No Brasil, os reflexos da violência comunitária na conformação e no desenvolvimento das ações dos serviços de saúde, na atenção primária, apresentam-se como uma realidade a ser melhor estudada, assim como merece também mais atenção às repercussões sofridas pelas equipes de saúde. O objetivo do presente estudo consistiu em explorar qualitativamente as representações dos agentes comunitários de saúde (ACS) e da gestora de uma unidade de saúde da Estratégia Saúde da Família (ESF) acerca da violência comunitária no território onde atuam, verificando a possibilidade de interferência desse fenômeno em relação ao trabalho que realizam. Pretendeu-se, ainda, investigar essa interferência na construção dos vínculos entre os ACS e a população atendida por eles. O percurso metodológico adotado foi o da pesquisa qualitativa, por meio de análise das representações sociais, tendo sido realizadas 12 entrevistas abertas com os ACS e uma com a gestora da unidade de saúde em questão, utilizando-se um roteiro previamente elaborado com perguntas flexíveis, valorizando a singularidade das respostas dos entrevistados. Destaca-se como resultado da pesquisa a confirmação da hipótese de que a violência comunitária prejudica a integralidade do cuidado, isto é, a elaboração de determinadas estratégias de promoção, prevenção e recuperação, principalmente com relação à abordagem do tema consumo de drogas. Evidenciou-se que a regulação das ações no campo da saúde é condicionada pelas restrições abertas ou implicitamente colocadas pelas dinâmicas sociais presentes no território. Ademais, a conformação desse fenômeno ajuda a explicar uma parte dos episódios que envolvem a violência ocupacional, expressa em ameaças, medo e receio dos ACS. A violência comunitária e as representações sociais interferem ainda na produção dos vínculos estabelecidos com os usuários - construídos com maior ou menor aproximação - a depender do usuário e das estratégias mobilizadas por cada trabalhador. Contudo, além de interferir, a violência e as representações são categorias coprodutoras de vínculos, no sentido mais amplo, na medida em que aproxima/vincula os trabalhadores a determinadas experiências que podem influenciá-los nas suas decisões e nas ações que são tomadas, de modo consciente ou não. Do ponto de vista das ciências sociais, foi destacada a centralidade que adquire o trabalhador na lógica de mediação nas fronteiras porosas, mas bem demarcadas, do legal, do formal, do informal e do \"mundo do crime\". A presença da violência comunitária na atenção primária apresenta-se como uma realidade com a qual os trabalhadores já convivem há muitos anos. Essa questão vem sendo discutida no campo da saúde coletiva, e necessita ser reconhecida e abordada nas esferas federal, estadual e municipal, visando a construção de políticas e estratégias que auxiliem a atuação desses trabalhadores que estão \"na ponta\" dos serviços comunitários / In Brazil, the reflexes of community violence in the formation and development of the health care service actions, in the primary health care, present themselves as a reality to be better studied, as well as deserve more attention towards the repercussions suffered by the health care staffs. This paper aims at exploring qualitatively the representations of the community health workers and the manager of a Health Care Family Strategy facility concerning the community violence where they work, verifying the possibility of interference in this phenomenon in relation to the work they do. It was intended to investigate this interference in the bonds construction between the community health workers and the population attended by them. It was adopted the qualitative research methodology through social representation analysis, 12 open interviews with the community health workers and one interview with the health care facility manager had been made using a previously elaborated script with flexible questions, valuing the singularity of the interviewees\' answers. It is highlighted as a research result the confirmation of the hypothesis that the community violence spoils the care integrality, in other words, the elaboration of determined strategies of promotion, prevention and recovery, related mainly to the approach about the drug abuse. It was evidenced that the actions regulation in the health care area are conditioned by the open restrictions or put implicitly by the social dynamics existents in the territory. Furthermore, the formation of this phenomenon helps to explain a part of the episodes, which involve the workplace violence pointed in threats, fear and