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TRANSCRIPT
Document of
The World Bank
FOR OFFICIAL USE ONLY
Report No: 80618-GH
INTERNATIONAL DEVELOPMENT ASSOCIATION
PROJECT APPRAISAL DOCUMENT
ON A
PROPOSED CREDIT
IN THE AMOUNT OF SDR 44.0 MILLION
(US$68.0 MILLION EQUIVALENT)
AND A
PROPOSED GRANT FROM THE
MULTI-DONOR HEALTH RESULTS INNOVATION TRUST FUND
IN THE AMOUNT OF US$5.0 MILLION
TO THE
REPUBLIC OF GHANA
FOR A
MATERNAL AND CHILD HEALTH & NUTRITION IMPROVEMENT PROJECT
April 25, 2014
AFTHW
Country Department AFCW1
Africa Region
This document is being made publicly available prior to Board consideration. This does not
imply a presumed outcome. This document may be updated following Board consideration and
the updated document will be made publicly available in accordance with the Bank’s policy on
Access to Information.
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CURRENCY EQUIVALENTS
Exchange Rate Effective {March 31, 2014}
Currency Unit = Cedi
US1 = 2.77 Cedi
US$1 = SDR 0.64698537
FISCAL YEAR
January 1 – December 31
ABBREVIATIONS AND ACRONYMS
ANC Antenatal Care
BIA Benefit-Incidence Analysis
BMCs Budget Management Centers
BoG Bank of Ghana
CAGD Controller and Accountant General’s Department
CBGP Community-Based Growth Promotion
CDs Communicable Diseases
CHNs Community Health Nurses
CHOs Community Health Officers
CHPS Community-Based Health Planning and Services
CMA Common Management Arrangement
CMAM Community Management of Acute Malnutrition Project
CPBF Community Performance-Based Financing
CPS Country Partnership Strategy
DAs District Assemblies
DACF District Assemblies Common Fund
DFID Department for International Development
DHIMS District Health Information Management System
DHMT District Health Management Team
DHS Demographic & Health Survey
ECNHA Essential Community Nutrition and Health Actions
EOI Expressions of Interest
EPA Environmental Protection Agency
EU European Union
FBS Fixed Budget Selection
FH Family Health
GDHS Ghana Demographic and Health Surveys
GDP Gross Domestic Product
GHS Ghana Health Service
GIFMIS Ghana Integrated Financial Management System
GPN General Procurement Notice
ii
GSS Ghana Statistical Survey
HASS Health Administration and Support Services
HIP Health Insurance Project
HRD Human Resource Development
HRITF Health Results Innovation Trust Fund
HSSP Health Systems Strengthening Project
IAs Implementing Agencies
IAU Internal Audit Unit
ICB Non-international Competitive Bidding
IDA International Development Association
IDD Iodine Deficiency Disorders
IEC Information, Education and Communication
IFRs Interim Financial Reports
IUFR Interim Unaudited Financial Reports
IYCF Infant and Young Child Feeding
LEAP Livelihood Empowerment Against Poverty
LCS Least Cost Selection
LLNs Long Lasting Insecticide Nets
MAF MDG Acceleration Framework
MBB Marginal Budgeting for Bottlenecks
MCHNP Maternal & Child Health & Nutrition Project
MDGs Millennium Development Goals
MICS Multiple Indicators Cluster Survey
MMR Maternal Mortality Ratio
MoF Ministry of Finance
MoH Ministry of Health
NGOs Non-Governmental Organizations
NHIA National Health Insurance Authority
NHIS National Health Insurance Scheme
NMCCSP Nutrition and Malaria Control for Child Survival Project
ORS Oral Rehydration Salt
PAD Project Appraisal Document
PDO Project Development Objectives
PH Public Health
PMHS Package of Maternal Health Services
PNC Postnatal Care
PPME Policy Planning, Monitoring and Evaluation
PPMED Policy Planning, Monitoring and Evaluation Division
PRAMS Procurement Risk Assessment System
QBS Quality Based Selection
QCBS Quality and Cost Based Selection
RBF Results-Based Financing
R&D Research and Development
RCC Regional Coordinating Council
RDHS Regional Director of Health Service
SBD Standard Bidding Documents
iii
SC Steering Committee
SSDM Supplies, Stores and Drugs Management
SSS Single Source Selection
TAG Technical Advisory Group
TFR Total Fertility Rate
UNDB United Nations Development Business
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WFP World Food Program
WHO World Health Organization
Regional Vice President: Makhtar Diop
Country Director: Yusupha B. Crookes
Sector Director: Tawhid Nawaz
Sector Manager: Trina S. Haque
Task Team Leader: Evelyn Awittor
Francisca Ayodeji Akala
iv
GHANA
Maternal and Child Health and Nutrition Improvement Project
TABLE OF CONTENTS
Page
A. Country Context ............................................................................................................ 1
B. Sectoral and Institutional Context ................................................................................. 1
C. Higher Level Objectives to which the Project Contributes .......................................... 8
II. PROJECT DEVELOPMENT OBJECTIVES ................................................................9
A. PDO............................................................................................................................... 9
Project Beneficiaries ........................................................................................................... 9
PDO Level Results Indicators ........................................................................................... 10
III. PROJECT DESCRIPTION ............................................................................................10
A. Project Components .................................................................................................... 10
B. Project Financing ........................................................................................................ 18
IV. IMPLEMENTATION .....................................................................................................18
A. Institutional and Implementation Arrangements ........................................................ 18
B. Results Monitoring and Evaluation ............................................................................ 19
C. Sustainability............................................................................................................... 21
V. KEY RISKS AND MITIGATION MEASURES ..........................................................22
A. Risk Ratings Summary Table ..................................................................................... 22
B. Overall Risk Rating Explanation ................................................................................ 22
VI. APPRAISAL SUMMARY ..............................................................................................22
A. Economic and Financial Analysis ............................................................................... 22
B. Technical ..................................................................................................................... 24
C. Financial Management ................................................................................................. 25
D. Procurement ................................................................................................................. 27
E. Social (including Safeguards)....................................................................................... 28
F. Environment (including Safeguards) ............................................................................ 29
Annex 1 Results Framework and Monitoring ..........................................................................30
Annex 2 Detailed Project Description .......................................................................................34
v
Annex 3: Implementation Arrangements .................................................................................44
Annex 4 Operational Risk Assessment Framework (ORAF) .................................................69
Annex 5: Implementation Support Plan ...................................................................................73
Annex 6: Financial and Economic Analysis .............................................................................76
Annex 7: Country Map ...............................................................................................................81
LIST OF CHARTS
Chart 1 Institutional Deliveries among Insured Compared to Uninsured (%), 2008..................... 4
LIST OF FIGURES
Figure 1 Trends in Maternal Mortality 1990-2010 ........................................................................ 2
Figure 2 CPBF Implementation and Roll out plan ...................................................................... 37 Figure 3 District Level Institutional Arrangements for the CPBF ............................................... 47
LIST OF TABLES
Table 1 Essential Community Nutrition and Health Actions for the Beneficiary Groups ........... 11
Table 2 Example of CPBF ........................................................................................................... 14 Table 3 Project Results Chain ...................................................................................................... 17 Table 4 Financing ........................................................................................................................ 18
Table 5 Risk Ratings Summary ................................................................................................... 22
Table 6 Example of CPBF ........................................................................................................... 38 Table 7 Disbursement Summary .................................................................................................. 53 Table 8 Key Procurement Risks and Mitigation Measures ......................................................... 61
Table 9 Thresholds for Procurement Methods ............................................................................. 62 Table 10 List of high value and ICB contract packages to be procured for the first 18 months . 63
Table 11 List of consulting assignments with short-list based on international competition ...... 64 Table 12 Implementation Support Plan ....................................................................................... 74
Table 13 Maternal Mortality and Under-five Mortality: Comparison between the Project
Scenario and the Status Quo ......................................................................................................... 79 Table 14 Project Benefits: comparison between the status quo and the project scenario ............ 79
vi
PAD DATA SHEET
Ghana
Maternal Child Health And Nutrition Project (P145792)
PROJECT APPRAISAL DOCUMENT
AFRICA
AFTHW
Report No.: PAD708
Basic Information
Project ID Lending Instrument EA Category Team Leader
P145792 Investment Project
Financing
C - Not Required Evelyn Awittor
Francisca Ayodeji Akala
Project Implementation Start Date Project Implementation End Date
20-May-2014 30-June-2020
Expected Effectiveness Date Expected Closing Date
01-September-2014 30-Jun-2020
Joint IFC: No
Sector Manager Sector Director Country Director Regional Vice President
Trina S. Haque Tawhid Nawaz Yusupha B. Crookes Makhtar Diop
Borrower: Republic of Ghana
Responsible Ministry : Ministry of Health
Responsible Agency: Ghana Health Services
Contact: Ms Salimata Abdul-Salam Title: Chief Director
Telephone (233) 0208876172 Email: [email protected]
Project Financing Data(in USD Million)
[ ] Loan [X ] Grant [ ] Other
[ X ] Credit [ ] Guarantee
Total Project Cost: 73.00 Total Bank Financing: 68.00
Financing Gap: 0.00
Financing Source Amount
BORROWER/RECIPIENT 0.00
International Development Association (IDA) 68.00
Health Results-based Financing 5.00
Total 73.00
vii
Expected Disbursements (in USD Million)
Fiscal
Year
2015 2016 2017 2018 2019 2020 0000 0000 0000
Annual 10.00 15.00 15.00 15.00 10.00 8.00 0.00 0.00 0.00
Cumulati
ve
10.00 25.00 40.00 55.00 65.00 73.00 0.00 0.00 0.00
Proposed Development Objective(s)
The project development objective is to improve utilization of community-based health and nutrition
services by women of reproductive age, especially pregnant women, and children under the age of 2
years.
Components
Component Name Cost (USD Millions)
Component 1. Community-Based Maternal and Child Health
and Nutrition Interventions
63.00
Component 2: Institutional Strengthening Capacity Building,
Monitoring and Evaluation, and Project Management
8.00
Component 3: Unallocated 2.00
Institutional Data
Sector Board
Health, Nutrition and Population
Sectors / Climate Change
Sector (Maximum 5 and total % must equal 100)
Major Sector Sector % Adaptation
Co-benefits %
Mitigation
Co-benefits %
Health and other social services Health 100
Total 100
I certify that there is no Adaptation and Mitigation Climate Change Co-benefits information
applicable to this project.
Themes
Theme (Maximum 5 and total % must equal 100)
Major theme Theme %
Human development Child health 30
Human development Health system performance 20
Human development Nutrition and food security 20
Human development Population and reproductive health 30
viii
Total 100
Compliance
Policy
Does the project depart from the CAS in content or in other significant
respects?
Yes [ ] No [ X ]
Does the project require any waivers of Bank policies? Yes [ ] No [ X ]
Have these been approved by Bank management? Yes [ ] No [ ]
Is approval for any policy waiver sought from the Board? Yes [ ] No [ X ]
Does the project meet the Regional criteria for readiness for implementation? Yes [ X ] No [ ]
Safeguard Policies Triggered by the Project Yes No
Environmental Assessment OP/BP 4.01 X
Natural Habitats OP/BP 4.04 X
Forests OP/BP 4.36 X
Pest Management OP 4.09 X
Physical Cultural Resources OP/BP 4.11 X
Indigenous Peoples OP/BP 4.10 X
Involuntary Resettlement OP/BP 4.12 X
Safety of Dams OP/BP 4.37 X
Projects on International Waterways OP/BP 7.50 X
Projects in Disputed Areas OP/BP 7.60 X
Legal Covenants
Name Recurrent Due Date Frequency
Recruitment of Independent
Verification Agent
No 01-Jan-2015 Once
Description of Covenant
The Recipient shall, not later than four months (4) months after the Effective Date, engage, in
accordance with the provisions of Section III of Schedule 2 of the Financing Agreement,
consultants to conduct independent verifications of the delivery of the package of maternal
health services (PMHS) by respective community health teams under the community
performance based financing (CPBF) Program.
Conditions
Name Type
Community Performance-Based Financing (CPBF) Services Grant Effectiveness
ix
Description of Condition
The HRITF Grant Agreement has been executed and delivered and all conditions precedent to
its effectiveness or to the right of the Recipient to make withdrawals under it have been fulfilled
Team Composition
Bank Staff
Name
Evelyn Awittor Senior Operations
Officer
Co-Team Lead AFCF1
Francisca Ayodeji
Akala
Senior Health
Specialist
Co-Team Lead AFTHW
Stephen Tettevie Team Assistant Support Services AFCW1
Luis M. Schwarz Senior Finance Officer Finance CTRLA
John Bryant Collier Operations Officer Operations AFTN3
Menno Mulder-
Sibanda
Sr Nutrition Spec. Nutrition AFTHW
Dominic S. Haazen Lead Health Policy
Specialist
Health policy AFTHW
Patricio V. Marquez Sector Leader Health AFTHD
Andrea Vermehren Lead Social Protection
Specialist
Social Protection AFTSE
Gabriel Dedu Governance Specialist Governance AFTP3
Edith Ruguru Mwenda Senior Counsel Legal LEGAM
Edit V. Velenyi Economist Economics AFTHE
Beatrix Allah-Mensah Senior Social
Development
Specialist
Social Development AFTCS
Dinesh M. Nair Senior Health
Specialist
Health AFTHW
Robert Wallace
DeGraft-Hanson
Financial Management
Specialist
Financial Management AFTMW
Noel Chisaka Sr Public Health Spec. Health AFTHW
Adu-Gyamfi
Abunyewa
Senior Procurement
Specialist
Procurement AFTPW
Anders Jensen Senior Monitoring &
Evaluation Specialist
M&E AFTDE
Moulay Driss Zine
Eddine El Idrissi
Sr Economist (Health) Health Economics AFTHW
x
Felipe Alexander
Dunsch
E T Consultant Economics DECIE
Non Bank Staff
Name Title Office Phone City
Anne Marie Bodo Pharmaceutical
Consultant
Washington
Monica Bleboo Communications
Consultant
233-208350113 Accra
Claude Sekabaraga Sr. Health Specialist -
RBF
00250788304133 Kigali
.
Locations
Country First
Administrative
Division
Location Planned Actual Comments
1
STRATEGIC CONTEXT
A. Country Context
1. Ghana experienced rapid economic growth over the past several years resulting in
substantial progress in reducing income poverty. GDP growth rose from 8 percent in 2010 to
close to 14.5 percent in 2011, making Ghana’s economy one of the fastest growing on the
continent. By 2012, Gross National Income per capita reached US$1940, reflecting Ghana’s
middle-income status. Poverty has been declining steadily, as reflected in the number of people
classified as poor, which dropped from about 8.0 million (i.e. slightly over 50 percent of the
population) in 1992 to 6.3 million in 2006 (less than 30 percent of the population). In spite of
these improvements, inequalities remain widespread in Ghana, and are reflected in significant
disparities in access to economic, social and political opportunities. There are also large
disparities in access to health services and health outcomes between the poor and non-poor, as
discussed below.
2. However, recent macroeconomic instability is putting at risk the gains in poverty
reduction. The fiscal deficit reached 12% of GDP in 2012 and 10.9% in 2013, and the current
account deficit reached 13% of GDP in both years. The government tackled the fiscal
imbalances by raising fuel prices as well as electricity and water tariffs, by around 60% in late
2013. The inflationary impact of the adjustment was reinforced by depreciation of the national
currency (Cedi). Hence the higher prices imply a lower income in real terms, which has the risk
of pushing many of the near-poor families into poverty. The pressure on household budgets and
the impact on poor households have been exacerbated by the lack of liquidity of the government
which has paid the Livelihood Empowerment Against Poverty (LEAP) cash transfers with
significant delays as well as payments to the District Assemblies Common Fund (DACF) which
is a mechanism for redistribution of resources at the regional level. Macroeconomic crises affect
disproportionately more the poorer members of society.
B. Sectoral and Institutional Context1
3. Ghana has made steady progress in improving health outcomes over the past two
decades. The total fertility rate (TFR) declined significantly over the past 20 years from 6.4
children per woman in 1988 to 4.1 children per woman in 2011 with the country reaching one of
the lower fertility rates in Sub-Saharan Africa. In spite of this progress, there are large
disparities between women in urban areas (3.1 births) and those in rural zones (4.9 births) with
the Northern region having the highest TFR (6.8 births). Ghana has also experienced a marked
decline in childhood mortality over the past 20 years, reaching a rate of roughly 78.0 deaths per
1,000 live births in 2011. Over two-thirds of child deaths occur in the first year of life with
Ghana’s infant mortality at about 50 deaths per 1,000 live births (2008). Neonatal deaths
account for 60 percent of deaths during the first year of life. While the Maternal Mortality Ratio
dropped steeply from a high of roughly 600 per 100,000 live births in 1990 to about 350 by
2010, it still remains high, particularly in relation to countries at similar socio-economic levels.
1 Most of the data used cited below comes from the Ghana Demographic and Health Surveys with the last available
survey published in 2008.
2
4. In spite of the solid overall progress to improve health outcomes Ghana is not on track
to meet all health related Millennium Development Goals targets. Three trends are worthwhile
noting. First, Ghana is not likely to meet all the child nutrition targets, especially stunting, as
the proportion of children under five who are underweight already reached 14 percent in 2008, in
comparison to the 2015 target of 11 percent. Second, the country is not likely to meet the 2015
child mortality target (53 per 1000 live births) even though it is proceeding in the right direction
but at a slower pace than needed. Third, Ghana is considerably off track to attain the maternal
mortality MDG of 160 per 100,000 live births (as seen in Figure 1 below), and needs to redouble
efforts in this area.
Figure 1 Trends in Maternal Mortality 1990-2010
5. In order to accelerate progress on childhood mortality Ghana will need to adopt a well-
targeted approach which expands access to cost-effective interventions focused on children
from poor households and rural areas. Key interventions which can be effectively delivered
through the country’s well established community based health program include: (i) providing
vitamin A supplementation which reaches only 56 percent of children under five and is one of the
single most effective child survival interventions; (ii) addressing iron-deficiency anemia with
over 87 percent of children from the lowest wealth quintile suffering from some form of anemia
but only 16 percent receiving iron supplements; (iii) conducting de-worming with a meager 21
percent of children under five from the lowest wealth quintile benefitting from treatment in
contrast to close to 60 percent of their counterparts from the highest wealth quintile; (iv)
strengthening growth monitoring to ensure early detection of malnourished children with 28
percent of children under five suffering from stunting; (v) promoting exclusive breast feeding
during the first six months which stands at only 63 percent; (vi) boosting immunization coverage
to reach the 20 percent of children 12-23 months old who are not fully immunized; and (vii)
improving infant and child feeding practices. Parallel efforts are required to continue expanding
access to quality child health services, particularly at lower-level facilities, as utilization for poor
children remains low (e.g. 41 percent of children under five from the lowest wealth quintile are
taken to a facility for fever in comparison to 80 percent from the highest wealth quintile). Health
services need to be strengthened to reduce the risk of dying from neonatal conditions which can
580 590 550
440
350 280
580
160
0
100
200
300
400
500
600
700
1990 1995 2000 2005 2010 2015Multidonor MMR estimation
Estimations to meet MDG target
Mat
ern
al M
ort
alit
y R
atio
(M
MR
) p
er 1
00
,00
live
bir
ths
3
be mitigated with quality care during pregnancy, safe and clean delivery by a skilled attendant,
and immediate postnatal care, as discussed below.
