Decentralisation policies have been adopted by most countries in Sub-Saharan Africa in the expectation of improved service provision. The benefits expected are two-fold: a) decentralisation will lead to better coordination and collaboration between different parts of the state at the local level and b) decentralisation will lead to increased consultation and responsiveness of local governments to their citizens. In this thesis I seek to explain why these benefits are realised in some contexts and not others. In most parts of Sub-Saharan Africa, the predominant form of decentralisation is a combination of devolution and deconcentration. Often these two policies are ambiguous and sometimes contradictory. What are the processes through which such mixed systems work? This thesis attempts to understand how mixed systems of devolution and deconcentration work in practice through a comparative study of Five Municipal Health Directorates in Ghana. The study explores the three sets of relationships that are critical for decentralisation to work well in such mixed systems a) between the Health Directorate and the District Assembly administration, b) between the Health Directorate and the elected members of the District Assembly and c) between the Health Directorate and selected civil society organisations working on health. The work is based on detailed qualitative interviews in the five municipalities. The main finding is that informal ties between the Health Directorate and the three sets of actors mentioned above are helpful in explaining why coordination and consultation seem better in some municipalities than others. Four kinds of ties are found to be important: ethnic/tribal links, family/kinship/neighbourhood relations, political party affiliations, and old-school networks. These ties between Municipal Health Directorates and senior officers of the Municipal Assemblies were found to facilitate Municipal Health Directorates' access to District Assemblies' Common Fund, which was controlled by the Municipal Assemblies. The existence of these ties between Municipal Health Directorates and elected Assembly members of Municipal Assemblies were found to enhance the quality of Municipal Health Directorates' policies and helped to gain public support. Finally, such ties between Municipal Health Directorates and leaders of selected Civil Society Organisations that mobilised around HIV and AIDS programmes were found to facilitate implementation of Municipal Health Directorates' policies around HIV and AIDS. The thesis' contribution is that it shows that informal linkages between different local bodies and between local government and civil society organisations seem important for improved coordination and collaboration among various actors, and better consultation with elected representatives of citizens and leaders of CSOs for effective service delivery at the local level.

This dissertation examined an implementation gap through a case study on implementing a District Health System (DHS) in the Western Cape Province of South Africa between October 2001 and April 2006. The research project explored why this implementation gap existed and what could be learnt about public policy implementation from studying this implementation gap. The main data collection methods included interviews, public and other documents and observations on the public health system in the Western Cape Province. I argue that implementation gaps could be interpreted as a signal of policy change instead of implementation failure. The key finding is that the Provincial Government of the Western Cape shifted its intentions regarding DHS implementation. The initial intention was to decentralise primary health care services to a metropolitan municipality. The decision, which was actively implemented, however centralised these services within the provincial government and started the process of the provincialisation of personal primary health care services in the Western Cape Province. This dissertation contributes to public policy implementation and public policy process literatures. It demonstrates why policy change is an alternative interpretation of implementation gaps to implementation failure and how policy change occurs during implementation. Policy change and public policy implementation are commonly two separate research themes within Public Policy Studies. The persuasion framework developed through this research project is an analytical tool that may be applied in research on implementation processes to examine whether an implementation gap is signalling policy change. The central theoretical elements in this framework that link policy change and implementation processes are the interactive effects of ideas and interests and the role of argument as a persuading factor that leads to policy change. The dissertation emphasises the role of language in public policy processes and argument and persuasion were deemed important elements in public policy processes.

This thesis explores the increasing medicalization of society, the process whereby social phenomenon are transformed into medical problems. Alike the general tendency of neuropsychiatric diagnoses, the number of people with ADHD (Attention Deficit Hyperactivity Disorder) has increased and expanded from a boys’ diagnosis to include both adult men and women. Studies on the latter category is however scarce. The objective of the thesis is to contribute with a micro sociological and critical perspective on the effects of the biomedicalization process, by focusing women's experience of getting and living with ADHD. The empirical material consists of narrative interviews with sixteen women, diagnosed with ADHD in adulthood. The participants, age 20 to 50, were enrolled via Swedish NGOs in 2010 and 2013. The thesis resides on four analytical themes: biomedicalization, pharmaceuticalizaton, functionality and gender. It shows how diagnostics evokes processes that involve learning and using a biomedical terminology to describe and understand oneself. ADHD is, in general, depicted as diffuse, expansionary, masculine and deviant sociability and cognitivity. Unlike depression and anxiety, described as temporary and unwanted illnesses, the ADHD-diagnosis embraces the whole personality. Hence, the women find it difficult to identifying and separating ADHD from the self. Furthermore, categorizations of oneself as a ‘woman with ADHD’ imply constructions of individual and collective identity that has ideological implications, i.e. the individual narratives are related to grand narratives. These contradictory grand narratives bring about ideological dilemmas that are handled rhetorically in the women's everyday life. The masculine connotation of ADHD, for example, render the women experiencing themselves as transgressing not only femininity but also ADHD-personhood. Additionally, as social actions are attributed to the ‘ADHD brain’, the brain is portrayed as a pathological deviant and dysfunctional object for pharmaceutical intervention. Nevertheless, this discourse is also contested by the women by pointing to 1) positive aspects of the ‘ADHD-brain’ in everyday life, or 2) gender inequalities and demands of the late-modern society. Concluding, the women in this study are not only victims of their bodies or societal norms, but also agents negotiating – adapting and opposing to – expectations of how to be an ideal citizen or woman.

