Discussion
Findings of the study suggest that policies for managing hypertension
and diabetes in Ghana emanate from a broad programme of periodic
scanning through a holistic assessment of the health sector and
identification of health needs. However, once needs are detected, the
initiation of the policy process is somewhat nebulous. Though by law the
MOH is expected to lead the policy formulation process, the process is
sometimes led by the GHS. This has undermined the role and authority of
the MOH in the policy formulation process. A far-reaching effect is that
the MOH is not able to play its leadership role in the process by
pulling all agencies along to work towards achieving desired policy
goals. The result of the unclear lines of authority is instances of
disagreements where certain agencies such as the Christian Health
Association of Ghana (CHAG) refuse to honour policy formulation
invitations by the GHS as they believe the CHAG and GHS are both
agencies of the MOH. A poor understanding of tasks or disagreements on
tasks which are not clearly defined in the right sequence has been seen
as having a negative impact on the formulation of policies (Sakyi,
2008).
Though major stakeholders are invited in the formulation of policies on
diabetes and hypertension, the mode of invitation has affected the
credibility of the whole process of engagement. Assembling all
stakeholders together in one location has negatively affected policy
formulation and implementation in many ways. First, some stakeholders do
not make any input during policy discussions because of fear of being
challenged or a lack of confidence to air their views on policies in
public; second, the most qualified people whose inputs would be more
beneficial to the policy do not attend these policy meetings; and third,
the flamboyant panoply of jargons by policy experts put the ‘fear of
God’ in certain stakeholders who then decide to mind their own business
though present in such meetings. In the end, though a tall list
detailing the number of stakeholders consulted is presented, the actual
input of these stakeholders and interest groups remain insignificant.
This leads to a lack of support for the policy which eventually affects
implementation effort. According to Smith (1973), in most developing
countries, the real impact of a poorly-managed stakeholder engagement
process is detected during the implementation stage of the policy
process where policies usually end up being abandoned or modified to
suit the interests of all stakeholders. Smith (1973) believes that this
represents a complete departure from what prevails in Western countries
where stakeholders know from the outset that policies would be
implemented once formulated and try to make the necessary input, as very
little could be done at the implementation stage of the process.
Luckily, policy-makers in Ghana hope to bring the engagement process to
the doorsteps of stakeholders by engaging them in the comfort of their
offices in an atmosphere bereft of intimidation.
Implementation of health policies has always been a problem not only in
Ghana but in other lower –and-middle-income countries (Sakyi, 2008). In
general, low commitment from stakeholders, communication challenges,
intra- and inter agency disagreements, and a lack of accountability are
among the factors that account for poor implementation of policies in
many LMICs (Brownson et al ., 2003). However, in Ghana, the way
the health system is organized affect implementation effort. The MOH has
a very little impact on policies once formulated, and implementation
falls to the agencies of health, creating a major gap. The presence of a
gap between policy formulators and implementers was viewed by Egonmwan
(1991) to undermine the whole policy process and widens the path between
purported policy objectives and goals that would be achieved at the end
of the day. Honadle (1979), in metaphorical terms, compares such a gap
between policy formulation and implementation to masons who fail to
build or stick to specifications and end up distorting the beautiful
building plan.
Also, the role of resources in the implementation of policies cannot be
discounted. In the case of Ghana, findings suggest that inadequate funds
to implement hypertension and diabetes policies is a big challenge for
policy-makers. Inadequate resources as a key impediment in the
implementation of policies correspond with other works by Bosu (2010)
and Makindle (2005).
In a country where people go to health facilities only when they are
sick, perhaps more attention and resources should be given to
prevention. Though policies on controlling risk factors have been
formulated, there are no established and sustained programmes to educate
people on the risk factors of hypertension and diabetes. Education on
risk factors remain spontaneous and inadequate and is carried out mostly
in health facilities (for those who already suffer from these
conditions) and occasionally in communities. In contrast to the
situation in Ghana, some LMICs have carried out risk factor intervention
programmes to good effect. A case in point is the Agita programme which
has successfully been implemented to encourage physical activity in Sao
Paolo, Brazil (Matsudo et al ., 2002). Other countries are
combining resources and ideas to combat hypertension and diabetes and
risk factors. A strategy to control obesity in the Arab countries has
been launched in Bahrain (Musaiger et al ., 2011) to maximize
efforts in the fight against NCDs.
Screening interventions are an important part of hypertension and
diabetes management. Apart from the main aim of early detection and
prompt treatment to avoid complications, evidence suggests that
systematic screening and testing programs have long-term cost-saving
benefits (Driskell et al ., 2014). Sadly, the unavailability of
established screening programmes in service delivery for diabetes and
hypertension management in Ghana means that the benefits of cost savings
would be lost as cases would be detected at complicated stages where the
cost of treatment is always high. Though mass screening programs are
usually not encouraged (Azevedo & Alla, 2008), it is still beneficial
for individuals with risk factors of hypertension and diabetes to avail
themselves and get screened. The lack of established screening programs
is not peculiar to Ghana. Studies confirm high levels of previously
undiagnosed diabetes in African populations including 83.7% in Nigeria
(Nyenwe et al ., 2003), 84.8% in South Africa (Motala et
al ., 2008) and as high as 100% in rural Guinea (Balde et al .,
2007).
Though clinical interventions have received more attention, this is far
from perfect. Patients struggle to have access to essential medication
for diabetes and hypertension throughout Africa. This is particularly
serious in countries like Mali, Mozambique, and Zambia (Azevedo & Alla,
2008). Evidence suggests that these challenges are partly the result of
over-emphasis on infectious conditions in Africa (Aikins, 2007; Bosu,
2010). Though inadequate, support comes from non-governmental
organizations, corporate entities, philanthropists and other civil
society organization. The activities of Novo Nordisk in the Ga South
Municipality is a perfect example of such success stories. Ghana is,
however, only one of several African countries to benefit from this
initiative which started in 2002 by Novo Nordisk, with over 30 countries
already benefiting from the initiative of establishing diabetes and
hypertension management centres in Africa (Azevedo & Alla, 2008).