Tesi sul tema "Public health administration"

Over the past two decades, development assistance for health and government health expenditure have both increased substantially. Despite the rise in public attention and funding levels internationally, there has been little empirical exploration of budgetary trends in global health funding. Through the use of public budgeting and finance theories, these three studies in aim to increase understanding of the flow of health funds between and within donor and recipient countries through time. Application of Punctuated Equilibrium Theory (PET) to multiple datasets of national health financing data illustrates a leptokurtic distribution for both own domestic health (government health expenditure) and other health (development assistance for health) spending. The distribution of change in government health expenditure by 15 OECD donor countries was found to be less punctuated that their development assistance for health to developing countries from 1990-2012, suggesting smoother, more constant pressures for “own health” spending versus spending for global health. Comparison of country-level annual changes in government spending on domestic health for 145 countries between 1995 and 2012 illustrated that overall, and when grouped by income, the distributions of countries’ pooled annual changes in government health spending were leptokurtic. There was a greater departure from the normal distribution as country income decreased across the highest and two lowest income groups, and the proportion of annual changes that were positive decreased. However, the high-income non-OECD and upper-middle income groups diverged from this trend in interesting ways. Empirical exploration of the changing organizational composition of the field through the lens of population ecology provides greater context for the funding trends in global health with a particular focus on the emergence of public private partnerships. Application of the Herfindahl-Hirschman Index (HHI) found a decrease in concentration in the organizational field of global health between 1990 and 2000, followed by stability in the field despite the introduction of a new organizational form. Over this period, there were increases in ‘market’ shares for non-profit organizations and PPPs within the global health organizational population. The grant making-behavior directed through PPPs by a significant US bilateral agency was explored to identify patterns in decision-making related to PPP lifespan, disease focus, program type, regional focus, implementing partner categories and financial commitment, as well as recession impact. The limited empirical research concerning actors in global health funding emphasizes the need for further exploration of this phenomenon.

On October 1, 2013, the most visible component of the Patient Protection and Affordable Care Act (Public Law 111-148) (ACA) went live. Health insurance marketplaces provided residents with a place to shop and receive subsidies for insurance plans that contained the essential health benefits required by the ACA. The ACA required each state to establish an exchange, but it also provided flexibility so if a state elected not to (or could not) build its own, the federal government would implement the marketplace. A handful of states chose a hybrid implementation, which used the federal HealthCare.gov website but left certain decisions to the states. In the end, twice as many states chose to use the federal HealthCare.gov website compared to states that created a state-based marketplace and website. This trifurcated approach to implementing the health insurance marketplaces where residents were either served by a federally-facilitated, state-based, or hybrid marketplace, provides a unique situation for comparison and analysis relating to federalism and public policy implementation.

This policy analysis examines the implementation of the ACA’s health insurance marketplaces in all 50 states and the District of Columbia. It discusses enrollment success during the first five open enrollment periods across all three marketplace types.

Among the federally-facilitated, state-based, or hybrid marketplaces, was one type more successful than the others at enrolling residents in health insurance? What factors may have played a role in success or failure? This study discusses the ACA marketplaces as a case study in federalism and public policy implementation.

Rising worldwide rates of noncommunicable diseases (NCDs) in the Middle East, principally Saudi Arabia, have put an increasing load on the health system and employers. Middle Eastern organizations have been slow to develop targeted health programs, which include an emphasis on employee productivity. The purpose of this study was to determine the relationship, if any, between employee lifestyle and workplace productivity. Productivity is the amount of work produced based on the time and cost required to do so. The underlying theoretical foundations of this research were the socioecological health model and the human capital model. The quantitative, ex post facto design relied on secondary data from Saudi Aramco. Lifestyle data were collected from a health risk assessment including the Stanford Presenteeism Scale. Data analysis consisted of both a correlational and multiple regression analysis. Correlational results indicated that exercise, tobacco use, body mass index (BMI), and nutrition were significantly related to workplace productivity. Exercise and nutrition had a significant positive correlation with workplace productivity, while tobacco use and increasing BMI were negatively correlated with workplace productivity. Multiple regression analysis results explained 21% of the variance in the dependent variable, a sizable percentage with such a large sample. Overall, these results suggest a strong influence of health choices on productivity. Since this research was the first to explore the unique cultural context and draw attention to the increasing NCD burden, the results are notable. Implications of this research should resonate with organizational leaders in the Middle East, and provide a clear opportunity to improve organization and human performance.

