Charles University in Prague, Faculty of Pharmacy in Hradci Králové Department of Social and Clinical Pharmacy Student: Klára Pousková Supervisor: PharmDr. Jan Kostřiba, Ph.D. Title of thesis: Opinions and Attitudes of Patients to Differences in Health Care Systems in the Czech Republic and Germany Key words: health care systems, extra care, questionnaire survey, Czech Republic, Germany Introduction: Czech Republic and Germany are two neighboring countries, located in central Europe, but there are number of differences between them. This thesis focuses on the differences in their health systems. Official statistics provide an objective view on the situation in both healthcare systems. Nevertheless those statistics don't include patient's opinions. A questionnaire survey was therefore created to include their point of view. Objectives: The aim of this thesis was to compare selected characteristics of the Czech and German health care systems, to recognize the major differences between them and to identify their greatest advantages and disadvantages. Methods: The survey was realized in selected towns in the Czech Republic and in Germany. All pharmacies in these towns were asked to take part. Patients were interviewed with adherence to the created questionnaire. The interview was conducted by the...

Resumo Estudo de cunho qualitativo, que se valeu do método descritivo-comparativo e do método analítico-descritivo com o propósito de identificar e descrever o processo histórico de conformação dos sistemas de saúde de países membros do Mercosul Argentina, Brasil, Paraguai e Uruguai -, tendo em vista o processo de integração regional em curso. O objeto de estudo circunscreve-se à compreensão dos antecedentes históricos que confluíram para a conformação dos sistemas sanitários nos países estudados, aspectos contextuais que influem nas suas dinâmicas de organização e as perspectivas, potencialidades e limites do espaço da integração regional em saúde do Mercosul. Os resultados revelaram que há ocasiões de maior aproximação entre os percursos dos países, como no período de expansão da seguridade social, na metade do século XX, e há períodos quando rupturas e circunstâncias particulares afastam um dos outros, como ocorreu no Brasil nos anos 1980. Quanto aos modelos, o Brasil baseia-se no tipo beveridgiano e configura-se num sistema universal, ao passo que os países de origem espanhola fundamentam-se na tipologia bismarkiana, considerados de competição gerenciada, tendo em vista a combinação dos subsetores público, privado e seguro social que conformam cada um dos sistemas. A incursão pela trajetória de conformação dos sistemas de saúde dos quatro países investigados revelou a existência de diversos e estreitos laços que os unem. Um deles se refere à subordinação do setor saúde às relações mais gerais de produção e reprodução social lançando mão de categorias e conceitos tais como a divisão internacional do trabalho, a acumulação de capital, as relações de poder e sujeição aos ditames de organismos internacionais. Prova disso foram os processos de reforma do Estado empreendidos na região da América Latina e, de modo especial, revelaram diretrizes bastante semelhantes para todos os países estudados. O processo de integração regional tem revelado potencialidades e contradições, avanços e retrocessos, como a área de produtos e das vigilâncias, porém a questão dos serviços de saúde tem avançado lentamente. Os coordenadores da Reunião de Ministros da Saúde e do Subgrupo de Trabalho 11 Saúde no Mercosul entrevistados relataram fatos históricos que marcaram o processo de conformação dos sistemas sanitários, tanto para exemplificar como para explicar o arranjo institucional dos sistemas na atualidade. No entanto, não houve menção à importância de recuperar as trajetórias e desenvolvimento dos sistemas objeto deste trabalho. A ausência de um consenso a respeito do modelo de integração que se busca alcançar parece ser um dos desafios centrais para o bloco na contemporaneidade. / Abstract This qualitative study, based on the comparative-descriptive and analytical-descriptive methods, identifies and historically describes the harmonization process of the health care systems of Mercosurs member countriesArgentina, Brazil, Paraguay and Uruguayin line with the regional integration process under way. It focuses on understanding (i) the historical antecedents of those countries health care systems; (ii) the contextual aspects influencing the organization of those systems; and (iii) the prospects, potentialities and limits of Mercosurs regional integration in terms of health care. The results show that there are occasions on which the strategies adopted by those countries tend to converge, such as the period of social security expansion, in the mid-20th century, and occasions on which one of them drifts away from the others due to specific breaks and circumstances, as Brazil did in the 1980s. Concerning models, Brazil adopts a beveridgian type system designed to be universal. In contrast, the Spanish-speaking countries under study adopt bismarkian model, described as based on managed competition in view of the combination of the public, private and social security subsectors that characterizes each one of them. The analysis of the path towards the harmonization of the health care systems of those four countries showed that they share different key features. One of them is that health care is determined by the more general relationship between production and social reproduction, based on factors and concepts such as international labor division, capital accumulation, power relations and adherence to the rules of international bodies. This fact is proven most clearly by the State reform processes in Latin America, which were conducted along very similar lines in all the studied countries. The regional integration process has revealed potentialities and contradictions, as well as advances and setbacks, such as the product area and surveillance. However, health care services have gradually made strides. The coordinators of the Health Ministers Meeting and of the Work Subgroup 11 Health in Mercosur that were interviewed reported historical facts that had marked the harmonization process of health care systems, both to exemplify and to explain the current institutional design of those systems. Nevertheless, the importance of retracing their history and developmentthe purpose of this study was never mentioned. The lack of a consensus regarding an integration model seems to be one of the major challenges for the bloc.

