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Efficient allocation of scarce resources to health programs involves measuring the economic benefits of life saving and/or improvement in health status. While several attempts have been made to quantify individual preferences for life, only a few, if any, have attempted to measure individual preferences for quality of life. In this thesis, we develop a methodology based on the estimation of individual preference functions to arrive at monetary measures of the value of marginal improvements in health status. / The first chapter reviews conventional methodologies for estimating the value of human life, and points out many theoretical and empirical propositions related to our own concerns. The second chapter analyzes various procedures used to quantify variations in health status. We distinguish non-monetary procedures, which combine recent psychometric techniques and research on health level scaling to obtain estimates of the relative desirability of a state of health, and monetary procedures which, we conclude, still need to be developed. / The third chapter presents a new methodology based on the direct estimation of bivariate welfare function of income and level of health. The theoretical basis of our approach and the data source are described in this chapter. Various functional forms were tried but we have finally retained the log-normal specification to derive estimates of the monetary value of a marginal change in the state of health for different subgroups of individuals. / We conclude with critical discussion of our results. Some improvements over the approach used are suggested in the fifth chapter.

Sexual health risk-taking behaviour is typically initiated during adolescence and continues throughout teenage years and early adulthood at higher levels than at other life stages. For some groups (e.g. deprived and vulnerable populations) the risks can be greater still. Risk behaviours in early youth are related to increased rates of risk-taking and the adoption of multiple risk behaviours in early adulthood. Prevention interventions implemented early on are shown to be most effective at preventing or reducing the poor health outcomes associated with risk-behaviours. Policies and prevention interventions are informed by current data showing patterns of risk behaviour, identification of emerging behaviour, factors associated with these behaviours and evidence of intervention prevention effectiveness. This submission presents a linking commentary which summarises and critiques a series of peer reviewed publications, supported by additional publications, all of which were carried out during my employment at Liverpool John Moores University. Studies have identified key factors affecting sexual development and associated behaviour; associations between sexual and other behaviours, such as alcohol behaviours; and the relationship between social and well-being factors and sexual behaviours in adolescents and young people. Studies also evaluate public health initiatives and review public health evidence of intervention effectiveness. These studies have contributed to understanding sexual development and its impact on behaviours during the life course; have highlighted the health service and education needs of young people; and have identified effective interventions and intervention components to inform national guidance, public health policy and intervention development.

Background and Significance: Severe childhood obesity, the fastest growing subcategory of childhood obesity, affects 4-6% of youth. Children from racial/ethnic minority groups and low income households are disproportionately affected. Severe obesity increases risk for metabolic syndrome, cardiovascular disease, non-alcoholic fatty liver disease, musculoskeletal problems, poor health-related quality of life, bullying, low self-worth, absenteeism, and adult obesity. One method of addressing childhood obesity is through school-based interventions. School nurses may be well-suited to lead obesity interventions because of their healthcare expertise, long-term relationships with students and families, and availability to students without financial burden. Purpose: The overarching aim of this mixed methods dissertation was to evaluate the implementation and efficacy of the Healthy Options and Physical Activity Program, a school nurse-led intervention for children with severe obesity attending New York City schools. This evaluation focused on the 2012/2013 school year, the first full year of program implementation. Methods: Aims 1 and 2 were conducted to prepare for the Healthy Options and Physical Activity Program evaluation. Aim 1 included conduct of a systematic review