Patients and staff who participate in PNC were surveyed by postal questionnaires and interviews to obtain a complete picture of the structures, processes and experiences which comprise it. 1249 newly delivered mothers and 648 health professional staff involved in PNC responded to the surveys (response rates 90.2% and 83.4% respectively). Maternal morbidity was reported by 85% of women in hospital, 87% at home in the first two months and 76% subsequently. Excess anxiety affected up to 27% of women, and depression occurred in around 16%. These factors influenced parental attitudes to their babies, as did aspects of babies' behaviour. 3% of women were readmitted to hospital for puerperal complications within the first two months, and 5% subsequently. At least one health problem occurred in 76% of babies in hospital, 82% in the first two months at home and 88% in the year thereafter, and the proportion treated increased with time. Readmission was necessary for 4% of babies in the first two months and 15% subsequently. Problems in PNC identified by respondents included lack of staff time, lack of continuity of care (resulting in conflicting advice), unrecognised maternal morbidity and need for support, high (and increasing) use of NHS services by babies, care focused on physical health problems rather than psychological and emotional ones, and deficiency in the quality of care after the first two months. Reorganisation of PNC so that the care of the patients (mother and baby) was its focus might enable the delivery of more effective and efficient care. A redefinition of the role of the midwife, greater autonomy and better professional recognition would increase job satisfaction and improve care. Forms of care which have been shown to be ineffective or harmful should be discontinued, and those which improve postnatal outcomes should be promoted.

In this study an economic analysis is conducted into the cost of the Scottish hospital sector from 1951 to 1981. The analysis is based upon data gathered from the Summarised Accounts of the Scottish Health Service, and additional published and unpublished data. The study suggests that many existing hypotheses on hospital cost inflation are inappropriate to the characteristics of the Scottish hospital sector, and that others have been overemphasised. The analysis presents a detailed account of changes in aggregate expenditure and, its components, showing these changes in current and constant prices and demonstrating the magnitude of the relative price effect. Using data on the changing conditions of service of hospital employees, the study then calculates an index of labour inputs to the hospital sector, which reveals that routinely published labour statistics considerably overstate the increase in working hours. Thus although wages and salaries have taken an increasing share of total hospital expenditure, the volume increase in labour inputs has been outstripped by that of non-labour inputs. In order to evaluate the hypothesis that hospital costs have increased as a result of the pay of hospital employees catching-up with other groups, the study compiles pay indices for the main hospital occupational groups and considers the influences on the patterns of settlement. The formal catching-up hypothesis is not supported by the evidence. Similarly, the study shows that the impact of compositional change in the hospital labour-force on total costs has not been significant, although substantial compositional changes are revealed. Finally, the study calculates the impact of demographic changes on hospital costs between 1951 and 1981, and concludes that, although the direct impact has not been great, such changes coupled to changes in rates of use may have brought about major long-term alterations in patterns of hospital care and resource allocation. Drawing on these and previous findings, the analysis is concluded with a discussion of policy and research implications.

Background. Implementation research is the scientific study of methods to promote the uptake of research findings in clinical practice. Cluster randomised trials are commonly adopted in implementation research, where interventions are generally targeted at health professionals or policymakers, in order to protect against contamination that would occur if individual patients were randomised. The application of cluster randomisation has important implications for design and analysis of trials evaluating implementation strategies. Case study: The Urological referral guidelines evaluation (URGE) has been used throughout this thesis, to explore the design and analysis issues of adopting a cluster randomised trial design in implementation research. URGE aimed to evaluate the effectiveness and efficiency of a guideline-based open access urological investigation service. This cluster randomised study adopted a 2X2 balanced incomplete block (BIB) design and collected data both prior to and following introduction of the intervention. The unit of randomisation was general practice and patients were recruited upon referral to secondary care. Aim: To investigate the implications of cluster randomisation for the design and analysis of trials evaluating implementation strategies. Objectives: This thesis has four distinct components. 1. A review of published cluster randomised trials in the field of implementation research. The methodological quality of these studies is assessed (Chapter 2). 2. An exploration of clustering within the URGE trial. Estimates of clustering and the imprecision in these estimates are considered for a number of endpoints, including process and outcome of care indicators and costs (Chapters 4 and 7). 3. The application of statistical methods in the analysis of cluster randomised trials. A number of approaches to the analysis of cluster randomised trials are described, applied and compared empirically. Incorporation of the BIB design and pre-intervention performance are also considered (Chapters 5 and 6). 4. Analysis of cost data collected from the economic evaluation conducted within the URGE trial. The analysis of skewed cost data collected within a cluster randomised trial design is considered (Chapter 7).

