Orientador: Gastão Wagner de Sousa Campos / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-22T14:11:19Z (GMT). No. of bitstreams: 1 Monte-Cardoso_Felipe_M.pdf: 1128961 bytes, checksum: 79bf3c446afd7b22c866befd436b70ff (MD5) Previous issue date: 2013 / Resumo: Dentre os impasses vividos pelo Sistema Único de Saúde (SUS), discutem-se atualmente questões relativas à privatização da gestão e da assistência, ao subfinanciamento, à separação entre ações de saúde curativa e de saúde preventiva e às profundas assimetrias sociais no acesso aos bens de saúde. Este estudo busca colocá-las em perspectiva histórica, ao analisar a formação do modo de produção de saúde durante a ditadura civil-militar de 1964 a 1985. Para tanto, se buscará compreender o problema da saúde nos marcos da questão social dentro do processo de formação histórica da sociedade brasileira a partir de revisão bibliográfica. O debate sobre a formação compreende o Brasil como uma sociedade capitalista dependente, caracterizada por uma dupla articulação que combina subordinação externa e segregação social, e advoga a necessidade histórica da superação deste padrão. Durante a ditadura, a lógica dos negócios como estruturante da política de saúde e a modernização dos padrões de consumo no setor foram aspectos estimulados pelo regime, reproduzindo o caráter segregador da saúde no Brasil. Com relação ao primeiro aspecto, a unificação do aparelho previdenciário favoreceu o aprofundamento do modelo de privatização, através do estímulo ao setor privado contratado, bem como aos convênios firmados com empresas, e incentivo estatal para construir e equipar hospitais privados para servir ao sistema previdenciário. O caráter dispendioso do modelo, o uso do fundo previdenciário para outros fins (grandes projetos de infraestrutura) e o acúmulo de casos de corrupção contribuiu para agravar a crise financeira da Previdência Social de fins da década de 1970. Os serviços de saúde previdenciários passaram por um processo de integração aos demais serviços do sistema público como forma de superar a crise, sem, no entanto, transformar o caráter segmentado, lucrativo, privatista e heterogêneo do sistema de saúde. Com relação ao segundo aspecto, a chegada das empresas transnacionais farmacêuticas e de equipamentos e insumos ao Brasil, potencializada pelo regime ditatorial, transformaram as práticas de saúde, aprofundando em escala inédita o trabalho centrado no médico e em procedimentos com alto grau de incorporação tecnológica e dissociados da realidade sanitária brasileira. Estas transformações, afinadas com a expansão do modelo previdenciário privatista, baseadas no mimetismo cultural dos países centrais, terminaram por agravar a dependência brasileira dos produtos das transnacionais, bem como as distorções geradas por este modelo. A crise dos anos 70 e 80 explicitou estas contradições e acelerou a maturação dos movimentos de contestação ao regime e ao modelo de saúde brasileiro, que se aglutinaram em torno da necessidade de uma Reforma Sanitária. Estes movimentos questionaram as bases das práticas sanitárias vigentes e propôs uma estratégia de mudança do setor centrada em reformas do aparelho de Estado apoiadas pela pressão popular. No entanto, a transição pelo alto que caracterizou o fim da ditadura representou a manutenção do monopólio de poder político nas mãos da burguesia dependente, sob a tutela dos organismos financeiros internacionais e em vigência de mais um ciclo de privatização da assistência à saúde, comprometendo o caráter profundamente transformador e democrático das proposições reformistas / Abstract: Among the dilemmas experienced by the Brazilian Unified Health System (SUS), current issues are related to the privatization of management and assistance, the underfunding, the separation between health actions curative and preventive health and the profound social inequalities in access to health goods. This study tries to put them in historical perspective, to analyze the formation of the health production mode during the civil-military dictatorship (1964 to 1985). To do so, it will be tried to understand the health problem in the framework of social issues within the historical process of the Brazilian society formation from a literature review. The debate over the formation comprises Brazil as a dependent capitalist society, characterized by a double articulation that combines external subordination and social segregation, and advocates the necessity of overcoming this historical pattern. During the dictatorship, the business logic structuring of health policy and modernization of consumption patterns in the sector aspects were encouraged by the regime, reproducing the segregated character of healthcare in Brazil. Regarding the first aspect, the unification of the social security favored deepening of the privatization model, by encouraging the private sector contractor, as well as agreements with companies and state incentives to build and equip hospitals to serve the social security health system. The expensive nature of the model, the use of social security fund for other purposes (such as large infrastructure projects) and the accumulation of corruption gates contributed to aggravating the late 1970s' financial crisis of Social Security. Health services went through a process of integration with other services in the public system as a way to overcome the crisis, without, however, transforming the segregated, profitable, privatized and heterogeneous character of the health system. Regarding the second aspect, the arrival of transnational corporations (pharmaceutical and medical equipment and supplies) to Brazil, boosted by the dictatorial regime, transformed health practices, deepening in an unprecedented scale work focused on medical procedures and with a high degree of technological incorporation disassociated from reality of Brazilian health needs. These transformations, in tune with the expansion of privatizing social security model, based on cultural mimicry of central countries, ended up aggravating the dependency of Brazilian products of transnational as well as the distortions generated by this model. The crisis of the 70's and 80 made these contradictions explicit and accelerated maturation of movements against the regime and Brazilian health model, which coalesced around the need for health reform. This movement questioned the basis of the existing sanitary practices and proposed a strategy for change in the sector based on reforms of the state apparatus supported by popular pressure. However, the "transition from above" that characterized the end of the dictatorship represented maintaining the monopoly of political power in the hands of the dependent bourgeoisie, under the tutelage of international financial organizations and in the presence of another cycle of health care privatization, compromising the profoundly transformative and democratic character of the reformists' propositions / Mestrado / Política, Planejamento e Gestão em Saúde / Mestre em Saude Coletiva

