The politics of tuberculosis and HIV service integration in Ghana

Social Science & Medicine 117 (2014) 42e49

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Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

The politics of tuberculosis and HIV service integration in Ghana Joshua Amo-Adjei a, *, Akwasi Kumi-Kyereme a, Hannah Fosuah Amo b, Kofi Awusabo-Asare a a b

Department of Population and Health, Faculty of Social Sciences, University of Cape Coast, Cape Coast, Ghana Department of Business Administration, Valley View University, Oyibi, Accra, Ghana

a r t i c l e i n f o

a b s t r a c t

Article history: Received 3 May 2013 Received in revised form 14 June 2014 Accepted 4 July 2014 Available online 5 July 2014

The need to integrate TB/HIV control programmes has become critical due to the comorbidity regarding these diseases and the need to optimise the use of resources. In developing countries such as Ghana, where public health interventions depend on donor funds, the integration of the two programmes has become more urgent. This paper explores stakeholders' views on the integration of TB/HIV control programmes in Ghana within the remits of contingency theory. With 31 purposively selected informants from four regions, semi-structured interviews and observations were conducted between March and May 2012, and the data collected were analysed using the inductive approach. The results showed both support for and opposition to integration, as well as some of the avoidable challenges inherent in combining TB/HIV control. While those who supported integration based their arguments on clinical synergies and the need to promote the efficient use of resources, those who opposed integration cited the potential increase in workload, the clinical complications associated with joint management, the potential for a leadership crisis, and the “smaller the better” propositions to support their stance. Although a policy on TB/HIV integration exists, inadequate ‘political will’ from the top management of both programmes has trickled down to lower levels, which has stifled progress towards the comprehensive management of TB/HIV and particularly leading to weak data collection and management structures and unsatisfactory administration of co-trimoxazole for co-infected patients. It is our view that the leadership of both programmes show an increased commitment to protocols involving the integration of TB/HIV, followed by a commitment to addressing the ‘fears’ of frontline service providers to encourage confidence in the process of service integration. © 2014 Elsevier Ltd. All rights reserved.

Keywords: Tuberculosis HIV Services Integration Ghana

1. Introduction An estimated one in four AIDS-related deaths each year is attributed to tuberculosis (TB) (Loveday and Zweigenthal, 2011). This association between TB/HIV suggests that the effective prevention of TB among people with HIV in particular is important (Loveday and Zweigenthal, 2011). Sonnenberg et al. (2005), for instance, observed that the risk of developing TB increases within the first few years of HIV infection. This clinical situation is even more critical for HIV patients with low CD4 counts; without timely interventions, the incidence of TB will remain high in this patient population (Loveday and Zweigenthal, 2011). In sub-Saharan Africa, where the mortality rate of HIV-related TB cases is more than 20 times higher than that in other regions of the world, reducing the

* Corresponding author. E-mail address: [email protected] (J. Amo-Adjei). http://dx.doi.org/10.1016/j.socscimed.2014.07.008 0277-9536/© 2014 Elsevier Ltd. All rights reserved.

dual burden of these twin epidemics requires the collaboration of individuals and institutions who are responsible for TB and HIV programmes (United Nations AIDS Programme, 2012). In this paper, our goal is to build on existing studies that have explored the debate concerning integration of TB/HIV service delivery by drawing on the contingency theory (Lawrence and Lorsch, 1967; Donaldson, 2001) to explore how the environment, the strategy, the size, and the potential implications of these on performance e TB/HIV services delivery, in this case. A better understanding of these matters can help inform policies aimed at improving the joint management of TB/HIV in both Ghana and other developing countries. The contingency theory views organisational performance as dependent on the fit between the structure of an organisation and exigencies, which comprise the environment, the strategy, and the size of the organisation (Lawrence and Lorsch, 1967; Donaldson, € tsch et al., 2013). The level of fit between 2001; Çakir, 2012; Gro an organisation's contingencies will result in high performance,

