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The Impact of HIV and AIDS Funding and Programming on Health System Strengthening in Ghana. Health System Research Series No. 3.

Authors:
i
KIT Development Policy & Practice
Adjei S, Nazzar A, Seddoh A, Blok L, Plummer D.
THE IMPACT OF HIV AND AIDS FUNDING AND PROGRAMMING ON
HEALTH SYSTEM STRENGTHENING IN GHANA
Health System Research Series No. 3 October 2011
ii
Royal Tropical Institute / Koninklijk Instituut voor de Tropen (KIT)
Development Policy & Practice
The Health System Research Series of the Royal Tropical Institute (KIT) presents
key ndings on current themes in international health system research to a multi-disciplinary
forum of policy makers, scientists, and management and development advisors conducting
international health and system research.
The Royal Tropical Institute (Koninklijk Instituut Voor de Tropen) in Amsterdam, the Nether-
lands, is an international institute, which specializes in the generation and sharing of knowl-
edge and expertise through institutional cooperation. The objectives of KIT are to contribute
to sustainable development to reduce poverty, preserve encourage the exchange of culture
diversity and disseminate this information to further these goals.
This Health System Research Series report was produced under the direction of:
Jenniskens F, Oosterhoff P, Tiendrebeogo G, Wolmarans L.
Royal Tropical Institute / Koninklijk Instituut voor de Tropen (KIT)
KIT Development, Policy and Practice
PO Box 95001, 1090 HA Amsterdam, Pays-Bas
Website: www.kit.nl
Text Edited by:
Martha Ann Overland
Design:
Sietse Bras, Dutch Portfolio
Partner organizations for this publication:
Center for Health and Social Services, Ghana
Royal Tropical Institute (KIT), Amsterdam
Co-investigators:
Fuseini Satara, Center for Health and Social Services, Ghana
Elvis Akpabli, Center for Health and Social Services, Ghana
Benedicta Bentum, Center for Health and Social Services, Ghana
Senu Nyanyovor, Center for Health and Social Services, Ghana
Suggested citation:
Adjei S., Nazzar A., Seddoh A., Blok L., Plummer D. (2011). The Impact of HIV and AIDS Fund-
ing and Programming on Health System Strengthening in Ghana. Health System Research Se-
ries No. 3. Edited by Jenniskens F., Oosterhoff P., Tiendrebeogo G., Wolmarans L. Royal Tropical
Institute (KIT), Amsterdam, 2011.
Copyright 2011:
KIT, Amsterdam, Pays-Bas KIT, Amsterdam, Pays-Bas
Acknowledgements
Funding for this case study was generously provided by the Netherland’s Ministry of Foreign Affairs, the STOP AIDS NOW partnership in the
Netherlands (ICCO, Hivos, Cordaid, Oxfam-Novib and Aids Fonds), Cordaid and the Global Fund to Fight Aids TB and Malaria (GFATM).
We are grateful to Ghana’s Ministry of Health (MoH), especially Mr. Emmanuel Owusu-Ansah, the point person for the study, for his tre-
mendous support. We would also like to thank the Ghana Health Service for its support through the National AIDS Control Programme, and
representative Dr. Stephen Addo and Deputy Director for Policy, Dr. Carolyn Jehu-Appiah.
We are grateful to the research team, which included Dr. Diana Baah-Odoom, who conducted the desk review; Mr. Dan Osei for his nancial
analysis; and Dr. Edith Tetteh, Mrs. Mercy Abbey and Mrs. Edith Wellington, the team’s social scientists. We also acknowledge the contribution
of the research advisory committee whose insights helped guide this work. Many people have contributed to this study. We wish to thank all the
data collectors and the people who helped with transcriptions and coding of the interviews. A special word of thanks goes to Thyra de Jongh for
scientic contributions, to Caroline Grillot and Christel Jansen for additional research and language and to Bart Vreeken for additional formatting.
Many thanks go to all the health professionals and community members who gave their valuable time to be interviewed and thus contributed to-
wards the successful completion of this work.
iii
Table of Content
Table of Content iii
Acronyms and abbreviations iv
Preface v
Synthesis of the multiple country study results vi
Key results and discussion Ghana xiv
Ghana Case study
1. Background to the Ghana Case study 1
1.1 Country context 1
1.2 General health prole 1
1.3 Overview of the health sector 5
1.4 The HIV and AIDS response in Ghana 8
2. Research Objectives 11
3. Methodology 12
4. Results 13
4.1 Alignment of (real and perceived) priority health needs, demands and supply 13
4.2 Interaction between the HIV and AIDS response and the health system 14
5. Discussion 23
6. Conclusion 26
7. Policy implications and emerging issues 27
Annex 28
References 29
Figures and tables:
Figure 1: The HIV prevalence, health expenditures and AIDS budgets
of ve sub-Saharan African countries that participated in the study. vii
Figure 2: Sampling framework within the countries ix
Figure 3: Map of Ghana 1
Figure 4: Maternal mortality ratio (surveys), recent and projected 2
Figure 5: Institutional Structure of Ghanaian public health services 5
Figure 6: Ghana health expenditure as a proportion of GDP 7
Figure 7: External resources for health as a percentage
of total health expenditure 7
Figure 8: Proportion of HIV sero-positive individuals among people who
participated in counselling and testing (CT) and PMTCT activities,
2007 - 2009 8
Figure 9: Global Fund contributions to HIV and AIDS nancing in Ghana:
2002 - 2010 10
Table 1: Number and interviews per country ix
Table 2: Top ten reasons for visits to outpatient departments in Ghana, 2009 3
Table 3: Selected national indicators 4
Table 4: Summary of selected donor funding 2002–2006 7
Table 5: Total Spending on Key Priorities or Intervention Areas, 2007 9
Table 6: Overview of selected communities 28
Table 7: Prole of district and national level respondents 28
Table 8: Interview Session lengths 28
Table 9: Data collection timing 28
Table 10: Total Number of Interviews 28
iv
AIDS Acquired Immune Deciency Syn-
drome
ART Anti Retro-Viral Therapy/Treatment
CSWs Commercial Sex Workers
CHAG Christian Health Association of Gha-
na
CT Counseling and Testing
CBOs Community Based Organizations
CSOs Civil Society Organizations
CL Community Level
CM Community Member
CHPS Community-based Health Planning
and Services
DANIDA Danish Development Association
DFID Department for International Devel-
opment
DPs Development Partners
DHS District Health System
DL District Level
DOTs Directly Observed Treatment
DHMT District Health Management Team
FGD Focus Group Discussion
FHI Family Health International
GAC Ghana AIDS Commission
GHS Ghana Health Service
GSS Ghana Statistical Service
GDHS Ghana Demographic and Health Sur-
vey
GHAFUND Ghana AIDS Response Fund
GoG Government of Ghana
GFATM Global Fund for AIDS, Tuberculosis
and Malaria
GAVI Global Alliance for Vaccines and Im-
munizations
HIV Human Immune Virus
HSMTDP Health Sector Medium Term Devel-
opment Plan
HSS Health System Strengthening
HRD Human Resource Department
HW Health Worker
HIRD High Impact Rapid Delivery
ITNs Insecticide- Treated Bed-Nets
IGF Internally Generated Funds
LMS Logistic Management System
KI Key Informant
KBTH Kole-Bu Teaching Hospital
MOH Ministry Of Health
MSMs Men having Sex with Men
MOFEP Ministry of Finance and Economic
Planning
MDBs Multi-Donor Budget Support
MDGs Millennium Development Goals
MTHS Medium Term Health Strategy
NACP National AIDS Control Program
NDPC National Development Planning
Commission
NHIS National Health Insurance Scheme
NHIA National Health Insurance Authority
NL National Level
NGO Non Governmental Organization
NIA National Identication Authority
OPD Out-Patient Department
PoW Programme of Work
PLHIV People Living With HIV/AIDS
PMTCT Prevention of Mother to Child Trans-
mission
PEPFAR President’s Emergency Plan for AIDS
Relief
QPH Quality Health Partners
KIT Royal Tropical Institute
RBM Roll Back Malaria
RH Reproductive Health
RCH Reproductive and Child Health
STI Sexually Transmitted Infections
SWAP Sector Wide Approach
SBS Sector Budget Support
SHARP Strengthening HIV/AIDS Response
Partnerships
SOPs Standard Operating Procedures
TFR Total Fertility Rate
TB Tuberculosis
TBA Traditional Birth Attendants
UNAIDS The Joint United Nations Program on
HIV/AIDS
USAID United States Agency for Interna-
tional Development
USG United States Government
UNICEF United Nation’s Child Education Fund
UNFPA United Nations Population Fund
VRA Volta River Authority
WHO World Health Organization
Acronyms and abbreviations
v
Preface
The call to improve the performance of African health systems has never been more urgent.
Rapidly increased funding for HIV and AIDS has made signicant changes for HIV and AIDS
treatment and prevention. Today, the majority of people who receive antiretroviral treatment
(ART) live in poor sub-Saharan African countries. The incidence of new HIV infections in the
most affected regions has been reduced by 25%. But it has become evident that these gains
cannot be sustained unless the wider health system is strengthened in parallel. Furthermore,
in the countries hardest hit by the HIV epidemic, large numbers of people also face other
health problems, such as maternal health conditions, malaria, respiratory infections, and
diarrhea, for which limited or no care is available.
Health systems have a reputation for insatiable appetites for both money and human re-
sources. In a time of global nancial crisis, it is of particular importance to understand how
disease-specic funding affects the capacity of health systems to respond to a variety of health
needs. While policy makers within the priority disease programs discuss ways to strengthen
the health system by making better use of available resources, critics argue that the approach
chosen to ght HIV and AIDS has led to fragmentation of the wider health system, and that
other important health needs have been neglected as a result.
The health systems research series is an urgent call to action to address the HIV-AIDS and the
health systems crises in synergy. People and communities infected and affected by HIV and
AIDS have many health needs that need an efcient response. A critical assessment of the
impact of HIV and AIDS funding on health systems is needed to develop such a response. An
effective response includes international and national development partners, donors, national-
level governments and non-governmental bodies, district-level health managers, individual
health workers and, last but not least, the men and women living in the communities infected
and affected by HIV and AIDS. They must not be regarded as victims. They are, in many
places, taking action to raise awareness and increase knowledge about the disease, expand
access to services, and ght HIV-related stigma and gender discrimination.
The views and contributions of individuals at all these levels as presented in this series are crit-
ical for a better understanding of current gaps, and the results of the case studies contribute
to formulating the need for further action. As long as the combined efforts of national policy
makers, donors and advisors do not lead to empowering people and communities to improve
their health, and as long as these efforts fail to build systems that allow all people to access the
AIDS and other health services they need, we have not achieved our goals. Strategies to im-
prove health access are pioneered every day on the ground, and it is of paramount importance
to learn from these initiatives. As a global community we should not rest until international
initiatives are effectively linked to the local context, to the realities of health providers and the
communities they serve.
This report grows out of our shared belief that the world must respond
to both the HIV and AIDS crisis and the health-system crisis. It high-
lights work that supports and energizes programmes that mitigate
the double crisis. I believe this series can be a valuable advocacy and
policy tool for addressing this complex challenge.
Marijke Wijnroks
Ambassador for HIV/Aids and sexual health at the Ministry
of Foreign Affairs, the Netherlands
vi
Synthesis of the multiple country study
results
Background of the study
In 2001, the United Nations declared HIV and AIDS an international crisis (United Nations,
2001). The HIV epidemic hit African countries that were already facing a multitude of problems
including weak governance, conicts and natural disasters.
That same year, the World Health Organization’s Commission on Macroeconomics and Health
and the UN’s Commission on HIV/AIDS and Governance in Africa concluded that the lack of
political will to sufciently increase spending on health at sub-national, national and interna-
tional levels was perhaps the most critical barrier to improving health in low-income countries
(Sachs, 2001; The Commission on HIV/AIDS and Governance in Africa, 2001). It was clear,
however, that removing nancial constraints alone would not be sufcient to improve health
outcomes and that progress also hinged on the ability of countries to increase the capacity of
their health sectors. In particular, the human resource shortage in Africa, which was exacer-
bated by the effects of AIDS, constituted a barrier to universal and sustainable access to health
services. Other weaknesses in the health system, such as poor infrastructure, the absence of
sustainable supply systems, fragmented health information systems and weak governance
structures, also needed to be addressed with short-, medium- and long-term perspectives.
The Millennium Development Goals, which were established in 2000, constituted a commit-
ment to improve health and have led to an increased emphasis on addressing priority health
needs, including HIV and AIDS. Since their inception, international spending for the ght
against HIV/AIDS has increased dramatically (UNAIDS, 2010).
As a result, by the end of 2009, 5.25 million people worldwide were receiving antiretroviral
treatment (ART); the majority - 3.9 million - live in poor sub-Saharan African countries. There
has also been a 25% reduction in the incidence of new HIV infections in 22 sub-Saharan coun-
tries (UNAIDS, 2010). In spite of this achievement, the health systems in these countries can
barely cope with increasing demands. The Millennium Development Goals (MDs) and other in-
ternational commitments such as the universal access to HIV prevention, treatment, care and
support will not be met unless system-wide barriers are effectively addressed (Travis 2004).
Most HIV-positive people are now accessing treatment in parts of the world where large num-
bers of people have limited or no access to primary health care, nutritious food, clean drinking
water and shelter (Tawk & Kinoti, 2003). This has affected opportunities for the further scal-
ing up of HIV and AIDS services and undermines the sustainability of achievements made to
date. Given that HIV and AIDS will remain an important international public health issue for
the next couple of decades, health systems in resource-poor settings will have to continue to
simultaneously address HIV and AIDS and other health priorities.
Although there is a global consensus that there is a health system crisis, there is disagreement
about how to deal with multiple burdens of disease in resource-poor settings. The continued
struggle for scarce resources within the health sector has led to erce debates among interna-
tional health development experts around the question of how local health systems should re-
spond to the additional threat posed by HIV and AIDS, and how investments in disease-specic
programmes could contribute to wider health system strengthening.
Some critics argue that the largely vertical approach chosen to ght HIV and AIDS has been
damaging and fragmented the wider health system, and that other important health needs
have been neglected as a result. Other international policy makers point at the potential mu-
tual benets from investments made (England, 2009; WHO, 2009a).
