Background: Maternal and child health initiatives are embracing the use of electronic or mobile technology, a branch of digital health popularly referred to as eHealth or mHealth. While digital health can offer extensive benefits, it has raised various challenges. For instance, digital health programs are not often designed with a focus on equity in distribution nor are they designed from a gender equity standpoint. Although digital health interventions for maternal healthcare focuses predominantly on women as beneficiaries, few studies explore gendered power relations and how they impact the success of maternal and child health projects in African contexts such as Nigeria. This gap in literature risks excluding women from engaging in the digital space and can worsen the negative and unintended consequences of participating in digital health. This thesis examines the impact and implications of digital health interventions for maternal health in sub-Saharan Africa. -- Method: Two secondary and three primary studies described the various implications of digital health in sub-Saharan Africa more broadly and in rural Edo State, Nigeria, specifically. The secondary studies involved a review and a systematic review of the literature, the primary studies involved focus group discussions and in-depth interviews with pregnant or postpartum women who were beneficiaries of a digital health program and their community members. -- Results: The first paper illustrated exclusionary practices of digital health programs in sub-Saharan Africa, the second paper showed how digital health programs can challenge and redress harmful and unequal gender norms, roles, and power relations that privilege men over women. Observations from the third paper indicate that while mHealth programs are helpful to women in many ways, they are not enough on their own to undo entrenched systems of power through which men control women's reproductive lives. The fourth paper affirms that a community-centered approach to implementing digital health programs enhances women's acceptance and sustained use of digital health. The fifth paper shows how women navigate patriarchal environments through negotiation, collaboration and maneuvering to yield the best possible maternal health outcomes. -- Conclusion: At the core of all the studies was the need to understand and redress overarching factors contributing to ill health and exacerbating health inequities in maternal health through gender transformative approaches. Potentially unintended consequences, side effects, and negative effects of digital health impedes its many benefits, therefore, to achieve meaningful impact, gender and digital inclusion must remain a priority in the development, implementation, and evaluation of digital health. This thesis illuminated the needs of those with the greatest barriers to health technologies for maternal health thereby contributing to the discussion on digital health social justice with overarching themes on how to achieve equitable opportunities for all women and girls to access, use and benefit from digital health for maternal health.