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although it does not assume one-size-fits-all orientation (Donaldson, 2001). Beyond the structure, the cognitive processes of sense making, creation and discovery, as well as social, economic, and political processes of developing and changing programmes, policies, and routines are very fundamental in how organisations deal with contingencies (Van de Ven et al., 2013). Lawrence and Lorsch (1967) proffered differentiation and integration as responsible organisational reactions to contingencies, and within the health sector, the two have become indispensable in an increasingly complex atmosphere for management decisions (Axelsson and Axelsson, 2006). While differentiation leads to fragmentation and professionalization, at some time, there is the need for integration (Axelsson and Axelsson, 2006). Differentiation in this sense is likened to traditional division of labour while integration seeks to achieve unity of effort in intra and inter organisational relationships to accomplish specific tasks (Lawrence and Lorsch, 1967). The overriding goal of both differentiation and integration is therefore geared towards high performance and survival by helping organisations with similar goals achieve comparative advantage (Liang et al., 2013). Given that in many countries TB/HIV services were established to respond to rising epidemics, there must be a requisite integration, which is the felt need for joint decision-making and delivery of services (Lawrence and Lorsch, 1967). Depending on the prevailing contingencies, public health organisations (in this case, TB/HIV programmes) may determine the level at which they desire to integrate (Van de Ven et al., 2013); whether full segregation [no recognised connections, with programmes operating with different structures], linkages/referral system [unstructured relationship with ad-hoc interactions], coordination [goal-oriented activities enhanced by working together on joint activities, whilst retaining a programme's distinctive structures and functions], and full integration [changes in both programme structures and/or functions, leading to the establishment of common governance responsibilities, the pooling of funding, the merging of service delivery or the unifying of information systems, which leads to onestop-shop services for TB/HIV patients] (Shigayeva et al., 2010; Ansah et al., 2012). In this paper, we define integration as the combination of services such as diagnosis, treatment, data management/surveillance, financing and monitoring and evaluation that hitherto existed separately (Waddington and Egger, 2008). The benefits of integration of TB/HIV services include the timely access to services (example, early diagnosis and initiation of joint treatment), lowering of treatment costs to patients by reducing commuting time between treatment centres (Nunn et al., 2007; Howard and El-Sadr, 2010; Gandhi et al., 2009; Kerschberger et al., 2012; Legido-Quigley et al., 2013) and integration of TB/HIV services has been found profoundly feasible (Shaffer et al., 2012). Although the debate on the integration of health programmes is neither new nor unique to TB/HIV (see Mayhew et al., 2000; Uebel et al., 2013), operational challenges such as the potential for stigma against jointly managed facilities, fears of nosocomial transmission of TB to HIV patients, funding constraints, management of drugedrug interaction (McIlleron et al., 2007; Gandhi et al., 2009), a lack of national and local leadership to dedicate resources (e.g. time), reluctance of specialists to lose professional autonomy, and disagreements about resource allocation (Dimitrova et al., 2006; Hill and Tan Eang, 2007) have sometimes rendered negotiating this course ineffective. Eventually, optimal healthcare delivery of services dually infected patients has become problematic in certain settings. 2. Research context In 2012, 1,118,000 (13%) of the 8.6 million people with TB were also infected with HIV and about 838,500 (75%) of these were in the

