Many authors suggest that low anthropometric levels are associated with higher mortality risk in adults, In developing countries however there have been few opportunities to test this hypothesis. In addition, there is increasing interest in the role of women's nutritional status in their own health and survival as distinct from its impact on infant outcomes. This thesis describes the results obtained from a longitudinal historical follow-up of a cohort of 2,314 rural Bangladeshi women over a period of 19 years (1975-1993). The demographic, socio-economic, and anthropometric characteristics of the study cohort are described with reference to the methods of data extraction, preparation and validation. The risk of mortality associated with different levels of the anthropometric indicators (height, weight, arm circumference and body mass index) were analysed using Cox's proportional hazards models. In addition to the basic survival models, the effects of confounding, early mortality, missing data, and young subjects, on the estimates are discussed. A significant association between BMI and mortality (p=0.009) was found in adjusted analyses which used categories that distinguished the women in the highest and lowest 10% of the cohort BMI distribution. Women with BMI levels between 10% and 90% and >90% had hazard ratios of 0.45 (95% confidence intervals 0.27,0.73) and 0.55 (0.25,1.22) respectively, when compared to women with BMI <10%. The strength of the association between BMI and mortality risk was reduced after adjusting the models for early mortality (<4 years), (p=0.068). No significant associations were found between height, arm circumference and mortality risk. In conclusion, these data provide no evidence that these anthropometric indicators would be useful in population-based screening programmes in rural Bangladesh to identify women at higher mortality risk. The findings are considered with respect to the study's methodological constraints and comparisons with other studies in order to produce recommendations for those working in research and health programmes in women's nutrition.

In Bangladesh, mothers rarely breastfeed exclusively. The national programme promoting exclusive breastfeeding has focused mainly on hospitals, but the majority of mothers deliver at home, and it is important to reach them there. This research aimed to assess the impact of community-based peer counsellors on the prevalence of exclusive breastfeeding. Other objectives were to assess the impact on infant morbidity and growth, and the acceptability of the lactational amenorrhoea method (LAM) for contraception. In Dhaka, 40 localities were randomised as intervention and control clusters. One woman in each intervention cluster was trained as a peer counsellor. The intervention comprised a minimum of fifteen counselling visits (two in the third trimester of pregnancy, two within 5 days of delivery, one between 10-14 days and then fortnightly), to help mothers establish and continue exclusive breastfeeding for 5 months. A total of 726 mothers, with mean of 4.5 years of school, from the lower-middle socioeconomic class, were enrolled during 1996, of whom 573 completed 5 months of follow-up. In the intervention group, 69% of mothers fed their infants colostrum as the first food compared to 11% of the controls (p<0.0001), and 70% breastfed exclusively for 5 months versus 6% of the controls (p<0.0001). Despite small differences in morbidity from diarrhoea, cough and fever, there was a substantial impact on weight gain. At the end of 5 months, the mean weight-for-length Z score was +0.1 (SD 0.8) in the intervention group and -0.9 (SD 0.8) in the control group (p<0.0001). The majority of mothers who breastfed exclusively, also accepted and practised the LAM (59% at 5 months). This trial has demonstrated that trained community-based peer counsellors can significantly increase exclusive breastfeeding and appropriate contraceptive practices, with benefits to infant health. Inclusion of peer counsellors in mother and child health programmes is recommended.

The thesis describes the development, research and evaluation of the applicability of a new model of care that involves GPs being employed on a sessional basis in A&E departments to treat patients attending with primary care needs. The main aim of the study was to research its cost and clinical effectiveness. A multi-faceted approach was taken to include consideration of patients' needs and preferences, professional concerns, organisational and structural issues within the health service, and planning and policy issues. Clinical, sociological, epidemiological, and economic perspectives are drawn upon, reflecting the context of the service development and to provide a firm base for discussion about the generalisability and applicability of the findings. The first two chapters provide a detailed review of the epidemiological, sociological, clinical, and organisational literature relating to the primary care/A&E interface. The incentives and disincentives that may act to increase or reduce demand and supply are explored, in addition to issues relating to the 'appropriateness' of demand, the organisational culture of A&E departments, and strategies used to curtail or cope with demand. The demand for primary care at A&E departments appears to cross national boundaries and hence, literature from other countries (particularly the USA) is included and its applicability to the UK considered. Relevant literature relating to the quality of A&E care, patient satisfaction, and the costing of care is also discussed. The main study was a prospective controlled trial that was conducted at King's College Hospital. This compared process variables, clinical outcome and costs of 'primary care' consultations performed by senior house officers (SHOs), registrars, and general practitioners working three-hour sessions in A&E. A new system of nurse triage was implemented to allow the prospective identification of patients presenting with primary care needs. A total of 27 SHOs, three registrars and one senior registrar were included, and the patient sample comprised 1702 patients seen by GPs, 2382 by SHOs, and 557 by registrars or the senior registrar. GPs were found to practice considerably less interventionist care than A&E medical staff, and the resource implications were substantial. The findings are discussed critically, and their applicability is considered drawing on empirical data from recent evaluations of A&E Primary Care Service developments in other parts of London. The policy and service implications of the study are considered and further research needs identified.

