BACKGROUND Integrated healthcare systems are believed to be enabled by the electronic exchange of clinical information. Canada and other national health systems are making substantial investments in information technology, in order to liberate and share clinical information between providers, improve the quality and safety of care, and reduce costs, yet we currently have no way of measuring these information flows, nor of understanding whether they contribute to the integration of care delivery. METHODS A literature review and consensus development process (nominal group) were used to provide guidance on system integration measures which are enabled by electronic information exchange. In order to conceptualize the components of electronic information exchange, establish a reference vocabulary for terminology, and guide the development of a questionnaire to gather field data, a formal ontology was developed. Validation of a sub-group of the survey data quality was achieved using the ontology and an unrelated database, demonstrating how ontologies may be used to adapt performance measurement methodologies to systems where constraints such as time-compression, lack of resources or access to needed information are prevalent. RESULTS The survey tool gathered cross-sectoral data from a regional health system which populated a summary measure of inter-provider electronic health information exchange (the eHIE), and measured perceptions of system integration from a single health region. The eHIE indicated that 7 -12% of clinical information that could be shared, was being shared electronically in the health region. ANOVA confirmed a significant correlation between the amount of information being exchanged electronically in this system and respondent perceptions of system integration suggesting that the eHIE may be used as a leading indicator for healthcare system integration. CONCLUSIONS It is possible to conceptualize and quantify inter-provider electronic health information exchange. As complex adaptive systems, healthcare systems are dynamic and open to correction; the use of a leading or proximal indicator such as the eHIE may inform effective policy-making and resource allocation in our pursuit of the goal of seamlessly integrated care.

The present study focuses on the financing and provision of health services in Italy and in Sweden. The purpose is to compare Italian and Swedish health system with respect to theseaspects. The intention is to provide new insights to how the financing and provision health care system in Italy and Sweden are organized and make a comparison analyzing different quantitative data. The study is organized in two part: one " qualitative, based on literature review, and one" statistical" based on critical analysis of data. In the theoretical part the financing flow of Italianand Sweden public health care system, which incentives are awarded to providers and which health services are provided, are reviewed. The statistical part shows how many resources (human and technological) are involved in the delivery process. The main findings, discussed in the conclusion section, suggest the need to improve the fairness in the financial contribution for the Sweden and the need for Italy to undertake cost-control and rationalization measures. Further research and especially greater availability of data remains to be done in order to make more complete the comparison.

Health authority administrators were interviewed for their perspectives on what makes a good health care system; on tailored population-specific services as a way to address health inequities; and on how they perceive themselves to be making good funding decisions on the public’s behalf. The qualitative descriptive research dataset includes 24 hour-and-a-half long interviews with administrators from four BC health authorities, health region documents, memos, and field notes. Participants support the continuation of a public health care system and all participants acknowledge using tailored services as a route towards reducing health inequities. However, these identified services have not been evaluated for their overall effectiveness. When it comes to decision-making, participants describe using a series of governance and bioethical principles that help them frame what and how issues can be considered. Decision situations are framed in a way that informs them whether they need to use formal or informal processes. In both cases participants collect information that allows others to understand that they have made wise decisions. The Recognition-Primed Decision Model accurately reflects the intuitive processes that participants describe using during informal decision-making and portions of formal decision-making. However, in relation to formal decision situations, there is less alignment with existing Decision-Analysis literature. Seven practice and future research recommendations are provided: 1. Increase health authority participation in intersectoral partnerships that address non-medical determinants of health. 2. Develop new strategies for addressing health inequities. 3. Evaluate the efficacy of using tailored services beyond their ability to remove barriers to access. In addition, increase focus on testing new strategies for reducing the inequities gap. 4. Enhance existing decision-making processes by including the explicit review of decision tradeoffs, value weighting, and mechanisms for requesting revisions. 5. Focus future research on developing and evaluating the usefulness of formal decision-making tools in health authority structures and their relation to decision latitude. 6. Launch a longitudinal research study that examines how health authority expert decision-makers use judgmental heuristics and how they avoid the negative effects of bias. 7. Commission public dialogue on shifting the current illness-based system to one that is wellness based.

