UNIVERSITY OF GHANA HEALTH SECTOR DECENTRALIZATION IN GHANA: EXPLORING THE IMPLEMENTATION CHALLENGES AT THE HOSPITAL LEVEL BY FRANCIS ADANE (10245289) A THESIS SUBMITTED TO THE DEPARTMENT OF PUBLIC ADMINISTRATION AND HEALTH SERVICES MANAGEMENT, UNIVERSITY OF GHANA BUSINESS SCHOOL, UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF AN MPHIL IN HEALTH SERVICES MANAGEMENT DEGREE JUNE, 2015 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I do hereby declare that this work is the result of my own research and has not been presented by anyone for any academic award in this or any other university. All references used in the work have been fully acknowledged. Nonetheless, I bear sole responsibility for all errors and omissions inherent in the study. ………………………… ……………………… FRANCIS ADANE DATE (10245289) University of Ghana http://ugspace.ug.edu.gh ii CERTIFICATION I hereby certify that this thesis was supervised in accordance with the procedures laid down by the University of Ghana. ……………………………………... ……………………… GORDON ABEKA- NKRUMAH DATE (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh iii DEDICATION I dedicate this work solely to my mother, Veronica Abenaa Twenewaa for her vast contributions and unwavering support to my well-being in the course of my academic career. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT Firstly, I thank GOD ALMIGHTY for giving me the strength, knowledge and guidance to complete this thesis. To my supervisor Dr. Gordon Abekah Nkrumah, I keenly appreciate your unflinching attention, encouragement and critical evaluation of this thesis. I would also like to acknowledge the efforts of Dr. Justice Bawole, head of department, Dr. Albert Ahenkan and all the staff of the department of Public Administration and Health Services Management for their priceless and intuitive contributions on this thesis right from the beginning. I am also appreciative of my family, my late father Mr. Simon Adane, my mother Mrs. Veronica Abenaa Twenewaa and my siblings Peter, Felicia, Monica, Mary, and Victoria for their constant support and counsel. Not forgetting Papa Kwaku Adane- Adjei and Kwarteng Adjei for their entertainment in times of stress and boredom. Finally, I say ayekoo to Maureen Ansah for her support throughout this program. To my friends Emmanuel, Acheaw, and Smith I am very grateful to you for your advice and encouragement. Finally I am indebted to all friends and family members who in diverse ways helped to make this thesis successful. University of Ghana http://ugspace.ug.edu.gh v TABLE OF CONTENTS Content Page DECLARATION .......................................................................................................................... i CERTIFICATION ....................................................................................................................... ii DEDICATION ............................................................................................................................ iii ACKNOWLEDGEMENT .......................................................................................................... iv TABLE OF CONTENTS ............................................................................................................. v LIST OF TABLES ...................................................................................................................... ix ABSTRACT ................................................................................................................................. x CHAPTER ONE .......................................................................................................................... 1 1.1 Background of the study ........................................................................................................ 1 1.2 Problem statement .................................................................................................................. 5 1.3 Objectives of the study ........................................................................................................... 7 1.4 Research questions ................................................................................................................. 8 1.5 Significance of the study ........................................................................................................ 8 1.6 Chapter Disposition ................................................................................................................ 9 CHAPTER TWO ....................................................................................................................... 11 REVIEW OF LITERATURE .................................................................................................... 11 2.1 Introduction .......................................................................................................................... 11 2.2 The Concept of Decentralization ......................................................................................... 11 2.3 The historical review of current decentralization policies ................................................... 15 2.3.1 Developed economies ....................................................................................................... 15 2.3.2 Developing economies ...................................................................................................... 16 2.4 Theoretical Framework ........................................................................................................ 17 2.4.2Operational definition of the variables ............................................................................... 20 2.4.3 Decentralization implementation process; an empirical review ....................................... 21 2.4.4 Policy process ................................................................................................................... 23 University of Ghana http://ugspace.ug.edu.gh vi 2.4.5 Agenda setting and policy formulation ............................................................................. 26 2.4.8 Empirical review of the link between Decentralization and some key reform measures for its successful implementation ....................................................................... 29 CHAPTER THREE .................................................................................................................... 57 DECENTRALISATION IN GHANA ....................................................................................... 57 3.1 History of Decentralisation in Ghana ................................................................................... 58 3.2 General Legal Regulatory Framework and revolution of Decentralisation in Ghana ......... 65 3.3 Review of the status of health sector decentralisation in Ghana .......................................... 72 3.6.1 Historical development of the hospital ............................................................................. 78 3.7 Justification of the study areas ............................................................................................. 80 3.8 Conclusions .......................................................................................................................... 80 CHAPTER FOUR ...................................................................................................................... 82 RESEARCH METHODOLOGY ............................................................................................... 82 4.1 Introduction .......................................................................................................................... 82 4.2 Research Methods ................................................................................................................ 82 4.2.1Research Paradigm ............................................................................................................. 82 4.3 Research Design ................................................................................................................... 83 4.3.1 Sources of Data ................................................................................................................. 83 4.3.2. Sampling/ Target population ............................................................................................ 84 4.3.3 Instruments for data collection .......................................................................................... 84 4.3.4 Data collection process ..................................................................................................... 85 4.3.5 Data management and analysis ......................................................................................... 85 4.3.6 Reliability and Validity ..................................................................................................... 86 4.3.7 Ethics ................................................................................................................................. 87 4.3.8 Limitations of the study .................................................................................................... 87 4.4 Summary .............................................................................................................................. 87 CHAPTER FIVE ........................................................................................................................ 88 University of Ghana http://ugspace.ug.edu.gh vii PRESENTATION OF FINDINGS ............................................................................................ 88 5.1Introduction ........................................................................................................................... 88 5.2 Description of findings ......................................................................................................... 88 5.3 Implementation challenges of decentralization at the hospital level ................................... 88 5.3.1 Funding ............................................................................................................................. 88 5.3.2 Communication barrier between key policy implementers .............................................. 90 5.4 Important contextual factors taken into consideration before decentralization at the hospital level ....................................................................................................................... 95 5.5 Implementation status of some key reform measures of decentralization at the hospital level .................................................................................................................................... 97 5.6 Summary of implementation status and major gaps of some selected policy reform measures of decentralization at the hospital level ............................................................ 105 5.7 Summary ............................................................................................................................ 106 CHAPTER SIX ........................................................................................................................ 107 DISCUSSION OF RESULTS .................................................................................................. 107 6.1 Introduction ........................................................................................................................ 107 6.2 Implementation challenges ................................................................................................ 107 6.3 Important contextual factors taken into consideration before decentralization at the hospital level. .................................................................................................................... 122 6.3.1 Socio-economic potential ................................................................................................ 124 6.3.2 Unequal endowment of local capacity ............................................................................ 