Philosophiae Doctor - PhD / This thesis purposes to examine the impact of financial development on health outcomes, health care expenditure and financial protection in health in 46 selected sub-Saharan African (SSA) countries from 1995 to 2014. It also estimates the impact of health care expenditure on health outcomes. The thesis is premised on the hypothesis that health care expenditure is a critical transmission mechanism through which financial development leads to better health outcomes. The health care expenditure channel is conspicuously absent in the literature on financial development and health outcomes; hence the need for this study to fill the gap in the literature. The thesis explores the effects of both depth and access dimensions of financial development on health outcomes, expenditure and financial protection. Throughout the study, financial access is measured by the number of automated teller machines (ATMs) and commercial bank branches per 100 000 people, while financial depth is measured by the proportion of broad money and bank credit to the private sector, to Gross Domestic Product (GDP). The study uses fixed and random effects and the Two-Stage Least Squares estimation approaches. The Generalised Method of Moments (GMM) is also used to estimate the impact of health care expenditure and health outcomes given the absence of valid instrumental variables. The results of the regression analyses show that financial development leads to increased health care expenditure and health outcomes. The analysis also shows that health care expenditure leads to better health outcomes. Additionally, the study indicates that financial development leads to financial protection in health care by reducing out-of-pocket health care expenditure. Well-developed financial systems provide financial protection from the risk of catastrophic health care expenditure and impoverishment resulting from illness. The study shows that health care systems financed through prepaid mechanisms reduce neonatal, infant and under-five mortality rates and increase life expectancy, while those relying on out-of-pocket expenditure have adverse effects on health outcomes.

This study describes the results of a cross-sectional survey conducted in Mambwe district in the Eastern Province in Zambia. It uses a One Health approach to assess the impact of veterinary, medical, environmental and social determinants on animal and human health and wellbeing. One Health is defined as a holistic and interdisciplinary approach that describes the complexities between people, animals, the environment and their health. Human wellbeing is defined in this thesis as 'a condition in which all members of society are able to determine and meet their needs and have a large range of choices to meet their potential' (Prescott-Allen, 2001). As a first step, eight focus group discussions with the inhabitants followed by key informant interviews with stakeholders in the area were conducted to give a primary impression and narrow down the problems in relation to animal and human health of the area in general. Following this, a randomized selection of 210 households was visited and in each household blood samples were taken from all humans and all animals belonging to five animal species, namely cattle, goats, sheep, pigs and dogs. A third of the households did not keep any of the animal species chosen for sampling, but their inclusion was important for the social analysis. In all of these 210 households a wellbeing questionnaire was administered and, for every human and animal sampled, a health questionnaire. The study area falls within the tsetse-infested region of Zambia. It has a high wildlife density reflecting the proximity of several national parks and is historically endemic for both human and animal African trypanosomiasis (HAT&AAT). Therefore humans and animals were tested for trypanosomiasis using internal transcribed spacer (ITS) polymerase chain reaction (PCR). Since it is important as a differential diagnosis, malaria was tested for by a rapid diagnostic test in the field from human blood. Sera from mature individuals from all animal species except pigs were tested in a field laboratory for brucellosis using the Rose Bengal test. Additionally, cattle and dogs were tested for five genera of tick-borne infections (TBI) including Anaplasma, Ehrlichia, Theileria, Babesia and Rickettsia using reverse line blot (RLB) in the laboratory at the University of Edinburgh (UoE). The blood samples for PCR and RLB analysis at UoE were stored on WhatmanTM FTA cards. A total of 1012 human samples were tested for HAT and none found positive. 1005 (seven people had been tested positive or treated against malaria shortly before the sampling) people tested for malaria showed an overall prevalence of 15% (95% CI 13.2-17.7). None of the 734 Rose Bengal tests showed up positive for brucellosis. The prevalence of AAT in 1275 samples tested was much lower compared to former samplings; in cattle 22% (95% CI 18-27.2), in goats 7% (95% CI 4.5-9.2), in pigs 6% (95% CI 3.2-9.4), in dogs 9% (95% CI 5.2-13.6) and no samples were found positive in sheep. The prevalence of TBIs is much more complex with many multiple infections. A total of 340 cattle and 195 dogs were tested. In cattle the number of samples positive for any microorganism was as follows; 92% (95% CI 88- 94.2). Overall there were fewer positive samples from dogs with 25% of animals infected (95% CI 19.2-31.8). The wellbeing and health questionnaires were designed to help to identify possible risk factors for the above-mentioned diseases and signs, such as fever, diarrhoea and seizures, indicative for several other diseases. The results of these surveys might also help to identify potential reasons for a lower or higher prevalence of trypanosomiasis and malaria found than expected from previous studies. Additionally, information on personal happiness, attitudes towards veterinary and medical services, medical treatments received, education, women's reproductive history, drug abuse, people's perceptions of changes in environment and agriculture, demography, poverty and migration were collected via the questionnaires alongside information on livestock demographics and fertility. One of the main conclusions is that both medical and veterinary health care systems suffer from a number of shortcomings. The distance to appropriate treatment and care facilities is far and the necessary drugs are often unavailable. Also, both the knowledge and technology for diagnosing selected diseases is not in place. This study suggests that neurocysticercosis (NCC) plays an important role in this area due to the high number of seizures reported in people, in whom treatment for epilepsy was unsuccessful. Samples taken from a few pigs indicated the presence of Taenia solium, the causal agent of NCC. Furthermore, many of the TBIs are of zoonotic nature and further investigations must be made to begin to assess the burden of these diseases in humans and animals. Environmental changes such as degradation of the vegetation are likely to have an influence on the prevalence of studied diseases and this aspect is being investigated further in other studies. Due to the nature of a cross-sectional study, only limited conclusions can be drawn on the causal relationships of disease prevalence, but the social analysis conducted in this study confirmed the interactions of selected factors related to health and wealth unique for this study area.

