Dissertationen zum Thema „Affordable medicines“

Philosophiae Doctor - PhD
The concepts of availability, affordability, accessibility and acceptability otherwise known as the 4As of ATM are key factors that influence access to essential medicines in any given health system. However, the exact scale and extent to which these 4As affect various populations in Nigeria remains unknown. This study investigates the Nigerian healthcare system with special focus on access to quality and affordable essential medicines in three Nigerian States; Abuja, Kaduna and Nassarawa, by drawing upon primary data, using qualitative and quantitative research methods.

Background: Health is a core human right. The right of health care includes access to affordable medicines. Affordability of medicines by individual patients in low-income countries is a significant factor influencing access to care and treatment. However, drug prices in low income countries are found to be higher than those in high-income countries. Although the health care system in Jordan is quite advanced in comparison to neighbouring countries, the access to affordable medicines remains problematic. It was reported that almost 80% of the public in Jordan pay for their medications through out-of-pocket payments. High medicine prices are of a great concern to patients and their finances, which can result in poor compliance. Moreover, non-compliance can lead to reduced productivity and increased medical costs. In fact, several studies found that the high out of pocket-costs can be a significant obstacle to medical adherence with prescription medication regimens. Aims: The aim of this thesis is to research medicine prices and policies in Jordan, in order to recommend feasible solutions to make these affordable. To measure the affordability of medicines in Jordan and to assess the extent by which the cost of medicines is high, prices and factors affecting them were compared with the United Kingdom (UK), a high income developed country. Methods: A mixed-method approach was used in this thesis to research medicine prices and policies. The thesis reviewed the relevant literature, followed by reviewing the health care and pharmaceutical systems in both countries and their impact on medicine prices. Quantitative studies to measure the affordability of medicines in Jordan were conducted to assess the extent by which the cost of medicines is high in comparison to the UK and the factors that may affect medicine prices. This was followed by a qualitative study on how and why high unaffordable prices occur in Jordan. Finally, a quantitative survey exploring patients', pharmacists' and prescribing physicians' opinions towards measures that could be used to achieve greater clinical effectiveness and economic efficiency from drug prescribing was conducted. All the findings from the thesis were synthesised to form policy recommendations, designed to ensure affordable medicines for the Jordanian population. Results and discussion: Factors that influence prices of medicines over time were identified. These included; competition, marketing strategies, time in the market, regulations and pricing policy, change of clinical guidelines, epidemiology of disease, change in therapeutic use/value and exchange rate. Although the income per capita is much lower in Jordan (almost 7 fold less) than the one the UK, the studies conducted within this thesis demonstrated that medicine prices were significantly higher in Jordan compared to the UK. Generic medicines are three fold more expensive than the equivalent prices of the same drugs in the UK. However, the difference in prices for many drugs was significantly higher than the 3 fold difference. For example, the average price of pravastatin and amlodipine generics was more than eight fold higher than the UK price. Moreover, the average price of omeprazole, citalopram and fluoxetine generics were around 10 fold higher than the comparable UK price. Additionally, originator brand medicines prices were also found to be 1.5-fold more expensive in Jordan compared to the UK. Many originators were extremely higher than this average. For example, the Jordanian price of misoprostol originator tablets was around 19 times the comparable UK price. The price of ranitidine originator in Jordan was more than seven times the UK price and lansoprasole originator was around 6 times more than the price in the UK. The current pricing policy and its application are believed to be the root causes for the high prices of medicines in Jordan, as revealed by the qualitative interviews. The expected patients' saving by using generic medicines instead of originators in Jordan ranged from 32% up to 74%. The median saving in Jordan was -30.65% compared to - 71.43% in UK. The average savings were 32.68% and 43.54% in both Jordan and UK respectively. This increased to 54.96% in the UK when one outlier was removed. However, the saving calculated in both countries would have been higher if the lowest priced generic was used. An extra saving of 6.86% was identified in Jordan if the lowest priced generics were used for cardiovascular diseases (the calculated saving increased from 32.71% when using the average generic price compared to 39.57% when using the lowest priced generic). The findings also showed a positive attitude of all stakeholders (patients, pharmacists and prescribing physicians) towards generic medications and their willingness and acceptance of strategies that encourage generic utilisation in Jordan such as generic substitution, lnternational. Non-proprietary Name (INN) prescribing and Electronic Prescribing (EP). Such measures will help reduce the high expenditure on drugs in Jordan which accounts for around one-third of the national health care budget. Conclusion: A range of policy measures and changes are required to improve access to medicines in Jordan. Recommendations made included amendments to pharmaceutical policies, better enforcement of the current regulations, encouraging the use of generic medicines by introducing measures such as generic prescribing, generic substitution and public awareness education programs. These changes should result in more affordable medicines in Jordan.

