Ghana - Second Health and Population Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No.: 18050 IMPLEMENTATION COMPLETION REPORT REPU]BLIC OF GHANA SECOND HEALTH AND POPULATION PROJECT (CR. 2193-GH) June 23, 1998 Human Development 3 Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS Currency Unit = Cedi US$1 = 368 C (1991) US$1 = 437 C (1992) US$1 = 652 C (1993) US$1 = 957 C (1994) US$1 = 1200 C (1995) US$1 = 1635 C (1996) US$1 = 2050 C (1997) (annual average exchange rate) WEIGHTS AND MEASURES Metric System FISCAL YEAR OF BORROWER January - December ABBREVIATIONS AND ACRONYMS CBD Community-based Distributor DCA Development Credit Agreement DHMT District Health Management Team HNP Health, Nutrition, and Population HPP (Second) Health and Population Project ICB International Competitive Bidding ICR Implementation Completion Report IDA International Development Association IPPF International Planned Parenthood Federation MIS Management Information System MOF Ministry of Finance MOH Ministry of Health MTHS Medium Term Health Strategy NCS National Catholic Secretariat NGOs Non-governmental Organizations NPC National Population Commission PMU Project Management Unit POW Program of Work PPAG Planned Parenthood Association of Ghana Vice President: Jean-Louis Sarbib (AFR) Country Director: Peter Harrold (AFC 10) Sector Manager: Helena Ribe (AFTH3) Task Team Leader: David Peters (AFTH3)  FOR OFFICIAL USE ONLY IMPLEMENTATION COMPLETION REPORT REPlJBLIC OF GHANA SECOND HEALTH AND POPULATION PROJECT [Cr. 2193-GHJ TABLE OF CONTENTS PREFACE EVALUATION SUMMARY ..................................... i PART I 1. INTRODUCTION ...................................... I A. COUNTRY BACKGROUND .......................................... I B. IDA's ROLE IN THE SECTOR ..........................................1 2. PROJECT OBJECTIVES .......................................... 2 A. ORIGINAL PROJECT OBJECTIVES ...........................................; 2 B. PROJECT DESCRIPTION AND COMPONENTS .......................................... 2 C. LOAN COVENANTS AND SPECIAL AGREEMENTS .......................................... 3 D. EVALUATION OF PROJECT OBJECTIVES .......................................... 4 3. IMPLEMENTATION EXPERIENCE AND RESULTS .......................................... 4 A. ASSESSMENT OF PROJECT'S SUCCESS AND SUSTAINABILITY ............................................... 4 B. SUMMARY OF COSTS AND FINANCING ARRANGEMENTS ............................................... 6 C. IMPLEMENTATION SCHEDULE ............................................... 6 D. ANALYSIS OF KEY FACTORS AFFECTING MAJOR OBJECTIVES ............................................... 7 E. ASSESSMENT OF THE BORROWER'S AND IDA 'S PERFORMANCE ................................................, 9 F. ASSESSMENT OF PROJECT'S OUTCOME ................................................ 9 4. SUMMARY OF FINDINGS, FUTURE OPERATIONS AND KEY LESSONS LEARNED ................... 9 A. IMPORTANT FINDINGS OF PROJECT IMPLEMENTATION EXPERIENCE ............................................................ 9 B. FUTURE OPERATIONS AND SUSTAINABILITY ..................................................................... 10 C. LESSONS FOR FUTURE PROJECTS IN THE SECITOR ..................................................................... 10 PART II STATISTICAL ANNEXES APPENDIX: Borrower's Contribution to the ICR This document has a restricted distribution and may be used by recipients only in the| performance of their official duties. Its c:ontents may not otherwise be disclosed without| World Bank authorization.|  IMPLEMENTATION COMPLETION REPORT REPUBLIC OF GHANA SECOND HEALTEI AND POPULATION PROJECT [Cr. 2193-GH] PREFACE This is the Implementation Completion Report (ICR) for the Second Health and Population Project in Ghana, for which Credit 2193-Gil in the amount of SDR 19.5 million (US$27 million equivalent) was approved on December 13, 1990 and made effective on June 18, 1991. The loan was closed on December 31, 1997, two years after the originally planned closing date. The last disbursement took place on June 5, 1998. SDR 18.9 million (US$27.4 million) had been disbursed, with the balance of SDR 0.56 planned for cancellation. The ICR was prepared by David Peters of the Africa Region and assisted by Betty Casely- Hayford (AFTH3), and reviewed by Irene Xenakis (AFTH3), Helena Ribe (Sector Manager for AFTH3), and Theresa Jones (Country Coordinator for Ghana). Preparation of this ICR began during IDA's final supervision mission in September 1997. It is based on mission's discussions with the project staff and on materials in the project file. The Borrower contributed to the Implementation Completion Report by commenting on the draft ICR during the April 1998 mission, and by preparing their own evaluation report of the project's execution (see Appendix).  IMPLEMENTATION COMPLETION REPORT REPUBLIC OF GHANA SECOND HEALTH AND POPULATION PROJECT [Cr. 2193-GH] EVALUATION SUMMARY 1. Introduction. The Second Health and Population Project (HPP) was the second IDA credit to the health, nutrition, and population (HNE') sector in Ghana. It followed the Health and Education Rehabilitation Project (Cr. 1653-GH, effective April 28, 1986), which was designed to meet some of the emergency requirements in these sectors, beginning three years after the introduction of Ghana's Economic Recovery Program. In an attempt: to provide a policy basis for the HPP, IDA also conducted a comprehensive review of the HNP sector in 1988 (Report No. 7597-GH, March 31, 1989), the recommendations of which motivated its design. 2. Project Objectives and Components. The objectives of the project were to: (a) improve the quality and coverage of health services; and (b) increase the availability and accessibility of family planning services. The project was originally divided into six components: (a) drug supplies and drug infrastructure rehabilitation; (b) strengtlhening the Ministry of Health (MOH); (c) regional and district hospitals; (d) primary health care (PHC); (e) population/family planning; and (f) a prizes fund to provide incentives to health workers and communities. As a means of improving equity, the project emphasized PHC services in three under-served, northern regions of the country. 3. Loan Covenants and Agreements. The effectiveness conditions for the project included the appointment of a full-time coordinator and procurement specialist for the project. The Development Credit Agreement (DCA) for the project also included many dated covenants, which were intended to guide sector development. These ranged from the establishment of the management arrangements for the project and its mid-term review date, to a requirement for a framework agreement for the MOH and non-governmental organizations (NGOs),. Dated covenants were also outlined for the schedule of hiring heads of district health management teams (DHMTs), plans to expand services (both outreach and PHC services), requirements to design and implement a management and health information system, and manpower plans (staLffing norms, a master manpower plan, and a training program). None of the legal covenants were met on time; they were either achieved late, formally amended, or informally ignored as other events rendered them less relevant. There were also four conditions of disbursement intended to assist implementation of policy reforms (operation of the drug "cash and carry" scheme; formalization of a competitive bidding policy for drugs; appointment of a maintenance engineer; and establishment of a national population commission). 4. Evaluation of Project Objectives. The main project objectives were, and are still, relevant to the development of in Ghana's HNP sector. They were also consistent with the interests of the MOH, and were generally accepted as good public policy. However, the management information system was quite rudimentary, and the proposed detailed project indicators were never adopted. As a result, monitoring of project progress during supervision limited itself to the monitoring of inputs and infrequent measurements of health and population status. It is thus difficult to establish a link between the project intentions, performance of the health system, and the impact on people's health.  IMPLEMENTATION EXPERIENCE AND RESULTS 5. Assessment of Project's Success and Sustainability. The project was successful in achieving its objectives in the narrow sense of contributing to improved access to, and quality of, health and family planning services. Many of the institutional and sector reform expectations of the project were made despite the design of the HPP. Most of the project-supported institutional reform initiatives were either marginalized, or they tended to detract from the efforts being made by the MOH. Yet the project played an important role in supporting the continued decentralization of health systems based on DHMTs. The sustainability of the health program that emerged during the HPP is likely, since the follow-up operation abandoned the traditional project approach, and became an integral part of Ghana's health sector. A comprehensive health policy and an operational framework has been established, concepts that the project had promoted, but was only able to support in limited ways. Borrower commitment and ownership of its health sector program is very high, and has received increased financial resources from the government and the support of a wide range of donors and other health partners. The sector operational plans are comprehensive, and appropriately address questions of institutional effectiveness, technical and financial viability, and local participation. 