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Background: Following the tenets of world polity and innovation diffusion theories, I focus on the coercive and mimetic forces that influence the diffusion of mental health policy across nations. International organizations' mandates influence government behavior. Dependency on external resources, namely foreign aid, also affects governments' formulation of national policy. And finally, mounting adoption in a region alters the risk, benefits, and information associated with a given policy.

Mental health is an integral part of health and well-being. Mental health enables people to realize their potential, cope with the stressors of everyday life, and make contributions to society. Mental, neurological and substance use (MNS) disorders constitute 13% of the global burden of disease. And yet, across all countries, public investment in preventing and treating this cluster of disorders is disproportionately low relative to this disease burden. Health systems have not adequately or sufficiently responded to the burden of MNS disorders: the gap between the need and supply of treatment ranges from 76% to 85% in low- and middle-income countries, and from 35% to 50% in high-income countries. Mounting evidence underlines the inequitable distribution, poor quality, and inefficient use of scarce resources to address mental health needs. Globally, annual spending on mental health is less than US $2 per person in high-income countries and less than US $0.25 per person in low-income countries, with 67% of these financial resources allocated to stand-alone mental hospitals. Flagrant abuse of human rights and discrimination against people with mental disorders and psychosocial disabilities have been found in such psychiatric institutions. The redirecting of mental health budgets toward community-based services, including the integration of mental health into general health care settings, is needed. To address this state of affairs, this dissertation takes a fresh look at the actions taken to formulate a comprehensive, coordinated response from health and social sectors. It is founded at the nexus of new institutional, world culture, and diffusion of innovation theories.This dissertation employs a mixed methods approach, combining statistical and survey analyses. A mental health policy is an official statement of a government that defines its vision, values, principles, and objectives to improve the mental health of a population. It also outlines the areas of actions, strategies, timeframes, budgets, targets and indicators used to realize the vision and achieve the objectives of the policy. In the first study, I examine the coercive and emulative isomorphic effects on the diffusion of mental health policy across geopolitical borders. Using discrete-time data for 193 countries covering the period from 1950 to 2011, I conduct an event history analysis to examine the influence of WHO accession, foreign aid, and peer influence on mental health policy adoption. The results confirm that the act of adopting mental health policy is partly owed to membership in the World Health Organization, as well as influence of neighbors in the same World Bank and World Health Organization regions. National mental health policy adoption is trumpeted as a milestone for mental health reform. Is mental health policy limited to a rhetorical plane or taken up for pragmatic reasons? The effectiveness of this "upstream" factor could be realized based on examining "downstream" models of deinstitutionalized programming. While mental health policy adoption is treated as an outcome of interest in the first study, it is treated as a predictor in the second study. More specifically, I test the phase of policy adoption as a determinant of psychiatric bed rate changes using panel data for the same 193 countries between 2001 and 2011. The analysis finds that late-adopters of mental health policy are more likely to reduce psychiatric beds in mental hospitals and other biomedical settings than innovators, whereas they are less likely than non-adopters to reduce psychiatric beds in general hospitals. Deinstitutionalization is a much more complex and sophisticated process than reducing dehospitalization, or the reduction of psychiatric beds. It is also about improving the quality of care provided by inpatient facilities while increasing access to care through the development of mental health services in other medical and community settings. However, progress towards mental health reform is often stalled because it is an essentially contested issue in professional and advocacy circles and a highly politicized one among governments. For these reasons, the third study gathers contemporary perspectives on deinstitutionalization from 78 mental health experts. The survey administered assesses their knowledge, attitude, and practices of expanding community-based mental health services and/or downsizing institution-based care. The respondents also attested to the enabling, reinforcing, and constraining factors prevalent in the 42 countries they collectively represent. The qualitative evidence is complementary to the quantitative evidence in that it portrays the contemporary mental health system as being controlled by a nucleus of inpatient care. It further suggests that innovations are made in linking specialty services with primary and social services to support people with mental, neurological, and substance use disorders and their families as they (re)integrate into their communities. Mental health care has branched out in new directions at the turn of the 21st century. Time and again when governments are in the throes of strengthening their mental health systems, a closer look into the setup of infrastructure, essential medicines, human resources, and civil society involvement becomes necessary. This dissertation demonstrates that deinstitutionalization is a result of mental health policies imposed from the top down by the government. The experience with deinstitutionalizing mental health care also involves grassroots mobilization of social change by citizens, clients, families, and other advocates. In parallel with service reorganization, advances have been made in training lay personnel to offer services to people with MNS disorders. Research and development have made treatment more cost-effective and accessible. Cutting across temporal and geographic borders, tradition and modernity, this dissertation probes into the permeability of mental health policy and unpacks the complexity of deinstitutionalization.

