Rozprawy doktorskie na temat „Healthcare reforms”

There are a lot of health sector reforms across the spectrum of high to low income countries. There are underlying pressures for reform regarding the role and responsibility of different actors in relation to healthcare financing, production, consumption and regulation. The health sector itself is usually a very significant economic sector in its own right, and thus changes to it have direct impacts on the economy and indirectly through their effect on health, yet there is little consideration of these wider macro effects. The wider macro-economic effects refer to the general equilibrium outcomes of the economy’s transmission mechanisms through wages,rents, factor demand and supply, foreign exchange rates and sectoral shares in output, which in turn affect changes at the macro level (including GDP, private and public consumption, investment, imports and exports, and poverty levels). There is an ever increasing attention to the question of how to increase financial resources for healthcare, particularly by governments. This thesis sets out to evaluate the economy wide impacts of healthcare financing reform policies, taking Uganda as a case study. Using a recursive dynamic computable general equilibrium (CGE) model, calibrated from a health-focused Social Accounting Matrix (SAM), the impact of healthcare financing reform policies is assessed. Three sources of fiscal space for health – prioritisation of the health sector, earmarked taxes for health, and aid for health – are analysed. Results showed that increasing resources to the health sector from any of the three sources of fiscal space for health coupled with the envisaged improvements in the population health status leads to higher GDP growth rates and reduces poverty. The tax for health policy showed the highest GDP growth rates while the aid for health policy achieved the highest reduction in poverty. Therefore, government should increase resources to the health sector in order to achieve the aspirations of the Uganda Vision 2040.

In the early 1990s, the deep political and socio-economic transformations showed that the Albanian pension and healthcare models inherited from Communism were inefficient, close to the point of fiscal breakdown, as well as inequitable. In order to address these challenges, the Albanian government promoted a shift towards a social insurance model – which was said to represent the “good way”, i.e. a viable solution to build a stable and especially an effective social protection system. In both policy sectors the government’s ultimate goal was to link benefits to contribution records. Consequently, the Albanian pension and healthcare systems started to converge towards a Bismarckian social insurance model. However, reform implementation was constrained and, after three decades of reforms, the full shift to an insurance-based model has failed in both pensions and healthcare. The 2014 reform transformed the pension system into a mixed-occupational model – according to Ferrera’s terminology (Ferrera 1993) – made up of a social assistance scheme – a means-tested, poverty-relief social pension – and a social insurance, contributory scheme aimed at income maintenance. In the healthcare sector, the last wave of reform, started in 2014, aimed at transforming the system from a social insurance model to a universalistic social security one. These reforms thus led to a partial policy reversal, with the healthcare changing into a mixed-universalistic model, implying a combination of social security and social insurance – respectively financed by the state budget and social contributions. The pension and healthcare systems currently differ in terms of institutional architectures, financing methods, coverage and benefits. This policy change and divergence that exist between these two policy fields is puzzling, given their similar starting position in the early 1990s. The situation becomes even more ambiguous when we take into account the strong influence international actors, supporting neoliberal recipes, had on both systems since the very beginning. In fact, existing research on the Albanian welfare state development focuses on the role of international pressures to explain social policy change, according to which it is the external actors, not domestic ones, that have driven reforms. This strand in the literature, which stresses the role of international organisations in favouring policy diffusion, implicitly assumes that national political factors have limited or no effect on the relationship between (international) economic circumstances and social policy and that governments respond similarly to external constraints (Haggard and Kaufman, 2008). However, considering the important role played by the World Bank during the decision-making process, we should have seen convergence towards a single social model, i.e., neoliberal direction. Yet, empirically we observe a divergence over-time and between different social policy domains in Albania. This suggests that in order to understand policy change and variation we should look at other factors, such as internal political dynamics which is significantly missing from the existing literature. In addition, radical policy change and processes of convergence or divergence across policy sectors over-time have clear implications vis à vis historical institutionalism, according to which we should have seen path dependency. In fact, focusing only on institutions can hardly account for what is driving policy change in the first place (Jessoula, 2009), therefore, other factors have to be introduced, such as the role of actors’ interests and ideas. This thesis aims at filling this literature gap by contributing to the understanding of welfare state reforms in Albania in terms of policy, politics and theoretical analysis. More specifically, it aims at answering the following research questions: Why pension and healthcare policies converged into a Bismarckian social insurance model in the early 1990s? Why did implementation of the Bismarckian insurance model fail in both sectors? What explains subsequent developments towards a mixed-occupational model in pension and mixed-universalism in healthcare? To achieve these aims, this study provides a detailed empirical investigation in order to reconstruct the policy-making processes in both fields. Building on this analysis, this study argues that social policy reform can be understood as a process formulated through ideas (actors’ cognitive and normative frameworks) and shaped by conflicts and compromises between the relevant interests (political exchange dynamics) and their interplay with the institutions inherited from the past (policy legacies).

In recent years, non-democratic regimes have introduced a host of participatory forums. This paper asks why, given the absence of binding constitutional or institutional designs, authoritarian governments introduce, at their own initiative, participatory forums? To respond to this question, the paper suggests three theoretical possibilities: fragmented authoritarianism, enhancing legitimacy and information-gathering. Looking at the drafting of China’s recent healthcare reforms--where the government enacted various forums of participation--the paper tests these theories. Its findings indicate that these theories are not mutually exclusive, as each could explain the causes for the introduction particular participatory forums. This paper argues that this analytical framework could extend beyond the scope of China’s healthcare reform, and be applied to other episodes of policymaking both in China, and other non-democratic regimes.

This study examines the local government reforms embodied in the Medical Teaching Institution (MTI) Act of 2015 in Khyber Pakhtunkhwa province (KP), Pakistan. The aim of the Act was to improve employee performance in the province’s public teaching hospitals, and this research explores the reforms from the perspectives of key stakeholders, especially with regard to the introduction of performance-related pay. This research fills gaps in the current body of knowledge on performance-related pay in developing countries and makes a significant addition to the few existing studies on this topic. It addresses the contradictory theoretical stance between the discourses of New Public Management and Public Service Motivation on performance-related pay in the public sector. The theoretical concepts are derived by integrating New Public Management, Institutional Theory, Public Service Motivation Theory and Cross-cultural Theory. The study uses a mico-meso-macro framework of analysis to investigate the actions and reactions of those affected by the reforms in three of the public teaching hospitals. The underlying philosophy is one of critical realism. Following the case study approach, a multiple case study involving three public teaching hospitals was designed. The data were collected in three phases from participants at the Khyber Teaching Hospital (KTH), Lady Reading Hospital (LRH) and Hayatabad Medical Complex (HMC), Peshawar, KP, Pakistan. The respondents were doctors, ward managers, members of the boards of governance and the provincial health minister. The semi-structured interviews, as the main data collection tool, were corroborated by participant observation, field notes, memo writing and MTI reforms documents. The MTI reforms were a political initiative by the newly elected government in KP province to address problems of performance, poor service structure and the corrupt appraisal system. Changes included decentralisation, autonomy, a new system of accountability and the introduction of performance-related pay in the case hospitals. Poor communication, conflict of interest, lack of consultation with local actors, poor planning and dismissive behaviour by the higher leadership were the main reasons for doctors’ resistance to the reforms. The research findings show that performance-related pay was acceptable to the study participants due to institutional and social realities in KP, Pakistan and that it did not undermine their public service motivation due to high professional standards and strong religious belief. The research makes a number of contributions. First, it provides rich empirical material on employees’ reactions to public-sector healthcare reform and offers valuable insight into how policy from a secular individualist culture can successfully integrate with a religious collectivist culture. Second, it addresses the contradictory stances of New Public Management and Public Service Motivation on performance-related pay in the public sector by taking an inter-disciplinary approach. Third, this research adds to the body of empirical research on public healthcare reform in a developing country, and fourth, it yields findings which, we hope, will inform and influence the academic community as well as public-sector policy-makers.

Healthcare reforms and restructuring have been a global phenomenon since the early 1980s. The major structural reforms in the healthcare system in New South Wales (NSW) including the introduction and implementation of the area health management model (1986), the senior executive service (1989) and performance agreements (1990), heralded a new era in management responsibility and accountability. It is believed that the reforms, the process of the reforms, and the instability brought about by the reforms may have not only resulted in the change of senior healthcare management practices, but also in the change of competencies required for senior healthcare managers in meeting the challenges in the new era. However, limited studies have been conducted which examined how health reforms affected its senior health executive workforce and the above changes. Moreover, no study on senior healthcare managers has focused specifically on NSW after the major reforms were implemented. The purpose of this research was to examine how reforms in the NSW Health public sector affected its senior health executive workforce between 1990 and 1999 in terms of their roles and responsibilities, the competencies required, and the challenges they faced. This study, from a broad perspective, aimed to provide an overview of the NSW reforms, the forces behind the reforms and the effects the reforms may have had on senior health managers as predicted by the national and international literature. This study also explored the changes to the senior health executive workforce in the public sector during the period of rapid change in the 1990s and has provided indications of the managerial educational needs for future senior healthcare managers. Both quantitative and qualitative data have been collected by this study using triangulated methods including scientific document review and analyses, a postal questionnaire survey, and in-depth telephone interviews. The findings from the two quantitative methods informed and guided the development of the open-ended questions and overall focus of the telephone interviews. This study found differences in the characteristics and employment-related aspects between this study and previous studies in the 1980s and 1990s, and identified four major tasks, twelve key roles and seven core competencies required by senior health executives in the NSW Health public sector between 1990 and 1999. The study concludes that the demographic characteristics and the roles and responsibilities of the NSW Health senior executive workforce since the reforms of the 1980s have changed. This study also identified seven major obstacles and difficulties experienced by senior health executives and suggested that during the introduction and implementation of major healthcare reforms in NSW since 1986, barriers created by the ‘system’ prevented the achievement of its full potential benefits. Although this study did not focus on detailed strategies on how to minimise the negative impact of the health reforms on the senior health executives or maximise the chance of success in introducing new changes to the system, some suggestions are proposed. Most significantly, the study has developed a clear analytical framework for understanding the pyramidal relationships between tasks, roles and competencies and has developed and piloted a new competency assessment approach for assessing the core competencies required by senior health managers. These significant findings indicate the need for a replication of the study on an Australia-wide scale in order to extend the generalisability of the results and test the reliability and validity of the new competency assessment approach at various management levels in a range of healthcare sectors. This is the first study acknowledging the impact of the introduction of the area health management model, the senior executive service and performance agreements in the NSW public health system through an original insight into the personal experiences of the senior health executives of the reforms and examination of the major tasks that senior health executives performed and relevant essential competencies required to perform these tasks. The possible solutions identified in this study can guide the development of strategies in providing better support to senior healthcare managers when large-scale organisational changes are proposed in the future.