6. Summary of Costs and Financing Arrangements. The total cost of the project was estimated at appraisal to be US$34.4 million with the government contributing US$7 million, IDA providing US$27 million, and the International Planned Parenthood Federation, Planned Parenthood Association of Ghana, and the National Catholic Secretariat combining for US$0.4 million. The project was closed on December 31, 1997. Government contributed US$1.5 million directly to the project, and has assumed the ongoing operational costs. Total disbursements of the credit at project closure was SDR 18.9 million (US$27.4 million equivalent); an outstanding balance of SDR 0.56 million is scheduled for cancellation. 7. Implementation Schedule. Preparation, Negotiations, Signing, and Loan Effectiveness followed a typical schedule for Ghana. However, implementation was moribund during the first two years of the project life, as effectiveness and disbursement conditions were not met, and the project management unit (PMU) was staffed by consultants taken from outside the MOH. Implementation began when the PMU was moved into the mainstream of the MOH in late 1992, using MOH staff. A mid-tern review of the project was conducted in June 1994, and brought in key actors of the sector to re-focus the project. Implementation and disbursement then accelerated rapidly. Because of the delay in project take-off, two one-year extensions were required to complete implementation. 8. Analysis of Key Factors Affecting Major Objectives. Project achievements were constrained by a number of factors. The more significant factors include: (a) a traditional project design which was over-compartmentalized and inflexible, and which contributed to further fragmentation of the health sector; (b) an initial lack of acceptance by the MOH of both the PMU and the project, which resulted in slow project implementation and little success in sectoral reforms through the project; (c) over use of conditionalities; (d) unstable management of key NGOs in the project; and ii  (e) poor supervision of civil works. 9. Assessment of the Borrower's ani IDA's Performance. The Borrower's performance was, on the whole, satisfactory. After the initial slow years, the Minister of Health incorporated the project into the MOH, with the MOH team resurrecting implementation of the project. The overall performance of IDA was satisfactory. Its iclentification of the project reflected the sector priorities at the time. However, IDA took part in the project design which "locked-in" the MOH through overly specified implementation details, used conditionalities in a way that became inappropriate. The project further fragmented the health system despite good efforts by IDA to collaborate with other donors. During implementation, IDA initially worked within the constraints of the project design, but increasingly made efforts to solve implementation problems flexibly, explore alternatives, and support project management. The use of the mid-term review was particularly helpful in this project. 10. Assessment of Project's Outcome. The Second Health and Population Project produced satisfactory results. The project helped to support major health sector reforms in policy and health systems development, institutional change, and improving services. Though limitations in access to, and quality of, health and family planning services remains an ongoing concern, the project contributed to improvements in these areas, particularly in under-served poor northern regions. Overall, utilization of health services and contraceptive prevalence are steadily increasing. SUMMARY OF FINDINGS AND KEY LESSONS LEARNED I1. Key lessons learned from the project experience are summarized below: (a) Ensuring ownership of the project is critical to its success. In this case, it meant placing the implementation unit within the MOH. (b) Conditionalities can be used to change policies, such as cost-recovery. However, changing policy does not necessarily assure that policies are well implemented. In some cases, the result may be counterproductive. The cost-recovery policies initially had significant negative effects on utilization, and there were no mechanisms established to monitor its effects or make changes in its application. (c) Conditionalities that were time-linked several years in advance soon became outdated, and became more of an obstruction to the dialogue within the Ministry than a means of facilitating change. Nonetheless, they did serve to bring health sector concerns to the attention of the Ministry of Finance (MOF) and other central agencies. (d) In a highly fragmented health. system with multiple funding sources, adding another project serves to create duplication and further dissipate energies of the MOH. Particular attention is needed to focus on the main reform agenda for the sector, which in the Ghana case meant giving up a traditional project approach. (e) Supervision of civil works in the Ghana health sector needs to change. Simply hiring consultant architects and engineers does not ensure adequate supervision. (f) Working in partnership with the MOH, other donor agencies, and NGOs is critical to more effective health systems in an environment like Ghana's. iii  IMPLEMENTATION COMPLETION REPORT REPUEBLIC OF GHANA SECOND HEALTH AND POPULATION PROJECT [Cr. 2193-GH] PART I: PROJECT IMP?LEMENTATION ASSESSMENT 1. INTRODUCTION A. COUNTRY BACKGROUND 1.1 Of all African countries, Ghana has had one of the longest relationships with the Bank. For years, Ghana was held up as a model of economic reform and adjustment for others to follow. Its bold economic reform program launched in 1983, laid the basis for 15 years of continuous economic growth. The Bank's performance indicators continue to rank Ghana among the higher performers in Africa, although Ghana's ranking in terms of macroeconomic management performance slipped badly in the 1990s. Upon receiving a second electoral mandate in December 1996, government restored fiscal discipline. The economy has miade a recovery, and is now growing at a rate of about 5 percent per year, with inflation dropping from 71 percent at the end of 1995 to 21 percent in end 1997. Nonetheless, there remains a high level of poverty, with an average per capita GDP of US$410, and over 31 percent of the population living below the poverty line. 1.2 In the health sector, Ghana has made remarkable achievements in the last decade, particularly in comparison with the rest of Africa. Health and population outcome and service provision indicators are better in Ghana than the average for Sub-Saharan Africa (for example, infant mortality rate is 66 deaths per 1,000 live births; total fertility rate is 5.5 children), with mortality trends improving at a faster pace. Although fertility iis declining and contraceptive use is increasing, population growth is still very high (estimated at 2.8 percent), and there are large unmet contraception needs. This picture describes a nation at the critical turning point in the demographic transition. Within Ghana, however, there are large regional discrepancies in health and fertility status. The Northern, Upper East and Upper Wiest Regions have pre-transitional indicators, with nearly double the mortality and fertility indicaitors of the Regions in the south. B. IDA's ROLE IN THE SECTOR 1.3 IDA's first involvement in the sector was the 1986 Health and Education Rehabilitation Project (CR. 1653-GH). This US$15 million I]DA credit provided emergency support for building and hardware purchases in the two sectors as part of the Economic Recovery Program, yet was implemented slowly due to limited involvement of senior MOH staff and the scattered activities of the project. In the sector analysis and identification stages of the HPP, IDA engaged discussion with a large group in the MOH and with a wide numrber of key partners in the sector on health priorities. With the HPP, IDA became one of the larger financiers of the health sector in Ghana (there were 14 1  other significant health donors in Ghana at the time). During the early years of the HPP, much of IDA involvement in the sector involved discussion on credit conditionalities, and on procurement for hardware aspects of the project. In later years of the project, IDA became more involved in working with the MOH to help it undertake its institutional reforms. However, to do this, IDA needed to recognize and lessen the burdens created by the HPP and other externally funded projects on the MOH, and adapt a sector-wide approach. This enabled government to articulate its vision for the health sector and the role of its partners, requiring IDA to ensure that its efforts were more fully consistent with this vision in order to meet sector needs. IDA played a role in supporting the MOH by changing its behavior and encouraging change in other partners to use a common policy and operational framework, and to develop and use the MOH implementation systems. As a result, IDA became less involved in concerns about project management, and had a greater role in discussions over sector policy, financing, resource allocation, and monitoring of the sector. 