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African Region and mortality associated with this co-infection was 320,000 (38%) (WHO, 2013). In response to the double burden of TB/HIV, the World Health Organisation (WHO), first in 2004 and later in 2012, proposed closer integration of TB/HIV programmes at least at the facility level (WHO, 2004, 2012). At the launch of the 2012 TB/HIV Collaborative Policy, the UNAIDS Executive Director, , indicated that people living with HIV are more likely Michel Sidibe to develop TB and that these patients require integrated health services. Integration is not just an ideal but also a necessity. The calls to integrate TB and HIV programmes are intended to improve the diagnosis, treatment and outcomes for dually infected patients (Abdool-Karim et al., 2004). In Ghana as in other areas of generalized HIV prevalence, all TB patients should be considered as possibly HIV infected. Estimated co-HIV/TB incidence, prevalence, and mortality in Ghana in 2012 were 72/100,000 (63e82), 92/100,000 (41e162), and 6.9% (3.5e11) respectively. Furthermore, 11,825 (78%) TB patients (15,207) were tested for HIV and of this, 2812 (24%) were HIV positive with 1891 (72%) and 1040 (37%) being on co-trimoxazole preventive therapy (CPT) and anti-retroviral therapy (ART) respectively but none was on isoniazid preventive therapy (IPT) (WHO, 2013). Some noted challenges regarding TB control include weak political commitment as reflected in the proportion of local (9%) versus external/ donor funding (37%) with a shortfall of 55%, weak targeted social interventions, low depth of suspicion among healthcare providers, inadequate infrastructure, weak coordination between TB/HIV programmes, inadequate quality of care and the emerging threat of drug resistant TB (Amo-Adjei, 2013, 2014; NTP, 2013; WHO, 2013). Regarding HIV/AIDS, similar challenges exist e extreme dependence on donor funding, about 70% of persons living with HIV/AIDS lacking regular access to ART among others (Ampofo, 2009). Individuals affected by both diseases also experience community as well as institutional stigma and discrimination (Dodor and Kelly, 2010; Oduro and Otsin, 2013). The Ghana Health Service (GHS) is the statutory body established to provide and supervise an equitable, efficient, accessible and responsive healthcare system in the country, a largely public funded body. As part of the mandate of the GHS, the 2007e2011 Program of Work of the GHS considered TB and HIV/AIDS as priority diseases. The main aim of establishing these specialised units is to provide prompt healthcare by reducing bureaucracies associated with the generalised health system. In 1994, Ghana established a National TB Control Programme (NTP) in response to the re-emergence of TB as a public health challenge in the face of the HIV and AIDS epidemic. The aim of the programme was to design policies and interventions that would address the potential threat associated with TB in the country. During the second half of 1996, a nation-wide surveillance system was implemented to help monitor progress on key treatment outcomes (i.e., cure, death, default, failure and completed treatment). The Danish International Development Association (DANIDA) provided the majority of the initial funding for the initiation of the programme until early 2000 when the Government of Ghana (GoG) took over funding, and in 2002, the Global Fund to Fight HIV/AIDS, TB and Malaria (GFATM) began to offer support for the initiative. HIV/AIDS in Ghana is currently managed under two state supported institutions: the Ghana AIDS Commission (GAC), which is a multi-sectoral body providing policy direction is under the office of the President, and the National AIDS Control Programme (NACP), which is an implementation agency, coordinated by the Ghana Health Service (GHS). In terms healthcare financing, the Government of Ghana (GoG) provides the greater proportion of funds required for effective general healthcare delivery although donors provide substantial

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 TB/HIV coordinators of one major health facility that provides both services in each selected district; and  A programme manager for a non-governmental organisation (NGO), which provides technical support for TB.

funds to specialised or “vertical” programmes such as TB, AIDS and Malaria for the procurement of drugs, equipment and other important inputs and in the last decade, the Global Fund to fight AIDS, TB and Malaria (GFATM) has provided much of the funds required for diagnosis and treatment and other operational costs for TB and HIV than the GoG (Adjei et al., 2011; Amo-Adjei, 2014). For instance, in 2013, GFATM provided 37% of funds required for TB programme with the GoG providing only 9% (WHO, 2013) and in 2013, the GFATM's support for treatment of HIV to the about 49,000 patients on ART was terminated. Currently, there are approximately 1057 TB treatment centres and 141 anti-retroviral therapy (ART) clinics in the country (NTP, 2009) e TB treatment is available at almost all levels of health delivery while HIV/AIDS is provided in only hospitals. The organisational structures of both programmes are similar e at the national level, each is headed by a programme director/ manager with support staff in monitoring and evaluation, clinical services, laboratory, administration, and other ancillary departments. At the regional, district, and health facility levels, there are respective coordinators. Because TB/HIV programmes are somewhat ‘vertical’, diagnosis and treatment outcomes are directly reported to coordinators at the next higher level. Whereas TB coordinators at the sub-national levels are mainly disease control/ public health personnel, HIV/AIDS coordinators are mainly clinical staff that is required to also manage opportunistic infections associated with HIV/AIDS. Following the WHO's (2004) Interim Policy on Collaborative TB/ HIV Activities, the NTP and NACP designed a local Technical Policy and Guidelines for TB/HIV Collaboration in early 2005 (Ghana Health Service, 2007). An agency to guide the collaborative TB/ HIV activities was created at the national level, which resulted in the establishment of a national TB/HIV coordinating team. Responsibilities were assigned to each programme, keeping in mind the need to coordinate budgets and avoid the duplication of efforts. The policy recognised the need for collaboration between TB/HIV control programmes consistent with WHO's recommendations on joint TB/HIV control.

