Previous epidemiological studies suggest that mood and anxiety disorders are highly prevalent among the general population and are a leading cause of disease burden. Furthermore, mental health disorders have major economic implications for wider society in terms of elevated healthcare costs as well as reduced productivity among those who suffer these conditions. The central aim of the current thesis was to undertake the first comprehensive investigation of the economic and social burden of mood and anxiety disorders in Northern Ireland, based on validated diagnostic estimates. This was achieved by 1) an examination of the prevalence and correlates; 2) and investigation of levels of service use; 3) an estimation of the societal economic costs; and 4) an examination of the experience, mental health impact and economic costs of psychological trauma. Analyses were based primarily on data from the Northern Ireland Study of Health and Stress, the largest epidemiological study of mental health in Northern Ireland based on validated diagnostic criteria. A range of additional data sources were drawn upon to produce economic cost-of-illness estimates. All analyses were implemented using Stata. The current thesis clearly demonstrates that mood and anxiety disorders represent a substantial public health burden in Northern Ireland. Prevalence rates are among the highest of all estimates produced around the world. Civil conflict has undoubtedly contributed to high levels of mental ill health, manifested by the rates of PTSD and other trauma-related disorders. Despite the elevated burden of mood and anxiety disorders, the majority of individuals do not seek help. Cost-of-illness estimates suggest that these disorders are associated with an annual economic burden of around £1.45 billion and £1.35 billion respectively. Evidence presented throughout the current thesis provides a robust evidence-base to inform the provision of effective services for these conditions and allocation of resources to those most in need.

The thesis examines how public expenditure on the National Health Service (NHS) was constituted as a political 'problem' resulting in expenditure constraint throughout the 1950s. It argues that the 'problem' related to the influence of estimates made during wartime planning which were frequently used to judge current expenditure from the beginning of the Service to 1960. Such estimates understated the costs of a future NHS and gave an exaggerated view of the extent to which expenditure was 'out of control'. This approach to evaluating Service expenditure was challenged by 'social accounting' reflected in the Guillebaud Report (1956). Social accounting situated NHS expenditure in the context of National Income and demonstrated that NHS expenditure increases were modest in real terms. However, such findings were resisted, particularly within the Treasury, and forms of financial control inherited from the inter-war period, continued to be used in the 1950s. The thesis explores two responses to this 'problem'. Firstly, capital expenditure is examined as a case of expenditure control. It is demonstrated that, while increased investment in hospitals was seen as promoting operational efficiency, the Treasury concern with restraining current expenditure created resistance to a larger capital programme in the 1950s. Secondly, 'managerial' techniques to promote efficiency are examined by looking at attempts to change accounting practice in the Service during the 1950s. It is argued that this experiment was constrained by criticisms of the appropriateness of applying such techniques in health; and because of their implications for medical autonomy. The overall conclusion of the thesis is that there was a disjuncture between the radical shift in health policy which led to the creation of the NHS and the perpetuation of conservative approaches to financial control.

As there is a recognised dearth of evaluation studies that examine a wider range of outcomes resulting from Leadership Development Programmes (LOPs), our knowledge about what these outcomes are and how these are experienced by learners remains limited. To redress this gap, this study takes learners' lived experiences of LDPs as a point of departure and explores all potential outcomes of LOPs. It also explores temporal dimensions of outcomes and participants' descriptions of the possible connections between the outcomes and the programmes. By using phenomenography and Goal-Free Evaluation technique, this study examined participants' lived experience of LDPs in a largest NHS organisation. Data were collected via semi-structured interviews, from 43 Middle-Managers who took part in one of 2 similarly-oriented LDPs, which were explicitly designed to create a community of leaders (i.e. social capital) in the chosen organisation. Participants were purposively sampled from 22 different cohorts, 3 to 24 months after completing the LDPs. Phenomenographic data analysis revealed that there were significant variations in the ways participants experienced LDP outcomes, which were more dynamic, fluid and plural than current outcome conceptualisations. Contrary to what most evaluators might expect, the participants did not report reactions, skill acquisition, behaviour modification and ROI as outcomes of the LDPs. This study identified and named three emergent outcome-categories such as symbolic, rejuvenation and engagement outcomes. By revealing the temporal dimensions of the outcomes, this study showed that time does not have a uniform effect on them. In addition, this study also discovered a fresh set of connections that link the reported outcomes with the LDPs in question. Implications for LDP evaluation theory, practice and policy are specified. LDP facilitators, programme managers, evaluators ahd evaluation commissioners may find these findings of value.

