Obama's law : analysis of a breakthrough law on healthcare access and lessons for the Portuguese health system management

ABSTRACT - The Patient Protection and Affordable Care Act shook the foundations of the US health system, offering all Americans access to health care by changing the way the health insurance industry works. As President Obama signed the Act on 23 March 2010, he said that it stood for ���the core principle that everybody should have some basic security when it comes to their health care���. Unlike the U.S., the Article 64 of the Portuguese Constitution provides, since 1976, the right to universal access to health care. However, facing a severe economic crisis, Portugal has, under the supervision of the Troika, a tight schedule to implement measures to improve the efficiency of the National Health Service. Both countries are therefore despite their different situation, in a conjuncture of reform and the use of new health management measures. The present work, using a qualitative research methodology examines the Affordable Care Act in order to describe its principles and enforcement mechanisms. In order to describe the reality in Portugal, the Portuguese health system and the measures imposed by Troika are also analyzed. The intention of this entire analysis is not only to disclose the innovative U.S. law, but to find some innovative measures that could serve health management in Portugal. Essentially we identified the Exchanges and Wellness Programs, described throughout this work, leaving also the idea of the possibility of using them in the Portuguese national health system.

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.

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 Sa��de Prim��rios s��o habitualmente o primeiro contacto com o sistema de sa��de e os profissionais de sa��de s��o mediadores chave na capacita����o dos cidad��os para cuidarem da sua sa��de. Em Portugal, nas ��ltimas d��cadas, t��m-se alcan��ado grandes melhorias nos indicadores biom��tricos de sa��de materno-infantil. Contudo, tem-se dedicado pouca aten����o �� dimens��o de sa��de mental, apesar do reconhecimento da sua import��ncia. A gravidez e primeira inf��ncia t��m sido apontadas como uma oportunidade crucial no ciclo de vida para a promo����o da sa��de mental. �� dado especial enfoque aos primeiros tempos de vida, dado o forte impacto na sa��de da crian��a. O impacte da vincula����o precoce entre a m��e e o beb�� na sa��de da m��e e da crian��a h�� muito que �� reconhecido. Esta vincula����o pode ser influenciada por v��rios factores, nomeadamente pelo ajustamento emocional da m��e. A focaliza����o nestes aspectos pode facilitar a cria����o de condi����es favor��veis e a implementa����o de medidas preventivas. O suporte familiar durante o per��odo de transi����o para a parentalidade tem sido enfatizado como uma medida eficaz e os Cuidados de Sa��de Prim��rios est��o numa posi����o privilegiada como fontes de informa����o e como mediadores. O projecto que apresentamos descreve um processo de investiga����o- ac����o desenvolvido em parceria entre investigadores acad��micos e profissionais de sa��de para abordar os aspectos referidos. Pretende-se capacitar os profissionais de sa��de para apoiarem as fam��lias na transi����o para a parentalidade, promovendo assim a sa��de mental das crian��as. O projecto baseia-se numa abordagem participativa, direccionada para a reorganiza����o dos cuidados durante a gravidez e primeiros tempos de vida. A mudan��a efectiva acontece quando os envolvidos est��o interessados e motivados, o que torna a sua participa����o t��o importante. A reflex��o acerca das pr��ticas e necessidades actuais e o conhecimento acerca de interven����es baseadas na evid��ncia t��m guiado a selec����o das altera����es a introduzir na pr��tica cl��nica, no sentido de promover o suporte familiar e o desenvolvimento de compet��ncias parentais e auto-confian��a. Neste artigo, apresentamos as etapas principais do desenvolvimento do projecto: avalia����o inicial da comunidade em estudo; processo de tomada de decis��o; programa de forma����o dos profissionais dos Cuidados de Sa��de Prim��rios; revis��o dos protocolos da consulta de sa��de materna, visita domicili��ria e educa����o pr��-natal; planeamento da implementa����o; plano de avalia����o da efectividade das altera����es introduzidas na presta����o de cuidados. O trabalho j�� desenvolvido tem mostrado que a motiva����o, lideran��a e aspectos

