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Introduction: Sustainability of health interventions in developing countries has been limited by the capacities of their health systems. As a result, efforts have been invested by the international community to make health systems thinking coherent. Aim: To examine the sustainability of a health system during and after cessation of international support from the Swiss Red Cross (SRC) in eye care services in the Brong Ahafo region, Ghana. Methods: Between July 2008 and January 2010, multiple case study approaches were applied to measure the sustainability of activities, identify the main shocks affecting health systems, and analyse the structure of social networks and their impact on the governance of health systems. This involved one-to-one in-depth interviews, dkect observations, document review, and social network analysis Findings: The district health systems were affected by shocks from different origins (local, regional and national). District hospital managers were able to respond to negative shocks of local origin but had limited capacity to find solutions to shocks originating from outside their district. Within the health system studied, it was apparent that health interventions that had the greatest observable effects, that were the least complex and the most compatible with the mandate of the hospital were more likely to be continued by hospital managers than the other activities Further, after the departure of SRC in 2006, the social network shifted from a dense network in which all the districts were connected with each other to a centralised network composed of five isolated districts. This led to a negative impact on the capacity of hospital mangers to respond to regional shocks and find appropriate solutions in a timely manner. Conclusion: International organisations need to transition from the management of health projects towards health systems approaches taking into account the governance of health systems.

Although academic and policy interest in health system resilience has grown considerably in recent years, the empirical literature on this topic is small and predominantly focused on effects arising from single shocks. Shocks are also under-theorised in the health systems literature. This thesis helps to address these deficits through an in-depth case study on the childhood vaccination delivery system in Lebanon, a country which has experienced a series of recent shocks overlapping in time and space, including large-scale refugee influx from neighbouring Syria, COVID-19 and a multi-dimensional political and economic crisis. The thesis opens with an overview of the theoretical literature on system resilience from health and a range of other research fields, highlighting insights regarding resilience conceptualisation, assessment and measurement that are of relevance to health systems. Two empirical papers then explore how sequential shocks have affected the vaccination delivery system in Lebanon, identifying independent and interacting vulnerabilities and their effects at multiple system levels, before tracing key system responses. These papers employ qualitative system dynamics modelling (SDM), an approach that maps out causal links between variables and feedbacks contributing, in this instance, to variations in routine vaccination coverage in Lebanon over time. A third empirical paper uses qualitative, thematic analysis to identify governance factors contributing to system responses to shocks over time. Collectively, these studies identify a series of leverage points potentially amenable to intervention, including delays affecting speed of shock recognition and mobilisation of human and financial resources. They also show how resilience-promoting measures introduced following one shock can paradoxically increase vulnerability to later ones. The final study - a realist-informed systematic review - links findings from the empirical work to intervention evidence from the wider health systems literature, to inform a series of policy recommendations for supporting system resilience in Lebanon over the medium-to-long-term.

More than any other public health intervention, handwashing with soap can reduce the burden of faecal-oral diseases. Over the last decade substantial research and programmatic investment have gone into better understanding the determinants of people's handwashing behaviour. However, this research base is derived almost entirely from work conducted in stable settings. When a humanitarian crisis occurs, whether it be a disease outbreak, a disaster or a conflict, the social and physical environments of the affected population are disrupted. At the same time, disease risk related to faecal-oral pathogens substantially increases. Given that we currently lack an in-depth understanding of the factors that drive behaviour in crises, hygiene programmes in these settings typically rely on a narrow set of 'traditional' interventions such as health education and the distribution of hygiene kits. Although knowledge about handwashing and enabling products are likely to be important, these interventions alone have been shown to be insufficient to lead to meaningful and sustained changes in behaviour. Recent systematic reviews and research agenda setting activities within the humanitarian sector have suggested that research on hand hygiene behaviour and improved hygiene programme design in emergencies should prioritised. This thesis is grounded in a pragmatic epistemology and uses a mix of methods drawn from the disciples of cultural anthropology and behavioural science. It aims to better understand what influences hygiene behaviour during crises and outbreaks and identify opportunities for effective hygiene behaviour change in these settings. The thesis includes five manuscripts. The first is a literature review which aims to identify and categorise the determinants of handwashing behaviour in stable settings, crises and outbreaks and to appraise the quality of this evidence. The second assesses the strengths and limitations of a survey-based tool which is commonly used in humanitarian crises to understand behavioural determinants. The third and fourth paper are qualitative case studies set in Iraq and the Democratic Republic of the Congo. Both explore how the determinants of handwashing behaviour are shaped by different types of crises. The thesis concludes with a paper about experiences and challenges faced by humanitarians when designing hygiene programmes in emergencies. Prior research on behavioural determinants was found to be poor quality and limited by methodological challenges and inconsistent definitions of determinants. The literature review was unable to draw conclusions about the determinants of hygiene behaviour in crises or outbreaks due to a lack of evidence. Current approaches to assessing determinants in crises were feasible to conduct but were methodologically limited and unable to fully account for contextual factors and the impact of the crisis on behaviour. The qualitative case studies indicated that the relative importance of certain determinants is likely to vary during crises and outbreaks. The characteristics that appear to affect the variation of behavioural determinants include the type of crisis; the phase of the crisis or outbreak; the physical and social context; and the broader consequences of the crisis or outbreak on the lives of the affected population. The determinants that seem to be most influential in driving hygiene behaviour during crises and outbreaks included risk perceptions; the prioritisation of time and resources, daily routines; and factors within the behavioural settings where handwashing takes place (such as access to handwashing facilities, water and soap). Interviews with humanitarians indicated that the constraints humanitarians faced when designing hygiene programmes, and the way they made decisions, were remarkably similar across contexts, leading to programming that was also relatively de-contextualised. Hygiene programme design processes were considered sub-optimal, but humanitarians struggled to implement the more ideal principles and processes that they aspired to due to time pressures; financial constraints; limited capacities; the infeasibility of assessment tools; unequal partnerships organisations; and poor sector learning processes. Given these constraints, most programmatic decisions were based on the intuitions and past experiences of managerial staff. The findings presented in this thesis offer opportunities for strengthening the assessment of behavioural determinants and improving hygiene programme design so that it can be done rapidly, while still being contextualised and evidence-based.

