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Maternal Fee Exemption Policies in Ghana Over Four and a Half Decades Augustina Koduah1,2*, Han Van Dijk2 and Irene Akua Agyepong3

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Maternal Fee Exemption Policies in Ghana Over Four and a Half Decades Augustina Koduah1,2*, Han Van Dijk2 and Irene Akua Agyepong3 Koduah et al. Health Research Policy and Systems (2015) 13:27 DOI 10.1186/s12961-015-0016-9 RESEARCH Open Access The role of policy actors and contextual factors in policy agenda setting and formulation: maternal fee exemption policies in Ghana over four and a half decades Augustina Koduah1,2*, Han van Dijk2 and Irene Akua Agyepong3 Abstract Background: Development of health policy is a complex process that does not necessarily follow a particular format and a predictable trajectory. Therefore, agenda setting and selecting of alternatives are critical processes of policy development and can give insights into how and why policies are made. Understanding why some policy issues remain and are maintained whiles others drop off the agenda is an important enquiry. This paper aims to advance understanding of health policy agenda setting and formulation in Ghana, a lower middle-income country, by exploring how and why the maternal (antenatal, delivery and postnatal) fee exemption policy agenda in the health sector has been maintained over the four and half decades since a ‘free antenatal care in government facilities’ policy was first introduced in October 1963. Methods: A mix of historical and contemporary qualitative case studies of nine policy agenda setting and formulation processes was used. Data collection methods involved reviews of archival materials, contemporary records, media content, in-depth interviews, and participant observation. Data was analysed drawing on a combination of policy analysis theories and frameworks. Results: Contextual factors, acting in an interrelating manner, shaped how policy actors acted in a timely manner and closely linked policy content to the intended agenda. Contextual factors that served as bases for the policymaking process were: political ideology, economic crisis, data about health outcomes, historical events, social unrest, change in government, election year, austerity measures, and international agendas. Nkrumah’s socialist ideology first set the agenda for free antenatal service in 1963. This policy trajectory taken in 1963 was not reversed by subsequent policy actors because contextual factors and policy actors created a network of influence to maintain this issue on the agenda. Politicians over the years participated in the process to direct and approve the agenda. Donors increasingly gained agenda access within the Ghanaian health sector as they used financial support as leverage. Conclusion: Influencers of policy agenda setting must recognise that the process is complex and intertwined with a mix of political, evidence-based, finance-based, path-dependent, and donor-driven processes. Therefore, influencers need to pay attention to context and policy actors in any strategy. Keywords: Context, Fee exemption, Maternal health services, Policy actors, Policy agenda setting, Policy formulation * Correspondence: [email protected] 1Ministry of Health, Ministries, P.O. Box MB 44, Accra, Ghana 2Wageningen UR (University & Research centre), Sociology of Development and Change, Wageningen, Netherlands Full list of author information is available at the end of the article © 2015 Koduah et al. Koduah et al. Health Research Policy and Systems (2015) 13:27 Page 2 of 20 Background LMIC setting. Secondly, it provides insights on how and The development path of health policy, whether as intent, a why maternal fee exemption policies in Ghana were main- practice, or a written document, can be difficult to predict tained over four and half decades despite the existence because it is a complex and intertwined process and does of at least eight distinct threats or opportunities for major not necessarily follow a particular format. Understanding policy reforms. why some policy issues remain and are maintained while others drop off the agenda (agenda setting and selection Ghana health sector of alternatives) is an important field of enquiry since it The Ghanaian health sector has had a hierarchical, pre- can give insights into this complex process. This is be- dominantly publically financed, publically administered and cause getting and maintaining policy issues on the agenda delivered, services model since independence in 1957. is an essential part of decisions made during policy However, a strong private sector participation in service development. delivery has always accompanied it. Out-of-pocket pay- Green-Pedersen and Wilkerson [1] argue that the expla- ments at point of service have also ensured continuing nations proposed for why some issues make it onto the ‘private’ financing. The sector underwent two major re- agenda and