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Explaining Radical Change in Ghanaian Health Care Policy EXPLAINING RADICAL CHANGE IN GHANAIAN HEALTH CARE POLICY A Thesis Submitted to the College of Graduate Studies and Research In Partial Fulfillment of the Requirements For the Degree of Doctor of Philosophy In the Johnson-Shoyama Graduate School of Public Policy University of Saskatchewan Saskatoon By ISHMAEL WIREKO Copyright Ishmael Wireko, November, 2015. All rights reserved. Permission to Use In presenting this thesis in partial fulfilment of the requirements for a Postgraduate degree from the University of Saskatchewan, I agree that the Libraries of this University may make it freely available for inspection. I further agree that permission for copying of this thesis in any manner, in whole or in part, for scholarly purposes may be granted by the professor or professors who supervised my thesis work or, in their absence, by the Head of the Department or the Dean of the College in which my thesis work was done. It is understood that any copying or publication or use of this thesis or parts thereof for financial gain shall not be allowed without my written permission. It is also understood that due recognition shall be given to me and to the University of Saskatchewan in any scholarly use which may be made of any material in my thesis. Requests for permission to copy or to make other use of material in this thesis in whole or part should be addressed to: The Director of Johnson-Shoyama Graduate School of Public Policy University of Saskatchewan Campus Diefenbaker Building 101 Diefenbaker Place Saskatoon, SK, Canada, S7N 5B8 i Abstract The existing literature about the causes of welfare state change, including health care reform, emphasizes stability, yet there is evidence of remarkable changes taking place in welfare systems in much of the developing world. This study analyzes health care reform in Ghana, a country which has experienced significant path-departing changes in just four decades (1957- 2003). These changes – the establishment of a National Health Service system with deep (first- dollar) coverage, the introduction of a user-fee system, and the transition to a social health insurance scheme – have been pursued despite key countervailing factors, especially the high political costs associated with them. The study argues that to adequately account for these changes, the policy process should be given special consideration, particularly through the examination of how new policy proposals moved onto the agenda; how they were formulated, adopted, implemented and sustained; and how the reformers managed the entire reform process over time. Based on this analysis, I identified three main interconnected contextual and agential explanatory factors: (a) conjunctural factors, which created windows of opportunity for the changes to occur; (b) policy entrepreneurs, whose leadership, commitment and strategies helped in taking advantage of these opportunities to propel, sponsor, design, adopt, implement and sustain the policy changes; and (c) the concentrated institutional configuration of Ghana, which limited the number and scope of the veto points available to interest groups opposed to the proposed changes. While these three factors contributed to why and how the changes occurred, I identified policy entrepreneurs’ commitment, leadership and strategies, including the feedback effects of those strategies, as the most crucial factors. The study contributes to existing health policy literature by showing how perspectives such as the window of opportunity thesis, the dynamic political process model, the historical institutionalist approach to radical policy change and, finally, the ideational scholarship on framing processes can be combined to enrich our understanding of radical policy change. The study also introduces ii additional mechanisms of policy change that involve the use of repressive strategies before suggesting some modifications to a number of widely-shared assumptions within the welfare state literature focusing on path dependency, globalization, partisan ideology and vested interests. iii Acknowledgements “A grateful mind is a great mind which eventually attracts to itself great things.” Plato My foremost gratitude goes to the almighty God for ordering my steps; I am at this height of my career due to His guidance, abundant blessings, and the numerous opportunities He created for me. However, experience shows that God works through people. In this respect, I wish to acknowledge the contributions of the following individuals to this dissertation. The first in line is my supervisor (Professor Daniel Béland). His trust in me, financial supports, motivations, and constructive criticisms and suggestions were fundamentally crucial for this outcome. In view of the outstanding contribution he made to my study, describing him as a supervisor will be an understatement; in fact, he took me as his son and mentored me throughout the PhD program. My prayer is that the Almighty God will richly bless him. Second, I am grateful to the members of my thesis committee, which include Professors Gregory P. Marchildon, Haizhen Mou and Aloysius Newenham-Kahindi, as well as my external examiner, Professor Frank Ohemeng. Their vital contributions towards reviewing drafts of this dissertation and in providing positive suggestions enriched the outcome. I am also grateful to Mr. Otto Langmagne, Mr. Mensah, Mr. Amenya and Mr. William Wireko for their help in recruiting participants for the study. Without their support, I would probably not have been able to identify many of the respondents for the study. My deepest gratitude also goes to my dad (Mr. Albert Darlington Kwaw Wireko), and my beautiful wife (Bridget Mame Afua Wireko) for their immense contributions towards my career. My dad was my greatest motivator throughout my education; his high expectations and standards for me have yielded this outstanding result. It was my wife’s prayers, encouragement and patience throughout my PhD career that kept me focused on pursuing this dissertation. Thanks also to Dr. Kwesi Jonah and Professor Kwame Ninsin. Working with you both in the University of Ghana and the Institute for Democratic Governance (IDEG), I was always inspired to pursue further studies. I also appreciate the contributions of Rosina Foli, Rachel Hatcher, Hilda Osae, Kaylee Ramage, Fredrick Reekie, Dora Conteh and Benjamin Adu-Gyamfi in editing crucial aspects of this dissertation. Their urgent response to my calls for help accounted significantly for this impressive outcome. Finally, I acknowledge the supports of colleagues, faculty, and staff of the Johnson-Shoyama Graduate School (JSGS) of Public Policy and the College of Graduate Studies and Research. Besides, support from my supervisor and JSGS, the Teacher Scholar Doctoral Fellowship and the George and Arlene Loewen Family Bursaries provided me with the needed financial resource to pursue my study. iv Table of Contents Abstract ...................................................................................................................................... ii Acknowledgements ................................................................................................................... iv List of Abbreviations ............................................................................................................. viii Glossary ..................................................................................................................................... x List of Tables ........................................................................................................................... xii List of Figures .......................................................................................................................... xii CHAPTER ONE ........................................................................................................................ 1 INTRODUCTION ..................................................................................................................... 1 1.1 Introduction ................................................................................................................. 1 1.2. Overview of Health Policy Change and Stability in Ghana ............................................ 5 1.3. Problem Statement .......................................................................................................... 7 1.4. Purpose/Objective and Research Questions .................................................................. 10 1.4.1. Purpose ................................................................................................................... 10 1.4.2. Research Questions................................................................................................. 10 1.5. Main Argument of the Study ......................................................................................... 13 1.6. Plan of the Dissertation ................................................................................................. 17 CHAPTER TWO ..................................................................................................................... 19 LITERATURE REVIEW ........................................................................................................ 19 2.1. Introduction ............................................................................................................... 19 2.1.1. The Functionalist Perspective ................................................................................. 21 2.1.2. Interests-based
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