There is growing interest in health systems research and implementation studies within public health, yet there is little in-depth research being carried out on the front-line health workers who implement interventions in the field. This study aims to add to our understanding of implementation processes through an in-depth ethnographic study conducted over a 12 month period of participant observation with field-level health workers in an urban leprosy project. The study employs a multidisciplinary approach, combining anthropological and public health methods and perspectives, and was carried out within one of India's largest leprosy organisations. The research is, in essence, a 'project ethnography' of the work and social identity of health workers, within the context of a rapidly changing policy landscape. The study argues that health workers are embedded in the structures they work within at the same time as they actively exercise agency within these structures. By understanding how health workers utilise agency within, rather than in opposition to, structure, we can come to understand health workers' social identity, as well as how they reconcile organisational intent with local strategies in the implementation process. There is a growing realisation within public health that health systems are complex social microcosms in which health workers play a pivotal role. The study argues that the application of social theory, that examines the relationship between agency and structure, will be instrumental in developing research frameworks that truly engage with the process and complexity of health systems.

Background The wealth index is a commonly-used measure of socio-economic position (SEP) in low- and middle-income countries. The approach arose from Demographic and Health Surveys (DHS) where few other options for SEP-measurement are available. Despite many unanswered questions the wealth index approach, and the methods of wealth index construction used by the DHS, have been widely-adopted by the epidemiological community. This thesis explores the appropriateness of the wealth index as a measure of SEP, using data from the Malawi Integrated Household Survey 2004/5 (IHS2) and Brazil DHS 1996. Main findings 1) The wealth index and consumption expenditure Some proponents of the wealth index claim it to be a reliable and rational proxy for consumption expenditure; a systematic review of the literature demonstrated this to be an unreasonable assumption. Analyses of IHS2 data showed that the agreement of the wealth index with consumption expenditure is largely unaffected by alternative equivalence scales for adjusting consumption expenditure for household size and composition, or by the range of items included in the consumption expenditure aggregate. 2) Are the methods of wealth index construction used by the DHS the most appropriate? The DHS use principal components analysis (PCA) to weight the indicators in a wealth index; issues in the use of PCA were considered and alternative weighting methods explored. When nominal or ordered categorical indicators are used, alternatives to PCA are considered preferable. A single wealth index is often constructed for urban and rural areas together; generating separate indices for each area had little effect on the final index. Agreement with consumption expenditure was lower in rural areas; various approaches to wealth index construction did not alter this. Expanding the range and number of indicators used by DHS wealth indices did not increase agreement with consumption expenditure, but it did reduce 2 the observed urban-rural differences and enhance the ability of the wealth index to differentiate between rural households. 3) What socio-economic processes contribute to the wealth index hierarchy? A key issue for any measure of SEP is its conceptual clarity; analyses of the IHS2 data demonstrate that the socio-economic processes leading to a wealth index hierarchy remain largely unknown, although both household- and community-level factors play a role. 4) Alternatives to the wealth index Potential alternatives to the wealth index were explored, and the consequences of using the wealth index versus these alternatives were assessed for different purposes. The uncertainty about the socio-economic processes being captured by the wealth index implies that in all situations, the wealth index should only be used after careful consideration of available alternative SEP indicators. Conclusions Using the wealth index in the DHS has allowed the quantification and comparison of health inequalities in low- and middle-income countries on an unprecedented scale, thereby playing a vital role in advocacy of health equity. Some alterations to the methodology of wealth index construction are recommended for future studies using the wealth index, but the use of the wealth index in primary data collection is questionable given the uncertainty surrounding the socio-economic processes it is capturing.

