Global health is an emerging concern in a rapidly changing world in which health issues transcend international borders. This study developed and validated a new self-report questionnaire to assess self-perceived global health competencies among international medical students and how they are influenced by international clinical experiences. A tool consisted of two scales and four subscales with moderate internal consistency. Comparisons between participants who completed retrospective pretest (after the intervention retrospectively) and those who completed traditional pretest (before the intervention) revealed that those participants who completed the questionnaires retrospectively provided lower pretest scores, suggesting that response-shift bias had occurred. Significant increases in scores after international clinical experience were reported for the majority of global health competency measures in IFMSA group. Linear regression identified participant’s age, gross national income (GNI) of country of medical studies, GNI of the country visited, duration of international clinical experience and years of medical school completed, as significant predictors of global health scores. This study contributes valuable information about the newly developed global health competencies measurement tool.

This study explores the global health diplomacy phenomenon by focusing on how and why health is integrated into foreign policy. Over the last decade or so, precipitated primarily by a growing concern about the need to strengthen global health security and deliver on the Millennium Development Goals, foreign policymakers have been paying more attention to health as a foreign policy concern and several countries have adopted formal global health policy positions and/or strategies. To elucidate a deeper and clearer understanding of how and why health is integrated into foreign policy, this thesis used a case study research design that incorporated literature and document review and interviews with twenty informants to conduct an in-depth analysis of the United Kingdom’s (UK) Health is Global: A UK Government Strategy 2008-13. Health is Global represents the first example of a formal national global health strategy developed using a multi-stakeholder process. Briefer background case reviews of three nations that are leaders in global health diplomacy - Brazil, Norway and Switzerland, were also conducted to inform the analysis of the in-depth case. Policy analysis included categorizing data into five areas: context (why?), content (what?), actors (who?), process (how?) and impact (so what?). The Multiple Streams Model of Policymaking and Fidler’s health and foreign policy conceptualizations - revolution, remediation and regression - were used to analyze the findings. Based on this analysis, the primary reason that the countries examined have decided to focus more on global health is self-interest - to protect national and international security and their economic interests. Investing in global health was also seen as a way to enhance a state’s international reputation. In terms of self-interest, Brazil was an outlier, however. International solidarity and health as a human right have been the driving forces behind its long-term investment in development cooperation to date. Investing in health for normative reasons was also a prevalent through weaker theme in the UK, Swiss and Norwegian cases. The study highlighted the critical role that policy entrepreneurs who cross the domains of international relations and health play in the global health policymaking process. In regards to advancing a conceptual understanding of global health diplomacy, the findings propose that the whole-of-government global health policymaking process is a form of global health diplomacy. The thesis elucidated factors that underpin this process as well as lessons for other nations, in particular, Canada. While ascertaining the impact of national global health strategies was not the main objective of this thesis, the study provided an initial look at the impact of these policy instruments and processes. Such impacts include better collaboration across government actors leading to enhanced policy coherence and a more strategic focus on global health. Finally, some have argued of late that the global health revolution is over due to the current world economic crisis. Considering the level of interest in whole-of-government global health strategies and the ever growing and sophisticated world-wide global health policy community, based on this thesis, the global health revolution is alive and well.

Global health is an emerging concern in a rapidly changing world in which health issues transcend international borders. This study developed and validated a new self-report questionnaire to assess self-perceived global health competencies among international medical students and how they are influenced by international clinical experiences. A tool consisted of two scales and four subscales with moderate internal consistency. Comparisons between participants who completed retrospective pretest (after the intervention retrospectively) and those who completed traditional pretest (before the intervention) revealed that those participants who completed the questionnaires retrospectively provided lower pretest scores, suggesting that response-shift bias had occurred. Significant increases in scores after international clinical experience were reported for the majority of global health competency measures in IFMSA group. Linear regression identified participant’s age, gross national income (GNI) of country of medical studies, GNI of the country visited, duration of international clinical experience and years of medical school completed, as significant predictors of global health scores. This study contributes valuable information about the newly developed global health competencies measurement tool.