127 6.3.3 Geographical factors ....................................................................................................... 129 6.3.4 Cultural factors and ethnic diversity ............................................................................... 132 6.4 Implementation status of some key decentralization reform measures ............................. 135 6.4.1 Policy issues and objectives ............................................................................................ 135 6.4.2 Organisational reform ..................................................................................................... 137 6.4.3 Planning and financing .................................................................................................... 139 6.4.4Human resource and capacity issues ................................................................................ 143 University of Ghana http://ugspace.ug.edu.gh viii 6.4.5Inter- sectoral coordination .............................................................................................. 146 CHAPTER SEVEN .................................................................................................................. 149 SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS ........................................... 149 7.1 Introduction ........................................................................................................................ 149 7.2Summary of Findings .......................................................................................................... 149 7.3 Conclusions ........................................................................................................................ 150 7.4 Recommendations from the study ...................................................................................... 153 7.5Contributions of the study ................................................................................................... 155 7.5.1Theory .............................................................................................................................. 155 7.5.2Policy ............................................................................................................................... 155 7.6 Suggestions for future research .......................................................................................... 156 REFERENCES ......................................................................................................................... 158 APPENDICES ......................................................................................................................... 169 Appendix A: Interview guide for key policy implementers at the hospital level .................... 169 Appendix B: Facility observation checklist ............................................................................. 170 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLES Table 5.6 Summary of implementation status and their major gaps for some key Reform measures………………………………………………………………….. 105 University of Ghana http://ugspace.ug.edu.gh x ABSTRACT This study explored the implementation challenges of decentralization at Dormaa Presbyterian Hospital and Sampa Government Hospital. Data were collected using qualitative research approach using interviews guide. Key informants who had in-depth knowledge and play role(s) in the implementation of decentralization at the district level were purposively selected. In all, 22 key informants were interviewed from the two districts (11 in each district).In addition, extensive analysis of key policy documents for the two hospitals was made. Findings from the study showed that there are challenges that militate against the implementation of decentralization reforms at the hospital level. These included: inadequate human resource and low capacity at both national and local and district level; lack of communication among key policy implementers at the district level; financial constrains; inadequate support from government; and non-involvement of community members in planning and management of health program. It was also revealed that implementation of decentralization policy at the hospital level was not the best as many of the important policy measures were never initiated or were only partially implemented. The challenges existed at both policy design and the implementation phases. To ensure successful implementation of decentralization at the hospital level, the following recommendations were made: There is the need to restructure local governance institutions which are mandated to carry out the implementation and monitoring of decentralization. There is also the need for broader participation during policy formulation process; the role of development partners, civil society and private sectors responsible for health decentralization must be specified. Furthermore, policy makers are to carry out capacity needs assessment for policy feedback and implementation at decentralized unit. Development of an appropriate human resource and management policy to address the needs of the decentralization policy is also prudent. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background of the study Decentralization, as defined by Crook (2003), refers to the transfer of power, authority and functions from the central to local authorities. The term decentralization is also defined by Muriisa (2008) as transfer of power and authority from the central government to regional or sub-national governments. The concept has been recognized globally as important means of improving delivery of public goods and services (Dillinger, 1994). Decentralization can be explained in general terms a ―socio-political‖ process of power sharing arrangements between central governments and local authorities in planning, management and decision making (World Bank, 2010; Smith et al., 1990). This desire is often triggered by the wish to bring politicians and policy makers closer to citizens(Powell et al., 2005; Rondinelli et al., 1989) and also to make public services efficient and effective (World Bank,2004). In recent years, many developed and developing countries have either experimented or fully decentralized the delivery of health services and/or other functions of the health system. In most cases, decentralization has been adopted to improve accountability to local population, efficiency in service provision, equity in access and resource distribution, or to increase resource mobilization (Coutolenc, 2012). Bossert (2002) argued that decentralization brings about community participation, inter- sectorial collaboration, effectiveness, efficiency and equity. In a similar vein, studies in most developing countries revealed positive outcomes of decentralization, consisting of increased access to central government resources for people who were previously neglected, especially those who were residing in the rural regions and local communities. This consequently was found to enhance participation and increased local administrative University of Ghana http://ugspace.ug.edu.gh 2 capacity to negotiate with central government organs so that they can later allocate more resources for local activities development (Bennett 1997; Cheema et al., 1983).However, the ability for local managers to handle more resources at the local level calls for more strategic measures to increase local capacity to handle additional responsibilities at the local level. Decentralization reform has a goal of enhancing equity, increase efficiency and ensuring more participation and responsiveness of government to citizens (Larson and Ribot, 2004).However, whether this reform is achieving these objectives especially in the public sector of most developing countries in managing public sector activities are not certain as results have been mixed in the decentralization literature. According to Bennett (1997), several decentralization efforts in developing countries have recorded positive results such as increased access to central government resources for people who were previously neglected. The author revealed that, those who were residing in rural regions and in local communities, there was enhanced participation and increased local administrative capacity. This ensured negotiation with central government organs so that they can later allocate more resources for local development activities. However, the benefits and challenges of decentralization show mix results, especially in the health sector. In many developing countries, these reforms may be happening at a much faster speed but with fewer resources as compared to similar reforms which have previously taken place in most western countries, thus making their implementation a considerable challenge. University of Ghana http://ugspace.ug.edu.gh 3 Amore recent study conducted by Frumence et.al(2013), showed that inadequate funding, untimely disbursement of funds from the central government, insufficient and unqualified personnel, lack of community participation in planning and political interference were the main challenges to the implementation of the decentralization policy in Uganda‘s health sector. Decentralization could create additional challenges to the national health system, thus, there is the need to develop strong organizational capacity, as an integral part of the decentralization process (Mayhew, 2003; Oyaya & Rifkin, 2003). In most developing countries, reform measures such as capacity issues, human resource, community involvement in decision making, and communication which are needed to take place in organizations before decentralization reform is implemented are often not given the necessary attention, and this might have caused the failure of this policy in most developing countries( Dhakal, 2009) Onyach-Olaa, (2003), found out that, though a lot of successes have been achieved in terms of improving governance and service delivery through democratic decentralization and community involvement, lack of capacity at sub-national levels of government was frequently cited as the challenge to the implementation of the decentralization. In most cases, capacity requirements and assessment at the local level do not exist. In cases where such capacity requirement exists, efforts to build capacity is often constrained by resources which happens to be acute at the local levels. Evidence from Tanzania and Uganda revealed that, the lower tier of government lacked the ability to manage finances and maintain proper accounting procedures. Since these were requisite for transferring money to the lower tiers, the money received was less University of Ghana http://ugspace.ug.edu.gh 4 compared to pre decentralization; it was clear as spending on primary health care fell from 33% to 16% during decentralization (Akin, 2001). In 1979, Indonesia established ―village governments‖ with locally elected village heads accountable to village council that would determine budget priorities. The study of the 48 villages showed that, since village heads chose the members of the council, accountability to the villagers was weak; only 3% of the village proposals were included in the district budgets. Those villagers who participated in decentralized government organizations were more likely to speak out at the village council meetings speaking out their worries and that of others in the village (World Bank, 2001). According to the World Bank (2005), for the past years, implementing decentralization policy in the health sector has been one of the most emphasized development issues in many developing countries. This implementation has appeared to focus on health sector reform, changes in health financing system, and human resource development (Green, and Collins, 2003), but less attention has been paid to the challenges facing the implementation of decentralization at the hospital level. As observed by the World Bank (2005), decentralization is not always helpful to strengthen the health systems in developing countries; however the limited research done in these areas especially in developing countries has still not made the evidence clear with regards to the challenges encountered in the implementation of decentralization reform at the hospital level(Larbi, 1998 ). A lot of official evaluations and researchers have investigated the factors affecting the successful implementation of health sector decentralization and reforms in Ghana (Batley and Larbi, 2004; Agyepong, 1998; Annan, 1997; Smithson et al., 1997). Though these previous researches equally studied important aspects of the reform, only few have extensively documented on the implementation challenges of decentralization at the University of Ghana http://ugspace.ug.edu.gh 5 hospital level. The question however is, will the challenges of health sector decentralization in general be the same as those at the hospital level? Given the above question, this study seeks to understand the challenges facing the implementation of decentralization at the hospital level in Sampa Government Hospital and Dormaa Presbyterian Hospital in the Brong-Ahafo region of Ghana. These hospitals were chosen because one is a private and the other is public. The researcher would like to know if the challenges will be the same for both private and public hospitals or there will be difference. If there are differences in such challenges what accounts for it. 1.2 Problem statement Many developing countries including Ghana have adopted the decentralization policy longer than twenty (20) years. About 85% of developing countries have undergone some type of decentralization reforms (World Bank, 2002; Burki et al. 1999). However, the implementations of such reforms have been constrained by many factors. In the health sector, the case is not different in spite of all the several reported achievements, there are also reported challenges facing health the sector. For instance, decentralization has failed to achieve its intended goal of increasing the power of local people, because many governments have often implemented de-concentration or delegation form of decentralization at the expense of devolution(Martinez-Vazquez et al., 2006).The lack of capacity at local units to implement and manage responsibilities for public services delivery, especially those related to public finances and maintenance of proper accounting procedures, has been reported as one of the factors that constrained the implementation of decentralized public services in Uganda and Tanzania according to Ahmad(2005). Similarly, centralized and weak management, weak legal and institutional framework, lack of implementation strategy, poor financial and human resource management system, lack University of Ghana http://ugspace.ug.edu.gh 6 of adequate preparation for managing the reform, weak capacity at all levels, and political instability were found to be the major drawback of effective implementation of decentralization in the public health sector (Dhakal et a.l,2009). These problems normally occur because the international literature on decentralization usually focuses on government and its main modalities and features. According to Coutolenc (2012),inadequate research on how decentralization operates in the health sector, the precise challenges it faces in addition to those facing the general decentralization has been problematic for it successful implementation. For a policy to achieve its intended purpose and be effective, two conditions must be met. Firstly, the given intervention should be able to produce the desired effect, that is policy design issues, and next the policy should be followed as intended and that is implementation issues according to (DPHO, 2007). In many cases, the challenge in implementation seems to lie both at policy design phase and implementation phase. Gilson (2005) argues that implementation failure can be the result of stressing policy outcomes but virtually ignoring the policy process. It is important that guidelines and working procedures should be prepared in consultation and the involvement of those who are in charge of implementation (Wattet al., 2005), but evidence in most developing countries indicates that reform efforts are in general politically motivated rather than addressing real policy needs(Jeppsson, Ostergen and, Hagstrom, 2003).This situation adversely affects the implementation process. It must be pointed out that, this problem is not different from what pertains in Ghana. Weak and fragmented management system, poor implementation strategy, lack of motivation, weak institutional framework, lack of financial and human resource, and staff attitude and behavior were found to be the dominant factors of ineffective implementation University of Ghana http://ugspace.ug.edu.gh 7 of health sector reforms in the literature according to Sakyi (2008). Though quite a number of official evaluations and researchers have investigated the factors that inhibited the smooth implementation of health sector decentralization and reforms in Ghana (Batley and Larbi, 2004; Agyepong, 1998Annan, 1997; Smithson et al., 1997), exploring the implementation challenges of this reform at the hospital level has not received much attention from the literature especially. Health sector decentralization has also been problematic because the district health management team, health workforce and stakeholders who are very instrumental in the implementation at the district level have limited information about the policy; because information is highly centralized (Sakyi, 2010). According to the author, it is an undeniable fact that a lot of benefits have been made from this reform, yet there is rich empirical and anecdotal evidence portraying the process and management of decentralization in the health sector has been faced with several problems. Most of these obstacles facing the implementation of decentralization process are still not understood as there is little evidence to understand these challenge. The major question is why the decentralization reform designed to address some of the major problems at the hospital level are not implemented as planned? This constitutes the core question of the study. The study therefore seeks to explore these problems.It will also suggest ways through which the identified problems can be solved. 1.3 Objectives of the study The overall aim of the study is to examine the challenges that militate against the implementation of decentralization at the hospital level in Ghana. University of Ghana http://ugspace.ug.edu.gh 8 The specific objectives are to; I. Find out the important contextual factors taken into consideration in the process of decentralization at the hospital level and how these factors influence the implementation of the decentralization policy at the hospital level II. Analyze the implementation status of some key reform measures of the decentralization policy at the hospital level 1.4 Research questions I. What are the challenges that militate against the implementation of decentralization at the hospital level? II. What important contextual factors were taken into consideration in the process of decentralization at the hospital level and how have these factors affected the implementation of the decentralization policy at the hospital level? III. What is the implementation status of some key reform measures of the decentralization policy at the hospital level? 1.5 Significance of the study The significance of the study can be viewed in three areas: research, practice and policy. Considering significance to research, this study extends beyond the current research on ascertaining the impact of decentralization on health sector performance, and implementation challenges of decentralization in the health sector in general, by exploring the challenges of this reform at the hospital level. Literature on the challenges of University of Ghana http://ugspace.ug.edu.gh 9 decentralization at the hospital level in Ghana is scarce; therefore the findings of this study will contribute to knowledge in this field of study. Concerning significance to practice, the study will enable local health and central managers to identify major challenges affecting successful implementation of the decentralization policy and to adopt appropriate options to address the challenges and sustain the opportunities provided by decentralization at the hospital level. With regard to its significance to policy, the study will provide information on the challenges faced at hospitals in implementing the decentralization policy. Finally, the study will enable policy makers to know how to take certain contextual factors into consideration before they decentralize, since each district has its own characteristics that need to be taken into consideration. 1.6 Chapter Disposition The work is organized in seven main chapters. The first chapter captures the introductory aspect of the study, statement of the problem that the research sought to address, the objectives and rationale for the study. The chapter also contains the relevant research questions that the study intends to answer. Important theoretical and empirical underpinnings of implementing decentralization in the health sector are discussed in chapter two. Chapter three gives an account of decentralization in Ghana and discusses the backgrounds of the two hospitals studied. Chapter four presents the methodology of the study and describes the research paradigm used for the study, design, data collection tools, sampling techniques among others. Analyses of data collected are presented in chapter five. Chapter six covers the discussions University of Ghana http://ugspace.ug.edu.gh 10 of results. The final chapter, seven includes the summary, recommendations, conclusions and gaps that need to be considered by future research. University of Ghana http://ugspace.ug.edu.gh 11 CHAPTER TWO REVIEW OF LITERATURE 2.1 Introduction This chapter examines the theoretical and empirical literature on the implementation challenges of decentralization at the hospital level. The main focus of this chapter is on the concept of Decentralization, and the evolution of decentralization in the context of Ghana. The chapter also reviews the decentralization of the Ghana Health System and explores the implementation challenges of decentralization at the hospital level. The empirical and theoretical literature explains the links between decentralization and human resource and capacity issues, planning and finance, inter-sectorial collaboration, communication, contextual factors, and community participation. 