Overview: A global shortage of over 7.2 million health workers poses a threat to service delivery particularly in sub-Saharan Africa. Sub-Saharan Africa bears a quarter of the global burden of disease; yet, it only has three percent of all health workers. Maldistribution and migration both to urban and international destinations pose persistent challenges to service delivery particularly to rural and remote populations. In Kenya, the health human resources are mostly concentrated in urban areas, and in some cases as high 70% of the health workers are serving only 20% of the population. Literature to date, particularly in the context of Kenya, has focused on doctors and more recently nurses. There has been a gap in analysis in exploring mid-level cadres such as clinical officers, a cadre of non-physician clinicians. Research objectives: The objectives of the research were to: 1) conduct a contextual analysis of human resources for health in Kenya; 2) understand the migration perspectives of Kenyan health professionals including doctors, nurses and clinical officers through an online survey; 3) explore the role of mid-level health worker cadre of clinical officers as a promising practice for Kenya. The thesis is presented in three papers congruent with the three research objectives. I interrogated these areas at a macro, meso and macro level using systems thinking theory. Findings: The first paper found significant developments in the policy context of managing health professionals in Kenya all of which have improved the working conditions for health professionals. International migration was found to have decreased over the past decade and was not deemed be a policy priority by government and development partner stakeholders. Health professional representatives, on the other hand, asserted that they continue to be disgruntled with the current situation and would not hesitate to migrate given the opportunity. The second paper found that the factors that discourage health professionals from staying in Kenya are similar to those available in the literature and include: dissatisfaction with remuneration, governance, working conditions and living conditions. Among health professionals considering migration, few had made short-term plans to leave. Family ties and fear of the unknown were found to be strong factors for continuing to work as health professionals in Kenya. Job security was found to be high in the government while recruitment agencies were not found to play a significant role in migration decisions of health professionals. The third paper found that there was general support for the scale of up clinical officers to enhance the Kenyan health workforce. Barriers to scale-up included resistance from medical doctors, who felt that clinical officers were not competent enough to handle complicated cases, and a lack of employment opportunities given a surplus of about 3,000 unemployed clinical officers in Kenya, who could potentially fill in the health workforce gaps. Conclusion: Overall policy developments have been implemented since 2007 presenting a promising future to the management of human resources for health (HRH) in Kenya. Although few health professionals are making concrete steps to migrate out of Kenya they continue to be dissatisfied with the current living and working conditions. Maldistribution and overall shortages of health professionals continue to hamper service delivery to vulnerable rural populations. Mitigating factors include the potential of scaling up the clinical officer cadre particularly through the surplus of 3000 unemployed clinical officers, a process that requires sufficient political and professional will. A holistic multi-level approach to health system planning is crucial to ensure that any new investments are well coordinated and involve an overall scale-up of health professionals.

O objeto deste trabalho é o movimento estudantil contemporâneo. O objetivo foi caracterizar os estudantes que participam do movimento estudantil contemporâneo, identificar os principais temas discutidos pelo movimento na atualidade, caracterizar as práticas e formas de organização do movimento estudantil e analisar as concepções de saúde tomadas pelo movimento. Trata-se de pesquisa descritiva em que a exposição do objeto se deu, tanto pela via qualitativa, como pela via quantitativa. A coleta dos dados quantitativos ocorreu durante o conselho nacional de entidades de base (CONEB) da União Nacional dos Estudantes (UNE) entre os dias 13 e 16 de abril de 2006; os dados qualitativos foram colhidos entre os meses de abril e novembro de 2006 em Campinas e São Paulo (SP). A população foi constituída de estudantes universitários que participam de centros acadêmicos e outras entidades estudantis. Foram distribuídos aos participantes do CONEB questionários com perguntas fechadas combinando: informações acerca do estudante; questões acerca das condições sociais de suas famílias; questões acerca da participação política e social dos estudantes. Num segundo momento, foram entrevistados apenas estudantes da área da saúde e da UNE. Esse foi o momento em que, através de questões abertas, os estudantes se manifestaram acerca dos temas, do sentido e do impacto do ME, sua relação com os partidos políticos, limites e possibilidades no encaminhamento das organizações estudantis, bem como informações sobre a concepção de saúde e prática relativa às questões de saúde. Foram entrevistados dois representantes