Health care marketing: the theory of planned behavior applied to patients' choise between private and public providers in the portuguese health care system.

Dissertation submitted in partial fulfillment of the requirements for degree of Master in Statistics and Information Management.

Technological adoption in health care

This paper addresses the impact of payment systems on the rate of technology adoption. We present a model where technological shift is driven by demand uncertainty, increased patients’ benefit, financial variables, and the reimbursement system to providers. Two payment systems are studied: cost reimbursement and (two variants of) DRG. According to the system considered, adoption occurs either when patients’ benefits are large enough or when the differential reimbursement across technologies offsets the cost of adoption. Cost reimbursement leads to higher adoption of the new technology if the rate of reimbursement is high relative to the margin of new vs. old technology reimbursement under DRG. Having larger patient benefits favors more adoption under the cost reimbursement payment system, provided that adoption occurs initially under both payment systems.

An assessment of the integration of the mental health component into the care of women affected by intimate partner violence in Peru

RESUMO: A violência contra as mulheres (VCM) é um problema de saúde pública e uma violação dos direitos humanos. Ele tem uma alta prevalência na América Latina e no Caribe; o Estudo da Violência Contra as Mulheres da Organização Mundial de Saúde (OMS) identificou que as mulheres peruanas sofrem o maior índice de violência. O Perú é signatário da CEDAW e da Convenção de Belém do Pará, com recomendações para resolver este tipo de discriminação e descrever o papel do setor da saúde. A lei peruana define a violência como um problema de saúde mental. Objectivos: As três orientações clínicas do Ministério da Saúde para avaliar a integração da componente de saúde mental no cuidado de mulheres afetadas pela VCM foram revistas. Método: A proteção da saúde mental foi avaliada nas orientações acima mencionadas. A lei peruana relevante para perceber o reconhecimento das consequências de VCM na saúde mental e os cuidados prestados neste contexto foram revistos. Usando esses padrões nacionais e internacionais, foi realizada uma análise de conteúdo dos guias peruanos para a atenção da violência para ver como eles se integram a saúde mental. Resultados: Estas orientações são muito extensas e não definem claramente a responsabilidade dos profissionais de saúde. Não incluem um exame de saúde mental na avaliação da vítima e são vagas na descrição das atividades a serem realizadas pelo prestador dos cuidados de saúde. As orientações recomendam uma triagem universal usando um instrumento com formato antiquado e pesado. Em contrapartida, as orientações da OMS não recomendam qualquer triagem. Conclusão: As várias orientações analisadas não fornecem a informação necessária para o profissional de saúde avaliar o envolvimento da saúde mental e, desnecessariamente, tratam as mulheres sobreviventes de VCM como doentes mentais. Recomenda-se que as orientações recentes da OMS (Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, 2013) para os cuidados de VCM sejam usadas como um modelo para o desenvolvimento de um único dispositivo técnico que incorpora directrizes com base científica. legislação com base no género, saúde, guias, prevenção e mujeres 6 RESUMO (PORTUGUESE) A violência contra as mulheres (VCM) é um problema de saúde pública e uma violação dos direitos humanos. Ele tem uma alta prevalência na América Latina e no Caribe; o Estudo da Violência Contra as Mulheres da Organização Mundial de Saúde (OMS) identificou que as mulheres peruanas sofrem o maior índice de violência. O Perú é signatário da CEDAW e da Convenção de Belém do Pará, com recomendações para resolver este tipo de discriminação e descrever o papel do setor da saúde. A lei peruana define a violência como um problema de saúde mental. Objectivos: As três orientações clínicas do Ministério da Saúde para avaliar a integração da componente de saúde mental no cuidado de mulheres afetadas pela VCM foram revistas. Método: A proteção da saúde mental foi avaliada nas orientações acima mencionadas. A lei peruana relevante para perceber o reconhecimento das consequências de VCM na saúde mental e os cuidados prestados neste contexto foram revistos. Usando esses padrões nacionais e internacionais, foi realizada uma análise de conteúdo dos guias peruanos para a atenção da violência para ver como eles se integram a saúde mental. Resultados: Estas orientações são muito extensas e não definem claramente a responsabilidade dos profissionais de saúde. Não incluem um exame de saúde mental na avaliação da vítima e são vagas na descrição das atividades a serem realizadas pelo prestador dos cuidados de saúde. As orientações recomendam uma triagem universal usando um instrumento com formato antiquado e pesado. Em contrapartida, as orientações da OMS não recomendam qualquer triagem. Conclusão: As várias orientações analisadas não fornecem a informação necessária para o profissional de saúde avaliar o envolvimento da saúde mental e, desnecessariamente, tratam as mulheres sobreviventes de VCM como doentes mentais. Recomenda-se que as orientações recentes da OMS (Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, 2013) para os cuidados de VCM sejam usadas como um modelo para o desenvolvimento de um único dispositivo técnico que incorpora directrizes com base científica.-----------------ABSTRACT: Violence against women (VAW) is a public health problem and a human rights violation. It is highly prevalent in Latin America and the Caribbean; the Multi-country Study on Violence against Women by the World Health Organization identified rural Peruvian women as suffering the highest rates of VAW. The country is party to CEDAW and Belen Do Para Conventions, which set forth recommendations to overcome this form of discrimination and describe the role of the health sector. Peruvian law defines violence as a mental health issue. Objective: The Ministry of Health’s three technical guidelines were reviewed to assess the integration of mental health into the care of women affected by violence Method: The protection of the woman’s mental health was ascertained in the conventions mentioned above. The recognition of the mental health consequences of VAW and the inclusion of its evaluation and care were assessed in pertinent Peruvian legislation. Using these international and national parameters, the three guidelines for the attention of violence were subject to content analysis to see whether they conform to the conventions and integrate mental health care. Outcome: These guidelines are too extensive and do not clearly define the responsibility of health workers. They do not include a mental health exam in the evaluation of the victim and are vague in the description of the actions to be carried out by the health care provider. Guidelines prescribe universal screening using an outdated instrument and moreover, WHO Guidelines do not recommend screening. Conclusion: These multiple guidelines do not provide useful guidance for health care providers, particularly for the assessment of mental health sequelae, and unnecessarily stigmatize survivors of violence as mentally ill. It is recommended that the World Health Organization’s document Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines (2013) be used as a blueprint for only one technical instrument that incorporates evidence -based national policy and guidelines.