concern of the community health workers. Moreover, the community violence and its social representations interfere in the production of the bonds stablished with the users - built with greater or shorter closeness, depending on the user and the strategies assembled by each worker. However, besides interfering, the violence and the representations are co-producers categories of bonds, in the broadest sense, as they approximate/bond the workers to determined experiences, which may influence them in their decisions and in the actions taken, consciously or not. In the social science\'s point of view was highlighted the centrality, which the worker acquires in the rationale of porous borders mediation, well designated from legal to formal and from the \"world of crime\". The presence of community violence in the primary health care presents itself as a reality in which the workers have been living with for many years. This issue has been discussed in the area of the public health and it needs to be recognized and approached in the federal, state and municipal levels aiming the construction of policies and strategies that assist the achievement of these workers who are \"on the edge\" of the community services

La «petite corruption» est un élément important de la relation entre personnels de santé et patients dans les contextes propices aux actes de corruption. Ce phénomène bien étudié en Europe centrale et orientale sous le nom de «paiements informels» (PIs), est peu documenté en Afrique. Pour contribuer à combler cette lacune, cette thèse propose une série d'analyses sur certains aspects clés de ce problème dans le contexte africain. Dans le chapitre 1, nous montrons que les PIs sont concentrés sur les plus pauvres. Ils sont plus susceptibles d’avoir fait face à l'absence de médicaments, à l'absentéisme des médecins et à des longs temps d'attente dans leur hôpital public local, ce qui accroît la probabilité d'encourir des frais non officiels. Une analyse plus approfondie de l'influence des facteurs d'offre dans le chapitre 2 confirme que les longs temps d'attente, la gestion du personnel de santé (par exemple, le recours à la délégation de tâches) et la perception des personnels vis-à-vis de leur revenu jouent un rôle crucial. Le chapitre 3 met en évidence l’existence d’effets de pairs dans la survenue des PIs lors de la consultation, l’effet étant plus important chez les plus pauvres. Enfin, avec un modèle théorique dans le chapitre 4, nous montrons qu’à l'équilibre, les PIs sont plus élevés en salariat pur qu’avec une rémunération basée sur la production. Aussi, une augmentation du paiement unitaire dans ce dernier système fait baisser les PIs, alors qu'une augmentation du salaire a un effet contraire. Un système mixte (salaire + rémunération à la production) semble être approprié pour assurer la participation des médecins et les inciter à réduire la recherche de rente. / « Petty corruption » is an important feature of the relationship between health workers and patients in settings that allow corrupt acts to happen. It has been well studied in Central and Eastern Europe under the term « informal payments » (IPs), but little has been done in Africa. To contribute in filling this gap in the literature, this thesis proposes a series of analyses to better understand some key aspects of this issue in the African context. In chapter 1, we show that the occurrence of IPs is concentrated on the poorest individuals. They are more likely to report having faced the lack of medicines, absenteeism of doctors and long waiting times in their local hospital, and these factors significantly increase the probability of incurring unofficial fees. In chapter 2, a deeper analysis of the influence of supply factors confirms that long waiting times, the management of the health workforce (e.g. using task shifting) and health workers’ perception vis-à-vis their earnings play a crucial role. In chapter 3, we highlight the existence of peer effects in the occurrence of IPs during consultation for HIV care, with a higher effect for the poorest patients. Finally, with a theoretical model in chapter 4, we show that at the equilibrium, the level of IPs is higher when the physician is paid by salary compared to output-based remuneration. Also, an increase of the unit payment in the later system leads to a reduction of IPs, while an increase of salary has the contrary effect. A blended remuneration (mix of salary and output-based remuneration) appears to be appropriate to both ensure the participation of physicians and introduce incentives to reduce rent-seeking.