Defining health law or the edgewood syndrome

ABSTRACT - The authors��� main purpose is to present ideas on defining Health Law by highlighting the particularities of the field of Health Law as well as of the teaching of this legal branch, hoping to contribute to the maturity and academic recognition of Health Law, not only as a very rich legal field but also as a powerful social instrument in the fulfillment of fundamental human rights. The authors defend that Health Law has several characteristics that distinguish it from traditional branches of law such as its complexity and multidisciplinary nature. The study of Health Law normally covers issues such as access to care, health systems organization, patients��� rights, health professionals��� rights and duties, strict liability, healthcare contracts between institutions and professionals, medical data protection and confidentiality, informed consent and professional secrecy, crossing different legal fields including administrative, antitrust, constitutional, contract, corporate, criminal, environmental, food and drug, intellectual property, insurance, international and supranational, labor/employment, property, taxation, and tort law. This is one of the reasons why teaching Health Law presents a challenge to the teacher, which will have to find the programs, content and methods appropriate to the profile of recipients which are normally non jurists and the needs of a multidisciplinary curricula. By describing academic definitions of Health Law as analogous to Edgewood, a fiction house which has a different architectural style in each of its walls, the authors try to describe which elements should compose a more comprehensive definition. In this article Biolaw, Bioethics and Human Rights are defined as complements to a definition of Health Law: Biolaw because it is the legal field that treats the social consequences that arise from technological advances in health and life sciences; Bioethics which evolutions normally influence the shape of the legal framework of Health; and, finally Human Rights theory and declarations are outlined as having always been historically linked to medicine and health, being the umbrella that must cover all the issues raised in the area of Health Law. To complete this brief incursion on the definition on Health Law the authors end by giving note of the complex relations between this field of Law and Public Health. Dealing more specifically on laws adopted by governments to provide important health services and regulate industries and individual conduct that affect the health of the populations, this aspect of Health Law requires special attention to avoid an imbalance between public powers and individual freedoms. The authors conclude that public trust in any health system is essentially sustained by developing health structures which are consistent with essential fundamental rights, such as the universal right to access health care, and that the study of Health Law can contribute with important insights into both health structures and fundamental rights in order to foster a health system that respects the Rule of Law.-------------------------- RESUMO ��� O objectivo principal dos autores �� apresentar ideias sobre a defini����o de Direito da Sa��de, destacando as particularidades desta ��rea do direito, bem como do ensino deste ramo jur��dico, na esperan��a de contribuir para a maturidade e para o reconhecimento acad��mico do mesmo, n��o s�� como um campo juridicamente muito rico, mas, tamb��m, como um poderoso instrumento social no cumprimento dos direitos humanos fundamentais. Os autores defendem que o Direito da Sa��de tem diversas caracter��sticas que o distinguem dos ramos tradicionais do direito, como a sua complexidade e natureza multidisciplinar. O estudo do Direito da Sa��de abrangendo normalmente quest��es como o acesso aos cuidados, a organiza����o dos sistemas de sa��de, os direitos e deveres dos doentes e dos profissionais de sa��de, a responsabilidade civil, os contratos entre institui����es de sa��de e profissionais, a protec����o e a confidencialidade de dados cl��nicos, o consentimento informado e o sigilo profissional, implica uma abordagem transversal de diferentes ��reas legais, incluindo os Direitos contratual, administrativo, antitrust, constitucional, empresarial, penal, ambiental, alimentar, farmac��utico, da propriedade intelectual, dos seguros, internacional e supranacional, trabalho, fiscal e penal. Esta �� uma das raz��es pelas quais o ensino do Direito da Sa��de representa um desafio para o professor, que ter�� de encontrar os programas, conte��dos e m��todos adequados ao perfil dos destinat��rios, que s��o normalmente n��o juristas e ��s necessidades de um curr��culo multidisciplinar. Ao descrever as v��rias defini����es acad��micas de Direito da Sa��de como an��logas a Edgewood, uma casa de fic����o que apresenta um estilo arquitect��nico diferente em cada uma de suas paredes, os autores tentam encontrar os elementos que deveriam compor uma defini����o mais abrangente. No artigo, Biodireito, Bio��tica e Direitos Humanos s��o descritos como complementos de uma defini����o de Direito da Sa��de: o Biodireito, dado que �� o campo jur��dico que trata as consequ��ncias sociais que surgem dos avan��os tecnol��gicos na ��rea da sa��de e das ci��ncias da vida; a Bio��tica cujas evolu����es influenciam normalmente o quadro jur��dico da Sa��de; e, por fim, a teoria dos Direitos Humanos e as suas declara����es as quais t��m estado sempre historicamente ligadas �� medicina e �� sa��de, devendo funcionar como pano de fundo de todas as quest��es levantadas na ��rea do Direito da Sa��de. Para finalizar a sua breve incurs��o sobre a defini����o de Direito da Sa��de, os autores d��o ainda nota das complexas rela����es entre este ��ltimo e a Sa��de P��blica, onde se tratam mais especificamente as leis aprovadas pelos governos para regular os servi��os de sa��de, as ind��strias e as condutas individuais que afectam a sa��de das popula����es, aspecto do Direito da Sa��de que requer uma aten����o especial para evitar um desequil��brio entre os poderes p��blicos e as liberdades individuais. Os autores concluem afirmando que a confian��a do p��blico em qualquer sistema de sa��de ��, essencialmente, sustentada pelo desenvolvimento de estruturas de sa��de que sejam consistentes com o direito constitucional da sa��de, tais como o direito universal ao acesso a cuidados de sa��de, e que o estudo do Direito da Sa��de pode contribuir com elementos