da UNE e um representante de cada executiva da saúde: biomedicina, educação física, enfermagem, farmácia, fisioterapia, fonoaudiologia, medicina, nutrição, odontologia, psicologia, serviço social, terapia ocupacional e veterinária (1 de cada curso), totalizando 15 entrevistas. Valeu-se da técnica de entrevista semi-estruturada. Resultados: os estudantes que fazem parte do movimento estudantil são em sua maioria homens, jovens brancos, solteiros, naturais do eixo sul-sudeste; quando consideradas a situação de trabalho dos pais, renda familiar, posse de moradia familiar, fontes de renda e gastos pessoais, prevalecem condições de existência relativamente estáveis. Os estudantes consideram o movimento estudantil um espaço de organização da juventude para lutar pela transformação social, espaço de formação política em que são discutidos diversos temas, sendo prevalentes os temas da educação e universidade, é um espaço também de disputa política com inserção importante dos partidos políticos. Os estudantes avaliam que o movimento está fragmentado entre executivas de curso e União Nacional dos Estudantes, apesar da sobreposição de atividades desenvolvidas pelas entidades. A concepção de saúde mais enfatizada entre as lideranças estudantis foi a multicausal, representada notadamente por fatores relacionados à esfera do consumo. Sobressaem também concepções que se aproximam do pensamento hegemônico “pós-moderno” centradas no indivíduo, na subjetividade e de caráter idealista. Poucos estudantes consideraram nas suas formulações, de maneira organizada, a categoria da reprodução social na determinação do processo saúde-doença. Pode-se concluir que na área da saúde os estudantes tendem a reproduzir os conceitos da saúde pública, fundamentados na concepção funcionalista da saúde-doença que propõe como intervenção a responsabilização do indivíduo pela sua saúde / The subject of this paper is the student movement. The goal was defining the students who take part of the student movement, identifying themes currently discussed by them, defining the practices and organizational ways of the student movement and analyzing the perception of health they have. It’s a describing research in which the exposure of the subject was done by both qualitative and quantitative ways. The collecting of quantitative data was done during the National Concil of Student Societies (CONEB) organized by National Union of Students (UNE) from April, 13th to April 16th, 2006; qualitative data were collected from April to November 2006 in Campinas and São Paulo (SP). Population was formed by university students who take part of a student society and other student organizations. Firstly, questionnaires were given to the participants of CONEB with open questions matching: information about the student; questions about the social conditions of their families; questions about their social and political initiatives. Secondly, natural science students and students from UNE were interviewed. At this moment, through open questions, students made themselves known about the themes, about the goal and impact of student movement, their involvement with political parties, limits and possibilities in student organizations, also, information about their perception of health and practices related to health issues. Two representatives of UNE and one representative of each regional society of natural science students were interviewed: biomedicine, physical education, nursing, pharmaceutics, physiotherapy, phonoaudiology, medicine, nutrition, dentistry, psychology, social work, occupational therapy and veterinarian medicine (1 of each field), totalizing 15 interviews. The technique of semi-structured interviews was used. Results: students who take part of student movement are most men, young Caucasians, single, from the Southeast; when parents’ jobs are taken into consideration, family income, owning a family dwelling, sources of income and personal expenses, relatively stable living conditions prevail. Students consider student movement an opportunity for youth organization fight against social changes, an opportunity for political constitution by the discussion of several themes, prevailing educational and university ones, it’s also a space of political dispute and the inserting of parties. Students believe that student movement is fragmented among regional societies of each science and National Student Union, despite the overlaying of activities developed by societies. The most mentioned perception of health was the multi-causal, clearly represented by factors related to consumption. Also, perceptions centered in the individual, related to “post modern” hegemony overlay, in subjectivity and idealistically. Few students take into consideration, in an organized way, the category of social reproduction while determining health-sickness process. We can conclude that in natural science field, students tend to believe public health concepts, based on functional conception of health-sickness that suggests the responsibility of each of us for our health as an intervention