Introduktion: SARS-CoV-2-pandemin resulterar i katastrofala både direkta och indirekta konsekvenser, speciellt i utvecklingsländer. Hälso- och sjukvårdspersonal påverkar samhällets åsikter, acceptans och beslutsfattande gällande vaccinering vilket gör att det är viktigt att förstå SARS-CoV-2-vaccintäckning, samt kunskap och attityd gentemot SARS-CoV-2-vaccin i denna målgrupp. Syfte: Att bestämma vilka variabler som är associerade med SARS-CoV-2-vaccination, samt kunskap och attityd gentemot det samma, hos hälso- och sjukvårdspersonal inom nivå 2- och 3-verksamheter i Nairobi. Metod: Ett kvantitativt frågeformulär delades ut till hälso- och sjukvårdspersonal som arbetar inom nivå 2- och 3-verksamheter i Nairobi. Data analyserades med hjälp av IBM SPSS Statistics 28. Chi-square test, Fisher’s exact test, t-test och envägs-ANOVA användes för att bestämma signifikant associerade variabler med SARSCoV-2 vaccinering, samt kunskap och attityd gentemot det samma. Resultat: Studien fann signifikanta samband mellan vaccinationsstatus och kunskapsindex (p=0,04). Gruppen sjuksköterskor, undersköterskor och läkare hade större sannolikhet att vara vaccinerade än andra yrkesgrupper (p=0,027). Positiva signifikanta samband hittades även mellan kunskapsindex och: ålder (p=0,031), att vara kvinna (p=0,029), erfarenhet (p=0,019), att vara vaccinerad (p=0,007), och attitydindex (p= <0,001). Studien fann även ett signifikant samband mellan kunskapsindex och subcounty (p=0,032). Dagoretti South, Embakasi East och Westlands hade de lägsta kunskapsindexen bland de subcounties som deltog i studien. Studien fann även positiva signifikanta samband mellan attitydindex och följande variabler: erfarenhet (p=0,022), att vara vaccinerad (p=<0,001) och kunskapsindex (p=<0,001). Resultaten visar även ett signifikant samband mellan attitydindex och yrke (p=0,025). Slutsats: Resultaten visar på hög vaccinationstäckning och en generellt positiv attityd. Dock belyser studien viktiga kunskapsluckor om COVID-19-vaccin hos deltagarna som bör adresseras i syfte att förbättrabåde kunskapsläget och vaccinationstäckningen i populationen. / Introduction: The pandemic caused by SARS-CoV-2 is having, and will have devastating indirect consequences, affecting developing countries in particular. The SARS-CoV-2 vaccine acceptance, knowledge and attitude among healthcare workers are important to understand since they influence public opinion, community vaccine acceptance, and decision-making regarding vaccination. Aim: To determine the associated variables with SARS-CoV-2 vaccine uptake, knowledge, and attitude among health workers in level 2 and 3 facilities in Nairobi.  Methods: A quantitative questionnaire was distributed to healthcare workers in level 2 and 3 health facilities in Nairobi. Data was analysed using IBM SPSS Statistics 28. Chi-square tests, Fisher’s exact tests, t-tests and one-way ANOVA tests were conducted to determine the associated variables with SARS-CoV-2 vaccine uptake, knowledge, and attitude. Results: A positively significant association was found between vaccine uptake and knowledge index (p=0,04). The group nurses, assistant nurses and physicians were more likely to be vaccinated than other health professions (p=0,027). A positively significant association was found between knowledge index and: age (p=0,031), being female (p=0,029), years of experience (p=0,019), being vaccinated (p=0,007), and attitude index (p=<0,001). A significant association was found between knowledge index and subcounty (p=0,032). Dagoretti South, Embakasi East and Westlands had the lowest knowledge indexes among the subcounties. A positively significant association was determined between attitude index and: years of experience (p=0,022), being vaccinated (p=<0,001), and knowledge index (p=<0,001). Health profession was also found to be significantly associated with attitude index (p=0,025). Conclusion: The results reflect a high vaccination uptake and a general positive attitude. However, the findings identified essential knowledge gaps regarding COVID-19 vaccines among the participants that should be addressed.