Analysis of mental health service financial models with a particular emphasis of Ireland

ABSTRACT: Financing is a critical factor in ensuring the optimal development and delivery of a mental health system. The primary method of financing worldwide is tax-based. However many low income countries depend on out-of-pocket payments. There is a report on Irish Health Care funding but none that deals exclusively with mental health care. This paper analyses the various financial models that exist globally with respect to financing the mental health sector, examines the impact of various models on service users, especially in terms of relative ���financial burden��� and provides a more detailed examination of the current mental health funding situation in Ireland After extensive internet and hardcopy research on the above topics, the findings were analysed and a number of recommendations were reached. Mental health service should be free at the point of delivery to achieve universal coverage. Government tax-based funding or mandatory social insurance with government top-ups, as required, appears the optimal option, although there is no one funding system applicable everywhere. Out-of-pocket funding can create a crippling financial burden for service users. It is important to employ improved revenue collection systems, eliminate waste, provide equitable resource distribution, ring fence mental health funding and cap the number of visits, where necessary. Political, economic, social and cultural factors play a role in funding decisions and this can be clearly seen in the context of the current economic recession in Ireland. Only 33% of the Irish population has access to free public health care and the number health insurance policy holders has dramatically declined, resulting in increased out-of-pocket payments. This approach risks negatively impacting on the social determinants of health, increasing health inequalities and negatively affecting economic productivity. It is therefore important the Irish government examines other options to provide funding for mental health services.

