This dissertation analyses public health service delivery at the Sir Seewoosagur Ramgoolam National Hospital (S.S.R.N.H.) in Mauritius. Particular emphasis is laid on the historical development of public health service delivery at S.S.R.N.H. Public health service delivery has been approached from the view points of its nature and scope. The core components of the research survey have been on some major obstacles and flaws in effective public health service delivery at S.S.R.N.H. The measuring instrument used for the research survey was a self­ administered questionnaire. The main findings were discussed especially absenteeism, personnel turnover, stress, burnout, morale, sexual harassment, lethargy and disobedience, nepotism, shirking responsibility, alcohol and drug abuse, active political interference, bribery and corruption, dishonesty and retaliation and neglect of duty. Attention was also devoted on the current national health policy for improving public health service delivery at S.S.R.N.H., inter-alia, the National Policy for Public Heath Act 17 of 2000 and the White Paper on Health Sector Development and Reform of December 2003. The public health environment is constantly altering. Therefore, it is essential to adjust to the changing health environment. This dissertation has addressed the future challenges in the micro health environment and macro health environment of S.S.R.N.H. Ultimately, a holistic instead of a parochial approach to addressing shortcomings identified in public health service delivery at S.S.R.N.H. has been advocated in this dissertation. / Public Administration / M.Admin. (Public Admin)

This dissertation analyses public health service delivery at the Sir Seewoosagur Ramgoolam National Hospital (S.S.R.N.H.) in Mauritius. Particular emphasis is laid on the historical development of public health service delivery at S.S.R.N.H. Public health service delivery has been approached from the view points of its nature and scope. The core components of the research survey have been on some major obstacles and flaws in effective public health service delivery at S.S.R.N.H. The measuring instrument used for the research survey was a self­ administered questionnaire. The main findings were discussed especially absenteeism, personnel turnover, stress, burnout, morale, sexual harassment, lethargy and disobedience, nepotism, shirking responsibility, alcohol and drug abuse, active political interference, bribery and corruption, dishonesty and retaliation and neglect of duty. Attention was also devoted on the current national health policy for improving public health service delivery at S.S.R.N.H., inter-alia, the National Policy for Public Heath Act 17 of 2000 and the White Paper on Health Sector Development and Reform of December 2003. The public health environment is constantly altering. Therefore, it is essential to adjust to the changing health environment. This dissertation has addressed the future challenges in the micro health environment and macro health environment of S.S.R.N.H. Ultimately, a holistic instead of a parochial approach to addressing shortcomings identified in public health service delivery at S.S.R.N.H. has been advocated in this dissertation. / Public Administration and Management / M.Admin. (Public Admin)

MHealth is an upcoming area promising to contribute benefits to health service delivery. The purpose of this study was to identify and describe the rate of mHealth utilisation as well as opportunities for mHealth and the barriers to use at one central hospital in Zimbabwe. A quantitative, descriptive, cross-sectional study was undertaken at the central hospital. Data collection was done using structured questionnaires. The entire population of medical doctors at the hospital (N=42) were the respondents of the research. The 18 mHealth activities were chosen from a possible of 101 available. The most used as well as the least used mHealth activities were identified and the reasons for use or lack of use were identified. The study revealed that 75% of the activities were currently being used and 95% had the potential of future use by medical doctors. This study highlights the potential of mHealth from medical doctors’ perspective. / Health Studies / M. A. (Public Health)

The history of psychiatry is littered with serious failures of governance, to the detriment of mentally disordered people, especially those resident in psychiatric hospitals. Current mental health providers, increasingly focussed on community care, have also struggled to develop effective internal governance systems. Nine peer-reviewed research papers, published by the author (mostly with others) and the wider literature, reveal deficits in mental health governance at a jurisdictional, professional, and corporate level. In this thesis new governance solutions are developed against this background, built on contemporary principles in mental health and healthcare management. A new model of mental health governance is presented, based on the key demands of the strategic and regulatory environment, articulated as rights, risks and recovery. This integrated healthcare governance approach, covering provider policy, staff training and service audit, can monitor and ensure the protection of patients’ rights, as well as those of others; it also promotes the management of clinical risks, and of patients’ recovery outcomes. Rights-based risk-reduction training is the core interventional element of the model, whilst the monitoring element can be formalised as part of a Balanced Scorecard reporting system. This thesis makes a contribution to research methodology, theory and practice in mental health, human rights, healthcare management and governance. The model generates specific propositions for testing in mental health governance, with the potential for application in wider settings of service provision.

