Acknowledgements
The study team would like to acknowledge the technical review support received
from staff of UNFPA/Ghana, Ms. Jane Wickstrom, USAID/Ghana and staff of
Frontiers in Reproductive Health Program, Population Council.
During fieldwork, Ms. Nancy Ekyem and Mr. Noble Adiku provided valuable
assistance that made the facility assessment possible. Our appreciation also goes
to Dr. Arde- Acquah, Dr. Morrison and Dr. John Eleeza who kindly provided in-
depth information about their regions and districts during the course of the
study. We would also like to thank all members of the Ho and Winneba District
Health Management Teams as well as the members of the District Assembly Sub
Committees on Health for their cooperation and insightful contribution to the
study.
We thank Ms. Isabella Rockson and Ms. Angela Gadzepko (Population Council,
Accra) and Ms. Joyce Ombeva (Population Council, Nairobi) for their
administrative support throughout the study.
Above all, we would like to thank all other individuals not listed here who
agreed to participate in this study.
v
Executive Summary
This report outlines results of an in-depth assessment carried out during the
period November 2004 – August 2005. The purpose of the assessment was to
provide a better understanding of key factors affecting reproductive health
prioritization at district level, make recommendation for policy dialogue,
advocacy, resource allocation and reproductive health programme
implementation. This study assessed whether there is harmony or discrepancy
between national and district priority setting for RH, and whether Health Sector
Reforms (HSR) facilitate or constrain priority setting for RH at the district level.
In particular, the study examined whether districts are or are not connecting to
the central process of priority setting and reasons for not connecting.
The study was conducted at the national, regional and district levels. It included two
districts: Awutu-Efutu Senya (AES) in the Central region and Ho in the Volta region.
Data for the study were gathered through a desk appraisal of key documents, group
discussions, in-depth interviews with key informants directly and indirectly involved in
the priority setting process, and facility assessment.
This study confirms that reproductive health is a “stated” priority at both the national
and district levels. But priority setting is essentially driven at the national level the
national level sets priorities and districts implement them.
Health sector reforms in Ghana tend to support and reinforce a focus on the RH
package at the district level in three ways:
Organization of services in health institutions makes the provision of RH almost
mandatory since all health institutions at the district have RH/FP units that are
responsible for safe motherhood and family planning services. This institutional
arrangement ensures that reproductive health services stand out as an entity even in
the integrated approach to health services in the country.
The sector-wide approach adopted key RH indicators that form the basis for
assessing sector-wide performance and ensuring accountability at the district level.
For that reason the dialogue at the sector level is about both RH service delivery and
systems development. It is assumed under these circumstances that HSR in Ghana
should lead to the delivery of RH interventions. However, findings seem to imply
that HSR are not translating into service delivery because of inadequate capacity in
terms of drugs, supplies, equipment and service protocols.
Financing reforms did not discriminate in favor of RH services; nevertheless, since
the late nineties the country has been introducing exemptions that have increasingly
focused on ANC and supervised delivery. This is to be reinforced under the NHIS
programme.
vi
Ghana is, however, currently facing the challenge of harmonizing a comprehensive
definition of RH and the reality of selective implementation at the district level. There
is, therefore, a gap between the RH components as stated in the national policy and the
components available at the district level. The reality districts face is that they do not
have enough capacity to do all that has been defined in the national policy and
therefore have to make choices within the institutional arrangements defined in the
health sector.
Program managers and service providers tend to focus on aspects of RH consistent with
their mission and comparative advantage. Both the public and private health
institutions tend to focus on safe motherhood, FP and STI/HIV/AIDS while NGOs tend
to focus on the abandonment of harmful traditional practices and promotion of sexual
health. The management of infertility and RH cancers is absent in both districts.
The fact that national level priorities are district level priorities leads us to conclude that
the thrust of activities at the district level is about building capacity to implement
national priorities rather that selecting priorities per se. Secondly, the challenge facing
RH is not HSR per se but the broad range of RH services and the capacity required to
ensure that they are fully integrated into the health system. The contribution of health
sector reforms to reproductive health is in ensuring that health systems development
under HSR keeps pace with the capacity needed to deliver RH interventions. In the case
of Ghana, it appears HSR has so far been unable to do so.
Recommendations for bridging the policy implementation gap include:
Ensuring that RH advocates participate in national policy dialogue
Investing in systems development for procurement and delivery of drugs and
supplies to the health institutions
Recognizing that other implementers, in particular NGOs, have a comparative
advantage in the delivery of certain components and mobilizing them to deliver
these packages to ensure availability of these services at the district level
Mobilizing District Assemblies to support RH activities.
vii
1.0 Introduction
1.1 Background
Ghana has recognized that improved Reproductive Health (RH) Services are
important in achieving the goals of the Ghana Poverty Reduction Strategy
(GPRS) and Millennium Development Goals (MDG). Reproductive health
services are implemented within the framework of the health sector reforms.
