Role of United Nations

1.1 Background

The United Nations (UN) Millennium Declaration was signed by 189 countries in 2001 and was translated into eight Millennium Development Goals (MDGs) for development and poverty eradication. Three of the eight MDGs (4, 5 and 6) are directly related to health, concerning child health, maternal health and disease control, respectively. The inclusion of health targets in the Millennium Development Goals supports the contention that good health is important for overcoming poverty and achieving the wider goal of socio-economic development (UN, 2007).

Achieving the MDGs has increasingly become the central focus of many multilateral and bilateral donor agencies. Although the developmental agenda emboldened in the MDGs address all countries of the world, there can be no doubt that sub-Saharan African countries (SSA) have the greatest problems and stand to benefit most from the promotion of its principles, as compared to other regions of the world. In comparison to the rest of the world, SSA countries have the highest rates of poverty and illiteracy, as well as the highest rates of child mortality, maternal mortality, HIIV/ AIDS and malaria (Okonofua, 2006).

By December 31, 2010, ten out of the fifteen years for reaching the targets and indicators of the MDGs would have passed. A relevant question is whether SSA countries can meet the targets and monitoring indicators within the stipulated time-frame, and if so, whether such an achievement can be sustained? If results would be achieved in Africa, there should be positive signs during the first decade of the millennium to point to this direction. Africa as a whole is off- track to meeting the MDGs on reducing child mortality and improving maternal health (Singh, 2006; Simwaka et al, 2005; Stuckler, 2010; UN, 2010).

The Term Paper on Millennium Development Goals

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Slow progress in low-income countries cannot simply be explained by their public health MDG targets being more challenging. Reducing child mortality by two-thirds or maternal mortality by three-quarters may be more difficult when death rates are already low, as in rich countries (Stuckler et al, 2010).

One possibility is that countries simply lack the financial resources needed to combat epidemics (i.e., low gross domestic product [GDP] per capita).

Even when funds are available, they may be allocated to other forms of social spending, military expenditure, or reserves, rather than health.

Health, being a public good, accrues positive benefits to society at large. Governments have a prime responsibility to ensure the provision, or at least the funding, of health systems. The responsibility of Governments to protect the health of their populations includes, ensuring equitable access to basic health care for all, with particular attention to the poor. The achievement of the health-related MDGs and the progress being made towards achieving the other MDGs, including the overall fight against poverty, will be compromised if the right to health is not secured for the most vulnerable groups.

Maternal and child health statistics are some of the indicators that show the greatest disparity between SSA and the rest of the world. The number of maternal deaths has shown no signs of abating in SSA African countries, with current trends indicating that Africa will not meet the target of reducing maternal deaths by 75 percent by the year 2015. The data for child mortality are even more depressing. Current estimates from the United Nations indicate in 2008, one in seven children died before their fifth birthday; the highest levels in Western and Central Africa, where one in six children died before age five (169 deaths per 1,000 live births).

All 34 countries with under-five mortality rates exceeding 100 per 1,000 live births in 2008 are in sub-Saharan Africa, except Afghanistan.

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Although under-five mortality in SSA has declined by 22 percent since 1990, the rate of improvement is insufficient to meet the target. Furthermore, high levels of fertility, combined with a still large percentage of under-five deaths, have resulted in an increase in the absolute number of children who have died- from 4.0 million in 1990 to 4.4 million in 2008. Sub-Saharan Africa accounted for half of the 8.8 million deaths in children under -five worldwide in 2008.

Achieving the Millennium Development Goals (MDGs,) and other internationally agreed development goals in Africa, holds the promise of saving millions of lives; empowering women; addressing the scourge of illiteracy, hunger and malnutrition; and ensuring that Africa’s children have access to high-quality education and good health to lead productive lives (ASG,2008).

While stronger health systems appear to be a prerequisite to achieving the health MDGs, there is currently little direct focus on systems strengthening. The drive to produce results for the MDGs has led many stakeholders to focus on their disease priority first, with an implicit assumption that through the implementation of specific interventions, the system will be strengthened more generally. Experience to date, however, suggests that if health systems are lacking capabilities in key areas such as the health workforce, drug supply, health financing, and information systems, they may not be able to respond adequately to such opportunities (Travis et al, 2004).

Furthermore, there is concern that already weak systems may be further compromised by over-concentrating resources in specific programmes, leaving many other areas further under-resourced.

Examining country situations in-depth indicates that policy reorientation to secure the health-MDGs for the poor may not be feasible in implementation by 2015. This is not to excuse a lack of ambition in policy, and countries must indeed aim to make rapid progress towards alleviating poverty as encapsulated in the MDGs (Singh, 2006).

It is, rather, to caution against unrealistic aspirations in the absence of the necessary institutional and systemic requirements on which this success is conditional. Attaining the ambitious targets pronounced in the MDGs will necessitate substantial acceleration of primary health care and further strengthen the health systems, with radical changes in policy as well as strong inter-sectoral co-ordination. Whilst aiming for such macro-level achievements, it is imperative to analyse the on-the ground realities of health systems at the country level (Accorsi, 2010).

The Research paper on Health Promotion and Community Development

Community Development Approaches to Health Promotion In this literature review, it has become apparent that there are problems with definitions at every turn. What is Health Promotion? What is community? What is Community Development? What are community development approaches to health promotion? It is also clear that the policy environment has progressively moved, both nationally and ...

The MDGs are quantifiable, time-bound, and focus on key aspects of development, as well as on establishing a partnership between developed and developing countries. However, the Goals are both ends in themselves and benchmarks for progress towards the overall goals of the Millennium Declaration: eradicating human poverty and fighting inequality. All countries have agreed to report back on progress to the United Nations and the public on the status of their efforts to implement the MDGs. In addition, at the 2005 United Nations World Summit, developing countries signed up to producing medium-term national development plans focused on the MDGs in 2006 (UN, 2008).

Health is central to the achievement of the millennium development goals, both in its own right (see goals 4, 5, and 6), and as a contributor to several others. For instance, the impact of poverty on ill health is well known and extensively documented. Ill health can also be an important cause of poverty through loss of income, catastrophic health expenses, and orphan-hood. Thus, improving health can make a substantial contribution to target, which aims to halve between 1990 and 2015 the proportion of people whose income is less than $1 a day. Haines (2004) observed that the millennium development goals should be considered as a mutually reinforcing framework contributing interactively to human development.

It is also clear that the goals do not say everything that needs to be said about health and development. It is best to think of them as a kind of shorthand for some of the most important outcomes that development should achieve: fewer women dying in childbirth, more children surviving the early years of life, dealing with the catastrophe of HIV/AIDS, and making sure people have access to life-saving drugs. The millennium development goals represent desirable ends; they are not a prescription for the means by which those ends are to be achieved (ibid).

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They say nothing, for example, about the importance of effective health systems, which are essential to the achievement of all of the health goals, or the importance of rural infrastructure (roads, telephones, etc) in reducing maternal mortality.

1.2 Problem Statement

The high incidence of maternal mortality in Ghana indicates the paucity in implementation of health policies in the country. The Ghana Demographic and Health Survey report (2008) indicates, the Maternal Mortality Ratio has improved from 560 maternal deaths per 100,000 live births in 2003 to 451 maternal deaths per 100,000 live births in 2008. And if the current trends continue, maternal mortality will reduce to only 340 per 100,000 by 2015, and it will be unlikely for Ghana to meet the MDG target of 185 per 100,000 by 2015 (Ghana MDGs report, 2010).

Governments all over the world have put in measures to address the problem of maternal deaths through the enactment and implementation of policies, legislations and services. In 1987, the World Health Organization (WHO) and other United Nations’ agencies like UNICEF launched the Safe Motherhood initiative which was accepted in Ghana. Since then, several Safe Motherhood programmes have been and will continue to be implemented in Ghana. Other interventions that have been initiated includes free antenatal care to all pregnant women; a policy of exempting all users from delivery fees in health facilities (Biritwum, 2004).

In spite of these and other interventions initiated by the government to achieve MDG 5, and thereby, reduce by three-quarters the maternal mortality ratio by 2015, progress seems to be very slow.

Achieving good maternal health requires quality reproductive health services and a series of well-timed interventions to ensure a woman’s safe passage to motherhood. Failure to provide these results in hundreds of thousands of needless deaths each year, a sad reminder of the low status accorded to women in many societies (Simwaka et al, 2005; UN, 2010).

It is widely agreed that the high maternal mortality ratio in many sub-Saharan African countries is a reflection of the status of women in these societies, since it vividly illustrates how acceptable a society finds such avoidable deaths.

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Maternal mortality continues to be high and specific attention will be paid to ensure that a larger proportion of deliveries are performed by skilled attendants in well equipped facilities (MOH, 2007).

In terms of access to skilled birth attendants, current data suggests that 10% of women have access to a doctor, 41% have access to nurses and midwives, 41% to traditional birth attendants and 17% use relations and other informal acquaintances. In terms of regional access, the three regions in the north have worst access to skilled birth attendants of 30% (MOH, 2008)

Aryeetey and Nimo (2004) found out that efforts and programs aimed at addressing the high incidence of maternal mortality are also confronted by many challenges, some of which are to minimize spatial inequalities, improving the reliability and timeliness in the release of data, documenting and disseminating information about gaps in access and utilization of services, and improving availability and retention of trained health personnel (which has become a major national problem), infrastructure and equipment.

1.3 Objective of the Study

The main objective of this study is to find out the challenges in the implementation of the millennium development goals to improve maternal health faced by health care providers in the Tamale Metropolis of Ghana.

1.3.1 Specific Objectives

The specific objectives are:

To find out the constraints facing skilled birth attendants (SBAs), specifically midwives in the Tamale Metropolis.

To find out the challenges of maternal health logistics in health care facilities in the Tamale Metropolis.

1.4 Research Questions

The research questions that this study addresses are:

What are the constraints facing skilled birth attendants (SBAs), specifically midwives in the Tamale Metropolis?

What are the challenges in maternal health logistics in health care facilities in the Tamale facilities?

1.5 Significance of the Study

The results of the study will help:

Policy makers and planners to be more responsive to issues of maternal health by realigning projects and programmes into the development plan agenda and review health policies in line with best practices.

Service providers assess the quality of their services and the areas to focus on maternal health interventions. It is also believed that they will be able to channel resources to areas where they are most needed.

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Donor agencies and the Government to tract the level of resources into specific maternal health programmes and what conditionality that is in favour or detriment to a particular programme.

