The role of policy actors and contextual factors in policy agenda setting and formulation: Maternal fee exemption policies in Ghana over four and a half decades

Health Research Policy and Systems, Volume 13, No. 1, Year 2015

Ukuhunyushwa

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.

I-AI Digest

Study Justification:

– The study aims to advance understanding of health policy agenda setting and formulation in Ghana, specifically focusing on the maternal fee exemption policy agenda.
– By exploring how and why this policy agenda has been maintained over four and a half decades, the study provides insights into the complex process of policy development.
– Understanding why certain policy issues remain on the agenda while others drop off is important for policymakers and researchers.

Highlights:

– The study used a mix of historical and contemporary qualitative case studies to examine nine specific fee exemption policy agendas for maternal health in Ghana.
– Data collection methods included reviews of archival materials, interviews, participant observation, and analysis of media content.
– Contextual factors, such as political ideology, economic crisis, and international agendas, played a significant role in shaping policy agenda setting and formulation processes.
– Policy actors, including politicians and donors, also influenced the agenda through their actions and decisions.
– The study highlights the complexity of policy agenda setting and the need for influencers to consider context and policy actors in their strategies.

Recommendations:

– Influencers of policy agenda setting should recognize the complexity of the process and the various factors that influence it.
– They should pay attention to contextual factors, such as political and economic conditions, as well as the actions and decisions of policy actors.
– A comprehensive understanding of the policy development process is crucial for effective policy formulation and implementation.

Key Role Players:

– Policy actors, including government officials, health sector organizations, international donors, and health professional bodies.
– Researchers and analysts who can provide evidence-based insights and recommendations.
– Civil society organizations and advocacy groups that can raise awareness and advocate for policy change.
– Media organizations that can help disseminate information and shape public opinion.

Cost Items for Planning Recommendations:

– Research and data collection expenses, including hiring researchers, conducting interviews, and accessing archival materials.
– Analysis and interpretation of data, including the use of policy analysis theories and frameworks.
– Communication and dissemination of findings, such as publishing research papers and organizing conferences or workshops.
– Capacity building and training for policy actors and influencers to enhance their understanding of policy agenda setting processes.
– Monitoring and evaluation of policy implementation to assess the effectiveness of the recommendations.

Amandla Obufakazi

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a mix of historical and contemporary qualitative case studies, which provides a comprehensive and in-depth understanding of the policy agenda setting and formulation processes. The data collection methods used, such as reviews of archival materials, interviews, and participant observation, are appropriate for studying this topic. However, the abstract does not provide information on the sample size or representativeness of the case studies, which could affect the generalizability of the findings. To improve the strength of the evidence, future research could consider increasing the sample size and ensuring a diverse range of policy actors are included in the study. Additionally, providing more details on the analytical framework used and the specific policy analysis theories and frameworks drawn upon would enhance the transparency and rigor of the study.

Abstract

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.

Izinto zokwakha

N/A

Emisha

Based on the information provided, it is difficult to determine specific innovations for improving access to maternal health. However, some potential recommendations based on the research paper could include:

1. Strengthening policy agenda setting and formulation processes: This could involve ensuring that policy actors have a comprehensive understanding of the contextual factors that shape maternal health policies, and that they actively involve key stakeholders in the decision-making process.

2. Increasing political commitment: Policy actors should work towards creating a supportive political environment that prioritizes maternal health and allocates adequate resources for its improvement.

3. Enhancing data collection and analysis: Improving the availability and quality of data on maternal health outcomes can help inform policy decisions and identify areas that require intervention.

4. Engaging international donors: Collaborating with international donors can provide additional resources and support for maternal health initiatives, but it is important to ensure that their involvement aligns with national priorities and does not undermine local decision-making processes.

5. Addressing financial barriers: Implementing fee exemption policies for maternal health services can help reduce financial barriers and improve access for vulnerable populations. This could involve exploring innovative financing mechanisms, such as health insurance schemes or public-private partnerships.

6. Strengthening health systems: Investing in the overall strengthening of health systems, including infrastructure, human resources, and supply chains, can contribute to improving access to maternal health services.

It is important to note that these recommendations are based on the limited information provided and may not fully capture the complexities of the issue. Further research and consultation with experts in the field would be necessary to develop more targeted and context-specific innovations for improving access to maternal health.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health would be to develop and implement a comprehensive maternal fee exemption policy. This policy should aim to remove financial barriers for pregnant women and ensure that they have access to essential maternal health services, including antenatal care, delivery, and postnatal care.

