In the late 80s and early 90s and before Ghana went into the fourth Republic, there were 70 administrative districts. As at now the number has risen to 275. With stable democracy couple with good communication systems now, it is much easier to be in touch with districts and be able to move about in peace without hindrance. With increase in the number of institutions, people are able to develop themselves for the job market including health. Thus a conducive environment for leadership development is laid.
The Constitution provides that local government and administration should, as far as practicable, be decentralised and stipulates the features what decentralisation should be. The Local Government Act and its Regulations paved the way for the establishment of a Local Government Service,2003, Act 656 with devolution as its form of decentralisation. However, the Constitution also mandates the setting up a health service and that of education. Hence these two are not part of the Local Government Service, but Act 525 mandates health leaders to administrative report to the local government political leadership. The form of decentralisation in the health sector is therefore deconcentration that basically transfers administrative authority to the district health system.
The national level provides administrative rules, guidelines and procedures for the achievement of targets set by the MOH, establish systems for effective collaboration and co-operation, and the harmonisation of programmes in the Service, ensures implementation of policies in the sector and gives advice to the Minister of Health Tertiary clinical care is provided at this level. Regional level ensures the implementation of the policies and decisions of the Council and provides secondary level clinical services. The district level implements the policies and decisions of the Council and provides primary level clinical services. The subdistrict and CHPS provide community level services
In the late 80s and early 1990s, it became clear that clinicians were being asked to lead the district health system with no managerial or leadership skills. The Ministry of health together with health partners developed an unique leadership training programme for District Health Management Teams (DHMT). The training empowered these teams to identify key challenges at the district level through the ‘but why’ approach and tried to address them. The training , the Strengthening of District Health System, was fully donor funded and had to be stopped when donor funds run out. However, the training empowered District teams to question the mode of resource allocation in the entire health sector. This led to the formation of the District Directors Group. With the training and maturity of the DHMTs, financial decentralisation was made possible hence district funds were transferred to be accessed directly through the District Treasuries. The districts’ empowerment also brought to the fore, the compelling need to have Regional and National level managers trained in order to be able to respond to and be able to suppervise the much improved district teams. Hence various senior leadership programmes were instituted The District Directors Group still functions to date with yearly annual congresses. However, the Senior leadership training could not go continue as a result of resource contraints.
In order assure sustainability, the SDHS programme was improved upon with the addition of leadership modules re-designate DISHOP and located in one of the MOH training institutions. The training was offered all year round and districts voluntary enrolled as central funding run out. With increasing demand on districts to produce results in so many areas, district managers could not afford to send teams into residence and hence this leadership training programme was suspended but still available for interested districts. In 2009, the Ghana Health Service and USAID started pilot leadership programme in one the regions using reproductive health as entry point using ‘Managers Who Lead’ manual from MSH as a resource material ( much more improved than the SDHS and DISHOP modules). The National level participated by sending a group. Trainers came MSH, GIMPA and the Ghana Health Service. With the success of this pilot programme, this module was adopted by the Ghana Health Service for use with amazing testimonies from the field. This presentation focuses on the experience of this leadership programme.
1.8 Dr Sory Ghana Presentation LMGConference 29 Jan13
The First National Conference on Health Leadership, Management and GovernanceThe Devolution Experience in Ghana Dr. Elias Kavinah Sory Former Director General, Ghana Health Service 29 January 2013
Presentation Outline• Ghana Profile• Decentralization in Ghana• De-concentration in the Health Sector• Leadership Development in the Health Sector• Challenges• Effective Approaches• Obstacles• Lessons Learned• Recommendations 2
Ghana Profile •Area;238,533 sq km •Pop 24,791,073 •10 administrative regions •275 Districts •Political System: multi party democracy •Communication: Line and cell phones, broadcast media, internet 4
Decentralisation in Ghana• Provided for under the 1992• Local Government Act, 1993, act 462• Ghana Health Service and Teaching Hospitals 1996, Act 525• Local Government Act, 2003 At 656 5
Decentralization in the Health Sector• National• Regional• District• Subdistrict• CHPS 6
Leadership Development in the Health Sector• Strengthening District Health Systems (SDHS)• District Directors Group formation• Strategic Leadership and Management Course for Senior Staff, Ghana Institute for Management and Public Administration (GIMPA)• Knowledge Management for Leaders Training for Senior Staff, GIMPA• Health Administration and Management Course for Senior Staff, GIMPA 7
Leadership Development in the Health Sector (continued)• District Health Systems Operation (DISHOP), Kintampo Rural Training School• Leadership Development Programme (LDP), Ghana Health Service 8
Challenges• Direct Medical and Public Health Interventions may be regarded more important than LDP as it might be seen as having a support function.• Frequent change of Ministers at MOH draws back the smooth implementation of programmes• Perceived threat of losing turf generates resistance at higher level. 9
Challenges (continued)• Inadequate funding and donor fatigue threatens sustainability• Certain political decisions directly affect the smooth implementation of the Programme.• In the case of frequent creation of new districts, there was the challenge of recruiting and training new ones when numbers were already inadequate. 10
Effective Approaches• LDP placed in the Human Resource Development Division as part of GHS Structure.• Decentralize training to the regional and district levels• Public/Private Partnership of Facilitators and Sponsors.• Health Partners support (Focus, Unicef, USAID, Global Fund etc.) 11
Effective Approaches (continued)• GHS as lead Implementing Agency of LDP in MOH.• All levels of the Health Sector (National, Regional , District ,SubDistrict are involved)• Clinical and Public Health Mix in LDP Training• Get Commitment of Director HRDD, D-G & his Deputy, Chief Director MOH, National Coordinator, GHS & External Facilitators.• Plan Workshops in consultation with local Managers, Facilitators and Sponsors. 12
Obstacles• Budget unavailability/ inadequacies from GHS for LDP activities• Involvement but not Commitment of some GHS Divisional Heads• Inadequate involvement of other Agencies of the MOH in LDP• Inadequate involvement of other Stakeholders at the District Levels e.g. DISTRICT ASSEMBLIES, in LDP,• Inadequate Manpower 13
Lessons Learned• Health Partners alone cannot be depended upon to fund vital programmes. Government Contribution is essential• Commitment by all (Ministry and its agencies and Health Partners) is essential for successful implementation of programmes.• Teams for training should have mix of professionals to enhance team concept.• Workshops should be held as near to points of implementation as possible to be effective 14
Lessons Learned (continued)• Changes that have occurred after teams have gone through have been phenomenal. Problems became challenges. More was done without additional funding.• Strong M&E is needed. Should be a key department of one of the Divisions.• Support by the Directors of the Ministry of Health and its Agencies assures acceptability 15
Recommendations• Be confident and positive that with LDP, decentralization will become easier• There are always many competing programmes such as clinical care and public health interventions that take most of the budget. But investing in LDP will give greater returns in decentralization.• Budget for LDP at all Levels should be assured. The MOH should reflect LDP PRIORITY on their Agenda into BUDGETARY ALLOCATION 16
Recommendations (continued)• Orientation of New Staff, particularly Directors, Heads of Units, Departments, and Institutions should include Leadership and Management• The programme should involve all stakeholders including health partners and other departments to assure acceptability and sustainability 17