The rising costs of health care and the lack of integration between parts of the delivery system has led to discussion and experiments on new forms of delivering care. Governments have included the development of ambulatory care in new statements of objectives and goals in the hope that expenditures might be reduced through the reduced use of acute care hospital beds. This is a study of the experience surrounding an acute care hospital's attempts to have a Medical Day Care Program accepted by the government as an adjunct to the existing Ambulatory Care Services of the hospital. As Director of Nursing at the hospital it was possible to follow the sequence of events, concept development, proposal design, ministry involvement, implementation and evaluation. A diary was kept for one year following implementation of the program as a pilot project and project documents have contributed to the analysis of events. What was not readily apparent were the many forces outside the hospital which were impacting on the likelihood of the proposal's acceptance. Since Ambulatory Care was the health policy of the 1970's it was puzzling to find the Ministry of Health unresponsive to a proposal which seemed most appropriate. In attempts to resolve the puzzle regarding the lack of interest in ambulatory care at the hospital level, other developments in the province were reviewed. Planning models were explored seeking explanation for inconsistencies observed between stated government objectives and government behavior in relation to the development of hospital ambulatory care. More satisfactory explanations were found in a political model than in planning models, in the light of actual developments. Some conclusions are drawn about the impact of political realities on management functions in health care institutions. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

This thesis examines the historical development and the present state of health services in the Greater Vancouver area. With particular reference to its advocacy of universal and comprehensive medical care coverage, the Hall Report is used as a framework from which these services are evaluated. Recommendations of the Report and implications of these for the future development of health services are considered. Basic concern about health needs has historically been an integral part of social work and social welfare. Although health and welfare have developed into separate areas of concern their common focus continues to be the provision of services adequate to meet existing need. This focus is the rationale upon which the thesis is based. Included in this study are public health services, hospitals, and non-profit medical care coverage plans. These are the major public institutions through which community health services are provided. Information was obtained through interviews with relevant personnel, and from a review of pertinent literature and legislation. On the basis of this information, the nature, extent, and organization of these services are described. The institutions are examined, both as to their individual programmes, and their part in the total network of health care. The findings and recommendations of the Hall Report are taken into consideration in assessing the present organization and provision of health services. It is concluded that although the organization and provision of health services, on an individual basis, appears adequate, optimum functioning could be achieved by a policy of over-all planning and coordination. / Arts, Faculty of / Social Work, School of / Graduate

The provision of health care and preventive services that has evolved in Canada was based on the concept of equality. Within any one province all but a few selected groups pay equal prepaid insurance premiums or tax and are given the same benefit; payment of the provider for services rendered. The concept of Distributive Justice suggests that those with special needs should receive special services but selective provision of care or services may give rise to feelings of Relative Deprivation in non-recipients. For a health service to be equitable and perceived as "fair" there must be maximal distributive justice and minimal relative deprivation. During a research project in the Kitimat-Stikine Regional District during the summer of 19 75, it was found that northern British Columbians viewed their health services as unfair. They believed they subsidized the care and services used by southern British Columbia residents. This study investigates the factors in the health service system which affect the utilization and provision of health services and compares the utilization of hospital services of the Kitimat-Stikine Regional District with three other regional districts; Cowichan Valley, North Okanagan and East Kootenay and with British Columbia as a whole province. The comparative regional districts were chosen on the basis of demography, lifestyle, industrial, ethnic and geographic similarities and differences. Statistical tools used were Frequency Distribution, Simple and Multiple Regression. Determinants of access to care are discussed; the perception of illness, convenience costs, financial costs, availability of manpower, programmes and facilities, social and geographic isolation. An examination is made of the distribution of power in the health system and the use that is made of it by political decision makers, government administrators and planners, professional organizations, educators and pressure groups. The health services in the Kitimat-Stikine Regional District are described with emphasis given to missing programmes. The regional district has a high facilities-population ratio and a low manpower-population ratio. The expectations of the residents of northern British Columbia for provision of health care are presented, noting a concentration of expectation on access to acute health care. The planner's expectations, arising from elements in the health system are delineated. Manpower, facility and hospital utilization data were obtained for the four regional districts and the province. The hospital utilization data, separations by disease of residents from hospitals within and without their domiciliary regional district are subjected to statistical testing to determine whether access to care is reduced in the remote regional districts. The data are adjusted for the age and sex composition of the populations of each region-.and the province. There is no indication from the examination of hospital utilization data that the barriers to access to care that exist are effective in reducing the access gained. In each of the four regional districts, the numbers of separations are higher than expected based on the age and sex composition of the populations. A breakdown of the data on the 186 diseases into disease grouping indicates that hospital utilization is significantly high in some regions for particular groups of diseases. The results indicate a need to examine lifestyle and environmental factors in the four regional districts that may be influencing hospital use for these diseases. There are implications for policy formulation and for health planning activities. There is a need for regional districts to broaden their area of concern to include health services other than hospitals, to control environmental health hazards of industries, agencies and homes within their boundaries and to educate the residents about their personal responsibility for their health status, the special needs of some groups of people, the services required to meet those needs and why some services cannot be offered locally but require referral outside the regional district. The health system which has developed, based on the concept of equality does not provide northerners with a perception of equity or fairness. There is a need to obtain innovative services to meet special needs and to ensure the people excluded from the extra benefit are aware of the special needs of those for whom it is provided. Services which provide a high degree of distributive justice and minimize relative deprivation would result in an equitable and unequal service that could be perceived as fair by all. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