<p>This study is aimed at empirically examining health seeking behaviours in terms of illness response on household level at South Africa using 2007 General Household Survey and other<br /> relevant secondary sources. It provides an assessment of health seeking behaviours at the household level using individuals as unit of analysis by exploring the type of health care provider sought, the reason for delay in health seeking and the cause for not consulting. This study also assesses the extent of dissatisfaction among households using medical centres and this factor in health care utilisation is considered as the main reason for not consulting health care services. All the demographic and health seeking variables utilised in this study are controlled for medical aid cover because it is a critical variable in health care seeking. Therefore this study makes distinction on illness reporting and they type of health care consulted by medical aid holders and non medical aid holders. Statistical analyses are conducted to explore and predict the way in which demographic variables and socio economic variables affect health care seeking behaviours.</p>

Although healthcare operations management has been an active and popular research direction over the past few years, there is a lack of formal quantitative models to analyze the ambulance o oad delay problem. O oad delays occur when an ambulance arriving at a hospital Emergency Department (ED) is forced to remain in front of the ED until a bed is available for the patient. Thus, the ambulance and the paramedic team are responsible to care for the patient until a bed becomes available inside the ED. But it is not as simple as waiting for a bed, as EDs also admit patients based on acuity levels. While the main cause of this problem is the lack of capacity to treat patients inside the EDs, Emergency Medical Services (EMS) coverage and availability are signi cantly a ected. In this thesis, we develop three network queueing models to analyze the o oad delay problem. In order to capture the main cause of those delays, we construct queueing network models that include both EMS and EDs. In addition, we consider patients arriving to the EDs by themselves (walk-in patients) since they consume ED capacity as well. In the rst model, ED capacity is modeled as the combination of bed, nurse, and doctor. If a patient with higher acuity level arrives to the ED, the current patient's service is interrupted. Thus, the service discipline at the EDs is preemptive resume. We also assume that the time the ambulance needs to reach the patient, upload him into the ambulance, and transfer him to the ED (transit time) is negligible. We develop e cient algorithms to construct the model Markov chain and solve for its steady state probability distribution using Matrix Analytic Methods. Moreover, we derive di erent performance measures to evaluate the system performance under di erent settings in terms of the number of beds at each ED, Length Of Stay (LOS) of patients at an ED, and the number of ambulances available to serve a region. Although capacity limitations and increasing demand are the main drivers for this problem, our computational analysis show that ambulance dispatching decisions have a substantial impact on the total o oad delays incurred. In the second model, the number of beds at each ED is used to model the service capacity. As a result of this modeling approach, the service discipline of patients is assumed to be nonpreemptive priority. We also assume that transit times of ambulances are negligible. To analyze the queueing network, we develop a novel algorithm to construct the system Markov chain by de ning a layer for each ED in a region. We combine the Markov chain layers based on the fact that regional EDs are only connected by the number of available ambulances to serve the region. Using Matrix Analytic Methods, we nd the limiting probabilities and use the results to derive di erent system performance measures. Since each ED's patients are included in the model simultaneously, we solve only for small instances with our current computational resources. In the third model, we decompose the regional network into multiple single EDs. We also assume that patients arriving by ambulances have higher nonpreemptive priority discipline over walk-in patients. Unlike the rst two models, we assume that transit times of ambulances are exponentially distributed. To analyze the decomposed queueing network performance, we construct a Markov chain and solve for its limiting probabilities using Matrix Analytic Methods. While the main objective for the rst two models is performance evaluation, in this model we optimize the steady state dispatching decisions for ambulance patients. To achieve this goal, we develop an approximation scheme for the expected o oad delays and expected waiting times of patients. Computational analysis conducted suggest that larger EDs should be loaded more heavily in order to keep the total o oad delays at minimal levels.

