加纳1992-98年间的公共卫生和教育支出：公平与效率问题(2001.4.12)

_PS Is 77 POLICY RESEARCH WORKING PAPER 2579 Public Health and Education In an economy facing fiscal constraints, public spending Spending in Ghana in in the social sectors needs to 1992-9 8 be linked to outcomes to ensure efficient and equitable delivery of services. Issues of Equity and Efficiency Sudharshan Canagara jab Xiao Ye The World Bank Country Director Groups Ghana Country Department and Africa Technical Families Macroeconomics 1 April 2001 H  POLICY RESEARCH WORKING PAPER 2579 Summary findings Using primary data from the health and education Enrollments in higher levels are lagging behind those in ministries and household survey data from the Ghana basic education. Statistical Service, Canagarajah and Ye analyze equity Ghana ranks high among West African countries in and efficiency issues in public spending on health and health indicators, although its health expenditures tend education in Ghana in the 1990s. to favor the nonpoor. While more of the rural Public expenditures in the education sector declined in population have gained access to health services in recent the second half of the 1990s. Basic education enrollment years, many still have limited access or none. Moreover, has been stagnant or declining in public schools but there is no link between the pattern of public increasing in private schools, resulting in a moderate expenditures-especially the pattern of immunization increase in total enrollment. Regional disparities are across Ghana-and health outcomes. significant, with lower public resource allocations and To ensure that social services are efficiently and lower enrollment ratios in the three poorest regions. The equitably delivered in a fiscally constrained economy, quality of basic education in public schools remains poor, Canagarajah and Ye argue, public expenditures need to while it has steadily improved in private schools. be linked to outcomes. This paper-a joint product of the Ghana Country Department, Country Director Groups, and Macroeconomics 1, Africa Technical Families-is part of a larger effort in the region to undertake and disseminate analytical work on issues related to poverty reduction strategies. Copies of this paper are available free from the World Bank, 1818 H Street NW, Washington, DC 20433. Please contact Melvina Clarke, room G8-118, telephone 202-473-1752, fax 202-522-3252, email address mclarke@worldbank.org. Policy ResearchWorking Papers are also posted on the Web athttp://econ.worldbank.org. The authors may be contacted at scanagarajah@worldbank.org or xye@worldbank.org. April 2001. (46 pages) The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the view of the World Bank, its Executive Directors, or the countries they represent. Produced by the Policy Research Dissemination Center  Public Health and Education Spending in Ghana in 1992-98: Issues of Equity and Efficiency Sudharshan Canagarajah* Xiao Ye *Authors are Senior Economist and Research Analyst, respectively, at the World Bank. We wish to thank the officials from the Ministry of Health, Ministry of Education, and Ghana Education Service who provided access to the necessary information for undertaking this study. We would also like to acknowledge the invaluable comments we received from E. Awittor, T. Apronti, B. Millot, S. Chao, F. Decaillet, L. Demery, T. Jones, J. Leno, and K. Yoshida.   Public Health and Education Spending in Ghana in 1992-98: Issues of Equity and Efficiency Table of Contents Abstract Section 1: Introduction 1 Section 2: The Education Sector 2 2.1: The Ghanaian Education System 2 2.2: International Comparison of Gross Enrollment Ratios 2 2.3: Public Expenditure Distribution System 3 2.4: Education Budget "Categories" 4 2.5: Trends in GOG Real Education Expenditures 4 2.6: Education Quality and Reasons for Not Attending School 8 2,7: Regional Disparities in Public Subsidies and Enrollment Ratio, Basic Education 9 2.8: Gross Enrollment Ratio 11 2.9: Benefit Incidence Analysis 13 2.10: Education Statistics 15 2.11: Summary of Main Findings 17 Section 3: The Health Sector 20 3.1: Introduction 20 3.2: The Health Care System in Ghana 21 3.3: An International Comparison on the Efficiency of the Health Care System 21 3.4: Public and Private Health Facilities by Region 23 3.5: Regional Variation in Access to Health Facilities and Health Personnel 25 3.6: Distribution of Public Health Expenditure among Different Levels of Health Facilities 27 3.7: Health Expenditure Distribution 28 3.8: The Financial Viability of the Health System 31 3.9: Regional Health Outputs and Health Facility Utilization 33 3.10: Benefit Incidence Analysis 36 3.11: Health Statistics 41 3.12: Summary of Findings 42 Section 4: Concluding Remarks 44 References 45   Section 1: Introduction As stated in the "Development Strategy for Poverty Reduction" (DSFPR) by the Ghana Ministry of Finance (MOF), the Government of Ghana (GOG) is committed to the reduction of poverty and a general improvement in the welfare of Ghanaians. To achieve broad-based growth resulting in effective poverty reduction, an investment in human capital has been identified as one of the high priorities. The GOG has decided to increase total government budget allocation to the social services from 17.4 to 22.5 percent by 2002, with an emphasis on improving access to services for the poor. However, increasing the budget is only half the battle. The systems that take the resources and produce the services must also be effective, efficient, and pro-poor, in order to make an impact on the ground. This public expenditure review and benefit incidence study, using primarily data from line ministries and household survey data from 1998, is the first part of a two-part study. The second part of the study, in a separate report, includes a tracking survey to estimate the proportion of the line ministries' spending that had actually reached service-providing facilities. The objectives of the public expenditure review (PER) and the tracking survey are consistent with the DSFPR. First, the PER is to evaluate the pro-poorness and effectiveness of the health and education sectors by examining the operating systems, resource distribution, and service utilization. The results of this study will be compared with a previous study on benefit incidence analysis by Demery et al (1995). Thus, the progress in providing basic services to the poor between 1992 and 1998 can be compared. Second, the objectives of the tracking survey report are to assess the efficiency of the public spending, and to assist the GOG in identifying the strategies and mechanisms to ensure easy access to public spending information at all government levels by civil societies, NGOs, and comrnmunities. This agenda is consistent with the overall decentralization policy identified by the GOG. Some intemational comparisons are also provided. The remainder of this paper is organized as follows: Section 2 is devoted to the education sector, while section 3 is devoted to health sector. Finally, section 4 provides concluding remarks and recommendations to improve the effectiveness and efficiency of the systems that provide health and education services.  