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Capacity issues in primary health Capacityissues in
care implementation: examples implementing
PHC andGhana
from Ghana
Nana Nimo Appiah-Agyekum 633
Department of Public Administration and Health Services Management,
University of Ghana, Accra, Ghana Received 24 June 2021
Revised 3 September 2021
Esinam Afi Kayi Accepted 15 July 2022
Department of Distance Education, University of Ghana,
Accra, Ghana
Josephine Appiah-Agyekum
Behavioural Research Center, University of Huddersfield, Huddersfield, UK
Joseph Gerald Tetteh Nyanyofio
Department of Business Administration, University of Professional Studies,
Accra, Ghana, and
Desmond Dzidzornu Otoo
Department of Public Administration and Health Services Management,
University of Ghana, Accra, Ghana
Abstract
Purpose –Resources as well as the capacity to employ them judiciously maywell be the key to the attainment
of the SDGs and other related health goals through primary health care (PHC). Within this PHC framework,
however, the source of resources for PHC as well as the systems for managing these associated resources
remain unclear, complex and lack substantive integration systems of implementing ministries, departments
and agencies (both local and international) in Ghana. These issues are addressed by this study.
Design/methodology/approach – The framework approach to thematic analysis was used to analyse
qualitative data collected from key PHC managers in Ghana selected purposively from the national, regional
and district levels. Data were collected through in-depth interviews specially designed in line with the study
objectives. The study was also governed by the Noguchi Memorial Institute for Medical Research which
provided ethical clearance for the study.
Findings – As per Alma Ata’s recommendation, PHC in its purest form is a resource dense activity with far-
reaching implications on individuals and communities. Without adequate resources, PHC implementation
remainedmerely on paper. Findings show that the key capacities required for PHC implementationwere finance,
human resource, technology and logistics. While significant cases of shortages and inadequacies were evident,
management and maintenance of these capacities appeared to be another significant determinant of PHC
implementation. Additionally, the poor allocation, distribution and sustainability of these capacities had a
negative effect on PHC outcomes with more resources being concentrated in capital towns than in rural areas.
Research limitations/implications – This study has significant implications on the way PHC is seen,
implemented and assessed not in Ghana but in other developing countries. In addition to examining the nature
and extent of capacities required for PHC implementation, it gives significant pathways on how limited
resources, when properly managed, may catalyse the attainment of the PHC goals. Subsequently, PHC
implementation will profit from stakeholder attention and further research into practical ways of ensuring
efficiency in the allocation, distribution and management of resources especially considering the limited
resources available and the budding constraints associated with the dependency on external stakeholders for
PHC implementation.
Originality/value –This study is part of a series on PHC implementation in Ghana. Quite apart from putting
core implementation issues into perspective, it presents first-hand information onGhana’s PHC implementation
Health Education
journey and is thus relevant for researchers, students, practitioners and the wider public. Vol. 122 No. 6, 2022
Keywords Developing countries, Community based interventions, Primary health care pp. 633-648© Emerald Publishing Limited
Paper type Research paper 0965-4283
DOI 10.1108/HE-06-2021-0095
HE Introduction and problem analysis
122,6 Primary health care (PHC) is “essential care based on practical, scientifically sound and socially
acceptable methods and technology, made universally accessible to individuals and families in
the community through their full participation, and at a cost that the community and country
can afford to maintain at every stage of their development in the spirit of self-reliance and self-
determination” (WHO, 1978, p. 1). Since its inception at theAlmaAta Summit, PHC’s promise of
a basic low-cost yet efficient health delivery system that addressed the immediate health
634 problems in resource constrained countries has been a key in ensuring its wide acceptance and
support across the globe (Taylor et al., 2020). By the turn of the century, therefore, the
comprehensive PHC or a selective variant was heralded in many developing countries as
flagship national health interventions evidenced through system-wide health initiatives or
concurrent vertical programmes (Krumholz et al., 2015; Rohde et al., 2008). Consequently, PHC
appears to enjoy significant attention from key health stakeholders in Ghana and many
developing countries and has been largely responsible for gains made in ensuring universal
coverage as well as increasing geographical and financial access to healthcare.
While some PHC activities may be present at the secondary and tertiary care levels
through some public health interventions, PHC implementation in Ghana is epitomized by the
Community-based Health Planning Services (CHPS). The CHPS initiative is a community-
based service delivery model aimed at changing PHC and family planning from a focus on
clinical care at district and sub-district levels to a new focus on convenient and high quality
services at community and doorstep locations (GHS, 2002). Adopted in 1999, Nyonator et al.