and meta-analysis of existing literature to examine the role and impact of nurses in school-based obesity interventions. Aim 2 studied application of 3 propensity score methods to the observational Healthy Options and Physical Activity Program data set to determine which best removed significant differences in 11 potential confounders between the 1,054 kindergarten through fifth grade children who participated in the program in 2012/2013 and the 19,464 children who were eligible but did not participate. Aims 3-6 comprised the Healthy Options and Physical Activity Program evaluation. Aims 3, 4, and 5, utilized a retrospective cohort design to examine program implementation and its one year impact on body mass index percentile, school absences, and walk-in school nurse visits. Analytic methods included descriptive statistics, Wilcoxon signed rank tests, McNemar’s test, and logistic regression. Aim 6 qualitatively explored perceived barriers to and facilitators of implementing the Healthy Options and Physical Activity Program from the perspective of school nurses, using individual semi-structured interviews. Interview data were analyzed using content analysis. Results/findings: Of 11 studies eligible for systematic review, 8 met inclusion for meta-analysis. Pooled findings suggest that school nurse led interventions decreased BMI percentile by -0.41 (95%CI: -0.60, -0.21; I2=0, Cochrane Q=2.0). The comparison of propensity score methods demonstrated that only propensity score matching removed all significant differences between children who received the Healthy Options and Physical Activity Program and children who were eligible for but did not receive the program. The program evaluation demonstrated that the program had limited reach (5% of eligible children) and low intensity (median 1 session/year, parent attendance at 3.2% of sessions). Factors associated with selection for program enrollment included attending a school with low school nurse workload (OR 2.4, 95%CI 2.0-2.8), low school poverty (OR 1.6, 95%CI 1.3-1.9), and lack of chronic illness comorbidity (OR 0.5, 95%CI 0.5-0.6). After propensity score matching, program participants failed to decrease body measures, school absences, or school nurse visits at 1 year. Themes of interviews with 19 school nurses suggest that nurses encountered barriers to program implementation: parental and administrative resistance, heavy workload, and obesogenic environments. Despite barriers, nurses implemented the program to the best of their ability using creativity and teamwork. Conclusion: As implemented, the Healthy Options and Physical Activity Program was not effective in reducing body mass index percentile, absences or school nurse visits in youth with severe obesity. Barriers such as limited time and lack of parental and administrative support prevented nurses from fully implementing the program. However, school nurses with their clinical knowledge base, cost-free accessibility to children and families, and long-term relationship with students may be able to successfully employ other school-based obesity interventions. Therefore future research should use rigorous methods to develop and test school-based interventions implemented by school nurses, with a focus on intervention feasibility and sustainability. Implications for the Profession: This dissertation has implications for nursing practice, health policy, and nursing science. Findings of this mixed methods evaluation suggests that nurses may not have the resources necessary to implement intensive school-based obesity interventions. Nurses who are planning to implement such an intervention may want to carefully consider program intensity and feasibility. In addition, careful attention to increasing parent buy-in and ensuring administrator support are key. In addition, policy that supports adequate school nurse staffing can support appropriate nursing workload and may allow nurses time to implement health promotion programs and obesity interventions. During the qualitative portion of this dissertation, nurses reported the obesogenic environment as a barrier to healthful living that impacted the program’s effectiveness; obesogenic environmental factors (e.g., unhealthy school meals) will need to be addressed via legislation. Lastly, nurse scientists can work to increase the literature surrounding school-based obesity interventions, particularly with randomized controlled trials of interventions and qualitative work with nurses, parents, school administrators, and children. In addition, school-based obesity interventions must be developed and tested that consider the challenges faced by vulnerable children such as children living and attending school in high poverty neighborhoods.

