The evolution of Ghana’s Networks of Practice: The influence of state and non-state actors on the implementation of a primary health care policy

Problem

Politics plays a key, sometimes underexplored, role in the allocation of public funds to healthcare. In addition to macro-level decisions about national funding, internal decisions about the distribution of those funds, and about optimal governance and service delivery models will be affected by the politics at play at multiple scales. In low- and middle-income countries in particular, non-state agencies (e.g., NGOs and multilateral funders) are often active actors in the policy-making arena as well as in policy implementation.Primary care networks, a primary health care (PHC) model, are viewed as an innovative way to link primary care stakeholders to achieve improvements in population health. Increasingly, such networks are viewed as an appropriate model of primary care governance and service delivery, especially in low-income settings where healthcare systems involve multiple state and non-state actors.Ghana is currently 'scaling up’ so-called networks of practice (NoP), a PHC model that has evolved since being piloted in 2017. This evolution has been largely unexplored.This study aimed to explore how the NoP’s implementation and evolution to date has been influenced by political processes associated with state and non-state actors, identifying the key mechanisms in this process.

Approach

This qualitative study involved semi-structured interviews and documentary analysis. Interviews were conducted with key stakeholders in Ghana's NoP policy and implementation process. Relevant documents were analysed, including grey literature on the broader political occurrences in the country. Capano and Pritoni’s policy cycle framework was used for data analysis, including agenda setting, formulation, adoption (decision making), implementation and evaluation.

Findings

Ghana’s NoPs have a clearly set agenda at each stage of its evolution, driven by various actors. This informed the policy formulation process. However, adoption has varied across the country depending on which actors took on a central role. We also found that NoP policy implementation shifted over time from a focus on financing to a service delivery approach, reflecting the priorities of influential state and non-state actors. Importantly, foreign donors also contributed to continued development of the network concept in specific areas, linking its implementation to targeted funding. The implementation and evaluation stages are still in progress, limiting a conclusive analysis of these stages.

Consequences

The policy process is significantly influenced by the political context, and state and non-state actors at play. Ghana’s example shows how changes in state authority and influence of donor agencies may define the policy cycle of a primary health policy. It also provides key lessons of necessary considerations to be made when PHC models are being implemented in low- and middle-income countries.