Supplementary private health insurance: The characteristics of subscribers

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

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

Continuidade de cuidados numa Unidade de Sa��de Familiar : o efeito nos custos

RESUMO - Caracteriza����o do problema: O sistema de sa��de portugu��s atingiu um patamar de inefici��ncia tal que urge ser reestruturado de forma a torn��-lo sustent��vel. De forma a atingir este n��vel de sustentabilidade, uma s��rie de solu����es podem ser consideradas das quais destacamos a integra����o de cuidados. Este conceito exige que os diferentes n��veis de sa��de sigam um ��nico caminho, trabalhando de forma coordenada e cont��nua. A integra����o de cuidados pode ser implementada atrav��s de v��rias tipologias entre as quais se destaca a integra����o cl��nica que por sua vez �� composta pela continuidade de cuidados. Assim, ao medir a continuidade de cuidados, quantifica-se de certa forma a integra����o de cuidados. Objetivos: Avaliar o impacto da continuidade de cuidados nos custos. Metodologia: Os dados foram analisados atrav��s de estat��sticas descritivas para verificar o seu grau de normalidade. Posteriormente foram aplicados testes t-student para analisar a exist��ncia de diferen��as estatisticamente significativas entre as m��dias das diferentes vari��veis. Foi ent��o estudado o grau de associa����o entre vari��veis atrav��s da correla����o de spearman. Por fim, foi utilizado o modelo de regress��o log-linear para verificar a exist��ncia de uma rela����o entre as v��rias naturezas de custos e os ��ndices de continuidade. Com base neste modelo foram simulados dois cen��rios para estimar o impacto da maximiza����o da continuidade de cuidados nas v��rias naturezas de custos. Conclus��es: No geral, verifica-se uma rela����o muito ligeira entre a continuidade de cuidados e os custos. Mais especificamente, uma rela����o mais duradoura entre o m��dico e o doente resulta numa poupan��a de custos, independentemente da tipologia. Analisando a densidade da rela����o, observa-se uma rela����o positiva entre a mesma e os custos totais e o custo com Meios Complementares de Diagn��stico e Terap��utica (MCDT). Contudo verifica-se uma rela����o m��dico-doente negativa entre a densidade e os custos com medicamentos e com pessoal. Ao analisar o impacto da continuidade de cuidados nos custos, conclui-se que apenas a dura����o da rela����o m��dico-doente tem um impacto negativo em todas as categorias de custos, exceto o custo com medicamentos. A densidade de cuidados tem um impacto negativo apenas no custo com pessoal, influenciando positivamente as outras categorias de custos. Extrapolando para o n��vel nacional se o n��vel de densidade de uma rela����o fosse maximizado, existiria uma poupan��a de 0,18 euros, por ano, em custos com pessoal.

