Ghana - Health and Education Rehabilitation Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 13240 PERFORMANCE AUDIT REPORT GHANA HEALTH AND EDUCATION REHABILITATION PROJECT (CREDIT 1653-GH) JUNE 29, 1994 Operations Evaluation Department 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 EdSAC = Education Sector Adjustment Credit GDP = Gross Domestic Product HERP Health and Education Rehabilitation Project ICB = International Competitive Bidding IEQ = Improving Educational Quality (Research project in Ghana) IMF = International Monetary Fund JSS = Junior Secondary School LSMS = Livings Standards Measurement Study MDPI = Management Development and Productivity Institute MoE = Ministry of Education MoH = Ministry of Health PBME = Planning, Budgeting, Monitoring and Evaluation (Ministry of Education) PCR = Project Completion Report PHN = Population, Health and Nutrition Department PHREE = Population and Human Resources Department; Education and Employment Division PMU = Project Management Unit PPF = Project Preparation Activities SAR = Staff Appraisal Report UNFPA = United Nations Fund for Population Activities UNICEF = United Nations Children's Fund USAID = United States Agency for International Development WAPED = West Africa Projects, Education Division FOR OFFICIAL USE ONLY THE WORLD BANK Washington, D.C. 20433 U.S.A. Office of Director-General Operations Evaluation June 29, 1994 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECT: Performance Audit Report on Ghana Health and Education Rehabilitation Project (Credit 1653-GH) Attached is the Performance Audit Report on Ghana - Health and Education Rehabilitation Project (Credit 1653-GH) prepared by the Operations Evaluation Department. No comments were received from the Borrower. This credit provided emergency support for Ghana's health and education systems which were at the time in a state of near collapse. It was meant to stop the deterioration until support for a comprehensive reform program could be developed and provided. It achieved this purpose in a satisfactory way, and (since the system did in fact survive thanks to continued donor inputs) the results can be said to be sustainable. Institutional development, a small part of this project, was modest. A few of the inputs proved to be inappropriate to the situation, suggesting that even in emergency situations some prior investigation is necessary to determine relevant inputs and ensure their proper use. 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 disclosed without World Bank authorization.  FOR OFFICIAL USE ONLY PERFORMANCE AUDIT REPORT GHANA HEALTH AND EDUCATION REHABILITATION PROJECT CREDIT 1653-GH TABLE OF CONTENTS PREFACE ......................................................... i BASIC DATA SHEET ............................................. i EVALUATION SUMMARY ........................................... v 1. BACKGROUND ................................................... 1 2. PROJECT OBJECTIVES AND CONTENT .............................. 2 3. IMPLEMENTATION ............................................... 5 4. PROJECT OUTCOMES ............................................. 6 5. FINDINGS, ISSUES AND LESSONS ................................... 9 APPENDIX 1: Allocation of Credit Proceeds ............................... 11 The authors of this report are Ronald G. Ridker (Task Manager) and Richard Sack (Consultant). Pilar Barquero provided administrative support. 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.  -1- PERFORMANCE AUDIT REPORT GHANA HEALTH AND EDUCATION REHABILITATION PROJECT CREDIT 1653-GH PREFACE This is a Performance Audit Report (PAR) for the Health and Education Rehabilitation Project in Ghana, for which an IDA Credit in the amount of US$15.01 million equivalent was approved in January 1986. The Credit was closed on December 31, 1991, after a one year extension from the original closing date. It was completely disbursed in May 1992. The PAR is based on a review of materials in Bank files, including the Report and Recommendation of the President (there was no Staff Appraisal Report) (Document No. P-4157-GH, December 24, 1985), the Credit Agreement dated January 31, 1986, correspondence with the Borrower and internal communications, supervision reports, and the Project Completion Report (Document No. 11080, August 31, 1992). This information was complemented by discussions with Bank Staff associated with the Project. An OED mission visited Ghana in November 1993 to discuss the project experience and outcomes with Bank field staff, and Government officials and other concerned parties. This PAR confirms the major findings of the PCR and focuses on a few issues and lessons not fully covered in the PCR. In particular, it focuses on the question of the extent to which the emergency nature of an operation warrants taking shortcuts with best practice in project preparation and implementation. Following OED procedures, copies of the draft PAR were sent to the Government on April 8, 1994 for comments but none were received. Y All references to the IDA's Credit amount in the text and tables of this report are in US$ equivalent. 9 - 11f - PERFORMANCE AUDIT REPORT GHANA HEALTH AND EDUCATION REHABILITATION PROJECT (CREDIT 1653-GH) BASIC DATA SHEET KEY PROJECT DATA APPRAISAL ESTIMATE ACTUAL 16.1 18.1 Total Project Costs (US$ m) +12.4% Difference Credit Amount (US$ m) 15.0 Disbursed 17.9 Cancelled 0.0 Institutional Performance Satisfactory CUMULATIVE ESTIMATED AND ACTUAL DISBURSEMENTS (US$ millions) FY86 FY87 FY88 FY89 FY90 FY91 FY92 Appraisal Estimates 1.90 8.70 13.00 14.30 14.60 15.00 Actual Disbursements!