A qualitative analysis of health care provider perceptions of depression and suicidality in Mozambique

Thesis (Master's)--University of Washington, 2016-06

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.

Indian Patent Policy and Publich Health : implications from the Japanese Experience

The introduction of pharmaceutical product patents in India and other developing countries is expected to have a significant effect on public health and local pharmaceutical industries. This paper draws implications from the historical experience of Japan when it introduced product patents in 1976. In Japan, narrow patents and promotion of cross-licensing were effective tools to keep drug prices in check while ensuring the introduction of new drugs. While the global pharmaceutical market surrounding India today differs considerably from that of the 1970's, the Japanese experience offers a policy option that may profitably be considered by India today. The Indian patent system emphasizes the patentability requirement in contrast to the Japanese patent policy which relied on narrow patents and extensive licensing. R&D by local firms and the development of local products may be promoted more effectively under the Japanese model.

Bounding ATE with ITT

We propose the bounds on ATE using intention-to-treat (ITT) estimator when there are compliers/noncompliers in randomized trials. The bounds are given as ITTNACE, (2) noncompliers' average treatment effect (NACE) is nonnegative. We give an example of poverty impacts of health insurance, and effects of adverse selection and moral hazard of health insurance.

Determinants of the use of health care services: multilevel analysis in the Metropolitan Region of Sao Paulo

OBJECTIVE To evaluate the individual and contextual determinants of the use of health care services in the metropolitan region of Sao Paulo.METHODS Data from the Sao Paulo Megacity study – the Brazilian version of the World Mental Health Survey multicenter study – were used. A total of 3,588 adults living in 69 neighborhoods in the metropolitan region of Sao Paulo, SP, Southeastern Brazil, including 38 municipalities and 31 neighboring districts, were selected using multistratified sampling of the non-institutionalized population. Multilevel Bayesian logistic models were adjusted to identify the individual and contextual determinants of the use of health care services in the past 12 months and presence of a regular physician for routine care.RESULTS The contextual characteristics of the place of residence (income inequality, violence, and median income) showed no significant correlation (p > 0.05) with the use of health care services or with the presence of a regular physician for routine care. The only exception was the negative correlation between living in areas with high income inequality and presence of a regular physician (OR: 0.77; 95%CI 0.60;0.99) after controlling for individual characteristics. The study revealed a strong and consistent correlation between individual characteristics (mainly education and possession of health insurance), use of health care services, and presence of a regular physician. Presence of chronic and mental illnesses was strongly correlated with the use of health care services in the past year (regardless of the individual characteristics) but not with the presence of a regular physician.CONCLUSIONS Individual characteristics including higher education and possession of health insurance were important determinants of the use of health care services in the metropolitan area of Sao Paulo. A better understanding of these determinants is essential for the development of public policies that promote equitable use of health care services.

Preliminary risk analysis applied to the handling of health-care waste

Between 75% and 90% of the waste produced by health-care providers no risk or is "general" health-care waste, comparable to domestic waste. The remaining 10-25% of health-care waste is regarded as hazardous due to one or more of the following characteristics: it may contain infectious agents, sharps, toxic or hazardous chemicals or it may be radioactive. Infectious health-care waste, particularly sharps, has been responsible for most of the accidents reported in the literature. In this work the preliminary risks analysis (PRA) technique was used to evaluate practices in the handling of infectious health-care waste. Currently the PRA technique is being used to identify and to evaluate the potential for hazard of the activities, products, and services from facilities and industries. The system studied was a health-care establishment which has handling practices for infectious waste. Thirty-six procedures related to segregation, containment, internal collection, and storage operation were analyzed. The severity of the consequences of the failure (risk) that can occur from careless management of infectious health-care waste was classified into four categories: negligible, marginal, critical, and catastrophic. The results obtained in this study showed that events with critics consequences, about 80%, may occur during the implementation of the containment operation, suggesting the need to prioritize this operation. As a result of the methodology applied in this work, a flowchart the risk series was also obtained. In the flowchart the events that can occur as a consequence of a improper handling of infectious health-care waste, which can cause critical risks such as injuries from sharps and contamination (infection) from pathogenic microorganisms, are shown.

Comparing German and British political culture through values : and analysis of the values of health care reform

This research sets out to compare the values in British and German political discourse, especially the discourse of social policy, and to analyse their relationship to political culture through an analysis of the values of health care reform. The work proceeds from the hypothesis that the known differences in political culture between the two countries will be reflected in the values of political discourse, and takes a comparison of two major recent legislative debates on health care reform as a case study. The starting point in the first chapter is a brief comparative survey of the post-war political cultures of the two countries, including a brief account of the historical background to their development and an overview of explanatory theoretical models. From this are developed the expected contrasts in values in accordance with the hypothesis. The second chapter explains the basis for selecting the corpus texts and the contextual information which needs to be recorded to make a comparative analysis, including the context and content of the reform proposals which comprise the case study. It examines any contextual factors which may need to be taken into account in the analysis. The third and fourth chapters explain the analytical method, which is centred on the use of definition-based taxonomies of value items and value appeal methods to identify, on a sentence-by-sentence basis, the value items in the corpus texts and the methods used to make appeals to those value items. The third chapter is concerned with the classification and analysis of values, the fourth with the classification and analysis of value appeal methods. The fifth chapter will present and explain the results of the analysis, and the sixth will summarize the conclusions and make suggestions for further research.