In 2008, the World Health Organization (WHO) and the Global Fund to Fight AIDS, Tubercu-
losis and Malaria (GFATM) among others, brought together health systems policy makers and
disease control experts to form the Maximising Positive Synergies Collaborative Group (WHO,
2008).
vii
This resulted in a paper in The Lancet reviewing interactions between global health initiatives
and country health systems. However, while the health policy makers from within health sys-
tems and disease control programmes tried to join forces to strengthen health systems, the
question whether priority programmes could contribute to overall health system strengthen-
ing and, if so, how this could best be organized, remained unanswered (Biesma, 2009; WHO,
2009b).
The Royal Tropical Institute in Amsterdam decided in 2008 to initiate a multi-country study
in order to examine the complex interactions between HIV programmes and larger national
health systems. Case studies were implemented in collaboration with local research institutes
in ve African countries: Madagascar, Malawi, the Democratic Republic of the Congo (DRC),
Burkina Faso and Ghana. The studies explored if and how HIV and AIDS programmes have
contributed to strengthening the health systems of each country. We aimed to contribute to
evidence-based policy and practise by examining the evidence and describing practical solu-
tions to address health systems weaknesses that health practitioners, policy makers, commu-
nity representatives and people living with HIV and AIDS (PLHIV) have developed within HIV
and AIDS programmes.
Methodology
This was an exploratory study using a multi-country, multi-level descriptive case design. The
study adopted a standardised data collection framework across countries that allowed for ag-
gregation of data and meta-analysis. At the same time, the research teams were encouraged
to zoom in on elements of specic interest in the respective case studies.
For the case studies, we used mixed methods by combining an analysis of epidemiological and
nancial data with key informant interviews and focus group discussions. We sought to obtain
and compare opinions and perceptions from policy makers, health care providers, as well as
beneciaries. Respondents were selected from key stakeholders at the international, national,
district and community level.
We used purposive sampling to select ve countries in Africa with the aim to reach a maximum
variation in terms of HIV prevalence, country context, robustness of the HIV response, the lev-
els of investment in the health systems and other health sector characteristics. The willingness
of national authorities to participate was essential.
Health systems are highly complex, consisting of different sub-systems, and composed of a
great variety of stakeholders from the community level all the way to national policy makers.
WHO denes them as follows: A health system consists of all organizations, people and ac-
tions whose primary intent is to promote, restore or maintain health” (WHO, 2007). Numerous
internal and external factors inuence its functioning and effectiveness.
Figure 1 : The HIV prevalence, health expenditures and AIDS budgets of ve sub-Saharan African coun-
tries that participated in the study.
viii
I
n 2007, WHO published a conceptual framework to assist in developing and strengthening health
systems, known as the “six building blocks” (WHO, 2007). Although different authors and research
groups have commented on the shortcomings of this framework, no other commonly accepted
framework had emerged at the time of our research (Marchal, 2009). Therefore the decision was
made to loosely base our study on the WHO health systems framework.
Multidisciplinary teams of experienced researchers with medical and social science backgrounds from
well-known research institutions in each country carried out the studies. Each research team was sup-
ported, as needed, by the staff of the Royal Tropical Institute during the different phases of the study.
Staff from the research institutions, health ministries and AIDS programs in the ve participating
countries took part in the study’s design phase during a ve-day workshop in Amsterdam in 2008.
In each country an inception workshop was organised, which included a workshop with multiple
stakeholders to create in-country ownership and to receive input for the sampling of districts and
selection of key informants and resources. During the inception workshop, the research teams
were familiarized with the aims and objectives of the study and the research methodology. Dur-
ing the inception phase, the interview guides were pilot tested and adapted to the local context.
The sampling framework for districts, communities and key informants were discussed and agreed
upon. Once the data collection was completed, an analysis workshop was held in each country,
followed by a multi-stakeholder meeting to validate the results.
Countries received continuing support by KIT staff through eld visits and e-mail correspondence.
At the end of the research period, researchers participated in a cross-country meta-analysis work-
shop to draw lessons from the other countries.
Data collection methods included:
Desk reviews using check lists and standard formats for context analysis, secondary diseas-
es trend analysis, and secondary analysis of nancial resources for HIV and health system
strengthening.
Listing of key stakeholders
Semi-structured interviews with key informants
Focus group discussions
Within each country we sampled two districts allowing for maximum variation in the effectiveness
of the HIV and AIDS responses and for maximum diversity in the health system (see gure 2). The
selection was based on discussions during the multi-stakeholder meetings and focused on districts
that were known to have examples of positive and/or negative interactions between the HIV and
AIDS program and the larger health system. In each district we sampled a minimum of six health
facilities and three communities, of which one community was the district capital, one in a rural
setting but with relatively good access to health services, and one remote community with limited
access to health services. Researchers conducted key informant interviews and held focus group
discussions (FGDs) with women, men, and young people, and with health workers in each district.
Respondents at the national level included government policy makers and planners, development
partners, and representatives of relevant line ministries and civil society organizations. At the
district-level, health planners and health workers were interviewed, as well as development part-
ners and representatives from civil society organizations and the private sector. At the community
level, community leaders, community members and representatives of civil society organizations
were interviewed through semi-structured interviews.
ix
Amsterdam www.kit.nl
District A
KI interviews (KII):
government staff
NGO/CBO/FBO
health staff
private sector
District B
KI interviews (KII):
- government staff
- NGO/CBO/FBO
- health staff
- private sector
National
- d
esk review
- KI-interviews multiple
stakeholders
- stakeholder meetings
(
Community A1)
district capital
(Community A2)
Remote but easy access
to health facility
(Community A3)
No access to health
facility
In each community
- KII community leaders
- KII community members
- KII representatives CSO/
PLWHA etc
- FGD community members
(women/men/youth)
Purposive sampling
Methods &
Sampling
Community
(
Community B1)
district capital
(Community A3)
No access to health
facility
(Community A2)
Remote but easy access
to health facility
A total of 258
interviews and 45 FGDs were conducted in the ve countries and given in the
table below:
Table 1 : Number and interviews per country
The combination of research instruments allowed investigators to explore answers to key re-
search questions. For example, interviewers asked about perceived health needs as compared
to actual disease burdens, prioritization of health needs, health policies, governance, nanc-
ing mechanisms, contextual issues, specic interventions and challenges to health system
strengthening (HSS) and HIV programming over time.
After obtaining consent, researchers recorded the interviews that were subsequently tran-
scribed. (In the Democratic Republic of Congo, researchers in the eld experienced technical
difculties with their recording equipment. In those instances they took detailed notes.) In cas-
es where interviews were conducted in a local language these the transcripts were translated
into English or French. All data was coded and analysed using ATLAS.ti software for qualitative
data analysis (version 6.2). Microsoft Excel was used for secondary analysis.
Ethical approval for this study was obtained from the KIT ethical review board as well as from
the respective countries’ research ethical review committees. All respondents were asked for
their consent before being interviewed or prior to participating in focus group discussions.
Figure 2 : Sampling framework within the countries
x
Limitations of the study
This is an exploratory qualitative study using purposive sampling describing examples of in-
teractions between HIV and AIDS programs and the wider health systems. Because only two
districts in each country were studied, the ndings are not necessarily representative of the
situations in other districts and cannot be extrapolated to represent the nations as a whole.
The researchers had the same nationality as the respondents, but differences in class, gen-
der, ethnicity and mother tongue may have inuenced respondents’ answers especially at the
community level. Being outsiders in poor communities, whether one is an international or a
national researcher, may also affect people’s expectations and responses. Translations from
national languages into French and English likely resulted in a loss of some meaning and de-
tails that are only clear to native speakers. Community members may have used the interview
as an opportunity to voice concerns to a larger audience or to try to mobilize funds to address
problems in these communities. The quality and quantity of the data generated by the na-
tional health system in all countries was very diverse, which limits both comparison between
countries and triangulation within countries. There was not enough reliable data available to
link shifts in health problems to health policy priority settings prior to 2000. Use was made of
international databases to try to ll the gaps in information.
Summary Results of the five African countries
Results are presented by subject areas, which covered the original research topics as well as
themes that emerged from the data during analysis.
Health Priorities
Policy makers at global, national and district levels in all countries invariably reported HIV and
AIDS as an important health problem that needs to be addressed. The level of importance
given to HIV as a health problem varied between countries depending on HIV prevalence rates
but was also found to correlate with the social and community afliations of the respondents.
People that work within HIV and AIDS programs tend to attach greater importance to the HIV
and AIDS response than people that work in other health programs.
Community-level respondents generally perceived HIV and AIDS as less of a health priority
than national level policy makers. HIV and AIDS were rarely identied as priority health needs
at the community-levels. Community representatives instead reported concerns about malaria
and childhood diarrhoea, lack of clean water and the need for better access to general health
services. National representatives mentioned that one of the positive benets of the interna-
tional support to combat HIV and AIDS is the increased attention to the health care needs of
marginalized populations.
These differences in reported health priorities reect the inuence of development partners
and the availability of funding on national health policy planning processes and health priority
setting. National awareness of HIV and AIDS has been successfully raised through advocacy
and multi-stakeholder processes as part of international development planning, implementa-
tion and evaluation processes. However, the availability of disease-specic funding for HIV and
AIDS and other priority programs has inuenced and distorted priority setting during health
planning processes.
The absence of robust health information and adequate analysis of disease trends in most
countries further undermines evidence-based priority setting and health planning. In general,
communities’ perceptions about priority health needs are inuenced by the health concerns
experienced on a day-to-day basis, such as malaria, diarrheal disease and access to clean wa-
ter. On the other hand, perceptions are coloured by cultural beliefs and stigma. In the case of
HIV and AIDS, moral judgements affect perceptions about what health problems deserve the
investment of scarce resources.
Funding
Funding, whether domestic or international, directly affects priority settings: respondents at all
levels indicated they would not decline available funding irrespective of whether it fully match-
es their priorities. In Ghana, a country that has adopted a multi-stage, bottom-up priority set-
ting and health planning approach, several respondents noted that the availability of specic
xi
sources of funding inuenced which priorities were passed on to the next level of planning. HIV
and AIDS funding made up a signicant amount of the money available in the national health
systems of the ve selected countries. International funding constituted the vast majority of
funding for HIV and AIDS. The highest percentage was in Malawi, where 98% of the HIV and
AIDS response in 2009 was funded with international monies.
All ve countries reported that a positive effect of increased donor funding was the improved
accountancy that has been a strict requirement of the donors. The accountability mechanisms
now require results-based monitoring and robust accounting mechanisms, as well as multi-
stakeholder program planning, implementation and oversight. Financial management capacity
building, linked with greater donor demands for quality reporting, all played a role. Potentially
these enhanced capacities can also be used to improve organizational structures and program
management in the larger health system.
Management and Governance choices
In recognition of the need for a multi-sectoral approach, HIV and AIDS programs in the study
countries have been accorded special status by their governments. This led to the formation
of separate oversight structures, in some cases outside of the ministries of health. This special
status is a reection of the priority that has been given to HIV and AIDS and has arguably
facilitated rapid and life-saving responses. However, real and perceived power differences be-
tween bodies, such as a national AIDS committee in the president’s ofce versus a ministry
of heath planning unit, have contributed to a divide. Access to signicant donor funding, ca-
reer opportunities, international conferences, better equipment and other favourable working
conditions within the AIDS programs has, in combination with the need to show quick results,
led to protectionism over resources within AIDS programs. This sometimes has bred envy and
even resentment among staff working in other health divisions.
Staff working in HIV and AIDS programs were granted these special benets at a time when
few people were willing to work in this eld. Before the advent of antiretroviral therapy (ART),
many staff were infected with HIV and died. Now that health staff have access to treatment,
and HIV infection is seen as ”just another disease”, the relative abundance of resources for
HIV and AIDS programming (human, nancial and equipment) is not always understood or
accepted by staff working in the wider health system. This angers some who feel that HIV and
AIDS patients are “undeserving”.
Infrastructure and supplies
HIV and AIDS funding has contributed substantially to the material infrastructure of these
countries’ health systems, through renovation, construction and refurbishing of health facili-
ties, particularly in terms of providing medical and laboratory equipment, and purchasing cars
and motorcycles. These improvements benet the health system as a whole. For example,
staff and a counselling room for HIV tests can also be used for counselling about other health
issues. However, in practice there are limitations on the wider usage of these structures and
supplies as patients may be reluctant to go to a stand-alone clinic that is associated with HIV
and AIDS.
Similar improvements to supply chain management, drug forecasting, stock management and
the establishment and enforcement of regulations and quality assurance mechanisms with re-
gards to medical procurement were believed to have a potential positive spin-off effect on the
wider system. However in most of the countries these systems were initially set up in parallel
to the existing system, and new skills and procedures were only gradually introduced for sup-
ply and procurement of other medical products.
Strengthening Human Resources for Health (HRH)
Although the availability of ART has transformed AIDS into a chronic condition for millions
of people, the disease still puts a great burden on the limited numbers of generally low paid
health staff. In the early days of the HIV and AIDS response, the effect on HRH was largely
negative as incentives, such as more favourable working conditions and better career op-
portunities, caused health staff to migrate to HIV and AIDS programs. (The exception to this
was Malawi.) In all countries, numerous and uncoordinated trainings caused frequent and
prolonged absenteeism of staff.
xii
More recently, however, HIV programs have begun to strengthen HRH through reducing AIDS-
related health worker mortality. The AIDS response in Malawi has contributed to the increased
availability of health staff through its “emergency human resource plan”. Salary top-ups for
all doctors and nurses and investments in pre-service training were instrumental in increasing
human resources for health in the entire health system, not just staff needed for HIV and AIDS
interventions.
Quality of care, responsiveness and patient-centred approaches
Quality of care was reported to have improved as a result of HIV and AIDS programs; these
include better use of equipment, infection control measures and hygiene practises as well as
improved staff attitudes and skills. Skills that have been learned within the context of the
HIV and AIDS response, such as counselling, can also be used in other health care settings.
The wider usage of such skills and exchange of skills between staff is facilitated by frequent
staff rotations among different departments. Client-centred care, patient support, and atten-
tion to privacy and condentiality were mentioned by both health staff and community mem-
bers as approaches used in AIDS programs that have improved interaction between health
staff and patients in other areas of care.