Abstract-Global consensus and national policies have emphasized deinstitutionalization, or a shift in providing mental health care from institutional to community settings. Yet, psychiatric hospitals and asylums receive the majority of mental health funding in many countries, at odds with research evidence that suggests that services should be delivered in the community. Our aim is to investigate the norms, actors, and strategies that influence the uptake of deinstitutionalization internationally. Our study is informed by prior literature on management and implementation science. The success and failure of mental health care operations depend on identifying and overcoming challenges related to implementing innovations within national contexts. We surveyed 78 experts spanning 42 countries on their knowledge and experiences in expanding community-based mental health care and/or downsizing institution-based care. We also asked them about the contexts in which said methods were implemented in a country. We found that mental health care, whether it is provided in institutions or in the community, does not seem to be standardized across countries. Our analysis also showed that moving deinstitutionalization forward requires meaningful engagement of three types of actors: government officials, health care professionals, and local experts. Progress toward deinstitutionalization depends on the partnerships formed among these actors and with diverse stakeholders, which have the potential to garner resources and to scale-up pilot projects. In conclusion, different countries have adapted deinstitutionalization in ways to meet idiosyncratic situations and population needs. More attention should be given to the management and implementation strategies that are used to augment treatment and preventive services.

Organizations instantiate multiple institutional logics, which operate in a nested fashion across levels of analysis. A demand on organizations in the Global South from aid donors is to adopt new management systems. Management systems like kaizen, a Japanese business philosophy of continuous improvement, have an inherent logic. Kaizen's adoption in Ethiopia, a postsocialist state, can be rendered ceremonial if its logic is not fully instantiated along with prevailing logics within recipient organizations. Our examination of the Ethiopian Sugar Corporation is an application of Besharov and Smith's 2014 framework. We assume there is a high degree of centrality in this state-owned enterprise, because any managerial logic absorbed would have to adhere to the state logic. We conducted interviews, supplemented by archival data review, to illustrate what actors do to improve compatibility with state logic. Our findings suggest three institutional logics were instantiated, in order: the macro logic of developmental authoritarianism; micro logics of production order and social control; and the meso logic of knowledge brokerage. We propose the concept of layered logic, or ordering of institutional logics, each serving a distinct purpose yet fitted with the others.

OBJECTIVES: Mexico and Chile implemented sugar-sweetened beverage (SSB) taxes in 2014. This study aimed to trace and compare the SSB tax policy process, and examine the role and perspectives of outside government stakeholders in the process. METHODS: Qualitative study design using key informant (KI) interviews and document review. We interviewed 24 KIs involved in the SSB tax policy process (16 researchers, 5 civil society organizations (CSOs), and 3 food and beverage industries, F&BI) to examine perceptions on the tax process, effectiveness and future. Two independent coders analyzed the transcripts, using emergent and a priori codes. The results were triangulated with a document review, including research and newspaper articles, and reports covering the pre- and post-tax periods (n = 347). RESULTS: In Mexico, the tax on beverages with added sugars (1 peso/liter, or a 10% tax) stemmed from a longer process, compared to Chile, where the tax resulted from a pre-existing one applied to beverages with more than 6.25 g of sugar/100 ml (increased from 13 to 18%). In both countries, CSOs and the F&BI had direct influence on policy makers. CSOs were key in facing F&BI opposition before and after implementation. Researchers' influence was indirect, providing evidence for or against the tax. There was agreement that the SSB tax alone was insufficient to address noncommunicable diet-related chronic diseases (NDCs). KIs noted needed tax improvements (e.g., increasing the rate, modifying the tax basis, and using revenue for public health initiatives). KIs against the tax argued for nutrition education as a better option to change SSB demand to encourage F&BI product reformulation. The results will examine the taxes within other public health initiatives in the countries and political considerations. CONCLUSIONS: While often touted as nutrition policy win, SSB taxes are one part of a larger nutrition policy toolbox. The study contributes to past research examining the Chilean and Mexican taxes, individually ...

Muslim community-based health organisations (MCBHOs) represent a new wave of non-profit organisations outside of mosques and Islamic community centres. In this article we examine MBCHOs' core management competencies because they are instantiations of institutional logics, which result in different forms of organisational hybridity within the third sector. Theoretically, we focus on the instantiations that are associated with a societal institutional logic (religion) and two organisational field logics (voluntarism and healthcare). Empirically, we draw from a survey, maps, tax filings and strategic plans. We observed convergences in financial and human resource management and divergences in community engagement and patient assessment among 110 MCBHOs located in the United States. Volunteering and patient care hold the meaning of faith. Our findings suggest that most MCBHOs resemble an assimilated hybrid, characterised by managerial practices that adhere to the core logics of healthcare and voluntarism, with traces of the Islamic religious logic. We thus introduce the concept of 'faithwashing'.