Table 2 Summary of policy actors, contextual situations, accompanying power sources, and policy outcomes

1963

Political Socialist Ideology

Actors:

Actors:

President-Dr Kwame Nkrumah

Ministry of Health (MOH) bureaucrats

Free antenatal service and minimal fees for other health services

Forces:

Forces:

Political power of government

Health care service expertise and administrative power of MOH

Political ideology at odds with charging fees for social services

Context:

Context:

MOH adjusting to the ‘new’ health sector administrative procedures post-independence

Euphoria after independence

Evidence:

Evidence:

Charging fees for health service was at odds with socialist ideology

None

Narrative:

Narrative:

Piecemeal effort to make free health for all practical

Government to provide free health care services for all

Interest:

Interest:

Provide health care services

Political gains and command of public attention

1969

Change in government

Actors:

Actors:

1. MOH Bureaucrats

Head of State – Major General Joseph Arthur Ankrah

Maternal user fee exemption policy of free antenatal services expanded to include free delivery service for multiparous patient

2. General Public

Forces:

3. Head of State – Major General Joseph Arthur Ankrah

Political power of the government

Forces:

Government took the evidence of health sector budget deficit

1. Health care service expertise and administrative

Context:

power of MOH

Deteriorating economy and growing health expenditure

2. Power of voice and numbers of the general public

Evidence:

Increased fees for other health services stipulated in the Hospital Fees Decree, 360

Health sector budget deficit

3. Political interest of military government to consolidate power overtook evidence of health sector budget deficit

Narrative:

Reintroduce hospital fee to generate health sector revenue

Interest

Context:

Generate health sector revenue to correct budget deficit

Existing free antenatal policy and minimal fees for other health services.

High maternal health related deaths

New military government

Evidence:

Popular hospital fees exemption policies and minimal fees for other health services

Narrative:

Go on with maternal user fee exemption policy

Interest:

MOH – provide health care services

General public – go on with maternal user fee exemption and minimal fees for other health services

1971

Change in government

Actors:

Actors:

Existing maternal user fee exemption policy maintained. The intent to increase minimal fees for other health services stipulated in the Hospital Fees Act, 387

1. Prime Minister – Dr Kofi Abrefa Busia

1. MOH Bureaucrats

2. General Public

2. Konotey-Ahulu committee

Forces:

Forces:

1. Political power of government

1. Health care service expertise and administrative power of MOH

2. Power of voice and numbers of the general public

2. Technical expertise of the Committee

Context:

Context:

Existing free antenatal policy and minimal fees for other health services.

Deteriorating economy and growing health expenditure

Evidence:

Public outcry about hospital fees

Health sector budget deficit

New democratic government

Narrative:

Evidence:

MOH – Free health service is not the way to go

Popular maternal user fee exemption policy.

Konotey-Ahulu committee – There could be no health service without fees

Narrative:

Interest

Prime Minister – Go on with exemptions and minimal hospital fees awaiting Konotey-Ahulu’s recommendations

Generate health sector revenue to correct budget deficit

General Public – No increase in hospital fees for health services and maintain ongoing maternal user fee exemption

Interest:

Prime Minister – Consolidate political power and maintain the status quo

General Public – Go on with maternal user fee exemption and minimal fees for other health services

1983

Under resourced public health services

Actors:

Actors:

Existing maternal user fee exemptions policy narrowed to antenatal and postnatal services

1. Military leader – Flight Lieutenant Jerry John Rawlings

1. MOH Bureaucrats

2. Multilateral agency: United Nations Children’s Fund (UNICEF)

2. Health professional bodies – Ghana Medical Association, Pharmaceutical Society of Ghana

Forces:

Forces:

1. Political power of government

1. Health care service expertise and administrative power of MOH

Fees for other health services stipulated in the Hospital fees Regulation, 1277

2. Medical expertise and financial power of UNICEF

2. Expertise of professional bodies

Context:

3. Evidence of shortage of medicines and consumables overtook political interest to keep the status quo

Context:

Existing free antenatal policy and minimal fees for other health services

Economic crisis and severe health sector budget deficit

Evidence:

Evidence:

Shortage of medicines and consumables

Strong political interest and support of government to keep the status quo

Narrative:

Narrative:

Go on with maternal user fee exemptions and minimal hospital fee for other health services

Charge hospital fees to generate health sector revenue

Interest:

Interest:

Military leader – Not to distress the general populace with hospital fees during economic crisis

Reintroduce hospital fee for all health services to correct health budget deficit

UNICEF – Advocate for free maternal health services

1985

Under resourced public health services

Actors:

None opposing

Maternal (antenatal and postnatal) user fee exemption policy maintained

1. Military leader – Flight Lieutenant Jerry John Rawlings

2. MOH Bureaucrats

Forces:

1. Political power of government

2. Health care service expertise and administrative power of MOH

Increased fees for other health services stipulated in the Hospital fees Regulation, 1313

Context:

Economic crisis

Structural Adjustment Programme

Existing free antenatal and postnatal services

Evidence:

Charged hospital fees could not recover full cost

Some health facilities already increased hospital fees to recover cost

Narrative:

Increase hospital fees to recover cost and maintain maternal

user fee exemption

Interest:

Generate health sector revenue and go on with maternal user fee exemptions policy

1997

Worsening national maternal health indicators

Actors:

Actors:

Existing maternal user fee exemption policy narrowed to four antenatal visits

President – Flight Lieutenant Jerry John Rawlings

MOH Bureaucrats

Forces:

Forces:

Political power of government

Health care service expertise and administrative power of MOH

Context:

Evidence of health sector budget deficit overtook government intent

Health sector full cost recovery under structural adjustment programme

Context:

Declining maternal health outcomes

Low health sector budget allocation

Evidence:

Evidence:

Low maternal supervised delivery in health facilities of 44 % as stated in the Ghana Demographic Health Survey [49]

Health sector budget deficit

High maternal mortality rate estimate of 214 per 100,000^a live births as stated in the Ghana Maternal Health Survey [73]

Narrative:

MOH cannot implement fully maternal user fee exemption policy as per the directive

Narrative:

Interest

Pregnant women are not accessing supervised delivery services in health facilities because of inability to pay

Ensure health service delivery

Interest:

Government intends to mitigate social consequence of the structural adjustment programme

2003

Ghana poverty reduction strategy and Heavily Indebted Poor Countries grant

Actors:

None opposing

Maternal user fee exemption policy linked to poverty reduction strategy priorities

1. President: John Agyekum Kufuor

2. Multilateral agency: World Bank group and International Monetary Fund

3. MOH Bureaucrats

Forces:

Maternal user fee exemption policy expanded to include delivery and postnatal services and narrowed to four deprived regions

1. Political power of government

2. Financial power of World Bank and International Monetary Bank

3. Health care service expertise and administrative power of MOH

Context:

Stagnant economic growth

Inequitable national poverty levels

New democratic government

Evidence:

Worsening poverty indicators such as maternal mortality rate

Narrative:

There exist a positive correlation between poverty and health outcomes

Interest:

Improve poverty related health indicators

2005

Worsening national maternal health indicators

Actors:

None opposing

Maternal user fee exemption policy linked to poverty reduction strategy priorities

1. Minister of Health: Major Courage Quashigah

2. Multilateral and bilateral agencies – health sector signatories to 2005 Aide Memoire (European Commission, Royal Danish Embassy, Royal Netherlands Embassy/Department for International Development*, United Nations Population Fund, UNICEF, USAID, Japan International Cooperation Agency, WHO and World Bank)

Maternal (antenatal, delivery and postnatal) user fee exemption policy expanded to all regions

3. MOH Bureaucrats

Forces:

1. Political and administrative power of the Minister

2. Technical expertise and financial power of the Donors

3. Health care service expertise, administrative power of MOH

Context:

National poverty reduction strategy

Election year

High poverty in non-deprived regions

Evidence:

High national maternal mortality rate of 503 per 100,000^b live birth as stated in the Ghana Millennium Development Goal Acceleration Framework and Country Action Plan [58]

Narrative:

Poverty and poor maternal health outcome exist in non-deprived regions

Interest:

Improve national maternal health indicators

2008

Maternal health declared a national emergency

Actors:

None opposing

Free maternal (antenatal, delivery and postnatal) care directive

1. President – John Agyekum Kufuor

2. Minister of Health – Major Courage Quashigah

3. MOH Bureaucrats

Forces:

1. Political power of the government

2. Political and administrative power of the Minister

3. Health care service expertise and administrative power of MOH

Context:

Election year

Suspended maternal user fee exemption policy

Evidence:

Routine health management information system data from the independent review of the 2007 Programme of Work shows:

(a) Increased institutional maternal mortality ratio of 187/100,000 live births in 2006 to 224/100,000 live births in 2007

(b) Decreased proportion of maternal supervised deliveries in healthcare facilities from 44.5 % in 2006 to 35.1 % in 2007

Narrative:

Suspended maternal user fee exemption policy contributed greatly to poor maternal health outcomes

Interest:

Improve maternal health indicators and consolidate political gains