6. The persistently high levels of maternal mortality will require a major effort to expand
access of poor women to a comprehensive package of high impact interventions. The limited
access and poor quality of essential maternal and reproductive health services, combined with
persistently high levels of fertility, contribute to high maternal mortality. The prevailing
maternal under nutrition, including high prevalence of anemia, is also a major determinant of
mortality and is associated with reduced physical capacity and increased susceptibility to
infections. This requires to be addressed to improve overall maternal health and pregnancy
outcomes such as low birth weight of neonates that leads to stunting. While there has been
marked improvement in antenatal care coverage over the past 20 years with 95 percent of women
receiving care from a health professional the timing of antenatal visits needs to be improved (i.e.
only 51 percent of rural women had their first antenatal care visit during the first trimester), other
essential services require further scale up, particularly in rural areas. By contrast, assisted
deliveries by a medically trained provider remains low nationwide (only 60 percent) and there
are large geographic and socio-economic disparities between urban (84 percent) and rural (43
percent) areas; and between the highest (95 percent) and lowest wealth quintile (24 percent),
suggesting that a substantial proportion of women deliver in sub-optimal conditions. This places
them and their newborn at greater risk, as reflected in the high rates of neonatal and maternal
mortality which are closely linked. Only 56 percent of women receive two or more tetanus
injections to protect against tetanus which is a leading cause of neonatal death. Postnatal care,
which is critical to avoid complications, is received by only 67 percent of women. Similarly,
high quality emergency obstetric care and diagnostic services are not widely available at lower
level health facilities. Moreover, while contraceptive use has doubled over the past 20 years,
only 24 percent of married women use a modern contraceptive method. In addition to
strengthening the availability of services, greater attention needs to be given to assisting poor
women to access modern health services, as they face numerous financial and socio-cultural
impediments, have inadequate access to information on early signs of complications and
difficulties navigating the health system, and often seek care with a delay and a poor prognosis.
Some challenges still remain on the supply side. These include: insufficient and poorly equipped
facilities (primary health centers, specialized care), inadequate trained staff, inequitable
distribution of health workers, staff retention especially in remote rural areas and financial access
to services. Additionally, the health workers’ attitudes also contribute to low utilization.
7. Ghana has made an impressive effort to expand access to health insurance to address
demand side impediments to health care. Initial results from the National Health Insurance
Scheme (NHIS) are promising with the insured using health services slightly more frequently
across all wealth quintiles compared to the uninsured. Beneficiaries are also expressing
satisfaction with public services due to availability of drugs, no co-payments or reimbursement
ceilings. Even though the magnitude of utilization for the insured and uninsured is 20 and 15
percentage points for the first and second quintile respectively, the poor who are enrolled in the
NHIS will be more likely to use public facilities than the poor who are not enrolled (see Figure 2
below). However, this is not the case with the richest quintile where the insured and uninsured
4
are almost at par2. Nevertheless, there are concerns that the non-poor may be capturing more of
the benefits from the subsidized and publicly financed scheme than the poor. While the NHIS
offers exemptions from premiums to a significant proportion of the population, enrollment
continues to remain low for poor and vulnerable groups with less than half registered by 2008.
Poor women are eligible for free maternal care at all NHIS-certified facilities and yet the uptake
has been modest, highlighting other barriers to accessing health care such as lack of information,
and difficulties in covering non-medical expenses (i.e. transportation). To address these
persistent inequalities, a concerted effort is needed at the community level to assist poor women
especially pregnant females and vulnerable households to enroll in the NHIS.
Chart 1 Institutional Deliveries among Insured Compared to Uninsured (%), 2008
Health Financing in Ghana: 2013
8. While Ghana has made a concerted effort to expand overall public spending on health
there are still substantial funding gaps and efficiency concerns. Public sector contributions
have increased from 44 percent (1995) to 53 percent (2009) of total health spending with the
biggest leap coming with the introduction of NHIS in 2005. In spite of this positive trend, in real
terms the rate of growth is much slower with Ghana allocating only 9 percent of its overall
recurrent budget to health in comparison to the Abuja target of 14 percent. The proposed
operation provides critical financing to roll out a more cost-effective model of care which relies
primarily on community health workers.
9. Ghana has established a common platform for accelerating progress on the MDGs and
designed a coherent strategy to tackle maternal and child health more forcefully. The recently
set up Ghana MDG Acceleration Framework (MAF) provides a common platform for
development partners and Government to work together to conceptualize, develop, and expedite
implementation of strategies to tackle the challenges of maternal and child heath in the country.
A MAF Steering Committee, comprised of key stakeholders from government and the donor
2. The wealthiest quintile uninsured has higher levels of institutional deliveries than the insured,
probably because of a number of options available for them and they can afford to go outside the
NHIS.
0%
10%
20%
30%
40%
50%
60%
70%
80%
Lowestquintile
Secondquintile
Middlequintile
Fourthquintile
Fifth quintile Ghana
Insured Uninsured
5
community, was established to provide oversight and guidance. The proposed project will
support the government to accelerate progress on maternal and child health within this common
framework, and ensure harmonization of efforts to maximize impact. The MDG Acceleration
Framework (MAF) – Ghana Action Plan was developed by the Ministry of Health and Ghana
Health Service in collaboration with development partners, particularly the United Nations
country team and other stakeholders in Ghana. The focus of the Action Plan is on MDG 5 in
reducing maternal mortality ratio by three-quarters by 2015. The MAF is to redouble efforts to
overcome bottlenecks in implementing interventions that have proven to have worked in
reducing MMR in Ghana. It focuses on improving maternal health at both community and health
care facility levels through the use of evidence-based, feasible and cost-effective interventions in
order to achieve accelerated reduction in maternal and new born deaths.
10. One of Ghana’s key strategies for addressing remaining disparities in access to
maternal and child health services is to mount a strong community health program to
complement other efforts on service delivery and health financing. The proposed Ghana
Maternal and Child Health & Nutrition Project (MCHNP) builds on efforts initiated by the
Ghana Health Service (GHS) to establish a national Community-based Health Planning and
Services program to reduce barriers to health care. With an initial focus on deprived and remote
areas, the program has adopted a promising strategy to strengthen the primary health care system
by introducing a mobile community-based, nurse driven care model which brings services closer
to beneficiaries and uses practitioners who are familiar with the socio-cultural context. The
program has a number of key features: (i) a bottom up planning process which fosters a dialogue
between community representatives and service providers; (ii) greater involvement of traditional
community leaders who are well respected and can effectively transmit messages about health
seeking behavior; (iii) structured training and mentorship program, whereby District Health
Management Teams (DHMT) ensure that community health workers have the requisite skills to
deliver a set of high impact interventions (e.g. immunization, assisted deliveries, postnatal care,
family planning); and (iv) reliance on personnel who are knowledgeable with the local context as
they come from the local community and are able to communicate effectively on sensitive
matters. The Community Health Officers (CHO) provides home-based services, and cover
catchment areas of up to 5,000 individuals. They are supported by volunteers who mobilize
communities, carry out growth promotion, counseling and maintain registers.
11. The World Bank has had long standing collaboration with the government of Ghana in
the health sector. The Bank has provided both financial and technical support, working in close
partnership with other donors. The findings from a major health financing study produced by the
Bank (The Health Financing in Ghana, 2013) is helping to inform the national debate on the
future of the NHIS and the design of a project aimed at strengthening the national health
insurance scheme. The recently closed Nutrition and Malaria Control for Child Survival Project
(NMCCSP) assisted the government to strengthen and roll out the Community-based Health
Planning and Services program. The project was innovative and successful. It established and
rolled out a strong community-based growth promotion program across 77 districts in 5 of the
country’s 10 regions. The program grew in scope and coverage, reaching roughly 310,000
children with a full range of services and information on infant and young child feeding
practices, breastfeeding, vitamin A supplementation, complementary feeding, and use of Oral
Rehydration Salt for management of diarrhea. The project also reached over 65,000 pregnant
6
women with a comprehensive package of pregnancy related interventions. The project, therefore,
contributed to increase access and utilization of community- based health and nutrition services
in the target regions and communities. This resulted in a significant reduction in the number of
malnourished children through early detection of cases during the monthly growth monitoring
sessions, and counseling of mothers and care-givers on appropriate health and nutrition practice
to prevent malnutrition among children. Other services such as immunization, vitamin A
supplementation, home visiting by volunteers contributed significantly to enhance health
outcomes in the target groups. It also contributed to expanding coverage of bed nets through the
procurement of roughly 1.4 million Long Lasting Insecticide Treated Nets.
12. In parallel the Government of Ghana is also preparing a Ghana Health Systems
Strengthening Project, which aims to improve the efficiency and equity of the NHIS. It will
support the expansion of an electronic claims management system, a capitation-based payment
system for primary health care, and enrollment of the poor and vulnerable, started under the
Health Insurance Project, to provide better financial risk protection. Thus, while the proposed
MCHIP will focus on scaling up the community-based health program, the health systems
strengthening operation will provide mutually reinforcing support to strengthen the NHIS. Other
donors are supporting critical investments such as equipment for emergency obstetric and
neonatal care and training to improve health to strengthen core health services.
13. The proposed MCHNP builds on lessons learned from the NMCCSP and other IDA-
supported programs in Africa as well as other community-based programs in other sectors in
Ghana. The most important lessons reflected in the project design are summarized below.
Technical lessons
Evidence from other countries such as Burundi, Rwanda, Zambia and Sierra Leone shows
that targeted evidence based financing will scale up access and utilization of basic essential
primary health care services. Hence, it is envisaged that similar results will be achieved in
Ghana.
Community nutrition programs should primarily target children below the age of two years
old.: Given the importance of health outcomes in the early stages of life, community health
and nutrition programs should primarily target children up to the age of two years; this period
is critical as the major damage caused by malnutrition takes place in the womb and during
the first two years of life and this damage is irreversible. The project therefore targets
children below the age of two years.
Communication and mobilization for behavior change: Behavior Change Communication
(BCC) can bring about improvements in nutritional conditions, without the reliance on
external food assistance. Dynamic community mobilization processes can significantly
enhance public service delivery systems. For that reason one-to-one communication and
counseling of mothers and care-givers will be strengthened as a prominent feature of this
project.
Strategic communication: Greater mobilization can be engendered through increased
awareness of the issues surrounding poor health and malnutrition, their scope and magnitude,
and the positive outcomes that can be achieved through direct intervention. Malnutrition, for
example, is not typically on the development agenda, be it at the household, community,
7
district, or national level. There are numerous reasons for this, including the fact that many
forms of malnutrition are invisible. Also, those who suffer most do not usually have a voice
in policy making and budgetary decisions. The project will, therefore, seek to put nutrition
firmly on the national agenda and that of District Assemblies (Das).
M&E and integrated community registers: A strong orientation toward management for
results strengthens the sense of ownership and performance of all stakeholders involved in
project implementation. Therefore, the project will test performance-based incentive systems
at the community level based on project-relevant outputs. A well-designed M&E framework
is critical to implementing such a system and achieving outcomes. Therefore, the e-Register
introduced under the project will be enhanced and rolled out nationwide. Evidence from
NMCCSP has shown that the use of the integrated community-based growth promotion
registers afforded the implementing communities to keep track of children less than two
years of age. This greatly enhanced the accurate determination of community populations.
Most community-based events were recorded into one register to avoid multiple records of
the same events. This was also presented in triplicate and worked well in reducing the burden
of reporting by the lower levels.
Availability of guidelines and protocols. The use of the sub-project manual and training
booklets for facilitators and participants ensured a uniform understanding and
implementation at all levels. Availability of copies at the regional, district and sub-district
levels of the guideline for establishing community-based growth promoters CBGP, trainers’
guides, growth promoters’ manual, sub-project implementation manual among others served
as reference materials in times of doubt or confusion. This approach culminated in
maintaining the quality of the project at all levels.
Supervision of community-based activities. The NMCCSP significantly enhanced monitoring
and supervision of community-level activities. Through the provision of additional funding
(to complement government and development partners contributions), the activities of the
CBGPs and health staff were closely monitored and supported regularly. This helped to
strengthen delivery of health and nutrition services in general.
Regular peer review meetings. In order to map out the progress of work and chart the way
forward, regular review meetings were held at all levels. These review meetings provided the
platform for sharing of innovations and best practices which were included into the delivery
of health services in other districts. The reviews also presented a platform where other issues
pertaining to the delivery of health services were discussed.
14. Institutional lessons
The NMCCSP provided continuous capacity building in new and evolving knowledge on
child health and nutrition at all levels and this has shown to be crucial for the success of
improved health and malnutrition reduction efforts. The NMCCSP has shown that promotion
of community accountability and ownership are essential for sustainability. The project
involved community leaders and created community implementation committees (CIC) to
increase ownership and ensure support at the community level. Hence the project will
continue to engage community members and especially the leadership.
Given the many partners and government efforts involved in health and nutrition services
delivery, lessons from the inter-sectoral coordination and collaboration activities under the
NMCCSP is necessary for the establishment of a coherent national program.
8
Clear definition of the roles of various implementing institutions is very important for a
smooth project implementation. The NMCCSP suffered implementation challenges due to
duplication of roles at the beginning of the project. The project was restructured to eliminate
the duplication and this led to improved implementation.
15. Operational lessons
Involvement of community volunteers provides a complementary and inexpensive method for
delivery of social services: Community growth promoters, also known as volunteers, were
essential for the success of the NMCCSP. Trained and equipped by the project, community
growth promoters conducted growth promotion and monitoring as well as assisted the
community health officers (nurses) in the delivery of health services every month, counseled
mothers and care-givers and carried out home visits. Scaling up community-based service
delivery through community volunteers is a cost-effective strategy, particularly in the context
of limited financial and human resources in the health sector.
Project design needs to be flexible to adapt to local realities: The initial criteria for selecting
community growth promoters in the previous project required that all selected individuals
could read and write. However, community literacy was a challenge. The experience
showed that the roles assigned to the community volunteers could be carried out by an
unlettered person as far as he/she could use the visual manuals developed by the project and
therefore the selection criteria was changed to take into account individual community
situations. These kinds of context-induced flexibilities are included in the project design.
Poor access to potable water hinders project outcomes: The project will promote stronger
links with other sectoral programs and projects that influence health outcomes such as water,
sanitation, agriculture, and education. Strategic communication will be employed to better
utilize available resources.
16. There is a strong partnership framework in the health sector and numerous partners
are contributing in various ways towards the attainment of the MDGs. The project will benefit
from technical assistance of the United Nations technical agencies and will complement
activities of other development partners. The World Health organization (WHO), the United
Nations Children’s Fund (UNICEF), the World Food Program (WFP) and the Micronutrient
Initiative (MI) will be providing technical assistance on policy and strategy development
including micronutrient deficiency control strategies as well as procurement and distribution of
vaccines. The World Bank will continue to support the implementation of the CHPS and roll out
the community-based growth promotion activities nationwide. The other donors such as the
Global Fund, the European Union (EU), the United States Agency for International Development
(USAID) and the United Kingdom Department for International Development (DFID) will
continue to support procurement and distribution of anti-malarial drugs and diagnostic test kits,
equipment for service delivery in facilities, training of clinical staff and strengthen the regulatory
system to ensure good quality inputs for service delivery.
C. Higher Level Objectives to which the Project Contributes
17. The new Country Partnership Strategy (CPS), seeks to support Ghana in addressing the
multiple challenges to improving the delivery of basic services and reducing disparities in line
9
with the country’s middle income status. The project will support the next medium term health
sector development plan (MTHSDP – 2014-17) which aims at contributing to socio-economic
development and wealth creation by promoting health and vitality, ensuring access to quality
health, population and nutrition services and contribute to the post 2015 development agenda of
ensuring universal coverage for the population. The proposed project will contribute to the above
goal by focusing on improved basic community health and nutrition services targeted to poor and
vulnerable groups in remote and disadvantaged regions.
II. PROJECT DEVELOPMENT OBJECTIVES
A. PDO
18. The project development objective (PDO) is to improve utilization of community-based
health and nutrition services by women of reproductive age, especially pregnant women, and
children under the age of two years.
19. The PDO will be achieved by: (i) increasing availability of high impact health and
nutrition interventions, and (ii) addressing access barriers using existing community-based
health service delivery strategies and communications channels to inform, sensitize and motivate
care-givers, community leaders and other key audiences. The project will thus strengthen the
delivery mechanisms for community health and nutrition services; enhance multi-sectoral
coordination and collaboration; and improve ownership and accountability of all stakeholder
efforts towards improved maternal and child health outcomes. The operation will bolster the
Community-based Health Planning and Services (CHPS) delivery platform, building on the
achievements of the earlier operation. A follow-on operation (Health Systems Strengthening
Project), which is under preparation on a parallel track, will focus on improving coverage of the
poor, increasing efficiency, and ensuring sustainability of the National Health Insurance Scheme.
20. The proposed project will address key disparities in access to high-impact maternal,
neonatal and child health services focused on remote and underserved areas. It will support
identification of pregnant women, registering both with the health system and the NHIS and
screening them for eligibility to benefit from the conditional cash transfer program – the LEAP.
While the previous project was implemented in 5 regions, this operation will now cover all 10
regions of the country, in order to reach a maximum number of beneficiaries. In the Northern,
Volta, Upper East and Upper West regions, the project will be implemented in all communities
to address the inequity gap to increase utilization while within each of the remaining 6 regions,
the project will cover at least 50 percent of communities, targeting the poor and deprived areas
based on the level of their health outcomes.
Project Beneficiaries
21. Within the participating communities the project will specifically target: (i) women of
reproductive age with a specific focus on pregnant women; and (ii) children under the age of 2
years to take full advantage of the window of opportunity for improving child survival, growth
and cognitive development. In addition to these two main beneficiary groups, others within the
community, especially children under 5 years, will also benefit from community-wide initiatives
10
for improved health and nutrition and public health interventions such as salt iodization, growth
monitoring, and encouraging enrollment of pregnant women in the NHIS. More specifically, the
proposed project will benefit about 1.6 million women of reproductive age including pregnant
women and about 5.6 million children under the age of 2 years cumulatively over 5 years.
PDO Level Results Indicators
22. The following indicators will be used to track achievement of the PDO: Both baseline
and end project data for the PDO and intermediate outcome indicators are from the district health
information management system (DHIMS), the 2008 GHS and 2011 MICS.
1. Proportion of pregnant women making first antenatal visit in the first trimester.
2. Births (deliveries) attended by skilled health personnel (number).
3. Proportion of children under two attending community growth promotion activities.
4. Proportion of children 0-6 months exclusively breastfed in the past 24 hours.
5. Proportion of new acceptors of modern contraceptives (females, 15-49).
6. Direct project beneficiaries (number).
7. Direct project beneficiaries that are female (percentage).
III. PROJECT DESCRIPTION
A. Project Components
23. To achieve the expected improvements in health and nutrition outcomes the project will
provide support to strengthen utilization of key interventions, remove barriers to health care
access, enhance accountability, and bolster institutional capacity. A key innovation in this
project, compared to the previous operation, is the introduction and piloting of a community
based performance-based financing approach to strengthen accountability, improve motivation of
community health workers, and focus attention on results. The project includes two mutually
reinforcing components. The first one will focus on service delivery and the second on capacity
building.
Component 1: Community-Based Maternal and Child Health and Nutrition Interventions (estimated cost, US$63 million: IDA US$58 million, HRITF $5 million). This component will
focus on strengthening supply, creating demand, and increasing ownership and accountability of
district level stakeholders, outreach workers, community leaders and household members. The
component will support the uptake of a package of essential community nutrition and health
actions (ECNHA) and address gaps in knowledge and community practices such as reproductive
behavior, nutritional support for pregnant women and young children, recognition of illness,
home management of sick children, disease prevention and care-seeking behavior. Table 1 below
provides details on the ECNHA for the various beneficiary groups.