Submitted by Irene Nascimento (irene.kessia@ufpe.br) on 2016-10-06T18:48:40Z No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) DISSERTAÇÃO2.pdf: 754979 bytes, checksum: 51a17a2de09de7deda62f365841d7fdd (MD5) / Made available in DSpace on 2016-10-06T18:48:40Z (GMT). No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) DISSERTAÇÃO2.pdf: 754979 bytes, checksum: 51a17a2de09de7deda62f365841d7fdd (MD5) Previous issue date: 2016-07-04 / Objetivo: Avaliar a garantia da integralidade das ações no serviço de saúde à pessoa idosa pela atenção domiciliar do Sistema Único de Saúde. Método: Foi utilizado o método de Análise do Discurso contido nos documentos governamentais sobre a atenção domiciliar em saúde principalmente os relativos ao Programa Melhor em Casa do Governo Federal. Ao mesmo tempo foi realizado um levantamento bibliográfico em torno da literatura especializada sobre a temática. Foram realizadas entrevistas em profundidade junto a pessoas idosas com idade maior ou igual a 60 anos, de ambos os sexos, inclusos no serviço de atenção domiciliar em uma unidade hospitalar na cidade do Recife; com profissionais de saúde do serviço; assim como cuidadores participantes do Serviço de Atenção Domiciliar. Foi elaborado um roteiro de entrevista a ser submetido ao Comitê de Ética, mediante assinatura do Termo de Consentimento Livre e Esclarecido, concordando em participar do estudo previamente aprovado pelo Comitê de Ética da instituição de ensino. Resultados: Todos os idosos relatam satisfação com o serviço, entendem as orientações dos profissionais e possuem boa relação com eles. Dois idosos referem terem sido pouco esclarecidos a respeito do mesmo antes de serem cadastrados, mas todos relatam algum avanço em sua saúde/vida após a inclusão no serviço. Ainda dois idosos afirmam que o serviço precisa de algumas melhorias, como por exemplo: a entrega de fraldas e medicamentos. No que se refere às cuidadoras e seu olhar sobre o serviço, todas as entrevistadas afirmam não ter conhecimento sobre o serviço, antes da sua inclusão. Todas Afirmam que o serviço atende as necessidades do idoso, estando, assim, satisfeitos com o serviço. Todas as entrevistadas afirmam ter boa relação com os profissionais e estes são claros no que diz respeito às orientações prestadas em casa. Duas cuidadoras afirmaram que o SAD não oferece tudo o que foi prometido para o cuidado, relatando a falta de visita médica e a falta de fraldas. Os profissionais do serviço explanaram sobre o conceito de integralidade da atenção à saúde dos idosos, onde três afirmam que o serviço exerce essa integralidade junto aos assistidos. Conclusão: o Programa Melhor em Casa, materializado pelo Serviço de Atenção Domiciliar, surge como uma resposta, uma estratégia de contenção de demanda, fundamental para reduzir o pleito por serviços hospitalares e de fomento à constituição de parcerias entre o sistema de saúde, famílias e comunidades, minimizando a responsabilidade do Estado no que diz respeito a provisão de cuidados em saúde. Um Programa Federal característico de uma contrarreforma do Estado, que expressa novas determinações e demandas ao conjunto dos profissionais da saúde. Tornase um espaço não de afirmação dos direitos dos idosos à saúde integral e humanizada, mas de resposta à necessidade do Estado. / Objective: To evaluate the guarantee of integrated care in the health service for the elderly for home care of the Unified Health System. Method: We used the discourse analysis method contained in government documents on the home health care especially for the program best Home Federal Government. At the same time it carried out a literature around the literature on the subject. depth interviews were conducted with older people with older or equal to 60 years, of both sexes included in the home care service in a hospital in the city of Recife; with health service professionals; as well as participating caregivers, Home Care Service. It was developed an interview script to be submitted to the Ethics Committee by signing the Consent and Informed by agreeing to participate in the study previously approved by the Ethics Committee of the educational institution. Results: All older people report satisfaction with the service, they understand the guidance of the professionals and have good relationship with them. Two seniors reported having been poorly informed about the same before being registered, but all reported some improvement in their health / life after inclusion in the service. Still two elderly say the service needs some improvements, such as: delivery of diapers and medicines. With regard to the caregivers and your eye on the service, all interviewed say they have no knowledge about the service prior to its inclusion. All claim that the service meets the needs of the elderly and is thus satisfied with the service. All respondents claim to have good relationship with professionals and these are clear with regard to the guidance given at home. Two caregivers said that SAD does not offer all that was promised to care, reporting the lack of medical visit and the lack of diapers. Professional service explanaram on the concept of integral health care of the elderly, where three claim that the service carries this wholeness with the beneficiaries. Conclusion: Program Best in House, materialized by the Home Care Service, is a response, a demand for containment strategy, key to reducing the vote for hospital services and fostering partnerships between the health system, families and communities, minimizing the state's responsibility regarding the provision of health care. A Federal program characteristic of a contrarreforma the state, expressing new determinations and demands to all health professionals. It is not a space of affirmation of the rights of the elderly to full and humanized health, but response to the state's needs.

