Rural areas in much of sub-Saharan Africa access needed health care from untrained and often poorly regulated drug vendor shops with concerns over the quality of products and services provided and their public health implications. The thesis undertook to understand market relationships in a rural retail drug market in the light of the structure-conduct-performance paradigm and isolate opportunities for potential policy interventions for improved access to quality and safer medicines. Data was collected from a sample of patent medicine vendors and drug purchasers in Katsina-Ala Local Government Area of Benue State, north central Nigeria, over 9 months in 2012. Information from drug vendors and drug consumers was generated through semi-structured questionnaires, in-depth interviews and systematic business transaction observations. Key state and national drug regulatory officials were also interviewed in-depth and related documentary data collected and evaluated. Data analysis focussed mainly on the relationships between market structure, provider conduct, consumer behaviour and the nature of regulation, with the aim of understanding market performance in relation to access to medicines and their rational use. The study established that patent medicine vendors were an important source of medicines for inhabitants of the local government for ambulatory primary health care. Drug retailers were said to be a reliable source of a wide range of drugs provided at relatively more affordable prices and in a convenient way that satisfied consumer expectations. However, a number of market failures existed: low quality of treatment due to poor provider knowledge of diseases and drugs and therefore inappropriate prescription and dispensing practices. Ineffective regulation was also demonstrated by way of inappropriate and inadequate regulatory regime, occasioned by wide spread regulatory infractions. To attain the desirable public health objective of sustained improvement in the quality of products and services obtainable at patent medicine vendor outlets, regulatory strategies must be contextually relevant, providers must be trained and offered financial and business incentives and consumers must be empowered by accessible and timely health information for informed choices against the backdrop of strengthened and better incentivized inspectorate unit in a systematically intertwined approach.

Retention of health workers is an area of sustained focus as health care organizations realize the impact of poor retention on cost, quality and continuity of care. An in-depth understanding of the experiences of health workers (HWs) and factors which cause them to leave their jobs is the fundamental basis of forming effective retention strategies. The lack of evidence on these experiences poses a challenge to health managers within the Private-Not-For-Profit (PNFP) sub-sector in Uganda on how to develop effective retention strategies. This research examined HWs experiences of working in PNFP hospitals and how these influence retention decisions. This mixed methods study included a quantitative survey (n=118) examining length of stay in the hospitals and the determinants. Experiences of 32 HWs including managers were explored through semi-structured interviews using a life cycle lens that took into account motivation for joining the profession, experiences of working in the hospitals and current retention strategies and their perceived effectiveness in influencing retention. God’s calling, role models in the medical field, death of close relatives and hopes for immediate employment influenced decisions to join the profession and there was a link between some of these reasons and retention. Median duration working in a PNFP facility was 3.8 years. The only individual factors statistically associated with retention were age and cadre. Three perceptions of organizational characteristics namely: having good interpersonal relationships, well-defined reporting lines, and good career growth potential were independently associated with a 75%, 51% and 35% respectively higher working length at a hospital. Interviews with HWs showed that PNFP organizational culture was predominantly bureaucratic with non-participative management styles and emphasized control and efficiency. Hospitals were implementing some limited retention strategies with weak evidence for their effectiveness. Systematic planning of retention strategies and transformation in organizational culture are necessary to improve retention of HWs.

This thesis aims to deconstruct the monotheism of public private partnerships (PPP) for health and demonstrate the polytheism of practices enabled by it. It contributes to the body of knowledge on PPP in two respects: theoretical and substantive. At a theoretical level, using a critical enquiry lens, I deconstruct the partnership phenomenon and the notion of shared power within these interactions. This diverges from the traditional problem solving approach intrinsic to ‘good’ governance literature on PPP, which focuses on how partnerships can be made more effective. The thesis gives a plural account of the rationale and emerging paradoxes and examines the role of structural (institutions and mechanisms) and ideational (ideas and discourse) factors in constituting and constructing the practice of PPPs. The substantive aim of the thesis is to advance the study on PPP by understanding the contingencies and plurality of practices as a departure from the rhetoric on global health PPPs. Drawing on the case of Global Fund to fight AIDS TB and Malaria (GFATM), one of the three largest global health partnerships, and its country wide operations with respect to HIV and AIDS in India, I also discuss the implications of the discursive practices for the management of HIV and equity in health care. Through a critical examination of the governance mechanisms and arrangements of GFATM it is argued that these have instilled an environment characterised by a proliferation of multiple unaccountable entities which emerge as sites where principles of partnership are subsumed by competition for resources, power and individual and organisational gains. This raises an important question that the thesis attempts to answer: How despite the tensions and ruptures is it possible for the global health PPPs to rise to prominence as a key mechanism in global and national health governance? In response to this, I focus on the role of the development brokers and street level bureaucrats who act at the interface of the global discourse and the local perspectives and create “order” by negotiating dissent, building coherent representations and translating common meanings into individual and collective objectives.