The Second Health Sector Five Year Programme of Work (2002 –2006) has
adopted seven reproductive health indicators, namely; maternal mortality ratio,
HIV seroprevalence among the reproductive age, family planning acceptor rates,
antenatal care coverage, supervised delivery, post natal care and maternal deaths
audited rates as core reproductive health indicators for measuring sector-wide
performance.
In recent years, several interventions have been developed for improving reproductive
health, which indicate the government’s high level of commitment to the issue. These
include a National RH Service Policy, Standards and Protocols; maternal death and
clinical audit guidelines; capacity building through skills development; supply of
equipment; advocacy at all levels, community-based health planning and services; and
a selective exemption policy for free antenatal care.
However, despite this level of commitment, maternal mortality still remains high at 214
deaths per 100,000 live births. Family planning acceptance has also remained
persistently low with a modern contraceptive prevalence rate of just 13 percent in 1998
and 19 percent in 2003 (GDHS). The proportion of women who give birth with the
assistance of a skilled birth attendant, a proxy measure of the risk of maternal morbidity
and mortality, is still rather low. Less than half (47 percent) of the births in Ghana are
delivered by a health professional (GDHS, 2003).
HIV/AIDS is an emerging challenge to health in Ghana and is feared to undermine all
the progress achieved in the health sector if not tackled (MOH & GHS 2002). The 2003
sentinel survey among women attending ANC clinics shows an HIV site prevalence
range of 0.6 – 9.2 percent (GHS, 2003).
The fifth MDG has set a target of reducing the maternal mortality ratio to 54/100,000 by
year 2015, while the GPRS has set a target of 160/100,000 by 2005 (UNFPA/MOH
March 2004). In order to meet these targets, Ghana will have to review strategies
influencing these key indicators and modify activities in the second 5 Year Programme
of Work (POW) during the coming year.
The key challenge is to ensure that RH is adequately funded and remains a priority at
the policy and implementation levels. For instance, a recent review on the role of
UNFPA in Sector Wide Approaches (SWAp) suggests that the level of priority setting
1
for RH differs between national (policy) and district (implementation) levels
(Enyimayew, 2003). Also, anecdotal evidence suggests that district managers may
allocate funds away from programs they perceive as having significant vertical funding
(for example HIV/AIDS and adolescent health).
While it is globally acknowledged that SWAp may have facilitated the interaction
between MOH and donors, Jeppsson (2002) has raised a number of issues concerning
the nature of the partnership between actors in the SWAp process in a decentralized
context. One critical issue that seems not to have been explicitly addressed is whether
SWAp affects the power balance and the relationship between the MOH on one hand,
and the district level on the other, and if so how this affects priority setting. Elsewhere,
Mayhew et al (2003) have also argued that in contexts where SWAp are implemented
alongside decentralization, reforms may impede priority setting for RH and/or even
polarize RH activities in district plans and actions in part because priority setting is
influenced by political and organizational factors that are not considered by current
priority setting tools such as Disability Adjusted Life Years (DALYS).
Recent international literature on Health Sector Reforms (HSR) observes that
Sexual and Reproductive Health (SRH) is almost invisible in the HSR agenda
(Standing, 2002; Hill, 2002; Mayhew and Adjei, 2004). Three major reasons
account for this. First, there is a serious language and discourse gap between
those participating in HSR and those responsible for SRH that rarely interacts
internationally, nationally or locally; when meeting, HSR actors tend to speak in
a managerial/technocratic language, while SRH actors tend to speak an
advocacy language. HSR discourse focuses mainly on system strengthening
interventions, such as financing mechanisms and human resources management,
while SRH discourse is pre-occupied with advocating for RH interventions,
packages and services. Secondly there is a debatable perception that health
sector reformers tend to see SRH as a vertical or special interest program, thus
neglecting it, while RH advocates tend to question the ability of health sector
reforms to focus on and deliver RH interventions. The situation is even made
more complex by the fact that SRH advocates have not sufficiently understood
the importance of engaging in systems reforms while health sector reformers
have not understood that reforms will be judged to be successful only if they
deliver health interventions including SRH interventions. Thirdly, and more
specific to Ghana was a desire by the SRH programme to want to remain semi-
independent, retaining its own earmarked funding and specialized cadre
(Mayhew and Adjei, 2004).
