Page 1 i CAPACITY ENHANCEMENT NEEDS ASSESSMENT SERIES Delivering Services to the Poor An Assessment of the Capacity to Deliver Education, Health, and Water Services to Local Communities in Ghana Guy Darlan and Kofi Anani World Bank Institute 35078 Page 2 ii TABLE OF CONTENTS ACKNOWLEDGMENTS iii ABBREVIATIONS AND ACRONYMS iv EXECUTIVE SUMMARY v INTRODUCTION 1 SUMMARY OF FINDINGS AND PROPOSED SOLUTIONS 4 1. Generic Capacity Constraints 4 - Weak Policy Framework 4 - Weak Regulatory Framework 6 - Confusion about Roles of Key Actors 7 2. Capacity Constraints by Sector 11 - Education 11 - Health 13 - Water and Sanitation 14 3. Proposed Solutions 16 - Recommendations by CENA Participants 16 - Observations and Recommendations by CENA Facilitators 23 ANNEXES 25 1. Application of CENA Methodology 26 2. Selected Data on Roles and Capacity Ratings of Actors in Education, Health, and Water Services 37 3. Local Governance Arrangements 46 4. District Profiles (Volta Region) 49 Page 3 iii Acknowledgments We would like to acknowledge, with thanks, Mr. Kofi Marrah for the coordinating role he played in organizing all phases of the assessment. Without his contribution, this work could not have been completed successfully within the allotted time and resources. We would also like to thank the government and donor representatives who provided us with support, suggestions, and encouragement during the CENA launch; in particular, Country Director Mats Karlsson, Eunice Dapaah, Arthur Swatson, Smile Kwawukume, and Emmabel Hammond, in the World Bank Office in Accra, and Dorothea Groth, in the German Development Cooperation in Accra. We thank the peer reviewers for their guidance as we were finalizing this report; namely, Reiner Woytek, Senior Knowledge Management Office, World Bank; Jean-Roger Mercier, Lead Environmental Specialist, World Bank; and Kwesi Appiah, Executive Director of the Civic Foundation in Ghana. Finally, we are grateful to the 1,180 community representatives, government officials, and service providers who took part in the assessment and to the local organizations who came together under the leadership of Wilbert Tengey (ACHD) and Emmanuel Laryea (MDRP) to facilitate it. We hope that the findings of the assessment will be helpful to all interested parties, in particular to the government as it seeks to strengthen its decentralization policies with a view to improving the provision and delivery of services at the local community level. But we also hope that the representatives of local communities and service provision agencies who participated in the assessment will make use of this report to reflect on the role that they can play in addressing the capacity constraints they identified. Page 4 iv Abbreviations and Acronyms ACHD African Centre for Human Development BC Beneficiary Community CBO Community-Based Organization CENA Capacity Enhancement Needs Assessment CHO Community Health Officer CHPS Community-Based Health Planning and Services CS Civil Society CSO Civil Society Organization CWSA Community Water and Sanitation Agency CWSP Community Water and Sanitation Project DA District Assembly DCD District Coordinating Director DCE District Chief Executive DHMT District Health Management Team DOT Directly Observed Treatment DWST District Water and Sanitation Team EXECO Executive Committee fCUBE Free Compulsory Universal Basic Education GES Ghana Education Service GETFUND Ghana Education Trust Fund GHS Ghana Health Service GIMPA Ghana Institute of Management and Public Administration GTZ German Technical Cooperation HIV/AIDS Human Immune Virus/Acquired Immune Deficiency Syndrome JSS Junior Secondary School MDRP MayDay Rural Project MP Member of Parliament MSD Multistakeholder dialogue NHIS National Health Insurance Scheme NGO Nongovernmental Organization PM Presiding Member PS Private Sector PTA Parent-Teacher Association SMC School Management Committee SSS Senior Secondary School TBA Traditional Birth Attendant WATSAN Water and Sanitation (Committee) WBI World Bank Institute Page 5 v EXECUTIVE SUMMARY This needs assessment sought to answer the question, how can the Ghanaian government’s capacity to deliver Education, Health, and Water/Sanitation services to the poor at the level of local communities be most effectively strengthened? The assessment was conducted in 12 communities located in the Volta and Eastern Regions, using a participatory approach to identifying capacity-building needs called the Capacity Enhancement Needs Assessment (CENA). Although the CENA approach does address traditional capacity factors such as the skills and knowledge levels of the actors concerned, it focuses mainly on the institutional environment, because institutions are frameworks of rules, procedures, and arrangements that can either provide incentives for action or constraints that impede actions. More than 1,000 development actors involved in the delivery of Education, Health, and Water/Sanitation services (including policy makers, policy implementers, and beneficiaries) participated in the assessment. 1 The five-step process of the CENA approach led to several main findings. First, it appears that the government still hesitates to fully implement its decentralization policy. This leads to confusion in the minds of the actors involved, particularly in Education. Although the Education sector is supposed to be decentralized, there is significant centralization of decision making at government headquarters in the capital. Officials at the district levels have no authority to make critical decisions, which leads to delays in actions on important issues and affects release of budgetary allocations, payment of salaries, and allowances and benefits due to staff. The incessant delays affect the morale and performance of teachers. Political interference in decision and policy making in Education is frequent. A second capacity constraint linked to the institutional environment stems from the lack of clarity of the government policies in the three sectors. As a result, the policies tend to be interpreted differently by the different actors concerned (when they are not completely misunderstood by the intended beneficiaries). For example, the CENA reveals that a number of community members are convinced that the government is using its decentralization policy to dodge its responsibility to deliver basic services to the poor. This impression is reinforced by the government’s insistence on imposing user fees intended to sustain the services without further government support. The fact that policies are interpreted differently creates confusion regarding government intentions and objectives. Therefore, government officials should pay attention to the damage that can be caused by introducing or implementing a development policy without proper explanations to intended beneficiaries. They should receive the proper training for interacting efficiently with community members. For example, in Health and Water/Sanitation in particular, they should be taught to help community members take a broader development approach to service delivery, whereby services are not considered as mere social amenities. In doing so, they would show beneficiaries the links between clean water and good health and between good heath and school performance of children. A third capacity constraint has to do with the regulatory framework. The rules and directives to help guide the different actors involved in the complex collective actions that the delivery of services to the poor requires are often inadequate. This weakness in the regulatory framework affects coordination among the many service providers; it also affects the government’s capacity to monitor and evaluate its policies. Furthermore, the few formal rules and guidelines that exist cater to modern governance arrangements and ignore the traditional arrangements by which communities get mobilized. Because 1 A total of 1,181 development actors participated in the assessment, 587 in the Volta Region and 594 in the Eastern Region. Page 6 vi the two systems must coexist at the local community level, efforts must be made to develop better frameworks for participation and interaction. A related issue has to do with the fact that community leadership is largely ineffective in the modern governance system. It needs strengthening because good community leadership is critical for community empowerment and strengthening community voice, which in turn are essential for improving the quality of services in Education, Health, and Water/Sanitation. A fourth capacity constraint exposed by the CENA stems from the confusion about the roles of key actors; this confusion is made worse by the friction between the modern system of governance that the government superimposed on the traditional governance arrangements. The absence of a clear demarcation line of authority between traditional chiefs and elected District Assembly officers was the example most often mentioned during the assessment; it seems to have the most damaging effect on community participation. This weakness in the institutional environment for service delivery is not due to the absence of well-defined roles; on the contrary, the government has carefully and explicitly defined the role that each key actor involved in service delivery must play. The weakness comes instead from the limitations of the regulatory framework mentioned in the previous paragraph. In other words, the players have been given clear, official roles, but the rules by which engagement, interaction, and conflict resolution will take place have not been clearly explained. This weakness is accentuated by the fact that some key actors, such as the District Assemblies and community representatives, have yet to develop the skills and experience to play the roles that the government has scripted for them. Interaction among actors often takes place in organizations or committees in which community representatives feel uncomfortable, which puts them at a disadvantage in relation to policy makers and service providers and leads to frustration on their part. A fifth institutional weakness relates to organizational arrangements. For example, the community is underrepresented in the current decision-making and management arrangements in the three sectors, particularly at the district level. In order to improve community voice, representatives of the various community management teams should be adequately represented at the district level in the different sector departments, such as the District Health Management Team and the District Water and Sanitation Team. Initial experimentation in this direction is promising, but remains limited. Following the CENA approach and after having identified constraints to Ghana’s collective capacity to deliver quality services to its poor, the participants in the assessment came up with an impressive list of possible solutions. The remedies proposed are organized in four broad categories: (a) strengthening the policy and regulatory frameworks (for example, traditional medicine should be fully integrated into the official medical system); (b) providing incentives for implementing the policy, for respecting the rules, and for behavioral change (for example, an alternative should be found to the current “best teacher award” system, because singling out good performers in this fashion goes against the prevailing culture of community members); (c) strengthening organizational arrangements (for example, District Assemblies should improve their revenue mobilization at the district level to be able to increase spending on Water and Sanitation services); and (d) disseminating information, enhancing skills and knowledge, and increasing awareness (for example, policy makers and implementers require orientation seminars on a regular basis to help them become more proactive; in addition, beneficiary representatives should join policy makers and implementers in training programs so that all can discuss their activities and problems and exchange experience regularly). The World Bank Institute (WBI) will use this information as a starting point for preparing programs to help strengthen Ghana’s capacity to deliver social services to the poor. On the usefulness of the CENA approach, the local organizations that served as CENA Facilitators had the following comments, among others. All three categories of stakeholders (policy makers, policy implementers, and beneficiaries) consider the CENA methodology as an effective tool for assessing Page 7 vii capacity development needs. The greatest advantage of the approach is its ability to mobilize stakeholders around development issues. The concept raises awareness of what can be accomplished, as well as how communities can address their problems. The process of going through the five logical steps of the CENA methodology provides a method that community organizations can use to increase their capacity on their own. Usually, communities have difficulty grasping the concept of capacity; they tend to see money as the panacea to their problems. However, the concept becomes clear to them when they engage in a structured CENA-type analysis of development objectives, actors involved, issues and impediments, and possible remedies. The CENA Facilitators indicated that another significant outcome of the exercise was the awareness generated among the participating community members about their right to hold government and frontline service providers accountable. Through the exercise, community members realized that the decentralization arrangements for service delivery may indeed provide windows of opportunity for them (for example, the opportunity to monitor and evaluate the quality of services provided by the frontline service providers). Furthermore, because community members generally agreed that their involvement in the management of their own development was the most important condition for sustainable development, the CENA became a confidence builder as it helped them realize that there exist relatively simple solutions to many of the problems they face. Without engaging in such problem-solving exercises, community members would continue to see problems only from the financial angle and from the standpoint of those who complain and fail to fully understand their own responsibility in solving the problems they encounter. On the other hand, the CENA approach also creates expectations on the part of the various stakeholders who participate in the assessment. For example, having admitted their shortcomings, the policy makers now expect that donor agencies, including the World Bank, will come to their assistance in the form of training, technical assistance, and funds to help solve some of their problems. Likewise, community members expect the government to pay attention to the findings and recommendations of the assessment and to help improve service delivery; they also expect the World Bank to provide support. These reactions to the CENA approach are extremely valuable to WBI as a training organization that is making the transition to capacity building. The CENA approach is based on the conviction that remedies to capacity weaknesses can be applied more effectively when the development actors concerned themselves clearly identify the constraints they face and suggest their own remedies. The awareness that takes place among the development actors during the assessment is a critical step for building a fertile ground for the follow-up, problem-solving stage that follows. Had this assessment been done by professional analysts, it would not have been as helpful in building that fertile ground. WBI is now following up with problem-solving activities that build on the assessment. Implementing the CENA at the community level will come with its full cohort of challenges for WBI. What will prove to be most difficult is to deliver sustained, targeted follow-up support from Washington. This is why the CENA Facilitators’ suggestion to teach the communities and other local actors how to apply the CENA approach on their own, with only limited support from local NGOs and community-based organizations, is excellent. In this way, the CENA would promote a community discourse that is independent of—rather than a response to—an external stimulus. WBI’s success in becoming an efficient capacity-building organization will, to a large extent, depend on its ability to show development actors how to engage in assessments and problem solving on their own. The first step should therefore be to show community-based organizations how to use the CENA approach. In addition, WBI is responding to the demand for assistance expressed in this assessment by preparing a number of capacity-building activities. First, a multistakeholder dialogue (MSD) involving some of the participants in the Volta and Eastern CENA will take place shortly. WBI is also coordinating with several projects that various Bank units and other donors are supporting in order to help sustain the Page 8 viii capacity-building effort beyond the assessment and the MSD. A concept note on local governance capacity development has been prepared in this context to help with that coordination. The local governance capacity development program would cover some of the issues identified during the assessment; namely, (a) familiarizing community leaders with practices of public sector management, (b) strengthening the adjudication capacity of traditional authorities, (c) supporting documentation and codification of traditional governance arrangements, and (d) establishing community knowledge centers. BOX – An Observer’s View of the CENA Approach In his review of this report, Dr. Kwesi Appiah wrote: Ghana’s decentralization policy provides a unique foundation for the promotion of popular participation in local governance, community development, and empowerment. The policy specifically seeks to empower communities so that they can take an active part in local development. However, the overall progress of the programme has been slow, encountering major challenges related to weak political support, direction, institutional leadership, and uncoordinated development. A significant drawback has been the lack of substantive input by the intended beneficiaries into local government decision making. Without development actors all having an objective and accurate understanding of their own needs, roles, problems, and resources, there can be no unified choice of priority solutions in problem solving, development, and poverty reduction. This, in many regards, is what the CENA approach seeks to achieve. The CENA approach generates ownership and voice. Once participants’ confidence and knowledge levels were boosted through participation in the CENA process, they became outspoken and made significant recommendations towards remedial action. In other words, they found their “voice,” which is a key step towards enabling the poor and excluded to become agents of change. In Ghana, it can be said that a large number of people are “voiceless” due mainly to ignorance of their rights, ineffective governance structures and systems, and more importantly the absence of communication channels for addressing concerns on development matters. There are also very limited functioning structures and systems to help the voiceless to be heard. As indicated in the report, the unit committees and other representative structures intended to facilitate the process are not effective. The CENA approach, though not necessarily its objective, could be one effective way of galvanizing all these defunct structures into action. The CENA findings reveal that the failure of government representatives to explain policies to community members is pervasive. This issue has more to do with commitment than with skills and awareness. A similar behavior can be seen in some community members who demand remuneration for their participation in unit committees while acknowledging that voluntarism should remain the basis of community participation. This apparent contradiction should be seen as a sign that some community members are unwilling to make sacrifices when government officials themselves are not capable of the same commitment and abnegation. Dr. Kwesi Appiah is Executive Director of the Civic Foundation, a nonprofit research organization based in Accra. Page 9 1 Introduction This Capacity Enhancement Needs Assessment (CENA) sought to answer the question, how can the Bank and other partners most effectively strengthen Ghana’s capacity to deliver Education, Health, and Water services to the poor at the level of local communities, and in the context of the government’s decentralization and community empowerment policy? The assessment was conducted in 2 regions (Volta Region and Eastern Region), 6 districts (3 per region), and 12 communities (2 per district). The criteria for selecting the districts are as follows: the districts should be representative of the whole region; they should reflect the situation in different environments (urban, periurban, and rural); and they should have a World Bank project in their vicinity in order to facilitate the World Bank Institute’s (WBI’s) response to the assessment. The assessment focused on the capacity to deliver Education, Health, and Water/Sanitation services at the local community level. It was facilitated by two local organizations familiar with the different interactors involved: the African Centre for Human Development (ACHD) for the Volta Region and the MayDay Rural Project (MDRP) for the Eastern Region. 2 More than 1,100 individuals, broken down into three stakeholder groups (policy makers, service providers, and beneficiaries), took part in the assessment (587 in the Volta Region and 594 in the Eastern Region; 66 percent were men and 34 percent women). The CENA Approach In this report, “capacity” is defined as the ability to access and use knowledge and skills to act in the pursuit of a development objective. The CENA is a participatory assessment designed to evaluate existing capacity, identify institutional constraints facing the actors involved, ascertain capacity strengths and weaknesses, and recommend possible remedies. 3 The CENA methodology encourages the development actors involved to begin the assessment with a clear idea of the specific task to be performed and the objectives to be achieved. It relies on development actors to carry out their own needs assessment and propose remedial actions. The outcome of the assessment is then used to prepare multiyear capacity enhancement programs. The approach builds on a shared vision among key stakeholders, which enables a given task team or stakeholder group to act collectively for achieving their common objectives. The emphasis is on performance and coordinated action. The methodology is adaptable to various contexts and can be aimed at specific results. It can be used as a learning instrument for understanding capacity issues at the heart of complex problems facing a country, a region, or a sector within the country. Or, as is the case in this CENA exercise in Ghana, it can be deployed by communities themselves as a first step to identifying and articulating needs, problems, opportunities, and challenges and mobilizing to address the constraints, set and pursue priorities, and achieve desired goals. Generally speaking, “capacity” can be described as the ability to perform a given task (for example, monitoring the government poverty reduction program) or achieve an objective (making the appropriate adjustments in the 2 In the report, we refer to ACHD and MDRP as the “CENA Facilitators.” It is important to understand why WBI did not want to carry out the assessment itself and therefore commissioned local organizations instead. If it had directly performed the assessment, the mere presence of WBI staff would have influenced the responses given by the participants. It is also important to note that the local consultants do not actually carry out the assessment; they merely facilitate it, using the CENA methodology in the process. The assessment per se is done by the development actors themselves. 