1.6 Scope and Limitation of the Study

The study focuses on challenges on maternal health within the health system in the Tamale Metropolis in the Northern Region of Ghana. It is also limited to public hospitals with focus on maternal health.

1.7 Definition of Terms

For the purpose of this study, the following definitions were adopted:

Skilled Birth Attendant(SBA): the term ‘skilled attendant’ refers to “an accredited health professional, such as midwife, doctor or nurse, who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management or referral of complications in women and newborns.” Traditional birth attendants, either trained or not, are excluded from this category of skilled health workers (WHO, 2004 cited in Nanda, 2005).

This study only considers midwives as skilled birth attendants.

Maternal health logistics: medicines and medical equipment that promote improved health outcomes. The terms “supplies”, “commodities” and “product” are used interchangeably. The term is also used to denote infrastructure.

1.8 Organisation of the Study

The study is composed of five chapters.

Chapter One…..

Chapter two gives the relevant literature on implementation issues from both the theoretical perspectives and empirical works in the area.

Chapter three provides the key methods for data collection for the study and a background to the study area.

Chapter four provides the results and discusses the findings of the study, and chapter five draws conclusions and makes recommendations.

CHAPTER 2

LITERATURE REVIEW

2.0 Introduction

The implementation of many health interventions in developing countries, particularly Ghana, has been enveloped by a number of challenges which are not given much attention. The review is presented into four main sections. The first section of the review presents the concept of implementation and the approaches to policy implementation. The second section highlights the views on successful implementation and implementation failure. The third section deals with issues pertaining to implementation problems in developing countries and Ghana. The final section of the review addresses the broad implementation of health policies and narrows it down to maternal health policies.

2.1 Concept of Policy Implementation

O’Toole (2000, pp 266) sees it as “what develops between the establishment of an apparent intention on the part of government to do something, or to stop doing something, and the ultimate impact in the world of action.” Some scholars include here both the assembly of policy actors and action, on the one hand, and the cause-effect relationship between their efforts and ultimate outcomes, on the other (for instance, Mazmanian and Sabatier, 1989).

Schofield (2001, pp 254) sees it as “policy becoming action”. According to Van Meter and Van Hon (1974: 447-8, cited in Brynard, 2005) “Policy implementation encompasses those actions by public or private individuals (or groups) that are directed at the achievement of objectives set forth in prior policy decisions”. They make a clear distinction between the interrelated concepts of implementation, performance, impact and stress. The observation is, impact studies typically ask “What happened?” whereas implementation studies ask “Why did it happen?” What is stressed among these definitions is the recognition that something has to be acted upon to bring about a desired outcome. It is also important to point out how to relate a policy to maternal health programmes that are implemented within the public and private sectors of health. It is a recognition that health policies or programmes are mainly formulated in the government agencies with little or no engagement with other sectors who also have to implement such a policy or programme.

Fixsen et al (2005) define implementation as a specified set of activities designed to put into practice an activity or program of known dimensions. They explained further, implementation processes are purposeful and are described in sufficient detail such that independent observers can detect the presence and strength of the “specific set of activities” related to implementation. In addition, the activity or program being implemented is described in sufficient detail so that independent observers can detect its presence and strength.

Accordingly, Fixsen et al have categorized the purposes and outcomes of implementation to be as follows:

Paper implementation means putting into place new policies and procedures (the “recorded theory of change”) with the adoption of an innovation as the rationale for the policies and procedures. Thus, paper implementation may be especially prevalent when outside groups are monitoring compliance (e.g., for accreditation) and much of the monitoring focuses on the paper trail. It is clear that paperwork in file cabinets plus manuals on shelves do not equal putting innovations into practice with benefits to consumers.

Process implementation means putting new operating procedures in place to conduct training workshops, provide supervision, change information reporting forms, and so on (the “expressed theory of change” and “active theory of change”) with the adoption of an innovation as the rationale for the procedures. The activities related to an innovation are occurring, events are being counted, and innovation-related languages are adopted. However, not much of what goes on is necessarily functionally related to the new practice.

Performance implementation means putting procedures and processes in place in such a way that the identified functional components of change are used with good effect for consumers (the “integrated theory of change”).

It appears implementation that produces actual benefits to consumers, organizations, and systems require more careful and thoughtful efforts.

2.2 Approaches to Implementation

There is no consensus as to the number of approaches to policy implementation. However, the popular ones are the top-down and bottom-up approaches, even though earlier attempts have been made to synthesize the two approaches (Matland, 1995).

This review focuses on the top-down and bottom-up approaches to implementation as it offers a lesson for national, regional and local managers involved in health policy interventions.

2.2.1 Top-Down Approach to Policy Implementation

Top-down models see implementation as the degree to which the actions of implementing by officials and target groups coincide with the goals embodied in an authoritative decision (Matland, 1995).

The top-down approach was dominated by the assumption that implementation begins with policy or legislative objectives, and that the processes of implementation will follow on in a fairly linear fashion from this. Such assumptions are a direct by-product of the rational, perfect public administration model which builds upon the bureaucratic assumption of the separation of policy from implementation; the presence of a myriad control measures and tight boundaries to discretion (Schofield, 2001).

Top-downers have exhibited a strong desire to develop a generalisable policy advice. This requires finding consistent, recognizable patterns in behavior across different policy areas. Belief that such patterns exist and the desire to give advice has given the top-down view a highly prescriptive bent and has led to a concentration on variables that can be manipulated at the central level. Mazmanian and Sabatier (1989, 4), for example, believe that implementation studies should address four central questions:

• To what extent are the outputs or outcomes of the implementation process consistent with the objectives enunciated in the original statute?

• Were the objectives successfully attained? Over what period of time?

• What factors affected policy outcomes or caused the goals to be modified?

• How was the policy reformulated over time in the light of experience?

Sabatier and his co-authors then went on to specify a series of six conditions for the effective implementation of policy: policy objectives should be clear and consistent; causal assumptions embodied within the policy must be correct; legal and administrative structures must be sufficient to keep discretion within bounds; implementing agents must be skilled and committed; there must be support from interest groups and other ‘critical sovereigns’; there must be no major socio-economic upheavals or disturbances. So far as these conditions are present, a policy will be effectively implemented to achieve the desire results.

The first strength of the top-down approach is the importance it attaches to legal structuring of the implementation process – one of its major innovations. Secondly, the framework emphasizes the importance of selecting implementing institutions supportive of the new program and suggests creating new agencies as a specific strategy. Thirdly, the six conditions of effective implementation have proven to be a useful checklist of critical factors in understanding variations in program performance and in understanding the strategies of program proponents over time.

The first criticism of the top-down model stems from the top-down researcher’s emphasis on the role of central government and the specific working of the primary legislation as being the embodiment of the policy objectives. This approach fails to recognize the role of political rhetoric in policy formulation (Schofield, 2001).

Secondly, policy is not made in a vacuum: there are other actors, other organizations and an overarching set of institutional structures within which political outcomes are bargained. (Jordan 1995).

Thirdly, it is doubtful whether the top downers’ prescriptions for successful implementation could ever be met in reality. Top downers seem to want an altogether unrealistic mixture of clarity and simplicity that seems to deny and renounce the very existence of politics. Fourthly, by viewing the implementation process from the top and tracing the influence of one policy through successive layers of administration, top downers run the risk of accrediting anything and everything that happens at the bottom to the effects of the statute or policy in question. Fifthly, it is often difficult to identify a specific occasion when a policy is made or packaged up ready for implementation, because policies become shaped and are made and remade as they are implemented (Hill, 1981, cited in Jordan 1995).

Finally, it is doubtful whether the application of discretion by those at the bottom is as deviant and pernicious as some top downers seem to portray. It may be that, in certain situations, the exercise of discretion is not only inevitable (i.e. legally and politically legitimate) but also desirable because by constraining it one loses the skill and expertise of those closest to the problem.

2.2.2 Bottom-up Approach to Policy Implementation

The bottom up approach starts by identifying the network of actors involved in service delivery (Cline, 2000; Blair, 2002) in one or more local areas and asks them about their goals, strategies, activities, and contacts. It then uses the contacts as a vehicle for developing a network technique to identify the local, regional, and national actors involved in the planning, financing, and execution of the relevant governmental and non-governmental programs (Sabatier, 1986).

Policy implementation occurs at the microimplementation and macroimplementation levels (Matland, 1995).

At the microimplementation level, local organizations react to the macro level plans, develop their own programs, and implement them; at the macroimplementation level, centrally located actors devise a government program.

Bottom-uppers argue, the goals, strategies, activities, and contacts of the actors involved in the microimplementation process must be understood in order to understand implementation, for that matter it is considered a democratic control (Long and Franklin, 2004, Mischen and Sinclair, 2007).

It is at the micro level that policy directly affects people (Matland, 1995).

In the view of Sabatier (1986) the bottom-up focuses on local implementation structures, and thus is better for assessing the dynamics of local variation.

The role of street-level bureaucrats is emphasized as key to successful policy implementation (Jordan, 1995; deLeon and deLeon; 2002; Bastien, 2009).

Street-level bureaucracy is a concept developed by Lipsky (1980) to refer to the role actors who implement policy changes have to play in the process. He emphasises that such individuals are not simply cogs in the process, but rather have substantial ability to mould policy outcomes. Street level bureaucracies are schools, welfare departments, lower courts, legal service offices, hospitals etc.

The literature suggests four sets of influences on street-level bureaucratic actions in implementing policy (Meyers and Vorsanger, 2003 cited in May and Winter, 2007).

One set is the signals from political and administrative superiors about the content and importance of the policy. The policy sets forth policy intentions (goals) that are signalled by the wording of the policy and by various pronouncements by politicians and guidelines that are offered in support of the policy. A second set of influences is the organizational implementation machinery. One important aspect of this for street-level bureaucracy is the extent to which organizations delegate authority to make decisions to the frontlines or limit that discretion. A third set of considerations is the knowledge and attitudes of the street-level bureaucrats concerning relevant tasks, their work situation, and clients. A fourth set is the contextual factors concerning workloads, client mix, and other external pressures. Contextual factors within the implementing environment can completely dominate rules created at the top of the implementing pyramid, and policy designers will be unable to control the process.

In summation, the work of the bottom-up writers can be characterized in three ways (Schofield, 2001).

First, their focus on the actions of local implementers, as opposed to the central government; secondly, their attention is given, not so much to the goals of a policy, but rather the nature of the problem which a policy is designed to address; thirdly, the bottom-up approach seeks to describe networks of implementation, and in so doing, has made an important methodological contribution to implementation analysis. Bottom-uppers are, therefore, concerned with the motives and actions of actors.