2. PROJECT OBJECTIVES A. ORIGINAL PROJECT OBJECTIVES 2.1 The objectives of the project were to: (a) improve the quality and coverage of health services; and (b) increase the availability and accessibility of family planning services. It was expected that the project would help bring about incremental changes in service coverage and quality, which would need continued attention beyond the scope of the project. The project was designed to address inequity by emphasizing PHC services in three under-served, northern regions of the country. The project also intended to support the implementation of other government sector priorities, involving policy, institutional and program changes, and improved public expenditure. Although specific targets were described at appraisal, only a set of targets for procurement activities, and the schedule of expected institutional changes were actually monitored. B. PROJECT DESCRIPTION AND COMPONENTS 2.2 The project was originally divided into six parts: (a) Drug supplies and drug infrastructure rehabilitation. This component included the purchase of drugs and vaccines, along with rehabilitation of medical stores, equipment, training, and technical assistance to strengthen the supply system. (b) Strengthening the MOH. This component provided office equipment, vehicles, training and technical assistance in key units of the Ministry. (c) District and Regional hospitals. The project provided for re-equipping and rehabilitation of 7 MOH and 4 mission hospitals in the northernmost Regions of Ghana, as well as a number of maintenance workshops. 2  (d) Primary health care. This cormponent including training for DHMTs in health service management, and provided for building DHMT offices and residential accommodation for district health officers. Funding was also made available for communications equipment, and for the financing of priority studies relevant to primary care. (e) Population/family planning. The project was designed to finance contraceptives and equipment for MOH family planning services, along with support for the Planned Parenthood Association of Ghana (PPAG) in the form of clinic rehabilitation, equipment, training, and contraceptive supply. International Planned Parenthood Federation (IPPF) was expected to continue to finance PPAG, along with grants from the MOH. (f) A prizes fund. This fund was intended to provide incentives for good performance to individual health workers and health teams, and to communities for undertaking health-promoting activities. 2.3 During the mid-term review in 1994, modifications were made to project activities, although there was no change in project objectives. The most notable of the changes is that the prizes fund was dropped. The public perceived that healtht services were still very poor, and complained loudly that the MOH was rewarding itself unjustifiably by giving itself prizes, even though prizes were also awarded to communities undertaking health initiatives. There was little support in government for the prizes outside the MOH, since no other ministries or agencies had been involved in the process. As a result, and senior politicians did not want to continue to expose themselves to bad publicity, and the experiment was dropped. C. LOAN COVENANITS AND SPECIAL AGREEMENTS 2.4 The effectiveness conditions for the project included the appointment of a full-time coordinator and procurement specialist for the project. The project also included many dated covenants specified in Schedule 4 (Implementation Program) of the Development Credit Agreement (DCA), which were intended to guide sector development. These ranged from a description of the management arrangements for the project and its mid-term review date, to a framework agreement for the MOH and non-governmental organizations (NGOs). Dated covenants were also outlined for the schedule of hiring heads of district health rnanagement teams (DHMTs), plans to expand services (both outreach and PHC services), and requirements to design and implement a management and health information system, and manpower plans (staffing norms, a master manpower plan, and a training program). None of the conditions were met on time. Each of the dated covenants were either achieved late, formally amended, or informally ignored as other events rendered them less relevant. There were also four conditions of disbursement intended to assist implementation (operation of the drug "cash and carry" scheme, formalization of a competitive bidding policy for drugs; appointment of a maintenance engineer; establishment of a national population commission). Prior to the mid-term review, a number of changes were made to allow for pre-installation works on Regional and District hospitals and to expand the categories of staff eligible for training. The dates on most of the covenants outlined in the Implementation Program were also delayed by two years. 3  D. EVALUATION OF PROJECT OBJECTIVES 2.5 The main project objectives were and are still relevant to the development of in Ghana's HNP sector. They were consistent with the interests of the MOH and generally accepted public policy. However, the management information system was quite rudimentary, and the proposed detailed project indicators were never adopted. As a result, monitoring of project progress during supervision was limited to the monitoring of inputs, and infrequent measurements of health and population status. During the mid-term review, there was an attempt to revise the monitoring of objectives, but little headway was made since most attention was on reinforcing implementation of project activities, and establishing processes to develop sector policy. It is thus difficult to establish a link between the intentions of a modest size project, performance of the health system, and the impact on people's health. 3. IMPLEMENTATION EXPERIENCE AND RESULTS A. ASSESSMENT OF PROJECT'S SUCCESS AND SUSTAINABILITY 3.1 The project was successful in achieving its objectives in the narrow sense of having improved access to, and quality of, health and family planning services. The physical objectives of the project were substantially achieved. Under the drugs supplies component, over US$4 million was spent on drugs and vaccines. Ten Regional medical stores and 1 teaching hospital medical store were refurbished. The headquarters and each Region also received vehicles to assist with supervision and drug delivery. During the height of the 1996-97 meningitis epidemic, HPP funds were able to be re- allocated and committed within one day of receiving the request from government to facilitate the immediate shipping of emergency vaccines and supplies to combat the epidemic. Without the timely funding, the meningitis vaccines would not have gone to Ghana. In-service training was completed for 350 physicians, 350 medical assistants, and 150 pharmacists and pharmacy technicians on safe prescription, as well as 500 health staff on the "cash and carry" system. The drug quality assurance laboratory at the University of Science and Technology was re-equipped and 3 staff trained in drug quality assurance; while the pre-service training for pharmacists and technicians was also expanded under the project. Under the component for strengthening District and Regional hospitals, the 7 MOH and 4 mission hospitals were re-equipped. Two of the 3 planned hospital equipment workshops were completed. In the last two years of the project, 2 health centers were physically upgraded to district hospitals, with plans to equip them initiated under the current health sector program of work. To support primary health care, 10 health centers were built and equipped, 1 1 DHMT offices were constructed and furnished, and 40 bungalows were constructed and furnished. All are fully operational. The physical support to DHMT teams, including staff housing, is considered by MOH as vital in attracting and maintaining good staff at the district level. In addition, medical equipment was provided for another 100 health centers, along mobile workshops to assist with maintenance and repairs. Five hundred motorcycles and a few other vehicles were also purchased to improve outreach services and supervision. The project also provided funds to extend the training in district health team planning across the country, so that all 110 districts now produce annual plans and budgets. As a result of these improvements in health services, the access to health services has increased, staff morale has improved, as has the quality at those facilities benefiting from the credit. Overall, per capita utilization of outpatient services in Ghana increased from 0.20 per capita in 1991 to 0.35 in 1997, a 75 percent increase. Outreach services are reported to be increasing, 4  nationally going from 7 outreach clinics per month per sub-district in 1996 to 7.7 in 1997. 