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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.
A longitudinal mix of historical and contemporary case studies of policy agenda setting and formulation for a specific issue – fee exemptions for maternal health services – was conducted for the period 1957 to 2008. The case study approach was ideal since it allowed collection and analysis of comprehensive, systematic, and in-depth information within a real life context [13, 14]. Nine specific fee exemption policy agendas for maternal health have been set since independence in 1957 and each of these was treated as a separate unit of analysis or case. To systematically attempt to reconstruct the dynamics surrounding the nine historical maternal fee exemption policy agenda setting and formulation events, we relied on mixed methods, and analysed data in the light of an appropriate conceptual framework. Data was collected between June 2012 and May 2014 using key informant in-depth interviews, a desk review of documents and archival materials including media content from independence (1957) through to 2008, and participant observation during a 20 month period of practical attachment at the Policy Planning Monitoring and Evaluation (PPME) directorate of the MOH by one of the authors (AK). The PPME is responsible for the coordination of policy formulation and strategic planning for the health sector. Participant observation there was therefore ideal for observing and understanding aspects of the processes involved in contemporary policy agenda setting and formulation. The focus of the in-depth interviews was to obtain real-life experiences of policy agenda setting and formulation processes from respondents. In total, 27 national level respondents were interviewed based on a semi-structured interview guide. Fifteen of these respondents were identified from health sector documents reviewed, while the rest (12) were suggested by other respondents. The in-depth interviews were conducted via face-to-face meetings, e-mails, and phone. Respondents included actors within government settings such as past and current officials of the MOH (10), the GHS headquarters (3), the National Health Insurance Authority (4), and a former Minister of Health (1). Respondents also included actors outside government settings such as officials of the Christian Health Association of Ghana (1), the Coalition of Non-Governmental Organizations in Health (1), international donors (4), and health professional bodies (3). Interviews were tape-recorded and later transcribed verbatim by a neutral person to maintain the original messages of respondents. Where permission was not granted to tape-record an interview, notes were taken and verified later with the respondent. All transcriptions were read and analysed repeatedly and organized into retrievable sections based on the analytical framework. Document and archival review and analysis were used to map the historical sequence of events, identify policy actors, and further triangulate findings with respondent’s information. The study greatly relied on varied documents to trace historical happenings. Documents were assessed based on four criteria developed by Scott [15]. Firstly, authenticity, which assesses that the evidence is genuine and of unquestionable origin. Secondly, credibility, which assesses whether the evidence is free from error and distortion. Thirdly, representativeness, which assesses whether the evidence is typical of its kind, and, if not, whether the extent of its untypicality is known. Finally, meaning, which assesses whether the evidence is clear and comprehensible [15]. National archives, the National Parliament Library, the George Padmore Research Library, and the Ghana Publishing Corporation were the sources of data for health legislative documents such as National Decrees, Acts of Parliaments, and National Regulations; old health-related reports and records of one national newspaper – the Daily Graphic were also used. We obtained access through the policy analysis unit of the MOH to archives of non-confidential official documents including letters, meeting minutes, memoranda, health sector review reports, health sector programme of work, national strategic plans, and agreements related to decisions to provide maternal user fee exemptions. Additionally, the web-based search engine Google Scholar was used to obtain published literature related to maternal fee exemptions. Relevant sections of all reviewed documents were highlighted and coded based on the categories identified in the analytical framework. To guide the analysis of the data we drew on several policy analysis theories, frameworks, and concepts in the literature. Grindle and Thomas [12] conceptualize context as including the structure of class and interest group mobilization in the society, historical experiences and conditions, international economic and political relationships, domestic economic conditions, the administrative capacity of the state, and the impact of prior or conterminously pursued policies. They also include in context, the individual characteristics of policy actors such as their ideological predispositions, professional expertise and training, memories of similar policy situations, position and power resources, political and institutional commitments, loyalties, and personal attributes and goals. They observe that policy actors are never fully autonomous. Instead, they work within several interlocking contexts that confront them with issues and problems they need to address, set limits on what solutions are considered, determine what options are feasible politically, economically and administratively, and respond to efforts to alter existing policies and institutional practices. Kingdon’s [16] theory and framework of agenda setting argues that active participants (policy actors) and the processes by which agenda items and alternatives come into prominence are key factors that affect policy agenda setting and choice. Policy actors in his USA study included the President, the Congress, bureaucrats in the executive branch, and various forces outside of government including the media, interest groups, political parties, and the general public. Policy agenda setting and choice processes are embedded within their context and, as such, influence how policy actors operate within these processes. Power is a key factor in health policy processes [17]. Contextual factors may serve as a source of power to influence policy actors’ action, inaction, and choice. Policy actors therefore can become influencers within a specific context to affect policy agenda setting and formulation processes. As noted by Mintzberg [18], to be an influencer, one requires some source of power – defined by control of a resource, a technical skill and body of knowledge, or stemming from a legal prerogatives – or authority, coupled with active involvement in ongoing processes in a politically skilful way. Drawing on these concepts of context, policy actors, and power, we attempted to systematically reconstruct nine historical agenda setting and policy formulation events. Working iteratively on data gathered, patterns, themes and categories that emerged were tabulated and further analysed. The analysis process involved mapping to our analytical framework – contextual situations, policy actors and their role, linkage among policies, specific policy content, power sources and how these influenced the agenda setting processes and why. We acknowledge the problems involved in mapping the exact sequence of events. To minimise this, varied sources of data were used to reconstruct, insofar as possible, the chronology and dynamics of maternal fee exemption policies agenda setting and formulation processes. This study forms part of a larger study – ‘Accelerating progress towards attainment of Millennium Development Goals 4 and 5 in Ghana through basic health systems function strengthening’ – for which ethical approval was granted by the GHS Ethical Review Committee and the School of Social Science Research Assessment Committee of Wageningen University and Research Centre. Informed consent was obtained from all respondents, and respondent’s anonymity was maintained and protected using codes as labels during the study.
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