Understanding the enablers, constraints, and sustainability of state–church health partnerships in Ghana: a qualitative study guided by the sustainability of innovation framework

State–church partnerships play a critical role in healthcare delivery across sub-Saharan Africa, yet limited empirical evidence explains how these collaborations are sustained in practice. This study examines stakeholder perspectives on the enablers, constraints, and sustainability of such partnerships in Ghana, focusing on the Christian Health Association of Ghana (CHAG). Drawing on the Sustainability of Innovation Framework, this qualitative study examines how state-church partnerships function within Ghana’s public healthcare sector. Participants were purposively selected from CHAG-affiliated facilities across four regions of Ghana (Ashanti, Volta, Bono East, and North East). Ten semi-structured interviews were conducted with hospital administrators and health service managers. Policy-relevant documents from 2013 to 2021, including CHAG annual reports and strategic frameworks, were reviewed to supplement and triangulate the findings. Based on participant-reported factors across the framework’s five domains involving political, organizational, financial, workforce, and innovation factors, the analysis identifies several influences on partnership sustainability: heavy reliance on government salary support for staff (84.6% of CHAG staff on government payroll by 2021); perceived insecurity about potential funding withdrawal; disparities in resource allocation between CHAG and government facilities; fragmentation in referral coordination; and facility-level coping strategies including contingency funds, revenue-generating innovations, and patient-centered care initiatives. One additional theme emerged inductively: faith-based adaptive capacity, which participants described as mission-driven flexibility in navigating systemic constraints. Participants reported that sustainability is shaped not only by formal policy frameworks but also by local responsiveness and adaptive practices at the facility level. State–church partnerships in Ghana are sustained through a combination of formal government support and adaptive practices at the facility level. Strengthening these partnerships requires addressing systemic inequities, enhancing integration, and supporting the adaptive capacities that enable resilience. These findings contribute to broader debates on health system strengthening and Universal Health Coverage in resource-constrained settings. • Sustainability of state-church partnerships depends on integration within national health systems, not only formal agreements. • Unequal government resource allocation to CHAG versus public facilities widens service disparities. • Long-term viability requires equitable access to medical stores, equipment maintenance, and infrastructure. • Move from transactional to co-constructed collaborations prioritizing mutual learning and accountability. Implications for public • Faith-based facilities provide essential care in rural Ghana where government services are limited. • Community access to these services depends on government workforce support, funding stability, and collaboration with public hospitals. • Understanding these dynamics helps communities advocate for sustainable partnerships that strengthen local health systems.