Potentially Inappropriate Prescribing (PIP) is common in Canada yet little is known about its health system costs or which PIPs have the greatest cost impact. This thesis examined the health system costs from hospitalizations, emergency department (ED) visits and medications from all PIP, and for distinct PIP. PIPs were identified in a cohort of older adults in Ontario using a subset of the STOPP/START criteria applicable to health administrative databases, and all analyses were conducted by comparing participants with and without PIP. In study one, the costs from hospitalization, ED visits and newly prescribed medications were identified using population attributable fractions. PIP was identified as responsible for a sizeable portion of all three cost categories, with hospitalization and ED visits costs most highly impacted. Study two compared the incremental costs due to PIP among four distinct PIP criteria selected based on differing frequency and crude costs to validate the use of such characteristics for priority-setting. The crude healthcare costs, as well as the cost of the drug causing the PIP and the frequency of the PIP were identified as likely key characteristics of high-impact PIP. Combined, these studies provide evidence on the overall burden of PIP, while also identifying likely characteristics of high-impact PIP. They suggest interventions at the health system level may be needed to address medication appropriateness and provide information which may be helpful to decision-makers when identifying which PIPs should be targeted for intervention, given no health system level interventions for PIP are currently in place.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / FundaÃÃo Cearense de Apoio ao Desenvolvimento Cientifico e TecnolÃgico / A avaliaÃÃo em saÃde tem sido um importante instrumento para o planejamento e a gestÃo de sistemas e de serviÃos de saÃde, nÃo sà no sentido de aferir a efetividade de intervenÃÃes e o uso eficiente dos recursos disponÃveis, mas tambÃm de satisfazer os profissionais de saÃde e a populaÃÃo usuÃria do sistema. Teve-se como objetivo geral avaliar a satisfaÃÃo dos usuÃrios e dos profissionais do Centro Integrado de Diabetes e HipertensÃo de Barbalha-CE. Utilizou-se como marco conceitual o modelo proposto por Avendis Donabedian para avaliar a qualidade em saÃde a partir dos componentes estrutura, processo e resultado. Trata-se de uma pesquisa avaliativa, com abordagem quanti-qualitativa que usou como estratÃgia de pesquisa o estudo de caso Ãnico. O estudo foi realizado com 97 usuÃrios e 8 profissionais do Centro Integrado de Diabetes e HipertensÃo de Barbalha, e, a coleta de dados efetuou-se no perÃodo de fevereiro a marÃo de 2012. Empregou-se, como instrumento para a coleta de dados dos usuÃrios, um questionÃrio semiestruturado, englobando as dimensÃes infraestrutura, acessibilidade e relaÃÃo usuÃrio-equipe. Para os profissionais, utilizou-se o Ãndice de PercepÃÃes Organizacionais, contendo as dimensÃes infraestrutura, gestÃo, clima e cultura organizacional. Os dados foram armazenados no programa Microsoft Excel, sendo processados pelo Statistical Package for the Social Sciences. Para as anÃlises de associaÃÃo, optou-se pelos testes qui-quadrado e razÃo de verossimilhanÃa. Os dados referentes Ãs questÃes abertas foram analisados mediante a anÃlise do conteÃdo. Obteve-se aprovaÃÃo pelo Comità de Ãtica em Pesquisa em Seres Humanos da Universidade Federal do CearÃ, n 324/11. Conforme os resultados mostraram, a maioria dos usuÃrios estava satisfeita com o Centro (63,9%). Quanto Ãs dimensÃes, a relaÃÃo usuÃrio-equipe foi responsÃvel pela maior prevalÃncia de satisfaÃÃo (92,8%) e a acessibilidade pela menor (67,0%). Na anÃlise das falas observou-se que os usuÃrios demonstravam insatisfaÃÃo com alguns aspectos nÃo verificados nas respostas fechadas: falta de adequaÃÃo estrutural para usuÃrios idosos e/ou com alguma deficiÃncia fÃsica; precÃria infraestrutura do banheiro; falta de organizaÃÃo do agendamento das consultas mÃdicas e de coleta de exames. NÃo se verificou associaÃÃo estatisticamente significante entre satisfaÃÃo dos usuÃrios e variÃveis sociodemogrÃficas ou controle glicÃmico. Quanto aos profissionais, a maioria (sete) estava satisfeita em trabalhar no Centro. No referente Ãs dimensÃes, o clima/cultura organizacional foi responsÃvel pela maior frequÃncia de satisfaÃÃo entre os profissionais. Os aspectos relacionados à insatisfaÃÃo foram observados nas dimensÃes infraestrutura, mais especificamente com a ambiÃncia e a seguranÃa; e na gestÃo, quando investigados os quesitos educaÃÃo permanente e remuneraÃÃo. Conclui-se que o Centro Integrado de Diabetes e HipertensÃo de Barbalha possui aspectos positivos, os quais devem ser reforÃados, e negativos, que