My research examines the adoption and implementation processes involved in transferring a global health policy into national-level practice. More specifically, I consider how high-level stakeholders adopted and street-level, private-sector retailers implemented the Phase I pilot of the Affordable Medicines Facility- malaria (AMFm) between mid-2009 and end-2011. The AMFm — a large-scale program housed at the Global Fund to Fight AIDS, TB and Malaria — sought to improve access to high-quality malaria treatment through financing and delivery strategies using the public and private sectors. To date, the median implementation outcomes have been considered in the Independent Evaluation commissioned by the Global Fund but country-level processes and nuanced considerations of outcomes have gone unexplored. To better understand the AMFm pilot in Ghana, I collected both quantitative and qualitative data between August and December 2011. To consider adoption, I first use a grounded, qualitative approach to address: What explains the stands taken by national stakeholders towards and against participating in the AMFm’s Phase I? I generate explanatory categories about the different views — stands — key stakeholders in Ghana took about joining Phase I. Public health goals; indirect policy goals; and concerns about personal, organization, and national reputation help to explain the views of different high-level stakeholders. Second, I consider the actions taken by different stakeholders: To what extent can a multiple-streams approach to policy adoption help clarify Ghana’s decision to join in the AMFm’s pilot? I find the Multiple-Streams Approach cannot be used to explain adoption of the AMFm pilot in Ghana. However, a modified version accounting for the global and national levels simultaneously can explain this case. To consider implementation, I ask: Do retailers in Northern Region comply with Ghana’s the advertised AMFm Recommended Retail Price among for-profit, private-sector retailers? And, does non-compliance vary systematically with features of retailer structure or conduct? I find high compliance based on reported retail prices. I also find that neither measures of spatial competition nor having seen regulation enforced in the past explain the pattern of non-compliance. Rather, variation in the terminal supply price is highly associated with a retailer’s decision to charge at or above the RRP.

In 2014, the individual mandate of the Affordable Care Act (ACA) came into effect. More than 7 million Americans paid a tax penalty for not carrying insurance during the previous tax year. Millions of others were forced to purchase a health insurance plan to avoid that penalty. This study filled a gap in public health policy research by incorporating qualitative data to offer narratives along with statistical data that could help explain health outcomes to make successful policy changes in 2019. The purpose of this study was to research the use of market competitive theory by learning people's lived experiences and how they made the decision to participate in the ACA. The theoretical foundation was based on the social justice theory when mandating that citizen's purchase or pay. The method for this research was a qualitative interpretive phenomenological thematic approach with triangulation using the snowball effect and the hermeneutic circle method of analysis. The sample size included 6 volunteers who identified as either purchasing health insurance or paying the individual mandate penalty during a recorded interview. The findings answered the first research question by showing that the 6 participants found reason to carry health insurance based on their lived experiences and desire to maintain wellness overall. Findings for the second research question indicated that the individual mandate penalty did not increase the likelihood that the 6 participants would purchase healthcare insurance based on their lived experiences. This study supports the need for continued ACA qualitative research to identify more themes on how people make decisions regarding their health care that could provide positive social health policy change for the future.

African American women are more likely than White women to be diagnosed with breast cancer after the disease has progressed to advanced stages. Further, African American women experience higher breast cancer mortality rates than White women at all stages of cancer diagnosis. The purpose of this quantitative comparative study was to examine differences between implementation of the Affordable Care Act (ACA) and 5-year breast cancer survival rates among African American and White women. The independent variable was African American women and White women who were survivors of breast cancer after the ACA implementation; the dependent variables were breast cancer survival rates after ACA implementation. Data were gathered from the Surveillance, Epidemiology, and End Results (SEER) program for the time period between 2010 and 2015. The theoretical foundation for this study was Penchansky and Thomas’s concept of healthcare access. This quantitative study followed a retrospective design using cohort data from the SEER program. Data were analyzed via independent samples t-test and chi-square test of association. Results indicated that White women had a higher 5-year survival rate than African American women; the association between race and survival was significant. White women survived also survived breast cancer for more months, on average, than African American women. Findings indicate that racial disparities in breast cancer survival have endured, post ACA. The primary social change implication is that more research is needed to improve the breast cancer survival rates of African American women. The ACA may be working to help reduce the racial disparities in breast cancer survival, but providing access to healthcare is not necessarily enough.

