Ghana - Second Health Sector Program Support Project

Report No. PID10725 Project Name GHANA-HEALTH SECTOR PROGRAM SUPPORT (@) PROJECT II Region Africa Regional Office Sector Health (100%) Project ID P073649 Borrower(s) GOVERNMENT OF GHANA Implementing Agency Address MINISTRY OF HEALTH Address: PO BOX MB-44, ACCRA Contact Person: Dr. Kwaku AFRIYIE Tel: (233) 21 665323 Fax: (233) 21 663810 Environment Category B Date PID Prepared December 17, 2002 Auth Appr/Negs Date November 6, 2002 Bank Approval Date January 30, 2003 1. Country and Sector Background Country Background. By international standards, Ghana GDP growth has been relatively good 4-5 percent per annum on average during the last 15 years). Following the initiation of Ghana's structural reform program in 1983, economic growth was rapid (5.2% p.a.) in 1985-89. Growth became much more volatile and exhibited a downward trend during the first half of the 1990s when the reform process stalled. Since then, the economic growth displayed a rising trend with the exception of 2000, when fiscal lapses during the election year resulted in a financial crisis and substantial exchange rate devaluation. Ghana's economic development has been accompanied by a steady reduction in poverty. Compared with other countries with similar growth rates, Ghana's poverty reduction appears quite rapid, decreasing from 52 % in 1992 to 40 % of the population in 1999, while the economy grew by 4.3% p.a. on average. Compared to other countries, Ghana's income inequality is low, which may explain why economic growth has such relative large impact on poverty reduction On January 7, 2001, the newly elected government inherited a difficult fiscal and social situation. Due to shortcomings in fiscal management and delays in adjusting public utility prices, the fiscal and quasi fiscal deficit had reached an estimated 23% of GDP in 2000, while contingent fiscal liabilities amounted to 8 percent of GDP. Both factors created the prospects of a debt trap with rising fiscal deficits being caused by domestic debt build-up and high real interest rates. Since then the Government has put in place a macro-economic program aimed at getting Ghana out of its debt trap by drastically reducing government's borrowing, cutting public enterprises' deficit and restructuring the domestic debt. As a result of much tighter fiscal and monetary policies, the exchange rate stabilized , external reserves reached 1.5 months of imports and the  domestic financing of the budget was cut from 8 W of GDP in 2000 to 0.8 ; in 2001. The new government also decided to avail itself of the debt relief possible under the HIPC initiative. In February 2002, Ghana reached its HIPC decision point with a floating completion point expected to be reached by end-2003. The debt relief provided under the HIPC Initiative would amount to an average of US$ 215 million per year in 2002-2011. The macroeconomic outlook for the period 2002-2006 depends crucially on the success in generating a domestic primary fiscal surplus. Without better expenditure control-especially on the capital budget- and improved revenue collection, stabilization will not been achieved. The 5t growth in GDP projected is to come from improved agricultural performance, industrial recovery and continued service sector growth. Health sector situation During the past decade, the health status of the population has significantly improved, reflecting progress achieved in several directions, including in the delivery of essential health services. From 1988 to 1998, life expectancy at birth has continued to increase while infant and under five mortality rates have been significantly reduced ( by 25%). Fertility has declined markedly in every age group with a nearly two child drop in the total fertility rate over the last decade. Ghana compares generally very favorably with other African countries. If trends recorded during the first part of the 90's have been maintained, Ghana would be moderately off track or almost on track with the Millennium Development Goals. ( the next Demographic and Health Survey is planned for 2003) Considering the low level of total spending on health (about US$20), Ghana has achieved a great deal. Progress towards achieving the health targets has, however, been less than anticipated and the spread of the gain in terms of improved health has been relatively inequitable. Outstanding challenges still confronting the health sector include the high maternal mortality rates, the persistence of communicable diseases like malaria and tuberculosis, and the newly emerging non communicable diseases and relatively high levels of death and injury from road traffic accidents. With a sero-prevalence at 3%, HIV/AIDS poses a major threat to health and development. During the period of the first Program of Work-POW of the Ministry of Health (1997-2001), 1) Geographical access to static health services continued to improve and utilization of publicly financed services increased by 25% , the highest increase in utilization (95%) being observed in the Northern (and poorer) belt of the country., 2) The coverage of key essential public health services was significantly improved. Immunization against measles increased from 