This study investigates the role that the notions of trauma and culture play in relation to the alleviation of distress within an war-affected population. It analyses how local, cultural conceptions of distress and those held by psychological service providers relate to one another, and how they contribute to improving the well-being of the displaced. Fieldwork was conducted with urban and rural displaced populations in the south-eastern province of Huila in Angola. Ethnographic, psychometric and participatory methods were used to examine issues of health, illness and distress amongst the displaced. Local idioms of distress in the form of pensamentos, mutima, madness and high and low blood pressure are common ways of expressing suffering related to war. The different explanatory models held about these illnesses and the various resources available in the popular, folk and professionals sectors of the health care system were explored. The religious and spiritual domains were found to be influential in the treatment of distress-related illnesses. The psychological services available in the war-displaced communities were examined in terms of their common theoretical and practical elements. These were then analysed in relation to the conceptualisations held by local populations, and points of similarity and difference were noted. Specifically, the conceptualisation of suffering as trauma and the cultural misunderstandings that arise as a result of this, and the representation of the displaced as traumatised and therefore dependent and passive people, are discussed. A particular subgroup in the community, the adolescents, was identified and participatory methods were employed to investigate the strategies and resources this group uses for coping with war-related distress. The youths predominantly make use of distraction, conselho, religious and cultural resources. The application of a PTSD scale, the EARAT, suggests that 71% of the adolescents had symptoms of trauma consistent with a diagnosis of PTSD. It is argued that for the vast majority such a conceptualisation does not reflect the adolescents' abilities to function on social, vocational, educational and physical levels. The implications of these findings for research and practice in the field of psychosocial work are discussed.

Ukraine is home to one of the world‘s fastest growing HIV epidemic and has received significant amounts of foreign aid to help it tackle the crisis. This study is an enquiry into the implementation of the Global Fund against AIDS, Tuberculosis and Malaria (GFATM) programmes in Ukraine, during the second decade of this country‘s post-Soviet economic and political transition. The discussion is positioned within a broader debate on aid effectiveness. By looking at the GFATM as an aid institution whose establishment was purported to improve the aid delivery process, the thesis offers a critical insight on the GFATM aid delivery model in the context of Ukraine. The thesis investigates the conduct and practice of INGO and national NGOs in their role as Principal Recipients of GFATM grants targeting HIV prevention in Ukraine. Based on ethnographical enquiry conducted in three oblasts in Ukraine, and in capital Kyiv, the thesis aims to understand how NGOs have implemented HIV prevention services in context of state-owned health care system and to determine the perceived effects of the GF programmes on the ground. The thesis situates analysis of NGOs into a broader socio-political context of post-Soviet Ukraine and questions their role as central actors in delivering essential HIV programmes in parallel with or instead of the state, as well as the consequences for sustainability of such programmes. Using the particular experience in Ukraine, the thesis shows the influence of global funding institutions on relationships between state and civil society and altering of civil society‘s roles in aid programmes. The thesis includes a comprehensive literature analysis about the Global Fund and other donor programmes working in Ukraine in the area of HIV/AIDS.