Resumo Estudo de cunho qualitativo, que se valeu do método descritivo-comparativo e do método analítico-descritivo com o propósito de identificar e descrever o processo histórico de conformação dos sistemas de saúde de países membros do Mercosul Argentina, Brasil, Paraguai e Uruguai -, tendo em vista o processo de integração regional em curso. O objeto de estudo circunscreve-se à compreensão dos antecedentes históricos que confluíram para a conformação dos sistemas sanitários nos países estudados, aspectos contextuais que influem nas suas dinâmicas de organização e as perspectivas, potencialidades e limites do espaço da integração regional em saúde do Mercosul. Os resultados revelaram que há ocasiões de maior aproximação entre os percursos dos países, como no período de expansão da seguridade social, na metade do século XX, e há períodos quando rupturas e circunstâncias particulares afastam um dos outros, como ocorreu no Brasil nos anos 1980. Quanto aos modelos, o Brasil baseia-se no tipo beveridgiano e configura-se num sistema universal, ao passo que os países de origem espanhola fundamentam-se na tipologia bismarkiana, considerados de competição gerenciada, tendo em vista a combinação dos subsetores público, privado e seguro social que conformam cada um dos sistemas. A incursão pela trajetória de conformação dos sistemas de saúde dos quatro países investigados revelou a existência de diversos e estreitos laços que os unem. Um deles se refere à subordinação do setor saúde às relações mais gerais de produção e reprodução social lançando mão de categorias e conceitos tais como a divisão internacional do trabalho, a acumulação de capital, as relações de poder e sujeição aos ditames de organismos internacionais. Prova disso foram os processos de reforma do Estado empreendidos na região da América Latina e, de modo especial, revelaram diretrizes bastante semelhantes para todos os países estudados. O processo de integração regional tem revelado potencialidades e contradições, avanços e retrocessos, como a área de produtos e das vigilâncias, porém a questão dos serviços de saúde tem avançado lentamente. Os coordenadores da Reunião de Ministros da Saúde e do Subgrupo de Trabalho 11 Saúde no Mercosul entrevistados relataram fatos históricos que marcaram o processo de conformação dos sistemas sanitários, tanto para exemplificar como para explicar o arranjo institucional dos sistemas na atualidade. No entanto, não houve menção à importância de recuperar as trajetórias e desenvolvimento dos sistemas objeto deste trabalho. A ausência de um consenso a respeito do modelo de integração que se busca alcançar parece ser um dos desafios centrais para o bloco na contemporaneidade. / Abstract This qualitative study, based on the comparative-descriptive and analytical-descriptive methods, identifies and historically describes the harmonization process of the health care systems of Mercosurs member countriesArgentina, Brazil, Paraguay and Uruguayin line with the regional integration process under way. It focuses on understanding (i) the historical antecedents of those countries health care systems; (ii) the contextual aspects influencing the organization of those systems; and (iii) the prospects, potentialities and limits of Mercosurs regional integration in terms of health care. The results show that there are occasions on which the strategies adopted by those countries tend to converge, such as the period of social security expansion, in the mid-20th century, and occasions on which one of them drifts away from the others due to specific breaks and circumstances, as Brazil did in the 1980s. Concerning models, Brazil adopts a beveridgian type system designed to be universal. In contrast, the Spanish-speaking countries under study adopt bismarkian model, described as based on managed competition in view of the combination of the public, private and social security subsectors that characterizes each one of them. The analysis of the path towards the harmonization of the health care systems of those four countries showed that they share different key features. One of them is that health care is determined by the more general relationship between production and social reproduction, based on factors and concepts such as international labor division, capital accumulation, power relations and adherence to the rules of international bodies. This fact is proven most clearly by the State reform processes in Latin America, which were conducted along very similar lines in all the studied countries. The regional integration process has revealed potentialities and contradictions, as well as advances and setbacks, such as the product area and surveillance. However, health care services have gradually made strides. The coordinators of the Health Ministers Meeting and of the Work Subgroup 11 Health in Mercosur that were interviewed reported historical facts that had marked the harmonization process of health care systems, both to exemplify and to explain the current institutional design of those systems. Nevertheless, the importance of retracing their history and developmentthe purpose of this study was never mentioned. The lack of a consensus regarding an integration model seems to be one of the major challenges for the bloc.

