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.

How to improve Sonae's processes of suppliers of services' management?

Sonae is one of the greatest retailers in Portugal. As the business got bigger, it centralized operations. Direcção de Serviços Administrativos processes all invoices sent by suppliers. However, there are many which deliver errors and are not processed automatically. As a result, there are lost invoices and suppliers who are not paid, while the company’s accountability becomes less transparent. Such is due to a lack of proactive attitude towards suppliers as well as to a lack of incentives for employees to perform well. Great savings may be achieved with little effort, if the right things are measured so that the right tools may be applied.

Barriers preventing the successful integration of mental health services into Primary Health Care in Nigeria : a mixed methods approach

RESUMO: A Nigéria tem uma população estimada em cerca de 170 milhões de pessoas. O número de profissionais de saúde mental é muito diminuto, contando apenas com 150 psiquiatras o que perfaz aproximadamente um rácio de psiquiatra: população de mais de 1:1 milhão de pessoas. O Plano Nacional de Saúde Mental de 1991 reconheceu esta insuficiência e recomendou a integração dos serviços de saúde mental nos cuidados de saúde primários (CSP). Depois de mais de duas décadas, essa política não foi ainda implementada. Este estudo teve como objetivos mapear a estrutura organizacional dos serviços de saúde mental da Nigéria, e explorar os desafios e barreiras que impedem a integração bem-sucedida dos serviços de saúde mental nos cuidados de saúde primários, isto segundo a perspectiva dos profissionais dos cuidados de saúde primários. Com este objetivo, desenvolveu-se um estudo exploratório sequencial e utilizou-se um modelo misto para a recolha de dados. A aplicação em simultâneo de abordagens qualitativas e quantitativas permitiram compreender os problemas relacionados com a integração dos serviços de saúde mental nos CSP na Nigéria. No estudo qualitativo inicial, foram realizadas entrevistas com listagens abertas a 30 profissionais dos CSP, seguidas de dois grupos focais com profissionais dos CSP de duas zonas governamentais do estado de Oyo de forma a obter uma visão global das perspectivas destes profissionais locais sobre os desafios e barreiras que impedem uma integração bem-sucedida dos serviços de saúde mental nos CSP. Subsequentemente, foram realizadas entrevistas com quatro pessoas-chave, especificamente coordenadores e especialistas em saúde mental. Os resultados do estudo qualitativo foram utilizados para desenvolver um questionário para análise quantitativa das opiniões de uma amostra maior e mais representativa dos profissionais dos CSP do Estado de Oyo, bem como de duas zonas governamentais locais do Estado de Osun. As barreiras mais comummente identificadas a partir deste estudo incluem o estigma e os preconceitos sobre a doença mental, a formação inadequada dos profissionais dos CPS sobre saúde mental, a perceção pela equipa dos CSP de baixa prioridade de ação do Governo, o medo da agressão e violência pela equipa dos CSP, bem como a falta de disponibilidade de fármacos. As recomendações para superar estes desafios incluem a melhoria sustentada dos esforços da advocacia à saúde mental que vise uma maior valorização e apoio governamental, a formação e treino organizados dos profissionais dos cuidados primários, a criação de redes de referência e de apoio com instituições terciárias adjacentes, e o engajamento da comunidade para melhorar o acesso aos serviços e à reabilitação, pelas pessoas com doença mental. Estes resultados fornecem indicações úteis sobre a perceção das barreiras para a integração bem sucedida dos serviços de saúde mental nos CSP, enquanto se recomenda uma abordagem holística e abrangente. Esta informação pode orientar as futuras tentativas de implementação da integração dos serviços de saúde mental nos cuidados primários na Nigéria.------------ABSTRACT: Nigeria has an estimated population of about 170 million people but the number of mental health professionals is very small, with about 150 psychiatrists. This roughly translates to a psychiatrist:population ratio of more than 1:1 million people. The National Mental Health Policy of 1991 recognized this deficiency and recommended the integration of mental health into primary health care (PHC) delivery system. After more than two decades, this policy has yet to be implemented. This study aimed to map out the organizational structure of the mental health systems in Nigeria, and to explore the challenges and barriers preventing the successful integration of mental health into primary health care, from the perspective of the primary health care workers. A mixed methods exploratory sequential study design was employed, which entails the use of sequential timing in the combined methods of data collection. A combination of qualitative and uantitative approaches in sequence, were utilized to understand the problems of mental health services integration into PHC in Nigeria. The initial qualitative phase utilized free listing interviews with 30 PHC workers, followed by two focus group discussions with primary care workers from two Local Government Areas (LGA) of Oyo State to gain useful insight into the local perspectives of PHC workers about the challenges and barriers preventing successful integration of mental health care services into PHC. Subsequently, 4 key informant interviews with PHC co-ordinators and mental health experts were carried out. The findings from the qualitative study were utilized to develop a quantitative study questionnaire to understand the opinions of a larger and more representative sample of PHC staff in two more LGAs of Oyo State, as well as 2 LGAs from Osun State. The common barriers identified from this study include stigma and misconceptions about mental illness, inadequate training of PHC staff about mental health, low government priority, fear of aggression and violence by the PHC staff, as well as non-availability of medications. Recommendations for overcoming these challenges include improved and sustained efforts at mental health advocacy to gain governmental attention and support, organized training and retraining for primary care staff, establishment of referral and supportive networks with neighbouring tertiary facilities and community engagement to improve service utilization and rehabilitation of mentally ill persons. These findings provide useful insight into the barriers to the successful integration of mental health into PHC, while recommending a holistic and comprehensive approach. This information can guide future attempts to implement the integration of mental health into primary care in Nigeria.