More than 50 million people were forcibly displaced from their homes at the end of 2014, the highest number since World War II; 38 million of these were displaced within their own country rather than crossing an international border. Many have been displaced multiple times by chronic and recurring conflict. Complex humanitarian emergencies caused by armed conflict are characterized by social disruption, population displacement and the breakdown of national health systems. The negative impact of war and displacement on women has long been recognized, including by compromising their right to sexual and reproductive health (SRH) services. The ten countries with the highest maternal mortality ratios in the world are affected by, or emerging from, war; these countries are also characterized by low contraceptive prevalence. The provision of SRH services is a minimum standard of health care in humanitarian settings; however access to these services is still often compromised in war. A 2012-2014 global evaluation on the status of SRH in humanitarian settings showed that although access to SRH services has improved in humanitarian settings, gaps persist and the availability of contraceptive services and information is still weak relative to other SRH components. This dissertation addresses this gap by providing evidence that good quality contraceptive services can be implemented in humanitarian settings and that women and couples will choose to start and continue contraceptive use. The first paper of this dissertation, a systematic review, explored the evidence regarding SRH services provided in humanitarian settings and determined if programs were being evaluated. In addition, the review explored which SRH services received more attention based on program evaluations and descriptive data. Peer-reviewed papers published between 2004 and 2013 were identified via the Ovid MEDLINE database, followed by a PubMed search. Papers on quantitative evaluations of SRH programs, including experimental and non-experimental designs that reported outcome data, implemented in conflict and natural disaster settings, were included. Of 5,669 papers identified in the initial search, 36 papers describing 30 programs met inclusion criteria. Some SRH technical areas were better represented than others: seven papers reported on maternal and newborn health (including two that also covered contraceptive services), six on contraceptive services, three on sexual violence, 20 on HIV and other sexually transmitted infections and two on general SRH topics. In comparison to the program evaluation papers identified, three times as many papers were found that reported SRH descriptive or prevalence data in humanitarian settings. While data demonstrating the magnitude of the problem are crucial and were previously lacking, the need for SRH services and for evaluations to measure their effectiveness is clear. Contraceptive services were mostly limited to short-acting methods and received less attention overall than other SRH technical components. In response to this lack of evidence for the implementation of contraceptive services in humanitarian settings, two contraceptive services programs implemented by CARE and Save the Children among conflict-affected populations in eastern Democratic Republic of the Congo (DRC) were evaluated. DRC has experienced chronic conflict for two decades, ranging from acute to post conflict phases. People have been displaced internally for many years while others have experienced repeated cycles of displacement and return. First, cross-sectional surveys in 2008 (n=607) and 2010 (n=575) of women of reproductive age using a multi-stage cluster sampling design and facility assessments were conducted in Maniema province. Data on the numbers of clients who started a contraceptive method were also collected monthly from supported facilities. Current use of any modern contraceptive method doubled from 3.1% to 5.9% (adjusted OR 2.03 [95%CI 1.3-3.2]). Current use of long-acting and permanent methods (LAPM) increased from 0 to 1.7%, an increase that was no longer significant after adjustment. Program changes were made to improve service quality in 2010; provider skills and counseling improved and commodities became consistently available. Service statistics indicate that the percentage of clients who accepted a LAPM at supported facilities increased from 8% in 2008 to 83% in 2014. This study demonstrates that when good quality contraceptive services, including LAPM, are provided among conflict-affected populations, women will choose to use them. Second, a retrospective cohort study measured 12-month contraceptive continuation in North Kivu province. A total of 548 women (304 short-acting and 244 long-acting method acceptors) were interviewed about their contraceptive use in the previous year. At 12 months, 81.6% women reported using their baseline method continuously, with more long-acting than short-acting method acceptors (86.1% versus 78.0%, p=.02) continuing method use. Use of a short-acting method (HR 1.74 [95%CI 1.13-2.67]) and desiring a child within two years (HR 2.32 [95%CI 1.33-4.02]) were associated with discontinuation at 12 months. Given the association between service quality and contraceptive continuation, the program’s focus on service quality including improvements to provider skills and activities to address provider attitudes likely contributed to these results. The impressive continuation rates found here indicate that delivering high quality contraceptives services in these settings is possible, even in a difficult and unstable setting like eastern DRC. This dissertation represents a major contribution to the field of SRH in humanitarian settings, and has implications for research and programs. First, these results strengthen the evidence base for the implementation of contraceptive services in humanitarian settings, and demonstrate to implementers and donors of humanitarian aid that effective programs resulting in adoption and continuation of contraceptive methods can be successfully implemented in these challenging settings. Second, these programs were implemented in full collaboration with the Ministry of Health (MOH), supporting MOH facilities and health workers, thus strengthening the health system. Third, the programs achieved these impressive results in rural DRC where they attracted early adopters, most of them first time contraceptive acceptors. In addition, these programs were implemented by multi-sectoral, as opposed to SRH-specific, non-governmental organizations that made good quality contraceptive services a priority, further reinforcing the inclusion of contraceptive services as a routine component of humanitarian health response. Finally, both programs evaluated in this dissertation focused strongly on improving the quality of contraceptive services with specific attention to training, supervision, provider attitudes, data use and commodities management. This program focus on quality contributed to the positive findings. Making good quality contraceptive services available is challenging and requires sustained commitment, funding and program adjustments, but, in the programs studied here, was ultimately successful. Given true choice, when a range of methods was routinely available, women, many of whom had no prior experience with contraceptive use, were able to choose the method that best served their needs and continued to use their preferred method. These results add to the limited evidence on contraception in humanitarian settings, and demonstrate that even in remote and unstable settings, when good quality contraceptive services, with a choice of short-acting, long-acting and permanent methods, are in place, women will not only choose to start, but also continue, to use contraception to exercise their right to reproductive choice.