Section 2: The Education Sector 2.1 The Ghanaian Education System Since 1987, the GOG has been reforming its education system. One of the main reforms was to change the pre-tertiary education system from 17 to 12 years, with six years of primary school, three years of junior secondary school (JSS), and three years of senior secondary school (SSS). The attendance of primary and junior secondary schools, which is also called basic education, is obligatory and free. However, in practice, basic education is not truly free because all schools collect obligatory contributions from students to supplement the government subsidies. Although basic education is mainly financed by the GOG, there are also a significant number of private schools, especially at the primary and JSS levels. Another area in which the private sector is active is vocational training, to which the GOG provides very few resources. Currently, the five subjects taught in lower primary schools are English, Ghanaian Language and Culture, Mathematics, Environmental Studies, and Religious/Moral Education. In addition to the above subjects, the subjects in upper primary schools also include Integrated Science (Science and Agricultural Science), and Physical Education (including Music and Dance). The JSS curriculum consists of English, Ghanaian Language and Culture, Mathematics, Science, Agricultural Science, Pre-technical Skills (including technical drawing), Religious/Moral Education, Social Studies, and French (optional). In addition, Music, Life Skills, and Physical Education are also offered but they are not subject to external examination. At the primary school level, teachers are assigned by grade. For example, a first grade teacher teaches one class for all subjects. At the JSS level and above, teachers are specialized by subjects. 2.2 International Comparison of Gross Enrollment Ratios Economically, Ghana has the second highest GNP per capita among the West African countries. Its pre-tertiary education indicators are on par with its economic development level, but the tertiary education indicator lags behind. Table I shows the average gross enrollment ratio (for both sexes) of primary, secondary, and tertiary education. In addition, it shows the ratio of female-to-male enrollments for pre-tertiary education, which we use to indicate the gender gap. The closer the female-to-male ratio to 100 (which indicates no gender gap) the smaller the gender gap. Among West Africa countries, Ghana has the fourth highest primary and the third highest secondary enrollment ratio, and the second smallest gender gap. However, the enrollment of tertiary education in Ghana is one of the lowest according to UNESCO statistics. The relatively high enrollment ratios in pre-tertiary education yield a relatively high literacy ratio-at 70 percent, the second highest in West Africa. In short, years of effort in promoting basic education by the GOG have resulted in improving the general literacy of the population. The low enrollment in the tertiary education, however, is worrisome given today's economic development needs for technical professionals. 2  Table 1. An International Comrarison or Education Indicators Gross Enrollment Ratios Literacy rate Conr Primary Secondary Tertiary population 15+ Country l _ FIM FIM FIM Year GER ratio Year GER ratio 1996 1999 ratio Benin 1996 78 58 1997 18 44 3.1 39 43 Burkina Faso 1995 40 65 - - 0.9 23 40 Congo 1995 114 91 1995 53 72 8.3 801 84 Cote d'lvoire 1996 71 74 1997 25 48 4.6 46 69 Gabon 1995 162 99 1995 56 89 7.9 - Gambia 1995 77 77 1995 25 62 1.8 36 66 Ghana 1997 84 92 1997 43 85 1.4 70 78 Guinea 1997 54 60 1997 14 36 1.3 - - Guinea-Bissau _ _- - 38 31 Mali 1997 49 68 1997 13 49 0.8 40 69 Mauritania 1996 79 89 1995 16 51 3.9 42 60 Niger 1997 29 63 19961 7 54 0.6 15 34 Nigeria 4 63 76 Senegal 1 971 71 84 1997 16 62 3.2 36 58 Togo 1996 120 71 1996 27 36 3.6 56 54 Sources: Gross enrollment ratios are from the UNESCO database as of August 18, 2000. The literacy rate is from the World Bank SIMA database as of August 16, 2000. The Ghana 1997 gross enrollment ratios for primary and secondary are calculated from the CWIQ. 2.3 Public Expenditure Distribution System The GOG finances and manages the education system through two managerial offices, the Ministry of Education (MOE) and the Ghana Education Services (GES). While the MOE primarily oversees budget allocation and education policies, the GES is an office with branches at both the regional and district levels to implement the budget and policies. In addition to MOE and GES, the Controller Accountant General (CAG) oversees the disbursement of all government employees' salaries through the banking system, including those working in the education sector. Thus, the GOG pays its employees directly, independent of any ministries or middle-level management offices. There are three main channels that distribute recurrent expenditures from the MOE to the school facilities. The first channel is CAG, which receives its budget from the MOF and distributes payment vouchers through the banking system directly to the teachers in public schools. Because of this direct distribution system, teachers are, in general, paid on time and in full. However, this does not imply that teachers are paid adequately. The second channel is the District GES, which receives its budget from the GES headquarters (GES-HQ), and distributes the budget to school facilities. The budgets that pass through the District GES are recurrent expenditures (excluding salaries), including, "Travel and Transport," "General Expenditures," "Maintenance/Repair/Renewal," and "Supplies and Stores." It is reported, pending verification, that district offices distribute resources proportionally to schools based on the district dues collected from schools. Thus, the schools 3  in poor areas may get fewer resources because they are likely to collect less dues than better- off areas. The third channel is from the GES-HQ to school facilities. GES-HQ receives allocations to procure education materials, such as textbooks and supplies, and it distributes the materials either through district GES or directly to the school facilities. The resources distributed through this channel are difficult to fully account for, because at the school level the value of the materials is unknown. Schools report that the delivery schedules are often delayed and when textbooks arrived, they may not meet the schools' needs. In addition to the above three channels, the District Assembly Common Fund (DACF) distributes the budget for rehabilitation and development purposes in all public sectors, including the education sector. It receives budget allocations from the MOF and channels the funding to the District Assembly Office, which in turn distributes the budget among all public facilities, including schools. In this paper, we primarily focus on recurrent expenditures, thus the first three financing channels. It is worth noting that in addition to GES-HQ and District-GES, there are also Regional GES offices. We do not discuss Regional GES at great detail because their primary functions are to coordinate the district and the HQ offices and they do not handle any major financing activities. 