(2005) explain that the major strength of the CHPS concept is its bridging of the geographical
barriers to access healthcare in Ghana and making basic healthcare services available at
every part of the country with emphasis on addressing local health conditions through basic
preventive, promotive and curative services. Consequently, CHPS has remained the flagship
PHC implementation policy in Ghana and an integral part of healthcare delivery.
However, a key issue in the design and implementation of PHC interventions has been the
paucity of resources together with one who bears the cost of PHC initiatives (Li et al., 2017;
Collins and Green, 1994). Though the PHC declaration suggests that the cost incurred in the
provision of essential services should be one that the community and country could afford to
maintain at every stage of its development (WHO, 1978), it provides no acceptable limits or
caps (Lafond, 2013). Nor does it provide practical guidelines for how much resource must be
made available by states for the attainment of the PHC goals (Macdonald, 2013).
In practice, therefore, Ghana and other PHC implementing countries have expended only
the barest minimum on healthcare and even more minute resources to PHC arguing that was
what they could afford looking at the stage of their development (Rohde et al., 2008; Appiah-
Agyekum, 2020). In these same countries, however, significant resources are channelled to
other sectors like sports and themilitary or even if it is in health, these resources go to tertiary
services and medical infrastructure (Mcpake, 2013; Collins and Green, 1994) rather than PHC.
PHC implementation in these countries have therefore lacked the resources and capacity to
fully operationalize PHC tenets, make healthcare universal and ensure its sustainability
(Krumholz et al., 2015; Taylor et al., 2020).
The attendant effects of the above include a limitation in the attainment of thePHCoutcomes
and the creation of a yawning gap between PHC policy intent and actual implementation in
practice. Again, knowledge and skilled persons to operationalize PHC and the related
disciplines will not translate into measurable outputs in health systems where requisite
resources and community support mechanisms are also non-existent (Pew Health Professions
Commission, 1995; Coreil, 2019). Further, developing countries are unable to sustain, in the long
term, investments in expanding health infrastructure and coverage of medical services unless
PHC implementers develop evidence-backed means of building and managing the capacities
directly and indirectly associated with PHC (Phillips, 1990; Talbot and Verrinder, 2009).
In addition to the above, there appears to be very limited research on the key capacity Capacity
issues driving its implementation to inform policy termination, continuance or reform issues in
decisions (Awoonor-Williams et al., 2015). In the absence of these essential evidential studies implementing
to guide its implementation, the practice appears to be that the health authorities together
with their development partners continually introduce initiatives and commit scarce PHC andGhana
resources to PHC without a holistic appraisal of its impact vis-
a-vis the required capacity to
operationalize them (El-Jardali et al., 2019; Rifkin, 2018). Black et al. (2017) for instance observe
that generally evidence on the capacity of implementers to back PHC decisions was lacking 635
while De Graft Aikins et al. (2013) also bemoan the little attention given to the management
and maintenance of existing resources towards an efficient attainment of PHC goals.
Using the above as a starting point, this study delves into the essence, adequacy and
management of capacity in PHC implementation in developing countries using evidence from
top and middle level PHC managers in Ghana as an example. In doing so, the study attempts
to answer the questions of what is required to implement PHC and from which sources, how
resources meant for PHC implementation are managed as well as how resource capacity
issues affect PHC implementation in Ghana.
Methods
The study was approached from an interpretivist perspective. The choice of interpretivism is
influenced by the situational nature of implementation processes which enforces the view
that there is no objective truth in implementation analysis (Palumbo and Calista, 1990).
Specifically, a qualitative case study approach was adopted using the PHC implementation
evaluation tools by Bhuyan et al. (2010) and El Bindari-Hammad and Smith (1992) as guides.
A qualitative case study approach was also considered suitable for this study’s quest to
answer “how” and “why” questions about PHC implementation from key informants whose
behaviour cannot be manipulated based on Yin (2014). Even though some modifications to
these assessment guides were made by the study to suit local conditions, the guides amongst
other things were essential in the study design, fieldwork and data management processes in
the study. To gain insights and on-hands evidence on capacities required for PHC
implementation and how they were managed in Ghana, the study focussed on key PHC
managers at the national, regional and district levels. Respondent selection was also
influenced and justified byMcpake’s (2013) findings that PHC implementation is drivenmore
by top and middle level implementers than by lower level actors.
The gained ethical clearance from the Noguchi Memorial Institute for Medical Research
with certificate numbers NMIMR-IRB 087/12-13, NMIMR-IRB CPN 087/12-13 revd. 2014. In
addition, appropriate permissions and official approval were given by the Ghana Health
Service and the Ministry of Health.
