Policy initiation and political levers in health policy: lessons from Ghana’s health insurance

Abstract

BackgroundUnderstanding the health policy formulation process over the years has focused on the content of policy to the neglect of context. This had led to several policy initiatives having a still birth or ineffective policy choices with sub-optimal outcomes when implemented. Sometimes, the difficulty has been finding congruence between different values and interests of the various stakeholders. How can policy initiators leverage the various subtle mechanisms that various players draw on to leverage their interests during policy formulation. This paper attempts to conceptualise these levers of policy formulation to enhance an understanding of this field of work based on lived experience.MethodologyThis is a qualitative participant observation case study based on retrospective recollection of the policy process and political levers involved in developing the Ghana National Health Insurance Scheme. The study uses a four-concept framework which is agenda setting, symbols manipulation, constituency preservation and coalition building to capture the various issues, negotiations and nuanced approaches used in arriving at desired outcomes.ResultsTechnical experts, civil society, academicians and politicians all had significant influence on setting the health insurance agenda. Each of these various stakeholders carefully engaged in ways that preserved their constituency interests through explicit manoeuvres and subtle engagements. Where proposals lend themselves to various interpretations, stakeholders were quick to latch on the contentious issues to preserve their constituency and will manipulate the symbols that arise from the proposals to their advantage. Where interests are contested and the price of losing out will leave government worse off which will favour its political opponent, it will push for divergent interests outside parliamentary politics through intense negotiations to build coalitions so a particular policy may pass.ConclusionsThis paper has examined the policy environment and the political leverages in retrospect at arriving at Ghana’s health insurance policy and design. New perspectives have been brought to the dynamics of the interactions of the 3 streams of problem, policy and politics. It provides lessons which suggest that in understanding the policy process, it is important that actors engage with the content as well as the context to understand viewpoints that may be expressed by interest groups. This will empower policy proponents to achieve easier results and limit the frustrations associated with the policy process. There are no straight and determined pathways for achieving outcomes so appreciating the evidence and basis for design, negotiation process and building coalitions along the way are skills to be mastered.

Unmet reproductive health care needs among rural Ghanaian women

“…Policymakers in our study noted poor application of economic evaluation to evaluate earlier SWAp processes. This view corroborates exiting studies in Ghana that indicated misinformation and poor stakeholder understanding greeted some sector polices on sexual and reproductive health (Mayhew & Adjei, 2004;Seddoh & Akor, 2012). Evidence from policymakers in our study also points to the poor application of economic evaluations to inform reproductive priority setting and decision making over the years.…”

“…In Ghana, priority-setting for reproductive health service interventions is known to be rudimentary with little wider stakeholder involvement (Mayhew & Adjei, 2004;Seddoh & Akor, 2012). Recent evidence in Ghana shows progress on family planning access, knowledge and awareness for reproductive health care (GSS et al, 2014).…”

National level maternal health decisions : towards an understanding of health policy agenda setting and formulation in Ghana

“…The papers by Agyepong and Adjei (2008) and Seddoh and Akor (2012) note this complexity. Actors and stakeholders who want to influence agendas need to pay attention to context and policy actors in any strategy.…”

“…Explaining decision making processes within these domains can provide some guidance to health practitioners and analyst who wish to understand national level decision making processes and entry points into the pluralistic (Ministry of Health, 2007) and sometimes elitist Adjei, 2008, Seddoh andAkor, 2012) Ghanaian health sector. People who want to influence national level decisions can actively participate in one or more of these decision domains.…”

“…Its use here is not to establish the validity of these approaches but rather to help explain what happened and as a result develop theoretical understanding of how maternal health policy decisions are made at national level. The thesis draws on elitist and pluralist power approaches, because the Ghanaian health sector is pluralist with many policy actors involved in decision making (Ministry of Health, 2007), and at the same time there are situations where only few policy actors have taken decisions Adjei, 2008, Seddoh andAkor, 2012).…”