151
7. Monitor and evaluate
6. Implement
5. Declare official policy
4. Reach a decision
3. Analyze ideas and design policy solutions
2. Incorporate ideas into the policy agenda
1. Generate ideas
Phase
An array of stakeholders can provide ideas. Top-down ideas can come from the Minister of Health, the Director General of the GHS, party manifestos, the president, and the Ministry of Finance. Bottom-up ideas can come from the Ghana Registered Nurses Association (which lobbied for better working conditions), the media (which have reported on staff shortages), and local officials (who pressed central decision makers to increase enrollment at midwifery schools in their regions). For ideas to be incorporated into the national policy agenda, proponents must share their ideas at regular government meetings with stakeholders and at monthly, quarterly, and annual meetings with development partners. The most important forums for dialogue are the health summits held twice a year in April and November. Recent issues discussed at these meetings included many of the ideas discussed in this book. The Ministry of Health appoints a technical working group to research the issue, seek input from stakeholders, and design policy options. The extent to which lobbying, political strategizing, or negotiating begin at this stage is not easily generalized. In some cases, technical groups are left to do their work “objectively.” In most cases, as one official put it, “politicians let the group do its work while monitoring them at arm’s length, and then intervene at critical stages.” Other stakeholders lobby for problem definition and policy design that best advance their interests. Such involvement reduces surprises but provides opponents greater opportunity to thwart an idea. The Ministry of Health determines whether the recommended policy is within its authority or requires cabinet or parliamentary actions. In this phase, policy options may also be discussed with development partners or other stakeholders. A decision is normally expressed publicly through a minister’s speech, a report from the president’s office, or some other public documentation process. The Ministry of Health’s Director for Policy, Planning, Monitoring, and Evaluation drafts operational guidelines and determines the bodies (such as the GHS and CHAG) responsible for implementing the policy. The GHS is normally responsible for crafting a detailed operational plan for carrying out the policy within its ranks; the extent to which such plans apply to the semiautonomous teaching hospitals, CHAG, and military hospitals is not clear. We address phases 6 and 7 together because respondents interviewed by Blanchet (2009) were not informative about the implementation and the monitoring and evaluation phases, suggesting that these phases are the “black boxes” of the health care personnel policy process. There was some follow-up to the aide memoires produced by the April health summits, but it largely involved communicating the policy to lower-level actors. There seems to be little monitoring of actions beyond convening more meetings. There are also often design-based obstacles to implementing a policy, such as unclear staffing norms that are prerequisite to implementing a new posting system. The thoroughness of a policy’s implementation is also constrained by the limited enforcement capacity of the Ministry of Health, especially over semiautonomous and private providers.
Description
Table 8.1 Proposed Phases of the Official Process of Policy Making on Health Care Personnel