Healthcare reforms and restructuring have been a global phenomenon since the early 1980s. The major structural reforms in the healthcare system in New South Wales (NSW) including the introduction and implementation of the area health management model (1986), the senior executive service (1989) and performance agreements (1990), heralded a new era in management responsibility and accountability. It is believed that the reforms, the process of the reforms, and the instability brought about by the reforms may have not only resulted in the change of senior healthcare management practices, but also in the change of competencies required for senior healthcare managers in meeting the challenges in the new era. However, limited studies have been conducted which examined how health reforms affected its senior health executive workforce and the above changes. Moreover, no study on senior healthcare managers has focused specifically on NSW after the major reforms were implemented. The purpose of this research was to examine how reforms in the NSW Health public sector affected its senior health executive workforce between 1990 and 1999 in terms of their roles and responsibilities, the competencies required, and the challenges they faced. This study, from a broad perspective, aimed to provide an overview of the NSW reforms, the forces behind the reforms and the effects the reforms may have had on senior health managers as predicted by the national and international literature. This study also explored the changes to the senior health executive workforce in the public sector during the period of rapid change in the 1990s and has provided indications of the managerial educational needs for future senior healthcare managers. Both quantitative and qualitative data have been collected by this study using triangulated methods including scientific document review and analyses, a postal questionnaire survey, and in-depth telephone interviews. The findings from the two quantitative methods informed and guided the development of the open-ended questions and overall focus of the telephone interviews. This study found differences in the characteristics and employment-related aspects between this study and previous studies in the 1980s and 1990s, and identified four major tasks, twelve key roles and seven core competencies required by senior health executives in the NSW Health public sector between 1990 and 1999. The study concludes that the demographic characteristics and the roles and responsibilities of the NSW Health senior executive workforce since the reforms of the 1980s have changed. This study also identified seven major obstacles and difficulties experienced by senior health executives and suggested that during the introduction and implementation of major healthcare reforms in NSW since 1986, barriers created by the ‘system’ prevented the achievement of its full potential benefits. Although this study did not focus on detailed strategies on how to minimise the negative impact of the health reforms on the senior health executives or maximise the chance of success in introducing new changes to the system, some suggestions are proposed. Most significantly, the study has developed a clear analytical framework for understanding the pyramidal relationships between tasks, roles and competencies and has developed and piloted a new competency assessment approach for assessing the core competencies required by senior health managers. These significant findings indicate the need for a replication of the study on an Australia-wide scale in order to extend the generalisability of the results and test the reliability and validity of the new competency assessment approach at various management levels in a range of healthcare sectors. This is the first study acknowledging the impact of the introduction of the area health management model, the senior executive service and performance agreements in the NSW public health system through an original insight into the personal experiences of the senior health executives of the reforms and examination of the major tasks that senior health executives performed and relevant essential competencies required to perform these tasks. The possible solutions identified in this study can guide the development of strategies in providing better support to senior healthcare managers when large-scale organisational changes are proposed in the future.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Public Health
Faculty of Health
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Ao longo dos últimos trinta anos, entre meados das décadas de 1980 e 2010, os sistemas de saúde da Alemanha, França e Reino Unido foram reformados, gerando uma crescente mercantilização no financiamento e na prestação de serviços. O trabalho analisa as raízes dessas mudanças, assim como identifica que a mercantilização não ocorreu nem mediante os mesmos mecanismos e nem com a mesma profundidade, havendo importante inércia institucional. As diferenças observadas atestam as especificidades de cada país, em termos de seu contexto econômico, de seus arranjos políticos, das características institucionais de cada sistema e das formas que assumiram os conflitos sociais (extra e intra sistema de saúde). Os sistemas de saúde alemão, francês e britânico, enquanto sistemas públicos de ampla cobertura e integralidade, são frutos do período após a Segunda Guerra Mundial. Um conjunto de fatores contribuiu para aquele momento histórico: os próprios impactos do conflito, que forjaram a ampliação na solidariedade nacional e a maior pressão por parte dos trabalhadores; a ascensão socialista na União Soviética; o maior apoio à ação e ao planejamento estatal; o forte crescimento econômico, fruto da emersão de um regime de acumulação fordista, pautado na expansão da produtividade. A acomodação do conflito capital-trabalho, neste contexto, ocorreu mediante a expansão dos salários reais e ao desenvolvimento do Estado de bem-estar social, ou seja, de políticas públicas voltadas à criação e/ou ampliação de uma rede de proteção social. No entanto, a crise econômica da década de 1970 corroeu a base de financiamento e gerou questionamentos sobre sua eficiência, em meio à transformação do regime de acumulação de fordista para financeirizado, levando à adoção de reformas constantes ao longo das décadas seguintes. Além disso, as transformações específicas do setor saúde complexificaram a situação, tendo em vista o crescente envelhecimento populacional, a demanda por cuidados mais amplos e complexos e, principalmente, os custos derivados da incorporação tecnológica. Este cenário impulsionou a implementação de uma série de alterações nesses sistemas de saúde, com destaque para a incorporação de mecanismos de mercado (como a precificação dos serviços prestados, a indução à concorrência entre prestadores de serviços), o crescimento da responsabilidade dos usuários pelo financiamento do sistema (como o aumento nos co-pagamentos e a redução na cobertura pública) e a ampliação da participação direta do setor privado na prestação dos serviços de saúde (realizando os serviços auxiliares, a gestão de hospitais públicos, comprando instituições estatais). No entanto, de forma simultânea, as reformas ampliaram o acesso e a regulamentação estatal, além da modificação na base de financiamento, principalmente na França. Isto significa que a mercantilização não foi o único direcionamento das reformas, em decorrência de dois fatores principais: a própria crise econômica expulsou parcela da população dos mecanismos pós-guerra de proteção à saúde, demandando reação estatal, e diferentes agentes sociais influenciaram nas mudanças, bloqueando ou ao menos limitando um direcionamento mercantil único.
Over the last thirty years, between mid-1980 and 2010 decades, Germany, France and the United Kingdom healthcare systems have been renovated, creating a growing marketisation in the financing and provision of services. This Thesis analyzes the roots of these changes, and identifies that marketisation did not take place or by the same mechanisms nor with the same depth, with important institutional inertia. The observed differences attest to the specificities of each country in terms of its economic context, their political arrangements, the institutional characteristics of each system and the different social conflicts (intra and extra healthcare system). The German, French and British health systems, while public systems of broad coverage and completeness, are the result of the period after the II World War. A number of factors have contributed to that historic moment: the very impact of the conflict, which forged the expansion on national solidarity and greater pressure from workers; the rise of socialism in the Soviet Union; a bigger support for action and state planning; strong economic growth, thanks to the emergence of a Fordist accumulation regime, based on the productivity expansion. The accommodation of the capital-labor conflict in this context occurred through the real wages expansion and the development of the Welfare State, ie public policies for the creation and / or expansion of a social safety net. However, the 1970s economic crisis eroded the funding base and raised questions about its effectiveness amid the transformation of Fordist accumulation regime in a finance-led one, leading to adoption of constant reforms over the next several decades. In addition, specific health sector transformation complicate the situation, given the growing population aging, the demand for broader and more complex care, and especially the costs derived from technological resources. This scenario boosted the implementation of a number of changes in the three systems, with emphasis on the incorporation of market mechanisms (such as the pricing of services, the induction of competition between service providers), the growth of the responsibility of users for funding the system (such as the increase in co-payments and the reduction in public coverage) and the expansion of the direct participation of the private sector in the provision of health services (performing ancillary services, public hospitals management, purchasing state institutions). However, simultaneously, the reforms expanded access and state regulation in addition to the change in funding base, mainly in France. This means that marketisation was not the only direction of the reforms, due to two main reasons: the very economic crisis drove portion of the population of postwar health protection mechanisms, requiring state reaction, and different actors influenced the changes, blocking or at least limiting a single market direction.

This case-study provides a critical evaluation of the effects of neo-liberal (market-driven) reforms in achieving the goal of human security in Sierra Leone after the civil conflict in 2002. In the context of Sierra Leone, there are fundamental questions about the basic security of the population. This mean the ability to live without fear of conflict and the security to do with the ordinary lives of Sierra Leoneans. This is absolutely central to the post-war reconstruction of that country. It represents a major concern for the international community, the Sierra Leone Government, foreign government donors as well as the NGO communities. Underlying these issues is the subject of which development paragon is best suitable in addressing these questions, and what impact will it have on the people. To understand this, the study has framed the issues of education and health, the two aspects which this thesis focuses upon, as a commitment to human security. Human security has become a dominant theme for many development organisations around the world because of it connection with security and development. Education and health are important because they are crucial social and basic human right that should be provided without any form of unfairness by the state. Because of their multiplier effect, they assist in eradicating poverty and further the attainment of human security. The reforms, which includes privatisation and decentralisation, has been imposed primarily by the World Bank and the IMF to transform the education and health system in order to improve the human security of the Sierra Leonean people. Proponents of these reforms argued that it would provide equal access, make the system more efficient, provide more choices for the population, and enhances accountability and citizens’ participation in governance. As a result of these, the study is important for three reasons: first, it assesses the success of these reforms; second, it offers a better understanding of socio-economic development related to education and health as they are now viewed as a commodity; and third, it suggests ways of enhancing the performance of its delivery intended to assist the population. The evaluation is informed by critical theory, the theoretical framework because: of its usefulness in understanding the concept of power/knowledge, ideology and governance, as neo-liberalism has become a discourse of global common sense that frames policy options as though they were natural or not to be questioned, and yet serve to reinforce the interests of dominant groups. Critical theory enable us to make sense of the hidden power relations in the way knowledge/policy is constituted. Second, critical theory is also a qualitative approach and hence comes as a way of critiquing quantitative methodology. The study argues that it is very problematic to imagine that this strategy (neo-liberal reforms) is actually for the great masses of people living in poor conditions, while it does not address their needs and does nothing to deal with the security of their lives. The study found that the reforms were considered undemocratic, and has led to unequal access thus augmenting fears of stratification on the basis of an individual being rich or poor. Therefore, the study recommends that if the goal of human security is to be achieved, it is important to strengthen citizens’ and other local actors’ voices in governance to develop effective local policies; and government intervention and commitment is also needed to improve the performance of public schools and health care institutions in order to make them more competitive so that they can co-exist with their private counterparts. Key Words: Neo-liberalism, critical theory, education policy, health policy, human security, privatisation, decentralisation, social justice, socio-economic development.

Este estudo problematiza a noção de coletivo na saúde, analisando os jogos e as disputas sobre essa expressão no campo das reformas sanitárias italiana e brasileira, visando compreender a singularidade da saúde coletiva. Tomando como ponto de partida o fato de que a saúde coletiva marca uma diferença no território da saúde, importa compreender a noção de “coletivo”, tomando-a como analisador, com a finalidade de acompanhar como ela se expressa na saúde e quais sentidos atualiza. Para fazer essa discussão, situamos nossa investigação em uma perspectiva genealógica, analisando a composição e a perda de sentidos dos territórios reformistas nos cenários italiano e brasileiro. Discutimos as imagens construídas para expressar o coletivo na saúde – a população, o grupo e a sociedade civil –, com o intuito de propor um modo diferente para pensar essa expressão, de caráter processual e intensivo, passando a entender o coletivo como potência. Não é a fixação dessa noção às formas que lhe são atribuídas que afirma a saúde coletiva, mas a força que caracteriza o coletivo como algo inespecífico, condição para a variação da potência. Acompanhando as experiências reformistas, ficou evidente que a imaginação e a composição de noções comuns são mecanismos disparadores da variação, ativando o desejo e as resistências. Analisar o coletivo na saúde coletiva de forma articulada com os movimentos reformistas italiano e brasileiro evidencia a singularidade dessa expressão no território da saúde. Considerar essa singularidade evita que, paradoxalmente, reproduza-se uma política que afirme os preceitos da medicina social ou da saúde pública no campo da saúde coletiva, abrindo a possibilidade para novas produções de sentido.
This study discusses the notion of the collective in healthcare through the analysis of the games and disputes that take place over this expression in the field of Italian and Brazilian healthcare reforms, with the objective of understanding the uniqueness of collective healthcare. Taking as its starting point the fact that collective healthcare marks a difference in the health area, it is impotant to understand the notion of "collective", taking it as an analyzer, with the objective of monitoring how it is expressed in healthcare and which concepts it updates. To make this discussion, we situate our research in a genealogical perspective, analyzing the composition and the loss of sense in reformist territories in the Italian and Brazilian scenarios. We discuss the images constructed to express the collective in healthcare – the people, the group and the civil society – in order to propose a different way to think this expression, that is procedural and intensive in character, comming to understand the collective as power. It is not the establishment of that notion to the forms assigned to it that asserts the public healthcare, but the strength that characterizes the collective as something unspecific, condition for the change in power. Following the reformist experiments, it became clear that the imagination and the composition of common notions are trigger mechanisms for variation, enabling desire and resistance. By analyzing the collective in collective healthcare in coordination with the Italian and Brazilian reform movements, we stress the uniqueness of this expression in the healthcare area. To consider this uniqueness prevents, paradoxically, the reproduction of a policy that affirms the precepts of social medicine or public healthcare in the field of collective healthcare, opening the possibility for new productions of meaning.