11
Table 1 Essential Community Nutrition and Health Actions for the Beneficiary Groups
Beneficiary Groups Essential Community Nutrition and Health Services
(ECNHA) Children under the age of two years - Community weighing of under two year olds
- Promotion/counseling on IYCF practices (Breastfeeding + Complimentary feeding)
including iodized salt
- Promotion/counseling on the management of sick children at the household level
(danger signs, feeding)
- Promote scaling up of community management of acute malnutrition (CMAM -
severe and/or moderate)
- Promotion of child spacing and modern contraception
- Community distribution of ARI antibiotic
- Distribution (including promotion and mobilization) of vitamin A, deworming,
invermectine
- Community distribution and promotion of bed net utilization
- Mobilization for and promotion of use of preventive child health services (e.g.,
immunization)
- Hygiene education
o Food hygiene (storage)
o Environmental hygiene (sweeping, disposal, recycling)
o Corporal hygiene (hand washing, bathing, running water
technologies)
- Promotion of basic safe water technologies (storage, household treatment)
- Promotion of the open defecation free status, use of sanitation facilities and proper
disposal of children feces
- Prevention of children smoke inhalation (separating kitchen from children space,
improved stoves)
Children under the age of five years - Community wide initiatives such as utilization of iodated salt
- Enrollment of into NHIS
Adolescents - Delay of first pregnancy (community awareness, education of male/female
adolescents on protection – peer educators for first contact and health workers –
modern contraception methods including condom and emergency contraception)
- Nutrition education of female adolescent - peer educators – at community level
including iodized salt
- Promote use of iron/folic acid supplementation of female adolescents including
promotion and monitoring of adherence
- Pilot (regional level) of nutritional screening – height, weight, hemoglobin through
outreach
Pregnant women - Mobilize women for early (first visit in 1st T) and minimum prenatal care3 (four
visits)
- Nutrition education at community level
- Community promotion of social care of pregnant women
- Promotion and monitoring of adherence to iron supplementation
- PBF for skilled delivery and first delivery at facilities
- Provision of delivery kit for every pregnant women who comes for delivery at
facility
- Queen mother – pregnant women groups
- Promotion of early post-natal care
- Promotion of household level newborn care
24. The component has two sub-components: (i) Strengthening Service Delivery; and (ii)
Piloting Community Performance-Based Financing.
25. 1.1 Strengthening Service Delivery (IDA US$53 million): This sub-component is the
centerpiece of the project, which will support community authorities to plan, program and
3 Content of Prenatal Care: IPT, iron/folic, TT, PMTCT, FP
12
implement critical activities aimed at increasing utilization of maternal and child health and
nutrition services. The bottom up process of planning and carrying out community-based
health and nutrition interventions provides flexibility to local authorities to identify their needs
and empowers them and makes them accountable for results which is in line with government’s
decentralization policy, and long standing practice of channeling funds to district level structures.
The project will continue using these structures and procedures to boost service delivery at
community level. To this end, this sub-component will fund three main types of activities:
Sub-grants for district level activities including: support to district level sub-projects
which refer to strategies and activities in the District Plan of Action that promote
utilization of community based health and nutrition services. These include (i)
community-based interventions promoting registration of pregnant women with the
community health officer and in the national health insurance scheme as well as
screening them to determine eligibility to benefit from the conditional cash transfer
program; (ii) complete antenatal care and delivery package (e.g. supplements, iron
tablets, immunizations, bed nets, assisted deliveries, referrals); (iii) counselling of women
of reproductive age, follow up home visits, and provision of commodities (e.g. family
planning); (iv) outreach activities to encourage improved management of childhood
illnesses at household level; and (v) mobilization of community members for growth
monitoring, immunization of children, and nutrition education. The sub-project will
provide ample flexibility for Districts to develop context-relevant implementation
strategies. The grants will also support training of sub-district staff and community
volunteers, workshops and incremental operating costs. The Operational Manual will
provide a description of the operational modalities and reporting arrangements.
Capacity building activities of relevant central, regional, and district governments to plan,
administer, and supervise the community-based health and nutrition interventions;
training of trainers, develop and implement an effective program of communication
strategies for behavior change and tailor messages appropriately to the target
beneficiaries by producing simple health education booklets; and design and conduct
community level training, and mentorship activities for community health and nutrition
service providers (e.g. community health officers and volunteers) and support district to
district, community to community knowledge sharing and learning exchanges. The
project will also support training of community health officers and volunteers on the
national medical waste management policy and printing of flyers or brochure’s to
distribute to staff and patients.
Critical inputs will be procured centrally, including weighing scales for pregnant women,
new born babies and children; motorbikes for CHOs and midwives in the communities;
pickup vehicles for selected needy districts; long lasting insecticide treated nets (LLINs);
vitamin A capsules and Oral Rehydration Salts (ORS).
26. Piloting Community Performance-Based Financing (CPBF) US$10.0 million (US$5.0
million IDA and US$5.0 million HRITF): This sub-component finances a pilot fee-for-services
community performance-based financing mechanism at the district and primary care level. A
carefully implemented ‘fee for services’ pilot will be initiated in 8 districts (two from each of the
four most vulnerable regions on maternal health indicators in the country) and compared with
controls using regular input based approaches. At the mid- term review, lessons learnt will feed
13
into decisions to scale up to additional vulnerable districts in the same regions. The selected four
regions (Northern, Volta, Upper East and Upper West) experience a high burden of maternal and
child health (MCH) conditions and lag behind the rest of the country in progress toward health
outcomes, especially among the lowest wealth quintile. The sub-component seeks to strengthen
focus on results and quality at the community level, and in the process increase coverage of high
impact interventions in districts with weak maternal and child health indicators.
27. Community Health Teams (CHT) made up of 2 Community Health Officers, at times
midwives, and between 4-6 volunteers depending on the size of the community. CHTs will be
contracted for the delivery of a specified package of essential MCH services within a particular
Community Health Planning Services (CHPS) zone. This sub-component introduces incentives
targeting the CHT to improve health behaviors and health service utilization respectively. CHTs
will be paid on a fee-for-service basis according to the quantity and quality of services achieved
in a given period. As part of the district sub-grants (see component 1.1) the District Health
Directorate (DHD) will sign a performance-based contract with the Office of the Regional
Director for supervision outputs and for mentoring related services they will provide to CHTs.
The package of services to be purchased is built around key interventions which can be
effectively delivered through the country’s well-established community based health and
nutrition program and which support delivery of high impact interventions that directly support
Ghana’s efforts to accelerate progress towards MDGs 4 and 5. The set of indicators which are
being considered for which CPBF payments will be made are: (i) identification and registration
of the pregnant women with the health worker and the NHIS; (ii) pregnant women making the
first antenatal visit in the first trimester; (iii) pregnant women making a minimum of four
antenatal visits and delivering in a health facility; and (iv) at least one post natal care visit within
seven days of delivery.
28. The CHPS zone is the main platform for CPBF implementation. The DHMT and a CHO
will sign performance-based contracts on behalf of each CHPS zone. Each contract will include a
costed set of activities supporting maternal and new-born care and will cover both quality and
quantity of health services to be provided by the CHT to the population within its catchment
area. The CPBF will pay for results achieved through outreaches, home visits and community
durbars. An example of a package of services provided by CHT is outlined in Table 2 below. A
more detailed description of definitions of indicators and their quality measures as well as
associated costing and weighting will be finalized before project effectiveness. The costing of
indicators has been done to ensure that the service package does not exceed the reasonable cost
of providing the community-based package. Challenges faced by CHTs in remote CHPS Zones
result in higher costs of delivering primary care services. The fee-for-service scheme will take
this into consideration by adjusting the fees of delivering services in more remote CHPS zones.
The pricing of the package of services and quality bonuses for CHTs will be informed by: (a)
operational costs for community outreach; (b) household out-of-pocket expenditures such as
those incurred when women go to health facilities; and (c) primary health priorities and goals of
Ghana. Each CHT can receive a maximum of about $3000 per annum for achieving the desired
results.
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Table 2 Example of CPBF
Service
Number
Provided/
Quarter
Unit Price Total Earned
Identification and registration of the
pregnant women
120 $0.5 $60
Pregnant women making the first
antenatal visit in the first trimester
90 $0.5 $45
Pregnant women making a minimum of
four antenatal visits and delivering in a
health facility
60 $4 $240
One post natal care visit within seven days
of delivery
45 $1 $45
Sub Total $390
Remoteness (Equity) Bonus +20% $78
Sub-Total $468
Quality correction 60% (of 468) $281
Total/Final Earnings $749
29. The project will make quarterly payments based on quantity of services delivered and the
outcome of the DHMT’s quarterly supervision for quality, which will include record reviews,
direct observations and administration of a checklist which assesses the adherence to set
standards for community primary care services in line with national policy. Each quarter,
Community Based Organizations (CBOs) will carry out community surveys within each CHPS
zone to generate a client satisfaction score to be used by DHMTs to calculate a portion of the
PBF subsidy paid to CHTs. Thus the total quality component will be made up of a technical
assessment score provided by DHMT upon completion of a supervision visit as well as the
community satisfaction score from client tracer surveys. Post payment, an independent
verification agency will undertake counter-verification and report its findings to the Office of the
Regional Health Director whose team will work with the DHMT to apply necessary rewards and
penalties on CHTs, CBOs and in some cases the DHMT itself. The Project Implementation
Manual (PIM) will outline in-depth details of the internal and external verification functions,
deliverables and timelines.
30. There will be considerable autonomy in how CHTs use the funds they earn. Each CHT
will develop an operational plan to guide the use of CPBF subsidies; these plans will be part of
the contracts signed with the DHMT. The operational plans will help the CHT develop their
ideas and innovations, and will describe how planned activities will be implemented. Operational
planning will be done every six months to allow the renewal of the contract in the first year of
the project, and thereafter it will be annual. The plans will identify key problems in the
catchment area, such as why health service objectives and targets are not achieved, and propose
realistic strategies, as well as resources, timelines, approaches and persons responsible to address
these problems. CPBF subsidies will cover expenses within broad categories including: (i) costs
associated with service delivery; and (ii) performance-based motivational team bonuses for the
CHT; and (iii) transportation of pregnant women at the time of delivery or due to pregnancy
15
related complications and for children for emergencies during the neonatal period. To set the
teams to function effectively the first payments will be issued based on credible evidence of (i)
the first six monthly plan of activities (ii) the availability of a signed performance contract (iii) a
bank account.
31. The Project Implementation Manual will describe the details of the CPBF model
including: (i) the governance structure at national level; (ii) national level management, technical
and fiduciary oversight of pilot districts; (iii) service package and fee schedule; (iv) the tool used
for quality supervision by DHMT and by the office of the Regional Director; (v) CBO
contracting and accountability for client tracer survey at community level; and (vi) the scope and
technical approach of the external verification work.
32. Given that this sub-component introduces CPBF innovations in Ghana, there will be
technical support to ensure that skills to manage a robust scheme are imparted to key national,
regional, district and CHT representatives to implement the program. The technical assistance
(TA) will also focus on building or strengthening key systems to enable management of a
decentralized PBF scheme. Aspects that could be strengthened include functioning of the
eRegistry system maintained by CHTs to ensure it can be used to verify and trigger payments;
(ii) capacity for managing the CPBF operational and strategic cycles; purchasing and verification
functions at all levels of the health system.
Component 2: Institutional Strengthening Capacity Building, Supervision, Monitoring and
Evaluation, and Project Management (estimated cost: IDA US$8 million)
33. The institutional strengthening component will support three main objectives, namely to:
(i) develop effective inter-sectoral coordination, ownership, and accountability for health and
nutrition towards the strengthening of a coherent national community health and nutrition
program; (ii) strengthen MoH capacity to provide stewardship, as well GHS capacity to
effectively coordinate, supervise and monitor implementation of the community-based services;
and (iii) evaluate the impact of the project. The operation will provide support for two broad
areas, as described below.
34. 2.1 Stewardship, Policy and Lessons Learning (US$1.5 million): This sub-component,
led by the Ministry of Health, will finance technical assistance, policy reviews, national
workshops, and incremental operating costs to provide stewardship for the sector and support the
GHS and its decentralized levels in the implementation of key interventions under Component 1
and will include technical support and inputs to:
Provide oversight for all project activities including procurement, financial management,
monitoring and evaluation.
Establish and build capacity for inter-sectoral coordination.
Develop and/or update strategies and policies to mainstream nutrition and health into the
multisectoral development agenda at all levels.
Develop health sector policies, protocols and procedures relating to maternal and child
health including community-based service strategy.
16
Ensure harmonization of health and nutrition policies, protocols and procedures with
those of other sectors at the community level.
Develop guidelines and tools for service quality improvements.
Support south-south knowledge sharing and learning exchanges.
35. 2.2 Supervision, Monitoring and Evaluation and Project Management (US$6.5
million): Led by the Ghana Health Service this sub-component will support capacity building for
implementation, supervision, project management, and M&E, including baseline and end-of-
project surveys. Community-based monitoring tools will be used to strengthen collaboration
between citizens and health facilities in monitoring key aspects of the project. Bank tested tools
and approaches such as the citizen score cards will be implemented to deepen community
participation for improved monitoring of community-based health and nutrition services
including the CPBF. The appropriate tool will be developed through a broad-based consultative
process and will seek to strengthen relations between communities and health service delivery
stakeholders by improving service provider accountability and community responsibility in
monitoring the utilization of community-based health and nutrition services. This component
will involve comprehensive capacity building for stakeholders, including government agencies,
community organizations and volunteers, and the roll-out of the innovative scorecards in selected
communities. A detailed description of the process and stakeholder responsibilities will be
provided in the scorecard implementation guidelines. Implementation of the national medical
waste management policy will also be monitored to ensure appropriate disposal of the minimal
waste that will be generated at the community level.
36. Evidence for Management and Policy Decision Making under the CPBF. The design
of the impact evaluation for the CPBF will be done in close consultation with the Ghana Health
Service (GHS). Evaluation activities agreed to by the Government and the Bank will be rolled
out to answer policy-relevant questions and strengthen evidence-based CBPF learning by policy
makers, technical staff in GHS and development partners. Comprehensive baseline data to be
collected includes administrative and HMIS data, population based surveys, and a dedicated
facility and health worker survey.
37. A Process Monitoring and Evaluation (PME) will be rolled-out to better understand
context specific factors that influence the performance of CHTs in the pilot districts and regions.
The PME will be a critical piece to inform the envisaged scale-up to additional districts. The
final design of the PME will be agreed jointly with the GHS after project effectiveness. The sub-
component will also support the hiring of an independent verification agency to validate the
CPBF results. Lessons learnt from the use of community score cards, decentralization to
communities and the contribution of the performance-based financing to service uptake will be
documented for wider dissemination. The table below illustrates the relationship between focal
areas as defined by MDGs, constraints to overcome and issues to be addressed, evidence for
proposed interventions, inputs, activities and the results chain for the project.
38. Unallocated (estimated cost: IDA US$2 million). These funds will be drawn into any
component upon justified need, as a means to secure additional flexibility to project activities.
17
Table 3 Project Results Chain
Major focus area Constraints/Issues Evidence MCHIP Inputs MCHIP
Activities/Outputs
MCHIP
Outcomes
MCHIP Impact
MDG 5:
Maternal mortality
Unequal use of
skilled birth attendance by
income quintile
Increased health
insurance coverage leads to
higher use, esp.
for the poor
Targeting
mechanisms, focus on the poor
Community-based
interventions: promoting
registration of
pregnant women and the poor with
NHIS
Higher health
insurance coverage and use
of health services,
including delivery
(PDO 2)
Improved
maternal outcomes due
to increased
inst. Delivery
Unequal use of skilled birth
attendance by
location (urban/ rural)
Community-based
interventions are
effective in reaching the
household level
leads to higher
utilization
especially in
rural areas
Physical inputs (scales,
motorbikes, etc.),
incentive payments to
community
health teams
(CHOs and
volunteers)
Community-based interventions:
community
referral, community
pregnancy care
Higher levels of skilled birth
attendance by
those reached with these
interventions
(PDOs 1 & 2)
Improved maternal
outcomes due
to increased inst. Delivery
Inadequate use of nutritional and
disease preventive
interventions by pregnant women
Community-based
interventions for
preventive health at household
level
Provision of LLINs through
focused ANC.
Other partners including
Government to contribute to
provision of
Antenatal package
Community-based interventions:
community
referral, community
pregnancy care
Higher levels of mothers
delivering without
medical and nutritional related
complications
(PDOs 1 & 2)
Improved maternal
outcomes due
to better maternal health
Inadequate use of
family planning for
birth spacing, and low age at first
pregnancy
Community-
based
interventions are effective in
promoting family
planning and addressing
adolescent sexual
health
Physical inputs
(scales, bicycles,
etc.), family planning
commodities,
incentive payments
Community-based
interventions:
family planning and adolescent
sexual health
counseling, distribution of
family planning
commodities
Increased spacing
between
pregnancies, and higher age at first
pregnancy due to
the use of family planning
(PDOs 4 & 6)
Improved
maternal
outcomes due to better birth
spacing and
higher age at first pregnancy
MDG 4 and 1 (c)
Infant and under
5 mortality, malnutrition
Bed nets provided
under the previous
project have a useful life of 3-5
years and are
starting to wear out
Provision of
replacement bed
nets lead to high population
coverage
Bed nets, Distribution of
bed nets
Community-based interventions:
promoting bed net
use
increase bed net
coverage and use
Improved
infant and
under-5 mortality and
decreased
morbidity due to increased
use of bed nets
Inadequate and
worsening infant and young child
feeding (IYCF) practices
Community
mobilization and community
social and behavior change
communication
leads to high
improvement in
IYCF practices
Physical inputs
(scales, motorbikes,
registers, etc), training, health
promotion and
educational
materials,
counseling
materials,
Community
mobilization, community-based
nutrition education and
IYCF counseling
Improved IYCF
practices
(PDOs 3 & 5)
Improved
infant and under-5 health
and nutrition outcomes due
to improved
IYCF practices
Inadequate management of
common childhood
infections at household level
Community-based education
and counseling is
effective in improving the
management of
childhood illnesses
Physical inputs (motorbikes,
registers, etc),
training, health promotion and
educational
materials, counseling
materials,
incentive payments
Community mobilization,
community-based
counseling and education
Improved management of
childhood
illnesses at household level
(PDO 5)
Improved infant and
under-5
mortality and decreased
morbidity due
to improved management of
childhood
illnesses
18
B. Project Financing
39. The project will be financed by a US$68 million equivalent IDA Credit and a US$5
million Grant from the Health Results Innovation Trust Fund (HRITF). The HRITF Grant has
been approved on February 7, 2014.
Table 4 Financing
Project Components Project cost ($ million) IDA Financing HRITF % IDA
Financing
1. Community-Based Maternal and Child Health
and Nutrition Interventions 2. Institutional strengthening Capacity Building,
Monitoring and Evaluation, and Project
Management 3. Unallocated
Total Costs
63.0
8.0
2.0
73.0
58.0
8.0
2.0
68.0
5.0
0
0
5.0
85.3
11.8
2.9
100
IV. IMPLEMENTATION
A. Institutional and Implementation Arrangements
40. As a repeater project, the MCHIP will continue to use the restructured implementation
arrangements under the recently closed NMCCSP. These arrangements were considered
satisfactory. As such the Ministry of Health (MoH) will be responsible for policy formulation
and overall stewardship for the project and the Ghana Health Service and its decentralized levels
for service delivery. The project will follow the Common Management Arrangement (CMA),
developed by the MoH, that sets out planning, financial management, procurement, monitoring
and evaluation procedures to be followed by Government and all partners within the health
sector.