The black box of health care expenditure growth determinants

In this paper, the determinants of growth of aggregate health expenditures are investigated. The study departs from previous literature in that it looks at differences across countries in growth (and not levels) of health care expenditures. Estimation is made for 24 OECD countries. Health system characteristics usually believed to influence health expenditures growth, like population ageing, the type of health system (public reimbursement, public contract or integrate) and existence of gatekeepers, are found to be non-significant. Nevertheless, there is evidence that health expenditures experienced a clear slower growth in the last decade. The explanation for this slowdown could not be found in the proposed model and should stimulate further research.

Health care costs of domestic violence against women – evidence from Portugal

Our main objective is to estimate the additional health care costs to the Portuguese National Health Service (NHS) due to domestic violence against women. We collected information through a survey addressed to health care centres’ female users. Both victims and non-victims of violence were inquired. We estimate costs according to five different groups – consultation costs, health care treatment and therapeutic costs, costs of complementary and diagnostic exams, drugs costs and transport costs. The estimations have been split into two perspectives – the NHS perspective (public perspective) and private perspective of inquired women (out of pocket payments). The timeframe of our calculations is one year, referring to all costs generated by domestic violence situations in the last twelve months. Essentially costs were estimated through the product of total number of episodes by the average estimated price per episode. Additionally, for the private costs, we also considered the costs originated by income losses, the opportunity cost of time spent on health care treatments and the work inability caused by sickness. The results suggest that the victims of domestic violence’s additional demand for health care is valued €140 per annum, that is about 22% higher than health care costs of non-victims. These results match those of similar studies for the United States, taking account of per capita differences in health care spending. A large proportion (90%) of the additional costs associated with domestic violence is supported by the NHS, where consultations and drugs are the most important contributors of such costs. Health consequences of domestic violence result from losses in quality of life and worst health status of victims and correspond to additional permanent economic costs of domestic violence episodes.

Double coverage and demand for health care: Evidence from quantile regression

An individual experiences double coverage when he bene ts from more than one health insurance plan at the same time. This paper examines the impact of such supplementary insurance on the demand for health care services. Its novelty is that within the context of count data modelling and without imposing restrictive parametric assumptions, the analysis is carried out for di¤erent points of the conditional distribution, not only for its mean location. Results indicate that moral hazard is present across the whole outcome distribution for both public and private second layers of health insurance coverage but with greater magnitude in the latter group. By looking at di¤erent points we unveil that stronger double coverage e¤ects are smaller for high levels of usage. We use data for Portugal, taking advantage of particular features of the public and private protection schemes on top of the statutory National Health Service. By exploring the last Portuguese Health Survey, we were able to evaluate their impacts on the consumption of doctor visi

Mental health promotion during pregnancy and early childhood : an action- research project in primary health care