archives@tulane.edu / Public health finance is still a relatively young field and, as such, many questions have yet to be asked—and answered. To date, few have examine how specific revenue streams—alone or in combination—shape local health departments’ (LHD) resources and capacity to accomplish their public health missions. Given ongoing policy conversations about financing for public health, it’s important for researchers to rigorously examine the and the potential costs and benefits associated with different revenue sources. Introduction Chapter: The central thesis for the body of work encapsulated by this dissertation is simple: where money comes from matters. This chapter critically examines published evidence and theory linking public health financing mechanisms and their interactions to LHD operations, outputs, and even outcomes. The chapter also introduces situates the specific research questions addressed in this dissertation within a broader conceptual framework. Paper 1: The first paper examines the relationship between revenue diversification and revenue volatility among Washington State LHDs. Using fixed effects linear regression models and revenue data reported during 1998-2014 by all LHDs operating in Washington State, the paper finds little evidence to suggest revenue diversification is significantly associated with revenue volatility. Paper 2: The second paper evaluates whether available revenue sources differentially effected the scope of programs provided by Washington State LHDs between 2000 and 2011. Using two measures of program scope and both linear and non-linear fixed effects panel regression models, the paper finds that only funding received from federal Medicaid was consistently and significantly associated with both measures of program scope. Paper 3: The third paper examines changes in total LHD expenditures in Washington State between 2006 and 2013 following introduction of a new state funding program to support core public health services and infrastructure. Using a pre-post design regression model to evaluate changes in LHD expenditures, the paper finds overall spending among LHDs significantly increased with receipt of the new state funds in the first years of the program. However, those increases were not sustained over the longer term Conclusion Chapter: The final chapter reviews findings from the three papers and discusses their implications for public health policy, practice, finance, and research. / 1 / Abigail Hope Viall

