Health care in context : policy into practice; a policy analysis of integrating STD/HIV and MCH/FP services in Ghana.

This research is one contribution to understanding the nature of policy and of power. the interaction of the state and its machinery with individuals at all levels, the tensions between public and private choices and responsibilities, between public health and clinical health care. Adapting a policy analysis approach, this thesis provides a case study of the development and implementation of reproductive health policies in Ghana. The aim is to enhance understanding of why there are differences between policy and practice and what the potentials are for integrating STD/HIV management into MCH/FP services in Ghana to improve reproductive health. This thesis argues that all elements of policy and policy analysis are located within a 'contextual framework' and are influenced by a range of contextual factors (defined and illustrated through the thesis) which are seldom taken into account in policy process and analysis. It is argued that understanding the different levels of context is fundamental to understanding the processes of policy development and implementation, the actions of actors at all levels and the policy outcomes. Using a multi-level focus and a combination of approaches, this thesis identifies the contextual factors and their manifestations at each level of the policy process and illustrates how they impact on policy. The analysis synthesises macro and micro dimensions gaining a more comprehensive understanding of the influences on and gaps between policy development and implementation. At the implementation level, 27 clinics were visited and 94 clinic staff interviewed in one rural region of Ghana, to ascertain what STD/HIV management services are actually being provided and what factors influence service provision (policy implementation). Interviews with community leaders and focus groups with villagers were conducted in the same region to explore community perspectives of disease and health care services and understand the factors influencing service utilisation (policy outcome). The role of the regional health administration as an intermediary was considered and understanding sought of the concepts of power which influence administrative and management structures. The national level interviews with government and Ministry of Health officials and with donor, NGO and national group representatives, provide further insight into the concepts of power and status and who influences policy making. Finally, all elements are brought together and discussed, a reworked framework is presented and suggestions for future policy and research directions are made