This dissertation addresses resource allocation problems that occur in both public and private health care settings with the objective of characterizing the tradeoffs that occur when simultaneously incorporating multiple objectives and developing methods to address these tradeoffs. We examine three resource allocation problems (i) strategic allocation of financial resources and limited staffing capacity for the mobile delivery of health care within African countries, (ii) real-time allocation of hospital beds to internal patient requests, and (iii) development of patient redirection policies in response to limited bed availability in units within a system of hospitals. For each problem we define models, each with a different methodology, and utilize the models to develop allocation strategies that account for multiple competing objectives and examine the performance of the strategies with computational studies. In Chapter 2, we model African health care delivery systems utilizing a mixed-integer program (MIP) which accounts for financial and personnel constraints as well as infrastructure quality. We characterize tradeoffs in effectiveness, efficiency, and equity resulting from four allocation strategies with computational experiments representing the variety of spatial patterns that occur throughout the continent. The main contributions include (i) the development of a model that incorporates spatial and infrastructure characteristics and allows for a study of equity in the delivery of care, rather than access to care, and (ii) the characterization of tradeoffs in the three objectives under a variety of settings. In Chapter 3, we model the real-time assignment of bed requests to available beds as a queueing system and a Markov decision process (MDP). Through the development of bed assignment algorithms and simulation experiments, we illustrate the value of implementing strategic bed assignment practices which balance the bed management objectives of timeliness and appropriateness of assignments. The main contributions of this section include (i) the development of new bed assignment algorithms which use stochastic optimization techniques and outperform algorithms which mimic processes currently used in practice and (ii) the definition of a model and methods for the control of a large complex system that includes flexible units, multiple patient types, and type-dependent routing. In Chapter 4, we model the impact of a patient redirection policy in a hospital unit as a Markov chain. Assuming preferences for patient redirection are aligned with costs, we examine the impact of incremental changes to redirection policies on the probability of the unit being completely occupied, the long-run average utilization, and the long-run average cost of redirection. The main contributions of this chapter include (i) the introduction of a model of patient redirection with multiple patient thresholds and patient preference constraints and (ii) the definition of necessary conditions for an optimal patient redirection policy that minimizes the average cost of redirection.