2.2The Concept of Decentralization The term decentralization according to the literature have different definitions therefore no single definition that has been fully endorsed by scholars as the concept of decentralization tends to be elusive and its explanation and application differ from one set- up to the other (Akonnor et al. 2009; Schneider, 2003; United Nations Development Program, 1999). Several conceptual approaches have been applied to the concept of decentralization involving, the public administration approach (Rondinelliand Cheema 1983), the local fiscal choice approach (Musgrave and Musgrave, 1989), the social capital approach (Putnam 1993), and the principal agent approach (Pratt and Zeckhauser 1991; Griffith 1966). Every approach contributes different elements to our understanding of the decentralization processes. For instance, the social capital approach suggests that localities with a long tradition of community organization, civic networks and solid local institutions will be more likely to be successful in a decentralization process. University of Ghana http://ugspace.ug.edu.gh 12 The principal agent approach allows examining the relationships between the center (Ministry of Health) and local governments. This explains how the former can influence the behavior of the later. The Public Administration approach provides an important and commonly used typology of modalities of decentralization based on the level and type of institutional responsibilities that are transferred to the local level. Some approaches look at the Decentralization in three angles; I. Delegation: shifts responsibility and authority to semi-autonomous agencies (e.g., a separate regulatory commission or an accreditation commission). II. Devolution: shifts responsibility and authority from the central offices of the Ministry of Health to separate administrative structures still within the public administration (e.g., local governments of provinces, states, municipalities). III. Privatization: transfers operational responsibilities and in some cases ownership to private providers. Other approaches also look at decentralization from three perspectives which include Political, Administrative, and Fiscal. Political decentralization: Political decentralization involves establishing local government structures and community participation mechanisms. From this dimension, decentralization should provide increased political accountability, transparency and representation (Pallai 2001). Administrative decentralization is usually defined in terms of the administrative structures and systems needed at the different levels of government, and where responsibilities should be vested. It implies the (re)organization and integration of administrative bodies at the local level to carry on the decentralized functions, and the responsibility of carrying out human resource functions. It thus relates to the issues of administrative capacity and accountability. Authority over staff and its management is often a source of conflict and University of Ghana http://ugspace.ug.edu.gh 13 misalignment in Decentralization processes, since execution of responsibilities may be decentralized while staff at local level may still be appointed centrally. Fiscal decentralization is the assignment of responsibility for mobilizing, managing and allocating funds to and within sub-national governments. It focuses on the main issues of who can raise revenues (fiscal autonomy) and who can spend them (financial autonomy). It relates to the issues of intergovernmental transfers, revenue mobilization at the local level, the budgeting process across government levels and fiscal/monitoring by the central government among others (Farrant and Clarke n.d.). The fiscal aspects of decentralization are quite important and tend to affect the accountability mechanisms of local governments and other dimensions of the decentralization process. In the light of this, several definitions and explanations have been put forward by different writers and scholars, Rondinelli (1981) defines decentralization as involving the transfer of responsibility for planning, management, and resource-raising and allocation from the central government to several bodies including (a) field units of central government ministries or agencies (b) subordinate units or levels of government (c) semi-autonomous public authorities or corporations; (d) area-wide regional or functional authorities; or (e) non-governmental organizations or private voluntary organizations. Ayee (2000) also defines it as ―the transfer of power and authority from the central government to sub- national units, either by political, administrative, economic and fiscal means‖. Thus decentralization generally denotes the transfer of power and responsibilities from the central government to actors at lower political or administrative tiers. As a political and administrative procedure, decentralization involves transferring decision-making capacity, University of Ghana http://ugspace.ug.edu.gh 14 resources and competencies to lower levels of the governmental ladder (Rondinelli, 1981; Ayee, 2000; Hutchinson & La Fond, 2004). Decentralization, sometimes used interchangeably with decentralized governance is viewed as a restructuring enterprise that puts in place a system of shared responsibility between the central government and lower tiers of governance based on the principle of subsidiarity. Thus, the mention of decentralization connotes a consideration of the relationships between regional, district, community, provincial and other lower tiers of government on one hand and the central government on the other hand. According to Work (2002), this relationship existing between the central government and the lower levels may be public, private or civic. Ayee (2000) cautions that decentralization should not be seen as a substitute to centralization since both are needed for the administration of the state. A desired goal or aim must be analyzed and pursued in the light of the complementary functions of both national and sub-national actors since decentralization involves the responsibilities and relationships of all societal players including government, private and civil society (United Nations Development Program, 1999; 1998). Consequently, the United Nations Development Program (UNDP) prefers the term ―decentralized governance‖ to decentralization (UNDP, 1999; 1998). Although there are different explanations to decentralization, there is a general consensus that transferring power and resources to the central government is not decentralization but decentralization connotes a shift of power and resources away from the central bureaucracy (Schneider, 2003). University of Ghana http://ugspace.ug.edu.gh 15 2.3 The historical review of current decentralization policies 2.3.1 Developed economies In developed countries, debates over either to centralize or decentralize have occurred in different environment or in different situations (Smith, 1985). Local government has historically been strong in many developed countries; indeed, central government powers have often been developed and strengthened somewhat later than those of local government. Many countries have therefore inherited local government structures that provide a wide range of services, often financed by local funds. However, central government has tended to place increasing restrictions on local government. A common theme in the expansion of powers of central government has been the need to promote greater equality of public services throughout the country by using central government policies, regulations, and specific and general grants to reallocate resources geographically. Though decentralization has remained the continuing cry in most of these countries, it is often raised in a background of strong factors promoting centralization. Recently, faced with economic downturn and eager to control public expenditure, some central governments have tried to limit local discretion further as in UK and Sweden (Greenwood, 1979). For instance, in the report of a committee of Enquiry into local government finance in 1976 in UK (Larmour & Qalo, 1985), there was a comment that ―what has been clearly visible over recent years is a growing propensity of government to determine, in increasing detail, the pace and direction in which local services should be developed, the resources which should be devoted to them and priorities between them. This has proceeded to the point where local authorities have been called the agents of central government with additional role of statutory pressure group (Eliott, 1981). Few countries were attempting to counter this trend, though many have minority political parties in favour of strengthening local democracy. University of Ghana http://ugspace.ug.edu.gh 16 2.3.2 Developing economies Decentralization trends in developing countries point to two major phases of interest in decentralization (Smith, 1985). In the 1950s and early 1960s, decentralization of local government which was promoted by the colonial administrators was seen as a vital element in the structure of a democratic state. It also served as means of establishing local responsibility for the provision of goods and services. The structures proposed and set up were usually based on models of British or French local government, though limited in their powers and functions. Independence, however, brought concerns of national unity to the fore and for a while decentralization ceased to be a major theme. In 1970s and 1980s, interest in decentralization re-emerged for different reasons. In some countries, particularly in Africa, governments felt sufficiently secured to contemplate relinquishing some of their tight control on power and decision making to local organizations. This also became more possible as corps of skilled administrators joined the administration process. In contrast to the experiences in developed countries, decentralization has been pushed by the center rather than the periphery. However, in some countries especially in the pacific area, like Australia, Japan and China, decentralization has occurred in response to pressure from local or regional groups for increased local authority (Larmour, & Qalo, 1985). The objectives of decentralization happen to be diverse. On the philosophical and ideological level, decentralization has been seen as an important political ideal, providing the means for community participation and local self-reliance, and ensuring the accountability of government officials to the population. On a pragmatic level, decentralization has been seen as a way of overcoming institutional, physical and administrative constraints on development. For instance, increased local control can result in a better response to local needs, improved management supplies and logistics and University of Ghana http://ugspace.ug.edu.gh 17 greater motivation among local officers, thus speeding up the implementation of development projects. It has also been seen as a way of transferring responsibilities for development from the center to the periphery, and in consequence a way of spreading the blame for failure to meet rural needs (Cochrane, 1983). 2.4Theoretical Framework (The policy process) (Source; Anderson, 2006:87, 133). The study employed the J.E Anderson‘s (2006) five staged policy implementation to explain and explore the implementation challenges of decentralization reform at the hospital level. Agenda setting, formulation and adoption stages are adopted to help explain implementation of the policy issues. Implementation stage remains the focus of the study. However, the study did not cover evaluation process as described in the policy cycle. The study will give a brief notes on the agenda setting, formulation, and adoption. In-depth discussion will be done at the implementation stage which is the focus of the study. The researcher adopted this policy because, in implementing the decentralization policy at the hospital level, all the processes involved in Anderson policy process is necessary for successful implementation at the hospital as explained in many policy research literature. To ensure successful implementation of policies, it is vital to address issues concerning organizational, professional and social contexts. Well intentioned political aims are not enough to change practice, and once there is a barrier in any of these contexts, the policy Agenda setting Formulation Adoption Implementa tion Evaluation University of Ghana http://ugspace.ug.edu.gh 18 stands a chance of failure in achieving its objectives (Watt et al., 2005). There are numerous organizational issues which need to be solved for smooth implementation of a policy. Some of these issues include setting up of proper structures, planning and coordination capacity within the ministry of health, clear roles and responsibilities among the ministry of health and its sub-units, intersectoral collaboration, transfer of resources and responsibilities to the decentralized level for delivering healthcare (Paalman, 2005). There is the need for restructuring of the system to support reform initiatives in general and decentralization in particular in terms of decision making, planning, financing, organization and management. A