/ 2.17 3.21 4.41 8.17 13.19 14.41 17.94 Actual as a % of Estimated 114.2% 36.9% 33.9% 57.1% 90.3% 96.1% 119.6% Disbursements Date of Final Disbursement: June 18, 1992 Because of the fluctuation of the US dollars against SDR, the project benefitted from additional funds equivalent to about US$3.0 million. All funds under Credit 1653-GH were disbursed and no cancellation was required. STAFF INPUS (STAFFWEEKS) FY84* FY85* FY86 FY87 FY88 FY89 FY90 FY91 FY92 FY93 TOTAL Preappraisal Appraisal 45.4 45.4 Negotiations 6.8 6.8 Supervision 11.3 20.4 12.7 6.3 13.2 10.6 20.0 .7 95.2 Other 9.0 .8 2.1 11.9 Total 72.5 21.2 14.8 6.3 13.2 10.6 20.0 .7 159.3 * Data are unavailable in the MIS - Iv - PROJECT TIMETABLE ITEM APPRAISAL ESTIMATE ACTUAL Identification 6/84 Preparation 11/84 Appraisal 5/85 Negotiations 12/85 Board Approval 1/23/86 Credit Signature 1/31/86 Credit Effectiveness 4/28/86 Credit Closing 12/31/90 12/31/911' / Project closing date was extended on December 21, 1990, to allow Government to complete key project activities. MISSION DATA TYPE OF MISSION MONTH/ No. OF STAFF DAYS IN REPORT RATING YEAR (SPECIALTIES) FIELD DATE Reconnaissance - Health 04/84 1 (P) 10 Reconnaissance - Education 04/84 1 (E) 6 Identification - Health 06/84 3 (P,P,A) 15 08/09/85 Identification/Preparation - Education 11/84 2 (Ed, TS) 10 Appraisal - Health 05/85 5 (P, OA, OA, E, A) 15 12/24/85 Appraisal - Education 05/85 4 (Ed, TS, E, E) 15 (same) Post-Appraisal - Health 08/85 2 (E,A) 10 Post-Appraisal - Education 07/85 2(PS, A) 12 Supervision- SPN I - Education 02/86 1 (Ed) 8 not rated SPN 2 - Health 07/86 2 (PO, E) 7 07/31/86 2 SPN 3 - Education 01/87 1 (Ed) 12 02/27/87 3 SPN 4 - Education 03/87 2 (Ed, A) 12 04/06/87 3 SPN 5 - Education 06/87 2 (Ed, TS) 5 06/26/87 3 SPN 6 - Health/Education 06/90 1 (A) 15 BTOR:07/19/90 not rated SPN 7 - Health/Education 04/91 2 (Ed, RA) 10 06/20/91 2 Completion 11/91 2 (PH, RA) 8 08/31/92 A- Architect; E - Economist; Ed Educator; OA = Operations Analyst; P Physician; PH * Population & Health Specialist; PO - Project Officer; PS - Public Sector Management Specialist; RA - Research Analyst; TS - Textbook Specialist. kl This project received continuous supervision from the Task Manager located in the Resident Mision since late 1987. PERFORMANCE AUDIT REPORT GHANA HEALTH AND EDUCATION REHABILITATION PROJECT (CREDIT 1653-GH) EVALUATION SUMMARY Introduction to strengthen Ministry of Health (MoH) 1. The Health and Education Rehabilitation and Ministry of Education (MoE) man- Project (HERP), supported by Credit 1653 of agement and planning capacity. FY86, was the first World Bank Group opera- tion in Ghana's social sectors. It was part of a 4. Project inputs included mainly: wider Bank strategy to support Ghana's Eco- nomic Recovery Program. This support began forhealth-emergencydrugs,physicalreha- with the Export Rehabilitation Project started in bilitation plus furniture and equipment for 1983 and continued with a series of Structural two hospitals, mopeds and basic equipment Adjustment Credits, the first of which was for community health workers, approved in April 1987. This effort was aimed policy/management studies, and overseas at reversing the deterioration of the economy and in-country training. through macroeconomic stabilization measures and through structural adjustment policies to * for education-textbooks and school correct distortions in incentives, supplies. 2. At the time of project preparation, the 5. The Credit was to be disbursed over five health and education sectors were in dire need years. of effective management and required targeted support. Implementation Experience Project Objectives and Content 6. The project was divided into two separate components - one for health and one for educa- 3. The Credit's objectives were: tion - with separate implementation units. It experienced serious delays in its first 11/2 years, * to provide emergency assistance to the mainly due to Ghanaian unfamiliarity with the health and education systems and to the Bank's mode of operations. However, in late Management Development and Productivi- 1987 the task manager was posted to the Resi- ty Institute (MDPI); dent Mission and implementation speeded up under continuous and intensive supervision that 2 to rehabilitate service delivery at the proved to be particularly effective. The project peripheral level of the public health sys- was closed with a delay of one year. tem, with special emphasis on immuniza- tion, family planning and nutrition; -v - Results Main Findings and Lessons 7. By and large, the project delivered the 9. The PCR focuses its discussion of lessons goods and services that were expected of it. on suggestions for improving performance of This helped to sustain the health and education Bank operations that are the first in a sector - for systems at the beginning of the Economic Re- example, the particularly high value of having covery Program. Several inputs were of limited the task manager located in the field in this effectiveness: the recommendations of the MoH situation. These suggestions are appropriate and policy/management studies were not directly sensible. This section supplements that discus- applied; mopeds and solar refrigerators for MoH sion by focusing on conclusions and lessons asso- either broke down shortly after being put into ciated with the emergency nature of this project. use or were not fully used by their recipients; and textbooks were only partially used by teachers for reasons related to a combination of 10. The principal point is that the emergency a negative incentive structure and inadequate nature of a project should not be used as a teacher training. reason for taking shortcuts in preparation and implementation. The text provides a number of Sustainability examples where the project goals were not well served by taking such shortcuts. 