Arguably, in common with many other nation states, Jordan could be said to have drifted into different ways of paying for health services without always foreseeing the long run consequences of taking the strategic direction necessary. In part, of course, as in many developing countries, the financing of Jordan's health care services has been influenced by its colonial past. This partly explains why, historically, Jordan has attempted not only to provide wholly free services, but to provide privileged access to medical services, not only to the military personnel but also to public servants in general. With world economic instability and recent economic difficulties, notwithstanding the opportunities created by Jordan signing the peace treaty with Israel, and the unclear but likely stark future conditions facing the Jordanian economy, it is highly improbable that Jordan will continue to be in a position to sustain, from central government monies, a health system which currently consumes about7percent of the GDP. Financing strategies will, therefore, have to address the heightened expectations for rising health expenditures. Options under active consideration at this time include: introducing or extending the present system of user charges; community financing (participation ); (increased) use of the private sector; public or private health insurance; and, improving efficiency in the use of hospital and community resources. These are all financing options open to the Jordanian government to adopt, whether singly or in combination, to generate more resources for the health system and to make better use of existing resources. Examining the range of different modalities of health services' financing reveals, not surprisingly, that there are advantages and disadvantages in each financing scheme. Nevertheless, depending on Jordan 's circumstances, some of the approaches may be more appreciated than others: that is from a political, cultural, socio-economic, or strictly fiscal point of view. This thesis focuses upon one particular health financing approach, "National Health Insurance (NU)", and is aimed to lead the government of Jordan to rigorously explore the concept, consider the options, and develop an implementation strategy benefiting, where appropriate, from other countries' experiences with systems of NHI. Specifically, the thesis first provides an overview (or situation analysis) of the healthiness of the Jordanian economy, its key demographic and epidemiological characteristics, and salient features of the Jordanian health sector. This is followed by a largely theoretical discussion of the principles of insurance, and its potential relevance to the unpredictability and uncertainty of health and disease. Methodological problems inherent in public or private health insurance schemes are highlighted, and then considered in a comparative context, drawing on lessons and experience around the globe. The thesis considers as its basic premise that a system of national health insurance is both desirable and feasible for Jordan as it faces the next millennium. To test that premise, the study is conducted by means of a series of investigations emphasising both secondary and primary sources of data, and a range of quantitative and qualitative research methods including: content and document analysis; experimental and survey methods; interviews; and questionnaires. The conclusions drawn from the evidence supports the contention that the introduction of NM is potentially both desirable and feasible in Jordan but subject to meeting very strict conditionalities, not least government ownership of the scheme, and the willingness to address the present choice and diversity in health service provision through health sector reform. These matters are as much political as technical matters. On the more technical front, nonetheless, the design of an appropriate NHI is shown to raise critical issues regarding: coverage; benefits; organisation and management; costing and financing; and, provider payment mechanisms. Various technical options are discussed in the thesis, and were consulted upon with key decision makers in Jordan. Further directions of research and development are also identified, which likely have applicability beyond the specifics of Jordan itself.

American Recommended Dietary Allowances (RDAs) and British Dietary Reference Values (DRVs) are used as the scientific benchmarks in a number of policies and surveys relating to food, nutrition and welfare. In the USA the RDAs have a number of statutory and regulatory involvements, particularly with respect to food assistance programmes and the definition of the poverty level. In the UK, although DRVs have no statutory role, they are the benchmarks against which diets of population groups are assessed or food supplies are determined, and hence they indirectly influence various policy decisions. Although RDAs and DRVs are often presented and used as if they were solely scientific standards, the thesis is premised upon the assumption that they are in fact a mixture of scientific, social and political factors. The thesis examines the way in which RDAs and DRVs are constructed, both the process and the products, by particular reference to the allowances for vitamin C in the USA and UK, and the controversy that surrounded the publication of the tenth edition of the RDAs in the USA in the 1980s. In particular, it focuses on what constitutes scientific evidence in the RDA arena, where and why boundaries are drawn between scientific and non-scientific evidence, and what are the judgements and interpretations included in the process and products of RDA and DRV construction. Research was carried out by means of a critical analysis of the literature to identify the relevant scientific evidence and areas of interpretation and selection. This was followed by in-depth interviews with key individuals who were involved in the most recent RDA and DRV report processes or in the disputed 1985 RDA report, or who have been advocates or critics of these standards over the years. The thesis shows that the science underlying the recommended figures is incomplete and the theoretical methods outlined for determining an RDA/DRV were not followed in practice. Even though the standards could be improved by strengthening the scientific evidence, they will always be subject to value judgements over the question of 'adequacy'. Influencing such judgements and also underlying the 1985 RDA controversy are the conflicting certainties and interests of different cognitive groups within science. With scientific credibility and scientific authority at stake, the boundary between science and non-science moves to suit the interests and beliefs of the different scientific groups. At the same time external groups align themselves with the cognitive evidence which reinforces their own position.