Background: The issue of human trafficking has risen up international and national political agendas in the last decade. Existing evidence suggests that many trafficked people suffer from a range of health problems as a result of their experiences. This research sought to analyse how health was incorporated into the UK response to trafficking between 2000 and 20 I O. Methods: Qualitative data was collected through semi-structured interviews, participant observation at policy-relevant events and document collection. Data analysis was organised according to the principles of framework analysis. Results: Trafficking has been defined in the UK as a problem of organised immigration crime and the dominance of this definition has limited the extent to which health was incorporated into the national policy response. Non-governmental organisations (NGOs) strategically used information about the health consequences of trafficking to support their arguments for the provision of support and protection to trafficked people. They did not use the information, however, to argue for health- related policy change. The Department of Health (OH) and healthcare providers were not engaged in trafficking policymaking and there was no discernable domestic pressure to develop a health- based response. A limited amount of health-related policy change did occur following the UK's ratification of the Council of Europe Convention on Action against Trafficking in Human Beings, but the scope of these changes was restricted by the lack of awareness in the health sector about trafficking and by the shortage of information relating to how trafficked people use health services. Conclusions: Future health-related policy change is likely to be limited so long as healthcare providers fail to act as advocates within the policymaking process and the OH remains on the margins of the policy subsystem

Universal Health Coverage (UHC), comprehensive access to affordable and quality health services, is a key component of the newly adopted 2015 Sustainable Development Goals (SDGs). Prior to formally adopting the goals at the United Nations in September 2015, several countries began incorporating elements of UHC into the domestic policy arena. Little research has been conducted on the process through which UHC financing policies have been contested in the political realm. In 2013, President Uhuru Kenyatta of Kenya announced initiatives aimed at moving the country towards UHC, which have proven controversial. This study drew on recent theoretical innovations in the field of critical policy studies to examine the ways in which actors understood and engaged with three highly contested health financing polices introduced as part of the movement towards UHC in Kenya: user fee removal, raising contributions to the mandatory health insurer, and the failed 2004 Bill on Social Health Insurance. In addition to document review, this study involved interpretive analysis of transcripts from 50 semi-structured interviews with leading actors involved in the health financing policy process in Kenya. The frame-critical analysis focused on how actors 1) make sense of the policy environment and create meaning through circulating finance ideas; 2) name various elements of the policy design through a process of selecting and categorizing; 3) tell stories and create narratives in ways that illustrate salient features of the process and generate shared understandings. Furthermore, this analysis also focused on what is subject to framing in this dynamic process, including 1) the substantive issues of the policies in question; 2) actor identities and relationships; and 3) the policy process itself. This study found that user fee removal was framed by finance experts as an achievable shortterm target for the Jubilee Coalition’s party manifesto. The rate increase for the mandatory insurer, the National Hospital Insurance Fund (NHIF), was consistently obscured by framing the debate around the shortcomings of NHIF and its damaged legacy. Lastly, the failed 2004 Bill on National Social Health Insurance has since fragmented into several incremental policy proposals that remain the subject of divisive framing contests. This study provides timely insight into the political dynamics surrounding the UHC movement, the policy process for health financing in Kenya, as well as theoretical and methodological considerations for frame-critical policy analysis and the field of critical policy studies more widely.

Patent medicines were a major constituent of the healthcare of late Georgian England, but their position in the medical market has escaped the attention of scholars. In this thesis, information from advertisements for medicines in runs of provincial newspapers have been combined with contemporary reports and opinions, surviving printed bills, some preserved financial accounts and official documents to provide a systematic and inclusive account of the industry. My argument is that the production, distribution and sale of patent medicines constituted a stable, substantial and largely respectable industry, with only a minority of its participants being irregular practitioners. The thesis first analyses the status of patent medicines and the imperfect boundary between regular and irregular practice before exploring the functional components of the industry, which include the crucial role of the printed word. The industry employed specific practices from fixed, longstanding, premises, the owners being predominately reputable tradesmen or medical practitioners and the wholesaling being led initially by London booksellers before passing to medicine specialists and chemists. The retail market was national and structured, with the wholesalers organising and paying for much of the publicity. Medicine vending was initially dominated by the newspaper printers and the booksellers, and it was a substantial part of the income of some of them: it was later shared with the druggists. The advertising built up confidence in the medicines by a predominately low-key factual approach and by repetition, and contemporary physicians were aware that this confidence often ensured that the benefits of the medicines were greater than the sum of their pharmaceutical constituents. Thus we can regard the printed word as an essential ingredient of an effective patent medicine. The findings necessitate a reassessment of the late Georgian medical market with the patent medicines industry positioned as a distinct entity, separate from orthodox and irregular medicine, but overlapping both of them.