57% in 1997 to 82.4% in 2001 while DPT3 rose from 51% in 1996 to about 80% in 2001. The TT2 immunization rate went up from 37% in 1996 to 73% in 2001. Antenatal coverage increased from 84% in 1996 to 98% in 2001. Supervised deliveries went from 38t in 1996 up to 52t in 2000 and post natal coverage (1 visit) increased from 33% in 1996 to 50% in 2001. -2-  Main sector Issues: Five main issues deserve particular attention in the context of the 2002-2006 Program of Work : (a) the persistence of deep inequalities in health, (b) the chronic under funding of the health sector, (c) the intense brain drain and unequal distribution of staff, (d) the untapped potential contribution from private providers and, e) the potential devastating impact of HIV/AIDS on the health sector, the economy and the society which makes it the single most important issue in the years to come. a) Persistence of deep inequalities in health: A "Profile of health inequalities in Ghana" was prepared in 2000 to define the extent of health inequalities in terms of health outcomes, gender, urban-rural location, regions, incomes, health resource allocation and health expenditure. The Profile showed that, in Ghana, the largest differential in health outcomes is by region of residence with the least differential being by gender. However, it was also observed that between 1988 and 1998, urban-rural differentials have got worse whereas regional differentials have remained, on the whole, largely constant. The northern section of the country is significantly disadvantaged on multiple health dimensions. The Under Five mortality rate there is 2.5 times higher than in the Greater Accra Region. Whereas the rate in Greater Accra Region is 62, it is 171 in the Northern Region, 156 in the Upper West Region and 155 in the Upper East Region. As a result of both higher public and private investments, health facility distribution also favors most affluent regions. The Greater Accra Region with about 12t of the national population account for 42t of total public doctors and 18t of hospital beds. In contrast the northern regions with 20t of the population account for 6t of total doctors and 14t of the total hospital beds. A disproportionate share of the funds is allocated to urban areas. It has also been estimated that the richest households benefit about three times more from government expenditures on health than the poorest (Canagarajah S and Xiao, WB, 2000). More positively, it has been observed that, on the whole, women benefit more than men from government expenditure on health b) Under funding of the health sector. The percentage of GDP allocated to public health care expenditures from government revenue through MOH decreased to reach a low level of barely 1l in the mid90s. With the start of the POW I, these allocations were increased and total public health care expenditures (incl. donor funding) amounted to around 2.3w of GDP over the period. The MOH recurrent expenditures as a percentage of total GOG recurrent expenditures (narrow, excl. interest) have decreased from 11.19 in 1991 to around 7T during the period 1994-96, but increased again to reach 11.49 in 2000 and 11.0w in 2001. During the same period, the share of the total government expenditures (all items) spent in the health sector decreased from 8.2w in 1991 to a level of around 4.6w in 1994-97 with a slight upward trend that continued ending at 6.9w in 2001. In spite of recent GOG efforts to increase its allocations to the health sector and mainly due to macro-economic constraints, total spending on health remains very low, estimated at about US$20 per capita, out of which approximately US$14 -3 -  (70%) are private expenditures. Excluding foreign finance, public health spending reached US$4.2 in 2000, below the level of US$6 available at the beginning of the 1990s and far below the level of US$10 per capita in 1978. Including external finance, the per capita public health spending was estimated at about US$6.4 in 2000. Continued progress will require a substantial increase in financing. In the current economic context, user fees and out-of-pocket payments cannot be increased much further without exacerbating inequalities. The GOG is committed not to increase out of limits the private payments, to progressively abolish the "Cash and Carry" front payment system and replace it with health insurance and community based prepayment schemes. Therefore, the required additional resources will have to come firstly from an increase in GOG budget allocations to the health sector (including inter alia funds freed by the HIPC debt relief initiative) and secondly from an increase in donor contributions to the MOH POW. c) Intense brain-drain The two national medical schools together train about 120 doctors, while the school of pharmacy trains about 80 pharmacists per annum respectively. All work at full capacity. Ghana also trains about 400 State Registered Nurses, 250 midwives and 200 Community Health Nurses annually and could produce more if the capacity of the schools is fully and effectively utilized. The final output, however, only just makes up for staff loss through attrition and brain drain every year. Government sources suggest that there are more