Objectives. To determine the factors associated with mortality during the first hospitalization of patients admitted to a hemodialysis unit. Materials and methods. Observational and retrospective study of patients admitted to “Dos de Mayo” National Hospital between January 2012 and December 2013. For the survival analysis we used the Kaplan-Meier method. A multivariate logistic regression was performed to evaluate the factors associated with hospital mortality. Results. 216 patients with a mean age of 56.9 ± 15.5 years were studied. 24% of patients (n = 51) died during their hospital stay. The mortality rate was 9.3 deaths/100 person-weeks (95% CI: 7.0 to 12.3). We found a tendency of less risk of death in patients with between 1 and 6 months from chronic kidney disease diagnosis (OR 0.84, 95% CI: 0.32 to 2.26) and in those with more than six months from chronic kidney disease diagnosis compared with those who had less than a month from chronic kidney disease diagnosis (OR 0.55, 95% CI: 0.19 to 1.57). Previous care by a nephrologist was not associated with differences in lower mortality (OR 1.14, 95% CI: 0.39 to 3.31). Conclusions. There is poor prior care among hemodialysis patients that form part of an inadequate health care structure and this is associated with high inhospital mortality. / Objetivos. Determinar los factores asociados a la mortalidad durante la primera hospitalización de una población incidente en hemodiálisis. Materiales y métodos. Estudio observacional y retrospectivo de pacientes que ingresaron al Hospital Nacional Dos de Mayo entre enero de 2012 y diciembre de 2013. Para el análisis de la supervivencia utilizamos el método de Kaplan-Meier. Se realizó un análisis de regresión logístico multivariado para evaluar los factores asociados a mortalidad intrahospitalaria. Resultados. Se estudiaron 216 pacientes con edad promedio de 56,9 ± 15,5 años. El 24% de los paciente (n=51) fallecieron durante la estancia hospitalaria. La tasa de mortalidad fue de 9,3 muertes/100 personas-semanas (IC 95%: 7,0 a 12,3). Se evidenció una tendencia a menor riesgo de fallecer en pacientes que tenían entre uno y seis meses con diagnóstico de enfermedad renal crónica (OR 0,84; IC 95%: 0,32 a 2,26), y en aquellos con más de seis meses comparado con aquellos que lo tenían hace menos de un mes (OR 0,55; IC 95%: 0,19 a 1,57). La atención previa por un nefrólogo no estuvo asociada a diferencias en la mortalidad menor (OR 1,14; IC 95%: 0,39 a 3,31). Conclusiones. Existe una deficiente atención previa entre los pacientes en hemodiálisis que forman parte de una inadecuada estructura de atención de salud y que está asociado a una alta mortalidad intrahospitalaria.

Philosophiae Doctor - PhD / National community health worker (CHW) programmes are to an increasing extent being implemented in health systems globally, mirrored in South Africa in the ward-based outreach team (WBOT) strategy. In many countries, including South Africa, a major challenge impacting the performance and sustainability of scaled-up CHW programmes is ensuring adequate support from and supervision by the local health system. Supervisory systems, where they exist, are usually corrective and hierarchical in nature, and implementation remains poor. In the South African context, the absence of any guidance on CHW supportive supervision has led to varied practices across the country. Improved approaches to supportive supervision are considered critical for CHW programme performance. However, there is relatively little understanding of how this can be done sustainably at scale, and effective CHW supervisory models remain elusive. Research to date has mostly positioned supervision as a technical process rather than a set of relationships, with the former testing specific interventions rather than developing holistic approaches attuned to local contexts.