3.2 As was the case for the health services components, the physical progress in population/family planning was substantial, atnd helped to increase access to family planning. Contraceptives for an amount of US$2.4 million were provided through the project, almost entirely through PPAG. The number of service points increased dramatically through the training and supplying of 750 community-based distributors. Five PPAG family planning clinics were rehabilitated, and computers supplied and traiining provided to PPAG staff. The project also supported the Ministry's training in Safe Motherhood, training health staff in new approaches to antenatal, delivery, and post-natal care. The project made a substantial contribution to the improvements in fertility conditions that are now beginning to be seen across Ghana. Between 1988 and 1993 (when national surveys were conducted), the national contraceptive prevalence increased from 5 percent to 10 percent, and total fertility dropped from 6.5 to 5.5 children. Preliminary evidence suggests that these parameters are continuing to improve slowly. 3.3 Several of the institutional objectives were achieved during the project period, though most of the progress in sectoral policy and health systems were made almost despite the project. At the mid-term review, it was recognized that for all practical purposes, the project had defined institutional development in terms of the procurement of hardware, rather than the development of systems and capacity utilization. Project institutional reform initiatives were either marginalized, or they tended to detract from the way different parts of the MOH wanted to pursue their reform agendas. During the project period, government health expenditures actually declined as a percent of recurrent revenues, although the project had hoped to stimulate increases in government financing. The reorganization of the MOH and its units occurred at a different pace than anticipated at appraisal, and in unexpected directions (the restructuring of the central MOH, the development of a Ghana Health Service, and the split of purchasers and providers were not anticipated, and the reorganization of the pharmacy unit and the National Drug Program was only partially completed). The National Population Commission (NPC) was established with some stimulation by the conditionalities of the project. The NPC then produced a new population policy and plan of action, but without close involvement of IDA. IDA ftunding for manpower development and the government aspects of the population program were replaced by grant funding from ODA (UK), JICA, USAID, UNFPA, and others, under the principle that IDA funding would be used as a last resort. It is also apparent that the imposition of IDA conditionalities in these areas, and IDA's inability to maintain a ongoing technical dialogue in these areas encouraged the MOH to seek help elsewhere. Nonetheless, the credit did provide for critical training in DHMT management, rational drug use, drug quality assurance, contraceptive management, and safe motherhood, which contributed to the institutional strengthening of the sector. The physical support to the DHMTs through offices, equipment, and housing is viewed by the MOH as important in allowing it to keep a district focus in its efforts, and particularly to keep good district medical officers in place, especially in rural areas. The project also supported a number of small research projects at the district level, though it had intended to make this a more prominent activity. National studies on the quality of care and non-communicable diseases were also conducted, which played a minor role in stimulating improvements in the management of clinical care. 3.4 The central role of procurement issues in the project has helped to strengthen the Ministry's technical capacity, although it still has consideirable needs. The project has resulted in more attention being paid to procurement, and has contributed to important procedural changes (for example, the use of a procurement committee) to make MOH procurement more transparent and efficient than in the past. The project was one of the early attempts to substantively address the issues of management of logistics, especially concerning pharmaceuticals, equipment, and maintenance. The Ministry has 5  since strengthened itself in each of these areas (although with less success in pharmaceuticals than equipment management), and has continued to take steps to improve its management of logistics after the HPP. 3.5 The major successes in developing a sector policy and operational framework were primarily achieved through the development of government's sector program, which occurred during preparation of the subsequent IDA credit. Nonetheless, the HPP was used to finance workshops and some technical assistance that was important to build consensus on the introduction of a Ghana Health Service, the requisite manpower planning, and government's Medium Term Strategic Framework. The other significant achievements that occurred during the project, but not as a result of the project, included an expenditure and financing framework for the entire health sector. As a result of government's new health program, its health expenditures increased in 1997 (from 6.9 percent of government recurrent expenditure in 1996 to 8.4 percent 1997), with greater allocations going to district-level services. The sustainability of the health program is likely, since the follow-up operation abandoned the traditional project approach, and became an integral part of the entire health sector in Ghana, for which a comprehensive health policy and operational framework have been established. Borrower commitment is very high, and the operational plans address institutional effectiveness, technical and financial viability, and local participation. B. SUMMARY OF COSTS AND FINANCING ARRANGEMENTS 3.6 The total project cost of the project was estimated at appraisal to be US$34.4 million with the government contributing US$7.0 million, IDA providing US$27 million, and the International Planned Parenthood Federation, Planned Parenthood Association of Ghana, and the National Catholic Secretariat combining for US$0.4 million. The project was closed on December 31, 1997. Government contributed US$1.5 million (1.8 billion Cedis) to the project, and has assumed the operational costs for the project investments. Total disbursements of the credit at project closure was SDR 18.9 million (US$27.4 million equivalent); an outstanding balance of SDR 0.56 million is scheduled for cancellation. C. IMPLEMENTATION SCHEDULE 3.7 The credit was signed on December 21, 1990, and became effective on June 18, 1991. Implementation was monitored through semi-annual supervision visits. The project was closed on December 31, 1997. The rate of implementation was extremely slow during the first two years of the project life, as effectiveness and disbursement conditions were not met, and the project management unit (PMU) was staffed by consultants outside the MOH. Implementation began when the PMU was moved within the MOH in late 1992 using MOH staff, and accelerated significantly after a mid-term review in June 1994. By involving key actors in problem-solving and by indicating that the project could be implemented with more flexibility, the mid-term review served as an effective way of enhancing commitment, resolving implementation problems, and clarifying the remaining work program. Because of the delay in project take-off, two one-year extensions were required to complete implementation. 6  D. ANALYSIS OF KEY FA,CTORS AFFECTING MAJOR OBJECTIVES 3.8 Project achievements were constrained by a number of factors. The more significant factors include: (a) A traditional project design. During preparation and appraisal, the Ghana health system was dominated by a series of donor project units and vertically oriented. With a long series of conditionalities and 14 disbursement categories for the project, the Ministry felt that the HPP had locked them in for five years, even though circumstances were changing. Although the project promoted the reorganization of the entire Ministry, the establishment of another PMU addressing specific components contributed to furthering the fragmentation of the health sector. This resulted in duplication of project systems (for example, different PMUs did similar tasks depending on the financier). It also tended to dilute the attention of senior Ministry officials, who spent more time dealing with different project issues and visiting missions from various donors than working on strategic issues and the leadership concerns for the sector. This type of fragmentation set up a situation in which the Ministry and donors worked at odds with each other. These problems were not well addressed until the development of a new sector-wide approach currently being supported by the follow-up IDA credit. The MOH has taken over the leadership of the forum with donors and technical partners, who now explicitly work under a single framework tovvard common objectives. (b) A lack of ownership in the project. The limited ownership at the beginning of the project became manifest through limited support from senior MOH officials for the project and a lack of timely counterpart funds. These factors delayed implementation during the initial years. In later years, when physical implementation of the project was working well, the lack of involvement of MOH managers at lower levels resulted in poor oversight of ithe activities in their areas. This was a problem particularly in the few cases in which contractors did not perform well, and contributed to delays in implementation. The fact that the PMU was initially staffed by outside consultants also made it difficult for the project to be engaged in sensitive sector reform