BackgroundAlthough there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP ‘works’ when it is introduced into a district health system in Ghana, and whether or not it supports systems thinking in district teams.MethodsWe undertook a realist evaluation to investigate the outcomes, contexts, and mechanisms of the intervention. Building on two working hypotheses developed from our earlier work, we developed an explanatory case study of one rural district in the Greater Accra Region of Ghana. Data collection included participant observation, document review, and semi-structured interviews with district managers prior to, during, and after the intervention. Working backwards from an in-depth analysis of the context and observed short- and medium-term outcomes, we drew a causal loop diagram to explain interactions between contexts, outcomes, and mechanisms.ResultsThe LDP was a valuable experience for district managers and teams were able to attain short-term outcomes because the novel approach supported teamwork, initiative-building, and improved prioritisation. However, the LDP was not institutionalised in district teams and did not lead to increased systems thinking. This was related to the context of high uncertainty within the district, and hierarchical authority of the system, which triggered the LDP’s underlying goal of organisational control.ConclusionsConsideration of organisational context is important when trying to sustain complex interventions, as it seems to influence the gap between short- and medium-term outcomes. More explicit focus on systems thinking principles that enable district managers to better cope with their contexts may strengthen the institutionalisation of the LDP in the future.

BackgroundDevelopment 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.MethodsA 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.ResultsContextual 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.ConclusionInfluencers 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.

ABSTRACT. We contend there are currently two competing scenarios for the sustainable development of shrimp aquaculture in coastal areas of Southeast Asia. First, a landscape approach, where farming techniques for small-scale producers are integrated into intertidal areas in a way that the ecological functions of mangroves are maintained and shrimp farming diseases are controlled. Second, a closed system approach, where problems of disease and effluent are eliminated in closed recirculation ponds behind the intertidal zone controlled by industrial-scale producers. We use these scenarios as two ends of a spectrum of possible interactions at a range of scales between the ecological, social, and political dynamics that underlie the threat to the resilience of mangrove forested coastal ecosystems. We discuss how the analytical concepts of resilience, uncertainty, risk, and the organizing heuristic of scale can assist us to understand decision making over shrimp production, and in doing so, explore their use in the empirical research areas of coastal ecology, shrimp health management and epidemiology, livelihoods, and governance in response to the two scenarios. Our conclusion focuses on a series of questions that map out a new interdisciplinary research agenda for sustainable shrimp aquaculture in coastal areas.

BackgroundWhy 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.MethodsWe 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.ResultsDuring 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.ConclusionThe 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.

& Shrimp farming is a major livelihood activity in the Mekong Delta in the southernmost part of Vietnam. The Vietnamese government has promoted shrimp farming as a way to reduce poverty, provide employment opportunities and increase exports to support economic development. The shrimp farming system, however, is economically and ecologically risky and may negatively influence the environment and the sustainability of local people's livelihoods. Because very little is known about the diversity of strategies people employ to deal with these risks, a study was performed in the Mekong Delta across four shrimp farming systems: (1) improved extensive non-forest, (2) mixed mangrove-shrimp, (3) intensive and (4) clustered intensive. The risks and livelihood strategies that were encountered differed systematically across the four farming systems. It was found that the uncertainties that the shrimp farmers faced include limited access rights to the mangrove forest, crop failure due to regular occurrence of shrimp disease, high investment costs and volatile markets for shrimp. Shrimp farmers have created several strategies for coping with these uncertainties, including redesigning farms, producing salt, changing the species farmed from Penaeus monodon to Penaeus vannamei, becoming involved in a cooperative cluster, integrating aquaculture and agriculture, and farming shrimp by organic standards.