others fail are wide ranging. Some are struc- forms in the 1990s. These were the creation of the Ghana tural, emphasizing how institutions are organized to Health Service (GHS) under the Ghana Health Service advantage some alternatives or issues over others. Some and Teaching Hospitals Act; and the adoption of a sector- are cognitive, emphasizing how individuals or even insti- wide approach in 1997. Prior to passage of the Ghana tutions process information in ways that limit what will be Health Service and Teaching Hospitals Act in 1995, the addressed at any given time. Others emphasize the role Ministry of Health (MOH) was the regulator of public of external events or public opinions, and how they can and private sector, the body responsible for health sector combine with political incentives to quickly shift atten- policy direction, coordination, monitoring and evaluation, tion to a new direction [1]. and the provider of public sector services. The Ghana Some issues, once on the agenda, are maintained over Health Service and Teaching Hospitals Act 525 created time and periodically re-examined to maintain their re- an agency model in the health sector. The MOH be- currence [2]. Political attention of vote-seeking politicians, came a civil service ministry responsible for overall sector for example, maintained health policy issues on the na- policy making, coordination, monitoring, and evaluation, tional agenda over time in Denmark and the United States with the GHS providing public health and clinical services [1]. There is, however, very little research related to how [5, 6]. Under the sector-wide approach, dialogue be- and why some policies have a long life and are maintained tween government and international donors shifted up over time despite periodic threats to their existence; while a level: from the planning and management of projects, others cease to exist. to the overall policy, institutional, and financial frame- The aim of this paper is to advance understanding of work within which health care is provided at national health policy agenda setting and formulation in low- and level [7]. The Government of Ghana, represented by the middle-income country (LMIC) settings by exploring how MOH, and international donors jointly agreed to national and why maternal (antenatal, delivery and postnatal) fee priorities expressed in the programme of work – which exemption policy agendas in the health sector in Ghana states the policies, strategies, targets, and resource enve- have been maintained over the four and half decades since lope and allocation for the sector [8, 9]. a ‘free antenatal care in government facilities’ policy In the immediate post-colonial period (March 1957) was first introduced in October 1963. Specifically, we and several years afterwards, the majority of policy agenda ask: How have maternal user fee exemption policies and formulation decisions were undertaken mainly by pol- evolved in Ghana since independence? Which actors iticians and a small group of bureaucrats [10]. The sector- have been involved in the policy agenda setting and wide approach created a new avenue for policymaking formulation and why? What contextual factors influenced platforms between the MOH, international donors, and the process over time, how and why? other actors broadening the scope and range of policy Advancing the understanding of policy agenda setting actors. As a result, expertise could be drawn from other and formulation process, especially how and why a policy actors in or outside the health sector to form groupings agenda item is maintained over time, is an essential area toguidetheprocess.Yet,theultimatepolicychoicestill of analysis to inform public social policy development rested with politicians and a few bureaucrats [11]. A and implementation. Nevertheless, there is limited research handful of policy elites taking the ultimate decision is and publications on policy analysis in LMICs [3] and in not peculiar to Ghana. In their work on developing coun- particular on processes of agenda setting and formulation tries, Grindle and Thomas [12] noted that small policy [4]. Our work firstly contributes to the general understand- elites – government officials and civil servants – strongly ing of policy agenda setting and formulation processes in a influenced the agenda and the nature of adopted policies. Koduah et al. Health Research Policy and Systems (2015) 13:27 Page 3 of 20 Methods Document and archival review and analysis were used A longitudinal mix of historical and contemporary case to map the historical sequence of events, identify policy studies of policy agenda setting and formulation for a actors, and further triangulate findings with respondent’s specific issue – fee exemptions for maternal health ser- information. The study greatly relied on varied documents vices – was conducted for the period 1957 to 2008. The to trace historical happenings. Documents
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