conceptual frame work is then derived from the implementation stage as to what should go into the implementation process of the decentralization policy at the hospital level. The researcher operationalized some key measures that should take place before the implementation of the decentralization policy at the hospital level. The reform measures which include legal frame work, organizational structure, human resource and capacity issues, information and communication, participation, planning, and financing were carefully selected based on the literature, and their expected outcome. It is expected that when all these measures are successfully put in place, policy implementation will bring about decentralized management of health facilities and services, improved authority and leadership, increased participation and coordination, effective management and capacity of personnel at both national and local levels, including efficiency in health service delivery. The diagram below is a pictorial representation of the conceptual frame work adopted by the researcher. University of Ghana http://ugspace.ug.edu.gh 19 Y= a +b +c +d +e +f + se 2.4.1Conceptual frame work Expected outcome Independent variables Figure 2: Conceptual framework showing dependent and independent variables. Y = Implementation (dependent variable) a, b, c, d, e, f = reform measures for successful implementation ( independent variables) Se= error term of the equation Expected outcome= Y predictor outcomes. Legal frame work (a) Organizational structure (b) Human resource (c) Information& communication (d) Participation (e) Planning & financing (f) Decentralized management of health facilities Improved authority & leadership Increased participation & coordination Efficient management & capacity of personnel at national and local levels Improved health service delivery Implementation(Y) (Dependent variables) University of Ghana http://ugspace.ug.edu.gh 20 NB: The arrow from independent variables to dependent variables (implementation) shows direct link of the factors to policy implementation. Arrow from dependent variable (implementation) to expected output shows the expected outcome of successful implementation. Again, blue arrow from independent variables to expected outcomes shows direct relationship between the two. (Source: Modified from Dhakal, 2009:15) 2.4.2Operational definition of the variables Health sector decentralization policy: It refers to the transfer of authority and responsibility from the central level to the district health offices and local health facilities for health services planning and implementation. Policy formulation: In this study, it refers to how the decentralization policy was designed, the nature of interaction that occurred with the policy community and what is entailed in the policy. Policy adoption: It refers to the decision making process of the policy makers. Policy implementation: Concerns with the process of translating decentralization policies and plans into reality. Decentralized management of health services: This refers to the management of health facilities and services by health policy implementers at the hospital level. Organizational structure: This refers to the institutional arrangement at the local level of the Ministry of Health with redefined roles and responsibilities of concerned authorities to implement the decentralization policy at the hospital level. University of Ghana http://ugspace.ug.edu.gh 21 Implementation challenges: Implementation challenges in this study refer to the plausible difficulties and obstacles serving as hindrance for successful achievement of the policy objectives. Capacity: It refers to the competence or skills of the stakeholders in formulating, adopting and implementing the decentralization policy. Improved authority and leadership: it refers to in this study as the power assigned to different levels of the health system to put the policy into action. Decentralized planning: It refers to bottom-up planning process envisaged in the decentralization policy where relevant stakeholders are involved in planning. Participation: It refers to the active involvement and contribution in both kind and cash by health management team, local government bodies, service users, providers and civil society to translate policy objectives into reality. Coordination: It refers to the shared understanding, sharing of experience on programming and planning among government agencies at both national and local levels to maximize the output of the program. Improved service delivery: It refers to the increased access and utilization of health services. Socio-political environment: It refers to the social, political and economic environment caused by variation in geography and development priority in the case districts. 2.4.3Decentralization implementation process; an empirical review Policy does not end after passage of the law. The next important stage is the implementation which is very crucial and critical to the policy implementation process. Policy implementation is the process by which the policy is put to practice by the public University of Ghana http://ugspace.ug.edu.gh 22 and the private individuals which is key in any development strategy. Every policy implementation must pay critical attention to some measures before it can successfully be implemented. Dye expressed that policy implementation should involve a clear strategy and planned activities and some of the activities he mentioned include creation of a new organizations, or the assignment of new responsibilities to existing organizations, development of rules and regulations and bureaucratic discretion (Dye,2004). Implementation is often perceived as managerial or administrative affairs (Walt & Gilson, 1994). To determine or assess the implementation status of every policy is determined by the way its objectives are achieved, and whether a policy will be successful or otherwise depends on the implementation process. However, evidence suggests that outcomes of policies are frequently different from policy intention (Grindle & Thomas, 1991). This situation is more frequent in developing nations than the advanced countries. Leighton (1996) opined that most of the obstacles to implementing health sector reforms in Africa were as results of conflicting policy goals, political instability, weak institutional capacity, poor economic conditions, incomplete sector development and information constraints. In view of the above findings, it is obvious that decentralization policy is not just a verbal expression by policy makers but rather having a holistic view of all the necessary arrangements needed to take place before the reform is put to practice. University of Ghana http://ugspace.ug.edu.gh 23 2.4.4 Policy process An outcome of a policy does not always follow a rational process but concerns itself with the contact with actors who are influenced by social, political, economic, and historical context in which the policy is shaped and implemented. It therefore involves the combination of concepts and tools to understand its process (Sutton, 1999; Walt, 1996). Authors have different ways of defining a policy, more importantly the public policy; however, the general purpose and intention for all policies are almost the same. A policy is relatively stable, purposive course of action followed by an actor or set of actors in dealing with a problem or matters of concern (Anderson, 2006). According to Dye, a public policy is what the government decides to do or not to do. Policy may take the form of a declaration of goods, course of action, general action and authoritative decision (Sapru, 2004). Policy is also defined from the perspective of its content (Hammer and Berman, 1995) to a broad course of action (Baker, 1996). A whole lot of activities are considered in the process of policy formulation that occurs in the area of political system, and implication of this is that policy occurs in identifiable stages and that each stage can be viewed separately. Anderson has identified five stages of the policy process model. These stages include; i. Policy Agenda: This is the problem that receives the attention of public officials. The rational is getting the government to consider action on the problem. ii. Policy Formulation: It is concerned with the development of the acceptable action for public issues. This is where there is a proposal of what is to be done about the problem. University of Ghana http://ugspace.ug.edu.gh 24 iii. Policy adoption: Development of policy proposal for legitimization. It involves getting the government to accept solution to the problem. iv. Policy Implementation: Refers to the application of the policy by the government. This is where the policy of the government is applied to the problem. v. Policy Evaluation: The effort by the government to determine policy effectiveness. The government tries to find out whether the policy worked or otherwise. Dye (2004) also identified six stages of policy process model which are: i. Problem identification ii. Agenda setting iii. Policy Formulation iv. Policy legislation v. Implementation vi. Evaluation Both Dye and Anderson believe that, the policy adoption stage involves decision making process which includes bargaining, competition, and persuasion and comprise among different groups, throughout the policy making process. In such instances, the decision taken by the policy formulator tends to focus on the means rather than the end. Findings according to Walt (1996) indicate that there are technical factors including contents that are essential in understanding the policy process when judging the policy outcomes. A critical rationale for policy change could be as results of changes that have occurred earlier in the conditions set earlier in those policies. A new policy may come from an old or existing policy or overlaps with an ongoing programs. Policy change can University of Ghana http://ugspace.ug.edu.gh 25 take place within the context of policy succession and in domain between innovation and maintenance and maintenance and policy termination (Hogwood& Peters, 1983). According to, it‘s important to understand the policy analysis aspects from the perspectives of what policies the government pursues, why governments pursue such policies, and what the consequences of such policies are. Policy analysis is concerned with who gets what in politics and more importantly why and what difference does it make (Dye, 2004). Various literatures have defined and explained different analytical models in this regard (Dye, 2004; Sapru, 2004; Anderson, 2006). Dye outline eight different types of such analytical models used in political science which are institutional model, process model, incremental model ,game theory model, elite model, public choice theory model, rational model, and group model ( Dye,2004). David Easton defines policy as the authoritative allocation of values for the whole society. He is of the view that political system contains all the institutions and the process that are involved in such allocation of values, and so policy has to larger extent been regarded as a‖ black box‖ of policy making which include all the institutions of government (Easton, 1965) that converts demands into policies but whose structure is seen to be unknown and inaccessible to observation (Sapru, 2004). In the policy process, the surrounding environment or the context in which it occurs is equally worth consideration. The environment widely considers factors relating to geographical characteristics such as climate, natural resources, and topography Demographic variables such as population size, age distribution, racial composition and spatial location, political culture, social structure, the class system, and the economic system (Anderson, 2006). Policy making has been identified as one of the most complex process as it includes various stages, approaches and cycles as opined by Anderson (2006) University of Ghana http://ugspace.ug.edu.gh 26 2.4.5Agenda setting and policy formulation The way a problem actually transforms into an agenda setting is well evaluated and described by various writers (Kingdom, 1995; Sapru, 2004; Anderson, 2006). Once an issue or a problem statement has high legitimacy, high feasibility, and high support, it may become a policy agenda (Kingdom, 1995). Agenda setting could be influenced by mainly three independent streams of activities; problem stream ,policy stream politics streams which open the policy‘ window‘ permitting some matters to reach government agenda ( Kingdom, 1995). After this, agenda becomes an issue of debate and it then enters to the second phase of policy process which policy formulation. Functional activities within the policy formulation stage and blending into policy adoption include formulation of policy plan, legitimizing the course of action, and budget appropriation which lead to a problem development (Burgess, 2004). Policy formulation is concerned with an intense political process in which different groups of participants bring competing definitions of proposals. 