This thesis contains a characteristic of ways, rules and resources of health care financing in various health care systems and their influence on impartiality, responsibility and efficiency. You can find an analysis of sources and expenditures on health in individual OECD countries - their structure, quality and development trend in this thesis too. The goal of the thesis is to approach the questions of responsibility of a patient, impartiality of health care system and its efficiency through financial stimuli.

India, the world’s largest democracy and second most populous country, is in the midst of an economic boom with gross domestic product growth averaging nearly 8% over the past several years despite a worldwide recession. The World Health Organization (WHO) has predicted that trauma case related deaths in India will move from ninth position up to the third position by 2020. The organization structure for an improved national trauma system in India will depend on a national inclusive strategy supported by resources and funding within a service quality framework to win public trust. This must include an integrated nationally coordinated approach to the organization of pre-hospital care facilities, hospital networking and communication systems, and the organization of in-hospital care.

A global epidemic of metamorphosed, conglomerated health care systems changed the face of public health care organizations. The problem is, public health care organizations merge into new systems, but the culture for each merged organization has not been formed under the new system. Public administrators, health care workers and the Department of Health and Human Services are affected when there are issues in health care behavioral practices and performance outcomes. Research found that employee motivation is hard to achieve when there are issues within the internal structure of a new system. Using Herzberg's motivation-hygiene and Tajfel and Turner's social identity theories as the foundation, the purpose of this correlational study was to examine the statistical relationship between growth opportunities, organizational culture, monetary compensation and employee motivation. Secondary data were used from a sample of 3,033 health care workers from 2 English hospitals in the United Kingdom. The data were examined using Point-Biserial Correlation Coefficient model statistical t test. The study's results concluded that growth opportunities, organizational culture, and monetary compensation significantly correlate with employee motivation. Recommendations included implementing systematic changes to the internal organizational structure by identifying and developing effective strategies to improve internal organizational practices and performance outcomes. Further research is needed for demographic comparisons. The study affects social change by informing the Department of Health and Human Services, health care organizations and public health administrators of various strategies that can be used to improve internal organizational practices performance outcomes.

Cette thèse de doctorat a pour objet d’évaluer les effets potentiels d’une concurrence accrue sur le marché de la santé. Elle porte une attention particulière aux effets de la concurrence sur l’efficacité allocative du système de santé en termes de soins et de dépenses de santé. Dans leur ensemble, nos résultats suggèrent que les effets canoniques de la concurrence ne s’appliquent pas nécessairement au marché de la santé, et détaillent des circonstances dans lesquelles une hausse de la concurrence pourrait nuire au bien-être social. Cette thèse comporte une introduction et trois chapitres (articles académiques), chacun portant sur un aspect diffèrent de l’efficacité du système de santé. Le premier chapitre analyse l’impact de la concurrence sur les pratiques de soins hospitaliers et leur régulation par tarification prospective. Le second chapitre détaille les enjeux de régulation liés à la nature incomplète de l’information sur les patients au moment de choisir la procédure de soins à adopter, à commencer par la décision de mettre en œuvre des tests de diagnostic supplémentaires. Le dernier chapitre de cette thèse discute les conséquences possibles de l’asymétrie qui peut exister entre fournisseur de soins public et privé en termes d’obligation de couverture et pouvant être appliqué au marché de l’aide à domicile des personnes âgées. / The purpose of this thesis is to study the potential effects of an increased competition between health-care providers on the allocative efficiency of the health-care system. In a theoretical framework it discusses the effect of competitive pressure considering the decentralization of treatment decisions, diagnostic tests’ performance, and the organization of care coverage. It is composed of an introduction and three chapters (essays), each of them focusingon a different aspect of the health-care system efficiency. Our findings globally suggest that the canonical effect of competition does not necessarily applies to the health-care market,and detail circumstances in which competition could degrade social welfare. The first chapter analyses the impact of competition on hospitals’ treatment praxis and their regulation through fixed-repayments. The second chapter details the regulation issues related to the incomplete nature of the information on patients’ illness before the decision to perform diagnostic tests.The last chapter of this thesis discusses the possible outcomes of the asymmetry of obligation of services between public and private competitors in an application to the home-care market for the elderly.