As Waddington and Egger (2008) highlight, integration could mean different things to users, providers, senior health policy makers, organisations and professional groups. Because our respondents were selected from both providers and senior policy makers with various professional and organisational experiences, we decided to ensure that discussions about integration were as open as possible. Nonetheless, the semi-structured instrument for this paper focused on existing working relationship between NTP and NACP, preferred relationships, resources mobilisation, challenges associated with ‘individual’ service delivery, and opportunities for joint delivery of services. The first author conducted all of the interviews and the transcription of audio recordings. With the exception of one, all respondents agreed to be tape-recorded. Individual verbal consent was obtained from each respondent prior to the interviews. None of the respondents declined participation in the study. The duration of the interviews ranged from 30 to 60 min. The analysis plan followed both deductive and inductive approach to qualitative data analysis. At the first stage, we explored for themes or quotations that fitted with the key constructs of the theory (Bernard, 2010). The second stage followed an inductive approach by further coding or exploring for sub-themes under the key constructs of the theory. To improve the validity of the findings, we used inter-researcher coding. The other coauthors reviewed the coding performed by the first author, and all authors resolved inconsistencies in the codes and subsequent themes. Another strategy employed to enhance validity was to request some of the respondents to read through the draft document as a way of member checking (Shenton, 2004; Padgett, 2008). The research protocol of the study was reviewed, and the University of Cape Coast Institutional Review Board offered ethical clearance.

3. Methods

4. Findings

This paper draws on a larger research data collected for a thesis. The study was an investigation of the policy context for TB control. Other dimensions of the study included a publiceprivate partnership, political commitment, as well as obstacles and prospects for TB control in Ghana. Data were collected between March and May 2012. The present paper is based on a sample of 31 respondents selected from the NTP and the NACP across the country. Further interviews were discontinued when we reached saturation (Guest et al., 2006). The selection of study sites and individual respondents was informed by purposive sampling. Five of the regions of the country with the highest TB/HIV rates were selected for the study with one of the regions being used to pre-test the interview guide. In the four regions where the data for this study were collected, the district with the highest TB/HIV figures was also selected. However, for ethical reasons, these regions are not indicated by name in this report. In each of the districts, the facility, which reported the highest TB/HIV cases, was also selected. The targeted respondents were included in the study because of their direct involvement in the routine implementation of policies and interventions. The selection of individual respondents was as follows:

The study findings are presented under two major categories: support or otherwise to integration and how these views are embedded in environmental, size, strategic/culture and how these implicate on performance. We begin by providing an overall picture of how the respondents viewed either integration or separate programming: of the 31 respondents, 18 (58%) expressed opposition to integration of TB/HIV services with more of those opposed being affiliated to the NACP. Five of the six national level respondents from both programmes opposed TB/HIV integration, particularly at the programme. Various reasons were offered in support of the respective positions, which we highlight in the following sections.

 Three national level officers from the NTP and NACP;  Four regional coordinators from the NTP and NACP;  Four district coordinators for each programme; and

5. Environment Two contrasting views emerged in respect of the environment for TB/HIV controls. Whereas a section of the respondents offered environmental reasons to support integration, another section argued against integration. For those in support, the matter was about ensuring effective and efficient application of resources especially in a resource poor country. To such respondents integration could help eliminate the duplication of activities, efforts and resources. Given that TB and HIV converge at some points clinically and socially, it was felt that it would be essential for the two programmes to pool their resources. This could include joining

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facilities, engaging the same personnel for service delivery among others. For example, it emerged from the interviews that on a number of occasions, the officers of the respective programmes planned and executed advocacy and community outreaches separately. This was observed to be a misuse of resources and therefore, unacceptable. A respondent surmised: Integration can ensure that duplications of functions are eliminated or reduced to the barest minimum … Each programme appears to be caught-up in individual programmes and this has created some gaps in our operations. There seems to be too much focus on individual activities e AIDS is interested in AIDS and TB interested in TB … with increasing decline in resources for both programmes, I think it will be better for us all if we able to work much closer than what it is presently … (NACP respondent) On the other hand, some respondents also cited the social environment for TB/HIV controls in the country as unfavourable for joint delivery of treatment and other related services. Here, some respondents viewed the potential stigmatisation of health facilities when TB/HIV services are delivered in the same facilities/rooms. To these respondents, the co-morbidity of TB/HIV with its attendant double stigma would discourage people who suspect that they suffer from one or both diseases and they may not seek help. Amidst such possibilities, some respondents intimated that the integration of services could heighten stigma. The following excerpts demonstrate the importance that some staff placed on the need to avoid creating stigma: Another issue that comes up has to do with stigma and discrimination. Although TB used to be more stigmatised than HIV, now the tables have turned … Stigma is now high towards HIV because people are becoming aware of cure for TB. For the sake of emphasis, the two programmes are better off remaining parallel since HIV is plagued more by stigma than TB. (NACP respondent) Thus, it was the opinion of some respondents that patients with TB only may not be as willing as co-infected patients to access care from a facility or room where both TB/HIV care services are provided. 6. Strategy Prevention of TB infection in persons with HIV, early diagnosis and treatment of HIV-associated TB, prevention of TB disease in HIV patients, provision of antiretroviral treatment for TB patients, HIV care and support during and after TB treatment, prevention of opportunistic infections in TB/HIV patients are key strategies for improving the control of each other. Many of the respondents conceded to some of these strategies as good reasons to support integration. These respondents held the view that the clinical interface between TB/HIV provides strong reasons for integration because persons living with the HIV had a high probability of being infected with TB. For some respondents, this was sufficient evidence for the two programmes to work seriously towards full integration. There were others who also argued that the high risk of nosocomial infection among HIV patients in one-stop-shop TB/HIV clinics made it awkward to congregate TB/HIV patients in the same facilities. One respondent said the following: You see, the issue of integration even at the facility level has to be approached cautiously. There is a danger of exposing HIV

