Model development for incorporating “indigenous” postnatal care into a midwifery healthcare system is of utmost importance in ensuring the provision of culturally congruent care. There has been only limited evidence of the availability of a model which addresses “indigenous” postnatal care practices in midwifery health care systems. As a result, the nurses operate from a modern healthcare point of view only, rather than combining the two worldviews. The main aim of the study was to develop a model for incorporating “indigenous” postnatal care practices into the midwifery health care system in Mopani District, Limpopo Province of South Africa. The study was conducted in three phases. During the first phase the meaning of the concept “incorporation” was analysed. The results guided the researcher during data collection in the second phase, consisting of in-depth individual and focus group interviews to explore the experiences and perceptions of postnatal patients, family members, traditional birth attendants, registered midwives, Midwifery lecturers and the maternal and child healthcare coordinators. The findings confirmed that currently the “indigenous” postnatal care practices are not incorporated in the Midwifery curriculum, books or guidelines for maternity care. As a result there is lack of knowledge amongst midwives regarding the “indigenous” postnatal care practices and it is difficult for them to provide culturally congruent care. Due to inadequate knowledge midwives are displaying negative attitudes towards the family members, traditional birth attendants and patients from diverse cultures. The participants confirmed that there is no teamwork between the registered midwives and the traditional birth attendants (family members). The study findings also confirmed that currently there are no follow-up visits by the midwives for patients during the postnatal period. The midwives are imposing their health beliefs an practices onto the patients on discharge after delivery, without the involvement of the family members or the traditional birth attendants, resulting in sub-standard postnatal care, leading to postnatal complications and an increasing maternal mortality rate. Based on the findings of phases one and two, a model for incorporating “indigenous” postnatal care practices into a midwifery healthcare system was developed and described. The implications for further studies suggested the evaluation and implementation of the model in the healthcare institutions, nursing colleges, clinics and hospitals as an initial step to assist the Department of Health in Limpopo Province in incorporating “indigenous” practices into healthcare systems. / Thesis (PhD)--University of Pretoria, 2012. / Nursing Science / unrestricted

In a democracy, what should a healthcare system do? It is a question of relevance to many disciplines. In this thesis, I examine that question, and add something original to the existing debate by drawing on, and synthesizing, thinking from several disciplines, and especially philosophical ethics, economics and systems theory. Paper 6 in this thesis, entitled “In a democracy, what should a healthcare system do?”, tackles the thesis question directly. The central conclusion of that paper, and of this thesis, is that a healthcare system in a democracy should do as much good as possible, although sometimes some overall good should be sacrificed for the sake of fairness, as John Broome has argued. However, what counts as the good of healthcare, and when good should be traded off for fairness, depend on your weltanschauung (or worldview). Political pluralism is normal, and every democracy has institutions and processes for making policy when people disagree because their worldviews differ. Ultimately, elected policymakers are accountable for making decisions. This analysis is complemented by paper 5, entitled “Accountability for reasonableness – as unfair as QALYs?”. It assesses the vulnerability of three theories of resource allocation to injustice. It concludes that Daniels and Sabins’ accountability for reasonableness approach is vulnerable because it does not require evidence of costs and benefits. Maximising quality-adjusted life years can also lead to large-scale injustice because it is concerned only with health gain, and not with fairness. I conclude that a “good and fairness framework”, which is drawn from the writing of John Broome, is the least vulnerable to large-scale injustice. There are four other papers in this thesis. “What has the state got to do with healthcare?” (paper 3) makes the case for an important assumption underpinning this thesis, namely that the question of what a healthcare system should do is a question of public policy. Paper 1, entitled “It’s time for rational rationing” argues that efficiency gains are not inexhaustible, and to continue with its austerity programme, policymakers should assess whether the NHS in England could do more good with the same money by doing different things. I explore how philosophical ethics can contribute to policy, and the importance of context when writing papers about policy, in: “Should policy ethics come in one of two colours: green or white?” (paper 2) and “How can one be both a philosophical ethicist and a democrat?” (paper 4).These latter two papers, and much of the narrative within this thesis, explain how my thinking has developed during the course of my PhD, and why I have looked within and beyond philosophical ethics for an answer to my central research question.