Community engagement in HIV and health
In each of the ve countries, HIV programs have catalyzed greater community involvement in
the delivery and implementation of HIV- and AIDS-related services. The HIV and AIDS response
has supported an increase in the numbers of much needed health volunteers and lay workers,
but the research also found concerns about the high turnover rates of these workers and the sus-
tainability of the remuneration schemes. Greater involvement of people living with HIV and AIDS
has been promoted by donors and national governments all over the world and is a prerequisite
of some donors, such as the Global Fund. PLHIV activists and civil society groups play a role in
holding governments accountable for their actions and liaise and mediate between communi-
ties and policy makers. National-level respondents in all countries mentioned increased com-
munity involvement in the AIDS response. In contrast, representatives at the community level
still seemed unaware of opportunities to access health services and participate in health efforts
in their community. In addition, most of these community service organizations (CSO) are now
almost exclusively funded with AIDS funds, and therefore tend to focus their attention on AIDS.
They could potentially increase their engagement in other health issues, but we did not nd evi-
dence to assume that this will happen until additional funding for this purpose is made available.
The availability of money for community involvement, though much appreciated when used to
remunerate community support activities, has undermined true community engagement to some
extent. For example, investigators found instances where community representatives would no
longer attend community meetings unless they were paid.
Monitoring and Evaluation (M&E)
Capacity for M&E of HIV and AIDS programs and research has improved at various levels through
increased funding and technical support. HIV and AIDS programmes have recruited additional
staff and trained existing staff in record keeping. Digitized reporting systems have been intro-
duced in all ve countries. Quarterly and annual review meetings, held to support evidence-based
management and decision-making processes, have also received funding. The extent to which
these improvements benet the wider health system varies by country and depends on the level
of M&E integration. Unfortunately, in most cases M&E systems were introduced as parallel struc-
tures, creating challenges during attempts to later integrate these with the general M&E system.
An ever-increasing list of indicators requested by donors and development partners further in-
creased the burden of reporting. Information and indicators requested by donors are not in all
cases aligned to the priority reporting needs of the Ministry of Health in the country.
Conclusions
Despite increased attention for the need to integrate the HIV and AIDS response with the national
health response, we found evidence of continued parallel systems. During recent years, policy
makers have called for more synergistic approaches to health system strengthening.
Our case studies showed that there is good potential for HIV and AIDS programmes to contribute
to the strengthening of the wider health systems.
xiii
Examples of such a contribution are found in better accounting, greater transparency and ac-
countability mechanisms, better quality of care and responsiveness of service providers, im-
proved infrastructure and supply systems, enhanced HRH capacity and stronger M&E systems.
Most of these positive effects on the health system as a whole were found to be spill-over effects
rather than a deliberate choice to strengthen the health system beyond the improvements that
are needed to serve PLHIV. We conclude that the potential benets for the wider health system
are not yet fully capitalized.
Negative effects of the HIV and AIDS programmes on the wider health system have had a distort-
ing effect on priorities in health planning. Staff from the general health services often migrate
towards HIV and AIDS programmes and many workers are frequently absent due to training.
Already overburdened staff must full additional and uncoordinated M&E requirements. Further-
more, there were some concerns over sustainability because many programs are highly depend-
ent on external donor funding, such as the increased involvement of civil society and community-
based organizations or are programs that offer incentive payments.
Because many of the effects on the wider health system, beyond improved services to PLHIV,
were effects that had not been planned, it was not possible to fully analyse the mechanisms that
contributed to the success or failure of health system strengthening. This means that only few
lessons can be drawn on successful approaches by disease-specic programmes towards health
system strengthening beyond the disease-specic system needs.
Recommendations
There is a strong need for developing and piloting more deliberate strategies for health sys-
tem strengthening through HIV and AIDS programmes, with a focus on documenting the
mechanisms used, their underlying assumptions and analysing contextual factors that inu-
ence the outcomes. Prospective studies and action research are needed to identify successful
approaches to use HIV and AIDS programmes to strengthen wider health systems and mitigate
potential undermining effects.
Sustainable national and international support to reduce the impact of HIV and AIDS needs
to take other health priorities into account, including those of local communities, and be more
prominently based on evidence generated by data from national health systems.
Communities can be more meaningfully involved in improving the health in their communities,
by discussing with community members the actual and perceived health problems based on
health system data including, but not limited, to HIV and AIDS. There needs to be a better
exchange of ideas about issues they face, their importance to the community, and their ability
and willingness to contribute to solutions.
Support to health system strengthening needs to be system wide and facilitate learning be-
tween and within the different levels of the system. In those cases where parallel structures
for HIV and AIDS programmes are deemed indispensable in the short term, the potential ben-
ets of AIDS specic programmes on strengthening the wider health system should be more
actively pursued by strengthening general systems in preparation for a smooth integration.
International and national support to health system strengthening in countries affected by HIV
and AIDS should have a multi-level approach and link the needs at the national, district and
community level. Enabling national-level policy environments are essential. However, these
will only be effective if they get translated into practical interventions at the health service,
community and beneciary level.
Efforts to strengthen monitoring and evaluation systems should focus on strengthening M&E
for the health system as a whole. This should take priority over disease-specic reporting
requirements of individual donors, especially in resource-poor settings where trained health
workers are scarce, in order to avoid using medical staff to perform administrative duties.
In a similar way, programs that aim at improving the HRH capacity, the material health infra-
structure and the medical supply chains will need to strive for immediate integration in order
to maximise the benets for the entire health system in a sustainable way.
xiv
Key results and discussion Ghana
A Policy and priority setting
Ghana’s Program of Work for 2007 2011 (GMoH, 2007 & 2007b) states that the country’s
health priorities are to improve maternal and child health and to control diseases such as HIV
and AIDS, malaria, tuberculosis and guinea worm. Yet the government has essentially made
HIV and AIDS a priority by creating specic agencies to address the issue, such as the Ghana
AIDS Commission and the National AIDS Control Programme. Perspectives on what the coun-
try’s priorities should be differ at different levels of the health system. In this study, policymak-
ers and programme managers at the national and facility levels all articulated that HIV and
AIDS were a priority. Some, however, thought that the attention given to HIV and AIDS diverts
focus away from other equally important programmes, particularly maternal health. They at-
tributed this to the inuence of the large sums of money being available and owing into HIV
programmes.
District health workers and community members were less concerned about HIV control as a
priority. Their attention was on the need for improved sanitation, clean water and malaria pre-
vention and treatment. They acknowledged, that the HIV programme had contributed to the
larger health system as a result of the increased resources, however there was also a sense
that further investment in the general health system is needed to improve access to good qual-
ity health services.
B. Interaction between the HIV and AIDS Response and the Health System
There are clear interactions between HIV programmes and the health system that have an
effect on the success of both. There was a general consensus, that the HIV programme has
had positive inuences on the health system as a whole. These were mainly in the areas of
upgrading infrastructure; providing laboratory equipment and reagents; enhancing the culture
of voluntary counselling and testing and respect for patient condentiality; and improving the
quality of care practices including injection and blood safety. It has improved information dis-
semination, advocacy and social mobilization skills, and monitoring and evaluation (M&E).
The HIV programme has also provided opportunities for skills to be developed in clinical care
and management. The programme has had signicant inuence on the organization of services
among health professionals. The training programmes have developed curricula that are ap-
plicable to providing services beyond just HIV, which many health professionals have beneted
from. Health information management with regard to patient care and nancial reporting have
improved. This is due to the performance-based nature of the HIV and AIDS nancing frame-
work. In a sector with limited resources, the additional funds brought into the system for the
HIV programme are seen as a welcome addition and are a signicant component of the health
budget. Where HIV and AIDS funds have been used to purchase vehicles and fuel, and created
incentives for workers, resource-poor programmes have also beneted.
At the community level, HIV and AIDS public education activities have created greater aware-
ness about health service delivery, the need to take personal responsibility for prevention, and
the importance of seeking early care. The programme has allowed community members to
participate and take on roles with regards to the health and welfare of the community. More
local non-governmental organizations (NGOs) have evolved and health education messages
have penetrated deeper into the communities. There is no clear indication within this study of
the extent to which NGO and CSO engagement has also increased for health in general.
There were, however, expressions of concern. Specic requirements of the HIV programme have
meant that some systems such as those for information management and nancial reporting
have been duplicated. With the limited numbers of staff available, there were visible signs of
work overload, fatigue and stress. Many were concerned that an overemphasis on HIV has led to
the strengthening of sub-systems rather than the entire system. Furthermore, the fact that the
AIDS programme is in many cases better resourced than other programmes, and that these re-
sources are often assiduously guarded, has led to tension between the different program staff.
xv
Stigma against HIV patients by community members and even by health workers continues to
be observed in Ghana. In some cases, however, stigmatization is subliminal and couched in in-
nuendo. Though reports suggest that stigma might be on the decline, interviews suggest there
is still concern about being associated with the disease. Several respondents were unhappy
that their towns had HIV diagnostic facilities, which attracted people who suspected they were
positive and resulted in reports of increased prevalence. They felt this negatively reected on
the local population.
Policy Implications for Ghana
HIV and AIDS continues to be a priority for the health sector especially with a view to fur-
ther reduce HIV prevalence. However, it is important that all stakeholders reach agreement
in terms of the level of priority in relation to other health priorities. Furthermore it is im-
portant that the aims and goals of the AIDS-specic response and its relation to the wider
health system needs are well articulated and that resource allocation and priority setting is
well understood by all stakeholders.
The AIDS programme has contributed to specic health system strengthening activities,
which otherwise may not have happened. In particular, it has improved laboratory quality,
health information and nancial reporting capacity. It has also led to the inow of signicant
resources that helped fund cooperation with other disease programmes that are resource
deprived. As most of these effects were aimed at improving the AIDS response rather than
the wider health system and a certain level of fragmentation and parallelism was observed,
there is need to investigate how the HIV programme can be developed to contribute in a
more efcient way to promoting synergies in building the health system.
This case study describes the contribution of the HIV and AIDS interventions towards
strengthening of the wider health system. However the question how to effectively build
and sustain the synergies across multiple programmes to the benet of the system as a
whole is not fully answered. Understanding this will enable the sector to develop appro-
priate policies to better manage the programme and its contributions to entire system
strengthening.
Funds for earmarked programmes, such as those for HIV, have generously supported and
improved laboratory infrastructure and equipment supplies and services. However, it is
clear that these project-type funding mechanisms are not sustainable particularly because
of their time-bound nature. There is a need to incorporate these advances in the HIV
programme into the country health strategy. The same applies to improved systems for
health information management, accounting and reporting. These “vertical” programme
approaches should be integrated and be used to strengthen the government lead systems
from the start.
One of the strengths of the HIV programme is its performance-based nancing system. This
has created an increased level of accountability and transparency. This is a positive that
should be looked at for scaling up of best practices to enhance the system.
Ghana Case study
Figure 3: Map of Ghana
1
1. Background to the Ghana Case study
1.1 Country context
The Republic of Ghana is centrally located on the West African coast. It is bordered by Togo to
the east, Burkina Faso to the north and northwest and Côte d’Ivoire to the west. It has a total
land area of 238,537 square kilometres. The Atlantic Ocean to the south forms a 560 km
coastline, which provides the country important shing grounds as well as maritime contact
with the outside world. The capital is located in the port city of Accra on the Gulf of Guinea.
Ghana has three main ecological zones:
A sandy coastline backed by a coastal plain vegetated by savannah grasslands, crossed by
several rivers and streams.
A middle belt and western parts of the country with thick forests, streams and rivers.
A northern savannah with the Black Volta and the White Volta as the main rivers.
The landmass consists of lowlands, except for a range of hills on the eastern border of the
country. Mount Afadjato lies west of the Volta River and is the highest point with an altitude of
884 metres above sea. The country has a tropical climate with temperature ranges between
26ºC to 29ºC. There are two distinct rainy seasons: April to June and September to November
and two relatively dry periods that occur in August and during the Harmattan season (Decem-
ber through March). The current population is estimated at 22.4 million. About 70% of the
population lives in peri-urban areas. Rural parts of the country generally lack basic develop-
ment infrastructure such as good roads, electricity and water supplies.
Ghana operates a multi-party democratic presidential system of government with an ex-
ecutive president elected for four years with a maximum of two terms. There is a par-
liament elected every four years, an independent judiciary and a vibrant media.
There are 10 administrative regions: Western, Central, Greater Accra, Volta, Eastern, Ashanti,
Brong Ahafo, Northern, Upper East and Upper West. The regions are sub-divided into 170
districts in an attempt to ensure equitable resource allocation and efcient and effective ad-
ministration at the local levels.
1.2 General health profile
The current estimated life expectancy is 57 years. The total fertility rate was 4.0 in 2008 com-
pared to 4.4 in 2006. The use of modern contraceptives was about 17% in 2009. The crude
death rate is estimated at 8.93 deaths per 1,000 population as of July 2010. The maternal
mortality ratio (MMR) is slowly improving compared to the previous decade. Between 1990
and 2007, the maternal mortality ratio had fallen to 451 per 100,000 live births, down from
740 according to the Ghana Statistical Services (GSS et al., 2009). At the current rate of
yearly reduction in maternal deaths, it is unlikely that Ghana will attain its Millennium Develop-
ment Goal of 185 deaths per 100,000 live births. It is estimated that the MMR will be 340 per
100,000 in 2015 (Figure 4).
2
Figure 4: Maternal mortality ratio (surveys), recent and projected
Source: UNDP (2010): Unlocking Progress: MDG acceleration on the road to 2015. Government of
Ghana (2008): Management Accountability Framework (MAF) for Maternal Health
The overarching strategy to achieve a lower maternal mortality rate is to promote use of skilled
birth attendants, and offer family planning services from the community health providers
through to teaching hospitals.
The 2008 Ghana Demographic and Health Survey (GSS et al., 2008) showed a decline in the
under-ve mortality rate, with 80 deaths per 1,000 live births down from 111 per 1,000 live
births in 2003. The infant mortality rate was 50 per 1,000 live births in 2008 compared to 64
in 2003 with the neonatal mortality rate falling from 43 deaths per 1,000 live births in 2003
to 30 in 2008.