3 See Darlan, Annex 1 of this report, for a description of the methodology. Page 10 2 program). In this case, “capacity” refers to the ability of the Ghanaian actors involved to deliver Education, Health, and Water services at the local community level in the context of the government’s decentralization and community empowerment policy. All development actions are collective actions, and for any collective action to succeed, the key actors must possess the skills and knowledge required to play their respective roles. If some actors have incapacitating weaknesses or if they face institutional constraints that prevent them from playing the roles expected of them, such weaknesses and constraints must be addressed. This basic principle holds particularly true in public service delivery to the poor at the community level, where the actors involved (policy makers, service providers, and beneficiaries) seldom share the same educational backgrounds, governance principles, and cultural values. Several factors can affect the capacity of actors. First, to be up to the task, the actors concerned must possess a clear understanding of the development action for which capacity is required and must know the roles that all key actors are expected to play in the pursuit of the common objective. Second, they must possess the required technical or professional skills to perform their roles. Third, they must acquire knowledge about the different ways the task can be carried out successfully. Although this first set of capacity requirements is critical, it determines only the readiness of individual actors to act; it does not provide a sufficient measure of the actors’ capacity to perform collectively . Hence, the second set of capacity requirements must address the quality of the institutional environment within which actors operate. At this point, it is useful to remind ourselves that institutions are frameworks of rules, procedures, and arrangements that can provide either incentives for action or constraints that impede action. The composition of the enabling environment can be broken down into formal arrangements specifically designed to coordinate individual contributions and facilitate collective actions and informal arrangements that influence individual behaviors (although they are not codified). Examples of formal institutions include laws, regulations, and guidelines. Examples of informal institutions include customs, traditions, and cultural values. Key Concepts Community Development – Development is about change aimed at improvement. Effective and sustainable development requires the ability to envision a future, plan and work toward this future, and monitor and sustain (positive) results at each step. Effective and sustainable development also involves changing roles and relationships, structures and mechanisms, and attitudes and behaviors to improve the quality and impact of development actions. At the country level, it requires that citizens and governments, as key stakeholders, work together to explore and learn to make choices appropriate to the context. At the community level, it also means that community groups understand and assert their rights to bring about desired changes in society. For this purpose, they need knowledge, skills, tools, and mechanisms, along with an enabling environment and the confidence in their own ability to become effective agents of change. Capacity Development – If capacity is the ability to act in the pursuit of a development objective, several questions need to be answered up front, including what kind of capacity is required? for whom? to what specific end? In many situations, the key problem is not so much “building” of capacity as it is mobilization, retention, upgrading, and redirection of capacity— hence the terms “development” or “enhancement.” A comprehensive approach to capacity development requires the identification of the problem that the community is facing, the functions and the collective actions that need to be performed by community members, the capacity of community groups and leaders, the capacity of other development actors involved, and the Page 11 3 surrounding conditions. The findings of such an assessment can then be followed up by several kinds of interventions. There will be implications for policies and strategies; programs and projects involving community participation; the institutional environment; and the knowledge, skills, attitudes, and behaviors of key stakeholders. Community Empowerment – Empowerment can be defined as the enhancement of assets and capabilities of diverse individuals and groups to engage, influence, and hold accountable the institutions and organizations that affect them. It is also the capacity to envision and achieve positive change. Voice is a key step toward enabling the poor and the excluded to become agents of change, a critical factor for empowerment. However, voice by itself is not sufficient to bring about change in society. It needs to be accompanied and enhanced by collective action. Page 12 4 SUMMARY OF FINDINGS AND PROPOSED SOLUTIONS In their reports, the CENA Facilitators presented the outcome of the assessment with regard to features that typically form the basis of training needs assessments, such as skills, know-how, and professional experience. In addition, the CENA approach helped focus on factors that are often neglected when conducting training needs assessments, although they are at the core of capacity weaknesses; namely, how well actors understand what is expected of the key individuals and organizations involved, including how well they understand their own roles, and how constraining or enabling the institutional environment is. In this report, we concentrate on the latter two sets of factors. The structure of the summary is as follows: (a) generic capacity constraints; (b) capacity constraints specific to the three sectors concerned (Education, Health, and Water/Sanitation); and (c) proposed solutions. (Additional information and data collected by the Facilitators can be found in the annexes 2, 3, and 4.) 1. Generic Capacity Constraints Weak Policy Framework The CENA reveals that a large number of community members do not consider themselves and the government as partners committed to a shared vision of better service provision and delivery. Strangely, a number of government service providers blame community members for not understanding the government policy on decentralized service delivery. They give the following examples to illustrate their point: Some community members question the rationale behind paying water user fees; some committee “volunteers” (for example, on a Water and Sanitation [WATSAN] Committee) resign because their request to be paid is turned down; some landlords insist on collecting rent for space provided for Community-Based Health Planning and Services (CHPS); a few community members refuse to release land for a community borehole. This finger- pointing on the part of government policy implementers seems strange because one would have expected that it was their responsibility to explain government policies to the intended beneficiaries. This is indicative of the kind of behavioral change that must take place before the institutional environment for effective service delivery can improve. The CENA reveals that the community members’ skepticism or cynicism about the government’s decentralization policy is caused in large part by the failure of government representatives to explain the policy when it is being introduced. As a result, misinformation and misinterpretations distort the communities’ understanding and perception of the concept. Many community members still believe that the real intention of the government is to dodge its responsibility to deliver basic services to the poor. The community reactions clearly indicate that the government could have saved everyone much frustration had it taken the time to explain its policies better. This being said, community members are discovering the objectives of the policy as it is being implemented, and from the CENA participants’ comments, it appears that a change in perception and attitude is taking place. Many are now aware of the opportunities that the policy is creating. They say, for example, that it is now possible for them to monitor and evaluate service delivery (which helps develop a customer’s mentality). But they also say that they will not be able to take Page 13 5 advantage of these opportunities if they do not have access to the necessary information or acquire the necessary knowledge and skills so that they can fully play their roles as customers. Because of their better understanding of the policy, community members are gradually realizing and accepting the roles that they are supposed to play in the service delivery arrangements. On the issue of remuneration of volunteers, the overwhelming majority position among community members is that community representatives who serve as members of the various management committees should serve as unpaid volunteers. They believe that remuneration of community members would be a departure from the emphasis on volunteerism. Introducing remuneration as an incentive, they argue, would undermine, and possibly destroy, the spirit of voluntarism. They add that the only motivation for volunteers should be the desire to help their communities. However, the fact is that some community members (especially in WATSAN) abandon their positions for lack of remuneration. In some cases, community members strongly disagree with the government on some aspect of the policy (for example, regarding the imposition of user fees). The overwhelming majority of community members still do not accept paying what they consider to be heavy fees for Education, Health, and Water services. In the minds of some, the fact that government is now charging for such services is proof that it is trying to run away from its responsibility to deliver basic services to the poor. Disagreement on policies, accentuated by the low quality —or the inaccessibility 4 or absence—of services offered through public agencies are leading the intended beneficiaries to search for alternative solutions that sometimes carry unfortunate consequences. For example, in order to cope with the difficult situation created by the inadequate service quality, some community members are withdrawing their children from public schools and placing them in private schools, even though this adds to their financial burden. Those who can afford it also employ the services of private tutors who visit their homes to organize extra classes for their children. As a result, the demand for public school is falling, while the demand for private school is rising. Another example of applying unsatisfactory solutions is provided by the Water sector. Because of the water pumps or pipes not being repaired for extended periods of time, many people in the urban communities now rely on water sold in small containers for their domestic daily use. 5 This may seem at first like an acceptable solution. However, less pressure is now put on the service providers to carry out repairs, which leaves those who cannot afford this alternative service to use polluted surface water. The assessment also reveals that there are many incoherent and inconsistent policy statements, especially on Health and Education, which confuse community members. Also, the same official policies are sometimes interpreted and applied very differently. For example, while CHPS services are reportedly provided free in Akuapem South District, the Yilo Krobo District nearby charges for them. The application of the “exemption policy” within the context of CHPS and the poverty reduction strategy is also not clear, which lead to different applications of that policy. 6 4 For example, in the Oterkporlu community, Yilo Krobo District, CENA participants report that the nearest school to the community is about five miles, which has forced their children to give up school and work in a quarry located in their area. 5 This is the case, for example, in the Nsawam community, Akuapem South District. 6 The health exemption policy was introduced in 1985 as part of the user fee strategy to provide free access to health care to the poor and certain vulnerable groups in the society. The policy targets selected user Page 14 6 In some cases, such as the handling of traditional medicine, the government policy seems to be going in the right direction, but there is still uncertainty as to the way it is being implemented. Community members explain that they do not rely on official Health services for a significant portion of their medical needs. Instead, they use the services of the traditional healers and traditional birth attendants (TBAs). There is a heavy presence of TBAs in many of the communities studied. CENA participants report that many of them feel more comfortable with traditional practitioners than with official Health attendants, which is another reason why Health clinics are only partially used even when the services they offer are in demand. The reliance on traditional medicine is so widespread that the government has officially acknowledged TBAs and traditional healers. A special unit has even been created in the Ministry of Health to assist them. Unfortunately, from statements made by community members, it appears that effective support to traditional medical practitioners has yet to materialize. Weak Regulatory Framework In some cases, the problem comes from the absence of regulations, guidelines, or agreed-on principles for facilitating collective actions. This seems to be the reason for the poor coordination so often mentioned by the CENA participants. A number of government agencies are involved in the implementation of service delivery policies in the three sectors, but there appears to be no overall coordination. This same deficiency in the regulatory framework seems to also account for the weaknesses in monitoring and evaluating the government decentralization and community empowerment policy. In other instances, the guidelines that have been adopted are counterproductive. The best examples of that are the rules and procedures in the decision-making process and the selection of District Assembly (DA) officials. Let us first rapidly examine the issue of community involvement in decision making as exposed by the CENA. Within the community, collective decisions are made through consultations, discussions, and contributions by members of the community. There is a high degree of unity of purpose that has been sustained through the enforcement and respect of traditional values and rules. On the other hand, at the local government level, community members are not consulted before decisions are made on their behalf. Most policy decisions are made from the top and communicated to the communities through their local representatives. These representatives themselves (Assembly members and Unit Committee members) do not consult their constituencies and are much too close to, and dependent on, government sector ministries. As a result, communities cannot influence the service delivery arrangements that affect them. Community members complain to traditional authorities for redress, but to no avail, given the constant tension between traditional leaders and District Assemblies. Being used to collective decision making within the community, community members feel mounting frustration for being constantly ignored in modern governance systems instituted by the government. This frustration is fueled by the increasing awareness of their rights as intended beneficiaries of government policies. The establishment of the various management committees for Water/Sanitation, Education, and Health has accelerated that awareness without solving the issue of community participation. There is plenty of evidence that the participation of community members in those committees is a strategy that promotes the development of local expertise and capacity; yet, the communities are still not able to influence service delivery arrangements because they are being ignored in the decision-making process. Being poor seems groups, specific diseases of public health concern, and health care professionals. The policy provides partial or whole exemption from user fee payment to the intended beneficiaries. Page 15 7 to create a stigma that deprives communities of a voice. This situation leads to frustration, passive behaviors, and skepticism about the decentralization policy. Another issue is the selection of district officers. Community members feel that there are fundamental problems associated with the procedures for selecting officeholders at the three levels of governance (District, Zonal, and Unit Committee levels). At the district level, the District Chief Executive (DCE) is appointed by the President of the Republic. In addition, one- third of the Assembly members are appointed by the government. At the Zonal and Unit Committee levels, 15 percent of the members are government appointees. This selection process marginalizes community residents. To make matters worse, in many cases, the selection of the District Chief Executives and other officeholders at the other two levels is based on their political affiliation. In other words, the DCEs and some of the members of the Zonal and Unit Committees are seen as representatives of the ruling party. Some of them are perceived to be kept in office in spite of their glaring incompetence. This situation leads to distrust and lack of accountability and adversely affects the functioning of District Assemblies. Confusion about Roles of Key Actors The CENA reveals confusion about the role of the key actors involved the delivery of services in all three sectors. The official roles and responsibilities of actors are generally well identified in official documents. 7 However, there is a great deal of confusion regarding their actual functions and responsibilities. This leads to friction among the different actors. The leadership roles are the responsibility of the District Assembly, the Unit Committees, and the traditional authorities. The role of the DA in the provision of services includes the formation of the various committees for Health, Education, and Water/Sanitation. It also coordinates and monitors the activities of the committees by liaising with the relevant decentralized government agencies. In some communities, it seems that it is this supervisory function that is the source of conflict between the traditional authority and the newly established local government leadership. 8 The main responsibilities of traditional authorities in the provision of services are the acquisition of land and the organization of communal labor. In most cases, the acquisition of land has not been a problem. By tradition, natural resources that are essential for survival belong to no one in particular, but to the community as a whole. This principle of participation enables the communities to access and utilize resources such as land, sand, and wood for the construction of their basic amenities (pit latrines, football parks, markets, boreholes, and so forth). Although this assertion is generally valid for all the communities studied, there are isolated cases of individuals who refuse to release the land for a community use. This is seen by some observers as a sign that the concept of communal ownership and use of common resources is under threat. 7 See Annex 2 for a description of the roles of actors who intervene in the delivery of Education, heath, and water services. 8 See Annex 3 for a more detailed discussion of local governance arrangements and the friction between the traditional and modern systems. Page 16 8 The village committees and organizations for service delivery arrangement 9 are often made up of a few members of the community, usually those with the highest education. The hope is that the community representatives would maintain good contacts with their base, but the CENA reveals the community members’ disappointment in them and suspicion that they end up conniving with the service providers to monopolize information for their own benefits. The lack of information filtering down to community members negates the majority rule because the majority of community members are not able to make informed decisions. In the three subsections that follow, we elaborate on the Facilitators’ analysis of the conflicts between District Assemblies and traditional authorities . Conflicts Between District Assemblies and Traditional Authorities The friction between traditional Chiefs and members of District Assemblies is often mentioned by CENA participants. One cause of the problem seems to be the absence of a clear demarcation line of authority between traditional authority and elected DA officers. PNDC Law 207, upon which the District Assembly concept was established, specifies the roles and responsibilities of the various officeholders such as the District Chief Executive (DCE), the Presiding Member (PM), and the Member of Parliament (MP). However, the CENA reveals that the guidelines in some of the districts have been either intentionally flouted or unintentionally misapplied. There is a sense that some of the conflicts between DAs and traditional authorities could have been avoided had traditional authorities been systematically consulted in the design and establishment of DAs. The weaknesses of District Assemblies and the traditional leadership system exacerbate the friction between them (see next subsection). Another reason often mentioned for the friction is the lack of adherence to the principles of transparency and accountability by some DA officers in charge of important financial transactions. CENA participants place high on their list of accountability issues the misuse of the different district or community funds (District Common Fund, GETFUND, HIPC Fund). 10 Another type of leadership conflict arises among DA officers 9 The main service organizations in the three sectors are as follows. In Education, the Parents-Teachers Association ( PTA) formulates policies and provides advice and guidance, whereas the School Management Committee (SMC) is the management entity that is responsible for interpreting PTA policies into strategic goals. In Health, the CHPS management committee assists the Community Health Officers deployed to the communities, protects the property of the CHPS center, and provides security for the Community Health Officer (CHO), and serves as a liaison between the community and the CHO. In Water/Sanitation, the WATSAN committee is responsible for managing the water points in the communities, collecting the community’s counterpart contributions, and keeping financial records of all transactions related to the operations of the water services. 