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patients to TB when we operate under one-stop-shop system. (NTP respondent) It also emerged from the interviews that community TB care, which is being pursued by the NTP of Ghana and others elsewhere make it impracticable to resort to integrated TB/HIV services such as treatment. Under community TB care, patients receive DOT in their various community supervised by treatment supporters, normally after two months of taking anti-TB drugs. With a possible drugedrug interaction arising from co-management/treatment of TB/HIV, some respondents felt that it is not advisable for integration since treatment supporters who are mainly laypersons cannot manage complications in the communities. One respondent noted: The problem for me is that, who will be held responsible in cases of emergency? I therefore do not consider it to be helpful to both the individual and the integrity of the entire health system. I think it should remain as it is presently. Whereas TB can be cured within six to eight months after diagnosis and initiation of treatment, HIV is not like that. It is a lifetime condition with intermittent opportunistic infections that can be treated and the patient continues with the ART. (NACP respondent)

7. Size Across almost all types of respondents (both NTP and NACP), integration was seen as having a potential of increasing workload, lead to leadership biases, and potential lack of ownership. Some respondents, especially those at healthcare delivery facilities expressed concerns about the potential increase in workload under an integrated TB/HIV diagnosis, treatment and care. They felt that patients with the respective conditions needed adequate attention and emotional support from specialists. That is, if the primary problem is TB, a specialist in TB should be responsible for the person, and if need be, he/she should be referred to the other specialist [linkage/referral services]. In this case, one person takes primary responsibility for a particular condition at a time, thus facilitating patient follow-up. Creating a situation in which “one or few” people provide for the needs of people infected with TB/HIV would overstrain staff: Integration, yes but it will increase the workload of the front liners. For instance, for both diseases, there is a need for counselling of patients and I am wondering how one person can do this alone. The important concern is for coordinators of the two diseases to be competent in managing either of the two. (NTP respondent) One dimension of the workload argument was also the view that the two programmes have different processes for capturing data. Each agency tries to compile data to enable it plan activities. The argument was that … These are two major diseases … different algorithms for capturing data are needed. Depending on where clients report first, screening for the other disease is undertaken and this should be enough. (NACP respondent) Most of the respondents who opposed full integration at the planning level of TB/HIV argued that biases could arise if a specific leader is more interested in one disease than the other. They contended that it is possible to have a programme manager who is more passionate about TB control than HIV or vice-versa. When that occurs, the person could give more attention to one than the

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other. Those in HIV control in particular contended that given the high level of public goodwill surrounding HIV control, its programme could overshadow that of TB. There was also the concern that HIV has a higher profile in the public eye and could overshadow TB when integrated at the programme level. The danger is that if you have a programme manager who is biased towards either HIV or TB, the other disease will suffer because of his/her passion towards that disease. (NTP respondent) On the balance, if we integrate, there is the danger that HIV/AIDS activities will swallow-up TB control. (NACP respondent) Again, some respondents described lateral programmes as a conduit for improving efficiency. This view was based on the fact that when the scope of work is limited, it offers an increased ability for in-depth concentration on a particular disease. To such respondents, the provision of quality service was akin to having minimal duties and responsibilities. It frequently indicated how the current arrangements improved resource mobilisation: The existing structures of the two programmes … ensure efficiency e the smaller the better. Moreover, in terms of resource mobilisation, it will be difficult for one organisation to provide resources for one huge programme: separation allows for easy access to funds. Those who provide funding are normally scared of big projects. (NACP respondent) Another concern some opponents raised was that integration would not be able to ensure ownership. Furthermore, some respondents claimed that the system might not pay attention to specialisation in an integrated system. The following demonstrates typical views by respondents who thought along these lines: I will not support full integration. If you give work to ‘Mr everybody, Mr nobody does it’. At the national level, we need specialists who can keep standards. Running a disease programme is not the same as administration (planning) where you can put one person in charge. People specialise in the management of specific diseases such as HIV, TB and malaria. What is needed is coordination that can cut down on duplication of activities. The speciality component should always be there … all that is needed is information sharing (coordination) … At the managerial level, different expertise are required. (NTP respondent)