Routine data from health facilities indicates that the major causes of neonatal deaths are as-
phyxia, low birth weight, birth injuries, neonatal tetanus, neonatal infections and severe con-
genital abnormalities. Current coverage for Penta-3 vaccine (Hib+DTP+Hepatitis-B) increased
from 84.2% in 2006 to 89.3% in 2009 (GHS, 2009). Malaria and acute respiratory infections
are the most common fatal diseases in children. Malaria accounted for 30% of under-ve
deaths in 2008 (GSS et al., 2008). Other common diseases include pneumonia, diarrhoea,
malnutrition and anaemia. Ghana is implementing the Health Impact Rapid Delivery (HIRD)
programme to scale up key cost-effective interventions delivered countrywide to improve child
health that will also benet maternal health (UNICEF, 2006). The programme delivers a broad
range of interventions aimed at addressing the most salient challenges in children’s health.
Generally Ghana is considered on course to attaining the child malnutrition target under the
Millennium Development Goals ahead of the 2015 target date. However, according to the
2008 Ghana Democratic and Health Survey, 28% of Ghanaian children are stunted; with 10%
being severely stunted (GSS et al., 2008). This represents a slight improvement over the
2003 gure, which showed that 30% of children under ve are stunted and 11% are se-
verely stunted. The extent of wasting, which is a sign of acute malnutrition, has actually
become worse in the last ve years. In 2003 seven percent of children under ve were found
to have acute malnutrition of which 1% was severely malnourished (GSS & GHS, 2004).
In 2008, 9% of children had acute malnutrition, with 2% being severely malnourished. Wast-
ing levels were found to be highest at ages 6-11 months, which made these infants more
vulnerable to illness.
The epidemiological prole of Ghana shows a concurrent signicant prevalence of communi-
cable and non-communicable diseases. Table 2 below shows the top ten reasons for visits to
health facilities in 2009.
3
Table 2: Top ten reasons for visits to outpatient departments in Ghana, 2009
Source: Centre for Health Information Management (CHIM) 2009
HIV and AIDS and tuberculosis. The Ghana Aids Committee estimated the HIV prevalence
among the adult population at the end of 2009 at 1.9% with an estimated 267,069 persons
living with HIV and AIDS (GAC, 2010). The burden of tuberculosis is estimated to be about 204
people per 100,000 with a case detection rate of 36%, well below internationally set targets of
70%. Case notication rates are currently 64 per 100,000. The number of children diagnosed
with tuberculosis increased from 352 in 2008 to 649 in 2009. This is an indication that the
index of suspicion for tuberculosis in children by doctors and clinicians is on the increase. The
tuberculosis case fatality rate is at 9%. Regional mortality trends in 2008 indicate high rates of
tuberculosis related deaths in the Upper East Region (12.5 per 100 000 population) compared
with 4.2 per 100 000 population in the Volta Region.
The Directly Observed Treatment Short-course (DOTS) programme was scaled up through ca-
pacity building in the public sector. The tuberculosis treatment success rate rose from 72.6% in
2006 to 84.7% in 2008. Default rates have declined from 11% in 2005 to 2.3% in 2008. There
were several issues identied that affect tuberculosis case detection and treatment outcomes.
The main challenges include weak procedures to detect tuberculosis, inadequate contact trac-
ing, inadequate engagement of community-based providers and inappropriate tools for effec-
tive supervision, monitoring and evaluation.
Malaria. Malaria is the leading cause of morbidity in Ghana and was the reason for approxi-
mately 40% of all out-patient visits in recent years. The under-ve malaria fatality rate, how-
ever, fell by more than 50% between 2002 and 2009. The disease accounts for 11% of mor-
tality in pregnant women. The use of insecticide-treated materials is still low (NMCP, 2009).
There has been a signicant scale-up in interventions under the National Malaria Control Pro-
gramme focusing on effective diagnosis including the use of rapid diagnostics kits at the local
level, improved treatment compliance and preventive measures using insecticide-treated bed
nets, indoor residual spraying and targeted use of larvicides and environmental management.
There is a move towards subsidizing anti-malaria drugs to make them generally affordable
to all. A signicant impact of these interventions on case incidence is yet to be seen (AMFm,
2010). This is because most anti-malaria activities lie outside the direct control of the health
sector and will require signicant inter-sector collaboration to achieve the MDG target.
Non-communicable diseases. Non-communicable diseases, many of which are life-
style-related, constitute a heavy and increasing disease burden. The most signi-
cant of these are cardiovascular-related diseases, diabetes and sickle cell anaemia.
Crude estimates suggest that disease incidence is expected to rise in the next ve to 10 years.
Generally, however, there is inadequate epidemiologic data to support decision-making and
strategy development.
REASON FOR VISIT TOTAL VISITS % of total
1 Malaria 6,146,523 44.55
2 Acute respiratory infections 1,151,132 8.34
3
Skin diseases and ulcers
574,604
4.16
4 Diarrhoeal diseases 536,846 3.89
5 Hypertension 494,125 3.58
6 Rheumatism and joint pains 416,416 3.02
7 Acute eye infection 264,042 1.91
8 Intestinal worms 249,812 1.81
9 Anaemia 203,906 1.48
10
Pregnancy and related complications
176,888
1.28
11 All other diseases 3,582,264 25.96
Total 13,796,558 100.00
4
Since non-communicable diseases are largely caused by lifestyle and nutritional choices, con-
tinued efforts are needed in the area of behaviour change communication, including integra-
tion into school curricula, in order to promote healthier future generations. Currently, the ag-
ship Regenerative Health and Nutrition Programme, developed under the 2007-2011 Program
of Work for health is aimed at addressing some of these lifestyle and nutrition issues (GMoH,
2007a).
Table 3: Selected national indicators
INDICATOR
YEAR
SOURCE
Socio-economic profile
Population
24.4 million
2010
WB data catalogue
HTTP://SEARCH.WORLDBANK.OR
G
/DATA?QTERM=POPULATION%
20G
HANA&LANGUAGE=EN
Population growth rate (%)
2.1
2008
World Bank
Urban population (% of total
population)
44
2000
Ghana Statistical Services
HTTP://WWW.STATSGHANA.GOV.
GH/KEYSOCIAL.HTML
GDP (billion $US, PPP)
16.7
2008
World Bank
GDP growth rate (%)
7.3
2008
World Bank
Human Development Index
0.526
2007
UNDP
Health profile
Life expectancy at birth (years)
57
2008
World Bank
Maternal mortality (per 100,000 live
births)
541
2008
WHO
Under-five mortality (per 1,000 live
births)
80
2008
GDHS
Estimated adult (15-49) HIV
prevalence (%)
1.9
2009
UNAIDS
Number of physicians
2,587
2009
HTTP
://
PORTFOLIO
.
THEGLOBALF
UND
.ORG/COUNTRY/INDEX/GH
N?
LANG
Nursing and midwifery personnel
(number)
22,834
2009
GHS Annual Report
5
1.3 Overview of the health sector
1.3.1 Organizational structure of Ghana’s health system
Ghana has over 3,000 health facilities distributed as illustrated in Annex A. Most health care
services are provided by the government through primary and secondary facilities managed
by the Ghana Health Service and the three teaching hospitals that serve as tertiary facili-
ties (CHIM, 2009). The organization of services is based on a cascading structure (Figure 5).
This, however, represents the ideal rather than the actual situation, as secondary and tertiary
facilities are known to also provide primary care services rather than fully concentrating on
specialised services.
Figure 5: Institutional Structure of Ghanaian public health services
It is estimated that there are over 700 private sector clinics and over 400 maternity homes
around the country. The Christian Health Association of Ghana (CHAG), which operates mission
hospitals and clinics, has grown from about 135 facilities in 2002 to 168 in 2009. (CHAG, 2010)
CHAG estimates that its facilities have over 7,500 beds and that they serve an estimated 35
to 40% of the country. These facilities are located primarily in rural areas and make CHAG the
largest non-governmental health care provider.
In 2007, CHAG signed a memorandum of understanding with the Ministry of Health to for-
malise their relationship. Under this agreement, the ministry funds CHAG to deliver an agreed
set of health care services based on annual plans. The precise allocation of the funds is left to
the discretion of the CHAG secretariat. Twenty-two of CHAG-afliated facilities are designated
“district hospitals” and are treated as government district hospitals, in terms of funding and
human resources. In addition, there are quasi-government health care facilities that include
the university, police, army and the prison services. There are also facilities run by business
organizations that provide services to their employees.
Pharmaceuticals and drug sales points are available country-wide. Records from the Pharmacy
Council indicate that over 6,000 licence applications were processed by the end of the third
quarter of 2009 for the establishment and operation of drug, chemical and pharmacy dispens-
ing facilities.
6
1.3.2 Health policy reforms in Ghana
In 1996, Ghana adopted a Sector Wide Approach (SWAp) (GMoH, 1996). A key feature of the
SWAp has been joint planning and nancing of agreed priorities and programmes, using mainly
a pooled funding mechanism known as the Health Fund. It involves a process of planning with
partners, and holding regular multi-stakeholder meetings to discuss policy development and policy
dissemination. There are 20 set indicators for assessing performance of the sector as a whole.
Formal review meetings are held twice a year with partners to determine priority action areas. A
Memorandum of Understanding is signed with the partners who contribute to the common fund
and this serves as a basis for priority action. Apart from these high-level summits and discussions,
there are monthly meetings to share implementation information as well as receive updates on
partner activities. Technical matters are normally covered in presentations at these meetings and
solutions to challenges are explored.
The practice of developing ve-year, three-year and annual Programmes of Work has continued
within the health sector. Since 1997, three ve-year PoWs have been developed (GMoH, 1996;
GMoH, 2002; GMoH, 2007), the last being the current PoW spanning 2007-2011. Its theme is
“Creating wealth through health”. The ve-year programme identies several priorities. It includes
addressing high infant and maternal mortality; high morbidity and mortality from communicable
diseases such as malaria, HIV and tuberculosis; the increasing prevalence of non-communicable
diseases; and the inadequate and inequitable distribution of human resources. The 2010 annual
PoW focuses on maternal and child health by addressing malnutrition and improving emergency
obstetric services. The PoW further concentrates on strengthening primary health care services
and health infrastructure, disease control and prevention with a focus on consolidating and scal-
ing up existing interventions to combat communicable diseases, and prioritizes human resource
development (GMoH, 2010).
Since 2004, the funding coordination mechanism has been transformed. Partners who earlier
supported the MoH Health Fund have moved either to multi-donor budget support (i.e., general
support to the government of Ghana) or to sector budget support, which is channelled to the MoH
through the Ministry of Finance and Economic Planning (MOFEP). Thus funding from most partners
goes to supporting activities in the PoW, and partners also offer other support services to ensure
the effectiveness of the PoW. However, an increasing number of development partners are provid-
ing earmarked funding for specic activities. These include both bilateral and multilateral partners
and increasingly international health initiatives such as the Global Fund to Fight AIDS, Tuberculosis
and Malaria (GFATM) and the Global Alliance for Vaccines and Immunisations (GAVI).
1.3.3 Progress in health system strengthening
In 1996, the MoH’s “Health of the Nation” report estimated that the total workforce in the public
health sector was 29,645. Approximately 51.6% were administrative support staff. The health pro-
fessional staff gures include staff of CHAG whose salaries are paid for by the government (GMoH,
2001). By the end of 2009, the total human resource gure was 48,975, showing a 60.5% increase
since 1996 (MoH, 2010).
The government of Ghana, through tax revenues, continues to be the major nancing source for
the health sector. Government expenditure on health as a proportion of gross domestic product in
2008 was estimated at 4.3% (Figure 6). External sources of funding dropped from 31% in 2004
to about 10% in 2008 (Figure 7). About 85% of government funding pays for salaries and allow-
ances. The large amount of money required for salaries in combination with shrinking external aid
have resulted in a signicant funding gap in the sector for service delivery.
7
Table 4: Summary of selected donor funding 2002–2006
Source: Adjei, et al. 2010
Figure 6: Ghana health expenditure as a proportion of GDP
Figure 7: External resources for health as a percentage of total health expenditure
Source: Trading Economics.com
Donor
Health sector funding
Program areas
USAID
$16.8m/year
Reproductive health/family planning, HIV and AIDS
European
Union
$2.9m/year
SWAp, medical supply procurement, technical assistance
for the Centre for Health Information Management, HIV
and AIDS, sexually transmitted infections
DFID
$15.2m/year
SWAp, HIV and AIDS, reproductive health and family
planning
DANIDA
$8.1m/year
SWAp, health reform, HIV and AIDS
UNFPA
$2.56m/year
Integrated reproductive health/family planning services
JICA
$1.1m/year
Training, technical assistance, community empowerment,
grassroots grant aid
UNICEF
$5.64m/year
Child health, maternal and neonatal health environmental
health, nutrition, school health
World Bank
$12m/year
SWAp, HIV and AIDS
Royal
Netherlands
Embassy
$17m/year
SWAp, national drugs programme, research, reproductive
health, family planning, female genital mutilation, people
living with AIDS
African
Development
Bank
$3.1m/year
Rehabilitation of three district hospitals and three
regional hospitals
GTZ
$700,000/year
Health sector reform
WHO
$2m/year
Health reform, child and adolescent health, maternal
health, TB, HIV and AIDS, malaria
Total
$87.1m/year
8
1.4 The HIV and AIDS response in Ghana
1.4.1 Burden of disease
The HIV prevalence among the adult population at the end of 2009 stood at 1.9% with an
estimated 267,069 persons living with HIV and AIDS. More women (58%) tested positive as
compared to men (NACP, 2011). In 2009, 284 HIV counselling and testing centres were estab-
lished across the country. This is a 54% increase over the previous year (GAC, 2010).
Approximately 865,000 people, or 2.9% of Ghanaians, were tested for their HIV sero-status
in 2009. This gure represents an 85% increase over the number of people who were tested
the previous year. The HIV prevalence among pregnant women was 4.2% compared to 6.2%
in 2008 (Figure 8). Some 55% of those who tested positive were given antiretroviral drugs for
preventing mother-to-child transmission (PMTCT). The GHS is working with other partners to
provide food assistance and counselling to 6,000 food-insecure PLHIV on ARVs and their im-
mediate family members.
