OBJECTIVES This paper examines policy implementation gaps of user fees plus exemptions and health insurance in providing financial access to primary clinical care for children under five in Ghana.   
 METHODS Methods included analysis of routine data, focus group discussions, in-depth interviews, and administration of a structured questionnaire.   
 RESULTS Providers modified exemptions policy implementation arrangements, sometimes giving partial or no exemptions. Clients who knew or suspected exemption entitlements failed to request them because of fear of negative reactions from providers. Providers attributed their modification of implementation arrangements and negative reactions to the threat posed to the financial viability of their institutions by reimbursement uncertainty and delays. At the time of the study insurance coverage was low and frontline workers were not noticeably modifying implementation arrangements. However, the underlying goal conflicts, resource scarcity, conditions of work and relationships between frontline workers and clients that fueled the exemptions policy implementation gaps were unchanged. The potential for the health insurance policy to stumble over implementation gaps as happened with the exemptions policy therefore remained.   
 CONCLUSIONS Policies that do not take into account the incentives for frontline worker adherence and align them better with policy objectives may experience implementation gaps.
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