Date of Award




Document Type


Degree Name

Doctor of Philosophy (PhD)


Department of Public Administration and Policy

Content Description

1 online resource (vi, 145 pages)

Dissertation/Thesis Chair

Erika G Martin

Committee Members

Ashley M Fox, David S.T. Matkin, Patricia Strach


health policy, HIV, injecting drug users, policy implementation, sex workers, stigma, HIV-positive persons, Sex workers, HIV infections

Subject Categories

Finance and Financial Management | Public Health


HIV contributes to the highest number of deaths from infectious diseases in low-income countries. In this three-paper dissertation, using the case of Pakistan, I focus on understanding how the exercise of power by actors at three different levels of the health system, individual, program and societal, influences policy implementation and shapes HIV program outcomes. The objective is to improve HIV service provision thereby achieving improved health policy outcomes. I adopt a mixed-methods approach and use quantitative (logit regression) and qualitative techniques (content analysis of newspapers and semi-structured interviews). One paper tests the role played by network operators in influencing condom use among commercial sex workers. I find that the protective effect of network operators only holds for transgender commercial sex workers suggesting that female commercial sex workers may be more vulnerable to exploitation by network operators. The findings highlight the importance of network operators as change agents. The second paper analyzes program and contextual challenges in achieving the global 90-90-90 target for HIV in Pakistan. My findings highlight both structural and implementation challenges in achieving this target, and suggest a need for strengthening the health system infrastructure and for greater collaboration among actors across the health system to accommodate public health goals such as these. The third paper focuses on analyzing how HIV and viral hepatitis are understood in Pakistan, and the role stigma plays in directing policy towards HIV risk groups. I find that hepatitis is understood only as medical disease but HIV is understood as a stigmatizing character trait. HIV disease understanding hampers HIV testing and treatment, suggesting a need to develop a counter narrative. My findings collectively highlight that service provision can be improved by acknowledging that actors at three levels of the health system, individual, program, and societal, exert influence over health policy outcomes.