41. The Ministry of Health will provide technical assistance, organize reviews, monitor and
evaluate project activities. These functions will be coordinated by the MoH Policy Planning,
Monitoring and Evaluation Directorate (PPMED). Oversight of project activities will be
provided under the framework of the Millennium Acceleration Framework (MAF) Steering
Committee (SC), the recently established framework to redouble efforts towards achievement of
MDGs 4 and 5 and chaired by the Chief Director of the Ministry of Health. The role of the SC is
to ensure complementarity and timely implementation of all related partner activities.
42. Technical oversight of the activities supported by the project will be provided by a
Technical Advisory Group (TAG) under the overall guidance of the Director General of the
GHS. It will include the following GHS divisions; Family Health (FH); Public Health (PH);
Policy Planning, Monitoring and Evaluation (PPME); Institutional Care (IC); Finance; Internal
audit (IA); Research and Development (RD); Human Resource Development (HRD); Supplies,
Stores and Drugs Management (SSDM); and Health Administration and Support Services
(HASS) as well as representatives from other sectors such as the Ghana Education Service
(GES), Ministry of Food and Agriculture, Local Government Service and Department of
Community Development. The TAG will (i) provide guidelines, standards, and technical
19
support; (ii) develop action plans to guide implementation; (iii) ensure multi-sectoral linkages at
the district level; and (iv) evaluate district plans of action. The GHS Policy Planning, Monitoring
and Evaluation Division (PPMED) will provide secretariat support for the project and also
perform the M&E role under the project. The chair of the TAG will report project
implementation progress to the senior management team of the GHS and to the MAF Steering
Committee on quarterly basis. The activities of the project will form part of the work-plan of the
agency and shall be subject to the agency rules and guidance on updates and reporting of
activities.
43. At the regional level, the Regional Director of Health Service (RDHS) shall be
responsible for the implementation and monitoring of project activities. A team made up of the
Deputy Regional Director, Public Health, the Regional Nutrition Officer and Disease Control
Officer will be responsible for the day-to-day operations including preparation of regional
quarterly progress report of activities of all districts within the region to the TAG. Project related
issues will be discussed and addressed within the framework of the Social Sector Sub-committee
of the Regional Coordinating Council (RCC).
44. The District Director of Health Service (DDHS) will coordinate the preparation and
implementation of the District Action Plan for sub-projects following operational guidelines
prepared by the GHS Headquarters. The guidelines will provide ample flexibility for Districts to
develop context-relevant implementation strategies. Each District Plan of Action for the sub-
projects will be approved by the Technical Advisory Group. Once approved funds will be
disbursed from the GHS to the District. The District Director will be the focal person for the
project in the district and will provide technical guidance and leadership for implementation and
monitoring within the framework of the Social Services Sub-Committee of the District Assembly
with membership from various sectors including Health, Food and Agriculture, Education and
Community Development to ensure linkages with other sectoral programs at the community and
household level. The district health management team (DHMT) will monitor and evaluate
activities of the sub-districts and the sub-district health teams will provide implementation
support to the CHOs and volunteers for the community-based interventions.
45. Community Health Officers (CHOs) and community volunteers are the principal change
agents in the project and with the support of NGOs will carry out outreach programs, home visits
and growth promotion activities. This project, learning from the experience of the NMCCSP will
support existing community structures to mobilize the community members, facilitate the
selection of community volunteers, oversee and provide support to the monthly growth
promotion activities by holding regular management meetings to discuss progress in the
community. The volunteers will assist with the organization of regular meetings with the
community to review progress of project activities. It will also use the existing local structures
to engage community leaders to take ownership and accountability for issues affecting the health
and nutritional status of the community.
B. Results Monitoring and Evaluation
46. As a repeater project the MCHIP will include a comprehensive M&E system as part of
the regular M&E process for the entire health sector and based on the experience from
implementation of M&E under the NMCCSP. The emphasis is on monitoring action relevant
20
information. The current monitoring system of the health sector is designed such that each level
feeds into the next and vice versa. At the level of the individual household, the registers serve as
the principal tool for monitoring and taking action to improve maternal health and child growth.
The CHOs and the volunteers keep track of the registers that were developed and tested under
the NMCCSP. Community and district level progress data (e.g. project activities, outputs and
outcomes) will continue to be collected monthly by the CHOs and volunteers and district focal
persons (District Director of Health Services), respectively. The aggregated information that is
channeled upwards to the district level is the basis for supportive supervision of community
activities by the DHMT and Regional Health Management Team (RHMT) to enhance
performance. The electronic register (eRegister), developed under the NMCCSP, captures these
transactional data and will be used as one of the primary sources of verification of community
level preventive services. The eRegister will be integrated to share data and upload into the
DHIMS for reporting health indicators. With the use of the eRegister, records of registration,
ANC, delivery, PNC and each growth monitoring visit will be used for internal CPBF
verification to validate data prior to payment. Thus the health staff earning the reward will ensure
that records of visits and attendances, including service data are entered into the system. The
independent verification agency of the CPBF will report its findings to the Regional Director
whose office will: (a) undertake necessary follow-up and enforcement of penalties and rewards;
and (b) share reports to the national level.
47. The aggregated information is also put into the district health information management
system (DHIMS) which is a national information management system covering activities of both
public and private sector and is used at all levels of the health system. The GHS PPMED will
ensure the timely reporting of progress on all indicators in the results framework and will collate
and present data from the various data sources. The project indicators with baselines and targets
are listed and the M&E arrangements are laid out in the results framework in Annex 1. Data will
come from the DHIMS as well as nation-wide-surveys as the Demographic & Health Survey
(DHS) for baseline and end of project target and the Multiple Indicators Cluster Survey (MICS)
in the mid-term of the project.
48. The DHMT sends quarterly and annual progress reports to the Director General and chair
of the TAG with copies to the Regional Director of Health Services. This information will be
incorporated in the quarterly financial statements (QFS) and half yearly progress report on the
entire health sector as provided for in the common management arrangements (CMA) by the
partners and the government. Currently, the MoH prepares QFS covering actual expenses,
procurement and physical progress and shares with all partners. Annual progress and plan of
work (PoW) for the following year are discussed during the health summit in April.
49. An independent evaluation involving two special surveys at the beginning (in the new
implementing districts) and end of the project is planned to measure the contribution of the
project to the achievement of outcomes. The evaluation study will be contracted out. For timely
feedback and unbiased monitoring, other process monitoring systems including operational
research will be incorporated. There will also be an independent verification of the CPBF results
by a third party engaged by the GHS as mentioned in previous paragraphs.
21
C. Sustainability
50. Sustainability of project activities will be assessed at two levels. First there will be an
assessment of community behavioral changes and, second, an assessment of the use and
implementation of systems, procedures and coordination mechanisms. With regards to the
former, continuous M&E will assess the impact of project activities aimed at empowering
communities to (i) prevent, recognize and deal with malnutrition, and promote healthy growth in
children; (ii) adopt positive changes in caring practices related to the preparation of food, feeding
and hygiene at household level, especially for children and pregnant and lactating women; and
(iii) utilization of services by all target beneficiaries especially pregnant women. By
implementing the project through the existing MoH/GHS systems this project will contribute to
strengthening the planning and management capacity for community-based health and nutrition
service delivery in such a manner that activities are incorporated into the regular sector annual
program of work right from the start and after the project closes. The fiscal burden generated by
the project is about one percentage point of Ghana’s health budget and the recurrent costs arising
from the project after the implementation period will be absorbed by the government’s budget.
As such, there is a moderate risk to financial sustainability of the CPBF approach beyond the
project term.
51. Furthermore, assessments will be undertaken of (i) the effectiveness of an inter-sectoral
approach to combat malnutrition and improve health status involving other sectors, departments
of district administrations and non-governmental organizations (NGOs); and (ii) the need for
NGOs and consultants to mobilize the district assembly and communities, and assist them in
implementing community-based health and nutrition interventions.
52. Encouraged by the NMCCSP experience, where communities still continue their child
growth promotion activities after the close of the project, it is expected that community
participation in both design and implementation of project interventions will foster a sense of
ownership and assure commitment to take appropriate action to improve utilization of health and
nutrition services at the community level. Additionally, lessons learned from NMCCSP
implementation have been used to improve the program and its delivery mechanism. The team
will continue to engage with both the MoH and the Ministry of Finance (MoF), during
implementation, to discuss the issue of financial sustainability, and to address it as part of the
larger discussion of financing for the health sector. This will ensure policies, strategies and
financing modalities are mainstreamed into national policies.
22
V. KEY RISKS AND MITIGATION MEASURES
A.
Table 5 Risk Ratings Summary
Risk Category Rating
Stakeholder Risk Low
Implementing Agency Risk
- Capacity Low
- Governance Low
Project Risk
- Design Moderate
- Social and Environmental Low
- Program and Donor Low
- Delivery Monitoring and Sustainability Low
Overall Implementation Risk Moderate
B. Overall Risk Rating Explanation
53. The overall project risk is rated as Moderate considering the introduction of CPBF carries
a higher than normal risk. In order to mitigate the risk associated with the introduction of CPBF,
the experience in other countries such as Rwanda and Burundi and other parts of the world will
be harnessed. Learning events will be organized and resources will be provided for technical
support. In addition monitoring and evaluation will be strengthened and capacity building
including mentoring will be emphasized. Beyond this, there has been a high level of engagement
on the part of the project counterparts, and they have actively participated in every aspect of
project preparation and design. This level of engagement signals a high level of commitment
and support for the project and its interventions, at the highest levels of MoH, GHS and the
Ministry of Finance. As a repeater project MCHIP builds on a recently closed NMCCSP, uses
the same management arrangements with established fiduciary and monitoring arrangements.
MCHIP essentially involves scaling up of existing project interventions which were established
in 77 districts out of a total of 216 existing districts. In addition capacity was also built for a large
pool of health workers and volunteers and this will be deployed to quickly roll out project
activities.
VI. APPRAISAL SUMMARY
A. Economic and Financial Analysis
Economic Rationale for Investing in Maternal and Child Health and Nutrition:
54. There is strong economic rationale for investing in maternal and child health and
nutrition in Ghana. While evidence from the Multiple Indicator Cluster Survey (2011) shows
23
improvement over time in access to and utilization of essential maternal and child health
services, nutrition supplements, and related health outcomes, regional, urban-rural, and socio-
economic disparities remain considerable (see more in Annex 6). Yet, despite increased attention
to maternal mortality and the availability of proven, high-impact interventions to address poor
maternal health, health systems and current financial commitments for maternal and reproductive
health may not be sufficient to achieve the MDGs 4 and 5, which focus on maternal and child
mortality.
55. The effectiveness and economic benefits of maternal and child health and nutrition
interventions go well beyond the health sector (see empirical evidence in Annex 6). Through the
channels of education and labor productivity these interventions affect the individual’s lifetime
earning potential and can lead to positive inter-generational wealth and poverty-reduction effects
at the household level, which in turn lead to measurable changes in the Gross Domestic Product
(GDP). For example, maternal mortality has a significant negative impact on economic growth
through its effect on the size of the labor force and adverse effect on human capital formation.
Similarly, maternal and childhood nutrition has substantial effect on economic growth, as
underscored in the Copenhagen Consensus (2012), and this is particularly relevant for Ghana
where nutrition is at the heart of economic development and poverty reduction efforts. Despite
the overwhelming evidence on the economic impact of maternal and child health and nutrition
interventions, the benefits of these services do not adequately reach the target groups in Ghana
because of both supply and demand side constraints, which include availability and quality
challenges (supply side) and physical and financial impediments to accessing care (demand
side).
56. To address these challenges and improve the availability and accessibility to good quality
maternal and child health and nutrition services, as defined in the PDO, the project proposes to
use simultaneous and reinforcing supply and demand side mechanisms, including: (i)
strengthening the community-based delivery platform; and (ii) introducing provider
incentives through community performance-based financing (CPBF). The interventions
financed by the project target resources to low-performing areas and the most vulnerable
segments of society, pregnant women and young children. Such targeting aims to contribute to
reducing both health outcome and poverty differentials in the country.
(i) Community-based service delivery has been attracting considerable policy attention
in low-income countries as an instrument that could bridge some of the health care
access and outcome gaps that unduly and adversely affect many of the poor and
vulnerable. Community-based approaches have been identified as one of the key
factors promoting improvements in health –and through the pathways of education
and labor market participation on broader economic wellbeing – even under very poor
economic conditions (see evidence in Annex 6). The community-based approach is
expected to generate additional benefits as it aims to shift the focus from traditionally
supply-side heavy interventions toward the demand side, which includes elements
such as decision-making at the local level, proximity to membership, personal
acquaintance of the members, empowerment of members by participatory design,
autonomous management, and lower-cost management due to reduced agency
24
problems and transaction costs. These attributes aim to foster service desirability and
affordability, which are critical for utilization, sustainability, and scale-up.
(ii) Performance-based financing (PBF) is an intervention that is gaining significant
momentum as a solution to poor performance and the health worker crisis in low-
income countries, particularly in Africa. Results indicate that PBF can play a role in
increasing the productivity of health workers and can have positive effects on health
service utilization. However – given the novelty, heterogeneity, and context-
specificity of PBF – to date the evidence base has been limited. To contribute to the
global knowledge base in this area and in line with the objectives of the HRITF
program, which supports the CPBF subcomponent, the project is subject to an impact
evaluation. The evaluation aims to gather evidence on the effectiveness, cost-
effectiveness, and equity implications of the intervention to inform design,
implementation, and policy decisions.
57. Rational for Engagement through the Public Sector: Working with the public sector
through this project is economically justified since: (i) there will be a focus on high impact and
cost effective interventions at the district level which are a public good, enabling better use of the
finite resources at community level; (ii) the presence of positive externalities produced by the
consumption or production of goods and services under the project that would otherwise not
have been consumed by members of the community; (iii) addressing market failures arising from
the imbalance between the knowledge of the supplier (health providers at the community and
facility levels) and the knowledge available to the consumer (information asymmetry) through
the community outreach activities and linkages of community members to the health facilities;
and (iv) providing financial risk protection (enrolling poor pregnant women and their families on
the National Health Scheme) to those who would otherwise have been prone to financial shocks
due to ill health.
58. The leadership of the World Bank in the preparation and implementation of
previous complex and similar projects in the health sector is acknowledged, and this has
led to a request for further assistance. The value added of the World Bank in this regard is its
in-depth knowledge of the health sector and the interventions to be implemented under the
MCHIP, as well as its extensive experience in Results-based Financing (RBF) in Africa and
other continents, which will be critical in successfully implementing the RBF activities.
Moreover, Word Bank technical support under the project (or in parallel) will significantly
contribute to the success of such a program.
B. Technical
59. Given the importance of mother and child care practices as determinants of child growth
and development, there is a widespread consensus on the need for community-based targeted
high impact maternal and child health and nutrition programs. The main thrust of community-
based nutrition and health programs is behavior change regarding maternal and child care
practices, and links to essential health services. A recent cross-country review of successful
programs has indeed shown that malnutrition can be reduced 2 to 4 times faster with availability
of such a program. The Maternal and Child Health Improvement Project aims to ensure
availability and utilization of such a program.
25
60. Scaling up nutrition programs is often faced by challenges with particular reference to the
country’s commitment and capacity to do so. A recent IDA publication4 highlights the reasons
for weak commitment to reduce malnutrition, which range from the invisibility of malnutrition,
to multiple stakeholders but no authorities in nutrition, to unawareness of the costs and
consequences of malnutrition and of successful direct interventions. The project is designed to
address these issues by making malnutrition visible at community level, increasing awareness of
the negative impact of malnutrition, showing that direct interventions work, and building an
alliance for nutrition in which all stakeholders adhere to a common vision for malnutrition
reduction.
61. In addition there is a link between malnutrition and disease and both have been shown to
increase the likelihood of the other. A sick child is more likely to become severely malnourished
and a malnourished child is more likely to die from disease. Hence good community practices
will help in improving both nutrition and health practices that in turn improve children’s growth
and cognitive abilities. Support to birth preparedness and complication preparedness is a key
component of safe motherhood programs, which helps ensure women reach professional delivery
care when labor begins and to reduce delays that occur when mothers in labor experience
obstetric complications. The community level interventions that center on equipping households
and communities with knowledge and skills will enable them to adopt practices and better
health-seeking behavior as well as help them recognize danger signs and symptoms related to
pregnancy and childbirth.
C. Financial Management
62. In line with the guidelines of the Financial Management Manual for World Bank-
Financed Investment Operations issued on March 1, 2010, a financial management (FM)
assessment was conducted on the Finance Sections/Units of the Ministry of Health (MoH) and
at the Ghana Health Services (GHS) – the two oversight and implementing agencies for the
Maternal and Child Health Improvement Project. Overall the financial management residual risk
rating for the project is assessed as Moderate. Details of the FM for the project are included
under Implementation arrangements in Annex 2.
63. Consistent with the default position of using country systems, the project’s FM
arrangement will to a greater extent adopt and rely on some aspects of the existing Government
of Ghana systems as regulated in the Financial Administration Act (2003) and the Financial
Administration Regulation (2004). This will be achieved by mainstreaming the financial
management staffing arrangements. The Financial Controller (FC) of the Ministry of Health
(MoH) has oversight responsibility for all financial management functions of all departments and
agencies under the MoH, including the Ghana Health Services. In order to support
implementation and allow for flexibility as per the proposed project design, whereby the MoH
and the GHS will perform some specific but related functions, the financial management
functions for implementing the project will also be handled separately by the respective agencies.
4 Reich MR, Balarajan Y (2012). Political economy analysis for food and nutrition security. World Bank,
Washington
26
64. Both the MoH and the GHS were involved in the implementation of the NMCCSP, and
have good financial management systems which will be used to support the MCHIP. The FM
staffing strength at MoH as well as GHS is strong although there will be a need to assign, for
each of the implementing agencies, an additional accounting staff from the Controller and
Accountant General’s Department (CAGD) to be dedicated to support project implementation.
65. MoH: With a view to mainstreaming the FM arrangements, the Financial Controller (FC)
of the MoH will have overall financial management oversight for the project. The responsibility
of the FC is to ensure that there are adequate financial management systems in place which can
report adequately on the use of project funds at all levels of implementation. However, in
carrying out this mandate, the specific day to day transaction processing and reporting will be
assigned to the dedicated “Project Accountant” assigned from the CAGD.
66. GHS: The Director of Finance is responsible for the finance and accounting functions of
the GHS. During project implementation, the role of the Director of Finance will be to ensure
that funds are used for the intended purposes as per the project appraisal document (PAD) and
also to ensure that there are adequate internal control arrangements at all levels of
implementation, including at the sub national level (regions, districts and sub-districts). To
support the work of the Director, the GHS will identify and assign a dedicated professionally
qualified accountant to serve as a focal person. Accounts personnel of the MoH and GHS have
been involved in implementing IDA and other donor-funded projects and are familiar with the
fiduciary requirements for managing IDA projects.
67. The GHS planning and budgeting cycle follows the annual budget guidelines as issued by
the Ministry of Finance (MoF). The budgets are work-plan based and fully integrated into the
MoH planning processes. During implementation, the MoH and the GHS will work together to
prepare a consolidated annual budget and work-plan based on the agreed program to be financed
as per the PAD and Financing Agreement. The activities and costs as per the annual work-plan
will be reviewed and agreed with (cleared by) IDA.
68. In terms of accounting systems, the GoG is in the process of rolling out an automated
integrated financial management system (GIFMIS) using Oracle Financials and is currently
transitioning from a manual-base system to an automated accounting system. Until such time that
roll out is fully completed, accounting for use of the project funds, using a cash basis of
accounting, is expected to be carried out by the MoH using a combination of spreadsheets and
manual ledgers.
