A ProgramaÃÃo Pactuada Integrada/PPI foi introduzida no Sistema Ãnico de SaÃde, em 1996, como instrumento de planejamento da alocaÃÃo de recursos mediante relaÃÃes intergovernamentais, no sentido da operacionalizaÃÃo do princÃpio da integralidade da atenÃÃo. Para analisar a implantaÃÃo e implementaÃÃo da PPI no CearÃ, entre 2007 e 2009, partindo-se de considerar as necessidades do cidadÃo, realizou-se um estudo quanti-qualitativo, com anÃlise de coerÃncia desta na garantia do acesso e da integralidade das aÃÃes de saÃde. No eixo qualitativo, foi assumido o referencial teÃrico do discurso do sujeito coletivo, de LefÃvre & LefÃvre, para abordar as percepÃÃes dos profissionais das equipes da gestÃo regional na conduÃÃo dos processos de pactuaÃÃo dos recursos financeiros destinados Ãs aÃÃes e serviÃos de saÃde. No eixo quantitativo, foi abordada a relaÃÃo entre a capacidade instalada das unidades de saÃde, as programaÃÃes fÃsico-orÃamentÃrias e as produÃÃes de serviÃos. A coleta de dados foi realizada com entrevistas, mediante aplicaÃÃo de questionÃrio semiestruturado e auto aplicado, alÃm da anÃlise de dados secundÃrios e de documentos. Os resultados evidenciaram a produÃÃo de uma programaÃÃo virtual e incoerente com a capacidade instalada e produÃÃo de serviÃos; assim comprometendo, desde a alocaÃÃo dos recursos, o acesso aos serviÃos e da integralidade das aÃÃes assistenciais. A anÃlise do discurso do sujeito coletivo reforÃou os achados. Ante os limites identificados e as possibilidades de pactuaÃÃo intergestores contribuir no processo de programaÃÃo, discutiu-se a perspectiva de ajustes desta ferramenta da gestÃo, com vistas ao atendimento das necessidades de saÃde da populaÃÃo. / The pactuation integrated programming was introduced in Cearaâs health care system since 1996, as a tool of planning resource allocation/PPI supported by intergovernmental relations, towards the operationalization of the principle of comprehensive care. To analyze the establishment and implementation of the PPI in Cearà between 2007 and 2009, starting to consider the needs of citizens, it was conducted a quantitative and qualitative study, with coherence analysis in ensuring access to comprehensive care. In the qualitative axis it was assumed the theoretical discourse of the collective subject of LefÃvre & LefÃvre, to address the perceptions of the management teams at the regional level in conducting agreements negotiation of financial resources, intended actions and health services. The shaft was quantitatively addressed the relationship between the capacity of health facilities, physical and budgetary schedules and production services. Data collection was carried out with interviews, applying semi-structured self applied questionnaire, as well as analysis of secondary data and documents. The results showed the production of a virtual and inconsistent programming with the installed capacity and services production just committed, since the allocation of resources, access to services and integrated care assistance. The analysis of the collective subject discourse reinforced the findings. Faced with the limitations identified and the possibilities for the managers negotiation contributed to the process of programming it was discussed the prospect of setting this management tool, with a view to meeting the population health needs.