<p>This study is aimed at empirically examining health seeking behaviours in terms of illness response on household level at South Africa using 2007 General Household Survey and other<br /> relevant secondary sources. It provides an assessment of health seeking behaviours at the household level using individuals as unit of analysis by exploring the type of health care provider sought, the reason for delay in health seeking and the cause for not consulting. This study also assesses the extent of dissatisfaction among households using medical centres and this factor in health care utilisation is considered as the main reason for not consulting health care services. All the demographic and health seeking variables utilised in this study are controlled for medical aid cover because it is a critical variable in health care seeking. Therefore this study makes distinction on illness reporting and they type of health care consulted by medical aid holders and non medical aid holders. Statistical analyses are conducted to explore and predict the way in which demographic variables and socio economic variables affect health care seeking behaviours.</p>

Background: Närsjukvården Österlen AB (=NÖAB) won a five-year contract, late in 2000, to operate the local health care services in Simrishamn on behalf of the Region Skåne. The economical forecast for 2002 was a loss of 18 million SEK. A turnaround was urgent. Aim: Primarily to evaluate Knowledge Management (=KM) techniques as a tool in the process of turning a health care organization around. Secondarily, to describe the means by which NÖAB became a more efficient health care organization. In order to evaluate the use of KM in the turnaround process it is necessary to answer three fundamental research questions. Did a turnaround take place? Did the individual projects contribute to increased efficiency? And finally can the approach used in the projects be characterized as KM. Method: The study was an ongoing case study using action research combined with evaluation. The Evaluation uses public data (both quantitative and qualitative) and evaluations done by third parties. That allows for a profound validation of the conclusions. Three central processes were singled out for the evaluation. 1) The makeover of the acute patients’ way into the system, 2) the disease management program (=DPM) for patients suffering from COPD and 3) the introduction of an error-management system. Results: The operating results were raised from minus 15 million SEK in 2002 to plus 10 million SEK in 2005. Manhours were reduced with 20.6%. The average cost for a consultations were reduced with 24.6%. The introduction of the COPD DPM resulted in a saving of approximately 1 million SEK a year. A total of 312 adverse event reports were filled during the first 10 month - an average of 31 a month. The introduction of KM turned the organization into a patient centered, lean health care organization. Changed the decisions making, and resulted in a significant shift towards an acceptance culture. Conclusion: From the nature of the described projects, the description of the landmarks used and the discussion on how the projects fit into a Knowledge Management way of thinking it is concluded that a Knowledge Management approach was applied. The success of the turnaround described in the case makes a strong argument for the use of Knowledge Management when faced with the need to optimize health care systems. / <p>ISBN 91-7997-162-8</p>

Although healthcare operations management has been an active and popular research direction over the past few years, there is a lack of formal quantitative models to analyze the ambulance o oad delay problem. O oad delays occur when an ambulance arriving at a hospital Emergency Department (ED) is forced to remain in front of the ED until a bed is available for the patient. Thus, the ambulance and the paramedic team are responsible to care for the patient until a bed becomes available inside the ED. But it is not as simple as waiting for a bed, as EDs also admit patients based on acuity levels. While the main cause of this problem is the lack of capacity to treat patients inside the EDs, Emergency Medical Services (EMS) coverage and availability are signi cantly a ected. In this thesis, we develop three network queueing models to analyze the o oad delay problem. In order to capture the main cause of those delays, we construct queueing network models that include both EMS and EDs. In addition, we consider patients arriving to the EDs by themselves (walk-in patients) since they consume ED capacity as well. In the rst model, ED capacity is modeled as the combination of bed, nurse, and doctor. If a patient with higher acuity level arrives to the ED, the current patient's service is interrupted. Thus, the service discipline at the EDs is preemptive resume. We also assume that the time the ambulance needs to reach the patient, upload him into the ambulance, and transfer him to the ED (transit time) is negligible. We develop e cient algorithms to construct the model Markov chain and solve for its steady state probability distribution using Matrix Analytic Methods. Moreover, we derive di erent performance measures to evaluate the system performance under di erent settings in terms of the number of beds at each ED, Length Of Stay (LOS) of patients at an ED, and the number of ambulances available to serve a region. Although capacity limitations and increasing demand are the main drivers for this problem, our computational analysis show that ambulance dispatching decisions have a substantial impact on the total o oad delays incurred. In the second model, the number of beds at each ED is used to model the service capacity. As a result of this modeling approach, the service discipline of patients is assumed to be nonpreemptive priority. We also assume that transit times of ambulances are negligible. To analyze the queueing network, we develop a novel algorithm to construct the system Markov chain by de ning a layer for each ED in a region. We combine the Markov chain layers based on the fact that regional EDs are only connected by the number of available ambulances to serve the region. Using Matrix Analytic Methods, we nd the limiting probabilities and use the results to derive di erent system performance measures. Since each ED's patients are included in the model simultaneously, we solve only for small instances with our current computational resources. In the third model, we decompose the regional network into multiple single EDs. We also assume that patients arriving by ambulances have higher nonpreemptive priority discipline over walk-in patients. Unlike the rst two models, we assume that transit times of ambulances are exponentially distributed. To analyze the decomposed queueing network performance, we construct a Markov chain and solve for its limiting probabilities using Matrix Analytic Methods. While the main objective for the rst two models is performance evaluation, in this model we optimize the steady state dispatching decisions for ambulance patients. To achieve this goal, we develop an approximation scheme for the expected o oad delays and expected waiting times of patients. Computational analysis conducted suggest that larger EDs should be loaded more heavily in order to keep the total o oad delays at minimal levels.