8. For a rehabilitation project whose main purpose is to provide a "fast injection of 11. A more general point leading to the same emergency assistance" and which is the first in a conclusion pertains to the implicit assumption of series of donor interventions, sustainability is this project that the provision of basic inputs like concerned with the survival of the system with- textbooks and drugs would be adequate for the out further deterioration until reforms or future purpose of system survival because everything projects take over. The deterioration appears to else is in place, in particular because the reci- have been halted. In health, the project suc- pients of these inputs could put them to good ceeded in introducing cost-recovery measures use. The concluding section discusses three im- and new approaches to drug supply improving portant instances in which this assumption did morale of ministry staff at all levels. In educa- not hold for HERP. The need for fast injections tion, sustainability is clearly linked to the high of emergency assistance should not obscure the level of subsequent donor interventions (the need for prior review of conditions to ensure Bank alone has committed US$227.1 million that effective utilization is likely and for ongoing through six projects after HERP). In these ways monitoring to quickly identify impediments to ef- the project contributed to the sustainability of fective use of inputs during their delivery. the system and is therefore itself rated as sustainable. PERFORMANCE AUDIT REPORT GHANA HEALTH AND EDUCATION REHABILITATION PROJECT (CREDIT 1653-GH) 1. BACKGROUND 1.1 Between 1970 and 1983, Ghana's GDP per capita (in 1987 prices) declined by a third. This was the result of poor economic management (large deficits, inflation, failure to adjust the exchange rate, increasingly restrictions on imports), political instability, deterioration in terms of trade, and in the early 1980s, a severe drought. In addition, during the latter part of this period, foreign donors including the World Bank reduced assistance to the country until such time as economic management improved. 1.2 The social sectors were particularly affected by this deterioration. Budgets declined, foreign exchange dried up, and low salaries and high inflation induced large numbers of better-trained health and education personnel to emigrate. In the health sector, between 1975 and 1984 public expenditures per capita declined by 77 percenty, the number of Ghanaian doctors working in Ghana declined by about 10 percent , and medical supplies and transport for the sector nearly disappeared from the majority of health facilities. While the vital statistics had not been updated since the end of the 1970s, all signs pointed to increased morbidity and mortality rates, particularly among children, with major increases in reported cases of cholera, meningitis nd yellow fever. All this was exacerbated by food shortages that resulted from the 1983 drought and disruptions in transportation. A similarly precipitous decline in public expenditures for the education sector occurred during this period2', with the result that textbooks and teaching materials dried up and teachers took on second jobs or left the country in search of better working conditions. While there are no good data for this period, some observers believe that nearly a quarter of trained teachers left the country during the first four years of the 1980s and that learning outcomes were minimal in the majority of schools during this period. 1.3 After coming to power in 1981, the Provisional National Defense Council (PNDC) began introducing a number of economic reforms which attracted support from donors, including the IMF 1/ E.M. King, P. Glewwe & W. AJberts. 1992. Human Resource development and Economic Growth: Ghana in the Nct Two Decades. World Bank, PHREE Background Paper Series (Doc. No. PHREE/92/57). / World Bank, 1989, Population, Health and Nutition Sector Review - Ghana Report No 7597, para 2.18, Washington, D.C. 3/ Figures vary between Bank reports. The HERP President's Report (1985) states (p. 15) that during the 1970s education expenditures as a proportion of GDP averaged 3.4% as compared to an average of 5.2% for other Sub-Saharan Anglophone countries. The Literacy and Functional Skills Project SAR (1992) states (on p.3) that public resources available for education went from 6.4% of GDP in 1976 to 1.4% in 1983. According to the Bank's 1988 policy study Education in Sub-Saharan Africa: Policies for Adjustment, Revitalization, and Expansion (p. 138), public expenditures on education as a percentage of GNP were 4.3%, 5.9%, 3.1% and 2.0% for 1970, 1975, 1980 and 1983, respectively. Weighted averages for all Anglophone countries were 4.0%, 5.1%, 5.7% and 4.3% for those years. 4/ P. Glewwe & H. Jacoby. 1992. Estimating the Determinants of Cognitive Achievement in Low-Income Countries: The Case of Ghana. World Bank, LSMS Working Paper No. 91. -2- and the World Bank. The latter, after suspension of lending for several years, provided several reconstruction import credits to support the recover program and, in 1984, reacted favorably when the Government requested emergency assistance for these especially hard-hit social sectors. 