Recent initiatives in healthcare have begun to take a person-centred approach to treatment and consultation. Quality of Life (QoL) measures have also developed, bringing a precision that enables their use with individuals. However, applications of QoL data have tended to focus on its use by care providers. This programme of research investigated whether QoL information, applied at an individual level, was associated with changes in people's perceptions of their wellbeing. A unique protocol was developed for feeding back results from the WHOQOL-BREF and WHOQOL Importance instruments. A new graphical summary profile was generated as the core mechanism for individualised feedback. Two alternative approaches were developed: verbal guidance given by a facilitator while the participant viewed his or her graphical profile, and written instructions for inspecting the profile, to be followed by the participant when inspecting the profile independently. Initial methodological development work examined the feasibility, acceptability and face validity of these components. A "proof of principle" pilot study then investigated whether thinking about QoL, without feedback, led to effects in scores on measures of wellbeing. The main study (N=129) examined the effects of providing structured feedback on QoL (WHOQOL-BREF and Importance), mood (PANAS), health status (EQ-5D) and goal-oriented QoL (adapted OOSS). A follow-up study examined qualitative reflections on receiving feedback and the psychometric properties of the QoL measures were also investigated.

This study investigates the relations between doctors, nurses and managers in a primary care trust in South East England in an era of neoliberal reform since the 1980s. Using two concepts from the work of the cultural theorist Raymond Williams – ‘epochal’ analysis and ‘structures of feeling’ – the case study group is seen as an ‘occupational tripartite’ within a dynamic cultural totality. Using interpretive phenomenological analysis, interview data is examined and reveals aspects of tradition being used by both doctors and nurses in ways that tend towards organisational inertia and support existing dominant structures. Residual elements are employed by managers in an attempt to maintain their influence in the face of organisational change. The three groups are highly differentiated in their views and feelings, only agreeing on the difficulty of working together. The study suggests that any attempt to create more effective cooperation between the three groups needs to acknowledge and deal with the differences that exist between them rather than rely on the dominance of hybridized clinical and non-clinical roles.

Health inequalities are the result of social inequalities and a major concern in the UK. In 1986 the Ottawa Charter for Health Promotion committed to tackling such health inequalities and defined health promotion as ‘the process of enabling people to increase control over, and to improve, their health’, with the concept of empowerment at the centre. Health promotion approaches can be broadly categorised into top-down and bottom-up programmes. Tensions between these exist and the value of a balanced approach has been recognised. However, it is not well understood if and how participants of programmes that take such different approaches experience empowerment and, if they could complement one another. This research was set in Stoke-on-Trent, a city with considerable health challenges and inequalities. Two ‘real world’ health promotion programmes were considered: (i) The Lifestyle Service (LS), a top-down individual-level programme; and (ii) My Community Matters (MCM), a bottom-up, community-level programme. Each was studied using longitudinal qualitative methods. Baseline interviews (n=23, LS; n=28, MCM) were analysed using thematic analysis. At one year, follow-up interviews were analysed using comparative analysis and following constructivist grounded theory (n=13, LS; n=17, MCM). For the LS, the thematic analysis revealed three master themes at baseline (past experiences, expectations, and barriers), and a model with three categories at follow-up (identification, planning, and action). The LS was primarily experienced with a providing role similar to person-centred approaches. For MCM, the thematic analysis revealed two master themes at baseline (community deterioration and perspectives towards community improvement), and at follow-up a model with four categories (power influences, community deciding, acting, and consequences). This programme was experienced with a providing role by ‘disengaged’ residents, but with a role of enabling action by ‘engaged’ residents. This provides novel insight into participant experiences of empowerment through individual- and community-level health programmes with recommendations of how such approaches can better collaborate and complement one another as part of an overall effort to improve health and reduce health inequalities.