Figure 8: Proportion of HIV sero-positive individuals among people who participated in counselling and
testing (CT) and PMTCT activities, 2007-2009
Source: Annual report of the MoH’s National AIDS/STI Control Programme, 2009
1.4.2 Institutional framework and the AIDS response strategy
Since the onset of the HIV and AIDS epidemic, there have been several international meetings
that have aimed to lay out a number of principles that can be adopted in various countries to
foster effective and efcient implementation of HIV- and AIDS-related activities. One of which
is the “three ones” principles, endorsed in April 2004 at the Consultation on Harmonization of
International AIDS Funding. It was agreed that the principles be applicable to all stakeholders
involved in the HIV and AIDS response.
One agreed HIV and AIDS action framework that provides the basis for coordinating the
work of all partners;
One national AIDS coordinating authority, with a broad-based multi-sector mandate; and
One agreed country-level monitoring and evaluation system.
The Ghana AIDS Commission is the coordinating body for all HIV- and AIDS-related activi-
ties in the country. It oversees an expanded response to the epidemic and is responsible for
carrying out the implementation of the National Strategic Framework on HIV and AIDS, the
rst of which covered 2001–2005. The Ghana AIDS Commission is currently reviewing the
National Strategic Framework II, covering 2006 to 2010, with stakeholders, and bilateral and
multilateral partners. The frameworks set targets to reduce new HIV infections, address ser-
vice delivery issues and individual and societal vulnerability, and promote the establishment of
a multi-sector, multidisciplinary approach to HIV and AIDS programmes. The National AIDS/
STI Control Programme was developed as a public sector institution under the Ghana Health
Service to provide technical support.
Ghana’s goal is to prevent new HIV infections as well as to mitigate the socioeconomic and
psychological effects of HIV and AIDS on individuals, communities and the nation. The rst
national strategic plan focused on ve themes: prevention of new infections; care and support
of people living with HIV and AIDS; creating an enabling environment for a national response;
decentralization of HIV and AIDS activities through institutional arrangements; research; and
monitoring and evaluation of programs.
9
The second national strategic plan, focused on: policy, advocacy and creating an enabling
environment; coordination and management of the decentralized response; mitigating the
economic, socio-cultural and legal impacts; prevention and behaviour change communication;
treatment, care, and support; research and surveillance; and monitoring and evaluation.
Multilateral and bilateral partners, nongovernmental organizations (NGOs), and civil society
organizations actively participate in the national response, with more than 2,500 community-
based organizations and NGOs reportedly implementing HIV and AIDS activities in Ghana.
Substantial funding for these activities comes from the United States, the United Kingdom,
the Netherlands, Denmark, Japan, Canada and United Nations agencies. Activities include the
ve-country, World-Bank-led HIV/AIDS Abidjan-Lagos Transport Corridor project; the World
Bank-funded Treatment Acceleration Program for public-private partnership in HIV and AIDS
management; WHO’s “3 by 5” initiative; and GFATM. Through the United States Agency for
International Development’s (USAID) SHARP Project, in collaboration with Catholic Relief Ser-
vices and Opportunities Industrialization Centres International, a program of nutritional sup-
port, psychosocial counselling and home-based support is providing services to people living
with HIV and AIDS and assistance to orphans and vulnerable children.
1.4.3 Financing the HIV and AIDS response
In 2008, Asante and Fenny on behalf of the Institute of Statistical, Social and Economic Re-
search, Ghana and UNAIDS, published an assessment of HIV and AIDS expenditures in Ghana.
The objective of the assessment was to track total public, private and foreign spending on HIV
and AIDS across different sectors.
The total expenditure on HIV and AIDS activities in Ghana captured in the National AIDS
Spending Assessment (NASA) report for 2007 was US$ 52 million. Funds from international
organizations comprised 78.3% of total spending on HIV and AIDS; public funds comprised
21.4% of the total expenditure while private sources of funding constituted 0.3%. The study
did not collect all private (businesses and household or individual out-of-pocket) spending on
HIV- and AIDS-related activities, hence this total from the private sector does not represent
their contribution to the total spending on HIV and AIDS in 2007. Specically, what is recorded
here is the total private spending from the Ghana Business Coalition against AIDS and the
Ghana Employers Association. Comparing the total expenditure on HIV and AIDS in 2007
to the $ 43.4 million budget for the national response, there was an over spending of US$ 9
million. A key nding was that out of the total funding by international organizations only 23
percent was sent to the pooled or earmarked fund overseen by the GAC. The remainder was
allocated to HIV and AIDS projects not overseen by GAC.
Most of the funds were spent on treatment and care (40%), administration and management
(35%) and prevention programmes (12%). The rest of the monies were shared among the
remaining ve priority areas.
Table 5: Total Spending on Key Priorities or Intervention Areas, 2007
Key areas of Expenditure
(US$)
(%)
Prevention
6,339,069.00
12.1
Treatment and care
21,026,047.00
40.1
Orphans and vulnerable children (OVC)
153,233.00
0.3
Programme management and administrative
strengthening
18,566,509.00
35.4
Incentives for recruitment and retention of
human resources
2,788,821.00
5.3
Social protection and social services (excluding
OVC)
1,256,559.00
2.4
Enabling environment and community
development
902,332.00
1.7
HIV- and AIDS-related research (excluding
operations research)
1,412,512.00
2.7
Grand Total
52,445,091.00
100.00
10
Global Fund monies have increased signicantly from US$ 429,599 in 2002, to US$ 128 million
in 2010. The greatest rate of funding increases was between 2008 and 2009 when the amount
rose from US$ 63.3 million in 2008 to US$ 107.7 million in 2009. The Global Fund accounted
for 50% of funding for the annual PoW for HIV and AIDS in 2006; 52% in 2007; and 57% in
2008. The Global Fund thus remains the most signicant source of funding for the ght against
the disease. Figure 6 shows the rapid increase in the amount of funding from the Global Fund.
Figure 9: Global Fund contributions to HIV and AIDS nancing in Ghana: 2002 - 2010
Source: NACP 2010 Annual Report: Funding and Support to Regions to support health systems 2010
(NACP, 2011)
11
2. Research Objectives
The overall aim of this case study was to identify practical strategies and solutions on how HIV
programmes can best contribute to overall health system development and vice versa.
Specic objectives were:
To understand the priority health needs and key health system strengthening needs in the
countries studied;
To explore the contributions that the HIV and AIDS response is making to strengthening the
health system; and
To examine the evidence and formulate practical solutions through which HIV and AIDS
policies and programmes can contribute to health systems strengthening
The topics for research covered policy and planning strategies, nancing human resources for
health, medical supplies, procurement and stock management, and service delivery issues.
12
3. Methodology
The study employed a case study approach to identify evidence of interactions between HIV
programming and initiatives to strengthen the wider health system. The study was designed
to collect and describe the evidence to answer three questions: a) what are the benets of
HIV programmes to system strengthening? b) how can these benets be maximised? and c)
how can their negative impacts be avoid or minimised? The study used three data collection
methods:
1. Desk review;
2. Key informant interviews held at the national, district, health service and community
levels
3. Focus group discussions (FGDs) at the community level.
Before the start of the study, copies of the study protocol, tools and informed consent forms
as well as proles of the principal investigators and the research institutions were presented to
the ethical review committee of the Ghana Health Service for clearance. When the clearance
was given, a stakeholder meeting was held to announce the design and intent of the study
and also to solicit support and stakeholder input. The meeting included staff from the Ministry
of Health, the Ghana Health Service, the Christian Health Association of Ghana, the Society
for Private Medical and Dental Practitioners, the Ghana Medical Association, the Nurses and
Midwives Council, various civil society groups and the media. The steering committee for the
study was headed by the Deputy Director General of the Ghana Health Service.
Sampling and recruitment of respondents
Data was collected at the national, district, and community levels, which possessed diverse
economic, social, epidemiologic and health system characteristics. Two districts were chosen
for their distinct characteristics. Lower Manya Krobo is a district with a high HIV prevalence,
where the HIV programme is very active. The district of North Tongu has a low HIV prevalence
and HIV programming is minimal. Within both districts, three communities were purposefully
selected with guidance from the district health management team (see table 6. in the annex).
One of the communities was in the district capital, one community was located near a sub-
district level health facility and one remote community was at a considerable distance from a
health facility.
Data collection through interviews and FGDs was performed in the period from September
2009 till January 2010. Sixteen national-level key informant interviews were conducted, twelve
district level key informant interviews and 10 interviews with health workers. This was followed
by 13 FGDs and 24 community level interviews in the two districts. In December 2009, halfway
through the time of data collection, a team from KIT was in the country for a three-day techni-
cal meeting with the research team. During the meeting the information collected so far was
reviewed and feedback was provided on interviewing techniques. This informed the second
phase of data collection.
The team from KIT was in Ghana again in March 2010 to guide the preliminary country analysis
of the data. This data analysis workshop lasted ve days. On July 5, 2010, a team from the
Center for Health and Social Services went to Amsterdam for an expert data analysis workshop
in July, where case study results were shared and compared with the ndings produced by the
other four country studies.
13
4. Results
4.1 Alignment of (real and perceived) priority health needs, demands and supply
Ghana has outlined clear strategic objectives for health at the national level and denes pro-
gramme priorities in specic disease strategies, including HIV and AIDS in its annual and
5-year programmes of work. The study investigated how these priorities have been articulated
and translated into action. It also sought to establish the gap between priorities and actions.
Respondents felt most diseases were being well addressed by the country’s health strategies
and disease-specic programmes, such as malaria, HIV and AIDS, hypertension, respiratory
tract infections and diarrhoea diseases. Respondents were also able to indicate conditions that
are more specic to rural areas including skin diseases. Though HIV and AIDS were mentioned
as priorities, there was a general sense that if these were to be ranked in order of ascending
importance, HIV and AIDS may not make the top ten diseases. This was specically mentioned
by a district respondent:
“Malaria and typhoid are very common among our clients. Diarrhoea is also com-
mon but it is seasonal; it only occurs during certain times of the year. HIV/AIDS is
now on the rise especially among pregnant women. However, HIV/AIDS will still not
rank among the top 10 diseases according to attendance.” [Quote by a district health
worker]
When the responses were disaggregated between health policymakers and development part-
ners, there was a sense that policymakers recognised conditions such as HIV and AIDS as
concerns but not as priorities. This provides an interesting challenge in pursuing a common
agenda. For instance, a development partner commented:
“I think the most important health problems identied by the ministry are under ve
morbidity and mortality, and maternal mortality. HIV does not come in but, well, if
you are talking of diseases it will be ranked as such. […] but it will be ranked low. […]
HIV doesn’t rank in my most urgent problems for Ghana” [Quote by health develop-
ment partner]
This discrepancy was not seen as a denial of the importance of the HIV and AIDS situation.
Rather, respondents were concerned that the focus on HIV and AIDS is taking away attention
from other equally pressing health conditions, such as the high rates of maternal and child
mortality. This opinion expressed by health policy makers is supported by surveillance in the
past ve years, where data has shown that the prevalence rate for HIV has remained quite sta-
ble. Indeed, when compared to other countries, Ghana is not experiencing the HIV and AIDS
crisis that others face, and the response strategy should reect this.
Community health workers, when asked for their opinion on what they consider as priority,
mentioned malaria, which they recognised as a disease with a high burden and direct impact
on the community. Also issues of access to health facilities and clean water and sanitation ser-
vices were mentioned as priority. The study also found that community members were able to
articulate disease challenges of complex nature such as bilharzias, hypertension, measles and
diabetes as common problems. HIV and AIDS however did not feature as priorities.
This overall sense of relativism by respondents from different levels towards the importance of
HIV and AIDS as a health priority seems to be somewhat in contrast with the amount of fund-
ing available for AIDS in comparison with the overall health budget.
Ghana has adopted a bottom-up health priority identication and health planning system.
For each planning cycle health priorities are aggregated, discussed and agreed on at dif-
ferent governance levels, starting from the community level up to central government.
Some respondents commented that availability of specic programmes may inuence these
discussions and have an effect on what lters through to the next level of aggregation.
14
The study also examined in how far the health sector set priorities based on evidence pro-
vided by routine surveillance, information about the burden of disease and research data.
The responses showed that though priorities may be set in policy and strategy docu-
ments based on evidence, in reality, implementation is based on a number of factors. Poli-
cymakers and managers were constantly challenged with competing demands and a con-
straint in resources and health sector capacity to deal with these demands. Yet the
earmarking of available funding is what determines what programme receives attention.
“The burden of disease I am not sure whether really that is what is driving what is
a priority and what is not. It is the money which is driving what is to be done…. So
that is why I believe personally that what has funding, internal funding earmarked
that dictates priority and of course HIV/AIDS is one. If you go to any of the districts
it is one of the priority interventions carried out now because there is money for it.”
[Quote from a National Programme Ofcer]
“Yes, with the different actors everybody thinks their programme is more important
than the others... Donor styles and ways of working to a large extent have been
disruptive. It’s like you dangle the carrot before the rabbit. Because they come with
money and you want this money, then you will have to stop all that you are doing and
do what they want you to do.” [Quote from a national level respondent]
At the community level there is a sense that AIDS is a lower health priority, as noted by a male
community member during a focus group discussion:
“If AIDS is a problem here I haven’t noticed it as a problem here.”
Community members are generally concerned with other health priorities and some mention
they see no benet in the resources spent on the AIDS programme.
“I think the government should stop the AIDS programmes and use the money for
more important things [such as] pipe borne water, hospitals, buy exercise books and
give to school children free of charge.” [FGD Community men]
A number of community members believed that people infected with HIV did not deserve all
the current attention and expensive services. Continued misconceptions on HIV and AIDS may
still inuence people’s perceptions and contribute to some level of continued stigma at the
community level.
As a disease, there is no doubt that the impact of HIV and AIDS on the population is acknowl-
edged. HIV and AIDS are regarded as priority programmes but probably not the greatest
priority. It is highly likely that if sufcient government resources were available generally, HIV
and AIDS would receive priority but possibly not to the current extent. However, given that
resources from government or those available to be allocated to other key priority programmes
are limited, the well-resourced programmes such as HIV and AIDS programmes may appear
to be “over-prioritised.
When funds are tied to a specic disease then it is only logical that those programmes are
given more attention. This is not entirely negative as the alternative would be that the pro-
gramme would suffer the same fate as the non-resourced programmes. Any resources that
are not owing through the government-established health planning system and health sector
budget, have the potential to generate distortions in promoting a balanced emphasis on prior-
ity programmes. As this study produced no hard evidence that equally important programmes
have suffered due to HIV and AIDS programmes, the reference to “over-prioritization” in fa-
vour of HIV and AIDS programmes is to be taken with caution. Investigators believe that the
responses are a reection of the general weaknesses in the existing health planning system
rather than a judgement on the HIV programme.