10 The District Common Fund is the money disbursed to the District Assemblies by the Central Government for the development of infrastructure and services such as water, health, and Education. The HIPC Fund is also money given to the District Assemblies by the Central Government. The HIPC Fund is the fund generated by the government of Ghana by declaring the country as a Highly Indebted Poor Country (HIPC). The GETFUND is the Ghana Education Trust Fund established by an Act of Parliament for the development of school infrastructure. The Tender Board is responsible for offering contracts in the district. The operation of the Tender Board in some of the districts has been marred by stories of kickbacks and other illegal practices in the award of contracts. Page 17 9 because of different political party affiliations. Officers have the tendency to think and act along party lines. This creates friction among officers from different parties. Even officers who belong to the same party, but who have political ambitions as aspiring candidates or as supporters of a candidate, clash with one another in the course of their work. Weaknesses of District Assemblies District Assemblies pose two sorts of problems. First, they are not capable of playing the leadership roles assigned to them, which creates a power vacuum that government agencies are only too happy to fill, thereby robbing the decentralization policy of its raison d’être. Second, DA members take advantage of their official positions to claim part of the authority of traditional leaders, creating frequent clashes with them. This is possibly the main cause of inefficiency in carrying out development policies at the local community level. It alienates the traditional Chief and community members. The District Assembly, with its substructures down to the Unit Committees at the community level, is designed to play the role of executive at the district level. It has overall responsibility for the general development of the district and communities. It is also supposed to represent the Central Government in service delivery at the district level. Decentralized government agencies are also supposed to be under the direction and management of the Assembly, but this has not happened. Many of the decentralized agencies have been turned into autonomous bodies (for example, the Ghana Health Service and the Ghana Education Service). The staff of these agencies receive their instructions directly from, and report to, their head offices in Accra. On the other hand, these agencies provide services to District Assemblies, which makes it very difficulty for DA members to fulfill their oversight responsibilities. Where there is poor delivery of service, the Assembly cannot take sanctions against the service provider. The Assembly does participate in the award of contracts and monitoring of performance (as in the case of the Water and Sanitation Agency); however, it has no say in key policy decisions such as paying 5 percent of total service as maintenance fee. Although the members of the Assembly think that this 5 percent service fee is bad policy because it deprives the poorer communities of urgently and critically needed water supply, they are powerless to change it. DA shortcomings considerably weaken the process of decentralization and community empowerment. Furthermore, members of local communities realize that the District Assemblies often lack the resources to improve service quality. Hence, communities’ expectations of the DAs are very low, and they continue to expect the individual government agencies to deliver the services. DA weaknesses also create confusion in the minds of community members as to the real purpose of the government’s decentralization policy because they see no direct link between the establishment of District Assemblies and improvement in the quality of services. They even perceive an inverse relationship between the establishment of the DA system and community empowerment. Yet, the government has just created 30 new District Assemblies, many of which will likely be incapable of performing their roles and meeting their responsibilities without substantial technical assistance. In order to use decentralization to the benefit of the community, there needs to be a collaborative arrangement between the traditional authority and Assembly members. However, the fact is that community members are much closer to their traditional Chiefs than to the people who are supposed to represent them in the District Assembly. To make things worse, Assembly members Page 18 10 enjoy a much closer relationship with government officials than the Chief does. This problem must therefore be addressed as a matter of priority. Strengths and Weaknesses of the Traditional Leadership System In Ghana, the traditional leadership system is an age- old establishment that has been “time-tested and time-honored.” The leadership arrangements are utilized for effective participation and decision making. The decision-making process follows an internal democratic principle whereby issues are discussed at the Council of Chiefs or at public forums. By tradition, natural resources that are essential for survival belong to no one in particular, but to the community as a whole (as mentioned earlier). This is the guiding principle of participation; it enables the communities to access and utilize resources such as land, sand, and wood for the construction of their basic amenities (latrines, football parks, markets, and so forth). The rapport among the different ethnic groups is cordial, and there is social cohesion, two factors that facilitate participation of community members in collective activities. On the negative side, the CENA reveals that some of the traditional community leaders lack the necessary technical and managerial skills or experience to effectively address the growing challenges in the lives of their people. 11 Also, there are many chieftaincy disputes in some of the communities in all three districts, which tend to discredit that institution in the eyes of DA and government officials. The disputes are affecting the development of the communities concerned. This being said, the positive aspects of the chieftaincy institution still dominate and make it a reliable platform for genuine community empowerment and mobilization. It should be given a greater place in the modern state, which would require strengthening the capacity of traditional authorities. 11 See capacity ratings in Tables 3, 6, and 8 in Annex 2. Page 19 11 2. Capacity Constraints by Sector In the previous section, we summarized the generic issues raised by the CENA participants. Most of the time, they result from the inability of the government to clearly explain its official policies, issue clear guidelines for coordinated action at the district and community levels, and provide incentives for behavioral change on the part of its front-line staff. It is also clear that some of the institutional arrangements created by the government clash with traditional systems of governance. All of these institutional weaknesses contribute to the low capacity to implement the government policy on service delivery to the poor. In this section, we present the main findings specific to the three sectors under study, which allows us to pinpoint some of the particular weaknesses that will need to be remedied. Education So far, the government’s efforts to deliver quality education services to local communities are not producing good results. The responses provided by the CENA participants suggest that this situation is caused by a combination of factors, including the poor understanding of the policy by the intended beneficiaries, the overcentralized decision-making process, the rather dismal performance and behavior of teachers, and the lack of commitment of government staff to implementing the policy. Policy – The government policy on basic education is not well understood by the intended beneficiaries. School levies are a particularly irritating issue for community members. Some parents defiantly refuse to send their children to school. They cite the high cost of levies paid as the main reason for their refusal. Not only do community members believe that some aspects of the government policy are misguided but many also believe that it is not being implemented properly. For example, with regard to girls’ education and school improvement, they argue that government implementers have lost sight of the policy objectives and guidelines. As a result, these aspects of the government’s basic Education policy are not even being addressed. One of the situations that government policy does not address is the special situation of HIV/AIDS orphans. Tradition dictates that relatives take care of the surviving children; unfortunately, in many cases, the relatives are grandparents who are themselves overburdened with poverty and cannot cope with the added financial obligations. This situation is contributing significantly to a decrease in enrollment in many communities, especially those of urban setting. 12 Teacher Performance and Behavior – Indiscipline among teachers and pupils is pervasive. For example, absenteeism, lateness, and drunkenness are noted in all the districts covered under the assessment. Teachers often engage pupils in personal errands during official school hours. Supervision and monitoring of teachers are deficient. From the teachers’ point of view, there are 12 Background note on the government policy – The policy framework for basic education delivery at the community level is based on the national policy of Free, Compulsory, Universal, Basic Education (fCUBE), which was launched nationwide in 1996. The main aim of this policy is to ensure better quality basic education for the Ghanaian child. The policy objectives are as follows: increasing access; increasing participation through decentralization; improving infrastructure at the basic level; revitalizing and motivating teachers and pupils, with improved access in a congenial classroom environment to enhance school work for success; training and retaining school managers working with other stakeholders to efficiently and effectively strengthen the school system; improving discipline and accountability in schools; and ensuring gender equity in education at the basic level. Page 20 12 many reasons for discouragement and leaving for alternative jobs, as large numbers of them have done. Many refuse to accept postings to remote or deprived rural communities; they give as main reasons the facts that there is no job satisfaction in the teaching profession in those remote areas, living there does not provide career development opportunities, and there are no satisfactory and regular in-service training programs for them (which adds to their isolation). Administrative Decision Making – Because of the poor working conditions and slow administrative process, the rate of retention of teachers is low. There is overcentralization of decision making at government headquarters in the capital, Accra, even though the Education sector is supposed to be decentralized. Officials at the district levels have no authority to make critical decisions, and this leads to delays in actions on important issues and affects release of budgetary allocations, payment of salaries, and allowances and benefits due to staff. The incessant delays affect the morale and performance of teachers. Procedures for recruiting teachers are cumbersome. Effective communication between the district directorate and school heads on administrative and welfare issues is lacking, and there is noticeable political interference in Education decision and policy making. Performance of Ministerial Staff – A number of departments in the ministry are involved in the coordination and implementation of policies on basic education. The assessment reveals that it is not the technical skills of these government staff that are at issue; it is their lack of commitment to implementing the policy and their lack of leadership ability when operating at the community level. Community Involvement – The government plan calls for decentralizing Education administration, involving the community in Education management, and making room for the District Assemblies to play a major role. The policy has very good intentions; however, the results have been very disappointing, in most cases. There are currently very little community involvement in the management of the Education system and no sense of community ownership of the schools. District Assemblies are also marginally involved in Education. Even though organizations such as Parent-Teacher Associations (PTAs) and School Management Committees (SMCs) have been created, their role has been marginal so far. One reason is that community members lack the capacity to engage effectively with government representatives and donors who have the power to decide and see the participatory process as a nuisance. Furthermore, the attitude of many school managers make parents feel that they do not have a role to play in school management. Many parents feel frustration in attending PTA and SMC meetings because of their lack of formal education and poverty condition. Many parents also have limited confidence in the school system because of high unemployment among school leavers and graduates. Parents feel that there exists an unhealthy relationship between pupils and teachers in many cases because of the frequent engagement of pupils in personal errands by school officials. Incentives – The poor state of school infrastructure creates a serious disincentive problem. The Volta and Eastern Regions suffer from the lack of teachers. Many classrooms do not have teachers, and the untrained teachers outnumber the trained ones. The CENA reveals that the main problems responsible for this situation are lack of living accommodations, low remuneration, and insufficient initial preparation and in-service training of teachers. These conditions affect the morale of teachers; as a result, they abandon the classroom in large numbers. There used to be opportunities for study leave, but that practice has been cancelled. The notion that the teaching profession offers job security and lifelong employment is a thing of the past. With regard to school infrastructure, the situation is as dire. Some schools operate under sheds and trees, and more than 70 per cent of all school buildings require major repairs. Some children sometimes have to carry their personal tables and chairs to school, walking over long distances. The “one Page 21 13 child, one textbook” policy is failing; in some instances, one book is shared among 10 pupils. There are very few school and district libraries, and when they do exist, they are poorly stocked and inefficiently managed. By the time pupils leave the education system, fewer than 5 percent of them will have used a computer. There are more facilities for education in the urban areas than in the rural areas because of the urban bias in public administration and investments in the country. However, the problem of dysfunctional infrastructure is general. Communities do not have the necessary resources to build school facilities by themselves. Health The CENA reveals that several factors stand in the way of delivering health services of better quality to the poor at the community level, including insufficient understanding of the government policy, inadequate infrastructure, significant staffing problems, insufficient involvement of communities in policy decisions, and incomplete integration of traditional health practitioners in the country’s official Health system. Policy – Generally speaking, the communities do not have a good understanding of the policy objectives and implementation strategy of the Community-Based Health Planning and Services (CHPS). The policy on exemptions and service provisions is not clear, not only to community members but also to Community Health Nurses. Furthermore, there is no enabling environment for local decision making. The system is centrally controlled, which brings frustration to the local people as they are unable to make decisions to meet their needs. 13 Infrastructure and Financial Obstacles to Policy Implementation – There is either a serious lack or inadequate quality of buildings for housing CHPS and of logistical means such as vehicles and motorbikes, which are considered critical for the implementation of the CHPS program. Land litigation in some communities is crippling the efforts of CHPS implementers. The construction of the CHPS compound is a joint responsibility of the District Assembly and the community; on one hand, local communities cannot readily afford to raise the needed funds for CHPS, and the DA on the other hand, does not always have provision for CHPS in the budget. The drug supply in the CHPS centers is inadequate. All of this makes implementation of the CHPS policy difficult. Staffing – The lack of health personnel to manage CHPS centers remains a major problem and has serious implications for CHPS implementation. Staff-related problems are found across the sector and are common to all areas (urban, periurban, and rural). There is inadequate staff (doctors, nurses, medical assistants) partly because of the freeze on hiring. There are no decent living accommodations for the few Community Health Nurses that have accepted the challenge of going to the rural communities. The main reasons given by Community Health Officers for their reluctance to accept positions as managers of CHPS centers are that there are no basic amenities (such as safe potable water and electricity) in remote areas. A number of Community Health Nurses complain of being forgotten, without the possibility of upgrading their skills through training, once they are posted in CHPS centers. In the rural areas especially, hospitals and health 13 The national health policy —often called by the name of the program, CHPS—is to provide the citizens with quality, affordable, and accessible health care. The Ghana Health Service is the provider of health care services throughout the country, while, in parallel, traditional medical services are allowed to coexist. There are both public and private practitioners in health delivery in the region. Public services are delivered mainly through hospitals and clinics. There are also private maternity homes. Page 22 14 clinics are not well attended, partly because of inadequate transport infrastructure, but mostly because the cost of health service is beyond the means of a large number of community members who do have the alternative that traditional medicine offers. The high cost of service encourages self-medication. Community Involvement – Community involvement in health care for modern medicine is limited to providing some local support for the construction and security of Health facilities. Communities have practically no say in Health management. In rural areas, there is more community support and ownership of Health facilities than in the urban and periurban areas. Community members in rural areas volunteer quite frequently to provide security, assistance in constructing Health facilities, labor for cleaning Health compounds, and surveillance to report communicable diseases to Health officials. Traditional Medicine – Cultural beliefs play a role in the selection of health care services by community members. It is estimated that community members still depend on traditional medicine for at least half of their needs. The traditional services include plant and herbal medicine, spiritual healing, birth attendance by traditional birth attendants (TBAs), and circumcision (carried out by local Wansams ). Yet, traditional health practitioners are not fully integrated into CHPS programs. This is unfortunate because traditional health practitioners are able to sustain their services in remote communities, are well integrated into the community, and are always available, and their fees are modest. In fact, in many areas, they have increased the scope of their services and their influence, thereby compensating not only for the staffing shortfalls mentioned above, but also for the shortages in the provision of drugs by hospitals and clinics. Traditional medical practitioners always manage to have their drugs available at all times. Water and Sanitation The CENA reveals that the quality of water infrastructure is a factor in the quality and reliability of water services to local communities, but it does not seem to be as critical as other factors (for example, weak capacity of communities to prepare proposals and supervise projects, inability of poorer communities to raise their share of the investment capital (5 percent), government’s inability to raise its own share (95 percent), weak capacity of community members to maintain the system properly, and inability of the system to provide technical support and training to communities). Policy – Of the three sectors, the Water policy of the government seems to be the best understood by community members. In both the Volta and Eastern Regions, the policy seems to be implemented mostly as prescribed. There has been a great effort to improve water supply, but more needs to be done to increase coverage to the poorer communities that cannot raise their counterpart funds (the sanitation picture is much different and is not addressed here). The main constraints in implementing the policy and improving service quality have to do with user behaviors, inability of some to pay the user and maintenance fees, and inappropriate management practices of water management committee officers. Also, the farther one moves away from urban areas and deeper into rural areas, the more serious the problems related to infrastructure become. 