Durant l’última dècada, l’Equador ha passat per moltes reformes enfocades en promoure objectius de salut basats en equitat i cobertura de salut universal. Sense embargament, les decisions basades en l’equitat poden afectar l’eficiència del sistema de salut, ja que una major demanda d’atenció mèdica requerirà un major ús dels recursos de salut. Això desperta interès en considerar l’estudi de l’eficiència del sistema sanitari. Esta tesis propone evaluar el desempeño de eficiencia de los hospitales públicos ecuatorianos; dada la marcada heterogeneïtat regional que caracteritza la realitat ecuatoriana, es proposa un marc d’anàlisi on l’estructura espacial juega un paper clau per comprendre i donar forma a la distribució heterogènia dels recursos i els seus determinants. En primer lloc, aquesta tesi s’enfoca en la medició de l’eficiència dels hospitals públics, desenvolupant una nova metodologia empírica que pren en compte la heterogeneïtat del sistema. Luego, respon si la variació de l’eficiència en un hospital afecta l’eficiència dels hospitals veïns i si les variacions de la demanda afecten l’eficiència hospitalària. Finalment, evidència fins a quin punt l’eficiència dels hospitals públics està determinant la mobilitat interregional dels pacients i el seu efecte indirecte en altres hospitals (espacialment correlacionats). En conclusió, se evidencia que l’augment en la demanda de tractament mèdic tuvo un efecte positiu general sobre el desempeño hospitalari, tant a través d’efectes directes com indirectes. Els impulsors potencials d’aquest efecte es refieren a l’ús ineficient dels recursos excedents i la capacitat dels hospitals públics. El temps que heu tingut els hospitals per adaptar-se a l’afluència de pacients abans de les reformes i la inversió pública desplegada també pot tenir una participació significativa en aquest efecte. Els resultats també proporcionen evidència de que una major eficiència dels hospitals especialitzats té un fort efecte d’atracció sobre els pacients de les regions menys desenvolupades. Esta afluencia de pacientes está siendo captada por hospitales vecinos, quienes aumentan su eficiencia para atraer dicha demanda, mostrando evidencia d’un efecto de competencia. Les implicacions polítiques dirigeixen l’atenció al disseny d’estratègies de salut bé planificades, considerant les externalitats territorials, la dotació tecnològica i el nivell d’especialització com a característiques clau. Es pot orientar una major inversió pública per augmentar l’oferta de tractament especialitzat en les regions menys desenvolupades. En les regions desenvolupades, els tomadors de decisions poden aprofitar els efectes indirectes per promoure l’eficiència, fortalecer les reformes hospitalàries i inversió pública (estratègicament assignada) per millorar el desempeño del sistema regional de salut.
Durante la última década, Ecuador ha pasado por muchas reformas enfocadas en promover objetivos de salud basados en equidad y cobertura de salud universal. Sin embargo, las decisiones basadas en la equidad pueden afectar la eficiencia del sistema de salud, ya que una mayor demanda de atención médica requerirá un mayor uso de los recursos de salud. Esto despierta interés en considerar el estudio de la eficiencia del sistema sanitario. Esta tesis propone evaluar el desempeño de eficiencia de los hospitales públicos ecuatorianos; dada la marcada heterogeneidad regional que caracteriza la realidad ecuatoriana, se propone un marco de análisis donde la estructura espacial juega un papel clave para comprender y dar forma a la distribución heterogénea de los recursos y sus determinantes. En primer lugar, esta tesis se enfoca en la medición de la eficiencia de los hospitales públicos, desarrollando una nueva metodología empírica que toma en cuenta la heterogeneidad del sistema. Luego, responde si la variación de la eficiencia en un hospital afecta la eficiencia de los hospitales vecinos y si las variaciones de la demanda afectan la eficiencia hospitalaria. Finalmente, evidencia hasta qué punto la eficiencia de los hospitales públicos está determinando la movilidad interregional de los pacientes y su efecto indirecto en otros hospitales (espacialmente correlacionados). En conclusión, se evidencia que el aumento en la demanda de tratamiento médico tuvo un efecto positivo general sobre el desempeño hospitalario, tanto a través de efectos directos como indirectos. Los impulsores potenciales de este efecto se refieren al uso ineficiente de los recursos excedentes y la capacidad de los hospitales públicos. El tiempo que tuvieron los hospitales para adaptarse a la afluencia de pacientes antes de las reformas y la inversión pública desplegada también puede tener una participación significativa en este efecto. Los resultados también proporcionan evidencia de que una mayor eficiencia de los hospitales especializados tiene un fuerte efecto de atracción sobre los pacientes de las regiones menos desarrolladas. Esta afluencia de pacientes está siendo captada por hospitales vecinos, quienes incrementan su eficiencia para atraer dicha demanda, mostrando evidencia de un efecto de competencia. Las implicaciones políticas dirigen la atención al diseño de estrategias de salud bien planificadas, considerando las externalidades territoriales, la dotación tecnológica y el nivel de especialización como características clave. Se puede orientar una mayor inversión pública para aumentar la oferta de tratamiento especializado en las regiones menos desarrolladas. En las regiones desarrolladas, los tomadores de decisiones pueden aprovechar los efectos indirectos para promover la eficiencia, fortalecer las reformas hospitalarias e inversión pública (estratégicamente asignada) para mejorar el desempeño del sistema regional de salud.
During the past decade, Ecuador has been going through many reforms focused on promoting equity-based and universal healthcare coverage goals. However, equity-based decisions can affect the efficient performance of the healthcare system, as more demand for medical care will require higher use of healthcare resources. The importance to care for the efficient performance then is drawn to attention. In this thesis, we propose to assess the efficiency performance of Ecuadorian public hospitals; given the marked regional heterogeneity that characterizes the Ecuadorian reality, we propose a framework of analysis where the spatial structure plays a key role to understand and shape the heterogeneous distribution of resources and its determinants. First, we focus on the efficiency measurement of public hospitals, developing a new empirical methodology that takes into account the heterogeneity of the system. Then, we answer whether efficiency variation in a hospital affects the efficiency of neighboring hospitals and whether demand variations affect hospital efficiency. Finally, we will disentangle to what extent the efficient performance of public hospitals is determining interregional patient mobility, and whether it has an indirect effect on other (spatially correlated) hospitals. We conclude that the increase in the demand for medical treatment had an overall positive effect on hospital performance, both through direct and spillover effects. Potential drivers of this effect refer to the inefficient use of the spare resources and capacity of public hospitals. The time that hospitals had to adapt to the forthcoming inflow of patients before the reforms and the public investment deployed may also have significant participation in the effect. The results also provide evidence that the efficiency performance of specialized hospitals has a strong pulling effect on patients from less-developed regions. This inflow of patients is being captured by neighboring hospitals who are increasing their efficiency to attract this demand, showing evidence of competition. Policy implications drive the attention to the design of well planned healthcare strategies considering territorial externalities, technological endowment and specialization level as key features. Higher public investment can be targeted to increase the supply of specialized treatment in less-developed regions. In developed ones, decision-makers can take advantage of spillover effects to promote efficiency strengthening hospital reforms and well allocated public investment to enhance the regional healthcare system’s performance.
Universitat Autònoma de Barcelona. Programa de Doctorat en Economia Aplicada

Thesis (M.S. in Management) Naval Postgraduate School, December 2000.
"December 2000." Thesis advisor(s): Doyle, Richard B. ; Barrett, Frank J. Includes bibliographical references (p. 75-81). Also available online.

Hälso- och sjukvården har genomgått stora förändringar genom åren och är idag en central del av vårt välfärdssamhälle. Utvecklingen går mot en mer primärvårdscentrerad vård vilket gör att hälso- och sjukvården står inför nya utmaningar gällande bland annat resursfördelning och prioriteringar. Idag styrs hälso- och sjukvården i allt större utsträckning av ekonomiska incitament där kopplingen till ersättning utgår från bland annat måluppfyllelse, prestation och resursinsatser. Hur ersättningsmodellerna utformas skiljer sig åt mellan olika huvudmän och varje huvudman utformar sin vårdvalsmodell efter sina prioriteringar av primärvårdsmålen.   Syftet med studien är att analysera om de olika ersättningsmodellerna i primärvården understödjer de mål man arbetar mot samt vilka erfarenheter aktörerna inom hälso- och sjukvården, dvs. politiker, administrativ ledning och profession, har av ersättningsmodellernas effekter.   För att studera hur ersättningsmodellen understödjer verksamhetsmålen i primärvården har två fallorganisationer valts ut, Landstinget Blekinge och Region Jönköpings län, där en komparativ forskningsdesign tillämpats. Data för den teoretiska referensramen utgår från publicerade artiklar, böcker och övrigt informationsmaterial från myndigheter. Primärdata har inhämtats från sex kvalitativa, semistrukturerade intervjuer. Sekundärdata för studien består av insamlad data från respektive region/landsting.   Att använda en ersättningsmodell för resursfördelning i primärvården anses vara ett bra styrmedel då monetära ersättningar motiverar. Målen tillgänglighet, jämlik vård, hög kvalité, personcentrerad vård, patientsäkerhet tillsammans med kostnadseffektiv vård kan ibland motverka varandra. God kostnadskontroll prioriteras ofta i styrningen samtidigt ger uppföljning och kontroll behov av mycket administration, vilket motverkar målet kostnadseffektiv vård.   Att styra primärvården med ersättningsmodeller är effektivt då monetär ersättning är inblandad men modellen används inte i första hand att styra mot mål utan för kostnadskontroll. Erfarenheterna av ersättningsmodellens effekter är att de ibland motverkar målen för hälso-och sjukvården och får oönskade effekter såsom manipulation av data och fokus på att det man utför genererar högre ersättning. Uppföljningen av ersättningsmodellerna kräver också mycket administration.
The health care system has undergone major changes over the years and is today a central part of our welfare society. The trend is to direct citizens towards the Primary Health Care sector, making the health care system face new challenges.  The primary challenges are related to the allocation of resources and guiding priorities for this. Today, health care is increasingly controlled by economic incentives, where the link to compensation is based on, compensation models. How the compensation model is designed varies between different principal stakeholders whom are designing their care choice model after its own priorities of primary health care objectives.   The aim of the current study is to analyse whether the different compensation models in primary care supports the goal to work towards and what experience the different operators, politicians, administrative management and profession, have of compensation models ' effects.   To study how the compensation model supports business goals in primary care two organizations has been selected, County Council of Jönköping and Blekinge on which a comparative research design has been applied. Data for the theoretical frame of reference is based on published articles, books and other information material from the authorities. Primary data has been gathered from six qualitative, semi-structured interviews. Secondary data for the study consists of data collected from each region/County Councils.   To use a compensation model for the allocation of resources in primary health care is considered to be a good instrument in which monetary remuneration justifies. Objectives as availability, equal treatment, high quality care, person-centred care, patient safety, along with cost-effective care can sometimes counteract with each other. Good cost control is often a priority when governing health care operations, monitoring and control the business needs much administration, thus undermining the objective of cost effective care.   Compensation model is effective way to control primary health care since monetary compensation is involved but the model is not used primarily to steer towards the target but for cost control. The experience of the effects of the compensation model is that they sometimes act counterproductive towards goal for the health care system and you might receiving unwanted effects as manipulation of data and focus what you can do to generate more compensation.  A vast amount of administration is needed to follow up compensation models.

Three chapters constitute the main structure of this contribution. The first chapter investigates the relationship between fiscal decentralization and regional health outcomes, as measured by infant mortality rates, in Italy. The paper employs a panel of all Italian regions over a period of 17 years (from 1996 to 2012), applying a linear Fixed-Effect model. Two different quantitative measures of fiscal decentralization are used, which capture the degree of regional decision-making autonomy in the allocation of tax revenues and the extent of regional transfer dependency from the central government (i.e vertical fiscal imbalance). Methodologically, to account for the temporal dynamics of the decentralization impact, the robustness of the findings is checked, among others, with respect to the use of an Error Correction Model, which allows to disentangle short and long run effects. The analysis also deals with the issue of heterogeneous distributional geographical responses by modelling the asymmetric impact of decentralization on infant mortality rates according to the level of regional wealth. The second chapter addresses the issue of convergence. Here the main research questions are whether health outcomes in Italy converge/diverge over time and, more importantly, whether decentralization has played a somewhat role in the convergence/divergence process. Using a pooled dataset with the same time span as the previous one, the conventional measures of sigma- and beta- (both absolute and conditional) convergence are estimated for two different regional health outcomes (i.e. infant mortality rate and life expectancy at birth). Again, two measures of decentralization are employed in order to catch both the degree of fiscal regional decision-making autonomy (i.e. the same indicator as in chapter 1) and the political decentralization dynamics (i.e. a dummy variable taking the value of 1 after the introduction of the 2001 constitutional reform). From a methodological point of view, the real novelty of the analysis is to take spatial dependence and neighbourhood effects among the regions into consideration. Modelling the impact of decentralization through an interaction term, the speed of convergence is found to be significantly affected by the level of decentralization. The third and last chapter deals with the issue of the effects of decentralization from a different but related viewpoint. Compared to the previous chapters, it examines descriptively the administrative aspects of decentralization by a lower (micro) level perspective, looking at the managerial autonomy of local healthcare structures. The emphasis is here on the role of intrinsic and extrinsic motivations in enhancing accountability and improving the performance of healthcare system, in general, and the quality of hospital care, in particular. Though the focus is not specifically on the Italian system, the analysis is particularly relevant for this country, where regional governments, in charge of the responsibilities for the financing and the delivery of healthcare, act through a network of Local Health Authorities i.e. public entities with their own budgets and management, which directly run small public hospitals -, public hospital trusts with full managerial autonomy and accredited for-profit private providers. The understanding research hypothesis here is that the way in which the financial incentive schemes for providers are designed and structured is likely to affect their effectiveness in pursuing the expected results (e.g. improved efficiency and quality of healthcare service delivery). However, the same incentive is expected to work differently according to the provider s degree of decision-making autonomy and its utility function.

Taiwan adopted its National Health Insurance (NHI) scheme in 1995. Presently, the scheme covers virtually all of the island’s citizens. However, it is under the threat of a serious imbalance between expenditure and revenue. As spending has become unsustainable, everyone has realised the need for financial reform. However, the reform process itself is beset by political confrontations. There is a need to deepen the understanding of the relationships and dependencies among the policy actors. With a view to helping address this problem, this study empirically examines the multiple types of ties prevailing between the policy actors and the resulting power distribution while the DPP government was working earnestly towards reforming the NHI’s financial system in the period 2000-2008. Apart from official documents, data are drawn from a network survey coupled with semi-structural interviews of 62 policy actors including government officials and related unofficial policy participants. Measures such as the in-degree centrality index and core/periphery model, betweenness centrality, structural hole index (effective size), density index, E-I index and CONOOR procedure (Blockmodeling and multidimensional scaling - MDS) are used to identify the major participants and network structures in the NHI domain and assess their relative influence-powers on the basis of information transmission patterns, resource exchanges, action-set coalition relationships and reputational attributions. It is shown that, although the public sector and the medical associations were at the helm of the NHI reform, financial reform remained unfulfilled mainly because of poor communications among societal actors. We then performed a social network analysis and systematically mapped the prevailing political conflicts among diverse policy stakeholders. We confirm that SNA is an effective research tool for political feasibility evaluation; it can facilitate smoother policy adoption by enhancing better interactions within networks.

This study examines how Canadian Medicare and the United Kingdom’s National Health Service (NHS) were represented in US newspaper coverage between January 2008 and the first quarter of 2010, a period marked by changing healthcare policy in America and dramatic shifts in the journalism industry at large. Through a content analysis of print news from the New York Times, Wall Street Journal, and USA Today, this paper tracked and assessed reporting dimensions and coverage themes to illustrate the quantity and quality of coverage. The analysis was based on the seminal work of Pauline M. Vaillancourt Rosenau, who performed a content analysis of newspaper coverage of Canada’s healthcare system between 2000 and mid-June 2005 in the NYT and WSJ. Findings from this thesis reveal that recent US newspaper coverage of Medicare, though narrow, is more accurate and balanced compared to coverage during Rosenau’s study timeframe. The NHS received far greater attention in US newspapers, indicating that outside factors, potentially including collaboration in the Iraq war, have spawned greater US media interest in the UK at large. On occasion, this study found coverage of the NHS to be critical, relying on anecdotal evidence to suggest systematic failure of aspects of healthcare in the UK. With respect to coverage themes, wait lines for treatment was a dominant issue in US newspaper reporting of both Canadian Medicare and the NHS. Medical tourism and problems associated with paying for universal healthcare also emerged in US representation of the NHS. This paper concludes with a discussion of outside factors that may have influenced American newspaper coverage during the study period. Considering the current state of print journalism, this paper predicts that, in the years ahead, American print coverage of foreign healthcare will continue to decline. However, in conjunction with this, it is likely that increased online representation of foreign healthcare stories will occur, as new journalism platforms, such as blogs, continue to proliferate. Finally, as American reporters continue to gain greater access to online healthcare research databases, this study suggests that the quality of US coverage of Medicare and the NHS is likely to improve.

