Abstract:
Background: Global health agendas have in common the goal of contributing to population health outcome
improvement. In theory therefore, whenever possible, country level policy and program agenda setting, formulation
and implementation towards their attainment should be synergistic such that efforts towards one agenda promote
efforts towards the other agendas. Observation suggests that this is not what happens in practice. Potential
synergies are often unrealized and fragmentation is not uncommon. In this paper we present findings from an
exploration of how and why synergies and fragmentation occur in country level policy and program agenda
setting, formulation and implementation for the global health agendas of Universal Health Coverage (UHC), Health
Security (HS) and Health Promotion (HP) in Ghana and Sierra Leone. Our study design was a two country case
study. Data collection involved document reviews and Key Informant interviews with national and sub-national
level decision makers in both countries between July and December 2019. Additionally, in Ghana a stakeholder
workshop in December 2019 was used to validate the draft analysis and conclusions.
Results: National and global context, country health systems leadership and structure including resources were
drivers of synergies and fragmentation. How global as well as country level actors mobilized power and exercised
agency in policy and program agenda setting and implementation processes within country were also important
drivers. Conclusions: There is potential in both countries to pull towards synergies and push against fragmentation in
agenda setting, formulation and implementation of global health agendas despite the resource and other structural
constraints. It however requires political and bureaucratic prioritization of synergies, as well as skilled leadership. It
also requires considerable mobilization of country level actor exercise of agency to counter sometimes daunting
contextual, systems and structural constraints.