Canadian undergraduate nursing programs have incorporated global health concepts and experiences in their curricula as these are elements of Registered Nurses’ entry-level practice competencies. With their knowledge of global health concepts, nursing students are aware of local, national, and international populations’ health needs. While there are multiple ways of promoting such knowledge, many nursing programs include optional clinical experiences abroad. This dissertation explored nursing students’ reentry process following immersive global health clinical experiences in resource-limited international settings. Charmaz’s Constructivist Grounded Theory approach was used and led to the development of a substantive theory named Reentry Process Theory. Data was gathered through face-to-face in-depth interviews with 20 participants recruited for the study, including Level 4 nursing students, nursing alumni, and faculty from a School of Nursing in Ontario. Data analysis identified 4 conceptual categories that explain processes embedded in participants’ reentry experiences: adjusting to being back, seeking understanding, making meaningful connections, and discovering a new self. Findings revealed the importance of understanding experiences and factors that impact the lives of nursing students who have lived and studied in resource-limited international settings not only in their role as students but also as individuals and soon to become professional nurses. Recommendations are made for education, research, policy and for future undergraduate students pursuing a global health clinical experience. / Dissertation / Doctor of Philosophy (PhD) / Many Canadian undergraduate nursing programs include optional clinical experiences abroad as a way of fostering nursing students’ knowledge of global health concepts as well as local, national, and international populations’ health needs. This dissertation investigated factors that impact nursing students’ reentry process following immersive clinical experiences in resource-limited international settings. The study adopted Kathy Charmaz’s constructivist approach to Grounded Theory and constructed a Reentry Process Theory that addresses nursing students’ personal and professional development. Data was gathered through face-to-face in-depth interviews with 20 participants, including Level 4 nursing students, nursing alumni, and faculty from a School of Nursing in Ontario. Data analysis identified 4 conceptual categories that underpin participants’ reentry experiences: adjusting to being back, seeking understanding, making meaningful connections, and discovering a new self. Recommendations are made for education, research, policy and for future undergraduate nursing students involved in immersive clinical experiences abroad.

This dissertation explores the lasting effects of recurrent temporary medical humanitarian operations through ethnographic research in communities, clinical facilities, nongovernmental aid organizations, and governmental bureaucracies in the northern Somali Region of Ethiopia. First, I found that medical humanitarian aid has altered persons' subjective experiences and expectations of biomedicine, spirit possession, health, and healing. Popular health cultures and conceptions of "biomedicine" as well as "traditional medicine" were changing, in part due to repeated exposures to relief operations. Second, I documented novel social formations to cope with recurrent aid: new labor relations to enable temporary work with international NGOs; new medical migrations to access comparable care and foreign medical commodities at distant private hospitals; and transnational extra-legal economies of medicine to fill gaps in care. Third, a set of racialized narratives have emerged in the interstices of aid that warn of malpractice and abuse by non-Somali Ethiopian clinicians. Such discourses echo Somalis' historical experiences of ethnic-based conflict with Ethiopian groups as well as their contemporary marginalization from Ethiopian sources of power. Accordingly, although aid is designed to improve immediate access to basic healthcare and medications, I find it also exacerbated medical insecurity. Northern Somalis' discursive expressions of medical insecurity have increased, paradoxically alongside steady improvements in their health and nutrition indicators. Finally, health and humanitarian interventions have altered local notions and practices of citizenship. In the last ten years, as Ethiopia has decentralized its health care delivery system, aid has been progressively channeled through Somali Regional State institutions. Accordingly, many Somalis now discuss the diverse ways in which they are increasingly interpolated into regional politics-often in opposition to the Ethiopian government. Medical humanitarian aid has shaped expectations of government as well as biomedicine. I argue that these new forms of citizenship have emerged primarily because of the intimate and profound nature of medical encounters themselves. The narrow humanitarian mission to minister to what social theorists call the "bare life" of victims, in actuality, is neither dispassionate nor removed from sociality and politics. Medical aid potentially provides spaces in which relations of care-giving, trust, and therefore responsive governance structures can develop.