Affordable Care Act (ACA) was passed and implemented to expand insurance coverage, reduce health care cost, and improve the quality of care. The purpose of this dissertation study was to investigate whether the ACA insurance expansion correlates with the number of visits made to emergency departments (EDs). The quasi-experimental design interrupted time series was utilized in the analysis. The ED visits were compared using MANOVA to determine the relationship between ED visits and ACA and canonical correlation analysis to assess the strength of the relationship and the extent to which independent variables could predict the dependent variable. The hypothesis was that the ACA will reduce the uninsured, increase the insured, and reduce the ED visits. The relationship between number of ED visits and the ACA will present whether the uninsured patients contributed significantly to the ED overcrowding. Analysis of secondary data from four EDs (H1, H2, H3, and H4) in the Chicago area showed that 484,742 visits were made, and 2,801 were excluded due to unknown payer type. Medicaid patients recorded the largest number of visits (181,226) while the uninsured patients recorded the least number of visits (56,572). The ED visits decreased by 6% from 2012 to 2013 (pre-ACA) and increased by 4% from 2013 to 2105 (post-ACA). The ACA implementation increased the people with insurance who visited the EDs by 11%. The results demonstrated a strong relationship between ACA and ED visits. The correlation of the variables (hospital and year) and ED visits demonstrated that the hospital could explain 97% of the Medicaid visits and 87% of uninsured while the year could predict 82.6% of the uninsured visits and 52.5% of Medicaid visits.

Les tests sur le lieu de soins sont très prometteurs car ils permettent d'effectuer des mesures en temps réel et en continu à un prix abordable et s'adressent à un large éventail de personnes. Cependant, le défi que représente la surveillance continue pour gérer la santé de manière proactive tout en réduisant les dépenses de santé est considérable. Il s'agit principalement de garantir la fiabilité des éléments de reconnaissance et la viabilité à long terme des sources d'énergie, en particulier des batteries. Cette étude a établi un capteur de lactate non enzymatique pour les tests sur le lieu de soins, en utilisant une approche holistique qui comprend la modification de la morphologie de l'électrode, l'électrodéposition de matériaux conducteurs et de catalyseurs à l'échelle nanométrique, l'intégration d'un liquide ionique pour la sélectivité, l'optimisation de la technologie d'alimentation sans fil et l'incorporation de systèmes de gestion de l'énergie dans des dispositifs de détection électrochimique conçus par l'utilisateur lui-même. Les principaux résultats comprennent la sélectivité des catalyseurs non enzymatiques pour la détection et la proposition d'un dispositif de mesure personnalisé alimenté sans fil. Plus précisément, la modification de la géométrie du noyau du transformateur en ferrite a amélioré la puissance de sortie maximale du transducteur magnétoélectrique, qui a atteint 1,63 mW. Le circuit de gestion de l'énergie proposé fournit du courant continu avec un rendement élevé (0,74 mW) et permet une charge plus rapide pour la transmission d'énergie sans fil afin de soutenir nos dispositifs électrochimiques. Les dispositifs d'analyse électrochimique tels qu'ils ont été fabriqués ont démontré des capacités de mesure précises. L'utilisation de l'électrode poreuse imprimée a permis d'améliorer la reproductivité, la conductivité et la surface. L'électrodéposition de graphène et de nanoparticules de Ni(OH)₂, dont la taille et l'état chimique ont été soigneusement réglés, a augmenté la sensibilité du capteur. La plage de détection étendue des capteurs d'acide lactique optimisés s'avère avantageuse pour la détection du lactate, ce qui présente des avantages significatifs pour le diagnostic de diverses maladies. Un liquide ionique synthétisé sur mesure a facilité la détection sélective de l'acide lactique, en bloquant les molécules d'interférence et en permettant une détection "en une étape" avec une large gamme (1 mM à 60 mM) et une sensibilité élevée (1,374 μA/mM). En outre, la performance électrochimique du capteur non enzymatique avec liquide ionique a été étudiée en corrélant le coefficient de diffusion avec la Stokes-Einstein relationship. En conclusion, cette recherche offre des perspectives précieuses sur des systèmes de tests de soins au point d'intervention entièrement intégrés avec des applications pratiques, notamment les capteurs de lactate non enzymatiques avec des liquides ioniques et les transducteurs magnétoélectriques pour le transfert d'énergie sans fil. L'effort continu visant à améliorer les dispositifs de tests de soins au point d'intervention souligne l'importance de la recherche et de l'innovation soutenues pour faire progresser les soins aux patients et la gestion des maladies dans divers domaines, y compris la médecine clinique, la gestion du sport et la recherche sur le cancer
Point-of-care testing (POCT) holds great promise for providing real-time and continuous measurements at an affordable price, catering to a broad range of individuals. However, the challenge of continuous monitoring to proactively manage health while reducing healthcare expenses is substantial. These challenges primarily revolve around ensuring the reliability of recognition elements and the long-term sustainability of power sources, particularly batteries. This study established a non-enzymatic lactate sensor for point-of-care testing, employing a holistic approach that encompasses the modification of electrode morphology, electrodeposition of nanoscale conductive materials and catalysts, integration of ionic liquid for selectivity, optimization of wireless power supply technology, and the incorporation of power management systems into self-designed electrochemical detection devices. Key findings include conferring selectivity on non-enzymatic catalysts for detection and proposing a custom wirelessly supplied measurement device. Specifically, modifying the ferrite transformer core geometry improved the magnetoelectric transducer's maximum output power, reaching 1.63 mW. The proposed power management circuit supplied DC with high efficiency (0.74 mW) and enabled faster charging for wireless power transmission to support our electrochemical devices. The as-fabricated electrochemical analysis devices demonstrated precise measurement capabilities.Using the porous screening printed electrode showed increased reproductivity, conductivity, and surface area. The electrodeposition of graphene and Ni(OH)₂ nanoparticles, carefully regulated in size and chemical state, elevated the sensor's sensitivity. The extensive detection range of the optimized lactic acid sensors proves advantageous for detecting lactate, offering significant benefits in various disease diagnoses. A custom-synthesized ionic liquid facilitated selective detection of lactic acid, blocking interference molecules and enabling "1-step" detection with a wide range (1 mM to 60 mM) and high sensitivity (1.374 μA/mM). Additionally, the electrochemical performance of the non-enzymatic sensor with ionic liquid was investigated by correlating the diffusion coefficient with the Stokes-Einstein relationship. In conclusion, this research provides valuable insights into fully integrated POCT systems with practical applications, including the non-enzymatic lactate sensors with ionic liquids and magnetoelectric transducers for wireless power transfer. The ongoing effort to enhance POCT devices underscores the importance of sustained research and innovation in advancing patient care and disease management across various fields, including clinical medicine, sports management, and cancer research