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“Why do immigrants and refugees need community health workers/lay health workers (CHWs) if Canada already has a universal health care system?” Abundant evidence demonstrates that despite the universality of our health care system marginalized populations, including immigrants and refugees, experience barriers to accessing the health system. Evidence on the role of CHWs facilitating access is both lacking and urgently needed. This dissertation contributes to this evidence by providing a thick description and thorough analytical exploration of a CHW model, in Edmonton, Canada. Specifically, I examine the activities of the Multicultural Health Brokers Co-operative (MCHB Co-op) and its Multicultural Health Brokers from 1992 to 2011 as well as the relationship they have with Alberta Health Services (AHS) Edmonton Zone Public Health. The research for this study is based on an instrumental and embedded qualitative case study design. The case is the MCHB Co-op, an independently-run multicultural health worker co-operative, which contracts with health and social services providers in Edmonton to offer linguistically- and culturally-appropriate services to marginalized immigrant and refugee women and their families. The two embedded mini-cases are two programs of the MCHB Co-op: Perinatal Outreach and Health for Two, which are the raison d’être for a sustained partnership between the MCHB Co-op and AHS. The phenomenon under study is the Multicultural Health Brokers’ practice. I triangulate multiple methods (research strategies and data sources), including 46 days of participant and direct observation, 44 in-depth interviews (with Multicultural Health Brokers, mentors, women using the programs, health professionals and outsiders who knew of the work of the MCHB Co-op and Multicultural Health Brokers), and document review and analysis of policy documents, yearly reports, training manuals, educational materials as well as quantitative analysis of the Health Brokers’ 3,442 client caseload database. In addition, data include my field notes of both descriptive and analytical reflections taken throughout the onsite research. I also triangulate various theoretical frameworks to explore how historically specific social structures, economic relationships, and ideological assumptions serve to create and reinforce the conditions that give rise to the need for CHWs, and the factors that aid or hinder their ability to facilitate marginalized populations’ access to health and social services. Findings reveal that Multicultural Health Brokers facilitate access to health and social services as well as foster community capacity building in order to address settlement, adaptation, and integration of immigrant and refugee women and their families into Canadian society. Findings also demonstrate that the Multicultural Health Broker model is an example of collaboration between community-based organizations and local systems in targeting health equity for marginalized populations; in particular, in perinatal health and violence against women. A major problem these workers face is they provide important services as part of Canada’s health human resources workforce, but their contributions are often not recognized as such. The triangulation of methods and theory provides empirical and theoretical understanding of the Multicultural Health Brokers’ contribution to immigrant and refugee women and their families’ feminist urban citizenship.

“Why do immigrants and refugees need community health workers/lay health workers (CHWs) if Canada already has a universal health care system?” Abundant evidence demonstrates that despite the universality of our health care system marginalized populations, including immigrants and refugees, experience barriers to accessing the health system. Evidence on the role of CHWs facilitating access is both lacking and urgently needed. This dissertation contributes to this evidence by providing a thick description and thorough analytical exploration of a CHW model, in Edmonton, Canada. Specifically, I examine the activities of the Multicultural Health Brokers Co-operative (MCHB Co-op) and its Multicultural Health Brokers from 1992 to 2011 as well as the relationship they have with Alberta Health Services (AHS) Edmonton Zone Public Health. The research for this study is based on an instrumental and embedded qualitative case study design. The case is the MCHB Co-op, an independently-run multicultural health worker co-operative, which contracts with health and social services providers in Edmonton to offer linguistically- and culturally-appropriate services to marginalized immigrant and refugee women and their families. The two embedded mini-cases are two programs of the MCHB Co-op: Perinatal Outreach and Health for Two, which are the raison d’être for a sustained partnership between the MCHB Co-op and AHS. The phenomenon under study is the Multicultural Health Brokers’ practice. I triangulate multiple methods (research strategies and data sources), including 46 days of participant and direct observation, 44 in-depth interviews (with Multicultural Health Brokers, mentors, women using the programs, health professionals and outsiders who knew of the work of the MCHB Co-op and Multicultural Health Brokers), and document review and analysis of policy documents, yearly reports, training manuals, educational materials as well as quantitative analysis of the Health Brokers’ 3,442 client caseload database. In addition, data include my field notes of both descriptive and analytical reflections taken throughout the onsite research. I also triangulate various theoretical frameworks to explore how historically specific social structures, economic relationships, and ideological assumptions serve to create and reinforce the conditions that give rise to the need for CHWs, and the factors that aid or hinder their ability to facilitate marginalized populations’ access to health and social services. Findings reveal that Multicultural Health Brokers facilitate access to health and social services as well as foster community capacity building in order to address settlement, adaptation, and integration of immigrant and refugee women and their families into Canadian society. Findings also demonstrate that the Multicultural Health Broker model is an example of collaboration between community-based organizations and local systems in targeting health equity for marginalized populations; in particular, in perinatal health and violence against women. A major problem these workers face is they provide important services as part of Canada’s health human resources workforce, but their contributions are often not recognized as such. The triangulation of methods and theory provides empirical and theoretical understanding of the Multicultural Health Brokers’ contribution to immigrant and refugee women and their families’ feminist urban citizenship.

