MAXIMIZING POSITIVE SYNERGIES - World Health Organization

Objectives and Methodology
The data collection for this case study included semi-structured interviews, field observations, and
examination of secondary data sources. Key informant interviews were conducted in a semistructured
fashion using a set of interview questions based on the Systemic Rapid Assessment
toolkit (SYSRA) and adapted to the analysis of integration of health interventions [8],[9]. Our
analysis focused on the HIV/AIDS and TB programmes at the central, regional and district levels.
We conducted a total of 40 individual and group interviews, selected purposively or by
snowballing to include a diverse range of implementers, policymakers, and partners. Two
conveniently selected districts in the neighbouring western region of the capital were visited, and
the regional and district health management staff, programme nodal officers and managers of
health facilities were interviewed.
The relevant portions of the interview were roughly coded to chart data to the health system
function. Secondary data sources (e.g. national strategy papers, annual reports, evaluation reports,
Global Fund proposals) were analysed in a similar thematic way. Primary and secondary data
sources were compared for internal validation of findings.
Results
Leadership and Governance
As part of the wider health sector reform process initiated in the mid 1990s, the government
undertook structural reorganization along the lines of a purchaser-provider split with the MOH as
the purchaser and regulator of service provision. Responsibility for service provision belongs to the
Ghana Health Services (GHS - the main service provider), along with the teaching
hospitals/specialized institutions, quasi government organizations, and the private sector
including non-governmental organizations (NGOs) and the traditional system.
As one of the beneficiaries of the enhanced HIPC Initiative, Ghana has benefited from large inflows
of external resources, accounting for nearly 30% of total health expenditure in 2003 and around
22% in 2006. Policymakers recognized the need to develop strategies for better donor
coordination in the context of an overall health sector policy set by the MOH, while protecting
national systems against the proliferation of parallel structures. To this end, the government
adopted SWAp, setting the stage for the development of a sector strategy that would embrace all
sources of funds and form the basis of planning and resource allocation by both the MOH and
donor partners. This initiated the medium-term strategic framework. The country is currently
implementing its third strategic framework (2007-2011), ‘Creating Wealth Through Health’, with
the goal of making Ghana a middle income country by 2015.
Common management arrangements; systems for partner coordination for the development and
implementation of an annual programme of work; and evaluation of progress against a set of
universally agreed benchmarks or targets, led to a gradual, systematic integration of donor
projects into a sector programme. At the centre of all these reforms was the strategic leadership
offered by the government, notably the MOH.
Against this background, Global Fund projects have been seamlessly integrated into the existing
systems, with Global Fund support viewed as a source of earmarked funds for AIDS/TB/Malaria, in
line with national strategic objectives. On the other hand, the creation of the CCM for grant
proposal preparation and monitoring of grant performance has been less successful, and is viewed
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