National level maternal health decisions: towards an understanding of health policy agenda setting and formulation in Ghana Augustina Koduah Thesis committee Promotors Prof. Dr J.W.M. van Dijk Professor of Law and Governance in Africa Wageningen University Prof. Dr I.A. Agyepong Professor of Public Health Research and Development Division, Ghana Health Service, Accra, Ghana Other members Prof. Dr B.J.M. Arts, Wageningen University Dr G.J. Quansah-Asare, Ghana Health Service, Accra, Ghana Prof. Dr J.E.W. Broerse, VU University Amsterdam Dr L. Bijlmakers, Nijmegen International Centre for Health Systems Research and Education This research was conducted under the auspices of the Graduate School of Wageningen School of Social Science National level maternal health decisions: towards an understanding of health policy agenda setting and formulation in Ghana Augustina Koduah Thesis submitted in fulfilment of the requirements for the degree of doctor at Wageningen University by the authority of the Rector Magnificus Prof. Dr A.P.J. Mol, in the presence of the Thesis Committee appointed by the Academic Board to be defended in public on Wednesday 9 November 2016 at 11 a.m. in the Aula. Augustina Koduah National level maternal health decisions: towards an understanding of health policy agenda setting and formulation in Ghana, xii +180 pages PhD thesis, Wageningen University, Wageningen, NL (2016) With references, with summary in English ISBN 978-94-6257-895-1 DOI http://dx.doi.org/10.18174/387956 Acknowledgements ‘All things work together for good’. This PhD process has been possible with the support of many individuals and organizations. I want to thank everyone who contributed to the process. I wish to acknowledge my promoters Prof Han van Dijk and Prof Irene Akua Agyepong for their continuous advice and guidance. Your constructive criticisms and comments have greatly improved my analytical thinking ability and academic skills. I am deeply grateful and thank you for your excellent supervision. I also thank the Accelerate project members – Dr Kojo Arhinful, Dr Evelyn Ansah, Dr Trudie Gerrits, Dr Kerstin Klipstein-Grobusch and Prof D.E Grobbee – for their contributions and feedback during project meetings. To my fellow project colleagues – Aku, Kayode, Lucy, Mary and Matilda - I say many thanks for the numerous discussions. I am grateful to my employer, the Ministry of Health, for granting the study leave for me to pursue the PhD. I want to acknowledge the following for their administrative support and guidance: Dr Sylvester Anemana, Mr Samuel Boateng, Mrs Martha Gyansa-Lutterodt, and Dr Afisah Zakariah. I want to thank the individuals that enabled me collect data. I wish to acknowledge Dr Moses Adibo, Mr Owusu Ansah, Mr Isaac Adams, Dr Patrick Aboagye, Mr Daniel Degbotse, Dr Nii Coleman and Mr Peter Korto and the many anonymous respondents for sharing their valuable experience and information with me. During my PhD, I had the opportunity to participate in the Emerging Leaders in Health Policy and System Research programme in the Western Cape University, South Africa, between 2013 and 2014. The programme was organised by the Consortium for Health policy and Systems Analysis in Africa (CHEPSAA). I want to thank Prof Lucy Gilson, Prof Uta Lehmann and Prof Helen Schneider for the learning and thought provoking opportunity. I want to thank current and former staff of the Sociology of Development and Change group secretariat especially Diana Dupain, Mariella Takes, Coby Aanhaanen-van Duijn, Annelies Coppelmans, Lucie van Zaalen for their administrative support in and outside Wageningen. Finally, I thank my family for their love and prayers. Maa and Papa I thank you so much for staying in Ghana to help with the children whenever I was out of town. I also thank my mother and father in-laws, brothers and sisters for their support. I am deeply grateful to my husband Patrick (Baby) for his love, understanding, patience, encouragement and playing the mother role during my sometimes long absence. To my children – Nana Aseda, Kwadwo Adom and Akua Nhyira, I know it’s been hard for you during my absence. The thought of missing interesting time with you all motivated me to work even harder, I therefore dedicated this work to you all – Patrick, Nana, Kwadwo, and Akua. v vi Table of contents Acknowledgements ............................................................................................................... v Table of contents ................................................................................................................. vii List of tables ............................................................................................................................ x List of figures .......................................................................................................................... x List of graphs ........................................................................................................................... x List of acronyms ..................................................................................................................... xi Chapter 1 .................................................................................................................................. 1 1 General introduction ..................................................................................................... 2 1.1 Introduction ............................................................................................................... 2 1.2 Research problem, objective and questions .......................................................... 3 1.3 Theoretical perspectives .......................................................................................... 5 1.3.1 Public policy and decision making ................................................................. 5 1.3.2 Power approaches to decision making........................................................... 5 1.3.3 Analytical concepts and framework ............................................................... 6 1.4 Structure of the thesis ............................................................................................. 11 Chapter 2 ................................................................................................................................ 13 2 Ghana context and research methodology .............................................................. 14 2.1 Ghana context .......................................................................................................... 14 2.2 Study design ............................................................................................................ 19 2.2.1 Field work process, data collection methods and analysis ....................... 21 2.3 Insider and outsider dilemma .............................................................................. 23 2.4 Ethical consideration .............................................................................................. 24 Chapter 3 ................................................................................................................................ 25 3 National level maternal health agenda setting and formulation: the pivotal role of policy actors and context ........................................................................................ 26 3.1 Abstract .................................................................................................................... 26 3.2 Introduction ............................................................................................................. 27 3.3 Methods .................................................................................................................... 29 3.4 Results ...................................................................................................................... 31 3.4.1 Policy actors and agenda setting ................................................................... 32 3.4.2 Contextual factors and agenda setting ......................................................... 35 3.5 Discussion and conclusions .................................................................................. 58 Chapter 4 ................................................................................................................................ 63 vii 4 ‘The one with the purse makes policy’: Power, problem definition and maternal health policies and programmes evolution in national level institutionalised policy making processes in Ghana ................................................................................... 64 4.1 Abstract .................................................................................................................... 64 4.2 Highlights ................................................................................................................ 64 4.3 Introduction ............................................................................................................. 64 4.4 Methods .................................................................................................................... 69 4.5 Results ...................................................................................................................... 73 4.5.1 Institutionalised decision making and maternal health policies and programmes evolution ................................................................................................. 73 4.5.2 ‘Reinterpretation’ pathway ...........................................................................