Evaluation of outpatient child-adolescent mental health services (CAMHS) in Attica-Greece

ABSTRACT: Background: Childhood is a critical time for social and emotional development, educational progress and mental health prevention. Mental health for children and adolescents is defined by the achievement of expected developmental, cognitive, social and emotional skills. The development of child-adolescent mental health services (CAMHS) is a necessity for each country, not only as a prevention measure for the wellbeing of people, but also as an investment to the future of countries. Qualitative evaluation of services is the only way to ensure whether services function under quality standards and increase the possibility of better outcomes for their patients. This study examines the greek outpatient CAMHS against the British Standards of National Institute of Excellence for community CAMHS. The Standards assessed refer to the areas of Assessment, Care and Intervention. Objectives: The main objectives of the study are 1) to evaluate Greek outpatient CAMHS in the Attica region 2) to promote the evaluation process for mental health services in Greece. Methods: Due to the fact that Greek services are based on the British model, the tool used was the British self-review questionnaire of Quality Network for Community CAMHS(QNCC).The tool was translated, adapted and posted to services. Twelve out of twenty outpatient CAMHS of Attica (including Athens) responded. Data was collected and performed by the Statistical Package for Social Sciences SPSS. Results: The study resulted that the CAMHS examined, meet moderately the British Standards of 1) Referral and Access, 2) Assessment & Care planning, 3) Care & Intervention. Two out of twelve services examined, meet the standards of "Assessment and Care" in a higher percentage between 75% and 100%. Conclusions: The paper describes a satisfactory function of CAMHS in Attica prefecture taking into consideration the extremely difficult political situation of Greece at the time of the research. Strong and weak domains are identified. Also the translation and adaptation of British tools promote the evaluation process and quality assurance of Greek CAMHS.

Self-reported health needs and use of primary health care services by adolescents enrolled in post-mandatory schools or vocational training programmes in Switzerland.