7.1. Implications of differentiation on performance Minded by our theoretical framework, we further explored perceived implications of non-integration on performance. Implications on key service delivery performance indicators were frequently mentioned: screening for TB/HIV as well administration of CPT and data and information sharing. 7.2. Screening and administration of CPT Though opinions were divided on the screening of patients for each condition as well as the provision of CPT, the general direction was that it was not being done efficiently. Many TB programme staff expressed concerns about HIV clinic staff inconsistencies in screening all HIV patients for TB. NTP staff members were also concerned about the irregular administration of co-trimoxazole to co-infected patients. The excerpt below reveals some form of disappointments expressed by a section of NTP staff.

Screening of HIV patients for TB is not fully implemented. Ideally, persons diagnosed to be HIV positive should be screened on the first day of diagnosis of TB and continuously for every six months because TB is one of the major opportunistic infections among people living with HIV … but this is not routinely done! … When TB is detected quite early, such persons can be treated, and then [the patients] can continue with HIV treatment. Unfortunately, they (NACP) are not doing that … if they were doing what is expected as we are doing, most deaths in TB/HIV co-morbidity cases would be prevented. (NTP respondent) On the other hand, some participants in the NACP indicated that the screening of all HIV persons for TB was not cost effective or time efficient. According to one participant: In 2009, of the 810 HIV cases, only 47 had TB. In 2010 too, out of 530 HIV cases, only 22 (10 females and 12 males) went to DOTS. Based on this, it is not practically possible to refer every HIV patient for TB screening. (NACP respondent) Views from both programmes' officers suggest not-too-good working relationships. There was the suspicion that one group was not really committed to providing adequate care to patients who were co-infected with TB/HIV, especially with respect to the administration of co-trimoxazole. We have some difficulties. The most pressing one here is about timing that the HIV clinicians put co-infected patients on cotrimoxazole prophylaxis; it is often delayed. We have advocated for some of the drugs to be kept at DOTS centres for easy access but this has not been done yet. (NTP respondent) Based on local arrangements, co-trimoxazole dispensation is expected to occur at ART clinics. There were claims, particularly from NTP respondents that this was not being appropriately implemented. However, other informants from the NACP provided contrasting views on these claims. They noted that health facilities are required to report on their use and needs for co-trimoxazole, and as a result, those health facilities that promptly reported on the number of co-infected persons were often supplied with cotrimoxazole: … Drug supplies for TB/HIV (co-trimoxazole) is always available. It is those facilities that do not report on co-trimoxazole who face difficulties in accessing drugs. Patients who are allergic to co-trimoxazole as well as pregnant women in the first trimester are also not allowed to take this drug. (NACP respondent)

7.3. Data and information sharing Poor coordination is at the core of the difficulties that are faced by existing TB/HIV working relationships. The concerns appeared intense and fervent among NTP respondents. Some respondents from the NTP perceived a lack of commitment to data sharing by some of the NACP staff: We (NTP) requested data from their (NACP) side and the response was that they don't have any appropriate format for capturing TB data. We felt this could be a reasonable excuse so we helped them develop a data-capturing format. We were then expecting returns from them (NACP) at the end of this quarter. Unfortunately, when I did a follow-up, they had misplaced the form and I had to give them another. So, you see where the problem is coming from? (NTP respondent)

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None of the participants from the NACP disagreed with the assertions from certain NTP respondents, although they did raise issues about their workload, which led to significant time constraints.