4.2 Interaction between the HIV and AIDS response and the health system
The AIDS response and the AIDS programme have had a number of effects on the health sys-
tem as a whole. While some of these were found to support the functioning of the wider health
system, other effects were considered to be less positive.
15
4.2.1 Effects on HS processes and management
Planning, management and coordination
The HIV and AIDS programme has over the years developed strong systems to be able to
respond to the various challenges and demands of government, health development partners
and various stakeholders. As a result, the programme seems to have attained a completely
independent status from the rest of the health sector. Respondents suggest that the Ghana
HIV programme has been designed to undertake all activities on its own with both positive and
negative effects on planning and organization of services. Several respondents expressed this
sentiment:
“What I should say is sometimes it’s a little bit difcult to view a situation where pro-
grammes are behaving like states within a state [and] what I said before is there is
the effect of verticalization and fragmentation at the district level of services”. [Quote
from a regional health ofcer]
Respondents suggested that the HIV programme management system and the organization of
services are not integrated into the wider health system with parallel structures emerging for
oversight, monitoring and programme management. Several respondents expressed concern
that the National AIDS Control Programme does not involve all relevant institutions in their
planning and budgeting processes. Respondents said that the HIV programme was not inte-
grated into the national planning system and its planning activities were not harmonised with
the planning cycle of the sector. The emphasis on scaling up the HIV and AIDS interventions
has created tension among various general health managers who see their operational territo-
ries split, sections related to HIV and AIDS taken away from their responsibilities, reorganized,
renamed and given to other operational managers and become better funded. Some respond-
ents were concerned about external inuence over programs and procedures that should ide-
ally be handled nationally.
On how to proceed, respondents were of the opinion that the HIV programme, if properly in-
tegrated into the health system, should support effective health system strengthening. There
were various discussions of what is possible and the opportunities that exist. In the words of
a respondent:
“The opportunity will be to really integrate the services and not make them vertical.
For instance if you have HSS [health system strengthening], you cannot have funds
for HSS for TB, HSS for malaria and HSS for HIV/AIDS. You should strengthen the
systems generally and they will use it for the other programmes. There should be
harmonization in planning at all levels”. [Quote of a national health ofcer]
Respondents suggested that the design of the HIV programme as a parallel programme was
not necessarily problematic. What they wanted most was to be allowed to participate in the
planning and decision-making processes. Respondents believe there could have been not only
better coordination between the HIV and AIDS programme and the general health sector man-
agement, but that plans for the Aids programme and general health sector plans should be
developed in collaboration and coherence.
“The missing link here is that you don’t get divisions but get the programs [Ghana
Health services and disease programs] talking to each other and making inputs into
each other’s plans. That is where the linkages are not fostered and that is very wrong.
[Quote by a national level health programme ofcer]
There is clearly a leadership gap in providing direction and pulling together the opportunities
inherent in the various programmes to benet health planning and system strengthening. The
effects of a lack of linkages and synergies trickle down to lower level programme implement-
ers as vertical programme requirements. The appeals for consistency are being made for HIV
programme planning and resources to be integrated into related programmes, such as repro-
ductive health planning, maternal health services and tuberculosis programme planning at the
national level.
Providing an alternative view, several respondents noted that while vertical systems do exist,
they have a minimal impact on actual service delivery. For example, health workers stated that
they do not compartmentalize health care services irrespective of where the funds come from.
16
When out in the eld, they address any and all issues that arise. Furthermore, health facilities
offer all types of services to their clients as a comprehensive package.
Separation of functions is a consistent and integral part of service organization based on the
peculiarity of the demands of the disease intervention. HIV and AIDS by its very nature do
evoke such peculiar need to isolate aspects of its services. Irrespective of this separation and
special focus, according to many respondents all services are given equal attention:
“No services have deteriorated because we have integrated all the interventions and
health issues together.” [Quote by district health worker]
The respondents at the district and local levels pointed out that family planning activities
have always been a part of HIV services and vice versa. Health workers run integrated pro-
grammes and services for all disease conditions and do not deal with each of them in isolation.
They claim that when they are going to talk about HIV and AIDS, they also talk about TB, ma-
laria and the other diseases. Thus, when they receive resources for specic programmes, they
end up using them for the other diseases as well.
Governance, transparency and corruption
The general opinion was that there has been an increased demand for transparency and ac-
countability in the health sector since the introduction of the HIV programme and this seems
to be yielding some positive dividends at all levels. There was a greater awareness that every
dollar spent needs to be properly accounted for and that failure at any level holds sanctions
for the entire system.
“I think the authorities now think about a lot of things, for instance that other people
will hold them accountable for their actions and in-actions. Maybe they have started
thinking that it is time things are done properly. For us, those who are on the ground,
we have started identifying ourselves as part of the solutions and so therefore put up
our best”. [Quote from district health ofcer]
Due to this requirement for high level of accountability, interviewees said that so far they
have not heard of any embezzlement. This suggests that the accountability requirements have
strengthened the nancial management system of the health sector. Managers intimated that
they always pressurize staff to seek value for money so that programmes are evaluated posi-
tively and funds may be released more easily.
These perceived increases in accountability and transparency have been extended to the im-
plementing agencies particularly at the community level. Smaller organizations at the district
level, which benet from HIV and AIDS funding, have to account for money spent. So far the
impression is that these NGOs use their money well.
“I can say that the NGOs utilize their funds well and they are serious about what they
do. The HIV intervention is multi-sectoral and of varied backgrounds. […] This led to
a system of checks and balances, which was built in the national response.” [Quote
from a district health worker]
While upward accountability has clearly improved and also downward accountability is taken
more seriously, many people at the grassroots level appear unaware what HIV funds are spent
on and who benets and why. There is still room for additional transparency and improved
communication to the general public as illustrated by the following quote:
“The issue is that we don’t have HIV/AIDS here, hence when they are given money for
programs we can’t tell. They haven’t used any money here. They only come to show
lms on how to protect ourselves and take care of those who have the disease. They
just gather us and show us lms and go and spend the money.” [FGD community
men, rural high prevalence]
Lack of transparency easily leads to distrust:
The funds released for HIV do not contribute to anything. Those monies end up in peo-
ple’s pockets […] [of] the Queen Mother’s Society.” [FGD community men, district capital]
17
4.2.2 Effects on health system inputs
Health nancing and funding
As explained above, since 2004, most donors have revised their funding modalities and have
increasingly turned towards general budget support or sector budget support, which is chan-
nelled to the MoH through the Ministry of Finance and Economic Planning (MOFEP). Thus fund-
ing from most partners goes to support activities in the programme of work (PoW) for health.
However, while channelling the funding through the government general and sector budgets
an increasing number of development partners are providing the funds as earmarked funding
for specic activities. These include both bilateral and multilateral partners, as well as the in-
ternational health initiatives such GFATM and GAVI. This means that funds within the budgets
are ring-fenced and that the country needs to show reaching certain targets against the money
spent.
Health infrastructure, equipment and drug management
Ghana overall has a reasonable number of health facilities. These are nanced by government
or through loans and grants from development partners. However, distribution remains poor,
particularly in the poorest districts and rural areas. Because of this, Ghana’s health infrastruc-
ture, including equipment, still falls short in relation to access and demand for health services
by the general population. Many respondents complained about the distance between facilities
and the fact that government and partners have not been able to build more health centres,
clinics or Community-based Health Planning and Services (CHPS) centres. Ghana has recently
begun to see infrastructure and equipment being improved with support from earmarked dis-
ease programmes such as that for HIV and AIDS. Many people expect that these programmes
will continue to support infrastructure development while recognising that disease specic
programmes cannot take on full rehabilitation of the entire health system.
“So there are many expectations of the programme to contribute to the system. For
instance, in infrastructure development, the programme can do rehabilitation and
maintenance but cannot do full construction. But in certain areas, it is important that
you do full construction to get the programme running”. [Quote from national ofcer]
A national-level respondent indicated that with funds from the Global Fund, construction was
on going at “...the centre at Efa Nkwanta, we are also upgrading the store in the Brong Ahafo
region. We are building a cold room for vaccines [and] related medicines at Korle-Bu. So if
nothing [at] all, these are three landmarks that everybody can point to and say that NACP
supported.”
In addition to the regular government budget provisions for renovations, health workers have
been able to use HIV and AIDS funds to support the renovation of some reproductive and child
health centres. One respondent stated that:
“It is the HIV funding which is helping us to renovate this structure here. They are
helping with the laboratory’s aluminium frames and doors for the labs and equip-
ments and the dispensary so, I can say that they have done a lot”.[Quote from district
health ofcer]
As to whether HIV and AIDS programmes inuence the number of health facilities, it was
observed that many facilities have remodelled their structures to include additional services
thanks to HIV and AIDS funds, but this does not lead to additional health facilities. As a re-
spondent stated:
For example, some pharmacies have consulting rooms, and laboratories have ex-
tension services and counselling. Programme funds have also been used to provide
small laboratory units to facilities all over the country”. [Quote from national planning
ofcer]
Laboratory investigations are one area in which HIV and AIDS programmes have had tre-
mendous impact. All facilities that offer ARV treatment have either had their laboratories re-
furbished or equipped by the NACP. This is to ensure the accuracy of HIV test results. These
laboratories have improved other medical diagnostics.
18
Respondents valued the fact that earmarked programmes such as HIV and AIDS have strength-
ened laboratory capacity, particularly the public health reference laboratories and facilities at
the Noguchi Memorial Institute for Medical Research. The HIV programme has supported the
procurement of reagents, PCR machines in each of the ten regional hospitals and CD4 count
machines for several health facilities.
These positive effects of the HIV programme on health infrastructure have contributed to im-
proved quality not only of health infrastructure and supplies but also the services rendered to
the clients who use these facilities. Where laboratories, equipment and drug storage facilities
have been provided, this has gone a long way to strengthen capacity for service delivery be-
yond any single programme.
Training and capacity building
With funding come opportunities for capacity development. Not only did the HIV and AIDS
programme refurbish and supply equipment, it also developed the capacities of the laboratory
staff. Existing health care workers had to be given skills to handle the new challenges involved
in HIV care and treatment. Most of the training was on-the–job training and generally focusing
on HIV and AIDS both nationally and internationally. The programme trained laboratory staff in
the use of new equipment, which allowed them to conduct more sophisticated investigations.
Training also covered advanced methods for collecting and analysing data, and the implemen-
tation of quality control measures. These skills are not only applicable to HIV and AIDS, but
can be used more widely.
“Capacity has been built for these laboratories as the HIV and AIDS programme has
trained the laboratory staff on the use of this equipment. Once in a while, technicians
from the NACP come around to service the equipment and check on quality assur-
ance.” [Quote from a laboratory technician]
“These have improved a lot. More logistics and equipment have been provided. Even
the staffs have been trained on the use of these new equipments. New staff has also
been posted to our facilities.” [Quote from district health worker]
During clinical training sponsored by the HIV programme, other technical training programmes
such as proper prescription for malaria and treatment of tuberculosis were provided. Manage-
ment skills improved too. Though disease specic, the HIV programme provided impetus for
generating interest in effective stewardship particularly in the areas of accountability, account-
ing and management capacity. This happened as a result of the need to demonstrate these
qualities in order to attract funding for the disease-specic programmes and the health sector
as a whole. Without the performance-based dimensions provided by the grant requirements,
this probably would not happen, as pointed out by one respondent:
“When we were dealing with government resources alone, I didn’t have any business
talking about good governance and transparency. However, we are now dealing with
people, money from multilateral sources and diverse sources. So you must under-
stand what those issues mean and develop your own capacity in terms of leadership
style and competence to be able to manage resources... So, the pandemic means
that more resources are going to come to the sector and you have to be much more
accountable in terms of transparency in the way you do things”. [Quote from national
health ofcer]
The same ofcer noted that the resources they are entrusted with have increased and that:
“nobody will entrust such huge resources into your hands if you’ve not demonstrated good
quality leadership style and capacity and competences”. Thus with increased resources even
from HIV programme sources, actors have come to appreciate the accountability responsibility
placed on them and are aware of the potential sanctions that may follow on inefcient use of
resources.
It is also evident that the HIV programme has undertaken measures to develop and strengthen
technical capacities, both within the programme itself and the health system as a whole. This
has been in elds such as health information management where professionals have been
trained in data collection, analysis and reporting, as well as quality control and quality assur-
ance in health service delivery.
19
Though the activities are meant to meet reporting requirements for HIV and AIDS, respond-
ents at the district level generally feel that the trainings have equipped them to use the skills
for other programmes.
Effect on workload
There has been an increase in the number of people who use and access care at the health
facilities, which is largely attributable to the introduction of the National Health Insurance
Scheme [NHIS] (Seddoh and Adjei, 2010). Opinions about whether HIV and AIDS programmes
increased the number of patients and the workload varied. Part of the respondents stated that
HIV counselling and testing and the requirements for reporting specic data for the HIV pro-
gramme had increased their workload.
We overwork ourselves. I do antenatal [clinic] after which I will have to help with the
clinical care for the positive mothers. The patients are many and the procedures each
client will be taken through are also many. This puts pressure on the few available
staff”. [Quote from district health worker]
“The workload has increased. The same number of staff has had to deal with
increasing number of cases. People’s tasks have increased.” [Quote from a district
health facility worker]
“HIV/AIDS clients need special services and for this reason they frequent the hospi-
tal more than the other clients. It must also be stated that the number of processes
which HIV/AIDS patient is taken through are so many which means an increase in the
workload of the clinical staff”. [Quote from a district health facility worker]
Other respondents stated that their jobs have not changed but rather their duties have in-
creased. Now they are required to account for the work they have done and the services they
have provided under the HIV and AIDS funding system. In the past, they could nish their
tasks in a normal workday. Now during peak reporting periods, some respondents indicated
that they end up working long hours and weekends.
“More time is now spent on lling of forms and data collection. When it is time to write
our reports, I come to work before 7:00 a.m. and close sometimes after 9:00 p.m.
Even sometimes I come to work during the weekend”. [Quote from national health
worker]
Other respondents said they did not believe that a particular disease or disease programme
had increased their workload. If their duties did increase, they could not attribute it to HIV and
AIDS patients or the HIV programme.
