Interest group politics (“Managing Outside”)
Different interest groups use different strategies to achieve their aim during the implementation of the IPTp-SP policy. In the Volta region, some interest groups frequently attempt to influence the IPTp-SP policy at diverse phases to reduce their costs and expand their benefits from the implementation of the IPTp-SP policy (12). It was found that in the Volta Region, the actors that influence the IPTp-SP policy include health workers, health insurance organizations, health facilities owners, and manufacturing companies of medicines and medical technology.
It is interesting to note that, doctors and midwives are the groups charged with the task of policy implementation, they are usually well structured and more influential than groups service users such as pregnant women who tend to be not well organized and weak. In this study, it was reported that policy recipients or service users are becoming progressively significant with the advancement in various mobile applications (apps) and social media, like the mobile midwife technology implemented by the MOTECH project of Grameen Foundation to provide short messages services (SMS) to the pregnant women about their pregnancy and services expected to be received from the health facilities (13).
One interesting thing to note is that individuals and their groups use numerous influential tactics to affect health policy implementation. Notably, in the Volta Region, some individuals could apprehend the governing organization liable for the activities of implementing the IPTp-SP policy to gain increased power on how the IPTp-SP policy is executed. This invasion of the state department by interest groups with the attempt to undermine the implementation or structure guidelines to fit their benefit, and also further their personal plans could slow or speed up the implementation of the IPTp-SP policy. Surprisingly, some groups may slow down the implementation of a policy by using their own discretionary powers to exert influence as they engage policy recipients (14).
Now the question is how can an implementation group for IPTp-SP policy resist influences by these parties’ concerns? A possible suggestion for this may be that when an influential individual vigorously contests or latently disregards a policy, the implementation group may design a policy to counter the group’s influence. It is also possible to initiate activities to organize the interest group to help implement the IPTp-SP policy in the frontline, specifically the district and community level. In some of the instances in the Volta Region when there was a demand on the implementation group to mobilized a fresh organization such as “mother support groups” and “pregnancy school” which has an absolute concern in inspiring execution or organize IPTp-SP service users to performs as an interest group in backing the implementation of IPTp-SP policy. This is supported by the quote below;
“Yes, we do have pregnancy school and mother support groups that help to educate the pregnant women in the communities to take antenatal care seriously” (Health worker 2, 21/05/2020).
Contrary to the expectation, this study did not find any interest group that uses of discretionary influence to resist the implementation of IPTp-SP policy in the Volta region.
Bureaucratic politics (“Managing within and Around”)
Several reports have shown that the main stakeholders tasked with the responsibility for the implementation of IPTp-SP policy are the bureaucrats. Bureaucrats i.e., frontline health workers or street-level bureaucrats, are sometimes not involved in the policy development process but however given the responsibility to execute the policy (2). This study found that at the national level there are many state departments with the responsibilities of implementing IPTp-SP policy, creating the problem of interdepartmental teamwork. Rivalry and struggle arise among similar departments to control policies and their implementation, as different departments try to increase their individual power, budget control, human resource, and overall influence on the IPTp-SP policy. This discrepancy in the level of influence, across different state agencies, can interrupt the policy execution, which can be aggravated by budget control politics (15). From our study, rivalry can also happen inside a single agency among divisions and units such as the Nation Malaria Control Program (NMCP) and Family Health Division (FHD) of the Ghana Health Service (2) which negatively affect the implementation of the IPTp-SP policy.
One of the issues that emerged from the findings is that effective Implementation of IPTp-SP policy also depends on the activities of frontline health workers. These frontline health workers become de facto frontline policymakers because of the utilization of unrestricted power for alteration, prevention, or endorsement of the supply of IPTp-SP policy benefits to policy recipients. Hence, this explains how in practice the IPTp-SP policy is delivered to pregnant women. This is corroborated by earlier findings from the work done by Lipshy that reported that frontline health service providers actually convert policy aims into action, persuading the lived experience of pregnant women (16). This is supported by the quote below;
“the midwives are the frontline health providers trained to provide the IPTp-SP services to the pregnant women and they follow them up until they deliver” (Regional Director 22/05/2020).
Also, the command-and-control tactics of controlling from the center present a challenge because the health system cannot be directed from the center. This study supported evidence from previous observations by Gilson, that recommends the distribution of leadership at every level of the health system with the objective of using the flow of energy and power to gather the wide array of actors at a different level of the health system to achieve full implementation of IPTp-SP policy (17).
However, it also discovered that to successfully implement IPTp-SP policy, further research should be undertaken by implementation teams to discover common grounds that transverse various actors so they can build trust and credibility (2).
Budget politics (“Managing Money”)
The current study found that the key bottlenecks in IPTp-SP policy execution are the inadequate budgetary allocation of resources for the activities necessary to effectively execute the IPTp-SP policy. This corroborates with earlier works done by Gomez-Dantes and colleagues, who reported that disbursement of resources and its fairness is one of the recurrent concerns which make the budgeting activity complex (18). The allocation of resources by the Ministry of Finance (MOH) to various departments with varied needs also presents a challenge. These financial resources are disbursed from the national level through regional and districts to the various health facilities as shown in the quote below:
“Usually, donor partners put their resources together and pass it through the Ministry of Health, who also allocates it to the Ghana Health Service (GHS). The GHS also have their way of allocating it to regions and districts, these decisions are being made at the national level. The region then will prepare a budget and disburse the funds to the districts according to the national guidelines.” (Regional Accountant, 22/05/2020).
