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Drawing on an analysis of the implementation of Ethiopia’s Productive Safety Net Programme (PSNP) in the Somali periphery, we consider how the programme is promoted as an ‘innovative’ social protection programme that links food security with development projects. Underpinning its ‘innovative’ role is a community-based approach, focusing upon the institutions, values and capacities of a community. Taking the case of the nomadic pastoralists in Ethiopia’s Somali region, we consider the role of clans as the ‘dominant’ grassroot socio-political organizations. Our analysis, drawing on ethnographic fieldwork shows how in the implementation of PSNP the mobilization and (re)deployment of clanship values and rules create legible and governable Somali pastoral subjects. This is in line with the Ethiopian state’s conception of ‘improvement’ and ‘modern’ way of life based on sedentary-based development and governance. We illustrate how clan leaders unwittingly (re)organize their clan (leadership) values and capacities to support this project. We argue that clan-based implementation of PSNP has become an ‘effective’ mechanism of extending state power and governing nomadic pastoralists, leading to changes in relations of authority and in forms of (inter)subjectivity between pastoralists, their clan (leaders) and the state. Towards this end, we put forward the concept of ‘government through clanship’ to reflect the assemblage of these practices, processes and changes which would offer critical analytical insights into social policies claimed to be community-based.

This paper explores how the Productive Safety Net Programme (PSNP), as an example of contemporary bottom-up development practices in the global South, governs nomadic pastoralists in the peripheries. Based on fieldwork in Ethiopia's Somali region, we show that PSNP practices of client targeting, community-based public works and (international) financial resource flows, both for their own sake and because of their entanglement with the sedentary metaphysics of Ethiopian state, have advanced sedentary governmental order into pastoral peripheries more than top-down state sedentarization interventions had ever done. Finally, we argue that bottom-up development practice is an effective tool for state-building in the periphery.

Change is of all times, but it would appear that in the drylands of Africa, the Middle East, and Central Asia/Inner Asia it is happening in an overwhelming manner. Climate change, growing political instability, and increasing enclosures of large expanses of land are some of the changes with far-reaching consequences for those who make their living in the drylands. This edited volume is about the changes that arise from the entanglement of global interests and narratives with the local struggles that have always existed in the drylands. In this chapter, the notion of ‘frontier’ is proposed as a metaphor to frame this entanglement and as a way to bring the different chapters in the volume together. Overviews of the chapters show that to understand the full politics of frontier processes, analytical approaches are necessary that take into account historical institutional changes and different forms of power relations.

This edited volume examines the changes that arise from the entanglement of global interests and narratives with the local struggles that have always existed in the drylands of Africa, the Middle East, and Central Asia/Inner Asia. Changes in drylands are happening in an overwhelming manner. Climate change, growing political instability, and increasing enclosures of large expanses of often common land are some of the changes with far-reaching consequences for those who make their living in the drylands. At the same time, powerful narratives about the drylands as ‘wastelands’ and their ‘backward’ inhabitants continue to hold sway, legitimizing interventions for development, security, and conservation, informing re-emerging frontiers of investment (for agriculture, extraction, infrastructure), and shaping new dryland identities. The chapters in this volume discuss the politics of change triggered by forces as diverse as the global land and resource rush, the expansion of new Information and Communication Technologies, urbanization, the COVID-19 pandemic, and the spread of violent extremism. While recognizing that changes are co-produced by differently positioned actors from within and outside the drylands, this volume presents the dryland’s point of view. It therefore takes the views, experiences, and agencies of dryland dwellers as the point of departure to not only understand the changes that are transforming their lives, livelihoods, and future aspirations, but also to highlight the unexpected spaces of contestation and innovation that have hitherto remained understudied. This edited volume will be of much interest to students, researchers, and scholars of natural resource management, land and resource grabbing, political ecology, sustainable development, and drylands in general.

This article proposes a framework for studying and understanding how people make claims to land and other natural resources. We argue that a focus on claim-making practices of actors (individuals, groups, institutions, companies, the state), and the processes of appropriation, accessing and contestation that come along with it, best responds to Sikor and Lund’s call to examine “the grey zone” between access and property. We identify and discuss three practices of claim making: “grounding claims” is the practice of inscribing or altering the landscape with visible markers connoting ownership; “talking claims” is when speech is used strategically to make, justify and contest claims; and “representing claims” is when claims are represented on material objects (maps, title deeds) that are detached from the resource. We contribute to debates on enclosure, large-scale land acquisitions and resource grabbing by providing a lens of claim making through which these processes can be conceptualized.

This paper explores claim-making to land in Burundi, where civil war and multiple waves of displacement and return have resulted in complex disputes over land. Zooming in on two different regions, the paper shows that, as people articulate their claims and defend their interests in land disputes, they strategically draw on a diversity of arguments, related to legal categories, notions of belonging and citizenship, social categories derived from (land) policy, but also victimhood, security concerns, and political loyalty. Post-peace agreement land policies play an important role in this, as they instrumentalise war-based categories of identity and victimhood, privileging certain groups of displaced people for political purposes. As we show in two case studies, claim-making tactics follow shifting political discourses and policy changes, as people seek to secure the support of (powerful) allies. A perspective on processes of making claims to land allows us to explore the entanglements between multiple waves of displacement, policy implementation and the instrumentalisation of identities in conflict-affected settings.

Redressing land dispossession in the aftermath of violent conflicts is daunting and complex. While land dispute resolution and restitution are expected to promote return migration, this outcome is contingent upon the changing social, economic and political conditions under which return takes place. Drawing on qualitative data from Makamba Province in southern Burundi, this case study highlights the politically and historically shaped challenges underlying the resolution of competing and overlapping claims on land following protracted displacement. These include the undocumented and fluid nature of customary land rights, institutional and legal pluralism and shifting land governance relations. This paper emphasises the centrality of the state in regulating returnees’ land dispute resolution and restitution processes. Violent conflicts and forced migration have enabled the state to expand its control over customary land tenure. The gradual exclusion or replacement of local authorities has shaped a competitive structure of jurisdictions and confused authority over land. National land restitution commissions have been used by the central government to shape land tenure and state–citizen relations and to exert pressure on land tenure institutions. Addressing competing claims on land following armed conflicts may fail if attendant struggles over public authority and changing political dynamics are insufficiently considered.

