Ghana - Health and Education Rehabilitation Project

Document of The World Bank FOR OMCIAL USE ONLY Rpot No. 11080 PROJECT COMPLETION REPORT GHANA HEALTH AND EDUCATION REHABILITATION PROJECT (CREDIT 1653-GH) AUGUST 31, 1992 Population and Human Resources Operations Division Western Africa Department Africa Regional Office 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 = Cedis US$ 1 = 60 Cedis (October 1985) US$ 1 = 410 Cedis (June 1992) FISCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS DCA = Development Credit Agreement DHMT = District Health Management Team GES = Ghana Education Service GOG = Government of Ghana GSC = Ghana Supply Corporation HERP = Health and Education Rehabilitation Project MDPI = Management Development & Productivity Institute MFEP = Ministry of Finance and Economic Planning MOE = Ministry of Education MOH = Ministry of Health PAB = Public Agreements Board PCR = Project Completion Report PER = Public Expenditure Review PHC = Primary Health Care PHN = Population, Health, & Nutrition PML = Princess Marie-Louise Hospital PMU = Project Management Unit PNDC = Provisional National Defense Council SCC = State Construction Corporation SDR = Special Drawing Right UNDP = United Nations Development Programme UNFPA = United Nations Population Fund UNICEF = United Nations Children's Fund WHO = World Health Organization  FOR OFFCAL4 USE ONLY THE WORLD BANK Washington, D.C. 20433 U.S.A. Ofice aE DOectnvCewal Op.atm Evatknti n August 31, 1992 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECT: Project Completion Report - Ghana: Health and Education Rehabilitation Proiect (Credit 1653-GH) Attached, for information, is a copy of a report entitled "Project Completion Report - Ghana: Health and Education Rehabilitation Project (Credit 1653-GH)" prepared by the Africa Regional Office with Part II of the report contributed by the Borrower. No audit of this project has been made by the Operations Evaluation Department at this time. Attachment '~~ 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 discloed without World Bank authorization.   FOR OMCIL US ONLY PROJECr COMPLETION REPORT GHANA HEALTH AND EDUCATION REHABIL1TATION PROJECr TABLE OPFCONIBITS Page No. PREFACE ...................................................... i EVALUATION SUMNMARY ...................................... iii Part L PROJECT REVIEW FROM THE BANK'S PERSPECTIVE ....... A. Project Identity ............................. 1 B. Project Background .... 1 C Project Objectives and Description ..................... 2 D. Project Design and Organization ............................ . 3 E. Project Implementation .............................5 F. Project Results ................. .............................. 7 G. Project Sustainability ............................. 8 IL Bank Performance .............................. 9 L The Borrower's Performance ..................................... 10 J. Lcssons Learned ................ .............................. 11 K. Project Relationships ..................... ..................... 12 L Consulting Services ..................... ...................... 12 M; Project Documentation .................... .................... 12 PART IL PROJECT REVIEW FROM THE BORROWER'S PERSPECIVE .... 13 A. Health Component .............. ............................. 13 B. Education Component ............. ............................ 17 C. Management Development and Productivity Institute .................. 27 PART Im lT TISTICAL WFRMAION ........... .. ............. 29 1. Related Bank Loans and/or Credits ................................ 29 2. Project Timetable ................ ............................. 31 3. Credit Disbursements ............. ............................. 31 4. Project Implementation ............. ............................ 34 5. Project Costs and Financing ..................................... 37 6. Complance with Covenants ..................................... 40 7. Project Results . ............................................... 42 & Usc of Bank Resources ............. ............................ 44 Annex I st of Participants in Completion Miuion ..................... 47 Annex 2 Ministry of Health Staff Granted Feilowships ................... 49 hAnx 3 Ministry of Health Staff Granted Short-term Training ..... ........ 51 Annex4 Communuties which Benefitted from the Weaning Food Production Program ...................................... 53 Annex S Production of Textbooks Under the Project .................... 55 This document has a restricted distribution and may be used by recipients only in the performance Of their officil duties. Its contents may not otherwise be disclosed without World Bank authorization.   -i- PROJECT COMPLETION REPORT GHANA HEALTH AND EDUCATnON REHABEUATAnON PROJECT Ihis is the Project Completion Report (PCR) for the Health and Education Rehabilitation Project (HERP) in Ghana, for which Credit 1653-GH in the amount of SDR13.8 miDion (equivalent to US$15.0 million on November 30, 1985) was approved on January 23, 1986. The Credit was closed on December 31, 1991 after a one year's extension from the original closing date. It was fuly disbursed with the last disbursement takdng place on May 5, 1992. This PCR was prepared by the Population and Human Resources Operations Division of the Western Africa Department (Preface, Evaluation Summary, and Parts I and M). Part ll was prepared by the three Government of Ghana (GOG) beneficiary agencies-the Ministry of Health (MOH), the Ministry of Education (MOE), and the Management Development and Productivity Institute (MDPI). Preparation of this PCR was initiated during the Bank's final Supervision/Completion Mission in November 1991. It is based, inter alia on the Report and Recommendation of the President, the Development Credit Agreement, supervision reports, correspondence between the Bank and the Borrower, internal Bank memoranda, and interviews with and other inputs from GOG officials and Bank staff involved with the project. A draft of Part I was discussed with GOG officials during a follow-up mission in early June 1992.  I  - iii - PROJECT COMPLETION REPORT GHANA HEALTH AND EDUCATION REHABEIrTATION PROJECr (CREDIT 1653-GH) EVALUATION SUMMARY 1. The main objectives of the Health and Education Rehabilitation Project (HERP) were to address the most urgent needs of the health and education sectors by: (a) providing emergency assistance to the health and education systems and to the Management Development and Productivity Institute (MDPI); (b) rehabilitating service delivery at the peripheral level of the public health system; and (c) strengthening the management and planning capacities of the Ministries of Health and Education. 2. Project implementation, especially the health component, got off to a very slow start When the new task manager was assigned to the Ghana field office (about 18 months after effectiveness), he endeavored to create stronger commitment to the health component. A major approach was to encourage Ministry of Health (MOH) officials to prepare proposals for new activities consistent with project objectives. Many of these eventually were carried out during project implementation. A few other activities were added later. In the case of the education component, however, changes were relatively minor, basically the addition of some new textbook titles in the area of social studies. 3. In spite of the best efforts of the resident task manager, the implementation of the health component continued basically on an ad hoc basis throughout the life of the project. The requirement to prepare, say, annual work plans was not included in the project documents, and never became a feature of the project. The absence of agreed detailed work plans, meant that senior MOH officials, the Project Management Unit (PMU), and the task manager were constantly caught up in discussions and exchanges of correspondence on the details of implementation arrangements as they emerged. In spite of these constraints, much of the implementation of the health component went reasonably well, albeit at a much slower pace than desirable. 4. Another major source of delay throughout the project was the elaborate local process of procurement approvals. The situation improved somewhat when MOH began using the procurement services of the Ghana Supply Commission (GSC), which did not need to go through all these approval layers. Contracts for rehabilitation of health facilities were let to a parastatal, the State Construction Corporation (SCC), but its performance was extremely poor with many delays and large cost overruns. 5. A further problem affecting the pace of obtaining project-financed textbooks occurred when Government ordered, just about at the time the HERP Credit was negotiated, a large number of textbooks that had been developed in the early 1970s. This effort was not adequately coordinated with those being procured under the project.  - iv - Project Results 6. The objectives of this project were rather general and non-quantifiable. They entailed provision of emergency assistance to the two sectors, which the project certainly did; expansion of service delivery at the periphery, which occurred during the lfe of the project, but was the result also of many inputs beyond the project and of the overafl improvement in the economy, and strengthening of the management and planning capacities of the two sectoral ministries and MDPI, which has shown mixed results. MOH officials uniformly give HERP much credit for the dramatic improvements in the performance and morale of health staff at various levels. As the availability of drugs and other supplies improved and staff morale increased, utilization of the health services has considerably increased. (Although corroborating data in this regard are not available). 7. Although most information on the impact of the project is impressionistic, MOH officials are convinced that specific elements of the health system improved noticeably as the result of HERP. For instance, work in the critical area of drug supply went much further than originally intended and extension of immunization coverage occurred as a result of improvements in the cold chain and provision of low cost transport to field staff. Safe motherhood got considerably more attention as a result of the project. The impact in nutrition has been mixed. The pilot effort to provide corn mills to selected communities has provided income generating opportunities for women, and was considered sufficiently successful that UNICEF has replicated it elsewhere, the overall national strategy for nutrition is still dominated by the curative approach. HERP did have a useful impact on selected support systems. For in-service training, which had been badly neglected, the project helped establish a workable system and supported considerable training as well. 8. Less successful has been the project's impact on long term planning and overall management capabilities. The project's main inputs in these areas were through technical assistance--studies and fellowships. The finance and manpower studies were seen by MOH officials as being too complex and very difficult to apply to their situation. On the other hand, MOH gives considerable credit for developing middle-level leadership in the sector to the project-financed fellowship program. 