This dissertation examined health care utilization patterns across conventional health care (CHC), complementary and alternative medicine (CAM), and public health care (PHC) systems among Canadians aged fifty and older. I argued that utilization research is currently limited by a primary focus on discrete use of health care services, largely within the CHC system (i.e., medical doctors, specialists, hospitals). However substantial growth in use of CAM and PHC, particularly among late middle-age cohorts, suggests the need to widen the research lens from discretionary service use within health care systems to include medical pluralism or use across health care systems. To address the lack of research on medical pluralism and the need for a comprehensive overview of service use, I used two different strategies to create discrete patterns of service use and non-use. To frame the predictors of these patterns, a medical pluralism paradigm was proposed, which suggests that there are distinct social location and health characteristics that may explain use across health care systems. Five hypotheses were tested using data pooled from two cycles of the Canadian Community Health Survey (Cycles 2.1 [2003] and 3.1 [2005]) to create an overall sample (n=117,824). Results from the deductive (variable oriented) and inductive (person centred) strategies were compared. Differences in both the number and form of patterns are apparent. Across both strategies, the most common pattern is dual use of CHC (medical visits, specialist visits) and PHC (flu shots, sex-specific screening) but not CAM (chiropractors, other CAM providers). Consistent with the literature, women use more types of services overall than do men. The gender effect is significantly mediated by age: older men are less likely to use services across the three health care systems than older women. Strong evidence for a socioeconomic gradient in medical pluralism is also found. Higher levels of income and education increase the likelihood of using services across the three health care systems compared to low and middle levels of both income and education. The relationship between race and health service use was much less significant. Long-term immigrants demonstrate tri-use patterns close to those of Canadian born individuals; however, service differentials remain even after controlling for health needs, in favour of native-born Canadians. Medical pluralism is also associated with health related-need as support was found for both illness and wellness care. Lastly, regional differences point to a greater likelihood of medical pluralism in western Canada, but not always in urban areas. In future, a longitudinal examination of medical pluralism is necessary and would help establish the sequencing of services and how services are used in relation to the disablement process. Health policy would thus benefit from insight into the extent of service duplication for specific conditions and clarify the role of medical doctors in referral processes. / Graduate

No description available.

Background: In South Africa (SA), women with breast cancer (BC) present to the health care system at advanced stages of the disease, resulting in poor prognosis. Limited awareness of the disease, large distances to health care centers, and lack of affordable transportation have all been implicated as factors delaying presentation. In addition, women in SA have limited social and financial independence, which may make it difficult for them to resolve their own health care needs. Despite this, little is known about what South African male partners know about breast cancer and what role they play in their partner’s access to health care. Methods: This interpretive qualitative case study, guided by the theoretical framework of hegemonic masculinity(ies), used semi-structured interviews to investigate perceptions and knowledge of BC and gender norms in regards to health care access in a group of black South African males (n=20) in long-term heterosexual relationships living in a resource-poor setting. Interview data was analyzed using thematic analysis and compared to observational data collected through opportunities with local BC organizations. Results: Participants demonstrated very little knowledge of breast cancer and cancer in general. Some specific misconceptions about cancer are reported, including confusion between cancer and HIV. Participants were positive about receiving health care for cancer but are burdened by barriers to reaching care and a lack of access to information about the disease. The men describe themselves as playing an active, mostly positive role in their partner’s access to health care. They demonstrate perspectives about gender relations that defy hegemonic forms of masculinity. Conclusions: Major public health efforts are required to increase awareness of BC in order to encourage earlier presentation to the healthcare system. These efforts should recognize the importance of the male partner in women’s health issues. / Thesis / Master of Science (MSc) / In South Africa, women with breast cancer often do not reach the conventional healthcare system until the disease has progressed significantly and chances of survival are poor. This occurs because of a lack of knowledge about the disease and large distances to health care centers. Furthermore, in the male-dominated society of South Africa, women have limited independence. Therefore, this study sought to determine what men in South African know about breast cancer and how they are involved in their partner’s access to health care. Interviews were conducted with 20 men living in a resource-poor setting. The men portrayed little knowledge and specific misconceptions about breast cancer and cancer in general. They appear to be playing an active and mostly positive role in their partner’s access to health care. Public health efforts should increase awareness of the disease and recognize the significant role of the male partner in women’s health issues.