A study was carried out to examine the role of private practitioners in a rural district in Malaysia and to identify the nature of their interactions with public health services. Underlying null hypotheses were that there is no difference in the nature of the services, the characteristics of the health workers or the clientele of public and private sector facilities and that the interactions between both types of providers were mutually beneficial. Five sub-studies were conducted among 15 private clinics and six public health facilities in Kuala Selangor district. Quantitative and qualitative techniques were used and efforts made to triangulate and validate findings. The nature of services in private clinics is influenced by competition with other facilities, the demand for the services by users and the attempt to maximise profits by the providers. Most private clinics offered a wider range of curative services, operated for longer and had more flexible hours than public facilities. However, private practitioners had a limited role in providing preventive services. Private clinics were mostly run by older doctors supported by younger and untrained staff while public facilities were run by younger doctors supported by older and more experienced staff. Users of private facilities were more likely to be non-Malays, of higher socio-economic status, seeking curative care for acute illnesses and financed by third party cover. Users of private facilities were prescribed more drugs and expensive investigations than those using public facilities. Weak and inappropriate policies, lack of incentives, poor inter and intra-agency collaboration and negative attitudes between the providers were among the problems identified in public-private interactions. Malaysian policy makers need to engage in a consultative process in order to define the best mix of regulations, incentives and other methods aimed at improving the services offered by the providers and improving their interactions.

Data on weights and heights of children 2-18 years old in Iran were obtained in a National Health Survey of families in 1990-2, with a sampling ratio of 1 in 1000. In total 10660 households were surveyed in random cluster samples of households in all 24 provinces of Iran. The data are hierarchically structured with children in families, families in clusters and clusters in provinces. The main aim of the thesis is to use the survey data on height and weight to model growth pattern of children and adolescents in Iran and the construction of growth charts for height and weight. After removing the outliers in the data by multivariate analysis, regional variation in growth patterns were studied by constructing multilevel models. The results of these analyses showed that the data from Urban Tehran can be used as a reasonable baseline for the country, and further investigations of distributions of different centiles confirmed this. Three recently developed techniques of chart construction were compared with a chart constructed from a multilevel model to see which method produces centiles which fit the data best. the data structure has little effect on estimates of population centiles. The HRY method using spline procedure is shown to produce the best fit, and this technique has been used to construct the growth charts of weight and height for Iranian boys and girls. Checks confirm that all these curves fit the data well. However, growth of rural children differs significantly from that of children in urban Iran; a practical solution enabling one set of charts to be used for both groups of children is proposed. In view of the difference between the Tehran charts and the NCHS reference centiles, it is concluded that charts presented here should be adopted as the new reference curves for children in Iran.

The thesis aims: - to analyse the extent of alcohol-related problems in Hungary, - to assess available policy options to reduce the incidence of alcohol-related problems - to understand Hungarian policy making in the alcohol field - to prepare recommendations for alcohol policy that are relevant to the Hungarian situation It consists of eight chapters. Chapters follow the aims by first introducing the target and the place of the study (Chapter 1), second providing evidence about the extent of alcohol related problems in Hungary and in comparison to other countries (Chapter 2), third summarising policy means to influence the incidence of alcohol related problems based on experiences of other countries and locate alcohol policy in the broader policy context (Chapter 3), then presenting the framework and the methods used for the analysis (Chapter 4), analysing the policy environment by looking at the legislative background (Chapter 5), the organisational structure and major alcohol policy movements of the past decades (Chapter 6), characteristics of public policy making in general and public health and alcohol policy making in particular (Chapter 7), and the current situation of alcohol policy through actors - their understanding, interests, influence, relation to each other and to specific alcohol policy instruments - (Chapter 8), finally summarising the findings and preparing feasible policy recommendations for Hungary (Chapter 9).