9. In the education sector, the project's objectives were very straightforward: getting more supplies and textbooks to students, particular at the primary and middle levels. HERP did produced and distnbuted 6.1 million books that were far more appropriate to the local situation than previous textbooks had been. A target had been set of having one textbook in each of three core subjects for every two students. In the end the project produced nearly one textbook per student in each of these subject areas along with some books in one other subject. Project Sustnability 10. Because of the emergency nature of the project, sustainability in the normal sense was not that much of a consideration. It was felt that vital inputs--largely of "consumables"-were required simply to prevent the health and education systems from further deteriorating to the point of no return. Nonetheless the project did introduce cost recovery measures in health, which has been comparatively successful, and, in conjunction with the -ollow-on EdSAC Project, in education as well. 11. In addition, certain systems in health, e.g., rationalized approaches to drug supply, have been introduced and will hopefully long outlive the project. Various training activities have been undertaken, the effects of which, unless appropriate follow-on training is undertaken, will begin to be diluted over time, although the overall strengthening of MOH's in-service capacity will have  - v - long-term impact. Also, the project had a discernable impact on MDPI's activities through the creation of a better environment, especially for its management training program. Fmdings and Lemons Learned 12. A number of lessons for other projects and to some extent for the Bank's overall work in Ghana can be extracted from the HERP experiences. First, with regard to project design and preparation: (a) For a first time borrower, it is essential to examine closely the scope and coverage of the project to ensure that it will not be unduly taxing on the borrower's implementation capacity; and (b) Beginning with project identification and certainly during preparation, every step should be taken with an eye to developing ownership and building consensus. Second, with regard to project implementation and supervision: (a) Where a project management unit is felt to be required, strong efforts should be made to ensure that it is institutionally and physically as closely integrated into the fabric of the host ministry as possible; (b) A launch workshop, which was not held in this case, can be a key means for developing broad understanding of Bank procedures and at the same time can focus attention on key actions needed around the time of effectiveness; (c) The Bank should ensure that adequate procurement training is provided to newly recruited staff who become task managers, particularly if they assume responsibility when a project is just beginning to take off; (d) During the early stages of project implementation, especially in the case of first time borrowers, supervision missions should be mounted rather frequently; (e) when supervision is undertaken by a task manager based in the field, there is a tendency to rely too heavily on that person and not to mobilize the range of technical skills desirable; (f) More attention should be paid by the Bank, e.g., in staff training, to effective means for dealing with maintenance problems throughout the project cycle (although, in fact, those associated with HERP did a credible job in this regard); (g) The perils of entering into contracts with parastatals, which have little need to be competitive, should be obvious from the performance of the State Construction Corporation (SCC). In the future, construction in the public sector, certainly in Ghana, should be open to competitive bidding and while it may not be possible or appropriate to exclude the SCC, its performance record should be subject to scrutiny through pre- or post-qualification; and (h) When public sector procurement is highly centralized, as in the case of the Ghana Supply Commission, there is an ideal opportunity for a borrower and the Bank to engaged in focussed procurement training and institutional development. The value of doing so was eventually realized, but rather slower than it should have been. Third, with regard to project conditionalities: (a) Initial deposit of counterpart funds, perhaps equivalent to half of the first year's requirement, should be made a condition of effectiveness in future projects; and (b) The preparation of annual work plans acceptable to the Bank should generally be a condition in legal agreements, with, perhaps, the first year's work plan being discussed during negotiations.   - 1 - PROJECT COMPLETION REPORT GHANA HEALTH AND EDUCATION REHABILITATION PROJECT (CREDIT 1653-GH) PART I. PROJECT REVIEW FROM THE BANK'S PERSPECTIVE A. Project Identitv Project Name: Health and Education Rehabilitation Project (HERP) Credit Number: 1653-GH Credit Amount: SDR 13.8 million (US$15.0 million equivalent in November 1985) RVP Unit: Africa Region, Country Department IV Country: Republic of Ghana Sector: Population and Human Resources B. Project Background 1. After strong positive economic growth through the 1950s and 1960s, Ghana's economy stagnated in the 1970s and early 1980s. Deterioration in export performance, combined with disenchantment on the part of donors with Ghana's performance, caused a perpetual foreign exchange crisis leading to increasingly restrictive import regimes. High rates of inflation eroded purchasing power, productivity fell substantially, and unemployment increased rapidly. By the mid-1980s half of Ghana's population of about 12 million was estimated to be living in absolute poverty. Among the major results of this situation were the rapid decline in social indicators and the mass exodus of large numbers of educated workers and professionals. 2. Particularly affected were the health and education sectors, which suffered major losses, not only in qualified personnel, but also in declining public investment. During the 1970s education expenditures, for example, averaged 3.4% of GDP--a level that was already below the 5.2% average for other anglophone sub-Saharan African countries. By around 1983-84, however, expenditure on education fell much further to about 1% of GDP. The result was a crippled school system with severe shortages of textbooks and basic school supplies compounded by the exodus of many qualified teachers. In health, overall conditions were poor throughout the late 1970s and early 1980s. Hospitals and other health facilities were essentially non-functional, being short of essential drugs, equipment, and personnel. Communicable diseases were back to levels that prevailed decades earlier. 3. The Provisional National Defense Council (PNDC), which came to power at the end of 1981, developed a wide ranging Economic Recovery Programme with assistance from the IMF and the Bank. A number of reforms were introduced beginning in early 1983. By 1984 economic performance showed clear improvement, government revenues increased substantially, and inflation was down markedly. After suspension of lending for several years, the Bank provided several reconstruction import credits in support of the recovery program. In mid-1984, a  Population, Health and Nutrition (PHN) Identification Mission recommended Bank support for rehabilitation of selected urban facilities and of MOH's infrastructure. 4. Early the following year, the Bank carried out a Public Expenditure Review (PER), which covered a number of sectors, including health and education. The results of the PER were a major additional source of guidance in formulating the contents of the first operation in these sectors, which became known as the Health and Education Rehabilitation Project (HERP). The PER showed skewed resource allocations that placed more emphasis on hospitals and curative care than on primary health care (PHC)/preventive care and more emphasis on university training than primary education. In both sectors, almost all expenditures were going to meet the wage bill, leaving very little for drugs, equipment, fuel for supervisory visits, textbooks, etc. For instance, available textbooks represented about 2% of what was required. In view of the fact that constraints in public expenditures in health and education were expected to continue, the PER emphasized the need to improve the use of existing resources--human and financial--and to introduce cost recovery to partially meet the required operating costs. C. Prolect Objectives and Description 5. The growing concern over the state of the social sectors and recognition of their important contribution to economic growth led the Government of Ghana (GOG) to request emergency assistance in the form of HERP to prevent their further deterioration. As the dialogue continued, it was also decided to include, with special reference to the health sector, support to begin addressing some of the longer term sectoral issues identified in the PER. In high-level discussions between the GOG and the Bank, it was agreed that the public sector had enormous needs for in-service training and management upgrading to increase its productivity. Hence, support for the Management Development and Productivity Institute (MDPI) was also included in HERP. In the end, it was agreed that the project should: (a) provide emergency assistance to the health and education systems; (b) expand service delivery at the peripheral level of the public health system, with special emphasis on immunization, nutrition, and family planning; (c) strengthen the management and planning capacities of the Ministries of Health (MOH) and Education (MOE); and (d) strengthen MDPI. 6. The project was divided into three parts: Part A--health, Part B--education, and Part C-- MDPI. Although the Development Credit Agreement (DCA) defined each in detail, considerable room was allowed for modification during implementation "as the Borrower and the Association may agree upon from time to time to achieve [the project] objectives." Part A was the most extensive, with two-thirds of the Credit or US$10 million allocated to it. It included (a) strengthening of PHC delivery and outreach activities by re-equipping and providing essential supplies, such as drugs, to about 100 rural health stations and 11 urban health centers; (b) rehabilitation of a children's hospital and several health centers; (c) strengthening district health management teams (DHMTs); (d) improving training systems for PHC; (e) strengthening of key programs in nutrition (nutrition surveillance, nutrition education, and weaning food production), immunization (especially by improving the cold chain), family planning (especially by developing a system to identify high risk mothers); (f) improving capacity to plan and manage PHC (especially through fellowships, study tours, and a system of radio communication); (g) support for long-range policy making and planning (especially through studies on health manpower, health financing, and  - 3 - an improved drug supply system; an inventory of facilities; and preparation of a long-term investment plan). Most of the remaining US$5.0 million was designated for Part B which included (a) printing and distribution of textbooks and teachers' guides in English, mathematics, and science for primary and middle schools; (b) provision of basic school supplies (exercise books, pens, and pencils); (c) provision of books to secondary school libraries and of books and joumals to university libraries; and (d) strengthening of MOE's capacity to manage the project and prepare future projects (by provision of equipment, supplies, and vehicles and by rehabilitation of depots for textbook storage). US$0.3 million was allocated to Part C for strengthening MDPI's training, consultancy, and research services through office rehabilitation and provision of equipment, vehicles, and supplies. D. Project Design and Organization 7. In retrospect, one could argue that the health component of the project was too complex and too ambitious, and yet, ironically, while some of the medium-term activities added at appraisal did reasonably well, some of the "emergency" elements experienced substantial implementation delays and difficulties. The emergency situation in the social sectors drove the initial discussions regarding both the health and the education components. By and large the education component never lost sight of this emphasis and directed almost all resources into meeting the serious shortfall in textbooks, related teachers' guides, and school supplies. In part this single-mindedness was possible because a dialogue was already getting under way that eventuated in a follow-on sector adjustment credit in education. In the case of health, however, internal pressure in the Bank mounted as the project evolved to include sectoral reforms, e.g., in cost recovery, and to redress imbalances identified in the PER. With the processing timetable basically driven by the "emergency" nature of the operation, there was little time for thorough technical analysis and preparation of much of the health component. The Project Brief had outlined highly appropriate design criteria for the "emergency" aspects of the project: (a) simplicity, (b) implementable through existing infrastructure, (c) focus on preventing further deterioration of still functioning institutions, and (d) emphasis on foreign exchange items. If these criteria had been followed, this first project would probably have been implemented faster and with less intensive inputs from the Bank. Just as the education component emphasized textbooks as a key missing ingredient, the health component might have focussed on a fewer things, such as drug supply and transport for supervision and outreach. Nonetheless, it is not easy to forecast, especially in a first project, the areas most likely to fail or succeed. 8. The pressure to add longer-term considerations was not the only thing that resulted in a complex health component. Another problem was the absence of a health plan and of any clear position within MOH on what the highest priorities in the sector should be. The development of such a plan was included in the project, but in the meantime a number of activities were agreed for inclusion in the project, apparently stemming from the fact that the needs were so great on every hand. It was not that these activities were unimportant or low priority, for they represented the internationally agreed core elements of PHC. There were just too many of them, and there was no time to prepare many of these sub-components. In the rush at least one area--sanitation-- was included that in fact is essentially not part of MOH's mandate and had to be dropped later. Some Bank staff cautioned about the complexity of the project, including the then Resident Representative, who argued that it would lead to implementation problems. 