Ghanaian doctors working abroad than in Ghana and that the total number of nurses working in Ghana has dropped from about 30,000 in the early 1990's to about 20,000 at present. Due to the low level of emoluments paid in Ghana and the attractiveness of international labor markets, it is unlikely that the exodus of health personnel can be stopped. Pragmatic interventions can certainly help retain at least the critical mass of health professionals required to deliver a package of basic services. However, it is unlikely that human resource issues can be addressed effectively without significantly increasing the wage bill. This poses a major challenge in terms of sustainability, as the health sector wage bill will need to be contained within an affordable sector budget. c) Untapped potential for contribution from non government health service providers The private provision of health care in Ghana is quite substantial and is recognized as an important and growing source of health services. Among the hospitals, 47% are government owned, 22% operate on a private not for profit basis and 31% on a private for profit basis. While the tertiary and secondary hospital and the health center levels are dominated by the government facilities, the lower level services are more pluralistic. It is estimated that in 1998/1999 almost half of all visits to health facilities occurred in the private sector . The mission facilities alone are estimated to cover 40% of the population, supplying an estimated 30% of beds and 35% of outpatient care. The Government has supported the need for closer cooperation with the -4 -  private sector throughout the 1990's. In many districts, the mission hospitals provide essential services and receive funds from MOH to pay salaries of staff seconded from MOH. Some mission hospitals that have been designated as district hospitals receive funds to cover other running costs. However, this has been very slow to reach its potential despite the establishment of a Private Sector Unit in the Ministry in 1997. The new government is however, emphasizing more strongly the importance of involving the private sector more in integrated service delivery and is committed to increasing its role in curative service to 65t in the long term. d) HIV/AIDS. The recently created Ghana AIDS Commission (GAC) estimates that the national sero-prevalence could rise from the current 3t to somewhere in the range of 4 to 9t in 2014, depending on the efficiency of prevention and control measures. At the current rate of infection, by the year 2005, 1.2 million people will be living with HIV and there will be about 200,000 children orphaned by AIDS. The potential devastating impact of AIDS on the health sector, the economy and the society makes it one the single most important issues in the years to come. The HIV/AIDS epidemic has for some years now been receiving more attention from government. A "strategic framework for HIV/AIDS" has been prepared to enable Ghana to implement a balanced, diversified, multi-sector response, engaging all relevant government sectors, nongovernmental organizations and grassroots initiatives. 2. Objectives The overall objective of the 2002-2006 MOH Program of work- titled "Partnerships for Health: Bridging the inequalities gap"- is to improve the health status of the population while reducing the geographical, socioeconomic and gender inequalities in health outcomes. The IDA financed Health Sector Program Support Project-II (HSPSP-II) will support the Government of Ghana efforts towards the above mentioned objective and the Ministry of Health in implementing its 2002-2006 Program of Work (POW-II), through financing a portion of the combined Government and external assistance budgets for policy development and operational program activities, including on going service delivery and new initiatives. 3. Rationale for Bank's Involvement There are several development agencies active in the health sector in Ghana, contributing with both financing and technical assistance to the MOH Program of Work. Although increasing, their financial support remains relatively insufficient to raise the total public health expenditure up to a level where the cost of a basic package of health intervention can be covered. The financial support of the Bank will bring one additional US$ dollar per capita and per year and will help cover the financing gap. The day to day implementation support of the Bank team will assist the MOH in improving its procurement and financial management systems. These are areas where the comparative advantage of the Bank is acknowledged by both the MOH and the partners. Waiting for the National Laws and Procedures to - 5-  be improved up to a level acceptable by all partners, the World Bank procurement procedures will be used for all ICB contracts to be financed under the Program, irrespective of the source of funding ( GOG budget and the Health Account). The fact that the World Bank will keep an oversight on procurement makes partners in the pool more confident regarding the use of resources. The Bank has gained substantial experience in supporting health sector reform programs and cost effective health interventions. Acting as a knowledge broker, the