Thesis (MBA)--Stellenbosch University, 2002.
ENGLISH ABSTRACT: The need for efficient and equitable health provision remains a challenge for all countries and economies of the world. Defining health, healthcare and health provision are contentious issues, and public debate rages on as governments throughout the world attempt to quell public demands and expectations. Healthcare scenarios differ vastly from country to country, each attempting to accommodate its own needs, given the limitations placed on the systems in terms of human and financial resources. These differences are large as will be seen when countries with developed market economies are compared to those in the less fortunate Third World. The financing of healthcare systems is a complex and challenging task. Affordability of healthcare is an issue for all nations of the world. Most countries enjoy a mix of private and public funding to ensure that some degree of good health is attained by the nation as a whole. South Africa has a unique health system in that it has two distinct and separate health systems. This is not by chance. South Africa is a country that boasts enormous diversity but huge inequalities in terms of race, culture, class and income. Systems had therefore developed along very defined lines where the privileged have had access to expensive, modern and private healthcare while the poor and indigent have had to use a poorly structured public service. The purpose of this literature review is to research and to define those issues and concepts which require clearer perspective. It will also look at healthcare.
AFRIKAANSE OPSOMMING: Die noodsaaklikheid vir effektiewe, billike en regverdige gesondheidsvoorsiening bly 'n uitdaging vir alle ekonomieë van die wêreld. Om gesondheid, gesondheidsorg- en gesondheidsvoorsiening te definieër, is 'n kontensieuse aangeleentheid en die openbare debat duur voort, soos regerings in die wêreld poog om te voldoen aan oorweldigende openbare eise en verwagtinge in hierdie verband. Gesondheidsorg-opsies verskil drasties van land tot land, wat elk poog om sy eie behoeftes te akkommodeer, gegewe die beperkings wat die sisteem belas in terme van menslike en finansiële hulpbronne. Hierdie verskille is beduidend, soos wat gesien kan word wanneer lande met ontwikkelde mark-ekonomieë vergelyk word met die lande in die minder bevoorregte derde-wêreld. Die finansiering van gesondheidsorg-sisteme is 'n komplekse en uitdagende taak. Die bekostigbaarheid van gesondheidsorg is 'n aangeleentheid wat al die lande van die wêreld raak. Die meeste lande van die wêreld het 'n gemengde gesondheidsorg-sisteem wat bestaan uit gedeeltelik privaat en gedeeltelik openbare fondse, sodat toegesien word dat 'n mate van goeie gesondheid bereik word deur die land as geheel. Suid-Afrika het 'n unieke gesondheidsorg-sisteem deurdat twee besondere en aparte gesondheidsisteme bestaan, wat beslis nie toevallig is nie. Suid-Afrika is 'n land wat spog met enorme verskeidenheid, maar beduidende ongelykhede in terme van ras, kultuur, klas en inkomste. Gesondheidsorg-sisteme het dus ontwikkel langs baie beslisde lyne waar die bevoorregtes toegang gehad het tot duur, moderne en privaat vesekerings-gebaseerde gesondheidsorg, terwyl die arm en armlastiges gebruik moes maak van 'n swakker gestruktureerde openbare diens. Die doel van hierde nagevorsde oorsig is om navorsing te doen om sisteme uit 'n globale perspektief te identifiseer en daardie beginsels toe te pas, wat voordelig kan wees in 'n plaaslike konteks. Daar word aanvaar dat die Suid-Afrikaanse gesondheidsorg-sisteem baie het om te leer van ervarings in beide die ontwikkelde en ontwikkelende lande. 'n Besondere begrip hiervoor, is die basis waarop 'n suksesvolle gesondheidsorg-sisteem in hierdie land gevestig kan word. Daar word gehoop dat deur die besondere perspektief te hê, sekere werkbare oplossings gevind en bereik kan word.

Healthcare spending in the United States has continued to rise with annual healthcare cost of $3.8 trillion in 2014. While costs and the population continue to rise, resources continue to dwindle. Consequently, Congress has imposed various price controls and healthcare reform measures over the past 20 years, including the recent Patient Protection and Affordable Care Act (PPACA), which aims to decrease spending while enhancing quality and safety of care delivery. As a result of the implementation of the PPACA, 34 million additional Americans may be eligible for healthcare in a system already needing additional resources, increased access to care, and strategies to offset increasing operational and fiscal challenges. The purpose of this descriptive study was to explore what strategies and changes 10 executive leaders of the nonprofit hospitals in Maryland used to address the operational and fiscal challenges of the PPACA. The conceptual framework for this study was built upon the general systems theory. The data were collected through semistructured interviews, cataloged and coded, analyzed using a modified van Kaam method, and reviewed by participants as part of member checking process. The findings revealed 3 emergent themes: investment in IT resources to support an EMR system, strategies to address healthcare workforce challenges, and strategies for sustainability for managed care outpatient services and patient safety and quality of care. The findings impact social change by presenting policies and processes that medical professionals can use to support local and national health care reform.

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.

In March of 2010, the 44th President of the United States, Barack Obama, signed into law a health care reform bill that will change the medical and business approach to healthcare that has been witnessed for quite some time. The Patient Protection and Affordable Care Act, aims to eliminate several inefficiencies encountered in our current health care system, as well as extend coverage by providing affordable care for the roughly forty six million Americans currently uninsured. Many of the changes will be implemented over the next several years, but hospitals, businesses, physicians, and insurance companies are no doubt planning ahead for the effects these changes will have on their particular industry. Although there will be many facets of change affecting all of the previously mentioned occupancies, the goal of this paper is to investigate the effect healthcare reform will have on private medical practices in the United States. The following sections will cover ways in which medicine has been practiced in the pre-reform era, historical attempts made to pass health reform legislation, several of the issues our current system faces along with the reform changes implemented to fix them. Then I will investigate the effect these changes will have, if any, and conclude by relating everything back to independent medical practices.

Globally, higher healthcare demand strains existing systems, already overburdened by a lack of resources and funding while longer life expectancy and increased disease burden force higher patient loads. A majority of the South African population is medically uninsured and therefore depend on emergency care; consequently, the healthcare service demand easily exceeds available acute care to prevent life threat. When this happens, emergency centres suffer from overcrowding and long patient waiting times, which increases morbidity and mortality, associated patient risk. Moreover, critical resources such as staff and hospital beds are required for an even flow of patients through hospitals, but are distributed inefficiently. The South African healthcare system configuration therefore delays access to and compromises the delivery of equitable, unbiased life-saving healthcare in an environment moreover challenged by economic pressures. This calls for sustainable, cost-effective reform. Therefore, more efficient healthcare can save more lives by improving access to life-saving care. Research on current Healthcare Information Systems (HIS) shows an incoherent knowledge body with conceptual gaps in theories on healthcare, which disengages transformation potential. Comprehensive reform tactics thus require a priori concept discovery and diagnostics to make research practically useful. The systematic use of BPM theories allowed for the qualitative assessment of as-is process activity at patient touch-points at three hospitals – two public and one private – in the Western Cape of South Africa. Because a strategic Information Systems (IS) methodology, Business Process Management (BPM) poses business process activity improvement, this research draws from successful BPM activity as a means to improve patient flow processes in Emergency Centres (ECs). Success is evaluated by drawing from empirically supported enabler categories and prescriptive guidelines because BPM practice is not yet fully understood. The results show a clear correlation between the improvement areas at the three hospitals; improvements on aspects of actions and decisions taken during patient-flow process activity, therefore support a pragmatic approach to reform. The data confirms disparity between public and private healthcare. Healthcare appears to be a “doctor driven” service, which, based on qualitative decision-making, navigates patients along defined flows, enabled by supporting human capital and hospital assets. Optimal patient flow is a product of symbiotic working relationships and depends on efficient integration with wider hospital functions. Shorter waiting times and hospital stays reduce process burden. This leads to more efficient resource usage and regulated access to healthcare. However, integrated healthcare reform must consider the time demands and rigidity of clinical processes. The challenge lies in finding the space to invite parallel business agility to drive the reform of the stricken healthcare industry in South Africa.

Changes in American healthcare over the last half century have created social and economic crises, presenting challenges for doctors and patients. The recently-implemented Patient Protection and Affordable Care Act is an incremental reform that does little to change the complex multi-payer financing characterizing American healthcare. There have been growing demands for more equitable financing arrangements, notably, a single-payer healthcare system in which medical care is financed through a single, non-profit payer and in which medical care is treated as a public good and medically-necessary care is available to everyone. Nationally-representative surveys have demonstrated widespread physician support for single-payer legislation. Yet, very little scholarship has examined physician activism and virtually no studies have examined physician activism for single-payer healthcare. It is important to examine physician activism for single-payer because their participation is considered fundamental to achieving the goals of the movement. If the movement is successful in implementing single-payer financing , more efficient use of healthcare resources will ensure that all residents have access to needed medical care without being saddled by financial burdens from their care. Oregon is one of several US states with a growing grassroots movement to enact single-payer healthcare at the state level. This study seeks to examine the determinants of collective action for physicians in the Oregon movement for single-payer healthcare by answering two research questions. First, what accounts for differences in activism among physicians who support single-payer healthcare system? And second, for those physicians who are active, what activities do they do and what shapes those choices of activities? Data includes 21 semi-structured interviews with physicians around the state of Oregon supplemented with participant observation data. The interview data was analyzed using techniques from grounded theory and thematic analysis. I find that among collective action theories, collective identity theory best accounts for whether or not a physician engages in single-payer activism. A strength of collective identity theory is that it brings to light the importance of subjective interpretations of structural conditions by movement actors. The findings suggest that differences in interpretation shape the influence of motivators for and barriers to an individual's decision to engage in activism. Physicians that become active are primed to engage in single-payer activism because of their moral value sets and frustrating work experiences. They seek out groups of like-minded physicians who then are part of the process of socially-constructing a collective identity. This collective identity is emotionally-laden, is a reaction to state policies, serves to distinguish insiders from outsiders, and facilitates activism. Activist physicians engaging in the process of collective identity come to believe that altering financing is the only way to solve healthcare system issues. The activists view the political and cultural barriers to single-payer as surmountable by their activism. In contrast, non-activists interpret structural conditions like American politics and American culture as immutable barriers that will prevent the attainment of single-payer at the national or state level. In addition, non-activists lack the collective identity activists share because their beliefs contradict key beliefs of activists. The combination of the lack of collective identity and the perception of immutable barriers results in their non-participation.

In the last decade, the reach of New Public Management (NPM) has stretched well beyond its Western origins as modernising African governments and their global health partners have sought to import new approaches. Public health systems in Africa are entirely different to those of the West however, and this sort of application introduces a number of contextually-specific questions that are not considered by the majority of the NPM literature. The few studies that do investigate NPM in Africa are evaluative in content, seeking to understand whether reforms work and to identify barriers to success. Invariably, whether they find in favour of public management reform or not, the same issues are highlighted: lack of capacity, weak institutions, and improper implementation. This thesis will build a theory of NPM reform that is particular to the African context. I develop this theoretical extension through an intensive ethnographic case study of one of the most important on-going public health reform efforts in Africa—the transformation of the entire Ethiopian hospital system to an NPM-style administrative regime. I develop a constructionist theory of African NPM through thick description of the hospitals under reform. I detail the various ways in which the reforms are indigenised as they meet up with local understandings, institutions, and market contexts, and the inevitable unintended consequences as managers seek to ‘make do’ in environments radically different to those of NPM’s origins. I then conduct a detailed consumer analysis to describe the strategies employed by patients seeking care. Patients from different class positions use very different strategies to get health services and I demonstrate that the reform has very different consequences for Ethiopians across classes. Many patients are not recognisable as the ‘customers’ described in the reform documents, and so the hospitals do not organise their reform efforts to serve them.

The capstone project reports the risk factors causing unplanned hospital readmission of vascular patients as well as the effects on healthcare cost. The methods for determining the risk factors include clinical indicators for risk prediction process, and the STAAR (State Action on Avoidable Rehospitalization) initiatives, which can be used as healthcare improvement projects to facilitate the cross-continuum team. The findings indicate a relationship between the patient’s engagement in the lower extremity vascular procedure, and effectiveness of follow-up after surgery in the reduction of hospital readmission and healthcare cost. Potential strategies to prevent the risk factors for readmission of vascular patients and to reduce the healthcare cost are discussed. Presenting unplanned readmission for vascular patients and reducing the cost associated with readmission is important for senior leaders and policy makers to improve health care outcome.

The aim of this study was to examine the extent to which U.S. newspapers covered the chatter surrounding the 2009/10 healthcare reform debate at the expense of the substance. Also of importance was how the political leanings of newspapers influenced the coverage they gave the issue in terms of tone and page or story prominence. Newspaper endorsement data from Editor & Publisher magazine were used to determine the political leanings of U.S. newspapers based on the candidate they endorsed in the 2008 U.S. presidential election. Newspaper articles related to the topic were retrieved from the Lexis-Nexis database and analyzed. The results showed that overall the healthcare reform debate received substantial coverage in U.S. newspapers; but the major part of the coverage was dedicated to the arguments, protests, and thoughts of people concerning the issue (90.3%) rather than the substance of the issue (9.7%). Implications of the results for media practitioners, communication scholars, and researchers were discussed.