precisam ser melhorados no tocante à avaliaÃÃo da qualidade, especificamente à satisfaÃÃo dos usuÃrios e dos profissionais. Segundo evidenciado, alguns aspectos avaliados negativamente saem da governabilidade dos profissionais e do gestor local do serviÃo de saÃde, logo, sÃo de responsabilidade da gestÃo municipal. Por isso recomenda-se sensibilizÃ-la. ReforÃa-se a importÃncia de pesquisas de satisfaÃÃo profissional e de usuÃrios como instrumento de gestÃo, pois poderÃo trazer melhoria para ambos. / Health evaluation has been an important tool for the planning and management of health systems and services not only to assess the effectiveness of interventions and the efficient use of available resources, but also to satisfy health professionals and the population user of the system. The objective was to assess the satisfaction of users and professionals of the Integrated Center for Diabetes and Hypertension of Barbalha, CearÃ, Brazil. The model proposed by Avendis Donabedian was used as a conceptual reference to assess the quality of healthcare from the components of structure, process and result. This is an evaluative study of quantitative and qualitative approach that used the single case study as a research strategy. The study was carried out with 97 users and eight professionals of the Center, and the data collection period was from February to March, 2012. The instrument applied for data collection of users was a semi-structured questionnaire encompassing the dimensions of infrastructure, accessibility and the user-staff relationship. For professionals it was used the Organizations Perception Index containing the dimensions of infrastructure, management, and organizational climate and culture. Data were stored in Microsoft Excel, and processed by the Statistical Package for the Social Sciences. The chi-square and the likelihood ratio tests were used for the association analysis. The data related to the open questions were analyzed by content analysis. The study was approved by the Ethics Committee of Research in Human Beings of the Federal University of CearÃ, n 324/11. According to the results most users were satisfied with the Center (63.9%). As for the dimensions, the user-team relationship was responsible for the greatest prevalence of satisfaction (92.8%) and accessibility for the lowest (67.0%). In the analysis of the speeches, users showed dissatisfaction with some aspects not checked in closed responses: lack of structural adequacy for the elderly and/or those with a physical impairment; bathroom poor infrastructure, lack of organization for scheduling medical appointments and sample collection. There was no statistically significant association between user satisfaction and sociodemographic variables or glycemic control. As for professionals, the majority (seven) was satisfied with working in the Center. The dimension of organizational environment/culture was responsible for the highest frequency of satisfaction among professionals. The aspects related to dissatisfaction were observed in the dimension of infrastructure, more specifically with the ambience and safety; and in management when investigating the aspects of continuing education and remuneration. The conclusion is that the Integrated Center for Diabetes and Hypertension has positive aspects that should be reinforced and negative aspects that need to be improved with regard to quality evaluation, more specifically with the satisfaction of users and professionals. According to evidences, some negatively reviewed aspects escape the competence of professionals and managers of the local health service, therefore are responsibility of the municipal management, hence the recommendation to sensitize it. Satisfaction surveys with professionals and users are extremely important management tools, because of the improvements it can bring to both, therefore these surveys should be encouraged.

This thesis deals with the health system in the Czech Republic, with a focus on the management of health insurance companies in revenue from premiums collected and expenditure on the health care insurance policy holders. The first part deals with the health system in general to get a general idea of the health system. It deals with various types of health systems, participants in health insurance and various types of health care. The second part is devoted to legal legislation, the history of the health system in the Czech Republic, different types of reimbursement of health care and health insurance status in the health system. The last part of thesis deals with analysis of health insurance, which is based on a comparison of the various health insurance companies in terms of insured persons, income from insurance premiums and expenses and health care.