Today, in 21st century healthcare at least 10% of hospitalised patients are subjected to some degree of unintended harm as a result of the treatment they receive. Despite the growing patient safety agenda there is little empirical evidence to demonstrate that patient safety is improving. Patient Safety Leadership Walk Rounds (PSLWR) were introduced to the UK, in March 2005, as a component of the Safer Patients Initiative (SPI), the first dedicated, hospital wide programme to reduce harm in hospital care. PSLWR are designed, to create a dedicated ‘conversation’ about patient safety, between frontline staff, middle level managers and senior executives. This thesis, explored the use of PSLWR, as a proactive mechanism to engage staff in patient safety discussion and detect patient harm within a Scottish healthcare system- NHS Tayside. From May 2005 to June 2006, PSLWR were held on a weekly basis within the hospital departments. A purposive sample, (n=38) of PSLWR discussions were analysed to determine: staff engagement in the process, patient safety issues disclosed; recognition of unsafe systems (latent conditions) and actions agreed for improvement. As a follow-up, 42 semi-structured interviews were undertaken to determine staff perceptions of the PSLWR system. A wide range of clinical and non-clinical staff took part (n=218) including medical staff, staff in training, porters and cleaners, nurses, ward assistants and pharmacists. Participants shared new information, not formally recorded within the hospital incident system. From the participants perspectives, PSLWR, were non threatening; were easy to take part in; demonstrated a team commitment, from the Board to the ward for patient safety and action was taken quickly as a result of the ‘conversations’. Although detecting all patient harm remains a challenge, this study demonstrates PSLWR can be a useful tool in the patient safety arsenal for NHS healthcare organisations.

The central hypothesis of this study was that the allocation system for NHS hospital and community health services between 1997 and 2003 was not meeting key principles of compensating for differences in the need for services and unavoidable costs. The review and analyses in this study indicate that the underpinning assumptions used when formulating the need adjustment were not robust and that this led to the selection of inappropriate proxies for need. In addition it is concluded that the age adjustment underestimated the costs of elderly care. This study has concluded that the pay adjustment, which was the largest in the formula, did not reflect actual unavoidable differences in cost because the Warwick studies that were used to set the adjustment ignored the monopsonistic nature of the NHS. As a consequence the pay adjustment was based on the assumption that NHS salaries should be related to local salaries. This study identified unavoidable additional costs of providing healthcare in rural areas. These findings were consistent with other comprehensive studies on healthcare costs in Scotland, Wales and Northern Ireland. This study concludes that the exclusion of a market forces adjustment for rurality was inconsistent with all other comparable allocation formulae in the Home Countries. The absence of a rurality adjustment resulted in rural areas receiving a lower proportion of NHS funding than was justified and this is referred to as the Inverse Share Law. This study concludes that the central hypothesis was correct and that a rurality adjustment was justified, but that the principal determinant of service quality was an adequate focus on efficiency.