This study explored the complex world of nursing at a time of humungous change in the delivery of health care services. The initial focus of the research was registered nurses' use of knowledge in professional practice; however this was largely displaced by contextual issues, which emerged from the data. Eraut's (1992,1994) concepts of professional knowledge informed the data generation and the analysis. A broadly qualitative approach drawing on grounded theory and constructivism provided the methodological framework and the research methods involved observation and interview. The sample comprised registered nurses undertaking a four-year part-time degree in nursing studies. Twenty-seven were observed in a variety of clinical settings: sixteen of this group were subsequently interviewed. Six of their managers were then interviewed. Data analysis followed a pattern of literal, interpretive and reflective coding and revealed a number of key issues for registered nurses working in the United Kingdom at the time of the research. The nurses fell into three categories, the survivors, the battle weary and the battle hardened; the largest group being the battle weary. The key causes of the weariness originated from organizational constraints such as low staffing levels, poor teamwork and an inability to give appropriate care to their patients. The effects of battle weariness included low morale, which affected their motivation, tearfulness and a general fatigue. The 'survivors' (a minority) were characterized by a sense of purpose and a fulfillment from their work. The contexts in which the battle weary worked were likened to a war zone with a clearly defined battlefield. Significant changes to the traditional role of the ward sister/charge nurse have left the majority of nurses in this study feeling unsupported and with a lack of clinical leadership. The nurses, often only working at 'D' or 'E' grade, frequently found themselves trying to cope with conflicts in practice with nursing colleagues, with patients and with doctors.Professional knowledge used in practice included communication and interpersonal skills, teamwork, delivering 'hands on' care to patients and coping with the ever changing demands on the nursing time. A number of recommendations are made and include an 'enabling curriculum' for educating nurses at initial and post registration level, a return of the clinical leadership role for ward sisters and charge nurses and a renewal of the focus of nursing practice.

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Municipal health commissions have been key elements in the reform of the Brazilian health system over the past thirteen years. The reform made publicly financed health care, in principle, universally accessible, while the system became better integrated as well as decentralised. Municipal health commissions have become a widespread institutional feature of the health system. They have gradually increased their planning and supervisory roles over health services located within their territorial jurisdiction. The participatory schemes of municipal health commissions can achieve better results in areas where they have the support of strong social and trade union movements. This is the case in the southern region of Brazil and, in particular, in Porto Alegre. This study analyses the ways in which users were involved in the municipal health commission of Porto Alegre, between 1985 and 1991, verifying which institutional-political factors have most influenced their involvement. The study develops a "methodology" for the assessment of user participation in statutory fora. The attendance lists and minutes of meetings, interviews with regular participants in the forum, and other sources of information, were used to build up indicators of user involvement and of the factors that could influence the participatory process. Two main sets of variables are identified. The first set of indicators is concerned with the ways in which users participated in the commission. Two indicator-variables were created to assess this participation: the attendance of users at weekly plenary meetings of the commission (the decision-making division of the forum) and the types of involvement of user representatives in the decision-making process. The second set of indicator-variables refers to institutional- political factors that could have most influenced the participation of users. Among these are; (a) major policy changes in the institutional framework of the Brazilian health system, (b) changes in the organisation of urban social movements in Porto Alegre (since trade unions had not regularly participated in the work of the commission), (c) changes in the relationship between public health professionals and leaders of urban social movements, (d) the types of interest which municipal, state and federal health authorities had in promoting the participation of user representatives in the decision-making process, and, finally, (e) the types of issues discussed in the majority of plenary meetings. Relationships were then established between both sets of variables to verify which factors most influence this involvement. The study concludes that, between 1985 and 1991, variations in the attendance of users at plenary meetings, as well as variations in the type of involvement user representatives had in the decision-making process of the forum, were strongly associated with important changes: (1) in the institutional framework of the Brazilian health system, (2) in the organisation of urban social movements in Porto Alegre and (3) in the relationship between public health professionals and leaders of urban social movements. The position of municipal health authorities on user participation has also influenced user involvement in the commission. The other factors, however, had apparently determined only short term changes in user involvement. The study also highlights the role of Brazilian health system reformers as promoters or stimulators of these changes. This policy community had a central role in attracting urban social movement activists to become involved in these formalised fora. They can be regarded as policy formulators as well as an active part of an alliance established between them and urban social movement activists. In the case of Porto Alegre, it is possible to affirm that social organisations, particularly those representing shantytown populations, sustained consistent involvement of their representatives in the overt political spaces of the local and municipal health commissions. These commissions had limited power over health services in the city, mostly due to delays in placing these services under municipality control. However, the case examined indicates the gradual formation of an alternative type of political relationship in the health sector in Porto Alegre, in which the interests of the urban shantytown residents are represented formally and publicly. In this sense, the consolidation of participatory fora can assist in the democratisation of Brazilian institutions, giving voice to social sectors traditionally excluded from the political system. Through their involvement in the commission, these representatives were also increasing the responsiveness of publicly financed health services to the needs of users who, individually, lacked the political power to sustain their demands.

This study explores the policy options for health insurance in Thailand, considering the present structure of the country and taking account of international experiences. The development of health insurance in Thailand is analysed from the supply side i.e. health services. The problem of inefficiency and inequity in the health care system has led to the search for better alternatives for organizing and financing. This coincides with the overall growth in the country's socio-economic situation and the policy of health insurance laid down in the Sixth Five Year Health Development Plan (1987-1991). These factors provide positive conditions for establishing health insurance in Thailand. The demand for health insurance from employers who are likely to join the scheme is investigated. A survey of 200 private establishments in Thailand was conducted. This investigation provides essential national baseline data for the organization of health insurance, particularly on the health care fringe benefits provided by employers, and the methods of paying health care providers. Methods of organizing health insurance are formulated from international experience. The historical development of voluntary health insurance and its modified forms, as well as that of compulsory health insurance, are examined. The arguments for and against each form of health insurance are analysed. The study also highlights salient issues of health care reforms which attract the world's attention. International experience has shown that methods of paying providers is a major issue in providing viable health insurance. The study comprehensively analyses the advantages and disadvantages of each method of paying the doctor and the hospital under health insurance systems. Finally, it explores the policy options for the future development of national health insurance in Thailand.