Assessing the operationality of the sub—district health system a case study of the ho district of the Volta Region
The Alma-Ata Declaration of 1978 ushered in the Health For All by the Year 2000 as the goal of all the member states of the World Health Organization (WHO 1978). Primary Health Care (PHC) was accepted as the means by which to achieve this goal. Ghana was one of the countries that adopted and implemented the PHC right from its inception. Many countries adopted several strategies to maximize the benefits of the PHC. One such strategy was the institution of the district health systems. In Ghana District Health Management Teams (DHMTs) were formed. District Directors of Health Services (DDHS) were appointed in 1979 to head these teams. In 1988, a programme of strengthening the district health system was initiated in Ghana to develop the managerial capacities of the DHMTs. Several managerial capacity building workshops were organized to strengthen the teams. The district health systems was given a further boost when it was singled out at the WHO sponsored Conference on health in Harare, Zimbabwe in 1987 (WHO 1987) as the framework within which the implementation of the PHC could be accelerated. In Ghana however, the Health managers have noticed that despite the investment in the district health systems, the desired impact in the areas of service delivery coverage and improvement in the health indicators were far below expectation. This compelled the Government to search further for more practical country specific strategies to make health services available to the people especially the over 70% that live in the rural areas. At a Regional Directors and Programme Heads, conferences held in Sogakope (1991) and Akosombo (1992) respectively the health managers were unanimous that the weak link in the health delivery system was the sub-district. The decision was to strengthen the sub-districts to act as an effective link between the district health system and the communities. A working group was formed and tasked specifically to come out with the guidelines and recommendations for the implementation of the sub-district health system. In 1993 based on the recommendations of the Working group there was a countrywide Zoning of the sub-districts. Sub-district health teams (SDHTS) were formed and inaugurated. The sub-district health system was to provide basic health care in the areas of clinical services inclusive of maternal and child health services, preventive services and basic laboratory services amongst others. The functions of the sub-district health teams which were to be in charge of the sub-district health system included amongst others, planning and budgeting for sub-district health activities, and provision of supervision and data management at the sub-district level. The teams were also to promote inter-sectoral collaboration and community involvement in the sub-district health care delivery. The categories of staff recommended for the sub-district included medical assistants, midwives, and technical officers/assistants (disease control, leprosy, nutrition, laboratory). They were to be supported by such staff as orderlies/ward assistants, revenue officers, and data managers. To concretize the sub-district health system the government designated the sub-districts as Budget Management Centres (BMCs) and decentralized financial allocations to the sub-districts. Seven years of the implementation of the sub-district health system have not brought the desired improvement in the health services coverage. Most health service indicators are still low and morbidity and mortality figures from preventable diseases supposed to be the focus of the sub-district health system are still high. Hitherto, diseases thought to have been eradicated (yaws) have resurfaced. The need to conduct an objective assessment of the sub-district health system, which was meant to address peripheral health problems, becomes paramount. The focus of such assessment is to identify the gaps in the implementation with special concern for the strengths and weaknesses.. This study was focussed on achieving that. The study adopted a descriptive approach using qualitative and quantitative methods to gather information. The methods included interviews and record reviews at the sub-district level, the DHMT, and at the regional level. The study population comprised of the SDHT of all the six (6) sub-districts of the Ho district, the DHMT, community members as well as other service providers in the district. The general objective of the study was to assess the operationality of the sub-district health system based on five main criteria inclusive of management structures of the sub-district, and management process instituted at the sub- districts. The others were to assess the provision of health and health related activities in the sub-district, funding for sub-district health activities, as well as human and logistical support to the sub-districts, and community involvement in health care delivery at the sub-district. Specifically, the study was aimed at assessing amongst others whether the management structures recommended for the sub-districts have been put in• place and whether the sub- districts have instituted the management processes of planning, budgeting, supervision and management information systems for effective management of the sub-district as required of them. The study assessed whether there has been adequate funding as well as human and material support (supplies, equipment, and logistics) for the sub-district health system. It also assessed whether the sub-districts have been providing all the services expected of them and whether they have promoted community involvement in the health care delivery in the sub-district. The study sought to identify the problems militating against the sub-district health delivery and to provide recommendations to the SDHT, the DHMT and the MOH national office as well as all stakeholders in health. Data collection took place between August 2001 and November 2001. The limitations to the study were mainly time constraint and inadequate funding.
A thesis submitted to the Department of Community Health, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology in partial fulfilment of the requirements for the award of MSc.degree in Health Services Planning and Management, 2002