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Asthma prevalence continues to increase across the United States of America, affecting more than 43.1 million people and projected to affect over 50 million people by 2025. Asthma prevalence differs by demographic characteristics, such as race, ethnicity, socio-economic status, education, age and gender. Poor quality of life is common among people who suffer from asthma, in addition to school and work absenteeism. In 2008, children 5-17 years old with at least one reported asthma attack missed 10.5 million school days in the past year (CDC, 2010). Healthcare use for asthma is high and disparities remain in asthma healthcare use and reimbursement. In community settings, reimbursement for asthma education and prevention has been problematic due to current reimbursement mechanisms (Bodenheimer et al. (2003); Halterman (2010); CDC (2011) and Laster et al. 2010) that do not go far enough in assisting low-income communities manage their asthma medically nor have uniform standards for billable services associated with asthma management provided by both healthcare professionals and public health workers. A change in reimbursement policy is advocated and the evidence for the effectiveness of community health workers in asthma management is examined.

Miesto sveikatos politika labiausiai domisi europarlamentarai ir miesto politikai (66,7 ir 60,0 proc.). Mažiausiai šiuo klausimu domisi miesto seniūnijų ir departamentų, skyrių ir darželių bei mokyklų vadovai (38,3 proc.). Politikų ir vadovų nuomone, sveikatos politiką lemiantis aspektas – už žmonių sveikatos stiprinimą ir išsaugojimą yra atsakingi visi (tiek valstybės institucijos, valstybės tarnautojai ir politikai, tiek pats asmuo) (p<0,05). Visų grupių respondentai pagrindine sveiko miesto formavimo sąlyga įvardino švarią, saugią, geros kokybės aplinką (p<0,05). Politikų ir vadovų nuomone (80 proc.), sprendžiant visuomenės sveikatos problemas, tarpžinybinis bendradarbiavimas yra tik iš dalies pakankamas, o vietos lygmenyje jo įgyvendinimas dar silpnesnis. Respondentai pagrindine bendradarbiavimo forma įvardino bendrų projektų, programų rengimą, dalinantis praktika ir patirtimi (p<0,05). Dauguma (apie 90 proc.) visų grupių respondentų išsakė nuomonę, kad būtina stiprinti tarpžinybinį bendradarbiavimą sprendžiant visuomenės sveikatos problemas ir įgyvendinant sveikatos politiką. Situacija, įgyvendinant visuomenės sveikatos politiką miesto savivaldybėje, nėra gera: administracijos atskirų departamentų vadovų žinios apie sveikatos politiką, jos prioritetus bei pagrindines sveikatos politikos strategines įgyvendinimo kryptis nepakankamos, stokojama teisinės bazės tarpžinybiniam bendradarbiavimui, nėra pakankamo veiksmų koordinavimo tarp atskirų žinybų. / Europarlamentarians and city politicians are interested in city health policy most of all (66.7 and 60.0 %). Directors of town elderships departments and divisions, headmasters of schools and kindergartens are least interested in this question (38.3 %). Pursuant to politicians and directors, the aspect determining health policy is everyones (state institutions, civil servants and politicians, each persons) responsibility for improving and preserving health of people (p<0.05). The respondents of all groups indicate a clean, safe and good-quality environment as the main condition for creating a healthy city (p<0.05). In the opinion of politicians and directors (80 %) interagency cooperation is only partiallty sufficient while solving public health problems and its implementation on the local level is even weaker. Respondents indicated joint projects and programmes for sharing practice and experience as the main form of cooperation (p<0.05). The opinion of the majority ( of around 90 %) of the respondents of all the groups was that it is necessary to strengthen interagency cooperation in addressing public health problems and implementing health policy. The situation in implementing the policy of public health in the city municipality is not good: knowledge of the heads of individual departments of the administration on the health policy, its priorities and key strategic implementation directions is insufficient, there is a lack of the legal base for interagency... [to full text]