Integrated care approaches and skills mix policies in Europe

ABSTRACT - Background: Integration of health care services is emerging as a central challenge of health care delivery, particularly for patients with elderly and complex chronic conditions. In 2003, the World Health Organization (WHO) already began to identify it as one of the key pathways to improve primary care. In 2005, the European Commission declared integrated care as vital for the sustainability of social protection systems in Europe. Nowadays, it is recognized as a core component of health and social care reforms across European countries. Implementing integrated care requires coordination between settings, organizations, providers and professionals. In order to address the challenge of integration in such complex scenario, an effective workforce is required capable of working across interdependent settings. The World Health Report 2006 noted that governments should prepare their workforce and explore what tasks the different levels of health workers are trained to do and are capable of performing (skills mix). Comparatively to other European countries, Portugal is at an early stage in what integrated care is concerned facing a growing elderly population and the subsequent increase in the pressure on institutions and professionals to provide social and medical care in the most cost-effective way. In 2006 the Portuguese government created the Portuguese Network for Integrated Care Development (PNICD) to solve the existing long-term gap in social support and healthcare. On what concerns health workforce, the Portuguese government already recognized the importance of redefine careers keeping professional motivation and satisfaction. Aim of the study: This study aims to contribute new evidence to the debate surrounding integrated care and skills mix policies in Europe. It also seeks to provide the first evidence that incorporates both the current dynamics of implementing integrated care in Portugal and the developments of international literature. The first ambition of our study is to contribute to the growing interest in integrated care and to the ongoing research in this area by identifying its different approaches and retrieve a number of experiences in some European countries. Our second goal of this research is to produce an update on the knowledge developed on skills mix to the international healthcare management community and to policy makers involved in reforming healthcare systems and organizations. To better inform Portuguese health policies makers in a third stage we explore the current dynamics of implementing integrated care in Portugal and contextualize them with the developments reported in the international literature. Methodology: This is essentially an exploratory and descriptive study using qualitative methodology. In order to identify integrated care approaches in Europe, a systematic literature review was undertaken which resulted in a paper published in the Journal of Management and Marketing in Health care titled: Approaches to developing integrated care in Europe: a systematic literature review. This article was recommended and included into a list of references identified by The King's Fund Library. A second systematic literature review was undertaken which resulted in a paper published in the International Journal of Healthcare Management titled: Skills mix in healthcare: An international update for the management debate. Semi-structured interviews were performed on experts representing the regional coordination teams of the Portuguese Network for Integrated Care Development. In a last stage a questionnaire survey was developed based on the findings of both systematic literature reviews and semi-structured interviews. Conclusions: Even though integrated care is a worldwide trend in health care reforms, there is no unique definition. Definitions can be grouped according to their sectorial focus: community-based care, combined health and social care, combined acute and primary care, the integration of providers, and in a more comprehensive approach the whole health system. Indeed, models that seek to apply the principles of integrated care have a similar background and are continually evolving and depend on the different initiatives taken at national level. . Despite the fact that we cannot argue that there is one single set typology of models for integrated care, it is possible to identify and categorize some of the basic approaches that have been taken in attempts to implement integrated care according to: changes in organizational structure, workforce reconfiguring, and changes in the financing system. The systematic literature review on skills mix showed that despite the widely acknowledged interest on skills mix initiatives there is a lack of evidence on skills mix implications, constraints, outcomes, and quality impact that would allow policy makers to take sustained and evidence-based decisions. Within the Portuguese health system, the integrated care approach is rather organizational and financial, whereas little attention is given to workforce integration. On what concerns workforce planning Portugal it is still in the stage of analyzing the acceptability of health workforce skills mix. In line with the international approaches, integration of health and social services and bridging primary and acute care are the main goals of the national government strategy. The findings from our interviews clarify perceptions which show no discrepancy with the related literature but are rather scarce comparing to international experience. Informants hold a realistic but narrow view of integrated care related issues. They seem to be limited to the regional context, requiring a more comprehensive perspective. The questionnaire developed in this thesis is an instrument which, when applied, will allow policy makers to understand the basic set of concepts and managerial motivations behind national and regional integrated care programs. The instrument developed can foster evidence on the three essential components of integrated care policies: organizational, financial, and human resources development, and can give additional input on the context in which integrated care is being developed, the type of providers and organizations involved, barriers and constraints, and the workforce skills mix planning related strategies. The thesis was successful in recognizing differences between countries and interventions and the instrument developed will allow a better comprehension of the international options available and how to address the vital components of integrated care programs.

Health systems efficiency after the crisis in the OECD

This work evaluates the efficiency position of the health system of each OECD country. It identifies whether, or not, health systems changed in terms of quality and performance after the financial crisis. The health systems performance was calculated by fixed-effects estimator and by stochastic frontier analysis. The results suggest that many of those countries that the crisis affected the most are more efficient than the OECD average. In addition, some of those countries even managed to reach the top decile in the efficiency ranking. Finally, we analyze the stochastic frontier efficiency scores together with other health indicators to evaluate the health systems��� overall adjustments derived from the crisis.

Assessing the community needs of mental health residential care service users in Republic of Moldova