A postcolonial queer analysis of aboriginal queer clients' experiences of health care services in St. John's, Newfoundland

This thesis examines the gaps between health care services aimed at Aboriginal queer individuals living in St. John’s, Newfoundland and their health care needs. I used a multi-methods research design that includes interviews and demographic surveys, unobtrusive observation and qualitative content analysis. I conducted semi-structured interviews with institutional representatives from selected health related organizations – Eastern Health, Planned Parenthood Newfoundland and Labrador, the AIDS Committee of Newfoundland and Labrador, and St. John’s Native Friendship Center; as well as a transgender activist and three people who identify as Aboriginal and queer. I conducted observational research at two public seminars on Aboriginal people and health. Finally, I carried out qualitative content analysis of organizational reports and webpages of the selected community organizations. Using a postcolonial queer framework that analyzes how Newfoundland and Labrador’s colonial history is reflected in current health care realities I argue that the lack of appropriate services and culturally insensitive delivery of services reproduce the historical marginalization of an already vulnerable group.

[strategies For Integration Of Health Care Practices And Sanitary Surveillance In The Context Of The Implementation Of Rede Cegonha - A Brazilian Mother And Infant Health Care Network].

Mother and infant mortality has been the scope of analysis throughout the history of public health in Brazil and various strategies to tackle the issue have been proposed to date. The Ministry of Health has been working on this and the Rede Cegonha strategy is the most recent policy in this context. Given the principle of comprehensive health care and the structure of the Unified Health System in care networks, it is necessary to ensure the integration of health care practices, among which are the sanitary surveillance actions (SSA). Considering that the integration of health care practices and SSA can contribute to reduce mother and infant mortality rates, this article is a result of qualitative research that analyzed the integration of these actions in four cities in the State of São Paulo/Brazil: Campinas, Indaiatuba, Jaguariúna and Santa Bárbara D'Oeste. The research was conducted through interviews with SSA and maternal health managers, and the data were evaluated using thematic analysis. The results converge with other studies, identifying the isolation of health care practices and SSA. The insertion of SSA in collectively-managed areas appears to be a potential strategy for health planning and implementation of actions in the context under scrutiny.

Health financing changes in the context of health care decentralization: the case of three Latin American countries

OBJECTIVE: The results of an evaluative longitudinal study, which identified the effects of health care decentralization on health financing in Mexico, Nicaragua and Peru are presented in this article. METHODS: The methodology had two main phases. In the first, secondary sources of data and documents were analyzed with the following variables: type of decentralization implemented, source of financing, funds for financing, providers, final use of resources, mechanisms for resource allocation. In the second phase, primary data were collected by a survey of key personnel in the health sector. RESULTS: Results of the comparative analysis are presented, showing the changes implemented in the three countries, as well as the strengths and weaknesses of each country in matters of financing and decentralization. CONCLUSIONS: The main financing changes implemented and quantitative trends with respect to the five financing indicators are presented as a methodological tool to implement corrections and adjustments in health financing.

The impact of night work on subjective reports of well-being: an exploratory study of health care workers from five nations

OBJECTIVE: To carry out a survey data collection from health care workers in Brazil, Croatia, Poland, Ukraine and the USA with two primary goals: (1) to provide information about which aspects of well-being are most likely to need attention when shiftwork management solutions are being developed, and (2) to explore whether nations are likely to differ with respect to the impacts of night work on the well-being of workers involved in health care work. METHODS: The respondents from each nation were sorted into night worker and non-night worker groups. Worker perceptions of being physically tired, mentally tired, and tense at the end of the workday were examined. Subjective reports of perceived felt age were also studied. For each of these four dependent variables, an ANCOVA analysis was carried out. Hours worked per week, stability of weekly work schedule, and chronological age were the covariates for these analyses. RESULTS: The results clearly support the general proposal that nations differ significantly in worker perceptions of well-being. In addition, perceptions of physical and mental tiredness at the end of the workday were higher for night workers. For the perception of being physically tired at the end of a workday, the manner and degree to which the night shift impacts the workers varies by nation. CONCLUSIONS: Additional research is needed to determine if the nation and work schedule differences observed are related to differences in job tasks, work schedule structure, off-the-job variables, and/or other worker demographic variables.

Provision of health care actions and services for the management of HIV/AIDS from the users’ perspective

Objective To analyse the provision of health care actions and services for people living with AIDS and receiving specialised care in Ribeirão Preto, SP. Method A descriptive, exploratory, survey-type study that consisted of interviews with structured questionnaires and data analysis using descriptive statistics. Results The provision of health care actions and services is perceived as fair. For the 301 subjects, routine care provided by the reference team, laboratory tests and the availability of antiretroviral drugs, vaccines and condoms obtained satisfactory evaluations. The provision of tests for the prevention and diagnosis of comorbidities was assessed as fair, whereas the provisions of specialised care by other professionals, psychosocial support groups and medicines for the prevention of antiretroviral side effects were assessed as unsatisfactory. Conclusion Shortcomings were observed in follow-up and care management along with a predominantly biological, doctor-centred focus in which clinical control and access to antiretroviral therapy comprise the essential focus of the care provided.


Diversity and regional inequalities: Assessing the outcomes of the Spanish 'System of Health Care Services'

The consolidation of a universal health system coupled with a process of regionaldevolution characterise the institutional reforms of the National Health System(NHS) in Spain in the last two decades. However, scarce empirical evidence hasbeen reported on the effects of both changes in health inputs, outputs andoutcomes, both at the country and at the regional level. This paper examinesthe empirical evidence on regional diversity, efficiency and inequality ofthese changes in the Spanish NHS using cross-correlation, panel data andexpenditure decomposition analysis. Results suggest that besides significantheterogeneity, once we take into account region-specific needs there is evidenceof efficiency improvements whilst inequalities in inputs and outcomes, althoughmore visible , do not appear to have increased in the last decade. Therefore,the devolution process in the Spanish Health System offers an interesting casefor the experimentation of health reforms related to regional diversity butcompatible with the nature of a public NHS, with no sizeable regionalinequalitiest.