Background Understanding decision-making processes that influence the fate of items on the health policy agenda at national level in low- and middle-income countries is important because of the implications for programmes and outcomes. This paper seeks to advance our understanding of these processes by asking how and why maternal health policy agenda items have fared in Ghana between 1963 and 2014. Methods The study design was a single case study of maternal health agenda evolution once on a decision pathway in Ghana, with three different agenda items as sub-units of analysis (fee exemptions for maternal health, free family planning and primary maternal health as part of a per capita provider payment system). Data analysis involved chronologically reconstructing how maternal health policy items evolved over time. Results The fate of national level maternal health policy items was heavily influenced by how stakeholders (bureaucrats, professional bodies, general public and developmental partners) exercised power to put forward and advocate for specific ideas through processes of issues framing within a changing political and socioeconomic context. The evolution and fate of an agenda item once on a decision pathway involved an iterative process of interacting drivers shaping decisions through cycles of ‘active’ and ‘static’ pathways. Items could move from ‘active’ to ‘static’ pathways, depending on changing context and actor positions. Items that pursued the ‘static’ pathway in a particular cycle fell into obscurity by a process that could be described as a form of ‘no decision made’ in that an explicit decision was not taken to drop the item, but neither was any policy content agreed. Low political interest was exhibited and attempts to bring the item back into active decision-making were made by actors mainly in the bureaucratic arena seeking and struggling (unsuccessfully) to obtain financial and institutional support. Policy items that pursued ‘active’ pathways showed opposite characteristics and generally moved beyond agenda into formulation and implementation. Conclusion Policy change requires sustaining policy agenda items into formulation and implementation. To do this, change agents need to understand and work within the relevant context, stakeholder interests, power, ideas and framing of issues.

The dry-salted trade of Nile perch or kayabo is important for many along the shores of Lake Victoria. The kayabo trade started in the 1990s and has been increasingly restructured due to changing regional and global trade relationships. This shift has led to the emergence of hierarchical trading relations, which create an exploitative network in which powerful middlemen control the access of trade for women from the Democratic Republic of Congo (DRC) and marginalizes the Tanzanian women, changing the organization from a poly-centric to a more centralized trade organization in the hands of a small group of powerful business men. We show in this paper that whereas the women traders from the DRC manoeuvred themselves in positions from which they could manipulate the network through bribery and conniving to derive substantial capital gains from the kayabo trade, their Tanzanian counterparts however are excluded from the decision-making processes, access to fish resources, financial capital, and negotiation power. They persevere by operating in increasingly competitive markets, relying on illegal fish that they sell with little profit at local and domestic markets. They survive in jobs that are insecure and risky by nature.

This paper seeks to advance our understanding of health policy agenda setting and formulation processes in a lower middle income country, Ghana, by exploring how and why maternal health policies and programmes appeared and evolved on the health sector programme of work agenda between 2002 and 2012. We theorized that the appearance of a policy or programme on the agenda and its fate within the programme of work is predominately influenced by how national level decision makers use their sources of power to define maternal health problems and frame their policy narratives. National level decision makers used their power sources as negotiation tools to frame maternal health issues and design maternal health policies and programmes within the framework of the national health sector programme of work. The power sources identified included legal and structural authority; access to authority by way of political influence; control over and access to resources (mainly financial); access to evidence in the form of health sector performance reviews and demographic health surveys; and knowledge of national plans such as Ghana Poverty Reduction Strategy. Understanding of power sources and their use as negotiation tools in policy development should not be ignored in the pursuit of transformative change and sustained improvement in health systems in low- and middle income countries (LMIC).

Background Pregnant women can misinform or withhold their reproductive and medical information from providers when they interact with them during care decision-making interactions, although, the information clients reveal or withhold while seeking care plays a critical role in the quality of care provided. This study explored ‘how’ and ‘why’ pregnant women in Ghana control their past obstetric and reproductive information as they interact with providers at their first antenatal visit, and how this influences providers’ decision-making at the time and in subsequent care encounters. Methods This research was a case-study of two public hospitals in southern Ghana, using participant observation, conversations, interviews and focus group discussions with antenatal, delivery, and post-natal clients and providers over a 22-month period. The Ghana Health Service Ethical Review Committee gave ethical approval for the study (Ethical approval number: GHS-ERC: 03/01/12). Data analysis was conducted according to grounded theory. Results Many of the women in this study selectively controlled the reproductive, obstetric and social history information they shared with their provider at their first visit. They believed that telling a complete history might cause providers to verbally abuse them and they would be regarded in a negative light. Examples of the information controlled included concealing the actual number of children or self-induced abortions. The women adopted this behaviour as a resistance strategy to mitigate providers’ disrespectful treatment through verbal abuses and questioning women’s practices that contradicted providers’ biomedical ideologies. Secondly, they utilised this strategy to evade public humiliation because of inadequate privacy in the hospitals. The withheld information affected quality of care decision-making and care provision processes and outcomes, since misinformed providers were unaware of particular women’s risk profile. Conclusion Many mothers in this study withhold or misinform providers about their obstetric, reproductive and social information as a way to avoid receiving disrespectful maternal care and protect their privacy. Improving provider client relationship skills, empowering clients and providing adequate infrastructure to ensure privacy and confidentiality in hospitals, are critical to the provision of respectful maternal care. Electronic supplementary material The online version of this article (10.1186/s12884-018-1916-9) contains supplementary material, which is available to authorized users.