“Why do immigrants and refugees need community health workers/lay health workers (CHWs) if Canada already has a universal health care system?” Abundant evidence demonstrates that despite the universality of our health care system marginalized populations, including immigrants and refugees, experience barriers to accessing the health system. Evidence on the role of CHWs facilitating access is both lacking and urgently needed. This dissertation contributes to this evidence by providing a thick description and thorough analytical exploration of a CHW model, in Edmonton, Canada. Specifically, I examine the activities of the Multicultural Health Brokers Co-operative (MCHB Co-op) and its Multicultural Health Brokers from 1992 to 2011 as well as the relationship they have with Alberta Health Services (AHS) Edmonton Zone Public Health. The research for this study is based on an instrumental and embedded qualitative case study design. The case is the MCHB Co-op, an independently-run multicultural health worker co-operative, which contracts with health and social services providers in Edmonton to offer linguistically- and culturally-appropriate services to marginalized immigrant and refugee women and their families. The two embedded mini-cases are two programs of the MCHB Co-op: Perinatal Outreach and Health for Two, which are the raison d’être for a sustained partnership between the MCHB Co-op and AHS. The phenomenon under study is the Multicultural Health Brokers’ practice. I triangulate multiple methods (research strategies and data sources), including 46 days of participant and direct observation, 44 in-depth interviews (with Multicultural Health Brokers, mentors, women using the programs, health professionals and outsiders who knew of the work of the MCHB Co-op and Multicultural Health Brokers), and document review and analysis of policy documents, yearly reports, training manuals, educational materials as well as quantitative analysis of the Health Brokers’ 3,442 client caseload database. In addition, data include my field notes of both descriptive and analytical reflections taken throughout the onsite research. I also triangulate various theoretical frameworks to explore how historically specific social structures, economic relationships, and ideological assumptions serve to create and reinforce the conditions that give rise to the need for CHWs, and the factors that aid or hinder their ability to facilitate marginalized populations’ access to health and social services. Findings reveal that Multicultural Health Brokers facilitate access to health and social services as well as foster community capacity building in order to address settlement, adaptation, and integration of immigrant and refugee women and their families into Canadian society. Findings also demonstrate that the Multicultural Health Broker model is an example of collaboration between community-based organizations and local systems in targeting health equity for marginalized populations; in particular, in perinatal health and violence against women. A major problem these workers face is they provide important services as part of Canada’s health human resources workforce, but their contributions are often not recognized as such. The triangulation of methods and theory provides empirical and theoretical understanding of the Multicultural Health Brokers’ contribution to immigrant and refugee women and their families’ feminist urban citizenship.