During the transition from a planned economy to a decentralized, market socialist economy, the Chinese healthcare system has evolved from a centralized, egalitarian public system (1949-1979) to one which is largely self-governed and can be characterized as �public identity, private behavior� healthcare system (1980-1999). With blurring of the distinction between public and private governing systems, and a shift in norms towards profit orientation, major concern has arisen about the extent of high cost, high volume services being offered through excessive entrepreneurial practices. This thesis is concerned with the regulatory strategies and options to reach 2010 health reform objectives of equity and efficiency under a mixed public/private market. While possible lessons can be drawn from established economies and transitional economies, China faces some unique challenges, given the diverse market structures and fragmented healthcare system across the country, and the underdeveloped framework for the rule of law. The thesis reviews policy documents from 1949 to 2004 and draws from interviews with senior health policy-makers and hospital directors in three different locations, in order to explore the role of the state in market regulation, the effectiveness of technical and social regulations, and how policy implementation and regulatory compliance occur. The research has found that the dynamics of the healthcare system are shaped by the financing arrangements for healthcare and the absence of arms-length governance of hospitals by health departments. Without an effective state health financing tool, nor mature market institutions, China is not able to use neither performance-based regulation nor technology-based regulation. China has adopted a management-based regulatory strategy but the absence of effective governance structure hinders effective regulation. If the reform objectives of improving healthcare quality while costs are to be attained, China will need to develop purchasing tools to alter the current perverse incentives for provider behavior. Government will also need to work with civil society organizations to develop tools for clinical governance, such as clinical audit for risk management and hospital accreditation programs. To do so requires establishing arms-length governance mechanisms between health departments and hospitals, and appropriate corporate governance structures within hospitals. Specifically, MOH needs to establish a technical policy think tank to investigate all the policy issues arising from the announcement of the 1997 health reform, including coordination with other line ministries and provincial authorities, and formulation and implementation of a policy research agenda, in order to attain a market-based governance system for health by 2010.

. Abstract Health reform is forcing healthcare administrators to make rapid changes. A tendency to resist change can present problems for these organizations, including the large, not-for-profit Catholic healthcare systems. In order to make positive contributions towards healthcare, it's important to recognize the nature of the organization's involvement to change. The transformational leadership style has been shown to be positively correlated with change however, the relationship among leadership styles, employees' behaviors, and motivation to change are still not well understood and require further study. Further, although Oreg's Resistance to Change (RTC) approach has been researched in direct patient care areas, RTC research in non-patient settings is lacking and necessary in delivering the full spectrum of patient care. This study focused on the relationship of transformational leadership to RTC and if the relationships leaders' have with subordinates' influence change. A customized survey that included the Multifactor Leadership Questionnaire, RTC, and Leader Member Exchange (LMX 7) was emailed to 500 random individuals of various ages and races from 3 non-patient areas. Thirty leaders and 133 raters responded. The regression analysis showed a strong correlation between transformational leadership and RTC. Additionally, each of the variables from the LMX 7 section of the survey showed associations indicating the relationship leaders develop with their subordinates and leader transformational scores were positive. This study may contribute to the awareness of RTC and utilizing transformational leadership style to move change in a positive direction for a healthcare setting.

This study aims to analyse the location choices made by private primary healthcare providers as a result of the Primary Care Choice Reform. This will be done by analysing a unique dataset covering all new private primary healthcare providers during the time period of 2008 to 2018 in Sweden’s 290 municipalities. In order to examine the probability of a private primary healthcare provider locating in a given municipality, two logit regression models based on the year 2018 containing the number of private primary healthcare providers as the dependent variable, will be used for the empirical analysis. The results are presented as marginal effects and are calculated from the coefficients of the two logit regression models. In addition, there exist alternative measures to the dependent variable when analysing the location choice of private primary healthcare providers. For this reason, an alternative regression will be presented where the dependent variable is the share of healthcare providers in the municipality that is privately owned, to see if any new conclusions can be drawn. There is a broad range of possible determinants for where to locate. Those included in this study are the Care Need Index, political party, domestic net migration, distance, socio-economic variables and a variable measuring the population size. Furthermore, all private primary healthcare providers will be grouped according to which county council they belong to, since all county councils have different reimbursement systems. The findings imply that private primary healthcare providers are, on average, less likely to locate in municipalities defined as rural, compared to municipalities defined as urban. Socio-economic factors such as elderly people and income further influence the location decision, where people with less socio-economic status are at a disadvantage. For this reason, there are some questions about if the objectives of the Primary Care Choice Reform have been achieved and for whom.

Implementing policy change is notoriously difficult, often marred by chronic delays or outright failure to achieve its originally desired mandate. This challenge drew the attention of many scholars who, over the years, published many studies attempting to describe and analyse what the policy change process looks like and most notably, strategies on how to better manage it. However, most of these studies tacitly committed themselves to strategic issues of managing change from a policy-maker s perspective, with very little consideration of what the change process actually looks and feels like from the perspective of the change recipients. Yet, it goes without saying that responses of these change recipients directly affect the outcomes of the change process. This study sought to address this gap in literature by exploring South Africa s prevailing National Healthcare Insurance (NHI) policy reform. Using a qualitative design and theoretical insights from political sciences, social sciences and organisational studies, the study analysed how the relevant stakeholders in the private healthcare industry were variously thinking about and responding to the proposed reforms. The findings of the study emphasised the critical role of temporally sequenced historical events in shaping an industry and influencing its change orientation. The study also weighed in on scholarly debates that challenged general characterisation of any recipients contradictory opinions as resistance to change . In this study, the stakeholders seemingly antagonistic attitudes and responses to the NHI policy were not necessarily a contestation against change in itself. Instead, the conflict was over compatibility with the policy s implicit secondary goals. This contestation evoked opinions and responses so strong that it overshadowed the stakeholders initial felt need for change. From this perspective, this research argued for a distinction to be drawn between diagnostic congruence and goal congruence. It further proposed that paying diligent attention to formulating an accurate diagnosis of the problems to be addressed through policy change could attenuate haggling and achieve far better results than finding the best way to attain an agreed upon goal across all relevant stakeholders.
Mini-disseration (MBA)--University of Pretoria, 2015.
nk2016
Gordon Institute of Business Science (GIBS)
MBA
Unrestricted

The health system in Abu Dhabi has undergone a series of far reaching reforms during the past six years, yet in spite of the structural transformations, public confidence in the performance of this vital sector is still skeptical at best and employee engagement is still low. The thesis was underpinned by the aim to reveal the challenges in public health system reform outside the context of western administration. This thesis is an attempt to analyse the intricate, multidimensional concept of organisational culture within the complex structure of public healthcare sector in a fast growing economy like Abu Dhabi. Managing organisational culture is increasingly viewed as an essential part of health system reform. Organisational culture in health care organisations has gained increased consideration as an important factor that affects health systems reform and influences the quality of health care. The research project aims to explore the context of health system reform in Abu Dhabi and to understand the organisational culture of the different constituents of its public healthcare sector. Using a multi-method investigation combining both qualitative and quantitative approaches using the Competing Values Framework as conceptual framework, this research aims to provide a critical assessment of organisational culture in healthcare sector in Abu Dhabi. Semi-structured interviews were conducted in the regulator, operator, and three public hospitals prior to the use of a survey instrument based on the Organisational Culture Assessment Instrument (OCAI). The data analysis revealed that the prevailing cultural model of the Abu Dhabi public sector organisations was concurrently governed by hierarchy and market cultures while the presence of clan and adhocracy models was relatively limited. Interesting variations in assessment of clan culture were found between UAE nationals and other nationality clusters. The findings also revealed a desired cultural shift manifested by a higher emphasis on clan and adhocracy cultures and a lower emphasis on hierarchy and market culture. Those results confirm the presence of two opposing or competing cultural dimensions clan/adhocracy vs. hierarchy/market. This research makes a considerable contribution to the sparse empirical studies in health system reforms and organisational culture in the Arab Gulf states, and proposes important explanations and possible solutions to the salient challenges facing the health system in Abu Dhabi.

Background China never stops taking effort to reform its health care system. Health care financing, which is one of the essential control knobs to health care system, has significant influences on the sustainability of the health system, the quality of services it delivers, the health status of the population as well as the success of the whole health care reform process. Objectives This article aims to summarize the evolution of China’s health care financing system, its current situation and challenges, discuss what lessons China can learn from the successful experiences or unsuccessful pitfalls of others countries on its health care financing reform. Methods Articles were searched through PubMed and CNKI. Further relevant articles were identified by searching the citations listed in retrieved articles manually. 96 articles were reviewed. Statistics about China’s health care system were mainly from government white paper, SHA technical paper, Chinese government websites and WHO website. The information about the performance of health care systems in other countries was mainly from OECD database and WHO website. Results In China, insufficient government expenditure and high out-of-pocket payments; social health insurance providing limited risk protection, with low-level risk pooling; escalation of costs; inefficient financing resources allocation in providers; disparities among regions and provinces all lead to the inequity and inefficiency of the health care financing system and create heavy financial burden on patients. Based on experiences from other countries, the total health expenditure in China could take an even larger proportion of GDP in the future; it is reasonable to increase general government expenditure to further reduce the household out-of-pocket payment and provide financial protection and ensure equity; expanding services coverage and proportion of the costs covered, gradually merging the risk-pool units and different schemes can make social health insurance a more powerful tool to make sure people’s access to basic health care; a new payment mechanism and stricter supervision on supply side can effectively contain the escalation of the costs; government should inject more funding to front-line institutions and the function of primary care in China can be stimulated by a good primary health care delivery system, in which the role of primary care provider is clearly defined as the gatekeeper of the health care system, with a proper referral mechanism; more responsibility should be taken by central government to allocate financing resources based on the fiscal capability of local governments; Chinese government should foresee the demand of aging population and take actions before it is too late. Conclusion It is consensus that China’s health care reform is heading at the right direction. However, there are a lot of problems in China health care financing system remaining to be solved. Health care financing system varies greatly in each country and there is no perfect health care financing system in the world. Thus no single country can be one hundred percent copied by China. But general principles and one or some most successful and advanced portions of other countries’ health care financing systems can still be used as references by China after further assessment. Unsuccessful oversea experiences are also precious lessons for preventing Chinese government from making same mistakes. A good health care financing system should be designed on the basis of a systematic review of all domestic financing policy and previous international experiences.
published_or_final_version
Public Health
Master
Master of Public Health

In this archival study, I explore reasons why India's economic takeoff into marketization in 1991 failed to meet the same success as China in 1979 when it made the same transition. I analyze the impact of education and healthcare on development and how investments in both sectors can yield significant returns privately and socially. The research in this paper seeks to answer the following question: Why was the Indian economy unable to meet the same success as China when developing a global, open market economy? In order to answer this question, I begin by proving a solid relationship between education, healthcare, and development. Then, I set out to undercover education and healthcare reforms enacted by China that helped contribute to the overall success of the new economy. After, I look at the holes in the education and healthcare sectors of India that contributed to the weak transition into the new economy, as well as new mandates that seek to repair these issues so that the economy can grow and prosper at a more favorable pace. The results of this study reflect that India was unable to meet the success of China when transitioning to a global market economy because poor social preparedness prevented the Indian people from reaching their full potential. With poor education and a major lack of healthcare, the population could not contribute to the growth of the new economy because they either did not understand how to stimulate it, or were simply too sick.

Healthcare is an organizational field that has undergone profound change in the last few decades, an era characterized by market reform. Healthcare production has revealed both economic and quality problems in past eras, and reporting on these problems can be seen to have contributed to pressures for social reform. Yet, the move toward more market-oriented governance structures and design solutions also reflects a wider isomorphic institutional tendency for organizing social order.The conceptual frame work of this study takes a pessimistic stance on whether the market reform has achieved the intended goals with respect to advancing organizational quality performance. The framework draws on institutional theory and complementary collective action notions in organization theory concerned with boundedly rational decision-making to reason that healthcare evidences certain contextual characteristics that are not a good fit with the market enterprise model of organizing organizations. Specifically, hazards to the efficient market thesis were considered to include uncertain outcomes, a high degree of technical and coordination complexity, and the need to account for intertemporal process transformations of significant duration.A longitudinal design was used to test efficient market thesis propositions. Inpatient administrative data was used to develop two latent hospital quality performance variables, a Mortality quality indicator and an Errors quality indicator. The two latent variables were derived from three selected AHRQ patient safety indicators and an inpatient mortality rate. The measurement model was validated as evidencing significant systematic between-hospital variation. Audited survey data, along with inpatient discharge data was used to develop hospital economic performance variables and process control variables.A set of predictive supply-and-demand models were used to test: 1) whether there is evidence of any trend in quality performance, and how market competition relates to observations of improvement; 2) whether quality cost more; and, 3) whether preferences for better quality outcomes related to hospital economic performance. A hierarchical linear model growth-curve design was employed to assess the predicted relationships and to account for unmeasured organizational dependent relations determinant of hospital quality performance. The unaccounted for systematic between-hospital variance was taken to estimate an "unspecified" hospital-specific institutional effect, independent of material-resource factors. The measurement model results for each of the quality indicators selected evidenced construct validity for patient-level risk-adjustment. Each quality indicator demonstrated a significant systematic between-group variance component in all of the four years studied. The two latent hospital quality performance variables also demonstrated systematic between-hospital variance in growth trajectories in the linear growth-curve model.The predictive models evidenced no significant growth rate trend for either of the quality indicators, indicating the competitive bar on quality performance was unaffected during this period of market reform. Neither was there any evidence that pricing mechanism were able to price the utility of better outcomes, as higher quality did not cost more. Neither was there evidence that consumer preferences for better quality related to better hospital economic performance, as measured by hospital operating margins.