About 50% of adults in the United States suffer from at least 1 mental health challenge in their lifetime. Annually, mental health and substance use disorders cost the United States about $800 billion, leaving individuals with unaffordable cost of care and the nation with diminished productivity and revenue. With the Essential Health Benefits and Medicaid expansion under the Patient Protection and Affordable Care Act (PPACA), healthcare resources were created to address gaps in behavioral healthcare. There is a need to understand how the healthcare law has influenced the availability of behavioral health services and access to needed care. This study explored the lived experiences of 10 behavioral health service recipients to identify the benefits and challenges of the PPACA on behavioral health services. Participants from Anne Arundel County, Maryland, were purposefully selected and interviewed face-to-face. Relative advantage, compatibility, and complexity were characteristics of the diffusion of innovation theory used for the exploration of this research. Based on the interpretive phenomenological approach, Nvivo 11 Pro was used for data coding, management, organization, and analysis. There was the shared belief among participants that the PPACA improved their access to adequate and affordable behavioral healthcare. Effective network of care and having health insurance seemed to have improved health outcomes. Findings from this study highlight issues of common interest to healthcare stakeholders while providing reasonable platforms for objectively addressing complex challenges, which tend to undermine the possibility of adopting policies that could yield positive dividends for all parties involved.

What is lobbying, properly understood, in the United States, and what strategies and tactics—including and especially those determined by contextual factors, as well as firm characteristics—are commonly employed by corporate lobbies as they operate in our American political environments? Considering this, what are the main strategies and tactics employed by the pharmaceutical lobby, with a particular focus on the Pharmaceutical Manufacturers and Researchers of America, or PhRMA? Finally, what roles did PhRMA play in the development and passage of the Obama administration’s Affordable Care Act, and what can this tell us about the lobbying strategies and tactics utilized by one of the most effective lobbies in modern times, as well as about how their strategies and tactics align, or not, with conventional conceptions of lobbying? Through effective use of key lobbying tactics such as direct lobbying and use of public awareness, PhRMA completed one of the more successful lobbying campaigns in recent history. When the White House came calling, they were first to the table, for they knew that with that seat came a position of leverage. From there, they were able to build both political and public support to complete a deal with the Obama administration that they positioned as necessary to keep the Affordable Care Act alive. This deal would ensure that the pharmaceutical industry would pay a flat rate of support for the act, and was therefore guaranteed protection from future government attempts to set or regulate the prices of their products and medicines. PhRMA played the long game, and they played it well.