issues that required leadership from the Ministry. The use of policy conditionalities, although intended to support the MOH reform agenda, served to antagonize MOH staff, making it difficult for the project to support such reforms. The availability of grant funding from other donors for similar activities added to the confusion, but resulted in a preference for the use of other financiers to support systems development in such areas as institutional reorganization, human resource and financial management, drug systems, and population/family planning. Nonetheless, the MOH itself was not a homogeneous unit, so that even when the PMU became part of the Ministry, differences between units in the MOH prevented smooth implementation of all components. The effects were most notable on the research activities, the supervision of civil works, equipment installation, and on support for policy and systems development through the project. (c) Over-use of conditionalities. The number of disbursement conditions resulted in delayed project start-up, and became a disincentive to project staff. The dated covenants "locked in" the MOH to a blueprint that became inappropriate over time, creating tension between the N4OH and IDA, and undermining the sector dialogue 7  rather than stimulating change. Some of the specific conditionalities became counterproductive. For example, the problems with weak procurement systems were not solved by the requirement to place procurement staff and formalize a bidding policy. The Ghana Supply Commission, which then handled much of the procurement of goods, proved to be an obstacle in procurement, as they did not adhere to the careful technical specifications on medical equipment and motorcycles, and did not involve the MOH in the evaluation and distribution phases. Nonetheless, the use of conditionalities was effective in bringing health sector concerns to the attention of government officials in central ministries. IDA's informal threat to suspend project disbursement unless the MOH was reorganized helped politicians to reach such an agreement. However, the process alienated MOH staff with IDA, but stimulated the MOH to reorganize itself in ways different than project consultants (who were felt to represent the views of IDA) had envisioned. (d) Unstable management of key NGOs in the project. The PPAG had financial constraints from their traditional financiers, partly because there was major personnel turnover during the project. This resulted in a need to retrain management staff, and caused a slow-down in project implementation. (e) Poor supervision of civil works. The MOH did not have the capacity to undertake technical supervision of the civil works. Although considerable effort was spent during early IDA supervision missions to improve the management of civil works, this resulted in improved procurement of works, but not of the supervision of works. The consulting supervisors did not identify poorly performing contractors until extensions were needed. They took few steps, if any, to deal with problem contractors unless reminded by MOH and Bank missions, though this was part of their terms of reference. There was little incentive for civil works supervisors to keep down costs of the contractors (supervisors were paid on a contingency basis), or to have contractors deliver on time, since no penalty clauses were enforced on supervisors or contractors. 3.9 A number of other factors that are generally considered under government control also affected the project. High inflation and devaluation, particularly from 1993-1996, threatened the viability of the drug "cash and carry" system because it made it difficult to keep up with rising drug prices. The user fee rates did not change during the life of the project (a carry-over conditionality from the previous Health and Education Rehabilitation Project), and there was little monitoring of the effects of these cost-recovery policies. One result has been a reported increase in unofficial charges for drugs and services, undermnining the integrity of financial controls and public confidence, and offering little protection for the poor. Although utilization of services fell rapidly after the introduction of user fees, it has been climbing slowly since then. However, it is not clear who is paying the most because of the changes in policies. Survey evidence in 1997 continued to show that the poor frequently do not use health services because of their cost and limited accessibility, particularly in the northern Regions (Core Welfare Indicator Questionnaire). 8  E. ASSESSMENT OF THE BORROWER'S AND IDA'S PERFORMANCE 3.10 The Borrower's performance was satisfactory. After the initial slow years, the Minister of Health incorporated the project into the MOH, and attended to resurrecting implementation of the project. The initially poor performance was clearly related to low ownership of the project, which changed when the institutional arrangements were altered. In several cases, the project was used as a starting point for key activities that the MIinistry took on without project support, even as implementation of the project proceeded. 3.11 The overall performance of IDA was satisfactory. IDA identified needs that were clearly a high priority at the time, and contributed to the development of significant policy changes. Yet IDA took part in project design which overly specified and compartmentalized implementation details. The appraisal was thorough and consistent with good practice at the time. However, the excessive use of conditionalities placed IDA and the MOH in an adversarial situation, though it sometimes produced positive results. IDA did provide significant resources during supervision, and assisted in restructuring the project at the mid-term review. Importantly, its flexibility in giving up the project approach, even as the HPP was being implemented, and the close manner in which it worked with other donors, helped give confidence to t]he MOH and other agencies that they could move to a sector-wide approach, where more emphasis is given on developing and using common implementation systems. F. ASSESSMENT OF PROJECT'S OUTCOME 3.12 The Second Health and Population Project has produced positive results. Although improvement in access and quality of health and family services remains an ongoing concern, the project contributed to improvements in these areas. Nationwide, utilization of health services and contraceptive prevalence are steadily increasing. The district-based approach to health services remains strong in a large part because of the project's support. The project contributed to developing managerial and technical skills needed to make health sector efforts sustainable, both at the district and central levels. Financial viability is mlore certain since the project was followed up by a comprehensive sector expenditure framework with government increasing its expenditures on health in an affordable manner. These factors, along with the technical quality and high degree of commitment to a Five-Year Health Sector Program of Work make the sustainability of the project highly likely. 4. SUMMARY OF FINDINGS, FUTURE OPERATIONS AND KEY LESSONS LEARNED A. IMPORTANT FINDINGS OF PROJECT IMPLEMENTATION EXPERIENCE 4.1 Implementation lessons include: (a) An overly prescriptive design, having the nature of a multiple-year blueprint, was not appropriate for the type of complex institutional changes that were being addressed. Greater flexibility is needed, with monitoring linked to the processes and timing of 9  government. (b) Any short-term gains that may have been hoped for by the establishment of a semi- independent PMU were immediately lost because of the effects of lack of ownership. Moving the management of the project more directly into the mainstream of the MOH was important. (c) The use of the mid-term review was critical to resuscitating the project. It not only re-focused the project activities, it also added some flexibility into the implementation. (d) Supervision of civil works in the Ghana health sector needs to change. The new sector program is dealing with this issue substantively, recognizing that simply hiring consultant architects and engineers does not ensure adequate supervision. B. FUTURE OPERATIONS AND SUSTAINABILITY 4.2 As a result of the HPP experience in the context of a fragmented health sector with a large reform agenda, IDA has abandoned the project approach for the Ghana health sector, and supported a sector-wide approach. This has increased the likelihood of success and sustainability in the health sector, and made IDA an effective and important partner in decisions on health policy, resource allocation, the design of health systems, and the monitoring of change. Government has developed and is implementing its comprehensive sector policies and implementation and monitoring guidelines for the entire sector, and has already effected significant reforms and increased its expenditures for health. C. LESSONS FOR FUTURE PROJECTS IN THE SECTOR 4.3 Key lessons learned for future projects in the sector include: (a) In an environment in which there are many donor agencies, separate projects divide attentions of the MOH and dilute their capacity, resulting in diffusion of efforts, duplication, and greater fragmentation of the health system. Project approaches may need to be abandoned in order to better build and utilize capacity and achieve sectoral goals. The Ghana experience may yet prove to be a model for how to move to sector-wide approaches. (b) Ensuring ownership of the project is critical to its success. In this case, it means placing the responsibility and the means for implementation within the MOH. (c) Conditionalities can be used to change policies, such as cost-recovery. However, changing policy does not necessarily assure that policies are well implemented. In some cases, the result created more harm. The user fee and "cash and carry" policies have had dramatic negative effects on utilization, and there were no mechanisms to monitor the policy effects, or the make changes. 