Parmi l'ensemble des pays d'Amérique latine, la Colombie et le Venezuela sont deux pays très proches, pour des raisons aussi bien historiques que géographiques et culturelles. Pourtant, les profondes réformes constitutionnelles des deux pays, réalisées au cours des années 1990, s'opposent sur de nombreux plans. Le système de santé, enjeu crucial des deux réformes dans la lutte contre la pauvreté, caractérise cette opposition : inspirée de la réforme du système de santé américain, la réforme colombienne laisse une place centrale aux assureurs privés tandis qu'au contraire, la réforme vénézuélienne se veut être le point d'ancrage du « Socialisme du 21ème siècle » et du réengagement de l'État dans le système de santé. Bien que très différent, chaque modèle a permis une amélioration sensible des indicateurs de santé, sans pour autant pouvoir résoudre les contradiction profondes auxquels ils sont soumis. / Among all Latin american countries, Colombia and Venezuela are the closest, for reasons as much historical as geographical and cultural. However, profound constitutional reforms in the two countries, completed during the 1990s, conflict on many levels. The health care system, a critical stake in both reforms, exemplifies this divergence: inspired by the reform of the American health care system, the Colombian reform reserves a central place for private insurers, whereas the Venezuelan reform claims to be the anchor of « 21st century socialism » and the re-engagement of the State in the health care system. Though very different, each model has allowed for measurable improvement in health indicators, without being able to resolve the deep contradictions to which they are subjected.

Magister Philosophiae - MPhil / This study is aimed at empirically examining health seeking behaviours in terms of illness response on household level at South Africa using 2007 General Household Survey and other relevant secondary sources. It provides an assessment of health seeking behaviours at the household level using individuals as unit of analysis by exploring the type of health care provider sought, the reason for delay in health seeking and the cause for not consulting. This study also assesses the extent of dissatisfaction among households using medical centres and this factor in health care utilisation is considered as the main reason for not consulting health care services. All the demographic and health seeking variables utilised in this study are controlled for medical aid cover because it is a critical variable in health care seeking. Therefore this study makes distinction on illness reporting and they type of health care consulted by medical aid holders and non medical aid holders. Statistical analyses are conducted to explore and predict the way in which demographic variables and socio economic variables affect health care seeking behaviours. / South Africa

Information Technology (IT) plays a vital role in improving health care systems by enhancing the quality, efficiency, safety, security, collaboration and informing decision making. Dementia, a decline in mental ability which affects memory, concentration and perception, is a key issue in health and social care, given the current context of an aging population. The quality of dementia care is noted as an international area of concern. Dementia Care Mapping (DCM) is a systematic observational framework for assessing and improving dementia care quality. DCM has been used as both a research and practice development tool internationally. However, despite the success of DCM and the annual generation of a huge amount of data on dementia care quality, it lacks a governance framework, based on modern IT solutions for data management, such a framework would provide the organisations using DCM a systematic way of storing, retrieving and comparing data over time, to monitor progress or trends in care quality. Data Governance (DG) refers to the implications of policies and accountabilities to data management in an organisation. The data management procedure includes availability, usability, quality, integrity, and security of the organisation data according to their users and requirements. This novel multidisciplinary study proposes a comprehensive solution for governing the DCM data by introducing a data management framework based on a data warehousing approach. Original contributions have been made through the design and development of a data management framework, describing the DCM international database design and DCM data warehouse architecture. These data repositories will provide the acquisition and storage solutions for DCM data. The designed DCM data warehouse facilitates various analytical applications to be applied for multidimensional analysis. Different queries are applied to demonstrate the DCM data warehouse functionality. A case study is also presented to explain the clustering technique applied to the DCM data. The performance of the DCM data governance framework is demonstrated in this case study related to data clustering results. Results are encouraging and open up discussion for further analysis.