£A 552 . DC,5 
Af2 
blthr C .l 
G347524
University of Ghana          http://ugspace.ug.edu.gh
MASTER OF  PUBLIC HEALTH  
UN IVERSITY  OF  GHANA  
LE60N
AN APPRAISAL OF INTERSEC 'ORAL  
COLLABORATION ON PHC IN THE 
i SANTE-AMM NORTH DISTRICT
A D ISSERTATION  SUBMITTED  TO THE  S CH OOL  OF  PUBLIC  
H EALTH ,  UN IVERS ITY  OF  C H A N A ,  L E 6 0 N ,  IN PART IAL  
F U L F I LM E N T  OF  THE R EQ U IR E M E N T S  FOR  
A  MASTERS  D E C R E E  IN PUBLIC  HEALTH
University of Ghana          http://ugspace.ug.edu.gh
DECLARATION
I hereby declare that this document is an original work produced by me under the 
supervision o f Dr. Eugene Nyarko and Professor Gilford Armah Ashitey fo r  the award o f  
a Master o f  Public Health Degree.
This document has never on any previous occasion been presented in part or whole to any 
Institution or Board fo r  the award o f  any Degree.
Signature .........................
Dr. Godwin Y. Afenyadu
SUPERVISORS
Signature.................
Dr. Eugene Nyarko
Signature-—
Prof. Gilford A. Ashitey
University of Ghana          http://ugspace.ug.edu.gh
m m c x n o s
■: -,p4L‘ L jfe.? -ra5?
p^!ferii|§liy^wB§t^ l3§3f ~ rfTr:
To ' 'hi. an l the kids Jor their patience, tolerance, and
■ . . . : . .■•••.•• .;• .  . :  ••...; ■ - ■ ■
uno ersta.*ding oj n j  ^emg away /rom home for a i \tle we* a $ [ f a r ,
u i . lO m rum saikr n.” •u^trU:.-HBru:1nfT7:‘5Ih:ii'.;. ~.:,ii:'-:~Wu ^ ftT :~i:
late toKius, I  hcpp vou. will always remember “ it’s never too t<
L^t  ^5^- ‘ii p ii- • >* j Pi- fini l: It ush^ «. it •1 ~ l- tini IL
•m .«learn . Ji't: :n,;\ ;>• * 'i;V V f  ’ If.. 1
...................2HiHE!It5HrtIili!S^i3HHI5!La:-iifinhu:u:tii^i:{ui s^j?rijts*i. J3^3H£5mi3n5I333rHm5HH!jj:ujn2ii:2ru^«:iRo^ a£oIit5Hrii
ii
University of Ghana          http://ugspace.ug.edu.gh
ACKNOWLEDGEMENTS 
The collection o f data for this dissertation would have been 
impossible without the cooperation o f the Asante-Akim North 
District Assembly and the heads o f the health-related decentralised 
departments. I  am grateful for their support, cooperation, and 
tolerance.
I  am also grateful to my field supervisors, Dr Joke de Graf and Dr 
George Amofah, RDHS(Ashanti Region) for reading through the 
document at its preparatory stages and for their very useful 
criticism and suggestions.
Thank you Dr de Graf, the Rural Health Service, and the 
management of the Agogo Hospital for your hospitality and 
support during my field residency at Agogo.
Finally, I am very grateful to my academic supervisors for making 
the time out of their busy schedules to keep me on my tract
University of Ghana          http://ugspace.ug.edu.gh
TABLE OF CONTENTS
CHAPTER 1 
INTRODUCTION
1.1 The Study Area 1
1.2 Historical Background 2
1.3 The Problem Statement 5
1.4 Limitations of the Study 8
CHAPTER 2
STUDY OBJECTIVES
2.1 Study Objectives 9
2.1.1 Main Objective 9
2.1.2 Specific Objectives 9
2.2 Operational Definitions 11
CHAPTER 3
LITERATURE REVIEW
3.1 PHC and Intersectoral Collaboration 15
3.2 Formal and Non-Formal Education and Health 15
3.3 Agriculture and Health 16
3.4 Water, Sanitation, Housing, the Environment and Health 17
3.5 Non-Governmental Organisations and Health 19
3.6 Previous Studies on Intersectoral Collaboration on PHC 19
3.7 PHC as a priority for the District Assemblies 20
3.8 Administrative Mechanisms for ISC 21
3.9 Problems often encountered with ISC 22
CHAPTER 4
METHODOLOGY 23
4.1 Study Type 23
4.2 The Study Unit 23
4.3 Data Collection Technique and Tools 24
4.4 Plans for Data Analysis 25
CHAPTER 5
The Structures put in place for ISC on PHC within the Asante-Akim North 
district (AAND) 33
FINDINGS
The District Assembly 33
The Subcommittees of the Assembly 34
The Social Services and Environment Subcommittee 35
The Works Subcommittee 36
University of Ghana          http://ugspace.ug.edu.gh
The Executive Committee 36
Departmental Priorities of the Asante-Akim North District Assembly 38
Understanding of the Concept of Intersectoral Collaboration on 
PHC Activities 40
The PHC Activities of Health Related Departments in Asante-Akim 
North District s ^
Social Welfare Department A T ^
Department of Community Development [Z  /  \  \  43
Department of Agriculture ' 1 ' ! 45
The District Mobilisation Programme 47
Department of Feeder Roads 48
Ghana Education Service ■---1- 48
National Service Secretariat 49
The Practice and Mechanisms of Intersectoral Collaboration on 
PHC in Asante-Akim North District 52
The Forum 52
Joint Action Plans 56
Implementation of Joint Action Plans 57
Contribution of Resources for the Implementation of Joint Action Plan 58 
Constraints on Intersectoral Collaboration 61
CHAPTER 6
DISCUSSIONS AND CONCLUSIONS
The Development Priorities of the Asante-Akim North District Assembly 64 
The Understanding and Perception of ISC on PHC 66
PHC activities by the Health related departments 66
The Constraints on ISC on PHC activities in the Asante-Akim North 
District 67
CHAPTER 7
RECOMMENDATIONS (The Way Forward ?)
Health as a Development Priority 74
Awareness Creation Amongst the health related departments on the PHC 
activities of other sectors 75
Forum for intersectoral planning of PHC Programmes 75
Increased Role of the District Assembly in facilitating ISC on PHC 76
Funding of Intersectoral PHC Activities 76
Training Needs 76
Reward and Motivation by Superior Officers 77
APPENDICES
A : Interview Guidelines for District Coordinating Director 78
B : Interview Guidelines for Heads of Decentralised Departments and NGOs 84
C : Interview Guidelines for DDHS 92
D : Local Government Act 1993 9 4
E : Departments Under the District Assembly 96
F : Functions of the Executive Committee 97
v
University of Ghana          http://ugspace.ug.edu.gh
G : Functions of the Social Services Sub-Committee 98
Functions of the Works or Technical & Infrastructure Sub-Committee 98
H : Focus Group Discussion Guidelines for Social Services and
Works Sub-Committee 100
I : Focus Group Discussion Guidelines for the DHMT Intersectoral
Collaboration on PHC 104
UST OF TABLES
1 . Variables and Indicators 10
2. Process Indicators on PHC Activities 31
3. Reports discussed by the Executive Committee at its Meetings 37
4. Expenditure of 1994 District Assembly’s Common Fund-AAND 39
5. Summary of the description of ISC on PHC in the Asante Akim 
North District using an analytical framework adapted from Rifkin et al
(1988). 60
6. Summary of the Understanding of the concept of PHC (by sector heads) 106
7. Summary of PHC activities undertaken by other sectors in the Asante Akim
North district(proportion of the 8 basic components) 107
8. Common grounds-PHC activities undertaken by other health related
sectors in the AAND 108
9. Focus Group Discussion Summary-Works Subcommittee 110
10. Focus Group Discussion Summary-DHMT 112
UST OF FIGURES
1 . The Continuum of a Process Indicator 28
2. The ISC polygon 29
3. The dynamic changes in the ISC polygon 30
4. Summary of ISC on PHC in AAND(adapted from Rifkin) 60b
REFERENCES
BIBLIOGRAPHY
115
117
University of Ghana          http://ugspace.ug.edu.gh
ABSTRACT
An appraisal of intersectoral collaboration on PHC in the Asante-Akim North 
District in October 1995 revealed that though PHC is high amongst the 
developmental priorities of the Assembly, there is hardly any effort to coordinate 
the activities of the various sectors engaged in the promotion o f PHC. Despite 
much common ground for collaboration, horizontal linkages amongst the 
decentralised departments engaged in PAC. activities remain weak or nonexistent
An analytical framework adapted from the work of Susan Rifkin^ and others on 
“Measuring Participation” was used to describe the extent of Intersectoral 
collaboration in the district The extent of Intersectoral collaboration can be 
described as limited.
The subcommittees established for the purpose o f preparing short, medium, and 
long term plans on PHC for the District Assembly have been unable to perform 
this role adequately. The members of these subcommittees have not been prepared 
(through training) for their new roles. Consequently, they have been found to lack 
the capacity to prepare district health development and promotion plans and to 
advocate for their implementation as envisaged by Local government law, Act 462.
The DHMT has ceased to be multi sectoral because its past relationships with other 
health related sectors were found to be unfruitful The team perceives the other 
sectors as not committed to intersectoral health activities and therefore unwilling 
to commit their resources to such activities.
University of Ghana          http://ugspace.ug.edu.gh
In view of the fact that donor funded joint action plans were smoothly and 
effectively implemented, it is believed that the implementation of composite 
budgeting may facilitate the implementation of intersectoral PHC activities in the 
future.
A training programme for the Assembly members elected to the subcommittees 
and the staff of the Assembly is advocated to strengthen their capacity to perform 
their expected roles. A “neutral” forum created and supported by the Assembly for 
coordinating the activities of all health related sectors is also advocated to further 
strengthen intersectoral collaboration in the district
University of Ghana          http://ugspace.ug.edu.gh
LIST OF ABBREVIATIONS
AAND Asante-Akim North District
AANDA Asante-Akim North District Assembly
DCD District Co-ordinating Director
DDHS District Director Of Health Services
DHMT District Health Management Team
GDHS Ghana Demographic Health Survey
GEAP Ghana Environmental Action Plan
GWSC Ghana Water and Sewerage Corporation
ISC Intersectoral Collaboration
KVIP Kumasi Ventilated Pit Latrine
LGA Local Government Act
MLG Ministry Of Local Government
MOH Ministry Of Health
NGO Non-Governmental Organisation
NRC National Redemption Council
PCG Presbyterian Church Of Ghana
PHC Primary Health Care
PNDC Provisional National Defence Council
SRC Swiss Red Cross
SSSC Social Services Sub-committee
TDR Tropical Diseases Research
TISC Technical and Infrastructure Subcommittee
UNICEF United Nations Children Fund
UPE Universal Primary Education
University of Ghana          http://ugspace.ug.edu.gh
DISTRICT MAP OF GHANAUniversity of Ghana         http://ugspace.ug.edu.gh
S A H i E. a l<IiVl N O R I H  b i s  I K I L  i MM i"
University of Ghana          http://ugspace.ug.edu.gh
CHAPTER 1
INTRODUCTION
1.1 The Study Area
The Asante-Akim North District is located within the forest belt of Ghana 
in the Ashanti Region. It is one of the 18 districts in the region and was 
carved out of the former Asante-Akim district in 1987 when 45 new 
districts were created by the erstwhile PNDC government It shares 
borders with Ejisu-Juabeng district in the west, Sekyere-East District in the 
north, Kwahu-South district in the east, and the Asante-Akim South district 
in the south. It has an area of 1360sq km, a population of 118,775 (1994, 
projected from 1984 census, GR. 3.1), half of which under 15 years of 
age. About 70% of the population live in the rural areas. Most of the 
roads are third class roads or what may be described as “dirt tracts”. The 
north eastern part of the district forms part of the Afram plains and is 
hardly accessible during the rainy seasons. Adult literacy rate is about 
60%. Most of Ihe common problems presented at the health institutions 
are largely preventable through appropriate health education, adequate 
nutrition, immunisation, prompt effective treatment of ailments, improved 
water and sanitation coverage. The district is administered by the District 
Assembly, the local political and administrative authority.
1
University of Ghana          http://ugspace.ug.edu.gh
1.2 Historical background
1.2.1 Local Government Administration
The history of local government administration in Ghana predates the 
countiy’s independence. The pre-colonial native authorities were 
handpicked representatives o f the people who merely assisted the 
colonialist to administer their localities and maintain law and order. 
Between 1859 and 1961, several ordinances were passed establishing 
different categories of local administrative structures which existed in 
parallel with local agencies of the central government. It was a period of 
dual hierarchy when local agencies o f the central government were simply 
field stations of their Accra offices. The poorly resourced local 
administrations were expected to provide amenities in their localities. 
These amenities included public health facilities such as those for waste 
management and food hygiene, e.g.. Slaughter houses and butchers shops. 
An attempt was made in 1974 to establish a single hierarchy at the district 
level through the Local Administration (Amendment) Decree 1974, NRC 
258. Some central government agencies were decentralised but the 
implementation of the decentralisation process was stifled or aborted by 
bureaucratic lethargy and feet dragging, weak managerial capacity at the 
local level, lack of a local elected political authority to oversee the new 
structures and gross mismanagement.
2
University of Ghana          http://ugspace.ug.edu.gh
The latest reforms, initiated by the promulgation of PNDC Law 207 (and 
later, Local Government Law, Act 462 of 1993) are aimed at creating a 
forum at the district level where a TEAM (caps mine) of development 
agents, the representatives of the people and other agencies such as NGOs, 
will agree on the developmental problems of the district, their underlying 
factors and decide on the COMBINED ACTIONS (caps mine) necessary 
to deal with them (MLG, 1994). Before the District Councils were 
established in 1974, the communities which constitute the present Asante- 
Akim North district were under the Juaso Local Council. The Asante- 
Akim District Council was later created in 1974 with Konongo as its 
capital. However, following the creation in 1987 of 45 new districts in 
Ghana, the district was divided into two, Asante-Akim North and South 
districts. The Asante-Akim North District Assembly as constituted now is 
however a baby of PNDC Law 207. The Assembly has the responsibility 
for the overall development of the district. This responsibility includes the 
development and promotion of health.