The goal of this thesis is to characterize healthcare systems in Czech and Slovak Republic. It compares and describes a development of specific metrics and it aims to create a clear picture of efficiency of a healthcare system in each particular country. In the first part the sole proprietors, employed persons, citizens without any taxable income and citizens insured by state are characterized. The focus of this part is also a description of health insurance system. This description aims mainly on contemporary legal situation, system of redistribution and historical development of healthcare systems. In the practical chapter a system of public health insurance from 2006 until 2010 is analyzed together with national insurance revenue, basic demographic and economic facts influencing the system of health insurance. The practical chapter further analyzes health insurance companies. This analysis is based on comparison of insurance companies from the perspective of insurance revenue and healthcare expenditure. The conclusion summarizes all results of analyses and comparisons.

Le point de départ de cette thèse est le constat que dans les systèmes de santé post-soviétiques les paiements informels aux professionnels de santé perdurent bien au-delà de la transition post-socialiste, et ce malgré les vagues de réforme successives du système de santé.Dans le même temps depuis l'indépendance de la République du Tadjikistan, une défiance profonde envers certains professionnels de santé s'est développée et le renoncement aux soins s'est accru, touchant plus particulièrement les populations vulnérables. Quel rôle jouent alors les différentes pratiques de rémunération informelle ? Sont-elles source de défiance ou un moyen de restaurer la confiance ? Les paiements informels sont-ils ajustés au niveau de vie des patients ou source d'inégalités entre patients ?D'après les indicateurs d'équité mobilisés et contrairement aux idées reçues, les paiements informels ne permettent pas de rendre le système progressif et de garantir l'accès à tous. Les populations les plus démunies cumulent plus de renoncement aux soins.Face à ces barrières à l'accès aux soins, différentes stratégies sont mises en place par les ménages : solidarités informelles, endettement, recours à la médecine traditionnelle, mobilisation de son capital social.On étudie alors, plus précisément, dans quelle mesure la migration, phénomène massif au Tadjikistan, fait partie de ces stratégies et dans quelle mesure les remises de fonds permettent aux ménages bénéficiaires d'améliorer leur accès aux soins. / This dissertation begins with the observation that informal payments to healthcare professionals in post-soviet health systems persisted well beyond the post-socialist transition and despite the successive waves of health care reform.During this transition period, since the independence of the Republic of Tajikistan, there has been a deterioration of trust towards certain health professionals which has been associated with increased forgone care, especially among vulnerable populations. What is the role played by the different informal payment practices? Are they a source of mistrust or a means of restoring trust? Are informal payments adjusted to patients' standard of living or a source of inequality between patients?According to the equity indicators mobilized and contrary to popular belief, informal payments do not make the system progressive and do not guarantee that there will be access for all. The poorest are more likely to forgo care.To cope with these barriers in accessing care, different strategies are put in place by households: informal solidarity, indebtedness, reliance on traditional medicine, mobilization of social capital.More specifically, we then study if migration, a relatively important phenomenon in Tajikistan, is part of these strategies and to what extent remittances enable beneficiary households to improve their access to healthcare.

