Report No. PIC3472
Project                             Ghana-Health Sector Support Program
Region                              Africa
Sector                              Population, Health & Nutrition
Project ID                          GHPA949
Implementing Agencies               Republic of Ghana
Dr. A. Isaaka-Tinorgah
Director, External Aid Coordination
Ministry of Health
Tel: 233-21-667967
Fax: 233-21-663810
Date Prepared                       October 1995
Projected Appraisal Date            July 1996
Projected Board Date                November 1996
1.   Country and Sector Background. Ghana has experienced drastic
changes since independence in 1957. After relative prosperity in the
1960s, the economy experienced unprecedented deterioration, with falling
GDP, soaring inflation, and devastating poverty. The government adopted
the Economic Recovery Program (ERP) in 1983, and turned the economy
around. Democratization and decentralization of political decision-
making is also underway in an effort to respond more effectively to
local people's needs. Since 1992, the macroeconomic situation has
become more fragile, and though the economy is growing, inflation is
again increasing.   Ghana remains a poor country with about 31t of the
population living in poverty. Ghana's future economic development
depends on a healthy and educated population to supply its labor force.
Support to the health sector is thus a central focus of the country's
development vision, as stated in Ghana Vision 2020, and the Bank's
Country Assistance Strategy.
2.   Ghana has made considerable progress in the health sector, with
life expectancy increasing from 45 to 55 years since independence. Yet
the health status of Ghanaians is still poor: the infant mortality rate
is about 66/1000, the total fertility rate is 5.5, about 89 of children
under 5 years suffer from severe malnutrition, and there are large
disparities between populations. Although access to health facilities
and safe water has increased, large portions of the population still do
not have access to these basic services (40w and 50t respectively). New
health issues, such as AIDS and chronic diseases, compete for attention.
Government has made considerable efforts to support the health sector
under the ERP, consistently allocating around 10t of its budget to the
health sector, nearly $5 per capita. Rather than targeting the poor,
government resources have been disproportionately spent on less cost-
effective tertiary levels of curative care. Salary expenditures have
been given priority at the expense of important supplies and
consumables. The quality of health care is suspect, resulting in low
utilization of services, particularly by the poor. Initially, high user
fees without concomitant improvements in the quality of services
probably contributed to a decline in utilization. Logistic support for



drugs, medical supplies, maintenance and equipment has only recently
improved, after decades of neglect. Yet drug shortages are still
common, medical equipment often does not work, personnel are not
effectively deployed, and staff morale suffers. Recent government
efforts have strengthened planning and management at the district and
regional levels, but only recently have finances been allocated to them
to implement their plans. Health services and management is
particularly weak at the community, subdistrict and district levels,
where people should be making first contact with the health system.
Linkages between the various levels of facilities are poor. Households
have not played a prominent role in the planning and evaluation of
health services, and often have limited knowledge about healthy
behaviors. Many donors have been supporting the health sector in Ghana,
though the previous lack of a health policy framework has impeded a
comprehensive and coordinated health system. This has resulted in
numerous vertical programs.
3.   Project Objectives. As a sector-wide operation, the purpose of the
Credit is to support the government's efforts in improving the health of
Ghanaians through implementation of its sector policy, articulated in
the Medium Term Health Strategy Toward Vision 2020 (MTHS). The MTHS
states that the goal of the health system is to improve the health of
Ghanaians by improving access, quality, and efficiency of health
services and forging linkages with other partners in health development.
The impact of the program will be measured by meeting targets set for
the year 2000 for life expectancy, infant, child, maternal and adult
mortality, and fertility and nutritional status.
4.   Project Description. The Credit will support a sector-wide
investment program financing a time-slice of the combined government and
external assistance budgets for developmental and operational activities
over the next five years. Activities for ten main strategies to be
financed over the medium-term are to: (a) redesign health services into
a basic package of care; (b) establish a decentralized health service
under a Ghana Health Service (GHS); (c) forge linkages between private
and public providers to work towards common objectives; (d) expand the
network of facilities providing a basic package to ensure they are
universally accessible; (e) develop and implement a program to train and
retrain health teams to provide services; (f) improve logistic support
systems for drugs, equipment and consumables; (g) institute a process of
quality assurance; (h) empower households and communities to identify
and solve health problems and to participate in planning, monitoring,
and evaluating health services; (i) improve financing systems to
concentrate public funds on the basic package while enabling private
resources for tertiary care; and (j) advocate for support in
intersectoral action, specifically in population, food and agriculture,
social welfare, local government, education, and water and sanitation
agencies, and particularly to finance intersectoral activities defined
in the National Population Policy Plan and the National Plan of Action
on Food and Nutrition.