Sampling for the study involved a combination of convenience sampling and snowballing
approaches. Sampling began with the use of convenience sampling to recruit two initial
respondents for the study and then using snowballing to recruit 17 subsequent respondents
with the aid of the initial respondents. The two initial respondents were the deputy director
general of the Ghana Health Service (GHS) and the director of the Health Promotion Division
of the GHS who were conveniently sampled from the national level through personal
networks. They then aided in recruiting the respondents from the regional level who
subsequently aided in recruiting respondents from the district level.
By combining these approaches, the study was able to traverse the initial limitations of
gaining access and recruiting the PHC implementers who also doubled as top level
bureaucrats in the Ghana Health Service and Ministry of Health. It also allowed the study to
draw on the personal links and goodwill of national PHC managers to traverse the
administrative bottlenecks in gaining access to prospective respondents across the 216 local
HE government areas in the 16 regions of Ghana. Similar approaches were recommended by
122,6 Bhuyan et al. (2010) who observe that they allowed the study to use existing chains of
command and reporting to overcome key challenges in recruiting top level PHC implementers
and administrative bottlenecks. Sampling and in effect, data collection was truncated when
saturation was reached after recruiting the 18th and 19th respondents. Details of sampling
and respondents are shown in Table 1.
Data were collected from respondents through in-depth interviews over a six month
636 period. Interviews lasted between 45 and 142 min and were guided by a semi-structured
interview guide design based on the key issues for assessing PHC implementation proposed
by El Bindari-Hammad and Smith (1992). The guide was non-restrictive and was facilitated
by probes and prompts that helped elicit authentic experiences of respondents on the key
issues under the study. The interviews were recorded, transcribed and later shown to
respondents for approval prior to analysis.
The data were analysed using the framework analysis approach. As a variant of thematic
analysis that is specially designed for applied policy research in health (Ritchie et al., 2003),
framework analysis facilitates the synthesizing of data gathered from original accounts and
observations into recognizable general categories and emergent themes. The actual steps of
analysing the data gathered included immersion, developing thematic frameworks, indexing,
charting and then mapping and interpretation in line with the prescriptions of Pope et al.
(2000). The emergent themes from the analysis were then discussed within the context of the
relevant literature.
Key findings
All respondents agreed that the full implementation of PHC required significant resources
without which all interventions, policies and activities remained merely on paper. However,
PHC was not being implemented in several geographical and service delivery areas because
of the lack of resources or stakeholder capacity to follow the prescriptions of the Alma Ata
declaration. Even in places where it was being implemented, there were still challenges in
getting required resources on time and in the needed quantities.
PHC is really good for us andwe had the necessary resources, wewould havemoved a lot of the ideas
from paper to the ground. The people are committed but the resources are just not there (R11,
Regional level)
A key resource issue in PHC implementation across national, regional and district levels was
the human resource capacity in terms of numbers and skill sets. Quite apart from the general
shortage of health workers across the country and the attrition to the western world, a
dominant theme was the attrition of trained health promoters and community health officers
for PHC to other medical professions or other non-medical professions. Findings also show
the fluid mobility of PHC workforce from rural to urban areas as well as the strong refusal to
accept postings to rural and deprived areas.
Level Designation Number
National Deputy Director General, GHS 1
Director, Health Promotion Division 1
Regional Regional director of GHS 3
Deputy regional director of GHS 3
Regional health research officer of GHS 3
Table 1. District Metropolitan/Municipal/District director of health 8
Study respondents Total 19
There are just not enough PHC workers on the ground generally but the situation is worse in rural Capacity
areas because no one wants to work there (R19, District level) issues in
Respondents linked human resource challenges to poor incentives and remuneration for PHC implementing
workers, lack of social amenities and public infrastructure in rural and underserved PHC andGhana
communities and a lack of recognition of PHC workers. Additionally, other respondents
identified the lack of training facilities and opportunities for PHC workers, poor enforcement
and management of transfers, promotions and postings amongst others. 637
The salary of PHCworkers are low and there are no incentives for them doing outreaches. Also, some
PHC workers can’t stay or refuse to come to this area because there are no good schools for the
children or proper social infrastructure for their families (R12, District level)
Though respondents shared varied opinions on the forms, sources and quantum of financial
resources needed for PHC implementation, they all agreed that funding was a critical element
in executing and sustaining PHC implementation. While some respondents expected
increased contributions from the central and local governments, others also bemoaned the
lack of contribution for PHC activities by the general public, community members and other
beneficiaries of PHC implementation.
