Start-stop funding, its causes and consequences: a case study of the delivery exemptions policy in Ghana


  • Sophie Witter,

    Corresponding author
    1. IMMPACT programme, University of Aberdeen, AB25 2ZD UK
    • IMMPACT programme, University of Aberdeen, AB25 2ZD UK.
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    • Sophie Witter is a health economist, working as a research fellow at the University of Aberdeen, with the IMMPACT programme, as well as carrying out consultancies. She is doing a PhD on the impact of fee exemptions for delivery care.

  • Sam Adjei

    1. IMMPACT programme, University of Aberdeen, AB25 2ZD UK
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    • Sam Adjei is a health system specialist. He is currently based in Aberdeen University as a Visiting Professor, working with the Initiative on Maternal Mortality Assessment (IMMPACT) as a policy adviser in residence.

  • We declare that we have participated in the design, implementation, analysis and writing of this article and that we have seen and approved the final version. We also declare that we have no conflict of interest in connection with this paper.


This article looks at the issue of sustaining funding for a public programme through the case study of the delivery exemptions policy in Ghana. The Government of Ghana introduced the policy of exempting users from delivery fees in September 2003 in the four most deprived regions of the country, and in April 2005 it was extended to the remaining six regions in Ghana. The aim of the policy of free delivery care was to reduce financial barriers to using maternity services. Using materials from key informant interviews at national and local levels in 2005, the article examines how the policy has been implemented and what the main constraints have been, as perceived by different actors in the health system. The interviews show that despite being a high-profile public policy and achieving positive results, the delivery exemptions policy quickly ran into implementation problems caused by inadequate funding. They suggest that facility and district managers bear the brunt of the damage that is caused when benefits that have been promised to the public cannot be delivered. There can be knock-on effects on other public programmes too.

Despite these problems, start-stop funding and under-funding of public programmes is more the norm than the exception. Some of the factors causing erratic funding—such as party politics and intersectoral haggling over resources—are unavoidable, but others, such as communication and management failures can and should be addressed. Copyright © 2007 John Wiley & Sons, Ltd.