14 14 The government policy aims to facilitate the provision of basic water services to rural communities and small towns that contribute to the initial investment of facility installation and subsequently cover all costs Page 23 15 Behaviors in Relation to Government Policy – In spite of the policy provisions, some communities do not maintain the water and sanitation facilities properly; as a result, the equipment breaks down frequently. There is indiscriminate dumping of refuse in the communities, especially in the urban and periurban areas, which contributes to the high incidence of water-related diseases. The problem is made worse in communities where there is an absence of household latrines. Most community members are against the policy of paying for water. Some communities have difficulty paying their counterpart contribution of 5 percent of the cost of providing the water facility, and those who can take a long time to do so. Rural communities are generally unable to pay. Some of the community members selected as WATSAN Committee members quit their jobs before their terms are up; many do so because they expect to receive financial incentives even though they were selected as volunteers. Water users are generally uncooperative because of lack of sensitization and the low quality of service. For water supply in urban areas, the system is so commercialized that there is no room for community involvement at the policy level, which hurts deprived communities most. Infrastructure – The quantity of potable water and sanitation facilities remains inadequate. For example, in the urban district of Ho (Volta Region), piped water is available to only 50 percent of the people. The situation deteriorates rapidly as one goes farther away from urban centers and deeper into rural areas. Communities that do not have access to clean water have to rely on unsafe ponds and dams or walk long distances for their needs. The level of salinity of many of the boreholes is quite high, particularly in the urban areas. Management – Trust in the WATSAN Committees has eroded because of the lack of transparency in managing accounts. This is making it more difficult for representatives of the community on the committees to accept making their contribution solely on a voluntary basis. Management of water facilities is ineffective, and budgetary allocation for operations and maintenance is inadequate. There are no maintenance engineers in rural districts. of operation and maintenance. The policy is designed to ensure sustainability of the facilities through a strategy of community ownership and management. It also aims to maximize health benefits by integrating water, sanitation, and hygiene promotion interventions. The types of service provided by the Community Water and Sanitation Agency (CWSA) and the modalities for delivery include the following: CWSA’s response to community demand depends on whether the community is willing and able to pay 5 percent of capital cost and 100 percent of operational and maintenance costs; signing of a contract between the CWSA and the community; a reconnaissance survey and selection of site by both community members and technical team; establishment of a Water and Sanitation Committee, with inclusion of community members to oversee the management of the facility; opening of a bank account where the money collected from operating the facility will be deposited for maintenance purposes; construction of the facility by contractors with community participation so that beneficiaries learn about the requirements for future maintenance; training of maintenance team selected from community members (the team must include women); and community assuming full responsibility for the operation and maintenance of the facility. Page 24 16 3. Proposed Solutions In the preceding sections, we have presented the findings of the assessment as reported by the CENA Facilitators. In this section, we present the recommendations of the CENA participants to correct the situation. The formulation of remedial actions to capacity constraints that the actors concerned have identified is an important part of the CENA approach. It provides a reliable starting point for the development of targeted capacity development programs. We first present the recommendations of the CENA participants, followed by general comments and recommendations made by the CENA Facilitators. Recommendations by CENA Participants The sector-specific recommendations for addressing the issues that the CENA participants identified are grouped into four categories where they feel progress must take place before capacity can develop: (a) strengthening policy and regulatory frameworks; (b) providing incentives for implementing the policy and respecting the rules (incentives for behavioral change); (c) strengthening organizational arrangements; and (d) disseminating information and strengthening skills, knowledge, and awareness. As suggested by the CENA methodology, these recommendations by the actors directly concerned should form the basis for a remedial capacity- building agenda. What is of particular interest is that the overwhelming majority of recommendations are made by representatives of the communities (that is, by the service users). This is to be expected because service users are the group that is most dissatisfied with the way the government policy on decentralized service provision is being carried out. Still, the outspokenness of community members deserves to be mentioned. Also, when one examines the recommendations closely, one is impressed by the specificity and coherence of the recommendations. The fact that stakeholders are prompt at acknowledging their own responsibility for remedying the situation is encouraging. Weak capacity is often the result of behavior and other informal institutional determinants. It is therefore critical that self-criticism by the stakeholders concerned takes place. It helps provide awareness, leading to meaningful change. Also noteworthy is the fact that the intent of the training recommended by the actors is much more oriented toward problem solving than skills building. 1. Strengthening Policy and Regulatory Frameworks Education · School should be compulsory for all children of school age. · Basic education should be truly free and devoid of levies. As a minimum, the District Education Office should streamline the levies paid by parents (recommendation made by community members, not necessarily shared by policy makers and service providers). Page 25 17 · Child labor should be outlawed, because it keeps children out of school; traditional authorities, women’s groups, and the community in general should ensure that the law is enforced. · The policy of having functional PTAs and SMCs that are fully functional and active in every school should be enforced. · Scholarship schemes should be designed to assist needy students with good potential. Health · Traditional medicine should be properly monitored and fully integrated into the official medical system. · Communities should be made to release land for CHPS. DAs should stay out of this arrangement; instead, they should direct their efforts to constructing the centers and providing facilities (electricity, potable water, and so forth) in CHPS communities. DAs should have a special line item in the budget for CHPS program on a yearly basis. · The Ghana Health Service (GHS) should develop and distribute guidelines for exemptions at CHPS centers in the communities. The policy of exemptions and service provisions should be explained clearly to the policy implementers (Community Health Officers [CHOs]) and the community members through information, education, and communication sessions. There should be adequate information and education on the National Health Insurance Scheme (NHIS) in order to help community members make informed decisions. Water and Sanitation · Laws and regulations regarding payment of user fees should be enforced. · Donors and project implementers (for example, contractors) should accept the payment of community matching funds in kind (for example, water, stone, sand, labor, and so forth), instead of insisting on cash payment and its deposit in a bank. · Ensure openness, transparency, and accountability from service providers. · Managers of water facilities at the community level should be made to respect delivery dates and carry out proper supervision of the facilities. · The community members, especially Chiefs, elders, Unit Committees, and opinion leaders, should monitor WATSAN Committees on a quarterly basis. · Honesty should be one criterion for selecting WATSAN manager and members. · Regulations that make it mandatory for landlords to provide toilet or latrine facilities in homes they rent to others should be passed and enforced. · The amount of matching funds required from deprived poor communities should be lowered. · The construction and use of household toilet facilities should be encouraged. The DA should pass regulations to enforce the construction of such facilities. Where land is a problem, four or more households should join together to construct a common toilet facility. · The District Assembly should use its discretion to determine the communities that cannot pay the 5 percent counterpart fund. Those communities that genuinely find it difficult to pay should be able to get assistance from the District Assembly. 2. Providing Incentives for Implementing the Policy and Respecting the Rules Education Page 26 18 Incentives for Teachers · An alternative must b e found to the current “best teacher award” system, which often acts as a disincentive to nonwinning teachers. People find the criteria for selecting “best teachers” unacceptable because the process is not safe from manipulations. Also, to single out good performers in this fashion goes against the prevailing culture of community members. · Service conditions of teachers must be improved to attract and retain them and also to improve their standing in the community. The Ghana Education Service (GES) should provide the incentive packages. The DA and the rural communities should provide accommodations for teachers (if possible, free of charge). · Special incentives should be provided to teachers in deprived or rural areas. It would motivate them to stay. Incentives for Pupils · To sustain the policy on girls’ education, incentive packages should be offered for girls and their parents. They could be in the form of food supplements for the girls and assistance to parents to undertake income-generating activities. · There should be at least one district library in each district, well stocked and properly managed. · Scholarship programs should be put in place and sustained for orphans and other children in particularly difficult situations. · Recreational and sports facilities should be provided for schools to attract and help keep children in school. · Given that financial problems are the main cause of dropping out, parents should be assisted to undertake income-generating activities. Financing of such activities could be worked out by the SMC and PTA in the various communities. Microcredit should be extended to needy parents for income-generating activities to make possible their children’s education. Health · Transportation for Health staff must be improved; for example, motorbikes should be provided to them to improve outreach activities. · Communities should provide residential accommodations for CHPS staff working in these communities. · The Human Resource Department of the GHS should work out conditions of service and career development opportunities for Community Health Nurses deployed for CHPS implementation. Water and Sanitation · DAs should make more funds available for the construction of additional facilities. It can do that by releasing more of the district’s common funds. · All community members, including the Chief and WATSANs and their families, should pay for the use of facilities; it would set a good example to others and increase revenues for maintenance and allowances to WATSANs. · The members of WATSAN Committees should demonstrate a high degree of transparency and accountability to convince people to pay for water. 3. Strengthening Organizational Arrangements Education Page 27 19 · Traditional authorities should be more proactive in helping to enact regulations banning pupils from video houses where they have access to X-rated movies. · District Assemblies should contribute to finding solutions to issues identified by communities. Other agencies that should be involved are the Ghana Education Service, nongovernmental organizations (NGOs), and private organizations involved in the implementation of social programs that benefit the communities. · There should be active collaboration between District Assembly and traditional authorities on matters pertaining to Education. · The Nonformal Education Division of GES should be strengthened and equipped to play a vital education role in educating the elderly. · Government should build at least one technical or vocational school in each district as a matter of urgency. · District libraries should be set up. Health · Greater efforts should be made to get community involvement in public health management, particularly in communities where CHPS is operational. Community involvement should be supported with information and education about the various policy areas of CHPS. Community volunteers can help in nonmedical areas (for example, preventive health services, monitoring and registration of births and deaths). Community involvement in family planning programs can help reduce the burden on medical staff. · District Assemblies and development agencies should sponsor the training of Community Health Nurses in management of CHPS centers. · Better financial resources mobilization: funds for administration should be increased and released in a timely manner. · The traditional birth attendants (TBAs) and the traditional health practitioners should work closely with the nurses. · As a stopgap solution to insufficient accommodations for CHNs, the idea of using mobile ocean freight containers should be explored with local and international NGOs. (MDRP had already indicated its readiness to spearhead this initiative). · The government should acquire site plots for CHPS in communities where land litigation appears to be an impediment. Water and Sanitation · Communities should be assisted in organizing fund-raising activities (for example, durbars , festivals, and so forth) in support of water and sanitation services. · The District Assembly should improve its revenue mobilization at the district level to be able to increase spending on water and sanitation services. · Inefficient and corrupt managers at all levels should be replaced. · Communities should consult the Environmental Health Unit of the District Assembly to assist them to select permanent dumping sites, which should be properly maintained. · Environmental Health Officers should, on their own initiative, visit communities to provide them advice and guidance in the selection and maintenance of permanent dumping sites and other water and sanitation facilities. · Donors, government, and the District Assembly should help construct feeder roads or bridges or both to allow easy access to inaccessible communities. · The District Assembly should provide incinerators or garbage containers at strategic locations. The provision of galvanized refuse trucks should also be considered. Page 28 20 · Donors, NGOs, and the District Assembly should provide financial support to help with income-generating activities. 4. Disseminating Information and Strengthening Skills, Knowledge, Awareness Education · The District Assembly has been sponsoring teacher trainees to come and serve in the district for a minimum of three consecutive years upon completion of their training. This program is ongoing and should be expanded and sustained. · Policy makers and implementers require orientation seminars on a regular basis to help them become more proactive. In addition, training sessions should bring together policy makers, policy implementers, and the communities (SMCs and PTAs) so that they can discuss their activities and problems and exchange experiences. · District Assemblies should be taught to value Education as a priority. · The attention of community members should be drawn to the effects of HIV/AIDS, child labor, and teenage pregnancy on basic education. The DA must increase the HIV/AIDS campaign in the district and get additional financial support from NGOs to assist orphans. · Local traditional authorities should be assisted to fully implement the fCUBE education policy. Civil society organizations should also help enforce the fCUBE. If all the children are in school, then the issue of child labor will be eliminated at the community level. Health · The policy of establishing a district health nursing school should be pursued. An establishment of that sort would enable the District Assembly to sponsor young men and women to be trained as Community Health Nurses. · The framework for public-private collaboration in health service provision should be accelerated. Good practices should be disseminated. The framework should integrate the TBAs and traditional healers such as herbalists and bonesetters into the CHPS program. · The skills of TBAs and Wansams should be enhanced to help expand the Health system. Traditional and herbal health practitioners should be assisted to improve their services, which would accelerate their integration into the official Health delivery system. · The CHPS concept as a policy objective for health service delivery must be made clear to all stakeholders, especially community members and policy makers (Assemblymen and Assemblywomen, traditional leaders, and so forth). The DA and the GHS, with the assistance of NGOs, should undertake an information, education, and communication campaign in the district on the CHPS concept. · The number of staff must be increased and the new staff trained. · More training centers should be opened to train middle-level personnel to supplement work of medical doctors. · Service delivery needs improvement because nurses deal with OPD cases only. · Changes in the attitudes of health workers will go a long way to increase efficiency and get more public support. · The National Health Insurance Scheme should be assisted to work effectively to reduce the burden of high and costly hospital fees on the poor in rural communities. The capacity of actors in this field should be developed. More public education on the scheme is needed. Page 29 21 · Mobilization of volunteers to assist Community Health Officers should be encouraged through training and other incentives. Water and Sanitation Focus on Suppliers · Further improvements in service delivery require, among other things, strengthening the implementation capacity of actors involved (DWST, WATSAN Committees, and Water Boards for small towns). · Managers of facilities at the community level should improve their human relations skills to avoid quarrels and strain relations with users. · The capacity of Water Board members needs to be strengthened. A capacity-building needs assessment is needed. · There should be regular in-service training for the WATSAN team responsible for the technical maintenance of the facilities. Some community members should also be trained, even though they are not members of the WATSAN; this would help ensure transfer of responsibility to the community, and sustainability. · WATSAN members should change their behavior at work, especially those who drink while on duty, do not keep to agreed-on time for opening the facilities, and do not provide adequate supervision to ensure that the facilities are used properly. · Continue educating landlords to provide adequate toilet or latrine facilities in the houses they rent. Focus on Users and Community Members · Continue education and awareness creation of community members on the objectives, roles and responsibilities, and benefits of Water and Sanitation programs and projects and on the proper and efficient use of facilities to ensure durability. · Community members should be educated on Water and Sanitation issues to bring changes to the practice of polluting rivers. Environmental and public hygiene education should be provided to community residents to help them develop a maintenance culture. The DA should assist in this effort. · Community members should stop gossiping about WATSANs’ activities and ask instead for clarification on Water and Sanitation issues that are not clear to them. 5. Strengthening Community Leadership A special effort must be made to strengthen community leadership. CENA participants all seem to agree that community leadership is critical to community empowerment and voice, which in turn can lead to improvement in the quality of Education, Health, and Water services. Unfortunately, for various reasons mentioned by the participants, community leadership seems ineffective. It therefore needs strengthening. Three types of leadership are needed: traditional leadership, women leadership, and youth leadership. Once leaders are identified, they will require assistance to play their roles. Traditional Leadership In all the regions and across all the communities, CENA participants stressed the importance of traditional authorities (Chiefs and Queen Mothers) as leaders of the community. The institution of chieftaincy has changed over the years. In some communities, the institution has been weakened by power struggles between two or more competing parties, the inability of one or more Chiefs to Page 30 22 perform effectively, and the neglect of their roles by some. But in general, the CENA revealed a very strong support of the institution. Many participants said that the role of the Chief as the natural leader of his people is more acceptable than the political leader imposed through the District Assembly system because the latter are constantly discrediting themselves in the eyes of community members by taking positions for government and against community interest in cases of disagreement. In discussing the poor performances of some service providers in all three sectors, the Chief is seen as the person willing to stand up and denounce bad practices and behaviors and as the only authority capable of combating the moral decadence that reportedly accompanies the proliferation of video houses. Naturally, the Chiefs are blamed for not being more active when certain issues surface (two examples: persistence of child labor, which is seen as the main obstacle to reaching 100 percent child enrollment in schools, and high school dropout rates). With the establishment of the DA system, the authority of the Chiefs has weakened; however, CENA participants seem to think that this need not be the case. In other parts of the country, there is evidence that traditional authority and local government coexist with good results. The traditional Chief has a comparative advantage in adjudication and conflict resolution, whereas elected officials (politicians) are better at modern management. For decentralization to succeed, a way must be found to reconcile the traditional and modern governance systems. Community empowerment also dictates that, together with traditional Chiefs, Queen Mothers be made to play a greater role in women welfare, teenage pregnancy, and irresponsible parenthood. They are seen as custodians of the values that govern family life. Unfortunately, this resource is not put to use. They might need assistance in playing their role in a more structured fashion than they used to when the only system that existed was the traditional system. Women Leadership Women need special support. In all three areas of the CENA, women have showed more interest in the welfare of the community than men. They are genuinely concerned about the negative effects of service provision on the household and community in general, if only because they are more directly affected by poor service quality. They have responsibility for water duties, the health of the family, and child education. Unfortunately, their capacity is rated one of the lowest among the actors involved (see Annex 2, Tables 3, 6, and 8). Women have little voice in decisions that affect the quality of the three services, with a possible exception in community Water and Sanitation, where efforts to involve women in some of the management structures have been made. However, their impact remains marginal because water is an isolated case, which is unfortunate because women command much respect in the communities. Their contribution in deliberation councils is limited by their low level of education. The solution to women’s empowerment seems tied to making the Queen Mother a more effective institution for community participation. Youth Leadership The youth are known to be curious, exploring, and innovative, and they are generally the critical mind and eye of the community. However, there is a sense that they are disillusioned with the current sociopolitical system and that their apparent apathy is a sign of distrust and silent rebellion. To address this situation, one must give them a chance to participate, or else they may seek less peaceful ways of venting their frustration. The objective of any remedial action would be to help the youth lead the process of change in the community. Page 31 23 5. Recommended Capacity Builders Following the CENA approach, the participants also identified the organizations or individuals who, in their opinions, could help provide solutions to the problems identified and help develop the capacity of the development actors concerned, either through traditional methods (such as training), adapting the policy and regulatory frameworks, providing incentives for behavioral change, or strengthening the front-line development agencies involved. Education Health Water and Sanitation - GES Staff Development Institute, Ajumako - District Directorate of Education - GNAT and NAGRAT - Faith-based organizations - Teacher training colleges - University of Education (Winneba) - University of Cape Coast - Ghana Institute of Management and Public Administration (GIMPA) - NGOs - PTAs and SMCs - DAs/government - UNESCO, UNICEF, DFID - World Bank Institute - School of Hygiene - University of Ghana Medical School - Kwame Nkrumah University of Science of Technology Medical School - Nursing training institutes - Master or mistress traditional birth attendants - NGOs with community mobilization skills - Health-related NGOs - DA - Donors - SDHC and DHMT - Ghana Health Service/government - World Bank Institute - NGOs working in water sector (for example, ACHD) - DANIDA staff - Community Water and Sanitation Agency staff - Regional Water and Sanitation Teams/DWST - Partner organizations - GIMPA - GTZ - Consulting firms in water and sanitation - Local banks - GWC - District Assembly - World Bank Institute - DANIDA/CWSP Observations and Recommendations by CENA Facilitators The sector-specific observations and recommendations by the CENA participants are complemented by those of the CENA Facilitators, who had an overview of the process. The Facilitators’ main observations can be summarized as follows. 