El acceso a un sistema de salud digno constituye uno de los derechos fundamentales de toda persona, en el Perú se han realizado grandes esfuerzos para mejorar la calidad de los sistemas de salud, es un desafío al bicentenario el brindar un aseguramiento de salud de calidad que pueda alcanzar a todos los peruanos. Este objetivo enfrenta grandes desafíos ya que existen deficiencias en los procesos de las instituciones que brindan servicios de salud, siendo la Aseguradora Pública de Salud uno de los principales actores en el aseguramiento de la salud en el Perú. Nuestra investigación se ha centrado en el proceso de Evaluación Automática (EA), que tiene como objetivo evaluar la validez de las atenciones brindadas por las Instituciones Prestadoras de Servicios de Salud (IPRESS) afiliadas a la Aseguradora Pública de Salud. Durante los años 2017 y 2018 se detectó que el 3.82% y 1.85% del total de atenciones presentaban irregularidades. Estudios hechos a nivel mundial muestran que el nivel de irregularidades en entidades similares se encuentra entre el 3% y el 10% por lo que existe la posibilidad de elevar la capacidad de detección de irregularidades en la citada aseguradora. A través de nuestra investigación hemos identificado que mediante el uso de modelos predictivos construidos mediante la analítica de datos en el proceso de Evaluación Automática (EA), específicamente en la etapa llamada Supervisión Médica Electrónica (SME), se puede incrementar el nivel de detección de irregularidades, para ello es necesario aplicar la metodología CRISP-DM y el software WEKA. / Access to a decent health system is one of the fundamental rights of every person, in Peru great efforts have been made to improve the quality of health systems, it is a challenge for the bicentennial to provide quality health assurance that can reach all Peruvians. This objective faces great challenges since there are deficiencies in the processes of the institutions that provide health services, with the Public Health Insurer being one of the main actors in health insurance in Peru. Our research has focused on the Automatic Evaluation (EA) process, which aims to assess the validity of the health care provided by the Health Services Provider Institutions (IPRESS) affiliated with the Public Health Insurer. During the years 2017 and 2018 it was detected that 3.82% and 1.85% of the total health care presented irregularities. Studies done worldwide show that the level of irregularities in similar entities is between 3% and 10%, so there is the possibility of increasing the ability to detect irregularities in the aforementioned insurer. Through our research we have identified that by using predictive models constructed through data analytics in the Automatic Evaluation (EA) process, specifically at the stage called Electronic Medical Supervision (SME), it is posible to increase the level of irregularity detection, for this it is necessary to apply the CRISP-DM methodology and the WEKA software. / Trabajo de investigación

The Swedish healthcare system is strained today, along with a rise in the number of elderly people in the country. Aside from the expected physical ailments facing this group, mental health issues such as depression are also common amongst older adults. It is the researchers’ assumption that these three societal challenges; the healthcare system being strained, the growing elderly population and the health issues present amongst this group, are connected. Virtual Reality (VR) technologies show promising benefits according to the scientific literature and may prove to be a useful tool in combating the listed challenges. However, the researched benefits of this technology can’t be utilized properly if the target group perceives it as negative or cumbersome, which is why it is imperative to explore this group’s attitude towards the usage of VR as a preventative part of their treatment. This paper aims to explore the perceptions of Virtual Reality technologies in treatment of elderly and to focus on their and the caretakers’ attitudes of its usage, in addition to eventual annoyances or limitations with their current applications by answering the research question: how is the usage of VR technologies in care related functions perceived by elderly people and their caretakers? A qualitative study with an inductive approach was performed by using a small-scale survey strategy, with a focus on the perceptions and experiences of people as well as their feelings and emotions, while aiming to describe and understand the lived experiences of the target demographic and their caretakers. Face-to-face interviews with a semi-structured format were employed at two recreational facilities for elders in Sweden, with participants consisting of three elders between the ages of 83 and 91 along with three caretakers, all of whom were female and had used some form of VR technology in the past. The collected interview data was then analyzed by way of thematic analysis, which generated a total of 2 themes, 8 categories and 21 codes. The results show that both elders and their caretakers generally have a positive attitude towards the use of VR, with none of the interviewees seeing any drawbacks towards its usage. All interviewees wished to see VR become a regular part of the offerings at the recreational facilities, with the frequency of use being deemed reasonable at 2 weeks by all elders who took part in the study. The preferred types of VR experiences consisted of either visiting familiar places or emulating activities that the elders were no longer capable of performing. It was concluded that nostalgia played a big part in what experiences the elders enjoyed, and generated positive effects including feelings of relaxation, escaping reality and increased socialization amongst the elders.