1.2.2 The Alma-Ata Declaration on PHC
In September 1979, an international conference was held on Primary 
Health Care (PHC) in Alma-Ata in the then Soviet Union. At the 
conference PHC was defined as “essential health care based on practical, 
scientifically sound and socially acceptable methods and technology, made 
universally available to individuals and families in the community through
3
University of Ghana          http://ugspace.ug.edu.gh
their fiill participation and at a cost that the community can afford to maintain at every 
stage of their development in the spirit of self-reliance and self-determination” WHO- 
UNICEF, 1978. Eight specific elements of the PHC were identified at that 
conference. These were:
• Promotion of nutrition
• Provision of adequate supply of safe water
• Provision of basic sanitation
• Maternal and Child Care, including Family Planning
• Immunisation against the major infectious diseases
• Prevention and control of locally endemic diseases
• Education concerning the prevalent health problems and the methods
of their prevention and control
• Appropriate treatment for common diseases and injuries
Central to the concept of PHC are Community participation, Equity and 
Intersectoral Collaboration (ISC). Ghana started experimenting with health 
concepts similar to that of the PHC sometime before the Alma-Ata conference 
(e.g. Danfa Project). However, a pilot programme of PHC was initiated in 
1979 soon after the conference. Asante-Akim district was one of the 
pioneering districts which participated in Ghana’s pilot programme.
4
University of Ghana          http://ugspace.ug.edu.gh
1.2.3 PHC in Asante-Akim North District
Formal health services were started in the district by the Basel Mission in 1931 
when the Agogo Hospital was built. The services were mainly curative and 
were handed over to the Presbyterian Church in 1961. Against the 
background of economic decline, Ghana started a pilot programme of Primary 
Health Care (PHC) in 1979. One district from each of the then nine regions 
was selected to participate in the programme. The then Asante-Akim district 
was selected out of the then ten districts of Ashanti region to participate in the 
programme. This marked the birth of the PHC Programme in the district. 
The DHMT constituted at that time consisted of only workers in the formal 
health sector. It had, through the collaboration with some NGOs, initiated a 
number of primary health care programmes. In 1987, the Asante-Akim district 
was divided into two, i.e. the Asante-Akim North and South Districts with 
Konongo and Juaso as the district capitals respectively.
1.3 The Problem Statement
The District Assemblies have the overall responsibility for developing their 
communities and improving the quality of life of the people. To enable the 
Assemblies do these, PNDC Law 207 confers on them executive, legislative 
and administrative powers. In order to create a single hierarchy at the 
local level (district) and also to give the vital technical support to the
5
University of Ghana          http://ugspace.ug.edu.gh
Assemblies, 22 (now 12) central government ministries have been decentralised 
and placed under the jurisdiction of the Assemblies. These decentralised 
departments include the Ministry of Health, Agriculture, Education, 
Community Development, Rural Water and Sanitation programme o f the 
Ghana Water and Sewerage Corporation, National Mobilisation Programme 
and the Department of Feeder Roads. Within the Assemblies are five 
substructures known as the subcommittees of the Assembly. Two of them are 
of particular relevance to the PHC. These are the Technical and 
Infrastructure Subcommittee (also known as Works Sub-Committee) which 
deals with roads, electricity, sanitation and water, and the Social Services Sub­
Committee which is responsible for education, health and social welfare. The 
Sub-Committee may co-opt members from any of the decentralised 
departments to assist them in their deliberations, however such co-opted 
members have no voting rights. It is expected that these two committees will 
be the fora where the activities o f the various stakeholders in health will be 
coordinated for effective planning and implementation of PHC activities. 
However, the potential benefits and outcomes of the above local government 
structural changes in facilitating combined action on PHC through the 
strengthening of horizontal linkages within the district have largely remained 
an elusion. The expected outcomes for PHC, as evidenced by health status 
indicators and the deplorable water and sanitation situation in most of our 
districts, have also consequently remained rather elusive. What could be
6
University of Ghana          http://ugspace.ug.edu.gh
the reason for this state of affairs, one may ask ?
Is PHC a development priority component for the districts ?
Why has a laudable concept such as ISC for PHC remained an 
illusion to most districts?
How is the concept understood by the various sector heads? 
What are their expectations of the mechanism or nature of 
intersectoral collaboration?
What are the structures and mechanisms set up to create an 
enabling environment for ISC for PHC, and are they functioning? 
How are attempts at ISC for PHC funded?
Are there conflicting hierarchies within some of the decentralised 
departments?
Are the structural changes implied by PNDC Law 207 understood 
by heads of the decentralised sectors?
It has been sixteen years since Ghana adopted the PHC strategy for achieving 
Health for All by the year 2000. The District Assemblies are seven years old whilst 
the 2000 is only five years away! It has become urgent to seek answers to the 
above and other questions to enable us consolidate the modest gains made so far 
and forge ahead towards the “Year 2000 AD”.
7
University of Ghana          http://ugspace.ug.edu.gh
In seeking answers to the above question, the focus for the purpose of this 
study, is on the Asante-Akim North District Assembly, its structures and some 
of the decentralised departments at the district level. It is however hoped that 
in addition to the district Assembly, the subdistrict structures such as the Area 
Councils, Unit Committees and the Subdistrict Health Teams will also find the 
final recommendations beneficial in strengthening ISC on PHC at the 
subdistrict level.
1.4 Limitations of the Study
Due to logistics and time constraints, the study was limited to Asante-Akim 
North District where I was attached for my field work. The findings in this 
self-selected district can therefore not be statistically representative of all the 
districts in Ghana It is however hoped that other districts in Ghana will find 
some of the results and recommendations of the study useful.
8
University of Ghana          http://ugspace.ug.edu.gh
CHAPTER 2
2.1 STUDY OBJECTIVES
2.1.1 Main Objective
This study aims at describing intersectoral collaborative action on PHC in
Asante-Akim North District, the administrative mechanisms set up to
facilitate the process and its strengths and weaknesses in order to make
relevant recommendations to strengthen the process.
2.1.2 Specific Objectives
• To describe the structures and mechanisms put in place by the
current Asante-Akim North District Assembly for ISC on PHC 
since its inception.
• To determine how PHC activities or programmes ranked as a
priority component of the implemented development projects of 
the Asante-Akim North District Assembly.
• To describe the understanding and perception of ISC on PHC by
the heads of health related decentralized departments in the district
• To describe the PHC activities performed by the health related
decentralized departments.
• To describe the mechanisms of the process of intersectoral
9
University of Ghana          http://ugspace.ug.edu.gh
collaboration (if any) on PHC activities by the health related 
decentralized departments.
To identify the constraints on ISC on PHC and make relevant 
recommendations to enhance the process of intersectoral 
collaboration.
2.1.3 Variables and Indicators
Table 1
A table of Variables and Indicators
VARIABLES INDICATORS
Developmental Priorities of the 
Assembly
• Percentage of District 
Assembly Common Fund 
allocated the various sectors.
• Expenditure preference of a 20 
million cedis unexpected bonus
ISC on PHC • Operation through Joint Action 
Plans with clearly defined tasks 
and roles
• Participation of joint 
implementation of (PHC) 
activities
• Contribution of resources such 
as manpower, finance, etc. by 
collaborating sectors to the 
implementation of joint action 
plans (pooling of resources 
tegefeer)
• Forum for intersectoral 
planning meetings
10
University of Ghana          http://ugspace.ug.edu.gh
2.2 Operational Definitions
2.2.1 Intersectoral Collaboration.
In this study the operational definition of intersectoral collaboration 
on PHC is adapted from Collins and is defined as “« process whereby 
personnel from health and health related sectors work together in a 
planned and coordinated fashion to improve the health o f  the 
population as a join t goal through PHC activities”.
To collaborate (with somebody or on something) according to the Oxford 
Advanced Learners Dictionary of Current English (4th Edition) means “to 
work together with somebody, especially to create or produce something”. 
Intersectoral collaboration may therefore be taken to mean different sectors 
working together to create something. That something, in our context, will 
be “the upliftment of the health of the people through Primary Health 
Care”. “Working together” in this context means the “coordination of 
policies, plans and activities” as recommended by the Alma Ata 
Declaration on PHC (Alma Ata 1978).
The Intersectoral collaboration on PHC which was envisaged in that 
declaration is a coordinating process characterized by the following:
Formal relationships are established based on either contractual 
agreements or operating through joint goals and activities
11
University of Ghana          http://ugspace.ug.edu.gh
• Clearer definitions of tasks, expected roles and linkages
• Pursuit of joint outcomes by collaborating sectors
• Pooling of resources together by collaborating sectors
• Involvement of central levels o f sector ministries in the process
• A greater restriction on the autonomy of the sector ministries 
involved or the elimination of dual hierarchies through 
decentralization
It is important, on the other hand, to note that the recommended intersectoral 
collaboration on PHC is different from cooperation, which has the following 
characteristics (Collins, 1993).
an informal relationship, not based on contractual agreements nor
operating through joint goals and activities
the linkages between the sectors are not well defined
each sector is primarily concerned with achieving its own
departmental goals- that is their departmental objectives remain
their top priority
personnel or management of the various sector ministries at higher 
levels are not involved in the process
sectors are reluctant to involve their resources in other sectors’ 
activities and sectoral autonomy is not much restricted
12
University of Ghana          http://ugspace.ug.edu.gh
2.2.2 Health related sectors:
• Ghana Education Service
• Ministry of Food and Agriculture
• Ministry of Community Development & Social Welfare
• Ghana Water & Sewerage Corporation
• Department of Feeder Roads
• National Mobilization Programme
• Non-Govemmental Organizations
2.2.3 PHC Activities
• Promotion of Nutrition
• Provision of adequate supply of safe water
• Provision of basic sanitation
• Maternal and Child Care including Family Planning
• Immunization against major infectious diseases
• Prevention and control of locally endemic diseases
• Education concerning the prevalent health problems and the 
methods of their prevention and control
• Appropriate treatment for common diseases and injuries
13
University of Ghana          http://ugspace.ug.edu.gh
2.3 Definition of Concepts
2.3.1 Health
Health has been defined as “a state of physical, mental and social well-being 
and not only the absence of disease or infirmity” (WHO 1977). Whatever the 
limitations of this definition, it has emphatically drawn attention to the fact that 
the concept of health encompasses activities outside the formal health sector 
which have substantial impact on health of the people. In feet, communicable 
diseases which used to be the major causes of mortality in the developed 
countries were controlled before the major discoveries of their cure and 
treatment were made (WHO 1986). This point was further emphasized at the 
Alma Ata Conference on Primary Health Care (PHC) in 1978, where it was 
declared that the attainment of optimal health “requires the action of many 
other social and economic sectors in addition to the health sector” (Alma Ata 
Declaration 1, PHC).
2.3.2 Ownership
An individual or a community is said to assume or share in the ownership of 
a programme or a project if they percieve the programme objectives as their 
felt needs and are therefore prepared to share in the cost and benefits of the 
implementation of such a programme.
14
University of Ghana          http://ugspace.ug.edu.gh
CHAPTER 3
LITERATURE REVIEW
3.1 PHC and Intersectoral Collaboration
PHC, as defined earlier, has been recommended as the key that could lead 
to the attainment by all people of the world, of that level of health which 
could permit them to lead a socially and economically productive life 
by the year 2000. However, the eight activities identified as essential 
components of PHC (see Introduction) are known to be controlled by 
sector ministries outside the formal health sector.
How does the activity of these sectors affect the health of the population?
3.2 Formal and Non-Formal Education and Health
Literate women are more likely to attend the Ante-Natal Clinic , deliver 
under supervision and ensure that their children are immunised (GDHS
15
University of Ghana          http://ugspace.ug.edu.gh
1993) than their illiterate counterparts. Educated women are more 
confident and exhibit a greater capacity to keep their children and 
themselves healthy by taking advantage of available health services. In 
fact, Orubayole and Cadwell have shown in a study that even where there 
are no health facilities, child mortality is higher amongst children of 
illiterate mothers than those of literate mothers (Orubayole et al, 1975). 
The fact that literacy level has a strong influence on child survival and 
maternal health underlies the call for Universal Primary Education (UPE) 
for all, but especially for girls. Education of school children on healthy 
practices and living puts them in a unique position to educate their peers 
and their families or household (especially in cultures where adults listen 
to the advice of children). Health may therefore form part of the school 
curriculum as is being practiced in Paraguay (Carderia, 1979).
3.3 Agriculture and Health
Inadequate quality and quantity of food intake, including breastmilk, cause 
growth Mure, decreased immunity, learning disabilities, poor reproductive 
outcome and reduced productivity. The most serious nutritional problems 
in most African countries have been identified as protein-energy 
malnutrition, anaemia, vitamin A deficiency and iodine deficiency. It has 
been shown that malnutrition underlies more than a third of infant and 
child mortality in Africa (McGuire and Austin 1986).
16
University of Ghana          http://ugspace.ug.edu.gh
National food security and the availability of food at the household level at 
affordable prices, combined with state health services have led to marked 
improvement in the nutritional status and health of all but particularly 
children in places like China, Costa Rica, Sri Lanka and Kerela in India 
(Hammad, 1987). On the other hand, activities in the agricultural sector 
such as irrigation dams may lead to health problems such as Bilharzia 
(TDR\WHO, 1995).
3.4. Water, Sanitation, Housing, the Environment and Health
In tite absence of safe and adequate water and facilities for safe disposal of 
human faeces and solid waste, communicable diseases such as diarrhoea, 
skin diseases and schistosomiasis prevail. Similarly, inadequate control of 
the environment and poor food hygiene may also lead to food poisoning, 
gastro-enterids and malaria. These diseases incidentally constitute the bulk 
of the morbidity burden in this country. It has been shown that improved 
water supply and sanitation often reduces child diarrhoeal mortality by 
between 50% and 80%, depending on the type of intervention and on the 
presence of risk factors such as poor feeding practices and maternal 
illiteracy (Esrey et al, 1991). It has also been shown in Lesotho that there 
was a 36% reduction in dianhoeal diseases as a result of improved excreta 
disposal (Daniels et al, 1990).
17
University of Ghana          http://ugspace.ug.edu.gh
Bush fires and indiscriminate felling of trees lead to deforestation and the 
loss of the vegetative cover of the Land. These in turn lead to subfertility 
o f the soil and consequently low agricultural output. A low agricultural 
output leads to high market prices of food and consequently to decreased 
household availability of food. The unfavourable consequences o f these, 
malnutrition, are most felt by the most vulnerable groups such as children, 
the aged, the poor and women.
Mining activities, legal or illegal (“gallamsey”) degrade the environment 
and pollute water bodies with heavy metals such as arsenic and mercury as 
seen in certain parts of the Western Region of Ghana (GEAP, 1994). 
Poorly designed, badly built and wrongly located buildings are often a 
source o f physical, mental and social distress to their occupants. The 
recent flood disaster in Accra (July 1995) left the occupants of such 
houses, built in low lying areas, either dead or emotionally traumatized 
due to loss of life and property. Overcrowding, poor ventilation, lack of 
toilet and other waste disposal facilities which characterize the slums in 
the urban areas of most developing countries are associated with high 
prevalence of communicable diseases. Overcrowding in economically 
depressed neighbourhoods such as James Town in Accra is believed to 
be a major facilitator of the spread of communicable diseases such as 
malaria which constitutes more than 40% of diseases diagnosed at the 
Out-Patient Departments of health institutions within the Accra 
Metropolitan Area (Lietmann, 1992).