Using data from the Household Component of the 1996 Medical Expenditure Panel Survey, the study compares (1) the accessibility, and (2) the predictors of health care services utilization among African American and non-Hispanic White males, 18 to 65 years old in the United States. Using ANOVA procedure in comparing the means for use of physicians, hospitals, doctors, and difficulty obtaining care, seven hypotheses were tested in the study. First, it was hypothesized that African American men of working age will have less access to health care services (physicians, hospitals, and dentists), and be more likely to report having experienced delay or difficulty obtaining care, compared to non-Hispanic white males of working age. Second, it was hypothesized that, controlling for health status, African American men of working age will have less access to health care services (physicians, hospitals, and dentists), and will also be more likely to experience delay or difficulty obtaining care, than non-Hispanic white males. This was followed by the third hypothesis which compared utilization of physicians, hospitals, dentists, and difficulty obtaining care among African American and non-Hispanic white males, controlling for health status and insurance coverage (any insurance, private insurance, any public insurance, and Medicaid). Hypotheses four through six compared the utilization of physicians, hospitals, and dentists, as well as difficulty obtaining care among African American and non-Hispanic white males, controlling for the following variables sequentially: health status and poverty status; health status and having a usual source of care; and health status and employment status, in that order. Finally, it was hypothesized that, controlling for health status, any insurance, poverty status, and employment status, African American men of working age will have less access to physicians, hospitals, and dentists, and experience more difficulty and delay obtaining care, compared to non-Hispanic white males of working age. Results from the study indicated that Hypothesis 1 was supported for use of physicians and dentists. Hypotheses 2, 3a and 3c were supported for use of physicians, hospitals, and dentists. Hypotheses 3b, 3d, and 4 received support for use of physicians, hospitals, dentists, and difficulty obtaining care. Additionally, both Hypotheses 5 and 6 were supported for use of physicians, hospitals, and dentists, with the last hypothesis being confirmed for use of physicians, hospitals, dentists, and difficulty obtaining care. The study calls for a closure of the gap in access to health care between African American and non-Hispanic white adult males in the US. A reform-oriented government-sponsored single-payer plan modeled after the Canadian health care system is recommended for the United States. A national health insurance plan is most likely to ensure equity of access, compared to others, in the sense that it is founded on the premise that everyone will be covered in a similar fashion. Considering the role of Community Health Centers in serving Medicaid and Medicare recipients, low-income uninsured and insured, the underinsured, as well as high-risk populations and the elderly, in the interim, they should be extended to every community in the United States.

This research investigated physician and emergency room use among representative samples of children in the Dallas metropolitan area (N = 1606) and among patients who used Children's Medical Center of Dallas' First Care services (N = 612). Through telephone interviewing, caregivers to children under fifteen years of age were asked about an array of health service use behaviors, social-psychological issues related to acquiring health care for their children, and demographic characteristics as outlined by the Andersen & Newman model of health care service use. Children's use of physician services is best predicted by whether or not they have medical insurance, their level of income, and whether or not they have medical homes. Although having commercial managed care and fee-for-service Medicaid insurance consistently predicted increased physician use, neither independently reduced reliance on emergency rooms for non-emergent care. Managed care insurance and Medicaid did, however, significantly improve the odds that children would have medical homes, which significantly decreased emergency room use for non-emergent care. Further, increasing physician use and reducing reliance on hospital emergency rooms for non-emergent care will require ensuring that children have medical homeseither private physicians or community health centersat which they can readily and consistently receive sick and well care. Although some ethnic differences were observed, few of the broad array of factors in the Behavioral Model significantly predicted either physician or emergency room use. Moreover, educational levels and health beliefs rarely, and if significant negligibly, influenced physician and emergency room use. Health policy for children would best be served by focusing on programs that facilitate parent's ability to secure health insurance for their children and allocating children to medical homes where they can readily and consistently access sick and well care.

Cette thèse traite des inégalités sociales en matière de comportements de santé tels que les modes de vie liés à la santé (spécifiquement, l’obésité et la consommation d’alcool) et l’utilisation des services de santé, dans plusieurs pays de l’OCDE. Ce travail repose sur une approche micro-Économétrique et utilise un grand nombre de bases de données nationales. Les objectifs de cette thèse sont de: (1) comparer les inégalités sociales de comportements de santé entre des pays ayant des caractéristiques différentes, (2) apporter un éclairage à la compréhension des disparités sociales des comportements de santé, et enfin (3) examiner comment l’auto-Déclaration peut affecter l’évaluation des comportements de santé, et donc affecter la mesure des inégalités. / This thesis deals with social inequalities in health-Related behaviours such as lifestyle risk factors for health (precisely, obesity and alcohol consumption) and the utilisation of health care services, in a number of OECD countries. This work relies on an applied micro-Economics approach, using several national health survey data. This thesis aims to (a) compare social inequalities in health-Related behaviours across countries with different settings; (b) shed light on the understanding of social disparities in health-Related behaviours; and (c) examine how self-Reporting may affect the rating of behavioural risk-Factors, and therefore affect the measurement of social inequalities.

