Ghana - Second Health and Population Project

Document of The World Bank FOR OFFICIAL USE ONLY Repwt No. P-5385-GH MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS OCN A PROPOSED CREDIT OF SDR 19.5 MILLION TO THE REPUBLIC OF GHANA FOR A SECOND HEALTH AND POPULATION PROJECT NOVEMBER 16, 1990 This document has a restricted distibution and may be used by recipients only In the performance of their offidal duies. Its contents may not otherwise be disclosed witbout World Bank autordzatlon.  CURRENCY EQUIVALENTS Currency Unit = Cedi (0) US$1.00 = 0340 (appraisal rate) 01 = US$0.003 ABBREVIATIONS AND ACRONYMS DHMT District Health Management Team IPPF International Planned Parenthood Federation HOH Ministry of Health NCS National Catholic Secretariat NGO Non-governmental organization PHC Primary health care PPAG Planned Parenthood Association of Ghana FISCAL YEAR January 1 - Deiember 31  FOR OMCI4L USE ONLY REPUBLIC OF GHANA SECOND HEALTH AND POPULATION PROJECT CREDIT AND PROJECT SUMMARY Borrowers Republic of Ghana Beneficiaries: Ministry of Health National Catholic Secretariat (NCS) Planned Parenthood Association of Ghana (PPAG) Amount: SDR 19.5 million (US$27.0 million) Terms: Standard, with 40 years maturity Onlending Terms: US$0.8 million to NCS, US$2.8 million to PPAG, US$0.3 million to other mission hospitals and US$0.1 million to other family planning NG0s, all as grants Financin& Plan: Government US$ 7.0 million PPAG USS 0.3 million IPPF US$ 0.1 million IDA US$27.0 million TOTAL US$34.4 million Economic Rate of Return: Not applicable Staff Appraisal Reports Report No. 9029-GRA Map: IBRD 22777 This document has a restricted distribution and may be used by recipients only in the performance of their of ficial duties. Its contents may not otherwise be disclosd without World Bank authortiaton.  MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO THE REPUBLIC OF GHANA FOR A SECOND HEALTH AND POPULATION PROJECT 1. The following memorandum and recommendation on a proposed development credit to the Republic of Ghana for SDR 19.5 million (US$27.0 million equivalent) is submitted for approval. The proposed credit will be on standard IDA terms with 40 years maturity and help finance a second health and population project. US$0.8 million of the proposed credit will be passed to the National Catholic Secretariat (NCS) and $0.3 million to other mission hospitals for hospital equipment and maintenance; and US$2.8 million to the Planned Parenthood Association of Ghana (PPAGI and $0.1 million to other NGOs for family planning, all on grant terms. 2. Background and Strategy. The Ministry of Health (MOH) is responsible for the largest part of health and family planning service delivery in Ghana, but with strong support from NGOs: mission health facilities (NCS being the largest) and population NGOs (PPAG being the largest). MOH and most of its services are functioning poorly. While there has recently been encouraging progress in immunization, and maternal and child health coverage is fair, there are major problems of health organization and management, drug supply, limited access in rural areas, finance and manpower; and contraceptive prevalence has not taken off. MOH's planning and implementation capacities are very limited at present. Many aid-financed projects have lagged. High levels of Government have become concerned to improve matters. A Bank population, health and nutrition sector review (Report No. 7597-GH dated March 31, 1989) recommended a sector reform program, covering policy, institutional and program changes, and revitalizing the family planning effort. The Government has accepted the recommendations of the sector review. 3. The ongoing Health and Education Rehabilitation Project (Cr. 1653- GH) was approved in December 1985. Its many components cover a first group of identified needs, especially: drug supply; rehabilitation of facilities for delivering primary health care and combating malnutrition; training; and studies of health policy, finance and manpower. Implementation was very slow for some time, but has now speeded up somewhat. Most of the US$4 million remaining balance will be committed in the next few months. The original closing date will be extended by one year to December 31, 1991 to finalize disbursements. Project implementation has shown the importance of borrower commitment, simple design (especially minimizing the number of separate procurement actions and in particular civil works contracts) and adequate staffing for project implementation. 4. Ghana is engaged in a program of structural adjustment. One element of this program is an improvement in the allocation and efficiency of use of public sector resources. In addition, the Government is increasing the emphasis on social sectors at this stage of the program as one important way to improve the social indicators as well as the conditions of vulnerable groups. In the health sector, it has embarked on a reform program aimed at rapidly improving the quality and coverage of services. This program  - 2 - emphasizes the key areas of expansion and strengthening of primary health care; procurement and distribution of supplies; institutional development; and human resource development. In population, the Government aims to address the long-run development issues through inter alia an expansion of the family planning program. IDA is supporting the reform and expansion efforts in both health and population through comprehensive sector work (completed in 1989); public expenditure reviews; promotion of a program to advance MOH's sector priorities; and financing of key inputs under the proposed project. 5. Rationale for IDA Involvement. The project will further the Government's and IDA's strategy in the sector outlined above. High levels of the Government and core agencies seek IDA input into reforms and into advancing the key sector priorities. IDA through its broad view of the sector, involvement with the economy-wide reform program including public expenditure reviews, and ability to finance a wide range of inputs across the sector (including infrastructure for management) is well placed to help the Government to see through its program. IDA will continue to cooperate closely with other donors in these efforts. The project will also help in the revitalization of Ghana's family planning effort, in concert with other donors. 