ABSTRACT
Objectives: To explore governance, coordination and implementation actors, structures and processes, facilitators, and barriers within local government and between central and local government in Ghana's COVID-19 response during the first wave of the outbreak. Design: Cross-sectional single case study. Data collection involved a desk review of media, policy and administrative documents and key informant in-depth interviews. Setting: Two municipalities in the Greater Accra region of Ghana Participants: Local government decentralised decision makers and officials of decentralised departments. Interventions: None. Main Outcome Measures: None Results: Coordination between the national and local government involved the provision of directives, guidelines, training, and resources. Most of the emergency response structures at the municipal level were functional except for some Public Health Emergency Management Committees. Inadequate resources challenged all aspects of the response. Coordination between local government and district health directorates in risk communication was poor. During the distribution of relief items, a biased selection process and a lack of a bottom-up approach in planning and implementation were common and undermined the ability to target the most vulnerable beneficiaries. Conclusions: Adequate financing and equipping of frontline health facilities and workers for surveillance, laboratory and case management activities, transparent criteria to ensure effective targeting and monitoring of the distribution of relief items, and a stronger bottom-up approach to the planning and implementation of interventions need to be given high priority in any response to health security threats such as COVID-19.