Why district assemblies disburse resources to district health systems for service delivery at district level in the context of decentralization: a comparative study of two districts in the Volta Region of Ghana

OBJECTIVES: To explore why the District Assembly disburses financial and other resources to the District Health System. DESIGN: Multiple case study with a single unit of analysis (holistic) using quantitative and qualitative methods of data collection involving a desk review, analysis of routine health management information system data and key informant interviews. SETTING: Two districts in the Volta Region of Ghana. PARTICIPANTS: Twelve key officials of each district assembly and the district health system (24 total) who had worked in the district at least a year or more. INTERVENTIONS: None. RESULTS: Both District Assemblies had moderate decision space which was influenced by their capacity, power and contextual factors like politics, economics, legal and situational factors. Disbursement of financial and other resources to the District Health Systems was influenced by financial capacity, use of power by stakeholders, context and the decision space of the District Assembly. Political actors appeared to have more power in resource disbursement decision making than community members and technocrats in a context of resource constraints and inadequate funding. The funding available was used predominantly for capital investments, mainly construction of Community Based Health Planning and Services (CHPS) compounds. CONCLUSION: It is important to make policies that will regulate the relative power among the political appointees like the District Chief Executives (DCEs), public and civil servants in decentralized departments and agencies and Community members to make resource disbursement more sensitive to communities and decentralized departments.