1. Understanding the Concept of Capacity At first, communities have difficulty grasping the concept of capacity. They tend to see money as the panacea to their problems. However, the concept becomes clear to them when they engage in a structured, CENA-type analysis of development objectives, actors involved, issues and impediments, and possible remedies. Given the enthusiastic reaction to the CENA exercise, community leaders and community-based organizations (CBOs) should be taught to apply the CENA approach for facilitating community debates, engaging in problem-solving exercises, and carrying out collective tasks. 2. Strengthening Policy and Regulatory Frameworks Page 32 24 Toward a Broader Development Approach to Service Delivery – In Health and Water/Sanitation in particular, service delivery should be perceived in a broader development context, instead of being considered by service providers and beneficiaries as merely social amenities. A better approach would show the links between clean water and good health and between good health and school performance of children. The capacity-building agenda should address this issue. Strengthening Coordination – More attention should be paid to the coordination of activities during policy implementation. In this context, it is important to strengthen the District Planning and Coordinating Unit so that it can play a more active role in coordinating sectoral programs. Strengthening Regulatory Frameworks for Collective Action – The regulatory frameworks for collective action are weak. The few formal rules and guidelines that exist address modern governance arrangements and ignore the traditional collective action arrangements that are less tangible because they are informal and not codified. Because the two systems must coexist at the local community level, efforts must be made to develop better frameworks for participation and interaction. This will probably require codifying some of the informal traditional arrangements for collective actions. Strengthening Community Voice – In order to improve the decentralized service delivery arrangements, representatives of the various community management teams should be represented at the district level in the different sector departments, such as the District Health Management Team (DHMT) and the District Water and Sanitation Team (DWST). Initial experience in this direction is promising, but remains limited. Developing this practice might require encouraging community volunteers to come together and form a loose network or community of practice at the subdistrict level. Once these networks are established, the idea of representation in the district sector departments would be pursued more easily. 3. Disseminating Information and Strengthening Skills, Knowledge, Awareness Educating Communities about Decentralization and Community Empowerment – Through proper information and communication, communities would be educated about the true meaning of decentralization and community empowerment. For example, they could be dissuaded that the government’s ultimate goal is to abandon communities to their fate regarding the provision of services. Instead, they should be persuaded that the government will work with them toward building a shared vision, in pursuit of common objectives, and in a development framework broader than the narrow concern for amenities. These goals can be achieved through a participatory process. All of this would help community members better understand the finality of community empowerment. Building Community Leadership – Community leadership is critical for community empowerment and strengthening community voice, which in turn are essential for improving the quality of services in Education, Health, and Water. For various reasons mentioned by the CENA participants, community leadership is ineffective and needs strengthening. Three types of leadership are needed: traditional leaders, women leadership, and youth leadership. Once leaders are identified, they will require assistance to play their roles. Page 33 25 ANNEXES List and Description of Annexes Annex 1: Application of CENA Methodology 1. An Introduction to the CENA Methodology 2. Comments by Facilitator for Volta Region 3. Comments by Facilitator for Eastern Region Annex 2: Assessment Data This annex contains, by sector, (a) the list and roles of the key actors involved and (b) ratings of the capacity of actors. Excerpts from the Volta Region report are presented here. Annex 3: Local Governance Arrangements 1. Traditional Governance Arrangements 2. Modern Governance Arrangements 3. Conflicts between the Two Systems of Governance Annex 4: District Profiles Excerpts from the Volta Region report, provided as an illustration Page 34 26 Annex 1 Application of CENA Methodology 1. An Introduction to the CENA Methodology Guy Darlan, World Bank Institute, December 2003 “Capacity” can be defined as the ability to access and use knowledge and skills to perform a task, to act in the pursuit of an objective. The task can be as simple as installing a macroeconomic model in the economic unit of the Ministry of Finance or as complex as delivering health services to the poor in a local community. Given this definition, capacity-building activities should achieve two critical objectives: (a) upgrade the knowledge and skills of the development actors involved and (b) ensure that the actors’ knowledge and skills are effectively applied in carrying out the development agenda. Therefore, it is essential that needs assessments for capacity building not stop at identifying the skills and knowledge gaps of development actors but also uncover the other critical impediments to successful implementation. The World Bank Institute (WBI) is moving from being a training agency to becoming a capacity- building agency that seeks to achieve measurable results in client countries. In search of an appropriate methodology that would help the WBI prepare capacity-building programs targeting clearly identified needs, the institute is piloting an approach called the Capacity Enhancement Needs Assessment (CENA). The CENA is a participatory assessment designed to evaluate existing capacity, identify capacity gaps and weaknesses, and recommend possible remedies. To help measure the effectiveness of ensuing capacity-building programs, a set of impact indicators is developed as part of the assessment. For a capacity-building program to have a chance to succeed, it is essential to clearly identify the reasons for weak capacity. Some of those reasons might be that the development actors involved do not have the skills required to do the job or that their understanding of the task to be performed is flawed. In that case, a skills enhancement (training) program might be sufficient to successfully address the problem. But if the main reason for poor performance is a lack of motivation (for example, due to an unfair promotion system) or an institutional system that creates perverse incentives (for example, a corrupt environment that encourages the sale of government information and services by public officials for personal gain), there is very little that a skills enhancement program could do to remedy the situation. On the contrary, in the latter case, the more government agents acquire information, knowledge, and skills, the more they will be tempted to use their advantage for personal gain and against public interest. In other words, there are several key elements of the capacity function—other than knowledge and skills—that directly affect the ability of individuals to perform. As suggested in Table 1, for a task to be performed successfully, development actors should (a) understand what is expected of them and (b) possess the technical skills, know-how, and professional experience to do the job. This first list of capacity requirements could be met through training, learning, hands-on support, and developmental assignment. But development actors are often trapped in institutional environments that adversely affect their performance and motivation, regardless of their skills and knowledge levels. Institutions act as vehicles for activities of individuals and organizations. They are frameworks of rules, procedures, and arrangements—formal or informal—that can either provide incentives for action or produce constraints that prevent action. Institutions are particularly important in group action to the extent that they are common responses to situations. Page 35 27 Hence, in addition to ensuring that the professional requirements mentioned in Table 1 are met, an enabling environment must also exist. The prevailing rules, behaviors, and practices must support implementation —or at least not present insurmountable obstacles to it. If it does, changes in the regulatory framework and incentive system must be made. For these reasons, in addition to helping identify weaknesses at the level of the individuals, the CENA approach is designed to uncover constraints and impediments in the work environment. It focuses on the task to be performed (or the development objective to be met) and relies on the development actors involved to carry out their own needs assessment. Let us elaborate on these two characteristics. First, a CENA-type assessment starts with the question, capacity to do what? It is imperative that the assessment begin with a clear understanding of the task and roles to be carried out and the objectives to be met. One must not assume that those who are asked—or who volunteer—to carry out a development activity have a clear picture of that activity and of what is expected of them. This is particularly true in cases where development interactors form very heterogeneous groups, as is the case in most programs targeting the poor. Hence, by focusing on acquiring a good understanding of their tasks and roles and of the objectives to be reached and how to reach them, the stakeholders gain better knowledge of what is expected of them and realize that completing the task successfully will likely require teamwork and cooperation. As a result, the remedial activities that they identify are likely to be more oriented toward results. Table 1: Capacity Requirements Categories of capacity requirements Capacity requirements Possible ways to ensure that the requirements are met Understanding of tasks, roles and responsibilities, rights, and obligations Learning Technical skills Training Professional requirements (technical knowledge and skills) Know-how (knowledge of how the task can be carried out successfully), professional experience Knowledge sharing and dissemination, team building, information sharing, networking, communication, developmental assignment, twinning, hands-on support Formal institutions: rules, procedures, and arrangements Institutional strengthening: new laws, regulations, organizational arrangements; incentives for change Enabling institutional environment a Informal institutions: norms, customs, arrangements, and behaviors Institutional strengthening: - New arrangements, rules, peer pressure, social contracts, and so forth - Incentives for change, peer pressure, and so forth Material and financial support Physical and financial resources Budget, projects, and so forth a Institutions are frameworks of rules, procedures, and arrangements that can provide either incentives for action or constraints that impede action. Page 36 28 Second, the development actors are the analysts. They carry out the assessment of their own capacity strengths and weaknesses —as individuals and as members of task teams—and suggest remedies. Their analysis then serves as the basis for developing multiyear capacity-building strategies and programs. This feature of the CENA is based on the conviction that the actors who are pursuing a shared development objective are best placed to (a) assess their individual weaknesses, (b) identify the conditions for successful implementation, and (c) suggest possible solutions. When this analysis is left to outsiders, they tend to overly focus on the more conspicuous impediments, such as low skills levels, and are likely to miss or dismiss the more subtle ones, often because the latter are of a more complex relational and institutional nature and are therefore more difficult to measure using traditional professional tools. In the case of multidisciplinary and intersectoral teams involving a variety of development actors, local intermediaries are needed to facilitate communication and help the stakeholders carry out the assessment. However, these Facilitators must be skilled enough to avoid influencing the outcome of the assessment. The outcome of the development actors’ analysis forms the basis of a capacity enhancement action plan. Critical Steps of the CENA Defining the Area Where Competence Is Required In answer to the question, capacity to do what? one must first identify the competency that must be acquired or developed for the task to be performed satisfactorily—for example, providing quality health services to the poor in Community X (or, from the community’s point of view, taking collective action to satisfy its basic health care needs). Identifying the Task Team This step entails identifying the development actors who should be involved if the task is to be carried out successfully (or if the development objectives are to be met)—for example, government policy makers, government policy implementers (doctors, nurses, and other front-line service providers), local deliberation councils, community-based organizations, faith-based organizations, traditional authorities, and local opinion leaders. Identifying Capacity Gaps The development actors involved identify what they perceive as critical obstacles to successful implementation. Their analysis is not limited to individual strengths and weaknesses; it also covers the critical elements of the institutional environment within which individuals and organizations operate. This is done for each category of interactors. Identifying a Remedial Action Plan The development actors concerned discuss possible solutions to their capacity weaknesses. In doing so, they consider solutions to meeting the “professional requirements” (for example, workshops and hands-on support) and possible remedies for improving the institutional environment (for example, adoption of formal rules, but also identification of incentives that might bring about behavioral change and facilitate collection action). Identifying Possible Capacity Builders Page 37 29 The needs assessment per se stops at the fourth step. However, before the assessment is shared with agencies that might be in a position to help bridge the capacity gap, the development actors try to identify possible capacity builders. This is intended to make the development actors fully realize the important role that they, themselves, must play to remedy the situation, particularly with regard to informal constraints —this part is essential for behavioral change. They are asked to identify possible individuals, organizations, and agencies who, given their comparative advantage, should play a role to bridge the capacity gap. In doing so, they distinguish between traditional capacity-building organizations (such as the WBI) and the development actors who must also play a role to help ensure that the required capacity is developed and an enabling institutional environment is put in place. Based on the discussions with the stakeholders, the Facilitator may also recommend appropriate tools and instruments that might be used to strengthen capacity and the institutional environment. 2. Comments by Facilitator for Volta Region General Observations The CENA approach to identifying capacity-building weaknesses sheds light on several premises and assumptions that are key to shaping the way the assessment is carried out. For example, it assumes that develop action (and therefore the capacity to carry out such action) is most likely to succeed when stakeholders participate actively in the process. Do they, and to what extent? Do community members see themselves as stakeholders in the delivery of services (that is to say, as customers with rights and obligations)? Or do they merely see themselves as passive beneficiaries? These questions are very important and must be answered, because of the underlying assumption of the CENA approach that development action is most likely to succeed when stakeholders participate actively in the process. And for them to participate actively and successfully, they must be consulted regarding what they perceive as impediments to action and possible remedies. Unfortunately, the institutional environment that prevails in Ghana does not give the opportunity or the space for community members to determine what they want and how they will organize themselves to get what they want. Instead, local communities have been relegated to a passive role imposed from above. Even the attempts in recent times to introduce a semblance of community participation in the development process have been thwarted and overridden by conflicting agendas and programs carried out by those who have a stranglehold on the means to decide and implement. In this context, the CENA methodology is crucial. It offers a tool to start giving the people at the grassroots an effective voice in determining future policies and programs. It provides a framework to involve people who are passive beneficiaries of public services and turn them into stakeholders who will demand effective and efficient delivery of such services. But this development will come because of a process. Presently, those identified as “stakeholders” do not feel that they could be so called. Development will result from initiating change, supporting change agents until they can fend for themselves, and focusing on sectors where a series of cumulative and self-sustaining events can be put in motion and lead to the adoption of a new order made of new formal and informal rules and behaviors that will combine to sustain change. The CENA approach has the ability to raise the hopes and expectations of stakeholders that it is possible to change their present situation for the better. The probing nature of the questions that CENA participants address and the chance given to the people to be vocal and demanding stir in Page 38 30 them a sense of hope and an opportunity to be heard at last. This, in itself, is an excellent way to trigger change. But what really makes CENA participants hopeful is that they identify the reasons for their predicaments and the possible solutions and, as a result, realize that solutions are not “out of this world.” The CENA approach brings to the surface the real reasons for weak capacity and inaction; but most important, it makes the intended beneficiaries realize what those reasons are, how relatively simple the remedies seem, and how unacceptable the status quo is. And if this “raising of expectations” can only come about via the intervention of external development partners such as WBI, then these external partners must step up and play their catalytic role. But they must also be responsible and follow up with the kind of support that is expected of them once they are seen as raising expectations. If they fail to follow up and provide support, they would have not only failed in their mission but also betrayed the stakeholders after having possibly exposed them to reprisals and victimization from antichange agents who are in positions of power. There is much frustration and bitterness among the people at the local community level about how they have been treated in the past in the development game. Hence, any process that cannot guarantee a follow-up sustained action for change might be doing more harm than good. In other words, it might be better to let “sleeping dogs lie in peace.” WBI, by promoting the use of such a powerful tool as the CENA process, helps raise the consciousness of the people and their expectations and will have to be responsible and follow up with appropriate support. Development can only come from change. The CENA helps point the finger in the direction where change must take place. It is up to all—stakeholders, government, and external development partners—to follow that direction and make the decisions to make change happen. Challenges to the CENA Facilitator The concept, methodology, and pedagogy of the CENA appr oach are new to Ghana’s development practice and to the African Centre for Human Development (ACHD) in its 25 years work in Ghana. Being a new concept, it posed many challenges to ACHD as Facilitator: ƒ Appreciating the fundamental changes in vision from a top-down development strategy to a bottom-up community empowerment philosophy of the WBI ƒ Understanding that the process