Therapy decision-making for patients with chronic diseases can be difficult. Such patients usually live with their illness(es) all their life, and therapies can only help them improve their condition by managing symptoms, not curing them. Patient-oriented approaches are common to caring for people with chronic conditions because patients’ priorities become relevant means of prioritizing therapies in the absence of a cure. While such type of approach is shown to be effective, it does not leverage evidence on the success of given therapies to achieve specific similar patient goals in the past. Evidence-Based Medicine (EBM) is a concept that was introduced to the medical field in the early 90s to invalidate previously accepted tests and therapies and replace them with new, more powerful, more accurate, more efficacious, and safer ones. Unfortunately, despite the prevalence of patient-oriented approaches for patients with chronic diseases, data collected on patients is not systematically leveraged to support therapy decisions. Combining evidence-based decision-making and patient-oriented approaches could potentially further improve patient outcomes by leveraging the most up-to-date data to recommend and discuss therapy options for patients with chronic conditions. The development and implementation of Learning Health Systems (LHS) is another solution to improving patient outcomes, one that the US Institute of Medicine strongly recommends. The development and implementation of a LHS to support therapy choice for patients with chronic conditions could improve related decisions by fostering continuous learning regarding which therapy may help better achieve which patient goals. However, a learning process that systematically leverages a relevant basis of evidence to support patient-oriented approaches has yet to be defined. As such, this study aims at articulating a learning process for therapy decision-making in the context of chronic conditions. The result is framework and a demonstration of its application using the Goal Attainment Scale (GAS) and synthetic data.

I. BACKGROUND: Following a review of donor funding priorities and concepts of health system strengthening (HSS) and resilience, this dissertation documents health system resilience factors existing in the Liberian health system in late 2014/early 2015 as the Ebola epidemic flared. The effectiveness of the WHO health system building blocks framework in addressing resilience was assessed, and specific factors that can promote health system resilience for Liberia going forward were identified. II. METHODS: Methods applied as part of this intrinsic case study include document and literature review, analysis of health facility and population-level statistics, and key informant and group interviews at the county and national levels. The methodology allowed for an in-depth assessment of how HSS (using the WHO health system building blocks) and resilience factors (using the WHO-defined key aspects of emergency preparedness) exist (or could exist) within the Liberian institutional and cultural context, and for tentative conclusions to be drawn about the importance of system factors to building specific health system capacities and overall health system resilience. III. FINDINGS: While dealing with myriad other public health priorities, public health preparedness went largely unaddressed in pre-Ebola Liberia where effectively none of the 16 key components or their 51 essential attributes listed in the WHO table of emergency preparedness were in place. The lack of integration of public health preparedness into HSS interventions left the country vulnerable to public health emergencies. There are two limitations to the government’s Ebola recovery and investment plan: (1) lack of a holistic approach to addressing emergency preparedness; and (2) not integrating emergency preparedness needs and corresponding activities into the existing national HSS framework. IV. CONCLUSION: By integrating emergency preparedness and response initiatives into HSS activities, health systems in Liberia and elsewhere can be strengthened to be more resilient, and thus better able to anticipate and adapt to challenges, and ultimately improve the system to be able to anticipate new future challenges. However, strengthening health systems so that they are resilient takes resources, including sector-wide, HSS resources that can be used to build functioning, integrated systems and skilled, networked individuals and groups across sectors.

There is a growing body of literature about public participation in health-system priority setting in different contexts and levels of governance, however, explicit focus on vulnerable populations’ participation is lacking. This dissertation incorporated a mix of methodological approaches to address this gap. First, a scoping review was used to synthesize the literature on priority-setting frameworks to understand whether and how applications of the frameworks involve the public and vulnerable populations in different contexts. Second, an interpretive description study was used to examine stakeholder participation at the district level in a low-income country, Uganda. Third, a qualitative description study design was used to qualitatively assess vulnerable women’s participation in health-system priority setting within a district in Uganda, from the perspectives of both vulnerable women and decision-makers. The research chapters complement and build on one another to make substantive, methodological, and theoretical contributions. Specifically, insights gained from the scoping review demonstrate that while priority-setting frameworks may require participation of all stakeholders, in practice certain stakeholder groups, namely the public and especially vulnerable populations, are not consistently integrated into priority-setting processes. The empirical research provides a rich understanding of the roles of different stakeholders in the