This medical anthropology dissertation is an intersectional study of the illness experiences of African-American women living with the chronic autoimmune syndrome systemic lupus erythematosus (SLE), commonly known as lupus. Research was conducted in Memphis, Tennessee from 2013 to 2015, with the aim of examining the healthcare resources available to working poor and working class women using public sector healthcare programs to meet their primary care needs. This project focuses on resources available through Tennessee’s privatized public sector healthcare system, TennCare, during the first phases of the Patient Protection and Affordable Care Act (ACA). A critical medical anthropological analysis is used to examine chronically ill women’s survival strategies regarding their daily health and well-being. The objectives of this research were to: 1) understand what factors contribute to poor women’s ability to access healthcare resources, 2) explore how shared illness experiences act as a form of community building, and 3) document how communities of color use illness narratives as a way to address institutionalized racism in the United States. The research areas included: the limits of biomedical objectivity; diagnostic timeline in relation to self-reported medical history; effects of the relationship between socio-economic circumstance and access to consistent healthcare resources, including primary and acute care, as well as access to pharmaceutical interventions; and the role of non-medical support networks, including personal support networks, illness specific support groups, and faith based organizations. Qualitative methods were used to collect data. Methods included: participant observation in support groups, personal homes, and faith based organizations, semi-structured group interviews, and open-ended individual interviews. Fifty-one women living with clinically diagnosed lupus or undiagnosed lupus-like symptoms participated in individual interviews. Additionally twenty-one healthcare workers, including social workers, Medicaid caseworkers, and clinic support staff were interviewed in order to contextualize current state and local health programs and proposed changes to federal and state healthcare policy.

Conselho Nacional de Desenvolvimento Científico e Tecnológico
O trabalho parte da hipótese de que os movimentos sociais potencializam sua capacidade de pautar agendas e normatizar suas demandas quando conseguem convergir para uma agenda única. Busca-se exemplificar essa tese por meio de uma análise do Movimento Sanitário e a subsequente Reforma Sanitária. A partir da atuação deste movimento foi possível incluir uma nova forma de entender a saúde na Constituição de 1988 e sua regulamentação via Lei Orgânica da Saúde LOS , responsável pela criação do Sistema Único de Saúde SUS. O objetivo norteador do trabalho é a compreensão do motivo pelo qual algumas políticas públicas de saúde foram implementadas com sucesso enquanto outras permaneceram no papel. Argumenta-se que o fato de muitas das premissas instituídas na Lei Orgânica ainda não terem sido efetivadas tem relação, entre outros fatores, com a crescente fragmentação e institucionalização dos movimentos pela saúde, ocorrida ao longo da década de 1990. Hoje o que se observa é uma grande heterogeneidade dos atores ligados ao setor, com os novos movimentos sociais pela saúde apresentando-se de forma cada vez mais difusa. No ano em que o Sistema Único completa 25 anos, é necessário repensar suas estratégias, falhas e sucessos. Destarte, o trabalho leva à reflexão de que ao se buscar a efetivação do SUS legal é premente que doravante se retomem os princípios fundantes da Reforma Sanitária.
The study departs from the hypothesis that social movements improve their ability to bring specific themes to the forefront and to introduce new regulations when they converge around a single agenda. It illustrates this thesis through an analysis of the Sanitary Movement and the subsequent Health Reform. Their actions allowed for a new way of understanding health in the 1988 Constitution and its regulation via Health Law - LOS - , responsible for the creation of the Unified Health System - SUS. The guiding purpose of this thesis is to explain why some public policies related to healthcare were successfully implemented while others were not. In other words, the study examines the factors behind the non-effectiveness of the premises established by the LOS, indicating that this occurred in part due to the increasing fragmentation and institutionalization of the healthcare movement throughout the 1990s. Today one can observe an expressive heterogeneity in the healthcare movement with new actors presenting themselves in an ever more diffuse way. In the year that SUS turns 25, we need to rethink its strategies, successes and failures. This thesis leads to the final reflection that in order for SUS to actually work it is pressing that all actors involved in the healthcare movements return to and reclaim the Sanitary Reform founding principles.

This thesis is about the business of nursing; the making and remaking of nurses’ work in the context of private healthcare. Nurses in Australia, as in other countries around the world, have experienced considerable workplace changes over the past 15 years due to governments and public and private healthcare organisations seeking to reform healthcare service delivery. These reforms have significantly changed not only how private hospitals manage care, but the nursing role in practice. This ethnographic study explores the impact of these reforms on nurses’ work in one Australian acute care private hospital. It critically examines nurses’ organising practices in light of the workload measurement method used to staff the hospital, unit and ward with minimum staffing. Using Foucault’s (1972) archaeological approach and drawing upon governmentality theory as the analytical framework, I will argue that within the political rationality of neo-liberalism, ‘care’ in nursing is a technology of governance. As such, nurses’ ‘care’ transforms contemporary healthcare policy, in particular policy pertaining to private healthcare, from a macro to the micro level of everyday practice. Care is the means of producing a ‘business savvy’ nurse; someone who is not only an expert clinician with transferable skills but who knows the private health market and is able to work within a competitive business environment. Analysis reveals the contradictions and tensions that exist for nurses between the clinical and economic foci, and the economics and business of health as the nursing role is played out within the organisational imperatives of their work. This study illustrates the shifting boundaries of nurses’ work in relation to the ascendancy of business concerns in healthcare delivery. While methods of workload measurement may well represent what counts as the nursing hours in healthcare organisations, the nurses in this study spoke at length of the strategies they used to make the nursing hours ‘work’. Findings indicate that nurses employ specific discursive strategies when talking about ‘nursing hours’. When addressing their workloads, their discourses centred on the business of care delivery, of nurse-to-patient ‘allocations’ and ‘handover’, or the many instances of ‘handing over’ their work. The study challenges nurses’ professional discourses about what nursing is, what nurses actually do and the sophistication with which this is accomplished at work. Conceiving of nurses’ work in terms of ‘nursing’ hours rather than patients in the business of health service delivery provides a different way of thinking about nursing workforce issues at a time when healthcare organisations and systems worldwide grapple with the question of how many nurses and what kind of nurses they need.

Mestrado em Desenvolvimento e Cooperação Internacional
A China é um país com uma população imensa, com recursos médicos insuficientes e distribuição desigual. Portanto, existem muitos problemas no serviço de saúde. Devido ao desenvolvimento atrasado do sistema médico, a qualidade dos recursos médicos é baixa, o custo é alto e a eficiência dos serviços médicos é baixa. Um dos principais fatores explicativos dessa situação é a falta de apoio do governo e seguro médico imperfeito. Para resolver esse problema, o governo começou a reformar o sistema de segurança médica. Desde a reforma do seguro médico de 1988, após várias mudanças, o sistema de seguro médico da China amadureceu gradualmente. A tese descreve brevemente a estrutura básica, o conteúdo e o caminho da mudança nos cuidados de saúde. E as deficiências do atual sistema de seguro médico. A análise introduz o papel da "Internet+" e da "big data" na reforma do sistema de seguro médico e avalia as potencialidades da sua introdução e operacionalização para a gestão e governança do sistema de saúde.
China is a population republic country has insufficient medical resources and uneven distribution. Therefore, there are many medical problems. Due to the backward development of the medical system, the quality of medical resources is poor, the efficiency of medical services is low, and the cost is high, which brings many difficulties for the Chinese people to seek medical treatment. However, one of the main factors of these problems is the lack of government support and imperfect medical insurance. To solve this problem, the government began to reform the medical security system. Since the 1988 medical insurance reform, after several changes, China's medical insurance system has gradually matured. The thesis will briefly describe the basic framework, content and path of change in health care. And the shortcomings of the current medical insurance system. According to the characteristics of the times, talk about the impact of "Internet +" and "Big Data" on the current Chinese industry, including people's lives. Therefore, the analysis introduces the positive role of big data Internet for the reform of medical insurance system, and provides convenience for the management and governance of medical insurance system. Analyze whether "Internet +" and "Big Data" can lead to new trends in the reform of the health care system.
info:eu-repo/semantics/publishedVersion

The original contribution to knowledge of my thesis is a comparative historical analysis of the rhetoric used by four Democratic presidents to expand access to and affordability of healthcare. Specifically, the thesis situates Democratic presidential healthcare reform rhetoric in relation to opposing conservative Republican ideologies of limited government and prioritization of negative liberty and their increasing prominence in the post-Reagan era. It examines how the American moral order and social imaginary has evolved and how Democratic presidential healthcare reform rhetoric was both informed by and responded to it. I employ Aristotle’s tripartite categories of ethos, pathos and logos to undertake rhetorical analysis. I illuminate how each president sought to persuade audiences, what rhetorical strategies they used and how they justified their healthcare reform efforts. I pay particular attention to the compromises entailed by the usage of specific strategies and their rhetorical effects. The thesis illustrates how Presidents Harry Truman and Lyndon Baines Johnson contextualized healthcare reform within their broader efforts to secure positive liberty and social and economic rights in the Fair Deal and Great Society, respectively. This is in contrast to Presidents Bill Clinton and Barack Obama who did not advance a comprehensive vision of government guaranteed positive liberty and citizen welfare. Rather, they made arguments for healthcare reform based on pragmatism and economic efficiency and appropriated tropes of conservative rhetoric such as efficiency to critique market failure. They showed deference to the conservative principle of maximizing the role of the private sector in healthcare provision. There is a marked contrast between Truman and Johnson’s explicit expressions of care for economically disadvantaged and working class Americans and Clinton and Obama’s rhetorical elision of these populations, and their focus on the ‘middle class.’ Despite these substantive differences a major continuity in the rhetoric is an enduring appeal to communitarian solidarity.