Background: International agencies such as the World Health Organisation have highlighted the potential of digital information and communications technologies to strengthen health systems, which are underpinned by the 'building blocks' of information, human resources, finances, commodities, leadership and governance, and service delivery. In high income countries, evidence of the positive impacts of 'eHealth' innovations on the cost-effectiveness of healthcare is growing and many governments are now providing incentives for their adoption. In contrast, the use of eHealth in developing countries has remained low and efforts to introduce these new approaches have experienced high failure rates. There is even scepticism regarding the feasibility of eHealth in low-resource settings, which may be hindered by high costs, indeterminate returns on investment, technical problems and socio-organisational barriers. More research is needed to document both the value of eHealth for strengthening resource-limited health systems and the challenges involved in their implementation and adoption, so that insights from such research may be used to inform future initiatives. While many studies of eHealth for patient care in low- and middle-income countries (LMIC) are taking place, evidence of its role in improving administrative processes such as financial management is lacking, despite the importance of 'good governance' (transparency and accountability) for ensuring strong and resilient health systems. The overall objective of this PhD was to elucidate the enablers, inhibitors and outcomes characterising the implementation and adoption of a modular eHealth system in a group of healthcare facilities in rural Malawi. The system included both clinical and billing modules. The specific objectives were (i) to understand the socio-technical, organisational and change management factors facilitating or hindering the implementation and adoption of the eHealth system, (ii) to assess the quality of data captured by the eHealth system compared with conventional paper-based records, and (iii) to understand how information within the eHealth system was used for service delivery, reporting and financial management. A further aim was to contribute to the corpus of mixed-methods case studies exploring eHealth system implementation processes and outcomes (including data quality) in LMIC. As described in the following chapters, the research also gave rise to unanticipated and serendipitous findings, which led to new lines of enquiry and influenced the theoretical perspectives from which the analysis drew.

This thesis focuses on the development of a malaria vaccine as an avenue to explore global health partnerships. In the last twenty years, public-private partnerships have become a prominent organizational form in global health. Hundreds of large transnational collaborations and countless smaller collaborations between the public, private and non-profit sectors have been established. Partnerships have been supported by the large increase of donor funding for research and control of infectious diseases in impoverished countries and many aim to develop or provide vaccines, medicines or interventions. Analysts generally agree that partnerships are saving many lives and revolutionizing drug and vaccine development for infectious diseases. However, while partnership is a notion that connotes equity and mutuality, often global health partnerships operate in contexts that involve vast disparities in power and resources and there is little known about the impacts of partnerships on the places where they operate. This raises the questions: How do global health partnerships operate in practice? What are their impacts in the places where they operate? Addressing these questions, this thesis examines a partnership established to develop the most advanced malaria vaccine, named RTS,S. Based on 17 months of ethnographic research in Tanzania and interviews with representatives of partnering organizations in Belgium and the United States, I trace the development of the RTS,S vaccine from laboratories to its clinical trials across Africa. I explore the social relationships formed between private companies, philanthropic institutions and non-profit organizations in the North, and research institutions and communities in north-eastern Tanzania, where a malaria vaccine clinical trial was conducted. Analyzing the impacts of the malaria vaccine partnership, I focus on community development, construction of infrastructure, the building of human capacity, provision of health care and extraction of data. The focus on partnerships is intended to improve understanding about this ever-increasing social, political and economic formation in global health, and contributes to discussions and debates about how partnerships operate and their role in international development, global health governance and transnational medical research.

acase@tulane.edu

acase@tulane.edu

acase@tulane.edu