (Mestrado em Avaliação de Políticas Públicas) – Universidade Federal do Ceará, Pro - Reitoria de Pesquisa e Pós-Graduação, Programa de Pós-Graduação em Avaliação de Políticas Públicas, Fortaleza, 2011. / Submitted by Ana Paula Paula (mappufce@gmail.com) on 2012-03-21T19:19:48Z No. of bitstreams: 1 2011_Di_ MonicaMPLIMA.pdf: 1422237 bytes, checksum: 6e0ef28dacd03092b4f154837d396356 (MD5) / Approved for entry into archive by Maria Josineide Góis(josineide@ufc.br) on 2012-03-22T13:26:27Z (GMT) No. of bitstreams: 1 2011_Di_ MonicaMPLIMA.pdf: 1422237 bytes, checksum: 6e0ef28dacd03092b4f154837d396356 (MD5) / Made available in DSpace on 2012-03-22T13:26:27Z (GMT). No. of bitstreams: 1 2011_Di_ MonicaMPLIMA.pdf: 1422237 bytes, checksum: 6e0ef28dacd03092b4f154837d396356 (MD5) Previous issue date: 2011 / In recent decades, the transplants have had a profound impact on the care of end-stage patients with several kinds of diseases. In Brazil, public policies regarding people who need transplants require thorough assessments. This research aimed to evaluate the performance of the Organ Notification, Harvesting and Distribution Center of the State of Ceará (CNCDO) and Intra-hospital Commission on Organ and Tissue Donation for Transplant (CIHDOTTs) from Fortaleza, instances considered decisive in the operationalization of the National Transplant Policy in the State of Ceará. The research was conducted by using secondary and primary data, both quantitative and qualitative, developed from July 2010 to February 2011. The president of CNCDO was interviewed. It was applied a form to be filled out by 12 coordinators of CIHDOTTs and structured observations were accomplished in three CIHDOTTs. The following results had been highlighted: CIHDOTTs with reduced teams and nurse predominance; CNCDO overloaded and performing activities which belong to the CIHDOTTs; CIHDOTTs working essentially in an active search for potential donors; the family members refusal is largely responsible for the non-confirmation of a significant number of donations; it was identified fragility in campaign, qualification and joint planning actions between CNCDO and CIHDOTTs; CNCDO and CIHDOTTs resent greater support from health professionals and hospital managers and also the lack of equipment and appropriate physical space; the great expenditure of energy of CNCDO and CIHDOTTs result in an insignificant number of effective donations; there are difficulties in the process of identifying likely potential donor, delay in the diagnosis of brain death and in the beginning of the hemodynamic maintenance of the possible donor. The indication that greater results are obtained from the campaigns which favor the regional language confirms the initial assumption that educational initiatives, due to their immediate impact on the population, has the potential to leverage the transplant process. We conclude that human, structural and technological factors pose serious obstacles to the implementation of the National Transplant Policy in the State of Ceará, with little significant impact on the sole waiting list in the country. We suggest actions on several fronts: to redirect the dissemination campaigns towards approaches which are more culturally related to the region and closer to people; to offer more frequent courses to raise awareness and to improve the skills of health professionals; to develop strategies to raise awareness of professionals and managers regarding the noble task of CNCDO and CIHDOTTs; to employ more professionals and train them to perform the detection and diagnosis of brain death faster and to ensure the accomplishment of the hemodynamic maintenance efficiently / Nas décadas recentes, os transplantes tiveram um profundo impacto no cuidado dos pacientes em estágio final de diversos tipos de doenças. No Brasil, as políticas públicas relacionadas com as pessoas que necessitam de transplante carecem de avaliações aprofundadas para desenvolvimento e aplicação de políticas públicas. A presente pesquisa teve como objetivo avaliar a atuação da Central de Notificação de Transplantes do Estado do Ceará (CNCDO) e das Comissões Intra-Hospitalares de Doação de Órgãos e Tecidos para Transplantes (CIHDOTTs) de Fortaleza, instâncias consideradas decisivas na operacionalização da Política Nacional de Transplantes no território do Ceará. A pesquisa foi realizada utilizando dados secundários e primários, tanto quantitativos quanto qualitativos, sendo desenvolvida no período de julho de 2010 a fevereiro de 2011. Foi realizada entrevista com a presidente da CNCDO, aplicado um formulário com 12 coordenadoras das CIHDOTTs e realizadas observações estruturadas em três CIHDOTTs. Destacam-se entre os resultados: CNCDO sobrecarregada e realizando atividades da alçada das CIHDOTTs; CIHDOTTs com equipes reduzidas e predomínio de enfermeiras, atuando essencialmente na busca ativa de potenciais doadores; a recusa dos familiares sendo a grande responsável pela não confirmação de significativo número de doações; identificadas fragilidades nas ações de campanha, qualificação e planejamento conjunto da CNCDO com as CIHDOTTs; ambas ressentem-se de maior apoio dos profissionais de saúde e dos gestores dos hospitais e também da falta de equipamentos e espaço físico apropriado; o grande dispêndio de energia da CNCDO e das CIHDOTTs resulta em números ínfimos de efetivas doações; há dificuldades no processo de identificação de provável potencial doador, demora no diagnóstico de morte encefálica e em iniciar a manutenção hemodinâmica do possível doador. A indicação de que são maiores os resultados obtidos com as campanhas que privilegiam a linguagem regional confirma o pressuposto inicial de que ações educativas, por impactarem imediatamente na população, têm potencial para alavancar o processo de transplante. Concluímos que fatores humanos, estruturais e tecnológicos representam sérios entraves à execução da Política Nacional de Transplante no Estado do Ceará, com impacto pouco significativo na fila de espera, que é única para o País. Indicamos ações em diversas frentes: redirecionar as campanhas de divulgação para abordagens mais identificadas com a cultura regional e mais próxima às pessoas; cursos mais frequentes para maior sensibilização e qualificação dos profissionais de saúde; desenvolvimento de estratégias para maior sensibilização dos profissionais e gestores quanto às nobres tarefas da CNCDO e das CIHDOTTs; maior número de profissionais e capacitação mais frequente deles para que realizem a detecção e diagnóstico de morte encefálica de forma precoce e mais agilmente e que assegurem a realização da manutenção hemodinâmica de quantos potenciais doadores sejam identificados.

nÃo hà / Nas dÃcadas recentes, os transplantes tiveram um profundo impacto no cuidado dos pacientes em estÃgio final de diversos tipos de doenÃas. No Brasil, as polÃticas pÃblicas relacionadas com as pessoas que necessitam de transplante carecem de avaliaÃÃes aprofundadas para desenvolvimento e aplicaÃÃo de polÃticas pÃblicas. A presente pesquisa teve como objetivo avaliar a atuaÃÃo da Central de NotificaÃÃo de Transplantes do Estado do Cearà (CNCDO) e das ComissÃes Intra-Hospitalares de DoaÃÃo de ÃrgÃos e Tecidos para Transplantes (CIHDOTTs) de Fortaleza, instÃncias consideradas decisivas na operacionalizaÃÃo da PolÃtica Nacional de Transplantes no territÃrio do CearÃ. A pesquisa foi realizada utilizando dados secundÃrios e primÃrios, tanto quantitativos quanto qualitativos, sendo desenvolvida no perÃodo de julho de 2010 a fevereiro de 2011. Foi realizada entrevista com a presidente da CNCDO, aplicado um formulÃrio com 12 coordenadoras das CIHDOTTs e realizadas observaÃÃes estruturadas em trÃs CIHDOTTs. Destacam-se entre os resultados: CNCDO sobrecarregada e realizando atividades da alÃada das CIHDOTTs; CIHDOTTs com equipes reduzidas e predomÃnio de enfermeiras, atuando essencialmente na busca ativa de potenciais doadores; a recusa dos familiares sendo a grande responsÃvel pela nÃo confirmaÃÃo de significativo nÃmero de doaÃÃes; identificadas fragilidades nas aÃÃes de campanha, qualificaÃÃo e planejamento conjunto da CNCDO com as CIHDOTTs; ambas ressentem-se de maior apoio dos profissionais de saÃde e dos gestores dos hospitais e tambÃm da falta de equipamentos e espaÃo fÃsico apropriado; o grande dispÃndio de energia da CNCDO e das CIHDOTTs resulta em nÃmeros Ãnfimos de efetivas