The high cost of prescription drugs has been an issue that numerous federal agencies have examined for years. In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, better known as Medicare Part D, in an effort to ease the burden of skyrocketing prescription prices for citizens 65 and older. While much of the discussion has focused on the impact on Medicare and Medicaid, the search for the source of high prescription drug prices has possible benefits for all patients. Unfortunately, the vast majority of research into this topic focuses only on the manufacturers of prescription drugs. This thesis examined the relationship between wholesale and retail prices of prescription drugs to discover whether this is another possible source of high prescription drug costs that policy makers need to consider. The findings suggest that more research is warranted. Many of the pharmacies surveyed reported unexpected negative mark-ups. Moreover, the Average Wholesale Rice evidently is not an accurate basis for comparison with actual retail prices. The findings suggest that more research is warranted, including studies by federal legislative and executive branch actors with investigatory authority. / Master of Arts

Cartas al editor / Revisión por pares

Introdução - A avaliação do crescimento infantil ultrapassa o olhar técnico expressando, indiretamente, os cuidados sociais e culturais que a criança está vivenciando. Objetivo - Avaliar o estado nutricional dos escolares da 1ª a 4ª série do ensino fundamental acompanhados pela Fundação de Apoio ao Menor de Feira de Santana (FAMFS) no Município de Feira de Santana-BA. Métodos - Trata-se de um estudo transversal, descritivo, observacional, a partir de dados da FAMFS dos escolares de 5 a 10 anos, de uma escola estadual, assistidos em seus programas. Foram utilizadas medidas de peso, estatura, circunferência do braço (CB) e medidas derivadas (índices de peso para idade - P/I; estatura para idade - E/I; CB para estatura - CB/E e, Índice de Massa Corpórea - IMC). Os pontos de corte adotados para os índices P/I, E/I e CB/E foram - 2,0 e + 2,0 escores z e, para IMC os percentis 5, 85 e 95, das curvas do Center for Disease Control and Prevention (CDC 2000). As comparações foram feitas a partir dos parâmetros de tendência central e dispersão de valores. Definiu-se nivel de significância alfa de 5%. Resultados - A prevalência de baixa estatura, utilizando-se o E/I, foi de 3,5% (IC95%: 1,9 - 6,5). Na avaliação do IMC, verificaram-se prevalências de baixo peso, sobrepeso e obesidade de 5,8% (IC95%: 3,6 - 9,4), 4,7% (IC95%: 2,7 - 8,0) e 2,3% (IC95%: 1,1 - 5,0), respectivamente. Os escolares apresentam tendência progressiva e significativa de aumento da prevalência de baixo peso, a partir de seis anos. A ausência do pai (26,1%) foi mais freqüente que a da mãe (8,9%). O número médio de pessoas no domicílio foi 4,9. A escolaridade dos genitores concentrou-se no ensino fundamental e suas ocupações em atividades braçais e de pouco grau de especialização. É grande a freqüência de mães que são donas de casa e pais pedreiros. Conclusão - As crianças apresentam prevalência de baixo peso e baixa estatura acima da esperada e menor que a esperada de sobrepeso e obesidade. Este cenário indica que esta população é passível de intervenções nutricionais que podem auxiliá-las a garantir seu potencial de crescimento. Contudo tais ações devem se inserir no contexto de proteção social a essas crianças e suas famílias. / Introduction - The assessment of children's growth surpasses the technical view expressing, indirectly, the social and cultural care experienced by the children. Objective - To evaluate the nutritional status of school children from the 1st to 4th grade of elementary school, assisted by the Fundação de Apoio ao Menor de Feira de Santana (FAMFS) in Feira de Santana county-Bahia. Methods - It's an observational, descriptive and transversal study based on data from FAMFS from school children of 5 to 10 years of age, from a public school, assisted by the programs of the above mentioned Foundation. Measures of weight, height, arm circumference and derived measures (indexes weight-for-age, height-for-age, arm circumference-for-height and body mass index for age - BMI-for-age) were used. The cut points adopted for the indexes weight-for-age, height-for-age, arm circumference-for-height were -2,0 and +2,0 z-scores and for the BMI-for-age the percentiles 5th, 85th and 95th, from the Center for Disease Control and Prevention curves (CDC 2000). The comparisons were made through parameters of central tendency and dispersion of values. It was accepted significance level alpha of 5%. Results - The prevalence of short stature using the height-for-age was 3,5% (CI95%: 1,9 - 6,5). Evaluating the BMI-for-age, it was observed prevalence of thinness, overweight and obesity of 5,8% (CI95%: 3,6 - 9,4), 4,7% (CI95%: 2,7 - 8,0) and 2,3% (CI95%: 1,1 - 5,0) respectively. The school children show a progressive and significant tendency to increase the prevalence of thinness, from six years of age. The absence of father in the homes (26,1%) was more frequent than that of mother (8,9%). The average number of people in the house was 4,9. The schooling level of the parents was concentrated on elementary school and their occupations were mainly physical work with low degree of specialization. There is a high frequency of mothers who are housewives and fathers who are bricklayers. Conclusion - The children show prevalence of thinness and short stature above the expected one and lower than the expected of overweight and obesity. This scene evinced that these children demand a nutritional intervention to improve their growth pattern. But such actions should be included in the context of social protection of these children and their families.