Background: Community engagement has become mainstream practice in many sectors, such that many might say that it has become another box to be ticked when planning and delivering projects. There are many potential benefits of community engagement to the residents, local stakeholders and external delivery agencies; however gaps have been identified in the evaluation of impact, barriers and facilitators of community engagement (NICE, 2008). This study prospectively looks at how the process of community engagement under the Well London programme (a five-year health promotion programme which addresses physical activity, diet and mental wellbeing) was delivered in multiple deprived neighbourhoods, and how this process influenced the different stakeholders and the health promotion projects delivered. Methods: This study used a mixed method approach to examine the process, perceptions, impacts, incentives, barriers and challenges of community engagement. Data were collected through literature review, questionnaire surveys, participant observation, qualitative interviews and evidence from documentary sources. Results: The study found that the World Café and appreciative enquiry approaches used were useful and effective tools for engaging communities; and the primary motivation for residents’ participation was the desire to belong to a community which they could help shape for the better. Key lessons from the process are the need to manage the expectations of local stakeholders and residents by effectively communicating programme goals and limitations; and the need for sufficient time to build relationships and trust for engagement. Residents’ level of engagement was influenced by past experiences of consultation processes, local politics and regeneration. There is a need to have good knowledge of the community that is being engaged, and to know the local context and peculiarities which differentiate communities. Conclusion: Residents of different ages, gender and cultures engage differently and processes should be sensitive to, and accommodate these differences. The impact of the CEP on the design and delivery of projects was inconclusive.

This thesis examines the problems of health financing and the emergence of Mutual Health Organisations under the health sector reforms in Ghana. Governments of sub-Saharan Africa region have embraced the Community-based health insurance schemes concept under the health sector reforms, with momentous enthusiasm. They believe that these newly emerging health financing arrangements could easily be utilised as platforms for initiating Social Health Insurance strategies to reach the economically deprived people. Without such schemes, citizens would become poorer because they would have had to dispose of their family's wealth in order to treat a member who falls sick. Ghana, a developing country in West Africa has introduced a National Health Insurance Scheme, which is fused with Social health insurance and Community-based health insurance schemes. This study examines pro-active plans to address the financial viability of the schemes, to prevent them from going insolvent. The study generally, investigates health sector reforms in the context of Ghana. Four operating District Mutual Health Insurance Schemes (MHOs) were selected using geographical locations, among other criteria, as case studies. Data was gathered through interviews. The findings of the empirical study were analysed and interpreted using social policy and community field theories with the support of available documents. The evidence from the study concludes that government's intervention (implementation of NIH Act 650) has increased and expanded the membership base of the schemes: from small group-based to district-wide schemes under the ambit of the District Assemblies. However, such intervention has equally led to diminished community initiatives in establishing, and the complete collapse of the original small group-based schemes. The study also finds among other things that: <ol> <li>The financial viability of the schemes depends on the provision of long-term government subsidy. However, they may not be financially viable beyond subsidy-funding due to uncontrollable high utilisation rate, occurrence of health insurance fraud, moral hazard and associated exorbitant claims made on them by health care providers.</li> <li>There are problems with late release of reimbursement funds for discharging with claims by the central government. This has impacted heavily on the financial and strategic management and decision making processes of health institutions in the operating districts.</li> <li>Health managers are unable to fulfil their contractual obligations to their suppliers as their capital funds are locked up with the Mutual Health Organisations that arc also unable to provide front loading for the health providers even up to a period of three (3) months of their financial operational requirements. </li> <li> There is therefore. a perceived tension between the schemes and the health institutions as the health institutions prefer to treat clients who come under the 'cash and carry' group since they provide prompt payment to the detriment of insured clients whose reimbursement is delayed causing the institutions to be cash-trapped. This is recommended for immediate attention.</li> </ol>

The concept of evidence-based policy to address public health issues has increasingly been adopted in England and U.S. as the standard for policy development, with the growing expectation that systematic reviews should be the primary source of evidence. Our understanding of the relationships between evidence and policy, and systematic reviews and evidence-based policymaking is tenuous at best, yet is of fundamental importance to evidence-based policy, particularly policy to address morally and ethically-grounded issues of equity and health inequalities. It is within these relationships that the process of evidence-based policymaking and the use of systematic reviews take place. If we understand this process, we have the opportunity to control the movement of evidence into policy from inside the process itself, in order to enhance the ability of systematic reviews to contribute fully and appropriately to policy. This is the crux of the original contribution of this thesis – to get at the heart of the process of evidence-based policymaking, so that we may see where and how we can and should guide the use of evidence to address policy issues and the use of systematic reviews in evidence-based policymaking. It does so in the context of a key public health challenge in England and the U.S. – health inequalities related to nutrition, infant feeding, and policy to promote and support breastfeeding.

