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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 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.
We used a case study design because it allows collection and analysis of comprehensive and systematic data at different points in a real-life context to trace policy discussions and change over time [21, 22]. Data was collected between July 2012 and August 2014 using in-depth interviews, document reviews, observations and feedback discussions with respondents. The in-depth interviews were conducted to obtain real-life experiences from key actors involved in the decision making and pilot implementation of the per capita payment system especially in relation to maternity services. The interviews lasting on average 1 h were conducted face to face using a semi-structured guide to investigate how policy actors included and later excluded primary care maternal services from the capitation policy. AK (one of the authors) interviewed twenty-eight respondents summarized in Table 2. For confidentiality, names and positions are not used. Ten of these were identified from the documents review and the rest (18) were suggested by other respondents. List of respondents by agency /role in the health sector in relation to capitation Document analysis was used to map the sequence of decisions and actions, identify actors’ roles and further triangulate findings with respondent’s information. We conducted content analyses of provider payment mechanism technical subcommittee meeting records and reports (2010–2012); press releases and media discussions from the Ghana News Agency archive related to the policy. To understand decision making dynamics and interactions in the Ghanaian health sector, a 20 month period of practical attachment at the MOH Policy Planning Monitoring and Evaluation Directorate (PPMED) was undertaken by AK (one of the authors) as a participant observer. The PPMED coordinates policy formulation and strategic planning for the health sector. As a result, there were interactions with the key regional and district health actors during the MOH joint monitoring team visit to Ashanti region (6th – 9th November 2012). Further interactions with key actors during a December 21–22, 2012 national health insurance stakeholder meeting in Accra and a February 12, 2013 capitation evaluation meeting in the Ashanti region gave insights into the varied opinions on the capitation policy. The initial findings were validated and further substantiated by a presentation for discussion, comments and critique at an August 29, 2014 provider payment mechanism technical subcommittee meeting. We drew from Mintzberg’s power concept to guide the analysis of what powers policy actors used to control decisions and actions related to the rise and fall of primary care maternal health service capitation policy. Mintzberg (1983) defines power as the capacity to effect (or affect) decisions and actions and labels an actor who seek to control decisions and actions as influencer. Mintzberg argues that influencer’s interpretative manoeuvres ability vary as each tries to use his or her own source of power as means of influence in a politically skilled way. He proposes the sources of power as the control of a resource, a technical skill, or a body of knowledge; authority by virtue of one’s legal and structural position; and access to those who can rely on the other four sources of power [23]. To analyse policy actors’ responses and actions related to the rise and fall of the policy; we drew on the concept of arenas of conflict of Grindle and Thomas (1991). Grindle and Thomas (1991) observed that decisions to change existing practice almost always generate conflict. They described two broad scenarios of reactions or response to policy change – conflict in the public arena and bureaucratic arena. Conflict to policy change in the public arena usually occurs during implementation and when the costs or burden of the reform has a direct impact on the public or on politically important groups in society. On the other hand, conflict in the bureaucratic arena is largely determined by bureaucratic agencies and public official’s response to the change. This usually occurs during policy formulation especially when the administrative content of the policy is high or it is technically complex and requires coordinated efforts of public officials and agencies through consensus building to design the reform [24]. To understand and analyse how providers were able to resist the policy in addition to their use of power; we drew on Sterman’s (2006) concept of policy resistance. Sterman (2006) conceptualises policy resistance as the tendency for a policy to be defeated by a system’s response to the policy itself. He argues policy resistance arises because the system is complex made up of separate but interdependent parts that interact with each other in many ways. The system is therefore dynamic, evolving, interconnected and governed by feedback loops. He further argues that within a system decisions and actions feedback on themselves, triggering others to act thus giving rise to a new situation. Policy actors operate within this complex system and their actions and decisions alter the system and, therefore may trigger unanticipated effects. Others seeking to achieve their goals and acting to restore the balance may also trigger intended and unintended consequences. Policy resistance arises because policy actors are not aware of the full range of feedback surrounding – and created – by their decisions [25]. Drawing upon these concepts, we systematically attempted to reconstruct the case of decisions and actions surrounding the rise and fall of primary care maternal health service capitation policy in the Ashanti region. The information was analysed first to map events and the power sources of key policy actors. A stakeholder analysis of actors as individuals, groups and institutions was done to further understand their position, interest and use of power to influence. Next the evolution of decisions and actions, the formation of groupings were identified. Finally, the analyses were synthesised to reconstruct insofar as possible the case. We acknowledge the difficulty in providing a full explanation of events as they unfolded within the dynamic health system – reconstructing who said what, where, when, to whom and how it was received. To minimise this multiple research methods and data sources were used. Where such data is available, it is noted; otherwise, the gap is noted and possible inferences are made from data analysis.
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