5.   Project Financing. About $650 million of public financing are
estimated to be needed over the next five years for the sector program.
Government is estimated to contribute about $360 million over this time
and other Cofinanciers about $240. As lender of last resort, the IDA
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contribution of $50 million will finance gaps in the program in support
of the MTHS. Households are estimated to contribute about half of total
spending on health, though this is mostly outside the public sector.
Households contribute about 10t of government's recurrent health
expenditures. The program is designed to make a continued assessment of
the appropriate mix of public and private financing and provision of
services, as well as to mobilize more funds to cost-effective health
services.
6.   Project Implementation.   The program will be implemented through
the regular channels of the government. No new project implementation
units will be established. The MOH will remain responsible for policy,
monitoring, coordination of donors and inter-sectoral agencies, and
public financing for health services. The newly formed GHS is
responsible for public service delivery. The GHS will prepare and
implement health budgets and monitor the performance of sector delivery
in a decentralized manner. District health management teams (DHMTs),
located in each of the 110 districts, are responsible for organizing the
local provision of health services. They prepare annual plans and
budgets for their districts, and are provided with finances for non-
salary recurrent expenditures. The ten Regional Health Teams play an
intermediary role between the DHMTs and the central GHS, providing
supervision and logistic support to districts, and organizing referral
hospital care. Government and donors will jointly review the detailed
action and financing plans on an annual basis.
7.   Project Sustainability.   The reason for the selection of the sector
program versus a project approach is to improve sustainability.
Financial sustainability will require long-term reallocation of the
public budget from tertiary to primary level services; much work is
planned to improve the financing options and tools to this effect. In
the medium term, increased donor support will be required to bring the
coverage and quality of the health system to a level which will improve
health outcomes and attract more household financing. Institutional
sustainability will be strengthened through a sector approach focusing
on improved management practices and restructuring in support of regular
institutions rather than separate project structures. The participative
approach to develop and operationalize the MTHS will help ensure the
social and political sustainability of the program.
8.   Lessons Learned from Past Operations.   The current IDA-assisted
Health and Population Project (CR 2193-GH) has demonstrated that
hardware for health services can be efficiently put in place. However,
a more comprehensive approach is needed if (i) policy, planning, and
systems development are to progress; and (ii) the tendencies to
duplicate efforts between donors is to be reduced. Lessons from two
World Bank studies are also instrumental in the development of the
program. The World Development Report 1993 has been used to guide the
development of a cost-effective package of services. The comprehensive
review of African experience, Better Health in Africa, outlines
processes for change along the lines of health policy and strategy
development, government commitment and collaboration with the private
sector, cost-effective approaches to the delivery of care, and
managerial development and institutional reform, all of which are
central to the MTHS.
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9.   Poverty Category. The project will help improve the efficiency and
effectiveness of social services. As such, it is part of IDA's core
poverty alleviation program. The health program is sector-wide and
addresses the entire population. Though the services are targeted by
level of care (i.e. preventive and basic curative services at the
district level), they are not explicitly targeted by income group, so
the project is not included in the program of targeted interventions.
The program is designed to redress differences in health status among
vulnerable population groups, particularly to provide cost-effective
services in poor rural areas, and is thereby structured to
preferentially improve public spending on the poor.
10. Environmental Aspects. The program will strengthen environmental
health management and improvement in sanitation, food hygiene, and
medical waste. The net effects of the program are thus expected to be
beneficial to the environment. It is expected to be classified as a
category C operation.
11. Program Objective Categories. The program aims to provide
accessible, efficient, equitable and cost-effective social services in
the population, health and nutrition sector, and is thereby part of
IDA's core poverty alleviation program.
Contact Point:            Public Information Center
The World Bank
1818 H Street N.W.
Washington D.C. 20433
Telephone No.: (202)458-5454
Fax No.: (202)522-1500
Note: This is information on an evolving project. Certain components
may not necessarily be included in the final project.
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