This study aimed to explore researchers' and policy stakeholders' perceptions of the usefulness of public health research for policy, using the example of maternal health in Ghana. Sixty-nine government decisionmakers, maternal health policy stakeholders and researchers were interviewed. Concepts of research were broad. Research was dichotomised into `big', formal research and 'small', applied research such as operations research. 'Small research' was highly valued, due to its speedy completion and its focus on topics pertinent to service delivery; big research was not always considered necessary. Effectiveness research, one type of `big research', was not highly valued. Interviewees tended to feel that 'effective' policies and programmes could be designed once there was a thorough understanding of the situation. There was an implicit assumption that as long as these interventions were implemented well, they would be effective. Six dimensionso f local applicability/transferabilitwye re identified.T he most influential factors were the ease with which the intervention could be implemented, the study's congruence with interviewees' previous experiences and the perceived need for the intervention. Little attention was paid to study findings. Judgements of an intervention's potential effectiveness tended to be based on the ease of implementation or knowledge of similar projects. Adaptation was considered to be crucial, although often conceptualised not as a factor within local applicability/transferability assessments, but rather a distinct, essential step in the research use process. This study suggests that the factors of local applicability/transferability frequently cited in the literature do not reflect those considered to be most important by stakeholders in Ghana.

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Individuals all over the world continue to utilise traditional health care, but there is very little understanding of why this is the case, especially in light of increased availability and accessibility of effective pharmaceutical medicine and other modern technologies. The overarching objective of this thesis is to investigate rationales for utilisation of traditional medicines, using Ghana as a case study. This thesis argues that institutional constraints and cultural preferences inherited from the past shape pluralistic health systems and, consequently, individual health-seeking behaviour. The thesis fuses investigative approaches from different disciplines (e.g. anthropology, economics, psychology) and uses statistical methods to analyse four aspects of medicines utilisation: the role of culture, income, the possibility of a placebo effect in use and finally, the distributional consequences manifested in utilisation inequities. Findings indicate that cultural attitudes and income constraints are associated with use of traditional systems, and users report high rates of satisfaction that are attributable to procedural factors. Inequities are shown to differ according to whether traditional medicines are included in analysis. Generally, this thesis advocates a holistic approach with respect to health systems, as opposed to interpreting traditional systems as simply appendages to modern health care systems; the latter perspective is liable to yield observers only a partial story of medicines utilisation and its impact on equity.

In light of recent emphasis on achieving Universal Health Coverage through social health insurance in low income countries, this thesis examined how the National Health Insurance Scheme in Ghana impacts on equity of access to healthcare in Tamale District of northern Ghana. Using mainly a qualitative approach, the thesis specifically examined whether the NHIS promotes equity in health insurance coverage and whether insured members are able to access healthcare equitably. Against this background, four broad findings were identified. Firstly, even though the NHIS improved insurance coverage in the Tamale District, enrolment was largely inequitable because most socially disadvantaged groups/individuals were less able to insure. This was mainly because such groups were predisposed to developing low willingness and low ability to enrol in the NHIS as a result of their individual and community characteristics as well as NHIS and healthcare system factors. Secondly, the NHIS improved the affordability of healthcare services and reduced the risk of catastrophic healthcare expenditure among insured members, particularly insured low income households. Thirdly, while the NHIS improved the financial resources of healthcare providers and the availability of medicines and medical supplies, it adversely impacted on the general quality of healthcare services mainly because the supply of healthcare resources failed to keep up with a high demand for healthcare services by insured members. Fourthly, the NHIS also improved the use of formal care, particularly among insured low income households due to their greater healthcare needs and previous inability to afford the cost of healthcare services. However, due to long waiting times associated with accessing NHIS healthcare, the improvement in financial access to healthcare by the NHIS failed to eradicate the use of ‘informal’ forms of care (e.g. drugstore, herbal/traditional medicine) among insured members. Based on these findings, this thesis concludes that the NHIS could enhance equity in access to care if there are opportunities created to enable socially disadvantaged groups to enrol in the scheme as well as improve the availability and quality of healthcare services for insured members.

Decentralisation policies have been adopted by most countries in Sub-Saharan Africa in the expectation of improved service provision. The benefits expected are two-fold: a) decentralisation will lead to better coordination and collaboration between different parts of the state at the local level and b) decentralisation will lead to increased consultation and responsiveness of local governments to their citizens. In this thesis I seek to explain why these benefits are realised in some contexts and not others. In most parts of Sub-Saharan Africa, the predominant form of decentralisation is a combination of devolution and deconcentration. Often these two policies are ambiguous and sometimes contradictory. What are the processes through which such mixed systems work? This thesis attempts to understand how mixed systems of devolution and deconcentration work in practice through a comparative study of Five Municipal Health Directorates in Ghana. The study explores the three sets of relationships that are critical for decentralisation to work well in such mixed systems a) between the Health Directorate and the District Assembly administration, b) between the Health Directorate and the elected members of the District Assembly and c) between the Health Directorate and selected civil society organisations working on health. The work is based on detailed qualitative interviews in the five municipalities. The main finding is that informal ties between the Health Directorate and the three sets of actors mentioned above are helpful in explaining why coordination and consultation seem better in some municipalities than others. Four kinds of ties are found to be important: ethnic/tribal links, family/kinship/neighbourhood relations, political party affiliations, and old-school networks. These ties between Municipal Health Directorates and senior officers of the Municipal Assemblies were found to facilitate Municipal Health Directorates' access to District Assemblies' Common Fund, which was controlled by the Municipal Assemblies. The existence of these ties between Municipal Health Directorates and elected Assembly members of Municipal Assemblies were found to enhance the quality of Municipal Health Directorates' policies and helped to gain public support. Finally, such ties between Municipal Health Directorates and leaders of selected Civil Society Organisations that mobilised around HIV and AIDS programmes were found to facilitate implementation of Municipal Health Directorates' policies around HIV and AIDS. The thesis' contribution is that it shows that informal linkages between different local bodies and between local government and civil society organisations seem important for improved coordination and collaboration among various actors, and better consultation with elected representatives of citizens and leaders of CSOs for effective service delivery at the local level.