9. Another apparent outcome of the rapid processing of the project was inadequate commitment on the part of MOH. There was no time to develop effective commitment to the project and individual activities through any process of consensus generation. Instead, Bank missions went to individuals and sought their views on what should be included. Afterwards, some MOH officials indicated that at times Bank staff seemed to be pressing their own personal  preferences. In addition, the project content was finalized with one person who was subsequently moved to a less central position. Moreover, Bank missions expressed the urgency about the project that came from the Bank's dialogue with the Ministry of Finance and Economic Planning (MFEP) and other core agencies. In retrospect, MOH officials believe this sense of urgency was never adequately conveyed to MOH directly, but they felt they had no choice but to go along. They also express in particular the feeling that various studies were forced on them by the Bank and the core agencies. This lack of ownership undoubtedly contributed to the limited utilization of the results of those studies. Thorough discussion of the studies did not occur until a year into project implementation. The overall health component had to be revisited some two years after effectiveness in order to get MOH more fully involved in working out project priorities (see para. 14). The above discussion of ownersbip and its importance has to be tempered by the fact that preparation of the follow-on Second Health and Population Project (Cr. 2193-GH) did entail from the beginning a number of actions intended to generate greater commitment on MOH's part, but it, too, has suffered substantial implementation delays. 10. In general, these issues do not pertain to the education component. Even under the greatly constrained conditions prior to the commencement of economic recovery, MOE had been working intensely on the development of a new textbook series, and for many books camera-ready copy was available. Hence the component was both timely and matched well with widely agreed sectoral priorities. 11. Some aspects of the management arrangements for project implementation also appear problematic in retrospect. It was decided to set up two project management units (PMUs), one in MOH and the other in MOE, the latter being responsible for Parts B and C. The small number of staff specified for the health PMU became a bottleneck. The list of staff for the health PMU included a procurement officer, as there was a great number of procurement actions involved in Part A, but by not including this post among those needing to be filled as a condition of effectiveness, the Bank seems to have signaled that this was a lower priority. The post was never filled until the Second Health and Population Project required it as a condition for its effectiveness. Putting Part C, which was being carried out by MDPI, under MOE and including the funds for Part C in the Special Account for Part B were understandable in view of the small size of Part C. Since MDPI is under another ministry altogether (Ministry of Mobilization and Productivity), it was, however, an awkward arrangement for both parties. MOE found it hard to be accountable for MDPI, having no control of its policy or budget. MDPI, in turn, sometimes found the education PMU to have little interest in the small Part C. Indeed, MDPI made a serious error early on in that it used Credit funds for 100% of construction costs (rather than 75%), which required nearly two years to rectify and nearly led to suspension of disbursements. In the end, after some delays and misunderstandings things worked reasonably well. 12. One or two things seem to have been missed in designing the textbook subcomponent that did lead to delays in its implementation. Most important was the implication of two existing arrangements between MOE and book publishers that were involved in development of the books to be printed through the project. One of these was the Co-publishing Project involving five local publishers which had invested their own funds in "editorial research and development." Since the implications of this arrangement were not perceived during preparation, it delayed implementation by over a year while an arrangement was worked out to reimburse these publishers for their inputs so that MOE could be free to go out for competitive tenders for printing the books. It also took a long time to clear the air regarding an existing arrangement with Macmillan related to 14 titles. 13. The small population element in the project was set up in a very flexible manner and hence was quite appropriate for the situation. The need for assistance in the revamping and  - 5 - redesign of the population policy and program had been identified by the Bank. Other sources of funding, especially UNEPA, were potentially available, however. Hence, to make certain that this important need was met one way or the other, funds were included in HERP with the notation that they would be reprogrammed if not needed, which indeed is what happened. This approach to uncertainties about other donors meeting key needs is worth emulating in other situations. Another innovative approach used in the project was to start meeting some of the most urgent emergency needs, largely for exercise books and pens and pencils, by using a PPF advance. No foreign exchange was available so provision for retroactive funding would not have worked. E. Project ImDlementatlon 14. When the new Task Manager was assigned to the Ghana field office (about 18 months after effectiveness), he endeavored to create stronger commitment to the health component. A major approach was to encourage MOH officials to prepare detailed proposals for new activities consistent with project objectives. They came with a number of ideas that were acceptable to the Bank for further elaboration, including the rationalization and rehabilitation of the central medical stores, provision to peripheral health facilities of additional equipment for maternal and child care, training of key staff in planning and administration, comprehensive rehabilitation of the Center for Health Statistics, and a nutrition survey. Many of these eventually took shape although some were funded by other agencies (e.g., the nutrition survey was supported by UNICEF). A few other activities were added later, especially in safe motherhood, and, at the Bank's suggestion, strengthening of in-service training for peripheral health staff. At this stage and subsequently, however, MOH pressed hard for major increases in the number of project- financed vehicles. Eventually it was agreed that in addition to provision of some new vehicles, the project would fund a major scheme for rehabilitation of vehicles that were off the road. (At the time, about three-quarters of all MOH vehicles were not functioning.) To this end a survey was undertaken to identify those vehicles meeting specific criteria. Hardly any of this scheme was implemented, however, among other reasons due, reportedly, to the administrative difficulties in making payments through MOH's field offices. To help increase the mobility of health extension staff, it was agreed that 1,000 mopeds could be procured. The need for a creative system of maintenance, e.g., by making them the property of the health workers in exchange for their maintenance and use for official duties, was encouraged by the Bank, but never put into place. Instead, although the mopeds are assigned to individual staff, they remain the property of the institution to which the worker is attached and that institution is responsible for maintenance. (Changes in the education component were relatively minor, basically the addition of some titles in social studies, which some MOE officials strongly felt were missing in the original project design.) 15. The main risk factor identified at appraisal was the weak implementation capacity of MOH. In response, considerable technical assistance was included in the component (16 man- years), but rather little of this was in fact focussed on improving implementation capacity. In the end, some MOH officials feel that the fellowships provided through the project contributed markedly to capacity building, especially among the critical Regional Directors of Health Services, three of whom received advanced training in public health. The relatively limited implementation capacity in MOH was not, however, as well mobilized as it might have been. The PMU was perceived as very separate from the ministry, being staffed with "outsiders" and, initially, also being physically remote from MOH headquarters. Throughout the project there was a gap between the PMU as the "mobilizers" of resources and the ministry's "users" even though the project director was responsible for all technical matters in the ministry. In any case, he was not readily able to call upon the administrative side of the ministry to work with the PMU. During the early stages of the project, when there were visiting Bank missions, they tended to work closely with the  - 6 - PMU, which became the sole repository of information on Bank procedures. This also created a situation where PMU had to argue for Bank procedures against MOH officials who for a long time were not effectively exposed to them due, for instance, to the lack of any systematic project launch. 16. In spite of the best efforts of the resident task manager and even, at times, of core GOG agencies, the implementation of the health component continued basically on an ad hoc basis throughout the life of the project. The requirement to prepare, say, annual work plans was not included in the project documents, and never became a feature of the project. This problem persisted in spite of the efforts on the part of an ex-minister who was sent to MOH by the Prime Minister's Office to develop a commitment to the preparation of implementation plans. The absence of an agreed, detailed work plan, meant that senior MOH officials, PMU, and the task manager were constantly caught up in discussions and exchanges of correspondence on the details of implementation arrangements as they emerged. Without any opportunity to examine, say once a year, the main thrust of the component in the context of a review of the annual work plan, it was easy for everyone to lose sight of what the main thrust in fact was. 17. Much of the implementation of the health component, in spite of the above constraints, did eventually occur, albeit generally after substantial delays. Major delays, in particular, occurred in the rehabilitation of the Princess Marie-Louis Hospital. The Bank had agreed at appraisal to the use of the existing contractor, the State Construction Corporation (SCC), under a new contract. Some of the items covered under the original contract seemed to be re-submitted for payment under the new contract. The work was of very low quality and the supervising architects and engineers, under another parastatal, seemed to be very lax. While most of the work was eventually finished, it is clear that the original contract should have been canceled and a new one let with a private sector firm. There does not appear to have been sufficient analysis during preparation and appraisal as to why the SCC had already been on the job nine years. 18. Another major source of delay, particularly during the early stages of the project was the elaborate local process of procurement approvals. Often contract awards could not be made until 8-12 months after bid closing. After evaluation was completed by a technical committee, it was first reviewed by the Ghana Central Advisory Tender Board. The Board's recommendations were, in turn, reviewed by the Public Agreements Board before being submitted to the PNDC Committee of Secretaries for ratification, after which final approval was given by the PNDC itself. (With a resident task manager to whom most procurement decisions were delegated, the Bank's review, on the other hand, was often completed in one-two days.) Many of these approval steps are not required when procurement is undertaken by the Ghana Supply Commission (GSC), which was given increasing responsibility for procurement for MOH during the course of project implementation. 