18
University of Ghana          http://ugspace.ug.edu.gh
3.5 Non-Governmental Organisations and Health
The Asante-Akim Rural Health Programme in Ashanti Region of Ghana 
is a good example o f a fruitful collaboration between the government 
health sector and non-governmental organizations, the Presbyterian Church 
of Ghana (PCG) and the Swiss Red Cross (SRC). The Swiss Red Cross 
provided funds through the PCG to support the Rural Health Service with 
logistics for the provision of hand-dug wells and pit latrines for some 
communities and for the construction of health centres for others. The 
health status of the district was found to have improved following an end 
of programme evaluation using admitted cases of measles as an indicator 
(Enyimayew et al. 1995).
3.6 Previous Studies on Intersectoral Collaboration on PHC
Studies on Intersectoral collaboration on PHC at the district are scarce in 
the literature though much has been written on the need for ISC on PHC. 
Understandably, the process of ISC on PHC presents problems in attempts 
to measure or evaluate it quantitatively. In their study of ISC on PHC 
(AaCbuo andEdusei, 1992) in three districts in the Ashanti Region, Asibuo 
and Edusei examined the activities which the Assemblies and their 
substructure (Town or Area Councils and Unit Committees) and the 
decentralised departments have initiated or completed in support of general 
mobilisation for community health. The study also explored how the
19
University of Ghana          http://ugspace.ug.edu.gh
District Assembly and the decentralised departments were supporting the 
activities of the sub structures of the Assembly and the community in 
health promotion. The study indicated that ISC on PHC was working well 
in the three districts studied but within some constraints. This study 
however explores how the decentralised health related departments are 
collaborating amongst themselves and with the Local Government to 
promote PHC in the district. It also explores the PHC activities engaged in 
by the individual health related departments in order to identify the 
common grounds for collaboration.
PHC as a priority for the District Assemblies
A study on how PHC activities rank in the developmental objectives of the 
District Assemblies was difficult to find in the literature. In 1993, before 
the introduction of the District Assemblies’ Common Fund, the District 
Assemblies in the Western Region of Ghana spent between 0.5% and 
3.5% of their total revenue on PHC activities, including sanitation. The 
pattern of expenditure showed a tendency to invest in PHC-related projects 
(involving construction), such as KVIP Toilets and Slaughter houses which 
could bring some revenue as well (Afenyadu et al, 1994). Where huge 
expenditures are made on health, the general impression from the 
Ghanaian media is that such funds are spent on the construction of health 
institutional infrastructures which the MOH often has difficulty in 
equipping and staffing (Lambon, 1995)
University of Ghana          http://ugspace.ug.edu.gh
3.8 Administrative Mechanisms for ISC
ISC as coordination
In their study, Asibuo and Edusei found that DHMT meeting was the 
forum where core members of the DHMT and heads of health related 
sectors met to plan and act in a combined fashion to address the health 
problems of the district. Health education campaigns, Child Survival and 
Sanitation programmes have been planned and implemented that way.
They also observed that Social Services Sub-Committee of the District 
Assembly served as the forum for coordinating activities on Family Health 
and Environmental Sanitation in some districts. In Ahafo-Ano district for 
example, the District Assembly, the G.W.S.C., the Department of 
Community Development and UNICEF collaborated on the planning and 
implementation of a Water and Sanitation programme.
Other mechanisms suggested are the establishment of National Health 
Councils with district equivalents which have members drawn from 
different sectors and are well oriented to PHC through training workshops. 
Coordination between the sectors is further enhanced by making special 
funds available for their joint programmes or projects (Ebrahim et al 
1988).
21
University of Ghana          http://ugspace.ug.edu.gh
3.9 Problems often encountered with ISC
The problems identified in Asibuo’s study pertained to the funding of 
collaborative activities, conflicting hierarchies as a result of the ignorance 
of heads of decentralised departments of the relevant changes envisaged in 
the PNDC Law 207[ as confirmed by other studies (Dovlo, 1994)], and 
the differences in target populations, area of operation and professional 
culture.
22
University of Ghana          http://ugspace.ug.edu.gh
CHAPTER 4
METHODOLOGY
4.1 Study Type
Hus is an explorative and descriptive study of the process of Intersectoral 
collaboration on PHC in a district and the identification of its constraints 
for the purpose of making relevant suggestions for the strengthening of the 
process.
4.2 The Study Unit
The choice of Asante-Akim North District was determined by my field 
attachment to that district in part fulfilment of the MPH programme 
requirements.
The following key informants were purposively selected for the study:
• District Coordinating Director (DCD)
• The Social Services-Environmental subcommittee and the Works
subcommittee
• The DHMT
• Sector heads of Education, Agriculture, Community Development 
and Social Welfare, GWSC, NGOs, MOH, Feeder Roads and 
National Mobilisation Programme
23
University of Ghana          http://ugspace.ug.edu.gh
As Ihe Secretary to the Assembly and the coordinator of all the activities of sectors 
under the jurisdiction of the Assembly, the DCD was found to be a reliable key 
informant to provide information on the activities of the Assembly and the 
decentralised departments. The DCD and the sector heads by virtue of their 
position as heads of departments were able to provide authentic information on the 
priorities and activities of their various departments.
The Social Service/Environmental and Works subcommittees and the DHMT 
made up of various actors which helped to evolve an authentic consensus on the 
constraints on the process of ISC on PHC suggested some practical ways forward.
4.3 DATA COLLECTION TECHNIQUE AND TOOLS
4.3.1 Inspection and Review of available Documents
The following documents, covering the study period, were examined for 
information on intersectoral planning and implementation of PHC activities 
within the district and also for the verification of data collected through the 
interviews wherever feasible:
• Minutes of the General Assembly meetings
• Minutes of the Executive Committee meetings
• Minutes of the SSSC and TISC( Works) meetings
• Records of Revenue and Expenditure
• Intersectoral Action Plans and evidence of resource contribution
24
University of Ghana          http://ugspace.ug.edu.gh
4.3.2 In-depth Individual Interviews
Interviews schedules (see Appendix A-C ) were used by the investigator to 
personally interview the DCD and the sector heads or their representatives. 
A tape recorder was used (with their permission) to record the interviews 
as a back up for validating the data written down during the interview. 
This technique was used to gather data on characteristics of the Assembly 
and the relevant subcommittees and their collaborative activities on PHC. 
It was also used to elicit the sector heads’ perception of what constitutes 
constraints on ISC on PHC and their suggestions on how to strengthen the 
process.
4.3.3 Focus Group Discussions
Focus Group Discussions were held with the DHMT, the Social 
Services/Environmental, and the works(TISS) subcommittees of the 
Assembly in an attempt to arrive at a consensus on the constraints on ISC 
on PHC and how the process of collaboration could be further 
strengthened.
4.4 Plans for Data Analysis
Data collected from all the sectors was summarised on a master sheet to 
facilitate easy interpretation. The main findings were also summarised
25
University of Ghana          http://ugspace.ug.edu.gh
under the following headings or sections
1. Structures and mechanisms put in place for ISC on PHC
2. Developmental priorities of the Assembly
3. The understanding and perception of ISC on PHC in the district
4. PHC activities by the health related sectors within the district
5. The mechanism of intersectoral collaboration on PHC activities by 
the health related sectors within the district
6. The constraints on ISC on PHC and Recommendations for 
strengthening the process
Focus group discussion findings were also summarised in a tabular lam. 
An analytical framework adapted from Rifkin (Rifkin et al, 1988) was used 
to describe the process of intersectoral collaboration on PHC in the 
district
The Analytical Framework for ISC on PHC (adapted from Rifldn et 
al, 1988)
The concept of intersectoral collaboration on PHC has been defined in the 
section under “operational definitions”. As stated in the earlier part of this 
paper the main objective of this study is to describe Intersectoral 
collaboration on PHC activities in the District. The Alma Ata Declaration 
on PHC recommends intersectoral approach to improving the health status 
of the people due to the recognition that there are several factors outside
26
University of Ghana          http://ugspace.ug.edu.gh
the formal health sector which influence the health of the people. 
Underlying that recommendation is the conviction that when the formal 
health sector and the health related sectors collaborate in their respective 
activities, the health status of the district will ultimately improve. However, 
it will rather be simplistic to attempt to establish a linear relationship 
between ISC on PHC and the health status of a district because of the 
numerous social, cultural, economic, and political factors that influence the 
latter. Consequently an analytical framework adapted from the work of 
Susan B. Rifkin et al (1988) on ‘Measuring Participation’ was adopted for 
measuring the process of ISC. In adapting this approach, suggested process 
indicators critical for the attainment of ISC on PHC, have been derived 
from the operational definition of ISC on PHC (adopted from Collins, 
1993). Each of these process indicators may be present in various degrees 
at different times within a district and may be linked up in a polygon to 
indicate the extent of ISC at a particular time or period.
The suggested process indicators are as follows:
1. Joint Action Plans by the collaborators with clearly defined tasks, 
expected roles and linkages.
2. Implementation of Joint Action Plans by collaborators.
3. Pooling of resources together to implement Joint Action Plans, and
4. Forum for interaction of health and health related sectors to plan 
and implement PHC activities.
The pursuance of joint outcomes has been omitted as a process indicator
27
University of Ghana          http://ugspace.ug.edu.gh
because the improvement of the health status of the communities is the 
expected outcome of all the PHC activities carried out by all the health and 
health related departments in the districts.
For each of these indicators, a range of a continuum depicted by a line is 
developed with the proximal end representing minimal ISC on PHC whilst 
the distal end represents strong or maximum intersectoral collaboration.
The continuum is then divided into a series of points each representing the 
extent or breadth of the process as regards that particular indicator. See 
Fig 1 The Continuum of a Process Indicator
1 2  3 4
l_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ I_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ L
MIN. ISC MAX. ISC
PROXIMAL DISTAL
The process is repeated with the other process indicators. (See Table 2 
for the process indicators for ISC on PHC.) The proximal points are 
joined together at the centre whilst the serial points marked on the 
continuum of each of the process indicators, for a particular study, are 
joined together in a spoke configuration forming a polygon, the area of 
which proportionately describes the extent of ISC on PHC (See Fig. 2).
28
University of Ghana          http://ugspace.ug.edu.gh
The first serial point (1) at the proximal end is not where the spokes join 
together. This is in recognition of the fact that some intersectoral activity 
occurs within the various sectors even if that may be described as informal 
cooperation. The polygon formed by joining serial points at position 1 
therefore constitute the very minimum measure of ISC on PHC.
Fig 2 The ISC polygon
A Forum for intersectoral B 3
Pooling resources together Joint Action Plans
That is area A l B1.C1JD1. therefore describes the very minimum measure 
of ISC on PHC whilst A2B2C2D2 may describe a hypothetical baseline 
study of the process in a particular district (see Fig. 2).
In using this analytical framework therefore, it was possible to state 
whether ISC on PHC was taking place or not and one could describe it in 
such a way that the description process could be repeated by other workers 
or by the same worker (at another time) using the same process indicators.
29
University of Ghana          http://ugspace.ug.edu.gh
The dynamic changes in ISC on PHC between the baseline study and a 
second study, say A3B4C2D4, are shown by the shaded area in Fig. 3
Fig 3 The dynamic changes in the ISC polygon 
A B
Through the use of process indicators the assessment of intersectoral 
collaboration and the description of its changes and dynamics in varied 
situations could be made possible. I may hasten to add that though the 
analytical framework of Rifkin et al is a rational way of measuring the 
process of ISC, it is veiy much dependent on the validity of the process 
indicators. However, the results can still be useful without actually testing 
the assumptions made.
30
University of Ghana          http://ugspace.ug.edu.gh
Table 2
Process Indicators on PHC Activities
PROCESS INDICATOR SERIAL POINTS
JOINT ACTION PLAN 1. No Joint Action Plan with other 
sectors
2. Occasionally seek support from 
and plan with other health related 
sectors on adhoc basis for some 
specific PHC activities
3. Intergrated Joint Action on 
district PHC activities by all
health related departments
IMPLEMENTATION OF JOINT 
ACTION PLAN BY  
COLLABORATORS
1. No joint implementation of 
intersectoral Joint Action Plans 
on PHC activities.
2. Some collaborators support or 
cooperate in the implementation
of an adhoc Action Plan for a 
specific PHC programme
3. Collaborators perform specific 
roles or tasks assigned to them in the 
implementation of an 
intersectoral joint action plan
COLLABORATORS POOL 
RESOURCES TOGETHER
1. No contribution of resources to
collaborative activities
2. Contribution of either manpower 
or equipment but not finances to 
the implementation of adhoc joint 
action plans for a specific PHC 
programme.
3. Collaborators perform their 
assigned tasks or roles based on a 
Joint or Integrated Action Plan using 
their departmental resources, 
including financial resources, when 
necessaiy to implement a district 
joint action plan on PHC
31
University of Ghana          http://ugspace.ug.edu.gh
PROCESS INDICATOR SERIAL POINTS
FORUM FOR INTERACTION 
OF HEALTH AND HEALTH 
RELATED SECTORS TO PLAN 
AND IMPLEMENT P.H.C. 
A cnvm ES
1. No effective formal forum for
intersectoral meeting on PHC
2. Adhoc fora created by some
health related sectors to meet 
the needs of some specific PHC 
programmes
3. A formal forum exists and is fully
and effectively utilised for 
regular intersectoral meetings and 
joint planning of district PHC 
activities
32
University of Ghana          http://ugspace.ug.edu.gh
CHAPTERS
F I N D I N G S
THE STRUCTURES AND MECHANISM PUT IN PLACE FOR ISC 
ON PHC WITHIN THE ASANTE-AKIM NORTH DISTRICT 
ASSEMBLY (AANDA)
The District Assembly
The present District Assembly of the Asante-Akim North District was sworn in on 
the 18th May 1994 after the District Assemblies elections . It consists of sixty-one 
(61) members, one third of whom are government appointees while the 
rest are elected representatives of the various electoral areas within the district 
The District Chief Executive was appointed by the president and approved by the 
General Assembly in accordance with section 20 of Local Government Act, 1993. 
The District Coordinating Director (DCD) is not an officer of the District 
Assembly but rather a member or an employee of the Ministry of Local 
Government. He is the Secretary to the Assembly and is tasked with the 
responsibility of coordinating the activities of the various structures and 
decentralised departments under the jurisdiction of the District Assembly. The
33
University of Ghana          http://ugspace.ug.edu.gh
current District Coordinating Director holds a Bachelors degree and a postgraduate 
Diploma in Public Administration.