“It has not inuenced the workload. I say so because anybody who comes to this
facility to seek care is a client and any client is a client. So I can’t say HIV/AIDS has
inuenced the workload here”. [Quote from a district health facility worker]
Incentives and the brain drain
The increased resources provided by the HIV programme have been a mixed blessing for
health professionals. In Ghana, the HIV programme offers incentives to health workers to
serve in areas others are unwilling to work in. It has not always been in the form of salary in-
creases, though that may exist in the form of eld allowances and training allowances. Instead,
programme funds have also been used to provide accommodation and services for staff posted
to poor districts. As noted by this health worker:
“Since last year we have been receiving funds from NACP and we use some for reha-
bilitation […] and other issues to make life easier for the staff”. [Quote from district
health ofcer]
20
The additional nancial incentives for those who work in HIV and AIDS programming, however,
have distorted some people’s expectations. Health workers have demanded additional pay-
ment even if the work is part of their normal duties. In the absence of these incentives, there
can be an indifferent attitude towards work, as noted by one health worker:
“Morale among the staff in this facility is low because there is no form of motivation or
incentives. When FHI was with us, they motivated everybody and you could see the
results”. [Quote from district health ofcer]
The HIV and AIDS programme, because it is well endowed with resources, tends to attract
highly qualied personnel with the requisite skills and knowledge. Financial incentives have
encouraged some health professionals to focus on HIV and AIDS and lose interest in other
public health programmes. Those who develop an expertise in HIV care and treatment also
become more marketable internationally and end up working for international organisations
rather than serving locally.
4.2.3 Effects on collaboration between sectors and stakeholders
Community and civil society engagement
The HIV programme had a positive effect in fostering a multi-sector response and encouraging
collaborations. District health management teams worked with the private sector, non-govern-
mental organizations (NGOs), civil society organizations (CSO) and community-based organisa-
tions (CBOs) to deliver services. A number of NGOs were contracted under the HIV programme to
get involved in health promotion and advocacy. This was widely acknowledged by respondents.
”There is now collaboration between the public and the private sectors on health issues.
For instance, there are now more NGOs in HIV/AIDS activities and other health issues.
What this means is that there is unity of purpose and the people have come to form a
common goal”. [Quote by national health ofcer]
“I will say that [the HIV response] has been a collective and collaborative responsibility
of the central government, the district assembly, the NGOs and CBOs all playing their
roles. We have maternity homes which play a vibrant role when it comes to HIV/AIDS.
Traditional authorities [and] a vibrant Queen Mothers Association, who help in HIV/
AIDS activities and helping the orphans”. [Quote by district health ofcer]
The HIV programme helped develop the competencies that have long been identied among
NGOs and CSOs as necessary to support community-based service delivery. Health professionals
in this study acknowledged that NGOs are able to engage community members. Their grassroots
activities allow them to bring people together and really affect behaviour change. Increased
funding to CSOs and NGOs reect this.
“There’s no way in health, in HIV and AIDS that government alone can do it without
having civil society, or community empowerment, especially if we are to pursue this
CHPS component, which is very important in Ghana”. [Quote from health development
partner]
The opportunity to access Global Fund monies was mentioned as a positive development by the
NGOs.
“Since the inception of this Global Fund a lot of these civil society organizations have
grown and made their voices heard. They’ve made their contributions to services deliv-
ery. Without [GF] nobody [would be able] to engage in service delivery”. [Quote from
a national non-government ofcer]
The value of the multi-sector response has not been lost on community members. Community
members acknowledged that there has been a great change in the way health services are man-
aged in the community. This is clearly seen in the formation of community health committees
and the change that occurred as a result of their quest for better health conditions. The com-
munities mobilized extra care for those who were ill and created support teams for the health
workers. These community mobilization efforts encouraged partnerships and experiences from
which subsequent programmes could benet.
21
It appears, though, that using community-based volunteers and organizations for HIV and
AIDS programmes has its own challenges. There are concerns about personal information,
patient condentiality and stigma that needed to be handled delicately. Thus, PLHIV have of-
ten chosen to start up their own support systems. The members of these associations often
voluntarily declare their status to encourage people to go for tests and access care. In what
respondents called “the module of hope”, PHLIV are involved in sensitization awareness pro-
grammes and support other HIV-positive people with counselling. By getting involved in pa-
tient care, PLHIV have developed a better understanding of the HIV programme.
4.2.4 Effects on health system outputs and outcomes
Efciency and quality of care
The HIV programme is generally cited as having brought signicant benets to the health sec-
tor particularly in improving professional standards and quality of care.
“The effect of HIV/AIDS quality of care is very dramatic because it improves our
safety system. In fact, even protection for the providers. I always give this example.
There was this young doctor, who died. I’ve always said that if [name withheld] was
alive in this day and age, he wouldn’t have died. He had a very violent type of hepa-
titis, which he caught from a patient simply because there were no gloves”. [Quote
from a national ofcer]
“Some things have changed. Though there were protocols and guidelines people
didn’t pay so much attention to them. However, with the current system, things
have changed, those standards are applied everywhere and you will be able to [see]
such protocols pasted on the walls in all the hospitals. This is a result of the fact that
monitoring is done on the use of such guidelines and protocols”. [Quote from a district
ofcer]
Respondents noted that the one area where there has been consistent improvement has been
in infection control. Health workers, especially the clinical staff, all take protective measures
such as wearing gloves or masks, hand, proper disposal of syringes and needles. The measures
were previously in place but workers said they never bothered to put them into the practice.
It was only with the arrival of HIV and AIDS programs, and the strict enforcement of infection
control measures, that workers began to adhere to them.
Modifying attitude towards clients
Respondents noted that stigma towards HIV and AIDS patients still existed among health
workers. As stated by this respondent:
“the main challenges here are that most of our healthcare workers, believe it or not,
are still not happy and condent in working with people living with HIV/AIDS. People
are afraid, which means that we have not been disseminating the right information”.
[Quote from a representative of a civil society organisation]
Some were unhappy that people living outside the community came to their local hospital for
HIV testing. When they test positive it skews the numbers for the local community, which up-
set one community member:
“If they are not from here, they must be asked to go to their [own] regions so that
the disgrace will come down”.
A greater understanding about how HIV is transmitted and can be treated has, however, im-
proved people’s perception of the disease. With antiretroviral therapy and treatment for op-
portunistic infections, it is no longer physically obvious who has AIDS and who does not. Health
workers are also less apprehensive about interacting with clients. Training in communication
and counselling is thought to have improved relations among providers, families and whole
communities.
22
The culture of patient counselling has resulted in the transformation of health facilities, such
as remodelling out-patient’s departments (OPD) to ensure auditory and visual privacy for HIV
and AIDS patients. Waiting rooms and additional counselling rooms have been built. As one
respondent stated:
“HIV/AIDS brought to the fore the need for greater condentiality because of the
stigmatization that it carries. I think the health sector now is more cautious about the
privacy of the individual”. [Quote from national ofcer]
It was reported that counselling is now a major aspect of health worker training. The culture
of counselling has become wide spread because of the extensive training associated with VCT.
Health personnel now speak with greater condence, which has improved how the messages
are delivered.
“Previously, even the educational messages on HIV/AIDS rather scared the people
away. But now the education messages are more friendly and encouraging. We also
use the “module of hope” in our activities. These are PLHIV who have been trained on
counselling and they help us a lot especially when it comes to a client who has just
tested positive. These PLHIV even help us in clinical care”. [Quote from district health
worker]
This new skill among health professionals has transferred into other service provision areas.
It is generally considered that if the same level of counselling and education on HIV can be
transferred to all the other diseases, the system will be strengthened.
23
5. Discussion
Ghana has an HIV prevalence rate that is low in comparison to other countries in sub-Sahara
African. Still, the numbers have dramatically uctuated over the past decade. Since 2000, the
median HIV prevalence rate among pregnant women in sentinel surveillance sites increased
from 2.3% to 3.6% in 2003 and then declined to 2.7 percent in 2005. It rose to 3.2 percent
in 2006 before falling to 2.6 percent in 2007. (NACP & GHS, 2007) So far the country has
managed to keep its HIV prevalence at 1.8% at the end of 2008 and a slight increase to 1.9
in 2009.
Policy and HIV as a priority programme
The Ghana PoW 2007 - 2011 identied the country’s health priorities as maternal and child
health, and control of communicable diseases such as HIV and AIDS, malaria, tuberculosis
and guinea worm. Annual reports from Ghana Ministry of Health and the Ghana Health Ser-
vice indicate that the country is making efforts to achieve its 2015 targets for the Millennium
Development Goals.
From the responses, HIV and AIDS is considered a priority programme by health service
providers, though some partners preferred to refer to it as a programme of concern. This is
because of other competing needs within the sector. When ranked in order of priority, malaria,
diarrhoea and maternal and child health were of greater concern. At community level HIV and
AIDS are understood to be an issue of concern, however it is generally not perceived as a prior-
ity to be addressed. Most community members would rather see further investments in health
to be focussing on increasing access to health services in general. This is not surprising given
the relatively low prevalence of HIV in Ghana. Some negative responses in relation to money
spend on HIV by community members should be seen in that same light, but it is not unlikely
that there is also an undercurrent of misconceptions and stigma that inuence the views of
community members.
There is a clear sense that donor funding and the amounts allocated to specic health topics in-
uences the overall resource allocation within the national health budget and the prioritization
in implementing health programmes. That notwithstanding, the emphasis on HIV and AIDS is
not considered misplaced by health policy makers, particularly in a resource-constrained en-
vironment. It is therefore generally appreciated that dedicated resources have been provided
for addressing the situation and it is this emphasis that has helped Ghana to maintain a low
HIV prevalence.
The main concern remains fragmentation within the health system as a result of emphasis
placed on the HIV programme. This is expressed not in terms of objecting to the money spend
on HIV and AIDS, but rather as observations towards a need to strengthen the linkages across
programmes so that synergies may be achieved. Although some development partners and
national level health policy makers commented critically on the effect of available AIDS fund-
ing on health priority setting, it is comforting to learn that respondents at district level felt that
no programme has suffered signicantly from the stated fragmentation at the national level.
This is explained by the fact that to some extent a re-allocation of resources and time from the
AIDS programme to other health programmes takes place at service delivery level.
Respondents suggested that there is a need to share information between the AIDS pro-
gramme, other priority health programmes and the health policy and planning ofces. Re-
spondents further recommended the different programmes to consult at the design, planning
and budgeting stage. These suggestions are worth taking given that any of the HIV interven-
tions is directly linked to elements of other programmes e.g. expectant mothers, reproductive
health or diseases that present as co-infections e.g. tuberculosis.
Community awareness about the importance of combating the AIDS epidemic varies between
different regions. In order to maintain high levels of support for AIDS programming, additional
investment in raising community awareness and reducing stigma is still warranted.
24
Effects of the AIDS programme on planning and management
The investments through the HIV programme in Ghana have had a direct effect on strength-
ening health systems in a number of areas. However, the design of the HIV programme has
introduced a management challenge that leaves questions to be answered as to which institu-
tion has oversight responsibility for it. Increasingly, HIV interventions assume an independent
programme status because of the large inow of funding provided by the Global Fund to Fight
AIDS, Tuberculosis and Malaria (GFATM). Given the parallel management structures, particu-
larly through the Country Coordinating Mechanisms (CCMs), it is difcult to determine which
institution within the public health system has oversight responsibility for the functions of the
National AIDS Control Programme. It was suggested during this study that the National AIDS
Control Programme, which is legally an institution under the Ghana Health Services, operates
as though it is an equivalent body. Meanwhile, the Ghana AIDS Commission, the government’s
central agency tasked with coordinating the national AIDS response, is resource constrained.
This has resulted in the Commission coming down to the level of other implementing agencies
and competing for the same resources that other implementing agencies are attempting to
access under the Global Fund nancing arrangement. In the process, it appears to have lost it
stewardship focus.
Effects of the AIDS programme on health professionalism and quality of care
The effect of the HIV programme on quality of care has been signicant. Notable changes have
included the enforcement of standard treatment protocols and guidelines and the increased
availability of infection control and risk reduction tools. As noted, these standards were often
already in place but respondents noted that adherence was attributed to the HIV programme.
The implementation of HIV and AIDS programmes has improved aspects of service delivery in
the general health delivery system. More attention is being paid to counselling and to privacy
and condentiality. However, more work needs to be done in order to scale this up. The HIV
programme is a good entry point but an integrated programme will be more sustainable in the
long run.
HIV/AIDS programmes and effects on the support system
There are still large inequities between health services in Ghana’s rural and urban areas, partic-
ularly with regard to infrastructure decits in the northern part of the country (GMoH, 2010b).
The HIV programme has helped to reduce these inequalities by improving infrastructure and
providing equipment and laboratory capacity strengthening. These efforts have gone a long
way toward strengthening capacity for health service delivery beyond any single programme.
Not only did the HIV and AIDS programme refurbish and supply equipment, it also developed
the capacities of the laboratory staff in many underserved areas. In 2004, Ghana was known
to have a decit of laboratory technicians in eight of the 10 regions in the country. The HIV
programme provided incentives for laboratory technicians to serve brief periods in these areas
and paid for others to relocate. The HIV programme in Ghana has also trained laboratory staff
in the use of new equipment. They are able to conduct more complex investigations, and col-
lect and analyse data, which is not necessarily related to HIV or AIDS.
There were transfer benets that arose in areas of management. The HIV programme pro-
vided an impetus for generating interest in effective stewardship, particularly in the areas of
accountability, accounting and management capacity.
Perceptions as to the effect of the HIV and Aids programme on the workload of health professionals
remains mixed. Ghana has a rather challenging health workforce prole. In 2001, it was estimated
that only 6% of the total workforce worked in the three northern regions of Ghana (GMoH, 2006).
Health care staffs are concentrated in urban areas. Forty-seven percent of the country’s medical
doctors worked in the two teaching hospitals and another 26% worked in the Greater Accra region.
This acute mal-distribution has implications for any additional demands made on health staff.