19. These procurement delays occurred in both the health and education components, but since there were so many more procurement actions under the health component, their overall impact was more noticeable. Delays in procurement of textbooks partially came about because the availability of paper and ink from a bilateral donor meant that printing contracts had to be let locally. Although they were to be completed in four to five months, some of these contracts were not fulfilled in three years and had to be canceled and relet to foreign printers. Another matter was felt by Bank staff to have contributed initially to the slow pace of obtaining the textbooks. That was Government's ordering with its own funds, about at the time the HERP Credit was negotiated, a large number of textbooks that had been developed in the early 1970s. In spite of intensive interaction with MOE officials during preparation and appraisal, the Bank's textbook specialists did not learn in advance about the plan to make this major purchase, for had it been known, there could have been more coordination between the two and HERP's inputs in the  education sector might have been designed differently, e.g., in terms of timing or selection of books for financing. F. Project Results 20. The objectives of this project were rather general and non-quantifiable. They entailed provision of emergency assistance to the two sectors, which the project certainly did; expansion of service delivery at the periphery, which occurred during the life of the project, but was the result also of many inputs beyond the project and of the overall improvement in the economy; and strengthening of the management and planning capacities of the two sectoral ministries and MDPI, which has shown mixed results. MOH officials uniformly give HERP much credit for the dramatic improvements in the performance and morale of health staff at various levels as a result of the increase in supplies, provision of transport, and re-equipping of facilities. As the availability of drugs and other supplies improved and staff morale increased, utilization of the health services has reportedly increased considerably. Corroborating data that are adequately comparable from one period to the next are not available, however. 21. Although most information on the impact of the project is impressionistic, MOH officials are convinced that specific elements of the health system improved noticeably as the result of HERP. This is perhaps most notable in the critical area of drug supply, where work went much further than just the provision of drugs as originally intended: an improved system for procurement was established; cost recovery, including a system of "cash-and-carry," was introduced; stores were rehabilitated and an improved system of inventory management developed; a quality control system and laboratory were launched; a process for developing and updating an essential drugs list was established; a better system for estimating drug requirements was institutionalized (albeit not in MOH itself); and MOH got useful feedback on prescribing practices. Extension of immunization coverage occurred as a result of improvements in the cold chain and provision of low cost transport to field staff. (Defective solar panels for the refrigerators was a problem, however.) Safe motherhood got considerably more attention as a result of the project. The impact in nutrition has been relatively limited in geographical terms. The pilot effort to provide corn mills to fifty communities has provided income generating opportunities for women and community-based growth monitoring was also introduced. This was considered sufficiently successful that UNICEF has replicated it elsewhere. Nationally, however, nutrition activities have not moved much beyond the country's longstanding curative approaches, and very little community-based growth monitoring is taking place. HERP did have a useful impact on certain support systems. For in-service training, which had been badly neglected, the project helped establish a workable system and supported considerable training as well. The capacities of the DHMTs were improved through, among other things, team training and increased mobility. Without doubt, however, the timely and well planned execution and distribution of these various project-financed inputs would have resulted in more concerted and rapid impact. 22. Less successful has been the project's impact on long term planning and overall management capabilities. The project's main inputs in these areas were through technical assistance--studies and fellowships. The finance and manpower studies were seen by MOH officials as being too complex and very difficult to apply to their situation--this in spite of the considerable involvement of MOH officials and other Ghanian specialists in carrying out the studies. In addition, although dissemination workshops were conducted, working groups or other mechanisms to follow through on the studies were never established. The fellowship program was originally focussed on strengthening the Health Planning Division, but very few of those trained abroad under the project returned to or stayed in that division, in part, perhaps, because a proper environment for application of their new skills did not exist. The division had no real head and was basically engaged in budgeting, which would provide little stimulation to anyone genuinely  - 8 - interested in health planning. MOH feels, however, that the fellowship programme had considerable impact on increasing the capacities of key MOH managers, especially in public health, pointing in particular to the three physicians who were appointed to the key posts of Regional Directors of Health Services as a direct result of their training. In addition, the head of the Rural Health Training Center benefitted from a project-financed fellowship. The project's inputs on improving MOH's communication system were also initially seen as being of limited value because of constant maintenance problems, but recently this problem was essentially solved through the issuance of a maintenance contract with the firm that supplied the equipment. 23. In the education sector, the project's objectives were very straightforward: getting more supplies and textbooks to students, particular at the primary and middle levels. HERP did a good job. It produced and distributed 6.1 million books that were far more appropriate to the local situation than previous textbooks had been. A target had been set of having one textbook in each of three core subjects for every two students. In the end the project produced nearly one textbook per student in each of these subject areas along with some books in one other subject. MOE calculates that sufficient books were produced to provide 100% coverage for a number of titles with the lowest figure being 74%. These coverage figures have to be interpreted, however, in the light of two facts: the expected life of a textbook is only about three years and the implementation period extended over nearly twice that period. Hence, at any one time, on the average, there was about one book for each two pupils. The coverage with teachers' guides was somewhat less successful. Every teacher should have had all the basic guides, and many did, but there were some titles that had as low as 63% coverage. The reasons for these discrepancies are not clear since the number of classroom teachers was known. The small element of HERP directed at strengthening MOE's planning and implementation capacity had little impact, which was further dissipated by MOE's decision to create a separate PMU for the follow-on EdSAC Project (Cr. 1744-GH) under a different Deputy Minister. HERP's modest inputs for MDPI were well received and are perceived by MDPI officials as having been a major stimulus to increasing in particular the institute's capacity in training and strategic planning. G. Project Sustainabililtv 24. For the emergency inputs under the project, sustainability in the normal sense was not that much of a consideration. It was felt that vital inputs--largely of "consumables"--were required simply to prevent the health and education system from further deteriorating to the point of no retum. Nonetheless the project did introduce cost recovery measures in the health sector. These measures succeeded in reaching 12% of recurrent expenditures at first against the agreed target of 15%, a not insignificant achievement compared to many countries. Later, the percentages dropped, for the collection of fees could not keep pace with rapid increases in the MOH's recurrent budget. EdSAC included conditionality regarding cost recovery for textbooks, which also applied to those purchased through HERP. Pupils in Primary 3 and above are charged user fees, which are recycled through a revolving fund. About 70% of the projected fees are being recovered, and MOE will soon republish books for the junior secondary schools from the revolving fund. 25. In addition, certain systems in health, e.g., rationalized approaches to drug supply, have been introduced, many of which can be expected to continue functioning for many years to come. A test of how well the new approaches to drug supply have been institutionalized will come soon, however, since the MOH official who was key in spearheading these reforms will soon retire. Various training activities have been undertaken, but unless follow-up training is undertaken, their effect will begin to be diluted over time. The overall strengthening of MOH's in-service training capacity will have undoubtedly have long-term impact, however. Regarding the physical inputs from the project, of which there were many in the health sector, maintenance has been a serious  - 9 - problem from the beginning. The Bank pressed, not always successfully, for long-term maintenance contracts (rather than procurement of stocks of vulnerable spare parts). While vehicles and various equipment have frequently been out of order, MOH appears to be paying somewhat more attention these days to their maintenance. An innovative scheme was proposed to MOH regarding the maintenance of the mopeds supplied to the field staff, which would have made it a personal responsibility in exchange for ownership rights in the vehicles (para. 14). Various inflexibilities in regulations (and in their interpretation) have inhibited the implementation of this scheme, however. The design of the Second Health and Population Project has picked up on various of these sustainability issues. H. Bank Performance 26. With a few exceptions, Government officials were pleased with the Bank's performance during project implementation. Indeed, MOE requested more frequent supervision missions during the early stages of implementation of Part B, to which the Bank was responsive, sending four missions during the first 18 months of implementation. (On the other hand, just one PHN supervision mission focussed on the larger Part A during this period of time.) Subsequently, to support HERP and other projects under preparation in the education sector, the Bank posted a senior educator to the resident mission in late 1987. As a result of the Bank's reorganization, he also assumed primary responsibility for supervising the health component. As a result of his presence the turn-around time on procurement and other matters was almost always just a matter of a day or two. He also worked hard to encourage Government to pursue the most cost- effective approaches to matters. By and large the Government also felt that the Bank was reasonably flexible regarding such matters as the extension of the closing date and reallocation of funds. In Part II of this report, MOH indicates, however, that the Bank should have been more flexible, especially with regard to the proposed expansion in the scope and duration of fellowships financed under the project. 27. There were some obvious shortfalls in the Bank's performance, especially during the early stages of project implementation. The combination of health and education in one project was largely a "marriage of convenience." The project was developed and launched prior to the Bank's 1987 reorganization while the PHN sector was still under a different vice presidency from education. Even during project processing, there seemed to be little genuine collaboration. Later there was even less. For instance, the greater experience of the education staff in procurement was not capitalized on through, for instance, a joint project launch. Neither were their skills in training used to support the development of the training aspects of the health component. Subsequently, when an education specialist took over as overall task manager and was deployed to the resident mission (para. 26), there was a long period when no other specialists were involved in supervision. Indeed, MOH has expressed concern about the Bank's not having fielded any public health specialists during implementation. 28. The Bank did not provide adequate support with regard to Bank procedures to the PHN task manager who was new to the Bank when he took over at about the time of appraisal. As a result the initial advice in procurement was not always adequate. For instance, the first PHN supervision mission left an aide memoire that confused local competitive bidding with prudent shopping. Indeed, the terms of reference for that mission were incomplete, omitting all reference to basic launch matters, such as establishment of accounts and submission of withdrawal applications, which would normally be priority matters in the case of a first time borrower. As one result, the first withdrawal application had to be returned since an account had not yet been established to receive the funds. Instead, the first mission's terms of reference focussed on the studies and getting agreement on their detailed objectives and scope of work. Urgent launch issues also seemed to get lower priority because Bank staff were pursuing more interesting  - 10- substantive matters. The first communique after Board approval reminded Government of the conditions of effectiveness, but also raised questions about the status of work on a specific technique (a reproductive risk protocol). 