BACKGROUND Integrated healthcare systems are believed to be enabled by the electronic exchange of clinical information. Canada and other national health systems are making substantial investments in information technology, in order to liberate and share clinical information between providers, improve the quality and safety of care, and reduce costs, yet we currently have no way of measuring these information flows, nor of understanding whether they contribute to the integration of care delivery. METHODS A literature review and consensus development process (nominal group) were used to provide guidance on system integration measures which are enabled by electronic information exchange. In order to conceptualize the components of electronic information exchange, establish a reference vocabulary for terminology, and guide the development of a questionnaire to gather field data, a formal ontology was developed. Validation of a sub-group of the survey data quality was achieved using the ontology and an unrelated database, demonstrating how ontologies may be used to adapt performance measurement methodologies to systems where constraints such as time-compression, lack of resources or access to needed information are prevalent. RESULTS The survey tool gathered cross-sectoral data from a regional health system which populated a summary measure of inter-provider electronic health information exchange (the eHIE), and measured perceptions of system integration from a single health region. The eHIE indicated that 7 -12% of clinical information that could be shared, was being shared electronically in the health region. ANOVA confirmed a significant correlation between the amount of information being exchanged electronically in this system and respondent perceptions of system integration suggesting that the eHIE may be used as a leading indicator for healthcare system integration. CONCLUSIONS It is possible to conceptualize and quantify inter-provider electronic health information exchange. As complex adaptive systems, healthcare systems are dynamic and open to correction; the use of a leading or proximal indicator such as the eHIE may inform effective policy-making and resource allocation in our pursuit of the goal of seamlessly integrated care.

Tuberculosis (TB) is a major public health problem in many low- and middle-income countries, including Indonesia. To accelerate TB case detection, and to improve the quality of diagnosis and treatment provided by all providers, the Public-Private Mix for implementing Directly Observed Treatment Short-course (PPM DOTS) was introduced in 2000. However, previous studies on PPM DOTS have focused on private practitioners and there has been a scarcity of research on PPM DOTS in the hospital setting. This dissertation aims to capture the potential of the PPM DOTS strategy, and identify the barriers to its implementation in hospitals in Indonesia. This dissertation is based on four separate but interrelated studies: 1. A costeffectiveness analysis, comparing incremental cost per additional number of TB cases successfully treated under three strategies of PPM DOTS in four provinces. 2. An evaluation of the access to TB services by a cross-sectional study among 62 hospitals, by estimating the proportion of TB cases receiving standardised diagnosis and treatment according to the DOTS strategy. The data were analysed using poststratification analysis. 3. The quality aspect was explored in a multiple-case study, including eight selected hospitals. The data were analysed using cross-case analysis. 4. The process of partnership was explored through a qualitative study. In-depth interviews were conducted with 33 informants, who were actors involved in PPM DOTS in hospitals in Yogyakarta province. Content analysis was applied to the qualitative data. PPM DOTS in hospitals was shown to be a cost-effective intervention in this particular context. However, the quality of the implementation was commonly suboptimal. In addition, a substantial number of TB cases did not get standardised diagnosis and treatment as per the DOTS strategy. The process of creating partnership among hospitals and National TB Programme was shown to be complex and dynamic. Process factors, such as commitment to collaboration and interaction and trust among the actors, were shown to be important. The rapid scaling-up of PPM DOTS in hospitals at the national level in Indonesia should be revisited. Indeed, considering the importance of hospitals in TB control, the implementation should be continued and expanded. However, more attention needs to be given to process, context and governance.

Primary health care represents a change from curative approach to preventive approach to rendering health care services. The study analyses the problems encountered in the administration of primary health care in South Africa with specific reference to the Emfuleni Local Authority. The study describes the role of international institutions in the administration of primary health care in South Africa. Furthermore, the historical development, the role of the National Department of Health in the administration of primary health care services is outlined. The study also investigates the role of the Gauteng Provincial Department of Health regarding the implementation of district health system, health promotion, the involvement of the private sector and NGO's in primary health care. Problems encountered by the Emfuleni Local Authority such as lack finance, personnel shartages, security, urbanisation, non-involvement of traditional healers and citizen apathy are investigated. Lastly, governmental relations for primary health care are described.

Over the past decade, concerns with the accessibility and quality of health services have led several individuals to bring tort claims against provincial governments. Unlike other types of health sector legal claims, which have been the subject of much commentary, this thesis provides the first treatment of the tort cases against governmental defendants. To date, Canadian courts have not been receptive to these claims, striking nearly all of them on pre-trial motions, on the basis that government defendants did not owe the plaintiffs a duty of care. In order to situate the health sector tort claims within the judiciary’s broader approach to governmental liability, I compiled a dataset of all tort cases against Canadian governmental defendants from the past decade. My dataset indicates that judges have dismissed more health sector tort claims than those arising from nearly all other sectors of government activity, even accounting for other explanatory variables. I also develop a framework to categorize the judicial approaches to the test for establishing a duty of care. Canadian judges now generally conduct a comprehensive analysis of the closeness and directness of the parties’ relationship and the policy implications of tort liability in determining whether a defendant owes a plaintiff a duty of care. However, judges adjudicating health sector claims fail to appreciate the government’s modern role in the health sector and are almost singularly concerned with the policy implications of their decisions. I conclude with two policy recommendations. First, I argue that judges should more frequently permit these claims to proceed beyond the pre-trial dismissal stage to a full trial, in order to evaluate the policy concerns both for and against governmental liability with the benefit of a full evidentiary record. Second, I argue that judges should more frequently permit health sector tort claims to proceed beyond the duty of care stage of the negligence analysis to an assessment of whether the government met the standard of care. While this approach would allow judges to scrutinize the reasonableness of the government’s decisions, improving transparency and potentially motivating an improved decision-making process, it would not necessarily lead to widespread liability.