Health authority administrators were interviewed for their perspectives on what makes a good health care system; on tailored population-specific services as a way to address health inequities; and on how they perceive themselves to be making good funding decisions on the public’s behalf. The qualitative descriptive research dataset includes 24 hour-and-a-half long interviews with administrators from four BC health authorities, health region documents, memos, and field notes. Participants support the continuation of a public health care system and all participants acknowledge using tailored services as a route towards reducing health inequities. However, these identified services have not been evaluated for their overall effectiveness. When it comes to decision-making, participants describe using a series of governance and bioethical principles that help them frame what and how issues can be considered. Decision situations are framed in a way that informs them whether they need to use formal or informal processes. In both cases participants collect information that allows others to understand that they have made wise decisions. The Recognition-Primed Decision Model accurately reflects the intuitive processes that participants describe using during informal decision-making and portions of formal decision-making. However, in relation to formal decision situations, there is less alignment with existing Decision-Analysis literature. Seven practice and future research recommendations are provided: 1. Increase health authority participation in intersectoral partnerships that address non-medical determinants of health. 2. Develop new strategies for addressing health inequities. 3. Evaluate the efficacy of using tailored services beyond their ability to remove barriers to access. In addition, increase focus on testing new strategies for reducing the inequities gap. 4. Enhance existing decision-making processes by including the explicit review of decision tradeoffs, value weighting, and mechanisms for requesting revisions. 5. Focus future research on developing and evaluating the usefulness of formal decision-making tools in health authority structures and their relation to decision latitude. 6. Launch a longitudinal research study that examines how health authority expert decision-makers use judgmental heuristics and how they avoid the negative effects of bias. 7. Commission public dialogue on shifting the current illness-based system to one that is wellness based. / Graduate and Postdoctoral Studies / Graduate

Background: Obesity and physical inactivity rates have reached epidemic levels in Canada, but differ based on whether they are self-reported or directly measured. Canadian research examining the combined and independent effects of social and built environments on adult physical activity (PA) and body mass index (BMI) is limited. Furthermore there is a lack of Canadian studies to assess these relationships using directly measured PA and BMI. Objectives: The objectives of this thesis were to systematically compare self-reported and directly measured PA and to examine associations between neighbourhood built and social environmental factors with both self-reported and directly measured PA and overweight/obesity in adults living in Ottawa, Canada. Methods: A systematic review was conducted to identify observational and experimental studies of adult populations that used both self-report and direct measures of PA and to assess the agreement between the measures. Associations between objectively measured neighbourhood-level built recreation and social environmental factors and self-reported individual-level data including total and leisure-time PA (LTPA) and overweight/obesity were examined in the adult population of Ottawa, Canada using multilevel models. Neighbourhood differences in directly measured BMI and PA (using accelerometry) were evaluated in a convenience sample of adults from four City of Ottawa neighbourhoods with contrasting socioeconomic (SES) and built recreation (REC) environments. Results: Results from the review generally indicate a poor level of agreement between self-report and direct measures of PA, with trends differing based on the measures of PA, the level of PA examined and the sex of the participants. Results of the multilevel analyses identified that very few of the built and social environmental variables were ii significantly associated with PA or overweight/obesity. Greater park area was significantly associated with total PA in females. Greater green space was shown to be associated with lower odds of male LTPA. Factors from the social environment were generally more strongly related to male outcomes. Further to the recreation and social environment, factors in the food landscape were significantly associated with male and female PA and overweight/obesity. Results of the directly measured PA and BMI investigation showed significant neighbourhood-group effects for light intensity PA and sedentary time. Post-hoc tests identified that the low REC/high SES neighbourhood had significantly more minutes of light PA than the low REC/low SES. BMI differed between the four neighbourhoods, but the differences were not significant after controlling for age, sex and household income. Conclusions: Results of this dissertation show that the quantity of PA can differ based on its method of measurement (i.e. between self-report and direct methods) with implications for the interpretation of study findings. It also identifies that PA and BMI can differ by neighbourhood and recognizes that the relationships between neighbourhood environments and PA and body composition are complex, may be differ between males and females, and may not always follow intuitive relationships. Furthermore it suggests that other factors in the environment not examined in this dissertation may influence adult PA and BMI and that longitudinal and intervention studies are needed.