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Objectives: To contribute to knowledge on the reliability and validity of the contingent valuation method (CVM) and explore the role of context-specific CVM question formats in Southeast Nigeria. Other objectives were to determine the factors that will explain actual willingness to pay (WTP) for insecticide-treated nets (ITNs). Methods: There was an extensive review of theoretical, methodological and empirical literature. A novel WTP question format that mimics price-taking behaviour in south- east Nigeria (called the structured haggling technique (SH)) was developed and compared with the bidding game (BG) and binary with follow-up technique (BWFU). The comparisons were for inter-rater and test-retest reliability, content, construct and criterion validity and the study conducted in three villages in Nigeria. Stated WTP was determined using a questionnaire administered to 810 household heads, while actual WTP was evaluated by offering the ITNs for sale to all respondents after one month of the first survey. Findings: There were considerable gaps in the literature regarding the reliability and validity of the CVM. In the empirical study, BG, BWFU and SH elicited reliable and valid estimates of WTP. The SH was the most content valid, while the BG and SH were the most construct-valid for ITNs and re-treatment respectively. The BG and SH were similarly criterion-valid while the BWFU was the least criterion-valid. All question formats were similar for tests of reliability. There were genuine reasons for divergences between the stated and actual WTP and for test and retest. Low-income status and physical accessibility were the major impediments to ITNs acquisition. Conclusion: The CVM could be used to elicit valid and reliable WTP estimates in the study area, but it was not clearly proven that better content-valid question formats would lead to more valid and reliable estimates of WTP. It is necessary to further determine how the validity and reliability of the SH and other WTP question formats could be improved. Finally, future studies should establish the content validity of question formats in settings where they will be used, and use bigger sample sizes, along with allowing less time between the survey and administering the criterion, for comparing stated and actual WTP.

Bangladesh introduced menstrual regulation (early abortion) into its national family planning program in 1979, and for more than 20 years women with unwanted pregnancies have been able to avail themselves of a relatively safe and accessible service. Over the years, however, concern has been expressed about deficiencies in the implementation of the policy, and by the mid-1990s, the menstrual regulation (MR) policy was approaching a critical juncture. The introduction of health sector reforms and the waning of international and domestic support raised questions regarding the sustainability of the policy. This study was conducted to determine the factors that influenced the development of and support for the MR policy in Bangladesh, in order to explore how far those factors might influence future sustainability. The study used an analytic framework based on literature from the policy field to test what factors were important in the policy process in Bangladesh. Qualitative data was gathered from interviews and documents in an inductive approach to determine the development of the MR policy, which was then subjected to a retrospective analysis of the entire life cycle of the MR policy-how it came to be placed on the policy agenda, how and why it was formulated the way it was, and why it was not implemented as well as it could have been. Data gathered from interviews and document reviews were then used in a political mapping exercise undertaken in a prospective analysis for the policy, providing insights in relation to the future sustainability of the MR policy. The research suggested that the analytic framework used was helpful in providing a systematic analysis of contextual conditions, agenda-setting circumstances, and policy characteristics that could explain much of the variability in the policy process. The role of international donors and attitudes toward religion were found to be particularly relevant to explaining the policy process. The study concluded that the MR policy would likely not be sustained in the future unless purposeful action were taken to mobilise additional bureaucratic and political resources in support of the policy.

This thesis is about the Utilisation of Maternal and Child Health Care Services (MCH) in Rural Bangladesh. Investigations have been made to identify the underlying causes of low use of the MCH services provided through the public sector health care facilities, which is a major concern for the government of Bangladesh. This thesis focuses on the factors that are affecting the use of MCH services both from population and provider perspectives. Socio-economic condition of people, their knowledge and attitudes towards the public sector health care services are considered as population factors, while different aspects of quality of public health services, access to the service facilities and provider's behaviour are explored as the providers' factors. Aims: The aim of this research was to provide policy recommendations for improving utilisation of the public health services at the primary health care level by redesigning more accessible, acceptable and quality health care services, especially for rural women and children. Scope: Maternal health services: antenatal care; tetanus vaccination; place of child delivery; and postnatal care are considered in this study. While two major killer diseases: diarrhoea and acute respiratory infections, and immunisation of children under five years of age are included as child health care services. Methods: A combination of qualitative and quantitative methods are used to collect data /information from 360 mothers, 28 formal and informal community leaders, 44 various types of health care providers and 22 public sector facilities in a rural area of Bangladesh. The World Health Organisation (WHO) recommended 30 cluster sampling method was used in sample design. Household survey, in-depth interview, informal and formal discussion, participant observation and document analysis have been carried out to obtain necessary information/data. Data analyses: The quantitative data have been analysed by using STATA and SPSS statistical computer programme, performing descriptive, bivariate and logistic regression analysis. The qualitative information has been analysed in a descriptive way. Results: The results show that the use of government health facilities: THC, FWC and VHCP is generally very low with an exception of the use of VHCP for TT vaccination to women and child immunisation. The use of VHCP is encouraging for the government policy makers and planners. THC is partially meeting the health care need of rural people and mainly serving the interest of people of relatively high socio-economic condition. FWC is the most unused health care facility at the rural areas of Bangladesh. The majority of people (86%) received health care from non - qualified health care providers. Among the socio-economic factors - family education and income were found to be significant both individually and jointly with the variations of use of MCH services. The majority of the sample population does not have knowledge about the MCH service availability and possessed negative attitudes towards the public sector MCH services. These are attributable to the under utilisation problem. Nine gaps have been identified between peoples' `reasonable expectation' and the `existing' MCH service delivery system. Peoples' involvement in the health service organisation at the thana and union level was found almost nil. However their involvement in the operation of VHCP was encouraging. Low (2-3 minutes) consultation time, lack of privacy in treatment, unregulated involvement of public sector provider in private practice, lack of accountability, supervision and improper behaviour of providers deteriorating the quality of services hence decreases the use of public sector facilities. Unavailability of drug was found to be the single most important reason that deters people from using public facilities. Difficulties in access to quality services were found to be a major problem than access to the service facilities. Conclusions: This thesis suggests that giving priority to improving the service qualities of the existing facilities rather than construction/development of additional facilities at PHC level. It also suggests the initiation of behaviour change programmes for public sector health care providers. Secondly an effective mechanism needs to be developed to ensure peoples' involvement in the management and operation of public health care facilities to enhance accountability of public sector provider to the population and reduce the gap between them. Initiatives could be taken to improve the quality of non-qualified health care providers, as they are the main source of health care for the majority of population. Finally, increasing the education level of rural population particularly for women could increase the use of health services.