Hospital managers’ power to exercise effective leadership in daily management can affect quality of care directly as well as through effects on frontline workers’ motivation. This paper explores the influence of contextual factors on hospital managers’ leadership styles and the motivation of frontline workers providing maternal and new born care in two public district hospitals in Ghana. It draws on data from an ethnographic study that involved participant observation, conversations and in-depth interviews conducted over 20 months, with frontline health workers and managers. Qualitative analysis software Nvivo 11 was used to facilitate coding, and common patterns emerging from the codes were grouped into themes. Ethical clearance was obtained from the Ghana Health Service Ethical Review Committee. Contextual factors such as institutional rules and regulations and funding constrained managers’ power, and influenced leadership styles and responses to expressed and observed needs of frontline workers and clients. The contextual constraints on mangers’ responses were a source of demotivation to both managers and frontline workers, as it hampered quality health service provision. Knowing what to do, but sometimes constrained by context, managers described ‘feeling sick’ and frustrated. On the other hand in the instances where managers’ were able to get round the constraints and respond effectively to frontline health workers and clients’ needs, they felt encouraged and motivated to work harder. Effective district hospital management and leadership is influenced by contextual factors; and not just individual manager’s knowledge and skills. Interventions to strengthen management and leadership of public sector hospitals in low- and middle-income countries like Ghana need to consider context and not just individual managers’ skills and knowledge strengthening.

Management and leadership in complex health systems have been little addressed as contributors toward improving maternal and newborn health. Widespread perceptions of weak district-level management and leadership have encouraged capacity strengthening interventions with a predominant focus on individual rather than systemic capacities. However, both types of capacities matter. Greater understanding is required about how managerial decision making and policy implementation are influenced by the systems in which managers operate. This article presents an exploratory case study to understand the balance of top-down and bottom-up dynamics influencing district manager decision making in one district in the Ghanaian health system. Our study was theory driven, drawing on concepts of decision space, power, and trust from the literature. Data collection methods included document review, participant observation, and semistructured interviews. Using analysis that drew upon complex leadership theory, we found that contexts of hierarchical authority and resource uncertainty constrained district manager decision space. These constraints also gave rise to a leadership type oriented toward serving the bureaucratic functions of the health system (more top-down than bottom-up). The analysis of this case study showed that, as a result, district-level management and leadership were less responsive to maternal and newborn health service delivery challenges.

It is widely accepted that environmental change can influence human migration. In particular, the environment plays a role in migration processes in drylands, in which environmental change—including increasing variability of rainfall, increasing frequency of droughts, chronic water shortage, and land degradation—can heavily influence migration. However, systematic large-scale studies of the relationship between environmental factors and human migration are rare, and a global, consistent picture of environmental drivers of migration is lacking. In this study, we sought to fill this gap by analysing spatial patterns of environmental drivers of migration in drylands by performing a cluster analysis on spatially explicit global data. In this analysis, we focused explicitly on precipitation, aridity, drought, land degradation, soil constraints, and availability of cropland and pastures as potential environmental drivers of migration in drylands. In addition, we linked the identified clusters to two observed hotspots of out-migration—Burkina Faso and Northeast Brazil—to gauge the cluster results. Our results show that environmental drivers can be grouped into eight distinct clusters, and we identified the most severe environmental constraints for each cluster. These results suggest that out-migration—both in absolute and relative terms—occurs most frequently in a cluster that is constrained primarily by land degradation rather than water availability.

Contains fulltext : 160936.pdf (Publisher’s version ) (Closed access) In Sub-Saharan Africa, Uganda has been hailed for embarking on an intensive decentralization programme. Whereas a lot of literature assumes that decentralization leads to improved service delivery, it is unclear to what extent this is the case in practice, especially when it comes down to decentralized land governance. This paper, which is based on ethnographic research carried out between 2011 and 2013, argues that decentralization of land governance in post-conflict Northern Uganda fails to realize the expected benefits and instead has increased tenure insecurity. Decentralization of land governance gave rise to institutional multiplicity by creating new institutions that add on to the already existing authorities and regulations. Institutional proliferation in land governance that is fuelled by legal pluralism and decentralization results into confusion in land dispute resolution and the failure of institutions to effectively resolve land disputes in post-conflict settings. This exacerbates the dilemma of people who do not know where to go to seek redress to land disputes. While this multiplicity of both statutory and customary institutions creates choices and opportunities for both people and institutions in relation to land governance and in particular land conflict resolution, they are also used by power holders and authorities in political competition at local level, complicating the process of land dispute resolution. The struggle for authority between representatives of the state and of customary land institutions becomes especially problematic because it merges with local and national politics. 04 juli 2016

Drylands cover 40 % of the earth’s surface and provide the basis for the livelihoods of 2 billion people, many of whom belong to the poorest of the world. Dryland forests provide these people with woods, fruits, fibre and pasture. Drylands are among the poorest and most problem-ridden areas of the world. Therefore a different approach to drylands and dryland forest management is needed. The chapter develops a framework for analysing dryland forest management departing from a forestry approach to a landscape approach putting the diversity and interconnectedness of different forest and non-forest resources in the centre of analysis. It departs from the assumption that dryland ecosystems are not in equilibrium and extremely dynamic. Therefore, management should focus on forest ecosystems as providing a large diversity of resources niches in time and space for diverse groups of users, ranging from pastoralists to smallholders, men and women, indigenous peoples and caste. Rules of access and resource tenure should take account of this diversity.The aim of this book is to examine the management of dryland forests from the perspective of social diversity and the gender dimension. Globally, dryland forests have received much less attention from policymakers and scientists than permanent green forests in humid regions (Blackie et al. 2014). Yet, drylands occupy 41 % of the world’s land surface and host around 2 billion people (MEA 2005). The majority of the rural people whose livelihood is dependent on dryland forests belong to marginal groups such as women, youth, pastoralists and indigenous people. In general, dryland areas are regarded as problematic because of the combination of low rainfall, fast-increasing populations and what has been labelled unsustainable land use technologies, which are all said to contribute to extensive land degradation and desertification. Moreover, private investment has been limited, and whenever there are interventions they rarely benefit the local population. Trees and forests are a major component of dryland ecosystems despite the image to the contrary. Dryland forests and trees fulfil numerous functions underpinning the livelihoods of rural people and are important sources of income and products such as wood, fuel, fruits, fodder, fibres, incense, honey and even insects. These products contribute in a myriad of ways to local livelihoods, especially in times of drought and famine when agriculture and livestock-keeping become difficult.