The demand for human services has grown exponentially in recent years. Self-help groups now fill the gap between consumer needs and the reach of traditional health care. This study examines the perception of the members of these groups toward the professional community. Four self-help groups, all based on principles of Alcoholics Anonymous (AA) and all primarily concerned with the control of excessive behavior were examined: (1) Parents Anonymous (PA), (2) Overeaters Anonymous (OA), (3) Alcoholics Anonymous (AA) and (4) Narcotics Anonymous (NA). A 60 item questionnaire was designed to obtain the following information: (1) demographic, (2) membership participation, (3) professional contact, and (4) attitude expression regarding respondents' perception of their particular self-help group, perceptions of health care professionals and perceptions of society's beliefs regarding their behavior. Among the 110 respondents from the four groups responding to the questionnaire, (overall return rate of 52%), there was strong support of the methods and conduct of the self-help groups. Criticism of the self-help groups was negligible. Criticism of the health care community was consistently strong, although respondents indicated relatively high usage of health care providers. The respondents from all four groups appeared to support any individual member's decision to pursue whatever assistance that individual might deem necessary, but maintained firm delineation between the individual's freedom to choose alternative or adjunctive assistance and the group's decision to remain "forever nonprofessional". Despite a common theoretical background, the groups have developed in different directions. PA, which has included health care professionals as group sponsors since its inception, was more open to professional involvement in group affairs than the others and cited a higher rate of professional referral to the group. OA, with less mental health contact and with more medical involvement, expressed greater reluctance to involve professionals in any aspect of the group's activities. AA and NA tended to take more intermediate positions, however, both groups were firmly against professional involvement in group activities. Information of this nature may assist professionals and self-help groups in developing a collaborative and respectful working relationship.

Many parts of South Africa face a shortage of doctors within the public health system. While the PHC system is driven primarily by nursing staff, there is a need for doctors to provide certain services at primary and secondary levels. In 1996, as part of its efforts to address the shortage of doctors, the DoH began recruiting Cuban doctors to work in South Africa. This programme, now underway in eight of the nine provinces, falls under a government-to-government agreement aimed at strengthening the provision of health care in the areas of greatest need: townships and rural areas. The programme has demonstrated tangible success. However, it has also been criticised in some sections of the medical community and the media, where it has been portrayed in a controversial light. All this underlines the importance of an analysis of the programme, but to date, no such evaluation has been carried out.<br /> <br /> This research assesses the Cuban Health Programme in Gauteng province. On the basis of this thorough assessment, the government can take steps to improve the national programme, using Gauteng as a case study. This study was conducted in July 2004, employing qualitative methods to develop an in-depth understanding of recruitment and induction processes in Cuba and South Africa, the scope of practice of Cuban doctors, professional relationships, adaptation to the health system and broader society, and other factors. The researcher also conducted a review of official documents. Gauteng began with two Cuban doctors at the outset of the programme in 1996. The number peaked at 32, and has since dropped to 15. All of these doctors were interviewed in the course of the research, along with five managers and five peers. The study revealed that all the interviewees, except one manager, firmly believe that the programme has achieved its objectives, and should continue. Peers and managers commended the high quality, comprehensive and caring approach of the Cuban doctors, and say they are satisfying a real need. The Cuban doctors, however, believe that because they are providing mostly curative services, they are under-utilised. Flowing from the research are a series of recommendations. These include a proposal that the government recommit to the programme and ensure its continuity, and review the current role of the Cuban doctors, taking into consideration their willingness to provide training and expertise in preventive interventions.