RESUMO: Background: Problemas de sa��de mental s��o um grande problema cl��nico e social na Rep��blica da Mold��via, representando uma quota significante de defici��ncia, sendo classificada no top cinco das dez linhas na hierarquia das condi����es. A taxa de incid��ncia tem sido crescente na Rep��blica da Mold��via, atingindo cerca de 15.000 por ano (14,655 em 2011), ou seja, 411,4 por 100 mil habitantes, e uma taxa de preval��ncia de 97.525 pessoas em 2011, ou seja, 2,737.9 por 100 mil habitantes. Sistema de atendimento psiqui��trico fornece servi��os de sa��de mental escassos a n��vel da comunidade, visando principalmente terapia hospitalar, centralizada, atrav��s de uma rede de tr��s hospitais psiqui��tricos, com 1.860 camas e 4 sanat��rios psico- neurol��gicos com 1890 camas, assim alimentando-se a estigmatiza����o do paciente. Objetivos: O objetivo deste estudo foi a avalia����o das necessidades individuais dos benefici��rios e do seu n��vel de autonomia dentro de cuidados residenciais, para o planeamento de reformas de sa��de mental e desinstitucionaliza����o na Rep��blica da Mold��via. Este estudo foi encomendado pelo Minist��rio do Trabalho, Prote����o Social e da Fam��lia e pelo Minist��rio da Sa��de, com o apoio da Organiza����o Mundial da Sa��de, para determinar o cumprimento eficaz do artigo 19 da Conven����o da ONU. O estudo tem os seguintes objetivos: Avaliar o n��vel de autonomia dos residentes nos hospitais psiqui��tricos e sanat��rios psico-neurol��gico, usando uma amostra representativa de 10 por ce nto do n��mero total de pacientes/residentes e compara����o cruzada; Para avaliar quatro sanat��rios psico-neurol��gicos para adultos e tr��s hospitais psiqui��tricos; Para desenvolver recomenda����es para o planeamento da desinstitucionaliza����o das pessoas com problemas de sa��de mental e coloca����o na comunidade com base nos resultados do estudo. Metodologia e resultados: O estudo fez uso de duas ferramentas globais: question��rio para a avalia����o individual dos residentes do estabelecimento de sa��de mental, e question��rio de avalia����o institucional. Todos os entrevistados foram divididos em quatro categorias conforme com o grau de depend��ncia e prepara����o de viver de forma independente na comunidade. Apenas 1,2% dos entrevistados de PNHB eram totalmente dependentes de terceiros ou servi��os especializados, tornando-se a categoria 4, que necessitam de cuidados e apoio cont��nuo. No PH esta categoria de pessoas �� ausente. Conclus��es: A condi����o dos entrevistados foi pior em PNBH que em PH. No entanto, ainda, aqueles que est��o prontos para ser desinstitucionalizados correspondem com a maior parte dos entrevistados. Todos os hospitais tinham o consentimento do utente para admiss��o e tratamento, enquanto n��o houve consentimento qualquer em PNBH. �� bastante ��bvio que tanto os hospitais como tamb��m a sistema de assist��ncia residencial n��o atingem a sua finalidade, o que significa que a maioria dos utentes pode ser desinstitucionalizados, sem qualquer terapia de suporte.------------------ABSTRACT: Background: Mental health problems are a major clinical and social issue in the Republic of Moldova,accounting for a significant share of disability and ranking in top five of the ten lines in the hierarchy of conditions. The incidence rate has been growing in the Republic of Moldova to reach approximately 15 thousand a year (14,655 in 2011), i.e. 411.4 per 100 thousand population, and a prevalence rate of 97,525 thousand people in 2011, i.e. 2,737.9 per 100 thousand population. Psychiatric care system provides for scanty mental health services at community level, aiming mainly at centralized hospital-based therapy through a network of three psychiatric hospitals tallying up 1,860 beds and 4 psycho-neurological boarding houses with 1,890 beds, thus fuelling up patient stigmatization. Objectives: The purpose of this study was to assess the individual needs of beneficiaries and their level of autonomy within residential care for the planning of mental health system reforms and deinstitutionalization in the Republic of Moldova. This study was commissioned by the Ministry of Labour, Social Protection and Family and by the Ministry of Health, with the World Health Organization support, to provide for effective enforcement of article 19 of the UN CRPD. The study pursued the following goals: To evaluate the level of autonomy of the psychiatric hospital and psycho-neurological boarding house residents by using a representative sample of 10 per cent of the total number of patients / residents and cross-comparison; To evaluate four psycho-neurological boarding houses for adults and three psychiatric hospitals; To develop recommendations for planning the deinstitutionalization of people with mental health problems and community placement based on the study findings.Methodology and results: The study made use of two global tools: questionnaire for individual assessment of mental health facility residents, and institutional assessment questionnaire. All interviewees were divided into four categories by one���s degree of dependence and readiness to live independently in the community. Only 1.2% of respondents from PNHB were fully dependent on a third party or specialized services, making up category 4, requiring continuous care and support. In PH this category of people is absent.Conclusions: The condition of respondents was worse in PNBH than in PH. However, yet, those ready to be deinstitutionalized accounted for most of respondents there. All hospitals had the resident���s consent to admission and treatment, whereas there was no consent in PNBH whatsoever. It is quite obvious that both the hospitals and residential care system do not achieve their intended purpose, meaning that the majority of residents may be deinstitutionalized without any support therapy.