This study investigated the performance of health workers in the decentralised services in Uganda in order to develop a management framework that may be used to improve performance. The study followed a mixed research methodology and was descriptive. The survey design was used to collect quantitative data by means of a structured questionnaire. Qualitative data was collected using a semi-structured interview guide. The study population for the quantitative strand comprised 276 health workers including doctors, clinical officers, and professional nurses working in four districts: Kumi, Mbale, Sironko and Tororo. The health workers were selected using stratified random sampling. The population for qualitative strand was health services managers (N=21) from the same districts. The managers were selected purposively. Quantitative data was analysed using SPSS version 18.0, while qualitative data was coded and analysed manually. The findings revealed that the performance of health workers is generally affected by health systems and work environment related factors. The findings indicated that health workers are skilled, competent, and generally have positive attitudes and behaviours towards their clients. The study uncovered loop holes in performance management in the district health sectors. In most cases there is no target setting, no performance management planning, performance indicators are not clearly defined, and the schedules for performance measurement are not always followed. There is limited career progression and lack of functional performance feedback and rewarding mechanisms. Although health workers are committed, there is widespread political interference and nepotism in the district health sector management. Overall, the researcher is optimistic that if the proposed performance management framework is implemented, the performance of health workers might improve. / Health Studies / D. Litt. et Phil. (Health Studies)

Public demands have forced countries to explore new ways of rendering primary health care to reach the poor who are not within reach of the modern health care systems. New categories of health care personnel, like lay health workers emerged. There are vast differences in the roles of these lay health workers as was revealed with an extensive literature search. The phenomenology qualitative research method was used to investigate perceptions of farm lay health workers regarding their roles in rural areas. A convenience, non-random sample (N=5) was used for focus group discussions and in-depth interviews to collect data. The latter revealed five main themes associated with the role of farm lay health workers: (1) community link; (2) carer; (3) community developer; (4) counsellor and (5) role model. Guidelines were formulated to enhance the role of lay health workers in the rural Western Cape Province and to improve the quality of care to rural communities / Health Studies / M.A. (Health Studies)

Questa tesi include tre capitoli che si concentrano sulle politiche pubbliche e la tutela della salute. Il primo capitolo esamina l’effetto dell’incremento delle aliquote dell’IVA su alcune bevande sul loro consumo. I risultati dell’analisi empirica suggeriscono che l'aumento dell'aliquota IVA ha ridotto il consumo di alcolici, birra e bevande gassate, mentre l’effetto sul consumo di vino non è statisticamente significativo. Tuttavia, questo risultato generale cambia se si considerano sotto-gruppi di individui. Il secondo capitolo studia l’impatto del salario minimo sulla salute della popolazione cinese. Le stime indicano che i salari minimi reali sono negativamente e significativamente correlati con lo stato di salute della popolazione sia nel breve che nel lungo periodo, un risultato che potrebbe essere spiegato dalle condizioni di lavoro più stressanti conseguenti all’introduzione di un salario minimo più elevato. Infine, il terzo capitolo analizza gli effetti dei meccanismi di incentivazione sui comportamenti degli operatori sanitari del settore delle cure primarie nell’ambito della gestione dell'ipertensione. La nostra indagine empirica suggerisce che gli incentivi finanziari negativi potrebbero motivare gli operatori sanitari a migliorare la qualità dei servizi legati alla gestione dell'ipertensione, mentre né gli incentivi finanziari né diverse modalità di valutazione delle prestazioni sembrano influenzare la qualità dei servizi. / This dissertation includes three chapters which focus on the relationship between public policies and healthcare. The first chapter examines whether tax policy is effective in changing the unhealthy drinking behaviours of individuals. My findings suggest that the VAT rate increase is effective in reducing the consumption of spirits, beer and carbonated beverages, while it is not effective for wine. However, this general result change when looking at sub-groups of individuals. The second chapter studies how real minimum wages affect population health in China. I conclude that real minimum wages are negatively and significantly related to population health, a result which might be explained by the role of more stressful working conditions as a consequence of a higher minimum wage. Finally, the third chapter analyses the effects of incentive mechanisms on the behaviours of primary health workers and the subsequent effects on the quality of hypertension management. The empirical investigation suggests that negative financial incentives could motivate primary health workers and improve the quality of hypertension management. However, neither positive financial incentives nor different modes of performance evaluation are significantly related to the quality of hypertension management.