Original research BMJ Glob Health: first published as 10.1136/bmjgh-2020-003896 on 13 January 2021. Downloaded from Transitioning from donor aid for health: perspectives of national stakeholders in Ghana 1 1 1 Wenhui Mao , Kaci Kennedy McDade , Hanna E Huffstetler, Joseph Dodoo,2,3 Daniel Nana Yaw Abankwah,4 Nathaniel Coleman,5 Judy Riviere,1 Jiaqi Zhang,1 Justice Nonvignon,5 Ipchita Bharali,1 Shashika Bandara,1 1 1 Osondu Ogbuoji, Gavin Yamey To cite: Mao W, McDade KK, ABSTRACT Key questions Huffstetler HE, et al. Background Ghana’s shift from low- income to Transitioning from donor middle- income status will make it ineligible to receive aid for health: perspectives What is already known? concessional aid in the future. While transition may of national stakeholders in ► When not properly managed, donor transitions can be a reflection of positive changes in a country, such Ghana. BMJ Global Health affect the different components of the health system, as economic development or health progress, a loss 2021;6:e003896. doi:10.1136/ lead to disruptions in service delivery and increase of support from donor agencies could have negative bmjgh-2020-003896 the risk of disease resurgence. impacts on health system performance and population ► Upcoming cohorts of countries that will graduate Handling editor Edwine Barasa health. We aimed to identify key challenges and from multilateral donor assistance in the coming opportunities that Ghana will face in dealing with aid Additional material is years, including Ghana, have less capacity than pre- ► transition, specifically from the point of view of country- published online only. To view, vious graduates to manage donor transition. level stakeholders. please visit the journal online ► Additionally, the transition process for upcoming (http:// dx. doi. org/ 10. 1136/ Methods We conducted key informant interviews with graduates could become even more challenging bmjgh- 2020- 003896). 18 stakeholders from the government, civil society since these countries are also experiencing substan- organisations and donor agencies in Ghana using a tial demographic changes, an epidemiological tran- semistructured interview guide. We performed directed sition and a shifting domestic financing landscape. WM and KKM contributed content analysis of the interview transcripts to identify key equally. themes related to anticipated challenges and opportunities What are the new findings? that might result from donor transitions. ► Overall, stakeholders identified challenges more fre- Received 5 September 2020 quently than opportunities. http://gh.bmj.com/ Revised 16 December 2020 Results Overall, stakeholders identified challenges Challenges include difficulty filling financial gaps left Accepted 19 December 2020 more frequently than opportunities. All stakeholders ► interviewed believe that Ghana will face substantial by donors, the shifting of national priorities away challenges due to donor transitions. Challenges include from the health sector, lack of human resources for difficulty filling financial gaps left by donors, the shifting health, interrupted care for beneficiaries of donor- of national priorities away from the health sector, lack funded health programmes, neglect of vulnerable populations and loss of the accountability mecha- of human resources for health, interrupted care for on September 30, 2021 by guest. Protected copyright. beneficiaries of donor- funded health programmes, neglect nisms that are linked with donor financing. of vulnerable populations and loss of the accountability ► Stakeholders also identified key opportunities that mechanisms that are linked with donor financing. transitions might present, including efficiency gains, However, stakeholders also identified key opportunities increased self- determination and self- sufficiency, that transitions might present, including efficiency enhanced capacity to leverage domestic resources gains, increased self-determina tion and self-sufficienc y, and improved revenue mobilisation. enhanced capacity to leverage domestic resources and What do the new findings imply? improved revenue mobilisation. ► The challenges could be addressed by conducting a Conclusion Stakeholders in Ghana believe transitioning transition readiness assessment, identifying health away from aid for health presents both challenges and sector priorities, developing a transition plan and © Author(s) (or their opportunities. The challenges could be addressed by mobilising greater political commitment to health. employer(s)) 2021. Re- use conducting a transition readiness assessment, identifying permitted under CC BY. ► The transition from aid could be turned into an op- Published by BMJ. health sector priorities, developing a transition plan with