Supplementary private health insurance: The characteristics of subscribers

Despite the fact that public medical care has being heavily subsidized through a statutory national health system there has been a growing number of people who opt to enroll in extra private coverage. Using a two part model to infer the insurance decision and subsequent amount of insurance chosen we found out that people���s decision over private health coverage is not related with their health. The pattern of consumption of medical care that is not available in the public sector and a good socio economic background were found significant modeling the demand for private health insurance.

Implementation progress of mental health services in Rwanda: Bugesera district case

RESUMO: O Minist��rio da Sa��de do Governo do Ruanda identifica a sa��de mental como uma ��rea de prioridade estrat��gica para a interven����o em resposta �� alta carga dos transtornos mentais no Ruanda. Ao longo dos ��ltimos 20 anos ap��s o genoc��dio, o sector p��blico reconstruiu sua Resposta Nacional de Sa��de Mental com base no acesso equitativo aos cuidados, atrav��s do desenvolvimento de uma Pol��tica Nacional de Sa��de Mental e novas estruturas de sa��de mental. A pol��tica de Sa��de Mental do Ruanda, revista em 2010, prima pela descentraliza����o e integra����o dos servi��os de sa��de mental em todas as estruturas nacionais do sistema de sa��de e ao n��vel da comunidade. O presente estudo de caso tem como objetivo avaliar a situa����o do sistema de sa��de mental de um distrito t��pico de uma ��rea rural no Ruanda, e sugerir melhorias, incluindo algumas estrat��gias para monitoras as mudan��as. Os resultados do estudo permitir��o ao Ruanda refor��ar a sua capacidade para implementar o Plano Nacional de Sa��de Mental ao n��vel dos distritos. O relat��rio tamb��m ser�� ��til para monitorar o progresso da implementa����o de servi��os de sa��de mental nos distritos, incluindo a presta����o de servi��os de base comunit��ria e a participa����o dos usu��rios, suas fam��lias e outros interessados na promo����o, preven����o, assist��ncia e reabilita����o em sa��de mental. Este estudo tamb��m procurou avaliar o progresso da implementa����o dos cuidados de sa��de mental a n��vel descentralizado, com vista a compreender as implica����es em termos de recursos desses processos. Foi realizada uma an��lise situacional num local do distrito, baseado em entrevistas com as principais partes interessadas respons��veis, usando o Instrumento de Avalia����o de Sistemas de Sa��de Mental da Organiza����o Mundial da Sa��de (WHO-AIMS). Os resultados sugerem que os recursos humanos para a sa��de mental e servi��os de base comunit��ria de sa��de mental no distrito continuam a ser extremamente limitados. Os profissionais de sa��de mental s��o adicionalmente limitados na sua capacidade para oferecer interven����es de emerg��ncia a pacientes psiqui��tricos e garantir a continuidade do tratamento farmacol��gico a pacientes com condi����es cr��nicas. Para planejar efetivamente, de acordo com as necessidades da comunidade, sugerimos que o sistema de sa��de mental deve envolver tamb��m os representantes das fam��lias e dos usu��rios no processo de planifica����o de modo a melhorar a sua contribui����o no processo de implementa����o das atividades de sa��de mental. Este estudo de caso do Distrito de Bugesera oferece a primeira an��lise de n��vel distrital dos servi��os de sa��de mental no Ruanda, e pode servir como uma mais-valia para a melhoria do sistema de sa��de mental, incluindo a advocacia para a melhoria da qualidade dos cuidados de sa��de mental a este n��vel, aumentando o financiamento para a implementa����o de servi��os cl��nicos de sa��de mental e os recursos humanos dispon��veis para a presta����o de cuidados de sa��de mental, principalmente a n��vel dos cuidados prim��rios.--------------------- ABSTRACT: To deal with the high burden of mental health disorders resulting from consequences of the 1994 genocide against Tutsis, the Rwanda Ministry of Health (MoH) considers mental health as a priority intervention. For the last 20 years, Ministry of Health focused on rebuilding a national and equity-oriented mental health program responding to the population needs in mental health. Mental health services are now decentralized and integrated in the national health system, from the community level up to the referral level. This study assessed the situation of mental health services in one rural district in Rwanda. It was aimed at assessing the progress of implementation of mental health care at the decentralized level, focusing on resource implications and processes. This study is based on interviews conducted with key stakeholders, using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). Findings show that human resources for mental health care and community-based mental health services of the assessed district remain extremely limited. Mental health professionals face limitation regarding the ability to provide emergency management of psychiatric patients and to ensure continuity of psychopharmacological treatment of patients with chronic conditions. To improve the implementation process of mental health interventions and activities, a planning process based on community needs and the involvement of representatives of families and users in planning process should be considered. The Bugesera case study on the situation of mental health services can serve as a baseline for improvement of the mental health program in Rwanda, in terms of quality care services, infrastructure and equipment, human and financial resources.