UNFPA/Ghana and other health sector development partners wanted a better
understanding of the key factors affecting RH prioritization at the district level. They
requested a study that would address the following issues:
2
Whether RH is a priority at the district level;
Whether there is harmony or discrepancy between national and district level RH
priorities; and
Whether HSR facilitates or constrains priority setting for RH at the district level.
The purpose of the study is, therefore, to inform UNFPA, MOH and other health sector
development partners on future strategies to ensure that RH is a priority at the district
level so that it will be adequately funded. It is expected that UNFPA and other RH
advocates in Ghana will use the findings from this study to press for greater focus on
RH at the district level. It will guide the MOH and other health development partners in
the health sector SWAp in negotiating an appropriate balance between concerns for
health systems strengthening and improved delivery and quality of RH services.
Information generated by the study is also useful in informing decisions on how to
reprioritize RH concerns at the district level in order to sustain policy targets.
1.2 Overall Objective
The overall aim of the study was to examine facilitating and inhibiting factors in RH
priority setting at the district level, and make recommendations for policy dialogue,
advocacy, resource allocation and RH program implementation.
2.0 Methodology
2.1 Conceptual Framework
The debate on priority setting is about government as an allocator of scarce health care
resources involving the selection of health services, programmes or actions that will be
provided first, with the purpose of improving the health benefits and distribution of
health resources. Ideally, priority setting is perceived as a technical process requiring
the quantitative analysis of the burden of diseases, premature mortality and disability
losses, the analysis of cost-effectiveness of alternative interventions to control the
diseases that cause the largest health losses and then the selection of a package or list of
interventions that can be delivered with the available budget through the current health
system (Ham, 1996; Bobadilla, 1996). In reality priority setting is more complex than
this. The process is frequently influenced by political, institutional and managerial
factors.
This study drew on two mutually reinforcing conceptual frameworks: 1) the Walt and
Gilson (1994) policy analysis framework
1
and 2) the Reichenbach’s (2002) framework
for measuring policy priority
2
.
1
Walt G, Gilson, L. 1994 Reforming the health sector in developing countries: The central role of
the policy analysis. Health Policy and Planning 9: 353-370.
3
The Walt and Gilson framework takes into account the content of policy and/or
program, the actors involved, the processes contingent on developing sector priorities
and implementing programmes as well as the context within which the priorities or
programmes are developed. We looked at the influence of the different actors, the
priority setting process, and contextual factors and how these interact to influence
priority setting in the health sector at the national and district levels. The Reichenbach’s
policy priority framework is about whether a specific health issue is receiving attention
or consideration on the policy agenda. The framework outlines three ways of
measuring attention: direct attention, process attention and political attention:
Direct attention refers to the commonly used systematic measures of RH status such
as incidence data, mortality and morbidity data, DALYS and actual costs.
Process attention covers the direct and indirect measures of social organizational
capacity to address a particular health issue, including physical resources such as
drugs, equipment, commodities and supplies, but also technical guidelines and
recommendations, treatment protocols and the number of training courses and
workshops organized for clinicians and other service providers to develop capacity
to address a health issue.
Political attention measures the extent to which groups or individuals in positions of
influence including politicians, civil servants and Ministers, NGOs – academic
organizations, women’s organizations, medical associations and the media are
engaged in advocacy and policy making, raising RH issues publicly and publishing
information.
The two frameworks were combined to provide a comprehensive approach to better
understand the priority setting processes. The combined framework was applied
retrospectively to understand:
The content of reproductive health;
The process of priority setting;
The influence of the different actors on the priority making processes; and
How these interact with the contextual factors to determine the level of attention RH
receives at the national and district levels.
2.2 Study Design
This in-depth assessment used both quantitative and qualitative methods of data
collection. The study was conducted at both the national and district levels. It included
two districts; AES in the Central region supposed to be receiving earmarked support for
2
Reichenbach, L. 2002 The Politics of Priority Setting for reproductive Health: Breast Cancer and
Cervical Cancer in Ghana. Reproductive Health Matters, Volume 10 Number 30, November
2002, 47 – 57.
4
RH from UNFPA and Ho in the Volta region that was not supposed to be receiving
earmarked funds for RH. However, after the initial data were gathered it was clear that
both districts received earmarked funds from various sources for reproductive health.
Therefore a comparative analysis of the two districts on the basis of this criterion was
not possible. Consequently, no attempt is made in this assessment to attribute
differences between the two districts to earmarked funds.
2.3 Data Collection
Data were collected through a desk appraisal of key documents, group discussions, in-
depth interviews with key informants directly and indirectly involved in the policy
setting process, and facility assessment.