Over the past decade, concerns with the accessibility and quality of health services have led several individuals to bring tort claims against provincial governments. Unlike other types of health sector legal claims, which have been the subject of much commentary, this thesis provides the first treatment of the tort cases against governmental defendants. To date, Canadian courts have not been receptive to these claims, striking nearly all of them on pre-trial motions, on the basis that government defendants did not owe the plaintiffs a duty of care. In order to situate the health sector tort claims within the judiciary’s broader approach to governmental liability, I compiled a dataset of all tort cases against Canadian governmental defendants from the past decade. My dataset indicates that judges have dismissed more health sector tort claims than those arising from nearly all other sectors of government activity, even accounting for other explanatory variables. I also develop a framework to categorize the judicial approaches to the test for establishing a duty of care. Canadian judges now generally conduct a comprehensive analysis of the closeness and directness of the parties’ relationship and the policy implications of tort liability in determining whether a defendant owes a plaintiff a duty of care. However, judges adjudicating health sector claims fail to appreciate the government’s modern role in the health sector and are almost singularly concerned with the policy implications of their decisions. I conclude with two policy recommendations. First, I argue that judges should more frequently permit these claims to proceed beyond the pre-trial dismissal stage to a full trial, in order to evaluate the policy concerns both for and against governmental liability with the benefit of a full evidentiary record. Second, I argue that judges should more frequently permit health sector tort claims to proceed beyond the duty of care stage of the negligence analysis to an assessment of whether the government met the standard of care. While this approach would allow judges to scrutinize the reasonableness of the government’s decisions, improving transparency and potentially motivating an improved decision-making process, it would not necessarily lead to widespread liability.

Health indicators in Papua New Guinea (PNG) are poor by virtually any standards and have declined over the last 2 decades. As in other developing countries that find it impossible to achieve ‘health for all’ through western medical services alone, the idea of developing an integrated health system, one that incorporates traditional medicine, has been proposed as a way of addressing poor health status. The idea of developing an integrated health system in PNG is not new but only recently has it translated into action with tangible results including a draft ‘National Policy on Traditional Medicine for Papua New Guinea’. Over many years researchers have bemoaned the paucity of information on cultural beliefs and treatment practices that could make the incorporation of traditional medicine into the health system, along the lines proposed in the National Policy, better informed. To date this information gap has not been filled. / The thesis includes a review of literature on traditional medicine around PNG and the results of a case study conducted by indigenous research assistants among the Nasioi speakers of Central Bougainville. An international perspective is brought to bear through a critique of theoretical models of integration and a review of practical experiences in other countries that have tried to develop various types of integrated health systems. Information from each of these sources is considered in an endeavour to address the urgent need for information to inform the implementation of the National Policy on Traditional Medicine for Papua New Guinea. / All available studies on traditional medicine in PNG were included in the literature review. Despite PNG's vast cultural diversity it became evident that some common elements exist between different cultural groups. / The case study used a focused ethnographic approach to examine treatment-seeking responses to illness and associated beliefs and decision-making criteria in relation to traditional and modern medicine. It also investigated the organization of traditional health services, attitudes towards an integrated health system and the potential for practitioners to collaborate with one another. The case study made it possible to focus on pertinent issues that had not been covered in earlier studies. The case study suggests that in areas where the organization of and attitudes toward traditional medicine resemble those in the Nasioi area there may be great potential for a health system that incorporates traditional medicine to deliver health benefits to communities. The case study also serves as an example of research that could be replicated or adapted by provinces that need more information about their own situation before embarking on the process of incorporating traditional medicine into the local health system. / The process by which integration might proceed in PNG is considered in the context of integration experiences in other countries. Although ideologically attractive, total integration is not realistic for PNG at this stage. The informality and lack of documentation on traditional medicine as well as the lack of resources to support the development of an integrated health system mean that PNG’s own version of an incorporated or collaborative model of integration is more appropriate. / It should be noted that in this thesis the term ‘integrated health system’ is used to cover the full range of varying degrees of integration of traditional with modern medicine and should not be taken to imply only a fully integrated system. Similarly, the terms ‘integration’ and ‘incorporation’ are normally used to refer to the process and not the outcome. / Even an incorporated health system may not be a viable proposition in all parts of PNG. Where it is feasible, incorporation would need to be progressed in a carefully considered and planned manner with a realistic and long-term approach. The process would require coordination at national level and the flexibility for provinces to participate according to their own prevailing circumstances and capacity. Incorporation should proceed slowly and will require government support including the allocation of resources. It may be possible to pilot and thus fine-tune PNG’s integration model in a few places, such as the Nasioi area, before expanding to multiple provinces. / The potential benefits of an incorporated health system include strengthening of primary health care, better access to services, more affordable services, cultural relevance, a holistic approach, preservation of traditional knowledge, increased autonomy and possibly cost savings. An incorporated health system is worth pursuing because, if carefully planned and implemented, it does have the potential to improve health status in a country where health indicators desperately need to be elevated.