priority-setting process and provides explanations about why vulnerable women, as a subset of the public, are not participating. This adds to the evidence base that policy-makers can access to guide future attempts to engage publics in health-system priority setting. These studies collectively contribute to a wider understanding of public’s and vulnerable populations’ participation in health-system priority setting in low-income contexts where health disparities are pronounced, and health resources are especially scarce. Policy-makers should aim to support vulnerable populations’ participation in health-system priority setting. Clear articulation of which vulnerable populations should participate and how they should participate can facilitate priority-setting processes. Co-developing participatory methods, frameworks, and guides with vulnerable populations can reinforce their participation and lead to mechanisms of participation that are more responsive to their needs. / Thesis / Doctor of Philosophy (PhD) / Public participation is often considered a cornerstone of fair and legitimate priority setting. Yet, little is known about whether and how the participation of vulnerable populations is operationalized in the field of health-system priority setting. An in-depth understanding of who participates and who does not, and how participation is enabled and/or hindered is essential to ensure that policy-makers can support participation. This dissertation addresses gaps in knowledge through: 1) a literature synthesis examining the operationalization of stakeholder participation within priority-setting frameworks, with specific attention to the publics’ and vulnerable populations’ participation, in cases where the frameworks have been applied to health-system priority setting; 2) supportive qualitative evidence on the roles, leverages, and challenges of different stakeholders’ participation in district-level health-system priority setting in Uganda; and 3) examining vulnerable women’s participation within one Ugandan district, specifically outlining barriers to their participation, and solutions to address these barriers and support vulnerable women’s participation in health-system priority setting. Collectively these studies can inform policy-making and development of public participation strategies that specifically target vulnerable populations for participation in health-system priority setting.

Many health systems are in the midst of transformation. They are slowly moving from the delivery of reactive care focused on individuals to considering proactive ways of supporting the health and well-being of populations. However, the road to what is often called ‘population-health management’ is rife with implementation challenges. One type of implementation support that has been used to navigate these challenges is technical assistance. Though the use of technical assistance is well documented, there is no consensus on a clear definition or understanding of how it can be used to support system transformation. This thesis contributes to the field of technical assistance through three qualitative studies. First, a critical interpretive synthesis develops a definition and logic model for technical assistance. This logic model integrates diverse academic and grey literature. It aims to draw clearer boundaries around technical assistance as a concept and provide a common language for researchers, technical assistance providers, and decision-makers to use. Second, a qualitative descriptive study explores the use of technical assistance in population-health management transformations in England and the U.S., examining what technical assistance has been provided, by whom, and in what areas of application. Finally, a case study unpacks the use of technical assistance for a recent health-system transformation in Ontario. It examines the influence that political factors related to institutions, ideas, interests and external events have on shaping its evolution. Together, these three studies provide greater clarity on the use of technical assistance in health-system transformations and the range of factors that may affect how it is conceptualized and operationalized. / Thesis / Candidate in Philosophy

The robustness and responsiveness of a country's health system predict access to a range of health services, including maternal and child health (MCH) services. The purpose of this cross-sectional study was to examine the influence of 5 health system characteristics on access to MCH services in Sierra Leone. This study was guided by Bryce, Victora, Boerma, Peters, and Black's framework for evaluating the scaleup to millennium development goals for maternal and child survival. The study was a secondary analysis of the Sierra Leone 2017 Service Availability and Readiness Assessment dataset, which comprised 100% (1, 284) of the country's health facilities. Data analysis included bivariate and multivariate logistic regressions. In the bivariate analysis, all the independent variables showed statistically significant association with access to MCH services and achieved a p-value < .001. In the multivariate analysis; however, only 3 predictors explained 38% of the variance (R� = .380, F (5, 1263) = 154.667, p <.001). The type of health provider significantly predicted access to MCH services (β =.549, p <.001), as did the availability of essential medicines (β= .255, p <.001) and the availability of basic equipment (β= .258, p <.001). According to the study findings, the availability of the right mix of health providers, essential medicines, and basic equipment significantly influenced access to MCH services, regardless of the level and type of health facility. The findings of this study might contribute to positive social change by helping the authorities of the Sierra Leone health sector to identify critical health system considerations for increased access to MCH services and improved maternal and child health outcomes.