The desk appraisal was undertaken
to address key questions about the
content and context of RH priority
setting. Several documents were
reviewed for their content in relation
to reproductive health including
policy documents, district
development plans, annual and
quarterly reports of the Ghana
Health Service (GHS), aide mémoire
for the joint review mission of the
Government of Ghana and partners
in the health sector, annual health
sector performance reports, mid-
term review reports for the health
sector strategic plan, POW and
health policy statements, program
documents of international technical
agencies and NGOs, and local
publications. Budgets and
expenditure records at both district
and facility level were also reviewed to generate information on funding for health in
general and RH services specifically. Programs of local media stations and print media
were reviewed for the past five years (where possible) to assess media attention to
reproductive health concerns.
Table 1: Actors Interviewed
Government
Organizations
1 MOH Key Informant
2 GHS Key Informant
1 Reproductive and
Child Health (RCH)
Programme manager
Private organizations
& NGOs
5 NGOs in Volta
Region
6 Private Health Care
Organizations
Health Development
Partners
1 UNFPA and 1 WHO
Officials
Regional Directors 2 Regional Directors
District Directors 2 District Directors of
Health Services
(DDHS)
Service Providers Public and NGO
providers
In seeking the views of individuals about priority setting in the health sector, several
actors (policy makers, program managers and service providers) at the national and
district levels were identified and interviewed from government organizations, private
5
organizations and NGOs, health development partners, technical assistance agencies,
district directors and service providers (Table 1).
The interviews elicited information on questions about the context, actors, process and
political attention. The process of carrying out key informant interviews covered a
period of two months.
Key actors from the districts were brought together in a forum to discuss issues related
to priority setting for RH within the context of SWAp in order to elicit group opinions,
attitudes, impressions, experiences and suggestions, and to observe the process of
interaction and debate between these actors. Four types of group discussions/meetings
were organized as follows: 1) 25 members of the District Health Management Teams
(DHMT) and 35 members of the Sub-district Health Management Teams (SDHMT), 2)
17 members of the District Assembly (DA), 3) 13 members of the District Health
Committees (DHC), and 4) service providers. The group discussions and/or meetings
aimed at understanding the priority setting process, context and political attention to
reproductive health concerns. A discussion guide was used covering three broad
themes including the process and context of priority setting, and political attention to
RH concerns at the district level.
A facility assessment was conducted at 41 public and private facilities in the Ho district
and 24 in the AES district that offer maternal and reproductive health services as well as
services for specific infectious diseases (sexually transmitted infections, HIV/AIDS).
The aim was to capture issues of availability of resources and support services for
different RH components, in terms of direct measurement of social and organizational
capacity to address particular RH issues, including physical resources (such as drugs,
equipment and other commodities and supplies), infrastructure, technical guidelines
and recommendations, treatment protocols, staffing and provider training.
3.0 Findings
3.1 The Content of RH in Ghana
The RH program in Ghana was adapted from the International Conference on
Population and Development held in Cairo (ICPD, 1994). Accordingly, Ghana’s
Reproductive Health Service Policy and Standards have defined reproductive health as:
“A state of complete physical, mental and social well-being and not
merely the absence of disease and infirmity in all aspects related to the
reproductive system and its functions and processes. Reproductive health
therefore implies that people are able to have a satisfying and safe sex life
and that they have capability to reproduce and the freedom to decide if,
when and how often to do so.”
6
The policy calls for universal access to a wide range of services and a comprehensive
package of interventions for promoting women’s health and well-being, employing a
human rights and client-centered approach within a multi-sectoral framework. The
specific components of Reproductive Health Services as spelt out in the policy are:
Safe Motherhood including antenatal, safe delivery, and postnatal care especially
breastfeeding, infant health, and women’s health;
Family Planning;
Prevention and treatment of unsafe abortion and post-abortion care;
Prevention and treatment of reproductive tract infections, including sexually
transmitted diseases and HIV/AIDS;
Prevention and treatment of infertility;
Management of cancers of the male and female reproductive tract, including the
breast;
Responding to concerns about menopause and andropause;
Discouragement of harmful traditional practices that affect the reproductive health
of men and women such as female genital mutilation; and
Information and counseling on human sexuality, responsible sexual behavior,
responsible parenthood, pre-conception care, and sexual health.
While the Policy spells out a broad package of RH, the Reproductive and Child Health
Unit (GHS) annual reports have tended to provide a more limited list of RH
components. These include:
Safe motherhood including infant health
Family planning
STI/HIV/AIDS prevention and management
Postabortion care
Prevention and management of cancers of the reproductive system.
The focus of RH in the district plans and the interviews with key stakeholders tended to
infer that an even more limited package is being delivered in reality. The common
components of reproductive heath services available at the district level were:
Safe Motherhood including antenatal, delivery and post natal care,
Family Planning, and
STI/HIV/AIDS prevention and management.
7
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