Health Sector Decentralization in Ghana Exploring the Implementation Challenges at the Hospital ...

181 Pages·2015·8.15 MB·English

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UNIVERSITY OF GHANA

HEALTH SECTOR DECENTRALIZATION IN GHANA:
EXPLORING THE IMPLEMENTATION CHALLENGES AT THE
HOSPITAL LEVEL

BY
FRANCIS ADANE
(10245289)

A THESIS SUBMITTED TO THE DEPARTMENT OF PUBLIC
ADMINISTRATION AND HEALTH SERVICES MANAGEMENT, UNIVERSITY
OF GHANA BUSINESS SCHOOL, UNIVERSITY OF GHANA, LEGON IN
PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF AN
MPHIL IN HEALTH SERVICES MANAGEMENT DEGREE

JUNE, 2015
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DECLARATION
I do hereby declare that this work is the result of my own research and has not been
presented by anyone for any academic award in this or any other university. All references
used in the work have been fully acknowledged. Nonetheless, I bear sole responsibility for
all errors and omissions inherent in the study.

………………………… ………………………
FRANCIS ADANE DATE
(10245289)

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CERTIFICATION
I hereby certify that this thesis was supervised in accordance with the procedures laid
down by the University of Ghana.

……………………………………... ………………………
GORDON ABEKA- NKRUMAH DATE
(SUPERVISOR)

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DEDICATION
I dedicate this work solely to my mother, Veronica Abenaa Twenewaa for her vast
contributions and unwavering support to my well-being in the course of my academic
career.

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ACKNOWLEDGEMENT
Firstly, I thank GOD ALMIGHTY for giving me the strength, knowledge and guidance to
complete this thesis. To my supervisor Dr. Gordon Abekah Nkrumah, I keenly appreciate
your unflinching attention, encouragement and critical evaluation of this thesis. I would
also like to acknowledge the efforts of Dr. Justice Bawole, head of department, Dr. Albert
Ahenkan and all the staff of the department of Public Administration and Health Services
Management for their priceless and intuitive contributions on this thesis right from the
beginning.
I am also appreciative of my family, my late father Mr. Simon Adane, my mother Mrs.
Veronica Abenaa Twenewaa and my siblings Peter, Felicia, Monica, Mary, and Victoria
for their constant support and counsel. Not forgetting Papa Kwaku Adane- Adjei and
Kwarteng Adjei for their entertainment in times of stress and boredom. Finally, I say
ayekoo to Maureen Ansah for her support throughout this program.
To my friends Emmanuel, Acheaw, and Smith I am very grateful to you for your advice
and encouragement. Finally I am indebted to all friends and family members who in
diverse ways helped to make this thesis successful.