In the 1990s, the coordination and management of aid in the health sector became more firmly established on policy agendas as a result of concern that the increased volume of aid and increasing number and diversity of donors in the sector was leading to an unmanageable proliferation of demands on recipient Governments. Global interest in coordination, coupled with a dearth of critically-informed, conceptual or empirical, analyses of the subject, gave impetus to this in-depth examination of the processes at work. Based on a review of the literature, this study began by defining the issues and developing a typology of instruments used to coordinate aid. A conceptual framework was developed for assessing coordination mechanisms. The framework was tested through an historical analysis of aid coordination revealing the enabling and constraining factors governing progress in this area of development management. Bangladesh was chosen as a case study, primarily due to a long-standing, concerted effort of the World Bank to coordinate a number of bilateral donors through a country-based Consortium. Drawing upon interviews with stakeholders, documentary analysis, as well as a questionnaire survey, an entrenched, non-comprehensive system of aid coordination and management exercised by donors was exposed. Caution on the part of Government officials in assuming a prominent role in aid management was exacerbated by fragile systems and weak capacity. This was reinforced by aid agency practices. Evidence suggests that coordination may be less concerned with the purported aims of rationalising external assistance to Government's programmes, than with the desire among competing agencies for leadership in the sector. Aid agencies and Government recognise that aid coordination provides a powerful tool with which to exercise leverage over the policy process. This consideration has coloured their desire to lead coordination processes and conditioned the extent and manner they wish to be involved in coordination arrangements. Given the findings of this study, the prospects for improvements and government leadership in aid coordination and management appear equivocal at best.

This study sought to examine the economic structure of the Philippine health care system, in the light of recent legislative initiatives in the country and global managed market reforms. In the context of a market-orientated system in the Philippines, the study modelled the interaction of health care agents in three markets: regulations, financing or insurance and health services. The bulk of the research examined the nature of exchange in the health services market, using neo-classical economics. Theories in industrial organization and public choice served as organizing frameworks for explaining other market elements. The study' s methodology used primary and secondary data analysis, as well as findings of other research, to bring together a coherent picture of the market structure of health care in the Philippines. The analysis of the regulatory market showed that the rent-seeking nature of Philippine social, political and medical institutions has weakened regulatory structures in health care. Compared to its Asian neighbours, the relative position of the country in the 60s in terms of major health indicators, has been eroded. Limited resources and allocative inefficiencies have affected the government's ability to fulfil its constitutional mandate to ensure minimum levels of care, especially for the poor. The performance of the market was examined in terms of health policy objectives of efficiency and equity in the financing of health care. Private sources, with households forming the bulk, comprised 64 percent of health care expenditures. The position of concentration curves drawn to illustrate the equity of household financing, showed inequities in health and health expenditures. The largely fee-for-service system operating in the health insurance market had caused risks to be borne largely by consumers and funders. Low coverage of the population and weak utilization rates, may have encouraged some providers to behave opportunistically. An examination of the prospects for an alternative system of compulsory health insurance, illustrated through a project with health maintenance organizations indicated the problems of contracting. Estimates of health service market conditions on the demand-side, from an outpatient provider choice model, showed low price and time cost elasticities, with the poor being more responsive than the rich. Simulations showed that the introduction of user fees in public services were likely to drive demand towards private care in urban areas, and out of the market in rural areas. The welfare effect estimates showed that if public hospitals were to charge one-half the price of private doctors, the welfare loss would be about 10 percent of household budget of the lowest income group. The amounts needed to compensate losers from the policy change can be transformed into contributions for risk -sharing schemes. From the supply-side, the distribution of facilities, productive resources and technology were shown to have wide variations across regions and types of facilities. The study cited research that showed that total cost structures in hospital firms were largely determined by the volume of services rendered. Moreover, variable costs were shown, by other research, to be neither influenced by scale nor by the scope of operations. The analysis of the market structure, based on a modified Hirschman-Herfindahl measure, showed that no hospital-firms had a dominant share of the market. Regression results, from the same research on total cost functions, showed that hospital outputs were unresponsive to actual competition. Price competition appeared to be swamped by nonprice competition. An examination of pricing behaviour showed widespread cost-price mark-ups, reflecting the 'market power' of providers. The co-existence of competitive and monopolistic tendencies in the health care market, combined with weak and/or distortive incentive structures, suggests that the tenets of contestability analysis were not fulfilled. The last chapter showed the limitations of the analysis in providing conclusive evidence on the behavioural underpinnings of the health care market in the Philippines. Conceptual and methodological difficulties, arising from data and measurement problems, imply that the results are at best exploratory; and that further work can use the issues raised as starting points. For health policy reforms in the Philippines, recent legislative initiatives could improve health sector performance from a three-pronged approach: enhancing access, agency and co-ordination.

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