1.4 The Bank's knowledge of these sectors was limited at the time. Prior to 1985, the Bank had not funded any projects in the education or health sectors. An education project was appraised in 1971 but never proceeded to negotiation because of a change in Government that disrupted most Bank activities. A Health, Population, and Nutrition Sector Review was prepared in 1978, several reconnaissance missions occurred during the first half of the 1980s, and a Public Expenditure Review covering the health and education sectors (among others) was undertaken in 1985. The latter confirmed the dramatic declines in expenditures, particularly for supplies, but also pointed out the very skewed nature of the remaining resources provided, most going to tertiary level institutions. 2. PROJECT OBJECTIVES AND CONTENT 2.1 The Health and Education Rehabilitation Project (HERP) was conceived and designed as a stop-gap project to provide a quick infusion of much needed life-blood into the health and education systems by addressing "the most urgent rehabilitation needs in health and education." Preparation of a more substantial and wide-ranging education project was well underway before HERP became effective' However, effectiveness of a follow-on health and population project awaited June 1991, six months prior to HERP closing. 2.2 The project's main objectives and content were straightforward: emergency rehabilitation and a "fast injection" of supplies to meet most urgent needs. The project had two major components - health and education - that were conceived, designed and implemented independently of one another. A small element that supported the Management Development and Productivity Institute (MDPI), a parastatal, was subsumed under the education component in the President's Report; ' in the PCR, MDPI is presented as a separate component. 2.3 The scope of the health component was broadened during the Appraisal mission to include support for medium-term activities such as training for management and planning, as well as studies for use in developing a longer-term sector investment plan. This was deemed necessary: (i) in order to improve complementarity with other donors (USAID, UNICEF and UNFPA); (ii) to respond to the need emphasized by the 1985 Public Expenditure Review Mission; and (iii) probably, although not stated in available documentation, to palliate for the fact that no health follow-on project was on the immediate horizon (as there was for education).2' In the education field, a comparable component, which aimed to strengthen MoE's capacity to manage the project and prepare future projects was limited to the provision of equipment, supplies, and vehicles. 5/ EdSAC pre-appraisal occurred in the same month (1/86) as IERP effectiveness. EdSAC became effective in April 1987; EdSAC I became effective in 1990 and three other education and related projects have become effective since. 6/ No Staff Appraisal Report was prepared. The Report and Recorrmnendation of the President of the International Development Association to the Executive Directors was the basic reference document. 7/ Issues Paper of June 27, 1985. -3- 2.4 Although there was no project conditionality per se, the President's Report mentions (in para 61) that assurances were received (concerning MoH) that Government would (i) use findings from studies to furnish IDA (by March 1987) with a preliminary long-term investment plan, including cost recovery measures, and (ii) complete the studies and the investment plan by end December 1987. 2.5 Several project preparation reports/studies (in addition to staff working papers) are referred to in Annex IV (p. 38-39) of the President's Report. Two reports used for preparing the education component were found in the files, but none for the health component.L' The most substantial of the reports is the Education Sector Review that stressed the need for rehabilitation (over reform) and provided a three-year rehabilitation investment program, a slice of which was financed by HERP. 2.6 A major difference between the health and education components is that the latter was developed at the same time that Government was embarking on a sector reform with the active support of the Bank and other donors.2' This meant that there was a fairly clear sense of direction and priorities for the education sector, which was not the case in health. It also meant that the Bank's education sector was channeling its policy concerns into the Education Sector Adjustment Credit (EdSAC), for which there was no equivalent in health. It is not surprising, then, that internal pressures in the Bank encouraged inclusion of policy considerations (eg. cost recovery) in the health component. 2.7 The Credit was prepared in close coordination with other donors active in the health and education sectors. In health, there was direct, project-related coordination with UNICEF, UNFPA, WHO, and USAID. 2.8 No provision was made for monitoring project results. For the education side of the project, this is mitigated by the fact that the project was part of a protracted Bank commitment manifested, at the time, by the intensive preparatory work for EdSAC. 2.9 Table 1 presents a synopsis of the project's objectives/subcomponents and associated activities/ inputs for each component. No significant changes in this picture took place during the project's life. 2.10 The Credit was estimated to be disbursed in about five years after effectiveness in April 1986. Credit Closing was expected for December 31, 1990. Disbursements for the health component were planned over the entire period, whereas for education it was expected that disbursements would be over a 2 year period. Also, two separate PMUs and foreign exchange Special Accounts were foreseen - one for health and another for the education component (including the MDPI). 