Compact SMB chromatography for binary separation

A thesis submitted for the degree of Doctor of Philosophy

A introdu����o de mecanismos de competi����o e o quadro legal b��sico do Sistema Nacional de Sa��de portugu��s : a perspectiva hospitalar��

RESUMO - O presente trabalho de projecto visa analisar a introdu����o de mecanismos de competi����o do ponto de vista do quadro legal b��sico ��� Constitui����o e Lei de Bases da Sa��de ��� que enforma o sistema de sa��de portugu��s e principalmente, o seu impacte ao n��vel do meio hospitalar. Pretende-se aferir se a implementa����o de ferramentas de mercado no meio em apre��o encontra previs��o naqueles diplomas legais, sendo por isso, permissivos quanto ao seu desenvolvimento ou se, por outro lado, o nosso enquadramento legal se revela hostil ao seu desenvolvimento. O estudo foi desenvolvido com recurso, essencialmente, �� pesquisa e revis��o bibliogr��ficas que ser��o transversais aos cap��tulos que comp��em o enquadramento conceptual, �� hermen��utica para efeitos de aplica����o �� tem��tica da descri����o do quadro legal b��sico e �� an��lise das hip��teses de trabalho apresentadas. Os resultados obtidos permitem concluir que, via de regra, o quadro legal b��sico do sistema de sa��de portugu��s �� permissivo �� introdu����o de mecanismos de competi����o, encontrando mesmo, alguns deles, eco legal em disposi����es datadas de final da d��cada de ���60. Este grau de permissividade tanto �� comprov��vel atrav��s de estatui����es que directamente prev��em determinada ferramenta, como atrav��s da aus��ncia de previs��o que no nosso ordenamento jur��dico, n��o �� sin��nimo de proibi����o. ----------------------------------ABSTRACT - This essay analyses the existing relation between the introduction of competition tools in the Portuguese health care system and its basic legal framework ��� the Constitution and the Health Bases Law ��� particularly from the hospital���s point of view. We aim to assess if the use and implementation of those tools are permissible by law or if, on the other hand, our legal system is hostile towards that introduction. Preferably we used bibliographical research in almost every chapter and hermeneutics allowed us to perform a detailed analysis of the basic legal framework. We conclude that, most of the times, the Portuguese basic legal framework is permissible to the use of such tools and some of the legislative acts date from the late sixties. That can be encompassed by existing or non-existing statutes ��� since in our legal system what is not specifically foreseen is not, necessarily forbidden.