2.4 Education Budget "Categories" The education budget is divided into six categories in the budget sheets. They are: 140 for the MOE budget, 141 for the GES-HQ, 142 for the District GES, and 145 for tertiary education. Category 143 includes education for children with disabilities. Categories 143 and 144 (national archives), accounting for less than one percent of the total budget, will not be addressed in this study. When calculating schools' recurrent expenditures, administrative expenditures from GES are assigned as overhead. However, MOE management expenditures are not considered overhead, and often account for less than 0.1 percent of the total education budget. Total overhead in the Ghana education system in 1998 was approximately 8 percent. Under each category, there are subcategories. Schools providing basic education obtain their recurrent expenditures through subcategories 02 and 03 under the category 142, which are earmarked for their use by the MOE, but disbursed through District GES. 2.5 Trends in GOG Real Education Expenditures Between 1994 and 1998, the share of public education expenditures as a percent of GDP has remained roughly 4 percent, which is on par with most other West African countries (World Bank SIMA data base). Education expenditures as a percentage of total government expenditures decreased from 22.2 to 18.7 percent between 1990 and 1994, although the total spending level maintained a 10 percent annual growth rate due to the rapid expansion of total government expenditures.' The share of education expenditures relative to total government expenditures, however, further declined to 11.4 percent in 1999. The GOG is determined to reverse the trend, and increase the education sector's budget allocation to 22.5 percent by See Perran Penrose 1995: 9. 4  2002. In terms of spending level, total government education expenditures declined by a total of 16 percent between 1994 and 1998. Table 2 presents the real expenditure comparisons by education level from 1990 to 1998. In order to calculate the per pupil subsidy, table 3 presents the total enrollment by education level in public schools. Dividing table 2 by table 3, table 4 presents the trend in real expenditure per pupil by educational level. Table 3 shows that real expenditures have declined for most education levels, with the exceptions of teacher training colleges, polytechnic, and vocational training. Overall education expenditures have declined by 4 percent annually between 1994 and 1998. Table 2. TotalActual Expenditures 1990-98 (constant 1998 '000,000 cedis) 1990 1991 1992 1993 1994 Average 1995 Average annual annua growth growth rate 1990- rate 199 94 98 _ _ _ _ _ _ __ _ ___ _ ___ _ _ ___ _ __ _ 49 Primary 194,672 216,298 283,955 304,914 277,099 9.2% 244,876 -3.0% JSS 110,627 125,190 183,121 208,049 184,833 13.7% 136,763 -7.3% Basic 305,300 341,488 467,076 512,963 461,932 10.9% 381,639 -4.7% education SSS 56,094 56,694 82,310 91,463 101,466 16.0% 91,838 -2.5% Polytechnic 2,874 3,553 3,253 3,861 3,167 2.5% 6,031 17.5% University 50,665 52,085 75,734 83,608 93,908 16.7% 66,399 -8.3% Subventions Vocation/ 8,342 9,867 11,408 12,823 11,021 7.2% 12,676 3.6% TechnicalI Teacher 8627 9313 16353 20073 24359 29.6% 37513 11.4%/ training Total * 431,902 473,000 656,134 724,791 695,853 12.7% 596,096 -3.8% Sources: Perran Penrose, Budgeting and Expenditures in the Education Sector, December 1995; and MOE Actual Expenditure Sheet, 1998. *This is the summation of all of the items listed in this table, which account for over 90 percent of total government education expenditures. Expenditures on special education, subventions, and MOE are not included here. In addition to the decrease in the real total budget, there have been changes with regard to the shares of different levels of education within the total education budget. Figure 1 shows that the share of basic education declined between 1990 and 1998. The largest increases are SSS and the Teacher Training budget. The most noticeable change is that about 90 percent of the total budget has been devoted to primary, secondary, and tertiary education, and very little has been earmarked for technical and vocational schools. In order to acquire the technical skills necessary for today's economic development in a relatively short period, the allocation for technical and vocational schools is probably an area that needs to be re-evaluated. Ghana needs to explore options for alternative financing - private provision, user fees etc. - of vocational education. 5  Figure 1. Budget Share by Education Level 50 ___ 41 -+-- Primary 40 '~ 30 ___ - H 30 6 23 20 12o . -x 15 --University I I 10 --= 6 -Teacher ____ .^ t- iA 3 training college -A-Technical 1990 1991 1992 1993 1994 1998 Source: MOE, "A Decade of Educational Reforms: Preparation for the Challenges of a New Millennium," National Education Forum background paper, November 1999. Ironically, the distribution of public education expenditures does not correspond to the changes in enrollment. While SSS enrollment fell below the 1991 level, its share of budget had been increased. While the tertiary enrollment doubled between 1994 and 98, the share of its budget actually declined. Based on the MOE data, pre-tertiary total enrollment has been stagnant. Between 1994 and 1998, there was a less than one percent annual increase for basic education enrollment. Given a three percent population growth rate, this implies a decline in basic education enrollment. Table 3. Total School Enrollment in Public Schools, 1990-98 1990 1991 1992 1993 1994 Annual 1998 Annua growth growth rate rate 1990-94 1994-98 Primary 1,803,148 1,807,223 1,848,300 1,903,749 1,960,861 2.1% 2,027,026 0.8% enrollment JSS 569,343 592,867 629,258 660,721 693,757 5.1% 695,468 0.1% enrollment SSS 168,000 199,260 225,277 247,496 236,527 8.9% 188,908 -5.5% Polytechnic - - 10,090 10,315 10,371 1.4% 9,942 -1.1% University - - 11,857 12,439 13,122 11.1% 26,684 18% Vocational/ - - - - - - 14,624 - Technical Teacher - - 21,000 - training college Source: MOE, "A Decade of Educational Reforms: Preparation for the Challenges of a New Millennium," National Education Forum background paper, November 1999. It should come as no surprise that the unit subsidies