There is a noticeable absence of studies reflecting the personal views and experiences of black British African Caribbean (BBAC) people as students and clinical participants in UK nursing careers. Previous research about their nursing career choices has always been reported as part of other mixed BME cohorts and migrant groups. Indications in the literature suggest that they were being actively discouraged by their families from choosing nursing as a career, because of their parents’ and grandparents’ negative experiences as migrant workers in the NHS, leading to very low or non-participation in the profession. This study set out to address this gap by giving them a distinct voice, independent of other cohorts. It explored the factors which influence their decision and their experiences, throughout a variety of life stages, from school through to university and into clinical practice. This was to identify whether the findings from earlier research are still relevant from their perspectives rather than that of their parents. Participants and schools in the study were recruited by purposive sampling, and data was collected in three phases, a pilot study phase, a survey phase and an interview phase. A quantitative and qualitative interpretive approach were adopted underpinned by a mixed methods design. Descriptive statistical analysis of the survey and qualitative content analysis (QCA) of the interview transcripts were utilised to enable interrogation of the data. Findings are discussed within the context of available empirical evidence, related policy perspectives and theoretical underpinnings. Four main themes emerged from the study, as specific influencing factors on their experiences. These are: careers advice and choice for nursing, support, discrimination/racism and personal resilience. The findings reveal that BBAC people receive little or no careers advice about nursing at any of their life stages. Consequently, they make uninformed decisions about modern nursing careers, leaving a gap in their knowledge. However, they are not discouraged from choosing nursing as a career, by their families. When they choose a nursing career, they are fully supported and encouraged by their parents and families, in order to survive as students and clinical practitioners. However, institutional support as students and practitioners is weak and very poor. Despite this, they do not intend to actively discourage their own children from making nursing a career choice. Racism, discrimination and racialisation remain core factors influencing their social, educational and other lived experiences, despite numerous equality legislation and implementation. These have a continuous negative impact on them as visible minority students and practitioners in the NHS. They respond to these negative experiences by developing personal resilience aided by strong social and cultural support provided by their families and community. These findings make a unique contribution to the knowledge base by giving BBAC participants their own distinct voice. This was achieved through listening to them at varied points in their life stages, from school through to university and as eventual professionals in nursing. This is important new knowledge, which has ensured a clear recognition of their personal perspectives, in their own voices. These insightful new observations are necessary to build a specific knowledge base about them and are very positive for future participation of BBAC people in nursing careers and the NHS. An adapted model for inclusive participation is proposed, based on the findings of the research.

Réalisé en cotutelle avec l'Université de Paris-Sud / La thèse a pour objectif d’étudier les rapports entre les besoins typiquement hétérogènes des personnes âgées vivant dans la communauté et l’utilisation conséquente des services médicaux et sociaux. Inspirée du concept de la fragilité, l’approche a d’abord consisté à modéliser l’hétérogénéité des besoins en classant les individus – par l’analyse de classes latentes (ACL) – dans des profils-types, chacun représentant une constellation particulière de problèmes de santé. Appliquée aux données recueillies dans le cadre du projet de démonstration du SIPA (Système de services intégrés pour personnes âgées en perte d’autonomie), l’ACL a révélé 4 profils qui se distinguent sur le plan qualitatif par les dimensions physique et cognitive, et sur le plan quantitatif par la gravité des incapacités que les individus manifestent (Article 1). L’analyse des transitions entre les profils sur 1 an et 22 mois montre des changements différenciés selon les profils et le sexe, et confirme la stabilité de la classification et sa sensibilité aux changements d’état de santé. En outre, les profils sont robustes aux effets de la mortalité et de l’attrition due aux sorties d’étude. Les rapports entre les profils, les variables sociodémographiques et les indicateurs de résultats tel l’hébergement et la mortalité appuient la validité de la classification. Les profils ont ensuite servi à modéliser les besoins dans des modèles économétriques ajustés pour étudier