Working paper 107
Despite substantial improvements in access to health services in Ghana during the last two decades, there has been limited progress in improving maternal health, and the country as a whole was unable to meet the Millennium Development Goal (MDG 5) in relation to maternal mortality. However, some administrative regions have made significant progress, with the Upper East, one of Ghana’s most impoverished regions, surprisingly recording the most dramatic progress in the reduction of maternal mortality during the last decade. This paper explains Ghana’s limited progress in reducing maternal mortality as a product of the country’s ‘political settlement’, in which ruling elites are characterised by a perennial threat of losing power to other powerful excluded elites in tightly fought elections, incentivising those in power to direct public investments to policy measures that contribute to their short-term political survival. Competitive clientelist political pressures have contributed to greater elite commitment towards health sector investments with visual impact, while weakening elite incentives for dedicating sufficient public resources and providing consistent oversight over other essential, but less visible, interventions that are necessary for enhancing the quality of maternal health. In the absence of system-wide drivers of improved performance, sub-national variations in the quality of maternal health services are strongly shaped by the capacity and commitment of regional and district health authorities in enforcing human resource management norms within the Ghanaian health sector, thus ensuring the accountability of health workers. In the largely impoverished Upper East Region, incentives for health workers’ performance are particularly driven by a hybrid form of accountability that combines top-down pressures from the Regional Health Directorate with horizontal forms of accountability among various health facilities.