Over the past 25 years, health care organization scholars have observed the dramatic emergence of hospital-based clusters in local markets throughout the U.S. These important organizational forms require same-system ownership of multiple general, acute care hospitals operating within a single local market, and as such they include multi-hospital systems that are entirely contained in a single urban market as well as clustered extensions or subsystems of larger regional and national systems. However, despite their noted growth as powerful forces in local markets, relatively few studies have examined these clusters, and as a result there remains a significant gap in our knowledge regarding their continued growth or the diverse components and configurations they may exhibit. This study endeavors to both describe and explain the diversity observed across hospital-based clusters. To fulfill this objective, a national inventory of clusters is updated to reflect cluster membership as of 2012, and a catalog of cluster components – including their hospital-based and non-hospital-based sites – is created, acknowledging that clusters today consist of more than just general, acute care hospitals. Cluster analysis methods are then employed to develop a taxonomy of cluster forms, using a sample of 114 clusters from local markets in Florida, Maryland, Nevada, Texas, Virginia, and Washington. Applying a conceptual framework informed by concepts from contingency theory and strategic management theory, cluster analysis methods yield a five-group solution, which is then externally validated using a multi-theoretical perspective synthesizing arguments from population ecology, institutional theory, industrial organization economics, transaction cost economics, and resource dependence theory. Results from descriptive and multinomial logistic regression analyses identify organizational and environmental factors that are significantly associated with various cluster forms. The study’s results suggest that today’s hospital-based clusters continue to grow and vary according to the dimensions of differentiation-configuration and integration-coordination. These findings provide a foundation for future examinations of hospital-based clusters, including their provision of services within and outside of hospital walls. These results also accentuate the importance of accounting for geographic considerations when examining health care organization forms, and they display the utility and value of employing a multi-theoretical perspective to examine and explain such complex forms.

Short range wireless data communication networks that are used for sport and health care are sometimes called Wireless Body Area Networks (WBANs) and they are located more or less on a person. Sole Integrated Gait Sensor (SIGS) is a research project in WBAN, where wireless pressure sensors are placed like soles in the shoes of persons with different kinds of deceases. The sensors can measure the pressure of the foot relative to the shoe i.e. the load of the two legs is measured. This information can be useful e.g. to not over or under load a leg after joint replacement or as a bio feedback system to help e.g. post stroke patients to avoid falling. The SIGS uses the ANT Protocol and radio specification. ANT uses the 2.4 GHz ISM band and TDMA is used to share a single frequency. The scheduling of time slots is adaptive isochronous co-existence i.e. the scheduling is not static and each transmitter sends periodically but checks for interference with other traffic on the radio channel. In this unidirectional system sole sensors are masters (transmitters) and the WBAN server is the slave in ANT sense. The message rate is chosen as 8 Hz which is suitable for low power consumption. Hence in the SIGS system, it is necessary to synchronize the left and the right foot sensors because of low message rate. In our thesis, we found a method and developed a prototype to receive the time synchronized data in WBAN server from ANT wireless sensor nodes in SIGS system. For this thesis work, a hardware prototype design was developed. The USB and USART communication protocols were also implemented in the hardware prototype. The suitable method for time synchronization was implemented on the hardware prototype. The implemented method receives the sensor data, checks for the correct stream of data; add timestamp to the sensor data and transmit the data to the Linux WBAN server. The time slots allocation in the ANT protocol was found. Alternative solution for the time synchronization in ANT protocol was also provided. The whole SIGS system was tested for its full functionality. The experiments and analysis which we performed were successful and the results obtained provided good time synchronization protocol for ANT low power wireless sensor network and for Wireless Bio-feedback system.

Das Dissertationsvorhaben greift zu Beginn einen Praxisfall im Krankenhaus auf und verdeutlicht exemplarisch, dass der Krankenhausarzt in einen Konflikt zwischen ökonomischen und ethischen Anforderungen gerät. Um die Frage beantworten zu können, wie die soziale Praxis der Krankenhausärzte gelingen kann, wird das Problem im ersten Schritt rekonstruiert. Nach der Diskussion verschiedener Lösungsansätze für das Problem im zweiten Schritt, werden im dritten Schritt Anregungen für die Praxis abgeleitet.