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TABLE OF CONTENTS
Content Page
DECLARATION .......................................................................................................................... i
CERTIFICATION ....................................................................................................................... ii
DEDICATION ............................................................................................................................ iii
ACKNOWLEDGEMENT .......................................................................................................... iv
TABLE OF CONTENTS ............................................................................................................. v
LIST OF TABLES ...................................................................................................................... ix
ABSTRACT ................................................................................................................................. x
CHAPTER ONE .......................................................................................................................... 1
1.1 Background of the study ........................................................................................................ 1
1.2 Problem statement .................................................................................................................. 5
1.3 Objectives of the study ........................................................................................................... 7
1.4 Research questions ................................................................................................................. 8
1.5 Significance of the study ........................................................................................................ 8
1.6 Chapter Disposition ................................................................................................................ 9
CHAPTER TWO ....................................................................................................................... 11
REVIEW OF LITERATURE .................................................................................................... 11
2.1 Introduction .......................................................................................................................... 11
2.2 The Concept of Decentralization ......................................................................................... 11
2.3 The historical review of current decentralization policies ................................................... 15
2.3.1 Developed economies ....................................................................................................... 15
2.3.2 Developing economies ...................................................................................................... 16
2.4 Theoretical Framework ........................................................................................................ 17
2.4.2Operational definition of the variables ............................................................................... 20
2.4.3 Decentralization implementation process; an empirical review ....................................... 21
2.4.4 Policy process ................................................................................................................... 23
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2.4.5 Agenda setting and policy formulation ............................................................................. 26
2.4.8 Empirical review of the link between Decentralization and some key reform
measures for its successful implementation ....................................................................... 29
CHAPTER THREE .................................................................................................................... 57
DECENTRALISATION IN GHANA ....................................................................................... 57
3.1 History of Decentralisation in Ghana ................................................................................... 58
3.2 General Legal Regulatory Framework and revolution of Decentralisation in Ghana ......... 65
3.3 Review of the status of health sector decentralisation in Ghana .......................................... 72
3.6.1 Historical development of the hospital ............................................................................. 78
3.7 Justification of the study areas ............................................................................................. 80
3.8 Conclusions .......................................................................................................................... 80
CHAPTER FOUR ...................................................................................................................... 82
RESEARCH METHODOLOGY ............................................................................................... 82
4.1 Introduction .......................................................................................................................... 82
4.2 Research Methods ................................................................................................................ 82
4.2.1Research Paradigm ............................................................................................................. 82
4.3 Research Design ................................................................................................................... 83
4.3.1 Sources of Data ................................................................................................................. 83
4.3.2. Sampling/ Target population ............................................................................................ 84
4.3.3 Instruments for data collection .......................................................................................... 84
4.3.4 Data collection process ..................................................................................................... 85
4.3.5 Data management and analysis ......................................................................................... 85
4.3.6 Reliability and Validity ..................................................................................................... 86
4.3.7 Ethics ................................................................................................................................. 87
4.3.8 Limitations of the study .................................................................................................... 87
4.4 Summary .............................................................................................................................. 87
CHAPTER FIVE ........................................................................................................................ 88
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PRESENTATION OF FINDINGS ............................................................................................ 88
5.1Introduction ........................................................................................................................... 88
5.2 Description of findings ......................................................................................................... 88
5.3 Implementation challenges of decentralization at the hospital level ................................... 88
5.3.1 Funding ............................................................................................................................. 88
5.3.2 Communication barrier between key policy implementers .............................................. 90
5.4 Important contextual factors taken into consideration before decentralization at the
hospital level ....................................................................................................................... 95
5.5 Implementation status of some key reform measures of decentralization at the hospital
level .................................................................................................................................... 97
5.6 Summary of implementation status and major gaps of some selected policy reform
measures of decentralization at the hospital level ............................................................ 105
5.7 Summary ............................................................................................................................ 106
CHAPTER SIX ........................................................................................................................ 107
DISCUSSION OF RESULTS .................................................................................................. 107
6.1 Introduction ........................................................................................................................ 107
6.2 Implementation challenges ................................................................................................ 107
6.3 Important contextual factors taken into consideration before decentralization at the
hospital level. .................................................................................................................... 122
6.3.1 Socio-economic potential ................................................................................................ 124
6.3.2 Unequal endowment of local capacity ............................................................................ 127
6.3.3 Geographical factors ....................................................................................................... 129
6.3.4 Cultural factors and ethnic diversity ............................................................................... 132
6.4 Implementation status of some key decentralization reform measures ............................. 135
6.4.1 Policy issues and objectives ............................................................................................ 135
6.4.2 Organisational reform ..................................................................................................... 137
6.4.3 Planning and financing .................................................................................................... 139
6.4.4Human resource and capacity issues ................................................................................ 143
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6.4.5Inter- sectoral coordination .............................................................................................. 146
CHAPTER SEVEN .................................................................................................................. 149
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS ........................................... 149
7.1 Introduction ........................................................................................................................ 149
7.2Summary of Findings .......................................................................................................... 149
7.3 Conclusions ........................................................................................................................ 150
7.4 Recommendations from the study ...................................................................................... 153
7.5Contributions of the study ................................................................................................... 155
7.5.1Theory .............................................................................................................................. 155
7.5.2Policy ............................................................................................................................... 155
7.6 Suggestions for future research .......................................................................................... 156
REFERENCES ......................................................................................................................... 158
APPENDICES ......................................................................................................................... 169
Appendix A: Interview guide for key policy implementers at the hospital level .................... 169
Appendix B: Facility observation checklist ............................................................................. 170

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LIST OF TABLES
Table 5.6 Summary of implementation status and their major gaps for some key
Reform measures………………………………………………………………….. 105

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