10  (d) Conditionalities that are time-linked over several years soon become outdated, and can create an adversarial environment between government and IDA. While this can sometimes stimulate change, it can "lock-in" both government and IDA, becoming more of an obstruction to the dialogue than a means of facilitating change. (e) Institutional development needs to focus more on software concerns such as systems, processes, staff capabilities and incentives, and less on the procurement of hardware. (f) Working in partnerships with MOH, other donor agencies and NGOs is critical to more effective health systems in an environment like Ghana's. 11  PART II: STATISTICAL TABLES Table 1: Summary of Assessments Table 2: Related Bank Loans/Credits Table 3: Project Timetable Table 4: Loan/Credit Disbursements: Cumulative Estimated and Actual Table 5: Key Indicators for Project Implementation Table 6: Studies Included in the Project Table 7: Project Costs Table 8: Project Financing Table 9: Status of Legal Covenants Table 10: Bank Resources: Staff Inputs Table l1: Bank Resources: Missions 12  Table 1: Summary of Assessments A. Achievement of Objectives Substantial Partial Negligible Not applicable Macro Policies [J Sector Policies i: O i:i Financial Objectives EJ E El Institutional Development [] i: i:i Physical Objectives El r El Poverty Reduction [] 5 El Gender Issues El El Other Social Objectives E] E I] Environmental Objectives [] E ]] Public Sector Management E] ]l Private Sector Development F] ri B. Project Sustainability Likely Unlikely Uncertain Highly C. Bank Performance Satisfactory Satisfactory Deficient Identification El El Preparation Assistance I] Appraisal ! 3 Supervision 0l Highly D. Borrower Performance Satisfactory Satisfactory Deficient Preparation E] E Implementation E El Covenant compliance iR El Elighly E. Assessment of Outcome Satisfactory Satisfactory Unsatisfactory 13  Table 2: Related Bank Loans/Credits Credit [ Purpose [ Year of approval [ Status Following Operations Cr. 20390 Water Sector Rehab 1989 Ongoing Cr. 21090 VRA/Sixth Power 1990 Ongoing Cr. 21570 Urban II (Sec. Cities) 1990 Ongoing Cr. 21800 Agric. Divers (Tree Crop) 1991 Ongoing Cr. 22240 Econ. Mgt. Support 1991 Ongoing Cr. 22470 Agric. Research 1991 Ongoing Cr. 23190 Feeder Roads 1992 Ongoing Cr. 23460 Agric. Extension 1992 Ongoing Cr. 23490 Adult Literacy 1992 Closed Cr. 24260 Environment 1993 Ongoing Cr. 25080 Primary School Dev. 1993 Ongoing Cr. 24280 Tertiary Education 1993 Ongoing Cr. 24410 Livestock 1993 Ongoing Cr. 24670 National Electrication 1993 Ongoing Cr. 25020 Enterprise Devt. 1993 Closed Cr. 24980 Urban Transport 1993 Ongoing Cr. 25550 Agric. Sector Invest. 1994 Ongoing Cr. 25680 Local Govt. Dev. 1994 Ongoing Cr. 26040 . Community Water 1994 Ongoing Cr. 26650 Priv. Sector Dev. 1995 Ongoing Cr. 27180 Private Sector Adj. 1995 Ongoing Cr. 26820 Thermal (P. VII) 1995 Ongoing Cr. 27430 Mining Sec. Dev. & Env. 1995 Ongoing Cr. 27130 Fisheries 1995 Ongoing Cr. 26950 Educ./Voc. Training 1995 Ongoing Cr. 27920 Non-Bank Fin. Ins. Ast. 1996 Ongoing Cr. 28360 Urban Env. Sanitation 1996 Ongoing Cr. 28580 Highway Sect. Inv. Prog. 1996 Ongoing Cr. 28770 Public Enterprise 1996 Ongoing Cr. 28850 Basic Education 1996 Ongoing Cr. 29250 Public Fin. Magmt. Tap. 1997 Ongoing N0200 Village Infrastructure 1997 Ongoing Cr. 29940 Health Sector Support 1998 Ongoing Cr. 27183 Private Sector Adj. 1998 Ongoing 14  Table 3: Project Timetable - | Date actual/ Steps in Project Cycle Date Planned latest estimate 03/16/87 Identification (Executive Project Summary) 08/15188 08/15/88 Preparation 01/90* 01/16/90 Appraisal 10/90* 10/17/90 Negotiations ___ 12/13/90 Board presentation 12/21/90 Signing l 03/91* 06/18/91 Effectiveness 12/31/97 Project completion 12/31/95 12/31/97 Credit closing *Dates obtained from MOP Table 4: Credit Disbursements: Cumulative Estimated and Actual (US$ millions) FY1991 FY1992 FY1993 FY1994 FY1995 FY1996 FY1997 FY1998 Appraisal estimate 1.4 9.5 16.3 23.1 27.0 Actual 1.10 2.20 5.73 13.64 18.56 25.94 27.35 0% 12% 13% 25% 50% 69% 96% 100% Date of final June 5, 1998 disbursement 15  Table 5: Key Indicators for Project Implementation Component Planned Action Results Effect 1. Health Services A. Improve drug supplies Procure essential drugs and vaccines US$ 4 million essential drugs and vaccines Improved availability to drugs and and infrastructure purchased and distributed, estimated to vaccines, improved quality of care cover 7% of national drugs needs, 80% of vaccine requirements met Procure office and data processing Procurement completed Restructured Pharamceutical Unit able to equipment, vehicle for Pharmaceutical function better unit Rehabilitate Medical Stores: Rehabilitation completed Medical stores able to store drugs - Central MS - 10 regional stores - Teaching Hospital Store Procure office and data processing Equipment procured, training completed Improved inventory management equipment Train staff by using local computer programming consultant Train 3 staff 2 staff trained, literature purchased, Drug quality control testing expanded Purchase technical library materials laboratory equipped Equip drug testing laboratory Support training of Pharmacists and Pre-service training expanded to 3 years Better pharmacy skills available Pharmacy Technicians In-service training of 350 physicians, Training completed Improved rationale drug prescribing 350 medical assistants, 150 pharmacists and pharmacy technicians  Component Planned Action Results Effect Establish Drug Information Center Not done Missed opportunity to improve drug safety Train 500 health staff on cash and carry Training completed More efficient "cash and carry" system procedures Procure 10 vehicles for Heads of Vehicles procured Increased supervision and delivery of Pharmaceutical Divisions at Central and drugs at all levels Regional levels B. Regional and District Upgrade 2 health centers into hospitals Initial phases completed at both sites. Part Improved first referral hospital services Hospital Rehabilitation of total equipment needs procured. in remote areas Re-equip 7 MOH hospitals and 4 Rehabilitation completed and equipment Range and quality of hospital services mission hospitals installed and in use increased Utilization at facilities increased C. Support Primary Build & furnish 40 staff bungalows in All 40 bungalows completed and furnished Staff morale improved, decreased staff Health Care remote areas turnover Build 11 DHMT offices All completed, furnished, and in use Improved efficiency Improved work performance Build 10 health centers Centers built, equipment supplied, facilities Increased access to health care in use Supply 100 sets of health center Equipment installed and in use Improved quality of care equipment Procure and use 2 mobile workshops, Mobile workshops used and poorly run, I Reduced average duration of repair build 3 fixed workshops fixed workshop built Reduced proportion of repairs delayed due to absence of spare parts Reduced proportion of spare parts missing Procure 500 motorcyles for DHMTs 500 motorcycles purchased and in use Increased supervision and outreach clinics  Component Planned Action Results Effect Radio communications for DHMTs Prototype tested, none installed DHMTs' basic operational needs met 2. Population Services A. Support Procure contraceptives $2.3 million in contraceptives for PPAG; Increased use of contraceptives with full Population/Family $100,000 in injectables for MOH range of methods available Planning Training of Community Based 800 CBDs trained and supplied through Increased access to family planning, Distributors (CBDs) PPAG improved quality of services Rehabilitate PPAG clinics 26 PPAG clinics rehabilitated and Improved access and quality to family equipped; 82 bicycles purchased and in use planning services by PPAG staff (CBD supervisors) Train MOH staff in safe motherhood Training completed Better quality of reproductive health services. 