Thesis (MCur (Nursing Science))--University of Stellenbosch, 2009. / ENGLISH ABSTRACT: The work environment in critical care units in South Africa is hampered by a profound shortage of nurses, heavy workloads, conflict, high levels of stress, lack of motivation and dissatisfaction among the staff. The task of managing a C.C.U. has therefore become a challenge. It is important that unit managers apply a leadership style that matches these challenges. The aim of this study was to investigate the ideal style of leadership. The objectives set for the study were to identify the ideal leadership style required in the following areas:  administrative functions  education functions  patient care  research An explorative, descriptive research design was applied, with a quantitative approach to determine the ideal leadership style for unit managers in critical care units of private health care institutions. The research sample consisted of all nurses working permanently in eleven private hospitals in the Cape Metropolitan area. A questionnaire consisting of predominantly closed questions was used for the collection of data, which was collected by the researcher in person. Ethical approval was obtained from the Committee of Human Science Research at Stellenbosch University. Permission to conduct the research was obtained from the institutions and informed consent from the participants. A pilot study was conducted to test the questionnaire at a private hospital which did not form part of the study. A 10% sample of the relevant staff, namely 27 participants were involved in this study. The validity and reliability was assured through the pilot study and the use of a statistician as well as experts in nursing and a research methodologist. Data was tabulated and presented in histograms and frequencies. Statistical significant associations were drawn between variables, using the Chi-square test. The Spearman rank (rho) order correlation was used to show the strength of the relationship between two continuous variables. Findings of the study show that participatory leadership style and transformational leadership approach were valued in all four (4) of the objectives. Emphasis was placed on consultation prior to any decisions. Nurses requested an opportunity to give feedback on a regular basis regarding the unit managers conduct (Chi-square test p = 0.025). They also agreed that unit managers should apply the necessary rules and procedures (Chi-square test p = 0.016). A huge request was made for integrity, trust, impartiality, openness, approachability and particularly honesty. The nurses also maintained that the nurse manager’s behaviour should be congruent. Furthermore, the results indicate that nurses would like to be empowered by:  being involved in the scheduling of off-duties  taking the lead in climate meetings  being granted opportunities (to all categories of nurses) to attend managerial meetings. N = 41 (48.2%) of nurses admitted that unit managers would instruct them to cope with insufficient staffing pertaining to ventilated patients, putting them under severe strain and at risk legally. N = 39 (47%) of nurses admitted that unit managers only consider qualifications and experience in the delegation of tasks if the workload in the unit justifies it. Safe patient care is not always a priority. N = 99 (96%) of nurses agreed that autocratic behaviour relating to task delegation exists. Recommendations included the application of transformational leadership and participatory management. The aim to create a healthier, more favourable work environment for critical care nurses will hopefully be attained through applying the ideal leadership style and leadership approach. / AFRIKAANSE OPSOMMING: Die werksverrigtinge in kritieke sorgeenhede in Suid-Afrika word deur ‘n ernstige tekort aan verpleegsters, hoë werklading, konflik, spanning, min motivering en baie ontevredenheid onder verpleeglui gekortwiek. Die leiding en bestuur van ‘n kritieke sorgeenheid is dus nie ‘n maklike taak nie. Dit is dus belangrik dat eenheidsbestuurders ‘n leierskapstyl aan die dag lê wat dié uitdagings doeltreffend aanspreek. Die doel van die studie is dus om ondersoek in te stel na die wenslike leierskapstyl vir kritieke sorgeenhede. Die doelwitte daargestel is dus om die ideale leierskapstyl in elk van die volgende funksies te bepaal:  administrasie  opleiding  pasiënte-sorg  navorsing Die ideale leierskapstyl vir eenheidbestuurders in kritieke sorgeenhede in privaathospitale is bepaal deur ‘n kwantitatiewe benadering met ‘n beskrywende ontwerp toe te pas. Die populasie het alle kritieke sorg verpleeglui ( permanent werksaam by een van elf privaathospitale in die Kaapse Metropool) ingesluit. Instrumentasie het ‘n vraelys behels (met oorwegend geslote vrae) en data is persoonlik deur die navorser ingevorder. Etiese toestemming is vanaf die Etiese Komitee van die Mediese Fakulteit te Universiteit Stellenbosch verkry asook die hoofde van die verskillende privaathospitale waar navorsing plaasgevind het. Ingeligte toestemming is ook van elkeen van die deelnemers verkry. Ten einde die vraelys te toets, is ‘n loodstudie by ‘n privaathospitaal ( wat nie by die studie ingesluit was nie) gedoen. Die loodstudie het N = 27 (10%) van die totale populasie behels. Die betroubaarheid en geldigheid van die studie is deur die loodstudie, die gebruik van ‘n statistikus, verpleegdeskundiges en die navorser-metodoloog versterk. Data is getabuleer en in histogramme en frekwensies voorgestel. Deur die Chi-square- toets te gebruik, is statisties betekenisvolle assosiasies tussen veranderlikes bepaal. Ten einde sterkte van verhoudings tussen twee opeenvolgende veranderlikes te bepaal, is die Spearman rangordekorrelasie (rho) aangewend. Die bevindings van die studie het getoon dat ‘n deelnemende bestuurstyl en transformasie-leierskapbenadering die mees aangewese keuse vir al vier doelwitte is. Die toepassing van veral ‘n deelnemende besluitnemingsproses het groot voorrang geniet, Verpleegkundiges wil daarbenewens ook op ‘n gereelde basis geleentheid hê om terugvoering oor die leierskapgedrag van die eenheidsbestuurder te gee (Chi-square toets p = 0.025). Ook verlang die deelnemers dat eenheidsbestuurders nie reëls en regulasies moet verontagsaam nie (Chi-square toets p = 0.016). ‘n Ernstige versoek is gerig ten opsigte van integriteit met pertinente verwysing na eerlikheid, vertroue, onpartydigheid, deursigtigheid, toeganklikheid en dat die leier se woorde en dade moet ooreenstem. Die resultate het verder getoon dat verpleegsters graag bemagtig wil word deur:  betrokkenheid in die skedulering van afdienste,  leiding in klimaatsvergaderings te wil neem,  geleentheid te hê om bestuurvergaderings by te woon (alle kategorieë van verpleegkundiges).. N = 39 (48.2%) van verpleegkundiges het erken dat hulle gedwonge personeeltekorte ten opsigte van geventileerde pasiënte ervaar en dus aan mediese geregtelike risiko’s en onnodige druk blootgestel word. N 39 (47%) van verpleegkundiges het erken dat eenheidsbestuuders kwalifikasies en ondervinding slegs in ag neem indien die werklading in die eenheid dit toelaat..Veilige pasiëntesorg kry dus nie altyd voorkeur nie. N = 99 (96%) van verpleegkundiges het erken dat outokratiese gedrag ( wat met werkstoewysing verband hou) wel voorkom. ‘n Transformasie leierskapsbenadering en deelnemende bestuurstyl is dus aanbeveel. Die hoop word dus uitgespreek dat deur aan die verpleegkundiges se versoeke ten opsigte van die ideale bestuursbenadering en bestuurstyl te voldoen, die werksatmosfeer binne kritieke sorgeenhede toenemend gesonder en dus aangenamer sal word.

