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Overcoming the constraints of competitive clientelism? Explaining the success of Ghana's Poorest Region in Reducing Maternal Mortality.
University of Ghana Business School

Corresponding Author:[email protected]

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Maternal mortality remains a health challenge that many developing countries struggle to address. Drawing on 64 key informant interviews, this article shows how Ghana’s most impoverished administrative region, the Upper East, emerged as a bureaucratic ‘pocket of effectiveness’ in reducing maternal mortality in a context where national political settlement dynamics are undermining progress in improving maternal health. At the national level, Ghana’s progress in reducing maternal mortality has been disappointing because public investments are disproportionately directed to reforms that contribute to the short-term political survival of ruling elites. Competitive electoral pressures have contributed to greater elite commitment towards health sector investments with visual impact, while weakening elite incentives for dedicating resources to interventions that are necessary for enhancing the quality of health. In the Upper East Region, the rapid reduction in maternal mortality in recent years has been driven by a hybrid form of accountability that combines top-down pressures from the regional health directorate with horizontal forms of accountability that result in a competitive spirit among health workers. These findings show that even in contexts where resources are limited, the capacity of sub-national leaders in devising local solutions to local problems can lead to improved performance of health systems at the sub-national level. The findings also suggest the need for academic debates to go beyond the binary distinctions regarding the usefulness of top-down versus bottom-up accountability measures and focus on building effective and legitimate forms of accountability that run both top-down and bottom-up when seeking to improve health service delivery.
05 May 2023Submitted to International Journal of Health Planning and Management
09 May 2023Submission Checks Completed
09 May 2023Assigned to Editor
09 May 2023Review(s) Completed, Editorial Evaluation Pending
20 May 2023Reviewer(s) Assigned
21 Aug 2023Editorial Decision: Revise Major
08 Sep 20231st Revision Received
13 Sep 2023Submission Checks Completed
13 Sep 2023Assigned to Editor
13 Sep 2023Review(s) Completed, Editorial Evaluation Pending
22 Sep 2023Reviewer(s) Assigned
19 Oct 2023Editorial Decision: Accept