Children are often referred to as the 'hidden' generation, a powerless group who in infancy and childhood depend on their parents and families/whanau to ensure they receive everything in life required to enable them to grow into healthy young people and adults. Some are more disadvantaged than others due to the socioeconomic circumstances they grow up in. This can have lasting effects on their health in childhood with associated impacts later in life. In New Zealand the populations of children most disadvantaged are those from Maori, Pacific and other low income families/whanau. The disparities that exist between children from these populations and other groups whilst lessening, is still significant. The purpose of this study was to explore with Maori, Pacific and low income parents and caregivers why they choose to 'seek' health services for their children, or not as the case may be. Patterns of use are established early in life therefore it is important to understand children's health care use. The literature suggests that children's access to health care is influenced by predisposing factors such as their socioeconomic status, ethnicity, the availability of services, choice of providers, availability of school–based health services, outreach services, relationships between the community and health service providers and having a regular source of primary health care. A qualitative exploratory design was the methodology chosen for this research. A modified 'community as partner' model (Anderson, 2008) formed the conceptual framework for the research. Sixteen Maori, Pacific and Pakeha parents and caregivers participated in three focus groups to discuss their perceptions of children's access to health care. Thematic analysis was used to identify codes, categories, themes and sub themes from the data. The New Zealand Child Health Strategy (Ministry of Health, 1998) was used as a model to inform the discussion. The main themes were: reality of life, visibility, knowing you, knowing me and kids come first. The findings suggest that relationships with primary health care providers, the cost of health care for children over five years, awareness of services and a need to prioritise children's needs, enable or prevent children's access to health care. Decisions made regarding further service provision for children will be enhanced by health providers and practitioners having a clearer understanding of the enablers and barriers to access and the factors that influence parental choice of services.

This Ph.D. thesis discusses the evolution and current situation regarding availability of healthcare for third countries migrants in the Czech Republic. In terms of methodology, the author has chosen a qualitative approach. The research design is a historical case study. The thesis uses a combination of "desk research" and empirical survey based on 56 in-depth interviews with migrants, healthcare providers and experts who come into contact with migrants during the course of their work. Based on the approach of historical institutionalism, the author is explaining policy of migrants' health insurance evolution in Czech Republic since 1993 till today. The author identifies the key events and the roles of particular actors within the observed "sub- system" of public policy. From the viewpoint of migrants and healthcare providers, the thesis also presents how the current institutionalised set-up of migrants' health policy transfers into the real access to healthcare for migrants. It also identifies the main barriers to health care accessibility and the consequences of possible health care unavailability. Key words: migrants, health care availability, health insurance, historical institutionalism, barriers to health care access

Practice managers are facing challenging expectations when deploying a managed-care paradigm. The problem addressed in this study was a gap in knowledge regarding practice managers' decision-making strategies that affect, or could be perceived to affect, a climate of excellence with business and client relationships, primary health care, physicians, and patients in a managed-care paradigm. The purpose of the qualitative exploratory study was to explore practice managers' decision-making strategies affecting primary health care, physicians, and patients. Guided by Simon's ideology of decision-making strategies in a management environment, the overarching research question and 3 subquestions centered on how practice managers delineate their decision-making strategies and how those strategies affect primary health care, physicians, and patients. To close the gap in knowledge, the study included (a) a homogeneous purposive sampling of 14 practice managers (n = 2, pilot study; n = 12, main study) as research participants; (b) face-to-face interviews with semistructured, open-ended questions to collect data; and (c) in vivo and pattern coding during data analysis. The study results indicated a need for change agents, interactions, partnerships, and accountability in a managed-care paradigm. Managing health care is complex and practice managers will continue to be challenged. Alliances between practice managers and stakeholders are recommended to meet those challenging expectations. As a result, positive social changes may be observed in improved access to primary health care, better health care treatments, and collaborative interactions in a managed-care paradigm.