Jordan (1995) presented the following two strengths of adopting the bottom view of policy implementation. Bottom up models are relatively free of predetermining assumptions about cause and effect, hierarchy or other structural relations between actors, or what should or should not occur during the implementation process. Again, bottom up models are far more capable of dealing with complexity and are well suited to situations when policies are layered upon each other. And because the point of departure is what actually happens on the ground, bottom uppers do not find themselves caught in the linguistic or methodological trap of having to differentiate policies from meta-policies and post-legislative fine-tuning.

However, it has been suggested that bottom-uppers are likely to overemphasize the ability of the periphery to frustrate the center, and for that matter, the failure to recognize that central actors and central policy are in themselves contingent factors to the local situation (Schofield, 2001).

Furthermore, it fails to start from an explicit theory of the factors affecting its subject of interest. Because it relies very heavily on the perceptions and activities of participants, it is their prisoner, and, therefore, is unlikely to analyze the factors indirectly affecting their behavior or even the factors directly affecting such behavior which the participants do not recognize.

Figure 1: The Bottom-Up View of Policy Implementation

Source: Adapted from Gilson and Erasmus (2008): Tackling implementation gaps through health policy analysis. EQUINET, policy series 21.

2.3 Views on Successes and Failures of Implementation

A policy implemented has a set of desired objectives and outcomes. The extents to which these objectives and outcomes are achieved or deviated can only be assessed in the process of implementation or given a time table specifications which are set to determine the success and failures of such a policy. The views on the successes and failures of implementation are discussed below.

2.3.1 Successful Implementation

The failure to specify what is meant by successful implementation causes considerable confusion (Matland, 1995).

Giacchino and Kakabadse (2003:3) define ‘success (or a case of successful policy implementation) to mean a policy implementation initiative in which the strategic action adopted by the administrative arm of government was considered to have delivered the intended policy decision and to have achieved the intended outcomes’. However, they were quick to point out the limitation as few policies managed comprehensively the intended objectives.

There is no single model of “effective implementation” (Ripley and Franklin1982); rather, implementation models vary according to policy type and contextual factors (Ripley and Franklin 1982; Lowi 1964, 1972, cited in Long and Franklin, 2004).

They further argued that there are a number of internal and external factors that must support the process for implementation to succeed. These factors include the number and nature of the actors involved, the nature of conflict over the policy in question, and the expectations concerning the goals and outcomes of the policy (Refer to Long and Frank, 2004).

Matland (1995) and Mischen and Sinclair (2007) refer to the work of Ingram and Schneider (1990) with the common definitions of success in the implementation literature, including: agencies comply with the directives of the statues; agencies are held accountable for reaching specific indicators of success; goals of the statute are achieved; local goals are achieved, or there is an improvement in the political climate around the program. In determining which of these definitions is appropriate, the decision hinges on whether the statutory designer’s values should be accorded a normative value greater than those of other actors, especially local actors.

For Imperial (1998) successful implementation results when the participants in an intergovernmental setting reach agreement on the scope and substance of a policy or program. In the view of Gilson and Erasmus (2009), the key things that cause policies to succeed include the nature of the policy and the meaning assigned to it and the work environments.

Cline (2000) stresses that communication is considered to be necessary if one wants to successfully implement a policy. However, important differences arise when the exact function of communication is discussed. One way to view communication is to emphasize the need for clarity and consistency in form and content in order to increase the likelihood of compliance and execution of a particular policy. Of course, if communication among parties is lacking in these respects, the resulting distortions could very well lead to implementation failure.

In contrast, Marsh and Mcconnel (2009) contend that claims that a particular policy has been a ‘success’ is commonplace in political life, and the key problem is that these claims or assessments about policy outcomes do not establish any systematic criteria for assessing success or failure.

The process of implementation and the way that challenges or obstacles are addressed can determine whether policies achieve their intended outcomes (Long and Franklin, 2004).

Granted, there may be flaws in the policy itself; however, the implementation process can weaken the impact of the policy. In some cases, through adaptation of the policy based on implementation experiences, it may improve upon the policy.

However, Cline has suggested that by viewing the implementation problem in terms of a success and failure dichotomy, it should be looked out in terms of outputs, processes, and outcomes.

2.3.2 Implementation Failure

Policy failure can result from non-implementation or from unsuccessful implementation. In the former case, a policy is not put into effect as intended. Unsuccessful implementation, on the other hand, occurs when a policy is carried out in full and external circumstances are not unfavourable, but the policy stills fails to produce the intended results or outcomes (Hunter and Marks, 2002).

In the words of Ayee (2000: 10) “implementation failure could be… failure to achieve objectives and failure in terms of policy efficiency”.

The point about policy failure is that it suggests there can be no sharp distinction between formulating a policy and implementing it. Barrett (2004: 252), reviewing the literature, noted the key common factors deemed to be perceived as the “implementation failure” include:

Lack of clear policy objectives; leaving room for differential interpretation and discretion in action;

Multiplicity of actors and agencies involved in implementation; problems of communication and co-ordination between the ‘links in the chain’;

Inter- and intra-organizational value and interest differences between actors and agencies; problems of differing perspectives and priorities affecting policy interpretations and motivation for implementation;

Relative autonomies among implementing agencies; limits of administrative control.

In a nut shell, maternal health programmes implemented at the local level may be failing when indicators like the maternal mortality rate, level of contraceptives acceptance by women, low delivery by skilled attendance at birth, low antenatal visits, among others, are below standards that have been agreed upon.

2.4 Problems of Policy Implementation in Developing Countries

It has been observed that policy implementation is one of the major problems confronting developing nations. Makinde (2005) has identified four factors that could lead to implementation of policies. These critical factors are Communication, Resources, Dispositions or Attitudes, and Bureaucratic Structure. The four factors operate simultaneously and they interact with each other to aid or hinder policy implementation. By implication, therefore, the implementation of every policy is a dynamic process which involves the interaction of many variables.

Makinde went further by explaining that there are usually problems that lead to implementation gap which can be traced to the policy maker and the policy environment. There could be implementation gap as a result of many factors, which could arise from the policy itself, the policy maker, or the environment in which the policy has been made. Implementation gap can arise from the policy itself when such a policy emanates from government rather than from the target groups. By this, it means that planning is top-down. And, by implication, the target beneficiaries are not allowed to contribute to the formulation of the policies that affect their lives. Using the Nigerian experience, Makinde enumerated a number of problems that plagued the Better Life Programme (BLP) and the Family Support Programme (FSP) in Nigeria. These problems include the lack of continuity of projects by successive governments, lack of participation of beneficiary groups, failure of the policy makers to take into consideration the social, political, economic and administrative variables when analyzing for policy formulation, bribery and corruption, inadequate provision of manpower, inadequate maintenance of equipment and inadequate monitoring of projects.

Similarly, since independence, Ghana has embarked on a number of policies and programmes to improve the living conditions of its people. However, the extent to which these policies and programmes have impacted on the lives of people appears not to be highlighted by commentators. Ayee (2000), for example, has noted that

“the vagaries of policy implementation have become the “missing link” in the realization of the goals and outcomes of public policies and programmes in Ghana. From Nkrumah’s Seven Year Development Plan, to Structural Adjustment Programme, Programme of Action to Mitigate the Social Costs of Adjustment (PAMSCAD), decentralization, education, agriculture, privatization, water and health policies and programmes, Civil Service Reform Programme, Public Financial Management Reform Programme (PUFMARP), incomes policy (for instance, Central Management Board overseeing the implementation of the controversial Price Waterhouse public sector pay review)and the Value-Added Tax, the main reason for their underachievement of objectives is ineffective or poor implementation (Ayee, 2000: 47)

Hutchful (1994, cited in Ayee, 2000), for instance, has catalogued a number of implementation problems that have adversely affected the goals of PAMSCAD. They include long delays in commencing the program; non-availability of local counterpart funds, particularly for the community initiative projects; inherent defects in the design of PAMSCAD, in particular the large number of projects and the tenuous links between them; scattering implementation over several sectors and sector ministries, giving rise to problems of coordination and conflicts over jurisdiction; absence of coordination and oversight of large number of agencies involved at the center as well as the regional and district levels; the credibility of PAMSCAD; implementation of the rest of the redeployment package was negligible; and lack of integration of PAMSCAD into the core design structural adjustment.

Again, Ayee further listed other forces or factors that have worked against the successful implementation of public policies in Ghana to include natural disasters; external factors such as the adverse global economy; static policies pursued by successive governments, inadequate involvement of the agencies expected to implement policies and programmes; inadequate skilled manpower; inadequate policy instruments, poor policy design and piecemeal or ad hoc approach to problems and issues.

Similarly, Sakyi (2008) has elucidated a number of constraints to the implementation of the civil service reform in Ghana. These are summarized to include the lack of political support for the reform; paucity of institutional capacity and human resource capacity; inter-agency conflicts; fragmentation and lack of ownership of reform; reform programmes were overly technological and absence of an overall framework for reform coordination. The review has highlighted a number of problems that hinder the implementation of policies in the country indicating that it is not usually the problem of policy formulation, but it is usually the problem of implementation in Ghana.

2.6 Implementation of Health Policies

The successful implementation of a Children Health Insurance Programme (CHIP) in the United States has been reviewed by Hanley &Iachini (2000).

The CHIP program is administered by the Center for Medicaid and State Operations within the HCFA. The implementation of the programme, however, involves a joint effort with the Health Resources and Services Administration (HRSA) to coordinate activities of all departments under the Department of Health and Human Services and virtually all federal agencies.

Coordination activities bring together federal and state health agencies in a collaborative effort. The federal component provides technical assistance to the states and ensures programmes meet statutory requirements and deadlines. These requirements promote equitable and appropriate coverage under the programme. Specifically, HCFA’s role with the states in CHIP implementation, supported by HRSA, is to coordinate three key agency initiatives: Technical Advisory Panels (TAPS), the Interagency Task Force (IATF), and the national campaign ‘Insure Kids Now.’

Although government bureaucrats play an integral role in shaping and implementing programs such as CHIP, most agencies work closely with congressional committees and must respond to the oversight by them. Interest groups compete to influence legislators and congressional and regulatory agency staff as they develop regulations and guidelines for implementation. The federal government provides the major source of funding for the CHIP programme. Programme planning is coordinated by federal and state agencies under the guidance of HCFA. Regional and state HCFA offices work in conjunction with their counterparts in state and local agencies to provide assistance to states implementing their programs with outreach activities.