Beach seine gear is one of the prominent fishing gears in Nile Perch fishery. Before Nile Perch was introduced to the lake, beach seines the species targeted with beach seine were Tilapia, Bagrus, Haplochromis, Protopterus and Labeo. In 1994, beach seines were banned in Tanzania and by 2004, this particular regulation and others, were harmonized and applied to the entire Lake as a result of implementation of Regional Plan of Action to Prevent, Deter and Eliminate Illegal, Unreported and Unregulated Fishing on Lake Victoria. The paper describes research findings on how the Nile Perch (NP) beach seine fishery is organized in Lake Victoria, Tanzania. The paper is guided by the following research questions: How is the Fisheries Department in Tanzania trying to govern the fisheries of Lake Victoria? How the beach seine fishery is governed in reality? What are the drivers for its continuity despite the ban? What are the counter-tendencies at local level and how and why do they emerge? We argues that it is the markets and associated graft – that drives coordination between the beach seine fishery; and the networks that depend on individuals’ network motivations – to get money, that together shape the fishery’s management and governance.

Background : Following the adoption of the Millennium Development Goal 4 (MDG 4) in Ghana to reduce under-five mortality by two-thirds between 1990 and 2015, efforts were made towards its attainment. However, impacts and challenges of implemented intervention programs have not been examined to inform implementation of Sustainable Development Goal 3.2 (SDG 3.2) that seeks to end preventable deaths of newborns and children aged under-five. Thus, this study aimed to compare trends in neonatal, infant, and under-five mortality over two decades and to highlight the impacts and challenges of health policies and intervention programs implemented. Design : Ghana Demographic and Health Survey data (1988–2008) were analyzed using trend analysis. Poisson regression analysis was applied to quantify the incidence rate ratio of the trends. Implemented health policies and intervention programs to reduce childhood mortality in Ghana were reviewed to identify their impact and challenges. Results : Since 1988, the annual average rate of decline in neonatal, infant, and under-five mortality in Ghana was 0.6, 1.0, and 1.2%, respectively. From 1988 to 1989, neonatal, infant, and under-five mortality declined from 48 to 33 per 1,000, 72 to 58 per 1,000, and 108 to 83 per 1,000, respectively, whereas from 1989 to 2008, neonatal mortality increased by 2 per 1,000 while infant and under-five mortality further declined by 6 per 1,000 and 17 per 1,000, respectively. However, the observed declines were not statistically significant except for under-five mortality; thus, the proportion of infant and under-five mortality attributed to neonatal death has increased. Most intervention programs implemented to address childhood mortality seem not to have been implemented comprehensively. Conclusion : Progress towards attaining MDG 4 in Ghana was below the targeted rate, particularly for neonatal mortality as most health policies and programs targeted infant and under-five mortality. Implementing neonatal-specific interventions and improving existing programs will be essential to attain SDG 3.2 in Ghana and beyond.

Background: Development of health policy is a complex process that does not necessarily follow a particular format and a predictable trajectory. Therefore, agenda setting and selecting of alternatives are critical processes of policy development and can give insights into how and why policies are made. Understanding why some policy issues remain and are maintained whiles others drop off the agenda is an important enquiry. This paper aims to advance understanding of health policy agenda setting and formulation in Ghana, a lower middle-income country, by exploring how and why the maternal (antenatal, delivery and postnatal) fee exemption policy agenda in the health sector has been maintained over the four and half decades since a 'free antenatal care in government facilities' policy was first introduced in October 1963. Methods: A mix of historical and contemporary qualitative case studies of nine policy agenda setting and formulation processes was used. Data collection methods involved reviews of archival materials, contemporary records, media content, in-depth interviews, and participant observation. Data was analysed drawing on a combination of policy analysis theories and frameworks. Results: Contextual factors, acting in an interrelating manner, shaped how policy actors acted in a timely manner and closely linked policy content to the intended agenda. Contextual factors that served as bases for the policymaking process were: political ideology, economic crisis, data about health outcomes, historical events, social unrest, change in government, election year, austerity measures, and international agendas. Nkrumah's socialist ideology first set the agenda for free antenatal service in 1963. This policy trajectory taken in 1963 was not reversed by subsequent policy actors because contextual factors and policy actors created a network of influence to maintain this issue on the agenda. Politicians over the years participated in the process to direct and approve the agenda. Donors increasingly gained agenda access within the Ghanaian health sector as they used financial support as leverage. Conclusion: Influencers of policy agenda setting must recognise that the process is complex and intertwined with a mix of political, evidence-based, finance-based, path-dependent, and donor-driven processes. Therefore, influencers need to pay attention to context and policy actors in any strategy.

Background and Objectives: This paper analyses why and how conflicts occur and their influence on doctors and nurse-anaesthetists' motivation in the provision of maternal and neonatal health care in a specialist hospital.Methodology: The study used ethnographic methods including participant observation, conversation and in-depth interviews over eleven months in a specialist referral hospital in Ghana. Qualitative analysis software Nvivo 8 was used for coding and analysis of data. Main themes identified in the analysis form the basis for interpreting and reporting study findings.Ethics Statement: Ethical clearance was obtained from the Ghana Health Service Ethics Review board (approval number GHS-ERC:06/01/12) and from the University of Wageningen. Written consent was obtained from interview participants, while verbal consent was obtained for conversations. To protect the identity of the hospital and research participants pseudonyms are used in the article and the part of Ghana in which the study was conducted is not mentioned.Results: Individual characteristics, interpersonal and organisational factors contributed to conflicts. Unequal power relations and distrust relations among doctors and nurse-anaesthetists affected how they responded to conflicts. Responses to conflicts including forcing, avoiding, accommodating and compromising contributed to persistent conflicts, which frustrated and demotivated doctors and nurse-anaesthetists. Demotivated workers exhibited poor attitudes in collaborating with co-workers in the provision of maternal and neonatal care, which sometimes led to poor health worker response to client care, consequently compromising the hospital's goal of providing quality health care to clients.Conclusion: To improve health care delivery in health facilities in Ghana, health managers and supervisors need to identify conflicts as an important phenomenon that should be addressed whenever they occur. Effective mechanisms including training managers and health workers on conflict management should be put in place. Additionally promoting communication and interaction among health workers can foster team spirit. Also resolving conflicts using the collaborating response may help to create a conducive work environment that will promote healthy work relations, which can facilitate the delivery of quality maternal and neonatal health care. However, such an approach requires that unequal power relations, which is a root cause of the conflicts is addressed.