for most education levels declined between 1994 and 1998. Table 4 shows that during this period, per pupil subsidies for 6  primary education has been reduced by a total of 15 percent and for JSS by a total of 26 percent. Despite the decrease in total expenditure on SSS, the unit subsidy has increased, solely due to the rapid decrease in the total SSS enrollment. Table 4. Unit Subsidv by Education Level, 1990-98 1990 1991 1992 1993 1994 Average 1998 Average annual annual growth growth rate rate 1990-94 _994-98 Primary 107,963 119,685 153,630 160,165 141,315 7.0% 120,805 -3.8% JSS 194,307 211,160 291,010 314,882 266,423 8.2% 196,649 -7.3% SSS 333,891 284,524 365,370 369,553 428,984 6.5% 486,153 3.2% Polytechnic - - 322,359 374,309 305,351 -2.7% 606,611 19% University - - 6,387,290 6,721,457 7,156,539 5.9% 2,488,363 -23% Vocational/ - - - - - - 866,809 - Technical Teacher - - - - - - 1,786,338 - training Source: Calculated from tables 2 and 3. Given that teachers' salaries account for more than 90 percent of total education recurrent expenditures, the change in the pupil/teacher ratio (PTR) is the main factor driving the changes in unit subsidies. This implies a higher PTR corresponding to lower unit subsidies, and vice versa. Based on MOE data, between 1994 and 1998 the primary PTR increased from 31 to 36, and the JSS PTR increased from 18 to 20, while the SSS PTR decreased from 20 to 17. These changes correspond to the decrease in per unit subsidy in primary and JSS education and the increase in the SSS unit subsidy, respectively.2 Compared with other West African countries, the PTR for Ghana is relatively low, as shown in table 5. Most West African countries have a PTR greater than 40 for primary schools, and for secondary schools the PTRs are mostly in the upper 20s.3 However, Ghana's PTR are comparable with other more developed countries, such as South Korea and Swaziland. In spite of a favorable PTR, public school enrollment has been stagnant over the last decade. The quality of public education is weak, as will be shown in the next section. The issue of linking public education inputs with the needs and outcomes of education must be resolved; such as planning the supply of teachers according to the needs and allocating more resources to improving the teaching environment and the supply of teaching materials. It has been suggested that financial incentives should be provided to teachers who are assigned to rural areas. In addition, a rotation system may be established to promote more qualified teachers to work in rural and remote areas. 2 Source: MOE, "A Decade of Educational Reforms: Preparation for the Challenges of a New Millennium," National Education Forum background paper, November 1999. 3 Based on the World Bank SIMA data base as of August 2000. 7  Table 5. Pu il/teacher Ratio by Education Level, 1990-98 19901910 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97 1997/98 Primary 29.1 27.8 30.2 30.9 30.0 32.6 32.7 35.9 iSS 18.5 17.8 19.1 18.2 18.5 20.4 18.3 20.0 SSS 21.7 22.5 22.5 20.0 17.6 17.6 17.0 NA Source: MOE, "A Decade of Educational Reforms: Preparation for the Challenges of a New Millennium," National Education Forum background paper, November 1999. 2.6 Education Quality and Reasons for Not Attending Schools The Ghana public education system practices automatic progression from primary school to JSS; as a result many pupils who are hardly literate and numerate upon the completion of primary school can still enter JSS (MOE 2000). The Criterion-referenced Tests (CRT) show very poor scores among public schools, especially among rural schools. Table 6 presents the CRT results from 1994 to 1997. The percentage of pupils who achieved "Reaching Mastery" level (PRM) within public schools in 1997 is extremely low, around 6 percent for English and 3 percent for Mathematics. The worrisome trend is that this low level of education quality has been persistent among public schools. By contrast, the PRM in private schools is about 70 percent for English and 40 percent for mathematics, a steady improvement over the performances of previous years. Not only is the percentage of students reaching master level much higher among private than among public schools, but also the average scores of private schools are also much higher. In addition, there have been steady improvements in mean scores among private schools, and limited improvements in public schools4. Table 6. Results of Criterion-referenced Tests, 1994-97 __ _ 11. . .English Mathematics _ ___ 1994 1996 1997 1994 1996 1997 Private PRM 51.4 56.5 68.7 31.7 31 40.4 Mean Score 58.8 61.0 67.4 47.3 47.0 51.7 Public PRM 3.3 5.5 6.2 1.5 1.8 2.7 _______ Mean Score 31.0 33.0 33.9 27.7 28.8 29.9 Source: MOE, "A Decade of Educational Reforms: Preparation for the Challenges of a New Millennium," National Education Forum background paper, November 1999: 33. In the 1998 CWIQ survey, children were asked why they were not attending school. In an attempt to investigate why children of school age do not complete the obligatory 9 years of education, we selected children age 6-16 who dropped out of school before completing JSS. There were 708 children who responded to the question "why [they were] not attending school." The most frequently chosen reason was that schools were useless and uninteresting (50 percent), the second was that school was too expensive (30 percent), and the third was that they were working (16 percent). Other reasons include: too far, illness, pregnancy, marriage, etc. However, very few children chose these reasons. These responses seem to 4 The high scores in private schools, among other factors, may also be due self selection bias. It is possible that better performing kids are enrolled in private schools which leads to higher CRT and PRM scores. 8  indicate that access to an educational facility is less of a problem, but improvements in curriculum and the teaching quality are imperative to further increasing enrollment. In addition, we investigated why children age 1 6-18 do not continue to SSS following completion of JSS. Interestingly enough, three-fourths of the children did not continue their schooling because they or their parents believed that they had completed their education. It appears that there are a variety of reasons for the insufficient demand for higher education. Among 421 children who would like to have continued to SSS, the most frequently cited reasons for not attending are: too expensive (42 percent) and working (13 percent). Again, distance was not cited as a reason for not attending school.5 2.7 Regional Disparities in Public Subsidies and Enrollment Ratio, Basic Education Because there are distinct economic variations between the different regions in Ghana, the regional distribution of public expenditure on education (or education subsidies) are explored in this section. Figure 2 presents annual public