The field interviews also point out that the Ministry of Health (MOH) repeatedly failed in providing convincing practical proof on the possible economic consequences of IPTp-SP policy. Additionally, in some of the cases voting of political leaders drives them to promise over ambitious health plans that may not have adequate funding means to see to their execution. A typical example is an announcement by the late President, Prof. JEA Mills on a one-time premium for national health insurance during the 2008 election which was never implemented due to the nonavailability of funds to support the policy. Furthermore, budget delivery and spending are mostly not clear or satisfactorily comprehended. For the implementation of the IPTp-SP policy to yield the needed high impacts, the principles of determining the budgets and their disbursement must be transparent and well explained to all the stakeholders (18).
This finding has important implications for the effective implementation of IPTp-SP policy. Thus, effective implementation cannot be achieved without teaming up with the finance ministry and the board that supervises budget preparation and endorsement.
Leadership politics (“Managing Up”)
A strong relationship between leadership politics and the effective implementation of health policy has been reported in the literature. One interesting finding from the field interviews was that the obligation and capability of leadership to the implementation of IPTp-SP policy greatly influenced its acceptance and full-scale implementation. These findings is consistent with that of Frenk who reported that the health systems want leaders with tactical foresight, practical understanding, influential abilities, and moral direction to move the process of policy implementation into action (19). To overpower the many countless sources of resistance to change involves dynamic leadership with strong organizational abilities. The results further discovered that only a few managers have the know-how as the leaders of a big organization and sometimes they rarely understand the significance of organization abilities (20). The quotes below show some of the management functions;
“For monitoring and supervision, the national does the supervision to the various districts to see what is going on. Aside from regional also does periodic supervision and districts also follow up to the CHPS zones, and at the facility level, we have midwives and CHN who are in-charges that see to these things” (Regional Director).
According to Gilson, for effective IPTp-SP policy implementation, managers must encourage, facilitate, and help in making decisions at each point of the health structure. In accordance with the present results, previous studies have also demonstrated that IPTp-SP policy is obstructed by the frontiers of service provision and during community mobilization (17). In a decentralized political system like Ghana, the center has restricted power to encourage valuable accomplishment at front-line stages. It is possible, therefore, that implementation teams need to engage and marshal senior, and local political actors in order to guarantee a full-scale implementation of the IPTp-SP policy.
Recipients’ politics (“Managing Down”)
Several reports have shown that in order to effectively implement the IPTp-SP policy, implementation teams need to discuss how the policy will improve on the current benefits (21). Another important finding from this study was that some policy recipients might perceive that their benefit could be restricted; others might perceive that their profits could increase. To fully operationalize IPTp-SP intervention, it is important to foster confidence with new service users, get their views and occasionally marshal them into the accomplishment of the policy. Policy recipient's opinions concerning IPTp-SP policy could be manipulated through contending notions of other groups, which can be a challenge. This can be curtailed by timely and consistent communication with policy recipients (2).
Another most interesting results of this study according to Roberts et al. (2006) was that the health organization has an opportunity to appeal to policy recipient groups to increase the provision of IPTp-SP policy and achieve improved health outcomes (20). The beneficiaries may also be encouraged to participate in planning meetings, to help promote their needs and interests. They also provide feedback on the implementation to the service providers which help in making the necessary adjustment for improvement. The quote is provided below;
“Most of the health facilities have a suggestion box for soliciting feedback from the service users and also do routine client satisfaction surveys to get their views for improvement” (Regional Director).
It was also reported that to improve health outcomes as well as uptake of IPTp-SP policy, you will need a strong institutional motivation, communal engagement to support direct answerability interactions between the IPTp-SP service user, the health workers, and the state (22). In the Volta Region, new opportunities exist with the advent of digital technologies for beneficiary engagement such as using mobile applications (apps) like the MOTECH (Mobile Midwife) implemented in North Tongu and South Dayi of the Volta Region can serve as a strong platform for updating policy recipient on their expectations and benefits, accessing basic information on the policy; offering opportunity to hold health providers liable; educating policy constituents; or developing a system of easily accessible compliant and feedback.
Donor politics (“Managing Externally”)
A strong relationship between donor politics and the effective implementation of IPTp-SP policy was reported in the literature over the years. It was found that actualizing the implementation of IPTp-SP policy includes handling numerous external stakeholders, comprising bilateral aid institutions, multilateral organizations, and international financial organizations, in addition to outside non-country stakeholders like non-state organizations and private for-benefit organizations. The results of the study indicate that the power that donors exert on IPTp-SP policy activities owing to their perceived stronger technical capability and power over funding sources creates numerous challenges, but can also bring good expectations (23). A few of these problems consist of dominating countries' programs, neglecting the capabilities of the country’s health care systems, providing terrible direction centered on philosophy or terrible encounters in other nations, and disrupting the country’s plan (23).
“Most of the donors come with their own activities and budget and sometimes their own human resource to train the providers” (Regional Director).
This feedback from the director corroborates earlier findings reported by Chan et al (2011) (23). The politics of donors have also been identified to influence the implementation of the IPTp-SP policy process positively. Lately, there has been a drift concerning condensed conditionality on financing and development in straight budgetary support, to guarantee that donor programs augment positively the nationwide agenda (24). This is believed to intensify health sector synchronization, develop country ownership and country-wide control. To drive full benefits from donors, policymakers must coordinate the activities of donors to harness their full contribution to the execution of IPTp-SP policy in such a way that it will be coherent with state priorities and subsequently will last after donor resources cease.