Designed as a qualitative multiple-case evaluation, this study assessed the nature of policy congruence in health care organizations by evaluating the relationship of policy implementation strategies in these organizations with policy objectives contained in legislative enactments. The Program of All-Inclusive Care for the Elderly (PACE) was the conduit for this study, and research emphasis focused on how PACE programs attempt to implement policy objectives engrossed in the Patient Protection and Affordable Care Act of 2010 (ACA), even when not specifically required to do so. The problem identified has been that questions of policy consistency with the ACA continue to permeate the discussions surrounding PACE, and its utility as an alternative elder care initiative as contrasted against those concepts promoted in the ACA. The purpose of this research project was to advance theory and the application of theory in policy analysis. No review of PACE had been conducted through a theoretical perspective, and the theories of public choice and new institutionalism served as the theoretical framework which guided this study. Phone interviews of twelve PACE managers were conducted to ascertain organizational response to policies promoted in the ACA. Observational research was conducted at three PACE locations where high levels of policy congruence with the ACA were detected. This was complemented with public record document review which served to triangulate the research project. The study’s key finding is that uncertainty in markets where PACE is located has led most PACE programs to reflect characteristics of mimetic isomorphism. Furthermore, the ACA can be seen as subtly coercive in that regard, whereby PACE managers migrate PACE towards policies promoted in the ACA, and attempt to attain institutional legitimacy through mimetic behavior, which leads to more homogenous health care organizations. This study confirms the utility of public choice theory and new institutional theory in the investigation of public policy, and organizational strategies associated with public policy implementation. Evaluating PACE through public choice and new institutional theory expands the understanding of these theories, and their applicability and utility in evaluating the linkage between the policy theory, promulgation, and implementation processes, and thus, consequent effective governance strategies.

Starting in late 2013, new direct-acting antiviral medicines (DAAs) offered the chance of a cure for chronic hepatitis C virus (HCV) infection. In clinical trials, DAAs helped more than 90% of patients achieve sustained viral response (SVR), commonly considered to be a cure that will stop progression of related liver disease and prevent transmission of the virus to others. Prices for these medicines are now around $20,000 per treatment after discounts from manufacturers, due to competition.

In late 2016, the medical director for D.C. Medicaid asked what it would take to eradicate hepatitis C in the city. This dissertation focused on that question for Medicaid alone, to inform policy discussions and identify next steps. I profiled beneficiaries with chronic HCV infection based on medical claims from 2014-2016; interviewed medical providers and policymakers to learn more about their decision-making processes and to identify opportunities to expand treatment, as well as potential barriers; and created an Excel-based Markov model that estimates outcomes and costs under different scenarios.

Only 799 individuals, about 10% of the D.C. Medicaid beneficiaries identified as having chronic HCV infection, received treatment with DAAs in 2014-2016. Providers and policymakers are committed to treating this population, but treatment rates remained low through 2018. I estimate that roughly 80% of Medicaid beneficiaries with chronic HCV had not been treated at the start of 2019.

Beneficiaries with chronic HCV infection often have other physical, mental, and behavioral health conditions that might keep them from seeking treatment for an often-asymptomatic HCV infection. They often miss scheduled appointments and/or are lost to follow-up. Most live east of the Anacostia River, where there are fewer providers. Even if they engage in care, government or health plan policies might discourage or prevent individuals with low levels of liver damage from getting prior authorization for treatment.

Broader use of DAAs in D.C. Medicaid will allow more people to achieve SVR, potentially decreasing future healthcare costs for some and saving lives. A moderate (50%) increase in treatment rates among those with low liver damage could enable about 300 additional patients to achieve SVR over 10 years, at a net cost of $6.1 million. A 50% increase in treatment rates among those with moderate liver damage could enable more than 500 additional patients to achieve SVR over 10 years, keep more than 160 from severe liver damage, and avoid 19 early deaths. The net cost of the second scenario is $6.5 million, a smaller increase per person achieving SVR because curing those with moderate liver damage is more likely to avoid high healthcare costs.

The District must weigh the upfront costs of expanding use of DAAs against uncertain long-term benefits and inherent budget limitations. I recommend that D.C. develop a more complete profile of Medicaid beneficiaries with HCV infection; work toward universal screening and sustained monitoring of at-risk populations; collaborate with key stakeholders to develop policies, practices, and tools to engage beneficiaries in care; and reduce prior authorization requirements that might deter or prevent treatment when beneficiaries and health care providers are ready.

The 2001 destruction of the World Trade Center and the subsequent anthrax attacks highlighted the inability of an antiquated public health system in the United States to respond effectively to emergencies. Little documentation exists to define how public health agencies can improve performance. The overarching research question was the extent to which drills and exercises improve performance in public health emergencies. Adult learning theory and deliberate practice theory were explored in this context. The research data were from 50 state public health departments, which were required to report performance information to the U.S. Centers for Disease Control and Prevention. The data were examined using Poisson analysis and logistic regression. Results indicated that drills and exercises had no statistically significant impact on public health performance for the 3 performance measures examined; of all predictors, what explained the most variance in reaching performance targets was the number of real emergencies to which a health department had responded in the past. Performing drills and exercises did not predict the likelihood of reaching performance targets. These findings have implications for positive social change for Congressional leaders and other government representatives. Such public servants could use this information to guide their efforts to redirect public health emergency preparedness funds away from drills and exercises and toward other fundamental public health activities. These more focused efforts could facilitate the improvement of public health laboratory capacity, the training of field epidemiologists, and the advancements in technology for enhanced reporting and surveillance.