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.

To-date primary care delivery - defined here as first-contact patient care delivered at the first level of health systems - in low- and middle-income countries (LMICs) has been an under-researched topic, with researchers tending to focus on specific diseases or vulnerable groups (e.g. children, pregnant women). Yet as vertical programs have evolved and expanded in the past two decades, interest in primary care has been renewed, specifically as operational challenges to delivering integrated care have surfaced. There is also growing recognition that vertical interventions benefit from a basic foundation of general clinical quality, which in turn, requires integration at the point-of-care. One of the few notable, yet comparably under-researched, efforts to advance integrated primary care delivery in LMICs, is the World Health Organization (WHO)'s Integrated Management of Adolescent & Adult Illness (IMAI). IMAI consists of simplified protocols addressing common adult and adolescent illness and targeted at health workers at first-level facilities. Unlike the better-known Integrated Management of Childhood Illness (IMCI) for children under-five, however, IMAI lacks an evidence base either for its validation or its impact on care. This thesis addresses this gap and describes an implementation research trial - using a pre-/post- intervention plausibility design - of the impact of IMAI training combined with a program of sustained mentoring and supervision, on the quality of care and on the performance of primary care nurses in one district in rural Rwanda. The main finding of this trial is that IMAI training and sustained supervision leads to significant improvements in basic quality indicators and behaviors such as taking of vital signs and screening and counseling for priority conditions, while also resulting in a greater than two-fold increase in the odds of agreement in diagnosis and treatment decisions by nurses, when compared to the reference standard. This effect remained for diagnosis with exposure to supervision alone, but in the absence of classroom-based didactic IMAI training, highlighting the importance of sustained mentorship to improving health worker performance and quality. This study is one of the first of its kind to focus specifically on the quality of integrated primary care delivery in itself, rather than through the lens of a specific proxy disease or population subgroup. It is also the first study to provide impact data on IMAI, and thus offers early evidence of its utility as an organizing protocol to improve integrated primary care delivery in LMICs.

The aim of this thesis is to demonstrate how the use of administrative health data (AHD) has evolved over time to be a valuable resource for quantifying disease burden. AHD are defined as data routinely collected for the purposes of payment, monitoring, priority setting, and evaluation of the provision of health services. While the primary purpose of AHD is not research, and researchers typically do not have a direct role in their collection, they represent a rich source of data for secondary analyses. The thesis presents and critiques 12 peer-reviewed publications to demonstrate how the use of AHD has evolved for better understanding the burden of disease. Each publication shows a natural evolution in thinking, and sophistication of methods that help to illustrate how secondary data can be used to augment primary data collection methods. The development of evidence using different methods, particularly when there are consistent results, works to strengthen our understanding of any given health issue. The thesis defines AHD, as well as its strengths and limitations, and how these data can be considered ‘big data’. Next, historical developments on secondary use and AHD are provided starting with the work of John Graunt, and ending with the present author. The value of AHD is explored critically through the following themes: role of mortality and hospitalisation data; development of algorithms for improving the accuracy of AHD for determining the presence of disease (case definition algorithms); strength and value of longitudinal designs; identification of rare health events; assessing the burden of co-morbidities; assessing health outcomes; and finally how AHD can support policy development. Future directions for research are highlighted, as well as how AHD can be used to inform policy, resource allocation, and practice.

The literature on inter-organisational collaboration, although wide-ranging, offers little guidance on collaboration as process. It focuses in the main on human attributes like leadership, trust and agency, but gives little consideration to the role of objects in the development of inter-organisational collaborations. A central aim of this thesis is to understand the interaction of objects and humans in the development of a particular health and social care partnership in the North East of England. This socio-material perspective was achieved through actor-network theory (ANT) as a methodology, in which the researcher is equally sensitised to the role of human and non-human entities in the development of a network. The case study is that of the North East Lincolnshire Care Trust Plus (CTP). This was a unique health and social care collaboration arrangement between North East Lincolnshire Council and North East Lincolnshire Primary Care Trust, setup to address heath inequalities in the region. The CTP was conceived and developed at a local level by the respective organisation’s decision makers in the face of considerable opposition from regional policy makers and national regulators. However, despite this opposition, the directors eventually achieved their goal and the CTP became operational on 1st September 2007. This study seeks to understand how the CTP was conceived and developed, in the face of this opposition. The thesis makes a number of original contributions. Firstly, it adds to the current body of literature on collaboration by identifying how objects can help problematize issues and cement inter-organisational collaborations. Secondly it provides a novel account describing how two public sector organisations created a unique collaboration, despite pressing resistance from the regulatory authorities; and thirdly it extends Callon’s (1996) notion of problematization to examine how, what is rather vaguely described as ‘context’ in the literature, becomes enmeshed in decisions to collaborate.

