Devolution and deconcentration in action: a comparative study of five Municipal Health Directorates in Ghana

Decentralisation policies have been adopted by most countries in Sub-Saharan Africa in the expectation of improved service provision. The benefits expected are two-fold: a) decentralisation will lead to better coordination and collaboration between different parts of the state at the local level and b) decentralisation will lead to increased consultation and responsiveness of local governments to their citizens. In this thesis I seek to explain why these benefits are realised in some contexts and not others. In most parts of Sub-Saharan Africa, the predominant form of decentralisation is a combination of devolution and deconcentration. Often these two policies are ambiguous and sometimes contradictory. What are the processes through which such mixed systems work? This thesis attempts to understand how mixed systems of devolution and deconcentration work in practice through a comparative study of Five Municipal Health Directorates in Ghana. The study explores the three sets of relationships that are critical for decentralisation to work well in such mixed systems a) between the Health Directorate and the District Assembly administration, b) between the Health Directorate and the elected members of the District Assembly and c) between the Health Directorate and selected civil society organisations working on health. The work is based on detailed qualitative interviews in the five municipalities. The main finding is that informal ties between the Health Directorate and the three sets of actors mentioned above are helpful in explaining why coordination and consultation seem better in some municipalities than others. Four kinds of ties are found to be important: ethnic/tribal links, family/kinship/neighbourhood relations, political party affiliations, and old-school networks. These ties between Municipal Health Directorates and senior officers of the Municipal Assemblies were found to facilitate Municipal Health Directorates' access to District Assemblies' Common Fund, which was controlled by the Municipal Assemblies. The existence of these ties between Municipal Health Directorates and elected Assembly members of Municipal Assemblies were found to enhance the quality of Municipal Health Directorates' policies and helped to gain public support. Finally, such ties between Municipal Health Directorates and leaders of selected Civil Society Organisations that mobilised around HIV and AIDS programmes were found to facilitate implementation of Municipal Health Directorates' policies around HIV and AIDS. The thesis' contribution is that it shows that informal linkages between different local bodies and between local government and civil society organisations seem important for improved coordination and collaboration among various actors, and better consultation with elected representatives of citizens and leaders of CSOs for effective service delivery at the local level.