Thesis (MBA)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: The aim of this study was to investigate the management skills of occupational therapy business unit managers on Assistant Director Level in the Public Health Sector (PHS) of the Free State (FS). For the purpose of this study, management skills referred to the occupational therapy business unit manager’s perception of the importance and competency experienced while doing their work within the Free State Department of Health. Occupational therapy form an integral part of the Free State Department of Health, which is a provincial public sector entity and solely responsible for health services to the majority of the population. An inquiry was initiated based on the researchers’ observation of occupational therapy business unit manager’s challenges regarding knowledge and skill when exposed to management. The investigation was conducted by making use of a questionnaire for the quantitative typical descriptive study design and semi-structured telephonic interviews for the qualitative study design. Electronic self-administrative questionnaires were distributed to all the occupational therapy business unit managers in the service of the Free State Department of Health. Ten (n=10) questionnaires, a hundred percent of employed occupational therapy business unit managers, were used for the analysis of quantitative data. Subsequently to this base-line data gathered, semi-structured telephonic interviews with open-ended questions were conducted among the target population. In conclusion the results of the study showed that the occupational therapy business unit managers in the PHS of the FS perceive a gap between their current and desired performance management skill levels. This was found to be in accordance with studies worldwide as clinicians promoted to a managerial post would prefer to utilize gained qualifications and experiences as managers within their specialty field.

This thesis describes research into the facilitation of mediated communication of health updates and support needs across the social network, on behalf of individuals experiencing acute or chronic health problems. This led to the user-centred design, development and evaluation of a prototype software tool. Investigatory applied research was conducted with the parents of sick newborn infants who were (or had previously been) cared for in a Neonatal Unit, and their social networks of family, friends, colleagues and neighbours. The thesis makes contributions to knowledge within Social Networks, Health Informatics, Adaptive Systems and User Modelling. The user-centred research was conducted using a Grounded Theory approach, progressively focussing on developing themes. An iterative approach was taken to evaluation of the resulting theory. In the Social Networks domain, a novel, intuitive mechanism for capturing the membership and structure of an individual’s personal social network has been defined and developed, grounded in the work of evolutionary anthropologist Robin Dunbar. Use of the highly visual mechanism requires low levels of literacy and computer skills. It is cross-culturally applicable, and makes no prior assumptions about an individual’s relationships. In the domains of Health Informatics, Adaptive Systems and User Modelling, a model has been defined for adaptive information sharing across the personal social network. This model provides a number of new insights about information sharing choices made by an individual experiencing a health crisis (the ego) and their supporters (alters).