Στην παρούσα διπλωματική εργασία αναπτύχθηκε μια web εφαρμογή για το Εθνικό Σύστημα Υγείας. Σκοπός ήταν η αναβάθμιση της ποιότητας των υπηρεσιών του εθνικού συστήματος υγείας προς τους πολίτες και κυρίως η καταπολέμηση της φοροδιαφυγής που συμβαίνει στον χώρο της υγείας ενώ ταυτόχρονα με μεθόδους που αναπτύχθηκαν προστατεύουμε τα κρατικά ταμεία από την κατασπατάληση του δημόσιου χρήματος για ανύπαρκτες ανάγκες. Δημιουργήθηκαν τέσσερις οντότητες : οι ασφαλισμένοι , οι γιατροί , οι φαρμακοποιοί και τα νοσοκομεία. Κάθε χρήστης ανάλογα με την ιδιότητα του έχει τον δικό του ηλεκτρονικό λογαριασμό στο σύστημα και αλληλεπιδρά με τους υπόλοιπους χρήστες. Ο ασφαλισμένος μπορεί να δει στον λογαριασμό του τον προσωπικό του ιατρικό φάκελο μαζί με όλο το ιστορικό του. Επίσης μπορεί να βλέπει όλες τις επισκέψεις του σε ιατρεία , νοσοκομεία και φαρμακεία καθώς κάθε επίσκεψη του καταγράφεται από το σύστημα σε μια προσπάθεια να καταπολεμηθεί η φοροδιαφυγή με την συνδρομή του χρήστη. Ο γιατρός με την σειρά του έχει και αυτός τον δικό του προσωπικό λογαριασμό και μπορεί να γράψει συνταγές για τον ασθενή που τον επισκέπτεται και να καταχωρήσει μια ηλεκτρονική απόδειξη στο σύστημα από την επίσκεψη του ασφαλισμένου στο ιατρείο του. Το σύστημα δεν προβλέπει την κυκλοφορία χρήματος και η νοσηλεία του ασφαλισμένου είναι δωρεάν όπως και τα φάρμακα του. Το κράτος δεσμεύεται να επιστρέψει αυτά τα χρήματα στους δικαιούχους γιατρούς και φαρμακοποιούς. Οι φαρμακοποιοί με την σειρά τους μέσα από τον λογαριασμό τους μπορούν να εκτελέσουν τις συνταγές των γιατρών , οι οποίες αποθηκεύονται στην βάσηδεδομένων. Τέλος υπάρχει πλήρης καταγραφή των νοσοκομείων της χώρας και των γιατρών που δουλεύουν σε αυτά. Υπάρχει πλήρης εικόνα των νοσηλευομένων και του νοσοκομειακού υλικού που χρησιμοποιείται και καταναλώνεται στα νοσοκομεία. Επίσης υλοποιήθηκε αυτοματοποιημένος μηχανισμός που τροφοδοτεί τα νοσοκομεία με φαρμακευτικό υλικό βάση συγκεκριμένων προδιαγραφών. Ο σκοπός μας ήταν να υπάρχει πλήρης ηλεκτρονικός έλεγχος σε όλους τους εμπλεκομένους στο ΕΣΥ έτσι ώστε να προστατευτεί το κρατικό χρήμα και να καταπολεμηθεί η φοροδιαφυγή στον χώρο της υγείας. / This project is an effort for the elimination of tax evasion in Greece's national health system. Unfortunately, lots of people avoid paying their taxes. We have developed a web application, which controls money flow at the national health system. Firstly, the citizens have a personal account, which includes their personal information and their medical data. The patients visit doctors who also have a personal web account. Doctors then write down the appropriate recipes, which are stored in a database. The patients do not pay for their visit and the doctors are paid from the state through the database created. Pharmacists have a personal web account as well and they give patients the medicine that the doctors prescribed. We have created an automatic system, which supplies hospitals with medicine and protects the state from tax evasion. To be more specific, we have created central stores which supply the hospitals with medicine under some specifications that we set. Our goal is to create a system which will control the total activity in Greece's health system and will protect the state's money from people who don’t respect the law and the society. Also, we want to upgrade the quality of the services at the national health system by creating a medical folder for every citizen. With this measure, the doctors will have the ability to get informed of the medical history of every patient and they will be able to make more accurate diagnosis for the patient's health.