Mobility is the most important response by the inhabitants of the Sahel to climatic adversity. This 'condition sahélienne', characterized by unstable climatic circumstances, irregular rainfall patterns and periods of drought, has an important influence on people's decision-making processes regarding their livelihood. Migration studies mainly focus on labour migration to urban areas. Although mobility is part of the repertoire of Sahelian people, the form it takes varies considerably between social groups and individuals, and over time. In this article we focus on a neglected and almost invisible category of rural-rural migrants in the Sahel, more specifically on Fulbe pastoral people and their developments over the last three decades in the Sahel and the Sudan zone of West Africa and the economic and social conditions in which they find themselves. It concludes that these rural-rural migrations are deeply engrained in cultural patterns in West Africa, exemplified by specific institutions for dealing with hosts and strangers. However, mobility is often not a planned process, and all kinds of survival strategies are used in a very flexible manner. The phenomenon has given rise to a specific character of cultural dynamics and ways of defining identify for the people involved.

Background: Although there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP ‘works’ when it is introduced into a district health system in Ghana, and whether or not it supports systems thinking in district teams. Methods: We undertook a realist evaluation to investigate the outcomes, contexts, and mechanisms of the intervention. Building on two working hypotheses developed from our earlier work, we developed an explanatory case study of one rural district in the Greater Accra Region of Ghana. Data collection included participant observation, document review, and semi-structured interviews with district managers prior to, during, and after the intervention. Working backwards from an in-depth analysis of the context and observed short- and medium-term outcomes, we drew a causal loop diagram to explain interactions between contexts, outcomes, and mechanisms. Results: The LDP was a valuable experience for district managers and teams were able to attain short-term outcomes because the novel approach supported teamwork, initiative-building, and improved prioritisation. However, the LDP was not institutionalised in district teams and did not lead to increased systems thinking. This was related to the context of high uncertainty within the district, and hierarchical authority of the system, which triggered the LDP’s underlying goal of organisational control. Conclusions: Consideration of organisational context is important when trying to sustain complex interventions, as it seems to influence the gap between short- and medium-term outcomes. More explicit focus on systems thinking principles that enable district managers to better cope with their contexts may strengthen the institutionalisation of the LDP in the future.