PHC implementation requires a lot of fundingwhich difficult to get in Ghana. Everyone is waiting for
government to provide and the local communities don’t even contribute a cedi (R15, National level)
Another point of consensus amongst respondents was the fact external stakeholders and
development partners committed more financial resources to PHC than both state and non-
state local actors. Importantly, respondent views suggest that because the Ministry of Health
(MoH) and theGHSmade very little financial contribution, they appeared to have little control
over the scope, pace and direction of PHC implementation. Community participation and
involvement in PHC also did not cover financial responsibility or bearing costs of services
which in turn made communities dependent on external stakeholders and the government.
Most of the funding for PHC comes from foreign governments and international NGOs who control
PHC and how it is implemented. . .it is their money so they determine who gets what and how it
should be used. The local people and even the government cannot do or say anything. . .(R17,
Regional level)
Respondents also revealed how funding for PHC and health promotion was often redirected
to other medical interventions or how politics influenced the disbursement of PHC funds and
caused inequitable distribution of PHC funds across regions and districts. Alongside the
inability to internally generate funds for PHC respondents also identified the poor healthcare
finance structures, poor financial contributions by local and central governments, corruption
and poor management, and accountability practices are also key causes of financial
challenges in PHC.
Even the small funds we have are given to control programmes and other clinical initiatives at the
expense of health promotion and PHC or simply not managed well (R7, Regional level)
The final theme that runs through respondents’ accounts was the challenges with logistics
and equipment. Respondents explained how most PHC initiatives could not be implemented
because the necessary equipment, tools and logistical arrangements were not available or
inadequate. For areas outside the capital towns, technology and connectivity were commonly
cited by respondents while maintenance and investments in replacing obsolete equipment
were key across all.
Sometimes the people are there to work but there are no tools to work with. Even stationary is a
problem in some rural areas (R3, District level)
HE Other key issues raised that cut across all respondent views were the poor supply chain
122,6 management system for both medical and non-medical consumables, resistance to changing to
online systems and poor transport and storage systems and the general poor knowledge in
using, managing and maintaining logistics. Even where logistics became available, they were
poorly distributed and skewed in favourof big townsandcities at the expense of communities on
the fringes. In several cases, respondents also explained how the necessary social infrastructure
for utilizing these systems were not present thereby rendering them obsolete.
638
I have several areas where they don’t have facilities and coolers to store vaccines and other items
they use for outreach. In some areas, we don’t even send vaccines there because there is not electricity
for the storage fridge to work (R9, District level)
In addition to the funding, personnel and equipment challenges that affected PHC
implementation in Ghana, respondents also tied the availability and sufficiency of PHC
resources to existing socio-economic conditions that hindered PHC implementation efforts
directly and indirectly. A common theme along this line were security, education and other
prevailing circumstances in local communities that influenced the commitment, contribution
and utilization of PHC implementation resources by stakeholders. Evenmore crucial were the
popular belief amongst respondents that the limited PHC resources available were mostly
mismanaged or subject to allocative inefficiencies, duplicated, poorly accounted for and in
several instances wasted.
The issue at times is not lack of resources or the inadequacy. Sometimes, resources are mismanaged,
poorly allocated or simply wasted (R1, District level)
Discussion
PHC as a monumental effort towards revolutionizing the way health is perceived and
approached requires the injection of significant resources to build and boost the capacity for
implementation (Andrews and Crooks, 2012). Without capacity, therefore, PHC remains
merely a declaration of intent without practical steps to achieve it. Findings in support show
how resources for implementation including the capacity to create, sustain and continually
improve the enabling environment conducive for PHC practice were essential especially in
rural communities. Additionally, PHC also implies that countries have the capacity to
establish a health promoting system, improve access and empower local communities to take
control of their health (Mcmanus, 2013; El-Jardali et al., 2019). Consequently, PHC is a dense
resource and capital intensive intervention requiring significant investments in human
resources, technology, logistics, institutions and sustainable funding. As findings show, the
absence of these in their appropriate quantities and required specifications hinder the
successful implementation of PHC even in environments where the concept of PHC has been
embraced and stakeholders are committed to implementation.