Introdução - A avaliação do crescimento infantil ultrapassa o olhar técnico expressando, indiretamente, os cuidados sociais e culturais que a criança está vivenciando. Objetivo - Avaliar o estado nutricional dos escolares da 1ª a 4ª série do ensino fundamental acompanhados pela Fundação de Apoio ao Menor de Feira de Santana (FAMFS) no Município de Feira de Santana-BA. Métodos - Trata-se de um estudo transversal, descritivo, observacional, a partir de dados da FAMFS dos escolares de 5 a 10 anos, de uma escola estadual, assistidos em seus programas. Foram utilizadas medidas de peso, estatura, circunferência do braço (CB) e medidas derivadas (índices de peso para idade - P/I; estatura para idade - E/I; CB para estatura - CB/E e, Índice de Massa Corpórea - IMC). Os pontos de corte adotados para os índices P/I, E/I e CB/E foram - 2,0 e + 2,0 escores z e, para IMC os percentis 5, 85 e 95, das curvas do Center for Disease Control and Prevention (CDC 2000). As comparações foram feitas a partir dos parâmetros de tendência central e dispersão de valores. Definiu-se nivel de significância alfa de 5%. Resultados - A prevalência de baixa estatura, utilizando-se o E/I, foi de 3,5% (IC95%: 1,9 - 6,5). Na avaliação do IMC, verificaram-se prevalências de baixo peso, sobrepeso e obesidade de 5,8% (IC95%: 3,6 - 9,4), 4,7% (IC95%: 2,7 - 8,0) e 2,3% (IC95%: 1,1 - 5,0), respectivamente. Os escolares apresentam tendência progressiva e significativa de aumento da prevalência de baixo peso, a partir de seis anos. A ausência do pai (26,1%) foi mais freqüente que a da mãe (8,9%). O número médio de pessoas no domicílio foi 4,9. A escolaridade dos genitores concentrou-se no ensino fundamental e suas ocupações em atividades braçais e de pouco grau de especialização. É grande a freqüência de mães que são donas de casa e pais pedreiros. Conclusão - As crianças apresentam prevalência de baixo peso e baixa estatura acima da esperada e menor que a esperada de sobrepeso e obesidade. Este cenário indica que esta população é passível de intervenções nutricionais que podem auxiliá-las a garantir seu potencial de crescimento. Contudo tais ações devem se inserir no contexto de proteção social a essas crianças e suas famílias. / Introduction - The assessment of children's growth surpasses the technical view expressing, indirectly, the social and cultural care experienced by the children. Objective - To evaluate the nutritional status of school children from the 1st to 4th grade of elementary school, assisted by the Fundação de Apoio ao Menor de Feira de Santana (FAMFS) in Feira de Santana county-Bahia. Methods - It's an observational, descriptive and transversal study based on data from FAMFS from school children of 5 to 10 years of age, from a public school, assisted by the programs of the above mentioned Foundation. Measures of weight, height, arm circumference and derived measures (indexes weight-for-age, height-for-age, arm circumference-for-height and body mass index for age - BMI-for-age) were used. The cut points adopted for the indexes weight-for-age, height-for-age, arm circumference-for-height were -2,0 and +2,0 z-scores and for the BMI-for-age the percentiles 5th, 85th and 95th, from the Center for Disease Control and Prevention curves (CDC 2000). The comparisons were made through parameters of central tendency and dispersion of values. It was accepted significance level alpha of 5%. Results - The prevalence of short stature using the height-for-age was 3,5% (CI95%: 1,9 - 6,5). Evaluating the BMI-for-age, it was observed prevalence of thinness, overweight and obesity of 5,8% (CI95%: 3,6 - 9,4), 4,7% (CI95%: 2,7 - 8,0) and 2,3% (CI95%: 1,1 - 5,0) respectively. The school children show a progressive and significant tendency to increase the prevalence of thinness, from six years of age. The absence of father in the homes (26,1%) was more frequent than that of mother (8,9%). The average number of people in the house was 4,9. The schooling level of the parents was concentrated on elementary school and their occupations were mainly physical work with low degree of specialization. There is a high frequency of mothers who are housewives and fathers who are bricklayers. Conclusion - The children show prevalence of thinness and short stature above the expected one and lower than the expected of overweight and obesity. This scene evinced that these children demand a nutritional intervention to improve their growth pattern. But such actions should be included in the context of social protection of these children and their families.