Maternal and neonatal deaths and morbidity still pose an enormous challenge for health authorities in Ghana, a lower middle income country. Despite massive investments in maternal and neonatal health and special attention through Millennium Development Goals (MDG) 4 and 5, Ghana still have high mortality rates. At national level, policy decision makers to improve maternal outcomes have over the years developed several public policies to increase financial and geographical access to maternal care; space child birth; provide essential obstetric care; expand midwifery coverage; make equipment available and many more. The problem of maternal mortality persist and this raises the question of what essentially goes into public policy making given the failure to achieve targets despite several maternal health policies developed for implementation. This thesis thus aims to advance our understanding of who makes maternal health policies and the agenda setting and formulation decision making processes through which they operate, in Ghana; and out of these understanding present potential lessons for policy actors to engage in making better informed policy decisions to improve maternal health. To understand factors and processes that influence national level maternal policy agenda and formulation decisions; we conceptualised that maternal policy decision making is predominately influenced by how policy actors within specific context use their power sources to define issues and frame accompanying course of action. The main research questions are: Which policy actors have been involved in maternal health policy agenda setting and formulation and what roles did they play and why?What are the decision making processes related to maternal health policy agenda setting and formulation?How did contextual factors influenced maternal health policy agenda setting and formulation and why?How did policy actors define maternal health issues and why? To investigate maternal policy agenda setting and formulation decision making in-depth, a multiple case study design with qualitative methods of data collection was used. The case study approach allowed me to look at maternal health policy decisions not merely as inputs and outputs but to better understand within context the processes and policy actors involved. Field work in the Ghanaian health sector, through observation and participation in the work of the Ministry of Health, steered the selection of the cases. Four cases: maternal (antenatal, delivery, and postnatal) fee exemption policy decisions, health sector programme of work maternal health policy decisions, free family planning as part of NHIS policy decision, and primary care maternal health service capitation policy decisions were investigated. The field work was conducted between May 2012 and August 2014. Multiple data collection methods including document review, interviews and observations were used to collect historical and current information and contribute to the validity and reliability of the research findings. Data were analysed drawing on an analytical framework in which concepts of organizational power, context, policy actors and problem definition were central elements. Case 1 Historical and contemporary fee exemption policies for maternal (antenatal, skilled delivery and postnatal) health services were explored. Specifically we ask: How have maternal user fee exemption policies evolved in Ghana since independence? Which actors have been involved in the policy agenda setting and formulation and why? What contextual factors influenced the process over time, how and why? Nine specific policies were identified along the pathway as, the policies evolved from user fee exemptions to national health insurance premium exemption. The policy was first introduced in 1963 and has remained on the government agenda over four and over decades in a fluid process of ebbs and flows rather than in a static fixed form. Contextual factors and various policy actors were the major influencers of the ebbs and flows. Contextual factors that influenced the ebbs and flows were: political such as Nkrumah’s ideology of free access to health care and education, changes in government, and presidential election year; economic crises and development partners’ austerity measures; worsening health and demographic indicators; historical events; social unrest; and international agendas such as the MDGs. These contextual factors served as a source of power for policy actors to sustain maternal fee exemption agenda over time. The case study showed that various categories of policy influencers (policy agenda advisers and advocates) and final decision makers (policy agenda directors and approvers) operated within these interrelated contextual factors, which sometimes worked as constraints and sometimes opened opportunities. These contextual factors shaped the timely manner in which policy content was formulated and level of deviation from the intended agenda at each specific decision period. For instance, contextual factors such as declined health budget allocation and high maternal mortality presented the ministry of health bureaucrats with an option to formulate the policy content in a less timely manner and away from the intended agenda of 1997 free maternal care presidential directive. Whilst, within the context of austerity measure and Ghana poverty reduction strategy, maternal fee exemption policy for four deprived regions was formulated in a timely manner and closely linked to the poverty strategy. Case 2 The case explored how and why maternal health policy and programme agenda items appeared and evolved in the framework of the Ghanaian health sector programme of work agenda between 2002 and 2012. Our specific research questions were: Which maternal health policies were prioritised? How did they evolve on the agenda and why? We examined decision maker’s problem definition and decision making processes, theorizing that a policy or programme’s appearance and fate on the POW agenda is predominantly influenced by how decision makers use their source of power to define problems and frame their policy narratives and accompanying course of actions. Ministry of health bureaucrats and donors used their power sources as negotiation tools to frame maternal health issues and design maternal health policies and programmes within the framework of the national health sector programme of work. The power sources identified included legal and structural authority; access to authority by way of political influence; control over and access to resources (mainly financial); access to evidence in the form of health sector performance reviews and demographic health surveys; and knowledge of national plans such as Ghana Poverty Reduction Strategy. Bureaucrats and donors used their power sources to define, frame and label issues for attention making some policies such as family planning long term fixtures on the agenda. They used labels such as ‘inadequate obstetric care’, ‘family planning unmet needs’, ‘maternal health a poverty issue’, and ‘poor maternal health a national emergency’ – for actions and to ensure the continuous flow of donor and government funding. Case 3 The case investigated how and why ‘free family planning as part of the NHIS’ policy attained a position on government agenda in 2012 but has not subsequently moved into formulation and implementation in Ghana. Relying on their power sources such as access to bodies of evidence; bureaucrats, donors, reviewers and reproductive health advocates framed inadequate budgetary allocation and disbursement for family planning and exclusion of family planning services from the national health insurance benefits package - as a major challenge to family planning contribution to maternal health care; and free family planning as potential life and cost saving. Drawing on their legal and structural access to institutionalized public policy processes in Ghana, they proposed the following policy options: include family planning service in the national health insurance benefits package and increase government and donor financial support. The interests of the supporting actors were two fold to eliminate out of pocket payments for family planning service and still sustain the financial needs of the family planning programme through the National Health Insurance Scheme. A window of opportunity opened when a Minister of Health receptive to these problem definitions and policy options publically voiced support for ‘free family planning as part of the NHIS; policy and therefore pushed it high and visibly onto the public policy /government agenda. However, the policy failed to move into formulation and implementation. Factors that influenced this failure included the lack of a stronger, broad based health sector actor support and related inability to agree on and develop policy implementation guidelines; and maintain political access and interest in the issue after it was moved up the agenda. Case 4 This case explored how and why less than three months into the implementation of a pilot prior to national scale up; primary care maternal services that were part of the basket of services in a primary care per capita national health insurance scheme provider payment system dropped off the agenda. During the agenda setting and policy formulation stages; predominantly technical policy actors within the bureaucratic arena used their expertise and authority for consensus building to get antenatal, normal delivery and postnatal services included in the primary care per capita payment system. Once policy implementation started, policy makers were faced with unanticipated resistance. Service providers, especially the private self- financing used their professional knowledge and skills, access to political and social power and street level bureaucrat power to contest and resist various aspects of the policy and its implementation arrangements – including the inclusion of primary care maternal health services. Arenas of conflict moved from the bureaucratic to the public as opposing actors presented multiple interpretations of the policy intent and implementation and gained the attention of politicians and the public. The context of intense public arena conflicts and controversy in an election year added to the high level political anxiety generated by the contestation. The President and Minister of Health responded and removed antenatal, normal delivery and postnatal care from the per capita package. Conclusions The general findings of the thesis are: (1) policy influencers (donors and bureaucrats) and final decision makers (Minister and President) used their power sources and contextual factors to define problems, promote their vested interest and justify actions and inactions; through technical, institutionalised, public and political decision making domains. (2) Policy influencers and final decision makers’ collective actions and inactions through interactions and power relations influenced decisions to their benefit at different levels. They used their control over and access to knowledge, authority and financial, material and human resources to push their interest and influence decisions. Therefore, this thesis concludes that the findings can serve as lessons for policy actors to strategize and make better informed policy decisions. We are in need of a health sector that pays more attention to context, power sources and power relations of final decision makers and influencers and the varied decision making domains in any maternal health policy decision.