8/ For health, the President's Report mentions two reports: "Action Plans - 1985," MoH, Accra, 13 March 1985; "Proposals for Areas of Immediate Term Cooperation between the MoH and the World Bank," MoH, Accra, May 1984. For education, there are: (i) a 20 page faxed report on book production facilities in Ghana by Philip Cohen, dated November 25, 1985; and (ii) a fairly comprehensive paper by Sherry Keith (consultant), Ghana: Education Sector Review and Proposed Investment Strategy, WAPED, August 9, 1985. For MDPI, there is a report dated August 1985. 9/ The 1985 Keith report (Education Sector Review and Proposed Investment Strategy) while generally supportive of the reform, advised against two major aspects (replacing Middle Schools with Junior Secondary School (JSS), while generally and vocationalization of the curriculum). -4- Table 2.1. Overview of Herp Objectives and Content ObJectives/Subcomponents Activities/Inputs Health Strengthening the delivery of (i) Re-equipping, rehabilitating, and supplying about 100 basic health, nutrition and rural and 11 urban health care centers which deliver primary family planning services by health care. It was expected that this support would immediate and cost-effective expand linkages between communities and the Ministry of means. Health (MoH). Project inputs include equipment, basic medical supplies and drugs, and civil works. (ii) Strengthening HoH field capacities through support for training & logistical support for about 50 percent of the district health management teams. Project inputs include vehicles, training and the installation of a radio communications system. (iii) Complementing UNICEF's support in rural areas related to activities of community women's groups in nutritional activities, water & sanitation. Project inputs include grinding mills, workshops and training. (iv) Strengthening MoH priority programs in imunization (coordinated with UNICEF), family planning & nutrition. Project inputs include cold storage facilities for vaccines and workshops. (v) Assisting nutrition-related activities in MoB health centers/stations & rehabilitating the referral hospitals specialized in treatment of malnourished children. Project inputs include civil works, furniture, supplies, vehicles and equipment for the rehabilitation of two hospitals (Accra and Kumasi), as well as workshops and studies. Fellowships and training in planning and management. Strengthening MoH to improve its overall capability Studies covering: health manpower; health care financing; Sectoral adjustment and policy the drugs system; an inventory of health delivery, training reform and storage facilities; and prototype design of urban and rural health centers. Education Urgently needed instructional (i) For primary and middle schools: printing and materials and essential back-up distribution of textbooks and teachers' guides in 3 core funding to support services subjects; basic instructional materials (exercise books, pens, pencils) to cover the needs of all pupils for 2 years. (ii) For Government secondary schools: Books for each of the principal subjects for the approximately 300 secondary schools in the country. (iii) For the Universities: Subscriptions to a basic set of journals and a limited number of library books. Strengthening education planning (i) Basic equipment, supplies and local training to MoE's and project implementation planning section. (ii) Support for MoE's Project Management Unit (PMU). MDPI Meeting emergency needs Civil works for repairs; essential supplies; technical assistance -5- 3. IMPLEMENTATION 3.1 Implementation for about the first year and a half of the project was slow for reasons related to: (i) Ghanian inexperience and unfamiliarity with Bank procedures, practices, and expectations;! (ii) the unavailability of counterpart funds (mainly for the health component); (iii) inordinate delays in textbook production (writing manuscripts and printing); (iv) poor knowledge of the project by MoH officials; and (v) elaborate Government procedures for procurement.L Once the Bank's task manager took up his post in the Resident Mission (about 18 months after effectiveness), the rate of implementation improved considerably and the project closed only one year later than originally planned. 3.2 Project supervision was done in an unusually effective manner. The bulk of supervision was carried out in-country by the task manager stationed at the Resident Mission as of October 1987 (to the present). Five missions were fielded before he arrived, four of which supervised the education component and one the health component. The future field-based task manager participated in all the education missions. No formal supervision missions occurred (and, therefore, no Forms 590 were filed) between June 1987 and June 1990. A supervision mission in June 1990 was brief, comprised only an architect, and no Form 590 was filed. A final health/education supervision mission occurred in April 1991. 3.3 The field-based supervision was intensive and, from all accounts, extremely useful. Continuous interaction between the task manager and project staff meant that information flowed smoothly and rapidly - in both directions - between the Bank and the Borrower. Problems were quickly identified and solutions found on an informal, verbal basis before formal correspondence between the Bank's task manager and Government.' An indicator of the intensity of project supervision-from-the-field is the frequency of correspondence between the task manager and Government officialsL" - correspondence that generally confirmed understandings already reached informally. 