This thesis examines entangled practices of care and place in one Berlin district. Situated within broader Welcome Politics of care efforts and a reanimation of integration debates following 2015's migratory movements, I examine a number of integration projects which practised various forms of care for migrant women. Over eighteen months' ethnographic fieldwork between 2017-2018, I sought to learn from women what these efforts might reveal about relations of place, politics of difference and practices of care, when the relationship between people deemed 'Other' and a certain 'locality' were taken as an assumed site of intervention. I describe how a multiplicity of alternative spatialities were accomplished by care in these projects, even whilst these projects were often tacitly presupposed by nation-state bound imaginaries of space. I observe this in classrooms, streets, a town hall, a hairdresser's, homes, market squares, parks and gardens, to describe everyday instances in which the reconfiguration of space through care had implications for the way terms of difference were negotiated, practised and materialised. Yet, as often as such alternative spatialities unsettled terms of difference, they also sustained them. And I find that such multiplicity was achieved as much through care as through conflict. Here, the processual nature of such spaces' becoming and unravelling became a significant parameter for examining their politics and negotiated existence. I seek to add to critical conversations on care and migration in the context of complex urban environments. by proposing one way in which thinking through care and place together may serve as a useful optic for examining material dimensions of political inequity, and help render legible fleeting or under-articulated makings of alternative spatial possibility.

Results-based financing (RBF) has been receiving increasing attention in recent decades. RBF involves a transfer of funds based on the attainment and verification of predetermined outcomes. Afghanistan has implemented RBF in the form of performance-based contracting (PBC) since 2003 and performance-based financing (PBF) between 2010 and 2015. The PBC experience was successful in delivering maternal and child health services. However, the PBF programme had minimal effect on the delivery of maternal and child health services. Using a political economy lens, this thesis answers the question of what factors shaped and affected the PBC and PBF programmes and their outcomes in Afghanistan. It also examines the cost-effectiveness of the PBF programme relative to standard practice. This thesis provides support for the assertion that both political economy factors and value for money are critical in the design, adoption and implementation of RBF programmes. RBF enforces different arrangements for the distribution of resources and provides opportunities or threats for actors through changing their functions and modifying institutional processes. Subsequently, a new economic and political situation comes into existence. Economic evaluation compares the costs and consequences of alternative courses of action recommending which health care investments are most efficient, guiding resource allocation in health. Therefore, careful consideration and caution is required when adopting and implementing RBF programmes. Policymakers and researchers should increasingly focus on the political economy aspect of RBF programmes in conjunction with economic evaluations, particularly in the context of fragile and conflict-affected setting to ensure that the technical outcomes of economic evaluations are suitably received in the context of highly political situations. If RBF programmes are designed around a full understanding of political economy and value for money, RBF can potentially be a powerful tool to achieve better outcomes.