2.4.6 Policy adoption: decision- making process Policy decisions are frequent issues encountered by policy makers and governments. They are made by public officials who give direction and content public policy action. It has to do with an action by a body or officials to accept, alter, or refuse a preferred policy option. Decision making process includes bargaining, competition, persuasion and compromise among different groups throughout the policy making process. In such situation the decision taken by the policy maker tends to focus on the means rather than the end (Dye, 2004; Anderson, 2006). Here, several approaches and forums take place at this stage. University of Ghana http://ugspace.ug.edu.gh 27 Afterwards, the panel gathers additional information and research, and models; invite comment from experts, staff and person(s) involved making the policy proposal, and secure the suitable legal and other advice as necessary to ensure the policy proposal when adopted will be in line with the state law. 2.4.7Policy Implementation (study focus) Policy making goes beyond the passage of the law. Another important stage in the policy cycle is the policy implementation which involves the process of putting the enacted policy into practice by both private and public individuals. Sapru (2004) identified that most studies in the 1960s and 1970s reported that policy designs should pay attention to capacity to implement. According to Dye, policy implementation should involve clear an planned activities, and some of the activities include policy making , for instance, the creation of new organization or the assignment of new responsibilities to existing organizations, development of rules and regulations and bureaucratic discretion(Dye, 2004). The implementation part of the policy process is often perceived as the administrative or managerial affairs (Walt& Gilson, 1994). Mostly the status of implementation is determined by the extent to which objectives are achieved (Sabatier, 1991). The process of implementation is a function of the success of the policy. However there is evidence that, outcomes are different from policy intention (Grindle& Thomas, 19991). Leighton (1996) found that obstacles to the implementation of health sector reforms include conflicting policy goals, political instability, weak institutional capacity, poor economic conditions, incomplete sector development and information constraints make implementation of reforms difficult. University of Ghana http://ugspace.ug.edu.gh 28 Legislative and judicial bodies, interest groups, community groups and political structure can influence public policy implementation (Sapru, 2004). It is obvious that, there is no blue print for effective model of policy implementation. In a nutshell, most of these studies on implementation take the form of either top-down approach or bottom-up approach. The top-down focus on the actions of top level officials whereas bottom up debate that it should rather focus on lower level officials and examine their relations with the ultimate clients as (Walt&Glisson1999; Walt &Gilson, 2006). However, for a policy to be effective, two conditions must be met. The first condition is that, the particular intervention must be able to cause the effect, and second is the policy carried as intended. The first is concerned with policy design and second involves the implementation of the policy. How a policy is implemented in an organization involved is very crucial to the overall achievement of the policy goals. Because national policies are carried out through hierarchy of bureaucratic agencies and coordination points, they are prone to implementation failure (Ratanawijitrasin et al., 2001). It is of importance that, policy evaluation process should take into consideration the policy content and implementation of the policy. Normally policy failure may lie with the policy design phase or the way it‘s implemented. The inability to identify which of these two factors leads to policy performance especially failure makes it difficult to judge if that particular policy is ineffective. For this reason looking into the process of how a policy is carried may generate lessons on policy experience as important as those to be learned from looking at policy outcomes. University of Ghana http://ugspace.ug.edu.gh 29 2.4.8Empirical review of the link between Decentralization and some key reform measures for its successful implementation There are some key links between some important reform measures and decentralization. Failure to consider these reform measures will always complicate the implementation of this policy. Empirical reviews of such links in both developing and developed nations are listed and explained below.  Decentralization and health sector reforms  Decentralization and organizational reforms  Decentralization and health system planning and financing  Decentralization, human resource and capacity issues  Decentralization and community participation  Decentralization, central –local relation and inter- sectorial coordination  Decentralization and service provision, efficiency and equity  Decentralization and communication issues  Decentralization and contextual factors 2.4.9Decentralization and health sector reforms in the world Health sector reforms are occurring frequently in both developed and developing countries and they are strongly influenced by political reform process that has become so common in the world. Decentralization of government system had become the major part of the democratic process in some countries with the objective of strengthening local government, allow greater participation of the local people and improve development across all sectors or sometimes to further their political goals (Brijlal et al., 1998). The motivation for decentralization has varied, for instance in Eastern Europe, and former Soviet union, it was part of the political and economic transformation; in Latin America University of Ghana http://ugspace.ug.edu.gh 30 the purpose was to reinforce the transition to democracy whilst in South Africa, Sri Lanka and Indonesia, it was a response to ethnic or regional conflict; and in Chile, Uganda and Cote d‘Ivoire, it was meant to improve the delivery of basic services (Shah and Thompson 2004). However, according to Gilson and Travis (1997), decentralization of the health sector occurred as a way of unifying and rectifying a fragmented and inequitable health system inherited from the apartheid era. Even when it is not explicit, improving service delivery is an implicit motivation behind most of these decentralization efforts. The reasons are twofold. First, these basic services, such as health, education, water and sanitation, all of which are the responsibility of the state, are systematically failing and especially failing poor people (World Bank 2001). The second reason why improving service delivery is behind most decentralization efforts is that, these services are consumed locally, and for that matter entrusting the management of these services into the care of the local people will better serve their needs than being managed at the central level. Historically, they were also provided locally as in the examples of Norway and Nepal where health systems and schools were run by locally- appointed health commissions until the 1930s; and communities until the 1960s respectively. Yet today the central government in these two countries (as well as most others) assumes responsibility for the delivery of these services. Many governments and their electorates associate the problems of service delivery with the centralization of these services. Further interest in decentralization was enhanced when the World Bank stressed the need for decentralization as a key reform strategy in its World Development Report 1993: Investing in Health (World Bank, 1993), as it is professed to increase the efficiency and quality of government health services (Bossert& Beauvais, 2002), decentralization of University of Ghana http://ugspace.ug.edu.gh 31 health sector is progressively recommended as an essential strategy of Health Sector Reform (HSR). It is argued that increased administrative efficiency is the prime drive for governments to decentralize (Therkildsen 2001:1; Conyers 2000:8 Increased service provision is also believed as one of the benefits of proper decentralization, as centralized government monopoly of service provision is argued to be the source of much inefficiency (Tendler 2000:118). With this argument, it is logical to introduce private firms, Non- governmental organizations (NGOs) and even local governments as providers to increase competition, thereby enhancing efficiency. However, the evidence that decentralization leads to better service provision is slim, and this is partly against the background that, the assumed causal relations are difficult to demonstrate (World Bank, 2000; Ribot 1999). Decentralization with respect to health came to light in the awake of the PHC conference at Alma-Ata in 1978 (Green, 2001). Nevertheless the implementation experiences of reform initiatives across countries were found prominently similar regardless of the socio- economic and epidemiological situations as most of these reform implementation was neither complete nor clear. The rationale behind the international community decision to push for decentralization was on the basis of its high potential in changing the centralized governance system. The advantages of decentralization in theory include; enhancing political accountability to the users of health services, greater innovation in health service delivery and local adaptation of services, improved intersectional coordination and ability to focus on developing PHC and speed up implementation of development programs (Bossert & Beauvais, 2002; Gilson& Mills, 1995). However, there are disadvantages for the above mentioned advantages (Mills, 1994). For instance local levels of government may not support University of Ghana http://ugspace.ug.edu.gh 32 national priorities, thus serving as a drawback for implementing the national policies and delivery of public goods. Decentralization is concerned mainly with intensifying health system performance or increasing health systems‘ ability to deliver quality and equitable health services that are efficient and responsive to the needs of the local people. It has been debated that, one of the best means of bridging the gap between those who have and those without is by means of decentralizing authority, and resources with effective and strict monitoring with adequate capacity measures put in place to enable local bodies to carry out people centered development programs (WHO, 2002). Conversely, it is difficult to attribute changes in health system performance to decentralization because there are other factors such as simultaneous financing reforms, political context or economic context, which may also control health system performance independent of decentralization ( Gilson & Mills, 1995). 