Badasu (nd) referring to the works of Agyepong (1999), Waddington and Enyimayew (1989; 1990) and Nyonator and Kuntzin’s (1999),have shown that the implementation of the User Fee and the Exemption Clause in Ghana has some outcomes. For instance, there was a fall in antenatal attendance, supervised delivery and outpatient attendance. The associated factors could be grouped into financial costs, problems of physical access and quality of services. Since physical access and quality of service have been long-term problems, financial costs emerged as a new component of the problems of health service utilization. There were also suspicions about the lack of drugs in the health facilities while they were found in private pharmacies. They suspected alliance between the health workers and the pharmacies, whereby the former promoted the business of the later by not having supplies and referring clients to the pharmacies to buy drugs at higher prices. Furthermore, though management skills for effective use of revenue has improved in the public facilities, the managers were having difficulty in using it to improve quality of care because they found the mechanism involved to be complex.

A study by Awenva et al (2010) identified major barriers to the implementation of the mental health policy in Ghana to include low priority of mental health to the Ministry of Health in Ghana, and to society at large. It was felt that there is a lack of interest in and understanding about mental health issues at the government level; the very low level of human resources in mental health, from psychiatrists to nurses and other health professionals as impeding the provision of quality mental health care; insufficient funding for mental health was an impediment to mental health policy implementation; lack of awareness of the policy by mental health professionals, primary health care workers, other professional groups and the general public, and the absence of training in policy implementation, among others.

2.7 Implementation of Maternal Health Policy

Campbell (2001), reviewing the maternal health policies in both developed and developing countries, has highlighted the role of Government and politicians (through early awareness of the problem, recognising that the deaths were avoidable, and mobilization of health professionals and the community and political contribution to policies that enabled medical advances to be delivered to the population at large, namely by making sure that modern obstetric care is available to all), Ministries of Health and health professionals (who have played a key role in organizing services), and women’s groups (through advocacy tools) have contributed in shaping maternal health policies in the West. The case of the developing countries has also similar experience. For instance Governments and Ministries of Health did institute maternal health programmes.

Mayhew (2000) has lamented that both health system/service-related factors and social context factors can affect policy implementation and will have an important influence on whether an integrated STI/FP/MCH service is actually being provided and provided well, and is accessible to and used by women in the community. At the health service delivery level, factors ranging from continuing segregation of service-delivery, limitations on training, poor resources and infrastructure, absenteeism of staff at primary care level, and medical and social hierarchies have all constrained change and impeded the provision of an integrated service. Similarly, an analysis of the maternal and child health policy of Pakistan by Siddiqi et al (2004) indicates that despite increasing emphasis, several gaps have remained: lack of an overarching comprehensive MCH framework; aspects of nutritional status have been overlooked; underestimation of neonatal and prenatal mortality’s contribution to the infant mortality; ensuing provision of emergency obstetric care has received inadequate priority; lack of financial risk protection mechanism for the mother and child, among others.

Witter et al (2010a) have reviewed and introduced the policy of exempting users from delivery fees in Senegal. The policy of free delivery care had the purpose of reducing financial barriers to using public maternal health services.

The package covered all women for normal deliveries at health post and health centre level, and at the national level, a coordinating committee was established to oversee the policy in the Ministry of Health, including representatives from the departments of primary health care, planning, finance, reproductive health, hospitals and districts structures. Initially, the department of primary health led the process of implementation, but that role passed to the reproductive health department at the beginning of 2006. In the process of implementing the policy, a number of challenges were encountered ranging from communication of policy, adequacy of kit, management and administrative issues, among others. For instance, dissemination was carried out effectively through official, hierarchical channels. While well disseminated, the policy was not well understood, and key informants highlighted a number of misunderstandings and ambiguities relating to it. Some, for example, cited beliefs that it only covered caesareans, or that it also included antenatal care, or that normal deliveries carried out in hospitals were included. Awareness at the community level was patchy, and there was little clarity of understanding of what the policy meant in practice. Similarly, there were not enough normal delivery kits, especially in the first year of operation.

Okiwelu et al (2007) have found out the Safe Motherhood initiative being implemented in Ghana and noted that most of the programmes of the Safe Motherhood initiative have multiple goals and aims stated in broad terms, with no clarity and specification. Again, the main types of interventions implemented by the programmes were training, the provision of physical infrastructure/equipment/supplies, transport/referral, and management/supervision/monitoring. All the programmes did not implement all the listed interventions, whilst other programmes implemented other interventions that are not part of those stated.

Similarly, Witter et al (2007b) have also found out that the experience of Ghana in implementing a User Free Exemption Policy to provide free maternal care has been with many challenges. The study revealed that there were shortfalls and unpredictability of funding. Funds were issued at the start of the financial year, without guidance for managers as to how they had been calculated, how long they should last or when they would be replenished. The funds were not adequate for a full year and further installments were expected, but not received until the next financial year. Moreover, a number of management failures were described by national level informants to explain the irregular funding flows. The complexity of funding channels and multiple actors meant that responsibility for the policy was unclear and monitoring weak. In addition, guidelines for monitoring were not enforced. At the national level, oversight information on numbers of deliveries carried out and delivery types and reimbursement amounts were not available. There was also misinterpretation of the package to the extent that the understanding was that the exemption covered deliveries only, but not complications during pregnancy or post-partum, among others.

2.8 Policies to Reduce Maternal Mortality in Ghana

The Safe-Motherhood Initiative is a National Reproductive Health Service delivery, which is delivered through the Primary Health Care (PHC) Programme. The major components of the Safe Motherhood programme include antenatal care, labour and delivery care, postnatal care, family planning, prevention and management of unsafe abortions, and health education.

Prevention Maternal Mortality Programme (PMM) is a component of the Safe Motherhood Initiative with the overall objective of promoting maternal health. The programme focuses on interventions that improve the availability, quality and utilization of emergency obstetric care. Activities range from improving services at health facilities to improving access to care.

Making Pregnancy Safer (MPS) Initiative is a major component of the Safe Motherhood Initiative. It is delivered through the Primary Health Care Programme. The interventions are in four parts: care during pregnancy, care during and after delivery, postpartum family planning, and community component.

Maternal and Neonatal Health Programme (MNH) is one of the key components of the Safe Motherhood initiative. It includes Antenatal Care, Labour and Delivery Care, Postnatal Care, etc.

Maternal Health Project emphasizes the prevention and promotion of safe motherhood interventions, including dissemination of a revised Reproductive Health Service Policy and Standards and protocols for reproductive health programmes; strengthening of institutional capacities to provide essential obstetric care, implementing exemptions for supervised delivery in deprived areas; strengthening post abortion care services; ensuring contraceptive commodity security; intensifying health promotion activities in safe motherhood and family planning.

Intermittent Preventive Treatment (IPT) is to control pregnancy associated with malaria. The programme is based on the assumption that every pregnant woman living in areas of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria. The intervention includes integrating IPT package of interventions within the Safe Motherhood programme, iron and folate supplementation, deworming, case management, and ITN.

High Impact Rapid Delivery (HIRD) program promotes high-priority, cost-effective interventions to improve maternal and child health at the district level. This program provides specific funding for service delivery with an aim to increase focus on and funding for reproductive and child health services by DHMTs (MOH, 2008).

2.9 Theoretical Frame Work

2.9.1 Walt and Gilson ‘Policy Analysis Triangle’

Walt and Gilson (1994) developed a policy analysis framework specifically for health, although its relevance extends beyond this sector. Their policy triangle framework is grounded in a political economy perspective, and considers how all four of these elements interact to shape policy-making and implementation. The framework has influenced health policy research in a diverse array of countries, especially in developing countries, and has been used to analyse a large number of health issues, including mental health, health sector reform, tuberculosis, reproductive health and antenatal syphilis control (Gilson and Raphaely 200, cited in Walt et al, 2008).

It is useful for this study as it provides a clear understanding of a multiplicity of factors that can bring about the challenges or failures associated with the implementation of a programme. The Walt and Gilson policy analysis triangle points to the importance of interactions between policy content features, contextual features, processes and actors.

The Walt and Gilson framework has helped to explain why certain policies get into the political agenda and others do not. Again, it has helped policy analysts to identify the multiple stakeholders in policy implementation and which stakeholders are likely to oppose a policy. Moreover, the model has been developed specifically for analyzing health policies in developing countries. One criticism of the framework is that some factors may not neatly fit into the main concepts of the model. The main concepts used in the preferred framework are explained below.

Content: policy content refers to a particular policy goal or set of goals and the particular actions planned to achieve those goals (Raney, 1968 cited in Khan, 2006).

Modern health paradigms require that attention be paid to health policy content in promoting health systematically and effectively.

Context: refers to systemic factors political, economic and social, both national and international which may have an effect on health policy (Buse, 2008; White, 2010).There are a variety of contextual factors that may affect how policy is implemented, and it is important to consider such factors when analyzing policy implementation, as they can have a substantial impact upon how policy is made, changed, or implemented.

Process: refers to the way in which policies are initiated, formulated, negotiated, communicated, executed and evaluated. In developing countries, health planning repeatedly leads to health plans that never appear to be implemented or only partly.

Actors: are at the center of the policy analysis framework. ‘Actor’ is a short-hand term, and may be used to denote individuals, groups, or even an organization. Some refer to actors as policy elites and decision makers, while others prefer to call them stakeholders. Mehriziet et al (2009) have observed that as a result of the “new public management” paradigm, the number and type of actors involved in policy implementation have increased, resulting in the emergence of a policy system where increasingly complex networks of actors operate. The notion of stakeholder has been defined differently depending on the approach, aim of analysis or policy area being examined.

This study adopts the framework focusing on only the contextual features. This has been informed largely by the works of Walt et al, (2008) and Green et al (2010) who have commented that health policy analysis in low and middle-income countries is attracting increasing attention. The bulk of research has focused on policy content, particularly evaluating technical appropriateness. However, the nature of the policy process, context and actors seem to be ignored. For the purpose of this study, context is used narrowly to denote resources that have a wider implication for maternal health. These include human resources in health and logistics for maternal health.

2.10 Conclusion

The review has sought to explain the concept of implementation as a set of activities designed to achieve an objective. The approaches on policy implementation have also been discussed focusing on the strength and weaknesses of the top-down and bottom-up approaches to implementation. The views on successful implementation and implementation failure have also been reviewed giving the myriad views on policy success and failures. The problem of policy implementation in developing countries, and in particular Ghana, reveals that inadequate human resources, corruption, poor communication have hampered the implementation of policies in developing countries. The implementation of health policies, particularly maternal health policies in Ghana, has been discussed, highlighting on their objectives.