Globally, higher healthcare demand strains existing systems, already overburdened by a lack of resources and funding while longer life expectancy and increased disease burden force higher patient loads. A majority of the South African population is medically uninsured and therefore depend on emergency care; consequently, the healthcare service demand easily exceeds available acute care to prevent life threat. When this happens, emergency centres suffer from overcrowding and long patient waiting times, which increases morbidity and mortality, associated patient risk. Moreover, critical resources such as staff and hospital beds are required for an even flow of patients through hospitals, but are distributed inefficiently. The South African healthcare system configuration therefore delays access to and compromises the delivery of equitable, unbiased life-saving healthcare in an environment moreover challenged by economic pressures. This calls for sustainable, cost-effective reform. Therefore, more efficient healthcare can save more lives by improving access to life-saving care. Research on current Healthcare Information Systems (HIS) shows an incoherent knowledge body with conceptual gaps in theories on healthcare, which disengages transformation potential. Comprehensive reform tactics thus require a priori concept discovery and diagnostics to make research practically useful. The systematic use of BPM theories allowed for the qualitative assessment of as-is process activity at patient touch-points at three hospitals – two public and one private – in the Western Cape of South Africa. Because a strategic Information Systems (IS) methodology, Business Process Management (BPM) poses business process activity improvement, this research draws from successful BPM activity as a means to improve patient flow processes in Emergency Centres (ECs). Success is evaluated by drawing from empirically supported enabler categories and prescriptive guidelines because BPM practice is not yet fully understood. The results show a clear correlation between the improvement areas at the three hospitals; improvements on aspects of actions and decisions taken during patient-flow process activity, therefore support a pragmatic approach to reform. The data confirms disparity between public and private healthcare. Healthcare appears to be a “doctor driven” service, which, based on qualitative decision-making, navigates patients along defined flows, enabled by supporting human capital and hospital assets. Optimal patient flow is a product of symbiotic working relationships and depends on efficient integration with wider hospital functions. Shorter waiting times and hospital stays reduce process burden. This leads to more efficient resource usage and regulated access to healthcare. However, integrated healthcare reform must consider the time demands and rigidity of clinical processes. The challenge lies in finding the space to invite parallel business agility to drive the reform of the stricken healthcare industry in South Africa.

During the last decade, there has been growing international interest in generating new knowledge regarding understanding, developing and evaluating mechanisms that support the use of research evidence by policymakers as a strategy to strengthen health systems in low-and middle-income countries (LMICs). This thesis contributes to this knowledge through three original scientific contributions that employ a mixed methods approach, with the goal of supporting the use of research evidence in the Colombian health system. Specifically, in the chapters I present: 1) the development of an analytical schema that explains the conceptualization of the Colombian government, research funder and universities of an evidence-informed health system; 2) two case studies that explain whether and how political factors influenced the role of research evidence in the agenda-setting and policy-development stages of two past health policy decisions in Colombia; and 3) a protocol for a randomized controlled trial evaluating the effectiveness of a multifaceted intervention in increasing the utilization of an evidence service and the intention to use synthesized research evidence by policy advisors and analysts at the Colombian Ministry of Health. As a whole, the chapters presented in this thesis provide substantive, methodological and disciplinary contributions to the field of health systems research and particularly to the study of efforts that aim to support evidence-informed policy in LMICs. They also help to provide insights that can be utilized to support a more nuanced approach to the use of research evidence in LMICs that takes into account the many factors that can influence health system policymaking. Ideally, this will help those engaged in developing mechanisms to support the use of research evidence in the policy process, and contribute to stronger health systems across the world. / Thesis / Candidate in Philosophy

Following recipes is an analogy for maintaining intervention integrity, or, fidelity. Fidelity is the extent to which an intervention is implemented as intended. This editorial presents a recipe for assessing fidelity in family and health systems. The author discusses the challenges posed by the complex recipes of families and health systems interventions, in both research and clinical practice. The author concludes that increasing the measurement and reporting of fidelity is paramount in the exploding literature around family and health systems research. Researchers and practice improvement champions must find ways to assess fidelity or its proximal indicators and work to innovate new, more efficient methods that allow for ubiquitous fidelity assessment and monitoring systems, ensuring the best care for the families and system stakeholders they serve.