The General Assembly has met for four sessions within the past one year. 
Subcommittees of the Assembly
The Assembly currently has the following six functional subcommittees:
• Finance and Administration Subcommittee;
• Social Services and Environment Subcommittee;
• Works subcommittee;
• Education subcommittee;
• Public Complaints subcommittee, and the
• Justice and Security subcommittee.
According to the DCD, a separate subcommittee on Education has been set up due 
to die importance the Assembly attaches to Education. This decision is however 
in consonance with the provisions of section 24 of the Local Government Act of 
1993. The members of the subcommittees are a blend of elected and appointed 
members. In selecting members to serve on the subcommittees, the Assembly 
considered the functions and responsibilities o f the subcommittees and selected 
members with the relevant and appropriate educational or career backgrounds to 
serve on them. Heads of the decentralised departments attend the subcommittee 
meetings and bring their expertise to bear on the deliberations and 
recommendations of the subcommittees to the Executive committee. It is however
34
University of Ghana          http://ugspace.ug.edu.gh
important to note that the heads of the departments, though members of the 
subcommittees, have no voting rights. The subcommittee meetings potentially 
offer tremendous opportunities for intersectoral collaboration. The subcommittees 
of the Assembly considered most relevant for intersectoral collaborative action on 
PHC are the Social Services/Environment and the Works subcommittees.
The Social Services and Environment subcommittee
This subcommittee is responsible for health, education, sports, the environment 
(bush fires, illegal mining activities, deforestation, etc.), and other social services. 
The heads of the following decentralised departments serve on the Sub-Committee 
in the As ante Akim North District:
• District Health Service (MOH)
• Department of Social Welfare
• Department of Community Development
• District Agriculture Department
• Ghana Education Service
• Ghana National Fire Service
The other members were selected from the general house of the Assembly
35
University of Ghana          http://ugspace.ug.edu.gh
The Works Subcommittee
The Works subcommittee is responsible for Water and Sanitation, Roads, drainage, 
electricity etc.
The heads of the following decentralised departments serve on the Works 
subcommittee of the Asante Akim North District Assembly (AANDA):
• Public Works Department
• Department of Town and Country Planning
• Department of Feeder Roads
• Department of Community Development
The other members, as in the case of Social Services subcommittee, were selected 
from the floor of the General Assembly. The health sector is however not 
represented on this subcommittee.
The Executive Committee
The Executive Committee of the Assembly performs the executive functions of the 
Assembly. Its functions are to coordinate the programmes of the subcommittees 
and to submit these as comprehensive Action plans to the Assembly. The 
committee is also charged with the responsibility of implementing the resolutions 
of the Assembly and overseeing the day-to-day administration of the district in 
collaboration with the office of the District Chief Executive (see Appendix F). The 
membership consists of twenty-one elected members, the District Chief Executive 
( the convenor), the D.C.D., the Presiding member, and the Heads of all the
36
University of Ghana          http://ugspace.ug.edu.gh
decentralised departments.
There were four meetings of the Executive Committee of the Assembly between 
October 1994 and October 1995. However the minutes of the fourth meeting were 
not out at the time of data collection (October 1995) and therefore not available 
for study. The agenda of these meetings were essentially the reports of the 
subcommittees of the Assembly. Table 3 (below) shows the subcommittees whose 
reports were discussed at these meetings.
Table 3
Reports discussed bv the Executive Committee at its meeting
DATE OF MEETING SUBCOMMITTEE REPORT 
DISCUSSED
OCTOBER 1994 EDUCATION SUBCOMMITTEE 
FINANCE & ADMINISTRATION
DECEMBER 1994 FINANCE & ADMINISTRATION
MAY 1995 ECONOMIC DEVELOPMENT/
PLANNING SOCIAL SERVICES
AND ENVIRONMENT
EDUCATION
JUSTICE AND SECURITY
WORKS
FINANCE & ADMINISTRATION
37
University of Ghana          http://ugspace.ug.edu.gh
While Finance and Administration matters were discussed at all three meetings, 
Educational matters were discussed at two whilst Works and Social Services 
minutes were discussed at only one of the meetings.
DEVELOPMENTAL PRIORITIES OF THE AS ANT E-AKIM NORTH 
DISTRICT ASSEMBLY
The main sources of the Assembly revenue within the past one year were, Property 
rates, Basic rates, Market tolls and the District Assembly Common Fund. For the 
past one year, locally generated revenue totalled about 100 million cedis whilst the 
Assemblies' share of the Common Fund in 1994 totalled about 270 million cedis. 
The district has been allocated about 372 million cedis as its share of the District 
Assembly Common Fund for 1995. This allocation is yet to be disbursed. For 
convenience or practical purposes, we limit our study to the disbursement of the 
District Assembly Common Fund as an indicator o f developmental priorities of the 
Assembly. Table 4 shows the disbursement of the 1994 Common Fund.
38
University of Ghana          http://ugspace.ug.edu.gh
Table 4
Expenditure of 1994 District Assembly’s Common Fund-AAND
SECTOR PROJECTS AMOUNT IN 
MILLION 
CEDIS
PERCENTAGE 
(%) OF 
TOTAL
HEALTH 1. Konongo 
Hospital project 
(Theatre and
35 13.1
wards)
2. Nyinamponase
5.8 2.2
Health Center 
3. Two water
18 6.7
closet projects TOTAL=58.8 21.9
EDUCATION 1. Central 
Government 
abandoned
70 26.1
projects. 
2. Assembly
20 7.5
initiated 8.6 3.2
projects.
3. School furniture
TOTAL=98.6 36.8
MARKETS 1. Agogo Stores 37.2 13.9
2. Konongo Stores 23.4 8.7
3. Stalls 3
TOTAL=63.6
1.1
23.7
FEEDER 13 4.9
ROADS
ACCOMMOD 34 12.7
ATION FOR 
STAFF
GRAND 268 100
TOTALS
39
University of Ghana          http://ugspace.ug.edu.gh
About 37% of the Common Fund was spent on Education, 22% on Health 
Infrastructure and 24% on construction of Market stores and stalls, whilst 13% and 
5% were spent on Accommodation for District Administration Staff and Feeder 
Roads respectively. Thus Education ranks first, Health and market stalls second, 
Staff accommodation third, and Feeder roads last in priority as regards the 
implementation of development projects. When asked what the Assembly would 
spend an unexpected gift of 20 million cedis on, the District Coordinating Director 
replied "In my opinion the money would be used to rehabilitate our school 
buildings".
UNDERSTANDING OF THE CONCEPT OF INTERSECTORAL 
COLLABORATION ON PHC ACTIVITIES
All the heads of the sectors interviewed except one understood PHC to mean 
promotive, preventive, curative and rehabilitative activities aimed at improving the 
health status of the people. Some of the eight basic activities specifically mentioned 
were the provision of basic curative services, safe drinking water, sanitaiy facilities, 
control of communicable diseases, nutrition education and supplementing feeding, 
and Family planning. (See Table 4).
The majority (88%) of the eight respondents perceived Intersectoral 
collaboration on PHC to mean "working together for a common goal". The 
common goal in this context is to improve the health status of the population.
40
University of Ghana          http://ugspace.ug.edu.gh
However, one respondent described it as "cooperation with each other to achieve 
our goals”, i.e. each department in trying to achieve its own goals should get the 
necessary support from other sectors.
THE PHC ACTIVITIES OF HEALTH RELATED DEPARTMENTS IN 
ASANTE-AK1M NORTH DISTRICT
This section describes the PHC activities of the various departments which could 
form "common grounds" for intersectoral collaboration.
Social Welfare Department
The main activities of this department which fall within the context of our 
operational definition of PHC are some of the components of their Welfare and 
Rehabilitation programmes.
Welfare Programmes
1. The Social education programme
This is aimed at promoting health and other desirable social changes. 
Health Education talks are given within various communities on prevalent 
or emergent social or health issues such as Drug Abuse, street children, and 
Teenage Pregnancy. The thrust of these talks is directed at the causes,
41
University of Ghana          http://ugspace.ug.edu.gh
social impact, and the prevention of these social and health problems.
2. The Family Welfare programme
This is aimed at ensuring harmony within families. Disputes over paternity, 
custody, and child maintenance are settled by arbitration committees. 
Ensuring harmony in families and the maintenance of children by parents, 
promote child survival, welfare and development.
Rehabilitation programme
This programme aims at the identification, registration and the integration of the 
disabled into the society. Those in need of orthopaedic treatment or corrective 
surgery are referred to the appropriate centres.
Currently, the department is engaged in a community-based rehabilitation 
programme (CBR). This programme, sponsored by the Ghana Government, the 
UNDP, and some other NGOs, is expected to be an intersectoral programme 
involving the District Health Service(MCH/FP and Psychiatric Nurses), and die 
Ghana Education Service. Local supervisors o f the disabled are to be selected from 
within the communities and trained on the causes, prevention, and rehabilitation 
of the disabled.
Collaborators
The officer in charge of the programme intimated that he is yet to involve the
42
University of Ghana          http://ugspace.ug.edu.gh
other collaborator. Similarly, the Welfare programmes are also implemented solely 
by the department.
Department of Community Development 
Child Survival Programme
1. Health Education talks are given at what were described as "Adult 
Education campaigns'' and "Mass meetings" by the respondent Talks are 
given at these meetings on Immunisation against the six childhood killer 
diseases, the need for "Weighing", Breast feeding, Buruli Ulcer and 
Family planning.
2. In what was described by the respondent as "study group activities", 
meetings are held with the chiefs, elders, and opinion leaders to assist them 
in the identification and assessment of their developmental needs. These 
interactions often result in such positive outcomes as the communities 
mobilising themselves to construct KVIP toilets, and Hand dug wells 
amongst others.
3. Weanimix Programme
The programme involves the teaching and training of women on how to
43
University of Ghana          http://ugspace.ug.edu.gh
prepare weanimix, a nutritious weaning food. This programme is aimed at 
promoting this high protein containing weaning food and thus preventing 
or reducing the incidence of malnutrition amongst children.
4. Home Science Services
In this programme women, especially those in rural communities are 
mobilised and assisted to acquire productive skills or engage in small 
income generating activities such as oil extraction and gari processing. In 
1995, women groups within the Dwease and Agogo communities were 
assisted to make cassava farms and are awaiting gari processing machines 
promised them by the First Lady, Mrs Konadu Agyeman Rawlings. 
Economically empowering women, in the view of the respondent, will 
enable them look after their children and themselves better. It will also 
enable them to patronise health services and pay the medical bills of their 
children and themselves, (especially those who are single parents) without 
depending absolutely on their sometimes non-supportive husbands. Child 
survival and development are therefore enhanced by these activities.
Collaborators
All the above activities except the mass education campaigns are carried 
out by the department without the involvement of other health related 
departments. Mass education on Buruli Ulcer, AIDS, and Tree planting
44
University of Ghana          http://ugspace.ug.edu.gh
were however supported by financial resources from the District 
Assembly. The respondent stated " the Assembly helped us" (take note of 
the implied perception of ownership of the programme).
Department of Agriculture
Control o f  zoonotic diseases
The term zoonosis is applied to those infectious diseases of vertebrate animals 
which are transmissible to man under natural conditions. The department is 
engaged in die control of rabies, taeniasis, and anthrax amongst others. Joint 
inspection of meat is done by the department and the sanitary officers (now Local 
Government Officials).
Promotion o f growing o f high protein containing food crops
The cultivation and consumption of Soya beans and " obatampa" maize are being 
vigorously promoted amongst farmers by the Crop Services division. The aim of 
this project is to help enrich the diet of Ghanaians, especially children, by 
encouraging the production of these protein rich beans and cereal. It is expected 
that the availability at affordable prices and the consumption of these agricultural 
products will help improve the nutritional status of our children.
45
University of Ghana          http://ugspace.ug.edu.gh
Women In  Agricu lture  Development
The activities of this group complement those o f the Crop services and the 
Extension officers in the introduction of Soya beans. The group, according to the 
respondent, is more concerned with educating women on the preparation of 
various dishes using Soya beans for the benefit of all especially, pregnant women 
and children.
Collaboration
The department has not had any interaction with the District Health Service within 
the past two years. They received support from the District Administration and the 
Information Services during Anti-Rabies campaigns last year. There is also some 
collaboration with the department of Community Development on the Global 2000 
project (obatampa maize).
46
University of Ghana          http://ugspace.ug.edu.gh
The District Mobilisation Programme (District Office of the N.MPf)z.
Mobilisation for development projects including Health Infrastructure
This sector has various units spread within the communities which are agents of 
social mobilisation for development. Mobisquads have been established in several 
communities to help undertake identified community projects. They mobilise for 
and assist in the construction of KVIP toilets and hand dug wells. In 1995, the 
people o f Ananekrom in the Afram plains sector of the Agogo subdistrict were 
assisted to construct a Primary Health Care centre. The people of Wuraponso were 
also mobilised and assisted to construct a hand dug well. The Saviour Church of 
Agogo, on the other hand, was assisted in building a KVIP toilet and a hand dug 
well.
Social Mobilisation for Improved patronage o f Mass EPI Campaigns and the 
Control o f epidemics
The NMP assisted the District Health Service in organising this year's mass EPI 
campaigns. It also assisted in planning and implementing control measures during 
the suspected cholera outbreak September 1995.
47
University of Ghana          http://ugspace.ug.edu.gh
Health  Education
Health Education talks are given within the communities on Family Health 
especially Child nutrition. Immunisation, and Family planning. This is done 
independent of the District Health Service.
Collaborators
District Health Service, Social welfare, District Administration 
Department of Feeder Roads
The department is engaged in no P.H.C. activity as defined in this study.
Ghana Education Service (GES)
The School Health Education Programme
The school health Unit of the GES is responsible for the supervision of food sold 
to Hie school children, school hygiene and the implementation of health education 
in the schools within the district. It achieves its objectives in the district by 
collaborating with the District Administration, District Health Service, Social 
Welfare department, Ghana Commission on Children and the 31st December 
Movement.
48
University of Ghana          http://ugspace.ug.edu.gh
N on -Fo rm a l Education D iv is ion  (N F E D )
This division is responsible for adult literacy programmes. Health Education 
Messages are incorporated into the primers used in teaching the adult learners. The 
topics introduced to the learners through the primers are Family Planning, Teenage 
Pregnancy, Nutrition, Safe Drinking Water, Safe Motherhood and Child Care, 
Immunisation, AIDS, Environmental Hygiene, Hygienic way of marketing fish 
(food hygiene), Community development, and drug abuse.
Efforts at Collaboration
The facilitators of the NFED individually and privately contact health workers to 
educate them on the health topics included in their primers. There is no formal 
collaboration between the NFED and the health sector.