3. Institution Building Strengthening MOH DHMT Training: District annual Plans of Actions completed Improved efficiency in district - Phase I in 3 regions management - Phase 11 in 7 regions Support for developing consensus and Workshops to develop consensus and GHS accepted and designs well designs for Ghana Health Service designs for development of GHS advanced; Bill passed to provide legal basis for GHS Support for development of human Workshops and consultancies to develop Human Resource Development Division resource plans consensus and plans for human resource prepared detailed policies, plans and planning procedures for managing personnel, training, and staff requirements Support for development of Medium MTHS workshops conducted, MTHS and Led to new health sector policy and Term Health Strategy and Program of POW completed, technical assistance used operational framework. A better Work articulated and comprehensive sector- wide program that is supported by donors and other health partners  Table 6: Studies Included in Project Purpose as defined at Study appraisaUredefined Status Impact of study District Studies: Anemia in Pregnancy Determine etiologic factors of anemia in Complete Led to increased treatment and prevention of pregnancy in Navrongo malaria in pregnancy Use of Medical Assistants in Review the development, training, and use of Complete Supported continuation of medical assistant PHC Medical Assistants in Ghana training Attitudes of doctors to rural Describe concerns of physicians in rural areas Complete Identifies types of incentives needed to retain postings in Volta Region physicians in rural areas Causes of infant malnutrition in Determine factors contributing to high infant Complete; Help health team to better design nutrition a fishing community malnutrition in a fishing community in Cape Study used messages in their communities Coast locally but not submitted to HQ National Studies: Quality of care assessment Provide a national baseline on perceptions of Complete Raise awareness of quality of care among public quality of care from providers and health and providers; provides a benchmark for future service users, and assess physical quality of monitoring sample of facilities Prevalence of non- Provide a baseline of the prevalence of non- Ongoing To be determined communicable diseases communicable diseases, risk factors, and disability  Table 7: Project Credit Costs Item Appraisal estimate (USS) Actual/latest estimate (US$) 1. MOH _ _l Civil Works 2,050,000 6,136,953.65 Drugs 3,380,000 3,937,964.23 Hospital Equipment & Spare Parts 2,850,000 3,689,638.35 Contraceptives 1,950,000 100,000.00 Other Equipment, spare parts, vehicles 7,880,000 7,410,488.84 fumiture, building materials, office supplies & vaccines Consultants' services & training 2,880,000 2,865,828.66 Operating cost 0 458,498.02 2. PPAG il Equipment, furniture, spare parts, 550,000 162,459.58 office supplies & vehicles l Contraceptives 1,700,000 2,337,065.51 Training 330,000 248,4444.23 3. NCS Hospital equipment, spare parts, vehicles & 750,000 20,828.81 maintenance equipment l Civil Works 0 24,162.79 Unallocated 2,670,000 0 TOTAL 27,000,000 27,354,390.55 Table 8: Project Financing Appraisal estimate (US$M) Actual/latest estimate (US$M) Source Total Total IDA 27.0 27.0 Non-govermmental organizations 0.4 -- |FGovernment of Ghana 7.0 1.5 20  Table 9: Status of Legal Covenants STATUS SELECTION NO. OF COVENANT C = In Comp. COMMENTS ACTION TAKEN OR CREDIT/LOAN CD = Compliance REQUIRED AGREEMENT after Delay CP = Comp. with Partially NC = Not in Compliance. NYD = Not yet due 2.02 (b) The Borrower shall open and maintain in dollars two special deposit C None accounts in a commercial bank on terms and conditions satisfactory to the Association. (i) Special Account PPAG for Part E.2 and 3 of the Project; and (ii) Special Account MOH for all other Parts of the Project. Deposits into and payments out of Special Account shall be made in accordance to Schedule 5. 3.01 (a) The Borrower declares its commitment to the objectives of the C On-going Project as set forth in Schedule 2 to this Agreement and, to this end, shall carry out the Project with due diligence and efficiency and in conformity with appropirate administrative, financial, public health, family planning and engineering practices, and shall provide, promtly, funds, facilities, services and other resources. 3.01 (c) The Borrower shall make available to NCS out of the proceeds of C the Credit, on a grant basis, an amount not exceeding the equivalent of SDR 590,000 for the purposes of Part C.2 of the Project under the NCS Agreement to be entered into between the Borrower and NCS under terms and conditions which shall bave been approved by the Association to protect the interests of both parties. 3.01 (c) (i) Require NCS to carry out Part C.2 of the Project with due diligence C and efficiency and in accordance with sound technical, financial, managerial and public health standards and to appoint a co-ordinator of its Project activities in accordance with Section II of Schedule 3 to this Agreement. 3.01 (c) (ii) Require NCS to maintain adequate records and accounts with respect C None to the Project activities and to have them audited in accordance with the provisions of Section 4.01 of this Agreement. 3.01 (c) (iii) Require that: (A) the goods and services to be financed out of the C None proceeds of the Credit shall be procured in accordance with Schedule 3 to this Agreement; and (B) such goods and services shall be used exclusively in carrying out the project, and 3.01 (d) The Borrower shall make available to PPAG out of the Credit, as a C grant not more than SDR 2,040,000 equivalent for Part E.2 and 3 of the Project under the PPAG Agreement. 3.01 (d) (i) Require PPAG to appooint a qualified coordinator of its Project C activities. 3.01 (d) (ii) Require PPAG to maintain records and accounts and to have them C audited in accordance with Section 44.01 of this Agreement. 3.01 (d) (iii) Require that: (A) goods and service to be finance under the Credit C be procured in accordance with Schedule 3 to this Agreement.  STATUS SELECTION NO. OF COVENANT C = In Comp. COMMENTS ACTION TAKEN OR CREDIT/LOAN CD = Compliance REQUIRED AGREEMENT after Delay CP = Coup. with Partally NC = Not in Compliance. NYD = Not yet due o 3.02 The Borrower shall make available to other NGOs out of the Credit, CP None as a grant, not more than SDR 220,000 equiv. for Part C.3 of the Project under agreements between the Borrower and respective NGO under terms and conditions approved by the Association and which shall include substantially the provisions in the NCS Agreement taking into account specific requirements of the mission hospitals. l 3.03 The Borrower shall provide contraceptives to NGOs involved in C Forwarded through family planning activities under arrangements acceptable to the PPAG Association. 4.01 (a) The Borrower shall maintain, or cause to be maintained, records and C Ongoing accounts adequate to reflect in accordance with sound accounting practices the operations, resources and expenditures in respect of the Project to be executed by the responsible departments or agencies of the Borrower. 4.01 (b) (i) The Borrower shall have the recoreds and accounts audited by C Ongoing independent auditors acceptable to IDA. __l 4.01 (b) (ii) The Borrower shall furnish to the Association, not later than six C r'3 months after the end of each fiscal year, a certififed copy of the audit report. 4.02 Until the completion of the Project, the Borrower shall, on the C occasion of the annual public expenditure review to be undertaken by the Borrower & the Association or, in the event that such a review does not take place, no later than Dec. 31 of each year, furnish to the Association MOH's recurrent budget for the next fiscal year and the 3-year public investment program in the health sector all acceptable to Association. 5.01 Additional effectiveness conditions are: C MOH has done expenditure review as part of Govt's PER in .__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1995. _ _ _ _ _ _ __19 9 5 5.01 (a) (a) the NCS Agreement has been executed on behalf of the Borrower C and NCS. 5.01 (b) (b) the PPAG Agreement has been executed on behalf of the C Borrower and PPAG; and 5.01 (c) (c) the Borrower has appointed within MOH and full-time C None coordinator and a full-time procurement specialist with qualifications and experience satisfactory to the Association and to be responsible for all projects in the health sector financed by the Association.  STATUS SELECTION NO. OF COVENANT C = In Comp. COMMENTS ACTION TAKEN OR CREDIT/LOAN CD = Compliance REQUIRED AGREEMENT after Delay CP = Comp. with Partially NC = Not in Compliance. NYD = Not yet due c 5.02 Additional matters to be included in the legal opinion or opinions to be furnished to the Association are that the NCS and PPAG Agreements have been duly authorized or ratified by the Borrower and NCS and PPAG, respectively, and are legally binding. , Schedule 4: 2 To facilitate the involvement of NGOs in carrying out the Project CP To be susperceded by and related activities in the health sector, the Borrower shall prepare, MTHS. not later than June 30, 1991, a master framework agreement acceptable to the Association governing the relationship between MOH and NGOs in areas of health and population activities. l Schedule 4:3 MOH shall continue its program of appointing full-time heads of the C District Health management Teams and appoint: 10 additional heads not later than December 31, 1991. Schedule 4: 4 MOH shall expand, not later than December 31, 1991, health care C outreach service to all regions. Schedule 4: 5 MOH shall prepare and furnish to the Association for its review and C Superceded by MTHS. comments, not later than December 31, 1991, a program for the expansion of the primary health care coverage. Schedule 4: 6 (a) (a) design not later than December 31, 1991, a management and CP There are two MIS health information systems; and systems in MOH, MOH will legitimize HRS MIS for HRD Division. Schedule 4: 6(b) (b) after having reviewed this system with the Association, C Sperceded by MTHS. implement such a system not later than December 31, 1992, taking into account the Association's comments. Schedule 4: 7(a) MOH shall prepare and furnish to the Assocation for its review and C Done in context of comments: (a) not later than September 30, 1991, staffing norms for MTHS. health facilities. Schedule 4: 7(b) (b) not later than March 31, 1992, a manpower master plan, and C None Schedule 4: 7(c) (c) not later than June 30, 1992, a master trianing program for health C None staff.  