CHAPTER 3

METHODS OF DATA COLLECTION

4.0 Introduction

This section presents the methods by which data was collected for the study. It describes the research design used, the study participants, data collection techniques which are in-depth interviews with key informants and focus group discussions, the research instrument used, the study site, data processing and analysis, and the profile of the study area.

4.1 Study Participants

The study participants comprised health mangers (medical superintendents and health services administrators), procurement officers and registered midwives in public hospitals in the Tamale Metropolis.

Table 1: Participants Selected for the Study

Participants Number

Medical Superintendents 2

Health Services Administrators 2

Procurement Officers 2

Midwives 24

Total 30

4.2 Data Collection Techniques

4.2.1 In-depth Interviews

In-depth interviews were held with health managers and procurement officers who were the key informants. These interviews were conducted in the offices of the key informants and were tape- recorded, lasting between twenty (20) to thirty (30) minutes in length, upon their permission. These key informants were selected based on their experience, knowledge and involvement in the implementation of health programmes at the facility level.

In all, six (6) in-depth interview sessions were held. The in-depth interviews sought information about the implementation of maternal health policies at the facility level, the processes and guidelines in the implementation of such policies, challenges with IST programmes, challenges of logistics for maternal health, training capacities of logistics personnel, challenges in the logistics management system, among others.

In-depth interview was used because it is useful in situations where either in-depth information is needed or little information is known about the area. Moreover, the flexibility allowed to the interviewer in what he or she asks of a respondent is an asset as it can elicit extremely rich information (Kumar, 1999).

It also allows for intensive and systematic note-taking. Furthermore, it has been informed largely to meet the objectives of the study.

4.2.2 Focus Group Discussions (FGDs)

The lists of practicing midwives were obtained from the Human Resource Units of the hospitals from which eight (8) midwives were drawn to participate in each FGD. The selection criteria for participation in the FGD were midwives who have been practicing for over five (5) years. The groups were homogenous with respect to the profession. All the participants in the FGDs were females. In all, three (3) FGDs were held.

FGD was used because it allows the exchange of views and opinions through discussions with a group who are known to be concerned with, and knowledgeable about the issues discussed. Again, FGD is used to obtain knowledge, perspectives and attitudes of people about issues, and seek explanations for behaviours in a way that would be less easily accessible in response to direct questions (Wong, 2008).

The FGDs were led by the researcher as the moderator who keeps conversations flowing, asks follow-up questions and seeks clarification to issues that are not clear in the course of the discussions. An assistant moderator trained by the researcher took notes from the discussions to remember a few comments and also operate the tape recorder.

The FGDs took place in the conference room and labour ward of the hospitals. Permission was sought from participants before recordings proceeded, although objections were raised by the participants for the fear that their voices may be heard on the radio. The researcher had to explain the purpose of the research that it was only for academic purposes. However, one group refused to be tape recorded. Each FGD lasted between thirty (30) to forty five minutes (45).

4.3 Research Instrument

A semi-structured interview guide was developed for the study. Walt and Gilson Policy Analysis Framework (1994) was used as a guide for developing the questions, taking into consideration the objectives of the study. Semi-structured interview questions have the advantage that they make room for the use of follow-up questions or probes (see Kumekpor, 2002).

4.4 Study Site

The fieldwork for data collection was undertaken in three weeks in March, 2011, in two public hospitals in the Tamale Metropolis. The hospitals included the Tamale Teaching Hospital and the Tamale Central Hospitals. These hospitals were selected because they are the main referral centers for health care services in the Metropolis. Moreover, considering financial and time constraints, it would have been impossible to cover all the health care facilities in the Metropolis. A more practical reason is that, considering the busy schedules of health professionals, it would be difficult to get more participants in the study.

4.5 Data Processing and Analysis

Qualitative data from the in-depth interviews, FGDs and field notes were transcribed, coded and tabulated using word processor files. Using the word-processing file, key phrases, content and common themes were coded and categorized. The themes, categories and content were reviewed and discussed thoroughly, with frequent reference to the review of the original transcripts.

4.6 Study Setting

Tamale Metropolitan Area is one of the twenty (20) administrative and political Districts in the Northern Region. It serves as Metropolitan and Regional capital. It is located in the centre of the region, approximately 175km east of longitude 10 west and latitude 90 north. Savelugu/Nantong District bound it to the north, to the south by West and East Gonja, to the east by Yendi District, and to the west by Tolon/Kumbungu District.

The Metropolis has a total population of 402,843 (projected at 2.9% regional growth rate from the 2000 census).

The actual growth rate of the Metropolis is 3.5%, that is higher than the regional and national growth rates of 2.9% and 2.8% respectively. It has a surface area of 1011 sq. km, which forms about 13% of the total land area of the Northern Region. Its population density stands at 384 persons per sq. km.

In urban Tamale where there is ethnic diversity, Dagombas still constitute almost 80% of the total population. There are people from other regions and ethnicity in the metropolis. Almost all the people in Tamale rural areas are Dagombas.

Islam is the predominant religion in the metropolis, with about 84% of the population affiliated to it. Christians constitute 13.6% (with Catholics forming 43.7%), traditional worshippers about 1.6%, and others forming less than 1%.

4.6.1 Health Care System

Health services in the Metropolis are managed at three (3) levels:

1. Metropolitan Health Administration level: responsible for overall planning, monitoring, supervision, evaluating, training, coordinating of all health programmes in the metropolis. It is also responsible for conducting operational research and linking up with other agencies and NGOs in health provision and promotion.

2. Sub-district level: each with a management team known as the Sub-district Health Management Team (SDHMT).

The SDHMTs are responsible for programme planning and implementation of health activities in their various sub-districts

3. Community level: health services are provided at the community level by sub-district staff and supported by trained community volunteers.

The Metropolis has forty (40) health facilities, excluding the Teaching Hospital. There are fifteen (15) Government owned health facilities in the Metropolis comprising three (3) health centers, nine (9) clinics and three (3) hospitals. The hospitals are Tamale Teaching Hospital, Tamale Central (Old) Hospital and West Hospital.

4.7 Conclusion

The study used a pure qualitative approach. In-depth interviews and FGDs were the main methods for data gathering, using a semi-structured interview guide. Processing and analysis of data were done through content analysis. The next chapter presents the results of the study.

CHAPTER 4

PRESENTATION OF RESULTS AND DISCUSSION

4.0 Introduction

This chapter presents the results from the data gathered from the fieldwork. The results are discussed under two broad themes: skilled birth attendants and logistics systems challenges of maternal health. Finally, inferences from the results are discussed with reference to the theoretical framework adopted for the study: the Walt and Gilson Policy Analysis Triangle (1994).

4.1 Skilled Birth Attendants Challenges

4.1.1 Inadequate In-Service Training (IST)

Participants in the focus group discussions stated that the in-service training organized by the Ghana Health Service (GHS) is ineffective. The content of most of the IST programmes does not address the scope of maternal health. Most of the IST programmes take a long time to be organized, usually more than a year. Most midwives complained that this is affecting the quality of maternal health services in the metropolis. This is because they lack current practices and knowledge in topics such as family planning, breast-feeding, and infection prevention, among others. Also, it was reported by the midwives that the selection process for participation in such IST programmes was unclear. Midwives also reported that most of them were not aware of such training programmes, and by the time they became aware, participants for such programmes would have already been selected.

Since I started working in this facility for about four years now, I have never been part of any in-service training programme. For almost two (2) years now, none of us here have attended any IST. I am still relying on what I have learnt from school to attend to clients. Sometimes, you encounter difficult situations, especially management of the third stage of labour that you were not taught in school. You have to do try an error to save the mother and the child.

What is even annoying is that, sometimes we hear of such training programmes from our colleagues and by the next moment the training programme is going on and we do not know the criteria they use to select people for such programmes. Most of the time, it is our boss who attend such programmes only. (Midwife).

Management in the health facilities also complained about their inability to organize such IST programmes as a result of inadequate funds. The IST programmes are mostly organized and funded by the GHS, and there is usually a delay in the release of funds, which has affected the frequency of such IST.

We as a facility do not organise any IST. It is the GHS who organise such programmes. Mostly funds have to be released from the Headquarters to the Regional Health Administration Directorate, based on the availability of funds, they will invite our midwives for training. But we as a facility, we are now putting in place an IST committee to see to the organization of such programmes depending on how much we are able to generate from our Internally Generated Funds (IGF).(Medical Superintendent).

4.1.2 Limited Knowledge of Maternal Health Policies and Guidelines

Majority of the midwives do not know the maternal health policies in the country and only a few are aware of the free maternal healthcare and the safe motherhood initiative. Others also hear of such policies from colleagues or from their immediate supervisors. It was also revealed in the FGD that of the few policies that they were able to mention, most of the midwives do not know the content of such policies and what specific issues they are addressing. Furthermore, several interpretations were assigned to the policies.

I know that the free maternal health care covers only delivery and when pregnant women come here to deliver they are not charged anything. But I’m not sure if complications, antenatal and caesarean sections are covered. (Midwife).

When asked about implementation guidelines for such policies, interview informants reported that they do not have any guidelines from the GHS. They explained that there were directives from the GHS to implement such policies, but no policy guidelines were issued to that effect.

As of now, we have not received any guidelines from the GHS and we are doing just as we have been told to do. It was a directive issued from the GHS to all public health care facilities in 2007 to start providing free services in the areas of antenatal care, normal delivery as well as child welfare services free of charge to women and their new born babies. The bills are forwarded to the NHIS for refund per the directives. (Medical Superintendent).

4.1.3 Workload and Shortage of Midwives

Workload was a major challenge in the provision of quality maternal health care services. Most of the midwives complained that they attend to more clients than usual and these reduce the time spent with clients. They omit certain aspects of needed care for women resulting in incomplete medical examination. The midwives further explained that the workload was a result of the fact that their numbers were inadequate. There are shortages of midwives in the health facilities and because of this, one midwife has to attend to more clients than usual. The midwives have an overwhelming range of duties and responsibilities. Combining these duties and responsibilities, in addition to attending to patients, sometimes leads to loss of concentration. Besides, they do not have enough time for rest and leisure, unlike the doctors who have been provided with a lodge to rest after work. Midwives considered the workload to be the cause of stress, and resulting in bent waist as you have to bend low when attending to deliveries.

