Massey Documents by Type

Permanent URI for this communityhttps://mro.massey.ac.nz/handle/10179/294

Browse

Filters

Settings

Subject: search.filters.subject.Medical policy

Search Results

Now showing 1 - 6 of 6
  • Thumbnail Image
    Item
    Understanding the social determinants of non-communicable diseases in Nepal : a systems perspective : a thesis presented in the partial fulfilment of the requirements for the degree of Doctor of Philosophy (PhD) in Health Sciences at Massey University, Wellington Campus, New Zealand
    (Massey University, 2020) Sharma, Sudesh Raj
    Non-communicable diseases (NCDs) constitute more than half of the total disease burden in Nepal. Global evidence indicates the problem of NCDs is influenced by the complex interaction of social determinants including behavioural, socio-economic and environmental. These determinants are the focus of global prevention strategies for tackling NCDs. The health system of Nepal, however, is yet to adopt this comprehensive prevention strategies. The main objective of this research was to understand the social determinants of NCDs in Nepal and identify leverage points for systemic actions in Nepal. The study utilized a systems thinking methodology which enabled a creative combination of case study methods and qualitative causal loop diagramming. In each of the two selected case districts (Bhaktapur and Morang), semi-structured interviews (n=39) and focus group discussions (n=12) were conducted with key stakeholders and community members. These case studies were informed by policy level interviews (n=24). Thematic analysis, guided by the adapted social determinants of health framework, helped to identify key themes and develop causal loop diagrams (CLDs). The findings of the thematic analysis, and CLDs, were then validated through local and policy sense-making workshops. The analysis showed four key interlinked thematic areas, each of which is being published as separate papers. The first paper describes the community and stakeholders’ perception and experience of the rising burden of NCDs. The social experience of NCDs metabolic risks such as hypertension and diabetes were shown to be normalised. Moreover, differences in social experience were observed based on gender and socio-economic circumstances. The second paper described the critical role played by tobacco and alcohol in the interaction of social determinants of NCDs. The analysis indicates that socio-economic circumstances was root cause of changing, and damaging alcohol and tobacco practices, and increased the vulnerability to exploitation by industries. The third paper revealed that poor dietary practices and physical inactivity were resulting due to changes in social practices shaped by worsening dietary and physical environment. Socio-economic circumstances, urbanisation and migration all contributed to the population being exposed to an obesogenic environment. While all three papers discussed specific health system challenges, the fourth paper elaborated on health sector challenges, including the curative focus and limited capacity of the health system both at district and policy or national level to prevent NCDs in Nepal. Three key leverage points for health system action on the social determinant of NCDs were identified by viewing the final CLD through the lens of Donella Meadows’ framework for identifying key health system action on the social determinants of health. These leverage points indicated that the health sector should focus on the development of a robust prevention system for effective NCDs action. Overall, the study highlighted the interactions of socio-economic, gender, commercial and health system determinants driving the NCDs problem in Nepal. The leverage analysis indicated that the health sector should focus on the development of a robust prevention system for effective action on complex problem like NCDs. The Ministry of Health could play a proactive role in creating the prevention system that could effectively guide all sectors towards collective action to impacting social and commercial determinants of health.
  • Thumbnail Image
    Item
    Inter-district flow transfers : health and economic impacts : a thesis presented in partial fulfilment of the requirements for the degree of Master of Business Studies in Economics at Massey University, Albany, New Zealand
    (Massey University, 2018) Bruce-Brand, Bronwyn
    As part of the introduction of the New Zealand Public Health and Disabilities Act in 2000, the introduction of the Population Based Funding Formula led to a change in the flow of funds for transfer patients. Prior to the PBFF, for the years 2000-2003, healthcare events were contracted on a fee-for-service basis and thus were borne by the DHB of treatment. From 2003 onwards, the cost of transfer patients followed the transfer back to their DHB of domicile. This study replicates and extends work done by Shin (2013) in assessing the impacts of this change in funding flows on the level of transfer and patient health outcomes. I use OLS and logistic modelling to empirically assess these effects and draw conclusions as to the effectiveness of the policy change and any potential efficiencies that are gained. I find evidence of a focus in the probability of transfers after the change in funding, where the overall probability of transfer decreases and the probability of transfer to tertiary DHBs increases. Additionally, patient outcomes demonstrate a concentration effect whereby after the policy is implemented, the pool of transfers is less diluted by low severity patient transfers and thus displays poorer health outcomes on average for the transfer group. The concentration of health outcomes suggests that the transfer decision is being considered more carefully now that costs are aligned to the DHB of domicile. A novel addition to this research is the analysis of regional DHB pairs. The analysis of five secondary-to-tertiary transfer flows provides insight into the necessity of a decentralised healthcare system in New Zealand and is mostly consistent with the analysis at the national level. Overall, the introduction of Inter-District Flow transfer funding has increased the efficiency of the transfer mechanism and enabled a more streamlined redistribution of funds to tertiary providers. This is an important finding because it reinforces the necessity of the transfer mechanism, specialist providers and local provision in a healthcare system such as New Zealand’s.