The study was undertaken when St. Bartholomew's Hospital, in Lytton, B.C., a 27 bed facility, was experiencing under-utilization and the threat of closure. This study examines the health and social services of the area, and suggests alternatives for the hospital. Three methods of investigation were used, involving survey methods, documentary analysis, and oral histories. Two survey instruments were prepared by the researcher and applied to a stratified sample of key informants from the community. The respondents in these surveys were divided into either provider or consumer categories, and stratified within each of these as to the degree of contact with the local hospital. Twenty-five such interviews were held with each major category for a total of fifty completed interviews. A comparative questionnaire was also given to patients of St. Bartholomew's Hospital, asking for specific comparison between that hospital and any other with which the patient may have had personal contact. Documentary analysis involved examination of data from three major sources. The hospital maintained records were examined to present utilization rates according to age, sex, diagnosis, residence location and ethnic origin of patients for specified years. Information from British Columbia Hospital Plan was relied on to provide similar information for the school district of South Cariboo, and for the Thompson-Nicola Regional District, for comparison with local rates. The Medical Services Commission of British Columbia was approached to supply information on the volume of physician visits in the local community for selected years. Oral histories were prepared from various persons in the local health field, and from many other individuals in the community. The purpose of these oral histories was to substantiate the factual material, and to generate new and different information not available from the data. The results of this study indicate that Lytton is probably not going to change much in the next decade, but that patterns of health care delivery, and modes of demand for health services are experiencing a significant change at the present time. The result is that the local hospital has become less favoured, and therefore less used by the local people in satisfying their health service wants. Five alternatives for this hospital were examined in some detail. Alternative A involved no change in the present system. From medical, economic and political viewpoints this alternative is not acceptable. Alternative B suggests a reduction in the present inpatient capacity of the hospital, a restructuring of the governing body, the attraction of a second primary health care worker to the area, and the placement of the present doctor and the additional primary care person within the hospital setting. The additional primary care worker could be either a nurse-practitioner, or a physician on salary to the hospital. This alternative has many strengths, but attempts to facilitate change in the hospital in isolation with little regard to the other health and social agencies in the area. Alternative C has all of the attributes of B but goes one step beyond to house the primary health care workers in a Community Clinic built adjacent to the hospital, and include most of the other health and social services available to this community. This alternative requires substantial initial capital, but represents the optimum for the people of Lytton. Alternative D suggests the closing of the inpatient services, and the creation of a comprehensive Diagnostic and Treatment Centre housing most of the health and social services. Alternative E would be for the hospital to close its doors, offer no services, and make no effort to meet the community's health care requirements. Similar to A, this alternative is deemed unacceptable. The last alternative suggests that the University of British Columbia Faculty of Medicine might take over the hospital as a teaching hospital providing rural exposure to a rotation of resident physicians as part of their formal education. The final report was presented to the Board of Directors of St. Bartholomew's Hospital for their consideration. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

This thesis explores how decision-making agency roles played by doctors, pharmacists and government affect the social efficiency of choices in the prescription drug market. The primary objective is to contribute to the quality of expenditure decompositions in this sector and, thereby, to draw attention to the real cost of drug consumption in Canada. Expenditure growth in the pharmaceutical sector may occur because Canadians are purchasing more drugs or more in terms of the health outcomes sought through drug consumption. Prices may also be rising for the drugs that patients consume. Furthermore, with new generations of prescription drugs replacing older and often equally effective ones, expenditure inflation may be due, at least in part, to growing inefficiencies in consumption. Deflating nominal expenditures with traditional economic price indexes is a commonly used approach to decomposing expenditure changes into changes in price, changes in productivity or both. This method may be biased because decision-making agency relationships and non-standard financial incentives give rise to possible inefficiencies in the pharmaceutical sector that would not commonly be found in other sectors. This proposition is explored theoretically and empirically. Potential biases stemming from financial incentives are explored in the context of the measurement problem posed by the entry of generic drugs. Traditional techniques of the economic approach to measurement do not capture the full effect of generic competition because decision-making agents do not always have incentive to consider the full price of drugs consumed. Potential information-related problems in pharmaceutical price and productivity measurement are explored within the context of the hypertension market. Health outcomes based indexes are constructed for this treatment category based on recognized national guidelines for the treatment of hypertension. Economic indexes of price and productivity appear to overstate social productivity in this segment because persistent non-compliance with national guidelines has resulted in higher costs without corresponding health improvements.

This thesis explores how decision-making agency roles played by doctors, pharmacists and government affect the social efficiency of choices in the prescription drug market. The primary objective is to contribute to the quality of expenditure decompositions in this sector and, thereby, to draw attention to the real cost of drug consumption in Canada. Expenditure growth in the pharmaceutical sector may occur because Canadians are purchasing more drugs or more in terms of the health outcomes sought through drug consumption. Prices may also be rising for the drugs that patients consume. Furthermore, with new generations of prescription drugs replacing older and often equally effective ones, expenditure inflation may be due, at least in part, to growing inefficiencies in consumption. Deflating nominal expenditures with traditional economic price indexes is a commonly used approach to decomposing expenditure changes into changes in price, changes in productivity or both. This method may be biased because decision-making agency relationships and non-standard financial incentives give rise to possible inefficiencies in the pharmaceutical sector that would not commonly be found in other sectors. This proposition is explored theoretically and empirically. Potential biases stemming from financial incentives are explored in the context of the measurement problem posed by the entry of generic drugs. Traditional techniques of the economic approach to measurement do not capture the full effect of generic competition because decision-making agents do not always have incentive to consider the full price of drugs consumed. Potential information-related problems in pharmaceutical price and productivity measurement are explored within the context of the hypertension market. Health outcomes based indexes are constructed for this treatment category based on recognized national guidelines for the treatment of hypertension. Economic indexes of price and productivity appear to overstate social productivity in this segment because persistent non-compliance with national guidelines has resulted in higher costs without corresponding health improvements. / Arts, Faculty of / Vancouver School of Economics / Graduate