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\begin{document}

\title{Overcoming the constraints of competitive clientelism? Explaining the
success of Ghana's Poorest Region in Reducing Maternal Mortality.}



\author[1]{ABDUL-GAFARU ABDULAI}%
\affil[1]{University of Ghana Business School}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\begin{abstract}
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 \emph{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.%
\end{abstract}%



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