Table 10: Bank Resources: Staff Inputs Stage of Planned Actual Project Cycle Staff Weeks US$ Staff Weeks US$ ('000) ('000) Preparation to appraisal 10.2 21.4 Appraisal 30.1 69.1 Negotiation through Board - - 34.1 82.5 approval Supervision* 37.8 66.3 144.5 280.4 Completion* 15.1 31.2 7.8 17.0 TOTAL 52.9 97.5 226.7 470.4 *Information available from FACT only for FY96-FY98. 24  Table 1 : Bank Resources: Missions Performance Rating Stage of Month/ Number Days Specialized* Implemen. Develop. project cycle year of in staff skills Status Objectives persons Field represented Preparation 04/89 3 12 SP,TM,HS Through 06/89 1 7 TM Effectiveness 08/89 1 14 TM 10/89 4 22 TM, SP, HS, PS 01/90 1 24 TM 06/90 2 12 TM, HS Supervision 03/91 4 20 PS, SP, OA, TM 11/91 3 18 PS, TM,SP 3 2 03/92 3 18 SP, TM, PO 06/92 2 8 SP, PO 3 3 02/93 2 16 SP, PO 3 3 08/93 3 20 PHS, HE, SPHS 2 3 09/93 3 18 PHS (2), HE 06/94 3 7 PO,SP, HE 10/94 2 7 HE, SP 05/95 3 5 PHS, PO, HE S S 09/95 3 22 PO, PHS, HE 02/96 3 2 PO, PHS, SOO 06/96 3 2 PHS, PO, OA S S 10/96 3 2 PHA, PO, OA 03/97 3 12 PHS (2), PO, S S Completion 09/97 3 5 PHS, PO, PHE S S 04/98 2 3 SPHS, PO _ _I *Key to Specialized Staff skills: TM=Task Manager; SP=Senior Planner; HS=Health Specialist; PS=Pharmaceuticals Specialist; PHS=Public Health Specialist; P-Procurement Officer, OA=Operations Analyst, PO= Project Officer, SPHS= Sr Public Health Specialist, HE= Health Economist, SOO=Sr. Operations Officer, PHE= Public Health Engineer 25  IMPLEMENTATICIN COMPLETION REPORT REPUBLIC OF GHANA SECOND HEALTH AND POPULATION PROJECT fCr. 2193-GH] APPENDIX Borrower's Contribution to the ICR  Page 1 of 4 SECOND HEALTH AND POPULATION PROJECT END OF PROJECT ASSESSMENT 'BY THE MINISTRY OF HEALTH, GHANA MAY 1998  Page 2 of 4 A. BACKGROUND The Second I-fealth and Population Project - 2HPP- (Cr 2193-Gil) was a follow on project to the Ihealth and .Education Jroject (REP) (Cr 1653-GH). The HI.P was an emlergency project to slow down the rate of deteioration and to eventually begin the rebuildin_4 process. The 2HPP built on the first project by attempting to movc from an emergency/supply project to a policy and institutional development projectL The objeeLi ves of the project were to (a) increase the quility and coverage of services and (b) increase the availability and accessibility of family planning services The project had 6 components as follows; * drug supplies and drug infrastructure rehabilitation * strcngthening the Ministry of HealtSh (MOR) * regional and district hospitals * prinaiay hcalth care (PHC) * zpopulaionlfaniily planning * prizes fund IMPLEMENTATION OF THE PROJECT Very little was achieved during the first two years of project implementation. This was mainly because project implemcntation was left in the hands of 'consultants' in the Projec Management Unit (PMU) whilst acion to meet conditionalities for effectivencss and disbursement was ecpected to be taken by line MOR stafE It was not until mid 1992, when steaf ;f i.Lc MOE. took over the PMU -that soinc progress started to be made. After a mid-termi review in Jlune 1994, several bottlenecks were eased and implementation improved aremendously. ProcurcmenE and Civil Works The areas where substantial progress was made was in the areas lhat involved procurement and civil works. Durng the lifc of the project, drugs procuremenr was importanc in re-capitalising the revolving drug fimd and maining operations. a substantial proportion of annual vaccine requirements (up to 80% in some years) were provided 1rom the credit and in thc last two years, medical consumables including laboratory reagents were provided. The civil works component involving rehabilitation of the Central Medical Stores and 7 Regional Medical Stores; construction of one new Regional Mcdical Storc, 40 Bungalows, 11 offices for District Health Managemnent Teams, 10 lealth Ccntres have beec completcd Also, the upgrade of two health- centres in Walewale and Zebilla to District Ilospit.ls Wcl1 provide hospital care to 2 under-servecd areas.  2Xf'. . 1_.4l 7 .-'^ 1i 227- F .C $ BANK GHAIt 'Page 3 of 4 Population and Family Plan Progress w.ade in this arca was mainLy limited to activities of NOOs - The Planned Par=nLhood Association of Ghana (PPAG) and the Mayday Rural Project Thcsc NG Os received conLraceptvc supplies tbro.zhot:t the project priod and PPAG was supported with cLinic furniture and equipment to expand their serviccs, and funds for the training and support of conrnunity based distr.butors of family plxming commodiries. Tn fact, PPAG has pioneered CBD training mad support maerialssystms in GTzia Their systEem for the LrUining and support of CBDs has eventually been the basis of the I014 progamTmie. ln addiionU, 8 trekking vehicles were bought for PPAG regional activities The MOIH ,ads h-owever not supported as planned under this component because most of the con czpUive needs were provide by UTSAM and LTNFPA H:owever, fands under the projec was used for the training of 4octors and nurses using thc safe motherhood guidelines atnd protocols. Primary i-tcalth Care (PHC) For PHC, die support came through the provision of furniture to DiFTMT offices mad Lle consauctioii of bunaLows for Dismict Directors of Health. SerVices. This in no small ;way faciiarca rfie place.ment of doctors to marage district healdh services. By the end of rhe projcct, disaicts wirh subsrantive Distric: Directors more Lhan doubled from below 40 to over 80 cdisrnicts (our of a total of 110 districts. Also. rhc prolision of hospital equipment to all dstrict hosprimls in the 3 Norther rei6ons as well as I o1 sets of hcalth centrc eqtiprment the consruction of 10 new health cencres and the reabilitiLaon of over 30 health centres in the northern sector all wenLt to improved rhe capacity co deliver disLrct health services. In last years of the project, the agreement to buy 500 motorbikes was a major boost to Pf:iC services, par-mcularly outreach. Pharm;ccuticals Apart from thle procurement of about S4 million worth of drugs and vacciacs, the pharmaccutdcal sector was supported w&ith 10 trekldng vehicles - one to each regional 'Cash andi C=riy' coordinator. Pharmacists were also trained in the manEagl of die drug revolving fund, so called 'Cash ancL catty'. The project. .upported the pre-service traLing of pharmacy techniciansinpoe s; n-servncc training of prescribers in rationOa prescripti on ad the provision o r equi p=et to the Univcrsity of Science and Tcchoio]O Pharnacy department to -support a quality testing I ahcx arozy.  Page 4 of 4 Institutionail IDevelopment The main activity under the project relaed to instiutrional dcvelopment was in thC reorganisaLion of the Ministry. This was a conditionaliLy and so a cOnsu]tanL vZas contractea to make a proposaL but this proposal was not acccpted by the MOL lnstead, the MOH starred a consiutalve proccss which has rcsulted in the cuirent structure of tlec MOH whichi now been rcorganscd from programmes to divisions based on functon. GENER4L CONMFNTS ON TBJZ ACIBEVEM-ENTS OF THE PROJE CT Iu physical tcrms, dhe projcct largely achicved its aim after 2 extensions which made up for the inital 2-yearinertiain implementation. The DMO bungalows, the health centes, the furnishing of DIIMT offices coupled with the requirement that the Govenment of CThana must build them, the rchabilitated medical stores, the drugs, vaccines, equipment and vehiJics procured etc, all provided much needed inputs lo the health sector. The project was much less successful in terms policy devcloprnaent and instional/system capacity developmen In the first half of the project fDA support concenLraced on policing the extent to wnich Bank Procedures were sictcrly adhered to, paricularly in the areaof procurement As a project with its separate PMU, most of these requiremeats which should havc resulted in wider institutioral improvements ended up as discrete and limited exercises to satisfy TDA. However. dunrng the second half of the project, IDA took the lead in supporting the refonr process in the he-alth sector of Ghana. In particular, IDA gave its no obiection to using credit Cunds to contribute to the development of a policy vision (The Medium Hcalth St-eregy); a programme of work ard a finmacing envelope (The 5-Year Programme of Work): and to defimng the maagermcnt anrangements thaL will allow several donors to support the 5-Year Programme of Work by combining their effort. Ihis reform provided a clcar policy vision as well as a credible programmc as the basis for health developmenit by both govcrnment and donors. This approach influenced the developmcnt of thc next credit and in the long terTm will form the basis for sustainable, progressrve improvements in the capacitv of the health sector to acliver the services required to keep iniproviiig the health of (ilanaians.