69. Given that there are two separate institutions involved in the project, there will be
separate flow of funds arrangements and designated accounts for the respective institutions. As
such, the project will operate two Designated Accounts (DAs). The First US$ Designated
Account is to be managed by the MoH and will be used to finance activities under component
2.1 only, which are the responsibility of the MoH. The authorized signatories for the Designated
Account will include representatives of the CAGD, MoF and the MoH. The second US$
Designated Account is to be managed by the GHS and will be used to fund activities under all
components of the project, except component 2.1.
27
70. The Financial Controller of MoH, working in collaboration with the Director of Finance
(GHS), is responsible for preparing and submitting to the Bank the consolidated periodic interim
unaudited financial reports (IUFR) to account for activities funded under the project. As use of
some elements of the country financial management system is anticipated under this operation,
the project will rely on the periodic consolidated financial reports of the Ministry which will be
due for submission to IDA within 45 days of the end of each fiscal quarter; however additional
annexes will be required in the form of statement of uses and sources of funds and other
schedules to support reporting and disbursements under the project.
71. In line with its mandate as per the Ghana Audit Service Act (Act 584), the Auditor
General is solely responsible for the auditing of all funds under the Consolidated Fund and all
public funds as received by government ministries, agencies and departments. As is the practice,
due to capacity constraints, it is usual for the audits to be contracted out to private firms. For this
project, the default position is to accept the annual audit of the MoH/GHS as sufficient for the
audit requirement of the project.
72. In conclusion, the financial management arrangements at the MoH and GHS are
considered satisfactory and there are adequate systems in place to support the implementation
of the project and that these arrangements satisfy the Bank’s minimum requirements under
OP/BP10.00. The overall FM risk has been assessed as Moderate.
D. Procurement
73. Procurement under the proposed project would be carried out in accordance with the
World Bank’s "Guidelines: Procurement of Goods, Works and Non-Consulting Services under
IBRD Loans and IDA Credits & Grants by World Bank Borrowers" dated January 2011;
"Guidelines: Selection and Employment of Consultants under IBRD Loans and IDA Credits and
Grants by World Bank Borrowers” dated January 2011; “Guidelines on Preventing and
Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and
Grants”, dated October 15, 2006, and updated January 2011; and the provisions stipulated in the
Financing Agreement. The various expenditure categories for items to be financed are described
below. For each contract to be financed by the credit, the different procurement methods or
consultant selection methods, the need for prequalification, estimated costs, prior review
requirements, and time frame has been agreed between the Borrower and the Bank project team
in the Procurement Plan.
74. The Ghana Health Service (GHS) will have the direct responsibility for the management
of the project, including procurement management. Procurements of certain types of medicines
and health products will be supported by MoH as per existing arrangements. The GHS played an
important role and has experience in implementing the recently completed Nutrition and Malaria
Control for Child Survival Project, having managed the day-to-day implementation and
supervision of the project including financial management, procurement, disbursement,
monitoring and evaluation, progress reporting and communication functions. The MCHIP will
continue to use this existing arrangement for implementation.
28
75. A detailed assessment of the capacity of the Procurement Unit of GHS to implement
procurement actions for the project as part of the Bank’s fiduciary requirements was conducted
in accordance with the Bank’s Procurement Risk Assessment System (PRAMS) on May 22,
2013 based on responses by the relevant agencies to questionnaires. The assessment is to ensure
that implementing agencies have systems, structures and capacity to administer procurement in
compliance with the Bank’s Procurement and Consultants’ Guidelines. The assessment reviewed
the organizational structure for implementing the project and the interaction between the
implementing units and their staff responsible for procurement. The observations on the
assessment of the capacity of GHS to handle procurement under the Bank’s Guidelines and
procedures are detailed in Annex 2. The assessment rates the overall risk for procurement as
Low. Implementation of identified mitigation action will at least maintain the risk at the same
level.
76. GHS procurement unit has developed a procurement plan for covering the entire project
period and this has been agreed at negotiations with the Bank. The procurement plan will be
subject to updates at least once a year and if necessary, more frequently, and such updates would
be subject to the Bank’s review and agreement.
77. Measures that will be required to address procurement issues that will be identified have
been provided in the PRAMS Summary Risk Table in Annex 3.
78. In addition to the suggested risk mitigation measures, the Bank will as part of the regular
twice yearly implementation support missions, ensure that procurement plans are monitored and
updated regularly and published on the Banks external website as required by the Bank's
disclosure policies.
79. Frequency of Procurement Post reviews on the project will be based on the assessed
agency implementation risk for procurement. The Bank will carry out procurement post reviews
(PPRs) or independent procurement reviews for contracts that are not subject to prior review by
the Bank and identified as such in procurement plans. Further details of procurement
arrangements and Risk Mitigation Plan developed for the project are included in Annex 3.
E. Social (including Safeguards)
80. The project did not trigger the involuntary resettlement policy (OP4.12) since project
activities will not lead to land acquisition, resettlement or restriction of access. The project target
populations are clearly defined. Besides the defined populations – namely women of
reproductive age, especially pregnant women, children under the age of 2 years – there is an
inherent gender issue due to socio-cultural practices. The project will ensure that partners of
target women are considered as key players and therefore get more interested and involved in
implementation activities. The participation of partners beyond the financial support will boost
the morale of the women. Information, Education and Communication (IEC) of the project will
specifically target the men. Other targets will be family members in general, mothers and mother
in-laws of targeted women in particular.
81. Considering the importance of social and cultural beliefs and practices that influence
maternal and child care, and subsequently nutrition and health outcomes, the project will pay
29
particular attention to existing communication strategies; existing communication strategies will
be reviewed and the updated and new strategies will be pilot tested. These will be culturally
sensitive information and communication strategies including beliefs surrounding pregnancy
very early, and initiation of breastfeeding and implication for the health of mother and baby.
82. The adoption of simple implementation strategies will encourage participation and
inclusiveness and engender ownership and sustainability through behavioral change. Such
changes will positively impact beneficiaries’ (individuals and communities) medium to long
term productivity beyond health and nutrition considerations. The project anticipates active
engagement of existing social capital and resources (institutions and skills) including NGOs,
traditional and religious bodies in the beneficiary communities. This is expected to improve
efficiency, encourage knowledge transfer and cost reduction, and most importantly reduce
possibility for competition and conflict. It is envisioned that this will improve understanding of
women’s role in health and eventually their status. A cornerstone of the project is community
mobilization whereby community committees will select community volunteers and monitor
their activities and achievements.
F. Environment (including Safeguards)
83. The Project is classified as environment screening category C, meaning that it is expected
to have minimal or no adverse environmental impacts. The project activities are outreach
activities around pre- and post-natal care that include both clinic and home visits. While the
Project will not procure the inputs for any immunization, the outreach financed activities may be
used as a vehicle for immunization; therefore, the Environmental Assessment Policy OP4.01 is
triggered due to the potential for medical waste generation and need for proper management and
disposal of the waste. The kind of wastes to be generated under the project will be in the form of
sharps from the immunization program and long term family planning methods. There is a well-
developed national disposal program that is implemented for this sort of waste. All staff and part
time employees involved in the delivery of outreach will be given brief training and materials on
the waste disposal policy.
84. Additionally, it is important to highlight the fact that Ghana and the health sector have
experiences regarding World Bank safeguards policies, instruments and compliance
requirements and also the sector has implemented projects that have dealt with management and
disposal of medical waste, hence not a new phenomenon. What this means is that the institutions
to be involved in the implementation of this project have the capacity to deal with the rather
manageable medical waste expected from the facilities to be supported under the project. The
Environmental Protection Agency (EPA) is very strong institutionally and technically to handle
environmental and social safeguards related issues and have collaborated well with the World
Bank over the years. In spite of this, implementing entities, especially those at the district levels,
will be trained in handling medical waste, management and disposal as outlined in the existing
National Health Care Waste Management Policy, which has been reviewed by the Bank and
found to be good practice and to meet acceptable national standards. It is expected that the
identified minor impacts will be handled appropriately and effectively by the client and with the
guidance of the Bank's safeguards team.
30
Annex 1 Results Framework and Monitoring
Country: Ghana
Project Name: Maternal and Child Health Improvement Project (P145792)
Results Framework
Project Development Objectives
PDO Statement
The project development objective is to improve utilization of community-based health and nutrition services by women of reproductive age,
especially pregnant women and children under the age of 2 years.
These results are at Project Level
Project Development Objective Indicators
Target Values Data
Source/
Responsibility
for
Indicator Name Core Unit of
Measure
Baseli
ne YR1 YR2 YR3 YR4
End
Target
Frequenc
y
Methodolo
gy
Data
Collection
Births
(deliveries)
attended by
skilled health
personnel
(number)
Number 180,00
0
300,000
350,000 400,000 425000 450,000
Annually DHIMS GHS
Proportion of
pregnant women
making the first
antenatal visit in
the first four
months of
pregnancy
Percentage 44.00 45 47 50 52 55 Annually
DHIMS/
Project
Data
GHS
Proportion of
new acceptors
of modern
Percentage 25 26 28 30 32 35 Annually
DHIMS/
Project
Data
GHS
31
family planning
methods females
(15-49 years)
Proportion of
children under
two in
intervention
areas attending
community
growth
promotion
activities
Percentage 0.00 15 30 45 60 75.00 Annually
DHIMS/
Project
Data
GHS
Children 0-6
months
exclusively
breastfed in the
past 24 hours
Percentage 46.00 - - 50 - 54.00 Annually
DHS/MICS GHS
Direct project
beneficiaries Number 0.00 566,000 1347000 2363000 3576000 5000000 Annually DHIMS GHS PPMED
Female
beneficiaries
Percentage
Sub-Type
Supplemental
0.00
84%
(477000)
82%
(1104000)
80%
(1894000)
80%
(2860000)
80%
(4000000) Annually
Project
Data GHS
32
Intermediate Results Indicators
Target Values Data
Source/
Responsibility
for
Indicator Name Core Unit of
Measure Baseline YR1 YR2 YR3 YR4
End
Target Frequency
Methodolog
y
Data Collection
Percentage of
children aged 6-
59 months
having received
vitamin A
supplement in
the last 6
months
Percentage 74.00 - - 78 - 80.00
Biennially
(every two
years)
DHS/MICs GSS PPMED
Percentage of
children aged 6-
23 months who
are fed from the
4+ food groups
the night
preceding the
survey
Percentage 46.00 - - 55 - 60.00 Biennially MICS GHS PPMED
Children under
five years with
diarrhea treated
in the two weeks
preceding the
survey given
ORT
Percentage 48.00 - - 55 - 60.00 Biennially DHS/MICS GSS
Adolescents 15-
19 years
attending health
and nutrition
education
sessions
Number
(cumulative) 0.00 50000 100000 250000 350000 500000 Annually
Routine
Project
Data
GHS
33
Pregnant women
reporting having
slept under an
ITN the night
preceding the
survey visit
Percentage 33.00 - - 45 - 50.00 Biennially DHS/MICS GSS PPMED
Long-lasting
insecticide-
treated malaria
nets purchased
and/or
distributed
(number)
Number 0.00 500000 - - - 500000 Annually Project
Data GHS PPMED
Health
personnel
receiving
training
(number)
Number
(cumulative) 0.00 800 2000 3000 5500
5500
Annually Project
Data GHS PPMED
Community
counselors
trained
Number
(cumulative) 0.00 10000 20000 35000 45000 55000 Annually
Project
Data GHS
Community-
based Planning
and Services
Zones receiving
supervision
visits from Sub-
District level
Percentage 0.00 20 40 60 70 80.00 Annually Project
Data GHS PPMED
Citizen score
card rolled out
in communities
in 4 districts in
Northern Region
Percentage 0 20 30 40 50 70 Annually Project
Data GHS PPMED
34
Annex 2 Detailed Project Description
1. To achieve the expected improvement in health and nutrition outcomes the project will
prioritize selected interventions directly linked to reduction of maternal and child under-
nutrition, morbidity and mortality. The project will support activities aimed at improving
knowledge and attitudes and behavior to ensure that the knowledge and skills caregivers require
as well as the needed enabling environment and support for improved maternal health and child
survival is available. It will create awareness, provide education and counseling on pregnancy
care among the target population. Additionally, the project will also focus on strengthening
community health systems to enhance the quality and quantity of services. A number of major
innovations have been included in this project, compared to the previous one. These include
active search and identification of pregnant women, registering them with the health system and
the national health insurance scheme and screening them for eligibility for enrolment into the
national conditional cash transfer program - the LEAP as well as the introduction of elements of
performance-based financing to increase the motivation, quality and results focus of community
health workers.
2. The project will have the following two components:
Component 1. Community-Based Maternal and Child Health and Nutrition Interventions
(estimated cost: US$63 million (IDA US$58 million, HRITF $5.0 million)).
3. The objective of this component is to improve availability and utilization of health and
nutrition services for women of reproductive age, especially pregnant women, neonates and
children under the age of two years. This will be done by strengthening supply, creating demand
and increasing ownership and accountability of district level stakeholders, outreach workers,
community leaders and household members. The component will support the uptake of a
package of essential community nutrition and health actions (ECNHA) and address the gaps in
knowledge, skills, and community practices such as reproductive behaviors, nutritional support
for pregnant women and young children, recognition of illness, home management of sick
children, disease prevention and care-seeking behavior. The component has two sub-
components: (i) Strengthening Service Delivery; and (ii) Community Performance-Based
Financing.
4. 1.1 Strengthening Service Delivery (US$53 million): This sub-component will finance
sub-grants to fund district level operational activities, technical assistance, training, workshops,
and goods for community-based health and nutrition services.
Sub-grants for district level activities: sub-grants will support district level sub-projects
which refer to strategies and activities in the District Plan of Action that promote
utilization of community based health and nutrition services. These include (i)
community based interventions promoting registration of women of reproductive age
especially pregnant women from poor households in the national health insurance
scheme; (ii) complete antenatal care and delivery package (e.g. supplements, iron tablets,
immunizations, bed nets, assisted deliveries, referrals); (iii) counselling of women of
reproductive age, follow up home visits, and provision of commodities (e.g. family
35
planning); (iv) outreach activities to encourage improved management of childhood
illnesses at household level; and (v) mobilization of community members for growth
monitoring, immunization of children, and nutrition education. The sub-grants will also
support training of sub-district staff and community volunteers, workshops and
incremental operating costs. The Operational Manual will provide a description of the
operational modalities and reporting arrangements.
Capacity building activities of relevant central, regional, and district governments to plan,
administer, and supervise the community-based health and nutrition interventions;
training of trainers, develop and implement an effective program of communication
strategies for behavior change and tailor messages appropriately to the target
beneficiaries by producing simple health education booklets; and design and conduct
community level training, and mentorship activities for community health and nutrition
service providers (e.g. community health officers and volunteers) and support district to
district, community to community knowledge sharing and learning exchanges. The
project will also support training of community health officers and volunteers on the
national medical waste management policy and printing of flyers or brochure’s to
distribute to staff and patients.
Critical inputs will be procured centrally, including weighing scales for pregnant women,
new born babies and children; motorbikes for CHOs and midwives in the communities;
pickup vehicles for selected needy districts; long lasting insecticide treated nets (LLINs);
vitamin A capsules and Oral Rehydration Salts (ORS).
Harmonization of all messages on health promotion
5. The CHOs and community volunteers will undertake home visits to: (i) counsel pregnant
women on health and nutrition during pregnancy; (ii) teach them to recognize danger signs; (iii)
encourage them to seek timely antenatal care (ANC); (iv) adhere to iron/folic acid
supplementation and malaria prophylaxis schemes; (v) ensure enrolment into NHIS; and (vi)
prepare the expecting mother for the immediate post-partum issues, including early initiation of
breastfeeding, colostrum feeding, and exclusive breastfeeding for the first six months; (vii)
facilitate facility delivery; and (viii) ensure post natal visit within seven days of delivery. As part
of improved delivery care, CHOs will ensure that new mothers receive a high-dose vitamin A
supplement soon after birth, start breastfeeding within the first hour after birth, and facilitate
birth registration. Finally, CHOs and community volunteers participate in monthly meetings
with the community to review progress of the community-based health and nutrition services
implementation. Through these community based activities, the project will enhance the
efficiency of existing Community-based Health Planning and Services (CHPS) activities.
6. The community volunteers, as in the NMCCSP, will carry out weighing of the children,
plot the weight chart and interpret the results, fill in the necessary data in the collecting tools for
analysis and reporting to sub-DHMT and assist in counseling mothers on feeding their children,
hygiene and environmental sanitation. The home visits will also follow up on children who failed
to gain weight and counsel their caregivers or refer them to the health officer for appropriate
action. It will also identify and follow up children who failed to turn up at growth monitoring
sessions.
36
7. The needs and opportunities for scaling up community-based health and nutrition
services may vary by District. Hence a significant portion of this component will be allocated in
the form of grants to supporting District-level ‘sub-projects’, which, as mentioned above, refer to
strategies in the District Plan of Action that promote the utilization of community-based health
and nutrition services. Working on the basis of District-level sub-projects has the advantage of
helping Districts to focus on specific areas while allowing the flexibility inherent in the
decentralization policy. The health sector has been disbursing a large portion of budget to the
district level structures called Budget Management Centers (BMCs) to implement planned
activities. Specific deliverables from the district plans will be agreed at the beginning of the
project.
8. This project will continue to use the existing structures to implement sub-projects. Sub-
projects will support implementation of activities such as monthly growth promotion sessions,
weekly community outreach programs and community durbars. It will also support training of
sub-district staff and community volunteers, workshops, supervision of the various district level
structures and incremental operating costs. A description of the operational arrangements of sub-
projects including contract mechanism, fund flow and reporting is provided in Annex 3.
9. 1.2 Community Performance-Based Financing (CPBF) US$10.0 million (US$5.0
million IDA and US$5.0 million HRITF): This sub-component finances a pilot fee-for-services
community performance-based financing mechanism at the district and primary care level. A
carefully implemented ‘Fee for services’ pre pilot will be initiated in 8 districts (two from each
of the four most vulnerable regions on maternal health indicators in the country) and compared
with controls using regular input based approaches. At the mid- term review, lessons learnt will
feed into decisions to scale up to additional vulnerable districts in the same regions. The selected
four regions—Northern, Volta, Upper East and Upper West—experience a high burden of
maternal and child health (MCH) conditions and lag behind the rest of the country in progress
toward health outcomes, especially among the lowest wealth quintile. Sub-component 1.2 seeks
to strengthen focus on results and quality at the community level, and in the process increase
coverage of high impact interventions in districts with weak maternal and child indicators. The
CPBF roll out plan is as shown in Figure 2 below.
37
Figure 2 CPBF Implementation and Roll out plan
2014-15 2015-16 2016-17 2017-18 2018-19
Districts 8 8 8 43 43
CHPS 240 240 240 1290 1290
Baseline Survey
Mid line Survey
Pilot Expansion
CPBF Implementation and Roll out plan
10. Community Health teams (CHT) made up of 2 Community Health officers, at times
midwives, and between 4-6 Volunteers depending on the size of the community. CHTs will be
contracted for the delivery of a specified package of essential MCH services within a particular
Community Health Planning Services (CHPS) zone. This sub-component introduces incentives
targeting the CHT to improve health behaviors and health service utilization respectively. CHT
are paid on a fee-for-service basis based on quantity and quality achieved in a given period. As
part of the district sub grants (see component 1.1) the DHD will sign a performance-based
contract with the Office of the Regional Director for supervision outputs and for mentoring
related services they will provide to CHT.