This qualitative case study examined the perceived effectiveness of executive leadership team processes at a community hospital in the southeastern U.S. in relation to the Value-Based Purchasing (VBP) requirements of the Patient Protection and Affordable Care Act (PPACA) through an analysis of documents and a repository database (http:www.hospitalcompare.hhs.gov) relating to service quality, patient satisfaction, and governmental reimbursements; and, structured interviews. Today, the PPACA or “Obamacare” continues to challenge the executive leadership teams at U.S. hospitals to effectively navigate the intricacies of the legislation in order to remain solvent in a volatile healthcare arena. The Plan-Do-Check-Act (PDCA) model was utilized to guide the theoretical framework for this qualitative case study in terms of process improvement. Hill’s (2010) team leadership model was also applied to examine the perceived effectiveness of the executive leadership team processes in terms of analyzing any change in core measures and patient satisfaction scores from the federal fiscal year (FFY) 2013 and 2014, respectively. The VBP data reflected consistent core measure scores in the 48th percentile and an increase in patient satisfaction scores from the 20th to 33rd percentile. The results revealed that the executive leadership team processes were perceived by the researcher as effective as evidenced by a strong collaboration among administration, the bord, and medical staff in implementing several strategies via a team oriented approach that impacted Medicare patients during the FFY of 2013-2014. This study offers a starting point in terms of generating more understanding of the importance of executive leadership team processes at a community hospital in relation to the VBP requirements of the PPACA which can be studied on a broader scale in the future.

The Patient Protection and Affordability Act of 2010 (PPACA) addressed the access to healthcare in the United States. One of the problems of this healthcare access was rooted in disproportionally lower access among minority populations. The purpose of this quantitative study, guided by the consumer behavior theory, was to examine the association between race/ethnicity and enrollment within the Covered California-?¢ (CoveredCA) Insurance Exchange. A cross-sectional study design was used to investigate the association between race/ethnicity and the use of Covered CA health benefit exchange. Logistic regression analysis was used to examine the relationship between enrollment and race/ethnicity, having adjusted for covariates of age, gender, and literacy. The results revealed that, while all other race/ethnicity groups were less likely to purchase Bronze level versus Silver and above coverage compared to the Hispanic race/ethnicity, Asians (OR =1.16, 95% CI: 1.11, 1.20) and Whites (OR = 1.12, 95% CI: 1.02, 1.14) were more likely to purchase Bronze level versus Silver and above coverage compared to the Hispanic group. Chi-square test results indicated a statistically significant difference in the proportion of individuals selecting the Bronze level coverage compared to the Silver and above among the various race/ethnicity groups ï?£2 (13, N= 763,531), 1922.083, p < 0.0001. The Hispanic race/ethnicity was more likely to enroll in the Bronze versus Silver and above compared to other race/ethnicities. The results of this study may contribute to positive social change by informing policy that besides income and age, race/ethnicity is an important determinant of the likelihood of enrollment in the Covered CA health exchange.

Relocating health behaviors within a political-economic framework, this article utilizes health behavior and health insurance governance perspectives to showcase the complexities of cultural and economic factors (e.g., job lock, wage differentials, social location, and health insurance status) that influence choices in efforts to mitigate the financial burden of health risk. By exploring the financial links to health behaviors that emerged through ethnographic participant observation and semistructured interviews with community and union members of the United Steelworkers and Retail, Wholesale, and Department Store Union in a metropolitan Central Appalachian community in 2007–8, this article argues for expanding the health behaviors concept to include a broader array of actions individuals and families take to better their health and well-being in the context of neoliberal shifting of risk management to individuals through increased consumer market-based cost-sharing health insurance disincentives. In so doing, this article argues for the importance of social and political-economic context in health behaviors and in evaluating health policy, including the Affordable Care Act.

The Patient Protection and Affordable Care Act (PPACA) of 2010 requires hospital systems in the United States to shift the culture of patient care from a focus on sick-care to a focus on prevention and wellness care. Little is known about how hospital systems will make this culture shift while retaining quality patient care. The purpose of this case study of a pioneering hospital-based PPACA-compliant initiative was to answer the research question of how Wallace's revitalization movement theory (RMT) "a rapid culture change model"could serve as a transferable evaluation framework for PPACA prevention and wellness care compliance in hospital-based programs. Kingdon's policy streams theory provided a conceptual framework. Data analysis included iterative, thematic coding of interviews with 3 primary stakeholders responsible for developing the policy, planning, and program implementation strategies of the Center for Total Health (CTH). Nineteen extensive primary source documents were included in the analysis as well. Findings supported the utility of the RMT structure and definitions in the identification of culture change dynamics in CTH. Additionally, this structure served as a scaffolding for grouping individual and institutional rapid culture change dynamics into stages that could be evaluated in terms of PPACA compliance. These stages effectively identified a Kingdon policy window in which PPACA mandates could be expected to result in culture change in multiple streams of public policy development, not only in wellness and sickness prevention, but also in local, state, and national health cost-saving initiatives in food-as-medicine, community identity, public health support networks. It could also reduce chronic disease and the rising institutional care delivery costs.