Household ability to pay (ATP) for health care services has become a critical policy issue in developing countries because of changes to health system financing and delivery that are likely to impose higher illness cost burdens on poor households. The research presented in this thesis was driven by widespread concern about ATP among different policy actors, and by the fact that conceptual and empirical understanding of the issue remains poorly developed. The thesis uses a conceptual framework for assessing ATP that is, at its core, concerned with the implications that illness costs and related coping strategies have for household livelihoods. The main research objectives were to measure the household costs of illness, examine the types of asset (e. g. financial, social) that are mobilised to cover illness costs, and to evaluate the impact of these illness cost burdens and coping strategies on household livelihoods in the medium term. In so doing, the thesis aimed to identify factors which make households robust or vulnerable to illness costs which development agencies might support. Research was conducted in two low-income communities in Colombo, Sri Lanka. A survey of 423 households was carried out to obtain a profile of illness, treatment actions and illness costs in the two communities, and to identify case study households. The main part, of the research was to follow 16 case study households for eight months, which enabled in-depth investigation of treatment seeking behaviour, expenditure patterns, asset strategies and their impact on household livelihoods. The main findings of the research were ' that free public provision of health services protected poor households from high treatment -costs. In particular, public tertiary hospitals protected households against potentially catastrophic treatment costs associated with inpatient care. This enabled households to access treatment without adopting risky coping strategies. However, aspects of the health system failed to protect households from illness costs, and in a context of low and insecure incomes, illness costs did not have to be high to exceed daily budgets and undermine ability to meet basic food needs. Consequently, households often required additional resources to meet illness costs, and people's financial and social resources were shown to be important factors influencing ability to manage illness costs. However, the research also found that income-poor households had weak social resource endowments which forced them into riskier borrowing or asset strategies. Policy actions to support household assets are examined.

This thesis analyses the state's capacity to pursue health reform. It argues that the feasibility of health reforms, as well as their final content, are in great part determined by their political context, and the political strategies reformers resort to when pursuing their policy agenda. The analysis is framed in the political context in which a reform initiative evolves, the political dynamics of and around the health reform process, and the characteristics and strategies of the teams in charge of leading policy change (change teams). The research aims to contribute to existing knowledge in the health policy field by furthering the analysis and explanation of the political feasibility of health reforms. A two case study comparative analysis is used based on primary and secondary sources and in-country interviewing. Colombia and Mexico, challenged by the need to attain universal coverage, and faced with large inefficiencies, set about to transform their health systems in the 1990's. While Colombia was successful in passing legislation and initiating implementation, Mexico made a series of similar attempts, but its reform was brought to a near halt. The analysis of these contrasting outcomes given the similar choice of political strategies in comparable political contexts, allows for a greater understanding of the factors at play. Key findings demonstrate the relevance of the political context in determining the potential of interested actors within and outside the state, to influence health reforms. The study also reveals the remarkable resemblance between the political strategies used by health reform teams, and those used by economic adjustment teams in the 1980's. While these strategies enabled the latter to introduce major policy change, they helped health reform teams only partially. As a result, health reformers were successful in enabling the creation of new private health financing and provider organisations, but the transformation of the old public health service institutions remains a challenge.