ABSTRACT – Background: Primary Health Care (PHC) is usually the first contact with the health system, and health professionals are key mediators for enabling citizens to take care of their health. In Portugal, great improvements have been achieved in the biometric indicators of maternal and child health during the last decades. Nevertheless, scant attention has been paid to the mental health dimension, in spite of the recognition of its importance, being pregnancy and early childhood crucial opportunities in the lifecycle for mental health promotion, especially in the early years of life, with a strong impact in the health of the child. The impact of early attachment between mother and baby on maternal and child health has long been recognized. This attachment can be influenced by some factors, as the mother’s emotional adjustment. Attention to these factors may facilitate implementation of both positive conditions and preventative measures. Family support during the transition to parenthood has been highlighted as an effective measure and PHC professionals are in a privileged position as information sources as well as mediators. Aims: The project we present describes an action-research process developed together among academic researchers and health professionals to embrace these issues. We intend to enable health professionals to support families in the transition to parenthood thereby promoting children’s mental health. Approach: The project is driven by a participatory approach intended to lead to reorganization of health care during pregnancy and early childhood. Effective change happens when those involved are interested and motivated, what makes their participation so important. Reflection about current practices and needs, and knowledge about evidence-based interventions have been guiding the selection of changes to introduce in clinical practice for family support and development of parenthood skills and self-confidence. Development: We summarize the main steps in development: the initial assessment and the picture taken from the community under study; the decision making process; the training programme of PHC professionals in action; the review of the protocols of maternal consultation, home visits and antenatal education; the implementation planning; the plan for evaluation the effectiveness of the changes introduced in the delivery of maternal and child health care units. The already developed work has shown that motivation, leadership and organizational issues are decisive for process development.-------------------------- RESUMO - Os Cuidados de Saúde Primários são habitualmente o primeiro contacto com o sistema de saúde e os profissionais de saúde são mediadores chave na capacitação dos cidadãos para cuidarem da sua saúde. Em Portugal, nas últimas décadas, têm-se alcançado grandes melhorias nos indicadores biométricos de saúde materno-infantil. Contudo, tem-se dedicado pouca atenção à dimensão de saúde mental, apesar do reconhecimento da sua importância. A gravidez e primeira infância têm sido apontadas como uma oportunidade crucial no ciclo de vida para a promoção da saúde mental. É dado especial enfoque aos primeiros tempos de vida, dado o forte impacto na saúde da criança. O impacte da vinculação precoce entre a mãe e o bebé na saúde da mãe e da criança há muito que é reconhecido. Esta vinculação pode ser influenciada por vários factores, nomeadamente pelo ajustamento emocional da mãe. A focalização nestes aspectos pode facilitar a criação de condições favoráveis e a implementação de medidas preventivas. O suporte familiar durante o período de transição para a parentalidade tem sido enfatizado como uma medida eficaz e os Cuidados de Saúde Primários estão numa posição privilegiada como fontes de informação e como mediadores. O projecto que apresentamos descreve um processo de investigação- acção desenvolvido em parceria entre investigadores académicos e profissionais de saúde para abordar os aspectos referidos. Pretende-se capacitar os profissionais de saúde para apoiarem as famílias na transição para a parentalidade, promovendo assim a saúde mental das crianças. O projecto baseia-se numa abordagem participativa, direccionada para a reorganização dos cuidados durante a gravidez e primeiros tempos de vida. A mudança efectiva acontece quando os envolvidos estão interessados e motivados, o que torna a sua participação tão importante. A reflexão acerca das práticas e necessidades actuais e o conhecimento acerca de intervenções baseadas na evidência têm guiado a selecção das alterações a introduzir na prática clínica, no sentido de promover o suporte familiar e o desenvolvimento de competências parentais e auto-confiança. Neste artigo, apresentamos as etapas principais do desenvolvimento do projecto: avaliação inicial da comunidade em estudo; processo de tomada de decisão; programa de formação dos profissionais dos Cuidados de Saúde Primários; revisão dos protocolos da consulta de saúde materna, visita domiciliária e educação pré-natal; planeamento da implementação; plano de avaliação da efectividade das alterações introduzidas na prestação de cuidados. O trabalho já desenvolvido tem mostrado que a motivação, liderança e aspectos

Effects of a mental health training program on health care worker's knowledge and attitude and practice in Belize

ABSTRACT This study was conducted to assess mental health knowledge, attitude and practices among health care workers in Belize before and immediately after a competency based training program in mental health. A baseline Knowledge, Attitudes and Practices (KAP) survey was given to health personnel, mainly nurses, working primary and secondary care. The intervention was a 13-week face-to-face training course for health care professionals with the objective of increasing their competency in mental health and reducing stigma. After the training a post intervention KAP survey was conducted among the original respondents. 88 health care workers completed the baseline survey and 61 of those respondents completed the post-intervention questionnaire. The results showed that the level of knowledge of the participants had improved by the training intervention and that in general, the intervention was effective in correcting some misconceptions about mental illness and reducing stigmatizing attitudes among the participants.