BACKGROUND: The barriers in accessing healthcare for gay, lesbian and bisexuals individuals are not well explored. These challenges as well as a lack of knowledge concerning this understudied group has prompted the Institute of Medicine to create a research agenda to build a foundational understanding of gay, lesbian and bisexual health and the barriers they encounter.1 the primary aim of this study will be to compare the differences in health care access and utilization between gay/lesbian, bisexual and heterosexual individuals using a large, nationally representative dataset of the U.S. population. METHODS: Data from 2001 to 2012 from the National Health and Nutrition Examination Survey was pooled. Using logistic regression, we calculated the unadjusted and adjusted odds ratios of having health insurance, having a routine place and seeing a provider at least one in the past year. RESULTS: We found that gay men were more likely to have health insurance coverage (ORadj:2.13 95%CI: 1.15,3.92), while bisexual men were at a small disadvantage in having health insurance coverage (ORadj:0.82 95%CI: 0.46,1.46). Bisexual men were more likely to have received health care in the past 12 months (ORadj:3.11 95%CI: 1.74,5.55). Lesbian women were less likely to have health insurance coverage (ORadj-lesbian:0.58 95%CI: 0.34,0.97). CONCLUSION: This study contributed to the limited knowledge on understanding the health care access and utilization among gay, lesbian and bisexual individuals, which was classified as a high priority by the Institute of Medicine. Expanding health insurance coverage through the Affordable Care Act and Universal Partnership Coverage may reduce the disparities among gay, lesbian and bisexual individuals.

BACKGROUND: The barriers in accessing healthcare for gay, lesbian and bisexuals individuals are not well explored. These challenges as well as a lack of knowledge concerning this understudied group has prompted the Institute of Medicine to create a research agenda to build a foundational understanding of gay, lesbian and bisexual health and the barriers they encounter.1 the primary aim of this study will be to compare the differences in health care access and utilization between gay/lesbian, bisexual and heterosexual individuals using a large, nationally representative dataset of the U.S. population. METHODS: Data from 2001 to 2012 from the National Health and Nutrition Examination Survey was pooled. Using logistic regression, we calculated the unadjusted and adjusted odds ratios of having health insurance, having a routine place and seeing a provider at least one in the past year. RESULTS: We found that gay men were more likely to have health insurance coverage (ORadj:2.13 95%CI: 1.15,3.92), while bisexual men were at a small disadvantage in having health insurance coverage (ORadj:0.82 95%CI: 0.46,1.46). Bisexual men were more likely to have received health care in the past 12 months (ORadj:3.11 95%CI: 1.74,5.55). Lesbian women were less likely to have health insurance coverage (ORadj-lesbian:0.58 95%CI: 0.34,0.97). CONCLUSION: This study contributed to the limited knowledge on understanding the health care access and utilization among gay, lesbian and bisexual individuals, which was classified as a high priority by the Institute of Medicine. Expanding health insurance coverage through the Affordable Care Act and Universal Partnership Coverage may reduce the disparities among gay, lesbian and bisexual individuals.

The Patient-Centered Medical Home (PCMH) is an innovative, team-based health care model that was applied during the implementation of the Affordable Care Act (ACA). However, the competencies for PCMH health care social worker team members are not identified within this model. Thus, the purpose of this phenomenological study focused on identifying the core competencies that will enable social workers to perform competently in PCMHs. This study also explored the roles and training needs as related to improving the competence of social workers. Sandberg’s and Parry’s conceptualization of the competency model was used as the theoretical framework. Data were acquired through interviews with 10 PCMH social workers. These data were then inductively coded and analyzed using a modified Moustakas method. Key findings indicated that these social workers believed that improvements in competencies may include training and knowledge with mental health and physical health knowledge which consist of diagnoses, interventions, medications, symptoms, and terminology. It was also noted that knowledge of evidence-based practices for mental health interventions and patient-centered, team-based principles were essential to ACA policy implementation. The positive social change implications of this study include recommendations to health care leadership, educational institutions, and other PCMH providers to develop competency-based training for social workers. Recommendations are also put forth to adapt social work curriculum to ensure the effective implementation of the principles of the ACA policy and to improve social work practice in PCMH health care settings.