Many parts of South Africa face a shortage of doctors within the public health system. While the PHC system is driven primarily by nursing staff, there is a need for doctors to provide certain services at primary and secondary levels. In 1996, as part of its efforts to address the shortage of doctors, the DoH began recruiting Cuban doctors to work in South Africa. This programme, now underway in eight of the nine provinces, falls under a government-to-government agreement aimed at strengthening the provision of health care in the areas of greatest need: townships and rural areas. The programme has demonstrated tangible success. However, it has also been criticised in some sections of the medical community and the media, where it has been portrayed in a controversial light. All this underlines the importance of an analysis of the programme, but to date, no such evaluation has been carried out.<br /> <br /> This research assesses the Cuban Health Programme in Gauteng province. On the basis of this thorough assessment, the government can take steps to improve the national programme, using Gauteng as a case study. This study was conducted in July 2004, employing qualitative methods to develop an in-depth understanding of recruitment and induction processes in Cuba and South Africa, the scope of practice of Cuban doctors, professional relationships, adaptation to the health system and broader society, and other factors. The researcher also conducted a review of official documents. Gauteng began with two Cuban doctors at the outset of the programme in 1996. The number peaked at 32, and has since dropped to 15. All of these doctors were interviewed in the course of the research, along with five managers and five peers. The study revealed that all the interviewees, except one manager, firmly believe that the programme has achieved its objectives, and should continue. Peers and managers commended the high quality, comprehensive and caring approach of the Cuban doctors, and say they are satisfying a real need. The Cuban doctors, however, believe that because they are providing mostly curative services, they are under-utilised. Flowing from the research are a series of recommendations. These include a proposal that the government recommit to the programme and ensure its continuity, and review the current role of the Cuban doctors, taking into consideration their willingness to provide training and expertise in preventive interventions.

This research study investigated the impact of staff education levels in ensuring implementation of effective health programmes: A comparative study of NPOs in City of Tshwane Metropolitan Municipality. The literature that was consulted explains the current level of education, worldwide and South Africa, challenges and reasons for lack of critical skills among health professionals and social workers. An exploratory approach was used in the study; by conducting a case study on two selected Non Profit Orgaisations (NPOs) namely, Hope for Life and Bophelong Life Community Hospice, both receiving funding from the Department of Health and Social Development and from the National Lotteries Distribution Trust (NLDTF) through the National Lotteries Board (NLB). Three methods of data collection were used to triangulate data, i.e. questionnaires, interviews and documentation reviews. Data was collected from staff members, NPO management and documentation from NPOs and Grant Funding System of the NLB. At the end of the study and using acquired information, a number of recommendations are made for the effective implementation of programmes for both NPOs and funding organisations such as NLB.