10/ The Presiden's Report signalled weak implementation capability in both ministries as the project's main risk. 11/ The initial burst of disbursements (114.2% of appraisal estimates for FY86) included: expenditures under the PPF (largely for emergency educational materials); a first provision of the special accounts that went largely unspent; and about US$300,000 overpaid to UNICEF (and reimbursed). 12/ As the education PMU director stated in an interview, "the World Bank ceased being a far away entity." 1/ A sampling of correspondence from the project files shows that the number of letters per month between the Bank and Government was: Month From Bank to From Government to Bank Government (including cc.'s) 10/87 6 4 01/88 9 5 03/88 21 3 04/88 8 4 11/90 24 25 Procurement was the topic most frequently addressed in these letters which generally went into great detail on all matters of project implementation. -6- 3.4 The health component, which necessitated many more procurement actions than did education, was rife with implementation problems and delays. As late as October 1990, about 35 (US$ 3.5m) of the credit proceeds remained undisbursed, mainly due to lack of adequate counterpart funds (MoH had made only one allocation in December 1987). MoH management was weak, which appeared to create tensions between the Ministry and its PMU. Major delays and/or inadequacies were encountered in hospital construction and in the procurement of mopeds. Civil works delays, along with shoddy work, were linked to problems with the original parastatal contractor agreed at appraisal and who was eventually replaced by a private firm selected after a competitive bidding process that, itself, was poorly managed. 3.5 A case in point is the provision of 1,000 mopeds for community health workers (at a cost of about US$ 300,000). Procurement took about two and one-half years, in large part because the original vendor failed to make delivery, thereby necessitating a repeat of the selection process. Then, many of the mopeds broke down so that today, there are very few operating. Whether this happened for lack of maintenance or because the mopeds were inappropriate for the terrain in which they were used is unclear from the record. What is clear is that an agreement with the Government to make the mopeds the property of individual workers (in order to give them a strong incentive to maintain them) was never implemented. A second example is the procurement of 30 solar vaccine refrigerators which became inoperative a few months after delivery from a supplier that subsequently went out of business. This resulted in a loss of about US$ 75,000. Replacement panels were financed under the second health project. This situation did not arise because of a failure to follow procurement procedures--at the time, the firm that won the ICB appeared to be a well-established company with a good reputation. The examination of this company, however, might have been less thorough than usual because of the relatively small size of this contract. 3.6 Implementation of the education component went more smoothly, with only about 10 (US$ 500,000) of the credit proceeds undisbursed by September 1990. Procurement involved mainly textbooks and school supplies. There were a few serious procurement delays for some textbooks. One of these problems was related to Bank ignorance of Government textbook policies (its "co- publishing" scheme) and actions about to be taken at the time of project preparation. As the PCR rightfully points out, better knowledge of this situation would have led to improved coordination between the Bank and the Ministry of Education (MoE) and HERP's textbook inputs would have been differently designed (in terms of timing or selection of books). 3.7 Implementation of the Management Development and Productivity Institute was fairly uneventful. The project financed the construction of two new classrooms, the rehabilitation of six others, and Initial objectives were modified and an all-purpose hall, as well as a study by overseas' consultants aimed at laying out the blueprint for MDPI's future directions. No equipment, supplies or vehicles were financed under the project. An error made by MDPI early in the project (using Credit funds for 100 of construction costs instead of 75) that nearly led to suspension of disbursements was resolved to the satisfaction of all (albeit with some delays). -7- 4. PROJECT OUTCOMES 4.1 An examination of the outcomes of this project could include: (i) assessing whether or not the project delivered the expected goods and services and the extent to which they contributed to the desired results; (ii) determining the impact of the rehabilitation effort on resuscitating the "collapsed"' health and education systems to "acceptable" levels of operation; and (iii) more ambitiously, reviewing the actual performance of the health and education systems in terms of, for example, delivery and staffing indicators for the former, and learning outcomes and enrollments for the latter. The first point is adequately covered by the PCR;L" the second was addressed by interviews in the field; the third requires data which are not available for the health system, but partially for education. 