This study examines tuberculosis discourse in order to understand the ideological factors surrounding the disease. It reveals that a dominant focus on biomedical issues and HIV/AIDS has undermined existing perceptions of the social causes of tuberculosis disease. The effect is an individualising of tuberculosis and its removal from a social context. This together with a hegemonic neo-liberal paradigm of development and state spending dictates that the biomedical reductionist treatment for certain diseases – like tuberculosis – is most “cost-effective” and thus is advocated for disease control. Consequently, the state is required to merely provide health-care in a manner that ignores the social context of disease. The responsibility for the outcome of health care (i.e. health) is therefore deferred to the individual. The unintended consequence is that as private organisations (both for- and not-for-profit) take up the state’s responsibility, citizens become disempowered by their limited ability to hold the state accountable, or to engage in meaningful ways that bring about structural change. As such, an environment that further disenfranchises the poor and defeats the purposes of health care in general is perpetuated and diseases like tuberculosis continue their deadly campaign. / Dissertation (MSocSci)--University of Pretoria, 2008. / Sociology / unrestricted

abstract: Over the last half century, global healthcare practices have increasingly relied on technological interventions for the detection, prevention, and treatment of disability and disease. As these technologies become routinized and normalized into medicine, the social and political dimensions require substantial consideration. Such consideration is particularly critical in the context of ableism, in which bodily and cognitive differences such as disabilities are perceived as deviance and demand intervention. Further, neoliberalism, with its overwhelming tendency to privatize and individualize, creates conditions under which social systems abdicate responsibility for social issues such as ableism, shifting accountability onto individuals to prevent or mitigate difference through individualized means. It is in this context that this dissertation, informed by critical disability studies and feminist science and technology studies, examines the understanding and enactment of disability and responsibility in relation to biomedical technologies. I draw from qualitative empirical data from three distinct case studies, each focused on a different biomedical technology: prenatal genetic screening and diagnosis, deep brain stimulation, and do-it-yourself artificial pancreas systems. Analyzing semi-structured interviews and primary documents through an inductive framework that takes up elements of Grounded Theory and hermeneutic phenomenology, this research demonstrates a series of tensions. As disability becomes increasingly associated with discrete biological characteristics and medical professionals claim a growing authority over disabled bodyminds, users of these technologies are caught in a double bind of personal responsibility and epistemic invalidation. Technologies, however, do not occupy either exclusively oppressive or liberatory roles. Rather, they are used with full acknowledgement of their role in perpetuating medical authority and neoliberal paradigms as well as their individual benefit. Experiential and embodied knowledge, particular when in tension with clinical knowledge, is invalidated as a transgression of expert authority. To reject these invalidations, communities cohering around subaltern knowledges emerge in resistance to the mismatched priorities and expectations of medical authority, creating space for alternative disabled imaginaries. / Dissertation/Thesis / Doctoral Dissertation Human and Social Dimensions of Science and Technology 2020