l’utilisation et les coûts par profil d’état de santé pour une gamme de services financés par le système public (Article 2). Ces analyses montrent que les profils permettent d’identifier des configurations distinctes d’utilisation et de coûts pour des sous-groupes représentatifs de la population âgée fragile. La sensibilité des profils aux différences d’accès et aux différences d’intensité d’utilisation révèle les choix de ces groupes cibles par les autorités locales dans la prestation des services institutionnels et des services de proximité. Enfin, une analyse fine de ces relations a été menée pour la couteuse période précédant le décès dans le but d’établir si l’intensification des coûts en fin de vie concerne les personnes âgées de manière homogène quelque soit la gravité de leur état de santé (Article 3). Les analyses comparatives des survivants et des décédés montrent une tendance inverse dans les coûts des services selon l’état de santé. Les personnes qui survivent dans des états de santé compromis coûtent significativement plus que leurs homologues relativement sains. En revanche, c’est chez les individus relativement sains, indépendamment de l’âge, qu’on retrouve les coûts de fin de vie les plus élevés – liés principalement aux hospitalisations de courte durée. Combiné aux résultats qui montrent que les coûts sont significativement moindres chez les sujets de plus de 85 ans, ce travail confirme l’hypothèse d’une compression des coûts attribuables à la morbidité chez les décédés les plus âgés. L’originalité de cette thèse tient au fait que très peu de travaux ont tenté de modéliser l’hétérogénéité de l’état de santé dans le but d’étudier ses conséquences sur l’accès, l’intensité et les coûts des services sociaux et médicaux pour notre population de référence. En outre, alors que la pertinence des soins de fin de vie et le maintien à domicile sont au cœur des préoccupations, ce travail est le premier à décrire les rapports entre l’état de santé et les coûts en fin de vie pour les personnes âgées fragiles vivant dans la communauté. / Abstract This thesis aims to study the relationship between the typically heterogeneous needs of community-living elderly and their consequent utilization of health and social services. Inspired by the concept of frailty, the approach consisted in modeling the heterogeneity – by latent class analysis (LCA) – to group individuals into homogenous categories of health status, each representing a constellation of health problems. Applied to the data collected for the demonstration project of the system of integrated services for frail elderly (SIPA), LCA revealed four health state profiles that distinguish the physical and cognitive dimensions of health and capture severity along the disability dimension (Article 1). Transition analyses over 1 year and 22 months showed differentiated and gender-specific patterns of transition probabilities, confirming the sensitivity of the profiles to change in health status. The profiles are stable over time and robust to mortality and lost to follow-up attrition. Relationships between the profiles, sociodemographic characteristics and distal outcomes, such as mortality and institutionalization, confirm the classification’s validity. These profiles were then used in two-part econometric models to study access and costs of several measures of publicly funded services (Article 2). Our results show the profiles are able to identify distinct configurations of service utilization and costs in substantially meaningful subgroups of the frail elderly population. What is important here is that the health state profiles are sensitive to differences, and changes, in available patterns of care in a specific milieu. These differences reveal choices of target groups by local authorities in delivering institutional and community-based services. Finally, a fine analysis of these differences was performed for the costly period preceding death to establish whether the high end-of-life costs affect all elderly homogenously irrespective of the severity of their health state (Article 3). A comparative analysis revealed that survivors’ and decedents’ costs of care trends according to health status go in opposite directions. Severely disabled survivors cost significantly more compared to their relatively healthy counterparts. In contrast, the highest end-of-life costs – driven by acute hospitalizations – belong to the relatively healthy, independent of age. Among survivors and among decedents, the oldest old (85+) cost significantly less compared to younger age groups. Combined, these results support the notion of a compression of costs due to morbidity in the oldest old decedents. The originality of this thesis rests on the fact that few very few studies attempted to model heterogeneity in health status with the goal of estimating its effect on patterns of service utilization. Moreover, in light of the shift towards community-based care as a response to economic pressures and population aging, our work is the first to describe the relationship between health status and end-of-life care in frail community-living elderly.