is to lead eventually to the empowerment of community members to take their destinies into their own hands ƒ Clearing one’s mind of the traditional assessment methodologies and give another dimension to the process, starting from the premise that the community people are the principal actors in the process of development and should be “calling the shots” ƒ Having confidence in the ability and capacity of local people to guide the process of development at the basic level and, as CENA Facilitators, being prepared to guide them in the process ƒ Developing the capacity to analyze the findings and turning those into a meaningful output, documenting the spirit of the approach in all its dimensions, helping stakeholders go beyond what they previously perceived as limitations of themselves, and producing a cause-and-effect analysis of the process ƒ Translating into the local language the concept, philosophy, and expected outcome of the process to local community members, taking into account time and logistic constraints ƒ Most important, avoiding the creation of expectations in the minds of community participants that some form of physical infrastructure is in the offing. Page 39 31 CENA Task Force Selection Criteria Knowledge base Being fully familiar with issues in at least two of the three sectors targeted. Practical operational experience in the Volta Region. Adaptability Being a mature person, with faculty to adapt to new ideas and willing to learn. Good listening skills. Gender Equitable representation of both males and females on the Team. Geographical base Having good knowledge of the Volta Region (candidate should have a base in one of the districts included in the assessment). Language Speaking the two major local languages (Ewe and Akan) in the areas visited. Personal character Being team players and prepared to share ideas. Special consideration Given that this exercise would be the first application of the CENA approach in Ghana, a priority was to recruit staff of other organizations who attended the WBI training workshop on CENA methodology in Accra in December 2003. Task Force Composition Staff from three organizations that attended the CENA workshop - African Centre for Human Development (Lead) - Network of Rural Radio - National Disaster Organisation Project in selected area - Sankofa Project (Kadjebi District) Gender consideration - Experienced female consultant Support team member - Natives of Volta Region Methods Used for Collecting Information Interview method: Each stakeholder was interviewed by the Task Team. The questionnaire made available by WBI was used. Focused group discussions: In each of the communities, stakeholders in each sector were brought together to have general discussions pertaining to their sector. This gave a good idea about what participants thought in general terms about issues raised. Miniworkshops: Twenty community representatives met with 40 district officers active in all three sectors in a miniworkshop. This gave the opportunity for cross-fertilization of experiences from the district and community levels. This brought about heated debates and arguments from all sides in a healthy exchange of opinions and experiences. Questionnaires: Guide questionnaires were prepared and used to collect information from relevant government departments and agencies. Page 40 32 Comments on the Process Opinion leaders were identified as Field Facilitators in all the communities visited (Asato, Dodi Papase, Klikor, Denu, Ho, Shia). Individual letters of invitation were addressed to each sector stakeholder/actor. In the letter of invitation, each person was given a specific time to meet the Team. This avoided stakeholders/actors waiting too long for their turn. In some cases, the Team met with more than one person at a time (for example, mothers, students/pupils, traditional authorities, Unit Committee members, women, teachers). Selected participants were also given another invitation letter to the miniworkshop. Every invited person turned up. From the experience gained by the Task Team members, the exercise went smoothly. The participation of the stakeholders/actors was impressive. They were anxious to know what the exercise was about. When they got the details, they became even more interested. The good working relationship that ACHD had with the communities and other parties involved was a major contributing factor to the process. At the district level, the district directors of the sectors (actors) were engaged in discussions from probing questions. The issues discussed at the district level focused more on policy, how they foresaw changes in the future, and some of the constraints that impeded their ability to reach their objectives. The miniworkshops with community representatives and district representatives generated much discussion, and at times emotions went high. This was a reflection of the frustrations that the communities had been feeling because of poor service delivery. District officials often tried to explain the situation, sometimes to no avail. The CENA exercise provided something that is dearly missing at the community level: a forum for service users to express themselves freely. Reactions of Participants to CENA Approach A total of 587 policy makers, service providers, and beneficiaries took part in the assessment in the Volta Region. They understood the essence of the approach and were very happy to have discussions, answer questions as honestly as possible, and give their views; however, they were frustrated that they did not have the power to change certain things. In their opinions, Central Government controlled all the resources and had all the decision-making power and was therefore the only party responsible for the deplorable quality of services. Community members have become very skeptical about change. Because of past treatment by development workers, they have little faith in anyone from outside their communities. This increases their impatience with research teams. Women feel left out of the decision-making process. Many have strong views and good ideas for improving the quality of services, but cultural norms do not allow them to participate actively at the community level, at least not without a fight. It takes exercises such as the CENA exercise, supported by influential parties such as the World Bank, to provide a forum in which they can express themselves. Someone should help them get better organized so that they do not have to wait for events such as the CENA to be taken more seriously and become effective change agents. Traditional authorities are a very important force to be reckoned with at the community level; however, they have become marginalized. Many of them feel sad that the traditional authority of Page 41 33 the Chief or Queen Mother has lost value. They believe they still have a lot to contribute to the development of the community. With regard to the youth, at first it appeared that the vitality, ambition, and drive for change that are typical of the youth were missing from stakeholders that were interviewed. Upon further inquiry, it became clear that the youth have not been involved in the affairs of community, particularly in the decision-making process. There was an aura of despondency and loss of hope on their part, but also much pent-up anger that might explode at any time. As a youth leader bluntly put it: “As far as some people are concerned, we the youth do not exist. Our views are not taken into account for anything. They always accuse us of creating trouble when we challenge the adults for doing wrong things. They see us as rebels and destructive elements, but it is not the case. It is the adults who are trying to destroy our future, and we do not want to go along. They see contractors doing the wrong things in our community, but they cannot talk because they are also part of the system. You wait and see; our time will come, and we shall show them.” Obviously, the youth have to be taken more seriously, and their capacity must be strengthened in different ways. They can join forces with others, such as organized civil society organizations and women’s groups. They will need some sensitization to awaken their senses of responsibility and develop their skills as change agents. 3. Comments by Facilitator for Eastern Region General Observations A total of 594 individuals took part in the assessment in the Eastern Region. All three categories of stakeholders (policy makers, policy implementers, and beneficiaries) considered the CENA methodology as an effective tool for needs assessment. The greatest advantage of the approach is its capacity to mobilize stakeholders around development issues. The concept raises awareness of what can be accomplished, as well as how communities can address their problems. The process of going through the five logical steps of the CENA methodology provides a method that community organizations can use to increase their capacity on their own. One significant outcome of the CENA assessment is the awareness generated among the participating community members about their right to demand accountability from front-line service providers. Through the CENA exercise, they realized that the decentralization arrangements for service delivery is in effect a good idea that provides windows of opportunity for them; for example, the opportunity to monitor and evaluate the quality of services provided by the front-line service providers. Members of the WATSAN Committee, SMCs and PTAs, and CHPS management committees can be evaluated, and if their performance falls below expectation, the responsible persons can be removed from office by the community. But the CENA approach also creates heightened expectations on the part of the various stakeholders who participated in the assessment. First, the policy makers, having admitted their shortfalls, now expect that donor agencies (including the World Bank) will come to their assistance in the form of funds, training, and technical assistance to help solve some of their Page 42 34 problems. Second, the communities expect policy makers and policy implementers to pay attention to the findings and recommendations of the assessment and to help improve service delivery. Finally, all the stakeholders noted and agreed that the most important condition for sustainable development is to have leaders and organizations in communities that can manage development on their own. The CENA methodology helps to build such confidence by forcing stakeholders to realize that there exist relatively simple solutions to many of the problems they identified. Without engaging in such a problem-solving exercise, community members would forever see the problem only from the side of those who complain; they would not see that they could be the source of many of the solutions. Coverage In accordance with our Terms of Reference, the needs assessment was conducted in 3 districts of the Eastern Region and 3 types of communities in each district: urban, periurban, and rural. The assessment targeted 3 categories of participants: policy makers, policy implementers, and beneficiaries (communities). Data collection was conducted in a total of 20 communities in the 3 districts combined. In all, 594 respondents were interviewed through a predesigned questionnaire. Secondary information was obtained through the consultation of documents and direct interviews with district officials, Paramount Chiefs, and Queen Mothers. Within the 3 categories, a broad spectrum of actors was consulted. Of the 594 participants, there were 228 (38 percent) from Yilo Krobo, 178 from Birim South (30 percent), and 188 from Akuapem South (32 percent). A total of 68 policy makers, 171 policy implementers, and 355 community members (beneficiaries) were involved. The selected districts where the assessment was conducted are Akuapem South District, Birim South District, and Yilo Krobo District. Within the districts, the following urban, periurban, and rural areas were selected for the assessment: Urban Periurban Rural Akuapem South District Nsawam Aburi Amanfo Nsakye Birim South District Oda Awissa Batabi Yilo Krobo District Somanya Oterkpelu Abrewanko The assessment followed the five-step approach of the CENA methodology. The Facilitators were free to use information- and data-gathering techniques that they found most appropriate to the local conditions. District officials, traditional rulers, and community members were briefed on the objectives and the scope of the study. The CENA was conducted in two phases: first, through a workshop, and second, through a more extensive collection of information to validate or modify the outcome of the workshop. The first phase consisted of bringing approximately 30 stakeholders for a workshop in each district. During the workshop, the participants were introduced to the CENA philosophy and the five steps of the methodology. In each area where capacity was required to achieve the development objectives, they identified the strengths and weaknesses of the actors involved, the constraints that they face in their daily environment as actors, and the possible remedies. This initial analysis was then tested during the fieldwork that followed, and that involved a much larger number of stakeholders. Data-Gathering Techniques Several methods were utilized in gathering the information needed for this study. Prearranged meetings were held with the Chiefs, elders, and opinion leaders of the various communities; Page 43 35 namely, Oda, Awisa, and Batabi (Birim South District); Nsawam, Aburi, and Nsakye (Akuapem South District); and Somanya, Oterkpolu, and Abrewanko (Yilo Krobo District). At each meeting, the purpose of the assessment was explained, and the expected roles of each group or individual members of the community were explained. Each meeting generated questions and answers sessions. Visits were made to the District Assembly in each of the three participating districts in order to brief the officials of the Assembly on this assignment. Discussions were held with the District Chief Executives (DCEs), the District Coordinating Directors (DCDs), and the Planning Officers on the logistics arrangements for the assessment. The sector heads of departments in Health, Education, and Water Supply were also contacted. In Birim South District, for instance, a special session was held with the Executive Committee of the District Assembly comprising 21 Assembly members and 20 representatives of the decentralized departments in the district. Public forums were held with the Nsakye, Batabi, and Abrewanko communities, respectively, in Akuapem South, Birim South, and Yilo Krobo Districts. Questionnaires were designed for each sector area of Health, Education, and Water/Sanitation. Each group of participants (policy makers, policy implementers, and beneficiaries) was asked an average of 16 questions per sector. The pretesting of the questionnaires was carried out with the help of the District Assembly officials. Specifically, the sector departments of Health, Education, and Water/Sanitation provided useful inputs. Their observations and comments were integrated into the questionnaires. Separate testing activities were also carried out with the help of the Field Agents who were involved in the data collection for the CENA. In the case of Water/Sanitation, the government’s standard “Application and Basic Data Form” for community participation in a Water and Sanitation project was used as an additional data collection tool. A combination of one-on-one interviews and focus group discussions were used to gather information. The one-on- one interviews were field-tested and analyzed in order to determine the remaining gaps in our data collection. This enabled us to plan our focus group discussions to fill these gaps. Selection and Orientation of Field Agents The data collection in each district took more than 14 days to accomplish. An average of 6 Field Agents selected by the participants during the preassignment workshops collected the data in each district. A full-day orientation session was conducted for these Field Agents. During the orientation session, the CENA Facilitators went through the data questionnaires line by line with the Field Agents. The Agents were also taught to use methods such as informal discussions, focus group discussions, and review of documents. The orientation session provided the Field Agents the opportunity to ask questions on some of the questionnaires. The Facilitators clarified all the points raised, and, whenever appropriate, the views and suggestions of the Field Agents were incorporated into the questionnaires before they were finalized. Data Compilation and Analysis The data compilation exercise consisted of classifying completed questionnaires into the different categories of stakeholders (policy makers, policy implementers, and beneficiaries). The exercise also consisted of quantifying similar responses on analysis grids that were designed by the Facilitators. The post-CENA analysis was carried out in each district during a one-day workshop conducted by the CENA Facilitators. The analysis was done by the same workshop participants (including the Field Agents) who had attended the first workshop. During the first workshop, discussion groups had been formed for each sector (Health, Education, and Water). During the Page 44 36 second workshop, data compiled by the Field Agents were presented to each sector group to analyze. Before the analysis, the compilation report on each sector was presented in a plenary session. With the help of the Facilitators, the workshop participants were tasked to analyze and interpret the results of the answers provided on the questionnaires. Based on all the information provided, they were asked to synthesize the capacity weaknesses, institutional constraints, and possible solutions that form the CENA findings. Page 45 3 7 A n n e x 2 S e l e c t e d D a t a o n R o l e s a n d C a p a c i t y R a t i n g s o f A c t o r s i n E d u c a t i o n , H e a l t h , a n d W a t e r S e r v i c e s ( I n f o r m a t i o n c o l l e c t e d b y C E N A F a c i l i t a t o r f o r V o l t a R e g i o n ) 1 5 T a b l e 2 : L i s t a n d R o l e s o f K e y A c t o r s i n E d u c a t i o n S e r v i c e s i n V o l t a R e g i o n A c t o r s / S t a k e h o l d e r s A b b r e v i a t i o n R o l e s a n d F u n c t i o n s S u p p l y / D e m a n d F u n c t i o n A r e a o f I n t e r v e n t i o n / J u r i s d i c t i o n N u m b e r o f P a r t i c i p a n t s i n t h e A s s e s s m e n t D i s t r i c t D i r e c t o r o f E d u c a t i o n D D E · I n c h a r g e o f o v e r a l l d a y - t o - d a y m a n a g e m e n t a n d a d m i n i s t r a t i o n o f t h e d i s t r i c t w i t h r e g a r d t o d e c i s i o n s o n p l a n s ; b u d g e t / c o s t ; a n d i m p l e m e n t a t i o n o f p o l i c i e s , p r o g r a m s , a n d p r o j e c t s · B a s e d o n t h e d i s t r i c t s i t u a t i o n a n d n e e d s , m a k e s a p p r o p r i a t e i n p u t s t o w a r d t h e f o r m u l a t i o n o f p o l i c i e s a n d p r o g r a m s · S o u r c e f o r a n d m o b i l i z e s r e s o u r c e s a n d f u n d i n g f o r e d u c a t i o n a l d e v e l o p m e n t p r o g r a m s a n d p r o j e c t s S e r v i c e P r o v i d e r s ( S P ) , P o l i c y ( P ) D i s t r i c t 3 D i s t r i c t O v e r s i g h t C o m m i t t e e D O C · A d v i s o r y b o d y o n e d u c a t i o n a l i s s u e s t h a t m a k e s d e c i s i o n s o n c o s t , e n r o l l m e n t , p u p i l - t e a c h e r r a t i o , a n d s o f o r t h P o l i c y ( P ) D i s t r i c t 3 S c h o o l M a n a g e m e n t C o m m i t t e e S M C · P o l i c y f o r m u l a t i o n f o r s e r v i c e p r o v i s i o n · E n a b l e e n r o l l m e n t d r i v e · V e n t i l a t i o n o f g r i e v a n c e s f r o m t h e v a r i o u s s t a k e h o l d e r s · A d v i s o r y b o d y t o t h e D O C a n d t h e c o m m u n i t y P o l i c y ( P ) C o m m u n i t y 6 P a r e n t - T e a c h e r A s s o c i a t i o n P T A · P r o v i s i o n o f f i n a n c i a l a n d m a t e r i a l s u p p o r t t o s c h o o l · I m p l e m e n t a t i o n o f p r o j e c t s f o r t h e e n h a n c e m e n t o f e d u c a t i o n i n s c h o o l s · A d v i s o r y b o d y t o s c h o o l m a n a g e m e n t a n d p u p i l s P o l i c y ( P ) , S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 3 P u p i l s / S t u d e n t s P / S t u · S c h o o l a t t e n d a n c e , l e a r n i n g , d o i n g a s s i g n m e n t s , a n d o b e y i n g a n d a b i d i n g b y r u l e s a n d r e g u l a t i o n s t o e n s u r e d i s c i p l i n e B e n e f i c i a r y ( B ) C o m m u n i t y 9 T e a c h e r s T · T e a c h i n g o f p u p i l s ; g i v i n g a n d m a r k i n g e x e r c i s e s ; a n d e n s u r i n g s c h o o l d i s c i p l i n e , s u p e r v i s i o n , g u i d a n c e , a n d c o u n s e l i n g o f p u p i l s B e n e f i c i a r y ( B ) , S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 2 4 D i s t r i c t A d m i n i s t r a t i o n D . A d m i n . · O v e r s e e s t h e i m p l e m e n t a t i o n o f p l a n s a n d d e c i s i o n s o f t h e D A · P r o v i s i o n o f t e c h n i c a l e x p e r t i s e f o r p o l i c y d i r e c t i o n a n d i m p l e m e n t a t i o n P o l i c y ( P ) , S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t 3 G h a n a A s s o c i a t i o n o f T e a c h e r s G N A T · T e a c h i n g o f p u p i l s ; g i v i n g a n d m a r k i n g e x e r c i s e s ; a n d e n s u r i n g s c h o o l d i s c i p l i n e , s u p e r v i s i o n , g u i d a n c e , a n d c o u n s e l i n g o f p u p i l s · A n a l y z e s i t u a t i o n a n d p o l i c y i s s u e s a n d a d v i s e o n a l t e r n a t i v e a n d r e l e v a n t i s s u e s f o r c o n s i d e r a t i o n i n f o r m u l a t i o n o f p o l i c i e s , p r o g r a m s a n d i m p l e m e n t a t i o n o f p r o j e c t s , a n d e d u c a t i o n o f t h e p e o p l e o n t h e s a m e P o l i c y ( P ) , S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t 2 5 a I n f o r m a t i o n f o r t h e E a s t e r n R e g i o n i s s i m i l a r . H e n c e , d a t a c o l l e c t e d f o r t h e V o l t a R e g i o n a r e r e p r e s e n t a t i v e o f b o t h r e g i o n s . Page 46 3 8 A c t o r s / S t a k e h o l d e r s A b b r e v i a t i o n R o l e s a n d F u n c t i o n s S u p p l y / D e m a n d F u n c t i o n A r e a o f I n t e r v e n t i o n / J u r i s d i c t i o n N u m b e r o f P a r t i c i p a n t s i n t h e A s s e s s m e n t N a t i o n a l A s s o c i a t i o n o f G r a d u a t e T e a c h e r s N A G R A T ( s a m e a s G N A T ) P o l i c y ( P ) , S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t 9 T r a d i t i o n a l A u t h o r i t i e s T A · R e l e a s e o f l a n d f o r t h e i m p l e m e n t a t i o n o f p r o j e c t s a n d p r o g r a m s · M a k e o p i n i o n s k n o w n t o g o v e r n m e n t a n d D A o n t h e e f f e c t o f p o l i c i e s , p r o g r a m s , a n d p r o j e c t s o n t h e l i v e s o f t h e i r p e o p l e · M o b i l i z a t i o n o f t h e i r p e o p l e t o c o n t r i b u t e l a b o r a n d c a s h a n d p a y l e v i