Funding crisis hits free childbirth policy in Ghana

Policymakers all over the world face the same problem: how to sustain funding for public sector programmes. In 2003, Ghana introduced a policy of free childbirth which won widespread support, only to be interrupted two years later due to inadequate funding. What causes high-profile and important initiatives to fail in this way?

New research by the University of Aberdeen, UK looks at the problem of start-stop funding(where initiatives start but stop when funding is removed), using Ghana’smaternity exemptions policy as a case study. This policy removed fees forsupervised childbirth, financial barriers being seen as a key factor in Ghana’slow rate of supervised care and high maternal mortality rate. Financed by theHighly Indebted Poor Country (HIPC) debt relief funds, the policy began in thefour most deprived regions of the country at the end of 2003, before expandingto the remaining six regions in early 2005.

The researchers used material from in-depthinterviews by Immpact (Initiative for MaternalMortality Programme Assessment) which took place both locally in Ghana's Centraland Volta regions and at a national level during October and November 2005. Thoseinterviewed included national policymakers, representatives of regional anddistrict health authorities, representatives of the District Assemblies, andheads of facilities from six focus districts in each region.

In Central region, facility managersreported that, in their view, use of services for deliveries had risen between20 percent and 500 percent over the two-year period. However, by October 2005, threeout of six districts had run out of funds and some had started to chargeclients again. In Volta region, funds had already run out in most districtsafter only six months of operating the policy. Five key factors emerged:  

• unpredictable and inflexible arrangements with donors, which madeit difficult to plan services
• competing policies, notably the planned National Health Insurancescheme (which also has exempted categories)
• different viewpoints and interests from officials at differentlevels of the health system
• poor communication between regional, district and facilitylevels leading to a lack of information about funding needs andavailability
• the manyagencies involved in the programme, who were able to blame each other andavoid taking responsibility.

The authors conclude that the policy failedpartly due to a lack of resources but also because of management and communicationproblems. They stress that starting and stopping initiatives, or providinginadequate or uneven funds, not only damages programme goals but also resultsin a more general loss of trust. Officials at different levels were suspiciousof each other while patients particularly lost confidence in district andfacility managers. This could threaten the success of future governmentprogrammes. The study recommends:

• building on existing changes to the way that aid is delivered whichare making it more predictable and easier for governments to use; this mayalso help to reduce conflict between policies
• using longer-term budgeting to develop realistic funding plansfor new programmes
• informing health staff at all levels about funding problems sothat they can plan appropriately
• improving communication within the health system to allowfeedback to policymakers and adjustment of policies
• laying down clearer lines of responsibility for monitoring theprogress of new initiatives
• ensuring thatan active media follows up on some of the initiatives that politicianslaunch and then forget.