BACKGROUND: The second Swiss Multicenter Adolescent Survey on Health (SMASH02) was conducted among a representative sample (n = 7428) of students and apprentices aged 16 to 20 from the three language areas of Switzerland during the year 2002. This paper reports on health needs expressed by adolescents and their use of health care services over the 12 months preceding the survey. METHODS: Nineteen cantons representing 80% of the resident population agreed to participate. A complex iterative random cluster sample of 600 classes was drawn with classes as primary sampling unit. The participation rate was 97.7% for the classes and 99.8% for the youths in attendance. The self-administered questionnaire included 565 items. The median rate of item non-response was 1.8%. Ethical and legal requirements applying to surveys of adolescent populations were respected. RESULTS: Overall more than 90% of adolescents felt in good to excellent health. Suffering often or very often from different physical complaints or pain was also reported such as headache (boys: 15.9%, girls: 37.4%), stomach-ache (boys: 9.7%, girls: 30.0%), joint pain (boys: 24.7%, girls: 29.5%) or back pain (boys: 24.3%, girls: 34.7%). Many adolescents reported a need for help on psychosocial and lifestyle issues, such as stress (boys: 28.5%, girls: 47.7%) or depression (boys: 18.9%, girls: 34.4%). Although about 75% of adolescents reported having consulted a general practitioner and about one-third having seen another specialist, reported reasons for visits do not correspond to the expressed needs. Less than 10% of adolescents had visited a psychiatrist, a family planning centre or a social worker. CONCLUSIONS: The reported rates of health services utilisation by adolescents does not match the substantial reported needs for help in various areas. This may indicate that the corresponding problems are not adequately detected and/or addressed by professionals from the health and social sectors.

The self-management approach of health education in the treatment of chronic illnesses

Health education is essential to the successful treatment of individuals with chronic illnesses. Self-management is a philosophical model of health education that has been shown to be effective in teaching individuals with chronic arthritis to manage their illness as part of their daily lives. Despite the proven results of arthritis self-management programs, some limitations of this form of health education were apparent in the literature. The present study attempted to address the problems of the self-management approach of health education such as reasons for lack of participation in programs and poor course outcomes. In addition, the study served to investigate the relationship between course outcomes and participation in programs with the theory upon which arthritis self-management programs are based, known as self-efficacy theory. Through a combination of qualitative and quantitative methodologies, data collection, and analysis, a deeper understanding of the self-management phenomenon in the treatment of chronic arthritic conditions was established. Findings of the study confirm findings of previous studies that suggest that arthritis self-management programs result in enhanced levels of self-efficacy and are effective in teaching individuals with arthritis to self-manage their health and health care. Findings of the study suggest that there are many factors that determine the choice of participants to participate in programs and the outcomes for the individuals who do choose to participate in programs. Some of the major determinants of enrollment and outcomes of programs include: the participant's personality, beliefs, attitudes and abilities, and the degree of emotional acceptance of the illness. Other determinants of course enrollment and outcomes included class size and length of time, timing of participation, and ongoing support after the program. The results of the study are consistent with the self-management literature and confirm the relationship between the underlying philosophies of adult education and Freire's model of education and self-management.

Perspectives of Urban Growth Management and Sustainable Development In West Bank, Hebron District as a case Study