29. After initial inadequate support in procurement to Part A, things improved greatly with the consolidation of the Bank's supervision under an experienced task manager. It is worth considering, however, whether supervision of procurement eventually went too far in the other direction. The close review of virtually all procurement documents, including those for actions well below the threshold for prior Bank review established in the DCA, did provide focussed guidance to Government. It also meant that at times savings occurred that might not have otherwise. In the case of the health component, this extensive review was felt necessary because MOH failed to appoint a procurement officer and because the PMU required the Bank's support to help ensure adherence to the procurement guidelines (para. 15). In the end, this intensity of involvement may, however, have militated against the development of an atmosphere of trust and of evolution of skills in procurement since there was little opportunity for people to learn from their mistakes. The Bank probably should have more actively encouraged the PMU gradually to assume greater responsibility for following the guidelines on its own. (From MOH's comments on Part I of this report, it also appears that PMU staff were not fully aware that the thresholds for prior Bank review were as high as they in fact were [$200,000 and $500,000], thinking that they were identical with the ceiling for prudent shopping [$10,000].) 30. Part C (support for MDPI) was initially an orphan within the Bank. Due to its small size, in some ways it is understandable that this component got little priority. Nonetheless the lack of Bank responsiveness on a key matter was disgraceful. The preparation by MDPI of a two-year work program was a condition of disbursement for Part C. This work plan was brought by the MDPI participant to negotiations, but it took over six months and numerous follow-up communiques from MDPI and the Resident Mission before the Bank signed off on the work plan--with no comments! I. The Borroweres Performance 31. The Borrower's performance led to a number of delays, but they were not unusual compared to what is experienced elsewhere inasmuch as this was the first Bank-assisted operation in the social sectors in Ghana. The main sources of these delays were the slow release of counterpart funding, complex processes for approval of procurement, failure to set up the agreed arrangements for project administration, lack of adherence to agreed activity plans after implementation commenced, and the abysmal performance of two parastatal bodies involved in construction. 32. MOH received only one allocation of counterpart funds (totalling less than $200,000 equivalent) for the first three years of project implementation. Indeed, after MOH made a nominal deposit to open the project account, two years passed without there being any counterpart funds for Part A. The problem started when MOH, out of ignorance, failed to include a request for counterpart funding in the estimates for the first year. In the absence of clear plans of operation and budgets for its components, MOH, in contrast with MOE, was hard pressed to estimate its requirements accurately and then to make a case for them. They appeared to get no help from MFEP in this regard even though MFEP had taken the lead initially in getting the Bank involved in the sector. 33. Procurement approvals in Ghana turned out to be very complex and time consuming (para. 18), although eventually much of the procurement under the project was undertaken by GSC, which does not need to go through the standard approval layers. GSC initially had  - 11 - difficulties understanding World Bank guidelines and devising adequate specifications for goods not commonly procured by the GOG (e.g., solar refrigerators and computers). In addition, GSC was initially very lax in enforcing penalty clauses in its contracts. The performance of GSC improved considerably over time, although even as late as 1991 draft contracts prepared by GSC sometimes omitted key items (e.g., delivery dates). 34. MOH failed to set up or carry through with some of the agreed arrangements for administering the project. The failure to appoint a procurement officer to PMU clearly contributed to delays in procurement. GSC officials pointed out that many complaints about the time-consuming procedures were unjustified since the user's procurement planning was inadequate (e.g., not enough lead time was being allowed for), which would have been one of the main functions of the procurement officer. To coordinate the complex set of activities under Part A, MOH agreed in mid-1986 to set up a Project Implementation Committee and hold monthly meetings. This mechanism, which was already somewhat deficient since it included no officials from the administrative side of the ministry, soon ceased to function, however. 35. Perhaps the most abysmal performance under the project was that of SCC, which appeared never to honor its contractual obligations and delayed construction for years. In turn, for various reasons, including its frequent inability to make timely payments of the counterpart portion of contracts, MOH found it difficult to press for enforcement of penalty clauses or the cancellation of contracts with SCC. The rehabilitation of the Kumasi South Health Center, a five-week contract, extended over a year, and the six-month contract for rehabilitation of the Princess Marie Louise Hospital took well over two years and was still not fully completed at project closing. J. Lessons Learned 36. A number of lessons for other projects and to some extent for the Bank's overall work in Ghana can be extracted from the HERP experiences. First, with regard to project design and preparation: (a) For a first time borrower, it is essential to examine closely the scope and coverage of the project to ensure that it will not be unduly taxing on the borrower's implementation capacity; and (b) Beginning with project identification and certainly during preparation, every step should be taken with an eye to developing ownership and building consensus. Second, with regard to project implementation and supervision: (a) Where a PMU is felt to be required, strong efforts should be made to ensure that it is institutionally and physically as closely integrated into the fabric of the host ministry as possible; (b) A launch workshop, which was not held in this case, can be a key means for developing broad understanding of Bank procedures and at the same time focus attention on key actions needed around the time of effectiveness; (c) The Bank should ensure that adequate procurement training is provided to newly recruited staff who become task managers, particularly if they assume responsibility when a project is just beginning to take off; (d) During the early stages of project implementation, especially in the case of first time borrowers, supervision missions should be mounted rather frequently; (e) When supervision is undertaken by a task manager based in the field, there is a tendency, which must be consciously countered, to rely too heavily on that one person and not to mobilize the range of technical skills desirable; (f) More attention should be paid by the Bank, e.g., in staff training, to effective means for dealing with maintenance problems throughout the project cycle (although in HERP's case Bank staff actually addressed maintenance more often than usual); (g) The perils of entering into contracts with parastatals, which have little need to be competitive, should be obvious from SCC's performance. In the future, construction in the public sector, certainly in Ghana, should be open to competitive bidding and while it may not be possible or appropriate to exclude SCC, its performance record should be subject to scrutiny through pre- or post-qualification; and (h) When public sector procurement is highly centralized, as in the case  - 12 - of GSC, there is an ideal opportunity for a borrower and the Bank to engaged in focussed procurement training and institutional development. The value of doing so was eventually realized, but rather slower than it should have been. Third, with regard to project conditionalities: (a) As suggested by MOH's PMU, the initial deposit of counterpart funds, perhaps equivalent to half of the first year's requirement, should be made a condition of effectiveness in future projects; and (b) The preparation of annual work plans acceptable to the Bank should generally be a condition in legal agreements, with, perhaps, the first year's work plans being discussed during negotiations. K. Project Relationships 37. Throughout the project cycle, relationships between the Government and the Bank were basically good. While there were no noticeable conflicts among ministries and Government departments, one cannot help but wish that MFEP had done more to assist the rather inexperienced staff involved in implementing HERP. MFEP could have done much more, for instance, to help with the critical problem of counterpart funding. More vigilance on the part of MFEP would also perhaps have prevented MOH and MOE from shifting foreign exchange from the credit to local currency faster than required. With careful cash flow planning, some of the losses at the early stages of the project (about 9 million cedes) could surely have been avoided. 38. UNICEF's relationship with the project has been uneven. Initially UNICEF was closely associated with HERP, helping with preparation of Part A and agreeing to assist with implementation. The Bank agreed to help support in selected districts the five-year plan for PHC worked out between UNICEF and MOH. Gradually, however, it appears that UNICEFs role largely became that of a procurement agent (with regard to both Part A and Part B), which led to several disappointments. UNICEF has a firm rule that it will conduct no procurement without an advance deposit equivalent to 110% of the estimated cost of the goods, including freight and insurance. After the delivery of goods, UNICEF was extremely slow in refunding the 10% "returnable buffer." UNICEF also had difficulties at times in meeting delivery schedules, requiring over 18 months to deliver some of the drugs and frequently changing prices and delivery schedules. L Consulting Services 39. Most of the consultants financed under the project were used by MOH. In many cases, it appears that the performance of MOH's consultants would have improved if more attention had been devoted to preparation of terms of reference and to subsequent screening of applicants. MDPI found the assistance it received in preparing its long-term plan to be very helpful, as validated by the fact that the plan attracted considerable external support. M. Project Documentation 40. Preparation of this PCR was purposely assigned to a staff member who had not been associated with the project at any stage of its development or implementation. This had some drawbacks with regard to access to project documentation since the project had been supervised from the resident mission for over two-thirds of the implementation period. While the Bank's replies were generally available in the central files, some pieces of correspondence from Government were not. In addition, project indicators were not formulated until the next to last supervision report. Finally, it should be noted that the original cost tables in the President's Report were difficult to use, perhaps because the project documentation was prepared hastily. The tables are inconsistent with each other and do not adequately show the amounts intended for some of the key project inputs on the health side, e.g., essential drugs.  - 13 - PROJECT COMPLETION REPORT GHANA HEALTH AND EDUCATION REHABILITATION PROJECT (CREDIT 1653-GH) PART II: PROJECT REVIEW FROM THE BORROWER'S PERSPECTIVE PART A: HEALTH COMPONENT The impact of several years of economic decline in Ghana on the health sector was very severe - Health institutions had deteriorated but could not be maintained. Broken-down equipment could not be repaired because of lack of spare parts. Drugs and other essential supplies were often in short supply. The minimum services provided were poor. Staff morale was low and there was hardly any job satisfaction. All this contributed to the severe brain drain which had peaked in the mid 1980s. It was against this background that the Health component of the Health and Education Rehabilitation Project was designed to address these deficiencies. The objectives of the project were: 1. To strengthen PHC service delivery; 2. To strengthen priority programmes of the Ministry of Health; and 3. To strengthen the overall capacity of the Ministry of Planning and management of the health services. Specifically, an inventory of all health care delivery facilities, training institutions and storage facilities was to be taken, their state of disrepair was to be established and estimates for their rehabilitation were to be prepared by the project architect. In addition prototype design of urban and rural health centres was to be prepared to enable the Ministry to prepare a programme for rehabilitation of existing facilities and the expansion of services. It was further envisaged that 100 rural health centres would be reequipped and essential supplies provided to both urban and rural health centres. An urban nutrition rehabilitation programme for Accra and Kumasi was to be supported through the completion of the new building and the rehabilitation of the old building of the P.M.L. (Princess Marie-Louise Hospital), and the supply of logistic support to seven urban polyclinics in Accra. In Kumasi, the Child Welfare Centre and two Urban Health Centres were to be rehabilitated and logistic support provided. To support a weaning food production programme, 50 selected communities were expected to be provided with corn-mills after a carefully planned survey to determine the most needy areas.  - 14 - In the area of Expanded Programme on Immunization, two large cold rooms and 30 solar-powered refrigerators were to be supplied. Three studies on National Health Policies, Health Manpower and Health Care Financing to support long term planning were to be undertaken. The design of the project was very complex given the fact that the Ministry is not used to operating projects. As implementation progressed, not without problems, it was felt that the loose nature of the project could be used to our advantage especially because of the persistent changes in the field. For example, out of ten Regional Directors, only five had appropriate training. Health Managers at various levels were not available. Thus the training needs of the Ministry were much greater at the time of implementation than were identified during the planning stage. IMPLEMENTATION There is no doubt that implementation of the health component of the project was fraught with numerous problems. In the first place, the P.M.U. was inadequately staffed. Knowing that this was the first time the Ministry of Health was going to be involved in project management, the Bank should have worked more closely with the M.O.H. in establishing a functional P.M.U. Secondly, the provision of counterpart funds was irregular. Even when this was budgeted for, funds were not provided in the budget. The procedure where the borrower has to seek approval from the lender in order to use the money he has borrowed and is going to pay back defies natural logic. ACHIEVEMENTS 1. Strenythening PHC Service Delivery: This objective was achieved through the delivery of 190 sets of equipment for midwifery services to health centres and health posts. Seventy sets of equipment and essential supplies were also provided for a number of Level "C" institutions. The seven polyclinics in Accra were supplied with their inputs of equipment and vehicles and drugs. The programme at the PML--completion of the new building, rehabilitation of the old building, supply of equipment and other logistic support--has been completed. The programme in Kumasi-- rehabilitation of C.W.C. (Child Welfare Centre), rehabilitation of two urban health centres and the supply of equipment, drugs and other logistic support--was completed by the time the project terminated. 1000 mopeds have been distributed to staff in rural health centres throughout the country to carry out their outreach and extended outreach services. The mopeds are the property of the health centre but assigned to the health worker so long as he or she remains at post and works for the institution. Each institution is responsible for the running and maintenance of the moped. Unfortunately, the mopeds have been found to be unsuitable for our environment. They are too fragile. Many of them have already broken down. 2. Strengthening of M.O.H. Priority Programmes (E.P.I.): The two cold rooms were supplied but both were installed in Accra instead of the original plan of one each in Accra and Kumasi (for the Expanded Programme of Immunization). Thirty solar-powered fridges were  - 15 - installed but have not worked because the panels were of poor quality. The company which supplied the panels had, in the meantime, gone into liquidation. Fifty corn-mills have been supplied and weaning food is being produced in various parts of the country. Patronage by mothers is high. Management of drugs supply including improvement to storage facilities was given an added boost. The estimation of drug requirements on a national as well as scientific basis has been institutionalized. Some rehabilitation of Regional Medical Stores has been carried out as part of the health component of the project. Radio-communication equipment has been installed at the M.O.H. Headquarters, Central and Regional Medical Stores, the two Teaching Hospitals, the Rural Training School, Kintampo and the offices of all Regional Directors of Health Services. 3. Strengthening Overall M.O.H. Capacity: The three studies on National Health Policies, Health Manpower and Health Care Financing were carried out but the final product of the studies did not find ready application as had been envisaged. They had not served the purpose for which they were intended. 4. Provision of Training: In all, there were 17 fellowships of one year duration and 17 fellowships for short courses of duration ranging from 35 days to 6 months. Out of the 17 fellows who pursued courses leading to an MPH (Master of Public Health) or similar degree, only two persons can be said to be lost to the system. They are Dr. Baah Asante and Dr. F.E.A. Martinson both of whom are still in the U.S. Mr. Maaweh is due back in July, 1992. He has had to stay on because his wife who joined him there fell ill and has been receiving treatment. Mrs. Abigail Kyei completed her course in 1991 and retumed home. She is at post in Kumasi Dr. Edith Clarke is also at post. So is Dr. E.A. Amuah. Dr. P.R Asman who was sponsored to do a diploma course in Biomedical Engineering did so well that the School offered him a fellowship to do a Masters in the subject. He is due back in August/September this year. Perhaps the most successful part of the project as far as the impact is concemed is the training component. Three of the doctors trained under the scheme namely Dr. D.Y. Dovlo, Dr. G.K Amofah and Dr. Eric Amuah are now Regional Directors of Health Services for the Eastern, Ashanti and Western Regions respectively. The Rural Health Training Centre where Medical Assistants, Technical Officers-Nutrition and Technical Officers-Disease Control and Field Technicians are trained is also being gradually transformed by Dr. S.A. Akor, a beneficiary of the scheme. The rest of the staff who benefitted from the programme are contributing immensely to the work of their various units. The systematic progress being made at the regional level and below in the entire health services is to a large extent a result of the training that most of the people in key positions now had under the project. It is most regrettable that the Bank Officials who worked on the project refused to see the need for training of more doctors in public health to enable them to assume management positions in the Ministry of Health.  - 16- It is important for the Bank to ensure that their staff who work with us do not pretend to be what they are not During the course of the project, Bank officials who are perhaps economists suddenly turned into health managers and used these false pretenses to take decisions on mattes they were not competent to address If this had not happened and more people had been trained as the Ministry of Health found necessary, even greater success would have been achieved. KLE. ADIBO (DR.) DIRECTOR OF MEDICAL SERVICES June 12, 1992 MINISTRY OF HEALTH  - 17 - MINISTRY OF EDUCATION HEALTH AND EDUCATION REHABILITATION PROJECT (CR. 16S3-GH) PART Bs EDUCATION COMPONENT 1.0 THE BACKGROUND SIMTUAlON 1.1 By 1985, there was an acute decline in the entire formal education delivery in Ghana, the most critical area being the basic education sector. The following were in evidence:- (i) Serve shortages of textbooks to the extent that one textbook to a class was not unknown; (ii) Stationery like pens, pencils and exercise books were scarce; (iii) In the absence of tools to work with, morale was low among teachers, many of whom sought economic well-being out of the country which in turn worsened the blight in schools. 1.2 It was in these circumstances that the Health and Education Rehabilitation Project was initiated on 31 January 1986. The project was in principle targeted to: (i) Arrest the decline within the scope of HERP rehabilitatory support; (ii) Promote the development of educational materials for schools; (iii) Provide logistical aid for the improvement of educational management and planning. 1.3 Thus the overall aim of the DEVELOPMENT CREDIT AGREEMENT signed between the Ghana Ministry of Education (MOE) and the International Development Association (the Association also referred to here as the World Bank) on 31 January 1986, in respect of the Ghana education sector, was to prevent further deterioration in the education system and to strengthen MOE's management and planning establishments (SCHEDULE 2 (i) and (iv). 1.4 Three organizations were involved in the Agreement. They were the Ministry of Health (MOH) referred to as Part A, the Ministry of Education (MOE) referred to as Part B and the Management Development and Productivity Institute (MDPI) referred to as Part C MOH had its own Project Management Unit (PMU) and so did MOE provided accounting service for MDPI in addition to its own. 2.0 EFFECTIVE OPERATIONAL DATES OF THE PROJECT 2.1 The MOE component of HERP became operational on 27 April 1986. It was expected to finish implementation on 31 December 1990 unless there was need to extend completion date. On 20 November 1990, the Ghana Ministry of Finance and Economic Planning applied for extension for six months. Reasons provided on behalf of the MOE component was that there was on-going commitment in the procurement of a number of core textbooks, whose production had reached advanced stages. The World Bank, however, after considering the levels of  - 18 - accomplishments of all the sectors of HERP at the time, extended the closing date of the Credit to 31 December 1991. 3.0 DESCRIPTION OF THE EDUCATION COMPONENT OF THE PROJECT 3.1 According to SCHEDULE 2, Part B (i.e. Description of Project) of the Agreement, the following were to be undertaken by HERP MOE PMU:- (i) Printing and distribution of English, Mathematics and Science Textbooks and Teachers Guides for primary and junior secondary schools. (ii) Provision of basic instructional supplies (exercise books, pens and pencils) to cover needs of primary and junior secondary schools for two years. (iii) Provision of textbooks for libraries of second cycle institutions. (iv) a. Strengthening of MOE in the preparation and execution of education projects. b. Provision of basic equipment, supplies and training of MOE departments of Planning and Statistics and of supplies to PMU; and minor repairs to MOE's regional and district textbooks depots. c. Provision of core journals, library books and periodicals for the universities. 4.0 SUPPLY OF STATIONERY: PENS. PENCILS AND EXERCISE BOOKS 4.1 The first salvage step was the procurement of pens, pencils and exercise books. The orders were placed through HERP in 1986 and delivered the same year after some delay. The suppliers were Unicef whose quotations were competitive. The consignments were paid for under the Project Preparation Facility. Breakdown of the supplies are as follows: (i) Sq. Exercise Books 1,210,000 (ii) Rule Exercise Books 6,256,000 (iii) Pencils 1,269,190 (iv) Ball Point Pens 4,291,190 4.2 Total Cost Of The Four Items Is USD 716.028.00 5.0 LIBRARY BOOKS AND CORE JOURNALS TO THE THREE UNIVERSITIES 5.1 The procurement of library books and core journals/periodicals was carried out in three phases:- (i) A limited quantity of books ordered in 1987, costing 60,206.45 UK pound. (ii) A core set of three hundred periodicals were subscribed to cover a three-year period in 1988. The cost was 50,127.30 UK pound. (iii) Further journal subscription was undertaken in 1989 costing US$102,890.09. (iv) An amount of US$180,000 was disbursed for further subscription of core journals/periodicals by the close of 1991.  - 19 - 6.0 SUPPLY OF TEXTBOOKS FOR LIBRARIES OF SECOND CYCLE INSTITUTIONS 6.1 These were procured in two batches as follows:- (i) 1988: 48,120 volumes costing 132,988.59 (ii) 1991: 18,000 volumes costing 58,331.75 6.2 The first lot were textbooks on English and science ordered for Forms 4 and 5 of secondary schools as well as a few quantities for Teacher Education Colleges and Vocational Institutes. The second order was for libraries of Teacher Education Colleges and was delivered to the Teacher Education Division of the Ghana Education Service (GES) for distribution to the 38 Teacher Training Colleges in October/November 1991. 7.0 PRINTING OF TEXTBOOKS 7.1 Introduction - The Co-publishing Project and MOE Textbooks Printing: At the time the Agreement came into force on 27 April 1986, MOE had already organized, dating back to November 1984, a Co-publishing Project. The Co-publishing Project is a textbooks publishing partnership between MOE/Ghana Education Service (GES) on one hand and the Ghana Publishing Corporation, Sedco Publishing Limited, Afram Publications (Ghana) Limited and Adwinsa Publications (Ghana) Limited on the other. It has undertaken the design and publishing of basic education textbooks written by Ghanaian textbook writing panels sponsored by GES and MOE. The purpose of the partnership has been: (i) to build up the Free Textbooks Scheme; (ii) to develop the local book industry; and (iii) to liberalize the book market. 7.2 Readiness of Manuscripts and Films: Fortunately, at the commencement of the implementation of the Agreement, the Co- publishing Project had been able to develop to film stage some forty-one manuscripts for basic education textbooks and these were ready for printing. Subject areas included English, Maths, Science, Social Studies, Music and Religion together with corresponding Workbooks on English Course for Ghanaian Schools Books 3, 4, 5 and 6. But as SCHEDULE 2 Part B (1) of the Agreement states, only English, Maths and Science texts and teachers' guides on them were eligible for printing. This in effect excluded the printing of the English Workbooks and the titles on Religion, Music and Ghana Social Studies series Primary 1, 2 and 3 and primary 5 and 6 for the time being only. So between 1986 and 1989 only films for textbooks and teachers' guides for the subjects specified in the Agreement were offered by MOE PMU for printing and Ghana Social Studies Series Pupil's Book 4. The total number was thirty-five. 7.3 Textbooks Printing 1986 - 1989: Copies i. Ghana Science Series: Junior Secondary Science Pupil's Book 1 230,000 ii. Ghana Science Series: Junior Secondary Science Pupil's Book 2 230,000  - 20 - iii. Ghana Science Series: Junior Secondary Science Pupil's Book 3 230,000 iv. Ghana Science Series: Junior Secondary Science Teachers' Book 1 10,000 v. Ghana Science Series: Junior Secondary Science Teachers' Book 2 10,000 vi Ghana Science Series: Junior Secondary Science Teachers' Book 3 10,000 vii. An English Course for Ghanaian Schools Pupil's Book 5 250,000 viii. An English Course for Ghanaian Schools Teachers' Handbook 5 8,000 ix An English Course for Ghanian Schools Pupil's Book 6 150,000 xI An English Course for Ghanaian Schools Teachers' Handbook 6 - 8,000 xi. Ghana Social Studies Series: Pupil's Book 4 250,000 xii. Ghana Mathematics Series: Junior Sec. Sch. Pupil's Book. 1 230,000 xiii. Ghana Mathematics Series: Junior Sec. Sch. Teachers' Guide Book. 1 10,000 xiv. An English Course for Ghanaian Schools Pupil's Book 4 250,000 xv. An English Course for Ghanaian Schools Teachers' Handbook 4 8,000 xvi Ghana Mathematics Series: Pupils's Book 4 250,000 xvii. Ghana Mathematics Series: Teachers' Handbook 4 8,000 xviii. Ghana Mathematics Series: Pupil's Book 5 95,000 xix. Ghana Mathematics Series: Teachers' Handbook 5 8,000 xx Ghana Mathematics Series:  -21 - Pupil's Book 6 260,734 xxi Ghana Mathematics Senes: Teachers' Handbook 6 8,000 muL Ghana Mathematics Series: Jun. Sec. Schools Pupil's Book 2 230,000 iL. Ghana Mathematics Series: Jun. Sec. Schools Teachers' Guide 2 10,000 mv. Ghana Science Series Pupil's Book 1 300,000 xxv. Ghana Science Series Pupil's Book 2 300,000 xvi. Ghana Science Series Pupil's Book 3 275,000 sViu. Ghana Science Series: Teachers' Guide Vol. 1 24,000 xvui. Ghana Mathematics Series: Pupils Book 2 300,000 xdL Ghana Mathematics Series: Teachers' Handbook 2 8,000 OXC Ghana Mathematics Series: Pupil's Book 3 275,000 miL Ghana Mathematics Series Teachers' Handbook 3 8,000 xxxiL An English Course for Gbanaian Schools Pupil's Book 3 275,000 mi. An English Course For Ghanaian Schools Teacher's Handbook 3 8,000 xxxv. Ghana Mathematics Series: Jun. Sec. Maths Pupil's Book 3 230,000 xxxv. Ghana Mathematics Series: Jun. Sec. Maths Teachers' Guide 3 10,000 A Total Number of 4,727,884 copies of books were therefore printed and distributed at basic education level in respect of these thirty-five dtl.es (Please see rearrangement of titles in Annex 5) 7.4 Production of Ghana Social Studies Series Books 4. 5 and 6. 1989 -1991: Prior to and in the coure of 1989-91, panels of GES textbooks writer had prepared manuscripts for Ghana Social Studies Series Primay 1, 2, 3, 4, S and 6 togedier with Tecben  - 22 - Manuals. These were sponsored by HERP MOE PMU under Part B, 4(a) of the Agreement. MOE's effort was enhanced further when the World Bank was able to approve the printing of Book 4, and thereafter Books 5 and 6. This ensured complete coverage of Upper Primary 4, 5 and 6 in Social Studies texts. Books 5 and 6 were written and printed in the course of 1989-91 and the two hundred and fifty thousand copies each of Books 5 and 6 were delivered to MOE by the end of August 1991. Similarly, Teachers' Manuals Books 1, 2, 3, 4, 5 and 6 were printed in December 1991 and delivered on average 11,000 each and passed on to MOE Logistics Division in January 1992. 7.5 Top-UR Printing: As a result of increased enrollments in schools between 1986 and 1991, it was considered necessary to bridge the gap in the supply of textbooks already printed and distributed to schools. Accordingly, the following titles and numbers were printed and delivered to MOE August 1991:- 1. Primary Mathematics Pupil's Book 2 60,000 2. Primary Mathematics Pupil's Book 3 54,000 3. An English Course for Ghanaian Schools Pupil's Book 3 54,000 4. Primary Science Pupil's Book 1 114,000 5. Primary Science Pupil's Book 2 60,000 6. Primary Science Pupil's Book 3 103,000 7.6 Textbooks Printing Costs 1986 - 1991: During the project period, therefore, total cost of textbooks, 1986 - 1991 is US$3,334,449.71 and the breakdown year by year is as follows:- 1986 US$ 249,589.00 1987 517,472.29 1988 589,652.57 1989 829,101.01 1990 615,936.28 September 1991 442,734.33 Special Commitment/ Replenishment 89,964.23 3,334,449.71  - 23 - During the entire project period, therefore, the total number of textbooks printed and delivered to MOE was 6.086,179. Please see Annex 5. 7.7 Retrospective Assessment of Textbooks Printing: (i) Apart from Ghana Social Studies Series Books 4, 5 and 6, the provision of SCHEDULE 2 Part B (i) of the Agreement has been adhered to strictly. In the process, a total of 5,672,884 copies of titles on English, Mathematics and Science have been printed and handed over to the Logistics Division of MOE for distribution. According to the Division. percentage of coverage of the books in schools has in no instance of a title been less than 63 percent. Average coverage has been 83.7 percent. Impact wise. therefore. the alleviating effect of HERP achievement in the provision of textbooks to Ghanaian Primary Schools has been tremendous over the six-year period. Please see Annex 5. (ii) The books were printed in the course of five years. Each copy was supposed to have a life span of three years on average use. So books delivered in 1987/88 needed either substantial replacements during the project period or perhaps rebinding by the beginning of the 1991/92 academic year, i.e., September 1991. (iii) Procurement procedures prescribed by the World Bank together with those in force locally adversely affected timetable for supplies and production. While contract awards were indeterminate and protracted, the school calendar year ticked away and book supplies to schools were delayed long after school reopenings. Contract award procedures were: preparation of bidding documents, approval of prepared bidding documents and preparation and presentation of bids internationally; opening of bids and preparation of evaluation reports on bids; study and consideration of evaluation reports by the Ghana Central Advisory Tender Board in its own time; study and consideration of bidding documents, evaluation reports and the recommendations of the Central Advisory Tender Board in its own time; study and consideration of bidding documents, evaluation reports and the recommendations of the Central Advisory Tender Board by the Public Agreements Board (PAB) in its own time; approval of the recommendations of the PAB by the PNDC thereafter. All these steps could hold up award readiness for eight to twelve months or more before the bid winner is notified to print the books in three or four months. The process certainly required time-saving review.* (iv) There is equally the need to have spread evenly the printing of core textbooks over the three main areas of basic education, namely literacy, numeric and socialization. By 1 January 1986, when the Agreement was signed, English, Science and Mathematics were probably perceived as the most critical textbook shortage subject areas that required emergency supply attention. Therefore printing of textbooks on these particular subjects were deemed more urgent than any other subject area. Their production was accordingly provided for at the exclusion of Music, Religion and Social Studies. Workbooks on English which were print-ready were not considered vital and teachers' manuals for socialization subjects for lower and upper primary were ignored. 8.0 STRENGTHENING OF MOE IN THE PREPARATION AND EXECUTION Of EDUCATION PROJECTS 8.1 There were three main operational areas under this provision:- (a) Textbooks Writing (b) Training of Book Industry Personnel  - 24 - (c) Other Education Projects 8.2 Under the Textbooks Writing Programme, the following titles with teachers' manuals were written, out of which, as can be seen, not all have been printed:- Social Studies Series For Primary Schools:- (i) Pupil's Book I and Teachers' -Written but only Manual Teachers' Manual printed (ii) Pupil's Book II and Teachers' -Written but only Manual Teachers' Manual printed (iii) Pupils Book III and Teachers' -Written but only Manual III Teachers' Manual printed (iv) Teachers' Manual for Book IV -Written and printed (v) Pupil's Book V -Published September 1991 (vi) Teachers' Manual for Book V -Written and printed (vii) Pupil's Book VI -Published September 1991 (viii) Teachers' Manual for Book VI -Written and printed 8.3 Total Amount Spent is US$70,351.59. 8.4 TRAINING OF BOOK INDUSTRY PERSONNEL: A workshop was organized at the University of Science and Technology, Kumasi, for the training of print personnel for the maintenance of printing machines. The training session lasted February 4 to 19, 1991. There were twelve participants drawn from the public sector book production presses. Certificates were awarded at the end of the training. Cost of the training workshop was US$30,000.00. 8.5 STRENGTHENING THE CAPACITY OF MOE PMU This entailed the provision of training courses for personnel of HERP PMU. They were Lawrence Adama Clocuh and Mr. Robert Ansah. Mr. Clocuh did a one-month course in procurement with the Crown Agents of Britain and Mr. Ansah took a refresher course in Financial Management at the Ghana Management Development and Productivity Institute in Accra. Cost: US$9,628.21  - 25 - 9.0 PROVISION OF BASIC EOUIPMENT, SUPPLIES AND TRAINING 9.1 These items were meant to strengthen MOE's Planning Division and Statistics as well as supplies the PMU. MOE was expected to carry out minor repairs to MOE's regional and district textbooks depots. On further consideration of the issue vis-a-vis existing facilities, it was decided to abandon, with the World Bank's approval, the rehabilitation of these unserviceable outfits for better located and properly designed ones put up by MOE itself. Please see section 10.1 9.2 However, a total of US$262,870.21 was expended on the purchase of five Nissan Patrol vans, one Corona and one Corolla cars, three photocopiers, two electronic typewriters, four air conditioners, a personal computer, sets of furniture, etc. to operate HERP PMU and to strengthen the operations of other relevant sectors as provided for in the Agreement. 10.0 OVERALL RETROSPECTIVE ASSESSMENT AND IMPLEMENTATION EXPERIENCE 10.1 The Four Main Targets of the Agreement set for the Education Sector were most successfully achieved with the only exception of 'minor repairs to MOE's regional and district textbooks depots'. Indeed, a national survey was carried out to assess the status and condition of depots and warehouses being held by the Ghana Education Service. A World Bank consultant carried out the assessment and made recommendations which depots/warehouses should be rehabilitated at Saltpond and Accra. However, rehabilitation could not be undertaken as the final estimates were found prohibitive and uneconomic. Besides time was and is felt very much needed. So the minor repairs items had to be abandoned and the money for them utilized on other approved items. 