National Service Secretariat
The Community Improvement Unit of the secretariat has the facilitation of PHC 
within rural communities as one of its objectives. Consequently, National Service 
Personnel are posted into the various communities to promote PHC.
Health Education
Primary Health Care Facilitators stationed within the communities educate them
49
University of Ghana          http://ugspace.ug.edu.gh
on the need for safe drinking water, methods of harvesting rain water, breast 
feeding, nutrition, sanitation and the need to immunise their children.
Water and Sanitation/ Health Infrastructure
Service personnel assist the communities technically to construct hand dug wells, 
VIP toilets, and community clinics. A community clinic was built at Nyamponase 
village through the assistance of the service personnel.
Tree Growing Exercise
This project assists communities to plant and nurture trees. The Agyareago 
waterhead has been adopted this year by the secretariat. Trees will be planted to 
protect the water head and the dam which is the source of water supply to 
Konongo.
Collaborators
Ministry of Agriculture assists the secretariat in helping communities to establish 
community farms.
50
University of Ghana          http://ugspace.ug.edu.gh
Summary
The PHC activities of the sectors interviewed in this study have been described. 
Though there is so much "common ground" for intersectoral collaboration, most 
o f the departments have been pursuing their PHC objectives in isolation or 
independent of the other departments often unaware that similar activities are 
being undertaken by other sectors. The "common grounds'* for intersectoral 
collaboration have been summarised in Tables 4 and 6.
51
University of Ghana          http://ugspace.ug.edu.gh
THE PRACTICE AND MECHANISMS OF INTERSECTORAL 
COLLABORATION ON PHC IN ASANTE-AKIM NORTH DISTRICT
This section describes the critical process indicators for the process of 
intersectoral collaboration on PHC in the district
THE FORUM
1. The Social Services and Environment Subcommittee
The heads of some of the departments which may be described as the key actors 
in Primary Health Care in the district (i.e. Community Development, Education, 
Social Welfare, Agriculture, and Health) are members of this subcommittee. 
However, the District Director of Health Services has not attended any of the 
meetings of the subcommittee for the period under study.
None of the intersectoral activities on PHC was planned at these meetings. The 
Executive Committee of the Assembly included the report of this subcommittee on 
the agenda of only one of its three meetings held over the study period. That report 
was however rejected as "irrelevant and out of context." The members of the 
subcommittee indicated, during a focus group discussion, that their meetings were 
irregular and pooriy attended. For now, this subcommittee therefore appears to be 
ineffective as a forum for joint planning for implementation of PHC activities.
52
University of Ghana          http://ugspace.ug.edu.gh
Some of the major issues raised in the rejected report were as follows:
• The failure of sand and stone contractors to fill excavations they created with 
refuse, as directed by the Assembly, leading to the accumulation and spillage 
of refuse in various parts of the district.
• Objection to the arrogation of the choice of a site for the construction of a 
Children's play ground to the Education subcommittee instead of the SSSC.
• Recommendation of the formation of a subdistrict Environmental management 
committees.
• Recommendation that subdistrict health teams should include non-health 
workers who could act as collaborators within the communities.
• Promotion of sports in the district.
• Provision of Identity cards for Assembly members.
• Complaints about the distribution of projects funded through the "Common 
fund"
• Relocation of Sawmills to areas outside the residential areas to prevent air 
pollution.
• encroachment on the lands of Ghana Railways Corporation
• The attention of MOH(?) be drawn to insanitary conditions around where food 
is sold opposite the Konongo-Odumase lorry park.
• Illegal timber felling in the district.
The subcommittee appears to be drawing the attention of the Assembly to health
and environmental problems by and large. The complaints about the encroachment
53
University of Ghana          http://ugspace.ug.edu.gh
on Ghana Railways Corporation lands and the complaint about the disbursement 
of the common fund may be considered as out place.
2. The Works Subcommittee
The membership consists of the Public Works Department, Town Planning, 
Feeder Roads, and Community Development. The District Health Service, 
however, is not represented. This Sub-Committee has made relevant 
recommendations to the Executive Committee over the study period. The main 
recommendations were the: -
• purchase of refuse trucks to cart accumulated refuse from the sanitary points 
to the final disposal sites.
• identification of final waste disposal sites.
• formation and operationalisation of unit committees and tasking them with the 
responsibility o f clearing and maintaining drains and gutters in their 
communities.
• acquisition of a portion of the land o f the Ghana Railways Authority to 
construct KVIP toilets for the Konongo Lorry Park.
Despite these commendable contributions, the subcommittee does not include all 
the key actors in PHC activities, as defined in this study. The recommendations of 
the subcommittee to the Executive Committee, if approved and implemented by 
die Assembly, will markedly improve sanitation in the district. The m e e tin g s of the
54
University of Ghana          http://ugspace.ug.edu.gh
subcommittee as constituted now, cannot be described or seen as a forum where 
health and the key health-related sectors can plan for implementation a district joint 
or integrated action plans on PHC activities. It however offers an opportunity to 
put "Water and Sanitation" infrastructure and equipment firmly on the agenda of 
the Executive Committee. The subcommittee, in a focus group discussion, 
recommended the inclusion of the health sector in the membership o f the 
subcommittee in the future.
3. The D.H.M.T.
The last intersectoral DHMT meeting held in the district was in September 1994. 
During the period under review, the DDHS did not find it necessary to invite other 
health related sectors. She remarked " they do not contribute much, I do not find 
them helpful, ....they are not committed, it is a question of ownership. They do 
not feel they own the programmes." The DHMT is seen as a Ministry of Health 
forum by both the heads of the formal health sector and the health related sectors. 
When asked why they do not attend DHMT meetings, ALL of them remarked 
they do not invite us."
5. The ADHOC forum
Adhoc in this context and according to the Oxford Advance Learners Dictionary 
means " made or arranged for a particular purpose only." In the absence of an 
effective forum for intersectoral collaboration on PHC activities, whenever a
55
University of Ghana          http://ugspace.ug.edu.gh
particular department is about to embark on a specific programme which needs 
the support of others, invitations are sent out to those departments for a meeting 
to discuss that particular programme. Thus adhoc meetings are held to deal with 
specific programmes. Such meetings are therefore not a forum for coordinating 
gU the PHC activities o f those sectors.
JOINT ACTION PLANS
No intersectoral joint action plan to coordinate the PHC activities of all the health 
related departments in the district has ever been made. Only the GES has an 
intersectoral joint action plan drawn with the departments mentioned earlier to 
implement the School Health Education Programme. A School Health Education 
Coordinating committee was constituted with members drawn from the District 
Health Service, Ghana Education Service, Ghana Commission on Children, Social 
Welfare Department, and the 31st December Movement with the D.D.H.S. as its 
Chairperson
The main objective of this committee is to coordinate all School Health Education 
programmes in the district A joint action plan was drawn by the committee to train 
teachers through a series of workshops with the objective of strengthening their 
capacity to teach their pupils the health subjects in the school curriculum. It is 
hoped that through these children, health messages will reach their peers and 
families at home.
The adhoc joint itinerary drawn by the DHS and the Mobilisation Programme for
56
University of Ghana          http://ugspace.ug.edu.gh
the mass EPI campaign and Cholera outbreak control programme were also 
available for inspection.
IMPLEMENTATION OF JOINT ACTION PLANS
1. School Health Education Programme
The facilitators were drawn from the District Health Service and the Fire Service. 
The health topics treated were the Prevention of Home Accidents, Balanced diet, 
Teenage Pregnancy, Family Planning, AIDS, EPI, Waste management, Food
Hygiene, and Drug Abuse. These topics were handled by facilitators from the 
health sector. A facilitator from the District Fire service handled topics on Bush 
Fires and Fire outbreak Prevention. The organisation of the workshop such as the 
selection of teachers and the writing of invitation letters were done by the GES. 
The participants also contributed some money towards their feeding. The bulk of 
funding for the workshops however came from the Agogo Rural Health Services.
2. EPI and Cholera Outbreak Control programmes
The role of the NMP in collaborating with the health sector was in the area of 
social mobilisation for participation and getting information through its units to the 
communities. The DHS maintained the ownership of the programmes and single 
handedly funded them.
57
University of Ghana          http://ugspace.ug.edu.gh
CONTRIBUTION OF RESOURCES FOR THE IMPLEMENTATION OF 
JOINT ACTION PLAN (POOLING OF RESOURCES TOGETHER)
As indicated earlier, no intersectoral joint action plans on district PHC activities are 
drawn in the Asante-Akim North District. Therefore the question of how such 
action plans are funded does not arise. However adhoc joint action plans have been
drawn and implemented for specific programmes such as the School Health
Education Programme, the EPI mass campaign, and the control of the recent 
outbreak of cholera (August/September, 1995).
1. The School Health Education programme
The GES selected and sent out invitation letters to participants to attend the 
workshop. They also arranged for the venue of the workshops. The Participants 
(teachers) also contributed financially towards the meals provided them. The D.S. 
and the District Fire Service provided facilitators whilst, as mentioned earlier, the 
Agogo Rural Health Service provided funds for other logistics and payment of an 
honorarium All the collaborators except the District Administration contributed 
some resources towards the workshop.
58
University of Ghana          http://ugspace.ug.edu.gh
2. The Mass EPI campaign and Cholera Outbreak Control
In both programmes the D.H.S. maintained ownership and was the sole sponsor 
of the programmes. The only collaborator, the NMP, acting as a representative of 
the District Administration, contributed time and manpower to these programmes. 
After assisting the DHMT, the NMP staff sometimes presented claims for night 
allowance to be paid by the Rural Health Service.
59
University of Ghana          http://ugspace.ug.edu.gh
Table 5
Summary of the description of ISC on PHC in the Asante Akim North 
District using an analytical framework adapted from Rifldn et al (1988).
PROCESS INDICATOR SERIAL POINT DESCRIPTION
FORUM 2 ADHOC Fora created by 
some health sectors to 
meet needs of some 
specific P.H.C. 
programmes
JOINT ACTION PLANS 2 Occasionally seek support 
from and with other health 
related sectors on adhoc 
basis for some specific 
P.H.C. programmes
IMPLEMENTATION 
OF JOINT ACTION 
PLANS
2 Some collaborators 
support or cooperate in 
the implementation of an 
adhoc action plan for 
specific PHC programmes
POOLING OF 
RESOURCES 
TOGETHER FOR 
IMPLEMENTATION OF 
P.H.C. ACTTVmES
2 Contribution of either 
manpower or equipment 
but not finances to the 
implementation of adhoc 
joint action plans for a 
specific PHC programme. 
Financing is left to the 
department which initiates 
or is perceived as 
“owners” of the 
programme
The above summary ( using process indicators shown on page 35\36) may be 
summarised schematically using the Rifkin's Analytical framework as shown on 
the next page.
60
University of Ghana          http://ugspace.ug.edu.gh
Summary of ISC on PHC in AAND(adapted from Rifkin et al)
Forum
Joint implementation 
of Action plan
Fig 4 Summary of ISC on PHC in AAND(adapted from Rifkin )
Pooling
resources
together
Inter grated 
joint action 
plan
60B
University of Ghana          http://ugspace.ug.edu.gh
CONSTRAINTS ON INTERSECTORAL COLLABORATION
The following constraints on intersectoral collaboration were identified by the 
respondents:
i. Lack of an effective forum for intersectoral meeting and planning on 
PHC;
ii. The formal Health sector not forging horizontal relationships with 
other sectors.
The DHMT meetings excluded health related departments, "they dont 
invite us", one respondent said. The formal health sector, on the other 
hand, is not regularly represented at the Social Services subcommittee 
meetings o f the Assembly.
iii. District Coordinating Director not taking initiative to facilitate 
intersectoral meetings for planning PHC activities.
"There is no encouragement from the top," said a respondent during the 
focus group discussions. The District Administration, according to another 
discussant " is not doing enough to make things easy."
61
University of Ghana          http://ugspace.ug.edu.gh
During the same focus group discussions, the participants recommended 
that PHC activities be coordinated within a proposed District Health 
Committee under the District Assembly.
Health sector does not motivate other sectors who support it in 
planning and implementing PHC activities.
A respondent said, "they have to share the T-shirts and the caps with us." 
T-shirts and baseball caps provided for programmes such as Breast 
Feeding Campaigns, TB control and others are shared only amongst the 
formal health sector personnel. The health sector on the other hand feels 
such motivations are demanded because the other sectors see health as a 
responsibility of only the health sector ministry.
Dual or Conflicting hierarchy.
There are varying degrees or extent of decentralisation within the various 
sectors. However, only one out of the eight heads of the decentralised 
departments interviewed had no idea about PNDC Law 207 and its 
implications for decentralised departments. All the departmental heads sent 
quarterly (some monthly) reports to the Assembly and when asked "who 
is your immediate boss?" , all except one responded "the District Chief 
Executive". However, interestingly enough, when asked where they send 
their quarterly reports, all of them indicated “to my regional boss with a
University of Ghana          http://ugspace.ug.edu.gh
copy to the Assembly”. In the new Administrative structure envisaged by 
Local Government Act of 1993, all the existing decentralised departments 
are now departments of the Assembly and are to provide quarterly reports 
to the Executive Committee through the office of the District Assembly.
vi. Funding of Intersectoral PHC activities
The lack of funds to implement intersectoral activities was attributed by 
FGD discussants to over-reliance on the District Assembly's Common fund 
and inadequate mobilisation of local revenue. Collaborators expect MOH 
to fund such activities or reward them for participating in health 
programmes since they perceive them as "MOH programmes." There is 
no shared ownership of the responsibility for health.
63
University of Ghana          http://ugspace.ug.edu.gh
CHAPTER 6
DISCUSSIONS AND CONCLUSIONS
1. The Developmental Priorities of the Asante-Aldm North District 
Assembly.
That Education is the main priority of the Assembly is shown by the fact that the 
sector had the lion's share of the 1994 District Assembly Common Fund. The 
sector also has a separate subcommittee responsible for its affairs in the Assembly. 
Finally, when asked what die Assembly will spend an extra 20 million on, the DCD 
replied "the rehabilitation of our schools."
Health ranks second amongst the top three priority areas for development. Health 
must not however be content with being ranked second to Education though 
increasing the literacy rate within a population (especially women) may have a 
profound impact on their health status and their development in general. The truth 
however is that the children must be healthy to benefit from the educational 
facilities and infrastructure being provided. Equal attention must therefore be paid 
to both Education and Health.