4.2 Health. The project provided, inter alia: (i) about US$ 3.8 million of drugs for distribution to hospitals and other health institutions; (ii) equipment for district and rural health stations (including two-wheel vehicles for out-reach activities and 50 grinding mills for weaning food production installed in selected communities); (iii) construction/rehabilitation (including provision of equipment, furniture, supplies and vehicles) for two hospitals; (iv) overseas training for 34 MoH staff (18 for 6-12 month courses; 16 for 1-3 month courses), mainly in aspects of planning, management and administration; (v) in-country training for more than 1,500 MoH staff through courses, workshops, technical assistance, computers, office and didactic equipment, and textbooks; (vi) the production of posters in seven languages and radio spots to support the oral rehydration therapy program; (vii) studies and a symposium aimed at improved organizational structures and managerial methods for MoH (including: development of a "cash and carry" system enabling hospitals and health centers to purchase drugs and supplies from regional, district and central medical stores; an audit and inventory of drugs at these stores; technical and software specifications for MoH computer purchases; a study on MoH financing, planning and manpower policies); and (viii) a radio communications system that covered MoH headquarters, central medical stores, ten regional medical stores and directors' offices and the two teaching hospitals. 4.3 By all accounts,' the project inputs related to hospital rehabilitation, provision of drug supplies and medical/technical equipment and training were effective and contributed to pulling MoH services away from the brink of collapse. Supplies and equipment are credited for improving the performance and morale of health staff at all levels. All but three of the staff trained overseas are LA/ Not all of the Ghanian officials interviewed agreed that the education system was in a state of total collapse. They pointed out that, even though there were no textbooks, there were teachers (albeit, poorly qualified and poorly paid), classes and examinations were held, and buildings were still standing. 5/ For the health component, the Final Report (of May 5, 1992) prepared by the PMU manager is useful. This document is not included in the PCR which contains the PMU director's report which, unlike the manager's statement is critical of Bank performance. j6/ Based on field interviews. -8- now in Ghana and almost all are working in areas for which they were trained.' The 50 grinding mills have provided income generating opportunities for women and given rise to replication of this approach by UNICEF in other countries. However, this innovation has not yet spread throughout Ghana. Also, the project contributed to a scheme for cost recovery measures and for rationalized approaches to drug supply. 4.4 On the downside, in addition to the very limited impact of the mopeds and solar refrigerators (para 3.5), the planning, management and policy studies have had little direct impact. Based on various accounts of the problems associated with the studies (too complex, not useful), it appears that they exceeded the Ministry's absorptive capacities. This lends credence to the project director's claim that more higher-level training was needed early in the rehabilitation process. One intended result of the studies - ministerial restructuring - eventually did occur, but not along the lines proposed in the project-financed study.ff Although the structure proposed by that study was not acceptable to MoH, the study did succeed in provoking the ministry into developing their own plan which has been implemented under the second health project. 4.5 Education. The project financed: almost 6.1 million textbooks and teachers' guides (35 titles in all) for primary and junior secondary schools; over 7 million exercise books; about 5.5 million pens and pencils; books and journals for the university library; and training programs for textbook writers, print personnel and PMU staff; plus vehicles and equipment for the PMU. The percentage of pupils/ teachers covered by the books varied from 63 percent to 100 percent, with twelve titles (five of which were teachers' books) covering 100 percent of the target audience. Although the target at appraisal was one textbook in the three core subjects for every two pupils, the project wound up producing and distributing nearly one textbook in these subjects per pupil. 4.6 The textbooks were distributed to the schools. However, various reports indicate little use was made of them.ff This is generally attributed to two factors: (i) teachers have a poor knowledge base and lost the habit of using textbooks; and (ii) the textbooks were designed to last for 3-5 years and inspectors checked the physical state of the books (under the teachers' responsibility). This provided a disincentive for the teachers to use the books, finding it more to their interest to keep them in good physical condition. 4.7 Management Development and Productivity Institute. Project inputs for this component were modest, accounting for about 3 of the Credit proceeds. Nevertheless, MDPI staff expressed great satisfaction with the project's inputs and claim they played a significant role in the subsequent 17/ Although not necessarily with the Health Planning Division for which training was originally intended. It should be noted that the quantity of overseas training provided under the project (in person/months) was about double that originally programmed. Even so, the project director thought that the project should have provided more training. 18/ Ghana Health Study (in 4 volnes v.1 - A Prescription for Restructuring Health Care; v.2 - Health Finance - Recovering Costs to Strengthen Pnmary Health Care; v.3 - Health Manpower - Putting the People in Primary Health Care; v.4 - Health Policy - Framework for a Ghanaian Prinmy Health Care Campaign). Submitted by Ontario International Corporation, Foundation for International Training, September 1988. 