This thesis contributes to the wider debate on Prudent Healthcare and Relational Practise. The study aimed to determine how to engage clinicians in cocreating health by developing a framework for cocreating health to support the patient-clinician interaction and to identify the factors in its successful implementation in health services. The interaction between patients and clinicians is at the heart of health care. They are the first point of contact and a familiar interaction with the health service for most patients. Within UK health services there are three hundred million consultations held every year. Consultations happen in a variety of contexts, locations and with many different clinical professions. The overwhelming majority of these interactions follow a set pattern, the rules of engagement, which governs how patients are examined, histories established, symptoms described, test results discussed, progress monitored, treatment options given and decisions made. However, the traditional medical model of consultation can reinforce a power imbalance between clinician and patient, and create paternalistic relationships that reduce patients' control, leading to their 'systematic disempowerment'. Cocreating health is about enablement, viewing patients as assets not burdens and seeks to support them to recognise, engage with and develop their own sense of resourcefulness building on their own unique range of capabilities. Cocreation means that health care services support people's individual abilities, preferences, lifestyles and goals. In a cocreating health model of interaction, patients work with a supporting clinician. Such interactions consider the patient's life goals, how they plan to work towards them and what support they need to help her get there. Working in cocreation, a clinician would support patients to think about goals that are meaningful and adaptive. A number of elements of cocreating health such as self-supported management and decision support have previously been developed. However, these have generally been implemented within the context of the traditional 'medical model' of consultation. In the development of the cocreating health framework, a mixed qualitative and quantitative approach was taken to explore different aspects of cocreating health and to triangulate knowledge obtained from the different methodologies. Principles of grounded theory were used in the qualitative research. Data and insights were obtained in two phases. In the first phase, over thirty workshops were held with over five hundred participants from Welsh Government, local authorities, voluntary sector and across the NHS in Wales including policy makers, leaders of health services and clinicians. Insights from these participants combined with knowledge gained from the literature review were used to develop a cocreating health framework for testing. The initial data suggested that for clinicians, working collaboratively with patients in agenda setting was the most unfamiliar and potentially transformative element of cocreating health. Accordingly, training was arranged for one hundred and sixty four clinicians whose attitudes towards cocreating health were explored using questionnaires. In the second phase, semi structured interviews were held with thirty one participants from

Background: Since 2008, more than half of the world's population now live an urban area. The consequences of this are strains on existing resources such as access to healthcare, housing and infrastructure. Therefore, access to data at the urban level is important for those involved in policy making in order to assess and address these issues. This is especially important for developing countries where resources are already limited without the added strain of urbanisation. This PhD study is nested within the EURO-URHIS 2 project, a DG Research, FP7 Programme project which is collecting data on a series of indicators deemed to be important to urban health. The first part of this PhD study investigates whether the EURO-URHIS 2 data collection tools designed for use in Europe can be replicated in Vietnam. During a preliminary fieldwork trip to Vietnam it was found that it would not be possible to obtain permission to interview policy makers or the urban population of Ho Chi Minh City within the study time frame. Therefore, the second part of this PhD study is to explore the use of existing data sources, functions and activities of Non-Governmental Organisations (NGOs) in Vietnam. Methods: The EURO-URHIS 2 existing data survey was used to collect country and urban area level data from Vietnam. The data for the NGO study was collected using an online questionnaire hosted on a server by the University of Manchester. Results: The study found that it was possible to use the EURO-URHIS 2 existing data tool to collect a range of health indicator data at the country and urban level in Vietnam. The online study determined the role of international NGOs working in Vietnam and barriers to using existing sources of information. The study also found low levels of NGO engagement with other NGOs, policy makers, local authorities and Vietnamese government organisations. Conclusions: The successful implementation of EURO-URHIS 2 existing data survey allowed the examination of the potential health implications of urbanisation in Vietnam. The NGO study identified key areas where international NGOs in Vietnam were active, barriers to using existing sources of data and NGO relationships with other actors. The study also suggested opportunities for further NGO engagement.

This work develops a means to encourage states to take advantage of the flexibilities of compulsory licensing in the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) which promotes access to medicines in a public health emergency. In pursuing this solution, the precautionary approach (PA) and the structure of risk analysis have been adopted as a means to build a workable reading of TRIPS and to help states embody the flexibilities of intellectual property (IP). This work argues for a PA reading of TRIPS and that states have the precautionary entitlements to determine an appropriate level of health protection from the perspective of “State responsibility” in international law. A philosophical review is conducted followed by the examination of existing international legal instruments including the WTO Agreement on the Application of Sanitary and Phytosanitary Measures, the WHO International Health Regulations, the Codex Alimentarius, and the Cartagena Protocol on Biosafety. The PA has been found to have a pervasive influence on risk regulation in international law, yet the application is fraught with fragmentations in different legal regimes. In order to reach a harmonious interpretation and application of the PA in the WTO, the legal status of PAs of different WTO instruments have been analysed. Further, a comparative study on PAs in terms of legal status in the exemptions of the WTO and TRIPS obligations has been proposed. The political and moral basis for compulsory licencing in a public health emergency has been bolstered through the interpretation and the creation of legal status of the PA in WTO/TRIPS law.

La thèse présente le système de santé en Chine à travers son évolution depuis les années 50 et en fait une analyse institutionnelle pour comprendre comment le gouvernement chinois a réagi pendant les différentes phases de développement face à la demande de la population en termes de protection sanitaire. L’idée de cette thèse est de combiner une analyse institutionnelle avec une étude de cas à Weifang en Chine pour comprendre en profondeur le système de santé Chinois, mais aussi pour essayer de fournir des supports utiles pour les autres études qui pourraient être menées sur ce sujet. / This thesis tries to explain the Chinese health system since the 50s, and make an institutional analysis to understand how Chinese government reacted during different steps of development face to population’s demand in terms of health protection. The purpose of this thesis is to associate an institutional analysis with a case study in Weifang in China to deeply understand chinese health system, at the meanwhile this thesis tries to provide useful support for other future studies on this subject.