Introduction<p>Depuis une quinzaine d'années en Afrique, cercles de qualité, audits cliniques, cycles de résolution de problèmes et autres 'projets qualité' ont été mis en oeuvre dans les services publics de santé pour améliorer la qualité des soins. Ces projets ont souvent mis l'accent sur des approches participatives, la résolution locale de problèmes et le changement, bousculant les pratiques managériales traditionnelles. A court terme, les évaluations montrent l'amélioration des résultats de programmes ou d'activités. Mais la pérennité de la dynamique reste largement à prouver. Le véritable aboutissement d'un programme d'assurance qualité devrait être apprécié à l'aune de sa capacité à mettre la préoccupation pour la qualité au cœur du management et du fonctionnement du système, et ce de façon continue. C'est en effet la vision moderne de l'assurance qualité déclinée dans les approches du management de la qualité totale, de l'amélioration continue de la qualité ou de l'organisation apprenante.<p><p>Méthode<p>La définition, la mesure et le management de la qualité en santé se révèlent être beaucoup plus qu'une simple procédure technique: c'est un processus social dans un système complexe dont l'étude requiert une approche méthodologique appropriée (Chapitre 1). Notre objectif est d'explorer dans quelle mesure les projets qualité ont permis aux systèmes de santé d'adopter les principes du management de la qualité. <p>Nous proposons de conduire une 'évaluation réaliste' de projets qualité en Afrique (Chapitre 2). Conceptualisée par Pawson et Tilley (1997) dans le domaine des sciences sociales, l'évaluation réaliste ('realistic evaluation') est une approche méthodologique de la famille des theory based evaluations. Au-delà du constat d'un effet produit par une intervention, l'évaluation réaliste cherche à comprendre ce qui marche, pour qui, dans quelles circonstances et comment. Alors que les résultats issus de la 'grounded theory', de la recherche action et d'autres méthodes de recherche sur les systèmes de santé restent très liés à un contexte, l'évaluation réaliste génère des théories intermédiaires ('middle range theories') qui permettent d'étendre la validité des interprétations au-delà d'un contexte particulier. Construite autour d'études de cas menées dans des contextes multiples et variés, l'évaluation réaliste met en effet l'accent sur l'interaction entre le contexte et la logique d'une intervention.<p><p>Résultats<p>Afin de construire une théorie initiale, nous comparons les systèmes de santé Européens et Africains à l'aide des configurations organisationnelles de Mintzberg (chapitre 3). Nous mettons ainsi en évidence le rôle joué par la nature bureaucratique ou professionnelle de la configuration des organisations de santé dans les résistances à l'introduction des principes du management de la qualité. <p>Nous menons ensuite une série d'études de cas au Niger, en Guinée, au Maroc et au Zimbabwe pour étudier cette interaction. Dans une première série comparative de trois études de cas (Chapitre 4), nous mettons en évidence la tension qui existe entre la logique de commande et de contrôle des organisations bureaucratiques et la logique de l'assurance qualité valorisant la prise d'initiative de changement par des équipes non hiérarchisées. Nous explorons ensuite cette tension dans trois études de cas distinctes au Zimbabwe et au Maroc. Laissées à la merci des contraintes bureaucratiques, les initiatives locales pour améliorer la qualité apparaissent dépendantes de la capacité des acteurs à développer des stratégies de contournement (Chapitre 6). Faute de quoi elles doivent réduire fortement leurs ambitions à moins qu'elles ne bénéficient d'un soutien émanant d'une institution située hors de la ligne hiérarchique mais reconnue légitime (Chapitre 5). Les systèmes publics de santé de ces pays, conçus comme des organisations bureaucratiques structurées autour de relations hiérarchiques de commande et de contrôle tolèrent une démarche qualité, valorisant l'innovation, la créativité, la prise d'initiative locale et le travail en équipes non hiérarchisées, à la condition qu'elle se déroule à l'abri d'un projet. Force est de constater que ces dimensions clé de la culture qualité n'ont pas fondamentalement ni durablement imprégné des pratiques de management restées bureaucratiques. L'émergence d'une véritable 'culture qualité', un produit attendu de l'introduction de projets qualité, ne semble pas s'être produite au niveau organisationnel (Chapitre 7). <p>Nous procédons ensuite à la synthèse 'réaliste' de l'ensemble de nos études de cas (Chapitre 8). Nous en tirons les leçons sous la forme d'un enrichissement progressif de notre théorie initiale. Nous pouvons alors formuler une théorie améliorée, toujours intermédiaire et provisoire, dérivée de nos théories intermédiaires successives.