The health of mothers and neonates is a concern for many countries, because they form the future of every society. In Ghana efforts have been made to address quality health care in order to accelerate progress in maternal and child health and reduce maternal and neonatal mortality through the implementation of a number of polices including a fee exemption for pregnant women for antenatal, delivery and postnatal care and a national health insurance scheme among others. However these interventions have not led to an improvement in the quality of health care and concerns have been raised whether health workers are sufficiently motivated to provide health care that is responsive to the needs of mothers and children. This study set out to study motivation as an individual quality of the worker, however it became obvious in the analytical phase that motivation is an outcome of interactions between the worker and the work environment. So the research resorted to analyse and understand the various ways in which interpersonal interactions and organisational processes contribute to the motivation of health workers and quality of care in a Ghanaian hospital setting. The research tried to answer the following questions: what are the interpersonal processes that influence health worker motivation; what are the organisational and managerial processes that influence health worker motivation; how does the setup of the Ghana health sector and its associated policies influence health worker motivation and how does health worker motivation influence health worker response to client health needs? The research focused on the quality of interpersonal interaction, such as attitudes, motivation, trust and conflict, on a number of organizational characteristics such as power relations, power being defined as the ability to affect organizational outcomes, uncertainty in decision-making and the provision of resources to deliver quality health care and on wider policy-making that affects the ability of health care institutions to take care of the staff (remuneration, human resource management) and the decision-making space of health facility managers. In order to investigate health worker motivation in a real life setting ethnographic research was conducted for twenty months in two hospitals; a specialist referral hospital and a district hospital that offer basic maternal and child health services in the greater Accra region in Ghana. Between 2011 and 2013, data was collected in mostly the maternity and new-born units of both hospitals. The researcher interacted with hospital staff including nurses, doctors, anaesthetists, orderlies, laboratory technicians, accounts officers and managers and collected data on daily activities and interactions in the hospital environment. The hospitals, which had different characteristics, were not selected for comparative purposes, but to enable a better understanding of how the organizational context influences worker motivation. Conversations were useful in helping the researcher to understand social phenomena. Interviews were conducted to explore social phenomena in depth. Participant observation was also a very important tool in helping the researcher to observe at first- hand how health care is provided in a natural hospital environment. An important source of information consisted of the reactions of hospital staff on the research and the researcher and the researcher’s emotional reactions to this, as it helped her to experience motivation, which was very useful in understanding and analysing motivational processes in the hospital environment. Ethical clearance was obtained from the Ghana Health Service Ethics Review board (approval number GHS-ERC:06/01/12) and the proposal was reviewed by the Wageningen School of Social Sciences board. Written informed consent was obtained from all interview participants. Verbal consent was obtained for conversations and pseudonyms are used for the names of the study hospitals and frontline workers throughout the thesis. Interpersonal processes including limited interaction and communication between collaborating frontline workers and perceived disrespect from colleagues and managers contributed to poor relations between frontline workers. A high number of frontline workers engaged in locum (private practice) in private hospitals. Such workers came to work late, or left early and some even skipped their official work to engage in locum practice. Workers also believed that some of their colleagues sneaked in their clients from their locum site to the hospital and charged them illegal fees, which they did not share with colleagues. Such practices and perceptions contributed to distrust relations among workers and to a poor organisational climate, which resulted in demotivation of staff, poor collaboration in the provision of health care, and eventually to conflicts. Conflicts contributed to delays in the provision of care and those who were willing to work felt disempowered, as they were unable to marshal their resources with collaborating professionals to respond to clients’ needs. They also contributed to angry and bitter workers and negative perceptions of other professional groups. Sometimes cases were postponed and on some occasions clients had to be referred to other facilities. Organisational and managerial processes equally influenced health worker motivation in various ways. Health workers perceived distributive, procedural and interactional injustice in organisational and managerial processes as they perceived that managers were not responding to their personal and organisational needs, which compromised their ability to offer quality health care. Health workers perceived distributive injustice in the fact that they worked hard and deserved to be given incentives to offset the stoppage of bonuses that the government initially paid to workers when the fee exemption for maternal health was introduced. Workers felt their managers were not meeting the hospitals’ needs for essential medical supplies, equipment and were incapable of putting up appropriate infrastructure to accommodate workers and an overwhelming number of clients. They perceived interactional injustice because of the fact that managers did not communicate with them on decisions that affected them and that managers were out of touch with the needs of workers. They complained that they were not respected by their superiors, who shouted at them when they made mistakes, and suggested that managers and superiors did not treat them with dignity in matters of discipline. Workers further argued that managers did not care whether they had adequate workforce to support them to provide quality health care. Some felt overworked and some felt burn out. However, managers felt disempowered at their level as well. The setup of the Ghana health sector and its associated policies remains largely centralised, so managers who are expected to meet the needs of frontline health workers and their hospitals, do not have the power to do so. They could not beef up staff numbers, since recruitment and allocation of staff to health facilities is centralised. In addition, managers received little financial support to run their hospitals. Their main source of funding was from reimbursement of funds from the National Health Insurance Authority, but reimbursement usually delayed for up to six months and they did not receive subvention from the Ghana Health Service or the Ministry of Health (MOH) to run their hospitals, so they were always cash strapped. Also the MOH, which is the body responsible for putting up infrastructure, could not meet the infrastructure needs of the hospitals. Additionally managers had to deal with conflicting policies including procurement policies that made decisions on purchasing essential supplies and drugs bureaucratic and slowed managers’ response to frontline worker and organisational needs. As a result, managers faced uncertainty in securing human and physical resources. To cope with uncertainties managers had to distribute their funds thinly among competing priorities of worker and organisational needs. At times managers had to sacrifice certain needs of workers and their hospitals in order to meet others. Consequently, workers lost trust in managers, which demotivated them in the provision of health care. Also the fee exemption policy made health care accessible to the general populace, but it did not lead to a commensurate increase in salaries, infrastructure development and increase in staff numbers. For that matter managers and frontline workers were overwhelmed with client numbers and had to turn some away. Both hospital managers and frontline workers perceived that policy makers and their superiors were not interested in how they provided care to clients or even their own safety, which demotivated them. It is important to note that some workers were observed to be intrinsically motivated and responded to the health needs of clients, despite the fact that they faced similar challenges as those who were demotivated. Such workers explained that their sources of motivation included a belief in a supreme being, the desire to maintain work standards and others perceived that clients had a right to quality health care. Also some indicated that they derived inner satisfaction when they were able to provide quality care to clients. Demotivation contributed to absenteeism, workers reporting to work late and some closing early as strategies to avoid collaborating with colleagues that they did not feel comfortable working with, which further worsened the conflict situation. Some workers also picked and chose to work with particular professionals. Workers exercised power negatively in two ways: 1. Some workers exhibited negative attitudes towards their colleagues, which contributed to poor interaction and poor communication. It further created gaps in clinical decision making. 2. Workers transferred their frustrations and disappointments to clients by shouting at clients and insulting them, which compromised with the quality of care that clients received. Another important consequence of demotivation was that workers got angry, some felt frustrated, and some reported experiencing high blood pressure. Consequently it affected the wellbeing of health workers who were supposed to cater for clients. Also demotivation became so deeply seated in some workers that they appeared to be beyond redemption. Some even hated the hospital environment that they worked in and others chose to leave the hospital. For health workers to be able to respond to the health needs of clients who visit the hospital there is the need that their personal needs including demand for better terms and conditions of service, incentives and training needs are catered for. Also their organisational needs including demand for essential supplies, equipment, appropriate infrastructure among others need to be addressed. Additionally managers have to be transparent, communicate and interact more frequently with frontline workers to enable them appreciate managers’ efforts in meeting workers’ personal and organisational needs. Also for managers to be able to meet the needs of frontline workers and their organisations managers must be given the power to make decisions on human and other resources. Also managers should be supported with the necessary funds, so that they can meet the multiple needs of their workers and hospitals. Health worker motivation in the hospital context is determined by an interaction of interpersonal and organisational processes that are shaped by external and internal influencers, who exercise power in their bid to influence organisational outcomes. Thus this study contributes to theory by propounding that motivation is not an individual quality of the worker, but it is an outcome of interactions between the worker and the work environment. Also power and trust relations within and outside the hospital influence worker motivation and for that matter theories on organisational power and trust relations are central to understanding and analysing worker motivation.