Recent events throughout the world and in the US lend support to the belief that another terrorist attack on the US is likely, perhaps probable. Given the potential for large numbers of casualties to be produced by a blast using conventional explosives, it is imperative that health systems across the nation consider the risks in their jurisdictions and take steps to better prepare for the possibility of an attack. Computer modeling and simulation offers a viable and useful methodology to better prepare an organization or system to respond to a large scale event. The real question, given the shortage, and in some areas absence, of experiential data, could computer modeling and simulation be used to predict the resource requirements generated by this type of event and thus prepare a health system in a defined geographic area for the possibility of an event of this nature? Research resulted in the identification of variables that surround a health system at risk, the development of a computer model to predict the injuries that would be seen in an injured survivor population and the medical resources required to care for this population. Finally, methodologies were developed to modify the existing model to match unique health system structures and processes in order to assess the preparedness of a specific geographic location or health system. As depicted in this research, computer modeling and simulation was found to offer a viable and usable methodology for a defined geographic region to better prepare for the potential of a large scale blast event and to care for the injured survivors that result from the blast. This can be done with relatively low cost and low tech approach using existing computer modeling and simulation software, making it affordable and viable for even the smallest geographic jurisdiction or health system.

A transposição dos agentes terapêuticos da esfera do conhecimento tradicional para a abrangência dos cuidados institucionalizados de atenção à saúde pressupõe responsabilidades dos executores destas ações. Esta premissa é aplicável também aos medicamentos oriundos de plantas medicinais. Deste modo, este trabalho foi elaborado a partir da constatação da inexistência de norma nacional específica para produção de medicamentos enquadrados como fitoterápicos, em escala magistral, no âmbito do serviço público de atendimento à saúde, mais especificamente no Sistema Único de Saúde (SUS). O emprego destes medicamentos, no entanto, é estimulado em diversas políticas públicas de saúde. Assim sendo, o objetivo desta pesquisa foi a de propor legislação sanitária para a cadeia destes produtos incorporando-os às ações do SUS. A metodologia da pesquisa teve características qualitativas e quantitativas, com o intuito de conhecer a realidade já instalada em algumas regiões do país e no mundo. Além da pesquisa documental em sítios eletrônicos de órgãos oficiais brasileiros e internacionais foi realizada coleta de dados pela aplicação de questionário estruturado com perguntas fechadas, em serviços públicos estaduais e municipais, que utilizam esta alternativa terapêutica. Os dados provenientes dos questionários e de visitas aos serviços foram analisados sob uma perspectiva exploratória. A partir destes dados foram avaliadas as fontes de risco das diversas fases de obtenção de um medicamento fitoterápico manipulado, empregando ferramentas da gestão do risco à qualidade, em especial a análise do modo de falha e seus efeitos (FMEA). Esta estratégia apontou os passos referentes à especificação, ao uso e à análise da matéria-prima de origem vegetal como os de maior relevância no sistema. Utilizando os resultados obtidos nestas três etapas foi elaborada a proposta de Regulamento Técnico de Boas Práticas para Manipulação de Fitoterápicos aplicável à rede pública de saúde, seguindo o modelo utilizado pelo órgão sanitário regulador nacional. A norma prevê cuidados que partem da matéria-prima vegetal, à sua manufatura e controle de qualidade em Oficinas Farmacêuticas, e sua dispensação. / The transposition from traditional to institutional health care system presumes the assumption of responsibilities from the executers of such actions. This prerogative is also valid for phytomedicines. From this point of view, this research was done due to the lack of a specific nationwide legislation for the production of herbal medicines at pharmacy level in the Brazilian Public Health System (SUS), although the use of such products is stimulated by several governmental health policies. Therefore, the aim of this work was to propose regulatory instruments for the whole chain of herbal drugs, incorporating them to the actions of the SUS in order to provide a rational and safe access of the population to such products. The research methodology was based on qualitative and quantitative investigative techniques, intending the knowledge of the existing services in the country and abroad. Further to the documental research in electronic sites from Brazilian and International governmental and nongovernmental organizations, data were collected using a structured questionnaire containing closed questions applied to Brazilian Health Units in State and County level which employ such therapeutic agents. In some cases individual interviews were done by visiting several units. The results from the questionnaires and local evaluations were first analyzed under an exploratory perspective. From the organized data and results a flowchart comprising all the points of the phytotherapy system was made and evaluated according to a risk analyses management process, using as tool mainly the Failure Mode and Effect Analysis. As the most critical stages the analyses pointed out the issues regarding the herbal raw material. The output of these three research steps allowed the proposition of a Technical Guideline of Good Compounding Practices for Phytomedicines applied to the SUS, following the models prescribed by the national regulatory board. The guideline contains attempts intended for the herbal raw-material, compounding and quality control directives to be fulfilled by pharmaceutical officines, and also indications concerning the correct dispensing of the phtytomedicines and the treatment efficacy tracking.