  • Thumbnail Image
    Item
    The caring commodity : transformations in the exchange character of medicine in New Zealand (1840-1985) : a thesis presented to the Dept. of Geography, Massey University in complete fulfilment of the requirements for the degree of Master of Arts
    (Massey University, 1985) Hay, Iain Mill
    Retrospective analysis of actions and interactions connected with health care makes evident their place as constituted and constitutive components of capitalist social relations. The contextually constrained activity of individuals to achieve certain ends has contributed to the production of outcomes which appear to be beyond individual control and which shape the social world. In explaining the main transformations in the character of medical services since the early days of European settlement emphasis is placed upon the multiple and differentiated emergence of various structures of relationships between, principally, doctors and patients, doctors and doctors, and those who, at various stages, have attempted to intervene in those relations. Over the period 1840-1985, medical practice has been transformed from a service provided on a user-pays basis, to one of collective provision, and back towards the "private" sector. In the six decades after 1840 medicine and the State became enmeshed. Some moves towards the State provision of health care services occurred. The period 1900-35 saw the supporters of both free enterprise and socialistic medicine inexorably drawn towards advocacy of some grand scheme of collective care, the character of which was extensively debated from 1935 until 1942. The outcome brought "free" provision of most medical care to those in need and also served the long term interests of capital. Since then, health care has been returning to the market. In part, the broad sweep from, and back to, commodity relations has arisen from actions to "solve" problems of health care provision and use. The solutions arrived at, however, have been compromises between conflicting demands. Although at times "solutions" may have facilitated the more humane allocation of medical services, the general tendency is for them to reproduce capitalist social relations.
  • Thumbnail Image
    Item
    A nation's health is a nation's wealth : perceptions of health, 1890-1914 : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in History at Massey University
    (Massey University, 2003) Deason, Anna Rachel
    This thesis is an examination of the way health issues were perceived in New Zealand from 1890 to 1914. It investigates how these views changed and the manner in which they were reflected in health policies and programmes. Perceptions of health are examined within their social, political and cultural context. It is argued that in the period from 1890 to 1914 health issues were increasingly prominent on the public agenda. The nineteenth century was characterised by a distinct lack of interest in health, primarily because New Zealand was believed to be an inherently healthy country. From the late nineteenth and early twentieth centuries this view was challenged by the growing importance of medical science, the increasing influence of the medical profession and a number of public health scares. With the biomedical revolution of the 1880s there was more scope for human intervention in health matters and a different understanding of health. More frequent debates about health increasingly characterised the health status of the population as a national asset. New Zealand's strength as a nation was thought to be connected with its health. This shift in perceptions was related to increasing government intervention to control and protect its population's health. The Liberal Government responded to this need by incorporating health into their programme of government intervention through a centralised bureaucracy. By looking at a number of health policies in their sociopolitical context this thesis provides a holistic view of the history of health in New Zealand. From this framework of analysis a number of broader themes are discussed: the changing role of medicine, the role of the government in providing for health, New Zealand's relationship with Britain, and the construction of a national identity.
  • Thumbnail Image
    Item
    Te mana whakahaere, te whaiora Māori : change management and Māori health development : a study on the management of Māori health strategies in a changing health sector from the 1991 health reforms to the year 2001 : a thesis submitted for the degree of Doctor of Philosophy in Social Science, Massey University, Palmerston North, January 2002
    (Massey University, 2002) Manaia, William Wiremu Lance