The National Health Planning and Resources Development Act. Public Law 93-641, the last major step in the regulation of the health care system, created a network of health system agencies and state level health planning agencies. Subsequent legislation, the Health Planning and Resources Development Amendment 1929, Public Law 96-79, amended 1974 Law and changed the role and function of health systems agencies to include more regulatory activities. By 1981, the activities of Health System Agencies were being curtained by the action of the Reagan administration. The Health promotion/wellness movement which seeks to improve health has been developing as a compliment to medical medicine for several years. Previous research has determined that health systems agencies were active in health promotion and identified several planning and implementation activities related to this involvement. This is a survey of health systems agencies to determine their efforts in healthy promotions. Resources allocated to these activities, and opinions of the director relevant to agency involvement in health promotion. All active healthy system agencies listed in the 1980. Directory of Health System Agencies (DHSH) were surveyed by a mailed questionnaire. Reponses were receive from 112 agencies (57%) and the respondents were found to be representative of the population. The results revealed health systems agencies to be involved in health promotion. More than 90 percent of the responders listed some type of health promotion activity in their Healthy System Plans for the 1979-1980 planning year. Approximately half of the responders reported some community activity in health promotion. The majority of executive directors saw health systems agencies as being only moderately effective in controlling health care costs: considered healthy promotion as a viable means of controlling health care cost: and believed that modifications of individual life-styles had the greatest potential for improving health status. The survey revealed that Healthy System Agencies did not restrict the wellness/health promotion activities to traditional health facilities, but were defining health broadly and working with a variety of agencies to develop services.

This project attempts to describe how a hospice and palliative care partnership program works. Through the assessment of one such program, the researcher sought to find out the essential components of the partnership including how the two partner organizations interact and work together. Data was collected using various methods: document review of organization documents such as newsletters, annual or quarterly reports, brochures and other available literature e.g. materials on organizations’ website and on social media; in-depth interviews with stakeholders of both organizations that included staff and board members; observation of staff working; and participant observation during organization events. The findings of the research shows that in order for organizations to have an effective partnership program in place, both partners need to have strong leadership in place, possess a willingness to learn from each other, maintain regular communication, and visit each other regularly. With this in place, several outcomes of the program are likely such as: increasing advocacy for hospice and palliative care, increasing visibility of the organizations both nationally and internationally, and provides an opportunity for organizations to network with other organizations in their locality in order to achieve partnership objectives. The study further reveals that global collaborations in the field of hospice and palliative care began with the advent of the international hospice movement. The assessment of this hospice partnership demonstrates how organizations can establish working relationships and the results likely to come out of such an initiative.

Wits Business School University of Witwatersrand Johannesburg, South Africa Master in Finance and Investment (2014) / Following decades of under-investment, gaps in Africa’s healthcare infrastructure are becoming disturbingly obvious. The interplay of governments’ fiscal policies of budget imbalance reduction and other political considerations present a seemingly insurmountable obstacle to overcoming the backlog in Africa’s healthcare infrastructure. The two main objectives of this study were to understand the sources of financing and the best way to structure the financing of healthcare infrastructure in Africa. Looking at financing arrangements in various industries; and how healthcare sectors in developed countries have been financed, the report draws on perspectives from the financiers on how the healthcare infrastructure gap should be filled in Africa. This study, which utilised survey questionnaires and in-depth interviews, identified government revenues, regional development banks, private equity and donor financing numbers as dominant funding sources for the financing of healthcare infrastructure in Africa. Further, the study explored various ways in which finance could be structured and found that within those various models of financing, donor financing and government revenue were statistically significant on structuring the finance, especially within public-private partnership arrangements. These include sale and lease back arrangements (p=0.0022), complete ownership of projects by the private sector (p=0.003), management operation contracts (p=0.00034) and other forms of PPPs. More perspectives were obtained on enablers and barriers to improving investability of the healthcare sector. Africa’s economic growth and the improving ease of doing business were major enablers for healthcare sector’s investability. However, the role played by government as both a financier and a regulator seemed a barrier. Some structural models that would need government back-up include subordinated debt; with pricing at marginal cost and matching risk and return recovered through the taxation system. The latter continues to characterise much of Africa’s publicly provided healthcare infrastructure. In conclusion, investments in healthcare may not be separated from a country’s level of financial deepening. As the sector develops, it then becomes possible to utilise the models aforementioned. It is recommended that any governments’ investments in healthcare be more catalytic, to unlock value that allows the private sector to compete, both as financiers and innovators in healthcare. Furthermore clear strategies on PPPs are urgently needed for healthcare in Africa including policy consistency in financing and regulating healthcare.