We are just working here like we are machines. When you arrive for work in the morning, you will be on your feet till the evening. On the average one midwife has to attend to about 60 to 80 pregnant women in a day and you have to ignore certain aspects of care that are very crucial. You have to also perform other duties such as assisting doctors in obstetrics and gynecology cases, conducting normal vaginal delivery, keeping of records at the labour ward… and if I want to mention all, it will take us another two hours.(Midwife).

When you close from work and you get to the house, you are not able to sleep well because you will be experiencing some waist pains (Midwife).

Key informants also reported that shortage of midwives in the metropolis is partly as a result of the perceived conflicts in the Northern Region. This has discouraged most health professionals from accepting postings to the metropolis for fear of their lives and their families. Moreover, specialists like Gynaecologists and Obstetricians are not adequate in the health facilities to attend to special cases that midwives are not competent to handle.

Every year, a number of health professionals are posted to this facility from other places, but they refuse to come simply because, they think they will be caught up in the ethnic conflict in the metropolis. We have even sent out notices to trainees in health training institutions about the lucrative opportunities we offer, but most of them have turn down our offer.

This year alone about 3 midwives have left this facility to other regions and the reason for their leaving was that they were scared of their lives.(Health Services Administrator).

4.1.4 Feeling of Humiliation

Midwives reported of feeling of humiliation in the workplace among doctors and their superiors. Other health professionals marginalize midwives and show little respect for their profession. Their low status and marginalization has brought about a lukewarm attitude to work.

The doctors are claiming we are not their colleagues because midwifery is for people who have had weak grades in their secondary education and therefore, not academically brilliant, so the only profession we can settle on is midwifery. (Midwife).

Most midwives complained that the level of interaction between them and their superiors are minimal. They are not given the opportunity to seek clarification on an issue they do not understand with their superiors. Additionally, they reported that their participation in decision making is limited. They are not consulted on any new development that is to be implemented. It is only top management who take and implement such decisions; their views and opinions are not sought.

There is no team work in this facility. The level of apathy is high in this facility as people are not prepared to exchange information and ideas.(Midwife).

Moreover, a culture of intimidation is created in the environment in which they work. They have been shouted at in the process of performing their duties and this makes them feel they are not part of the facility. Most midwives have been shouted at by doctors and their superiors because they failed to follow a procedure or did not seek permission before carrying out an assignment.

Shouting is the order of the day in this facility. You are always shouted on by your boss in an attempt to seek clarification to something you do not know the process of starting it or when you commit a simple mistake like not dressing up a bed. They always expect that we should be perfect human beings in everything that we do. You are not given the opportunity to even explain yourself when you flout a simple procedure in front of your boss. (Midwife).

4.1.5 Inadequate Supervision and Evaluation

The midwives reported that there was no time for supervision by the senior midwives. In most instances, senior midwives are attending meetings, training programmes, travelling, among others. The midwives elaborated that the focus of supervision is on mistakes and gaps in work, rather than real evaluation of the quality of work. These errors are translated into “punishment” as they are denied certain vital entitlements like off duty hours, depending on the gravity of the error. Failure to follow certain aspects of care like taking the BP of a client, follow-up on clients laboratory tests, among others, were seen as common types of errors. The midwives also reported that, sometimes they are viewed as trusted professionals and there is no need for supervision.

The evaluation process follows a routine traditional style that is confidential, non-participatory, and is not based on merit. Although they were not able to tell the basis of their evaluation, most of them consider it to be unfair, inadequate, takes a long time and sometimes they are never informed about the results of the evaluation for them to improve upon their performance.

There is no one to always give you guidelines as you are working. Most of the time our boss just walks in stand for some few minutes and leave without talking to anyone. When you are given your evaluation report, you always feel like weeping, because most of the comments are not pleasant at all. After all these “donkey work” our boss will not appreciate it(Midwife).

4.1.6 Problem of Communicating with Clients……………………………………………….

The midwives reported of the difficulty in communicating with women and their families due to their low educational status and illiteracy. Most of the midwives are not able to speak the local dialect and this makes communication difficult between them and the clients.

I cannot speak Dagbani and most of the pregnant women I attend to cannot speak English. I have to rely on colleagues who have to do the interpretations for me.(Midwive).

Moreover, the clients do not disclose full information about their conditions that will enable the midwives to write a full report of their cases and that could lead to the identification of possible causes of complications. This has forced most of the midwives to display feelings of harshness toward clients and their families when providing care. They also spent a lot of time trying to get information from clients who are not cooperative in their interaction.

Some of the patients do not report early to seek treatment. They resort to self medication and when there are complications, they rush to the facility. About three days ago, a young lady attempted to abort a pregnancy by using a tablet called cytotec recommended only to be administered by health professionals. She did not disclose this to us when she was rushed in here. We have to “push her to the wall” and she confessed that it was her friends who influenced her to take that tablet. (Midwife).

Again, some of the pregnant women who attend antenatal clinic ignore completely some basic maternal care practices instructed to follow like nutrition, iron-folate supplementation, intermittent preventive treatment of malaria during pregnancy, among others. These uncooperative attitudes of clients have sometimes forced midwives into difficult situations, making them prescribe the wrong diagnosis for such cases.

4.1.7 Risk of Infections

The midwives complained that in the course of performing their duties, they are exposed to various risks of infections, including HIV/AIDS and Tuberculosis. This is as a result of the fact that most of the infection prevention items for delivery are inadequate or lacking. The midwives reported that there is a high risk of infection and this has discouraged most of them from performing delivery. The midwives complained that these occupational risks occur when they get in contact with blood and body fluids during child birth. This has pulled away a number of midwives currently practicing in the area of delivery, family planning, antenatal care, among others, into other areas of specialty.

This job is too risky. We come in contact with blood and other body fluids. In the process of performing our work like delivery and caesarian sections, some of our clients who have contracted deadly diseases like HIV/Aids, tuberculosis and hepatitis B, which can easily be transmitted to you, especially when you do not wear protective gadgets.(Midwife).

4.1.8 Aging Workforce

The retirement of aging midwives is also contributing to the diminishing cadre of practicing midwives. The majority of practicing midwives are over fifty (50) years old in the facilities, and many would be retiring very soon. An in-depth interview with key informants has shown that the number of young midwives entering the profession is limited. Also, most people are not interested in the profession and the intakes to midwifery training schools are decreasing. It was further revealed that the number of midwifery schools is very few in the country.

Over sixty percent (60%) of our midwives are over 50 years old. This year, seven of them will be retiring and this will have serious consequences on our workforce strength. We have been facing this problem every year, and we do not have authority to recruit midwives ourselves. It is the GHS who post midwives to our institution and we do not have control over that. For about two years now, no fresh graduate midwife has been posted to this facility.(Medical Superintendent).

4.1.9 Low Motivation

The questions exploring motivation were centered on several themes, including salaries, promotion and transportation to work. It is believed that those engaged directly in implementing a policy should be motivated well enough to ensure the successful implementation of such a policy. The midwives complained that motivation in the profession is nothing to write home about. Most of the midwives agreed that their salaries were too meager and they have not seen any increment in their salaries for a long time. The delay in the payment of salaries is also frequent and most of them have to find other ways of complementing their income.

If you want to compare the work that we do in relation to our salaries, it is nothing to write home about. The salary is too small that it cannot take you home considering the economic conditions in the country and the numerous responsibilities at your hands. For about four (4) years now, I have been receiving the same salary even though I know that from time to time there have to be an adjustment in salaries. There was even a time my salary stop coming for about three months. I have to make several complains to the authorities before it was finally restored. I do not even receive extra duty allowance for the time work that I do. The delay in the payment of salaries is also worrying. At the end of the month, it usually takes a week or more before your salary reflects in your account.(Midwife).

Apart from low salaries, delays in promotion have also been mentioned by the midwives as a factor causing dissatisfaction in the profession. They believe the current system of promotion is not fair and usually takes a long time, and at times it is not effected at all. At times, there have to be follow-ups to ensure they are promoted, and in so doing they have to bribe the officials to ensure that they are promoted.

I will be going on retirement next year and I have applied for promotion since last year and up till now I have not heard anything from the authorities. When I decided to trace up I was given excuses here and there that they are still processing it.(Midwife).

Personal transportation to work was also reported by the midwives. Most of them do not have personal means of transport to work and they have to rely on public transport to work. As a result of this most of them have come to work very late.

Every day I have to pick a taxi to work which cost me GHC 3.00. I have to stand by the road side in order to board a taxi. Most of the cars that pass by are always full. You have to stand for a long time before you finally get one to board, by the time you get to work it is late and you are blamed for coming to work late.(Midwife).

4.2 Health Logistics Challenges

4.2.1 Limited Equipment and Supporting Infrastructure

The environment under which most midwives operate is very appalling. Most of the midwives reported that there are no sufficient equipment like Manual Vacuum Aspirators (MVA), surgical gloves, wheel chairs, among others, to enable them perform their duties successfully. This has sometimes resulted in a feeling of frustration among midwives.

Most of our equipment are not in good shape at all. Most the wheel chairs are broken down, and this has made the movement of patients in and out of the operating theater very difficult for us. At times there are frustrations all over you, because when you go to the store room to request for surgical gloves, you are told the stocks have run out.(Midwife).

The rooms under which they examined pregnant women are too small and do not have adequate ventilation.

The room in which I examined pregnant women is too small. When you want to examine a pregnant woman, you have to pack your documents, table and seat to one corner of the room so that there will be enough space to lay the stretcher for the woman to lie down. After examining her, you arrange everything back and write your report. The room is also warm all day. As you can see, there is no ceiling fan or air conditioner to reduce the heat in the room. It is like you are working in an “oven”(Midwife).

Also, essential infrastructure like water and electricity are most of the times interrupted.

The electricity and water supply systems are not reliable. There are usually intermittent power outages that usually put us in difficult situations, especially during caesarian sections, the power can go off without any prior notice and we do not have a stand by generator.(Midwife).

Drugs needed to perform BEmOC are sporadically or completely unavailable.

4.2.2 Inadequate Ward Space for Delivery and Resting

The inpatient wards for delivery are too small to accommodate a large number of pregnant women who come to deliver. Deliveries are done one at a time and pregnant women have to form a queue waiting for their turn. Sometimes, most of the pregnant women have to lie on the bare floor due to the fact that the delivery beds are not enough.

You can see for yourself. The delivery beds are not enough so when we finished with a delivery case the mother and the child has to lie on the floor.(Midwife).

