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).