Background: Social protection is increasingly used by governments in low- and middle-income countries (LMICs) as a strategy for alleviating poverty "in all its forms". People with disabilities are frequently targeted as key beneficiaries due to high levels of poverty and marginalisation. Little is known, however, on whether people with disabilities are accessing existing programmes, and whether these programmes adequately meet their needs. Aim: To explore the need for, access to and adequacy of social protection amongst people with disabilities in LMICs. Methods: Systematic reviews were used to compile and evaluate evidence from across LMICs on 1) the link between monetary poverty and disability, and 2) access to and impact of social protection amongst people with disabilities. Case studies were then undertaken in the districts of Cam Le, Vietnam and Tanahun, Nepal in 2016 to explore in-depth the need for, access to and adequacy of social protection amongst people with disabilities in these areas. Data was collected through population-based surveys (n=12,397, across both settings), with nested case-control studies of people with and without disabilities (n=359, each) matched by age, sex and location. Further, qualitative research was conducted with people with disabilities recruited from the surveys and key informants involved in the design or implementation of social protection. Need for social protection was assessed using monetary and multidimensional indicators of poverty amongst people with disabilities ages 15+. Access to social protection was measured through participation in disability-targeted and non-targeted programmes. Adequacy of social assistance was then evaluated by measuring levels of monetary and multidimensional poverty amongst social assistance recipients. All analyses compared indicators between people with and without disabilities, and amongst people without disabilities (e.g. recipients versus non-recipients). Key findings: Evidence from the systematic review and research in Nepal and Vietnam indicate a high need for social protection among people with disabilities. In the systematic review, 80% of the 150 included studies found a link between disability and economic poverty. In both Vietnam and Nepal, people with disabilities were more likely to be living in both monetary and multidimensional poverty compared to people without disabilities, and faced high disability-related extra costs. People with disabilities in Vietnam and Nepal were more likely to access social assistance compared to people without disabilities (Vietnam: aOR 9.6, 5.6-16.5; Nepal: aOR 3.0, 1.6-5.3). However, evidence from the case studies and from the systematic review indicate that many people with disabilities are not accessing social protection benefits for which they are eligible. Factors affecting access included the accessibility of the application process, complexity of disability assessment procedures, awareness of programmes and their eligibility requirements and the perceived utility of benefits. Further, the systematic review and research in Vietnam and Nepal indicated that social protection is often inadequate to protect many recipients with disabilities from poverty. For example, a quarter to a third of social assistance recipients with disabilities were living in monetary poverty and half were multidimensionally poor in Vietnam and Nepal. Social protection was particularly insufficient at promoting social inclusion amongst people with disabilities, as well as ensuring sustainable livelihoods. Conclusion: People with disabilities face a substantial need for social protection, given high levels of monetary and multidimensional poverty, in both absolute terms and relative to people without disabilities. However, many people with disabilities were not accessing programmes for which they were eligible, indicating a need to increase awareness of programmes and address barriers encountered during the application process. Further, evidence from this research indicates that more transformational approaches to social protection design and delivery are necessary, such as providing meaningful coverage for disability-related extra costs and addressing drivers of social exclusion.

Introduction: This dissertation develops a grounded and dynamic theory of primary care transformation (PCT) in a health service delivery organization (HSDO) implementing the Patient-Centered Medical Home model, in the United States of America. The focus of this theory is on the structural facilitators and challenges to achieving and sustaining high quality primary care. Methodology: Fieldwork performed included semi-structured interviews conducted across the HSDO (n=82), direct observations (n=10 clinics) and archival review. This dissertation utilizes newly-developed methods for theory development and validation, in concert with existing system dynamics methods; with an improved potential to integrate findings across quantitative and qualitative research directions. Results: My theory illuminates how the actions of various stakeholders (medical assistants, managers, clinicians and patients) interact with each other and with the fundamental characteristics of primary care service delivery to create diverse transformation trajectories. Two types of leverage points are identified: policies and preferences. The latter are more difficult to modify as they require changing stakeholders’ mental models. It is the combination of policies and preferences interacting within the system structure that produces hoped-for and feared transformation trajectories. There is no policy that induces success regardless of stakeholder preferences. There are some preferences that induce success or failure regardless of the policies being implemented. Conclusion: Sustaining success requires understanding the system structure within which policies and preferences operate – how decisions are made, their consequences, and the delays involved. Otherwise, transformation risks being overwhelmed by unintended consequences, misunderstood system behavior or impatience. This work presents an improved understanding of what PCT involves, and of how operational and cognitive aspects intersect. Overall, this work is more than a study of transformation. It presents theory, methods and a case for the development of an integrative methodology and paradigm.