e s a n d t a x e s f o r p r o g r a m s a n d p r o j e c t s a s c o m m u n i t i e s ’ c o n t r i b u t i o n B e n e f i c i a r y ( B ) , S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 9 O p i n i o n L e a d e r s O L ( s a m e a s T A ) B e n e f i c i a r y ( B ) C o m m u n i t y 6 D i s t r i c t A s s e m b l y D A · P l a n n i n g , b u d g e t i n g , a n d i m p l e m e n t a t i o n o f p r o g r a m s a n d p r o j e c t s t o a d d r e s s n e e d s a n d p r o b l e m s · C o l l e c t i n p u t s a n d i s s u e s f r o m o t h e r s t a k e h o l d e r s i n d i s t r i c t o n n e e d s a n d p r o b l e m s , a n d f o r w a r d t o g o v e r n m e n t f o r i n p u t t i n g i n t o p o l i c i e s a n d p r o g r a m s · M o b i l i z a t i o n o f s o c i e t y a n d f u n d s f r o m w i t h i n a n d o u t s i d e t o w a r d i m p l e m e n t i n g p r o g r a m s a n d p r o j e c t · P r o m u l g a t i o n o f b y l a w s t o r e g u l a t e a c c e s s a n d u s e o f f a c i l i t i e s a n d s e r v i c e s P o l i c y ( P ) , B e n e f i c i a r y ( B ) , S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t ( D A ) & C o m m u n i t y ( D A m e m b e r s ) 6 W o m e n ’ s G r o u p W G · P a y m e n t o f t a x e s a n d l e v i e s t o w a r d t h e i m p l e m e n t a t i o n o f p r o g r a m s a n d p r o j e c t s · M a k e i n p u t s t h r o u g h t h e i r A s s e m b l y m a n o r A s s e m b l y w o m a n t o w a r d t h e d e v e l o p m e n t o f g e n d e r - s e n s i t i v e p o l i c i e s , p r o g r a m s , a n d p r o j e c t s B e n e f i c i a r y ( B ) C o m m u n i t y 6 F a i t h - B a s e d O r g a n i z a t i o n s F B O · S o u r c i n g a n d r a i s i n g o f f u n d s f o r t h e c o n s t r u c t i o n o f s c h o o l s · H a v e b e e n t h e f o r e r u n n e r s i n s e r v i c e d e l i v e r y a n d m a k e v e r y i m p o r t a n t c o n t r i b u t i o n t o w a r d p o l i c y f o r m u l a t i o n , i m p l e m e n t a t i o n , a n d e v a l u a t i o n P o l i c y ( P ) , S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 3 P r i v a t e S e c t o r ( p r i v a t e s c h o o l o w n e r ) P S · P r o v i s i o n o f h e a l t h s e r v i c e s t h r o u g h t h e e s t a b l i s h m e n t o f c l i n i c s , c h e m i c a l s t o r e s f o r t h e s a l e o f d r u g s · P a y m e n t o f t a x e s a n d l e v i e s a s c o n t r i b u t i o n t o w a r d t h e i m p l e m e n t a t i o n o f h e a l t h s e r v i c e s · B r i n g s p r e s s u r e t o b e a r o n g o v e r n m e n t a n d D i s t r i c t A s s e m b l i e s t o e n s u r e t h e d e v e l o p m e n t a n d i m p l e m e n t a t i o n o f h u m a n - c e n t e r e d p o l i c i e s , p r o g r a m s , a n d p r o j e c t s P o l i c y ( P ) , S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 3 C o m m u n i t y - B a s e d O r g a n i z a t i o n s C B O · B r i n g s p r e s s u r e t o b e a r o n g o v e r n m e n t a n d D i s t r i c t A s s e m b l i e s t o e n s u r e t h e d e v e l o p m e n t a n d i m p l e m e n t a t i o n o f h u m a n - c e n t e r e d p o l i c i e s , p r o g r a m s , a n d p r o j e c t s · E d u c a t e s c o m m u n i t i e s o n g o v e r n m e n t p r o g r a m s a n d p o l i c i e s a n d i t s e f f e c t o n t h e m · P a y m e n t o f t a x e s a n d l e v i e s a s c o n t r i b u t i o n t o w a r d p r o g r a m s a n d p r o j e c t s S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y – N o n g o v e r n m e n t a l O r g a n i z a t i o n N G O · A n a l y z e p o l i c y i s s u e s a n d m a k e a p p r o p r i a t e i n p u t s o n b e h a l f o f c o m m u n i t i e s f o r t h e a t t e n t i o n o f g o v e r n m e n t · S o u r c i n g f o r a n d i m p l e m e n t i n g i n t e r v e n t i o n p a c k a g e s i n s u p p o r t o f c o m m u n i t i e s S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 3 M e d i a M e d i a · A n a l y z i n g a n d r e p o r t i n g o n g o v e r n m e n t p o l i c i e s , p r o g r a m s , a n d p r o j e c t s t o i n f o r m a n d e d u c a t e t h e p u b l i c · G a t h e r i n f o r m a t i o n a n d d a t a f r o m t h e p e o p l e o n t h e i r n e e d s , p r o b l e m s , a n d i s s u e s o f p o l i c y i m p l e m e n t a t i o n f o r t h e a t t e n t i o n o f g o v e r n m e n t a n d p o l i c y m a k e r s S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t & C o m m u n i t y 3 Page 47 3 9 T a b l e 3 : C a p a c i t y o f A c t o r s i n E d u c a t i o n S e r v i c e s : A v e r a g e R a t i n g s o f t h e T h r e e D i s t r i c t s i n V o l t a R e g i o n 1 6 DDE DOC D. Admin. GNAT Media CBO NGRAT NGO DA SMC PTA PS Teachers TA/OL WG FBO CSO P/Stu D e v e l o p m e n t A c t o r s C a p a c i t y R e q u i r e m e n t s S P P S P P S P P P S P S P S P P S P S P P S P B P P S P S P S P B B B S P P P S P B T e c h n i c a l s k i l l s 6 5 4 4 5 4 6 6 6 3 4 5 4 4 5 3 5 4 5 2 5 4 4 2 3 2 3 4 1 U n d e r s t a n d i n g o f t a s k s , r o l e s a n d r e s p o n s i b i l i t i e s , r i g h t s a n d o b l i g a t i o n s 6 6 6 6 6 5 5 6 6 5 4 6 5 5 6 4 6 6 6 6 6 6 4 4 5 5 4 5 K n o w - h o w ( k n o w l e d g e o f h o w t h e t a s k c a n b e c a r r i e d o u t s u c c e s s f u l l y ) 6 6 6 5 5 4 5 6 6 4 4 6 5 5 5 4 6 5 6 5 6 5 5 3 6 5 4 5 P r o f e s s i o n a l e x p e r i e n c e 7 6 6 5 4 4 4 5 6 3 3 5 5 4 4 4 4 4 5 3 6 5 5 1 6 5 2 3 I n s t i t u t i o n a l e n v i r o n m e n t F o r m a l L a w s , l e g a l f r a m e w o r k , r u l e s a n d p r o c e d u r e s ; o p e r a t i o n a l d i r e c t i v e s ; s y s t e m s f o r c o l l e c t i v e a c t i o n s ; m a n a g e m e n t i n f o r m a t i o n s y s t e m s 5 5 5 5 5 5 5 6 5 4 4 5 5 4 4 4 4 3 4 4 4 4 4 3 4 4 3 3 2 I n s t i t u t i o n a l e n v i r o n m e n t I n f o r m a l R u l e s , p r a c t i c e s , a n d b e h a v i o r s ; s y s t e m s f o r c o l l e c t i v e a c t i o n s … 6 5 5 5 7 5 5 5 6 5 4 5 6 5 6 5 5 5 4 5 7 4 5 4 5 4 4 5 4 a D u r i n g t h e a s s e s s m e n t , e a c h d i s t r i c t w a s r a t e d s e p a r a t e l y . T h e r a t i n g a c r o s s d i s t r i c t w a s c o n s i s t e n t , w h i c h a l l o w s f o r t h e m e a n i n g f u l a v e r a g e p r e s e n t e d i n t h i s t a b l e . T h e s a m e a p p l i e s f o r H e a l t h a n d W a t e r ( T a b l e s 6 a n d 8 , b e l o w ) . Page 48 4 0 R a t i n g o f c a p a c i t y : f r o m 1 t o 1 0 ( 1 = l o w e s t , 1 0 = h i g h e s t ) S P = S e r v i c e P r o v i d e r ; P = P o l i c y M a k e r s ; B = B e n e f i c i a r y S o u r c e : O f f i c i a l d o c u m e n t s . A c r o n y m s a r e s p e l l e d o u t i n T a b l e 2 a b o v e . Page 49 4 1 T a b l e 5 : L i s t a n d R o l e s o f K e y A c t o r s i n H e a l t h S e r v i c e s A c t o r s / S t a k e h o l d e r s A b b r e v . R o l e s a n d F u n c t i o n s S u p p l y / D e m a n d F u n c t i o n A r e a o f I n t e r v e n t i o n / J u r i s d i c t i o n N u m b e r P a r t i c i p a n t h e A s s e s s D i s t r i c t H e a l t h M a n a g e m e n t T e a m D H M T · A d m i n i s t r a t i o n a n d m a n a g e m e n t o f r e s o u r c e s · P l a n n i n g , b u d g e t i n g , r e s o u r c e m o b i l i z a t i o n , a n d i m p l e m e n t a t i o n o f H e a l t h p r o g r a m s , p r o j e c t s , a n d s e r v i c e s · M o n i t o r i n g a n d e v a l u a t i o n o f h e a l t h s e r v i c e d e l i v e r y t o e n s u r e e f f e c t i v e n e s s a n d e f f i c i e n c y a n d t a k e r e m e d i a l a c t i o n , w h e n n e c e s s a r y · D i s e a s e s u r v e i l l a n c e t o e n s u r e p r e v e n t i o n , t i m e l y c o n t r o l , o r a p p r o p r i a t e a c t i o n S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t 3 G h a n a H e a l t h S e r v i c e G H S · C o l l e c t s i n p u t s f r o m o t h e r s t a k e h o l d e r s a n d c o m b i n e s t h i s w i t h i t s e x p e r i e n c e i n H e a l t h s e r v i c e d e l i v e r y t o d e v e l o p H e a l t h p o l i c i e s · P l a n n i n g , b u d g e t i n g , r e s o u r c e m o b i l i z a t i o n , a n d i m p l e m e n t a t i o n o f H e a l t h p r o g r a m s , p r o j e c t s , a n d s e r v i c e s · M o n i t o r i n g a n d e v a l u a t i o n o f h e a l t h s e r v i c e d e l i v e r y t o e n s u r e e f f e c t i v e n e s s a n d e f f i c i e n c y a n d t a k e r e m e d i a l a c t i o n , w h e n n e c e s s a r y P o l i c y ( P ) D i s t r i c t 3 D i s t r i c t A s s e m b l y D A · C o l l e c t s i n p u t s / i s s u e s f r o m o t h e r s t a k e h o l d e r s i n d i s t r i c t o n h e a l t h n e e d s a n d s e r v i c e d e l i v e r y a n d f o r w a r d s t o g o v e r n m e n t f o r i n p u t t i n g i n t o H e a l t h p o l i c i e s a n d p r o g r a m s · P l a n n i n g , b u d g e t i n g , a n d i m p l e m e n t a t i o n o f H e a l t h p r o g r a m s a n d p r o j e c t s t o a d d r e s s n e e d s / p r o b l e m s · I m p l e m e n t a t i o n o f p o l i c i e s a n d p r o g r a m s o n H e a l t h · I n s t i t u t e , p l a n , d e v e l o p , a n d i m p l e m e n t D i s t r i c t - W i d e I n s u r a n c e S c h e m e t o a d d r e s s t h e h e a l t h n e e d s o f t h e p e o p l e P o l i c y ( P ) , S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t ( D A ) & C o m m u n i t y ( D A m e m b e r s ) 3 S u b - D i s t r i c t H e a l t h C o m m i t t e e S D H C · A d v i s o r y b o d y t o D H M T , G H S , a n d D A o n H e a l t h p o l i c i e s a n d i s s u e s · M o n i t o r i n g a n d e v a l u a t i o n o f H e a l t h d e l i v e r y s e r v i c e s , p r o g r a m s , a n d p r o j e c t s t o e n s u r e e f f e c t i v e n e s s a n d e f f i c i e n c y S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t & C o m m u n i t y 3 P u b l i c / C o m m u n i t y H e a l t h N u r s e s P / C H N · P r o v i s i o n o f h e a l t h s e r v i c e s t h r o u g h d i a g n o s i s ; a d m i n i s t e r i n g o f t r e a t m e n t , d r u g s , a n d e d u c a t i o n ; a n d t r a i n i n g o f p e o p l e o n d i s e a s e s a n d h e a l t h i s s u e s S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 9 T r a d i t i o n a l B i r t h A t t e n d a n t s / W a n s a m s T B A · D e l i v e r y o f e x p e c t a n t m o t h e r s i n t h e c o m m u n i t y S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 1 2 M e d i a M e d i a · A n a l y z i n g a n d r e p o r t i n g o n g o v e r n m e n t p o l i c i e s , p r o g r a m s , a n d p r o j e c t s t o i n f o r m a n d e d u c a t e t h e p u b l i c · G a t h e r i n f o r m a t i o n / d a t a f r o m t h e p e o p l e o n t h e i r n e e d s , p r o b l e m s , a n d i s s u e s o f p o l i c y i m p l e m e n t a t i o n f o r t h e a t t e n t i o n o f g o v e r n m e n t a n d p o l i c y m a k e r s S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t & C o m m u n i t y 3 W o m e n ’ s G r o u p W G · P a y m e n t o f t a x e s a n d l e v i e s t o w a r d t h e i m p l e m e n t a t i o n o f H e a l t h p r o g r a m s a n d p r o j e c t s · M a k e i n p u t s t h r o u g h t h e i r A s s e m b l y m a n a n d A s s e m b l y w o m a n t o w a r d t h e d e v e l o p m e n t o f g e n d e r - s e n s i t i v e p o l i c i e s , p r o g r a m s , a n d p r o j e c t s B e n e f i c i a r y ( B ) C o m m u n i t y 6 M o t h e r s M o t h e r s ( s a m e a s W G ) B e n e f i c i a r y ( B ) C o m m u n i t y 9 O p i n i o n L e a d e r s O L · R e l e a s e o f l a n d f o r t h e i m p l e m e n t a t i o n o f H e a l t h p r o j e c t s / p r o g r a m s · M a k e o p i n i o n s k n o w n t o g o v e r n m e n t a n d D A o n t h e e f f e c t o f p o l i c i e s , p r o g r a m s , a n d p r o j e c t s o n t h e l i v e s o f t h e i r p e o p l e · M o b i l i z a t i o n o f t h e i r p e o p l e t o c o n t r i b u t e l a b o r a n d c a s h a n d p a y l e v i e s / t a x e s f o r H e a l t h p r o g r a m s / p r o j e c t s a s c o m m u n i t i e s ’ c o n t r i b u t i o n B e n e f i c i a r y ( B ) C o m m u n i t y 2 7 Page 50 4 2 A c t o r s / S t a k e h o l d e r s A b b r e v . R o l e s a n d F u n c t i o n s S u p p l y / D e m a n d F u n c t i o n A r e a o f I n t e r v e n t i o n / J u r i s d i c t i o n N u m b e r P a r t i c i p a n t h e A s s e s s F a i t h - B a s e d O r g a n i z a t i o n s F B O · S o u r c i n g a n d r a i s i n g o f f u n d s f o r t h e c o n s t r u c t i o n o f c l i n i c s , H e a l t h p o s t s , a n d h o s p i t a l s i n c o m m u n i t i e s t o p r o v e h e a l t h d e l i v e r y s e r v i c e s · H a v e b e e n t h e f o r e r u n n e r s i n h e a l t h s e r v i c e d e l i v e r y , m a k e v e r y i m p o r t a n t c o n t r i b u t i o n t o w a r d p o l i c y f o r m u l a t i o n , i m p l e m e n t a t i o n , a n d e v a l u a t i o n S e r v i c e P r o v i d e r s ( S P ) , P o l i c y ( P ) C o m m u n i t y T r a d i t i o n a l A u t h o r i t i e s T A B e n e f i c i a r y ( B ) , P o l i c y ( P ) C o m m u n i t y 1 8 S c h o o l H e a l t h E d u c a t i o n P r o g r a m m e S H E P · E d u c a t i o n o f p u p i l s o n t h e i m p o r t a n c e o f g o o d h e a l t h a n d s a n i t a t i o n · M o n i t o r i n g p u p i l s ’ b o d y a n d e n v i r o n m e n t a l h y g i e n e a n d p r o v i d e a p p r o p r i a t e a d v i c e / g u i d a n c e · E d u c a t e f o o d v e n d o r s a n d m o n i t o r t h e i r o p e r a t i o n s t o e n s u r e t h a t t h e i r r e s o u r c e s t o t h e p u p i l s a n d t e a c h e r s a r e h y g i e n i c a n d s a f e S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 9 P r i v a t e S e c t o r P S · P r o v i s i o n o f h e a l t h s e r v i c e s t h r o u g h t h e e s t a b l i s h m e n t o f c l i n i c s , c h e m i c a l s t o r e s f o r t h e s a l e o f d r u g s · P a y m e n t o f t a x e s a n d l e v i e s a s c o n t r i b u t i o n t o w a r d t h e i m p l e m e n t a t i o n o f h e a l t h s e r v i c e s S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 3 T r a d i t i o n a l H e a l e r s T H · D e l i v e r h e a l t h s e r v i c e s t h r o u g h t h e s a l e o f h e r b a l d r u g s a n d a l s o a d m i t t i n g a n d t r e a t i n g s i c k p e o p l e a s a n a l t e r n a t i v e h e a l t h d e l i v e r y s e r v i c e · C o n t r i b u t e t a x e s a n d l e v i e s t o w a r d h e a l t h d e l i v e r y p r o g r a m s a n d p r o j e c t s S e r v i c e P r o v i d e r s ( S P ) , B e n e f i c i a r y ( B ) C o m m u n i t y 1 2 N o n g o v e r n m e n t a l O r g a n i z a t i o n N G O · A n a l y z e p o l i c y i s s u e s a n d m a k e a p p r o p r i a t e i n p u t s o n b e h a l f o f c o m m u n i t i e s f o r t h e a t t e n t i o n o f g o v e r n m e n t · S o u r c i n g f o r a n d i m p l e m e n t i n g h e a l t h i n t e r v e n t i o n p a c k a g e s i n s u p p o r t o f c o m m u n i t i e s S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t 6 C i v i l S o c i e t y O r g a n i z a t i o n C S O · B r i n g s p r e s s u r e t o b e a r o n g o v e r n m e n t a n d D i s t r i c t A s s e m b l i e s t o e n s u r e t h e d e v e l o p m e n t a n d i m p l e m e n t a t i o n o f h u m a n - c e n t e r e d H e a l t h p o l i c i e s , p r o g r a m s , a n d p r o j e c t s · E d u c a t e s c o m m u n i t i e s o n g o v e r n m e n t p r o g r a m s a n d p o l i c i e s a n d i t s e f f e c t o n t h e m · P a y m e n t o f t a x e s a n d l e v i e s a s c o n t r i b u t i o n t o w a r d H e a l t h p r o g r a m s / p r o j e c t s S e r v i c e P r o v i d e r s ( S P ) , B e n e f i c i a r y ( B ) D i s t r i c t D i s t r i c t - W i d e I n s u r a n c e S c h e m e D W I S · P l a n s , d e v e l o p s , a n d m o b i l i z e s s o c i e t y a n d r e s o u r c e s ; i m p l e m e n t s a n d e v a l u a t e s h e a l t h i n s u r a n c e s c h e m e · D e v e l o p s s y s t e m s w i t h h o s p i t a l s a n d c l i n i c s t o e n s u r e t h a t c o n t r i b u t o r s t o t h e s c h e m e b e n e f i t f r o m i t s s e r v i c e s w i t h o u t a n y h i n d r a n c e s S e r v i c e P r o v i d e r s ( S P ) , P o l i c y ( P ) D i s t r i c t 3 P h a r m a c i e s / C h e m i c a l a n d D r u g S e l l e r s P / C H E · S a l e s a n d a d m i n i s t e r i n g d r u g s / m e d i c i n e t o t h e s i c k · P a y m e n t o f t a x e s a n d l e v i e s a s c o n t r i b u t i o n s t o w a r d h e a l t h d e l i v e r y p r o j e c t s / p r o g r a m s S e r v i c e P r o v i d e r s ( S P ) , B e n e f i c i a r y ( B ) C o m m u n i t y 2 G r o w t h P r o m o t e r s G P · E d u c a t i o n o n s a n i t a t i o n a n d g o o d h e a l t h t o m o t h e r s , c h i l d r e n , p r e g n a n t w o m e n , a n d o t h e r c h i l d c a r e g i v e r s · V i s i t t o c o m m u n i t i e s t o a s s e s s h e a l t h s t a t u s o f c h i l d r e n , m o t h e r s , a n d p r e g n a n t w o m e n a n d g i v e a p p r o p r i a t e a d v i c e / g u i d a n c e S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 2 Page 51 4 3 T a b l e 6 : C a p a c i t y o f A c t o r s i n H e a l t h S e r v i c e s : A v e r a g e R a t i n g s o f t h e T h r e e D i s t r i c t s i n V o l t a R e g i o n SDHC P/CHN TBA Mothers WG OL FBO TA SHEP PS TH CSO P/CHEN DHMT GHS DA Media NGO D/WIS D e v e l o p m e n t A c t o r s C a p a c i t y R e q u i r e m e n t s S P S P S P B B B S P P B P S P S P P S P P P S P S P S P S P S P P S P S P P S P T e c h n i c a l s k i l l s 6 6 4 1 2 4 6 4 4 3 5 3 3 3 3 3 4 5 6 5 4 5 3 3 2 U n d e r s t a n d i n g o f t a s k s , r o l e s a n d r e s p o n s i b i l i t i e s , r i g h t s a n d o b l i g a t i o n s 6 6 4 4 5 5 5 5 4 4 4 4 5 3 3 4 4 6 6 5 4 6 2 4 4 K n o w - h o w ( k n o w l e d g e o f h o w t h e t a s k c a n b e c a r r i e d o u t s u c c e s s f u l l y ) 5 5 4 3 4 5 5 5 5 5 5 4 6 3 3 4 4 6 6 5 3 5 2 4 4 P r o f e s s i o n a l e x p e r i e n c e 6 6 3 4 4 3 5 4 4 4 4 3 4 3 4 4 5 6 4 5 4 5 2 1 1 I n s t i t u t i o n a l e n v i r o n m e n t F o r m a l L a w s , l e g a l f r a m e w o r k , r u l e s a n d p r o c e d u r e s ; o p e r a t i o n a l d i r e c t i v e s ; s y s t e m s f o r c o l l e c t i v e a c t i o n s ; m a n a g e m e n t i n f o r m a t i o n s y s t e m s 5 3 2 3 2 3 4 4 4 4 3 3 2 3 3 3 4 5 5 5 4 4 2 3 4 I n s t i t u t i o n a l e n v i r o n m e n t I n f o r m a l R u l e s , p r a c t i c e s a n d b e h a v i o r s ; s y s t e m s f o r c o l l e c t i v e a c t i o n s … 6 4 5 5 6 4 6 5 5 5 4 5 4 4 4 5 5 5 5 6 6 5 4 4 5 R a t i n g o f c a p a c i t y : f r o m 1 t o 1 0 ( 1 = l o w e s t , 1 0 = h i g h e s t ) S P = S e r v i c e P r o v i d e r ; P = P o l i c y M a k e r s ; B = B e n e f i c i a r y S o u r c e : O f f i c i a l d o c u m e n t s . A c r o n y m s a r e s p e l l e d o u t i n T a b l e 5 a b o v e . Page 52 4 4 Page 53 4 5 T a b l e 7 : L i s t a n d R o l e s o f K e y A c t o r s i n W a t e r a n d S a n i t a t i o n S e r v i c e s A c t o r s / S t a k e h o l d e r s A b b r e v i a t i o n R o l e s a n d F u n c t i o n s S u p p l y / D e m a n d F u n c t i o n A r e a o f I n t e r v e n t i o n / J u r i s d i c t i o n N u m b e r o f P a r t i c i p a n t s i n t h e A s s e s s m e n t D i s t r i c t W a t e r a n d S a n i t a t i o n T e a m D W S T · H a r m o n i z a t i o n o f p r o v i s i o n o f w a t e r a n d s a n i t a t i o n s e r v i c e s · P r o v i s i o n o f t e c h n i c a l e x p e r t i s e t o D A a n d c o m m u n i t i e s o n W a t e r a n d S a n i t a t i o n p r o g r a m s a n d p r o j e c t s · E d u c a t i o n o f c o m m u n i t i e s o n W a t e r a n d S a n i t a t i o n p o l i c i e s , p r o g r a m s , a n d p r o j e c t s S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t 9 G h a n a W a t e r C o m p a n y / W a t e r B o a r d G W C / W B · M o b i l i z a t i o n o f s o c i e t y , r e s o u r c e s , a n d f u n d s f o r t h e i m p l e m e n t a t i o n o f p r o g r a m s a n d p r o j e c t s · M a i n t e n a n c e a n d r e p a i r s o f W a t e r a n d S a n i t a t i o n f a c i l i t i e s · E d u c a t i o n o f c o m m u n i t i e s o n W a t e r a n d S a n i t a t i o n p o l i c i e s , p r o g r a m s , a n d p r o j e c t s S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t 9 W a t e r a n d S a n i t a t i o n C o m m i t t e e s W A T S A N · M o b i l i z a t i o n o f c o m m u n i t i e s ’ c o n t r i b u t i o n o f f u n d s t o w a r d W a t e r p r o j e c t s · D a y - t o - d a y m a n a g e m e n t , m a i n t e n a n c e , a n d r e p a i r o f f a c i l i t i e s S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t 1 5 P a r t n e r O r g a n i z a t i o n s P O · A n a l y s i s o f s i t u a t i o n s o f c o m m u n i t i e s i n r e s p o n s e t o p o l i c y i m p l e m e n t a t i o n a n d m a k i n g o f r e l e v a n t o r a p p r o p r i a t e i n p u t s / s u g g e s t i o n s t o g o v e r n m e n t i n t h e f o r m u l a t i o n o f p o l i c i e s · M o b i l i z a t i o n a n d e d u c a t i o n o f c o m m u n i t i e s o n p o l i c i e s , p r o g r a m s , a n d p r o j e c t s · T r a i n i n g o f W A T S A N s a n d o t h e r a r t i s a n s t h a t w o r k i n t h e s e c t o r S e r v i c e P r o v i d e r s ( S P ) , P o l i c y ( P ) D i s t r i c t D i s t r i c t A d m i n i s t r a t i o n D . A d m i n . · P l a n n i n g , b u d g e t i n g , i m p l e m e n t a t i o n o f p r o g r a m s a n d p r o j e c t s t o a d d r e s s n e e d s / p r o b l e m s · C o l l e c t s i n p u t s / i s s u e s f r o m o t h e r s t a k e h o l d e r s i n d i s t r i c t o n n e e d s a n d p r o b l e m s ; f o r w a r d s t o g o v e r n m e n t f o r i n p u t t i n g i n t o p o l i c i e s a n d p r o g r a m s · M o b i l i z a t i o n o f s o c i e t y a n d f u n d s f r o m w i t h i n a n d o u t s i d e t o w a r d i m p l e m e n t i n g p r o g r a m s a n d p r o j e c t · P r o m u l g a t i o n o f b y l a w s t o r e g u l a t e a c c e s s a n d u s e o f f a c i l i t i e s a n d s e r v i c e s S e r v i c e P r o v i d e r s ( S P ) , P o l i c y ( P ) D i s t r i c t 3 D i s t r i c t A s s e m b l y D A · O v e r s e e s t h e i m p l e m e n t a t i o n o f W a t e r a n d S a n i t a t i o n p l a n s a n d d e c i s i o n s o f t h e D A · P r o v i s i o n o f t e c h n i c a l e x p e r t i s e f o r p o l i c y d i r e c t i o n a n d i m p l e m e n t a t i o n S e r v i c e P r o v i d e r s ( S P ) , P o l i c y ( P ) D i s t r i c t ( D A ) & C o m m u n i t y ( D A m e m b e r s ) 6 B e n e f i c i a r y C o m m u n i t y / I n s t i t u t i o n B C / I · R a i s i n g o f f u n d s a n d p a y m e n t o f t a x e s a n d l e v i e s a n d p r o v i s i o n o f c o m m u n a l l a b o r i n s u p p o r t o f p r o g r a m s a n d p r o j e c t s B e n e f i c i a r y ( B ) C o m m u n i t y