4.2.3 Problem with Transportation

Transportation difficulties, such as inadequate and unreliable means of transport were mentioned by the key informants. The ambulances at the facilities serve multiple purposes and may not be available at certain times. When patients are to be referred to a higher level or to another facility at the same level, the patient has to bear the cost of fueling the ambulance, which most patients are not able to afford. Most of the ambulances are over-aged and often break down most of the time.

Our budget is insufficient to buy fuel for our ambulance and let alone purchase a new one. At the moment we have one ambulance that we use for the referral of pregnant women and other patients in complications we cannot handle to other facilities. We are sometimes caught in the ‘web’ because we usually have multiple cases that we have to use one ambulance for all the cases one at a time.(Health Services Administrator).

Moreover, trucks to convey maternal health logistics from the Regional Medical Store (RMS) to the health facilities are lacking. Most maternal health logistics are kept in RMS for a long time before they are finally delivered to the facilities.

Currently we do not have trucks that will convey logistics from the RMS to the hospital. We sometimes use our official vehicles or hire trucks to convey the logistics to the facility.(Health Services Administrator).

4.2.4 Difficulties in Following the Procurement Act (Act 663, 2003)

Managers at the facilities level complained about the difficulties encountered when using the Public Procurement Act (Act 663, 2003) in the process of procuring essential commodities for maternal health. Key informant interviews show that the Public Procurement Act (Act 663, 2003) does not allow for emergency purchases. Most of the times, there are shortages for essential commodities for maternal health in the facilities which require urgent replenishment, but because the procurement law has to be followed, it delays the process of purchasing such commodities.

There are at times things are needed so urgently and you are being asked to follow the procurement law. If you do emergency purchase it is difficult to convince the auditors why there was such an emergency purchase and you have to do a lot of documentation to convince them.

The Act is very strict. You cannot procure without the requirements of the law. And the way the law is, it does not allow you to address some emergencies. If you require anything, the tender entity committee looks at it and approves it, then you go and invite bids, the bids come in, you open the bids in front of the public, and after that a committee is formed to evaluate the tenders, after evaluation, the tenders go to the tender entity committee for final approval… and a supplier is selected.(Procurement Officer).

4.2.5 Forecasting

Projections for essential drugs are done using morbidity and demographic data. Due to lack of data, it is very difficult to know the current stock in the facilities at the different levels of consumption rates. This makes accurate forecasting difficult. Most of the data sources are available but not complete for forecasting, As a result, the available data sources for forecasting are based on the projected number of patients to be treated; however, in reality there are no accurate records for patients as some patients embark on medical shopping.

Interviews with informants revealed that staff at the logistics department have not received adequate training on the use of Microsoft Office Excel for forecasting. Also, the rates of consumption of maternal health logistics are not known in the facilities and as a result, they cannot project the future consumption levels that will be needed.

Most of the store keepers are not good at the use of the Microsoft Office Excel for forecasting. We did a number of trainings to improve upon their knowledge but they are still having difficulty in their forecasts. We take six months stock to determine a month’s stock. Most of the staff have difficulty in recording this data into the Excel spread sheet.(Procurement Officer).

4.2.6 Warehousing and Storage

The availability of a well organized storage space for essential drugs and commodities leads to quality delivery health care as drugs and equipment are readily available. There is no basic shelving in most of the stores at the health facilities. This makes it difficult for the store keepers to organize and distribute products. Most health logistics are not arranged in any particular order or into categorization for easy identification. Some of the products are not seen for a long time, leading to their expiry.

Moreover, most of the storekeepers are not trained in basic storekeeping procedures. There are no order by which stocks are issued out like the First in First out (FIFO) and Last in First out (LIFO) methods of issuing out stocks, and providing the appropriate temperature control for the logistics in the store room.

Our store rooms are very small. They look more like cubicles that we store our logistics. When we order for four months stocks, we do not have a large space to store them. We store them in other rooms that do not have the accurate temperature for the stocks. Within a very short period, most of them start spoiling.(Procurement Officer).

4.2.7 Inventory Control

Inventory control relates to the logistics functions of product handling and the processes involved in a product’s withdrawal of use, as well as to the information for stock management. Logistics officers reported that maternal health stock cards are not kept to date, and this has made it very difficult for the logistics managers to know the current stock level of logistics. In most of the facilities, there was usually not a stock card kept for maternal health logistics. While there is no column for losses and adjustments, most of the storekeepers were aware that they should record it as negative balance. None of the records reviewed had a record entered for losses and adjustments.

Again, the storekeepers lack inventory control and management skills. The storekeepers interviewed could not tell the amount of logistics that are issued to the various departments on a daily basis. Furthermore, the storekeepers lack ordering skills to base orders on maximum and minimum levels. The storekeepers could not tell the re-order quantity level that must be kept in order to start ordering for new logistics.

The storekeepers do not know how to use the Requisition Issues and Receipt Vouchers (RIRV) to capture logistics data for essential drugs and as a result of that we are not able to report to the next level. Currently, we have run out of stock card and we have not updated our records for three months (Procurement Officer).

4.2.8 Logistic Management Information System

This system makes information available on a timely basis for decision-making on logistics. Logistics officers reported that there are a set of logistics forms that allow one to record all the essential data items (stock on hand, losses and adjustments, and consumption) in order to manage a logistics system for each level. However, these data are recorded at different places but are not brought together to make logistics decisions, such as determining order quantities. The HMIS manual provides instruction on how to fill out the various forms and how to use the data. However, there is little evidence that the data was being used at the facility level for making logistics decisions. Moreover, reports that are sent to the Headquarters are incomplete or delayed for about three (3) to six (6) months.

The feedback from the user departments are not channeled well. When they run out of stocks, they do not report early for you to start the procurement process. The next thing is that they just come and tell you that they need this item urgently. We do not also have a monitoring and evaluation team that will make timely information for us to take decisions.(Procurement Officer).

4.2.9 Human Resource Capacity

The management of logistics for the delivery of efficient health care requires experts to manage the logistics systems. It was reported by the logistics officers that most of the staff do not have training in logistics. This has slowed the work of the logistics department. The officers complained that most of the staff had their previous training in accounting and are not well conversant with the procurement processes and the procurement law. Besides, there are no refresher trainings for these staff to acquire any knowledge in logistics systems.

Again, roles and responsibilities of each staff involved in the management of the logistics system are not clarified or documented. This has put the staff in a difficult situation as they do not know which of them is in charge of the various logistics functions.

Most of our staff are not permanent. They are mostly National Service Personnel with background in Accounting and they will be leaving very soon. This means that we do not have permanent staff that we can train in logistics management.(Procurement Officer).

4.3 Discussion

This study considers the implementation challenges of the MDG 5 to improve maternal health by health care providers using the Walt and Gilson Policy Analysis framework (1994), focusing on contextual factors that affect policy implementation. The implementation of a policy depends upon the interactions of many variables including, the environment or conditions in which the policy is formulated and implemented.

The implementation of any policy, such as to improve maternal health, depends on contextual features to be successful. The findings from the study have been grouped into skilled birth attendants and logistics systems challenges as contextual factors that affect the successful implementation of MDG 5 in the Tamale Metropolis of Ghana.

The United Nations fifth Millennium development Goal (MDG 5) aims to improve maternal health. This goal is structured around two key targets: 1 to reduce maternal mortality rates by 75% between 1990 and 2015, and 2 to achieve universal coverage of skilled care at birth by 2015. Inequitable access to maternal health is a big challenge globally.

There is also inequality of access to skilled care at delivery. The inequalities to maternal health are discussed with reference to the contextual factors in the Walt and Gilson Model (1994).

As a useful starting point, the provision of adequate in-service training (IST) is considered vital in developing and keeping midwives with up to date practices in the field of maternal health care. The provision of adequate IST will go a long way to reduce maternal mortality. The clinical competencies of midwives need to be addressed through frequent IST and their curricular must have relevance in modern health care delivery practices. One of the major reasons explaining why so many countries still have inadequate numbers of skilled midwifery providers is because those grappling with human resources have not paid attention to the need for ‘proficiency’ in the various competencies required to assist women and newborns. For too long it has been accepted that as long as the health worker received some (often too little) training in midwifery, this was sufficient (Fauvea et al, 2008).

There has to be a clarity as to the understanding of competence- ability to perform aspects of the job and competencies- the basic knowledge skills and behaviours required of a midwife to practice safely in any setting (Ireland et al 2007).

The implementation of any policy requires that those involved in implementing such a policy have adequate knowledge of the policy. Those engaged in the implementation of a policy must be engaged in the formulation process of the policy. This will ensure the success of such a policy as their commitment and support will be high. Most of the policies in developing countries tend to be implemented through a top-down approach and are not communicated to those engaged in direct service delivery of health services. Communication is an essential ingredient for the success of a policy. Failure to communicate a policy effectively may lead to implementation failure. As discussed earlier, by specifying and given clarity on the policy and ensuring that the policy is transmitted to the appropriate personnel, given adequate information and instructions of how the policy is to be implemented must be given priority. Besides, different meaning and interpretations assigned to the policy are minimal. In Thailand and the United States, most health professionals have low to moderate knowledge about the national policy, and their levels of involvement in policy formulation and implementation is low (Kunaviktikul et al, 2010; Deschaine and Schaffer, 2003).

The low motivation of health professionals has contributed to the high exodus of health professionals out of the country, to international organizations and to the private sector. This has created shortages of midwives resulting in heavy workloads in health care facilities. Moreover, the low status and recognition accorded to midwives have discouraged people who want to pursue that profession. To be able to achieve the MDG 5 requires well motivated and dedicated midwives who will show commitment towards the delivery of quality maternal health services. Several studies have shown that the low motivation in the health sector has impeded the implementation of most policies and reforms in Ghana (Sakyi, 2008; Agyepong et al, 2004).The low motivation of health professionals have forced some to supplement their income by engaging in other occupations.

To enable midwives function effectively, there has to be the provision of an “enabling environment”. Provision of an adequate environment for midwives will ensure delivery of quality maternal health care and reduction in maternal levels. A skilled attendant should have the necessary equipment and medicines and adequate referral means to be effective in reducing maternal mortality. The environment can also be viewed broadly to include the political and policy context in which skilled attendants must operate, the socio-cultural influences, as well as the more proximate factors such as pre-and in-service training, supervision, deployment and health systems financing. The enabling environment should also ensure there are sufficient skilled attendants with the necessary skills, satisfactory pay scales and career advancement opportunities; continuing education opportunities to maintain and upgrade skills; supportive supervision mechanisms; and possibilities of skilled attendants to refer women and newborns directly to higher level care if necessary (WHO, 2004 cited in Nanda et al, 2005).