Prescription drugs play an increasingly significant role in the Canadian healthcare system. Drug spending accounts for a considerable share of total healthcare expenditure and continues to be one of the fastest growing expenditure components in Canada. But, drug manufacturers’ price setting behaviours are not well understood in the literature. I develop a framework of oligopoly theory with two-dimension product differentiation based on a synthesis of the literature on the institutional history and development of the Canadian pharmaceutical system. I find that: (1) The differentiation in perceived quality between brand-name and generic drugs can explain the generic competition paradox. The degree of the product differentiation can be pivotal in shaping the brand-name drug manufacturers’ price setting behaviours in response to the shift in patients’ preference and changes in government policies. (2) Copay and generic drug price-cap policies are commonly adopted by the Canadian public drug plans to contain drug reimbursement cost. Policy-makers should use caution when applying these policies in combination or separately in order to reach the intended outcomes. (3) The generic drug price-cap can elicit competition among brand-name drug manufacturers, but it may need coordinated regulations on patented drug prices. Without full coordination among major stakeholders and across jurisdictions, the benefits of lowered drug prices for some can become additional costs for others. I innovatively adopt the multilevel model to analyze the pharmaceutical market structure and evaluate the net effect of the generic competition paradox. The empirical research on the drug price dynamics is consistent with the predictions of the previously developed theory. I find that: (1) More generic substitutes in a drug molecule are associated with a net effect of increases in drug prices, after other contextual variables are properly controlled for. (2) More therapeutic substitutes do not have a net effect of lowering drug prices. (3) When a generic substitution policy is in place, the studied brand-name drugs maintain net price premiums over their generic substitutes. But, the net price premiums in the case when there is a generic substitution policy are lower than those where there is no such policy.

Asthma is the second most common chronic condition among Aboriginal youth. This three-phase study aims to understand the psycho-social barriers facing asthmatic Mi’kmaq youth and their parents/caregivers living in Cape Breton, Nova Scotia and facilitate health promoting behaviours at the community-level. A community-based participatory research approach was undertaken to: 1) identify the support needs/intervention preferences of asthmatic Mi’kmaq youth and their parents/caregivers; 2) design and pilot test a culturally appropriate support-education intervention that meets these preferences; and 3) identify the implications of the findings for asthma programs, policies, and practices and determine dissemination strategies. The findings suggest that there is a lack of community-level asthma support available to Mi’kmaq families managing the condition despite a strong desire for these services. This study offers three community-driven recommendations to increase available support: improve school-based asthma policy, develop asthma expertise within each community health center, and implement an annual, culturally appropriate asthma camp.

Is public health policy based on scholarly evidence? With the manifold variables that policy makers must consider, is evidence-based policy even realistic? While strategies exist to translate research into policy, a need to understand better how that can play out in real-life remains. Using interviews from informants occupying a range of positions, and considering the atmosphere created by media reports, this study examines the case of smoking privileges at East Coast Forensic Hospital. After a patient committed murder while on leave, apparently to smoke, public pressure over public safety, a relative lack of relevant scholarship, ethical considerations, and the divergent voices of stakeholders created challenging circumstances for policy makers. Through the use of case study methodology, this project identifies the kinds of information that are employed in the creation or modification of policy and offers insights concerning how the influences exerted on policy makers determine how information is employed.

Over the past years, mental health has attracted increased attention throughout the world, in the form of initiatives, programs, support groups, etc. all with goals to increase awareness and support of mental health. The stark discrepancy between the vision driving this mental health movement and our reality comes from a basic misunderstanding. While there are both legislative and cultural efforts in place to reform our mental health system, the two must work hand in hand in order to affect substantial change. Rather than producing a collaborative effort, our legislators and society tend to ignore each other, resulting in isolated attempts at reform that are doomed to failure without the support of the other side. This thesis examines the obstacles that mentally ill individuals face in the U.S. today after receiving formal “mentally ill” diagnoses. In our current system, these individuals face limited options, all of which include a number of steep costs. This thesis proposes a shift toward a more collaborative approach in order to transform the costs and fear of diagnosis into benefits and desire for diagnosis. However, an approach such as the one suggested can only be successful after a fundamental shift in the perception of mental illness occurs. Whether or not such a shift is possible – and if so, how? – is a question too large to explore in the confines of this thesis, but one that the reader should consider.