'Continuity' is frequently cited as a core value for UK general practice, and in this context usually appears conceptualised in terms of personal continuity or ongoing relationships between patients and general practitioners (GPs). Formal definitions include other dimensions such as continuity of information, and the co-ordination of care, and these are more promoted in recent UK policy documents and by organisational change. Two studies were conducted for this thesis. The first used multilevel regression analysis of survey data from over 25,000 patients in 53 general practices to explore the distribution of 'continuity' in the sense of whether or not patients were seeing their 'usual or regular' GP. The key findings were that measured 'continuity' was lower in larger practices and those with shared lists where patients can see any GP. Younger patients and those without chronic disease were less likely to be seeing their usual or regular GP, although whether the age association represents a cohort or lifecycle effect cannot be addressed with cross sectional data. In the second study, thirty-two patients and sixteen GPs were interviewed about what they valued about general practice. Interviews were semi-structured, and the data were analysed qualitatively. A thematic analysis of which dimensions of 'continuity' were valued by patients and GPs, and how these related to other valued processes and outcomes of general practice care was developed. Further analysis focused on the ways that GPs used 'continuity' to construct a particular kind of professional identity, and whether patients accepted or rejected the claims to a particular identity made by GPs. Both GPs and the majority of patients emphasised the importance of personal continuity. A key difference was that patients talked about routinely balancing personal continuity against access, with their preference varying with the nature of the problem to be discussed. The majority of patients said that they usually preferred to wait to see 'their' GP, but a few solely prioritised speed or convenience of access. GPs and patients ascribed a similar range of advantages to personal continuity, but GPs focused on benefits in terms of better diagnosis and management of problems, whereas patients emphasised feeling more at ease, being able to be more active in consultations, and increased trust and legitimacy. In formal definitions, the different dimensions of'continuity' are made conceptually distinct. But for these GPs and patients, different dimensions of continuity were interwoven. Personal continuity (an ongoing relationship) and longitudinal continuity (seeing the same GP) were routinely conflated, and GPs described complex interactions between the different ways of knowing the patient associated with personal continuity and with continuity of information embodied in the medical record. Personal continuity was frequently deployed by GPs to distinguish themselves from hospital doctors. This boundary was repeatedly constructed without prompting throughout the GP interviews, suggesting that it was a problematic area. This appeared to be because of hospital doctors' greater expertise in diagnosis and management of particular diseases or problems, something acknowledged by GPs and taken for granted by patients. In contrast, GPs appeared to assume that their control of medical knowledge made their identity with regard to nurses unproblematic. Supporting this, patients talked about nurses' work largely in terms of the tasks done, and said they did not greatly value ongoing, personal relationships with nurses. Underpinning both of these boundaries was a shared assumption of medical work as primarily being the diagnosis and management of problems, with a stronger biomedical emphasis than was immediately apparent in talk about 'personal continuity'. The data are used to discuss the ways in which personal continuity appeared central to patients' and GPs' experience of general practice, and to the construction of a stable professional identity for GPs. The usefulness of 'continuity' as a research or policy concept is then explored. Although formal definitions of'continuity' are conceptually helpful, different dimensions of'continuity' are likely to be interdependent within an individual health care system. Understanding 'continuity' therefore requires a sensitivity to this wider context. Finally, possible implications of current organisational change for the experience of 'continuity' by patients and the professional identity of GPs and general practice are examined.

The Indicative Drug Target Scheme was introduced to the General Medical Services (GMS) scheme in 1993 with a view to encourage more rational and efficient prescribing. Each GP practice's drug budget is determined chiefly by the number of people on the GP's GMS panel adjusted for national age-related average prescribing expenditure. This thesis examines the factors associated with variations in GMS prescribing expenditure, proposes a number of alternative ways of constructing GMS drug budgets and examines the potential budgetary consequences. A unique dataset of individual-level and GP-level factors is constructed, including the first research application of an administrative database of demographic, socio-economic and access-related variables, the generation of chronic illness indicators, and the application of new measures of GP prescribing style. Multiple imputation of missing values and imputation of income are two additional innovations. Drawing on recent advances in risk-adjustment and the microeconometrics of health care utilisation, various specifications of an expenditure function are examined, given the skewed distribution of prescribing expenditure. These include logarithmic transformations, generalised linear models and finite mixture models. Quantile regression and outlier identification techniques are used for exploratory data analysis and to assist model specification. The principal determinants of prescribing expenditure are chronic illness, disability and age. Access to services and GP characteristics also have important effects. A number of competing models of budget setting are tested for predictive performance and distributive consequences. Most alternatives are an improvement on the current model. Compared to the current approach, the preferred model has greater explained variance, lower prediction error, is more pro-poor and has lower prediction error for vulnerable groups such as the disabled and the chronically ill.