Health system governance has to do with decision-making – who makes decisions, when, where, how and why. At the district level – the level of care which operationalises health policies – governance is critical, yet remains little understood. Governance has the ability to influence health system performance, and this is essential in maternal and newborn health, where timely decisions are required to support policy implementation. In this regard, district managers are particularly important. They are the link in the middle of the health system, connecting top-end policy formulation to bottom-end implementation. Their abilities to interpret, translate, support and challenge policy will have an effect on what gets operationalised. However, capacity weaknesses in district management and leadership are often cited as a factor in poor health system performance. This thesis seeks to deepen understandings of district-level management, leadership and decision-making for policy and programme management and implementation for maternal and newborn health. Within this, the thesis also seeks to understand the scope for change that an intervention to strengthen management and leadership capacities can bring. This thesis contributes to the applied field of health policy and systems research by drawing on policy implementation theory, organisational management theory and complexity theory as its theoretical basis. A realist approach methodology was undertaken to understand the contexts in which district managers are embedded, how this influences their decision-making, and what the effects of a managerial intervention are, given these contexts. The thesis followed an embedded case study flexible design. The first case study was an exploratory qualitative case study to understand how and why district managers make decisions in maternal and newborn health policy implementation. The second case study was an historical case study of district manager decision-space over time. The third case study was an explanatory qualitative case study of the management and leadership intervention. The final validation of our theorising throughout the cases was achieved through the administration of a questionnaire across all district health management teams of the Great Accra Region. This thesis demonstrates that district managers find themselves in contexts of strong hierarchical authority and resource uncertainty – in particular, lacking financial transparency. This promotes a management and leadership typology which attunes managers towards serving the health system bureaucracy, resulting in reduced district-level responsiveness to maternal and newborn health challenges. The outcome is that district manager decision-space is narrow surrounding resource allocation decisions, and this in turn affects local planning programming and management. The thesis further demonstrates that broader patterns of centralised governmental decision-making have affected the development of the district health system over time. Particularly, the sequencing of decentralisation processes has ensured that national-level decision-making has remained empowered in contrast to district-level decision-making. System fragmentation – through reduced Government of Ghana funds and increasingly verticalised donor funds – has also been a contributor. This accounts for the observed hierarchical authority and resource uncertainty which affects district managers. As a result of these contexts, this thesis also showed that an intervention to strengthen management and leadership capacities was limited in its sustainability. This thesis raises the issues of health system organisation as critical to the potential of district management and leadership effectiveness. It provides evidence that weaknesses in district management and leadership arise out of the organisational governance mismatches in autonomy and responsibility. It suggests that in strengthening management and leadership, approaches which seek to address organisational capacities, not only individual capacities, are needed to convey sustainable change. Advancements in this regard have the scope to improve district manager decision-making for maternal and newborn health policy and programme implementation in the future.

Contesting Control: Land and Forest in the Struggle for Loita Maasai Self-government in Kenya Angela Kronenburg García Contesting Control is about the Loita Maasai in Kenya who, faced with increasing outside interventions and pressure from neighbouring communities, the state and other agencies, have been struggling to maintain access and control over the land they inhabit and the forest they use. They have been on the losing side in territorial struggles with neighbouring Purko Maasai and (non-Maasai) Sonjo. However, with regard to the state, NGOs and environmental organizations, the Loita have successfully navigated policies and projects and retained access and control of their land and forest. Interventions have, nevertheless, changed the way people engage with the land and forest and with each other on these issues. This study investigates the (in)direct effects of interventions and how they have articulated with existing relations, practices, processes and struggles in Loita. It considers the state-led land adjudication programme of the 1960s that sought to convert Kenya’s pastoral lands into privately owned group ranches, the attempt by Narok County Council to turn the Naimina Enkiyio Forest into a nature reserve for tourism in the 1990s, and a forest co-management project carried out by IUCN in the early 2000s. This volume captures the process of property-in-the-making and socio-political change among the Loita Maasai as they struggle for autonomy and self-government.

Thesis abstract The thesis explored how the global market for Nile Perch fish has reconfigured the social and the natural in dramatic ways. The demand for Nile Perch and Dagaa played, willingly or unwillingly, an important role in converting its products into regionally and globally desired commodity. It has also simultaneously restructured the organisation of fisheries into a complex and aggressively managed sector. In fishing and fish trade, one needs to externalize costs and risks to the lower actors in the production and business hierarchy. From an historical point of view, power has shifted from many points of coordination and decision making into a few hands, those that own fishing camps and export processing factory. Moreover, illegal fishing and trading are continuous and corruption is rife to safe guard individual interest in turn shaping the local practices (governance) of Lake Victoria. Finally the debate about fisheries policies and fisheries regulation in L. Victoria does not address local realities and are largely irrelevant and that the real focus of power and driver of change is the international and regional markets for Nile Perch and Dagaa and global players with a lot of capital.