Burnout is a psychological syndrome characterized by feelings of exhaustion, cynicism, and inefficacy, and is particularly prevalent in surgical specialties. Despite the widespread recognition that burnout is the result of exposure to chronic job stressors, research on burnout among physicians has primarily focused on individual correlates and solutions to this issue. We also have a limited understanding of what kinds of interventions have become available to physicians following the pandemic and what the most effective options are for those in independent practice. Thus, this thesis serves to fill a gap in the literature on physician burnout by using a validated organizational framework to identify the organizational drivers of burnout among surgeons and McMaster and update the literature on the state of burnout interventions in medicine. The first chapter explores the state of the literature on physician burnout, with a specific focus on surgical specialties and the theoretical gaps that exist in this field. Chapters two through four describe the design and findings of a mixed methods study exploring surgeons’ experiences with burnout and the workplace stressors associated with its symptoms. Chapter five consists of a systematic review and meta-analysis evaluating the effectiveness of interventions for physician burnout and provides a methodological critique of the available studies in this field. Finally, chapter six integrates the finding from the quantitative and qualitative strand of the mixed methods study while considering the findings in reference to available interventions. The findings presented in this thesis provide tangible recommendations to McMaster’s Department of Surgery on how to improve burnout symptoms with specific reference to the role of payment structures, tensions among leadership positions, patient care burden, moral injury, workplace incivility, and gender inequity. It also highlights opportunities for future intervention development focusing on health system stressors and organizational structures. / Dissertation / Doctor of Philosophy (PhD) / Burnout is a condition that results from issues in the workplace and is extremely common among physicians. Although we generally know where burnout comes from, what causes burnout tends to take different forms in different medical specialties and workplaces. Given the negative effects that burnout has on both physicians and the quality of patient care they are able to provide, it is important that we identify the specific stressors leading to burnout within different medical settings and identify effective interventions for the problems they face. Using a range of evaluation methods, including surveys, interviews, and reviews of the current research on this subject, this thesis looked to identify issues leading to burnout among surgeons at McMaster University, and provide specific recommendations on how to address them.

Many health systems are in the midst of transformation. They are slowly moving from the delivery of reactive care focused on individuals to considering proactive ways of supporting the health and well-being of populations. However, the road to what is often called ‘population-health management’ is rife with implementation challenges. One type of implementation support that has been used to navigate these challenges is technical assistance. Though the use of technical assistance is well documented, there is no consensus on a clear definition or understanding of how it can be used to support system transformation. This thesis contributes to the field of technical assistance through three qualitative studies. First, a critical interpretive synthesis develops a definition and logic model for technical assistance. This logic model integrates diverse academic and grey literature. It aims to draw clearer boundaries around technical assistance as a concept and provide a common language for researchers, technical assistance providers, and decision-makers to use. Second, a qualitative descriptive study explores the use of technical assistance in population-health management transformations in England and the U.S., examining what technical assistance has been provided, by whom, and in what areas of application. Finally, a case study unpacks the use of technical assistance for a recent health-system transformation in Ontario. It examines the influence that political factors related to institutions, ideas, interests and external events have on shaping its evolution. Together, these three studies provide greater clarity on the use of technical assistance in health-system transformations and the range of factors that may affect how it is conceptualized and operationalized. / Thesis / Candidate in Philosophy

Yes / Corruption in the health sector costs over 500 billion USD every year, weakening health system preparedness and response to health crises like the COVID-19 pandemic. The lack of resources to deal with a shock limit the capacity to protect the population, exposing them to a greater risk of infection and mortality. There is an urgent need to improve health policy to reduce corruption in the health sector during times of crisis. This article aims to propose a prepare and response strategy to address corruption during times of health crises. We first explore the inherent characteristics of health systems that make them vulnerable to corruption and present the different faces corrupt practices take. We then explain why anticipatory governance is fundamental in addressing corruption in health systems and draw upon examples of corruption during the COVID-19. Finally, we conclude by proposing that anticipatory governance could decrease the impact of corruption during health crises by increasing the availability of resources required to improve the population’s health.