11. The package of services to be purchased is built around key interventions which are
delivered through the country’s well-established community based health program and support
delivery of high impact interventions that directly support Ghana’s efforts to accelerate progress
towards MDGs 4 and 5. The indicators for which CPBF payments will be made are: (i)
identification and registration of the pregnant women with the health worker and the NHIS; (ii)
pregnant women making the first antenatal visit in the first trimester; (iii) pregnant women
making a minimum of four antenatal visits and delivering in a health facility; and (iv) at least one
post natal care visit within seven days of delivery.
12. The CHPS zone is the main platform for CPBF implementation. The DHMT and a CHO
representative of the entire team will sign performance-based contracts representing each CHPS
zone. Each contract will include a costed set of activities supporting maternal and new-born care.
The signed performance-based contract will cover both quantity and quality of health services to
be provided by the CHT to the population within its catchment area. The CPBF will pay for
results achieved through outreaches, home visits and community durbars. An example of
package of services provided by CHT is outlined in Table 6 below. A more detailed description
of definitions of indicators and their quality measures will be finalized before project
38
effectiveness as well as associated costing and weighting of the indicators. The costing of
indicators has been done to ensure that the service package does not exceed the reasonable cost
of providing the community-based package. Challenges faced by CHT in remote CHPS Zones
result in higher costs of delivering primary care services. The fee-for-service scheme will take
this into consideration by adjusting the fees of delivering services in more remote CHPS zones.
The pricing of the package of services and quality bonuses for CHO teams will be informed by:
(a) operational costs for community outreach; (b) household out-of-pocket expenditures such as
those incurred when women go to health facilities; and (c) primary health priorities and goals of
Ghana. Each CHT can receive a maximum of about $3000 per annum for the achieving the
desired results.
Table 6 Example of CPBF
Service
Number
Provided/
Quarter
Unit Price Total Earned
Identification and registration of the
pregnant women
120 $0.5 $60
Pregnant women making the first
antenatal visit in the first trimester
90 $0.5 $45
Pregnant women making a minimum of
four antenatal visits and delivering in a
health facility
60 $4 $240
One post natal care visit within seven days
of delivery
45 $1 $45
Sub Total $390
Remoteness (Equity) Bonus +20% $78
Sub-Total $468
Quality correction 60% (of 468) $281
Total/Final Earnings $749
13. Costing of CPBF: The average real cost of providing health services through the
existing public health system is much higher than what CPBF will pay for its menu of essential
services. This can be intuited in several ways. First, the all-in real cost of providing public
services is calculated as a function of plant, equipment, staff salaries, materials and system
overheads. With health service usage levels being limited owing to poor health worker
motivation, inadequate staffing and equipment, poor service quality and essential drug stock outs
in most health facilities – an evaluation carried out as part of preparation confirmed that the all-
in cost per service is grossly elevated. It is important to therefore note that in the short term
CPBF will reduce the average real cost of service delivery by increasing the denominator—
patient visits and consequent services delivered, in addition to strongly increasing the quality of
those services. 5
5 BASINGA, P., GERTLER, P., BINAGWAHO, A., SOUCAT, A., STURDY, J. & VERMEERSCH, C. (2011)
Effect on maternal and child health services in Rwanda of payment to primary health-care providers for
performance: an impact evaluation. The Lancet, 377, 1421-28.
39
14. A simplified calculation illustrates this point. Let us assume that a CHPS Zone caters to
a population of 5,000. The average public health budget is about US$3 per capita per year, which
leads to a cost to the public purse of about US$15,000 per year for this CHPS Zone. Current
activity levels at 26% institutional deliveries in the Northern regions would mean about 5
deliveries each month. For the sake of argument, let us assume that all services combined are
around 100 per month for this CHPS Zone. CPBF would inject, over a period of time, on average
about US$0.6 per capita per year additional public financing – all performance based--into this
system. The total public financing would on average be about US$3.6 per capita per year, or
US$18,000. Previous PBF experience suggests, PBF would typically raise deliveries and other
maternal child health services to 65% over a period of let us say two years. This would be on
average 250 consultations per month and 13 deliveries per month. So whilst in the pre-PBF case,
we had an average cost of 15,000/ (100*12) = $12.5 per service, we have in the PBF era a new
average cost of 18,000/ (250*12) = $6.00 per service. In addition to the volume increase the
quality would have also increased from a baseline of 17% to on average 65% going by previous
experiences. This means that every single service output was achieved with increased quality in
providing ‘value for money’.6 It also demonstrates that the PBF cost of service payments are
well below current service provision costs.
15. To put this in perspective, per capita health spending in Ghana circa 2010 was around
US$39.12 per capita. In Ghana the public sector share of health expenditure is about 39%,
roughly $15.25. Hence adding US$0.6 as proposed for PHC services is still significantly below
the WHO calculation of required per capita funding of US$21pc7 (1991 prices). In effect, the
PBF payment is expected to leverage the US$15 pc producing much higher service delivery at
significantly lower cost per capita.
16. This simplified approach focuses on the incremental effect of monetary incentives
provided through the CPBF intervention with respects to costs and benefits. However, it is well
understood from practice and the literature that the cost effectiveness of community-based
interventions is defined by more than the monetary cost of incentives to the providers. To obtain
estimates on cost-effectiveness an observational study is proposed to measure the incremental
cost-effectiveness of CPBF relative to the current regime. This broader cost effectiveness
analysis will consider provider and, possibly, consumer costs, and intermediate and final
outcomes on the benefits side. The proposed analysis is part of the learning agenda, included in
the evaluation component (Component 2.2.) and also discussed in the economic and financial
analysis section of the appraisal (Section VI).
17. To set the PBF payment levels for unit costs the team relied upon field experience in
Rwanda, Burundi, DRC, CAR, Benin, Zambia and Cameroun, which set incremental unit costs
in terms of relative effort and opportunity costs of delivering the service and a diagnostic health
worker income and labor costs in Ghana. A cost of $0.6 per capita has been used for the initial
startup phase and will be further refined with implementation experience. The methodology
consists in (i) identifying the menu of key (health- MDG related) services to be delivered, (ii)
forecasting from baselines their expected increase as PBF is rolled out, and (iii) forecasting
expected payments for individual services working with baseline prices reflecting field based
6 OECD (2010) Value for Money in Health Spending. OECD Health Policy Studies. OECD. 7 WB (1993) World Development Report 1993: Investing in Health. New York, Oxford University Press
40
experience of the relative effort/cost of the intervention weighted for importance and the
availability of funds for PBF payment. A model is used to generate payment forecasts and annual
unit fees based upon these and other parameters.
18. A key characteristic of the model is the ability to re-negotiate and recalculate fees as
service volumes increase more than they are expected to. Technically this is a provider payment
method which is ‘open-ended’ at the micro level and ‘closed’ at the macro level (the available
budget is capped).
19. Fundamentally, the model focuses on (a) remaining within a given output budget given
model driven quarterly expenditure forecasts; (b) monitoring moral hazard consisting of neglect
or overproduction of defined facility services; and (c) maximizing results for the given PBF
output budget. A web-enabled application will create payment orders, facilitates amendments
and has a dashboard with various user friendly visual aids to track performance improvements
and budget expenditures.
20. The project will make quarterly payments based on quantity of services delivered and the
outcome of the DHMT’s quarterly supervision for quality, which will include record reviews,
direct observations and administration of a checklist which assesses the adherence to set
standards for community primary care services in line with national policy. Each quarter,
Community Based Organizations (CBOs) will undertake community surveys within each CHPS
zone to generate a client satisfaction score to be used by DHMTs to calculate a portion of the
PBF subsidy paid to CHT. Thus the total quality component will be made up of a technical
assessment score provided by DHMT upon completion of a supervision visit as well as the
community satisfaction score from client tracer surveys. Post payment, an Independent
Verification Agency will undertake counter –verification and report its findings to the Office of
the Regional Health Director whose team will work with the DHMT to apply rewards and
penalties, necessary on CHT, CBOs and in some cases the DHMT itself. The Project
Implementation Manual will outline in-depth details concerning the internal and external
verification functions, deliverables and timelines.
21. There will be considerable autonomy in how CHT use the funds they earn. Each CHT
will develop an operational plan to guide the use of CPBF subsidies; these plans will be part of
the contracts signed with the DHMT. The operational plans will help the CHT develop their
ideas and innovations, and will describe how planned activities will be implemented. Operational
planning will be done every six months to allow the renewal of the contract in the first year of
the project, and thereafter it will be annual. The plans will identify key problems in the
catchment area, such as why health service objectives and targets are not achieved, and propose
realistic strategies, as well as resources, timelines, approaches and persons responsible to address
these problems. CPBF subsidies will cover expenses within broad categories including: (i) costs
associated with service delivery; and (ii) performance-based motivational team bonuses for the
CHT; and (iii) transportation of pregnant women at the time of delivery or due to pregnancy
related complications and for children for emergencies during the neonatal period. To set the
teams to function effectively the first payments will be issued based on credible evidence of (i)
the first six monthly plan of activities (ii) the availability of a signed performance contract (iii)
the initiation of a bank account.
41
Evidence for Management and Policy Decision Making
22. The design of the impact evaluation will be completed in close consultation with the
Ghana Health Service (GHS). Evaluation activities agreed to by the Government and the Bank
will be rolled out to answer policy-relevant questions and strengthen evidence-based CBPF
learning by policy makers, technical staff in GHS and development partners. Comprehensive
baseline data to be collected includes administrative and HMIS data, population based surveys,
and a dedicated facility and health worker survey. A Process Monitoring and Evaluation (PME)
will be rolled-out to better understand context specific factors that influence the performance of
CHO teams in the pilot districts and regions. The PME will be a critical piece to inform the
envisaged scale-up to additional districts. The final design of the PME will be worked out jointly
with the GHS after project effectiveness.
23. The Project Implementation Manual will describe the details of the CPBF model
including: (i) the governance structure at national level; (ii) national level management, technical
and fiduciary oversight of pilot districts; (iii) service package and fee schedule; (iv) the tool used
for quality supervision by DHMT and by the office of the Regional Director; (v) CBA
contracting and accountability for client tracer survey at community level; and (vi) the scope and
technical approach of the external verification work. The Bank will review and clear the PIM as
a condition of disbursement for performance-based subsidies.
24. Given that this sub-component brings CPBF innovations to Ghana, there will be technical
support to ensure skills to manage a robust scheme are imparted to key national, regional, district
and CHO representatives. The TA will also focus on building or strengthening key systems to
enable management of a decentralized PBF scheme. Aspects that could be strengthened include
functioning of the eRegistry system maintained by CHT to ensure it can be used to verify and
trigger payments; (ii) capacity for managing the PBF operational and strategic cycles; purchasing
and verification functions at all levels of the health system.
Component 2: Institutional Strengthening Capacity Building, Supervision, Monitoring and
Evaluation, and Project Management (estimated cost: IDA US$8.0 million)
25. This component will support three main objectives, namely namely to: (i) develop
effective inter-sectoral coordination, ownership, and accountability for health and nutrition
towards the strengthening of a coherent national community health and nutrition program; (ii)
strengthen MoH capacity to provide stewardship, as well GHS capacity to effectively coordinate,
supervise and monitor implementation of the community-based services; and (iii) evaluate the
impact of the project. The operation will provide support for two broad areas, as described
below.
26. 2.1. Stewardship, Policy and Lessons Learning (US$1.5 million): This sub component,
led by the Ministry of Health, will provide stewardship and lesson learning from the project for
wider application. It will finance technical assistance, training, workshops, and incremental
operating costs to:
42
provide oversight on all project activities, including procurement, financial management
and monitoring;
establish and build capacity for intersectoral coordination mechanisms;
develop/update and implement strategies that mainstream nutrition into the multisectoral
development agenda at all levels;
harmonize implementation of policies, protocols and procedures of other sectors at the
community level;
develop guidelines and tools for service quality improvements;
27. 2.2 Supervision, Monitoring and Evaluation and Project Management (US$6.5
million): The second sub-component led by the Ghana Health Service will support capacity
development for implementation and project management, supervision, and M&E, including
carrying out the base-line and end-line surveys.
28. This component will enable the harmonization and implementation of health sector,
protocols and procedures using the community based service delivery strategy. Many activities
to strengthen coordination and implementation of a coherent national program will be carried out
through carefully crafted advocacy and strategic communication strategies that will build on and
interact with the program communication strategy. The communication strategy will be reviewed
and enriched on a periodic basis to adapt to new opportunities and challenges.
29. Community-based monitoring tools will be used to strengthen collaboration between
citizens and health facilities in monitoring key aspects of the project. Bank tested tools and
approaches such as the citizen score card will be implemented to deepen community
participation for improved monitoring of community-based health and nutrition services
including the CPBF. The appropriate tool will be developed through broad-based consultative
process and will seek to strengthen relations between communities and health service delivery
stakeholders by improving service provider accountability and community responsibility in
monitoring the utilization of community-based health and nutrition services. This component
will involve comprehensive capacity building for stakeholders, including government agencies,
community organizations and volunteers, and the roll-out of the scorecard in selected
communities. A detailed description of the process and stakeholder responsibilities will be
provided in the scorecard implementation guidelines. The sub-component will also support
assessments and evaluation of the CPBF (procurement of research agency for technical
assistance, data collection and analysis). The project will aim to learn from the use of community
score cards, decentralization to communities and the contribution of the CPBF to service uptake.
The evaluation details will be finalized prior to roll out and the Bank will provide technical
support.
30. In summary this component will finance technical assistance, training, workshops, and
incremental operating costs to:
revise and integrate community registers and forms and incorporate into the
electronic register;
strengthen health information management systems at the sub district level;
introduce community score card;
43
carry out internal reviews of the RBF results; and
manage the project;
develop an efficient M&E system for better planning and management (e.g.
operational research) of community-based health and nutrition service; and support
program coordination; and
develop and implement a “balanced scorecard” approach to be used in the regular
supervision of community level services and structures.
Unallocated (estimated cost: IDA US$2 million)
31. These funds will be drawn into any component upon justified need, as a means to secure
additional flexibility to project activities.
44
Annex 3: Implementation Arrangements
A. Institutional and Implementation Arrangements
1. Ghana’s health sector arrangement is unique by having separated the health service
delivery, i.e. GHS, from the overall health policy, procurement and coordination responsibilities,
i.e. MoH. The MoH is a civil service institution with responsibilities towards itself and
functional responsibilities towards both public and private sector health and health related
service providers. In performing the latter role, the MoH is responsible for: (i) sector policy
formulation to ensure equity and maximum outcomes; (ii) coordination of the sector programs to
ensure consistency at the strategic level; (iii) resource mobilization for the sector as a whole; and
(iv) multi-sectoral action. At the service level, it is concerned with health status outcomes,
consumer satisfaction and financial risk protection.
2. The GHS has been established by an Act of Parliament to manage the delivery of health
services through the decentralized Health System. District Health Management Teams (DHMT)
are responsible for organizing and managing the local provision of health services. They prepare
annual plans and budgets for their areas of responsibility according to guidelines and budgetary
ceilings with regard to non-salary recurrent expenditures. At each level, fiduciary management is
ensured by Budget Management Centers (BMC). The Regional Health Management Teams
(RHMT) play an intermediary role between the central GHS and the DHMTs, providing
technical support, supervision, and referral services. At each level, there are Health Committees
composed of a broad range of stakeholders including representatives from Local Governments
and civil society, e.g. women’s group, faith-based organizations, to advise the health teams on
health care needs.
3. The GHS also recognizes the Local Government, i.e. the District Assembly (DA) as the
primary provider of public services, including primary and community-based health care. The
restricted District Planning and Coordination Unit and the broader Social Services sub-
Committees of the District Assembly are the principal forums for planning, coordination and
review of multi-sectoral District plans of action. The DHMT is represented in the DA
institutions to coordinate and provide technical support and advice on health issues in the
District. In the current set up, GHS and DA have duplicated roles in ensuring the provision of
health services. Under the decentralization policy, DAs are expected to gradually take on more
of the responsibilities that are currently managed through by the GHS.
4. As a repeater project, the MCHIP will continue to use the restructured implementation
arrangements under the Nutrition and Malaria Control for Child Survival Project (MCCSP) as
they were considered satisfactory. As such the project will be implemented by the MoH and the
GHS. The MoH will have oversight responsibility for the entire project and specifically lead
policy formulation, lessons learning activities and implement a monitoring and evaluation
program to monitor the implementing agency. The GHS will be responsible for service delivery.
5. The MoH will provide technical assistance, organize reviews, monitor and evaluate
project activities. These functions will be coordinated by MoH PPMED. Oversight of the
activities supported by the project will be provided through the framework of the existing
45
Millennium Acceleration Framework (MAF) Steering Committee (SC) which is chaired by the
Chief Director of the Ministry of Health. The PPME-MoH provides secretariat support to the SC.
The project will follow the existing Common Management Arrangement (CMA) for the health
sector, which sets out financial management, procurement, and monitoring and evaluation
policies and procedures to be followed by all partners in the sector.
6. The GHS will submit project progress reports including updates on the performance
indicators as indicated in the project document and will report implementation progress at
quarterly health partner business meetings. The GHS PPMED will provide secretariat support
for the project and will appoint a coordinator to be responsible for overall project activities at the
agency level. The PPMED will also perform the M&E role under the project. The activities of
the project will form part of the work-plan of the agency and shall be subject to the agency rules
and guidance on updates and reporting of activities.
7. GHS will have a project Technical Advisory Group made up of directors of the following
divisions of the GHS; Family Health (FH); Public Health (PH); Policy Planning, Monitoring and
Evaluation (PPME); Institutional Care (IC); Finance; Internal audit (IA); Research and
Development (RD); Human Resource Development (HRD); Supplies, Stores and Drugs
Management (SSDM); and Health Administration and Support Services (HASS). The DG will
assign a director to chair the Technical Advisory Group (TAG). The secretariat for the TAG will
be the GHS PPMED. The chair of the TAG will report project implementation progress to the
senior management team of the GHS every quarter.
8. At the regional level, the Regional Director of Health Service (RDHS) shall be
responsible for the implementation and monitoring of project activities. Project related issues
will be discussed and addressed within the activities of the Social Sector Sub-committee of the
Regional Coordinating Council (RCC).
9. The District Director will coordinate the preparation and implementation of the district
sub-projects, provide technical guidance and leadership for implementation and monitoring at the
CHPS level through the sub-district. The community-based interventions will be supervised by
the sub-district health team.
10. Community Health Officers (CHOs) and community volunteers are the principal change
agents in the project and with the support of NGOs will carry out outreach programs, home visits
and growth promotion. This project, learning from the experience of the earlier project
(NMCCSP) will support community structures to mobilize the community, facilitate the
selection of community volunteers, oversee and provide support to the monthly growth
promotion activities by holding regular management meetings to discuss progress in the
community. The volunteers will assist with the organization of quarterly meetings with the
community and CHOs to review progress of the project activities. Using the local structures the
project will support meetings of the chief and elders to create a platform for taking ownership
and accountability to discuss issues affecting the health nutritional status of the community.
46
Project administration mechanisms
11. Project management will be undertaken by the staff of the Ghana Health Service with
oversight from the Ministry of Health. A schematic presentation of the institutional arrangements
is provided in the diagram below.
Figure 3 below summaries the district level institutional arrangement for the CPBF.
MoH
Oversight of and stewardship for the project will be provided by MoH with a Steering Committee (SC) under the overall guidance of the Chief Director of he MoH. The Chief Director of the MoH will chair the Steering Committee meetings.
GH
S-H
Q The Ghana Health Service will coordinate implementation of the
project. GHS will be responsible for providing technical guidance to regions and districts and will monitor overall indicators of the project. A Technical Committe at GHS will advice the DG on issues concerning the project.