9/ IThis has been documented (for a limited sample of schools) by an in-depth research project carried out by members of the Faculty of Education at the University of Cape Coast. Research Reports on Availability and Utilization of Materials in the Central Region of Ghana, Phase I Study (Draft). Center for Research on Improving Quality of Primary Education in Ghana, IEQ Occasional Paper No.1. October 1993. -9- development of the Institute. The consultant's strategy study was considered useful and provided a basis for MDPI's development orientations. 4.8 One indicator of the improved sustainability of the Institute's activities is the change in the level of its self-financing capacity. Table 4.1 shows that the rate of MDPI self-financing has increased from about 10 in 1984 to about 30 in 1989 and since then has hovered around 45. For this reason, in a Government ranking of parastatals, MDPI is considered as being "ready' to forego Government subventions. Although one cannot establish a cause and effect relationship between HERP inputs and MDPI improvements, these inputs have clearly played a role in the recent development of the Institute. Table 4.1. MDPI Revenues, Expenditures & Government Subventions -1984- 1992 (In Thousands of Current CEDIS) 1984 1989 1990 1991 1992 1. Revenues generated by MDPI 1,304 48,324 65,649 107,176 138,466 (Training & consultancies) 2. Total expenditures 13,420 93,845 121,200 144,703 252,275 3. Government subvention 12,116 65,337 71,188 77,949 139,484 4. Percent Govt. Subvention 90.3 69.6 58.7 53.9 55.3 (3/2 x 100) Source: MDPI - 10 - 5. FINDINGS, ISSUES AND LESSONS 5.1 The PCR focuses its discussion of lessons on suggestions for improving performance of Bank operations that are the first in a sector--for example, the particularly high value of having the task manager located in the field in this situation. These suggestions are appropriate and sensible. This section supplements that discussion by focusing on conclusions and lessons associated with the emergency nature of this project. 5.2 First, sustainability must have a special meaning in such a project. While most of the inputs into this project were meant to be consumables rather than having lasting value, they were meant to halt the deterioration that was occurring until other external support could be mobilized to focus on longer-run needs. This operation is most appropriately viewed as a necessary part of a program the overall effect of which should be to achieve a sustainable outcome. Thus, despite the fact that most inputs were consumables, we rate the project as sustainable given the fact that these other operations did in fact come along. 5.3 Second, the emergency nature of a project should not be used as a reason for taking shortcuts in preparation and implementation. In this case, there was little prior investigation to determine the nature of the health and education system needs and little attempt to establish a proper monitoring and evaluation system. As the PCR pointed out, the project goals would have been better served had the construction contract been opened to competitive bidding rather than being awarded to a parastatal that had never faced competition, and had two conditions of effectiveness been added--one requiring an initial deposit of counterpart funds, perhaps half of the first year's requirements, in the PMUs' accounts, and the other requiring preparation of a detailed work plan acceptable to the Bank for at least the first year of operations--even though these conditions might have slowed down initiation of this emergency project. In at least two cases--procurement of mopeds and solar refrigerators, considerable loss might have been avoided had more time been taken to investigate the situations. 5.4 Put somewhat differently, the implicit assumption underlying this project was that the provision of basic inputs like textbooks and drugs would be adequate for the purpose of system survival because everything else was in place, in particular because the recipients of these inputs could put them to good use. In at least two cases, this assumption did not hold in HERP: (i) textbooks were not adequately utilized, with the result that substantial improvements in enrollment and learning outcomes do not appear to have taken place (para 4.6, 4.7); and (ii) studies expected to orient MoH reorganization either exceeded the Ministry's absorptive capacity or were not considered appropriate by MoH staff (para 4.4). Although staff morale in the two ministries improved as a result of HERP inputs--an important outcome--these examples suggest that attention must be paid to conditions required for effective use on inputs even in a rehabilitation project. The need for fast injection of emergency assistance should not obscure the need for prior review of conditions to ensure that effective utilization is likely and for ongoing monitoring to quickly identify impediments to effective use of inputs during their delivery. - 11 - APPENDIX 1 Allocation of Credit Proceeds (US$'000) Category Original Allocation Actual Expenditure Health Education Health Education (1) Civil Works 957.5 242.1 952.0 119.7 (2) Equipment, furniture, materials and 5,514.8 223.5 7,904.3 238.4 medical supplies (3) Technical assistance and training 2,099.7 115.0 1,920.8 175.9 (4) Textbooks, teachers' guides, school 4,290.8 supplies, journals, periodicals and library books (5) Project operating costs 1,325.7 166.3 696.2 249.3 (6) Refunding PPF advance (instructional 125.0 875.0 0.0 1,014.6 materials, school supplies; vehicles; office equipment and supplies; technical assistance) (7) Unallocated 0.0 0.0 274.4 103.7 10,022.7 5,002.2 11,747.7 6,192.4 Totals Total Credit Proceeds 15,024.9 17,940.0