The issue of capacity is a well-discussed one especially as it was a major thrust of the
selective primary health care (Obimbo, 2003; Birn, 2018). Initially restricted to financial
capacity, it was acknowledged that many developing countries at the inception of PHC were
confronting inflation, recession, and economic adjustment policies, and suffocating foreign
debts (Cueto, 2004). Ghana was, for instance, undergoing a series of economic and
administrative reforms to stabilize the economy after successivemilitary coups and economic
mismanagement in the periods between the Alma Ata declaration and the Ottawa charter
(Mba and Kwankye, 2007). It was therefore ill resourced to implement the resource-intensive
PHC declaration. Ghana’s case is made clear by Mcpake’s (2013) argument that addressing
these economic and developmental issues in developing countries had taken a severe toll on
public health resources and their specific commitment to PHC. In addition, human resource,
logistics and technical challengeswere also associatedwith PHC implementationwithin these
countries (Tunkulaite_ and Kontrimiene_ , 2021; Parfitt, 2018). However, evidence from this Capacity
study while showing that capacity is and will always be key to PHC implementation, issues in
importantly contributes to the evidence base by stressing that addressing capacity issueswill implementing
require more than merely ensuring availability of sufficient funds, personnel and equipment.
Findings confirm that of Krumholz et al. (2015) that the human resource capacity for PHC andGhana
Ghana’s PHC is inadequate across levels and regions and further worsened by limited skilled
professionals and health promoters involved in mainstream activities. While the
medicalization of PHC may play a part in the limited numbers of health promoters and 639
non-medical PHC personnel (Mcmanus, 2013), findings recognize a general shortage of health
sector workers and a high attrition of skilled personnel to the western world. Similar findings
were made by Awoonor-Williams et al. (2015) who explain how high attrition rates limit the
ability to scale up community-based PHC initiatives, and Bach (2008) who attempts to
distinguish between brain drain and brain exchange.
Findings also note a high level of uni-directional mobility of PHC labour from rural areas
to urban areas, and fromnon-medical cadres tomedical cadres of PHC personnel. This creates
a shortage of PHC staff in rural and underdeveloped areas and a surplus in urban and
developed areas in Ghana with serious implications on access, utilization and the quality of
PHC service provision. Also, the increasing numbers of community health officers (CHOs),
public health officers and health promoters converting to clinical roles and other medical
professions reduced the available numbers of personnel for real PHC work. Generally, intra-
sector mobility of labour must not be a key setback if backed by appropriate promulgation
and enforcement of legislations to control, restrict and reverse the movement of labour (Dutz
et al., 2013; Mason et al., 2020). Alternatively, the much more subtle approach of incentivizing
affected professions and jobs to make it attractive has also been used for decades with
significant results (Crisp, 2018; Krugman, 2005; Doeringer and Piore, 1985).
Though not in the majority, some respondents in this vein supported Thompson and
Smith (2010) and Van Ham (2002) that some level of professional mobility was essential for
knowledge transfer, experience sharing, creativity and entrepreneurship that will lead to
growth and efficiency. In Ghana’s case, however, findings suggest that poor promulgation
and enforcement of legislations on postings and transfers as well as poor incentives for PHC
workers in rural areas were key catalysts of the scarcity of PHC personnel in rural areas.
Findings, generally linked mobility decisions of PHC staff and health sector workers in
general to socio-economic factors, general level of development, available public
infrastructure and standards of living of the location of their jobs and their job roles.
However, determinants like gender, intra-organizational mobility (Valcour and Tolbert,
2003), societal characteristics of regional segmentation and discrimination (Ng et al., 2007)
and workforce characteristics (Parfitt, 2018) were not supported by findings.
This study also identified several challenges in the recruitment, training and distribution of
PHC personnel across the country. Issues of remuneration, incentives and motivation are also
common challenges for all PHC interventions across the country even though it was more
challenging for CHOs and other local level workers. Contrary to Ibrahim (2007) and B€ohmig
(2010), PHC personnel seemed to be influenced more by non-financial motivators like
recognition and opportunities for development than they were by financial incentives.
Importantly, findings reiterate Manongi and Marchant (2006) call for a closer examination of
off-the-job conditions rather than job-related conditions as the decision to accept postings and
commitment, and output levels of PHC staff in this study were strongly linked to the comfort,
safety and convenience of their families and dependents. The apparent inferiority of CHOs and
other CHPS workers to clinic-based health workers was also a key de-motivator for PHC staff.
Cueto (2004) andKane (1984) had earlier presenteddiscussions onhow the “barefoot doctor” tag
reduced the appeal of PHC ancillary work in China. Similarly, connotations of inferiority
associated with “basic health nurses” made PHC personnel appear as second class healthcare
HE providers in Nigeria (Okonofua et al., 2018). This study further places strong emphasis on the
122,6 poor mentorship, coaching and career development of PHC personnel especially at the local
level as well as the poor human resource planning and policies of the health sector in general.