Subjects: This diploma thesis is dedicated to the topic of time management in nursing - it deals with four generations of time management and with its different techniques. Furthermore it describes functions and roles of a manager. Objectives: The main objective of this thesis is to analyse time management issues that concern nurse managers working in intensive care. The main goal of the research is to answer following question: How do nurse managers in intensive care use and organise their working time? Secondary goals are: to name priorities of nurse managers on an ordinary working day, to find out which timekeeping devices do nurse managers use for direct measuring of time consumption, to analyze managerial strategies used by nurse managers for their time management, to sum up the most frequent tasks postponed by nurse managers for a later time and find the reasons of procrastination. Methodology: Data were gained through a combined quantitative and qualitative research design. Quantitative research was done through the use of a time frame of a working day and a working week of nurse managers. Results were presented in boxes and charts to provide a better overview. Data for qualitative analysis were gained through semi-structured interviews in three focus groups. Qualitative data were processed...

Objetivo. A integralidade das ações, diretriz finalística do Sistema Único de Saúde brasileiro, é mnuito referenciada no plano discursivo, mas pouco estudada. Este trabalho buscou apreender teórica e empiricamente princípios, mecanismos e desenhos organizacionais que possam contribuir para operacionalização dessa diretriz, à luz de proposições de modelos de atenção inseridos em práticas municipais. Essa apreensão se faz nas dimensões política ético-normativa, tecnológica, e sobretudo no plano organizacional-gerencial implicado. A tese defende o espaço organizacional enquanto dimensão privilegiada da condução do processo de transformar as diretrizes políticas do modelo de atenção em conjuntos de processos de trabalho com ações de saúde informadas pela integralidade da atenção. Recuperação Bibliogrática. Foi realizada uma revisão em publicações especializadas sobre o uso da expressão integralidade em saúde ou equivalente (integração assistencial, medicina integral, ações integradas em saúde, atenção integral à saúde, integração sanitária, e similares). Discriminou-se como suas principais modalidades conceituais: dimensão coletiva do objeto de trabalho em saúde; integralidade dos cuidados ao indivíduo; integração sanitária, integralidade da promoção à saúde; e, integralidade da atenção, enquanto prestação integrada das ações de um sistema local de serviços de saúde para resolver problemas de saúde de sua área de abrangência. O movimento historicamente recente da saúde pública brasileira permite afirmar que a integralidade em saúde é um princípio ético que se define no campo filosófico do direito à saúde, o que informa sua tradução em uma diretriz política, e que tem uma proposição organizacional e tecnológica. Metodologia. Trata-se de uma pesquisa qualitativa desenvolvida em uma secretaria municipal de saúde selecionada entre os maiores municípios do estado de Santa Catarina, que mostraram no estudo exploratório possuir um plano de saúde tendo como prioridade a mudança do modelo de atenção de acordo com o princípio e diretriz da integralidade em saúde. Para a apreensão empírica fez-se um estudo de caso organizacional, desenvolvido através de 17 entrevistas abertas realizadas em profundidade. Os entrevistados foram selecionados em razão de sua inserção no movimento de mudança do modelo de atenção no SUS do respectivo município. Para análise do material empírico procedeu-se ao ordenamento dos dados, no seu processamento foram sendo delineadas categorias evidenciadas nos relatos e os resultados se apresentam através da construção de um discurso do sujeito coletivo, com adapações metodológicas próprias. Resultados. A análise do material empírico, iluminada pelo quadro teórico construído, permite organizar a partir das dimensões política, tecnológica e organizacional teoricamente constatadas, a formulação de um desenho para contribuir em processos de transformação organizacional, referidos à mudança do modelo de atenção em saúde. Trata-se de sete vias organizacionais que, em seu conjunto articulado apresentam potencialidade de operar a integralidade em saúde, quais sejam: um trabalho a partir da rede básica, o processo de planejamento no sistema municipal de saúde, funcionamento da estrutura organizacional, comunicação da estratégia, gerenciamento loco-regional, participação democrático-popular na gestão e a via pedagógica. Considerações Finais. Por referência às evidências relatadas são enunciados princípios e mecanismos potencialmente construtores de concepções e condições organizacionais na perspectiva da integralidade em saúde. Discute-se, finalmente, a necessidadde de considerar tais concepções enquanto arranjos históricos específicos apontando para a determinação social e histórica da integralidade como conceito e como prática. As implicações para futuras pesquisas são aventadas, recomendando-se estudos adicionais / Objective. The idea of integrality has been the most important ethical and normative principle of the Brazilian Health System (Sistema Único de Saúde). Nevertheless it has not been well studied. This work tried to identify the organizational conditions required carrying out activities in such a way as to aim municipal health systems to reach the principle. This thesis advocates the management features as a special dimension in reaching effective integrality. Bibliographic review. It was done a review of specialized publications on the use of the expression integrality of health or any expression with a similar meaning. The main concepts identified were briefly described. The review also described the ideas and practices on comprehensiveness in the recent history of Brazilian health system. Methodology. This is a qualitative research developed in one of the major municipal health secretariats located in the state of Santa Catarina, Brazil. Data was collected through open interviews with health professionals. The professionals were selected in terms of their participation in the movement for changing the working model of health services. They were interviewed using open questions. The analysis of the empirical data was carried out through the construction of a collective discourse, using the appropriate methodological adjustments. Results. The analysis and discussion of the empirical data enabled the organization of seven different ways, which together present the potential for operating integrality: health attention centered on a primary care net; political-organization, local-regional management, democracy, learning organizations and pedagogy. Final considerations. Using the discussion above, it was possible to define the principles and tools that can help to carry out the integrality in a right way. Implications of that in future research are discussed, and additional studies are recommended