Patient safety is a high priority for everyone working within healthcare (Vincent 2006, Walshe and Boaden 2006). However, while over the last decade or so there has been an outpouring of information to improve the safety of patient care, unfortunately, putting the recommended changes into practice has fallen short of their envisioned potential (Mulrow 1994, Berwick 2003, Elwyn et al. 2007). The project context was the NHS in England and Wales with the scope of the project limited to the acute care hospital setting in England and Wales. The project sought to identify how the NPSA could support improvement in implementation. It sought to explore the factors that help or hinder successful implementation, through a collective effort, using my personal experience and expertise, that of NPSA colleagues, external experts and the views of staff in acute care hospitals across England and Wales together with the literature. The findings led to the design and development of an implementation toolkit, initially targeted at NPSA staff and other national bodies responsible for issuing guidance and safer practices. The project output therefore comprises a product in the form of an implementation toolkit supported by a critical commentary on the development of the product. These will provide an original contribution to my own knowledge and understanding, as well as that of my work place, the NPSA, my professional areas, nursing and patient safety, and the knowledge base of the Middlesex University. Post-doctoral activity will involve the promotion, use and evaluation of the toolkit in 2009.

This practice-based study investigates the implications for NHS leadership, leadership development and organisation development of the current government's vision of the future NHS as set out in the NHS Improvement Plan (2004). The study is based on two projects; an in-depth organisation development programme located in a high security mental health hospital and a pilot project on the future role of leadership carried out on behalf of the five Strategic Health Authorities in London. The research paradigm is that of naturalistic inquiry using action research and a single case method involving participant observation. Focus groups and a modified Delphi-consultation are used to elicit views about future leadership roles and competences. The two-project design was developed to address the range of leadership roles to be explored, the interplay between leadership development and organisation development and the need to understand both current realities and future developments. The study concludes that successful realisation of the vision set out in the NHS Improvement Plan will require a re-conceptualisation of the roles and competences of both organisational leaders and leaders working at the interface with service users. The study suggests that organisational leaders will need to become adept at shaping the cultures and practices of organisations and systems of organisations (enabling leadership) whereas leaders working at the interface with service users will need to become adept at case management. The study also suggests that leadership development and organisation development need to be closely integrated if either is to make a worthwhile contribution to the development of the NHS. Finally, the study suggest that success in past or current leadership roles in the NHS is likely to be a poor predictor of future success as the leadership requirements of the future will be significantly different from those which prevail currently or which have prevailed in the recent past.

The project investigated a practice question. How can public and third sector managers and clinicians develop their capability to be constructively awkward? That is, to confront and challenge while keeping relationships in tact. The literature on ineffective leadership links such out comes to a failure of followership and the loss of an individual and collective capacity to critically evaluate accepted ways of behaving and thinking and their consequences for self and others. The experience of leaders and practitioners is that while challenge is espoused by the leadership literature and frameworks, there is insufficient guidance on how to enact such challenge, belying the ambivalence towards challenge in the workplace. Ten people were interviewed, each with a reputation for constructive awkwardness and the ability to reflect on times when they had been silenced. The data was transcribed and analysed according to grounded theory principles and a Critical Realist ontology. The major elements of the theory to emerge were: the presence of a self-authorisation mechanism, constituents of which were reflexivity, holding a boundary position and having an explicit value base; a self-silencing mechanism reflecting the anxiety some felt in relation to looking stupid; and a reparation mechanism, that some used to backtrack when their emotive expression alienated the recipients of their challenge. The project theory was consistent with the finding of Archer (2003) and her study of reflexivity as the means by which personal concerns are negotiated with one’s social context. The project suggests that the capacity for self-authorisation was relied on more by community-based practitioners, who could not rely on professional and institutional derived authority. The project drew upon the insights into the causes of bad leadership and suggested how an active followership, described in the literature as necessary, could be practically enacted via a valid development activity. The conclusion notes the project’s shortcoming in relation to the lack of ethnic and cultural diversity in the interview group. This resulted in a lack of depth to the conclusion that community-based leaders may authorise their interventions differently. The conclusion ends with four propositions. It would be useful to: further develop the theory in relation to self-authorisation; to continue to explore the application of the concept of the psychological contract to understanding how one learns about how to manage feelings and challenge in the workplace; to test the assumption that community leaders authorise their interventions differently to public sector practioners and that there is a distinctive community-based leadership theory that is different to the public sector discourse that currently defines such leadership.