Esta pesquisa teve como objetivo conhecer o trabalho do Assistente Social nos Núcleos habilitados para desenvolver Programa de Implante Coclear do Brasil. De acordo com Cadastro Nacional de Estabelecimentos de Saúde (CNES) Brasil -07/2015 foi identificado um universo de 27 Núcleos habilitados para Programa de Implante Coclear pelo Ministério da Saúde objeto deste estudo. A abordagem foi quantiqualitativa e tipologia descritiva transversal. Para a fundamentação teórica foi realizada uma consulta às bases de dados Pubmed, Lilacs e Social Services mediante os descritores: políticas públicas de saúde, deficiência auditiva, surdez, implante coclear, auxiliares de audição, e serviço social. Para a coleta de dados junto aos 27 Núcleos foi elaborado um questionário on-line contendo perguntas abertas e fechadas que sustentaram ao objetivo da pesquisa. O mesmo foi aplicado com um Assistente Social de cada serviço. A análise dos dados quantitativos obedeceu ao método estatístico descritivo com base no objetivo do estudo e referenciais da literatura. Os dados qualitativos foram analisados pelos princípios da análise de conteúdo por método descritivo temático-categorial e teve como norte, o objetivo da pesquisa, as evidências da literatura e a experiência investigativa profissional. Este estudo ampliou o conhecimento acerca dos Programas de Implante Coclear do Brasil, uma vez que, na literatura nacional e internacional não foram identificados estudos anteriores sobre estes e suas equipes. Os resultados permitiram uma análise das atribuições e ações dos Assistentes Sociais nestes Programas que revelaram suas dimensões: investigativa e interventiva. / This research aimed to know the work of the social worker in enabled Services to develop Cochlear Implant Program of Brazil. According to National Health Facilities (CNES ) Brazil -07/2015 identified a universe of 27 enabled services Cochlear Implant Program by the Ministry of Health - the subject of this study. The approach was Quantiqualitative and cross descriptive type. For the theoretical foundation was held a query to the Pubmed, Lilacs and Social Services through the descriptors: public health policies, hearing impairment, deafness, cochlear implants, hearing aids, and social work. To collect data from the 27 services was prepared a questionnaire online with open and closed questions and that supported the purpose of the research. The same was applied to a social worker\'s for each service. The analysis of quantitative data followed the descriptive statistical method based on the purpose of the study and reference literature. Qualitative data were analyzed by the principles of content analysis by thematic-categorical and descriptive method was to the north, the research objective, the evidence from the literature and professional investigative experience. This study expanded the knowledge of the Cochlear Implant Program of Brazil, as in national and international literature were not identified earlier studies of these and their teams. The results allowed an analysis of the atributions and actions of social workers in these programs that showed its dimensions: investigative and interventional.