Researchers all around the globe have not yet come to an end as regards the supposed positive impact of traditional performance management systems in healthcare, and some research has shown that, paradoxically, performance management policies do not always lead to improved hospital performance. Despite the extensive research identifying the “pitfalls” of the NPM reforms around Europe and the unintended consequences for hospital staff and patients, little is known about the mechanisms that caused those negative effects, which essentially creates a research gap worth investigating. This PhD study tries to address this gap and show why do traditional PM Systems in healthcare not always lead to improved performance, by outlining the unintended consequences of the Greek healthcare reform in a public hospital. By conducting empirical research using a case-study, and by adopting a systemic perspective, this research addresses this gap and sheds light on how hospital performance is perceived by stakeholders of a Greek public hospital and what mechanisms drive its dynamic behaviour. Following a systemic approach, the selected case study - which is a real hospital in the Greek Healthcare system - allowed us to investigate the causing mechanisms of the negative consequences of the Greek healthcare reform on the performance of the case hospital. In doing so, we framed our analysis using the Dynamic Performance Management methodology. Recently, researchers have started to see those negative outcomes as “system pitfalls”, occurring from the non-linear interconnection and the dynamic interaction of the different elements and factors that comprise the health system and the healthcare institutions, i.e., their structure, the policies implemented, the behaviour and the decisions of healthcare workers and patients inside this system. The implementation of a systemic performance assessment methodology in Healthcare is sponsored by many recent scholarly contributions in the field (Arnaboldi et al., 2015; Costanza et al., 2014; Bivona, 2010, 2015; Bivona & Cosenz, 2017a, 2017b; Bivona & Noto, 2020; Davahli et al., 2020; Franco-Santos & Otley, 2018; Fryer et al., 2009; Helal, 2016; Renmans et al., 2017; Mwita, 2000; Noto et al., 2020; Vainieri, Ferrè, et al., 2019; Vainieri, Noto, et al., 2020; Wang et al., 2020). Adopting a systemic perspective means taking as a unit of analysis the organisation as a whole, and not one unit or department; acknowledging its internal and external environment and culture in which health care is performed; and considering the concurrent existence of the pitfalls documented as inherent to the structure of the system and the policies implemented. Studies using such a methodology would be necessary in order to address the gap in existing knowledge, as well as to support policy-makers in designing better, more quality-oriented healthcare policies, interventions and reforms in the future. The purpose of this study was to empirically conceptualise a qualitative model of hospital performance as perceived by stakeholders of a Greek public hospital and use the DPM analysis in order to help policymakers in Greece re-design performance management policies and foster hospital performance. We adopted a systemic, participatory, inductive and dynamic approach by combining the Group Model Building and System Dynamics methodologies into the Dynamic Performance Management approach (Bianchi, 2016). Other research traditions identified in our study are the Stakeholders Theory and Participation. All those approaches stand in the constructivist side of the continuum as research approaches, because they all consider realities as subjective, complex and multi-layered, actively shaped by perceptions and opinions of stakeholders (De Gooyert, 2019; Lane & Schwaninger, 2008). Mixed methods were used to facilitate our approach, combining primary qualitative data from two Group Model Building sessions; four open, unstructured preliminary interviews; and seven semi-structured, disconfirmatory interviews; with secondary, qualitative and quantitative data from a scoping literature review and from a critical literature review; as well as from official, open-access, online text-documents and closed-access, internal text-documents of the hospital’s interdepartmental communication. An open call for participation in the research was sent by email to around 70 different hospitals in the cities of Athens and Thessaloniki in Greece, and the gatekeeper was identified. Starting from the gatekeeper, snowball sampling was used to select 10 participants in the case hospital for the Group Model Building (GMB) sessions, including at least one person from each main key-stakeholder category that our extensive stakeholder analysis identified (i.e., managers, doctors, nurses, paramedics and patients), with the purpose of “eliciting” their mental models and “capturing” them in a qualitative system dynamics model (causal loop diagram). Four of the participants were also interviewed before the GMB sessions (face-to-face, one-to-one preliminary interviews). Convenient sampling was used in order to identify seven more public hospital stakeholders from other public hospitals in Greece for the disconfirmatory interviews. The data analysis included a Scoping Review of the International Literature of Performance Management in the Health Sector; a Critical Review of the Literature on the Greek Healthcare Reform; a Stakeholder Analysis; a Narrative Analysis of Preliminary Interviews and Documents; a Qualitative System Dynamics Analysis (Causal Loop Diagram) of the Simplified version of the Conceptual Model of Hospital Performance created during the GMB sessions; and, finally, the Dynamic Performance Management (DPM) analysis. The GMB sessions helped hospital stakeholders gain a better understanding of what hospital performance is in a more systematic way; define it; show its trend (dynamic behaviour) in the hospital during the last decade in a diagram; and conceptualise it as a system, depicted as a qualitative system dynamics model of hospital performance (CLD - Causal Loop Diagram). The two final versions of this CLD Model (i.e., the Conceptual and the Policy Models of Hospital Performance, available in Appendixes 21 and 22 respectively and thoroughly described in terms of the variables and links they contain in Appendix 24) are the main outputs of the GMB sessions, and formed the basis of our analysis and research findings. The Conceptual Model of Hospital Performance is a CLD model that depicts the actual structure of hospital performance and can be used to explain its currently low levels, whereas the Policy Model of Hospital Performance is extended to incorporate the policy structure, i.e., the changes in the system structure which are necessary, according to our participant stakeholders, in order to improve hospital performance. Hospital performance was defined by the participant stakeholders as the provision of patient-centred care to the patient, with safety (for the patients and the staff); responsibility (adherence to protocols, proportions and procedures) and dignity (nice and clean facilities, reduced waiting times and no informal payments). The historical trend of the Hospital performance in the case hospital was also depicted in a diagram over time called Reference Mode (available in Appendix 19). The Reference Mode created and agreed upon by the participants showed that, despite the counterintuitive negative outcomes documented, the level of the overall performance in the case hospital has been slightly increasing after the healthcare reform and is now stabilizing. Our research showed that the Performance Management policies introduced during the Greek healthcare reform had a negative impact on many aspects of hospital performance in general, and in our case hospital in particular. The new policies undeniably contributed to the reduction of hospital spending, but they simultaneously contributed to the deterioration of hospital service quality. Goal-setting, the main PM strategy followed by Greek public hospitals according to Law N4369/16, is until today not properly implemented in the case hospital and managers seem to treat performance objectives as completely separated from performance and quality, and to consider them totally outside of their everyday tasks. Those findings of the preliminary interviews and documents analysis were validated from the findings of the pretests, conducted before the GMB sessions. Four of the goals that were set by the division managers of the case hospital came up during the GMB sessions and were integrated in the CLD model that the participants built: Standardization of the nursing forms of the nursing departments and units; Standardization of clinical procedures; Use of an Information System in the Interdepartmental Communication; and Application of digital signature and electronic document management. We combined our findings from the documents’ analysis with the descriptions of those goals, as set by the division managers, and we informed them with the findings from our DPM instrumental and objective analysis, which allowed us identify the activities and the resources that are needed for the achievement of each of those four goals. In that respect, we found that apart from the “tangible” strategic resources identified by the managers of the case hospital (e.g., financial and human resources) as essential in the achievement of each of those four goals, Management Capacity - which is an intermediate, administrative product of the hospital, built by the public workers - was equally necessary. Out of all the unintended negative outcomes of the Greek healthcare reform documented in the literature, we found the following seven negative outcomes to be present at the case hospital: (1) Low Quality and Safety of Services perceived by health workers and patients; (2) Low Patient Satisfaction; (3) Informal Payments; (4) High Mortality Rates; (5) Numerous Medical Errors; (6) High Nosocomial & Multidrug-Resistant Bacteria Infections Rates; (7) Low adherence to Clinical Guidelines and Treatment Protocols. Regarding those seven negative outcomes, the analysis of the simplified version of the Conceptual Model of Hospital Quality which the participant stakeholders created during the GMB sessions at the case hospital, showed that: (1) Low Quality and Safety are mostly associated with the variables Survival Rate / Patients' Health Status & Quality of Life and Complications of our model, and can be explained by the dominance of the balancing loops B3 - Actual Time Available & Errors, and B4 - Actual Time Available and Adherence to Guidelines & Protocols, both of which cause those two variables to decrease as in the Limits to Success archetype, resulting at less Proper Communication & Attendance to Patients’ Needs, more Errors and Complications, longer Length of Stay, higher Nosocomial Infections Rate, and, finally, to lower Survival Rate and Patients’ Health Status & Quality of Life after treatment (Dynamic Hypothesis 1). (2) Low Patient Satisfaction can be explained by the dominance of the loops B1 – Word of Mouth & Waiting Times, B2 – Patient Satisfaction & Attendance to Patients’ Needs, B3 - Actual Time Available & Errors, and B4 - Actual Time Available and Adherence to Guidelines & Protocols, all of which lead to a gradual decrease and stabilisation of Patient Satisfaction and of Hospital Reputation in the long run as in the Limits to Success archetype, resulting at less Proper Communication & Attendance to Patients’ Needs, more Informal Payments for early Surgery/Admission longer Waiting List for Surgery or Admission, longer Waiting Time in ER & Outpatient Services and, finally, to lower Survival Rate and Patients’ Health Status & Quality of Life after treatment. (Dynamic Hypothesis 2). (3) The existence of Informal Payments can be explained by the Loop R2 – Informal Payments & Corruption, which leads to a perpetual increase of private spending and to the outspread of corruption between the case hospital doctors, given the good reputation of the case hospital and the long waiting lists that are already in place. This phenomenon is sustained by the current policies in place, which favour the creation of long waiting lists. However, this phenomenon is also sustained by factors external to the case hospital and to our model, such the relative tolerance of the Ministry of Health and of the authorities, and the widespread idea between patients in Greece that informal payments are necessary for a timely and proper treatment. (Dynamic Hypothesis 3). (4) High Mortality Rates can be explained by the Loops B3 - Actual Time Available & Errors, and B4 - Actual Time Available and Adherence to Guidelines & Protocols, both of which lead to a gradual decrease and stabilisation at a low level of the Actual Time Available per Patient and of the Adherence to Guidelines & Protocols in the long run as in the Limits to Success archetype, resulting at less Proper Communication & Attendance to Patients’ Needs, more Errors and Complications, longer Length of Stay, higher Nosocomial Infections Rate, and, finally, to higher Failure & Mortality Rates. (Dynamic Hypothesis 4). (5) Numerous Medical Errors can be explained by the Loop B3 - Actual Time Available & Errors, which leads to a gradual decrease and stabilisation at a low level of the Actual Time Available per Patient and of the Adherence to Guidelines & Protocols in the long run as in the Limits to Success archetype, resulting at higher Difficulty of Shift Schedule for nurses and doctors, less Proper Communication & Attendance to Patients’ Needs and, finally, to more medical, nursing and patients’ Errors (Dynamic Hypothesis 5). (6) High Nosocomial & Multidrug-resistant bacteria Infections Rates can be explained by the loops R5 – Multidrug Resistance in the General Population and B4 - Actual Time Available and Adherence to Guidelines & Protocols, both of which cause Nosocomial Infections to increase in the long run, resulting at more Complications and higher Multidrug Resistance in the General Population (Dynamic Hypothesis 6). (7) Low Adheremce to Clinical Guidelines and Treatment Protocols can be explained by the loop B4 - Actual Time Available and Adherence to Guidelines & Protocols, which leads to a gradual decrease and stabilisation at a low level of the Actual Time Available per Patient in the long run, as in the Limits to Success archetype, resulting at increased Difficulty of Shift Schedule for nurses and doctors, low Availability of Equipment, ICT, Standard Procedures & Digital Forms and, finally, to low Adherence to Guidelines & Protocols. In order to test those seven hypotheses, a quantified SD model (a stock-flow diagram) would be needed, as that would enable us to run simulations and test our hypothesis in different scenarios to analyse the loop dominance. Such a model is out of the scope and purposes of the present, qualitative study and is not included, but is recommended for future research. However, we used the Dynamic Performance Management analysis as an alternative method, in order to: (1) identify Strategic Resources, Performance Drivers and End Results of hospital performance and show their role in the hospital performance management and measurement; (2) show how the time factor influences the overall hospital performance; (3) understand the contribution of each one of the four hospital divisions (the Medical, the Nursing, the Administrative & Financial and the Technical division) on the End Results (i.e., the final hospital services produced); (4) allow the division managers to start concentrating on the core intermediate, administrative products that divisions are required to deliver on the process that leads to the final end-results; (5) map the ultimate and intermediate services value chain provided to both external and internal users of the case hospital; (6) make performance measures (i.e., the drivers and end-results associated with the delivery of products) explicit and then link them to the goals and objectives of the division managers of the case hospital; (7) discuss the insights that the DPM analysis offers us for a sustainable Performance Management in Greek public hospitals in general, and in the case hospital in particular. The identification of Strategic Resources, Performance Drivers and intermediate End Results, as well as the different views that our DPM analysis offered (i.e., instrumental, dynamic, subjective, objective) provided the hospital decision-makers with signs of potential future shift in End Results, and can help public hospital managers in Greece interpret and calculate the consequences of an incident or the implications of a policy; show possible discrepancies on performance; and try to mitigate it. The performance measures we identified could be helpful to foresee possible changes in the financial and clinical results of public hospitals in Greece. When framed in a wider sense than budgetary control, transaction cost drivers can provide hospital managers and policy makers in Greece with valuable information for strategic planning, such as the opportunity to identify trade-offs in space and in time (e.g., higher costs for investments and for managerial capacity building in the short-run, versus investments in equipment, ICT, and facilities that would increase performance in the long run). Thus, the performance management policies adopted at the case hospital during the healthcare reform ( i.e., structure and process reforms undertaken) and their overall impact for Greek public hospitals’ outputs and outcomes, can now be examined through a different “lenses” by the hospital managers; lenses that will allow them overcome the seven counterintuitive, negative outcomes documented, and align the hospital’s and the different division’s and departments’ goals and actions to achieve improved efficiency and effectiveness, along with better hospital service quality for patients.
Researchers all around the globe have not yet come to an end as regards the supposed positive impact of traditional performance management systems in healthcare, and some research has shown that, paradoxically, performance management policies do not always lead to improved hospital performance. Despite the extensive research identifying the “pitfalls” of the NPM reforms around Europe and the unintended consequences for hospital staff and patients, little is known about the mechanisms that caused those negative effects, which essentially creates a research gap worth investigating. This PhD study tries to address this gap and show why do traditional PM Systems in healthcare not always lead to improved performance, by outlining the unintended consequences of the Greek healthcare reform in a public hospital. By conducting empirical research using a case-study, and by adopting a systemic perspective, this research addresses this gap and sheds light on how hospital performance is perceived by stakeholders of a Greek public hospital and what mechanisms drive its dynamic behaviour. Following a systemic approach, the selected case study - which is a real hospital in the Greek Healthcare system - allowed us to investigate the causing mechanisms of the negative consequences of the Greek healthcare reform on the performance of the case hospital. In doing so, we framed our analysis using the Dynamic Performance Management methodology. Recently, researchers have started to see those negative outcomes as “system pitfalls”, occurring from the non-linear interconnection and the dynamic interaction of the different elements and factors that comprise the health system and the healthcare institutions, i.e., their structure, the policies implemented, the behaviour and the decisions of healthcare workers and patients inside this system. The implementation of a systemic performance assessment methodology in Healthcare is sponsored by many recent scholarly contributions in the field (Arnaboldi et al., 2015; Costanza et al., 2014; Bivona, 2010, 2015; Bivona & Cosenz, 2017a, 2017b; Bivona & Noto, 2020; Davahli et al., 2020; Franco-Santos & Otley, 2018; Fryer et al., 2009; Helal, 2016; Renmans et al., 2017; Mwita, 2000; Noto et al., 2020; Vainieri, Ferrè, et al., 2019; Vainieri, Noto, et al., 2020; Wang et al., 2020). Adopting a systemic perspective means taking as a unit of analysis the organisation as a whole, and not one unit or department; acknowledging its internal and external environment and culture in which health care is performed; and considering the concurrent existence of the pitfalls documented as inherent to the structure of the system and the policies implemented. Studies using such a methodology would be necessary in order to address the gap in existing knowledge, as well as to support policy-makers in designing better, more quality-oriented healthcare policies, interventions and reforms in the future. The purpose of this study was to empirically conceptualise a qualitative model of hospital performance as perceived by stakeholders of a Greek public hospital and use the DPM analysis in order to help policymakers in Greece re-design performance management policies and foster hospital performance. We adopted a systemic, participatory, inductive and dynamic approach by combining the Group Model Building and System Dynamics methodologies into the Dynamic Performance Management approach (Bianchi, 2016). Other research traditions identified in our study are the Stakeholders Theory and Participation. All those approaches stand in the constructivist side of the continuum as research approaches, because they all consider realities as subjective, complex and multi-layered, actively shaped by perceptions and opinions of stakeholders (De Gooyert, 2019; Lane & Schwaninger, 2008). Mixed methods were used to facilitate our approach, combining primary qualitative data from two Group Model Building sessions; four open, unstructured preliminary interviews; and seven semi-structured, disconfirmatory interviews; with secondary, qualitative and quantitative data from a scoping literature review and from a critical literature review; as well as from official, open-access, online text-documents and closed-access, internal text-documents of the hospital’s interdepartmental communication. An open call for participation in the research was sent by email to around 70 different hospitals in the cities of Athens and Thessaloniki in Greece, and the gatekeeper was identified. Starting from the gatekeeper, snowball sampling was used to select 10 participants in the case hospital for the Group Model Building (GMB) sessions, including at least one person from each main key-stakeholder category that our extensive stakeholder analysis identified (i.e., managers, doctors, nurses, paramedics and patients), with the purpose of “eliciting” their mental models and “capturing” them in a qualitative system dynamics model (causal loop diagram). Four of the participants were also interviewed before the GMB sessions (face-to-face, one-to-one preliminary interviews). Convenient sampling was used in order to identify seven more public hospital stakeholders from other public hospitals in Greece for the disconfirmatory interviews. The data analysis included a Scoping Review of the International Literature of Performance Management in the Health Sector; a Critical Review of the Literature on the Greek Healthcare Reform; a Stakeholder Analysis; a Narrative Analysis of Preliminary Interviews and Documents; a Qualitative System Dynamics Analysis (Causal Loop Diagram) of the Simplified version of the Conceptual Model of Hospital Performance created during the GMB sessions; and, finally, the Dynamic Performance Management (DPM) analysis. The GMB sessions helped hospital stakeholders gain a better understanding of what hospital performance is in a more systematic way; define it; show its trend (dynamic behaviour) in the hospital during the last decade in a diagram; and conceptualise it as a system, depicted as a qualitative system dynamics model of hospital performance (CLD - Causal Loop Diagram). The two final versions of this CLD Model (i.e., the Conceptual and the Policy Models of Hospital Performance, available in Appendixes 21 and 22 respectively and thoroughly described in terms of the variables and links they contain in Appendix 24) are the main outputs of the GMB sessions, and formed the basis of our analysis and research findings. The Conceptual Model of Hospital Performance is a CLD model that depicts the actual structure of hospital performance and can be used to explain its currently low levels, whereas the Policy Model of Hospital Performance is extended to incorporate the policy structure, i.e., the changes in the system structure which are necessary, according to our participant stakeholders, in order to improve hospital performance. Hospital performance was defined by the participant stakeholders as the provision of patient-centred care to the patient, with safety (for the patients and the staff); responsibility (adherence to protocols, proportions and procedures) and dignity (nice and clean facilities, reduced waiting times and no informal payments). The historical trend of the Hospital performance in the case hospital was also depicted in a diagram over time called Reference Mode (available in Appendix 19). The Reference Mode created and agreed upon by the participants showed that, despite the counterintuitive negative outcomes documented, the level of the overall performance in the case hospital has been slightly increasing after the healthcare reform and is now stabilizing. Our research showed that the Performance Management policies introduced during the Greek healthcare reform had a negative impact on many aspects of hospital performance in general, and in our case hospital in particular. The new policies undeniably contributed to the reduction of hospital spending, but they simultaneously contributed to the deterioration of hospital service quality. Goal-setting, the main PM strategy followed by Greek public hospitals according to Law N4369/16, is until today not properly implemented in the case hospital and managers seem to treat performance objectives as completely separated from performance and quality, and to consider them totally outside of their everyday tasks. Those findings of the preliminary interviews and documents analysis were validated from the findings of the pretests, conducted before the GMB sessions. Four of the goals that were set by the division managers of the case hospital came up during the GMB sessions and were integrated in the CLD model that the participants built: Standardization of the nursing forms of the nursing departments and units; Standardization of clinical procedures; Use of an Information System in the Interdepartmental Communication; and Application of digital signature and electronic document management. We combined our findings from the documents’ analysis with the descriptions of those goals, as set by the division managers, and we informed them with the findings from our DPM instrumental and objective analysis, which allowed us identify the activities and the resources that are needed for the achievement of each of those four goals. In that respect, we found that apart from the “tangible” strategic resources identified by the managers of the case hospital (e.g., financial and human resources) as essential in the achievement of each of those four goals, Management Capacity - which is an intermediate, administrative product of the hospital, built by the public workers - was equally necessary. Out of all the unintended negative outcomes of the Greek healthcare reform documented in the literature, we found the following seven negative outcomes to be present at the case hospital: (1) Low Quality and Safety of Services perceived by health workers and patients; (2) Low Patient Satisfaction; (3) Informal Payments; (4) High Mortality Rates; (5) Numerous Medical Errors; (6) High Nosocomial & Multidrug-Resistant Bacteria Infections Rates; (7) Low adherence to Clinical Guidelines and Treatment Protocols. Regarding those seven negative outcomes, the analysis of the simplified version of the Conceptual Model of Hospital Quality which the participant stakeholders created during the GMB sessions at the case hospital, showed that: (1) Low Quality and Safety are mostly associated with the variables Survival Rate / Patients' Health Status & Quality of Life and Complications of our model, and can be explained by the dominance of the balancing loops B3 - Actual Time Available & Errors, and B4 - Actual Time Available and Adherence to Guidelines & Protocols, both of which cause those two variables to decrease as in the Limits to Success archetype, resulting at less Proper Communication & Attendance to Patients’ Needs, more Errors and Complications, longer Length of Stay, higher Nosocomial Infections Rate, and, finally, to lower Survival Rate and Patients’ Health Status & Quality of Life after treatment (Dynamic Hypothesis 1). (2) Low Patient Satisfaction can be explained by the dominance of the loops B1 – Word of Mouth & Waiting Times, B2 – Patient Satisfaction & Attendance to Patients’ Needs, B3 - Actual Time Available & Errors, and B4 - Actual Time Available and Adherence to Guidelines & Protocols, all of which lead to a gradual decrease and stabilisation of Patient Satisfaction and of Hospital Reputation in the long run as in the Limits to Success archetype, resulting at less Proper Communication & Attendance to Patients’ Needs, more Informal Payments for early Surgery/Admission longer Waiting List for Surgery or Admission, longer Waiting Time in ER & Outpatient Services and, finally, to lower Survival Rate and Patients’ Health Status & Quality of Life after treatment. (Dynamic Hypothesis 2). (3) The existence of Informal Payments can be explained by the Loop R2 – Informal Payments & Corruption, which leads to a perpetual increase of private spending and to the outspread of corruption between the case hospital doctors, given the good reputation of the case hospital and the long waiting lists that are already in place. This phenomenon is sustained by the current policies in place, which favour the creation of long waiting lists. However, this phenomenon is also sustained by factors external to the case hospital and to our model, such the relative tolerance of the Ministry of Health and of the authorities, and the widespread idea between patients in Greece that informal payments are necessary for a timely and proper treatment. (Dynamic Hypothesis 3). (4) High Mortality Rates can be explained by the Loops B3 - Actual Time Available & Errors, and B4 - Actual Time Available and Adherence to Guidelines & Protocols, both of which lead to a gradual decrease and stabilisation at a low level of the Actual Time Available per Patient and of the Adherence to Guidelines & Protocols in the long run as in the Limits to Success archetype, resulting at less Proper Communication & Attendance to Patients’ Needs, more Errors and Complications, longer Length of Stay, higher Nosocomial Infections Rate, and, finally, to higher Failure & Mortality Rates. (Dynamic Hypothesis 4). (5) Numerous Medical Errors can be explained by the Loop B3 - Actual Time Available & Errors, which leads to a gradual decrease and stabilisation at a low level of the Actual Time Available per Patient and of the Adherence to Guidelines & Protocols in the long run as in the Limits to Success archetype, resulting at higher Difficulty of Shift Schedule for nurses and doctors, less Proper Communication & Attendance to Patients’ Needs and, finally, to more medical, nursing and patients’ Errors (Dynamic Hypothesis 5). (6) High Nosocomial & Multidrug-resistant bacteria Infections Rates can be explained by the loops R5 – Multidrug Resistance in the General Population and B4 - Actual Time Available and Adherence to Guidelines & Protocols, both of which cause Nosocomial Infections to increase in the long run, resulting at more Complications and higher Multidrug Resistance in the General Population (Dynamic Hypothesis 6). (7) Low Adheremce to Clinical Guidelines and Treatment Protocols can be explained by the loop B4 - Actual Time Available and Adherence to Guidelines & Protocols, which leads to a gradual decrease and stabilisation at a low level of the Actual Time Available per Patient in the long run, as in the Limits to Success archetype, resulting at increased Difficulty of Shift Schedule for nurses and doctors, low Availability of Equipment, ICT, Standard Procedures & Digital Forms and, finally, to low Adherence to Guidelines & Protocols. In order to test those seven hypotheses, a quantified SD model (a stock-flow diagram) would be needed, as that would enable us to run simulations and test our hypothesis in different scenarios to analyse the loop dominance. Such a model is out of the scope and purposes of the present, qualitative study and is not included, but is recommended for future research. However, we used the Dynamic Performance Management analysis as an alternative method, in order to: (1) identify Strategic Resources, Performance Drivers and End Results of hospital performance and show their role in the hospital performance management and measurement; (2) show how the time factor influences the overall hospital performance; (3) understand the contribution of each one of the four hospital divisions (the Medical, the Nursing, the Administrative & Financial and the Technical division) on the End Results (i.e., the final hospital services produced); (4) allow the division managers to start concentrating on the core intermediate, administrative products that divisions are required to deliver on the process that leads to the final end-results; (5) map the ultimate and intermediate services value chain provided to both external and internal users of the case hospital; (6) make performance measures (i.e., the drivers and end-results associated with the delivery of products) explicit and then link them to the goals and objectives of the division managers of the case hospital; (7) discuss the insights that the DPM analysis offers us for a sustainable Performance Management in Greek public hospitals in general, and in the case hospital in particular. The identification of Strategic Resources, Performance Drivers and intermediate End Results, as well as the different views that our DPM analysis offered (i.e., instrumental, dynamic, subjective, objective) provided the hospital decision-makers with signs of potential future shift in End Results, and can help public hospital managers in Greece interpret and calculate the consequences of an incident or the implications of a policy; show possible discrepancies on performance; and try to mitigate it. The performance measures we identified could be helpful to foresee possible changes in the financial and clinical results of public hospitals in Greece. When framed in a wider sense than budgetary control, transaction cost drivers can provide hospital managers and policy makers in Greece with valuable information for strategic planning, such as the opportunity to identify trade-offs in space and in time (e.g., higher costs for investments and for managerial capacity building in the short-run, versus investments in equipment, ICT, and facilities that would increase performance in the long run). Thus, the performance management policies adopted at the case hospital during the healthcare reform ( i.e., structure and process reforms undertaken) and their overall impact for Greek public hospitals’ outputs and outcomes, can now be examined through a different “lenses” by the hospital managers; lenses that will allow them overcome the seven counterintuitive, negative outcomes documented, and align the hospital’s and the different division’s and departments’ goals and actions to achieve improved efficiency and effectiveness, along with better hospital service quality for patients.