Background: Performance-based financing (PBF) is a healthcare reform that is widely adopted in low- and middle-income countries (LMICs). PBF is an intervention designed to strengthen healthcare systems in LMICs. It represents a fundamental shift towards improving healthcare amongst the most vulnerable, with a focus on maternal and child health services. Broadly, there are gaps regarding PBF’s effect on healthcare systems and various aspect of healthcare, including efforts to implement universal healthcare coverage. PBF introduced an innovative component—the PBF equity instrument—geared towards achieving universal health coverage. The effect of this equity instrument has not been studied. There is significant gap regarding how it is defined and implemented in various context. Cameroon has one of the highest maternal mortality rates in sub–Saharan Africa and with high out-of-pocket expenses that impede access to maternal health services. PBF was introduced in Cameroon in 2012 with a focus on maternal health services and was adopted in 2017 as a national strategy towards achieving universal coverage, however, the definition and implementation of the PBF equity elements remain a gap in Cameroon and sub-Saharan Africa. This dissertation is focused on studying the PBF equity elements in Cameroon in order to get a broader perspective on the effect of the PBF equity elements as a policy tool in improving the lives of the most vulnerable population to ensure no one is left behind in the efforts towards achieving universal health coverage. Objectives: This dissertation aimed (1) to investigate and characterize the effect of the PBF equity elements in improving equity in access to selected maternal services (2) to understand how the equity elements is defined and implemented in Cameroon; and (3) to generate a framework that will facilitate the identification of gaps and challenges, in turn informing policy development that is relevant to PBF equity elements in Cameroon and PBF research on equity in other countries; and (4) to explore health providers experiences before and after the introduction of PBF in Cameroon. Methods: This dissertation employed a mixed methods approach to address the above objectives, involving the use of multiple frameworks and triangulation across and within objectives. First, to investigate the effect of PBF on equity in improving access to maternal services, I designed a systematic review with a focus on one of the equity elements—subsidizing user fees to reduce out-of-pocket expenses to improve access to maternal health services. The aim was to get a broader overview of the PBF equity element and to understand the effect of PBF on out-of-pocket expenses in improving access to selected maternal health services in sub–Saharan Africa. Second, I narrowed the assessment to a specific context-Cameroon. Given the heterogenous nature of care delivery in Cameroon, I investigated the effect of PBF on out-of-pocket expenses in improving access to selected maternal health services across healthcare sectors using a before-and-after study design. The rationale was to address the limitations of an earlier PBF impact evaluation in Cameroon, in particular, potential heterogeneity across settings and sectors which had not been considered. Third, to describe and define the implementation of the PBF equity elements in Cameroon, I conducted a grounded theory study -given that it is a new policy that has not been well studied -to understand the social processes and actions from health facilities, health providers, PBF managers and the community, and generated a theoretical framework to inform the challenges and gaps in the implementation process. Finally, as a newly adopted health reform, I conducted an in-depth qualitative study to understand the experiences of health care provides before -and-after the implementation of PBF and its equity elements and the potential for sustainability of the policy especially the equity strategies in Cameroon. Findings: The findings provide an overarching understanding on the effect of one of the PBF equity elements in improving access to maternal health services in sub–Saharan Africa, and in particular, an understanding of the effect of the PBF equity elements in improving access and utilization of selected maternal services in Cameroon. At the health system level, the findings provide an understanding of the focus of the equity elements within the context of Cameroon and further insight on the gaps and limitations in the implementation of the PBF equity elements and the potential challenges in sustainability towards achieving universal health coverage. At the health facility level, it provides an understanding on how the PBF equity elements is understood, defined, and implemented and provides directions on the challenges to inform policy and to guide research. At the individual level, it provides an overview of the expectations of health care providers from a supply side perspective and the potential effect it has on demand creation from women and households in improving access to maternal health services. Overall, the findings provide insight on how the equity elements are defined and implemented but also provides opportunity and areas of improvement and detailed how PBF equity elements can be further assessed and how delays in payment of PBF incentives can potentially affect the realization of the equity elements in improving access and utilization of maternal health services amongst the poor and vulnerable. Conclusion: Equity is central and essential to the delivery of services to achieve universal health coverage. The adoption of PBF in Cameroon is a step toward achieving universal health coverage with the recognition that universal health coverage cannot be effectively implemented in an institution without good governance. The PBF initiative is viewed as an entry point for universal health coverage, in order to evaluate the level of preparedness of health facilities to embrace universal health coverage in terms of quality of health care, production, good managerial skills, and financial management. However, due to administrative bottlenecks, the government has yet to accept some of the established principles of PBF—this in turn causes delays in payment and this hampers the effective implementation of some of the PBF equity strategies. Therefore, though PBF is a national policy, the actors at the central level, i.e., the Ministry of Public Health, are not playing their role effectively in enabling full implementation of PBF best practices and theories.

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The choice of a suitable site for any aquaculture practice is a critical decision to make since it has a large impact on the economic profitability of the venture, considering the fact that location defines the amount of capital needed, production costs, yield and access to market. The limited public and private sector support for small-scale aquaculture can be optimized if farms are zoned into areas with relatively similar performance and needs. Considering the high rate at which aquaculture is increasing globally and its consequent impact on the environment, it is projected that improvements will be made in the practices employed in aquaculture. As these improvements are made, there is the need for the review of the location of aquaculture infrastructure and services in order to increase the productivity of the sector. Also, aquaculture statistics such as location of farms and production estimates are fundamental to policy making and development planning at both national and global levels. Aquaculture statistics are however chronically scanty or unreliable in developing countries such as Ghana. Thus, the goal of this study was to show the relative suitability of areas in Ghana for aquaculture and identify the key variables to be considered in the development (including improvement of existing farms) of the aquaculture sector of the country. I used satellite imagery and GIS data in combination with field observations and questionnaires, to develop a map of the feasibility of pond aquaculture in Ghana and provide a reliable estimate of the number of ponds, their areas, productivity and aggregate production in the country. The main factors that have influenced the current distribution of pond aquaculture in Ghana are population density (indicating the availability of markets, input and labor) and proximity to stream and road networks. My results show a gross underestimation of the number of fish ponds in the country and smaller sizes of ponds than existing records suggest. The average water depth of ponds in Ghana is only half of the recommended depth which explained over 80% of the variation in productivity among farms. I estimated the contribution of ponds to domestic fish production to be two to three times what has been previously reported, but still well below the potential. The results of this study will be vital to current national and international efforts to improve aquaculture enterprises in Ghana. / Master of Science