25
As noted, there has been an increase in the number of people who use and access care at the
health facilities which is largely attributable to the introduction of the National Health Insur-
ance Scheme [NHIS] (Seddoh and Adjei, 2010). With the increasing workload and paper work
requirements associated with the NHIS, the additional duties and reporting required for the
HIV and AIDS programme naturally translates into a heavier workload. It is therefore a com-
bination of different requirements rather than a single disease that is creating the workload
situation. The situation, however, needs to be addressed as it can have negative effects for
both the HIV programme and the health system in general.
Ghana tried to introduce an incentive system but efforts have produced few successes. In
2004, Ghana introduced the “additional duty hours allowance” to compensate for the generally
low salaries that existed in the country (Ruwoldt, 2007). In 2005, the “hire purchase vehicle”
scheme was introduced. Unfortunately, these failed to stem the migration of health personnel
and did not help retain skills in any particular area.
There are, however, some positives lessons emerging from this study. For instance the inno-
vative use of programme funds to provide accommodation for willing staff to deprived areas
looks promising but its contribution to their retention in those areas needs to be studied in
more depth. If it turns out to be positive it is worth looking for ways to replicate this by other
programmes. Training opportunities under the HIV programme has also resulted in advancing
the skills of health professionals and upgraded them to internationally recognised standards.
Stigma and attitudes
Awareness around HIV/AIDS has reduced to some extent the negative reactions and has con-
tributed to the development of some protective policies. This is reected especially in attention
for the human rights of patients.
Stigma towards HIV/AIDS patients however is still a noticeable problem and cuts across a wide
spectrum of the population. Among the respondents of all levels in society there was a com-
mon desire to ght the disease and provide comfort and services to those affected. District
health management teams willingly allowed the private sector, NGOs, CSOs and CBOs to be
involved in service delivery. A number of NGOs were contracted under the HIV programme to
get involved in the health promotion and advocacy. This is widely acknowledged.
Planned Health systems strengthening through the AIDS programme
Although the resources brought in by the AIDS programme have contributed to health system
strengthening, most of the planned effects were to be found in improved performance of the
AIDS response and services targeted towards prevention, treatment and care of HIV and AIDS.
Positive spin-off effects on the wider health system were observed when it came to the quality
of care, staff attitude, infrastructure, accountability and planning and management capacity.
Some of the effects could have been greater if the systems such as the M&E system had been
set up in a more integrated way from the start.
26
6. Conclusion
In conclusion, it was observed that the HIV programme has inuenced the health system both
positively and negatively in Ghana. The AIDS programme has brought resources that had a
catalytic effect towards provision of better services in other disease conditions. There are,
however, real challenges that need to be addressed. The ndings show that:
HIV and AIDS in Ghana remains a disease of high priority, though respondents were not in
agreement on the level of priority AIDS should be awarded in comparison to other health
needs. The underlying reasons for addressing the AIDS epidemic in Ghana as one of the
priorities needs to be more clearly articulated and the programmes will need to be designed
to bring synergies to other programme areas.
The HIV programme has contributed to health system strengthening. In particular, the pro-
gramme has helped to improve infrastructure, equipment and laboratory services at various
levels of the system. Management capacities have improved to promote transparency and
accountability. However, the vertical planning and management of the AIDS programme
has led to levels of fragmentation that prevented maximisation of the benets of the po-
tential positive synergies. Stakeholders will need to reach agreement on the key issues to
be addressed in health systems strengthening and their implications and effect on work
organisation at all levels.
The interventions in training, redistribution of staff and infrastructure development par-
ticularly in the resource-poor areas of the country have increased service availability to the
target populations beyond HIV/AIDS services to some extent, though community members
in rural areas still feel they face difculties in timely accessing good quality health services.
Incentives paid to health staff by some organisations, however, have led to higher-pay ex-
pectations and unwillingness to perform certain duties without additional payment.
The programme has introduced innovations in community mobilization and service delivery
by promoting the use of patients directed service promotion. The engagement of NGOs and
CSOs in service delivery in the HIV and AIDS is increased in Ghana. There is no clear indica-
tion within this study of the extent to which NGO and CSO engagement has also increased
for health in general.
The increase in general service utilization as a result of the introduction of the National
Health Insurance Scheme in 2004 has meant a higher workload among the available skilled
health workers. This is likely to affect the quality of HIV services that can be offered through
established systems even though the NHIS does not cover AIDS patients. No comprehen-
sive review has been conducted to assess the impact of this policy and the exclusion of HIV
and AIDS from the coverage package.
Finally, it is apparent that respondents appreciated the contribution of the HIV programme
to general health system strengthening. However, to be sustainable and in order to reach its
full potential, it needs to increase linkages and collaboration with other programmes within
the country.
27
7. Policy implications and emerging issues
HIV and AIDS continues to be a priority for the health sector especially with a view to fur-
ther reduce HIV prevalence. However, it is important that all stakeholders reach agreement
in terms of the level of priority in relation to other health priorities. Furthermore it is im-
portant that the aims and goals of the AIDS-specic response and its relation to the wider
health system needs are well articulated and that resource allocation and priority setting is
well understood by all stakeholders.
The AIDS programme has contributed to specic health system strengthening activities,
which otherwise may not have happened. In particular, it has improved laboratory quality,
health information and nancial reporting capacity. It has also led to the inow of signicant
resources that helped fund cooperation with other disease programmes that are resource
deprived. As most of these effects were aimed at improving the AIDS response rather than
the wider health system and a certain level of fragmentation and parallelism was observed,
there is need to investigate how the HIV programme can be developed to contribute in a
more efcient way to promoting synergies in building the health system.
Our study describes the contribution of the HIV and AIDS interventions as a part of a
“vertical” programme towards strengthening of the wider health system reasonably well.
However the question how to effectively build and sustain the synergies across multiple
programmes to the benet of the system as a whole remains unanswered. Understanding
this will enable the sector to develop appropriate policies to better manage the programme
and its contributions to entire system strengthening.
Funds for earmarked programmes, such as those for HIV, have generously supported and
improved laboratory infrastructure and equipment supplies and services. However, it is
clear that these project-type funding mechanisms are not sustainable particularly because
of their time-bound nature. There is a need to incorporate these advances in the HIV
programme into the country health strategy. The same applies to improved systems for
health information management, accounting and reporting. These “vertical” programme
approaches should be integrated and be used to strengthen the government lead systems
from the start.
One of the strengths of the HIV programme is its performance-based nancing system. This
has created an increased level of accountability and transparency. This is a positive that
should be looked at for scaling up of best practices to enhance the system.
28
Annex
Annex A: Distribution of interviewees
Table 6: Overview of selected communities (and numbers of key informant interviews and FGDs)
Table 7: Prole of district and national level respondents
Table 8: Interview Session lengths
Table 9: Data collection timing
Table 10: Total Number of Interviews
Manya Krobo (A)
North Tongu (B)
KII’s @ District (11)
KII’s @ Community
(12)
FGD (6)
KII’s @ District (6)
KII’s@ Community
(9)
FGD (6)
District capital
Kpowornor
Odumase (2)
Mafi Tsetsekpo
Kpogede (2)
Sub-district
level
Bellakope
Ayemersu (2)
Mafi Avedo
Kutime (2)
Remote
Gyakiti Krobo
Agatorm (2)
Melenu Dorfor
Kpomkpo (2)
District
National
1.
District Health Director and other District
Health Management Team members.
2. Primary Health Care Facility Directors
and Staff
3. Private Midwives
4. Malaria Control Officer
5. NGO’s Representatives
6. District AIDS focal person
7. Accountant GHS district
8. Finance, Planning and Budget officer of
Local Government
9. District Coordinating Director
(multisector coordination)
10. MOH – 9 respondents
11. GHS – 11 respondents
12. Development partners and donors – 5
respondents
13. NACP – 2 respondents
14. GAC, - 1 respondent
15. Coalition of health NGO’s – 1 respondent
16. CHAG – 4 respondents
Interview
FGD
National
17
X
District A
11
X
District B
6
X
Community A
12
6 (8-10 people)
Community B
9
6 (8-10 people)
2009
Interview
FGD
National
17 Sep – 9 Nov
X
District A
7 Dec – 11 Dec
X
District B
28 Dec – 31 Dec
X
Community A
24 Dec – 28 Dec
21 Dec – 23 Dec
Community B
29 Dec – 30 Dec
27 Dec – 29 Dec
Interview
FGD
National
1:15 (45-2+ hrs)
X
District
0:40 (30-1hr)
X
Community
0:30 (20-45)
1:45 (1:30-2:30)
29
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KIT Development Policy & Practice
... This inquiry forms part of a larger qualitative multi-country case study conducted in 2010 in five sub-Saharan countries, which aimed to explore synergies between HIV programmes and HSS efforts [14-18,40]. ...
... Over the same period, while total aid for health tripled, funding for health systems strengthening (HSS) fell from 62.3% to 23.9% of total funding, resulting in the stagnation of HSS support [13]. Overall, the HIV epidemic prompted an extraordinary response in terms of funding, speed and scale, and is often portrayed as overfunded and reinforcing vertical, disease-specific approaches [14-18]. ...
Article
Full-text available
Background: Health systems have experienced unprecedented stress in recent years, and as yet no consensus has emerged as to how to deal with the multiple burden of disease in the context of HIV and AIDS and other competing health priorities. Priority setting is essential, yet this is a complex, multifaceted process. Drawing on a study conducted in five African countries, this paper explores different stakeholders' perceptions of health priorities, how priorities are defined in practice, the process of resource allocation for HIV and Health and how different stakeholders perceive this. Methods: A sub-analysis was conducted of selected data from a wider qualitative study that explored the interactions between health systems and HIV and AIDS responses in five sub-Saharan countries (Burkina Faso, the Democratic Republic of Congo, Ghana, Madagascar and Malawi). Key background documents were analysed and semi-structured interviews (n = 258) and focus group discussions (n = 45) were held with representatives of communities, health personnel, decision makers, civil society representatives and development partners at both national and district level. Results: Health priorities were expressed either in terms of specific health problems and diseases or gaps in service delivery requiring a strengthening of the overall health system. In all five countries study respondents (with the exception of community members in Ghana) identified malaria and HIV as the two top health priorities. Community representatives were more likely to report concerns about accessibility of services and quality of care. National level respondents often referred to wider systemic challenges in relation to achieving the Millennium Development Goals (MDGs). Indeed, actual priority setting was heavily influenced by international agendas (e.g. MDGs) and by the ways in which development partners were supporting national strategic planning processes. At the same time, multi-stakeholder processes were increasingly used to identify priorities and inform sector-wide planning, whereby health service statistics were used to rank the burden of disease. However, many respondents remarked that health system challenges are not captured by such statistics.In all countries funding for health was reported to fall short of requirements and a need for further priority setting to match actual resource availability was identified. Pooled health sector funds have been established to some extent, but development partners' lack of flexibility in the allocation of funds according to country-generated priorities was identified as a major constraint. Conclusions: Although we found consensus on health priorities across all levels in the study countries, current funding falls short of addressing these identified areas. The nature of external funding, as well as programme-specific investment, was found to distort priority setting. There are signs that existing interventions have had limited effects beyond meeting the needs of disease-specific programmes. A need for more comprehensive health system strengthening (HSS) was identified, which requires a strong vision as to what the term means, coupled with a clear strategy and commitment from national and international decision makers in order to achieve stated goals. Prospective studies and action research, accompanied by pilot programmes, are recommended as deliberate strategies for HSS.
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This paper reviews country-level evidence about the impact of global health initiatives (GHIs), which have had profound effects on recipient country health systems in middle and low income countries. We have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV/AIDS control in resource-poor countries: the Global Fund to Fight AIDS, TB and Malaria, the World Bank Multi-country AIDS Program (MAP) and the US President's Emergency Plan for AIDS Relief (PEPFAR). This paper draws on 31 original country-specific and cross-country articles and reports, based on country-level fieldwork conducted between 2002 and 2007. Positive effects have included a rapid scale-up in HIV/AIDS service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries' national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems. Sub-national and district studies are needed to assess the degree to which GHIs are learning to align with and build the capacities of countries to respond to HIV/AIDS; whether marginalized populations access and benefit from GHI-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV and AIDS programmes funded by the GHIs. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.
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Effective interventions exist for many priority health problems in low income countries; prices are falling, and funds are increasing. However, progress towards agreed health goals remains slow. There is increasing consensus that stronger health systems are key to achieving improved health outcomes. There is much less agreement on quite how to strengthen them. Part of the challenge is to get existing and emerging knowledge about more (and less) effective strategies into practice. The evidence base also remains remarkably weak, partly because health-systems research has an image problem. The forthcoming Ministerial Summit on Health Research seeks to help define a learning agenda for health systems, so that by 2015, substantial progress will have been made to reducing the system constraints to achieving the MDGs.
Assessment of the Additional Duties Hours Allowance (ADHA) Scheme: Final Report, The Capacity Project and the Ghana Ministry of Health
  • P Ruwoldt
Ruwoldt, P. et al., 2007. Assessment of the Additional Duties Hours Allowance (ADHA) Scheme: Final Report, The Capacity Project and the Ghana Ministry of Health. Dec 2007.
Everybody's Business -Strengthening Health Systems to Improve Health Outcomes . WHO's Framework for Action. Geneva: WHO WHO eds Maximizing Positive Synergies between Health Systems and Global Health Initiatives World Health Organization
WHO, 2007. Everybody's Business -Strengthening Health Systems to Improve Health Outcomes. WHO's Framework for Action. Geneva: WHO WHO eds., 2008. Maximizing Positive Synergies between Health Systems and Global Health Initiatives. In Report on the Expert Consultation on Positive Synergies between Health Systems and Global Health Initiatives, WHO, Geneva, 29-30 May 2008. World Health Organization, Geneva.
The impact of HIV/AIDS on health systems and the health workforce in sub-Saharan Africa
  • L Tawfik
  • S N Kinoti
Tawfik L, & Kinoti S.N., 2003. The impact of HIV/AIDS on health systems and the health workforce in sub-Saharan Africa. Washington DC: Support for Analysis and Research in Africa (SARA) Project, USAID, Bureau For Africa, Office of Sustainable Development; 2003
Management Accountability Framework (MAF) for Maternal Health Country Programme Action Plan
  • Ghana Government
Government of Ghana (GoG), 2008. Management Accountability Framework (MAF) for Maternal Health 2008. Accra, Ghana Government of Ghana (GoG) and United Nations Development Program (UNDP), 2006. Country Programme Action Plan 2006-2010. Accra