The main objective of this PhD research study is to provide a perspective on the urban growth management and sustainable development in Palestine, and more specifically in Hebron district as a case study. Hebron is located 36 km south of Jerusalem, with an overall population size of around 600,000 people living in a total area around1246km2. Hebron is the biggest Palestinian district that has 16 municipalities and 154 localities. The research discusses and analyzes the urban planning system, economical and environmental policies and the solution required to manage and integrate the development elements to develop a sustainable development plan for Hebron. The research provides answers for fundamental questions such as what kind and definition of sustainable development are applicable to the Palestinian case?. What are the sustainability problems there and how the Israeli occupation and unstable political condition affect the sustainable development in Palestine? What are the urban growth management and sustainability policies and actions required from government, public and privets sector in Palestine? The fast urban growth in Palestine is facing many problems and challenges due to the increase in the population size and the resulting impact of this increase including, but not limited to, the demand of new houses, need for more infrastructure services, demands on new industrial, commercial, educational and health projects, which in turn reduces the area of agricultural lands and threatens the natural resources and environment. There are also other associated sustainability problems like the absence of effective plans or regulations that control urban expansion, the absence of sufficient sustainable development plans at the national levels for the district, new job requirements, Israeli restrictions and occupation for more than 60 years, existence of construction factories near residential areas, poor public awareness and poor governmental funds for service projects and development plans. The study consists of nine chapters. Chapter One includes an introduction, study objectives, problems and justifications, while Chapter Two has a theoretical background on sustainability topic and definitions of sustainability. The Palestinian urban planning laws and local government systems are discussed in Chapter Three and the methodology of research is detailed in Chapter Four. As for Chapter Five, it provides a general background on Hebron District including demographical and economical profiles, along with recommendations related to sustainable development for each profile Chapter Six addresses the urban environment, sustainability priorities and policies required. Chapter Seven discusses and analyzes infrastructure services including transportation, water and wastewater. As for Chapter Eight, it addresses the land use, housing and urban expansion beside the cultural heritage, natural heritage with relevant sustainable development polices and recommendations. Finally, Chapter Nine includes a conclusion and comprehensive recommendations integrating all of urban and sustainability event in one map. Hebron has a deep history including a rich cultural heritage aged by thousands of years, with 47% of Hebron district population under 14 years old. Being the biggest Palestinian district, Hebron has thousands of industrial and economical organizations beside a large agricultural sector at Palestine level. This gives Hebron a potential to play major roles in developing a national sustainability plan, as the current urban planning system in Palestine needs urgent reform and development to fulfill the sustainability requirement. The municipalities and ministers should find permanent financial aid for urban planning and development studies so as to face future challenges. The Palestinian government can benefit from available local human resources in development projects; hence Palestinian people have sufficient qualifications in most sectors. The Palestinian people also can invest in the privet sector in Palestine in case businessmen have been encouraged and clear investment laws and plans have been developed. The study provides recommendations associated to the sustainable development in Palestine in general and Hebron, as a case study, in specific. Recommendations include increasing the privet sector as well as the public involvement in urban growth management, and stopping unplanned urban expansion, subjecting granting building permits of new projects to the no-harm environmental impact assessment, increasing the coordination and cooperation between localities and central bodies, protection and renovation of old cites and green areas, increasing the quality and quantity of infrastructure services, establishing district urban planning department to coordinate and organize urban planning and sustainable development activities. Also, among recommendations come dividing Hebron into three planning and administrative areas (north, central and south), and dividing the sustainable development and implementation period (2010 to 2025) into three main phases. Finally, the study strongly recommends benefiting from the same urban development plans in similar districts at national and international levels, also to use new technologies and information systems in urban planning process.

Resources for an Intersectorial Management of Public Policies: Mobility and Access

The objective of this paper is to integrate mobility as across component of the management of specific public actions. The case of study concerns the public health services in Argentina, and mother’s mobility conditions in the suburban of the Buenos Aires Metropolitan Area. In terms of methodology, the paper working on the concept of access trying to identify, measure and evaluate the relationship between mobility conditions and maternal health care. Access is weighted according to the realization of health services, and not according to the arrival at the places where they are offers. The result is innovative empirical evidence, useful as an indicator to make more relevant the role of mobility within the public agenda of transport and others specific sectors, asa basic social right behind the access that requires coordinated actions and cross-sectoral approaches.

The effect of intensive case management on the relatives of patients with severe mental illness

Objective: Relatives play a vital role in caring for patients with severe mental illness but receive inadequate support from psychiatric services. Evidence suggests that although intensive case management is directed primarily at patients, relatives may benefit a's well. This study examined whether relatives of patients who were receiving intensive case management had more contact with mental health professionals than relatives of patients who were receiving standard case management. It also examined whether relatives of patients receiving intensive case management appraised caregiving less negatively and experienced less psychological distress than relatives of patients receiving standard case management. Methods: The sample was drawn from the pool of patients participating in the UK700 randomized controlled trial of intensive case management. Prospective data on contact between case managers and the relatives of 146 patients were collected over a two-year period. At a two-year follow-up assessment, relatives of 116 patients were. interviewed with the Experience of Caregiving Inventory and the 12-item General Health Questionnaire. Results: Considerably more relatives of patients receiving intensive case management had contact with a case manager during the study period than relatives of patients receiving standard case management (70 percent compared with 45 percent). However, relatives of patients receiving intensive case management did not-appraise caregiving less negatively or experience less psychological distress than relatives of patients who were receiving. standard case management. Conclusions: Reducing case managers' caseloads alone. will not guarantee adequate support for relatives.. Instead, providing more support will need to be an explicit aim, and staff will require specific additional training to achieve it.

