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  • The MoH institutionalized policy-making processes: The role of the pharmacist
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    By: Augustina Koduah.  PhD (Public Policy), MSc (Health Policy), BPharm, FGCPharm,

     

    The Ministry of Health provides policy direction and coordinates activities within the health sector, and as such wields power over the health policy decision-making processes. Policies at the national level often emerge as a result of continuous negotiations, compromises and contestations of health ideas among people at all levels within and outside the sector. The Ministry for example engages in horizontal discussions and planning with its service delivery, financing, research/training and regulatory agencies to consolidate ideas and priorities for its day to day’s activities. Additionally, the Ministry engages with other government institutions, professional bodies, private service providers, civil society groups, donors and many more people with interest in health related issues to firm up the ideas and health issues that come up and build consensus to inform policy. The Ministry is therefore involved in multilevel and multi-stakeholder discussions and negotiations with a variety of health partners to consolidate new and old ideas and make fully informed strategic choices for the sector's program of work which outlines priorities, policies, targets, and resources allocation.

     

    To actively engage and interact with others, the Ministry has institutionalized its policy dialogue processes. The Ministry’s involvement of others to have a say in national level health decisions is not new. The Ministry has over the years engaged researchers, donors, service providers at the health peripherals to generate evidence to inform policy decisions and practice. Starting from the late 1990s however, the Ministry institutionalized a series of health sector dialogue processes to engage with people within and outside the health sector in a regular manner. As a result of these engagements, stakeholders traditionally not involved in the decision-making processes such as professional bodies, private service providers and civil society groups gained access and legitimacy to join the Ministry to set health agendas and priorities for policy and planning. The institutionalized arrangements included the biannual (review and planning) health summits, business meetings and health sector working groups meeting also known as the partners' meeting. The dialogue arrangements had evolved over the years and in 2012 the planning health summit was replaced with a business meeting for effective dialogue processes.

     

    The health summit consists of a routine sequence of actions. First, a joint team of service providers, Ministry of Health officials, donors and researchers assesses the health sector performance based on specific indicators in the preceding year’s program of work. The joint team is selected based on expertise in the area of interest for the health sector assessment. Findings and recommendations from the performance review feed into health sector discussions, pre-setting the frame for which issues can be discussed and which ideas can float around ignoring others. Additionally, the Ministry and its agencies and donors also undertake monitoring visits to selected regions to understand and contextualize policy implementation problems and successes. Regions to visit and problems to study are informed by current trends and happenings within the sector. For instance, in 2012, there were discussions around the supply and availability of artemisinin-based combination therapy medicines (especially the Affordable/Green Leaf) in health facilities and repositioning of the Community-Based Health Planning and Services as a result of the monitoring visits focused on these two issues.

     

    Secondly, multi-stakeholder meetings are organized in the 2nd quarter of the year (usually between April and May) for everyone with interest in the health sector to come and share their views and ideas. Participants usually include officers of the Ministry and its agencies; representatives of regional and district health management teams; other sector ministry representatives such as the Ministry of Finance and Economic Planning; donors; representatives of coalition of NGOs in health; Christian Health Association of Ghana; quasi-government institution representatives; private practitioners; regulatory agencies; professional bodies and the media. At these meetings, findings and recommendations obtained from monitoring visits and performance review are presented by the Ministry of Health after which interactive and sometimes healthy confrontational discourse take over to propose strategies to mitigate identified problems and replicate good practices and lessons. Where participants fail to agree and build consensus on specific issues, smaller subgroups are tasked to further study the problem and report back to the Ministry. The open multi-stakeholder meeting usually occurs within two days, after which the Ministry prepares key decisions for the next (third) action – a business meeting.

    The business meeting is an important component of the summit because participants firm up the ideas that floated around and decisions taken during the meetings. The business meeting is a closed-door meeting because active participation, that is, contribution to discussions is limited to senior officials of the Ministry of Health and its agencies by virtue of their positional authority and donors by virtue of their financial support. The meeting is usually chaired by the Minister of Health and the negotiated decisions made at the summit business meeting are detailed in an Aide Memoire – a policy agenda summary for the next (fourth) action – signing of the Aide Memoire. Final action of the review process is that the Minister of Health and donors who contribute financially to implement the negotiated health sector priorities sign the Aide Memoire. The Aide Memoire feeds into the prioritization and design of the program of work.

    In the 3rd quarter, mid-year review and business meetings are held to take stock of the health sector priorities implemented between the period of January to June. Again prior to the mid-year review meeting, the Ministry and its agencies as well as health partners undertake joint monitoring visits to specific regions. Discussions of ideas at the review meetings are firmed up or dropped off the health sector agenda at the business meeting. In the fourth quarter (usually in November) another business meeting is held to consolidate and review the implementation of the Aide Memoire and other heath sector priorities not captured in the Aide Memoire. Figure 1 is a schematic outline of national level institutionalized dialogue processes, summarizes and illustrates the different levels of the dialogue process, actors involved and the routine sequence of actions.

    The national level institutionalized dialogue process is one of the many ways in which one could get ideas and suggestions across for further debates, consolidation and contestation. As ideas and suggestions float around, they can progress unchanged, modified or completely ignored along the way. There is no guarantee that engaging in such processes will get one's ideas and suggestions onto the national agenda or into policy implementation and practice. What is guaranteed though is that ideas and suggestions when persistently advocated can influence the decisions that others take and this is an important way to participate and contribute to the national level policy discourse. The institutionalized dialogue process as entry points into national level decision making and influence therefore presents a window of opportunity for pharmacists. As custodians of medicines pharmacists are in the best position to persistently propagate and advocate pharmaceutical values, evidence and arguments that can shape the way a pharmaceutical problem or solution is presented. Pharmacists must as a matter of urgency actively scout for possible openings within the dialogue processes to formulate and influence sustainable pharmaceutical policies.

    Currently pharmaceutical issues are topical and on the agenda of government, Ministry of Health, National Health Insurance Authority, health facilities and service providers. For instance, the President of Ghana listed as part of key elements of industrial transformation, the expansion of the domestic production of pharmaceuticals in his maiden state of the nation address February this year. There are also discussions at national level on improving pharmaceutical supply chain, creating transparency and equity around raw material sourcing to active ingredients manufacturing through formulation, packing and distribution to the patient. There also seems to be an unending discourse on medicines pricing and appropriateness of NHIA reimbursements. In all of these getting pharmacists' ideas and suggestions across whether through the national institutionalized dialogue processes or other channels the pharmacist's focus is to ensure that patients receive medicines suitable to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at value for money to them, service providers, managers and the country as a whole.

     

    References:

    1. Ministry of Health. 2007. National Health Policy: Creating Wealth through Health. Accra.
    2. State of the Nation Address, 21st February 2017. 
    3. Koduah A, Agyepong IA, van Dijk H. 2016. The one with the purse makes policy’: Power, problem definition and maternal health policies and programs evolution in national level institutionalized policy making processes in Ghana. Social Science & Medicine.