The capacity to finance PHC is an important determinant of PHC success. Generally, it is
recognized in the implementation literature that without the funds to execute, policies often
remain a mere expression of intent that makes no impact in the lives of people (Wildavsky
and Presman, 1973; Datnow and Park, 2009). Findings in support of Magawa (2012) place
640 significant emphasis on finance as the lifeblood of PHC implementationwith varying levels of
success recorded on different PHC components depending on the levels of funding. Quite like
Nazzar (2012), findings link the availability of finance to the success and sustenance of PHC
initiatives in Ghana. However, in contrast to Mc Sween-Cadieux et al. (2019), findings suggest
that finance is not a passive resource but the active determinant of the pace, direction and
scope of implementation.
An important theme was the sources of funding and the relationship between local and
external financiers of PHC initiatives. Even though various forms of financial contributions
were recorded from varying stakeholders, external stakeholders appeared to be the main
financiers of PHC in Ghana with the GHS and government rather playing a minor role. When
compared to those of Kai (2009), findings suggest a reversal of roles that deviates from the
ideal situation where local stakeholders are the main financiers of implementation with
external stakeholders playing a supporting role. This however appears to be the norm with
PHC in SSA with similar findings made by Rohde et al. (2008) and Hone et al. (2018).
The source of policy funding is an important consideration in the policy cycle not only
because it determines the progress and sustainability of implementation (Honig, 2006;
Mazmanian and Sabatier, 1983) but also because it determines the nature and type of
relationship existing between implementing stakeholders (Majone, 1984; Love, 2004). Instead
of a partnership relationship where proportionate financial contributions are made by all
implementing stakeholders (Hupe, 2011), findings in contrast suggest the existence of an
agency relationship where the GHS, MoH and other local PHC stakeholders acted as
implementing agents of external partners who provided funding. This is in spite of PHC
policy documents naming the GHS, the government and external stakeholders as PHC
implementation partners. Butterfoss (2007) similarly suggests the lack of clear relationships
between stakeholders of local health interventions especiallywhere an imbalance exists in the
financial contributions of named stakeholders.
Distinctively, this study makes a significant contribution to the evidence base by
highlighting that the agency relationship in some cases may further degenerate into a master–
servant relationship where implementing stakeholders who havemade little or no contribution
appear to have no control or influence over implementation decisions and actions and have to
obey financing stakeholders unquestioningly. In particular, findings show several instances
where theGHSand other local stakeholders hadnopower to refuse, alter, abate and reviewPHC
implementation decisions and actionsbydonors and international organizations. This confirms
the classical implementation construct (Elmore, 1979, Mclaughlin, 1987) where power and
influence of the policy cycle may be exerted by assuming full responsibility for funding.
The power play associatedwith financingPHC is varied and has strong implications for PHC
implementation success. Because of the strong link between financing and the ability to control
policy progress and outcomes, policy stakeholder relationships are often characterized by
struggles for financial responsibility and in effect policy control (Fry and Raadschelders, 2013).
However it appears that the GHS, the MoH and the Ghanaian government have rather not
maximized the opportunity; this presents for directing PHC. Instead, findings point to them
having relinquished financial decisions and responsibilities to external partners, and with it,
their rights of control over PHC implementation. This gives external stakeholders unlimited
access and control over PHC outcomes which may sometimes have negative implications when
seen in the context of Deleon and Deleon (2002) that different policy actors have different, Capacity
sometimes ulterior interests and motivations for funding policy. Though no clear instance was issues in
recorded by findings, other studies (Hjern and Porter, 1993; Nakamura, 1987; Mason et al., 2020) implementing
have shown how control of public policies drawn from sole financial responsibility have been
negatively used to discriminate or exploit local people for pecuniary gain. PHC andGhana
The politics of financing public policies (Nakamura and Smallwood, 1980; Pu€lzl and Treib,
2006) evidenced by the remarkable increase in the ability to determine who gets what, when,
how and inwhat quantitieswas also confirmed by findings. Generally, findings recognized that 641
the approaches, professionals, equipment and benchmarks used for health interventions were
generally dictated by financiers more than by the bureaucratic implementation structure and
processes in line with Weber (2004) and Kosar (2011). Especially when financing is done by
multiple stakeholders whose activities are poorly coordinated, it is common to get divergent or
conflicting policy directives fromdifferent financing partieswith varying preferred approaches
and expected outcomes (Stewart andGray, 2006). Findings in this vein presents the frustrations
of PHC implementers on having tomeet different often conflicting requests of different funding
parties for PHC interventions. Importantly, the group struggles associated with the politics of
policy finance (Kraft and Furlong, 2012) were captured by findings in two instances, firstly, in
the struggles amongst professional groups for financial support for either clinical or public
health interventions and secondly, in the struggles and competition amongst local NGOs, the
GHS and other agencies of the MoH for donor funding at national, regional and district levels.