To tackle one of the world’s worst maternal, neonatal and child health outcomes and a chronic shortage of human resources for health, the Afghan Ministry of Public Health deployed volunteer Community Health Workers (CHW) in rural areas of Afghanistan in 2003. This thesis documents the Afghan CHW program, exploring organizational and community contexts. The research design in this study is a mixed methods case study. The actual Afghan CHW program was situated with an Afghan complex adapative health system, mainly guided by the policy of the health system but was also largely influenced by the power and gender dynamics of the community context in which it was implemented. The tasks of CHWs were numerous but CHWs role was more than just the sum of their tasks; they occupied a unique location juxtaposed between formal and informal HRH systems. It is important to acknowledge the assembly of so many national and international organizations in achieving a shared goal of providing health services to a large population in an unstable and partially insecure environment. The shared goal in the Afghan context may have been interpreted only in terms availability of services, though the goal carries with it, either explicitly or implicitly, the values of effectiveness, efficiency, timeliness, and costliness – known as quality by some participants of this study. The community component was another layer of the complex adaptive system that made up the Afghan CHW program. Political-ethnic power in the community and legal-rational authority of the health system influenced the way communities were mapped in an inequitable manner, in turn, contributed to the unfair distribution of resources to the populations. Finally, the intersection of the gender equity approach and the gendered nature of the work as a cross-cutting layer added to the complexity of the Afghan health system.

This project is at the controversial intersection of medicine patent protection and access to medicines at the international level. Advocates for medicine access argue that medicine patent protection may allow prices to become elevated, thereby frustrating medicine access. But advocates for medicine patent protection argue that the patent system incentivized the research and development to make the product possible in the first place. While this ideological debate is valuable, this doctoral project acknowledges the patent system’s existence and seeks to produce research to advance medicine access pragmatically within this context, especially in developing countries and especially for drugs appearing on the World Health Organization’s Model List of Essential Medicines (MLEM). In cooperation with the World Intellectual Property Organization, this project commenced with a legal study to assess the patent status of the entire MLEM (375 medicines) in 137 developing countries. Gathering these patent data and verifying them with global pharmaceutical suppliers was this project’s principal data collection. The patent data were further linked to development indicators of the countries implicated by our study and to economic data detailing medicine procurements made by those working with assistance from international organizations. Building upon the techniques refined during the MLEM study, three supplementary patent studies were performed to investigate very specific questions regarding medicine patenting and medicine access. With these patent data collected, we investigated companies’ medicine patent filing behaviours internationally. Various policy approaches to accelerating access at the international level were compared, including those that disregard patent protection and those are based on cooperation between medicine suppliers. Of the approaches considered, the cooperative approaches appeared to be the most efficient, especially voluntary licensing practices (i.e., originator companies license generic manufacturers to supply the product to developing countries in exchange for royalties). We find that while patents may detour generic competition at times, we also find they may serve as springboards for collaborative endeavours and global medicine access campaigns, like the one for HIV drugs. This thesis concludes by arguing that improved international medicine patent transparency by pharmaceutical suppliers is one of the most powerful ways to foster such collaborations to improve medicine access.

