National level maternal health decisions : towards an understanding of health policy agenda setting and formulation in Ghana

Maternal and neonatal deaths and morbidity still pose an enormous challenge for health authorities in Ghana, a lower middle income country. Despite massive investments in maternal and neonatal health and special attention through Millennium Development Goals (MDG) 4 and 5, Ghana still have high mortality rates. At national level, policy decision makers to improve maternal outcomes have over the years developed several public policies to increase financial and geographical access to maternal care; space child birth; provide essential obstetric care; expand midwifery coverage; make equipment available and many more. The problem of maternal mortality persist and this raises the question of what essentially goes into public policy making given the failure to achieve targets despite several maternal health policies developed for implementation. This thesis thus aims to advance our understanding of who makes maternal health policies and the agenda setting and formulation decision making processes through which they operate, in Ghana; and out of these understanding present potential lessons for policy actors to engage in making better informed policy decisions to improve maternal health. To understand factors and processes that influence national level maternal policy agenda and formulation decisions; we conceptualised that maternal policy decision making is predominately influenced by how policy actors within specific context use their power sources to define issues and frame accompanying course of action. The main research questions are: Which policy actors have been involved in maternal health policy agenda setting and formulation and what roles did they play and why?What are the decision making processes related to maternal health policy agenda setting and formulation?How did contextual factors influenced maternal health policy agenda setting and formulation and why?How did policy actors define maternal health issues and why? To investigate maternal policy agenda setting and formulation decision making in-depth, a multiple case study design with qualitative methods of data collection was used. The case study approach allowed me to look at maternal health policy decisions not merely as inputs and outputs but to better understand within context the processes and policy actors involved. Field work in the Ghanaian health sector, through observation and participation in the work of the Ministry of Health, steered the selection of the cases. Four cases: maternal (antenatal, delivery, and postnatal) fee exemption policy decisions, health sector programme of work maternal health policy decisions, free family planning as part of NHIS policy decision, and primary care maternal health service capitation policy decisions were investigated. The field work was conducted between May 2012 and August 2014. Multiple data collection methods including document review, interviews and observations were used to collect historical and current information and contribute to the validity and reliability of the research findings. Data were analysed drawing on an analytical framework in which concepts of organizational power, context, policy actors and problem definition were central elements. Case 1 Historical and contemporary fee exemption policies for maternal (antenatal, skilled delivery and postnatal) health services were explored. Specifically we ask: How have maternal user fee exemption policies evolved in Ghana since independence? Which actors have been involved in the policy agenda setting and formulation and why? What contextual factors influenced the process over time, how and why? Nine specific policies were identified along the pathway as, the policies evolved from user fee exemptions to national health insurance premium exemption. The policy was first introduced in 1963 and has remained on the government agenda over four and over decades in a fluid process of ebbs and flows rather than in a static fixed form. Contextual factors and various policy actors were the major influencers of the ebbs and flows. Contextual factors that influenced the ebbs and flows were: political such as Nkrumah’s ideology of free access to health care and education, changes in government, and presidential election year; economic crises and development partners’ austerity measures; worsening health and demographic indicators; historical events; social unrest; and international agendas such as the MDGs. These contextual factors served as a source of power for policy actors to sustain maternal fee exemption agenda over time. The case study showed that various categories of policy influencers (policy agenda advisers and advocates) and final decision makers (policy agenda directors and approvers) operated within these interrelated contextual factors, which sometimes worked as constraints and sometimes opened opportunities. These contextual factors shaped the timely manner in which policy content was formulated and level of deviation from the intended agenda at each specific decision period. For instance, contextual factors such as declined health budget allocation and high maternal mortality presented the ministry of health bureaucrats with an option to formulate the policy content in a less timely manner and away from the intended agenda of 1997 free maternal care presidential directive. Whilst, within the context of austerity measure and Ghana poverty reduction strategy, maternal fee exemption policy for four deprived regions was formulated in a timely manner and closely linked to the poverty strategy. Case 2 The case explored how and why maternal health policy and programme agenda items appeared and evolved in the framework of the Ghanaian health sector programme of work agenda between 2002 and 