A research report submitted to the Faculty of Commerce, Law and Management, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, November 2015 / The aim of this study was to give an account of what it means to be a hospital consultant in a national health service that has been undergoing change for almost three decades. Classic grounded theory was used to identify the main concern of hospital consultants sampled for the study and how they resolved this concern on a routine basis. Data were obtained from three sources: interviews, observation and document analyses. Classic grounded theory procedures of constant comparison and theoretical sampling were used and Rolling with the Punches emerged as the pattern of behaviour through which the hospital consultants dealt with their main concern, which was managerialism. Rolling with the Punches involves four modes: Stabilising Temporarily, Resisting, Limiting the Impact and Adjusting to/Living with. The mode of behaviour was contingent on a central and on-going Weighing-up process, in which the hospital consultants used their personal narratives, beliefs and commitment structures to make sense of what was happening and what they could possibly do about it. Hence, the mode of behaviour was contingent, historicised and in flux. The Weighing-up process can set off triggers that can lead to a change of mode that need not be linear. Key words: doctors, managers, grounded theory, weighing up, stabilising temporarily, resisting, subverting, quibbling, limiting the impact, lying low, faking it, living with, adjusting to, going with the flow, complying, waiting it out. / MB2016

Significant out-of-pocket spending to afford medications to control blood glucose in elderly people with diabetes is one of the chief challenges to medication adherence. In an effort to reduce the financial burden of prescription drugs on the elderly, Medicare Part D was created and went into effect in 2006. However, one in four Medicare Part D beneficiaries experiences a coverage gap where they must pay 100% of total prescription drug costs. Approximately a quarter of those individuals discontinued their drugs when they reached the coverage gap. Currently, with the Patient Protection and Affordable Care Act of 2010, the coverage gap will be eliminated by 2020. This dissertation examines which factors affect medication adherence in adults with diabetes (Aim 1) and whether the recent policy effort of Medicare Part D effectively decreases the financial burden of prescription drugs on the elderly with diabetes (Aim 2). Chapter One provides the significance of out-of-pocket costs for medication adherence in elderly individuals with diabetes as well as background information on Medicare Part D and its coverage gap. Chapter Two reviews the literature to synthesize current knowledge that has informed the methodology for this dissertation. This chapter also identifies gaps in this body of work. These include comparing advantages and disadvantages of medication adherence as measured by patient self-report, pharmacy refills, and electronic lids on medication containers. Two systematic reviews are conducted in order to determine the most commonly used measurements and definitions of medication adherence measured by pharmacy claims data, and to identify barriers to and facilitators of medication adherence among adult diabetes patients. Lastly, previous studies that focused on the impact of Medicare Part D and its coverage gap on out-of-pocket pharmacy costs and medication adherence are reviewed. Chapter Three describes the methodologies to address Aims 1 and 2 including the study design, information on the data source, sample descriptions, a conceptual framework, study variables and analytic plans. Chapter Four presents key findings of this study, and Chapter Five concludes with summaries and interpretations of the findings, implications for practice and policy, and recommendations for future research.

The increasing adoption of electronic health records (EHRs) has led to an unprecedented amount of patient health information stored in an electronic format. The ability to comb through this information is imperative, both for patient care and computational modeling. Creating a system to minimize unnecessary EHR data, automatically distill longitudinal patient information, and highlight salient parts of a patient’s record is currently an unmet need. However, summarization of EHR data is not a trivial task, as there exist many challenges with reasoning over this data. EHR data elements are most often obtained at irregular intervals as patients are more likely to receive medical care when they are ill, than when they are healthy. The presence of narrative documentation adds another layer of complexity as the notes are riddled with over-sampled text, often caused by the frequent copy-and-pasting during the documentation process. This dissertation synthesizes a set of challenges for automated EHR summarization identified in the literature and presents an array of methods for dealing with some of these challenges. We used hybrid data-driven and knowledge-based approaches to examine abundant redundancy in clinical narrative text, a data-driven approach to identify and mitigate biases in laboratory testing patterns with implications for using clinical data for research, and a probabilistic modeling approach to automatically summarize patient records and learn computational models of disease with heterogeneous data types. The dissertation also demonstrates two applications of the developed methods to important clinical questions: the questions of laboratory test overutilization and cohort selection from EHR data.