Chronic disease is rising globally, but LMICs may require novel approaches to management suited to a low-resource setting. Private health care providers in LMICs have experimented and developed new models for organizing, financing, and delivering care. This thesis examines some of the innovations that have emerged in LMICs to manage chronic disease. Using a common performance measurement framework and drawing from a database of over 1200 innovative health programs, I identify and evaluate 46 programs addressing chronic disease in LMICs. I then go on to identify, innovative practices used by the subset of 19 diabetes focussed programs and catalogue them according to the Chronic Care Model (CCM). Delivery system design is the most commonly used domain of the CCM, which even earlier has shown to have great potential to impact health outcomes. Few of the identified innovations may also have the potential for ‘Reverse innovation’ in high income countries.

Background: To address the huge human resources for health (HRH) crisis that Zambia and other low and middle income countries (LMICs) are experiencing, most LMICs have engaged the services of small scale community-based health worker (CBHW) programmes. However, several challenges affect the CBHWs’ ability to deliver services. Integration of national CBHW programmes into health systems is an emerging innovative strategy for addressing the challenges. Integration is important because it facilitates recognition of CBHWs in the national primary health care system. However, the integration process has not been optimal, and a more comprehensive understanding of the factors that shape the integration process is lacking. This study aimed at addressing this gap by analysing the integration process of national CBHW programmes in health systems in LMICs, with a special emphasis on Zambia. Methodology: This was a qualitative study that used case study and systematic review study designs. The case study focused on Zambia and analysed the integration processes of Community Health Assistants (CHAs) into the health system at district level (Papers I-III). Data collected using key informant interviews, participant observation, in-depth interviews and focus group discussions were analysed using thematic analysis. The systematic review analysed, using thematic and pathways analysis, the integration process of national CBHWs into health systems in LMICs (Brazil, Ethiopia, India and Pakistan)-(Paper IV). The framework on the integration of health innovations into health systems guided the overall analysis. Results: Factors that facilitated the integration of CHAs into the health system in Zambia included the HRH crisis which triggered the willingness by the Ministry of Health to develop and support implementation of the integration strategy-the CHA strategy. In addition, the attributes of the CHA strategy, such as the perceived competence of CHAs compared to other CBHWs, enhanced the community’s confidence in the CHA services. Involvement of the community in selecting CHAs also increased the community’s sense of programme ownership. However, health system characteristics such as limited support by some support staff, supply shortages as well as limited integration of CHAs into the district governance system affected CHAs’ ability to deliver services. In other LMICs, as in Zambia, the HRH problems necessitated the development of integration strategies. In addition, the perceived relative advantage of national CBHWs with regard to delivering health services compared to the other CBHWs also facilitated the integration process. Furthermore, the involvement of community members and some politicians in programme processes enhanced the perceived legitimacy, credibility and relevance of programmes in other LMICs. Finally, the integration process within the existing health systems enhanced programme compatibility with health system elements such as financing. However, a rapid scale-up process, resistance from other health workers, ineffective incentive structures, and discrimination of CBHWs based on social, gender and economic status inhibited the integration process of national CBHWs into the health systems. Conclusion: Strengthening the integration process requires fully integrating the programme into the district health governance system; being aware of the factors that can influence the integration process such as incentives, supplies and communication systems; clear definition of tasks and work relationships; and adopting a stepwise approach to integration process.

Internal labour migration is an important livelihood strategy for poor groups worldwide. <b>Aims and objectives</b> This research aims to answer the question "What is appropriate policy framework to address the health needs of the Indian urban migrants?" The research analyses existing policies and compares policies in arrange of countries that have developed mechanisms to address migrant's health needs. Transferable lessons will be drawn to develop a policy framework to address health needs of Indian migrants. Recommendations to improve the health of urban migrants will be made. <b>Methods</b> The research involves a mixed methods approach - literature review, questionnaire survey, qualitative interviews and site visits to understand successes and challenges in the implementation of migration and health policies in India and other countries. A literature review was conducted to understand the impact of migration - its health outcomes and policies in India and abroad. A pre-tested, interviewer-administered questionnaire survey was conducted using random sampling with 4000 migrants in Nashik to understand their access to health care. In-depth interviews were conducted with policy makers in ministries including health and labour, migrant's organizations and international agencies in India, China, Philippines, Sri Lanka and Vietnam to understand the successes and challenges in the implementation of migration and health policies and learn from their experiences. <b>Conclusions</b> Internal migration is rising in India mainly from the scheduled tribes and castes. Lack of migration specific data, state specific programmes/policies linked with state citizenship and lack of federal structures are key challenges to meet the unique needs of Indian migrants. Lessons for India were learnt from other countries included initiating a migration census, introducing a national portable health insurance and a comprehensive 'whole government approach'. Recommendations were made to enable the government to facilitate appropriate policy to improve the health and status of the migrants.