6. Proiect Ob3ectives. To bring about (i) a progressive improvement in the quality and coverage of health services, and (ii) an increase in the availability and accessibility of family planning services. These objectives will be achieved largely through pursuing several key sector priorities recently identified by Government: management and institution building; expansion and strengthening of primary health care (including family planning); and improvement in the supply system for essential drugs, contraceptives and other medical supplies; and through the supply and maintenance of hospital equipment. 7. Project Description. The project will support (a) a 1991-93 program to implement MOH priorities in health and population, and (b) annual agreement on the public sector expenditure program in health (annual MOH recurrent budgets and three-year rolling public investment program in health). The lending instrument is a sector investment credit, with a mid-term review. Project components will support priority activities in four areas: (a) MOH institution-building, including the district-level management of primary health care and a prizes fund to motivate improved performance; (b) family planning service expansion by MOH, PPAG and other NGOs; (c) drug and vaccine supply and drug infrastructure rehabilitation; and (d) hospital equipment and its maintenance for MOH, NCS and other mission hospitals in the three northernmost regions. The project, to be carried out over five years, provides funds for civil works; equipment, furniture and vehicles; drugs, vaccines, contraceptives, supplies and materials; training; technical assistance; and prizes. 8. The total cost of the project is estimated at US$34.4 million equivalent, with a foreign exchange component of US$24.5 million (71%). A breakdown of costs and the financing plan are shown in Schedule A. Amounts and methods of procurement and disbursements, and the disbursement schedule  - 3 - are shown in Schedule B. A timetable of key project processing events and the status of Bank Group operations in Ghana are given in Schedules C and D, respectively. The Staff Appraisal Report, No. 9029-GHA dated November 16, 1990, is also attached. 9. The project has been sized, and its requirements kept simple, to match implementation capacity. Arrangements were agreed at negotiations for MOH's project management unit responsible for the project, and for MOH to share implementation tasks with other beneficiaries and a procurement agency. 10. Agreed Actions. The implementation of an agreed program of actions to further MOH priorities in health and population, and agreement on public expenditure programs in health, will be the basis for IDA support through this project. The major proposed conditions of different stages of processing ares 11. Effectiveness: (a) Full-time coordinator and full-time procurement specialist for IDA-financed projects in place; (b) Signature of Government's project agreements with NCS and PPAG with major provisions agreed with IDA, including passing US$0.8 million equivalent to NCS and US$2.8 million equivalent to PPAG out of the IDA credit as grants, and that the NGOs will follow Bank guidelines in respect of proc-:rement and audit. 12. Disbursement: (a) For drug supply: Government competitive bidding policy for drugs affirmed, advisory MOE tender committee established, and drug cash and carry system effectively started; (b) For supply of hospital equipment to MOH: MOH equipment maintenance engineer in place for project regions; (c) For supply of contraceptives to MOH: national population commission established. 13. The main assurances agreed are that the Government will: (a) implement MOH priorities in health and population through monitorable actions and a timetable agreed with IDA, notably: (i) PHC expansion program by December 31, 1991; (ii) expanded outreach services in all 10 regions by December 31, 1991; (iii) appointment of full-time district medical officers of health to head district health management teams: 10 by December 31, 1991, another 15 by December 31, 1992 and another 15 by December 31, 1993; (iv) MOH-NGO framework agreement on activities in health and population by June 30, 1991; (v) management information system design by December 31, 1991 and implementation by December 31, 1992; and (vi) staffing norms for health facilities by September 30, 1991, manpower master plan by March 31, 1992 and master training program by June 30, 1992. (b) agree annually with IDA the MOH recurrent budget and three-year rolling public investment program in health;  - 4 - (c) carry out a mid-term review with IDA by December 31, 1992; and (d) cause NGOs to follow the Bank's guidelines for procurement, reporting, and audit. 14. Benefits. The benefits would be a substantial improvement in health service quality and coverage, especially for the poorer population; and a more efficient supply of essential drugs and service provision. The project will supply about 72 of Ghana's total drug needs in 1991-93, and enough vaccines to immunize all 700,000 children born annually in 1992-94. The hospital equipment will benefit 300,000 patients annually and indirectly a total population of 3 million. The project will provide family planning services to another 100,000 acceptors (one-third of current users) with multiple demographic, health and other social and economic benefits. 15. Risks. The major risk is of insufficient MOH implementation capacity, despite the limited project scope and simplified implementation arrangements. This risk has been addressed through focusing on a manageable number of sector priorities, the proposed reorganization of MOH headquarters, through strengthening the MOH project management unit and sharing implementation with the other beneficiaries and a specialized procurement agency. A lesser risk is that of insufficient Government commitment to implement the MOH sector priorities, especially allocating sufficient resources to PHC and bringing about a major expansion of family planning ptograms. This risk has been addressed through securing high-level Government approval of MOH priorities in health and population; requiring agreement with IDA on the public expenditure program annually; and coordinated donor support for the Govarnment's population program. 16. Recommendation. I am satisfied that the proposed credit will comply with the Articles of Agreement of the Association and recommend that the Executive Directors approve the proposed credit. Barber B. Conable President Attachments Washington, D.C. November 16, 1990  5- Schedule A REPUBLIC OF GHANA SECOND HEALTH AND POPULATION PROJECT ESTIMATED COSTS AND FINANCING PLAN Estimated Costs a/ Local Foreign Total