8. Discussion Integrating TB/HIV services remains one of the most useful strategies for the efficient and effective co-management of the two diseases (WHO, 2012). Recent studies (Kerschberger et al., 2012; Chehab et al., 2013; Ikeda et al., 2014; Uyei et al., 2014) have provided evidence in support of at least the same clinical team delivering TB/HIV diagnosis and treatment services. Although Ghana is not one of the high burden TB/HIV countries in sub-Saharan Africa, the current paradigm in global public health on the effective treatment of TB/HIV makes it imperative to explore contextualised issues surrounding integration of TB/HIV control activities. The findings presented here should therefore be seen in that context. Despite the important limitations in our data, which are based solely on participants' narratives and are not compared with relevant TB/HIV statistics, we have aimed here to explore concerns surrounding the integration of TB/HIV care, which may be useful for policy design and implementation. These views are discussed taking into consideration issues about organisational context/environment, strategies and size and how they knowingly or unknowingly shape respondents views on integration. TB/HIV services delivery in Ghana and other resource poor countries are largely donor driven (Adjei et al., 2011) and the funding environment driving these programmes are more volatile, swiftly fluctuating, series of burst and instabilities and therefore compel immediate innovative designing (Shiffman, 2008; Van de Ven et al., 2013). Thus, the environment for infectious disease control is inherently organic e continuously evolving, depending on the problems, policies and politics (see Kingdon, 1984). Although the trio of HIV, TB and malaria have enjoyed comparative goodwill, translating into more funding and in some cases have generously supported and improved laboratory infrastructure and equipment supplies and services within the general health systems, the time-bounded nature of these funding raises concerns about sustainability (Shigayeva and Coker, 2014) and these concerns validate the need for integration, particularly disease control programmes which share similar manifestations (Chan, 2007; Adjei et al., 2011). Despite the usefulness of integrated service delivery, we are also reminded that it is not the equivalent of efficiency although it may be an alternative to inadequate resources (Waddington and Egger, 2008). However, evidence from Cambodia suggests that a sector-wide approach to HIV/TB and nutrition programmes could lead to an increase in resource allocation (Atun et al., 2010). Our work reveals how the sociocultural milieu of HIV and TB can obstruct implementation of important innovations such as integrated TB/HIV care. Some frontline health service providers opposed integration due to the manifestations of possible stigma and discrimination that people infected by one of the two diseases may experience for sharing treatment facilities with those of the other disease. Stigmas, which TB patients are likely to encounter for utilising facilities where TB/HIV are managed have been reported in some previous studies (Daftary, 2012). Bond and Nyblade (2006), however caution that the issue of double stigma, although a possibility, often arises from how public health programmes advertently or inadvertently shape the social constructions of TB/HIV stigma. Within the Ghanaian setting, Dodor and Kelly (2009) have demonstrated that stigma within the health sector and the general public challenge TB control.

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The findings presented here indicate that the clinical linkage between TB/HIV was perceived both as an opportunity as well as a threat for integration. On the one hand, there was the argument that TB/HIV presented with similar clinical manifestations, although not with reverse causality e latent TB could be heightened by HIV infection into active disease. On the other side of the argument was that whereas TB is curable, HIV is not and that integrating treatment services could potentially expose TB patients to nosocomial infections (Dong et al., 2007; Gandhi et al., 2009; Legido-Quigley et al., 2013). The high risk of nosocomial infection appears to be one of the major obstacles to service providers' willingness to support integration of TB/HIV services, especially for untreated TB (Gandhi et al., 2009). In this context, the infectious nature of the disease (environment) is seen as disincentive to integration. However, service delivery improvements, which have led to early diagnosis, active case finding, the provision of properly ventilated waiting rooms and “cough” monitors in health facilities, could provide avenues for averting the nosocomial transmission of TB (Gandhi et al., 2009). With respect to size and structure, some of our respondents were also concerned about integration being potentially harmful to managerial efficiency as a result of increase in organisational size. These arguments were based on the “smaller-the-better” perceptions. Organisations that are simple and not bureaucratic in terms of structure may shudder to contemplate integration because of fears of creating complex and bureaucratic institution (Child, 1972; Donaldson, 2001). Individuals and institutions could perceive integration as an avenue to compromise on efficiency. Indeed, certain fears have been raised as to whether integration should be implemented among well functioning sub-units within poorly functioning wider health systems in developing countries. Berlin € m (2008) summarise such disinterest towards inteand Carlstro gration as emanating from the desire to achieve stability, preferring repeated and well-known behaviour. The fear is that integration may collapse high quality services being delivered in narrow programmes (Waddington and Egger, 2008). Another issue related to organisation size was about the likelihood of managerial biases towards one programme over the other as a result of integration. At the international level, Ogden and Walt (2003) have reported similar experiences. They observed that at a certain period, the leadership of the WHO prioritised child health issues over adult health problems citing ethical responsibilities towards children over adults. These views are akin to uncertainties associated with integration and such uncertainties could have negative impacts on goals, leadership and roles following integration (Wihlman et al., 2008) particularly when those who call the €tsch et al., 2013). shots do not approve or support integration (Gro Per chance, it is within this milieu that the majority of senior level management members of both programmes express reservations about integration. Wihlman et al. (2008) have also indicated that managerial staff interest in ‘protecting’ their turf could account for unwillingness to support integrated care. Of note, another finding is that the apparent lethargy characterising the appropriate coordination and collaboration of TB/HIV services has resulted in the inadequate administration of certain important services (for example, provision of IPT and CPT) for TB/ HIV patients although such services are important strategies (WHO, 2013) for dealing with the dual epidemic. The strategies of the two institutions in the present form fit a unidirectional approach because each of the programmes appears to be “comfortable” in doing their own thing. Howard and El-Sadr (2010) show that significant progress can be made if TB/HIV services are delivered in one-stop-shop facilities, as it allows for convenient care to patients as well as timely screening and treatment of co-infected patients. The WHO (2012) also asserted that effective joint planning of TB/