INTRODUÇÃO: Países de baixa e média renda representam mais de 85% da população mundial de 7 bilhões de pessoas. Nesses países, a população idosa apresentou acelerado crescimento nas últimas décadas. Esse rápido crescimento está sendo acompanhado pelo aumento dos agravos relacionados ao envelhecimento e por mudanças no padrão de morbimortalidade. Entre as condições que têm demonstrado associação com aumento de mortalidade, está a depressão. Porém, grande parte das pesquisas sobre a associação da depressão com mortalidade é de países de alta renda. OBJETIVOS: 1) Investigar a associação entre depressão e mortalidade em idosos de países de baixa e média renda. 2) Investigar a associação de depressão/sintomas depressivos e mortalidade por todas as causas e causas específicas em uma coorte de idosos residentes na zona oeste de São Paulo em um período de 10 anos de seguimento. MÉTODOS: 1) Foi realizada uma revisão sistemática para identificar estudos observacionais que investigaram a associação entre mortalidade e depressão em países de renda média ou baixa. Dois revisores trabalharam independentemente para selecionar artigos, extrair dados e avaliar a qualidade dos estudos. Uma meta-análise foi realizada a partir dos dados extraídos dos estudos incluídos na revisão sistemática. 2) Foi realizado um estudo de coorte utilizando a amostra do \"São Paulo Ageing & Health Study\" (SPAH), investigação que incluiu idosos com 65 anos ou mais, residentes de áreas economicamente menos favorecidas na região Oeste da cidade de São Paulo. Os participantes foram identificados por arrolamento domiciliar e entrevistados em seus domicílios seguindo protocolo padronizado de pesquisa. A definição de depressão e sintomas depressivos foi realizada a partir dos instrumentos Geriatric Mental State (GMS) e Inventário Neuropsiquiátrico (NPI). Os dados de seguimento foram extraídos a partir das declarações de óbitos dos residentes do estado de São Paulo através de procedimento de linkage de dados com os bancos de declarações de óbitos da fundação SEADE. Foram examinadas as associações independentes entre depressão e sintomas depressivos e mortalidade através de modelos de riscos proporcionais de Cox e também foi elaborada curva de sobrevida de Kaplan Meier. RESULTADOS: 1) Foram incluídos 10 estudos, com um total de 13.828 participantes (2.402 deprimidos e 11.426 não-deprimidos) de 6 países (Brasil, 4 artigos; China, 2 artigos; Botswana, Índia, África do Sul e Coréia do Sul, 1 artigo). O risco relativo total não ajustado (RR) de mortalidade em idosos com depressão em relação aos não deprimidos foi de 1,62 (IC95% 1,39-1,88; p < 0,001), com alta heterogeneidade (I2, 66%; IC95% 33-83; p < 0,005). Após o ajuste para o viés de publicação, o RR geral diminuiu para 1,60 (IC95%; 1,37-1,86). Não foram observadas diferenças significativas entre os subgrupos, exceto aqueles definidos pela qualidade do estudo. Os estudos de alta qualidade tiveram um RR agrupado de 1,48 (IC95% 1,32-1,67), enquanto os estudos de baixa qualidade resultaram em um RR agrupado de 1,82 (IC95% 1,25-2,65). 2) Dos 1.967 participantes do SPAH, 443 (22,52%) apresentaram sintomas depressivos e 90 (4,58%) preenchiam critérios para diagnóstico de depressão pela CID-10 no início do seguimento. Foram observados 688 (34,98%) óbitos no seguimento. Presença de sintomas depressivos (HR=1,23; IC95% 1,03-1,46; p=0,022) e depressão (HR=1,75; IC 95% 1,29-2,37; p < 0,001) no início do seguimento estiveram positivamente associadas à mortalidade por todas as causas. Sintomas depressivos (HR=1,26; IC 95% 1,04-1,53; p=0,018) persistiram associados a mortalidade mesmo após controle por variáveis confundidoras, enquanto depressão (HR=1,20; IC95% 0,85-1,67; p=0,296) perdeu significância estatística ao se adicionar ao modelo variáveis relacionadas a comorbidades. Considerando causas especificas de óbitos, sintomas depressivos apresentaram associação significativa com óbitos por doenças cardiovasculares (HR=1,48; IC95% 1,12-1,95; p=0,006) e depressão apresentou associação com óbitos por câncer (HR=2,26; IC95% 1,17-4,36; p=0,015). CONCLUSÃO: A depressão está associada ao excesso de mortalidade em idosos que vivem em países de baixa e média renda. Além disso, esse excesso de mortalidade não difere substancialmente do encontrado em países de alta renda. Já sintomas depressivos e depressão estiveram associados ao aumento de mortalidade em idosos entre os participantes do SPAH. Dado que sintomas depressivos e depressão aumentam o risco de óbito, um melhor entendimento sobre essa relação e estratégias de provisão de serviços de saúde mental, em especial em países de média e baixa renda, são necessários já que essas condições clínicas modificáveis muitas vezes não são reconhecidas ou tratadas adequadamente / INTRODUCTION: Low and middle income countries represent more than 85% of the world population of 7 billion people. In these countries, the elderly population has grown rapidly in recent decades. This rapid growth is being accompanied by the increase in aggravations related to aging and changes in the morbidity and mortality pattern. Among the risk factors that have been shown to be associated with excess mortality are depression. However, much of the research on the association of depression with mortality is from high-income countries. OBJECTIVES: 1) To investigate the association between depression and mortality in the elderly living in low- and middle-income countries 2) To investigate the association of depressive / depressive symptoms and all-cause and specific-cause mortality in a cohort of elderly living in the western zone of São Paulo over a period of 10 years of follow-up. METHODS: 1) A systematic review was conducted to identify observational studies that investigated the association between mortality and depression in middle- and low-income countries. Two reviewers independently worked to select articles, extract data, and evaluate the quality of the studies. A meta-analysis was performed from the data extracted from the studies included in the systematic review. 2) A cohort study was carried out using a sample from the São Paulo Aging and Health Study (SPAH), an investigation that included elderly people aged 65 years and over, from economically disadvantaged areas in the western region of the city of São Paulo. Participants were identified by household survey and interviewed in their homes following a standardized research protocol. The definition of depression and depressive symptoms was performed using the Geriatric Mental State (GMS) and Neuropsychiatric Inventory (NPI) instruments. The follow-up data were extracted from the statements of deaths of the residents of the state of São Paulo through a data linkage procedure with the database of death declarations of the SEADE foundation. We examined the independent associations between depression and depressive symptoms and mortality through Cox proportional hazards models and also elaborated the Kaplan Meier survival curve. RESULTS: 1) Ten studies were included, with a total of 13,828 participants (2,402 depressed and 11,426 non-depressed) from 6 countries (Brazil, 4 articles; China, 2 articles; Botswana, India, South Africa and South Korea, 1 article) were included. The overall unadjusted relative risk (RR) of mortality in depressed relative to non-depressed participants was 1.62 (95% CI 1.39-1.88; p < 0.001), with high heterogeneity (I2=66%; 95% CI 33-83; p < 0.005). After adjustment for publication bias, the RR decreased to 1.60 (95% CI 1.37-1.86; p < 0.001). No significant differences were observed between subgroups except those defined by study quality. The high quality studies had a pooled RR of 1.48 (95% CI 1.32-1.67; p<0.001), while the low quality studies resulted had a pooled RR of 1.82 (95% CI 1.25-2.65; p < 0.005). 2) Of the 1,967 participants, 443 (22.52%) had depressive symptoms and 90 (4.58%) had a diagnosis of depression by ICD-10 at the beginning of follow-up. There were 688 (34.98%) deaths at follow-up. Presence of depressive symptoms (HR=1.23; 95% CI 1.03-1.46; p=0.022) and depression (HR=1.75; 95% CI 1.29-2.37; p < 0.001) at the beginning of follow-up were positively associated with all-cause mortality. Depressive symptoms (HR=1.26; 95% CI 1.04-1.53; p=0.018) persisted associated with mortality even after controlling for confounding variables, while depression (HR=1.20; 95% CI 0.85-1.67; p=0.296) lost association when variables related to comorbidities were added to the model. Considering specific causes of death, depressive symptoms had a significant association with death due to cardiovascular diseases (HR=1.48; 95% CI 1.12-1.95; p=0.006), and depression was associated with cancer deaths (HR=2.26; 95% CI 1.17-4.36; p=0.015). CONCLUSION: Depression is associated with excess mortality in the elderly living in low- and middle-income countries. In addition, this excess mortality does not differ substantially from that found in high-income countries. Depressive symptoms and depression were associated with increased mortality in the elderly. Given that depressive symptoms and depression increase the risk of death, a better understanding of this relationship and strategies for providing mental health services, especially in middle- and low-income countries, are necessary since these modifiable clinical conditions are often not recognized or properly handled

