title: Responses to donor proliferation in Ghana's health sector: a qualitative case study.
abstract: OBJECTIVE
  To investigate how donors and government agencies responded to a proliferation of donors providing aid to Ghana's health sector between 1995 and 2012.
  
  
  METHODS
  We interviewed 39 key informants from donor agencies, central government and nongovernmental organizations in Accra. These respondents were purposively selected to provide local and international views from the three types of institutions. Data collected from the respondents were compared with relevant documentary materials - e.g. reports and media articles - collected during interviews and through online research.
  
  
  RESULTS
  Ghana's response to donor proliferation included creation of a sector-wide approach, a shift to sector budget support, the institutionalization of a Health Sector Working Group and anticipation of donor withdrawal following the country's change from low-income to lower-middle income status. Key themes included the importance of leadership and political support, the internalization of norms for harmonization, alignment and ownership, tension between the different methods used to improve aid effectiveness, and a shift to a unidirectional accountability paradigm for health-sector performance.
  
  
  CONCLUSIONS
  In 1995-2012, the country's central government and donors responded to donor proliferation in health-sector aid by promoting harmonization and alignment. This response was motivated by Ghana's need for foreign aid, constraints on the capacity of governmental human resources and inefficiencies created by donor proliferation. Although this decreased the government's transaction costs, it also increased the donors' coordination costs and reduced the government's negotiation options. Harmonization and alignment measures may have prompted donors to return to stand-alone projects to increase accountability and identification with beneficial impacts of projects.
authors.affiliation: Yale School of Public Health, PO Box 208034, New Haven, CT 06520-8034, United States of America (USA).
authors.forename: Sarah Wood
authors.initials: SW
authors.lastname: Pallas
authors.affiliation: School of Public Health, University of Ghana, Accra, Ghana .
authors.forename: Justice
authors.initials: J
authors.lastname: Nonvignon
authors.affiliation: School of Public Health, University of Ghana, Accra, Ghana .
authors.forename: Moses
authors.initials: M
authors.lastname: Aikins
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA .
authors.forename: Jennifer Prah
authors.initials: JP
authors.lastname: Ruger
mesh_terms: D003906:Developing Countries; D005381:Financing, Organized / Q000191:economics / Q000458:organization & administration*; D005869:Ghana; D019981:Health Care Sector / Q000191:economics / Q000458:organization & administration*; D006285:Health Planning / Q000191:economics / Q000458:organization & administration*; D006291:Health Policy; D006801:Humans; D007391:International Cooperation; D007857:Leadership; D009026:Mortality; D011057:Politics; D036301:Qualitative Research; D012189:Retrospective Studies