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HIV at the national, regional and district and health facilities levels do not require additional funding, although additional funding for infrastructure and personnel may be required initially. These findings reveal that despite the availability of proven strategies for effective management of TB/HIV services, it seems that strong institutional attachments have stifled such interventions. As the WHO (2013) has shown, critical services for TB/HIV patients in the country are being missed. Probably, the apathy towards seamless integration as espoused by the WHO (2004, 2012) in the country could be driven by the not-too-high comorbidity burden of the two diseases in the country. In South Africa for instance where the dual burden of TB/HIV is high, integration appears to be catching-up with service despite some inherent challenges (Chehab et al., 2013). Despite the important observations in this paper, some limitations are worth noting. First, the non-inclusion of co-infected TB/HIV patients in the study limits our ability to understand their perspectives on integration of services related to the diseases. Similarly, the sample for this study is not sufficiently large to allow extrapolation to the whole country. Instead, we aimed at “provocative and theoretical generalisation … the extent to which readers, across contexts, to generalise to ‘worlds not yet,’ by rethinking and reimagining current arrangements” (Fine, 2006). That our sample was drawn from high burden regions of both diseases in the country also provides useful insights into the views of key programme drivers on integration of TB/HIV services. This helps to situate the findings in the direct “lived experiences” of our participants. 9. Conclusion In conclusion, the paper hopes to address two issues in relation to policy practice and theory reflection. With some important TB/HIV care practices (e.g. CPT or IPT) being missed due to separate/isolated service delivery, we propose that extra efforts from the managements of the respective programmes towards integration, at the minimum, treatment and diagnosis and data collation and management, is urgently needed. It is, however, important that various levels of stakeholder consultations are undertaken to help broaden the scope of implementation guidelines so as to effectively respond to fears of key programme drivers, whether those concerns are real or imaginary. On the theoretical side, since the contingency theory does not portend “one best way” and institutional cultures are not static or organic but nevertheless has important application to integration of disease control programmes, hopefully more theoretical informed research will illuminate the various aspects better going forward. Acknowledgements We thank our respondents who willingly shared their experiences with respect to TB/HIV services in all the study sites. The kind assistance of the programme managers of TB and HIV control programmes are duly acknowledged. The first author. References Abdool-Karim, S., Abdool-Karim, Q., Friedland, G., Lalloo, U., El Sadr, W., START Project, 2004. Implementing antiretroviral therapy in resource constrained settings: opportunities and challenges in integrating HIV and tuberculosis care. AIDS 18, 975e979. Adjei, S., Nazzar, A., Seddoh, A., Blok, L., Plummer, D., 2011. The impact of HIV and AIDS funding and programming on health system strengthening in Ghana. Health Syst. Res. Ser. 3. Amo-Adjei, J., 2014. Political commitment to tuberculosis control in Ghana. Glob. Public Health 9 (3), 299e311. Amo-Adjei, J., 2013. Views of health service providers on obstacles to tuberculosis control in Ghana. Infect. Dis. Poverty 2 (9). http://dx.doi.org/10.1186/20499957-2-9. Ampofo, W.K., 2009. Current status of HIV/AIDS treatment, care and support services in Ghana. Ghana Med. J. 43 (4), 142.

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