Americans spent nearly $2.6 trillion, or $8,000 per person for medical and administrative costs in 2010. By 2015, healthcare spending in the United States increased to 5.8% reaching $3.2 trillion or $9,990 per individual. By tackling healthcare administrative costs, it is estimated that healthcare providers could reduce these costs by $20 billion yearly. This case study explored strategies for streamlining hospital administrative procedures to reduce costs. The business process reengineering model formed the conceptual framework for this study. Data were gathered through semistructured face-to-face interviews guided by open-ended questions with a purposeful sample of 4 hospital managers in Atlanta, Georgia. This study identifies important themes regarding cost reduction and hospital administration based on participant interviews. Themes included participants' unfavorable perspectives of the Spell out PPACA (PPACA) legislation, employment of physicians, PPACA reimbursement method, follow-up services, hospital administrative governance, and lack of business education. The themes comprised steps hospital managers could take to streamline administrative procedures to reduce costs. The implications for positive social change included the potential to provide strategies for streamlined processes that could lead to savings passed on to patients from low socio-economic backgrounds through accessibility to affordable healthcare services.

Patent protection grants the patent holder with a market monopoly, free from market competition allowing the patentee to charge any price; therefore medicines are sold at prices much higher than the marginal cost of production and distribution. The connection between international trade and intellectual property has aggravated human rights and public health concerns surrounding the inaccessibility of essential medicines. The World Trade Organisation‘s Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement is an international instrument which has greatly impacted intellectual property rights protection and access to medicine. It has globalized intellectual property law by obliging all Members to subscribe to the minimum international standards of protection for intellectual property. South Africa is an example of the issues faced whilst attempting to bring their domestic laws into compliance with the Agreement. The government had to attempt to strike a balance between creating an effective intellectual property infrastructure whilst realizing the therapeutic needs of those affected by HIV/AIDS. The South African Patents Act 57 of 1978 did not comply with the Agreement and was subsequently amended in order to bring its patent legislation in full compliance with the Agreement. Currently, South Africa grants patents for new uses or formulations of existing medicines consequently lengthening the period of patent monopoly by allowing pharmaceutical companies to obtain new patents for slight modifications to existing medicines. It is submitted that South Africa‘s patent legislation is more extensive than is necessary under international law, examples of this being disclosure standards and the process for compulsory licensing. In addition, it has not made use of provisions in its existing law to take measures to improve access to essential medicines, nor has it implemented legislative amendments consequent to the flexibilities established in the Doha Declaration. This dissertation seeks to review the steps South Africa has taken in its compliance with the TRIPS Agreement with respect to the relevant intellectual property legislation that has been enacted, including its implications for access to essential medicines. The intention behind this dissertation is to assess the efficacy of the intellectual property legislation in South Africa and its impact on access to medicines.
Thesis (LL.M.)-Univeristy of KwaZulu-Natal, Durban, 2012.

The World Health Organization estimates that about 10-30% of pharmaceuticals in the world are either substandard or counterfeit. The number is even higher in the developing countries. From a public health perspective, a key contributor to the development and proliferation drug resistant strains of infections, including tuberculosis (TB), malaria and other infections that are leading killers in resource limited settings is poor quality medicines. Most of the main causes are profit driven corruption in many pharmaceutical companies, the poor manufacture and quality control, and/or the inappropriate storage conditions. Poor quality drugs lead to loss of life, create morbidity, strain the financial structure of the health system and lead to long-term drug resistance that affects us all. The current technology for screening poor quality drugs can be divided into 2 categories: the high end, precise and high cost technologies (such as High Performance Liquid Chromatography) and lower cost and qualitative technologies (such as Thin-Layered Chromatography). The high-end methods can give a precise measurement of active pharmaceutical ingredient (API) concentration and the presence of impurities in the tablets, but require trained personnel, advanced machine and lab set up, not suitable for field testing where most of poor quality pharmaceuticals have been found. The lower cost techniques require little training and simple equipment to operate at a relatively inexpensive price, but only gives qualitative results. In addition, most of current methods do not look at the dissolution profile of the tablets simultaneously with the concentration of API. Therefore, we propose to develop an assay that can quantify the concentrations of multiple APIs simultaneously and measure dissolution rates. In order to address current gaps in knowledge, my research proposal has three main parts in the assay development: 1) Development of an fluorescent/luminescent assay for detection of counterfeit/substandard antimalarial using small-molecules-based methods and field testing in Ghana; 2) Development of a fluorescent assay for detection of water-soluble pharmaceuticals using SELEX; and 3) Design a detection platform using microfluidic chips for real time quantification of multiple active pharmaceutical ingredients. For proof-of-concept, an antimalarial drug (artesunate and amodiaquine) and antibacterial antibiotics (sulfamethoxazole and trimethoprim) are selected to demonstrate the probe development and test the chip performance. Overall, the assay will be rapid, robust, portable, inexpensive, multiplexed, quantitative, specific, and sensitive. At a big picture level, emphasizing drug quality and creating robust mechanisms of drug testing will improve health outcomes and enhance treatment efficacy in resource limited settings.