doaÃÃes; hà dificuldades no processo de identificaÃÃo de provÃvel potencial doador, demora no diagnÃstico de morte encefÃlica e em iniciar a manutenÃÃo hemodinÃmica do possÃvel doador. A indicaÃÃo de que sÃo maiores os resultados obtidos com as campanhas que privilegiam a linguagem regional confirma o pressuposto inicial de que aÃÃes educativas, por impactarem imediatamente na populaÃÃo, tÃm potencial para alavancar o processo de transplante. ConcluÃmos que fatores humanos, estruturais e tecnolÃgicos representam sÃrios entraves à execuÃÃo da PolÃtica Nacional de Transplante no Estado do CearÃ, com impacto pouco significativo na fila de espera, que à Ãnica para o PaÃs. Indicamos aÃÃes em diversas frentes: redirecionar as campanhas de divulgaÃÃo para abordagens mais identificadas com a cultura regional e mais prÃxima Ãs pessoas; cursos mais frequentes para maior sensibilizaÃÃo e qualificaÃÃo dos profissionais de saÃde; desenvolvimento de estratÃgias para maior sensibilizaÃÃo dos profissionais e gestores quanto Ãs nobres tarefas da CNCDO e das CIHDOTTs; maior nÃmero de profissionais e capacitaÃÃo mais frequente deles para que realizem a detecÃÃo e diagnÃstico de morte encefÃlica de forma precoce e mais agilmente e que assegurem a realizaÃÃo da manutenÃÃo hemodinÃmica de quantos potenciais doadores sejam identificados. / In recent decades, the transplants have had a profound impact on the care of end-stage patients with several kinds of diseases. In Brazil, public policies regarding people who need transplants require thorough assessments. This research aimed to evaluate the performance of the Organ Notification, Harvesting and Distribution Center of the State of Cearà (CNCDO) and Intra-hospital Commission on Organ and Tissue Donation for Transplant (CIHDOTTs) from Fortaleza, instances considered decisive in the operationalization of the National Transplant Policy in the State of CearÃ. The research was conducted by using secondary and primary data, both quantitative and qualitative, developed from July 2010 to February 2011. The president of CNCDO was interviewed. It was applied a form to be filled out by 12 coordinators of CIHDOTTs and structured observations were accomplished in three CIHDOTTs. The following results had been highlighted: CIHDOTTs with reduced teams and nurse predominance; CNCDO overloaded and performing activities which belong to the CIHDOTTs; CIHDOTTs working essentially in an active search for potential donors; the family members refusal is largely responsible for the non-confirmation of a significant number of donations; it was identified fragility in campaign, qualification and joint planning actions between CNCDO and CIHDOTTs; CNCDO and CIHDOTTs resent greater support from health professionals and hospital managers and also the lack of equipment and appropriate physical space; the great expenditure of energy of CNCDO and CIHDOTTs result in an insignificant number of effective donations; there are difficulties in the process of identifying likely potential donor, delay in the diagnosis of brain death and in the beginning of the hemodynamic maintenance of the possible donor. The indication that greater results are obtained from the campaigns which favor the regional language confirms the initial assumption that educational initiatives, due to their immediate impact on the population, has the potential to leverage the transplant process. We conclude that human, structural and technological factors pose serious obstacles to the implementation of the National Transplant Policy in the State of CearÃ, with little significant impact on the sole waiting list in the country. We suggest actions on several fronts: to redirect the dissemination campaigns towards approaches which are more culturally related to the region and closer to people; to offer more frequent courses to raise awareness and to improve the skills of health professionals; to develop strategies to raise awareness of professionals and managers regarding the noble task of CNCDO and CIHDOTTs; to employ more professionals and train them to perform the detection and diagnosis of brain death faster and to ensure the accomplishment of the hemodynamic maintenance efficiently.