Bank will team bring this knowledge and experience to Ghana including sharing best practices approaches from other countries to addressing specific health problems as well as fostering a debate on new ways of doing business in the health sector, with a particular focus on continuing further programmatic support, promoting public-private partnerships, new ways of addressing human and financial resource challenges, and broadening health financing options. The Bank also plays an important role in the overall policy dialogue with the GOG. It is engaged in policy-related programs particularly at the macro-level and this will help improve the consistency between the health, economic and development policies. This has proven to be effective in the past. For instance when the new government had to put in place tighter fiscal and monetary policies, the Bank's interventions sectors resulted in a relative protection of HD sector from cutbacks. 4. Description Government Strategy and Program of Work The 2002-2006 Ministry of health Program of Work ( POW-II) is an integral part of the Ghana Poverty Reduction Strategy (GPRS). The objective for the period 2002-2006 is to continue to improve the health status of the population while focusing efforts on reducing inequalities in health. The POW-II serves as a plan for the whole health sector and describes those health activities funded through public resources, including Government, donors, and internally generated funds. The Program covers both policy development and operational activities and ongoing delivery as well as new initiatives. The details of the MOH POW are expected to change from year to year as reflected in annual work programs and budgets. The POW-II is built on five strategic pillars (the same as for the POW- I): 1) To increase (geographical, financial and socio-cultural) access to health services, 2) To improve quality of health delivery, improving health worker performance and responsiveness to clients needs, 3) To improve the efficiency of health service delivery, improving cost effectiveness and planning, management and administration, 4) To foster partnerships in improving health (with households and communities, between public and private providers, with other ministries, departments and agencies, with development partners and 5) To improve financing of the health sector, extending prepayments schemes to replace the "Cash and Carry" systems, developing an appropriate policy and regulatory environment for health insurance, increasing public expenditure on the poor and vulnerable. -6-  Within the overall framework, the MOH will focus its efforts on the 10 following areas: 1-Strengthening priority health interventions, 2) Developing human resources for health services, 3) - Enhancing infrastructure and support services, 4) Fostering partnerships for health, and promoting private sector participation in health service delivery, 5) Improving regulation, 6) Reforming organizational arrangements, 7) Improving the health sector financing, 8) Improving financial management systems, 9) Further strengthening management information systems and performance monitoring, 10) Linking with traditional medicine. The projected resource envelope for the POW-II operates with a high and low case scenario. The total resource envelope for the 5 year sector program is estimated to be US$ 1.013 million in the low case scenario and US$ 1,113 million in the high case scenario. The MOH Program of Work will continue to be funded from four broad sources: (i) Government budget will finance 50% o the total Program budget, (ii) Internally Generated Funds (IGF- user fees) will finance about 11% , (iii) the donor Health Fund and (iv) other parallel donor financed activities (traditional projects, earmarked funds) will finance the remaining 38/399 of the total cost. The sector policy guidelines for resource allocation are to: (i) make more resources available for the attainment of universal access to primary health services, (ii) achieve a better balance between development and recurrent budgets and, (iii) realign existing inequalities in regional allocations. The US$237 million proposed capital investment plan is based on the following set of guiding principles: retention of staff through the provision of staff accommodation; development of human resource capacity through the rehabilitation and expansion of training schools; reduction of geographical inequities in accessing health care; enhancing complementarity to avoid duplication at all level levels; increased collaboration and partnership between Ministries Department and Agencies (MDA's) Development Partners and the Private Sector; and Directing adequate resources to the provision of facilities in the deprived regions in line with the GPRS. On average, 43? of the total resource envelope will be allocated to wages. The share for wages is planned to increase from 38% in 2002 to 48% in 2006 in order to recruit and maintain the necessary staff. On average, 43% of the total resource envelope will be allocated to cover the costs of administration and services (item 2 and 3). Only minor shifts in resource allocation by level of service of non-wage recurrent costs (item 2-3) between