The DCD defined PHC as "carrying health services to the door steps of the 
people." Admittedly, accessibility and equity are important principles of PHC, 
however PHC encompasses more than these. About 70% of the total amount of
64
University of Ghana          http://ugspace.ug.edu.gh
the 1994 District Assembly Common Fund expenditure provision on health was 
spent on the construction of health institutional infrastructures. Little or no 
expenditure was made on funding operational plans on Health Education, 
Immunisation programmes, and Buruli ulcer control for example. Funding a 
schistosomiasis control programme in the district has remained elusive due to 
financial constraints on procuring praziquantel, the drug used in the mass treatment 
of the disease. The idea of having a hospital in the district capital, Konongo may 
be understandable. However, a district hospital should not necessarily be situated 
in the district capital. For all practical purposes, Agogo Hospital is undoubtedly 
saving the purpose of a district hospital efficiently. Agogo is also accessible from 
the district capital and has the largest catchment population in the district. In my 
opinion, in view of the scarcity of development funds, spending an amount of 
about 35 million cedis on efforts to convert the Konongo Health Centre into a 
hospital whilst the district has no refuse trucks to cart away rapidly accumulating 
refuse in the urban communities of the district may not be the best o f decisions. 
In fact, when asked what were the main health problems of the district, the DCD 
remarked " lack of water, inadequate toilets, lack of incinerators and refuse trucks." 
His answer is further substantiated by the fact that the top five causes of OPD 
attendance in the district are malaria, Upper Respiratory Tract Infection, diarrhoea, 
skin diseases, and intestinal parasites. These diseases are all related to poor drinking 
water and deplorable sanitary conditions. The expenditure of the Assembly's share 
of the 1994 Common Fund on health unfortunately did not reflect some of these 
perceived or felt needs as expressed by the DCD. It is suggested that the Assembly 
pays more attention to sanitation and rural water supply by providing the necessary
65
University of Ghana          http://ugspace.ug.edu.gh
equipment, facilities, and infrastructure and by enforcing sanitary bye-laws. The 
prosecution of sanitary offenders will not only act as a deterrent to others but will 
also bring revenue into the coffers of the Assembly.
2. The Understanding and perception of ISC on PHC
The concept of intersectoral collaboration is well understood by the majority of the 
key informants though its operationalisation is poor. This confirms the common 
belief that it is how to make the concept operational rather than the lack of 
understanding of the concept which constitutes a problem for the potential 
collaborators.
3. PHC activities by the Health related departments
A striking finding in this study is that almost all the health related sectors are 
involved in one PHC activity or the other but without knowing much about those 
PHC activities undertaken by the other sectors. Three out o f the seven health 
related departments, on which this study focused, are engaged in the activities of 
4 out of the 8 basic components of PHC. In my view, there is the need to create 
awareness amongst the various health-related sectors on the "common grounds" 
for PHC activities and explore the possible strategies for an effective intersectoral 
collaboration. A workshop could be organised for that purpose.
66
University of Ghana          http://ugspace.ug.edu.gh
4. The Constraints on ISC on PHC activities in Asante-AJdm North
District
L The lack o f an effective forum  fo r Intersectoral planning and 
coordination o f PHC activities
Three traditional fora for intersectoral activity were examined in this study. These 
were the Social Services subcommittee(SSSC), the Works subcommittee, and the 
District Health Management Team.
The functions of the Social Services subcommittee (see appendix G) include 
amongst others, preparing a long, medium and short term social development plan 
for the district. It is to consider the implication o f such plans, including those of 
health, on the other subcommittee proposals and submit such plans to the 
Executive Committee for harmonisation. The Works subcommittee is to do 
likewise in their area of jurisdiction which includes water and sanitation 
programmes (MLG, 1994). However, neither of these subcommittees could 
produce such plans for the consideration of the Executive Committee. The Social 
services subcommittee's proposals were not considered worth discussing by the 
Executive committee for lack of substance and relevance. Attendance at meetings 
was also poor. The DDHS has neither been invited to nor did she attend any of 
the meetings of this subcommittee over the study period. The SSSC has not 
produced for consideration of the Executive committee, for example, a proposed 
district action plan on the control of Buruli ulcer and Urinary schistosomiasis
67
University of Ghana          http://ugspace.ug.edu.gh
which are major health problems in the district. This weakness and near 
irrelevance of the Social Services subcommittee could be due to the calibre of 
personnel as regards their capacity and expertise to carry out their functions. It 
could also mean that the subcommittee members are not fully aware of their area 
of jurisdiction. In fact, the subcommittee members unanimously agreed during a 
focus group discussion that there is the need to train newly appointed members on 
their roles and responsibilities.
In a study in the Eastern region of Ghana, the impression gained was that the 
members o f the SSSC did not meet to share ideas and coordinate planning but 
rather to report on individual basis to the Assembly through the committee (Dovlo 
et al, 1992). In the Asante-Akim North district, the SSSC meets irregularly to 
identify problems on adhoc basis and make recommendations to the Executive 
committee.
The Works subcommittee, on the other hand, made relevant contributions to the 
deliberations of the Executive Committee, however, no comprehensive long or 
medium term programme of action has been proposed for the consideration of the 
Assembly. Their recommendations over the study period were unfortunately 
limited to activities in Agogo and Konongo, the two urban communities within the 
district. The formal health sector is not represented on this subcommittee and in 
ray view the exclusion of the formal sector from this subcommittee is unfortunate 
since that subcommittee is responsible for Water and Sanitation. In a focus group 
discussion with the members of this committee, they suggested the inclusion of a 
health personnel in the subcommittee.
University of Ghana          http://ugspace.ug.edu.gh
The DHMT as presently constituted is a team made up of the heads of the 
divisions within the District Health Service(DHS). The DDHS does not find the 
participation of the health related sectors helpful. In fact the DHMT in a focus 
group discussion stated, in reference to the absence of the health-related sector 
heads from their meetings, " we do not miss them". The health sector perceives 
them as uncommitted to and exhibiting a profound lack of ownership of health 
programmes they participated in. They perceived the DHMT as a District Health 
Service oigan which they can "help" at their convenience.
On the other hand, the other sectors could not attend the DHMT meetings because 
"we are not invited". In fact, the last time any of them was invited to such a 
meeting was in September 1994.
How can common or shared ownership be fostered? Who should facilitate 
intersectoral meetings by creating an appropriate forum? The formation of a 
District Health Committee as the appropriate forum was suggested by FGD 
participants to ensure "common ownership" amongst others. (See table 5)
i i  Lack o f commitment o f District Administration to facilitating inter­
departmental collaboration on PHC. Need fo r a District Health 
Committee?
When asked why the District Administration does not support intersectoral 
activities on PHC, the DCD remaiked " they continue to receive their money from
69
University of Ghana          http://ugspace.ug.edu.gh
Accra and KumasL" The District Administration, in the DCD view, has no control 
over the finances of the decentralised departments. This perhaps explains the 
apparent reluctance to commit funds to their activities unless there are 
tangible(political or social) reasons to do so. The district composite budget is yet 
to become operational. While waiting for the decentralisation to evolve to that 
level, a possible strategy of fostering commitment to intersectoral planning is again 
the creation of a District Health Committee by the District Assembly or the Local 
Government Administration. This committee apart from being a "neutral" forum 
for intersectoral coordination of operational plans of district PHC activities, will 
also hopefully ensure common ownership by all including the District 
Administration. The Assembly should ultimately own and fund such a committee 
and its activities whilst the DCD plays the role of a coordinator and thereby create 
the necessary enabling environment for intersectoral collaboration. These were the 
recommendations of the participants of the focus group discussions held with the 
SSSC and the Works subcommittee. This scheme however can only be feasible 
where there is a strong political commitment and will, since it implies the 
Assembly assuming more responsibility for health. It could also be greatly 
facilitated when the district composite budgeting becomes a reality. It is however 
prudent at this point to state that there is no guarantee that a district assembly will 
commit funds to facilitating intersectoral collaboration when composite budgeting 
becomes operational, unless the political will is favourable.
Political commitment to PHC activities could also be courted and nurtured by the 
District Director of Health Services persistently enlightening the DCD and the 
Assembly on the Health status and needs of the district.
70
University of Ghana          http://ugspace.ug.edu.gh
In summary, three traditional fora were examined in this study. Each o f them was 
found weak and ineffective as a forum for intersectoral harmonisation o f long, 
medium, and short term plans on PHC activities. Though there is a need to 
strengthen the relevant subcommittees o f the District Assembly, the possibility o f 
creating a new forum o f common or shared ownership for intersectoral and 
integrated operational planning has been suggested. The heads o f the 
decentralised departments will be able to perform their roles in the various 
subcommittees better i f  they are appropriately oriented through training to their 
new responsibilities. The DDHS should also canvas for political support for  
intersectoral action on health by playing the role o f an advocate
71
University of Ghana          http://ugspace.ug.edu.gh
Unwillingness ofsectors to commit funds to intersectoral PHC activities
The practice of making joint action plans for PHC activities is essentially 
on ad hoc basis only. Joint intersectoral(ad hoc) action plan on PHC 
activities were made for specific programmes such as the School Health 
Education, the EPI, and Cholera control programmes. It must be 
recognised however that the operation of these plans become feasible 
by and large because of the financial support of the formal health sector 
and the Rural Health Service of the Presbyterian Church of Ghana 
(Agogo). May be the other sectors are genuinely financially incapable of 
contributing to these joint programmes. On the other hand it has been 
stated elsewhere in this report that some view their contribution as doing 
the MOH a favour and expect to be motivated financially or materially by 
the District Health Service. In the absence of a district composite budget, 
there is the need for the re-orientation of the district heads of the health 
related departments for them to share in the ownership of joint action plans 
and for them to budget for the PHC activities in their departmental action 
plans. They mav then be willing to commit some of the resources (such as 
Financial Encumbrance) at their disposal to the implementation of 
intersectoral programmes. The Assembly could in addition mobilise more 
funds for the implementation of health activities by strengthening its local 
revenue collection and by enforcing sanitary bye-laws. Fines imposed on 
sanitary offenders could be a good source of income for the Assembly. It 
also has the added advantage of improving sanitation in the district.
University of Ghana          http://ugspace.ug.edu.gh
iv. Weak planning capacity in the district
Preparation of Joint Action plans have been generally poor in quality. During one 
of the in-depth interviews, a joint itinerary was tendered in by a head of 
department as an action plan. This could be a reflection of lack of knowledge of 
and the capacity to draw action plans. Quite often heads of departments find 
themselves in the position of leadership as a result of promotion due to their hard 
work. It is often forgotten to train them for their new responsibilities such as 
preparing year action plans for their departments. It is suggested that a training 
programme similar to the Strengthening District Health Systems Initiative of the 
MOH, be adopted to enhance the capacity of the heads of decentralised 
department in the district to plan better. In a Focus Group Discussion with the 
SSSC and the Works subcommittee, participants unanimously agreed that there is 
the need for a training workshop for the Subcommittee members soon after their 
appointment to educate them on their new responsibilities and the scope of their 
mandate. This was in reaction to the fact that neither of the subcommittees was 
able to develop a short, medium, and long term health development plans nor 
proposals for submission to the Executive Committee of the Assembly.
73
University of Ghana          http://ugspace.ug.edu.gh
CHAPTER 7
THE WAY FORWARD?
This study has demonstrated that the concept of intersectoral collaboration on PHC 
was generally understood by the heads of decentralised health related departments 
and the members of the Works and Social services and Environment 
subcommittees. The concept has been lauded because it is believed that a team 
approach to the planning and implementation of health programmes by all the 
actors in health within the district, will lead to the efficient and effective 
improvement of the health status of the people. What remains a bottleneck is how 
to operationalise the concept within the context of the partially implemented Local 
government reforms. It is envisaged that as the provisions of Act 462 are translated 
into reality, the decentralised departments will see themselves more as the staff of 
the Assembly rather than "district representatives of their Accra offices."
RECOMMENDATIONS
Health as a development priority
It is recommended that equal priority be given to health and education for reasons 
stated earlier. The provision of water and sanitary infrastructures for the rural 
communities and sanitary equipment such as wheel barrows and refuse trucks 
should be regarded as components of development and be funded from the 
Common Fund. The AANDA should certainly consider supporting disease control
74
University of Ghana          http://ugspace.ug.edu.gh
programmes (such as schistosomiasis, EPI, and Buruli Ulcer) and health 
education programmes( for example on AIDS).
Awareness creation amongst the health related departments on the PHC 
activities of other sectors
It is important for the various actors in health within the district to know what PHC 
activities the others are engaged in and what resources or expertise for the 
promotion of PHC is available within those sectors. A workshop is recommended 
for that purpose. It is hoped that an opportunity to identify common grounds for 
intersectoral action will be created by such a workshop.
Forum for intersectoral planning of PHC programmes
It is recommended that a "neutral" forum whose ownership is shared by all the 
"actors" in PHC including the District Assembly be created. The importance of 
health cannot be over emphasised and the Assembly is permitted to form any 
committee it deems important. The committee should however be responsible to 
the Executive Committee of the Assembly. It is envisaged that this forum will 
deliberate on all health issues including infrastructures. The Works and Social 
Services subcommittees may continue to exist and concentrate on other issues apart 
from health (See Reports on FGD with the SSSC and Works sub-committee for 
the suggested membership).
75
University of Ghana          http://ugspace.ug.edu.gh
Increased role of the District Assembly in facilitating Intersectoral 
collaboration on PHC
The DCD has the mandate to co-ordinate the activities of all the departments and 
officers of the District Assembly. living up to this responsibility by facilitating 
intersectoral meetings and planning for the development of health in the district will 
greatly enhance collaboration.
Funding of intersectoral PHC activities
All the sectors engaged in PHC activities should as a matter of necessity budget for 
those activities. Joint action plans should be drawn and roles assigned to each 
participating department. Each department then budgets for the responsibilities 
assigned to it. It is hoped that this strategy will ease the pressure on MOH as a 
financier of PHC activities. The implementation of composite budgeting will also 
facilitate the funding of joint action plans. The AANDA should intensify local 
revenue mobilisation and not over-depend on the Common Fund. It will then be 
in a position to commit more funds to health and other development programmes.
Training needs
Decentralisation as envisaged in Local Government Law Act 462 brings along with 
it new responsibilities. The District Administration and its various subcommittees 
need an orientation course to help them adjust to their new roles and
76
University of Ghana          http://ugspace.ug.edu.gh
responsibilities. Since the Assemblies have been charged with the over all 
development of the district, planning capacity must be carefully nurtured within all 
sectors of the district The Assembly and its subcommittees must move away from 
adhoc measures and be empowered to prepare short, medium, and long term 
development plans for implementation. These plans should cover the area of health 
development or PHC promotion as well.
Reward and Motivation by Superior Officers
Regional and higher officers of the sector ministries of the decentralised health 
related departments should endeavour to reward their district officers who are able 
to forge strong and effective working relationships with other sectors in achieving 
their departmental objectives.