2.7.1Organizational reforms and implementation of Decentralization in the health sector Health sector reform implementation, must take into consideration the existing organizational structures and culture of the Ministry of Health in order to enhance the chances of successful implementation (Sakyi, 2007). For any effective implementation of health sector reform policy, reorganization and restructuring of the Ministry of Health is a crucial step (Dhakal, 2009), and such processes should be based on the functional analysis of the structure to achieve the desired objectives. However, this is different in most developing countries where restructuring of the Ministry is more often than not driven by political motives rather than functional analysis of the health system. This is also partially true for the reason that most of the reorganization is influenced by the support from donors as opined by Jeppsson et al., (2003).The implementation of decentralization policies University of Ghana http://ugspace.ug.edu.gh 33 requires detailed planning and co-ordination, which in turn requires the establishment of organizational structures and procedures designed specifically to facilitate the implementation process (Matovu, 2008). Failure to do so tends to result in very slow implementation progress, disorganized decentralization, and/or the decentralization of functions without a complementary reorganization and contraction of central government activities. In all reforms, agencies will face the challenge of restructuring their resources and organizations to meet the needs of policy implementation. As new tasks are developed and procedures are created, responsibilities will shift, some divisions or departments will gain importance while others may even be abolished, and new patterns of internal resource allocation will emerge in accordance with the demands of the new policies. Restructuring also may be necessary across agencies. Some tasks may be reassigned or reallocated from one agency to another, resources will be redistributed in accordance with the new policies, some agencies will gain in importance or stature while others decline, and a greater level of coordination may be called for to ensure successful operation. The colonial structure in most developing countries encourages a centralized hierarchical administration culture with little or no involvement of district health managers and other stakeholders in planning and implementation of health services (Annan, 1997; MOH, 1996). However, these policies are often implemented in most developing countries without considering all these factors which mostly affects its implementation. According to Annan (1997), fragmented structure of health system is responsible for difficulties encountered in sectoral coordination and implementation program at national, regional and district levels; and there is a direct linkage between organizational structure and culture of the health system as indicated by Agyapong (1998). University of Ghana http://ugspace.ug.edu.gh 34 Agyapong opined that, the issue of organizational structure is closely linked to the organizational culture of the health system especially with reference to staff orientation, and this linkage was found to be constraining the practice of health decentralization at district level. As explained by Dhakal, agenda of restructuring of a system may not always be a suitable suggestion, unless it benefits the interest of an individual or the group .For instance, in the reorganization exercise in Uganda, the role of the Ministry of Health was reduced to policy formulation, planning, supervision, setting standards and inspection, management of national programs, ensuring appropriate quality, provide specialized logistical support that were not available in the district markets and even after decentralization, Ministry of health was still working the way they had in the past, that is managing vertically organized programs from the center down to local level (Jeppsson et al, 2003). Restructuring is mostly overlooked in the decentralization process, but it‘s vital to restructure and redefine the roles expected of the national and sub-national levels to prevent confusion about their respective new roles. In Nepal and Kenya, the central level was not restructured in line with decentralization reform, and roles of managers were not re-defined. This brought about the problem of vertical program, where managers dominated the central level decisions because their roles were not redefined to reflect the policy objective (Dhakal & Singh, 2006; ADB, 1999). Decentralized health systems have more administrative levels and governance structures than centralized systems and this multiple lines of responsibility can be a source of confusion for actors at all levels, with none having a clear understanding of their respective new roles ( Brijlal et al., 1998), as it was seen in the case of Zambia where the National Ministry of Health delegated all responsibilities for direct service delivery to the Central Board of Health which then contracted district health management team and hospital boards to provide services at the district and hospital levels in that order. University of Ghana http://ugspace.ug.edu.gh 35 This situation brought about confusion of roles and responsibilities and delay in timely decision making according to Bossert et al. (2003). 2.4.10Decentralization and Health System Planning and Financing Districts vary widely according to the specific needs of their population, and even more so in terms of existing interventions and available resources. Strategies, therefore, must be district-specific, not only because health needs vary, but also because people's perceptions and capacities to intervene and implement programs vary. In centrally designed plans, there is little scope for such adaptation and contextualization, hence decentralized planning becomes crucial (Gopal&, Mondal, 2007). There is also the need to evolve from a more "command and control" orientation of public health officials towards the community, to an attitude of participation, openness and accountability, recognizing the rights of the poor and the vulnerable. Decentralized planning according to the World Bank (1993) is seen as a way of coping with the changing patterns of diseases and regional disparities in health. Conyers (2000:7) provides four broad categories to outline decentralization objectives: local empowerment, administrative efficiency and effectiveness, national cohesion, and central control. However, Oyugi (2000) argues that the merits mentioned above are claims and expectations and not hard facts. He continued to posit that these outcomes depend on conditions relating to real power sharing and meaningful participation and without these, the effects may encounter the objectives. Segall (1983) is of the view that, creating conditions for the national health programming to be carried out at local level by the people should be in close contact with the local needs and conditions. Approach of this nature tries to emphasize local health programming than on detailed planning of large national health programs; and this approach is capable of University of Ghana http://ugspace.ug.edu.gh 36 reinforcing the values of planning system such as equity, need to involve communities in decision making processes; recognition of multi sectoral nature of factors affecting health and need to ensure that the interventions that are adopted are appropriate in drawing attention to promotional activities. Oyugi also asserts that when interventions are meaningful to local population and perceive their participation to be beneficial in a development situation, they are willing to contribute. A study conducted in India revealed that decentralized health planning identified the target based approach as one of the problems for implementation. The central government always imposes districts with targets without taking into account local factors that can constrain the achievements of such targets. Despite the fact that budget ceiling was provided, the large portion of the fund was used for salaries, whilst very little was spent on district specific programs. Evidence revealed that districts which put much of their efforts and focused on addressing the problems of implementation of national programs were very successful in meeting the objectives set for decentralization. In most cases, the success of decentralized planning is a function of the extent to which administrative and implementation support provided by the central ministry. Getting administrative support is far better if there is a clear understanding at the level of program planners about what can be and cannot be done at various levels and if there is confidence that plans have been developed based on rational analysis of local needs. There is no program that can be planned without understanding the situation of the district in micro level planning, and this further suggest the view that planning without identifying the viable place is likely to face challenges as opined by Collins et al, (2003).The central problem of planning is integrating local needs and aspirations into the national planning process without losing the broader development objectives that planning can serve or University of Ghana http://ugspace.ug.edu.gh 37 undermining the inclusive/participatory processes that decentralization is supposed to embody. Strategies to mobilize more resources to finance decentralization process are very vital for the success of the reform. In such situation, most hospitals will be independent and autonomous in the areas of finance which serves as a major barrier to many policy reforms. This also means that financial resource will be channeled to areas of needs to society. Many governments rely heavily on donor funding (Bossert, 1998; Walt, 1996), and this means that government is likely to have little ownership with respect to the nature and course of the reform in their country. This is because most of these funding agencies attach some conditions to the amount donated as to where the money should be invested at the expense of the needs of the local people. The imposition of user‘s fees by local government may prevent the poor people in community from accessing basic health services. User fees that were initiated in most of African countries which excluded vulnerable groups from vital services, and exemption systems proved ineffective (Dhaka, 2009). For instance, in Uganda, user fee was abolished at public facilities in 2001 in order to encourage access to healthcare and this resulted in increased utilization of ambulatory services (Kawonga, 2003). Experience from different countries show that, decentralization reform could have an influence on resource allocation mechanisms. Bossert & Beauvais (2002) examined the decentralization experiences ranging from devolution to delegation in Ghana, Uganda, Zambia and Philippines, and the results revealed that, in all countries, health expenditure increased at the local level and decreased at the central level as a result of decentralization reform. Despite this, higher spending at the local level did not result from any significant increase in revenue generation at the level but rather from increased transfers from the central government. University of Ghana http://ugspace.ug.edu.gh 38 A recent study by Cuttolenc (2012) showed that in Ghana there was a substantial delay in transfer and release of funds, both by government of Ghana and NHIS, which hampered the functioning of local governments and local facilities and programs alike. In addition, fiscal decentralization in Ghana is more apparent than real as over 50 percent of public health expenditure is allocated to the district level, but the larger part of these resources are allocated and controlled by the central government; local authorities ,whether DAs or GHS District Offices and facilities have little real decision power on resource allocation. Evidence is that continued control from the central government over salary and personnel severely limit local fiscal autonomy and hinder cost control efforts (Bossert& Beauvais, 2002). However, it is crucial to constantly monitor the local level by the central level with regards to how local financial decision are made in a decentralized system, because health may be given a low priority in relation to other sectors, and may receive a smaller financial share of limited local council grants. 