Esta pesquisa teve como objetivo conhecer o trabalho do Assistente Social nos Núcleos habilitados para desenvolver Programa de Implante Coclear do Brasil. De acordo com Cadastro Nacional de Estabelecimentos de Saúde (CNES) Brasil -07/2015 foi identificado um universo de 27 Núcleos habilitados para Programa de Implante Coclear pelo Ministério da Saúde objeto deste estudo. A abordagem foi quantiqualitativa e tipologia descritiva transversal. Para a fundamentação teórica foi realizada uma consulta às bases de dados Pubmed, Lilacs e Social Services mediante os descritores: políticas públicas de saúde, deficiência auditiva, surdez, implante coclear, auxiliares de audição, e serviço social. Para a coleta de dados junto aos 27 Núcleos foi elaborado um questionário on-line contendo perguntas abertas e fechadas que sustentaram ao objetivo da pesquisa. O mesmo foi aplicado com um Assistente Social de cada serviço. A análise dos dados quantitativos obedeceu ao método estatístico descritivo com base no objetivo do estudo e referenciais da literatura. Os dados qualitativos foram analisados pelos princípios da análise de conteúdo por método descritivo temático-categorial e teve como norte, o objetivo da pesquisa, as evidências da literatura e a experiência investigativa profissional. Este estudo ampliou o conhecimento acerca dos Programas de Implante Coclear do Brasil, uma vez que, na literatura nacional e internacional não foram identificados estudos anteriores sobre estes e suas equipes. Os resultados permitiram uma análise das atribuições e ações dos Assistentes Sociais nestes Programas que revelaram suas dimensões: investigativa e interventiva. / This research aimed to know the work of the social worker in enabled Services to develop Cochlear Implant Program of Brazil. According to National Health Facilities (CNES ) Brazil -07/2015 identified a universe of 27 enabled services Cochlear Implant Program by the Ministry of Health - the subject of this study. The approach was Quantiqualitative and cross descriptive type. For the theoretical foundation was held a query to the Pubmed, Lilacs and Social Services through the descriptors: public health policies, hearing impairment, deafness, cochlear implants, hearing aids, and social work. To collect data from the 27 services was prepared a questionnaire online with open and closed questions and that supported the purpose of the research. The same was applied to a social worker\'s for each service. The analysis of quantitative data followed the descriptive statistical method based on the purpose of the study and reference literature. Qualitative data were analyzed by the principles of content analysis by thematic-categorical and descriptive method was to the north, the research objective, the evidence from the literature and professional investigative experience. This study expanded the knowledge of the Cochlear Implant Program of Brazil, as in national and international literature were not identified earlier studies of these and their teams. The results allowed an analysis of the atributions and actions of social workers in these programs that showed its dimensions: investigative and interventional.

Purpose: The thesis determined how policy implementation and change management can be improved in Nigeria, with the health insurance scheme as the basis for narrative exploration. It sets out the similarities and differences in assumptions between supra-national organisations such as the World Bank and World Health Organisation on policy implementation and change management and those contained in the Nigerian national health policy; and those of people responsible for implementation in Nigerian organisations at a) the federal or national level and b) at sub-federal service delivery levels of the health insurance scheme. The study provides a framework of the dimensions that should be considered in policy implementation and change management in Nigeria, the nature of structural and infrastructural problems and wider societal context, and the ways in which conceptions of organisations and the variables that impact on organisations' capability to engage in policy implementation and change management differ from those in the West. Design/methodology/approach - A qualitative approach in the form of a case study was used to track the transformation of a policy into practice through examining the assumptions and expectations about policy implementation of the organisations financing the policy's implementation through an examination of relevant documents concerning policy, strategy and guidelines on change management and policy implementation from these global organisations, and the Nigerian national health policy document. The next stages of field visits explored the assumptions, expectations and experiences of a) policy makers, government officials, senior managers and civil servants responsible for implementing policy in federal-level agencies through an interview programme and observations; and b) those of sub-federal or local-level managers responsible for service-level policy implementation of the health insurance scheme through an interview programme. Findings - There are conflicts between the rational linear approaches to change management and policy implementation advocated by supra-nationals, which argue that these processes can be controlled and managed by the rational autonomous individual, and the narratives of those who have personal experience of the quest for 'health for all'. The national health policy document mirrors the ideology of the global organisations that emphasise reform, efficiencies and private enterprise. However, the assumptions of these global organisations have little relevance to a Nigerian societal and organisational context, as experienced by the senior officials and managers interviewed. The very nature of organisations is called into question in a Nigerian context, and the problems of structure and infrastructure and ethnic and religious divisions in society seep into organisations, influencing how organisation is enacted. Understandings of the purpose and function of leadership and the workforce are also brought into question. Additionally, there are religion-based barriers to policy implementation, change management and organisational life which are rarely experienced in the West. Furthermore, in the absence of future re-orientation, the concept of strategy and vision seems redundant, as is the rationale for a health insurance scheme for the majority of the population. The absence of vision and credible information further hinder attempts to make decisions or to define the basis for determining results. Practical implications: The study calls for a revised approach to engaging with Nigerian organisations and an understanding of what specific terms mean in that context. For instance, the definitions and understanding of organisations and capacity are different from those used in the West and, as such, bring into question the relevance and applicability of Western-derived models or approaches to policy implementation and change management. A framework with four dimensions - societal context, external influences, seven organisational variables and infrastructural/structural problems - was devised to capture the particular ambiguities and complexities of Nigerian organisations involved in policy implementation and change management. Originality/value: This study combines concepts in management studies with those in policy studies, with the use of narrative approaches to the understanding of policy implementation and change management in a Nigerian setting. Elements of culture, religion and ethical values are introduced to further the understanding of policy making and implementation in non-Western contexts.

