Spatial dimensions of health inequities in a decentralised system: evidence from Ghana

Type Thesis or Dissertation - Doctor of Philosophy in Public Policy and Administration
Title Spatial dimensions of health inequities in a decentralised system: evidence from Ghana
Publication (Day/Month/Year) 2014
Decentralisation has been considered by many as one of the most important
strategies in public sector reform in several of the developing countries. Both donors
and governments have regarded decentralisation as a tool for national development
through the realisation of the objectives of enhancing popular participation in
development and the management of development at the regional or local level.
Countries are expected to reap the benefits of decentralisation through improved
service delivery, namely, through bringing service delivery closer to the consumers,
improving the responsiveness of the central government to public demands and,
thereby, reducing poverty and inequalities, improving the efficiency and quality of
the public services and empowering lower levels of government to feel more
involved and in control.
However, decentralisation also has the potential to widen the gap in fiscal resources
at the sub-national level and this may, in turn, result in inequities in service delivery
to citizens of the same country and depending on where they live. Over the years
Ghana has experimented with a mix of decentralisation reforms with the current
policy integrating elements of political, administrative and economic
decentralisation. The current system of local government in Ghana is based on a
decentralisation programme that was launched in 1988 with the introduction of
district assemblies (DAs) by the Provisional National Defence Council (PNDC)
government. Nevertheless, years after the launch of the decentralisation process there
are still significant disparities and inequities between districts and regions in Ghana
as regards health variables.
This study set out to investigate the link between decentralisation and health
inequities by exploring the spatial dimensions of health equities in Ghana. The
thesis used a concurrent mixed method approach by combining a quantitative
inequality indices analysis and a qualitative analysis of interviews with policy
makers in both the health sector and the decentralised system. The analysis used
household level data from the Ghana Demographic and Health Survey 2003 and
2008 to construct inequality curves and indices in order to illustrate the existing
inequities across and within regions in Ghana after an increase in the intensity of
decentralisation. The study then decomposed the indices to determine the extent to
which these inequities were accounted for by variations both within the regions and
between the regions. The thesis also used available data from the common fund
records of district assemblies to assess the level of inequities in selected health
resources across districts. The thesis then investigated the micro-foundations of
health decentralisation using the qualitative and quantitative descriptive analyses.
The analysis conducted revealed that inequities in maternal health utilisation
decreased between 2003 and 2008 ‒ the two data points used based on the research
design. However, these inequities were attributed primarily to within region
inequities as the level of between regions inequities was significantly lower for both
the concentration index and the Theil’s index. However, although, at the regional
level the general trend revealed that inequities had also decreased between 2003 and
2008, some individual regions had recorded increases. The concentration index,
which provided information on the gradient of the inequities, revealed that the health
inequities in Ghana ‒ the total health inequities and also for both years between and
within regions ‒ were pro rich. In the instances of the regional inequities these
inequities generally manifested a pro rich nature, with the exception of the Upper
East region which had showed pro poor inequities in 2008. The analysis of the
district level inequities in selected health resources and as regards health facilities,
doctors and nurses indicated that the distribution of these facilities favoured the
richer districts as the inequities revealed a pro rich gradient. The inequities in the
health facilities at the district level were highest in respect of the nurses, followed by
doctors and health facilities with scores of 0.32, 0.29 and 0.084 respectively.
The analysis of the qualitative data corroborated the results of the quantitative
analysis as it emerged that policy makers at all levels believed that, over the years
since the decentralisation, inequities had reduced, albeit marginally. The policy
makers highlighted the high levels of the inequities in health resources, especially
human resources, as a major area of concern. However, they also raised major
concerns regarding inequities within regions, arguing that a number of factors,
including the nature of the decentralisation regime in Ghana, the variations in the
economic strength of districts and certain political factors, continued to cause
inequities within the decentralised system. They argued that these factors impacted
on the ability of both districts and regions to address inequities at a local level. In
addition, they also pointed to the need to re-examine the definition of inequities in
the Ghana health sector, inequities which result from focusing the attention on a
number of regions and areas to the detriment of others.

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