levels are planned with the share of resources to the district level maintained at about 42%. This implies that the expected increase in the resource envelope for non-wage recurrent costs will primarily benefit the lower levels of care. The three northern regions and Central region have been identified as priority areas. Overall the percentage of recurrent expenditure on disadvantages districts of the country should increase. Therefore, the target is to allocate 39% of recurrent expenditures to the three northern and central regions (which amount for 26.7% of total population of Ghana according to the 2000 population census). IDA Support -7-  The IDA Financing ( including a US$ 15.9 million Grant and a US$ 71.4 million IDA credit) will finance a portion of the combined Government and external assistance budgets for policy development and operational activities, and both on-going service delivery and new initiatives. The 2002-2006 Program of Work, the detailed annual Work Programs, Budgets and procurement plans prepared by the Ministry of Health will continue to provide the basis for which the World Bank will operate. IDA will first provide US$7.5 million in reimbursement of expenditures incurred in 2002. IDA will then provide US$ 15 million in 2003 and a baseline financing of US$20 million per year in, 2004, 2005 and 2006. A US$7.5 million unallocated component is set aside to allow for adjustment of the annual IDA allocation during the implementation of the POW. Prerequisites for IDA transfers would be as follows: 1- Organization by the Borrower of an annual sector performance review and presentation/discussion with stakeholders including the civil society and the development partners of the review report during the April/May health summit and endorsement of the review findings and conclusions; 2- Presentation by the Borrower of a draft annual POW for the upcoming year during the September/October Health Summit and endorsement of this POW by all core donors and, submission for review and clearance by the Bank of a three year rolling procurement plan.3- Submission by the Borrower of the annual MOH budget that is submitted to parliament; and, 4-Submission of the external independent procurement and financial management audits for the previous year as well as action plans to address issues identified. In addition to its financial support, the Bank will provide implementation support. Year 2002: US$ 7.5 Year 2003: US$ 15 million Year 2004: US$ 20 million Year 2005: US$ 20 million Year 2006: US$ 27.5 (including the 7.5 US$ million unallocated component for adjustment of the IDA allocation 5. Financing Total ( US$m) BORROWER $637.86 IBRD IDA $74.10 LOCAL COMMUNITIES $75.00 IDA GRANT FOR POOREST COUNTRY $15.90 FOREIGN SOURCES (UNIDENTIFIED) $310.00 Total Project Cost $1112.86 6. Implementation Program implementation arrangements The program will be implemented through the regular channels of the Government. The MOH will remain responsible for policy, monitoring, coordination of donors and inter-sectoral agencies, and public financing for health services as well as regulation within the sector. The Ghana Health Service and two Teaching Hospital Boards have been established to - 8 -  manage the delivery of a decentralized public health service more efficiently. District Health Administrations, located in each of the 110 districts, are responsible for organizing the local provision of health services. All these will prepare and implement health budgets and monitor the performance of serviced delivery with responsibility and authority delegated to various (about 350) Budget Management Centers-BMCs. All BMCs will prepare annual plans and budgets for their area of responsibility according to issued guidelines and budgetary ceilings with regard to non-salary recurrent expenditures, for which they will be provided with finances. Agreement has been made between donors and MOH to use, as far as possible, common implementation arrangements for planning and budgeting, implementation, including procurement of civil works, goods and TA, as well as financial management (disbursement and management of funds, accounting and audit) and reporting on progress. Institutional arrangements: There will be no separate implementation unit and the World Bank support will be implemented using the regular channels of the Government. The MOH will remain responsible for policy, performance monitoring and coordination of partners, whereas the Ghana Health Service, the Teaching Hospitals Boards and other Budget Management Centers as well as the contracted mission sector will be the executing agencies. IDA Disbursements: No IDA Special Account will be established. Most of the funds committed by IDA will be disbursed directly into the common separate US dollar bank account under the Health Account. The Health Account is under the direct control of MOH headquarters and the Controller and Accountant General. These disbursements by the Bank will be made in reimbursement of a portion of already incurred expenditures. Withdrawal applications will be submitted to the Bank by the Financial Controller of the MOH. IDA funds are planned, in principle, to be disbursed into the Health Account on a quarterly