In this comparative policy development analysis, I utilize path-dependence theory and presidential records to analyze President Lyndon Johnson's success in passing Medicare and Medicaid and President Bill Clinton's failure to pass national health care reform. Findings support four major themes from the Johnson administration: 1) President Johnson had a keen understanding of the importance of language in framing debate; 2) He placed control of the legislative process in the hands of a small, select group of seasoned political operatives and career policymaking professionals; 3) He paid considerable attention to the details of negotiations and the policy consequences; and 4) He had a highly developed sense of the political and legislative processes involved in passing major legislation. The case study of the Clinton administration reveals five major themes: 1) There is a lack of evidence that President Clinton remained actively engaged throughout the policy development and legislative processes, instead choosing to delegate the process to the First Lady; 2) There was a naiveté on the part of the Clintons and many administration staff members with regard to the legal and political ramifications of their decisions; 3) The Clintons tried to make the plan fully their own, sharing little credit for its development with Congress; 4) Their attempts to incorporate existing corporate health care delivery structures with their vision for universal coverage proved unworkable; and 5) The extended time from task force launch to bill delivery gave opponents ample time to marshal their opposition forces. I conclude that in developing health care legislation, Johnson had the advantages of: 1) a small group of key policymakers; 2) multiple, simultaneous legislative initiatives which diffused the attention of a more limited media; and, 3) national crises which promoted an environment conducive to sweeping policy change. I suggest that major, national health care reform will not occur until: 1) an economic or geopolitical crisis sets the stage for change; 2) business interests and progressive interests find common ground; and, 3) Americans achieve a new cultural understanding of universal health care as both economically just and economically necessary. / text

Since the economic reform in 1978, China’s health system moved from a commune-based system to a market-driven system. This drastic change resulted in various market failures, including cost inflation, perverse incentives for providers and supplier-induced demand for unnecessary care, increasing inequality in access across regions based on economic status, and other problems. Though China attempted to correct its policy mistakes and reform its inadequate and unjust health care system in order to provide basic universal health coverage for all over the past decade, not everyone has equal access to the same quality of affordable health care, especially the non-resident workers, the poor urban residents, and the rural population. This research uses the framework of the five intellectual tasks to assess the history of China’s health policies, the political economy factors that have driven and shaped the reform of China’s health system, the likely projections of policy options, and potential alternatives for policymakers.

People who use illegal drugs all too often experience stigma and discrimination, criminalization and marginalization in Canada. Substance use has both immediate and chronic health consequences that may require healthcare. However, people who use illegal drugs often experience difficulty accessing equitable care, and stigma has been identified as a key barrier to access. This study explores the provision of health care by nurses in an emergency department for people who use illegal drugs, and the impact of hospital policies and procedures on nurses’ capacity to provide care. The study uses data from in-depth interviews with nurses and policy leaders, and analyses policy documents discussed by nurses in the interviews. This study found that neoliberal policies that result in downsizing of social programs means that patients come to emergency departments with a broad set of health and socials needs that extend beyond what nurses can do. The study also uncovered a lack of cultural safety for Aboriginal patients seeking care. Finally, the study discovered the existence of a culture of stigma in the emergency department. The culture of stigma is transmitted and taken up through individual attitudes, relations of power, intake and treatment protocols, critical policy absences and problematic policy. This study concludes with recommendations for policy development and for future research in this area. / Graduate / 0680 / 0573 / 0569 / heyriver@shaw.ca