The National Audit Office uses OR to assess the value for money of public services

Supreme audit institutions (SAIs) have an important role in assessing value for money in the delivery of public services. Assessing value for money necessarily involves assessing counterfactuals: good value for money has been achieved if a policy could not reasonably have been delivered more efficiently, effectively, or economically. Operations research modelling has the potential to help in the assessment of these counterfactuals. However, is such modelling too arcane, complex, and technically burdensome for organisations that, like SAIs, operate in a time- and resource-constrained and politically charged environment? We report on three applications of modelling at the UK's SAI, the National Audit Office, in the context of studies on demand management in tax collection, end-of-life care, and health-care associated infections. In all cases, the models have featured in the audit reports and helped study teams come to a value-for-money judgment. We conclude that OR modelling is indeed a valuable addition to the value-for-money auditor's methodological tool box.

Scalable model-based configuration management of security services in complex enterprise networks

Security administrators face the challenge of designing, deploying and maintaining a variety of configuration files related to security systems, especially in large-scale networks. These files have heterogeneous syntaxes and follow differing semantic concepts. Nevertheless, they are interdependent due to security services having to cooperate and their configuration to be consistent with each other, so that global security policies are completely and correctly enforced. To tackle this problem, our approach supports a comfortable definition of an abstract high-level security policy and provides an automated derivation of the desired configuration files. It is an extension of policy-based management and policy hierarchies, combining model-based management (MBM) with system modularization. MBM employs an object-oriented model of the managed system to obtain the details needed for automated policy refinement. The modularization into abstract subsystems (ASs) segment the system-and the model-into units which more closely encapsulate related system components and provide focused abstract views. As a result, scalability is achieved and even comprehensive IT systems can be modelled in a unified manner. The associated tool MoBaSeC (Model-Based-Service-Configuration) supports interactive graphical modelling, automated model analysis and policy refinement with the derivation of configuration files. We describe the MBM and AS approaches, outline the tool functions and exemplify their applications and results obtained. Copyright (C) 2010 John Wiley & Sons, Ltd.

The Adequacy of Health Care Services for the Elderly in China

This study examines the adequacy of health care services for the elderly in China, specifically focusing on the influence of location, method of payment, living situation, and financial status. The study finds that rural residents, respondents living alone and respondents unable to meet all of their daily costs have a lower probability of reporting the availability of adequate health care. It also investigates the reasons why elderly respondents do not visit the hospital when it is necessary, concluding that financial and distance constraints are main deterrents. Finally, changes in the reported adequacy of health care over time are taken into consideration, and are found to follow a likely pattern given the history of the health care system in China. This is an important investigation given the historical background of health care in China, the current cost problems facing residents, and, consequently, the policy changes that will need to be implemented by the Chinese government in the near future.

Breastfeeding knowledge and practice of health professionals in public health care services

Objetivou-se avaliar conhecimentos e práticas sobre aleitamento materno de profissionais que atendem lactentes em unidades de atenção básica, ou maternidades públicas, de município do interior paulista, Brasil. É estudo epidemiológico, sendo a população composta por 89 enfermeiros e médicos. Suas respostas a um questionário estruturado foram analisadas no total e segundo o local de trabalho, aplicando-se o teste de diferença de proporções (qui-quadrado), considerando-se p<0,05 como nível crítico. Como parâmetros de acertos foram consideradas as recomendações do Ministério da Saúde. As diferenças significativas para conhecimentos e práticas, segundo o local de trabalho, foram restritas a alguns aspectos, com resultados discretamente melhores dos escores médios de acertos dos profissionais das unidades de atenção básica. Independente do local de trabalho, verificou-se desempenho regular e ruim em diferentes aspectos estudados, indicando que possíveis intervenções para a capacitação nessa temática deverão incluir profissionais de todos os níveis de atenção à saúde.