Clinical leadership and engagement across organisational boundaries has been gaining significant attention over the last few years. Within the NHS, there has been an increased focus within policy directives and the literature on partnership working, collaborations, cross-organisational and cross-professional working. These innovative ways of working are seen as a means of improving the quality and co-ordination of patient care across the pathway, thus impacting on the patients‟ experience. Despite this focus, the evidence of what constitutes and therefore what can deliver effective inter-organisational clinical leadership and engagement within this context is sparse. This study identifies the characteristics and impact of effective clinical leadership, clinical engagement and team effectiveness when working across organisational boundaries. „Practical Recommendations‟ have been developed as a mechanism to disseminate the findings. This research is based in the real world, which is complex and messy. The study uses an interpretative stance and gains insights from a number of different perspectives. The methodological approach is action research with a single case study design. Both quantitative and qualitative data are used and these are collected through a team effectiveness tool, focus groups and semi-structured interviews. The study demonstrates there are significant improvements in the delivery of healthcare and patient experience when clinicians work effectively across the whole patient pathway, spanning organisational boundaries. The study findings are: the need for a focus or forum and for clinicians to have the time and space to initiate inter-organisational working; the power of the patient‟s voice, involvement and leadership in delivering impactful change; the need to understand organisational and personal barriers and risks to inter-organisational working; the requirement to align incentives and accountability; the need for the NHS to value service improvement approaches as well as randomised controlled trials; the necessity for clinicians to have managerial and leadership skills to effectively run inter-organisational projects; and, the necessity for senior management and corporate engagement. These findings are supported by the existing literature, whilst also contributing to knowledge and understanding. The study aligns with the current direction of increased inter-organisational working within the NHS, and illustrates the benefits of working in this way. It demonstrates the fundamental role of clinicians (especially doctors) and patients when using this approach. The „Practical Recommendations‟ offer clinicians and managers an opportunity to consider the key elements that determine the success of improvement initiatives spanning a whole pathway or health system. Additionally, this study raises several new research questions and highlights some key recommendations such as: the need to agree the level at which NHS organisations can support inter-organisational working whilst remaining financially and competitively viable; the requirement urgently to review and revise training for doctors to ensure that in the future it equips them for effective participation in inter-organisational working; and the need to ensure the patient voice is focussed on enhancing quality of life through improvements in healthcare, rather than just simple redesign projects.

The recent economic crisis has prompted many organizations to review their maintenance operations with the main objective of controlling costs while trying to maintain a similar level of services and quality. The healthcare industry in Saudi Arabia faced a similar set of problems as the main sponsor (i.e. the Government) received lower revenues from oil export. As intimated by Saudi government officials, the current growth rate in healthcare expenditure is unsustainable in the longer term and efforts are being made to manage resources more efficiently. One area under consideration is the maintenance functions of Saudi hospitals and clinics, as these operations accounted for the bulk of the maintenancerelated expenditure. As the largest strategic hospital in the Kingdom, the Riyadh Military Hospital (RMH) has a long term plan to improve the quality and reliability of its services, through better utilization of resources. The present project forms part of the on-going strategic review of the hospital’s current maintenance operations including outsourcing and subsequent management of contractors and suppliers. A key challenge is to understand how maintenance activities could be managed more successfully and implemented in a cost-effective way. Two sets of questionnaires were designed and distributed to the staff including contractors in the Maintenance Department. The questionnaire surveys were supplemented by interviews to assess the managers’ awareness/understanding of the importance of leadership, change management, transparency, documentation, communication and clarity of strategy. By means of statistical analysis, the data/information thus gathered was analyzed using a range of quality and reliability tools and techniques. A number of correlations have been identified which confirmed the observations of previous studies. For example, there appeared to be a significant correlation between "the clarity of strategy" and "consistency of maintenance performance", and between "a happy worker" and "the clarity of instructions" and "availability of appropriate tools". Five main parameters have been identified as critical to the success of the maintenance operations at RMH: clarity of policies and procedures; support of senior management; organizational structure; employee qualifications (i.e. technical knowledge and skills); and clarity of maintenance contracts (including communications with external contractors). Informed by the work of others for the engineering and related industries, a maintenance management framework has been proposed for the healthcare industry in Saudi Arabia. Part of the framework has been implemented at the case study hospital to facilitate validation. It was found that the framework provides a useful means for integrating various maintenance-related activities and to allow guidelines to be provided on the monitoring and control of the processes. This in turn enabled a substantial revision to be made to the current maintenance procedures at the hospital. The effectiveness of the revised maintenance procedures has been investigated using limited field studies. It is pleasing to note that encouraging results have been obtained. For example, the total number of dockets (i.e. maintenance work orders) issued for general maintenance over a 4-month period fell by 23% when compared with the figure for the previous year. The present study has made a significant contribution in the development of a maintenance management framework for the healthcare industry in the Kingdom of Saudi Arabia.

No description available.