The tremendous need for comprehensive healthcare among underserved populations has been well documented. Most of the healthcare resources have been allocated to major metropolitan areas and largely populated cities. In Massachusetts alone, 500,000 people are not serviced by proper healthcare because they are unemployed or underinsured. They do not have a home base for their needs, most visit emergency rooms or minute clinics for care. They lack continuity of care. For minorities and underserved populations, there is a gap in the healthcare system. Statistics have shown that the lower your socioeconomic status, the more advanced the disease has progressed before it is diagnosed, leading to fewer treatment options and poorer outcomes. This is often due to Healthcare Deserts / Health Professions Shortage Areas in the US where there is a true lack of access to healthcare resources. One effective system for healthcare belongs to the Cuban government. Since the revolution in 1949, one of the main goals of the Cuban government was to provide primary care to all its population. The system before the revolution was centralized in the cities and was available mostly to the wealthy and urban populations while the remaining population was left with a substandard and underfunded system like many developed and undeveloped countries. In this paper, we will explore the success of the Cuban system and extrapolate some aspects of its system to use in the underserved populations that inhabit Healthcare Deserts. Implementation of systems will create an Oasis of providers that will naturally improve the well-being of populations leading to the well-being of federally funded state and local resources. The Cuban system divided the country into a grid system and each grid was subsequently divided into even smaller areas with a population of approximately one thousand. A primary care team consisting of a doctor and a nurse was assigned to each grid, including a dental component, and charged with the health and well-being of the population. This system was so successful that it was exported to other countries such as Venezuela, and it was adopted by the World Health Organization as the healthcare model standard to be followed in their world efforts. These programs have been implemented in Latin America, Africa, and Asia with different levels of success due to resource availability and financial constraints. In Venezuela during the Chavez administration, the system was implemented and achieved its highest level of success by benefiting the poor and underserved while Chavez was in power, creating thousands of clinics and improving the healthcare of the population. In Africa, Tanzania adopted the primary care approach at its new dental school and is producing strong clinicians versed with this approach. In Asia, the WHO has made progress in some areas; however, success has proven dependent on the country’s political and financial situation. The primary care approach that the system embraces, emphasizes prevention and education at a very early stage. This is key, and the data proves the success of campaigns even with limited resources provided there is the involvement of the local population. In contrast, United States resources are concentrated on the coasts and urban locations such that the rural areas have the least resources, and people in rural locations often travel long distances to access healthcare. A few states in the US have implemented programs that have been successful – Colorado, North Carolina, and New Mexico. If we successfully transplant teams of healthcare providers, including doctors, dentists, nurses, pharmacist, optometrist, obstetrics /gynecology, pediatricians, and a complete and sustainable health center into empty grids, slowly a series of Oasis will be created and access to care will improve. This change needs to happen at multiple levels, it is a task that must be taken collectively, from the teaching institutions exposing healthcare students to the need for providers in these rural and underserved areas, increasing funding to provide more scholarships and programs that funnel recent graduates into these areas with a sustainable and self-replenishing model, and most important, emphasizing education and prevention in dental school curriculum as the key to improving healthcare, and creating Oases in the current deserts.

Obesity, a condition of excess body fat, is one of the most complex problems facing health systems. Lifestyle management programs that combine diet, physical activity, and intensive behavioral therapy have been shown by research to support a degree of weight loss that produces health benefits (i.e., at least a 3-5% initial body weight). However, it has been difficult for research-developed programs to be delivered in typical practice to have a meaningful impact. Integrated research-practice partnerships that involve the coming together of academic researchers, health system administrators, and program delivery staff may help overcome this gap, especially during this transformational time in the healthcare sector. This dissertation aimed to develop an understanding of how using the integrated research-practice approach would facilitate and sustain evidence-based lifestyle management strategies across a health system to treat obesity among patients and employees. An integrated research-practice partnership with Carilion Clinic, a health system in western Virginia, served as an example for the study. From 2013-2016, the Carilion Clinic integrated research-practice partnership conducted a series of trials testing different strategies for delivering weight loss and weight loss maintenance support. An evaluation guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was conducted to describe implementation processes and outcomes for each strategy. Lessons learned from the evaluation support the value of the integrated-research practice partnership approach as a solution for overcoming gaps in obesity care. A shared priority perspective between research and practice was identified as the powerful process for supporting facilitation and sustainability of strategies. In addition, findings from the evaluation produced evidence to inform the future development of a system for Carilion Clinic to help patients and employees lose weight and keep it off through lifestyle management. / Ph. D.