subsidies per school-age child by region and education level. It should be noted that we chose per school-age child to reflect what would have been available if all school-age children are enrolled in schools.6 The regions in figure 2 are arranged based on poverty incidence from lowest to highest. It shows that for both primary and JSS education, the poorest three or four regions receive the lowest subsidy per school-age child. Accra is an exception; but in Accra an active private education sector is fulfilling a large proportion of educational needs. Figure 2. Regional Subsidy per School-age Child ('000 1998 cedis) Prnmary school subsidy JSS subsidy 12 0 120v 80 ~~~~~~~~~~~100 t epe,eS L <80 60 ~~~~~~~~~~~60 40- 40"- 20 - 20 0 0 Source: MOE, "A Decade of Educational Reforms: Preparation for the Challenges of a New Millennium," National Education Forum background paper, November 1999. This pattern is also persistent in the distribution of teachers and classrooms. Figure 3 shows school-age children per teacher and per classroom, respectively, which also accounts for s It is possible that cost concerns include distance considerations, depending on how respondents answered the question. 6 It is worth noting that this approach also enables us to better understand the cost implications of achieving Universal Primary Education (UPE) which Ghana wants to attain. 9  private resources. Thus, figure 3 shows all that is available to school-age children, including both public and private resources. In general, the three poorest regions, Northern, Upper West, and Upper East would have critical shortages for both classrooms and teachers at both the primary and JSS levels, if all school-age children were to enroll. Therefore, teacher and classroom issues need to be addressed in these regions if the universal enrollment ratio is to be achieved. In the other regions, the ratio of school-age children per teacher is relatively reasonable, except there is an apparent shortage for primary school teachers in Accra. The number of school-age children per classroom is equitable for all regions, except Accra and the three poorest regions. But, it shows somewhat crowded conditions at the JSS level for most regions. In short, years of effort in promoting basic education have resulted in a teaching capacity with a reasonable coverage in seven out of 10 regions. The three poorest regions require a fturther strengthening of teaching capacity. Figure 3. Ghana: Teaching Capacity by Region Primary school-age children per JSS school-age children per I teacher teacher 100 7 86 1 80 7 80t50 5862 60I 47 60- 38 38 36 41 337 3032 2 24 40- t[4 40 1 32 32 20 -20 Primary school-age children per JSS school-age children per classroom classroom 188 150 120 200 T 161 50o 37 41 37 41 39 40 -oo 1172 54 50 44 58 54 43 I 50 LLLLLLLL 46E 5064 0 7Ijj7I,16l 0 IL IL IV _ ___ ___ ___t__ ___ ___ ___ ___ ___ ___-- Source: MOE, "A Decade of Educational Reforms: Preparation for the Challenges of a New Millennium," National Education Forum background paper, November 1999. 10  2.8 Gross Enrollment Ratio Based on MOE data, the gross enrollment ratios in public primary schools have been declining.7 The primary school gross enrollment ratio dropped from 79 percent in the 1991/92 academic year to 73 percent in 1997/98. According to the MOE report, the JSS gross enrollment ratio has increased slightly, from 56 to 58 percent, including both private and public schools. As shown in table 7, these results are largely consistent with the household survey data for this period. Table 7. Public School Enrollment Ratio Quintile Primary school Secondary school 1992 Male Female Tota Male Female Total 1 79 68 74 33 23 29 2 85 75 80 39 26 33 3 87 77 82 45 35 41 4 84 85 85 55 36 46 5 77 77 77 62 46 52 Accra 70 62 66 65 49 57 Other urban 89 81 85 55 41 48 Rural 82 76 79 38 27 33 Total 83 76 79 45 33 39 1997 Male Female Tota Male Female Tota 1 69 61 65 40 28 35 2 78 71 75 40 34 37 3 76 73 74 44 38 41 4 81 71 76 41 40 40 5 72 74 73 50 43 47 Accra 58 61 59 48 46 47 Other urban 74 73 73 53 40 46 Rural 77 70 74 39 33 36 Total 75 70 72 43 36 40 Source: 1992 figures are based on the calculation using the 1992 household survey data (GLSS3) and 1997 figures are based on CWIQ survey data. See note for table 8 for explanation of how enrollment ratios were calculated. Table 7 shows that there has been a widespread decline in public primary school enrollment ratios across all income groups and localities. The decrease is larger for the poor than for the non-poor population. The public primary enrollment ratio in 1998 is about 90 percent of the 1992 level. The public secondary enrollment ratio did not change between 1992 and 1998. However, the secondary enrollment ratio of the poor increased significantly, although it began at a low level. In short, public primary school enrollment did not keep pace with the population growth rate, especially for the poor. The public secondary enrollment ratio is stagnant, with an increased enrollment ratio among the poor but decreased enrollment ratio among the rich. 7 Alternative data sources give different numbers for enrollments, but the regional disparities in the North still remain. 11  Table 8. Gross Enrollment Rates 1989-97, (public andprivate enrollments Quintile Accra Other urban Rural Ghana Primary Mak Female Al Male Female Alf Male Female All Male Female AL 1989 77 53 63 92 82 87 69 56 63 73 60 67 127 96 108 95 71 82 76 67 72 83 69 76 90 92 91 93 69 80 90 75 83 90 74 82 4 97 97 97 107 88 97 96 76 85 99 81 89 5 110 83 96 83 79 81 93 75 84 93 77 85 Ali 102 86 93 94 77 85 82 68 75 86 72 79 1992 1 96 76 84 92 76 84 79 63 72 83 67 75 2 108 104 107 100 98 99 91 82 87 94 87 91 3 123 79 98 105 97 101 90 81 85 95 85 90 4 105 105 105 102 93 98 91 81 86 95 86 91 S 96 108 103 122 95 108 98 95 97 105 97 101 All 106 94 99 103 92 97 88 79 84 93 83 88 1997 1 88 82 86 87 76 81 70 62 66 74 66 70 2 89 106 98 98 91 94 82 75 79 86 80 83 3 95 92 94 92 106 98 86 76 81 88 82 85 100 94 97 100 96 98 93 82 87 94 86 90 S 98 94 96 94 102 98 94 90 92 95 92 94 Al 96 94 95 93 91 92 84 76 80 87 80 84 Secondary 1989 1 50 21 30 43 26 35 35 19 28 37 20 29 2 45 44 45 37 21 31 38 26 33 38 26 33 3 53 23 39 46 31 38 42 33 38 43 32 38 73 38 54 51 31 40 48 36 43 52 35 43 67 42 55 46 27 34 51 30 40 54 32 42 Al 64 37 49 44 28 36 42 28 36 44 29 37 1992 1 61 25 44 34 18 26 30 21 26 33 20 27 2 58 48 53 50 43 46 39 31 35 43 36 40 3 50 23 39 46 35 40 42 30 36 44 31 38 4 60 49 56 55 48 51 46 32 40 50 39 45 S 82 51 64 57 43 49 47 29 39 54 37 45 Al 61 42 52 48 38 431 40 29 35 44 33 39 1997 1 44 57 51 57 40 49 36 22 30 42 30 36 2 48 36 41 50 47 48 38 32 35 41 37 39 3 59 50 54 59 44 51 41 37 39 46 40 43 411 59 57 58 58 45 51 39 40 39 45 43 44 5 65 63 64 73 49 59 51 42 47 57 48 52 Ali 58 55 56 58 45 51 41 34 381 46 39 43 Source: GLSS2 and GLSS3 (calculated by Demery et al), and 1997 (calculated by