Introduction: Despite Colombia having adopted a health system based on an insurance market, Bogota in 2004, as part of a left-wing government (elected for first time in the city), decided to implement a Primary Health Care (PHC) strategy to improve quality of life, level of population health and reduce health inequities. The PHC strategy has been implemented through the HomeHealth program by three consecutive governments over the last eight years in the context of continuous political tension stemming from differences between national and district health policies. This thesis is an attempt to provide a better understanding of the overall experience of implementing a PHC strategy in the context of a market-oriented health care system. The research aimed to evaluate results of the PHC strategy through the intervention of the Home Health program and to identify factors that have enabled or limited the on-going PHC implementation process in Bogota. Methods: This study used a combination of quantitative and qualitative methods. A descriptive analysis was performed to assess direct results of the PHC strategy in terms of progress in the Home Health program coverage and increases in health personnel ratios reaching out to poor and vulnerable groups in Bogota. A cross sectional analysis was carried out to evaluate qualities of the delivery of PHC services through the attainment of PHC essential dimensions in the network of first-level public health care facilities. An ecological analysis was performed to estimate the contribution of the PHC strategy, through the Home Health program, to improve child health outcomes and to reduce health inequalities. A qualitative multiple case study was conducted to identify contextual factors that have enabled or limited the on-going PHC implementation process in Bogota. Results: The descriptive analysis showed a notable initial increase and rapid expansion in the development of the PHC strategy between 2004 and 2007, followed by a period of slower growth and stagnation between 2007 and 2010. The cross-sectional analysis suggested that the Home Health program could be helping to improve the performance of first-level public health care facilities. Ratings assigned to PHC dimensions by different participants pointed out the need to strengthen family focus, community orientation, financial resources distribution, and accessibility. The ecological analysis showed that localities with high PHC coverage had a lower risk of under-five mortality, infant mortality and acute malnutrition as well as a higher probability of being vaccinated than low PHC coverage localities. The belonging to a high-coverage locality was significantly associated with risk reductions of under-five mortality (13.8%) and infant mortality by pneumonia (37.5%) as well as increases in the probability of being vaccinated for DPT (4.9%). Concentration curves and concentration indices indicated inequality reductions in all child indicators betwen 2003 and 2007. In 2007 (period after implementation), the PHC strategy was associated with a reduction in the effect of the inequality that affected disadvantaged localities in under-five mortality (24%), infant mortality rate (19%), acute malnutrition (7%) and DPT vaccination coverage (20%). The main facilitators of the results achieved so far by the PHC strategy were all related to the commitment and good will of actors at different levels. Longterm political commitment, support by local mayors and hospital managers, organized communities historically active in the process of social participation, as well as extramural work carried out by community health workers and health care teams were highly valued. Barriers to the implementation included the structure of the national health system itself, lack of a stable funding source, unsatisfactory working conditions, lack of competencies among health workers regarding family focus and community orientation, and limited involvement of institutions outside the health sector in generating intersectoral responses and promoting community participation. Conclusion: Despite adverse contextual conditions and limitations imposed by the Colombian health system itself, Bogota’s initiative of a PHC strategy has helped to improve the performance of first-level public health care facilities in the essential dimensions of PHC and has also contributed to improvement of child health outcomes and reduction of health inequalities associated with socioeconomic and living conditions. Significant efforts are required to overcome the market approach of the national health system. Structural changes to social policies at the national and district level are needed if the PHC strategy is expected to achieve its full potential. Specific interventions must be designed to have well-trained and motivated human resources, as well as to establish available and stable financial resources for the PHC strategy.

Prescription opioid pain reliever utilization has been increasing since the 1990s, due in part to changes in recommendations for the treatment of chronic pain, but also to abuse and diversion. One innovative policy solution to the abuse and diversion of prescription opioids is state prescription drug monitoring programs (PDMPs), which provide prescribers and other selected parties with patient controlled substance dispensation history; thereby, correcting an information asymmetry problem between prescribers and patients. The widespread implementation of state PDMPs, which vary in program design and requirements, has resulted in a variety of intended and unintended consequences. Previous PDMP evaluations have suggested such outcomes as the reduction of consumer access to opioids, the influencing of healthcare provider prescribing behaviors for opioids, and the re-shaping of the United States market for prescription opioids. PDMPs may also be associated with unintended outcomes: namely, the restriction of pharmaceutical opioids could be associated with an increase in heroin use, as evidenced by increases in heroin substance abuse treatment facility discharges. The analyses in this project examine the influence of PDMPs on healthcare providers and the market for prescription drugs by comparing trends in opioid utilization in states with varying PDMP features using Medicaid prescription utilization data and commercial insurance claims. The effect of PDMPs on consumers is explored with an analysis comparing substance abuse treatment facility discharge data for heroin abuse with pharmaceutical opioid prescriptions before and after PDMP regulatory change. Finally, the impact of other related opioid policy interventions, opioid overdose medication access laws, are analyzed by comparing opioid overdose mortality across states with differing overdose medication access policies over time. Contributions to the understanding about the impacts of these state-level opioid abuse and diversion policies can be used to improve or amplify intended outcomes and ameliorate unintended consequences.