BACKGROUND Children and youth with intellectual disabilities have a right to participation in life just like any other children. AIM This study aims to explore the most influential factor on the participation of a child with intellectual disability and to compare the level of participation between children with ID from South Africa and China. To this day there is still insufficient information on what can influence the participation of children with intellectually disability and how to improve their attendance in everyday activities. METHOD A cross-sectional study using secondary data was conducted. The data was collected through the ‘Picture my participation’ tool that explores the self-perceptions of children with ID in everyday activities. Study participants were 191 children and youth from South Africa and China, ages 6 to 21, who have intellectual disabilities. A multiple linear regression was conducted to find an answer to the research questions. Data of this study was retrieved from the CHILD group at Jönköping University. RESULTS The findings of this study show that children with intellectual disabilities have a lower participation rate in social and community activities than in home activities. It shows that children who live in South Africa have a higher participation mean than children in China. Within China children who live in an urban area show higher participation than the children living in the rural area CONCLUSION The level of participation of children and youth with intellectual disabilities is highly influenced by the social environmental factors in the child’s life. Cultural contexts include the country, socio-economic status, poverty, and ethnicity. A child and his environment are all part of a greater cultural context.

Sensory inputs of hearing and vision during early childhood development support the achievement of language, speech and educational milestones. The early detection of sensory impairment is essential for facilitating early childhood development, socio-emotional well-being and academic success, in addition to obtaining sustainable educational development goals. The majority of children with sensory impairment live in low- and middle-income countries where services are often unavailable or inaccessible, because of the absence of systematic screening programmes for children, prohibitive equipment cost, a shortage of trained personnel and centralised service-delivery models. Therefore, research is needed to investigate whether a community-based mobile health (mHealth) supported service-delivery model for hearing and vision screening can increase access to hearing and vision services for children in resource-constrained settings. This study aimed to describe an implemented hearing and vision screening programme and evaluate its success in terms of acceptability (consent return numbers), coverage (number of eligible children screened), referral rates and quality indicators (duration of tests and number of hearing tests conducted under conditions of excessive noise levels). The study also explored the challenges faced during a community-based screening programme and the strategies developed to address these. Four non-professionals were appointed and trained as community health workers (CHWs) to conduct combined sensory screening using mHealth technology (hearScreen application, hearXGroup, South Africa and Peek Acuity application, Peek Vision, United Kingdom) on smartphones at preschools in low-income communities in Cape Town, South Africa. The consent form return rate was 82.0%, and the coverage rate was 94.4%. An average of 501 children were screened each month, at a cost of US$5.63 per child. The number of children who failed hearing and vision screening was 435 (5.4%) and 170 (2.1%), respectively. Failing of hearing tests was associated with longer test times (odds ratio [OR]: 1.022; 95% confidence interval [CI]: 1.021–1.024) and excessive background noise levels at 1 kHz (e.g. OR for left ear: 1.688; 95% CI: 1.198–2.377). Failing of visual screening tests was associated with longer test duration (OR: 1.003; 95% CI: 1.002–1.005) and younger age (OR: 0.629; 95% CI: 0.520–0.761). The study also aimed to describe and compare the performance of two screening protocols that were used in this preschool hearing screening programme to determine optimal referral criteria that is responsive to available resources. Secondary data analysis was done to compare a protocol using a single-frequency fail criterion (which 2,147 children were screened with between 1 October 2017 and 25 February 2018) with a screening protocol using a two-frequency fail criterion (which 5,782 children were screened with between 26 February 2018 and 30 November 2018). For both protocols, screening was done at a 25 dB hearing level (HL) at 1000, 2000 and 4000 Hz. Both protocols included an immediate rescreen at the frequencies that were failed. The referral rate was 8.7% (n = 186) for the one-frequency fail protocol and 4.3% (n = 250) for the two-frequency fail protocol. Compared to the one-frequency fail protocol, children screened with the two-frequency fail protocol were 52.9% less likely to fail (OR: 0.471; 95% CI: 0.385–0.575). Gender (OR: 0.807; 95% CI: 0.531–1.225) and age (OR: 0.996; 95% CI: 0.708–1.402) had no significant effect on screening outcomes. Maximum permissible ambient noise levels (MPANLs) were exceeded in 44.7% of cases in at least one ear at 1000 Hz across both protocols. There was no significant difference between the protocols for both true positive cases and false positive cases. Protocol (OR: 1.338; 95% CI: 0.854–2.098), gender (OR: 0.807; 95% CI: 0.531–1.225) and age (OR: 0.996; 95% CI: 0.708–1.402) demonstrated no significant effect on the odds of producing true positive results. Average time for conducting the screening was 72.8 s (78.66 SD) for the one-frequency fail protocol and 64.9 s (55.78 SD) for the two-frequency fail protocol. Estimating the prevalence and describing the characteristics of sensory loss in a preschool population in low-income communities are important steps to ensure adequate planning and successful implementation of community-based hearing and vision care in this context. The study therefore also investigated the prevalence and characteristics of hearing and vision loss among preschool children (4 to 7 years) in an underserved South African community after implementing mHealth-supported community-based hearing and vision services. Children who failed hearing and vision screening were seen for follow-up assessments at their preschools. Follow-up assessments were also performed with smartphones and hearing and vision testing applications (hearTest application, hearX Group, South Africa and PeekAcuity app, Peek Vision, United Kingdom). A total of 10,390 children were screened at 298 preschools over 22 months. Of the children screened, 5.6% and 4.4% of children failed hearing and vision screening, respectively. Community-based follow-up hearing tests were done at the preschools on 88.5% (514) of the children, of whom 240 children (54.2% female) presented with hearing loss. A preschool-based follow-up vision test was conducted on 400 children (88.1%). A total of 232 children (46.1% female) had a vision impairment, and a further 32 children passed the test but had obvious signs of ocular morbidity. Logistic regression analysis found that age was a significant predictor of vision loss (p < 0.001): with every 1-year increase in age, participants were 51.4% less likely to have vision loss (OR: 0.49, 95% CI: 0.39–0.60). Age was not a significant predictor for hearing loss (OR: 0.821; 95% CI: 0.667–1.011). Gender was not a significant predictor of hearing loss (OR: 0.850; 95% CI: 0.658–1.099) or vision loss (OR: 1.185; 95% CI: 0.912–1.540). The prevalence of hearing loss at a pure tone average (PTA) of 25 dB HL ranged between 2.3% (240 out of 10,390; assuming none of the non-attenders and children who were unable to be tested had hearing loss) and 3.1% (321 out of 10,390; assuming all the non-attenders and children who were unable to be tested presented with hearing loss). The prevalence of vision loss ranged between 2.2% (232 out of 10,390; assuming none of the non-attenders had vision loss) and 2.8% (286 out of 10,390; assuming all the non-attenders presented with vision loss). Findings of this research project indicate that mHealth-supported CHW-delivered hearing and vision screening in preschools provide a low-cost, efficient and accessible service that can improve the provision of affordable hearing and vision care. This service-delivery model is affordable and scalable, because the same staff, needing minimal training, and the same equipment are used to screen for both vision and hearing. Timely identification of sensory losses is essential to ensure optimal outcomes and can be facilitated through community-based hearing and vision services by trained CHWs using mHealth technology. Future studies should aim to report on outcomes and the uptake and impact of interventions on the children diagnosed with sensory impairments following identification through a decentralised screening programme. / Thesis (PhD (Audiology))--University of Pretoria, 2021. / Sonova AG / Hear the World Foundation / Speech-Language Pathology and Audiology / PhD (Audiology) / Unrestricted

