Understanding priority setting for maternal health in Ghana ethnographically

Health Summit attendees gather in conference hall. Photograph by L. Wallace, 2018.

by Lauren J. Wallace

“Jump off the cliff and build your wings on the way down” – Ray Bradbury

From the back of the conference hall an elephant-like trumpeting sound emerges. Everyone turns to find out where the commotion is coming from. Laughter and awe rumble through the room as the audience realizes that the man making the high-pitched noise is using his lips rather than playing an instrument.

Pointing towards the musician, the chairman remarks: “we need to find out if he swallowed a trumpet. If we can achieve playing a trumpet without a trumpet, then we should be able to achieve Universal Health Coverage with no money!” Gesturing towards the dignitaries on the stage, and listing their accolades and accomplishments, he exclaims “so why should we have a problem?” The audience claps wholeheartedly in response.

Photo 2-resized
After the dignitaries finish their speeches, Ghana’s health sector’s performance for 2017 is presented as a “mixed bag.”. For instance, coverage of important health interventions has increased but the supervised delivery ratio between the best performing region and the worst performing region (a proxy indicator for Universal Health Coverage) has not changed significantly.

 

 

Focus on maternal health

Drawing on observations at health planning meetings and interviews with development partners and policy-makers, my postdoctoral research examines national priority setting [i] for maternal health in Ghana.

This time, instead of doing community-level ethnography [ii] with families in dusty villages in Ghana’s Upper East Region, backpack in tow, I am an institutional ethnographer [iii], carrying a briefcase between the Ministry of Health, Ghana Health Service, and the offices of Development Partners in the capital city, Accra.

Health Summit

It is 10 am on April 23, 2018 at the Labadi Beach Hotel conference centre, a luxury 5-star venue in Accra. As business people and tourists pull up in front of the lobby in Ubers and shiny SUVs, hotel guests sit by the pool enjoying the sunny weather and the tropical landscaped gardens. All of this is happening just metres from the shores of the Atlantic Ocean. Inside the modern, AC-chilled 600-seater conference centre, the 2018 National Health Summit is underway.

The ‘who’s who’ in the health sector –including members of parliament, representatives of health development partners and heads of government departments and agencies – sit in business attire at round tables. At the front of the room are two screens projecting the 2018 Health Summit theme “Achieving Universal Health Coverage through Innovative Approaches.” In between the screens is a stage atop which distinguished guests sit, including the first woman WHO Regional Director for Africa, Ghana’s Minister for Health, the Vice President of Ghana, and a former Deputy Director-General of the WHO.

As I sat at the Health Summit, shivering in the AC – I had forgotten my suit jacket! – I was overwhelmed. I had only just started my research. Out of hundreds of people, I was familiar with only a handful. At the same time, this event was a huge opportunity to start collecting data. But instead of immediately getting into action, I sat paralyzed, thinking about how to begin, my eyes flickering around the room. Who should I approach first? Doubts about my capabilities as a researcher were not helping matters. Did I know enough about the health sector yet to start ‘intelligent’ conversations with policy-makers? Would I simply be perceived as a naïve ‘obroni’ – Twi term for white person?

Task ahead

An institutional ethnography of policy-making in the health sector was exciting but at the same time so unfamiliar. Traditionally, medical anthropologists have focused on gaining in depth knowledge of a single field site such as a hospital or community. Studying how policies are made requires ethnographers to understand actors and activities in multiple institutions with differing levels of institutional primacy and power. For instance, in Ghana, the Ministry of Health is the parent institution of the health sector. The Ministry, in itself, is vast. It also has 23 agencies. To understand priority setting for maternal health in its entirety, I would need to map and observe units, actors and their activities in multiple institutions.

During the morning of the health Summit, I made an important decision. Instead of being intimidated by the task of charting a new research direction, I got up and started introducing myself to as many people as possible. I ended up meeting many key informants and new friends. It was a quote from British actor Hugh Laurie that reminded me about the importance of jumping in before you feel ready.

“It’s a terrible thing, I think, in life to wait until you’re ready. I have this feeling now that actually no one is ever ready to do anything. There is almost no such thing as ready. There is only now. And you may as well do it now. Now is as good a time as any.” — Hugh Laurie

Is there an area in your life where overthinking [iv] is killing action and results? What are you waiting for? Jump in!

Lauren J. Wallace is a Postdoctoral Fellow in the Department of Health, Aging and Society at McMaster University, where she completed her PhD in 2017, supported by a Vanier Scholarship from the Canadian Institutes of Health Research (CIHR). Lauren’s current research is also funded by CIHR. Her research, at the intersection of medical anthropology and health policy and systems research, advances a critical perspective on the study of the development and implementation of global maternal and reproductive health policies. Lauren’s current research program examines national priority setting for Maternal Health in Ghana, where she is a Visiting Postdoctoral Fellow in the Department of Social and Behavioural Sciences in the School of Public Health, University of Ghana.

Endnotes

i. Priority setting, a process involving decision-making about the allocation of limited resources between competing population health demands and needs, is one of the most critical health policy challenges of the 21st century because of the gaps between increasing population health demands and the resources that are needed to meet them (Kapiriri & Razavi, 2017). Priority-setting for health interventions can occur at various levels, including the global level, the national level, and within programs (Kapiriri & Martin, 2007). Priority setting decisions are expressed in strategic plans and policies, which, ideally, should be accompanied by implementation through the allocation of resources.

ii. Ethnography offers an open-ended, in depth, flexible, interpretive, and reflexive approach which is well positioned to take on the non-linear, complex nature of priority setting processes and the policies associated with them. Priority setting exercises in global health are inherently anthropological. As a decision-making process, priority setting is linked with issues of power, interpretation and meaning, ideology, rhetoric and discourse, the politics of identity and interactions between the global and the local (Wedel & Feldman, 2005).

iii. Institutional ethnography involves an investigation of the “activities, knowledge, and concerns of a group of people related to their involvement with a particular institutional complex”. Here institution refers to “clusters of ruling relations organized around specific functions, such as social services, education or health care” (see Smith, 2005, p. 225; Sinding, 2010, p. 1657).

iv. See psychologist Ben Hardy’s reflections on how overthinking and overplanning can kill ‘magic’, how to turn anxiety into excitement, why experiments are the best form of goal-setting, and how to continually disrupt yourself and others https://medium.com/@benjaminhardy/go-to-the-next-level-of-your-life-before-you-feel-ready-15b76743bc9c

References

Kapiriri, L., & Razavi, D. (2017). How have systematic priority setting approaches influenced policy making? A synthesis of the current literature. Health Policy, 121: 937- 946.

Kapiriri, L., & Martin, D.K. (2007). A strategy to improve priority setting in developing countries. Health Care Analysis, 15: 159–67.

Sinding, C. (2010). Using institutional ethnography to understand the production of health care disparities. Qualitative Health Research, 20: 1656-1663.

Smith, D. E. (2005). Institutional ethnography: A sociology for people. Toronto, ON, Canada: AltaMira Press.

Wedel, J.R. & Feldman, G. (2005). Why an anthropology of public policy? Anthropology Today, 21: 1-2.