Yes / Interoperability within different healthcare systems (clinics/hospitals/pharmacies) remains an issue of further research due to a barrier in sharing of the patient’s Electronic Health Record (EHR) information. To solve this problem, cross healthcare system collaboration is required. This paper proposes an interoperability framework that enables a pharmacist to access an electronic version of the patient’s prescription from the doctor using a RESTFul API with ease. Semantic technology standards like Web Ontology Language (OWL), RDF (Resource Description Framework) and SPARQL (SPARQL Protocol and RDF Query Language) were used to implement the framework using JENA semantic framework tool to demonstrate how interoperability is achieved between a pharmacy and a clinic JENA was used to generate the ontology models for the pharmacy called pharmacy.rdf and clinic called clinic.rdf. The two models contain all the information from the two isolated systems. The JENA reasoner was used to merge the two ontology models into a single model.rdf file for easy querying with SPARQL. The model.rdf file was uploaded into a triple store database created using FUSEKI server. SPARQL Endpoint generated from FUSEKI was used to query the triple store database using a RESTFul API. The system was able to query the triple store database and output the results containing the prescription name and its details in JSON and XML formats which can be read by both machines and humans. / Supported by a Institutional Links grant, ID 261865161, under the Newton-Ristekdikti Fund partnership. The grant is funded by the UK Department for Business, Energy and Industrial Strategy and Indonesia Ministry of Research, Technology and Higher Education and delivered by the British Council.

As mudanças ocorridas no Sistema Único de Saúde nos últimos anos, associadas às mudanças nas políticas educacionais, forçaram uma modificação na atuação do profissional farmacêutico. Nesse sentido, o farmacêutico necessita adquirir capacitação para atuar em conjunto com a Equipe Multiprofissional de Saúde. O objetivo deste trabalho foi avaliar se o ensino superior em Farmácia no Brasil capacita o farmacêutico a atuar em colaboração com a Equipe Multiprofissional de Saúde dentro dos preceitos do Sistema Único de Saúde. Com base em metodologia quanti-qualitativa, este trabalho analisou projetos político-pedagógicos e o cenário clínico de hospitais universitários de cinco instituições de ensino superior brasileiras, e estudou, a partir de questionários qualitativos, aplicados a diversos profissionais de saúde, as necessidades da equipe em relação à atividade do farmacêutico. Verificou-se inserção ainda modesta do farmacêutico, muitas vezes causada pela falta de conhecimento da equipe sobre sua função ou por uma sensação de falta de preparo do próprio profissional. Também, a análise dos documentos oriundos dos cursos permitiu a constatação da falta de um olhar direcionado para o Sistema Único de Saúde e para a formação clínica. Poucas iniciativas curriculares tem surgido nesse sentido. Por fim, são apresentadas propostas, por meio de mapeamento conceitual, para se pensar um currículo em que coexistam a formação técnica, já tradicional, e a formação clínica, permitindo abarcar essa última, deixada de lado a partir de meados do século XX, que retorna hoje como uma demanda social. / Recent modification in the Brazilian\'s Public Health System, associated with changes in educational policies for higher education, forced a change in the pharmacist\'s professional performance area. Accordingly, the pharmacist needs to acquire capacity to act in conjunction with the Health Multidisciplinary Team. The objective of this thesis was to evaluate whether higher education in Brazil Pharmacy Schools enables the professional to work in collaboration with the Health Multidisciplinary Team within the precepts of National Public Health System. Based on quantitative and qualitative methodology, this study analyzed political-pedagogical projects and the clinical setting of university hospitals of five Brazilian higher education institutions, and studied from qualitative questionnaires applied to various health professionals the needs of the Multidisciplinary Health Team in having as a team member the pharmacist. There was verified a still modest insertion of the pharmacist in health teams, often caused by lack of staff knowledge about their function or by a sense of lack of readiness of the professional himself. Also, the analysis of documents from Pharmacy courses led to confirmation of the lack of educational policies directed to the National Public Health System and clinical training. Few curriculum initiatives have arisen in this regard. Finally, proposals are developed through conceptual mapping, to think of a Pharmacy course curriculum that can coexist in both the technical training as clinical training, allowing embrace this professional area of actuation that was set aside from the mid-twentieth century and returns today as a social demand.