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Explaining Radical Change in Ghanaian Health Care Policy



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The existing literature about the causes of welfare state change, including health care reform, emphasizes stability, yet there is evidence of remarkable changes taking place in welfare systems in much of the developing world. This study analyzes health care reform in Ghana, a country which has experienced significant path-departing changes in just four decades (1957-2003). These changes – the establishment of a National Health Service system with deep (first-dollar) coverage, the introduction of a user-fee system, and the transition to a social health insurance scheme – have been pursued despite key countervailing factors, especially the high political costs associated with them. The study argues that to adequately account for these changes, the policy process should be given special consideration, particularly through the examination of how new policy proposals moved onto the agenda; how they were formulated, adopted, implemented and sustained; and how the reformers managed the entire reform process over time. Based on this analysis, I identified three main interconnected contextual and agential explanatory factors: (a) conjunctural factors, which created windows of opportunity for the changes to occur; (b) policy entrepreneurs, whose leadership, commitment and strategies helped in taking advantage of these opportunities to propel, sponsor, design, adopt, implement and sustain the policy changes; and (c) the concentrated institutional configuration of Ghana, which limited the number and scope of the veto points available to interest groups opposed to the proposed changes. While these three factors contributed to why and how the changes occurred, I identified policy entrepreneurs’ commitment, leadership and strategies, including the feedback effects of those strategies, as the most crucial factors. The study contributes to existing health policy literature by showing how perspectives such as the window of opportunity thesis, the dynamic political process model, the historical institutionalist approach to radical policy change and, finally, the ideational scholarship on framing processes can be combined to enrich our understanding of radical policy change. The study also introduces additional mechanisms of policy change that involve the use of repressive strategies before suggesting some modifications to a number of widely-shared assumptions within the welfare state literature focusing on path dependency, globalization, partisan ideology and vested interests.



Policy change, health policy, health politics, Ghana health



Doctor of Philosophy (Ph.D.)


Johnson-Shoyama Graduate School of Public Policy


Public Policy


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