    Two themes form the basis of this thesis. One is Maori health development, and the other is Māori health management or, in particular, the management of health sector change by Māori health professionals. Both themes are inextricably linked. One is about definitions of Maori progress and is focussed on health gains. The other is about process. Although both are examined in the context of positive development and differing perspectives, this research is essentially about Māori health management strategies, or processes through change for achieving best outcomes for Maori health service delivery. This thesis is primarily focussed within the time span 1991 to 2001, though there are speculations that go beyond that period of time. For convenience sake, the focus period for this thesis is continuously referred to as 'the 1990s'. In 1991 the National Government introduced a series of significant health reforms which accelerated a privatisation trend, making the health sector more accountable in business and commercial terms. Democratic control of hospital boards was replaced by appointed boards with business objectives, thus forming a market place within the health sector. This transformation was justified by the needs for efficiency, cost containment and accountability to consumers but in the process it increased the growing importance of management through social policy reform.
  • Thumbnail Image
    Item
    Kimihia hauora Māori = Māori health policy and practice : a thesis submitted in fulfillment of the requirements for the degree of Doctor of Philosophy, Massey University, Albany, New Zealand
    (Massey University, 2001) Kiro, Cynthia A., Ngāpuhi, Ngāti-Hine, Ngāti Te Rangiwewehe
    Health reforms in New Zealand during the 1990s introduced a new term to our lexicon, 'by Māori for Māori providers'. These providers are an expression of a policy attempt to marry two distinctive government intentions in respect of Māori. One intention was the inclusion of Māori to address political concerns such as tino rangatiratanga (Māori control over Māori lives). The other was the devolution of responsibility for Māori health outcomes to the Māori community itself, in line with other neo-liberal policies adopted between 1984 and 1999. This research examines the effects of the health reforms announced in 1991 in respect of Māori health policy and Māori health services within the Auckland region. In particular, the research is concerned with how North Health enacted these reforms. North Health was the northernmost Regional Health Authority responsible for the largest Māori population in New Zealand, the largest metropolitan centre, and areas of high Māori health need in Northland, South Auckland and West Auckland. They developed a distinctive approach to Māori health policy that would have pervasive and lasting effects on health policy in the rest of the country. In particular, their identification of three strategies for Māori health purchasing, including support for by Māori for Māori providers, mainstream enhancement and Māori provider development, formed the basis of Māori health services within Auckland for many years. This thesis is not an attempt to tell the story of the Māori health providers who form the basis of the case studies. Many have started this process themselves. Rather, it is an attempt to place their experiences within the broader context of public policy analysis during a period of considerable change in New Zealand. It also provides an opportunity for understanding the ideas of North Health as the health services purchaser. These ideas remain as significant influences on current Māori health policy through the Health Funding Authority. Furthermore, this more contextualised analysis is consistent with the Ottawa Charter's emphasis on healthy public policy. Such policy must take account of its impact on the well-being of populations within society. This policy is not limited solely to that of the health sector, but includes all public policy that impacts on health such as housing, education, income maintenance and other significant social factors. While a great deal has been written about the health reforms in New Zealand, little has been written about the implications of these reforms for Māori. Even less has been written about the specific experiences of Māori providers and the policies the underpin Māori health services and health in New Zealand. The research found that there has been considerable innovation on the part of Māori policy makers and purchasers in an attempt to shift resources to Māori communities to provide services themselves. This was part of a broader move within government policy to devolve responsibility for service provision and risk to communities of interest from the late 1980s to 1999. Strategies to promote by Māori for Māori providers enabled Māori communities (especially iwi communities) to become more directly involved in health decisions and service provision, but they also allowed weakened government accountability for Māori health outcomes. While Māori providers have displayed considerable innovation and energy in establishing services. They have developed a distinctive community development approach that is at the forefront of changes in primary care incorporating community health workers, extensive community networks and health promotion programmes. However, these elements are often under-valued within their services and they remain heavily dependent upon the GP service at the core of their health centres. Mainstream enhancement among large health providers has been largely an afterthought considered too difficult and without the political rewards of independent Māori providers. Yet the overwhelming majority of Māori continue to use mainstream services and therefore require urgent reorientation of these services to better meet their needs. The provision of local Māori services is an essential complement to what already exists and these should be strengthened and promoted because they provide suitable primary care models of care for all New Zealanders. However, this approach must be part of a broader population based and macro policy approach that informs government policies that impact on Māori health and wellbeing. The provision of highly targeted primary care services will not change Māori health status without the accompanying shift in macro-environments such as labour market participation, cultural pride and greater egalitarianism.