While struggles may lead to improved services, efficiency and healthy interaction amongst
competing institutions (Kai, 2009), findings suggest that unhealthy competition may also
flourish amongst competing agencies especially where external funding is the main source of
financing PHC activities and funding sources are limited.
The financial challenges of PHC are also linked by findings to the inability to generate
resources for health internally. Generally, findings show that local communities are limited in
their ability to fund PHC as a result of poor socio-economic conditions, unemployment and low
standards of living. This appears to be the situation in many developing countries where local
communities are solely reliant on central government funding for public services including
health (Tanner and Harpham, 2014; Green, 2007). However, findings show that central
government funding for PHC directly has for years been non-existent and very scant for the
health sector in general. Even where local governments are involved, their capabilities and
levels of commitment are linked to the quantum and frequency of financial support received
from central government. Findings along this line confirm those of Apetorgbor (2009) that the
interest and financial commitmentmade by local governments to CHPS in Ghanawas strongly
dependent on the frequency and amount of district assemblies common fund received from the
central government. For PHC in particular, financial responsibility may be a shared function
between local and central governments (Logie et al., 2010) or the sole responsibility of either the
central or local government (Li et al., 2017). In Ghana’s case, findings show the lack of clearly
defined roles and responsibility for local level healthcare finance with PHC torn between local
and central governments who are each currently shirking and tossing financial responsibility
to the other. Consequently, findings contribute to the evidence base by identifying
decentralization and the politics associated with it as a strong determinant of PHC finance
and specifically, the ability and responsibility to finance PHC initiatives from within.
Generally, PHC activities appear to be constrained by the fact that the limited funds
available are channelled into medical interventions rather than in health promotion and PHC
initiatives. Findings in particular note how funds meant for empowerment go into training
health workers to empower local people rather than actually empowering local people. In
addition to increasing paternalism and professional elitism in PHC activities (Macdonald,
2013), it fosters a sense of powerlessness and dependence of local people on health
professionals and limits community participation in PHC activities. Consequently, the study
HE contributes to PHC practice by drawing attention to the negative effects of misplaced
122,6 prioritization and utilization of scarce PHC funds. Corruption, financial mismanagement and
low levels of accountability that characterize health sectors in SSA (Lewis, 2006; Dietrich,
2011) were also believed to be rife in Ghana by PHC implementers.
Besides the financial and human resource paucities, findings suggest that logistics and
equipment were also lacking for PHC interventions. Manongi and Marchant (2006) believe
that most PHC initiatives are doomed to fail from the start because the necessary equipment
642 and tools needed are in most instances not readily or fully available. Findings in confirmation
show how essential items like motorbikes, vehicles, stationary, refrigerators and spaces
needed for storing and preserving vaccines and medicines were not available or inadequate.
Similar claims aremade byAwoonor-Williams (2014) who further contributes that sterilizers,
disposable gloves, syringes, thermometers and other supplies were also in short supply
thereby increasing exposure of PHC staff and service users to infections. This issue appears
to be an SSA one as similar findings were also made by Logie et al. (2010). It is thus
unsurprising that Pandey (2018) concludes that PHC has generally not been backed by the
technological and logistical capacity needed for its smooth implementation.
While the over-reliance on existing technology and available equipmentmay be responsible
for this (Bosu, 2013), limited commitment and investment from stakeholders towards technical
and logistical growth of PHC activities is unearthed by findings. Importantly, the study
highlights the need for continuous assessment and revision of logistical and technological
needs for PHC initiatives considering the high volumes of outdated and obsolete techniques,
technology and logistics that epitomize Ghana’s PHC. The poor maintenance culture recurring
across findings of this study appears to be a general problem of PHC in developing countries
(Ogembo-Kachieng’a and Ogara, 2004; Taylor et al., 2020), that is linked to the lack of human
and financial resources to maintain donated or procured equipment.
Generally, high resistance tomodern technology and approaches has been associatedwith
policy resistance especially amongst core health staff lacking continuous professional
development and familiarity to e-health systems (Witz, 2013). In SSA for instance, some PHC
personnel have resisted attempts at modernizing PHC services out of contentment with the
status quo or for fear of losing their relevance or jobs to electronic systems (Macdonald, 2013).