BACKGROUND: Evidence supports the importance of Early Childhood Development (ECD) interventions to improve children's health, lifelong productivity, and human capital. However, ECD programs are not scaled sufficiently to reach many of the 250 million young children globally who are not meeting their developmental potential. Practical guidance is limited on how to scale ECD programs effectively. This mixed-method study explored the contextual and implementation determinants of scaling up ECD programs in Zambia, using one large-scale, community-based parenting group program (Scaling Up Early Childhood Development in Zambia (SUpErCDZ) program) as a case study. The goal was to generate recommendations for policymakers and implementers in Zambia and other LMICs. METHODS: This study was guided by the WHO/ExpandNet scale-up framework and the Intervention Scalability Assessment Tool (ISAT). A total of 30 key informant interviews were conducted with program staff, government officials, academic partners, implementing partners of other ECD programs, and donors. Qualitative transcripts were analyzed using thematic analysis according to the framework method. A budget impact analysis (BIA) was conducted using prospectively collected program cost and implementation data supplemented by online sources and interviews with program staff. The total cost of scale-up over five years using three scenarios (low, medium, and high intensity) was modeled. RESULTS: According to government officials, donors, and partners, the most common contextual factors influencing scale-up ECD programs are political commitment, availability of an overarching or multisectoral ECD policy, availability of resources, and integration of ECD programs into existing government structures. In addition, multisectoral collaboration, stakeholders’ engagement, and sociocultural factors emerged as themes essential to scale-up. From the perspective of the program staff, the key facilitators of ECD implementation were stakeholders’ engagement, sociocultural factors (cultural norms and beliefs), adaptation of the intervention to the context, integration into existing government structures, and intervention characteristics. In addition, providing incentives to Community-Based Volunteers (CBVs) emerged as critical to sustainability. The main barriers to implementation identified by the program staff were the use of culturally inappropriate activities within the ECD curriculum, lack of incentives (financial or in-kind) to caregivers and CBVs, and unforeseen contextual circumstances (COVID-19 pandemic and insecurity). The budget impact analysis showed that the total cost and budget for scaling up SUpErCDZ or a similar ECD program depends on the magnitude of the scale-up in terms of geographic breadth and depth (coverage within specific geographic areas). Based on our scale-up scenarios, the estimated cost of scaling up this program over five years ranged between US$1.74M to US$4.3M depending on the breadth (how many provinces) and depth (how many health facilities, CBVs, and caregivers) of implementation. CONCLUSION: Multiple complex and interrelated contextual and implementation factors influence the scaling up of ECD programs in Zambia. To ensure equitable access to ECD programs for children under five in Zambia, policymakers and implementers will need to consider these when planning to scale up ECD interventions in Zambia. / 2025-08-04T00:00:00Z

Introduction: Over 80% of the world’s one billion tobacco smokers reside in low- and middle-income countries (LMICs); therefore, it is important to understand factors that promote intention to quit smoking in these countries. This study evaluated factors associated with three stages of intention to quit tobacco smoking among adults in LMICs. Methods: Data from 43,540 participants of the Global Adult Tobacco Survey in 14 LMICs were analyzed. Intentions to quit smoking were categorized into precontemplation (referent category), contemplation, and preparation stages based on the transtheoretical model. A multinomial logit model was used to estimate odds ratios (OR) and 95% confidence intervals (CI). Results: Approximately 82%, 14%, and 4% of the smokers were in precontemplation, contemplation, and preparation stages, respectively. Rural residents had increased odds of being in contemplation stage (OR = 1.41, 95% CI = 1.09–1.83) compared to urban residents. Compared to homes where smoking was allowed, smoke-free homes were associated with increased odds of contemplation (OR = 1.77, 95% CI = 1.41–2.23) and preparation (OR = 2.18, 95% CI = 1.78–2.66). Exposure to anti-smoking messages in more than one media channel was associated with increased odds of contemplation (OR = 1.60, 95% CI = 1.33–1.92) and preparation (OR = 1.73, 95% CI = 1.28–2.33) compared to no exposure to anti-smoking messages. Conclusion: The results suggest that anti-smoking media campaigns and smoke-free policies may promote intention to quit smoking in LMICs. While these suggest the need for implementation of comprehensive anti-smoking campaigns and smoke-free policies, longitudinal studies are required to confirm these findings and to evaluate how intention to quit translates into quit attempts in LMICs.

