Ghana - Second Health and Populaton

 ICRR 10151 Report Number : ICRR10151 ICR Review Operations Evaluation Department 1. Project Data : OEDID: OEDID : C2193 Project ID : P000897 Project Name : Second Health and Populaton Country : Ghana Sector : Other Population Health & Nutrition L/C Number : C2193 Partners involved : Prepared by : Charles Derek Poate, OEDST Reviewed by : Timothy A. Johnston Group Manager : Roger H. Slade Date Posted : 08/14/1998 2. Project Objectives, Financing, Costs and Components : Objectives: (i) improve the quality and coverage of the health services; and, (ii) increase the availability and accessibility of family planning services . As a means of improving equity, the project emphasised services in three, underserved, northern regions of the country . Components: (i) drug supplies and drug infrastructure rehabilitation; (ii) strengthening MOH; (iii) re-equipping and rehabilitation of regional and district hospitals; (iv) the provision of infrastructure, equipment and training for PHC; (v) population/family planning; and (vi) a prizes fund for health workers and communities. Costs and financing: The total project costs were US$ 28.5 million (US$ 34.4 million at appraisal) of which the Bank financed US$ 27.4 million (US$ 27 million at appraisal). The Bank credit was approved on December 13, 1990, was made effective on June 18, 1991 and was closed on of December 31, 1997, two years after its originally planned closing date . The credit was fully disbursed on June 5, 1998, with the a balance of US$ 0.56 million planned for cancellation . 3. Achievement of Relevant Objectives : The physical objectives were substantially achieved . The project helped increase physical access to population/family planning services in underserved districts, and provided training for health staff . Several of the institutional objectives were achieved, particularly in strengthening district capacity . Policy dialogue was initially hindered by excessive Bank conditions, but following a mid -term evaluation, the Bank adopted a more flexible approach to policy dialogue and project implementation, and MOH ownership of the project increased. Health service utilization and contraceptive prevalence increased over the course of the implementation, but it is not clear the extent to these are attributable to the project . The prizes fund, while innovative, was not well explained outside the MOH, and was dropped after a public backlash . 4. Significant Achievements : The project supported infrastructure and capacity building at the district level , which strengthened decentralized planning and management and helped retain district medical officers . All districts now produce annual plans and budgets. The project also contributed to government's decision to adopt a sector-wide approach for subsequent donor programs--in part, ironically, by contributing to government's frustration with the project approach, but also through constructive dialogue following the mid -term review. Despite shortcomings in project design, the government's strong commitment to the sector investment program increases the likelihood that project achievements will be sustained . 5. Significant Shortcomings : Several shortcomings were the result of deficiencies in project design and supervision : (i) Excessive conditions in the original project agreement and rigidities in project budgets undermined government ownership and alienated MOH officials, and meant that the Bank initially was marginalized from key policy discussions; (ii) poor supervision of civil works; (iii) capacity building was initially defined as a hardware issue. Several factors external to the project also affected implementation : (i) weaknesses in the MOH information system meant that project indicators were never collected, and the impact of increased cost recovery for drugs on the poor was not monitored (the MOH has subsequently strengthened MIS); and (ii) unstable management of NGOs supported by the project; 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Marginally Satisfactory See discussion of shortcomings above. Institutional Dev .: Partial Modest Sustainability : Likely Likely Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory 7. Lessons of Broad Applicability : The original project design suffered from a mismatch between objectives and instruments . It attempted to use a blueprint investment project, coupled with detailed policy conditions, as a vehicle for promoting sector reforms. As a result, both the policy objectives and project implementation suffered . Specific lessons include: (i) Although conditionality can be used to change government policies, this does not ensure that the new policies will be well implemented, and may obstruct rather than facilitate change . (ii) In a health system with multiple funding sources, separate projects can dilute the capacity of the MOH and increase the fragmentation of the health system. (iii) sector-wide investment programs can be an effective vehicle for policy dialogue, but government's strong desire to move away from the project approach has been a key to its current success. (iv) successful decentralization requires a long -term sustained effort to build planning and management capacity at the district level; improved housing can help attract and retain qualified district medical officers . 8. Audit Recommended? Yes No 9. Comments on Quality of ICR : The overall quality of the ICR is satisfactory . It contains a frank discussion of the initial shortcomings in project design and implementation, and assesses the factors that led to improve performance subsequently. Because of the project's failure to collect indicator data, however, the ICR is unable to say much about impact. In particular, projects that promote increased cost recovery at health clinics should do a better job of monitoring the impact on the poor.