authors). We used CWIQ instead of GLSS4 to calculate the enrollment ratio because GLSS4 did not distinguish between pre-school and primary school enrollment ratio, nor did it distinguish between private and public schools. The primary school gross enrollment ratio is calculated as total enrolled primary school students divided by children age 6-11. For the secondary school enrollment ratio, the range of school-age children used for GLSS2 is not clear, but we used children age 11-17 as the denominator for GLSS3 and GLSS4. Table 8 presents the total gross enrollment ratio, including both private and public schools. At the national level there has been an overall decrease in the primary enrollment ratio among all income groups between 1992 and 1998. The decrease was, however, much less profound among the girls than among the boys. Total secondary school enrollment ratio increased from 39 to 43 percent (table 8). Compared with table 7, in which the public 12  secondary enrollment ratio dropped for the non-poor but increased for the poor, the increase in secondary school enrollment comes mainly from a rapid expansion of private secondary school enrollment among the rich, and an increase in the public enrollment among the poor. Table 9 shows that private secondary school enrollment has increased from one percent of total enrollment to seven percent, with the largest increase found in Accra. The percentage of private enrollment among primary schools, although remaining the same at the national level, decreased in Accra but increased in rural areas. The overall message seems to be that once students entered primary school, they are more likely to remain in school than was determined in previous surveys. The higher quintiles of population began using public primary education more than previously, but probably switch their children to private secondary education. The poor have started using more private education at both the primary and secondary levels. Table 9. The Proportion ofPrivate Students amon Total Enrolled Students Primary Secondary Quintile 1992 1997 1992 1997 1 5 7 0 4 2 6 10 1 5 3 12 12 1 6 4 16 15 1 8 5 27 22 3 11 ccra 43 37 2 16 Other 20 20 3 9 urban Rural 5 8 0 4 Total 13 13 1 7 Source: CWIQ 2.9 Benefit Incidence Analysis In previous sections we discussed the regional disparity in the distribution of public education expenditures. The basic conclusion was that the three poorest regions benefited the least from public spending, while they were probably the regions that needed public subsidies most. Given this regional disparity in public resource distribution, the purpose of this section is to evaluate how public education spending benefits the poor compared with the non-poor. One difference in the methodology used here is that we take into consideration the different demographic compositions among households of different income levels. In general, the lower income households tend to have a larger number of young children than the higher income households. For example, based on 1998 household survey data, 23 percent of primary school-age children (5-11) are in the lowest quintile, while only 17 percent are in the highest quintile. To account for the demographic differences, this section will calculate benefit incidence based on the proportion of school-age children in each quintile group rather than on the proportion of quintile population, as is commonly done. 13  Based on the 1997 Core Welfare Indicator Questionnaire Survey, public education is predominant in most parts of Ghana, except in Accra.8 In Accra, public schools provide education for 67 percent of primary students, and for 80 and 90 percent of JSS and SSS students, respectively. In all other regions, public schools provide education for 88 percent of primary students, and for about 95 percent of JSS and SSS students, respectively. The private facilities tend to increasingly provide education services at lower levels. The benefit incidence analysis for public expenditures in 1998 shows the share of subsidies captured by population groups of different income levels and locations, compared with 1989 and 1992 data (see table 10). To take into account demographic differences among different income groups, we created an index that is the ratio of the share of subsidy received by the children to the share of the children. If the index is greater than 100, it indicates that a particular group received more than its fair share of the subsidy in relation to the proportion of the children. This index is available for both 1992 and 1998 data. Between 1992 and 1998, the benefit incidence of public primary school subsidies for the poor population (the bottom two quintiles) had either declined or stabilized, but for the richest quintile it has increased. Compared with other regions, Accra had greater gains proportionally in capturing the primary education subsidy, while other regions remained the same. In spite of somewhat unfavorable changes, the primary education subsidies, while not particularly pro-poor, do serve more than three-fourths of children equitably. Public primary education has the most difficulty reaching the poorest of the poor, and has resulted in a deterioration in recent years. Although not shown in table 10, a similar bias against the poorest children also exits in JSS.9 At the higher education level, the encouraging trend is that the share of secondary and tertiary education subsidies for the poorest of the poor (the lowest quintile) has been increasing, although they are still under-subsidized compared with other income groups. For SSS (not shown in the table 9), the lowest quintile received about 80 percent of their fair share. The largest inequality, not surprisingly, occurs at the tertiary level, where the poor population receives slightly more than 50 percent of what they should receive, while the richest captures 165 percent of what they should receive. In conclusion, the education system is certainly not pro-poor, but up to the secondary level, it provides reasonably equal access to a majority of the population. Due to data limitations, it is not possible to evaluate the differences in the quality of education received by the poor and non-poor. However, we can say with great certainty that rural and poor children receive an 8Three details need to be mentioned here. First, we use the Core Welfare Indicator Questionnaire Survey instead of GLSS4 because in GLSS4 no question was asked as to whether a student was attending a private or a public school. Thus, we could not calculate public subsidies using GLSS 4 data. Second, we use 1997 enrollment rates from the CWIQ together with 1998 expenditure figures to derive benefit incidence for 1998. Third, we use the national average cost per student to calculate the total benefit, rather than using the estimated regional cost. This is because we believe that the regional variation in the cost largely reflects the variation in the utilization of school facilities, not the quality of education. For example, the high cost in other regions reflects the under-utilization of the school facilities, compared with Accra. 