Understanding the effects of the Global Fund TB grants on tuberculosis control within the health system of Ghana
There is an ongoing debate about if and how vertical disease-specific programme funding undermines performance of health systems in recipient countries. Ghana, a low middle-income country, benefited from the Global Fund against Tuberculosis, HIV infection and Malaria (GF) grants intended to strengthen national tuberculosis control programme between 2003 and 2017. In 2015, one component of the GF provision (enablers’ fund) which aimed to support frontline health workers, treatment supporters and TB patients, was withdrawn. To date, a full understanding of the effects of the grants and the enablers’ fund withdrawal on TB services delivery in Ghana is largely unknown. This thesis aims to examine the effects of the full GF TB grants on TB service delivery and how the enablers’ fund withdrawal in-fluenced work practices of health systems actors including managers, frontline health work-ers, and TB treatment supporters. Van Olmen’s health systems conceptual framework was used to provide analysis of the im-pact of the GF TB grants, in particular the enablers’ fund, on functioning of TB service de-livery. A case study approach was applied to examine the TB control programme. Health systems actors included purposively selected managers, frontline community health workers, and treatment supporters who participated in TB patients’ supervision and care. Data collec-tion included key informant interviews (n=7) with national managers and health systems ex-perts, in-depth interviews with district level managers (n=18) and focus group discussions with frontline community health workers and treatment supporters (n=10). A retrospective record review of 3,019 TB cases was conducted in 30 randomly selected TB facilities to compare the patterns in TB treatment outcomes (treatment success and adverse outcomes) during the implementation period of the full GF TB grants (2012-2014) and after withdrawal of the GF enablers’ fund (2015-2017). The GF TB grants enhanced institutional capacity with systems ‘hardware’ (provision of vehicles, office space, microscopes, GeneXpert machines for TB diagnosis, regular supply of TB medication and increased human resources density) for the delivery of TB services. The GF TB grants also strengthened working collaborations systems ‘software’ among actors due to regular supervision, monthly meetings, and payment of incentives for communication. Interviews with frontline health workers and treatment supporters indicated motivation to provide TB patient’s supervision during the enabler’s fund period was due to material incen-tives. Treatment success was 78% during the enablers’ fund period and 88% after withdrawal. Chi-square test of independence showed that there was no significant association between TB patient treatment period (enablers’ fund or withdrawal period) and treatment outcome (treatment success and adverse outcome), X2 (3, N=3019) =6.1, p= .104. To sustain TB pa-tients’ treatment supervision during the period following withdrawal of the enablers’ fund, managers integrated community outreach with TB patient’s supervision and care. Interviews with frontline health workers and treatment supporters showed lack of incentives resulted in work apathy as frontline health workers and treatment supporters felt under-appreciated. The study contributes to the on-going debate on the impact of funding for disease-specific programme on the health system in Ghana and TB control in similar contexts. Using Van Olmen’s framework enabled analysis of the effects of GF funding on TB healthcare within the general health system. This study suggests that through the GF TB grants TB healthcare infrastructure (hardware) was strengthened due to additional resources (financial, human resources, medication, and supplies). However, policymakers need to recognise the changing motivation of frontline workers and the demotivating effect of unsustainable incentives provision in low-income countries.