Introduction: Tuberculosis (TB) is an infectious disease that causes significant morbidity and mortality. Despite the fact that the total burden of TB has decreased dramatically, the distribution of that burden across the Canadian population has not changed. A century ago, the Indigenous population of Canada had a significantly higher TB mortality than the non-Indigenous population. This gap still exists today. TB is a disease of poverty, and understanding the role of the social determinants of health (SDH) may provide insights into the causes of persistence of TB in the Indigenous population. Research questions: This thesis tackles three questions: 1) Can a TB outbreak that took place over a century ago be reconstructed? 2) What can we learn about the relationship between the disease, the population it afflicted, and the environment in which the outbreak took place? 3) How can reconstruction of a TB outbreak be used to evaluate policy interventions? Area studied: Analyses were limited to the Qu’Appelle Agency, located in Southeastern Saskatchewan. Methodology: An agent-based model of socioeconomic environment of the Qu’Appelle Agency was developed to study the relationship between TB and SDH. Data on TB mortality, demographics, agricultural production, material circumstances, and economic factors of production were used to study the relationship between TB and SDH at the aggregate level. Results: 1) Extensive aggregate data analyses were carried out and an agent-based model of TB transmission and of the socioeconomic environment of the Qu’Appelle Agency was developed. 2) Results of these analyses identify a number of important parameters responsible for the high TB mortality in the Agency. These parameters include biological factors, housing, social characteristics, agricultural output, and policies of the Department of Indian Affairs. Conclusions: This research demonstrates that reconstruction of an outbreak of an infectious disease that took place over a century ago is a complex undertaking that hinges on availability of data and significant expertise in a variety of fields, such as health sciences, economics, mathematics, and modelling approaches. The further one goes into the past, the more one is forced to rely on assumptions, which make the reconstructed web of relationships between agent, host, and environment that caused the outbreak less certain. Despite the inherent uncertainty, the process of outbreak reconstruction provides a deep and multi-faceted understanding of the interactions among the agent, the host, and the environment. The resulting model is a useful way of studying policy interventions that could be applied in other contexts as well – to other infectious diseases or TB outbreaks on other reserves. Keywords: [population health, epidemiology, tuberculosis, Indigenous peoples, agent-based modelling, social determinants of health]

Background: This thesis presents three research papers that evaluate the current tools and methods used to assess the availability of health resources and services during humanitarian emergencies. Methods: A systematic review of peer-reviewed and grey literature was conducted to locate all known health facilities assessment tools currently in use in low- and middle-income countries. The results of this review were used to generate a framework of essential health facilities assessment domains, representative of seven health systems building blocks. Using this framework, a field-based evaluation of tools used to assess the availability of health resources and services in emergencies in Haiti and the Darfur states of Sudan was conducted. The collected assessment tools from these countries were compared against the framework from the systematic review, as well as the Minimum Standards for Health Action in the Sphere Humanitarian Charter and Minimum Standards in Humanitarian Response, and the Global Health Cluster’s Set of Core Indicators and Benchmarks by Category. A coding system was developed using all of these frameworks that enabled the comparison of the assessments collected in both countries. Field-based interviews were conducted with key informants using a convergent interviewing methodology, to gain perspectives on data collection and the use of evidence in formulating health systems interventions in emergencies. Results: 10 health facility assessments were located in the systematic review of the literature, generating an assessment framework comprised of 41 assessment domains. Of the included assessments, none contained assessment criteria corresponding to all 41 domains, suggesting a need to standardize these assessments based on a structured health systems framework. In Haiti and Sudan, a total of 9 (Haiti, n=8; Sudan, n=1) different assessment tools were located that corresponded to assessments of the availability of health resources and services. Of these, few collected data that could reasonably have corresponded to the different assessment domains of the health facilities assessment framework or the Sphere Standards, nor could many have provided the necessary inputs for calculating the Global Health Cluster’s indicators or benchmarks. The exception to this was the one tool located in Sudan, which fared reasonably well against these criteria. The interviews with participants revealed that while evidence was viewed as important, systematically-collected data were not routinely being integrated into program planning in emergency settings. This was, in part, due to the absence of reliable information or the perceived weaknesses of the data available, but also due uncertainty as to how to best integrate large amounts of health system data into programs. Conclusions: Greater emphasis is needed to ensure that data on the availability and functionality of health services during major emergencies is collected using methodologically-sound approaches, by field staff with expertise in health systems. There is a need to ensure that baseline data on the health system is available at the outside of emergency response, and that humanitarian health interventions are based on reliable evidence of needs and capacities from within the health system.

The goal of this study was to determine relationships between health information behaviors and population health as well as their relationships with particular facets of urban ecology.