9 Table 10 shows a combined figure for both JSS and SSS to be consistent with the categories of the previous years. 14  inferior education compared with urban and non-poor children. This likely plays an important role in these children's decision to drop out of school. A slight deterioration at the primary level occurred between 1992 and 1998, but significant improvements have been made at the higher levels. Continued improvement is necessary at the secondary level, and careful monitoring should be applied to the benefit incidence of primary education. 2.10 Education Statistics Ghana possesses a wealth of statistics about the education sector. Every year, GES conducts an education census that surveys all schools in Ghana, including both private and public schools. The survey collects detailed information on students, teachers, facilities, and teaching materials. However, it is not clear if the data are promptly entered into the computer system. It is our impression that the data have not been explored to the extent that the analysis of the data would provide MOE with timely inputs into the policy decision and budget allocation procedures. Particularly, it appears that data are stored somewhere in the computer system that is not readily retrievable or sometimes discarded after one or two years. While the survey capacity exists, overall administrative capacity needs to be strengthened. Additionally, the technical capacity needs to be expanded. Finally, strengthening the analytical capacity is expected to improve efficient resource allocation and target the poor regions. 15  Table 10. Allocation of Public Spending Subsidies 1989, 1992, and 1998 Percent of subsidies captured Share of subsi Column share to (%/) Share of children 1989 1992 1998 1992 1998 Primary education Quintile Quintile 1 21.2 21.8 20.4 1 94 90 2 22.1 23.6 20.8 2 104 103 3 22.2 21.7 20.9 3 105 103 4 20.3 18.8 20.9 4 104 105 5 14.3 14.0 17.0 5 92 101 total 100.0 100.0 100.0 of which: of which: Accra 6.3 5.3 7.4 Accra 74 82 Other urban 23.1 24.6 17.8 Other urban 102 101 Rural 70.6 70.1 74.8 Rural 102 102 Percent of subsidies captured Share of subsidy to Secondary education Share of children Quintile Quintile 1992 1998 1 16.8 14.9 18.8 1 67 83 2 18.0 21.8 18.8 2 103 97 13 21.8 21.1 19.0 3 97 98 4 23.4 23.5 20.9 4 121 101 5 19.9 18.6 22.5 5 121 124 total 100.0 100.0 100.0 Total of which: of which: Accra 11.1 12.0 14.9 Accra 135 121 Other urban 23.3 30.1 25.2 Other urban 110 119 Rural 65.6 57.8 59.9 Rural 91 90 Percent of subsidies captured Share of subsidy to Tertiary education share of children Quintile Quintile 1992 1998 1 7.7 6.0 12.5 1 39 66 2 3.8 9.5 10.9 2 56 56 3 19.2 19.0 21.1 3 100 109 4 19.2 20.2 19.2 4 91 95 5 50.0 45.2 36.4 5 170 165 total 100.0 100.0 total of which: of which: Accra 42.3 27.4 41.8 Accra 258 318 Other urban 34.6 47.6 36.5 Other urban 178 156 Rural 23.1 25.0 21.6 Rural 40 34 Source: 1989, 1992 (calculated by Demery et al) and 1998 (calculated by authors). Unit subsidies in 1998 are as shown in table 3. 16  2.11 Summary of Main Findings This chapter evaluated public education provision from several aspects: (a) the pattern of public resource allocation; (b) regional disparities in education resources and enrollment ratios; and (c) benefit incidence analysis. The main findings include the following: * Among West African countries, the quantity of education output (enrollment ratio) of Ghana is on par with its economic development level, and the gender gap is low. * Total public spending in the education sector declined significantly - at an annual rate of 5 percent per annum - between 1994 and 1998. * Less than 5 percent of total public education expenditures have been devoted to vocational training. * Teaching capacity (teachers and classrooms), including both private and public resources, is distributed unevenly, with the greatest shortage found in the three poorest regions but relatively good level of capacities for other regions. * Between 1989 and 1992, there was a broad-based increase in the primary school enrollment ratio, especially among girls. Between 1992 and 1998, the enrollment ratio declined slightly, coinciding with the public education spending cut during that period. At the national level, the primary gross enrollment ratio reached 84 percent in 1998. However, regional disparity is great, with the three poorest regions reporting a 50 percent enrollment ratio and a greater gender gap. * Between 1989 and 1998, the secondary gross enrollment ratio has generally improved, from 37 to 43 percent. The largest increase occurred among girls living in urban areas and the boys living in urban areas other than Accra. The regional gap is much narrower at the secondary level, with a 32 percent enrollment ratio reported among the three poorest regions. * Up to the secondary level, a majority of children benefit from the provision of a public education more or less equally. It is the children of the poorest households who do not receive the full benefits. * Test scores imply that the quality of public education is lower than that of private schools. There has been very little improvement in education quality among public schools, but continued improvements have been observed in private schools. Based on the above findings, the following recommendations are made. The three poorest regions, Northern, Upper West, and Upper East, are in urgent need of financial resources in order to expand their teaching capacity, in terms of both physical facilities and the number of teachers. It is apparent that trained teachers do not want to be assigned to the poorest 17  regions. Thus, extra incentives need to be provided for those who are willing to relocate. In addition, a rotation system could be designed with a specific length of assignment for qualified teachers to work in remote rural areas. The school headmaster, however, should hold the position for a relatively long period to encourage local accountability and continuation in school administration. In all but the three poorest regions, the existing teaching facilities appear to be sufficient. Thus, improving the teaching quality within the existing capacity should be the first priority. Improving quality will most likely have a significant, positive impact on the enrollment ratio, because "school is useless/uninteresting" was the most frequently cited reason for school-age children not attending school. While a comprehensive plan to improve the quality of education is beyond the scope of this paper, a few points can be made, based either on the findings of this study or discussions in other literature. First, the salary component