Regio
nal
Health
Directo
rate
The RHD will receive and transfer project funds to districts, sign and assess district performance and monitor district activities. Progress on implementation will be reported to the Regional Coordination Council Meetings.
Dis
tric
t H
ealt
h
Directo
rate
The district will coordinate project activities at the district in addition to monitoring subdistricts and attend district coordinating council meetings of the assembly.
Su
bd
istr
icts
The sub-districts will be aligned to the area/town councils and will be required to present project updates at the monthly zonal meetings
CH
PS
Zone
At the community, the CHPS Zones will link with the Unit Committees of the local government
47
Figure 3 District Level Institutional Arrangements for the CPBF
District Health Management Team
Sub DHMT (Health Facility)
Community Health Officer
PopulationCBO
Inde
pend
ent A
genc
yQuality verification (supervision)
Client tracing
Counter Verification
Contract for Service Delivery
Office of Regional Director/ National GHS
Contract for Supervision of Outputs
Service Delivery
District Steering Committee(Representatives from DHMT, NGO, CBO, local government)
Quantity and quality verification
(supervision)
Contract for Counter
verification
Cont
ract
for C
lient
trac
ing
Quantity verification
Counter Verification
Counter Verification
Financial Management, Disbursements and Procurement
12. The Overall FM assessed risk for this project is Moderate.
13. In line with the project design of splitting the technical aspects of implementation
between MoH and GHS, the financial management functions for implementing the project will
be done separately by the respective agencies. The FM staffing strength at MoH as well as GHS
is fairly strong although there will be a need to assign for each of the implementing agencies one
qualified accountant staff to dedicatedly support project implementation.
14. MoH: As the default position of using country systems for financial management, and
also adopting a mainstreamed approach, the Financial Controller of the MoH, will have overall
financial management responsibility during implementation. The responsibility of the FC is to
ensure that throughout implementation there are adequate financial management systems in place
which can report adequately on the use of project funds. However, in carrying out this mandate,
the specific day to day transactional processing and reporting will be assigned to a Project
Accountant assigned from the CAGD.
15. GHS: The Accounting function at the GHS is headed by a qualified chartered accountant,
in the person of the Director of Finance who administratively reports to the Financial Controller
(MoH). The Director is supported by a team of accountants of varying degrees of qualifications
and experience responsible for managing both GoG and donor funds. The finance staff of the
GHS has been involved in implementing IDA and other donor funded projects and recently
implemented successfully the Nutrition and Malaria Control Project (P105092) and are familiar
with the fiduciary requirements for managing IDA projects.
16. Additionally, to strengthen the FM arrangements particularly in regards to financial
reporting, the Accounts and Internal Audit Units will be supported with technical assistance in
48
the form of training and capacity building to assist in regular field visit, training of staff at the
sub national levels, undertake value for money audits to help track and report on expenditure and
be able to produce the required financial reports under the project.
17. In summary, both MoH and GHS have in depth prior experience of implementing Bank
and donor-financed projects and this knowledge can be relied upon to support the current project.
Budgeting Arrangements
18. MoH and GHS: The MoH follows the budget preparation guidelines as per the Financial
Administration Act (2003), the Financial Administration Regulation (2004) and also the annual
budget guidelines issued by the Ministry of Finance. The Government of Ghana budgeting
processes are assessed as adequate and will be relied upon during implementation for preparing
budgets and also monitoring budget utilization. The GHS planning and budgeting cycle follows
the annual budget guidelines as issued by MoFEP. The budgets are work plan based and fully
integrated into the MoH planning processes. For the current project, the MoH and the GHS will
work together to prepare a consolidated annual budget and work plan based on the agreed
program to be financed as per the PAD and Financing Agreement. The annual work plan will be
reviewed and agreed with the IDA and cleared (no- objection) issue by the Bank for activities
agreed in the work plan. This will also be supported by procurement plan thus giving
management a good idea of expected project cash flow needs.
19. The project’s budget will be incorporated into the quarterly interim un-audited financial
statements for comparison with actual expenditure on a quarterly basis. The budgeting for the
IDA/HRITF project will follow the same GoG processes and include discussion with
stakeholders - i.e. the participating BMCs. The current budgetary control processes used mostly
for the government’s discretionary budget are capable of monitoring commitments and
outstanding balances. Under this project, The MoH/GHS are expected to make available to the
Bank for review, the consolidated annual work plan. In conclusion, the assessment indicates that
the existing budgeting processes are satisfactory and can be relied upon to reflect the various
components to be implemented.
Accounting Arrangements
20. MoH: The FC at the MoH will be responsible for overall fiduciary aspects of the Project.
The FC, a staff of CAGD, is a qualified chartered accountant with relevant years of experience,
having worked at different MDAs within the government service and on other donor funded
projects. Though the FC has overall oversight, the daily operational accounting functions will be
handled by the Principal/Chief Accountant.
21. GHS: The Finance and Accounts Section of the GHS will be responsible for the
accounting functions of the Project. The unit is headed by the Director of Finance, who is a
qualified chartered accountant with requisite technical skills and experience and assisted by a
team of dedicated schedule officers. To support the daily transactional processing, accounting
and reporting, a qualified accountant will be assigned to serve as a focal person for the project.
49
22. In terms of accounting systems, the GoG is in the process of rolling out an automated
integrated financial management system (GIFMIS) using Oracle Financials and is currently
transitioning from a manual based system to an automated accounting system. Until such time
that roll out is fully completed, accounting for use of the project funds, using a cash basis of
accounting, is expected to be carried out by the MoH through using a combination of spread
sheets and manual ledgers.
23. At the GHS, presently the accounting function is being supported through the use of
‘Accpac’ which is considered adequate but will be made redundant once Oracle Financials is
rolled out fully. It is expected that roll out will be completed by end of the year 2014. Generally,
systems at the implementing agencies be they manual or automated, were assessed to be
adequate to support implementation.
Internal Audit and Control
24. In adopting country systems for implementation, the project’s internal controls will be
based on the government’s established accounting and internal control guidelines as documented
in the Financial Administration Act (2003) and the Financial Administration Regulation (2004),
and informed by the Internal Audit Agency Act (2003). Both implementing agencies have laid
down internal control procedures and processes that ensure that transactions are approved by
appropriate personnel and ensure adequate segregation of duties between approval, execution,
accounting and reporting functions.
25. MoH: The MoH has a functioning Internal Audit Unit (IAU) headed by a Director, who
is responsible for ensuring compliance to established internal control procedures and processes
that ensure that transactions are approved by appropriate personnel and ensure segregation of
duties between approval, execution, accounting and reporting functions.
26. GHS: The GHS also has its own Internal Audit Unit (IAU) which provides internal audit
and control services to the agency and will be expected to do same for the project. The internal
audit function will be supplemented by periodic reviews and field visit to the participating
regions and districts/BMCs. Like most internal audit units in the public sector, these units tend
to focus more on transaction oriented than risk based audits. Even though the BMCs are
governmental establishments and have the required staff, there are often capacity challenges at
the sub national level (regional and district) and this will require the GHS to establish good
controls system for monitoring their processes, including their periodic financial reporting. The
monitoring role of the IAUs will include periodic field visits to the BMCs to review their
financial management activities, validate expenditure returns, and perform such control
procedures as required to ensure compliance by the districts and BMCs. The assessment
indicated that though the internal audit and control environment is adequate for project
implementation, the role of the internal audit will require to be enhanced in order to ensure that
the control risk is mitigated at all levels of implementation by adopting a risk based approach and
a more proactive approach to monitoring with a focus on systemic checks and controls. This is to
ensure that the role is not limited to transactional reviews (pre-auditing) but adds value to the
overall control environment.
27. Funds Flow and Disbursement Arrangements: The proposed financing instrument is
an investment project financing of an amount estimated at US$68 million of IDA and Health
50
Results Innovation Trust Fund (HRITF) Grant of US$5 million to be implemented by the MoH
and the GHS over a five year period. Given that there are two separate implementing agencies
involved in the implementation of the project, it has been agreed that there will be separate flow
of funds arrangements and designated accounts for the respective agencies. To facilitate funds
flow from IDA/HRITF (which will be pooled) to the GoG and the eventual disbursements to
project beneficiaries, two parallel arrangements will be implemented, requiring the operation of
two Designated Accounts (DAs) as follows:
i. The First US$ Designated Account is to be managed by the MoH. This US$
designated account would be opened with Bank of Ghana (BoG) and managed by the
Financial Controller of MoH. This will be used to finance some activities under
components 2.1 which are the responsibility of the MoH. These include support
government policy on decentralization and it uses the health sector CHPS strategy to
collaborate and increase community mobilization and empowerment within the sector.
The authorized signatories for the Designated Account will include representatives of the
CAGD, MoFEP and the MoH.
ii. The second US$ Designated Account is to be managed by the GHS: The second US$
Designated Account (Pooled) is to be managed by the GHS - the account will be a pooled
account receiving funds from both IDA and HRITF. This second designated account will
also be opened at the Bank of Ghana (BoG) and managed by the Director of Finance -
GHS. This second DA will be used to fund activities under all components of the project
including, activities at the GHS headquarters, the sub-grants for community-level
activities and pilot community based performance financing. The authorized signatories
for the Designated Account will include representatives of the CAGD, MoFEP, MoH and
GHS.
iii. These designated accounts will be established in US Dollars with the BoG and will be
denominated as a sub-account of the Consolidated Fund of the GoG. There will also
be established a local currency account (subordinated to the US Dollar Account) to
receive transfers to that account for purposes of (a) disbursing local currencies for project
implementation activities related to projects’ direct activities (sub projects), and (b)
where applicable providing periodic replenishable imprest funds to regional and district
office/BMCs of the GHS to enable them implement activities.
28. Community Performance-Based Financing (CPBF): Under component 1.2, funds will
be allocated to support the community performance-based financing program under the project.
This sub-component introduces incentives targeting the CHO teams—comprised of qualified
nurses, at times mid-wives, and a team of volunteers—to improve health behaviors and health
service utilization respectively. This sub-component will finance a pilot fee-for-services
community performance-based financing mechanism at the district and primary care levels in 8
districts (two from each of the four most vulnerable regions on maternal health indicators in the
country). Funds for the CPBF will constitute part of the funds allocated to the GHS and will be
transferred initially to the GHS Designated Account for subsequent transfer to participating rural
banks for payment to beneficiaries.
51
Funds Flow Diagram
MOH (Component 2.1)
IDA &
HRITF
Funds Flow
Sub Projects (District Health
Accounts)
Reporting on Fund Use
GHS (Components 1.1,
1.2 and 2.2)
Community Performance
Based Financing
Other Activities by
GHS
A summary of the funding process (to be further elaborated in the PIM) for the components to be
implemented is as follows:
Component 1.1
i. As part of the normal GoG budget cycle the qualifying district heath offices will
prepare their Budgets and Annual Work Plans (AWP) and submit copies to the GHS
HQ for verification and approval by the Director General.
ii. Once the individual district AWPs have been approved these will be consolidated and
presented to IDA for review and final clearance and as a basis for determining the
allocations to be made for each participating district. (Note the district AWP will
include cost estimates for all components).
iii. Based on the approved AWP, the GHS will transfer an initial advance equivalent to
the forecast cash requirements for the three (3) month to the District Health Accounts
which is part of the GoG health accounts systems and maintained by the District
Health Administration (DHA).
iv. The participating DHA will undertake eligible project activities and once they have
spent at least 70% of the initial advance, they shall submit returns to GHS HQ a claim
for reimbursement, including necessary supporting documents.
v. As an additional control measure, on a quarterly basis, the GHS HQ team will meet
with the participating districts to review and validate their expenditure claims which
will serve as a basis for further transfers.
52
Component 1.2
i. On a periodic basis - i.e. quarterly - based on verification of performance by the
DHMT and corroborated by an independent verification agency, the DHMT will
provide data to the GHS on the performance of districts under the pilot CPBF.
ii. Based on the data provided, the GHS will determine the funds to be made available to
each participating community health teams (CHT) and the total package of incentive
earned by each Team.
iii. CHPS/CHO Teams will open bank accounts within their locations with the rural
banks
iv. Funds will then be transferred from the GHS to the rural banks located in the districts
for onward payment to the beneficiary CHTs.
v. The lead community health officer (CHO) and the lead volunteer in the Teams will be
the joint signatories for receipt of funds; the distribution formula amongst members of
the Teams will be defined in the PIM. On a periodic basis, the GHS will undertake
reconciliation between the transfers and the payment made on its behalf by the rural
banks.
29. Disbursement arrangements and use of funds: Proceeds of the facility will be used for
eligible expenditures as defined in the Financing Agreement. Disbursement arrangements have
been designed in consultation with the Recipient after taking into consideration the assessments
of the implementing agencies’ financial management and procurement capacities, the
procurement plan, cash flow needs of the operation. The disbursement categories are designed to
allow flexibility and are based on the project components and each component would fund
eligible expenditures in the areas of goods, consultancy services, non-consultancy services and
operating costs.
30. MoH: Based on the assessment of the financial management arrangements at the MoH,
MoH will use transaction-based reporting (Statement of Expenditures) to request for funding
and report on the use of funds. The maximum amount (ceiling) for the MoH Designated account
will be US$250,000.
31. GHS: Based on the assessment of financial management arrangement at the GHS, the
proceeds of the credit will be disbursed to the project using report based disbursement
(Interim Financial Reports) arrangement. An initial advance will be provided to the designated
account, based on a forecast of expenditures against each component and disbursement category
for the first six months. The forecast will be based on the annual work-plans that will be
provided and cleared by the Bank prior to implementation. Subsequent replenishments of the
DA would be done quarterly by way of withdrawal applications, based on the net cash
requirements for subsequent 6 months, linked to approved annual work-plans and supported by
Interim Financial Reports (IFRs). Supporting documentation will be retained by the GHS for
review by the IDA missions and external auditors.
32. Additional instructions for disbursements will be provided in the Disbursement Letter.
The project will have four disbursement categories as defined in the table below for the IDA
Credit.
53
Table 7 Disbursement Summary
Category Amount of the
Financing
Allocated
(expressed in
US$ million)
Percentage of Expenditures
to be Financed
(inclusive of Taxes)
(1) Goods, non-consulting services,
consultants’ services (Sub-grants)
under Subprojects for Part A.1(a) of
the Project
30.0 100%
(2) CPBF Services Grants under Part
A.2 of the Project 5.0 50%
(3) Goods, works, non-consulting
services, consultants’ services,
Operating costs and Training for Parts
A.1(b) and B of the Project
31.0 100%
(3) Unallocated 2.0 100%
TOTAL 68.0
For the HRITF Grant, there will be only one category as defined in the Table below:
Category Amount of the
Grant Allocated
(expressed in
USD$ million)
Percentage of Expenditures to
be Financed
(inclusive of Taxes)
(1) CPBF Services Grants under Part
A.2 of the Project 5.0 50%
TOTAL AMOUNT 5.0
33. Retroactive Financing – Retroactive financing not exceeding US$2,500,000 will be
considered eligible for expenses incurred under all components except sub-grants and not later
than twelve months prior to the signing date of the Financing Agreement. Activities to be
financed under the retroactive financing include project preparation, preparation of project
implementation manuals, training and capacity building for the project, development of reporting
formats, determination of population of target communities, mapping of nearest health facilities
for referrals, and stakeholder engagement.
54
34. Financial Reporting Arrangements: The Financial Controller of MoH, working in
collaboration with the Director of Finance (GHS), is responsible for preparing and submitting to
the Bank the consolidated periodic interim unaudited financial reports (IUFRs) to account for
activities funded under the project. In the spirit of ‘use of country financial management
systems’, the project will rely on the periodic consolidated financial reports of the Ministry;
however additional annexes will be required in the form of statement of sources and uses of
funds, and other schedules to support reporting and disbursements under the project.
35. IUFRs for the project are expected to be submitted not later than 45 days after the end of
each calendar quarter. These reports must cover all IDA /HRITF funds received for the project as
a whole as well as government (counterpart) funds (if any). The formats and content of reporting
have been agreed to.
36. The constituents of the additional annexes to the quarterly project IFRs, that will be
submitted shall include (a) source and uses of funds (b) actual and forecast cash flow statements
according to components, sub components and activities; (c) use of funds by activity within a
component including statements indicating transfers to BMCs and outstanding balances; and (d)
designated account reconciliation statement. In addition to the quarterly reports, the Financial
Controller and the Director of Finance would prepare and submit to IDA, the MoH annual
audited financial statements.
37. Independent Auditing: In line with its mandate as per the Ghana Audit Service Act (Act
584), the Auditor General is solely responsible for the auditing of all funds under the
Consolidated Fund and all public funds as received by government ministries, agencies and
departments. As is the practice, due to capacity constraints, it is usual for the audits to be
contracted out to private firms. For this project, the default position is to accept the annual audit
of the MoH/GHS as sufficient for the audit requirement of the project. Such reports are due for
submission not later than nine months after the year end. In the unlikely event that there are
challenges in meeting the submission dates, the Project reserves the right to contract private
auditors, subject to the Bank’s necessary procurement and technical clearance of the audit terms
of reference (TOR). This is to ensure that there are no delays in complying with the financial
covenants for submission.
38. Conclusion of the Assessment: In conclusion, the financial management arrangements
at the MoH and GHS are considered satisfactory and there are adequate systems in place to
support the implementation of the project and that these arrangements satisfy the Bank’s
minimum requirements under OP/BP10.00. The overall FM risk has been assessed as Moderate.
55
39. Procurement
A. General
40. Applicable Guidelines: Procurement under the proposed project would be carried out in
accordance with the World Bank’s "Guidelines: Procurement of Goods, Works and Non-
Consulting Services under IBRD Loans and IDA Credits & Grants by World Bank Borrowers"
dated January 2011; "Guidelines: Selection and Employment of Consultants under IBRD Loans
and IDA Credits & Grants by World Bank Borrowers” dated January 2011; “Guidelines on
Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA
Credits and Grants”, dated October 15, 2006, and revised in January 2011; and the provisions
stipulated in the Financing Agreements.
41. The general description of various expenditure categories for items to be financed are
described below. For each contract to be financed by the credit, the different procurement
methods or consultant selection methods, the need for prequalification, estimated costs, prior
review requirements, and time frame are agreed between the Borrower and the Bank project
team in the Procurement Plan. The Procurement Plan will be updated at least annually or as
required to reflect the actual project implementation needs and improvements in institutional
capacity.
42. Exceptions to National Competitive Bidding Procedures - For National Competitive
Bidding (NCB) for goods and works, the Borrower may follow its own national procedures that
are governed by the Ghana Public Procurement Act 663 of 2003, with the following exceptions
noted below:
(i) Procuring entities shall use appropriate standard bidding documents acceptable to
the Association.
(ii) Foreign bidders shall be allowed to participate in National Competitive Bidding
procedures and foreign firms shall not be required to associate with a local partner in
order to bid as a joint venture, and joint venture or consortium partners shall be
jointly and severally liable for their obligations.
(iii) Bidders shall be given at least 30 days to submit bids from the date of the invitation
to bid or the date of the availability of bidding documents, whichever is later.
(iv) No domestic preference shall be given for domestic bidders and for domestically
manufactured goods.