U n i t C o m m i t t e e s U C · M o b i l i z a t i o n o f c o m m u n i t i e s a n d f u n d s t o w a r d i m p l e m e n t a t i o n o f p r o j e c t s · F o c a l p o i n t f o r d i s c u s s i o n o f i s s u e s a n d m a k i n g i n p u t s t o t h e D A · S u p p o r t i n t h e e n f o r c e m e n t o f b y l a w s B e n e f i c i a r y ( B ) , P o l i c y ( P ) , S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 9 Page 54 4 6 A c t o r s / S t a k e h o l d e r s A b b r e v i a t i o n R o l e s a n d F u n c t i o n s S u p p l y / D e m a n d F u n c t i o n A r e a o f I n t e r v e n t i o n / J u r i s d i c t i o n N u m b e r o f P a r t i c i p a n t s i n t h e A s s e s s m e n t A r e a C o u n c i l A C ( s a m e a s U C ) B e n e f i c i a r y ( B ) , P o l i c y ( P ) , S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 1 5 W o m e n / M o t h e r s W / M · E d u c a t i o n o f m o t h e r s a n d w o m e n o n i m p o r t a n c e o f g o o d s a n i t a t i o n a n d w a t e r t o h e a l t h y l i v i n g / l i f e · O r g a n i z a t i o n o f c l e a n u p e x e r c i s e s · P a y m e n t o f l e v i e s f o r W a t e r a n d S a n i t a t i o n p r o j e c t s B e n e f i c i a r y ( B ) C o m m u n i t y 1 8 M e d i a M e d i a · A n a l y z i n g a n d r e p o r t i n g o n g o v e r n m e n t p o l i c i e s , p r o g r a m s , a n d p r o j e c t s t o i n f o r m a n d e d u c a t e t h e p u b l i c · G a t h e r i n f o r m a t i o n / d a t a f r o m t h e p e o p l e o n t h e i r n e e d s , p r o b l e m s , a n d i s s u e s o f p o l i c y i m p l e m e n t a t i o n f o r t h e a t t e n t i o n o f g o v e r n m e n t a n d p o l i c y m a k e r s S e r v i c e P r o v i d e r s ( S P ) D i s t r i c t & C o m m u n i t y S c h o o l H e a l t h E d u c a t i o n P r o g r a m m e S H E P · E d u c a t i o n o f p u p i l s o n t h e i m p o r t a n c e o f g o o d w a t e r a n d s a n i t a t i o n · M o n i t o r e n v i r o n m e n t a l h y g i e n e a n d s a n i t a t i o n o f s c h o o l c o m p o u n d s ; p r o v i d e a p p r o p r i a t e a d v i c e / g u i d a n c e t o r e m e d y a n y b a d s i t u a t i o n · E d u c a t e f o o d v e n d o r s a n d m o n i t o r t h e i r o p e r a t i o n s t o e n s u r e t h a t t h e i r r e s o u r c e s t o t h e p u p i l s a n d t e a c h e r s a r e h y g i e n i c a n d s a f e S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 1 2 A r e a M e c h a n i c s A M · R e p a i r a n d m a i n t e n a n c e o f f a c i l i t i e s i n c o m m u n i t i e s · T r a i n i n g o f o t h e r p e o p l e i n t h e c o m m u n i t i e s t o a s s i s t i n r e p a i r a n d m a i n t e n a n c e w o r k S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 9 S p a r e P a r t s S e l l e r s S P S · M a k i n g o f W a t e r a n d S a n i t a t i o n f a c i l i t i e s a v a i l a b l e i n d i s t r i c t · P a y i n g o f t a x e s a n d l e v i e s S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 2 L a t r i n e A r t i s a n s L A · C o n s t r u c t i o n o f l a t r i n e s f o r c o m m u n i t i e s a n d i n d i v i d u a l h o u s e h o l d s S e r v i c e P r o v i d e r s ( S P ) C o m m u n i t y 2 D i s t r i c t M a n a g e m e n t C o m m i t t e e D M C ( D W S S C ) · A n a l y z e s i t u a t i o n a n d p o l i c y i s s u e s a n d a d v i s e o n a l t e r n a t i v e a n d r e l e v a n t i s s u e s f o r c o n s i d e r a t i o n i n f o r m u l a t i o n o f p o l i c i e s , p r o g r a m s , a n d i m p l e m e n t a t i o n o f p r o j e c t s · A d v i s o r y b o d y o n W a t e r a n d S a n i t a t i o n S e r v i c e P r o v i d e r s ( S P ) , P o l i c y ( P ) D i s t r i c t 3 T A / O p i n i o n L e a d e r s T A / O L · R e l e a s e o f l a n d f o r t h e i m p l e m e n t a t i o n o f p r o j e c t s / p r o g r a m s · M a k e o p i n i o n s k n o w n t o g o v e r n m e n t a n d D A o n t h e e f f e c t o f p o l i c i e s , p r o g r a m s , a n d p r o j e c t s o n t h e l i v e s o f t h e i r p e o p l e · M o b i l i z a t i o n o f t h e i r p e o p l e t o c o n t r i b u t e l a b o r a n d c a s h a n d p a y l e v i e s / t a x e s f o r p r o g r a m s / p r o j e c t s a s c o m m u n i t i e s ’ c o n t r i b u t i o n B e n e f i c i a r y ( B ) C o m m u n i t y 6 Page 55 4 7 T a b l e 8 : C a p a c i t y o f A c t o r s i n W a t e r a n d S a n i t a t i o n S e r v i c e s : A v e r a g e R a t i n g s o f t h e T h r e e D i s t r i c t s i n V o l t a R e g i o n DWST Media GWC/WB DA D. Admin. AM SPS DWSSC SHEP WASTAN PO BC/INS UC AC W/M LA TA/OL D e v e l o p m e n t A c t o r s C a p a c i t y R e q u i r e m e n t s S P S P S P P S P S P P S P P P S P S P S P S P P P S P B P S P B S P P B T e c h n i c a l s k i l l s 6 6 5 3 5 4 3 5 3 4 4 5 5 3 3 3 3 2 3 2 2 3 4 4 U n d e r s t a n d i n g o f t a s k s , r o l e s a n d r e s p o n s i b i l i t i e s , r i g h t s a n d o b l i g a t i o n s 5 6 5 3 5 5 3 5 4 4 5 5 5 5 5 4 4 3 4 4 4 5 4 5 K n o w - h o w ( k n o w l e d g e o f h o w t h e t a s k c a n b e c a r r i e d o u t s u c c e s s f u l l y ) 4 6 6 3 4 4 3 5 4 4 5 5 4 3 3 3 3 3 4 3 3 3 4 4 P r o f e s s i o n a l e x p e r i e n c e 4 5 6 3 4 4 2 5 3 3 4 4 4 3 3 2 2 3 4 2 2 3 2 3 I n s t i t u t i o n a l E n v i r o n m e n t F o r m a l L a w s , l e g a l f r a m e w o r k , r u l e s a n d p r o c e d u r e s ; o p e r a t i o n a l d i r e c t i v e s ; s y s t e m s f o r c o l l e c t i v e a c t i o n s ; m a n a g e m e n t i n f o r m a t i o n s y s t e m s 4 5 5 3 3 4 4 4 3 3 4 4 3 3 3 3 2 2 3 2 2 2 2 2 I n s t i t u t i o n a l E n v i r o n m e n t I n f o r m a l R u l e s , p r a c t i c e s , a n d b e h a v i o r s ; s y s t e m s f o r c o l l e c t i v e a c t i o n s … 5 6 5 4 5 6 5 4 4 4 5 5 5 4 4 4 3 3 3 4 4 5 6 5 R a t i n g o f c a p a c i t y : f r o m 1 t o 1 0 ( 1 = l o w e s t , 1 0 = h i g h e s t ) S P = S e r v i c e P r o v i d e r ; P = P o l i c y M a k e r s ; B = B e n e f i c i a r y S o u r c e : O f f i c i a l d o c u m e n t s . A c r o n y m s a r e s p e l l e d o u t i n T a b l e 7 a b o v e . Page 56 48 Annex 3 Local Governance Arrangements 1. Traditional Governance Arrangements The source of legitimacy of the traditional Chief is historical, religious, and spiritual, which confers respect and reverence on the chosen leader. The choice of a leader is based on the consent of the people. This means that a leader cannot be imposed on the people in a village, and ignoring this fact is a recipe for chaos. Striving to reach consensus is a cardinal principle of the decision-making process and arrangement. The people expect the leader to be accessible to them, to respect and listen to them, to act fairly in the sharing and distribution of the benefits of resources within the polity, and to seek concurrence of the Council of Advisers in arriving at decisions and choice of actions. Villages join to form a Paramountcy, which is an elaborate structure of links comprising families, lineages, villages, and divisions, with corresponding heads and Chiefs. Villages choose their divisional leader among themselves and, in turn, a Paramount Chief is chosen to whom the Chiefs of all the villages making up the Paramountcy pay allegiance and homage. It is important to note the village- level Chiefs are not chosen by the Paramount Chief and that the Paramount Chief is chosen with the consultation and consent of the people by the chiefmakers, consisting of the village Chiefs. The village Chiefs and the Paramount Chief constitute the traditional Ruling Council of the Paramountcy. Specific provisions allocate responsibilities among the Chiefs within the Paramountcy, thereby circumscribing the extent and scope of their powers. Decisions taken at Council meetings are passed down to the communities through their respective Chiefs. In many cases, direct participation in decision making is made possible through public forums at the request of the Chiefs. At the village level, there are subchiefs based on lineages. The villages are composed of groups of lineages, and the lineages are made up of families that usually would trace their ancestry to one major original settler in the community. Family representations are made at the lineage level in a lineage- level assembly comprising representatives of all the major families within that lineage. Discussions are held regularly at lineage-level assemblies to identify mutual problems and ways of solving them. The lineage members select one or more of their own to represent them at the village-level assembly. The management of community resources revolves around the operating principle that “when there is enough for one then there is enough for all” or “the problem of an individual in the community is a problem for the whole community.” It is these guiding principles of participation that have made it possible that the community as a whole is the beneficiary of the natural resources that the land offers, even though land might belong to clans, individuals, or the Chief. As a result, the community members feel that natural resources such as water, firewood, bamboo, wild fruits, stones, and sand, which are essential to their very survival, belong to no one in particular, but rather to the community as a whole. It is these same guiding principles of participation that enable the communities to access and utilize resources for their basic needs (schools, pit latrines, football parks, markets, and so forth). A community member usually first articulates his or her interest or grievances at the lineage-level assembly. If the case is considered beyond the jurisdiction of the lineage, it is referred to the village assembly that the village Chief presides over. In the same way, a case considered to be beyond the capacity of one village assembly is first referred to the divisional assembly, and if still unresolved, the matter goes to the paramount assembly. Before a matter reaches the paramount assembly, it means that Page 57 49 almost all the possibilities at the family, lineage, village, and divisional category levels for resolving it have been exhausted. These measures are designed to resolve conflicts of coexistence amicably, with the ultimate goal of long-term peace within and outside the Paramountcy. The outcome is more of a win-win situation, rather than a winner-takes-all scenario. A feature of this arrangement is the visible involvement and participation of all segments of society, particularly women. The women’s leadership is structured around a Queen Mother. Women are considered the embodiment of wisdom and are consequently assigned the role of choosing potential candidates to be considered by the chiefmakers and monitoring the conduct and behavior of leaders. A Chief cannot rule without the support of women, and women have the power to reprimand any leader who might lose sight of the well being of the community. One of the positive features of the traditional leadership institutions is that there is a high degree of respect for human dignity, respect for one another and for collective decisions. This has been the pillar on which the chieftaincy institutions have thrived over the years in the communities. It has ensured peaceful coexistence of different families and clans under one authority. Another strength of the traditional leadership is its ability to resolve interfamily conflicts through the arbitration system of justice. Considering the cost and complexity of the conventional law court system of justice, the arbitration administered by Chiefs may be the most effective option for community members to seek redress for any wrong done to them in the community. 2. Modern Governance Arrangements The District Assembly (DA) concept was established by PNDC Law 207 in 1988 to create 110 districts. Recently, the government has carved out 30 more districts, making a total of 140 districts throughout Ghana. The District Assembly is now the highest authority to perform executive, legislative, political, and administrative functions through the Local Government Act 462 of 1993. A District Chief Executive (DCE) is appointed by the President of the Republic with the prior approval of at least a two-thirds majority of the members of the District Assembly present and voting. The membership of the Assembly is made up of two-thirds elected members and one-third appointed members, in consultation with the local people and the traditional authorities. Each DA has five statutory committees: Finance and Administration, Social Services, Justice and Security, Technical Infrastructure, and Economic Development. Depending on the local situation in each district, the Assembly is allowed to create additional committees, as deemed appropriate. The DA General Assembly is chaired by a Presiding Member, elected by a two-thirds majority. In addition to the General Assembly, there is an Executive Committee comprising one-third of the members of the Assembly and chaired by the DCE. At the subdistrict level, there are Area or Zonal councils, depending on the size of the district. Within each Zonal Council, there are a number of Unit Committees that focus on development matters. The number of Unit Committees depends on the size of the Zonal Council. At both Zonal and Unit Committee levels, 15 percent of the membership is appointed by the government. The Unit Committee is the point where the traditional leadership and the decentralization governance structures interface at the community level. The Unit Committees are in close touch with the community members and assist in organizing communal labor, revenue mobilization, the maintenance of environmental sanitation, and the implementation of development projects (including those in Health, Education, and Water Supply). Page 58 50 3. Conflicts between the Two Systems of Governance Before the introduction of the District Assembly concept under PNDC Law 207 in 1988, traditional Chiefs used to enjoy certain facilities and privileges, such as the collection of revenues and local taxes. These privileges were taken away with the establishment of the new local government system. The District Assembly system combines executive, legislative, administrative, and technical functions at the local level and creates a parallel leadership structure in the communities. The CENA reveals that there is a great deal of confusion as to the actual functions of the Assembly members and the Unit Committees. Some Assembly members think that their powers supersede those of the traditional authorities. Many incidents arise because of the desire of each leadership structure to maintain its power base. Apart from weakening traditional authorities, this situation threatens the social cohesion of the communities because each of the leadership structures has its own followers. In addition, the power struggle between the two structures defeats the very reason why the decentralization arrangements were put in place. In the opinion of the CENA participants, it should be possible to utilize the two systems for effective mobilization and management of existing community resources, including the collection and dissemination of information for development. The assessment also reveals the quality and dedication of some of the Chiefs consulted during the assessment. Some are highly educated, but even those who are illiterate are surrounded by educated people. Most of these Chiefs appear to be competent in their own domain and have good relationships with their entourage. It is also evident that many of the social organizational groups or associations (such as village cooperatives, farmers’ associations, the water and sanitation committee, the school management committee, and the PTA) are being led by local elites. Page 59 51 Annex 4 District Profiles (Volta Region) Ho District (Urban Area) Ho is the district and regional center of the Volta Region. The District Assembly is the administrative machinery for implementing development projects, with a District Chief Executive (DCE) and 70 members. A District Coordinating Director, District Planning Officer, Budget Officer, and Finance Officer administer the district. The district has 11 decentralized departments. The Volta Regional Coordinating Council supervises, monitors, advises, and coordinates the activities of the departments through the District Assembly, which is supported from the Central Government and the District Assemblies’ Common Fund. At the local level and communities, Urban/Town/Area Councils and Unit Committees (in communities within the zones) help in the administration of the district. There exists also an Advisory Body Executive Committee (EXECO), made up of selected persons from among Assembly members. The population of the district is estimated at 272,500. Females form about 52 percent of the district population. The city of Ho is the district capital and the regional capital of the Volta Region. The district has a network of roads totaling approximately 639 kilometers. In addition to trading and kente weaving, farming is one of the income-generating occupations and occupies 64 percent of the population. Among the crops farmed are maize, cassava, yams, plantains, bananas, citrus fruit, rice, mangoes, avocadoes, pears, sugar cane, pineapples, and honey production. Ho District has 130 preschools, 258 primary schools, and 123 junior secondary schools. In addition, 14 senior secondary schools and 5 commercial vocational schools provide secondary education. Tertiary education is provided by a polytechnic and adult education institute in the district. Health service delivery is provided in 3 hospitals and 31 Health centers/posts/clinics. For water supply, 246 communities have boreholes, 10 have hand-dug wells, 11 have gravity water systems, and 63 have pipe-born water. Ho District has phone facilities, a regional post office, Internet access, and postal agencies in surrounding villages. Under the Rural Electrification Project, about 65 percent of the Ho District has been connected to electricity. Ketu District (Periurban Area) Ketu District is one of the 12 districts in the Volta Region. It has a land area of 1,130 square kilometers, and it is located in the southeastern part of the region. The district serves as the eastern gateway from the Republic of Togo to Ghana, where much cross-border trading activity takes place. The district’s population is made up of 53.2 percent females and 46.8 percent males. About 35 percent of the population lives in the urban areas, while 65 percent are found in 707 settlements. The district has a population density of about 210 persons per square kilometer. Land holdings are small, especially in the farming communities. The heavy population in the district puts pressure on the existing social infrastructure. The district has a heterogeneous ethnic composition. The prominent ethnic groups include Ewes, Akans, Gans, Hausas, and Ga Adagbes. About 85 percent of the population are Ewes; Akans, Gans, and Hausa constitute 15 percent. Diverse ethnic groups are found largely at Aflao, Agbozume, Denu, and the coastal towns. The major religious groups are Christians (44 percent), traditionalists (40 percent), and Muslims (16 percent). Page 60 52 Education – There are 325 educational institutions in the district, of which 71 (21.8 percent) are at preschool level, 155 (47.7 percent) at the primary level, 90 (27.7 percent) at the junior secondary school (JSS) level, 8 (2.5 percent) at the senior secondary school (SSS) level, and only 1 (0.3 percent) vocational school. According to the Ghana Education Service, the gross school enrollment rate is about 70 percent, and enrollment for girls is 65 percent. About 20 percent of enrolled children drop out. The teacher-pupil ratio in the district is 1:35. Two science resource centers have been provided by the government. The district also has a tertiary institution, the Ohawu Agricultural College, that trains middle-level manpower for agriculture. There are 4 public libraries. Health – There are 6 hospitals and 16 clinics in the district. The most-reported health problems are malaria, pregnancy-related complications, respiratory-tract infections, diarrhea, skin ulcers, accidents and burns, intestinal worms, hypertension, and typhoid fever. Water and Sanitation – There are 52 boreholes currently serving some rural communities. There is also the Ghana-German Technical Cooperation (GTZ) water scheme for Dzodze, Penyi, and Ehi. The majority of the people do not have access to potable water. About 85 percent of the population is without organized garbage or refuse disposal or collection. The district has only 1 refuse truck and 11 garbage containers. Also, 60 percent of the settlements in the district do not have access to decent toilet facilities; 39 percent of the settlements rely on traditional pit latrines and pan latrines. Kadjebi District (Rural Area) The population of Kadjebi District is about 53,000. The district is a settler community (90 percent), made up of 50 percent Ewes; 40 percent Kotokolis, Kabres, and Basares; and the remaining 10 percent the indigenous Akans. The main languages spoken are Akan/Twi and Ewe (the two are mostly used at social gatherings, state functions, and churches), Hausa, Kotokoli, Chamba, and Basare. The English language is used by the educated. The religions practiced are Christianity, Islam, and traditional. Land tenure and ownership is classified by the following categories: stool lands, clan/family lands, purchased land, tenancy user rights, and hired land. Clan/family lands and purchased land can be inherited. The district has a political administrative and local governance system. It has a District Assembly made up 30 elected and appointed members. The District Chief Executive is the political head of the district. There exists also an Advisory Body Executive Committee (EXECO) made up of selected persons from the 30-member Assembly. There are 6 Area/Town Councils, which help in the administration of the 6 zones of the district, and under them are 78 Unit Committees in communities within the zones. Five administrative departments, 11 decentralized departments, and 8 non- decentralized departments administer and provide services in the district. The district is represented at the national-level parliament by a Member of Parliament. For Health delivery, there exists a private hospital and 9 clinics/Health posts. These institutions are under the auspices of the district Health Management Team. Common disease problems include malaria, typhoid fever, meningitis, pneumonia, hypertension, skin diseases, and gynecological and pregnancy disorders. There are 76 primary schools, 32 junior secondary schools, and 1 senior secondary school to provide access to education in the district. Water coverage in the district is 52 percent. There are 85 boreholes with pumps, 5 piped systems, 1 hand-dug well, and 22 boreholes under construction. Sanitation coverage in the district is 16 percent. Electricity is supplied to many communities in the district. There are 2 banking institutions in the district. One post office and telecommunication facility exists in the district capital, Kadjebi. The district has 5 markets, of which 4 have fairly good infrastructure. Page 61 53