This dissertation focuses on identifying the poor in Sub-Saharan Africa (SSA) and the potential of social assistance programs to address their condition. Each essay is related to one particular key step of the poverty alleviation agenda: poverty definition and measurement in Zimbabwe; targeting poor households in Cameroon; and impact evaluation of anti-poverty interventions in Niger. The first essay explores changes in poverty across multiple dimensions in a period of dramatic economic crisis and recovery in Zimbabwe. The essay analyzes changes in household well-being between 2001, 2007 and 2011/12, using an Alkire-Foster multidimensional poverty index. Results indicate a large increase in multidimensional poverty across between 2001 and 2007, followed by a (smaller) decrease in poverty between 2007 and 2011/12 (recovery period after the hyperinflation peak in 2008). However, decomposition of the index shows significantly different trends in poverty dimensions over time, as for instance health related dimensions continued to deteriorate after 2007. The second essay contributes to the policy debate on targeting by studying the ex-post efficiency of two targeting mechanisms employed in a cash transfer project in rural Cameroon: Proxy Means Testing (PMT) and community targeting. Results show a poor performance of community targeting in selecting households with low per capita consumption, compared to PMT targeting—whose errors remain high nonetheless. Communities tend to select small, isolated households with low physical and human capital, regardless of their actual consumption level, but produce variable outcomes. Overall results suggest that a higher coverage contributes to reducing targeting errors, and that better guidance should be provided to communities if the policy objective is to select low per capita consumption individuals. The third essay investigate whether cash transfers induce investments in assets and productive activities that survive the termination of program payments using data from an unconditional cash transfer project in Niger 18 months after its termination. Based on quasi-experimental methods, results indicate that local saving/credit systems (tontines) participation and livestock ownership significantly increased among project participants. There is also evidence of improvement in private assets, micro-enterprises and agriculture. The findings imply that cash transfer programs can have long-term sustainable impacts in rural SSA. / Ph. D.

Yes / Extant research has established that environmental sustainability orientation (ESO) has a positive influence on performance outcomes. Nevertheless, several contingencies tend to affect the strength of this relationship. In this study, we draw on natural resource-based theory to introduce competitive strategies as moderators in the ESO-performance nexus. Using time-lagged data obtained from 269 firms in Ghana, this study finds that firms pursuing the differentiation strategy can positively boost performance outcomes with ESO than without differentiation strategy. We also find that firms can use the low-cost or the integrated strategy to get higher impact on performance with ESO respectively. Based on the results, firms in Ghana do not need differentiation strategy in order to boost the effect of ESO on financial performance. Theoretical and practical implications are discussed.

Yes / While previous research has emphasized the role of stakeholder pressures, firm‐specific factors, as well as CEO characteristics as important drivers of corporate social responsibility (CSR) implementation, our understanding of how political connections impact small and medium‐sized enterprises' (SMEs') CSR implementation expenditure is quite limited. In this study, we contribute to filling this gap by investigating the effects of political connections and CSR expenditure and explain the conditions that impact this relationship. Using data from 473 SMEs in Ghana, we find that political connections negatively influence CSR implementation expenditure. However, the negative effect is weakened when a firms' reputation and competitive CSR implementation pressures are high. Implications for theory and practice are discussed. / University of Economics Ho Chi Minh City, Vietnam