Finally, it is my sincere hope that the AANDA will find these recommendations 
worth implementing for a stronger intersectoral collaboration on PHC in the 
district.
77
University of Ghana          http://ugspace.ug.edu.gh
APPENDIX A
INTERVIEW GUIDELINE FOR DISTRICT CO-ORDINATING 
DIRECTOR
INTRODUCTION
The purpose of this interview is to get information on how the District Assembly, 
the decentralised departments, and the NGOs operating in the district are working 
together to improve the health of the people through PHC. This exercise in part 
fulfilment of the requirements of MPH degree programme. I hope we will have a 
frank and fruitful discussion. A copy of the completed work will be made available 
to you for your study.
1. NAME____________________________________________________
2. EDUCATIONAL BACKGROUND___________________________
3. PREVIOUS WORK EXPERIENCE
4. How is the General Assembly constituted and how many times did it meet 
within the past one year? _________________________
78
University of Ghana          http://ugspace.ug.edu.gh
5. What were the main developmental concerns discussed by the Assembly 
within the past one year ? (list and note those which were about PHC 
activities)
6. What would you say were the major achievements of the District Assembly
in terms of development projects within the past one year ( completed and 
on-going) [ List projects and note those which were on PHC activity 
r e l a t e d  projects] ________________________________
7. What were the Assembly's main sources of revenue during the past one 
year ? Do you consider them enough to carer for the planned development 
and other activities in the year ?
8. In which major areas were the funds available spent ? [List areas and 
amounts expended and check later on supporting document or other 
evidence]
79
University of Ghana          http://ugspace.ug.edu.gh
9. If 20 million cedis were made available to the Assembly , what in your 
opinion would the Assembly want to spend that money on?_________
10. What do you understand by Primary Health Care ?________________
11. What do you see as the main health problems of the district ?________
12. What has been the Assembly's role in addressing these problems ?___
13. Which of the 12 decentralised departments are actually present in the
district ?_________________________________________________
14. Do they attend all Assembly meetings or only when summoned ?
15. Do they report on their activities to you quarterly, half yearly, and annually
?
80
University of Ghana          http://ugspace.ug.edu.gh
16. Which sub-committees have the Assembly constituted and for how long 
have they been in existence ?
17. How are the Social services and the Technical and Infrastructure sub­
committees constituted ? ___________________________
18. How often have they met within the past one year ?
19. What were their main recommendations and action plans submitted to the 
Executive Committee within the past one year.? [ List and look out for 
PHC activities. Cross check from minutes of the sub-committees]
20. Which of the various sectors under the Assembly has been contributing
81
University of Ghana          http://ugspace.ug.edu.gh
towards improving the health of the people ? [ List]
21. How has each of them been contributing ?
22. How do you understand Intersectoral collaboration ?
23. In your opinion is ISC beingpractised in the district? Why?
82
University of Ghana          http://ugspace.ug.edu.gh
How do you think the Assembly could strengthn horizontal linkages 
betwen the various sectors including NGOs to improve the health of 
your people?
THANKS
University of Ghana          http://ugspace.ug.edu.gh
APPENDIX B
INTERVIEW GUIDELINE FOR HEADS OF DECENTRALISED 
DEPARTMENTS AND NGOs
INTRODUCTION
The purpose of this interview is to gather information to write a dissertation in 
partial fulfilment of my requirements for the MPH degree programme. It is not an 
attempt to audit your performance. You may indicate any information you want 
treated confidential. I look forward to a frank and fruitful discussion with you.
1. DEPARTMENT
2. NAME
3. RANK
4. Ghana has adopted PHC as its strategy of achieving Health for All by Year 
2000. What activities constitute PHC ?
84
University of Ghana          http://ugspace.ug.edu.gh
5. What have been your major departmental activities within the past one year 
?
6. Which of these activities do you describe as PHC activities ?
7. Which other sectors in the District do you work with in activities which 
may improve the health status of the people of the 
district ?
7a. If none, why ( probe for difficulties and constraints ) ?
85
University of Ghana          http://ugspace.ug.edu.gh
7b. Ifyour department works with other sectors in activities that will improve 
the health of the people, do you plan these activities with them?
8a. If YES[ Ref 7b ], how do you meet to plan these activities ?
8b. Who calls these meetings ?
8c. Do you draw joint action plans ? [Evidence ?]
86
University of Ghana          http://ugspace.ug.edu.gh
8d. How is the implementation of your plans funded ( Who or which 
organisation) ?
8e. What were your contributions and roles (resources-manpower, funds, 
logistics ) in the implementation of the 
plans?
9. Do you attend DHMT meetings ?
10. If yes [Ref Q9], how often within the past one year ? (Explore reasons for
Irregular attendance )
87
University of Ghana          http://ugspace.ug.edu.gh
11. If no [Ref Q9], why ( probe for constraints and difficulties )?
12. Do you attend Social services sub-committee meetings ?
13. If yes [Ref Q12], how often within the past one year ?
14. What were the main issues raised by your departments at these meetings 
[Ref Q12] within the past one year ?
88
University of Ghana          http://ugspace.ug.edu.gh
15. If no [Ref Q12], why (probe for constraints and difficulties ) ?
16. Do you attend Technical and Infrastructure Sub-committee ?
17. If yes[Ref Q16], how often within the past one year ?
18. What were the main issues raised by your department at these meetings 
[Ref Q16] ?
89
University of Ghana          http://ugspace.ug.edu.gh
19 If no[Ref Q16], why (probe for constraint and difficulties ) ?
20. What are your departmental action plans for the next one year ? [ check for 
PHC activities]
21. Who is your immediate administrative superior officer ?
22. Do you submit quarterly, half-yearly, and annual reports to the assembly?
23. If No [Ref Q22], Why ?
24. Are you aware of PNDC Law 207?
25. If yes[Ref Q24], what are the implications of this Law as regards the 
organisational relationship between you and the District Administration 
and your Regional Officer ?
90
University of Ghana          http://ugspace.ug.edu.gh
26. How do you understand the concept of intersectoral collaboration on 
PHC?
27. Do you think theconcept is operational in this district ?
28. If YES (ref Q27) why?
29. If NO (ref Q27) what are the constraints.
30 What are your suggestions to strengthen the process ?
THANK YOU.
91
University of Ghana          http://ugspace.ug.edu.gh
APPENDIX C
INTERVIEW GUIDELINE FOR DDHS
1. NAME___________________________________________
2. QUALIFICATION__________________________________
3. What is the composition of vour DHMT ?
4.. How often did you meet within the past one year ?
5. Which decentralised departments in the district, in your view, could help 
in improving the health status of the people of this district through their 
activities ?
6. What roles do you expect them to play ?
7. Do the heads of other sectors attend your meetings regularly ?
8. If YES [Ref Q7], which are these sectors ?
9. Do you draw joint action plans [Ref Q7] ?
10. What have been the contributions and roles of each of these sectors [Ref 
Q7] to PHC activities in the district within the past one year ? (List name 
and contributions)
11. How were those activities funded ?
12. If No[Ref Q7], why ?
13. How in your opinion can this working relationship, if any, be improved ?
15. Do you attend District Assembly meetings ?
16. If no[Ref Q15], why ?
17. If yes [Ref Q15], which committee meetings did you attend within the past
92
University of Ghana          http://ugspace.ug.edu.gh
one year ?
18. What have been your main contributions at each of these meetings within 
the past one year ? [ State committee and indicate contribution]
19. Which decentralised departments have been supportive of PHC activities 
in the district and how ?
20. How were those activities planned, implemented and funded ?
21. What in your view has been the contribution of the District Assembly to 
PHC activities within the district in the past one year ?
22. What has been your difficulties working with other sectors in the district in 
planning and implementing PHC activities ?
23. How in your view can this relationship, if any, be improved ?
THANK YOU.
93
University of Ghana          http://ugspace.ug.edu.gh
APPENDIX D
LOCAL GOVERNMENT ACT, 1993 
EIGHT SCHEDULE 
(Section 161)
DEPARTMENTS OR ORGANISATIONS CEASING TO EXIST IN
DISTRICTS
(0 Department of Social Welfare;
(ii) Department of Community Development:
(in) Department of Town and Country Planning;
(iv) Public Works Department;
(v) Department of Parks and Gardens;
(vi) Department of Rural Housing and Cottage Industries;
(vii) Births and Deaths Registry;
(viii) Forestry Department;
(ix) Controller and Accountant General's Department;
(x) Office of the District Medical Officer of Health;
(xi) Department of Feeder Roads;
(xii) Department of Animal Health and Production;
(xiii) Fisheries Department;
94
University of Ghana          http://ugspace.ug.edu.gh
(xiv) Agricultural Extension Services Division;
(XV) Crop Services Division;
(xvi) Department of Agricultural Engineering;
(xvii) Office of the District Sports Organiser;
(xviii) Office of the National Youth Organising Commission;
(xix) Department of Co-operatives;
(XX) National Fire Service;
(xxi) Ghana Library Board;
(xxii) Department of Game and Wildlife.
95
University of Ghana          http://ugspace.ug.edu.gh
APPENDIX E
DEPARTMENTS UNDER THE DISTRICT ASSEMBLY 
LGA, 1993. FIRST SCHEDULE 
(Section 38)
(i) Central Administration Department;
(ii) Finance Department;
(iii) Education, Youth and Sports Department;
(iv) District Health Department;
(v) Agriculture Department;
(vi) Physical Planning Department;
(vii) Social Welfare and Community Development;
(viii) National Resources Conservation Department, Forestry Game and Wildlife 
Division;
(viv) Works Department;
(x) Industry and Trade Department.
96
University of Ghana          http://ugspace.ug.edu.gh
APPENDIX F
FUNCTIONS OF THE EXECUTIVE COMMITTEE
(I) Co-ordinate plans and programmes of the Sub-committees and submit
these as comprehensive Plans of Action to the District Asembly;
(ii) Implement resolutions of the District Assembly;
(iii) oversee the day-to-day administration of the District in collaboration with 
the office of the District Chief Executive;
(iv) recommend, in the case of non-decentralised agencies in the District, to the 
appropriate Government Ministry/Department/Agency the appointment 
and replacement on stated grounds of officers within the area of authority 
of the Assembly;
(v) adopt measures to develop the activities and execute approved plans of the 
units, areas and towns and sub-metropolitan districts within the aea of 
authority of the Assembly;
(vi) when necessary appoint or dissolve adhoc committees of the Executive 
committee.
97
University of Ghana          http://ugspace.ug.edu.gh
(1) FUNCTIONS OF THE SOCIAL SERVICES SUB-COMMITTEE
APPENDIX G
(I) take a comprehensive and long term look at areas of social development in
the district, in particular education, health, social welfare, sports, culture, 
etc.
(ii) develop the information base on these area of social development;
(iii) identify the strenghts and weaknesses in thesocial services areas;
(iv) prepare a social development plan (long, medium and short term), for the 
district;
(v) examine the implications of the social development plan on other sub­
sectors of the district economy; and
(vi) submit plans to the Executive Committee for harmonisation.
(2) FUNCTIONS OF THE WORKS OR TECHNICAL AND 
INFRASTRUCTURE SUB-COMMITTEE
The function areas of the Works sub-committee includes roads, electricity, 
sanitation, water, etc. The specific functions are the following:-
(I) take a comprehensive look at the infrastructure needs and problems of the
98
University of Ghana          http://ugspace.ug.edu.gh
develop an information base on each of these programme/functional areas; 
map out, initiate and phase out programmes for their development and/or 
provision;
examine the implications of such actions for the other sub-committe 
proposals, and
submit the programmes to the Executive committee for harmonisation and 
action.
district;
University of Ghana          http://ugspace.ug.edu.gh
APPENDIX H
FOCUS GROUP DISCUSSION GUIDELINE FOR SOCIAL SERVICES 
AND WORKS SUB-COMMITTEES
INTRODUCTION
Thank you for the opportunity to meet the Executive committee of this august 
Assembly. My name is Dr Godwin Afenyadu and my helpers are Mr Tetteh of the 
regional office MOH and Mr Apraku of the DHMT.
It has been recognised that improving the health of a people means more than 
treating the diseases that they suffer from. Health is now being defined as the 
physical, social, and mental well being and not merely the absence of disease or 
infirmity. There are therefore several factors outside the formal health sector which 
greatly contribute to health. For example the improvement in water and sanitation 
wiQ reduce the incidence of diarrhoeal diseases, malaria and typhoid. Availability 
of nutritious and cheap food through good agricultural policies will help in 
reducing malnutrition amongst our children. High literacy levels are known to be 
associated with better demand for and use of services such as family planning, 
ante-natal clinic etc; and therefore better health status of the population.
Decentralisation through Law 207 and later LGA 462 of 1993 has given us the 
hope that the various health related departments and the Assembly will work 
together to improve the health status of the Assembly. It is expected that through
100
University of Ghana          http://ugspace.ug.edu.gh
the Social Services and the Works sub-committees a short, medium, and long 
term district health plans will be submitted through the Executive committee to the 
Assembly for adoption and implementation.
What has been observed however is that several departments are engaged in health 
promoting activities in the district, however each appears to be working in isolation. 
There are several "common grounds" for intersectoral collaborative effort. For 
example, Hke the formal health sector, the departments of Agriculture, Community 
Development and Social welfare are engaged in activities aimed at improving chid 
survival and development, however each of these departments are doing their "own 
thing" in isolation. Intersectoral committees such as the district Child survival 
committee and SSSC appear weak or dead. Our discussion this afternoon will be 
geared towards finding the reasons for this weaknesses and identify ways to 
overcome them.
UNDERSTANDING OF THE CONCEPT OF INTERSECTORAL 
COLLABORATION
1. Following the creation of the district Assemblies and the decentralisation 
of 22 departments,it was envisaged that the departments under the 
Assembly would work together to achieve development. What does this 
working together mean to you ?
101
University of Ghana          http://ugspace.ug.edu.gh
IMPORTANCE OR BENEFITS OF ISC
2. Do you think it is important for the various sectors to work together ?Why 
? What benefits in your opinion could be derived from the sectors working 
together towards a common goal ?
MECHANISM
3. Supposing different sectors see the need to work together( based on the 
common grounds mentioned in my introduction) what should be the nature 
of such a relationship ? Probe cooperation or coordination? Which forum 
may be Ihe best place for the various actors in health, including the district 
administration to meet and plan health projects and programmes for the 
entire district.
Probe (i) SSSC (ii) WORKS (iii) DHMT (iv) new concept ? District Health
Committee.
PLANNING CAPACITY (TRAINING NEEDS)
4. Has your committee (SSSC or WORKS) submitted short, medium and 
long term proposals on health to the Executive committee? If no, why ?
