Paper short abstract:

This paper explores the drivers behind the generation of maternal health user-fee policies in West Africa, in particular whose voices are heard and the dynamics and tensions between international and local aims, agendas and evidence.

Paper long abstract:

To decrease maternal mortality rates, increase facility delivery and reduce financial burdens on women, policy makers in several African countries have recently instituted user fee reduction or exemption plans in maternal health care. Less attention in the literature has been paid to how these policies came to be generated (Meesen et al 2009, among others), instead, more has been written about their implementation and impact. One of the aims of the FEMHealth project was to go beyond policy content and “what happened” and explore the often neglected question of “what explains what happened”(Gilson & Raphaely 2008). This paper is based on global level interviews with actors in maternal health policy and financing, and draws on further case study research in Benin, Burkina Faso, and Morocco – all countries that have recently initiated policies in this domain.

Analysis suggests that while international influences have been important in shaping the global climate which permeates the three countries, decision-making was created in a context of locally driven goals and objectives. Having gone in a circle from free health care, to user fees, and now to selective fee removal policies, donor advice was given a new rank – one that became devalued as aid-dependent countries rallied for technical and financial support from other sources. This paper explores how a few key individuals were able to establish roles that brought about policy changes at both local and international levels, and what this can tell us about the ways in which ideas and ideologies are translated into policies.