basis. However, this periodicity could be revised and IDA direct disbursements into the Health Account used as a swing payment" to help manage cash flow variations of the MOH. The MOH will have also the option to request part of the credit to be drawn down using the Bank's direct payment and special commitment procedures. Although it is not possible to determine ex-ante the exact portion of the Credit that may be used under this disbursement procedure, it is expected that a part of the annual credit funds will be used to assist MOH with: 1) Advance payments to the UN agencies for the supply of vaccines, drugs, medical equipment and vehicles and, 2) direct payments to international suppliers for major procurement for MOH carried out using ICB procedures. Flow of funds The MOH operate 1) a US dollar account into which all donor contribution (from those donors participating in the pooled arrangements) are paid to finance the agreed POW and, 2) a Ghana cedi account into which transfers from the dollar account are paid. A separate Ghana cedi account will be used for the funds provided by GOG. Funds are then transferred to the BMCs accounts. All BMCs operate at least three accounts for a) Government of Ghana releases, 2) donor pooled funds from the Health Account and 3) internally generated funds. Once IDA and other donor funds reach the Health Account, there will be no further identification of the origins of funds by donor 9  Eligible expenditures: The Health Fund (and therefore the IDA credit funds pooled into the Health Account) will not finance wages, honorarium and salary top-ups, taxes and land acquisition. Eligible expenditures include all non wage categories of expenditures, including civil works, goods and services, drugs, vehicles, operating costs, training and consultants as long as these conform to the approved annual budget, work program and budget as well as procurement plan and adhere to the agreed procurement procedures. Procurement: All procurement under the Program of Work will be carried out following the provisions of the Procurement procedures Manual of the MOH. As agreed with MOH and partners, all contracts for works, goods financed under the Program (including those funded directly by the Government) through International Competitive Bidding (ICB) and consulting services will be procured in accordance with the relevant World Bank's Guidelines. In the event of mis-procurement (whether identified in the annual audits or otherwise), IDA will reserve the right to declare mis-procurement on any contract in the joint financed pool and will cancel the entirety of the declared mis-procured contract or a part of the credit based on IDA' share of the pool . Accounting procedures and financial reporting: The MOH's own financial accounting manual- known as the Accounting Treasury and Financial procedure rule book (ATF rules) adopted in 1998 will continue to be used to guide financial management staff in the conduct of their operational activities. Budgeting and reporting systems will continue to be maintained at adequate levels and accounting staff of all Budget Management Centers will be re-trained in the use of the rule book. As a condition for effectiveness, the MOH will adopt a Financial Procedures supplement satisfactory to the co-operating partners setting out any additional financial management arrangements, organizational structure (including internal audit function), staffing, standard accounting forms, books, ledgers and reporting format content and frequency of the regular financial monitoring reports to be provided by MOH during the implementation of the Program. . Budget Management Centers-BMC will submit monthly financial report to the next higher levels. he regional level will monthly consolidate all reports for the region and submit it quarterly to the Reporting and Analyzing Unit in the Finance Department in MOH.Quarterly consolidated financial statements for the entire sector will continue to be prepared and certified, as since the inception of the first program, by the MOH Financial Controller. Auditing: In addition to internal audits carried out by the MOH and the GOG Auditor General Office, the MOH will appoint 1) an independent auditor acceptable to the Co-operating partners to audit the consolidated set of financial statements (including the financial monitoring reports and Health Account) for the overall Program of Work of the MOH for each fiscal year ended. The TOR for the audit shall be acceptable to the cooperating partners and the audit will have to be conducted in accordance with auditing standards acceptable to the Co-operating partners, consistently applied and ii) an independent agent to review the procurement that took place during the end. While audits would normally be provided annually, when particular risks have been identified, any - 10 -  cooperating partners (and the Bank) may request a special audit to be conducted or may send addition missions for further investigations. Monitoring and Evaluation arrangements: Joint government and donor monitoring of the program will occur on a regular schedule. Government and donors have agreed on a set of 25 indicators (30 including health status indicators) to monitor the sector performance and sector wide progress over the years. This system will be progressively extended to private facilities and MOH will regularly compare the performance of public and private services (as it has been done already for hospitals).On the basis of the regional reports as well as other specific studies and surveys, an independent team (comprising both local and international experts) will annually appraise the overall sector performance and will identify policy and strategic issues and make recommendations for action. The independent report will then be presented and discussed with MOH and all interested parties during the April/May health summits. 