To develop this policy, it is important to consider the following:

1. Contextual factors: Understand the political, economic, social, and historical factors that have influenced the policy agenda in the past. This will help in identifying the key drivers and barriers to policy formulation and implementation.

2. Policy actors: Engage with a diverse range of stakeholders, including government officials, health professionals, NGOs, international donors, and community representatives. Their perspectives and expertise can contribute to the development of an effective policy.

3. Evidence-based approach: Use available data on health outcomes and the impact of fee exemptions on maternal health to inform policy decisions. This will help in designing a policy that is grounded in evidence and has the potential to achieve positive health outcomes.

4. Financial sustainability: Consider the financial implications of implementing a fee exemption policy and explore mechanisms for funding, such as reallocating existing resources, seeking external funding, or introducing innovative financing mechanisms.

5. Monitoring and evaluation: Establish a robust monitoring and evaluation framework to track the implementation and impact of the policy. Regularly assess the policy’s effectiveness and make necessary adjustments based on the findings.

6. Collaboration and coordination: Foster collaboration and coordination among different stakeholders involved in maternal health, including government agencies, healthcare providers, and community organizations. This will help in ensuring a coordinated and integrated approach to service delivery.

By implementing a comprehensive maternal fee exemption policy that addresses these recommendations, it is possible to improve access to maternal health services and ultimately reduce maternal mortality and morbidity rates.

AI Innovations Methodology

Based on the provided description, it seems that you are looking for innovations to improve access to maternal health and a methodology to simulate the impact of these recommendations. Unfortunately, the description does not provide specific recommendations or a methodology for simulation. However, I can provide some general recommendations for improving access to maternal health and suggest a methodology for simulating their impact.

Recommendations for improving access to maternal health:

1. Strengthening healthcare infrastructure: Investing in healthcare facilities, equipment, and trained healthcare professionals in areas with limited access to maternal health services.
2. Mobile health clinics: Implementing mobile clinics that can reach remote areas and provide essential maternal health services.
3. Telemedicine: Utilizing technology to provide remote consultations and support for pregnant women in areas with limited healthcare resources.
4. Community health workers: Training and deploying community health workers to provide education, prenatal care, and postnatal support to pregnant women in underserved communities.
5. Transportation support: Providing transportation services or subsidies to pregnant women in remote areas to ensure they can access healthcare facilities for prenatal care, delivery, and postnatal care.
6. Financial incentives: Implementing financial incentives such as cash transfers or insurance schemes to encourage pregnant women to seek and utilize maternal health services.
7. Health education and awareness campaigns: Conducting targeted campaigns to raise awareness about the importance of maternal health services and address cultural or social barriers that may prevent women from seeking care.

Methodology for simulating the impact of recommendations:

1. Define the target population: Identify the specific population that will be affected by the recommendations (e.g., pregnant women in a specific region or country).
2. Collect baseline data: Gather data on the current access to maternal health services, including the number of pregnant women receiving care, distance to healthcare facilities, and any existing barriers.
3. Define indicators: Determine the key indicators that will be used to measure the impact of the recommendations, such as the number of pregnant women accessing prenatal care or the reduction in maternal mortality rates.
4. Develop a simulation model: Create a simulation model that incorporates the recommendations and their potential impact on the defined indicators. This model should consider factors such as population size, healthcare infrastructure, and resource availability.
5. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. Adjust the parameters of the recommendations (e.g., coverage, cost, implementation timeline) to explore different scenarios.
6. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. Compare the different scenarios to identify the most effective strategies.
7. Validate and refine the model: Validate the simulation model by comparing the simulated results with real-world data, if available. Refine the model based on feedback and additional data to improve its accuracy and reliability.
8. Communicate findings: Present the findings of the simulation study to stakeholders, policymakers, and healthcare providers to inform decision-making and prioritize interventions that can improve access to maternal health.

Please note that the methodology provided is a general framework and may need to be adapted based on the specific context and resources available for the simulation study.

Umbhali

Dima Health

Statistics:

Citations: 34

Identifiers:

DOI: 10.1186/s12961-015-0016-9

Research Areas:

Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Ghana

Study Design:

Case Study, Cohort Study, Ethnographic Study, Grounded Theory, Phenomenological Study

Study Approach:

Mixed-methods, Qualitative

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