How effective are brief interventions in smoking cessation: project of a cohort study in a family health care unit

ABSTRACT: Tobacco use remains the most significant modifiable cause of disability, death and illness1. In Portugal, 19,6% of the population aged ten years or more smoke3. A Cochrane review of 20087 concluded that a brief advice intervention (compared to usual care) can increase the likelihood of a smoker to quit and remain nonsmoker 12 months later by a further 1 to 3 %. Several studies have shown that Primary Care Physicians can play a key role in these interventions8,9,10. However we did not find studies about the effectiveness of brief interventions in routine consultations of Family Doctors in Portugal. For this reason we designed a Cohort Study to make an exploratory study about the effectiveness of brief interventions of less than three minutes in comparison with usual care in routine consultations. The study will be implemented in a Family Healthcare Unit in Beja, during six months. Family Doctors of the intervention group should be submitted for an educational and training program before the study begin. Quit smoking sustained rates will be estimated one year after the first intervention in each smoker. If, as we expect, quit smoking rates will be higher in the intervention group than in the control group, this may change Portuguese Family Doctors attitudes and increase the provision of brief interventions in routine consultations in Primary Healthcare Centers.

Estimating demand for primary health care services

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and Economics

Primary public health care and socioeconomic asymmetries in Portugal

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and Economics

Economic analysis in health care regulation : three essays

ABSTRACT - It is the purpose of the present thesis to emphasize, through a series of examples, the need and value of appropriate pre-analysis of the impact of health care regulation. Specifically, the thesis presents three papers on the theme of regulation in different aspects of health care provision and financing. The first two consist of economic analyses of the impact of health care regulation and the third comprises the creation of an instrument for supporting economic analysis of health care regulation, namely in the field of evaluation of health care programs. The first paper develops a model of health plan competition and pricing in order to understand the dynamics of health plan entry and exit in the presence of switching costs and alternative health premium payment systems. We build an explicit model of death spirals, in which profitmaximizing competing health plans find it optimal to adopt a pattern of increasing relative prices culminating in health plan exit. We find the steady-state numerical solution for the price sequence and the plan’s optimal length of life through simulation and do some comparative statics. This allows us to show that using risk adjusted premiums and imposing price floors are effective at reducing death spirals and switching costs, while having employees pay a fixed share of the premium enhances death spirals and increases switching costs. Price regulation of pharmaceuticals is one of the cost control measures adopted by the Portuguese government, as in many European countries. When such regulation decreases the products’ real price over time, it may create an incentive for product turnover. Using panel data for the period of 1997 through 2003 on drug packages sold in Portuguese pharmacies, the second paper addresses the question of whether price control policies create an incentive for product withdrawal. Our work builds the product survival literature by accounting for unobservable product characteristics and heterogeneity among consumers when constructing quality, price control and competition indexes. These indexes are then used as covariates in a Cox proportional hazard model. We find that, indeed, price control measures increase the probability of exit, and that such effect is not verified in OTC market where no such price regulation measures exist. We also find quality to have a significant positive impact on product survival. In the third paper, we develop a microsimulation discrete events model (MSDEM) for costeffectiveness analysis of Human Immunodeficiency Virus treatment, simulating individual paths from antiretroviral therapy (ART) initiation to death. Four driving forces determine the course of events: CD4+ cell count, viral load resistance and adherence. A novel feature of the model with respect to the previous MSDEMs is that distributions of time to event depend on individuals’ characteristics and past history. Time to event was modeled using parametric survival analysis. Events modeled include: viral suppression, regimen switch due virological failure, regimen switch due to other reasons, resistance development, hospitalization, AIDS events, and death. Disease progression is structured according to therapy lines and the model is parameterized with cohort Portuguese observational data. An application of the model is presented comparing the cost-effectiveness ART initiation with two nucleoside analogue reverse transcriptase inhibitors (NRTI) plus one non-nucleoside reverse transcriptase inhibitor(NNRTI) to two NRTI plus boosted protease inhibitor (PI/r) in HIV- 1 infected individuals. We find 2NRTI+NNRTI to be a dominant strategy. Results predicted by the model reproduce those of the data used for parameterization and are in line with those published in the literature.

Primary and hospitalar health care: Building a happy marriage

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Management from the NOVA – School of Business and Economics

Health care needs and resources distribution: How to allocate financial resources in primary care trust?

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and Economics

Benchmarking in primary health care: An application of the stochasticd frontier analysis and the grades of membership approach to Portuguese family health units

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and Economics