Governance gaps and system-feasible reforms at the sub-district level: Evidence from two Atwima Kwanwoma and Kwadaso districts in Ghana’s primary health care system

Background Sub-districts in Ghana are expected to coordinate first-contact primary health care (PHC) outreach, referrals, supervision, and routine data use, yet they often remain administratively peripheral. This study examined sub-district governance functionality and how constraints in decision space, managerial capacity, stakeholder coordination, and operational readiness shape PHC performance. Methods : We conducted a mixed-methods descriptive case study in two Ashanti Region districts without government district hospitals: rural Atwima Kwanwoma District and peri-urban Kwadaso Municipality. Structured surveys were administered to health workers (n=114; response rate 88.5%) and in-depth interviews were conducted with Sub-district Heads (n=4) and District Directors of Health Services (n=2). Descriptive statistics and thematic analysis were integrated using a joint display and interpreted through a four-domain governance functionality framework. Results : Although 68% of respondents rated the sub-district governance structure as “Good” or “Best,” decision space and formal recognition were limited. No Sub-district Heads reported receiving job descriptions or budget authority, and managerial preparation was low (1.75% fully trained in health administration and management; 69% reported only awareness). The absence of Budget Management Centre status constrained autonomy, delayed procurement, and limited participation in planning and budgeting forums. Conclusion : In these two case settings, sub-districts were operationally central to PHC but institutionally under-recognized. System-feasible reforms including “BMC-lite” delegation, standardized induction and job descriptions, structured coordination forums, and targeted logistics and retention supports strengthen sub-district governance functionality and support PHC performance.