Musculoskeletal trauma including fractures, represents a significant burden of disease for Low- and Middle-Income Countries (LMICs). Within LMICs, women possess reduced agency to make health care decisions and represent a vulnerable population. In this thesis, I aimed to characterize priority fractures among women within LMICs, and investigated whether women were delayed in hospital admission following an orthopaedic trauma. In Chapter 1, I introduce and review the existing literature on injury burden, health care deficiencies, and gender inequities within LMICs. In Chapter 2, we analyzed regional distributions of fracture burdens across 9,934 female orthopaedic trauma patients across 17 LMICs. Half of our study patients were ≥ 60 years old. We determined that the major burden of orthopaedic trauma among women within LMICs were fractures among the elderly. Fracture burden in Africa was notably different. A majority of patients were between the ages 18-59, and common fractures included tibia/fibula and femur fractures. In Chapter 3, we analyzed 26,910 orthopaedic trauma patients across 17 LMICs to determine whether women were delayed in hospital admission by >24 hours. After controlling for confounds, sex was not a significant predictor of delay. We found that instead, the severity and type of fracture influenced the delay of patient’s hospital admission. Closed fractures, falling-related injuries, pelvic, spine and hip fractures were associated with increasing delay. Irrespective of sex and region, inter-hospital referrals accounted for nearly half of the reasons patients were delayed. These two chapters highlight regional trends in orthopaedic burden sustained by women, pointing to the high frequency of fragility fractures. In addition, this thesis identifies critical gaps within LMICs’ health care systems infrastructure, demonstrating the need for improved hospital referral systems and ambulatory services. This analysis will enable policymakers, and future researchers to target interventions to address the rising global burden of injuries especially among women. / Thesis / Master of Science (MSc) / Fractures represent life-threatening injuries within Low- and Middle-Income Countries (LMICs), and globally are a top-ten leading cause of death and disability. Within LMICs, due to gender inequalities, women may be restricted from receiving hospital care following an injury. We investigated the most common types of fractures in women within LMICs and determined that women most frequently experienced fractures due to old age. We further examined whether women were delayed in reaching a hospital after sustaining a fracture, and found that sex did not significantly play a role in determining delay. Instead, injury associated factors, such as the type and severity of the fracture influenced whether a patient was delayed. In addition, transferring patients between hospitals was the most common reason for delay. As a result, policymakers in LMICs should explore strategies to treat the high burden of fractures in the elderly and improve communication between hospitals to reduce delays.

Health is deemed central to a nation’s development. Accordingly, health care reform and expansion are key policy priorities in developing countries. Many such nations are now testing various methods of funding and delivering health care to local disadvantaged populations. Similarly, India launched the Rashtriya Swasthya Bima Yojana (RSBY) national health insurance programme for low-income groups in 2008. The RSBY intends preventing catastrophic health-related expenditure by improving recipients’ access to hospital-based care. This thesis is an in-depth qualitative evaluation of the RSBY in Delhi state. It examines the RSBY’s effectiveness in fulfilling its goals and meeting local health care needs. Walt and Gilson’s (1994) actors-content-process-context model informs the research design and an actor-centred “responsive” (Stake 1975) or “constructivist” approach guides data analysis. Three research questions are examined: (i). Why was a health insurance programme launched and why now? Why was this model favoured over alternate methods of service expansion? (ii). Is the RSBY delivered as intended? If not, why? (iii) How does the RSBY affect patients’ access to services? The findings are based on documentary sources, observation of implementation sites and activities and 164 semi-structured interviews with RSBY policymakers, insurers, NGOs, doctors, and patients. The results show improved access to curative and surgical care for RSBY patients. However, RSBY’s focus on hospitalisation and omission of primary and outpatient services had undesired negative effects. The lack of ambulatory facilities led RSBY patients to self-medicate or use dubious quality informal providers. By only allowing inpatient care, the RSBY also seemingly encouraged the substitution of outpatient care with costlier hospitalisations. In effect, the RSBY’s design contributed to cost increases and poor patient outcomes. While more funds and human resources were needed to improve RSBY implementation, the performance of frontline agencies could potentially improve through more stable, longer-term contracts. Similarly, modifying RSBY’s monetary incentives for doctors may lead to better service delivery by them. By evaluating the RSBY’s strong points and shortcomings, this thesis provides key lessons on strengthening policy design and health service delivery in developing countries. Thereby, it makes a broader contribution to understanding the determinants of successful policymaking.