10.2 Obviously a key word in the Agreement is rehabilitation. By 1985, the textbooks supply situation to basic education institutions was so grave that the restriction of printing and distribution of textbooks to three subjects only i.e. English, Maths and Science made administrative sense perhaps; but it was educationally narrow as socialization in the curriculum was overlooked. It is to the credit of the implementation process that this anomaly was recognized and some allowance was made to address it. Credit should go to the World Bank and to its Resident Representative, Mr. Nicholas Bennett, for this. It is, however, unfortunate that the redress by the end of the implementation period could not cater for the publication of Social Studies Series for lower primary Pupil's Books One, Two and Three. 10.3 The provision of textbooks for libraries of second cycle institutions was well conceived when weighed against the paucity of good textbooks other than single prescribed core texts in class use. Generally, however, secondary schools in Ghana are relatively better provided for in library books than teacher education colleges. Towards the end of the implementation of the Agreement, effort was made to refurnish and upgrade the book supply situation in teacher education colleges. In this regard, books written by indigenes and non-nationals worldwide were supplied to expose students to a universal book world beginning from their own environment. No books were provided for primary school libraries in the Agreement. This is unsatisfactory as the habit of voluntary reading is best inculcated at this stage. 11.0 RECOMMENDATIONS 11.1 (i) HERP MOE PMU provided accounting service to MDPI. MDPI is not accountable to MOE. Its sector Ministry is Mobilization and Social Welfare. This created problems regarding policy and implementation. It is recommended that Sector Ministries be made to provide and control accounting service.  - 26 - (ii) Fluctuations in dollar value in Ghana, usually on the depreciation side, created problems of audit evaluation. It is hoped that this could be accorded easier World Bank understanding in future. (iii) It is recommended that the World Bank would have greater flexibility in accommodating moves in a project of this nature to ensure more rounded education. This would have averted the inability to print Ghana Social Studies Series Pupil's Books 1, 2, and 3. (iv) A rehabilitation project of the HERP kind should have been flexible enough to provide sustainable book printing capacities for local book printers. Print runs not more than 50,000 to 75,000 lots in four to six months would have been ideal if staggered in those lots to keep the presses running all the time. 12.0 CONCLUSION It must be placed on record that HERP, PMU has during the implementation period, 1986-1991, gratefully and generally enjoyed the co-operation and understanding of the World Bank and in particular of the Resident Representative, Mr. Nicholas Bennett. There were no hitches that throughout the implementation hindered eventual satisfactory achievement. All concerned deserve congratulations including all our disbursement agencies, suppliers, and above all, the World Bank itself; for given the facts of this report, HERP has had salutary impact, whatever the difficulties or shortcomings, in helping to salvage a national education mishap. S.A. AMU DJOLETO MANAGER HERP MOE PMU 20 MARCH 1992  - 27 - MANAGEMENT DEVELOPMENT AND PRODUCTIVITY INSTITUTE HEALTH AND EDUCATION REHABILITATION PROJECT (CR. 16S3-GH) PART C: MDPI COMPONENT The Development Credit Agreement signed between the Government of the Republic of Ghana and the International Development Association (IDA) of the World Bank on 31st January 1986, specifically sought to rehabilitate Ghana's health and education services: in the latter case, provision was made for the strengthening of the Management Development and Productivity Institute (MDPI). The MDPI Component of the Health and Education Rehabilitation Project (HERP) has, indeed, enabled the Institute to offer improved management training, consultancy and research services through, inter alia, the following activities: (a) Rehabilitation of classrooms and offices; (b) provision of essential office equipments and supplies; (c) acquisition of vehicles; (d) strategic study on the MDPI; and (e) construction of a multi-purpose hall at the MDPI. In sum, the MDPI Component of HERP has had a significant impact on the Institute: it has not only enhanced the performance of the Institute but also improved the infra-structural facilities at the Institute for the benefit of its course participants and client organisations, as well as the staff of the Institute. But more significantly, given the critical role that the MDPI plays in Ghana's socio-economic development process (especially in the area of human resources development), the Project's positive impact on the Institute has been of immense benefit to Ghana as a whole. It is, therefore, the determination of the MDPI to ensure that its observed enhanced capacity and enabling institutional environment, made possible through HERP and other projects, will be sustained throughout the 1990s and beyond for the benefit of the Ghanaian economy. Dr. H. Akuoko-Frimpong Ag. Director Management Development & Productivity Institute 21st November 1991 Accra, Ghana   - 29 - PROJEC COMPLETION REPORT GHANA HEALTH AND EDUCATION REHABILITATION PROJECT (gumDI 16SOGH PART IM STATISTICAL lNFORMATION 1. Related Bank Lo= and/or Credits Credit Number and Title: Credit 1744-GH - Education Sector Adjustment Credit Purpose: To improve pedagogic effectiveness, and to recast the financing of education so that public and private expenditures are cost effective within modest growth expectations. Specifically, to reduce length of pre-university education from 17 to 12 years, to expand access to primary education and to introduce a practical orientation to basic education. Year of Approval: 1986 Status: Closed in December 1991. Credit Number and Title: Credit 2140-GH - Second Education Sector Adjustment Credit. Purpose: To support the second three years of Government's education reform efforts, which aim at increasing access, improving pedagogic effectiveness and relevance, restructuring pre-university education and ensuring financial sustainability. To help consolidate the reforms that have already taken place at the primary and junior secondary levels, and extend them to the senior secondary level (grades 10-12). Year of Approval: 1990 Status: On-going. Credit Number and Title: Credit 2193-GH - Second Health and Population Project. Purpose: In health: to bring about a progressive improvement in the quality and coverage of the health services especially in terms of primary health care (PHC). To improve equity through a focus on the underserved three northern-most regions of Ghana. In population: to bring about an increase in the availability and accessibility of family planning services. To support the implementation of Government sector priorities, involving important policy, institutional and program changes, and improved public expenditures programs in the sectors. To increase and further institutionalize the role of NGOs in health and population. Year of Approval: 1990  - 30 - Credit Number ad Title: Credit 2278-GH - Community Secondary Schools Project. Purpose: To ensure that junior secondary school graduates from backward and deprived areas of the country have opportunities to enter senior secondary day schools in their neighborhoods; to ensure that essential physical facilities are constructed at about 140 schools; to ensure that local communities and district assemblies take responsibilities for the development and running of the new secondary schools, and feel that the schools are their schools; and to encourage schools to establish hygienic toilet facilities. Year of Approval: 1991 Stats: On-going Credit Number and Title: Credit 2349-GH - Literacy and Functional Skills Project. Purpose: To support and consolidate, over the period FY1993-95, the Government's program of functional literacy: (i) To assist in strengthening the institutional capacity of the Non-formal Education Division (NFED) to manage effectively the entire literacy program; (ii) to ensure that all program aspects are subject to frequent evaluation and monitoring, and that research and evaluation become key inputs in the development of any new initiatives; (iii) to improve the existing literacy program so that a large proportion of the 840,000 adults who will be allowed to participate become fully literate; (iv) to ensure that all new literates, whether from the school system or from the literacy program, have access to a range of reading materials in Ghanaian languages; and (v) to help expand the coverage of the FM broadcasting system to support the functional literacy program and to increase the frequency of educational broadcasting in Ghanaian languages. Year of Approval: 1992 Status: Not yet effective.  - 31- 2. Project llmeabl 1im Original Date Revised D Actud Dat Identification 06/84 Preparation 11/84 Pre-appraisal n.a. Appraisal Mission 05/85 Credit Negotiations 12/85 Board Approval 01/23/86 Credit Signature 01/31/86 Credit Effectiveness 04/28/86 Credit Closing 12/31/90 12/31/91 12/31/91 I/ 1/ Project closing date was extended on December 21, 1990, to allow Government to complete key project activities. 3. Credit Disbursements A. Cumulative Estimated and Actual DisburseMents (USS million) IDA Fiscal Year EY8 FY87 EY88 EY8 E EY9 EY9 Appraisal Estimate 1.90 8.70 13.00 14.30 14.60 15.00 Actual 1/ 2.17 3.21 4.41 8.17 13.19 14.41 17.94 Actual as % of Estimate 114.2% 36.9% 33.9% 57.1% 90.3% 96.1% 119.6% 1/ Because of the fluctuation of the US dollars against SDR, the project benefftted from additional funds equivalent to about US$3.0 million. All funds under Credit 1653-GH were disbursed and no cancellation was required.  - 32 - B. TIME LINE OF APPRAISAL ESTIMATE AND ACTUAL DISBURSEMENT Us IMIIIIe Equivalent 1986 1987 1988 1989 1990 1991 1992 IDA Pleefl *arw Appralsal Estimate - Actual  - 33 - Table C: Allocation of Proceeds . ............................... ......................................... ............................ ................................ ................................ In SDR In US .............................................. ............... OrIginal Actual Category of Expenditures Allocation Disburoments 1/ Ealance Baltnce 2/ ......................................... .......... .................................... ............... PAMT A: HEALTB COMPONENT 1-A Civil Works: Construction mterilas, rehabilitation 740.000 732,327 7,673 9,974 2-A Equipment Furniture haterials, and Vehicles and Medical Suppltes 4,880,000 6,080,168 (1,200168) (1,560,218) 3-A Technical Assistance nd Training: Local/Foreign consultants; Overseas/ local training; fellowships; PHU (1) Populatlon Studies and Training 460 000 117.570 342,430 45,159 (ii) Other Itoem 1,565.000 1.359U867 205,133 266,673 S-A Project Operating Costs: Vehicles (OIN); wages; local travel; supplies 1,015.000 535,542 479.458 623.296 6. Refunding PPF Advance 0 0 0 0 7-A Unallocated 3/ 430.000 211,071 218.929 284,608 Subtotal Part A: 9.090.000 9,036,545 53,455 69,492 PARTS B AND C: EDUCATION COMPONENT & NDPI 1-U/C Civil Works: Minor repairs to regional nd district textbook depots nd renovation of NDPI 190.000 92,066 97,914 127.288 2-I/C Equipment Furniture, Naterials ond Vehicte 190.000 183,384 6.616 8.601 3-3/C Technical Assistance nd Local Training 145,000 135.291 9,709 12.621 4-A Textbooks, Teachersc Guides and School Suppties 2,485.000 2,583,423 (98,423) (127,949) 4-8 JournaLs. Periodicals mnd Library Books 550.000 717.151 (167,151) (217.297) 5-3/C Operating Costs: Vehicels (COM); Office SuppLIes; Nfscellenaous 140,000 191,784 (51,784) (67,319) 6. Eefunding PPF Advance: Instructional Materials nd School Suppiles; Vehicles- Office Equlpnent and Supplies; Technical Assistance 930,000 780,494 149,506 194,358 7-8 Unallocated 3/ 80,000 79,842 158 205 Subtotal Parts I and C: 4,710,000 4*763,455 (53.455) (69,492) ......................................... .................. ..................................... .......................... TOTAL 13,800,000 13.800,000 (0) (0) ......................................... .............................................................................................................. ......................................... 1/ Based on Loan Database of Nay 11, 1992. 2/ At exchange rate of USS1.30 * 1 SOR. 3/ Actual Disbursements Colun: amount is extracted from the disbursed coluan against Speclal Account for Parts A, B and CM from Loan Database printout of May 11, 1992.  _ 34 - 4. Project Implementation ............ .......................... SAR Project Cowponents Unit Estimte. Actuat Comments