The district health system in Ghana today is characterized by high resource-uncertainty and narrow decision-space. This article builds a theory-driven historical case study to describe the... Show moreThe district health system in Ghana today is characterized by high resource-uncertainty and narrow decision-space. This article builds a theory-driven historical case study to describe the influence of path-dependent administrative, fiscal and political decentralization processes on development of the district health system and district manager decision-space. Methods included a non-exhaustive literature review of democratic governance in Ghana, and key informant interviews with high-level health system officials integral to the development of the district health system. Through our analysis we identified four periods of district health system progression: (1) development of the district health system (1970–85); (2) Strengthening District Health Systems Initiative (1986–93); (3) health sector reform planning and creation of the Ghana Health Service (1994–96) and (4) health sector reform implementation (1997–2007). It was observed that district manager decision-space steadily widened during periods (1) and (2), due to increases in managerial profile, and concerted efforts at managerial capacity strengthening. Periods (3) and (4) saw initial augmentation of district health system financing, further widening managerial decision-space. However, the latter half of period 4 witnessed district manager decision-space contraction. Formalization of Ghana Health Service structures influenced by self-reinforcing tendencies towards centralized decision-making, national and donor shifts in health sector financing, and changes in key policy actors all worked to the detriment of the district health system, reversing early gains from bottom-up development of the district health system. Policy feedback mechanisms have been influenced by historical and contemporary sequencing of local government and health sector decentralization. An initial act of administrative decentralization, followed by incomplete political and fiscal decentralization has ensured that the balance of power has remained at national level, with strong vertical accountabilities and dependence of the district on national level. This study demonstrates that the rhetoric of decentralization does not always mirror actual implementation, nor always result in empowered local actors. Show less
Background: Why issues get on the policy agenda, move into policy formulation and implementation while others drop off in the process is an important field of enquiry to inform public social policy... Show moreBackground: Why issues get on the policy agenda, move into policy formulation and implementation while others drop off in the process is an important field of enquiry to inform public social policy development and implementation. This paper seeks to advance our understanding of health policy agenda setting, formulation and implementation processes in Ghana, a lower middle income country by exploring 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. Methods: We used a case study design to systematically reconstruct the decisions and actions surrounding the rise and fall of primary care maternal health services from the capitation policy. Data was collected from July 2012 and August 2014 through in-depth interviews, observations and document review. The data was analysed drawing on concepts of policy resistance, power and arenas of conflict. Results: 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. 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. Conclusion: The tensions and complicated relationships between technical considerations and politics and bureaucratic versus public arenas of conflict are important influences that can cause items to rise and fall on policy agendas. Show less
Health and healing in Africa have increasingly become subject to monetization and commodification, in short, the market. Based on fieldwork in nine countries, this volume offers different... Show moreHealth and healing in Africa have increasingly become subject to monetization and commodification, in short, the market. Based on fieldwork in nine countries, this volume offers different perspectives on these emerging markets and the way medical staff, patients, households and institutions navigate them in their quest for well-being. Contributions: Introduction: Economic ethnographies of the marketization of health and healing in Africa (Rijk van Dijk and Marleen Dekker); Milking the sick: medical pluralism and the commoditization of healthcare in contemporary Nigeria (Akinyinka Akinyoade and Bukola Adeyemi Oyeniyi); Organizing monies: the reality and creativity of nursing on a hospital ward in Ghana (Christine Böhmig); Market forces threatening school feeding: the case for school farming in Nakuru town, Kenya (Dick Foeken et al.); Dashed hopes and missed opportunities: malaria control policies in Kenya (1896-2009) (Kenneth Ombongi and Marcel Rutten); The market for healing and the elasticity of belief: medical pluralism in Mpumalanga, South Africa (Robert Thornton); Medical knowledge and healing practices among the Kapsiki/Higi of northern Cameroon and northeastern Nigeria (Walter E.A. van Beek); The commodification of misery: markets for healing, markets for sickness (Zanzibar) (Nadine Beckmann); Individual or shared responsibility: the financing of medical treatment in rural Ethiopian households (Marleen Dekker); Can't buy me health: financial constraints and health-seeking behaviour in rural households in central Togo (Andr‚ Leliveld et al.); Marriage, commodification and the romantic ethic in Botswana (Rijk van Dijk). [ASC Leiden abstract] Show less