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Conselho Nacional de Desenvolvimento Cient?fico e Tecnol?gico
Psychologists‟ insertion in mental healthcare ambulatory clinics occurred during the decade of 1980, in the context of the claims disseminated by sanitary and psychiatric reforms, of the formation of minimum mental healthcare teams and of the retraction of the private clinic. Historically, this migration had been accompanied by the importation of practices traditionally applied at the clinics. Furthermore, the lack of clear guidelines from the Health Ministery occasioned the opening of ambulatory clinics with diversified structures at each city. The objective of this dissertation was to study the practices of psychologists at mental healthcare ambulatory references at Aracaju-SE. Were interviewed psychologists of these services and managers of the municipal health secretary using a semi-structured interview guideline, in addition to the analysis of management reports. It was observed that the mental healthcare references had experienced substantial changes referred to its structures and operation, leading to a present framework of expansion and readjustment. It was realized that there is an effort by the psychologists to maintain individual and group assistance, using adjustments in the frequency of the sessions and in the focus of the activities. Besides the progresses, the relation with the psychiatrist still works basically through the medical record, blocking advances on joint discussions of the cases. Some advances toward the amplified clinic are notable, like the overcoming of the isolated usage of psychiatric diagnostic and the replacement of the line‟ criterion by the urgency one. Sheltering had become an interesting strategy on flux ordination, however the mismatch between offer and demand seems to be a matter which extrapolates the psychologists‟ sphere at the references. For this reason the narrow of the relation with family healthcare centers seems to be the major challenge to be faced by psychologists at mental healthcare ambulatory references
A inser??o do psic?logo nos ambulat?rios de sa?de mental ocorreu na d?cada de 1980, no contexto das reivindica??es propagadas pela reforma sanit?ria e psiqui?trica, da forma??o de equipes m?nimas de sa?de mental e da retra??o da cl?nica privada. Historicamente, essa migra??o foi acompanhada da importa??o de pr?ticas tradicionalmente aplicadas no consult?rio. Ademais, a falta de diretrizes claras por parte do Minist?rio da Sa?de ocasionou a abertura de ambulat?rios com estruturas diversificadas em cada munic?pio. O objetivo desta disserta??o foi estudar a atua??o do psic?logo nas Refer?ncias Ambulatoriais em Sa?de Mental de Aracaju-SE. Foram entrevistados psic?logos desses servi?os e gestores da secretaria municipal de sa?de a partir de roteiro semiestruturado, al?m da an?lise de relat?rios de gest?o. Observou-se que as Refer?ncias em Sa?de Mental sofreram transforma??es substanciais quanto ? sua estrutura e funcionamento, levando a um quadro atual de expans?o e de readequa??o. Percebeu-se um esfor?o por parte dos psic?logos em manter os atendimentos individuais e de grupo, a partir de ajustes na frequ?ncia nas sess?es e no foco das atividades. N?o obstante os progressos, a rela??o com o psiquiatra ainda se processa basicamente pelo prontu?rio, impedindo de avan?ar na discuss?o conjunta dos casos. S?o not?veis alguns avan?os em dire??o ? cl?nica ampliada, como a supera??o do uso do diagn?stico psiqui?trico de forma isolada e da substitui??o do crit?rio fila pelo de urg?ncia. O acolhimento tornou-se uma estrat?gia interessante de ordena??o do fluxo, por?m o descompasso entre oferta e demanda parece ser uma quest?o que extrapola o ?mbito dos psic?logos das refer?ncias. Por essa raz?o, o estreitamento da rela??o com as unidades de sa?de da fam?lia parece ser o maior desafio a ser enfrentado pelos psic?logos das Refer?ncias Ambulatoriais em Sa?de Mental