Probe (i) perceived weakness in planning? (i) need for management training
102
University of Ghana          http://ugspace.ug.edu.gh
(especially problem identification, analysis and planning) for officers of the 
Assembly
CONSTRAINTS
5. What may be considered as some of the difficulties in the way of the 
various health related sectors planning together and harmonising their 
activities in the district o ensure that they achieve their common goal at the 
least cost and without the duplication of efforts ?
How should integrated plans or activities on health be funded ?
Probe (i) Funding-each department to the roles and responsibilities 
assigned to it ?
(ii) Role of the District Administration ?
(iii) Lack of ownership/ conflicting hierarchies ?
(iv) Delay in the implementation of composite budget, a 
constraint ?
(V) Sole responsibility of MOH ?
SUGGESTIONS ON THE WAY FORWARD
In your opinion, how can we strengthen intersectoral collaboration on PHC in the 
district ?
103
University of Ghana          http://ugspace.ug.edu.gh
APPENDIX I
FOCUS GROIJP DISCUSSION GUIDELINE FOR THE DHMT 
INTERSECTORAL COLLABORATION ON PHC
AWARENESS OF OPPORTUNITIES FOR COLLABORATION 
Q. 1 Which departments are engaged in PHC activity in one form or the
other in the district?
Q.2 Which of these departments will you consider as possible allies or 
collaborators in promoting Primary health care in the District.
Q.3 What roles do you expect these departments (ref. Q.2) to play ?
MECHANISM OF COLLABORATION
Q.4 Have you been receiving any support from these possible allies ?
If NO, Probe Why
If YES, Probe (i) nature of support ? (ii) at what price?
CORE DHMT vrs EXTENDED DHMT
Q.5 The extended DHMT has not been meeting for some time now, does 
this affect your operational performance ?
If No, Why?
If Yes, why?
104
University of Ghana          http://ugspace.ug.edu.gh
Q. 5 What are some of the difficulties experienced in your attempts to work
together with other sectors?
RECOMMENDATIONS ON THE WAY FORWARD
Q.6 How can we forge a stronger collaboration with other sectors in the 
planning and implementation of PHC activities.
CONSTRAINTS
105
University of Ghana          http://ugspace.ug.edu.gh
APPENDIX J
Table 6
SUMMARY OF UNDERSTANDING OF THE CONCEPT OF PHC
SECTOR HEAD COMPONENTS
MENTIONED
RANKING OF 
UNDERSTANDING
Mobilisation Programme Safe drinking Water 
Sanitation 
Nutrition 
Control of
communicable diseases 
Immunisation 
Family Planning
6 out of 8
Ghana Education 
Service
Nutrition
Safe Drinking Water 
Sanitation 
MCH & Family 
Planning 
Control of
communicable diseases 
Treatment of minor 
ailments
6 out of 8
Community
Development
Nutrition 
Immunisation 
Safe drinking water 
Sanitation
4 out of 8
National Service 
Secretariat
Sanitation 
Safe drinking water 
Immunisation 
Promotion of nutrition
4 out of 8
Social Welfare 
Department
Sanitation 
Immunisation 
Health Education
3 out of 8
District Co-ordinating 
Director
Provision of basic 
curative services 
Immunisation against 
major infectious diseases
2 out of 8
Ministry of Agriculture Immunisation 1 out 8
106
University of Ghana          http://ugspace.ug.edu.gh
Table 7
SUMMARY OF PHC ACTIVITIES UNDERTAKEN BY OTHER 
SECTORS IN THE ASANTE-AKIM NORTH DISTRICT
SECTOR TYPES OF BASIC 
COMPONENTS OF PHC 
ACTTVmES UNDERTAKEN
TOTAL 
NUMBER OF 
COMPONENTS
Mobilisation Programme 1. Provision of basic sanitation
2. Provision of safe drinking 
water.
3. Immunisation against major 
infectious diseases.
4. Health Education.
4 out of 8
Community
Development
1. Health Education.
2. Provision of basic sanitation.
3. Provision of adequate supply of 
safe drinking water.
4. Promotion of Nutrition.
4 out of 8
National Service 
Secretariat
1. Health Education.
2. Provision of safe drinking 
water.
3. Provision of basic sanitation. 
4 Promotion of nutrition.
4 out of 8
Social Welfare 
Department
1. Health Education.
2. Appropriate treatment for 
common diseases and injuries.
2 out of 8
Ministry of Agriculture 1. Promotion of nutrition.
2. Control of communicable 
diseases(e.g. rabies).
2 out of 8
District
Administraton/Assem­
bly
1. Provision of basic sanitation 
2. Provision of adequate 
supply of safe drinking water.
2 out of 8
Ghana Education 
Service
Health Education 1 out of 8
107
University of Ghana          http://ugspace.ug.edu.gh
offi
w
a
co
d
§
U) NJ
orr
W
C lco6>c?.o3
00o
2.
572O0
E
a
R
1o
a
CD
Table 
8 
CO
M
M
ON 
G
RO
UINDS- PHC 
AC
TIV
ITIES 
UNDERTAK
EN 
BY 
OTHER 
HEALTH 
RELATED 
SECTOR 
IN
University of Ghana          http://ugspace.ug.edu.gh
sUniversity of Ghana          http://ugspace.ug.edu.gh
Table 9 FOCUS GROUP DISCUSSION SUMMARY-WORKS SUBCOMMITTEE
TOPIC RESPONSES
Understanding the 
Concept of Intersectoral 
Collaboration
“ different sectors working together to improve the living 
standard of the people”
Benefits or Advantages 
of Intersectoral 
Collaboration
“sharing and exchange of ideas amongst different sectors”
“ the heads of departments are technical people. They will 
advise the elected members on technical issues”
It avoids the wastage of resources such as time, energy, and 
money. The decisions taken at intersectoral meetings reach the 
various sectors faster.
Forum for intersectoral 
planning for health
Several subcommitees were mentioned (SSSC, 
Justice&Security, Works, Education) however the consensus of 
the SSSC was that the Environmental and SSSC should be the 
forum. They however stated that the attendance at their 
meetings was poor, said a respondent “ more people do not 
attend”. The Works subcommittee, on the other hand, easily 
reached a concensus. “ Health transcends all the subcommittees. 
A special subcommittee should be formed to be responsible for 
all health programmes/projects and this should be called District 
Health Committee” They suggested the following membership- 
Health, Education, P.W.D , Town Planning, representatives of 
Religious bodies, and the Traditional councils
Planning and other 
training needs?
The general concensus was that the various subcommittee 
members should have an oreintation course soon after their 
appointment. The District Administration should also be trained 
on their new roles as envisaged by Act 426. Both 
subcommittees have not proposed to the Executive Committee 
any short, medium, or long term action plans on PHC activities 
or projects in the district. They agreed that for now, they make 
proposals as and when they identify any health ot heath-related 
problem( that is on adhoc basis)
“ Some of the assembly members are new and there is a need to 
train them to update their knowledge.”
“ Yes, training will help greatly
110
University of Ghana          http://ugspace.ug.edu.gh
TOPIC RESPONSES
Funding of Intersectoral 
Action plans on PHC
In the view of the discussants, the district Administration should 
fund health plans of the Assembly. This in their view has been 
difficult for the Assembly because of the over-reliance on the 
Common Fund. The situation where the the central government 
commits part of the Common Fund on some projects without 
consulting the “grassroots” was described as unfair e.g. buying 
vehicle for the Assembly and the money being deducted at 
source from the Assembly’s Common Fund allocation.. 
Assembly should intensify revenue collection and prosecute 
sanitary law offenders and penalise them by imposing fines on 
them. Such monies should be used to fund health programmes. 
Assembly should also make contacts with NGOs to assist it in 
funding health projects.
Constraints on 
Intersectoral collaboration 
on PHC
The MOH in the district is not much involved in the health 
plans of the SSSC i.e. not regularly represented at meetings. 
Lack of funds or the will to implement the recommendations of 
the subcommittees.
The District Administration is “not doing enough to make it 
easy”i.e. Creating the enabling environment.
Percieved problems faced 
by the sub-committees 
(SSSC& WORKS)
Subcommittees do not meet regularly 
Assembly members are not held in any esteem by community 
members and the Assembly does not seem to be doing anything 
to discourage this.
Works subcommitte members are not given the means of 
transport to inspect contracts being done.
Feel frustrated by the non-implementation of their accepted 
proposals by the Assembly.
Lack of proper planning by the Town Planning department 
sometime ago has led to the construction of unauthorised 
structure; “this frustrates the implementation of some of our 
recommendations due to litigation”
Suggestions on the way 
forward i.e Stregthenning 
intersectoral collaboration 
on PHC
Creation of a District Health committee as the forum to be 
responsible for the planning of health projects and programmes. 
Give more prioriy to health in the disbursement of the district 
Assembly common fund.
Generate funds for health programmes by enforcing sanitary 
bye-laws and imposing fines on them or by imposing a health 
development levy.
The DCD and the DCE should encourage intersectoral action 
on health by creating a forum and nurturing it to delver the 
goods because “ charity begins at home”
I l l
University of Ghana          http://ugspace.ug.edu.gh
Si O' o> *1
1  5 ’
H
o
3
o
o
o
c/5
H
H H
§
- S I ! ?
2
C/5M
Table 
10 
FO
CUS 
GROUP 
DISCUSSIO
N 
S
University of Ghana          http://ugspace.ug.edu.gh
OJ to
*0oo
55o
o^
cT
H
O
l-H
O
o
&
o
University of Ghana          http://ugspace.ug.edu.gh
00
I I
CJC.o3
O3
Kn
o3
O3
&O
8*
*
T3
O
0Q
O
3
B"
o
S’ HO
O o L/l
2 9o o
H
O13 >—«oo
50
o
C/2
H
O
Z
o
oSE.
OQ
a  —
° 5T* ^  3“
W O ST
i t !
2.
3 - » T 3  f f O  J
9  2  ET 5  S  3 s3 -  I  -e* 3 H
f | l ? l B
' 8 3 1 1
E N  B  S . 
„  _ § & g* a
s l f  * *  io 0'5 2 3 3  
^  3 § o H^ 0 - 0  3 •-►
S i r & r *
H 3 2  i  S. a
I  “  §  a 
3 « § 2 
5
*>' * ’ I  «^  &> * 0  C l.  
f t  JO  n  £
m C 3 
3 n £f O- < a w _ < d.« & 8. 3 =f2 09 °  °
a  3 O £ ft ■§ 
c  o o a  
§ °- §. § 
3  fl I I  S g3* Q JT o V!
a  a 5  & -
sr S: * “0*0 0
& “r-. §• -
?  i i  F
2 & f ’ «
i  -3 s-o  °
s
►t)
o
z
c/5m
University of Ghana          http://ugspace.ug.edu.gh
REFERENCES
Afenyadu, G; Kumbatazie, E; Wunu, W; Dogbe, P; Ackon, K Report on the 
Constraints on S ocial Mobilisation for PHC activities in the Western Region of 
Ghana. 1994 (Unpublished report WVI/CPHA/MOH document.
Asibuo, S K; Edusei, J The role of the District Assemblies in Intersectoral 
collaboration for Health Promotion and Development in Ghana. 1992 
(Unpublished report).
Carderia, M Rural Water Supply and Sanitation Education in Paraguay. 1979 
Assignment children No. 45/4.
Collins, C Intersectoral Co-ordination. 1993 (Unpublished monograph)
Daniels, D L; Cousens, S N; Makoe, L N;Feachem, R G. A case control study of 
the impact of improved sanitation on diarrhoea morbidity in Lesotho. Bulletin of 
the WHO; 68(4) : 455-63.
Dovlo, D; Nyonator, F; Kanlisi, N. A Report on Decentralisation and Health 
Systems Performance in the Eastern Region of Ghana fPhase onel. 1992. 
(Unpublished document)
Enyimayew, N Evaluation of the Swiss Red Cross and the Rural Health Service 
Collaborative programme in Asante-Akim District 1995. (Unpublished document).
Esrey, S A; Potash, J B; Roberts, L; Schiff, C. Effects of Improved Water Supply 
and SanitationtExcreta disposal') on Ascaris. Diarrhoea. Dracunculosis. 
Hookworm. Schistosomiasis, and Trachoma. Bulletin of the WHO, 1991; 69(5): 
602-21.
Gilson, L; Kilima, P; Tanner, M. Local government decentralisation and the 
health sector in Tanzania. 1994. Public Administration and Development, Vol. 14, 
452-477
Godal, T. Tropical Diseases Research. 12th Programme Report. UNDP/World 
Bank/ WHO; 1995: 77-86.
Hammand, A B. Health through Development : Intersectoral co-operation. 
Proceedings of the 1987 Summer Scientific Conference of the Roval College of 
Physicians of the United Kingdom in collaboration with the WHO. 1987.
Laing, E (Ed) Ghana Environmental Action Plan. 1994 Vol 2, pp. 4-14.
Lambon, B R District Assemblies and Community Develpoment “ Ghanaian 
Times” of 12th September, 1995.
115
University of Ghana          http://ugspace.ug.edu.gh
Lietmann, J F.nviromnental Management and IJrhan Development in the Third 
World : A tale of health, wealth, and pursuit of pollution from four cities in Africa. 
Asia. Eastern Europe, and Latin America. Phd Thesis, University of Carlifonia, 
Berkeley.
Orubulaye, I O U; Cadwell The Impact Of Public Health Services on Mortality. 
A study of morbidity differentials in a rural area in Nigeria. Population studies, 
1975 29(2): 259-272
Rifkin, S B; Muller, F; Bichman, W Primary Health Care: On Measuring 
Participation. 1988. Social Science Medicine, Vol. No. 9, pp. 931-940.
116
University of Ghana          http://ugspace.ug.edu.gh
BIBLIOGRAPHY
Alma Ata Declaration, 1978. Joint Report of the Director General of the WHO 
and the Executive Director of the United Nations Children’s Fund.
Ebrahim, G J; Ranken, J P Primary Health Care, Reorientating organisational 
support, 1988 MacMillan.
Ghana Demographic Health Survey, 1993. Ghana Statistical Service/Demographic 
and Health Surveys. Macro International Inc.
Mills, A; Vaughan, J P; Smith, D L; Tabibzadeh, I. HEALTH SYSTEMS 
DECENTRALISATION. Concepts, issues and country experience. WHO.
The New Local Government System. Ministry Of Local Government, 1994. 
Global Publications Ltd.
MacGuire, J S; Austin, J E. Beyond Survival: Children’s Growth for national 
Development. 1980, Cambridge Mass. : James E Austin Associates.
Intersectoral Collaboration for Health, 1986. Technical Discussions Background 
document, WHO.
117
University of Ghana          http://ugspace.ug.edu.gh