<p><p>Discussion<p>Notre discussion s'organise autour de deux thèmes (chapitre 9). <p>Dans une première partie, nous discutons le potentiel et les limites de nos résultats et de l'approche réaliste de l'évaluation. Nous montrons que nos résultats sont des théories provisoires et incomplètes, deux caractéristiques d'une middle range theory. En dépit de ces limites, l'approche réaliste est potentiellement très riche pour interpréter les effets d'interventions dans des systèmes complexes. Elle se situe dans une perspective d'aide à la décision pour orienter l'action sur le terrain plutôt que dans une perspective de genèse de lois universelles. Elle représente une avancée méthodologique particulièrement pertinente pour la recherche sur les systèmes de santé dans un monde turbulent où de multiples initiatives se télescopent. <p>Dans une deuxième partie, nous discutons les conséquences de nos résultats pour le futur de l'assurance qualité dans les systèmes de santé. Les projets qualité étudiés ne parviennent pas à changer une culture organisationnelle bureaucratique qui compromet pourtant leur pérennisation. Nous envisageons alors les stratégies susceptibles de permettre à la culture qualité de s'épanouir et au contexte organisationnel d'évoluer en conséquence. Décentralisation et nouveau management public, en vogue hier et aujourd'hui, montrent leurs limites. Il faut probablement trouver un équilibre entre trois idéaux-types décrits par Freidson: l'idéal-type bureaucratique, malmené par les stratégies de débrouille locale, l'idéal-type du marché, valorisant l'initiative, et l'idéal-type professionnel, émergent mais encore embryonnaire en Afrique. Finalement, à côté des mécanismes du contrôle et de la compétition, un troisième mécanisme régulateur devrait prendre toute sa place: la confiance.<p><p><p><p>Introduction<p>For nearly two decades in Africa, quality circles, clinical audits, problem solving cycles and other quality projects have been implemented in public health services to improve quality of care. Challenging traditional managerial practices, these projects usually emphasized participatory approaches, local problem solving and change. At short term, evaluation shows improvement in programs and activities output. However the capacity to put quality at the heart of system's management should be considered as the genuine achievement of a quality assurance program. Did quality projects contribute to the adoption of quality management principles by health systems ?This is the question addressed in the present thesis.<p><p>Method<p>Our methodology belongs to the realistic evaluation paradigm conceptualized by Pawson and Tilley and focuses on the interaction between an intervention mechanism and its context in order to understand what works, for whom, in what circumstances and how ?Based on case studies in various contexts in Niger, Guinea, Morocco and Zimbabwe, we build a middle range theory, that explains organizational behavior towards quality management. <p><p>Results<p>Based on Mintzberg's models, we show the role of health care organizational configuration in resisting to quality management principles. We then explore the tension between the bureaucratic organization's command and control approach and the quality assurance approach promoting initiative and change through team work. Local initiative had to develop coping strategies to overcome bureaucratic constraints. Failing to do so, ambitions had to be reduced unless there was support from an external, yet legitimate institution. Public health systems of these countries, structured as command and control hierarchical organizations, allowed innovation, creativity, local initiative and non hierarchical relationships as long as they developed within the boundaries of a project. However, these key characteristics of a quality culture did not permeate routine management. The quality culture shift expected from quality projects does not seem to have happened at organizational level. <p><p>Discussion<p>We first discuss the potential and limitation of realistic evaluation which appear particularly relevant for complex health systems research. We then discuss consequences of our results on the future of quality assurance in health systems. Since quality projects fail to transform a bureaucratic organizational culture, which in turn undermines their sustainability, alternative strategies must be sought to promote quality culture and relevant organizational change. Decentralization and new public management show their limitations. We suggest a balance between three ideal-types described by Freidson: The bureaucratic ideal-type, challenged by local coping strategies, the market ideal-type, which is fashionable today and promote initiative, and the professional ideal-type, emerging and promising, yet still embryonic in Africa. / Doctorat en Sciences de la santé publique / info:eu-repo/semantics/nonPublished