2012. Our specific research questions were: Which maternal health policies were prioritised? How did they evolve on the agenda and why? We examined decision maker’s problem definition and decision making processes, theorizing that a policy or programme’s appearance and fate on the POW agenda is predominantly influenced by how decision makers use their source of power to define problems and frame their policy narratives and accompanying course of actions. Ministry of health bureaucrats and donors used their power sources as negotiation tools to frame maternal health issues and design maternal health policies and programmes within the framework of the national health sector programme of work. The power sources identified included legal and structural authority; access to authority by way of political influence; control over and access to resources (mainly financial); access to evidence in the form of health sector performance reviews and demographic health surveys; and knowledge of national plans such as Ghana Poverty Reduction Strategy. Bureaucrats and donors used their power sources to define, frame and label issues for attention making some policies such as family planning long term fixtures on the agenda. They used labels such as ‘inadequate obstetric care’, ‘family planning unmet needs’, ‘maternal health a poverty issue’, and ‘poor maternal health a national emergency’ – for actions and to ensure the continuous flow of donor and government funding. Case 3 The case investigated how and why ‘free family planning as part of the NHIS’ policy attained a position on government agenda in 2012 but has not subsequently moved into formulation and implementation in Ghana. Relying on their power sources such as access to bodies of evidence; bureaucrats, donors, reviewers and reproductive health advocates framed inadequate budgetary allocation and disbursement for family planning and exclusion of family planning services from the national health insurance benefits package - as a major challenge to family planning contribution to maternal health care; and free family planning as potential life and cost saving. Drawing on their legal and structural access to institutionalized public policy processes in Ghana, they proposed the following policy options: include family planning service in the national health insurance benefits package and increase government and donor financial support. The interests of the supporting actors were two fold to eliminate out of pocket payments for family planning service and still sustain the financial needs of the family planning programme through the National Health Insurance Scheme. A window of opportunity opened when a Minister of Health receptive to these problem definitions and policy options publically voiced support for ‘free family planning as part of the NHIS; policy and therefore pushed it high and visibly onto the public policy /government agenda. However, the policy failed to move into formulation and implementation. Factors that influenced this failure included the lack of a stronger, broad based health sector actor support and related inability to agree on and develop policy implementation guidelines; and maintain political access and interest in the issue after it was moved up the agenda. Case 4 This case explored how and why less than three months into the implementation of a pilot prior to national scale up; primary care maternal services that were part of the basket of services in a primary care per capita national health insurance scheme provider payment system dropped off the agenda. During the agenda setting and policy formulation stages; predominantly technical policy actors within the bureaucratic arena used their expertise and authority for consensus building to get antenatal, normal delivery and postnatal services included in the primary care per capita payment system. Once policy implementation started, policy makers were faced with unanticipated resistance. Service providers, especially the private self- financing used their professional knowledge and skills, access to political and social power and street level bureaucrat power to contest and resist various aspects of the policy and its implementation arrangements – including the inclusion of primary care maternal health services. Arenas of conflict moved from the bureaucratic to the public as opposing actors presented multiple interpretations of the policy intent and implementation and gained the attention of politicians and the public. The context of intense public arena conflicts and controversy in an election year added to the high level political anxiety generated by the contestation. The President and Minister of Health responded and removed antenatal, normal delivery and postnatal care from the per capita package. Conclusions The general findings of the thesis are: (1) policy influencers (donors and bureaucrats) and final decision makers (Minister and President) used their power sources and contextual factors to define problems, promote their vested interest and justify actions and inactions; through technical, institutionalised, public and political decision making domains. (2) Policy influencers and final decision makers’ collective actions and inactions through interactions and power relations influenced decisions to their benefit at different levels. They used their control over and access to knowledge, authority and financial, material and human resources to push their interest and influence decisions. Therefore, this thesis concludes that the findings can serve as lessons for policy actors to strategize and make better informed policy decisions. We are in need of a health sector that pays more attention to context, power sources and power relations of final decision makers and influencers and the varied decision making domains in any maternal health policy decision.