0 / SPK / specialcollections@tulane.edu

Background and Aims: The Sohar Industrial Zone (SIZ), Oman, which started to operate in 2006, contains many industries that possibly affect the health of the local population. This study was carried out to evaluate the health effects in a population living near SIZ. Methods: Retrospective health care visits for acute respiratory diseases (ARD), asthma, conjunctivitis and dermatitis were collected between 2006 and 2010 for 2 large provinces with geographic proximity to SIZ. Exposure of the surrounding villages was classified using proximity to SIZ. Three exposure zones were defined according to the distances from the SIZ: ≤5, >5-10, ≥20 km representing high, intermediate and control exposure zones respectively. Age and gender-adjusted monthly counts of visits for the selected diseases were modelled using generalised additive models controlling for time trends. The high and intermediate exposure zones were later merged together due to similarity of effects. Exposure effect modification by age, gender and socioeconomic status (SES) was also tested. Results: Living within 10 km from SIZ showed greater association for ARD (RR: 2.5; 95% CI: 2.3-2.7), asthma (RR: 3.7; 95% CI: 3.1-4.5), conjunctivitis (RR: 3.1; 95% CI: 2.9-3.5) and dermatitis (RR: 2.7; 95% CI: 2.5-3.0) when compared to the control zone, for the population of <20 years. For the population of ≥20 years, these risks were: (RR: 2.0; 95% CI: 1.9-2.2), (RR: 3.6; 95% CI: 3.0-4.4), (RR: 2.8; 95% CI: 2.5-3.2) and (RR: 2.1; 95% CI: 1.9-2.4), respectively. Greater exposure effects were observed amongst ages ≥50 years and lower SES groups in the ≥20 years group. Models showed no differences between the gender groups. Conclusion: This is the first study conducted in Oman examining the adverse health effects on the population living near SIZ. We hope that these findings will contribute to building up an evidence-based environmental and public health policy in Oman.

Background: An appreciation of the broader social determinants of health and wellbeing has led to the inclusion of new public health principles and practice within health and social care. End-of-life care has been no exception and there exists a favourable policy context, significant body of theoretical work, substantial practitioner interest and numerous practice examples. Despite this context, there has been little empirical exploration and the approaches remain poorly characterised. Aims and objectives: The aim of this study was to understand the impact a new public health approach to end-of-life care project can have when initiated through a hospice. Specifically this study sought to explore how a compassionate community project is experienced, what tensions exist, what processes support or impede the work, what specific challenges such a project developed from within this sector presents and what learning exists for the wider field. Methods: A mixed methods study employing multiple methods of data collection was performed. Data collection methods included: interviews; focus groups; participant observation; documentary analysis and service records. Ethics approval was obtained. Data were analysed according to modified grounded theory and using online software tool Dedoose. Results: Twenty-one interviews, two focus groups and 19 episodes of participant observation were conducted, 11 documents and service data on 180 Compassionate Neighbours and 173 Community Members were also included. Six key actions facilitated integration of new public health approaches with service provision approaches. Impacts from the work were wide ranging and included a reduction in loneliness, improvements in wellbeing and changes to hospice practice. Further to this, three underlying drivers emerged that underpinned the work as a whole. They were seen to translate the observed actions of the project into the impacts and included: altered power dynamics, expression of reciprocity in relationships and the development of agency. Discussion: The three drivers allow a deeper appreciation of the factors involved in the development of a compassionate community. The redressing of power dynamics within traditional provider-recipient relationships allowed for more equity, and created a space for reciprocal and mutual relations to emerge. Not only were these reciprocal relations observed between those at the end of life and those visiting them, but also between participants in the project and the hospice. In order to adequately capture these new perspectives offered through this study, a new term collective social capital is introduced. This moves beyond existing conceptualisations of social capital in end-of-life care to provide novel perspectives on the role of reciprocity and interdependency between the lay and professional worlds. Conclusion: This study provides a reflexive and critical account of the processes and impacts of compassionate communities work in practice. It situates reciprocal relationships as its foundation and forces an assessment of the nature of power and agency in all interactions. Through the presentation of the new concept of collective social capital, it presents a collaborative and interdependent path forward for new public health and end-of-life care in the future.

Thesis (Ph.D.)--McMaster University, 2002. / Adviser: John Eyles. Also available via World Wide Web.

Thesis (Ph.D.)--McMaster University, 2002. / Adviser: John Eyles. Also available via World Wide Web.