portunity to integrate vertical programmes into a a budget to continue critical health programmes and For numbered affiliations see more comprehensive health system. end of article. mobilising greater political commitment to health. The loss of aid could be turned into an opportunity to integrate INTRODUCTION Correspondence to vertical programmes into a more comprehensive health Ghana has undergone rapid economic Dr Gavin Yamey; system. development, and in 2010, it moved from gavin. yamey@ duke. edu being a low-income country (LIC) to a lower Mao W, et al. BMJ Global Health 2021;6:e003896. doi:10.1136/bmjgh-2020-003896 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2020-003896 on 13 January 2021. Downloaded from middle- income country (LMIC). Between 2000 and in unique and varied ways. Some countries may lack 2018, its gross national income (GNI) per capita multi- the human resources or technical capacity needed plied more than six times.1 However, this impressive to continue activities formerly led by donors, such as economic development has not been entirely matched medical product procurement or programme manage- by improvements in Ghana’s health financing or popu- ment.13 14 Parallel systems for service delivery (eg, lation health outcomes.2 Current health expenditure delivering HIV or maternity services) may have been accounted for 3.3% of gross domestic product (GDP) established by donors without sufficient local buy- in, and in 2017 and 40.3% of health expenditure came from therefore, donor exits may leave a vacuum for particular out- of- pocket payments.3 In health outcomes, Ghana populations. Each of these challenges can lead to disrup- achieved the Millennium Development Goal (MDG) tions in service delivery, which can increase the risk of 1 target of halving the poverty rate from 1990 to 2015, disease resurgence.15 An analysis by Yamey et al found but was unable to meet the MDG 5 target of reducing that the upcoming cohort of countries that will grad- the maternal mortality ratio by three- quarters over the uate from multilateral donor assistance in the coming same time period. HIV/AIDS remains a major cause of years, including Ghana, have less capacity than previous morbidity and mortality. Ischaemic heart disease rose graduates to manage the donor transition.16 They found from being sixth on the list of top 10 causes of death in that “the upcoming cohort seems to have, on average, 2007 to fourth on the list by 2017.4 5 With an ageing popu- lower per capita income, greater indebtedness, weaker lation,6 Ghana is faced with a ‘double burden’ of disease capacity to efficiently use public resources, more limited from both infectious diseases and non-communicable and less effective health systems, weaker governance and diseases (NCDs) and an unfinished MDG agenda of high public institutions, and greater inequality.” Additionally, child and maternal mortality. the transition process for upcoming graduates could In 2019, Ghanaian President Nana Akufo-Addo become even more challenging since these countries announced his government’s policy agenda for moving are also experiencing substantial demographic changes, Ghana ‘Beyond Aid’.7 The intention of this policy is to an epidemiological transition and a shifting domestic further the discussion about moving away from devel- financing landscape.17 opment aid for critical functions, such as the health Research on transitions from donor assistance for and education system, towards self-reliant sustainable health have primarily examined the perspective of bilat- financing. A decreasing reliance on foreign aid, whether eral and multilateral donors and certain disease areas. driven by a donor or a recipient country, can be referred The role of recipient countries in transition planning and to as transition from aid. In particular, in this paper, we the concerns of recipient countries may have been under- refer to transition as a change in an external funder’s represented.18 To identify the challenges and oppor- policy, financing level or programming with the inten- tunities in transition from health aid from a recipient tion of giving more responsibility to a country to sustain country’s perspective, we conducted a qualitative study of the health gains from external funds in its preparation stakeholders in Ghana to understand their perspectives http://gh.bmj.com/ for an era beyond aid.8 as the country navigates the transition process. Realising a self- reliant health system in Ghana will be a challenge.9 Although Ghana primarily funds its health system through domestic government funds and out- of- METHODS pocket payments, in 2017, development partners funded Study design 19% of all current health expenditures. By 2022, the We used a cross-sectional qualitative