7. Sustainability The sustainability of the Program would be determined by two key elements: (i) ownership and, (ii) the availability of financial resources (including donor funds). The Ghana Health Sector Program has been designed and prepared through a participative process that included a large number of stakeholders including the civil society and the mission and private sector. Together with the improved transparency in the planning, budgeting, implementation, reporting, accounting , auditing and monitoring processes, the organization of annual health sector performance reviews and other consultation mechanisms will continue to increase ownership. Availability of sufficient financial resources for the sector, which depends mainly on a) macro economic and fiscal factors, b) policy decisions at the GOG level regarding allocations to the sector and c) the continuation of the good relationship between GOG and donors. 8. Lessons learned from past operations in the country/sector The Bank and MOH have been collaborating for more than 15 years. Many lessons have been drawn from this collaboration and the implementation of various types of support provided by the Bank. The first lesson learned is that systemic improvement in health and behavior change requires a long-term and sustained effort. The SWAP approach has given rise to a strong partnership between core donors and MOH. From this experience, we learned that a more comprehensive approach is useful if: (i) national development policies provide the framework for strategic planning and partner/stakeholder participation; (ii) resource allocation is linked to objectives and results; and (iii) the "natural tendency" to duplicate efforts is reduced through interaction and dialogue. This experience has clearly demonstrated that appropriate efforts and investments can rapidly build up national capacity and significantly improve systems. The effects of the budget support in terms of generally improved performance are obviously quite difficult to track. First of all, impact - 11 -  and even outputs are influenced by a number of factors mostly outside the control of a donor and many even beyond the control of the government. Secondly, in severely under-financed systems the marginal effect of donor support is quite difficult to estimate, as the under-financing renders many assumptions and factors difficult to assess, for example, staff efficiency. Nevertheless, the Ghana sector programme or SWAP is internationally recognized as one of the few actually producing tangible improvements. We also noticed that governance was improved when donors used national systems and procedures instead of their own. Although it has survived a number of conflicts, the unique relationship between Government and donors is still relatively fragile. It is largely dependent on the capacity of both the MOH and donor agency staff to keep the dialogue going and to compromise when needed. To do this, donors need to keep up to date on developments in the sector. A local technical presence is necessary to maintain the technical and policy dialogue; more frequent missions are needed; and the donor team must include an adequate skill mix with capacity to analyze the issues and propose alternatives. 9. Environment Aspects (including any public consultation) Issues The MOH program is not expected to generate major adverse environmental effects. Possible environmental risks include the handling and disposal of infected materials. The inappropriate handling of infected materials constitute a risk not only for the staff in health facilities and in municipalities who are involved in waste handling, but also for families and children who scavenge on dump sites. To address this, the MOH Program of Work will include a bio-safety sub-program for health care facilities, including the revision of relevant technical guidelines and training of personnel. This sub-program will include measures towards improving the appropriate separation, transport and disposal of hazardous medical waste. 10. Contact Point: Task Manager Francois Decaillet The World Bank 1818 H Street, NW Washington D.C. 20433 Telephone: 32-2-772-3313 Fax: 32-2-770-2923 11. For information on other project related documents contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 Web: http:// www.worldbank.org/infoshop Note: This is information on an evolving project. Certain components may not be necessarily included in the final project. - 12 -  This PID was processed by the InfoShop during the week ending December 20, 2002. - 13 -