of the education recurrent expenditure is more than 90 percent, which leaves few resources to provide teaching materials. Based on our tracking survey, there are resources that are unaccounted for in the education financial system. Therefore, it is possible that the teachers' salaries and the non-salary recurrent expenditure can be increased by simply making the financial system more efficient and effective. It has been reported that the state-procured materials frequently arrive late or do not match the schools' needs. The delay in the distribution of school supplies needs to be improved if teaching quality is to improve in Ghanaian schools. In addition, decentralized public services, especially social services have been suggested for some time in Ghana. It may be the right time to take appropriate actions on this front. Questions have arisen about whether the automatic progression from primary school to JSS discourages rigorous academic training. While basic education is obligatory and every child should have a right to attend JSS, it is not necessarily in the best interests of the children that they know whether or not they perform well, they will end up in JSS. It is imperative to introduce some incentive structure that, on the one hand encourages academic performance, but on the other hand, is not exclusive. Incentives should be also provided to teachers to achieve a high quality of training. Parents' and students' commitment to education and to the quality of education is another factor of paramount importance. It is apparent that in recent years, once students enter a school, they tend to stay in school. Through parents' involvement, we see an increased awareness for the value of education. Involving parents in improving the quality of education can prove effective. It is apparent that factors beyond the education sector also greatly affect enrollment. These may be numerous and may be imbedded in the economy and cultural beliefs. Some apparent reasons include parents' unemployment or low incomes, lack of returns in the labor market for people with basic education, and domestic demands placed on girls. 18  Although tertiary education is skewed toward the urban and better-off populations, the trend of attending higher education among the lower income groups is encouraging. Given the very low level of enrollment in tertiary education compared with other West African countries, it is important to address the needs of higher education, given its importance in today's economic development. Another issue is vocational and technical training, which has been neglected in recent years; the resources allocated to these institutions are extremely low, about 3 percent of the total education budget since 1989. Given that fiscal constraints will not allow a greater allocation by the government, alternative financing options need to be explored for vocational education. 19  Section 3: The Health Sector 3.1 Introduction In the late 1 970s, the GOG adopted the primary health care strategy as the vehicle for achieving Health for All by the year 2000. The economic crisis in the early 1980s drastically reduced resources available to the health sector, resulting in a deterioration in the population's health status. Ghana has re-embarked on a Medium-Tern Health Strategy (MTHS) that aims to achieve Health for All, by improving service quality and efficiency. As the MOH (2000) states "Since 1995, health policy has been based on Ghana's MTHS which seeks to promote greater equity in access to health and outcomes. In pursuit of this objective, Ghana's MTHS aims at strengthening district health services, promoting community involvement in the delivery of health services, redirecting health resources to the needy or deprived areas." Although it is difficult to discern the factors that have contributed to the improvement in some health indicators, there is no doubt that the health reform has, to some extent, contributed to the improvements. Based on World Bank data, between 1990 and 1998, infant mortality decreased by a total of 16 percent, infant mortality under five by 24 percent, and life expectancy at birth increased by 5 percent in Ghana. HIIV/AIDS prevalence, however, has been on the rise in Ghana. Among antenatal clinic women tested for HIV, 3 percent were positive in 1998, compared with 1 percent in 1990. As of 1999, although HIV/AIDS prevalence among adults is relatively low, a national average of 3.6 percent, it has reached well above the epidemic level in some urban areas such as Kumasi and Agonmanya and among certain social groups such as STD patients and prostitutes. According to UNAIDS estimates, 33,000 Ghanaians died from AIDS in 1999, leaving 1 19,000 cbhIdren under age 15 orphaned. These statistics highlight that in addition to existing challenges in increasing access to preventive and curative health services, additional resources are required to fight the rapidly increasing HIV/AIDS epidemic and its consequences. In 1998 the budget allocation to the Ministry of Health (MOH) was maintained at the previous level in cedi terms, with a significant contribution by the non-wage recurrent budget from structural adjustment money. The question then became: has the reform improved the sector's efficiency to an extent that the system can be self-sustaining with substantially improved services reaching all segments of population, or has the system moved in this direction. This chapter takes an in-depth look into this question, mostly seeking answers by comparing data at the disaggregated levels, such as among regions, facilities of different levels, and the population of different income groups. The rest of this section is organized as follows. First, we briefly describe the health system. Second, we make an international comparison on the efficiency of the health system. The third part of the analysis focuses on the distribution of health facilities and health personnel, as well as the population's access to health facilities and the utilization of facilities among the 10 regions. The fourth part of the analysis looks at the budget allocation among the different levels of health facilities and their financial viability. The third and fourth parts of 20  these analyses are essentially health care inputs. The fifth part investigates the efficiency of the health system by comparing the health inputs and outputs. The sixth part evaluates the benefit incidence of health subsidies to deternine if the public health subsidy has reached all segments of the population as intended. Finally, based on our analysis we provide recommendations on improving future health system performance, and summarize the findings that are meant to stimulate further policy discussions. 3.2 The Health Care System in Ghana Similar to the education sector, the health sector is managed by two offices, the MOH and Ghana Health Services (GHS).'