In Ghana, however, findings in contrast show that technology and IT systems were
unavailable in PHC centres even though personnel were trained, ready to use and had
requested them. Similar to earlier findings byGyenfie (2005), computers, printers, phones and
Internet connection were only present at the regional offices and in some district offices with
serious implication on communication and information search, storage, transmission and
reporting at the local levels. Besides these, this study contributes by pointing out the poor
supply chain management, centralized management of PHC supplies and the storage
capacity across the country that have had an effect on the preservation, distribution and
availability of medicines and general items for PHC across the country.
Additionally, medical supplies and equipment were more readily available in local
communities rather than those needed for health promotion and PHC. Further, findings show
a chronic shortage of information materials and essentials needed for health education and
behaviour change communication outreaches while those on treatment, approved cure and
care in hospitals were relatively easier to find. Similar findings were made by Conrad (2008)
and Macdonald (2013) who blame the dominance of medicine and the control exerted by
medically oriented national health services for this situation. In contrast, Bosu (2014) explains
that the epidemiological landscape of developing countries makes tropical and infectious
diseases a key priority for health sector stakeholders such that more effort were likely to be
put towards these conditions than in the prescriptions of the Ottawa charter. While the both
cases may be true in Ghana, stakeholder perspectives link the availability of supplies and
materials for PHC to the well-resourced vertical programmes and national disease control
programmes. Consequently, medication, supplies and equipment for TB, HIV/AIDS and other Capacity
vertical programmes were very available even though availability was limited to focus areas issues in
and targeted sections of the population. PHC supplies, vaccines and equipment were however implementing
limited, poorly distributed and relatively difficult to obtain.
PHC andGhana
Conclusion and contributions
Generally, the bane of implementation appears not to always be about the lack or inadequacy
of resources or capacity as several examples exist of well-resourced policies that did not 643
achieve desired results (Appiah-Agyekum, 2020; Abbas and Riaz, 2013; Honig, 2006; Majone,
1984). For PHC policy sustenance and effective implementation, evidence from conventional
backward mapping in policy analysis (Elmore, 1979) has long suggested that regardless of
resource scarcity or surplus, effective resource management based on context-specific policy
limitations may still lead to implementation success. In addition, effective and proportionate
resource allocation and distribution based on specific local needs and contextual differences
appears to be more beneficial in implementing PHC and public policies over a wide
multicultural geographical area than routine and equal distribution of resources. As
demonstrated in Ghana’s PHC implementation, different PHC components had different
levels of importance and unique implementation conditions across the multicultural
Ghanaian society. However, the uniform distribution of resources and PHC interventions
across the breadth of the country resulted in shortages in some areas and surpluses in others
based on varying local needs and utilization levels. These together with the poor
management of capacity, wastage and other inefficiencies of the resource management
and supply processes limit PHC implementation.
Based on findings, the study contributes that capacity in PHC goes beyond ensuring
availability of resources into having the ability to make judicious use of resources in a
timely and purposeful manner. In implementation, capacity strives at efficiency rather
than effectiveness and is concerned about making optimum outputs from limited inputs
(Bhuyan et al., 2010). Consequently, this study contributes to the evidence base that PHC
success might not be tied to piling up resources for implementation but rather the ability to
manage and sustain PHC with the limited resources available. For other logistics and
equipment, the watchwords have always been servicing, maintenance, storage and proper
usage. Clearly, findings suggest that significant investments in new machinery,
equipment and technology will yield no benefits without the proper use and
maintenance culture. In addition, findings show that effort at building capacity to
implement PHC must focus on enhancing the ability to generate and sustain resources
from within, and putting them to judicious use. While spreading resources too thin may
restrict capabilities and capacities, focussed interventions also limit equity and fairness in
the provision and subsequent utilization of PHC interventions across the country.
Importantly, focus must be put not on the acquisition and building of capacities but on the
efficient management and utilization of acquired capacities. Additionally, the study raises
the need for further research into finding evidence-based solutions to the capacity
challenges in PHC implementation in Ghana that is grounded in the experiences of
implementers. It also raises the need for further studies on the contributions of external
stakeholders to PHC vis-
a-vis that of the government and how their relative contributions
influence their power and control over PHC implementation activities. Ultimately,
innovation and creativity in resource generation and management inspired by local people
offers a key pathway to addressing capacity issues affecting PHC.
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Corresponding author
Nana Nimo Appiah-Agyekum can be contacted at: nappiah-agyekum@ug.edu.gh
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