De facto health governance policies and practices in a decentralized setting of Ghana: Implication for policy making and implementation

Current Universal Health Coverage (UHC) considerations confirm the need for strong governance in improving health sector performance. However, empirical evidence on the effects of decentralized health system governance remains limited in Low-and-middle-income countries (LMICs). This paper assesses the de facto health governance policies and practices of the decentralized health system of Ghana and its implications, for better policy formulation and implementation. The study employed a cross-sectional design, comprising of systematic literature review (SLR) and in-depth interviews on health governance components. The literature review (n=103) was performed to document the factors that affect health governance management and policy uptake. A total of 32 purposively sampled key health system actors were individually interviewed face-to-face between January and February, 2018. Thematic content analyses of literature and interviews were done. Tension regarding power relationships exists between the policies governing the health sector of Ghana, which has rendered the decentralization reform effort in health governance policies and practices uncoordinated, incoherent and sometimes contradictory. Implication of the de facto decentralized health governance policies and practice include: limited involvement of sub-national level in policy development; weak interaction between policy formulators and implementers; and political interference in policy implementations compromising evidence-based policy formulation. Drawing on diverse literatures and opinions of key health actors, this paper contributes to knowledge on health governance practices in a decentralized and resource constrained health system, and offers practical accounts of the implications of the de facto health governance system of Ghana for health policy formulation and implementation.