2.4.11Decentralisation and human resources management and capacity issues Human resources are the most important aspect of health care system in converting available pharmaceuticals, medical technology, and preventive health information into a better use for every nation. But the absence of clear human resource policies has been one major problem encountered in the health sector reforms. Decentralization which is a popular feature of most public sector reform programs is viewed as an opportunity to improve Human resource management, but the current evidence according to Wang et al. (2002) is open to doubt. Effective delivery of health services is seriously affected by human resources constraints (Narasim-ham etal. 2004). The major concerns has been inappropriate numbers and types of staff and the way they are been distributed, as well as the performance of the staff. Dhakal ( 2009) also identified University of Ghana http://ugspace.ug.edu.gh 39 similar problems as he opined that, quantitative mismatch, Qualitative disparity, unequal distribution and lack of coordination between HRM functions and health policy objectives have been the key issues, and that decentralization reform cannot succeed if these issues are not addressed in a timely manner. Appropriate HRM policies and practices can improve human resource (HR) outcomes and consequently lead to the effectiveness of the workforce, which in the long run bring about improved organizational performance. HRM policies and practices that are aligned with appropriate health service objectives, improvement in HRM leads to improved health outcomes. Increasing number of low-skilled health workers and the fall of demand at rural health facilities in part due to the loss of their most experienced personnel was found to be the cause of the falling productivity of health workers in china (Martineau et al., 2004 Gong et al. 1997). As public sector organizations become exposed to new public management reforms, human resource activities will be required to play a greater role. Sakyi was of the view that understanding the importance of human resource management practices is therefore important for reform implementation. Four main factors were obtained as contributing to HR problems in Ghana, particularly in the Ghana health sector (Agyepong et al., 2004; Dovlo, 2003). The recruitment and selection of employees is one such challenge because of the influence of social and political connections and patronage in Ghanaian public organizations (Price, 1975). Another challenge is the wastage of public health sector workforce through misapplied skills, absenteeism, poor support and lack of supervision (Dovlo, 2005b). Furthermore, the problem of ghost workers on payroll is affecting human resource development policy University of Ghana http://ugspace.ug.edu.gh 40 making and implementation in many ways as expressed by Ackon, (1994). This aspect of the problem is not thoroughly explored. Therefore, it is important for reformers and donors to also consider seriously how to deal with these problems in the public health sector. Another related issue involves the development of human capital among Ghanaian health workers (including other public sector employees), most of these employees tend to work within the limits of their job descriptions and scarcely try new work activities. Therefore, it is important for public management reform programs to address the issue of on the job training and detailed description of tasks that public Officials are expected to perform (MOH, 2001). The issue of HR issues is very important as the quality of health services, their efficacy and accessibility depend mainly on the performance of those who deliver them (WHO, 2000). How the workforce performs is determined by the policies that define the number of staff, their qualifications, deployment and their working conditions. In view of this, it‘s necessary to deal with some of the necessary processes and dimensions that influence the performance of workers. Experience from other countries show that, there is the likelihood of serious implication of decentralization on workforce (Collinet al., 2003; Aitken, 2004). Three issues whose resolution calls for active collaboration between international and national authorities, stand out clearly among the numerous and must be given the necessary consideration. Urgent need to define the essential human resource policy, planning and management skills that national human resource managers working in decentralized units must have is the first one, decentralization purported negative impact on staffing equity due to lack of promotion and other incentive mechanisms at different level is the next, and the third is the continuous poor motivation and performance in decentralized system (Dhakal, 2009). University of Ghana http://ugspace.ug.edu.gh 41 Capacity is topical in almost all studies on new public management reform implementation, including decentralization of health services. However, this implementation has tended to focus on health sector reform, changes in the health financing system, and human resource development (Green ,& Collins, 2003 ), with less attention paid to the institutional development of health systems undergoing decentralization (Green & Collins, 2003; Gilson & Mills, 1995). Without institutional capacity, health facilities do not function well by themselves, especially at the district level, where they provide primary health care to communities (Oyoya & Rifkin, 2003). Studies indicate that a critical factor influencing the practice of decentralization is the technical and managerial as well as logistical feasibility of its implementation (Sakyi, 2007; Batley and Larbi, 2004; Agyepong, 1998; Larbi, 1998). It is important to note that, capacity can be measured in quantitative terms. But, in the context of local governance and service delivery, it is more often seen from the perspective of how decision-making processes are being organized, what quality of services is being provided, and what are the results and outcomes that are being achieved. This implies that such 'qualitative' capacities require a lot of development and contextualization for the sake of relevance, quality and acceptance. In most developing countries, the required capacity for effective decentralization to take place is lacking, and most often frequently asked questions by reform analysts is whether the required managerial capacity and capabilities are in existence in these countries. For instance, Larbi (1998) found that district health management teams failed to implement several components of decentralized management because the technical and managerial staffs are incapacitated. Studies emphasized the importance of human capacity to effective implementation (Grindle, 1997; Turner and Hulme, 1997), as health service is a labour University of Ghana http://ugspace.ug.edu.gh 42 intensive industry and human resource remains a critical component for successful service delivery (Dovlo and Nyonator, 2004; Dovlo, 2003). Capacity problems can seriously affect decentralization reform initiative, and an example was found in Kenya where the shift in the responsibility of drug purchase to the districts was reversed after one year due to the poor performance of the district resulting from poor capacity. In the same way, short of capacity was found to be major hindrance to AIDS control initiatives, and as a result The Ministry of Health was compelled to maintain a centralized system (Kawonga, 2003). Limitation in capacity can serve as a hindrance to the implementation of policies, and this can range from human resource, inappropriate skill training and lack of adequate preparedness for their new functions. Gottret & Schieber (2006) expressed that, to successfully implement decentralization policy, the leadership capacity of new managers must be strengthened, as must be the institutional capacity of new systems at the local level and capacity building must occur before and after decentralization. However, despite these positive correlation between policy implementation and capacity building, a review of 140 countries on the impact of decentralization on immunization services, showed no evidence that institutional capacity and policy implementation correlated (Gottret &Schieber ,2006). 2.4.12Decentralisation and community participation Community participation is often described as the major benefit of decentralization and mostly assumed to be the regular benefit arising from decentralization processes. It is a luxury for the poor people who are faced with problems of illiteracy, poor health, hunger, economic emaciation and poor infrastructure, among others. According to Gaventa (2001), poor people are excluded from participation in governance and state institutions are often neither responsive, nor accountable to the poor. Francis and James (2003) carried out a University of Ghana http://ugspace.ug.edu.gh 43 study in Uganda, which revealed that ―decentralization structures and processes did not constitute a genuinely participatory system of local governance‖. Community participation was initially used by the WHO as a tactic in promoting health. Community participation is often seen as a crucial aspect of health programs in developing countries (Bracht and Tsouros 1990, Rifkin 1991). As spelt out in article 4 of the Alma-Ata declaration ―the people have the right and duty to participate individually and collectively in planning and in the implementation of their health care‖ (Alma-Ata Declaration 1978). Eckerman et al. (2005) is of the view that community participation is not just a component of primary health care but a life blood philosophy, and referred to as not just the involvement of the community but an active involvement of ownership and control. Community participation is thus defined as a social process that allows people of a specific geographic location to be involved in identifying their needs (Rifkin 1986; Anderson and McFarlane 2008). The United Nation Economic and Social Council Report (UNESC 1956), defines community participation as the process by which the efforts of the people are united with those of the government authorities in order to improve the economic , social and cultural conditions of communities, with the view that such communities will be integrated thereby contributing fully to national progress. There are numerous reasons why community members should partake in the provision of health care, and one such reasons is ensuring accountability of health services to users who are regarded voters, tax payers and consumers ((Tritter and McCallum 2006). The active participation of communities and community based originations in planning and management of local health care activities is essential and can make important contributions to service quality and efficiency. Consultation with and the participation of implementers is a function of successful implementation of policies and it‘s important for two main reasons; the first is to improve University of Ghana http://ugspace.ug.edu.gh 44 the quality of change by including the views and experiences of health sector staff and users; and secondly, to develop a sense of ownership among the same group (Bossert, 2004b), and therefore implementers must be made part of the policy d