Improving access to maternal health logistics is an essential component of strengthening maternal health programs and outcomes. Maternal health challenges in the entire health system come with deeply embedded issues of human resources, infrastructure competing priorities and community engagement. The shortages of maternal health logistics have a direct barrier to the utilization and positive outcomes at health facilities. Maternal health logistics often require a more highly trained health care provider who is available all the time. These providers are trained sufficiently on how to use these logistics. An efficient logistics system should be responsive to the needs of the end-users, that is the patients. Improving logistics systems and ensuring product availability requires focusing on the customer regardless of the supply chain being considered. A reliable and efficient transportation system should be a key to the success of logistics systems and should be able to respond to emergencies and also ensure that products are in constant supply.

A legal system that does not allow for easy access to logistics have implications on the way health logistics are procured, and could be detrimental to achieving quality maternal health care. Laws and legislation could impede the successful implementation of health policies, especially during the formulation of such policies, when provisions were not made to take consideration of such legislations.

Furthermore, the logistics management system should effectively function in each of the components to ensure that there are no hindrances in handling maternal health logistics. In many developing countries, logistics systems for public health facilities have been centralized, with central ministry offices responsible for planning, forecasting, procurement, warehousing and the distribution of essential drugs, contraceptives and vaccines. These systems have been notoriously inefficient and in many cases incapable of providing adequate supplies on a timely basis (Bossert et al, 2007).

In essence, the availability of resources is an important ingredient in ensuring the success of policy implementations. As reviewed earlier, without adequate resources, implementation of health policies would encounter challenges as resources to ensure the execution of such programmes are insufficient or lacking.

4.4 Conclusion

Contextual factors affect the successes and failures of policy implementation. Implementation of maternal health policies depend to some extent on the availability of requisite personnel and resources for successful implementation. The challenges of maternal health in care facilities in the context of this study lies within midwives’ constraints and logistics challenges. The next section presents a summary of the study findings and lessons for policy implementation.

CHAPTER 5

SUMMARY, CONCLUSIONS AND RECOMMENDATION

5.0 Introduction

This section gives a summary of the study findings, offers some useful recommendations and draws conclusion. It also offers policy lessons for health policy makers and analysts.

5.1 Summary of Key Findings

From the results of the study, the following key findings emerged as the challenges facing

health care providers in the implementation of maternal health in the Tamale Metropolis.

Inadequate In-Service Training (IST) programmes for Skilled Birth Attendants (SBA) are poorly

funded, infrequent, inadequate and ineffective, affecting the quality of maternal health services

and resulting in low competence in maternal health care delivery. There is little awareness of

any impending IST and selection process for participation is not transparent.

Skilled Birth Attendants have limited knowledge of maternal health policies and initiatives in the country

because such information is not widely made available to them. Additionally, there is a lack of policy

guidelines from the GHS on how to implement these policies.

The shortage of midwives in health care facilities has resulted in an increase in workload of the

limited staff and the quality of time and attention due patients. The perceived conflicts in the north

is partly responsible for the shortage. Lack of trained specialists like Gynaecologists and Obstetricians,

add to the workload of midwives.

There is a general feeling of marginalization by doctors and superiors which has affected midwives’ attitude to work. There is also a culture of intimidation and humiliation which has led to the low status and feeling of inferiority among midwives and has strained the relationship with doctors and their superiors.

There is low supervision by senior midwives as a result of their busy work schedules, and there is no real or transparent evaluation process to enable midwives assess, know and improve on their performance. Consequently, there is unfair punishment meted out on midwives in case of poor performance on the work.

Inability of midwives to speak local dialects and illiteracy of women they deal with have caused a communication gap between the two parties. Clients fail to disclose full information about their condition, making it difficult for midwives to diagnose cases and write complete medical report for examination.

Infection delivery items are lacking in these centers, exposing midwives to various risks of infections in their work. This has discouraged most of the currently practicing midwives to move into other areas of specialty.

Most practicing midwives are aging and approaching their retirement. There is also a general lack in interest in the profession and intakes into midwifery schools are few in the country.

Motivation among maternal health workers is very low. Salaries are generally meager and pay increment is usually delayed. As a result, midwives have to supplement their income doing extra jobs. Promotion is infrequent or delayed among midwives, and personal transportation to work is a problem, making them report to work late.

The environment under which most midwives operate is not favourable, with inadequate ventilation in the already small treatment rooms, etc. There is inadequate equipment and supporting infrastructure to deliver quality maternal health care. Essential utilities services, like water and electricity are often interrupted.

Transportation problems such as inadequate and unreliable means of transport, over-aged ambulances, and the situation where referred patients pay for the cost of fueling the ambulance. Trucks to convey logistics from the Regional Medical Stores are lacking and there is usually a delay in carting logistics from the RMS to the health facilities.

The Public Procurement Act does not allow for emergency purchases. The Procurement Act itself is already difficult to follow and does not make it possible to do emergency purchases without first following it as a matter of procedure.

Lack of data makes it difficult to make informed decisions of taking inventory of current stock in the

facilities, or to know the accurate records of patients. There is no basic shelving in most of the stores at

the health facilities, making it difficult for storekeepers to organize and distribute products. Scattered data

in various sources shows the logistics management information system is not properly utilized and there

is a lack of properly trained personnel to manage its use.

5.2 Conclusions

It can be drawn from the findings of the study that contextual factors affect the implementation of health policies. Implementation of health policies should take into consideration the environment under which a policy is to be implemented to ensure that such a policy is successful. The challenges emanating from maternal health care delivery in the health system indicates that human resources for health and logistics have a direct bearing and influence on the way policies are implemented. To ensure that policies are successful, these issues need to be given priority in the implementation phase.

The provision of frequent IST to update midwives knowledge and skills can lead to early detection of complications of pregnant women and their newborns, and therefore, life threatening conditions of women can be more adequately managed through competency based training. The top-down approach to policy implementation has contributed to the limited knowledge of maternal health policies among midwives and their support and contribution towards the success of such policies. The low motivation in the health sector has not been given priority, and most health policies have not factored this concern in the formulation of such policies. Without the requisite and adequate human resources in health, implementation of health policies will be a mirage stemming from a dissatisfied workforce that will migrate to other sectors where conditions of service are perceived to be better.

The absence of efficient logistics systems in health care facilities has contributed to the challenges of delivering quality products to the final consumers i.e patients. Without adequate supply systems, programmes and policies designed to reduce maternal mortality will not be achieved. The inability to have skilled personnel to manage the supply chain also means that products cannot be handled well and the quality of such products may be compromised and, therefore, may not lead to improvement in health of women their babies.

5.3 Recommendation

Health facilities should frequently provide In-service Training programmes that are well designed to

address the full scope of maternal health care delivery, to enable midwives upgrade their knowledge and

competency level in these issues. Additionally, Information about such training programmes must be

openly circulated to all midwives and the selection process for participation be transparent. Funds for the

organization of these programmes must be released on time by the GHS, to ensure that such programmes

are regular.

Health professionals, including midwives should be a part of the health policy development

process through to its implementation, to secure their support and commitment towards that

policy. Furthermore, the policy and its guidelines must be communicated clearly enough to the

full understanding of all the midwives, since the success of its implementation depends on the

level of knowledge of the midwives.

Team-work should be promoted among midwives, doctors and their superiors to ensure their commitment to the facilities through participation in decision-making and open forum to exchange ideas and information. If doctors and superiors respectfully treat midwives as colleagues, rather than subordinates, this will boost their self-esteem and confidence, and consequently enable them give their best to the health practice.

Human resource policies and plans should be developed and implemented to address the low pay scales, promotion, career advancement, working conditions and transportation to work that midwives have complained about. Motivation of this nature inspires midwives to excel in their work, with heartfelt dedication and commitment.

The Ministry of Health and the Ghana Health Service must ensure that adequate infrastructure and equipment are provided to enable health care facilities run efficiently. Thus, a transportation system, such as an ambulance should be put in place by the health care facilities to respond to emergency situations. Adequate warehouse and storage facilities should be constructed by the health care facilities to ensure the safety of maternal health products.

Management of maternal health logistics must be assigned to highly trained health care providers

who are able to use the logistics management system, are available all the time and know how to use these

logistics. Thus, the functions of such personnel will include forecasting, inventory control and

management-documented store procedures. Maternal health logistics must be easily accessible and in

constant supply, with the availability of an efficient transportation system to ensure that regular supply.

Additionally, monitoring teams must be put in place to track the consumption of user departments in the facilities and report early for replenishment of stock. The procurement Act should be reviewed and made flexible enough to allow for emergency purchase, since a rigid legal system could impede access to and procurement of logistics.

5.4 Lessons for Policy and Future Research

A number of important lessons emerged from the findings of the study that should serve useful lessons to health policy implementers and policy analysts in developing countries. Unless these bottlenecks in the health system are taken into consideration, any attempts at achieving a reduction in maternal health may not achieve the desired objectives.

One important lesson that emerged out of the study findings is the top-down approach to policy implementation of health policies in the country, without stakeholder consultation expected to implement the policy. These policies are mostly formulated at the national level and disseminated to implementers at the local level without guidelines accompanying such policies, even though these guidelines may exist. The guidelines are mostly kept at the national level without conscious efforts to disseminate them. Local level implementers often use their own discretions, resulting in several meanings and interpretations assigned to the policy.

Moreover, most health policies have demonstrated a weak link towards addressing the paucity of human resources in health in the contents of the policies. These policies are designed most of the time, specifying how programmes are to be executed, but have failed to address the issues of motivated workforce and capacities of personnel driving the implementation of such policies.

Furthermore, most policies are implemented without the provision of adequate resources to ensure smooth implementation. Without adequate resources and infrastructure in place, health policy implementations in developing countries run into difficulties, because no consideration is given to the required infrastructure and resources. It is expected that future policy implementation would take into consideration the required infrastructure and resources before implementation proceeds.

It is also important to consider institutional bottlenecks that tend to hamper successful policy implementation. Most policies in developing countries often conflict existing laws and legislations, creating bureaucratic implementation. In so doing, the policies fail to achieve their intended purpose.

The study findings only consider implementation challenges faced by health care providers. Future research can explore the challenges faced by users in maternal health care, especially at the household and community level. The study uses only contextual factors in the Walt and Gilson framework to assess health policy implementation. Future research can extend to the other variables in the model, especially actors in health policy implementation, focusing on the challenges of Non-governmental Organizations (NGOs) in health.