The connection between patents for pharmaceuticals and access to affordable medicines has elicited considerable attention and highly stimulating debates since the emergence of the World Trade Organisation (WTO) Agreement on Trade Related Aspects of Intellectual Property Rights (the TRIPS Agreement) as part of the Marrakesh Agreement Establishing WTO in 1994. The TRIPS Agreement is the first international convention to make it mandatory for all countries to make patents available in all fields of technology provided the invention to be patented meets the criteria for patentability. Consequently, countries like India, Brazil, China and Thailand that used to refuse to grant patents for pharmaceuticals were constrained to amend their patents laws to bring them in line with the WTO standard. Many developing countries did not even have legislation for a number of the intellectual property rights areas covered by the agreement at the time it was adopted. The TRIPS Agreement has been criticised as being a significant part of the global access to medicines problem and strong arguments have been raised for having more flexible standards for the protection of patents particularly in relation to pharmaceuticals. This thesis examines the WTO regime for patent protection in the context of pharmaceuticals and the existing flexibilities in the TRIPS Agreement that countries seeking access to affordable patented pharmaceutical products might adopt. The effectiveness of the TRIPS compulsory licensing regime is examined, with particular focus on the limitations resulting from the TRIPS requirements for test data protection. The concepts of parallel importation and exhaustion of intellectual property (IP) rights are also examined with aview to ascertaining the extent to which they may serve as legal stratagems for developing countries seeking access to affordable medicines. The thesis argues that the existing frameworks for the right to health and the right to development in international law may provide a strong justification for the broad interpretation of the existing flexibilities in the TRIPS Agreement without the need for going through the very rigorous process of amending it. The thesis considers the patents and access to medicines problem in the context of the special and highly complex challenges people in Sub-Sahara Africa are currently encountering. It recommends the establishment of an African Free Trade Area to make it easier for Africa as a continent to make better use of the TRIPS flexibilities. The thesis argues that more than ever before, the time has come for Africa to harness her resources to address her access to medicines problem through the use of all the available options in international economic law and international human rights law.

Right to good health and wellbeing is an inalienable basic human right and is recognized in a number of national and international legal instruments. Part IV of the Constitution of India, which enshrines ‘Directive Principles of the State Policy’ makes a reference to Constitutional commitments in Articles 39(f) and 47, to provide for health care Provision of universal healthcare for its people is a fundamental duty of every nation, more so, of the signatories to the 1948 ‘Universal Declaration of Human Rights’, and the ‘International Covenant on Economic, Social, and cultural Rights’India is a signatory to both the Declaration and the Covenant, and its track record on human rights, is periodically subjected to peer review by member states of the UN Human Rights Committee, as part of United Nations’ Universal Periodic Review process in Geneva.at periodic intervals. Article 18 of the Constitution of the World Health Organization (WHO) a specialized agency of the United Nations, concerned with international public health. declares that ‘the enjoyment of the highest attainable standard of healthis one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition’, and recognizes that the objective of the WHO shall be the attainment by all peoples of the highest possible level of health

Health care reform in America has been controversial since its inception in the early twentieth century. The passage of the Affordable Care Act (ACA) by President Obama in March 2010 represents the most recent chapter in a protracted struggle between Democrats and Republicans over fundamental tenets of health care—is health care an essential human right or is it a commodity? Who should bear the financial burden of paying for health care? Should this be a federal or state issue? And how do we insure more individuals but still cut rising costs? This thesis explores the history of health care reform, from pre-World War I to post-Cold War, and then delves into the basic provisions of the ACA. An overview of the impending physician shortage, including the methodology of the physician supply and demand projections, the different variables included in the analysis, and how physician supply and demand can be expected to change over time given the different variables, is included. After reviewing the ACA and the doctor shortage independently, the next stage of analysis incorporates this information to explore the impact of the ACA on the impending doctor shortage. The discussion section provides further insight into this subject and concludes with future considerations—including the upcoming presidential election—as well as limitations of this thesis and ideas for additional research.