This thesis shows how the Process Analysis Method (PAM) can be applied to assess technologies used to mitigate arsenic from drinking water in rural India, using a set of sustainability indicators. Stakeholder perspectives, gathered from a fieldwork survey of 933 households in West Bengal in 2012, played a significant role in this assessment. This research found that the ‘Most Important’ issues as specified by the technology users are cost, trust, distance from their home to the clean water source (an indicator of convenience), and understanding the health effects of arsenic. It was also found that none of the ten technologies evaluated are economically viable, as many do not charge user-fees, which creates reliance upon donations to meet recurring costs. Utilisation of a technology is strongly related to sociocultural capital, but in many cases, features that contribute to sociocultural value, like regular testing of the treated water, are not included in the financial budget. It is suggested that increased awareness might change attitudes to arsenic-rich waste and its disposal protocols. This waste is often currently discarded in an uncontrolled manner in the local environment, giving rise to the possibility of point-source recontamination. All technologies proved to have difficulties in dealing with waste, except the Tipot and Dug wells which produce no waste. Of the methods considered, the BESU technology scored highest, but still only with 47-62% of the maximum scores achievable within each domain. This explains the widespread failure of mitigation projects across the region. The indicators and metrics show where improvements can be made. A model scheme based on these findings is outlined which could be applied with the objective of increasing utilisation and improving sustainability. It can be concluded that a product stewardship approach should be taken in regard to design, implementation and operation of the technologies, including the creation of a regulated toxic waste collection and disposal industry.

All governments aim to ensure better health and nutrition to children. The Rajasthan state (India) has implemented a unique frontline coordination model where Accredited Health Social Activist (ASHA) Sahyoginis are expected to support two other frontline workers (FLWs) i.e. the Anganwadi Workers from the Integrated Child Development Services and the Auxiliary Nurse Midwives from the Health department to improve child health. This thesis focuses on examining the existing coordination between the three groups of FLWs in Rajasthan by exploring FLWs' participation in child immunisation and Vitamin A supplementation (two common activities), service coverage and beneficiary's' knowledge (expected outcomes), and the challenges faced and areas that need improvement for better frontline coordination. A mixed methods design was used. Sixteen villages from two blocks (tribal and non-tribal) of Udaipur district (Rajasthan) were selected using multistage purposive sampling. The formative stage included 12 FLWs' in-depth interviews (IDIs) as well as a review of FLWs' job descriptions to understand the process and government expectations on their participation in routine childhood immunisation, polio camps, routine Vitamin A supplementation and Vitamin A campaigns. The next stage included data collection from the 16 selected villages i.e. structured questionnaire survey of FLWs (46), observations of Maternal and Child Health and Nutrition Day (16), review of FLWs' immunisation and Vitamin A registers (32) and a structured questionnaire survey of registered infants' mothers (321)-all to ascertain the actual participation of FLWs in these four activities and the outcomes. IDIs with FLWs (46) and FLWs' line managers (17) were conducted to understand their experience, issues and solutions for better frontline coordination. The participation of FLWs in three of the four activities (except Polio Camps) was found to be limited. The FLWs and their line managers were also dissatisfied with coordination between FLWs. Poor outcomes also indicated unsatisfactory coordination. Overall, frontline participation and outcomes were better in tribal than non-tribal villages. A variety of factors (i.e. personal, professional, organisational, and geo-socio-cultural) appeared to affect coordination between FLWs. Appropriate recruitment, training, monitoring and supervision and rewards to the FLWs along with greater political commitment for coordinated approached and addressing intra-departmental challenges are proposed to improve frontline coordination and child health in Rajasthan.