Trust for health care professionals (interpersonal trust) and the health care system (institutional trust) is imperative for the performance of health care systems. However, at the same time, contemporary societies today are characterised by decreasing levels of trust and citizens today are increasingly inclined to seek health information from sources beyond health care professionals. Sociologists have argued that societal institutions, such as the health care system, are subject to individuals’ increasing mistrust, which has created a “critical distance” between lay citizens and modern medicine. In this critical distance, the health care system and its representatives are continually questioned why citizens’ trust for the medical institution can not be taken for granted. Because individuals living in the modern society are more inclined to take control over their health by engaging in health information seeking behaviour, the present study aims to examine whether there exists an association between interpersonal and institutional trust and differences in health information seeking behaviour. This study focuses on the Swedish context, where decreasing levels of trust for societal institutions - including the health care system, have been reported. Multivariate logistic regression analysis using data from European Social Survey (2004) was utilised to answer the research questions “Is the degree of trust for the health care system in Sweden associated with individuals' health information seeking behaviours?” and “Is the degree of trust for health care professionals in Sweden associated with individuals' health information seeking behaviours?”. The majority of the results from this study were not statistically significant, why the null hypothesis can not be ruled out. More recently collected data and more representative operationalisations of variables might generate more valid results. The study topic provides a potentially fruitful and valuable route for future scientific research, why it is considered important to further investigate whether mistrust for the healthcare system and its experts motivates individuals to consult alternative sources rather than health care professionals when seeking health information.

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Medicalization has been discussed at length in the sociology of health and illness literature. Typically, dialogue has centered on the effects of medicalization and the process as a phenomenon in professional fields alone. This work is an attempt to study medicalization using a theoretical model, structuration, that allows for inclusion of the larger social system in understanding health system changes and to include consumers of health services in the process as active agents. The example of oral aesthetics provides an opportunity to identify the agents of change, the process of medicalization in the larger social context, and possible indicators of the phenomenon. An attempt to operationalize the complex concept of medicalization marks a move toward creating testable theoretical models for the variety of behaviors and conditions under study as medicalized. Using content analysis of professional dental journals and lay magazines and a review of system rules and resources, shifts in language use and the emergence of medical frameworks were documented to determine if a medicalization of oral aesthetics had occurred. Results show two distinct periods within the last century when oral aesthetics have been medicalized in the United States. Evidence of turn-taking behavior among the agents is noted as well as the relationship of technology and technological language to the process. A model for future testing is suggested that encompass the identified agents, the language and framework, and the elements of social context.

The purpose of the present study is, by employing the methods of process-tracing and pattern-matching, to compare the policy-processes with regards to the cases of student and patient mobility. While the case-study approach to EU policy-making from a comparative perspective was introduced in the late 1970s, so far there has not been a study, which compares the cases of student and patient mobility. This gap in the academic literature is important in order to examine what conclusions can be drawn from such a comparison and as a result their consistency with previous theoretical work. In particular, and in contrast to current theoretical themes in the field of European studies and in the policy studies literature more generally, both of which stress policy change as opposed to policy stability, the comparison stresses the latter due to the interests of the most powerful member-states, that is, France, Germany and Britain. The role of interests is manifested with the adoption of the Erasmus Programme and of the European Health Insurance Card, which do not concern the free movement of students and patients. Through a synthesis between liberal intergovernmentalism and the concept of path-dependence it has been possible to create a model in order to explain why those particular policies were chosen when the alternative of free movement was also available. This interest-based account comes in direct opposition with those studies which stress the role of ideas in the policy-process but it also emphasizes the role played by the supranational institutions more specifically the Commission and the court.

This thesis centres on the lives of women who live in Khayelitsha and who receive AIDS biomedicines through South Africa's public health system. It is tiered across five ethnographic chapters to elucidate a single overarching argument: biopolitical precarity is networked into the permeable body. This argument is based on ethnographic research and seeks to challenge the discursive construction of distance that divorces women's lives and bodies from the governance of AIDS biomedicines as life-­giving technologies. The multi-­sited ethnography underpinning this thesis was configured to follow the networked threads that weave women's embodied precarity into the governance of technologies and the technologies of governance. To this end, fieldwork was conducted in South Africa from October 2010 – July 2011 in order to understand the embodied and political dimensions of access to AIDS biomedicine. Thereafter, fieldwork was conducted in Brazil from August 2011 – September 2011 to explore the networked connections spanning activist organisations, government coalitions and economic blocs to move out from the intimate spaces of women's lives and bodies to locate them in the regional and global spaces of biomedical developments and health policy dynamics. This thesis argues that although it is crucial to anchor technologies in people's lives, it is also analytically and politically necessary to link people's lives - and the technologies that sustain them - back into the global assemblage that is networked around the governance of medicine. Therefore, I locate biomedical technologies in social and political contexts of lives of the people with whom I worked in Khayelitsha, and I argue further that their lives also need to be understood as part of a complex network of actors (spanning international organisations, regional coalitions and national governments) and actants (HIV and ARVs) that assemble in dynamic configurations and that are woven into and through the body.