(v) Each bidding document and contract financed out of the proceeds of the Financing
shall include provisions on matters pertaining to fraud and corruption as defined in
paragraph 1.14(a) of the Procurement Guidelines. The Association will sanction a
firm or an individual, at any time, in accordance with prevailing Association
sanctions procedures, including by publicly declaring such firm or individual
ineligible, either indefinitely or for a stated period of time: (i) to be awarded an
Association-financed contract; and (ii) to be a nominated sub-contractor, consultant,
manufacturer or supplier, or service provider of an otherwise eligible firm being
awarded an Association-financed contract; (g) in accordance with paragraph 1.14
(e) of the Procurement Guidelines, each bidding document and contract financed out
of the proceeds of the project shall provide that: (i) bidders, suppliers, contractors
56
and subcontractors shall permit the World Bank, at its request, to inspect their
accounts and records relating to the bid submission and performance of the contract,
and to have said accounts and records audited by auditors appointed by the World
Bank; and (ii) the deliberate and material violation by the bidder, supplier, contractor
or subcontractor of such provision may amount to an obstructive practice as defined
in paragraph 1.16 (a) (v) of the Procurement Guidelines, and (h) The Association
may recognize, if requested by the Borrower, exclusion from participation as a result
of debarment under the national system, provided that the debarment is for offenses
involving fraud, corruption or similar misconduct, and further provided that the
Association confirms that the particular debarment procedure afforded due process
and the debarment decision is final.
43. Advertising procedures: In order to get the broadest possible interest from eligible
bidders and consultants, a General Procurement Notice (GPN) will be prepared by each
participating country and published in United Nations Development Business online (UNDB
online), on the Bank’s external website and in at least one national newspaper, or technical or
financial magazine of wide national circulation in the Borrower’s country, or a widely used
electronic portal with free national and international access; after the project is approved by the
Bank Board, and/or before Project effectiveness. The borrower will keep a list of received
answers from potential bidders interested in the contracts.
B. Procurement Arrangements
44. Procurement activities under the project are expected to be very simple and similar to the
recently completed Nutrition and Malaria Control for Child Survival Project implemented under
the same arrangements. The GHS procurement staff have enormous experience to manage the
procurement activities under the project without much problems. Procurements of certain types
of medicines and health products will be supported by MoH as per existing arrangements. Major
procurement anticipated under the project includes public health inputs such as vitamin A
capsules and Oral Rehydration Salts (ORS) and equipment such as weighing scales for mothers,
infants and children, simple goods and average consultancy assignments, for which GHS is very
familiar and has enormous experience. Component 1 will fund Community Performance Based
Financing which has no procurement implication as well as procurement of motorbikes,
medicines and medical tools and equipment, registers, tools for volunteers as well as software
and hardware for community interventions reporting and recording systems. Procurement under
component 2 will mainly involve consultancy assignments in development of guidelines and
tools for service quality improvements, drafting policies and regulations, conduct of baseline and
end-line surveys, training and capacity building, provision of various technical assistance; and
audits.
45. Procurement of Works: At project preparation, no plans for works procurement under
this project have been identified. In case the need for minor works arises during implementation,
the use of shopping procedures will be adopted for works estimated to be less or equal to
US$200,000. NCB procedures will be used for works costing more than US$200,000. For NCB,
National Standard Tender Documents satisfactory to the Bank will be used while shopping
procedures will be in accordance with paragraph 3.5 of the Procurement Guidelines and based on
57
a model request for quotations satisfactory to the Bank. Direct contracting may be used in
exceptional circumstances with the prior approval of the Bank, in accordance with paragraphs
3.7 and 3.8 of the Procurement Guidelines.
46. Procurement of Goods (approximately US$18 million): Goods procured under the
project would include health goods, motorbikes, vehicles, computers and accessories, other
office equipment, tools and equipment such as weighing scales, training materials, information,
education and communication (IEC) and behavior change communications (BCC) materials,
registers, tools for volunteers as well as software and hardware for community interventions
reporting and recording systems. Contracts for goods estimated to cost US$3,000,000 equivalent
or more per contract shall be procured through ICB. On the other hand, specific items estimated
to cost less than US$3,000,000 but not available on the local market could also use ICB method
of procurement. Goods orders shall be grouped into larger contracts wherever possible to achieve
greater economy. Contracts estimated to cost less than US$3,000,000 but above US$100,000
equivalent per contract may be procured through NCB. The procurement will be done using
Bank’s Standard Bidding Documents (SBD) for all ICB and for all others the National Standard
Tender Documents satisfactory to the Bank. Contracts estimated to cost less than US$100,000
equivalent per contract may be procured using shopping procedures in accordance with
paragraph 3.5 of the Procurement Guidelines and based on a model request for quotations
satisfactory to the Bank. Direct contracting may be used in exceptional circumstances with the
prior approval of the Bank, in accordance with paragraphs 3.7 and 3.8 of the Procurement
Guidelines.
47. Procurement of non-consulting services (approximately US$1 million): Procurement
of non-consulting services such as services for organizing workshops, servicing of office
equipment, surveys, etc. will follow procurement procedures similar to those stipulated for the
procurement of goods, depending on their nature. The applicable methods shall include ICB,
NCB and shopping.
48. Selection of Consultants (approximately US$3 million): Services of both national and
international consultants will be required under the project to carry out assignments in various
areas of expertise, including: development of guidelines and tools for service quality
improvements, drafting policies and regulations, conduct of baseline and end-line surveys,
training and capacity building, provision of various technical assistance, CPBF external
verification, audits, etc.
49. (a) Firm - Consultancy services through firms would be selected using Request for
Expressions of Interest, short-lists and the Bank’s Standard Requests for Proposal, where
required by the Bank’s Guidelines. The selection method would include Quality and Cost Based
Selection (QCBS), Quality Based Selection (QBS), Fixed Budget Selection (FBS), Least Cost
Selection (LCS), Single Source Selection (SSS) as appropriate. Contracts for consulting services
will generally be procured through Quality and Cost Based Selection (QCBS) method. However,
depending on the complexity and cost of the assignment other selection methods could be used.
Procedure for Quality-Based Selection (QBS) would be followed for assignments which meet the
requirements of paragraph 3.2 of the Consultant Guidelines; Procedure of Fixed Budget (FBS)
would be followed for assignments which meet the requirements of paragraph 3.5 of the
58
Consultant Guidelines; and Procedure of Single-Source Selection (SSS) would be followed for
assignments which meet the requirements of paragraphs 3.10-3.12 of the Consultant Guidelines
and will always require the Bank’s prior review regardless of the estimated cost. Consulting
services estimated to cost less than US$300,000 per contract under this project may be procured
following the procedures of Selection Based on Consultants’ Qualifications (CQS). Least-Cost
Selection (LCS) would be used for assignments for selecting the auditors. For all contracts to be
awarded following QCBS, QBS, LCS and FBS, the Bank’s Standard Request for Proposals will
be used.
50. (b) Individual Consultants - Specialized advisory services and technical assistance to
MoH and GHS and its decentralized agencies may be provided by individual consultants.
Procedures of Selection of Individual Consultants (IC) would be followed for assignments which
meet the requirements under Section V of the Consultant Guidelines.
51. Assignments estimated to cost the equivalent of US$300,000 or more would be
advertised for expressions of interest (EOI) in United Nations Development Business (UNDB)
online, in the Bank’s external website through client connection, and in at least one newspaper of
wide national circulation. In addition, EOI for specialized assignments may be advertised in an
international newspaper or magazine. Shortlist of firms for assignments estimated to cost less
than US$300,000 may be composed entirely of national firms in accordance with the provisions
of paragraph 2.7 of the Consultant Guidelines provided a sufficient number of qualified national
firms are available and no foreign consultants desiring to participate have been barred. In such
instances, the requests for expression of interests would be advertised nationally.
52. Procedure of Single-Source Selection (SSS) would be followed for assignments which
meet the requirements of paragraphs 3.8-3.11 of the Consultant Guidelines and will always
require the Bank's prior review regardless of the amount. Procedures of Selection of Individual
Consultants (IC) would be followed for assignments which meet the requirements of paragraphs
5.1 and 5.6 of the Consultant Guidelines. For all contracts to be awarded following QCBS, LCS
and FBS, the Bank's Standard Request for Proposals will be used.
53. The use of civil servants as individual consultants or a team member of firms will strictly
follow the provisions of paragraphs 1.9 to 1.13 of the Consultants Guidelines.
54. Strengthening Implementation Capacity: A number of target trainings and workshops
are anticipated under the project to build capacity of MoH, GHS and other beneficiary agencies
to assure efficient implementation, provide required knowledge for service delivery to ensure
quality service and sustainability. All training and workshop activities would be carried out on
the basis of approved annual programs that would identify the general framework of training
activities for the year, including: (i) the type of training or workshop; (ii) the personnel to be
trained; (iii) the selection methods of institutions or individuals conducting such training; (iv) the
institutions which would conduct the training; (v) the justification for the training, how it would
lead to effective performance and implementation of the project and or sector; and (vi) the
duration of the proposed training; (vii) the cost estimate of the training. Report by the trainee
upon completion of training would be required.
59
55. Supervision, Incremental Operating and Monitoring and Evaluation and Project
Management: Operating costs financed by the project are incremental expenses arising under
the Project, and based on annual work plans and budgets approved by the Association to cover
project implementation related expenditures such as office supplies, vehicle operation and
maintenance, maintenance of equipment, communication and insurance costs, office
administration costs, utilities, rental, consumables, accommodation, travel and per diem, salaries
of local contractual staff, but excluding the salaries of the Recipient’s civil service.
56. Sub-projects: Sub-projects could cover any activities that promote the utilization of
community based health and nutrition services, including purchasing minor goods (e.g. bicycles,
volunteer identification packages), training and workshop, and incremental operating cost.
Grants for sub-projects will be disbursed directly to participating districts against the number of
target population to be reached and serviced based on the district plan of actions. Details of
criteria for identifying activities under the sub-projects for utilization will be described in the
sub-project manual and agreed with the Bank.
57. Community Performance-Based Financing (approximately US$10 million): This is
not a procurement activity and its implementation arrangements will be detailed out in an
Operational Manual.
58. The procedures for managing these expenditures will be governed by the Borrower’s own
administrative procedures, acceptable to the Bank.
Assessment of the Agency’s Capacity and Risks to Implement Procurement
59. Institutional Responsibilities for Procurement: The MoH will have the overall
oversight responsibility of the project and the day to day management of the project, including
procurement management will be the responsibility of the GHS. This arrangement was used for
the NMCCSP and it worked very well and helped achieve the desired procurement results.
60. Capacity Assessment: An assessment of the capacity of the GHS to implement
procurement for the Project was carried out in accordance with the Procurement Services Policy
Group (OCSPR) guidelines dated August 11, 1998, and the newly developed Procurement Risk
Assessment & Management System (P-RAMS). The objectives of the assessment were to (a)
evaluate the capacity of the executing agency and the adequacy of procurement and related
systems in place, to administer procurement; (b) assess the risks (institutional, political,
organizational, procedural, etc.) that may negatively affect the ability of the agency to carry out
procurement; (c) develop an action plan to address the deficiencies detected by the capacity
analysis and to minimize the risks identified by the risk analysis; and (d) propose a suitable Bank
procurement supervision plan for the project compatible with the relative strengths, weaknesses
and risks revealed by the assessment. P-RAMS organize the assessment into eleven risk factors
that relate to controls at the level of the Implementing Agency (i.e. GHS).
61. The assessment concludes that the GHS is in compliance with the country’s procurement
law, having a functional procurement department in the organization, having adequate internal
technical and administrative controls and anti-corruption measures, and satisfactory appeal
60
mechanisms for bidders. The Procurement department is also fully staffed with qualified
personnel with knowledge in World Bank and other Donor procurement procedures as well as
the national procedures. The head of department as well as all the three other key staff have
masters’ level education and requisite training in procurement while two others have bachelor’s
degrees.
Key Procurement Risks and Mitigation Measures
62. The assessment rates the overall risk for procurement as low. However some suggestions
are made to ensure that risk will be maintained as low and to help the project achieve its project
development objectives.
63. The Table below summarizes key risks identified and proposed mitigation measures and/
or actions to be agreed upon to maintain the risk at low.
61
Table 8 Key Procurement Risks and Mitigation Measures
64. Procurement Documents: The procurement will be carried out using the latest Bank’s
Standard Bidding Documents (SBD) or Standard Request for Proposal (RFP) respectively for all
ICB for goods and recruitment of consultants. For NCB, the borrower shall submit a sample
form of bidding documents to the Bank for prior review after incorporating the exceptions listed
above and will use this document throughout the project once agreed upon. The Sample Form of
Evaluation Reports developed by the Bank, will be used. NCB SBD will be updated to include
No Key risks Mitigation Actions By Whom By When
1 Non-alignment
of existing
Procurement
Manual with
Revised
Procurement
Guidelines.
Agency staff
may not
understand fully
the roles and
responsibilities
Update existing procurement manual to
incorporate recent revisions of the World Bank’s
procurement guidelines
Organize a project launch workshop for key staff
of GHS and its decentralized agencies
GHS
Before Effectiveness
Before Effectiveness
2 Possible delays
in processing
procurement and
payments.
Prepare and get first batch BDs, TORs and RFPs
ready prior to project effectiveness
Setting of standard processing times
Continuous tracking and monitoring of contract
performance.
Undertake yearly post-reviews in addition to
compliance audit by Internal Audit Agency.
GHS
Continuous
3 Inadequate
Record
Management
Continue to maintain good filing and data
management system. Conduct refresher training
in data management and filing for all staff
Project
Coordinator
Within first year of project
implementation
4 Lack of Realistic
procurement
plans
A comprehensive procurement plan covering at
least 18 months should be developed and bidding
documents for the initial contracts prepared to
ensure readiness and avoid delays
GHS
5 Unaligned NCB
procedures
Agree with the Bank a list of unacceptable NCB
issues and remove them from documents to be
used for Bank financed procurement.
GHS
6 Fraud and
Corruption
(Kick-backs)
Enforce provisions of World Bank Guidelines,
the Public Procurement Act, the Financial
Administration Act and Internal Audit Agency
Act on Fraud and Corruption.
Observed cases to be referred to Auditor General
for further investigations.
Annual project audit including procurement and
financial management
MoH Chief
Director
External
Auditors
Throughout project life
62
clauses related to Fraud and Corruption, Conflict of Interest and Eligibility requirements
consistently with the World Bank procurement guidelines dated January 2011.
Procurement Plan
65. The Borrower has developed a procurement plan for activities that have been identified
upfront which provides the basis for the procurement methods. This plan has been agreed
between the Borrower and the Bank and will be made available in the image bank and made
publicly available online. This plan will be updated annually to reflect the latest circumstances. It
will also be available in the project’s database and in the Bank’s external website and also
available in the Project’s database.
66. Prior-Review Thresholds: The Procurement Plan shall set forth those contracts which
shall be subject to the World Bank’s prior review. All other contracts shall be subject to post
review by the World Bank. However, relevant contracts below prior review thresholds listed
below which are deemed complex and/or have significant risk levels will be prior-reviewed.
Such contracts will also be identified in the procurement plans. Summary of prior-review and
procurement method thresholds for the project are indicated in Table 9 below. All terms of
reference for consultants’ services, regardless of contract value, shall also be subject to the
World Bank’s prior review.
Table 9 Thresholds for Procurement Methods
Expenditure Category
Contract Value (Threshold)
(US$)
Procurement
Method
Contract Subject to Prior
Review
1. Goods and Non-
Consulting
Services
≥ 3,000,000 ICB All contracts
<3,000,000 NCB
Specified contracts as indicated
in the procurement plan
< 100,000 Shopping None
No threshold Direct contracting All contracts
≥ 300,000 QCBS, QBS, FB All contracts
2. Consultancy
Services <300,000
QCBS; QB, FB, LCS;
CQ; Other
First 2 contracts or Specified
contracts as indicated in the
procurement plan
≥50,000 IC All contract of 50,000 and more
<50,000 IC
Specified contracts as indicated
in the procurement plan
No threshold
Single Source
(Selection Firms &
Individuals) All contracts
3. Training Annual Plan All Training
All TORs regardless of the value of the contract are subject to prior review ICB – International Competitive Bidding QCBS – Quality and Cost-Based Selection method NCB – National Competitive Bidding CQS – Consultants’ Qualification Selection method
IC – Individual Selection method
67. Frequency of Procurement Supervision: In addition to the prior review supervision
which will be carried out by the Bank, the procurement capacity assessment recommends at least
one supervision mission each year to visit the field to carry out post-review of procurement
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actions and technical review. The procurement post-reviews and technical reviews will cover at
least 5 percent of contracts subject to post-review. Post review consist of reviewing technical,
financial and procurement reports carried out by the Borrower’s executing agencies and/or
consultants selected and hired under the Bank project according to procedures acceptable to the
Bank.
Details of the procurement arrangements involving high value contracts and international
competition bidding
(a) Goods and Non Consulting Services
Table 10 List of high value and ICB contract packages to be procured for the first 18
months
1 2 3 4 5 6 7 8 9
Ref.
No.
Contract (Description) Estimated
Cost
Procure
-ment
Method
P-Q Domestic
Preferenc
e (yes/no)
Revie
w by
Bank
(Prior
/ Post)
Expected
Bid-
Opening
Date
Comment
s
1 Procurement of 10 units of
4X4 Station Wagon and 25
units of 4X4 Double Cabin
Pick Up Vehicles and
Accessories 1,550,000 NCB No Prior 11-Sept-14
2 Procurement of 400 units
of Motorcycles 1,600,000 NCB No Prior 17-Sept-14
3 Procurement of
100x125,636 packs of Zinc
Sulphate Tablet, 20mg and
2,053,702 Sachet of Oral
Rehydration Salt, 12.3g
(WHO Formula 2004) 1,313,147 ICB No Prior 2-Oct-14
4 Procurement of
Anthropometric equipment
(16,000 hanging scales,
8,000 baby electronic
scales, 5,000 mother/child
scales, (height measuring
instrument and MUAC for
children) 2,650,000 UNICEF No Prior 2-Sept-14
5 Procurement of
600,000units of Long
lasting Insecticide Treated
Nets 2,100,000 ICB No Prior 25-Oct-14
6 Procurement of 500,000
units of Maternal Delivery
Kits (Mackintosh, Sanitary
pads, disinfectant, 2 yards
of soft cotton cloth) 1,500,000 NCB No Prior 14-Oct-14
7 Procurement of 400 units
of Motorcycles 1,600,000 NCB No Prior 17-Oct-14
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68. ICB contracts for Goods and non-consulting services identified in the procurement plan,
and all Direct Contracting will be subject to prior review by the Bank.
(b) Consulting Services
Table 11 List of consulting assignments with short-list based on international competition
1 2 3 4 5 6 7
Ref.
No.
Description of Assignment Estimated
Cost
Selectio
n
Method
Review
by
Bank
(Prior /
Post)
Expected
Proposals
Submissio
n Date
Comments
1 Engagement of a Consulting firm
to manage volunteers under the
PBF
300,000 QCBS Prior 31-Nov-14
2 Engagement of a Consulting firm
to conduct needs assessment,
develop curriculum and conduct
TOT training in Financial
Management
300,000 QCBS Prior 16-Jan-15
3 Engagement of a Consulting firm
to conduct Baseline survey for
newly enrolled districts
400,000 QCBS Prior 18-Oct-14
4 Engagement of a Consulting firm
to conduct Endline survey for
MCHIP
800,000 QCBS Prior 7-Aug-18
69. Consultancy services estimated to cost US$300,000 equivalent or more per contract with
firms and US$100,000 or more per contract with individual consultants and all Single Source
Selection of consultants will be subject to prior review by the Bank.
70. Shortlists of consultants for services estimated to cost less than US$500,000 for design
and supervision assignment and US$300,000 for other consultancy assignments per contract may
be composed entirely of national consultants in accordance with the provisions of paragraph 2.7
of the Consultant Guidelines.
71. Publications of Awards and Debriefing: For all ICBs, request for proposal that involves
international consultants and direct contracting, the contract awards shall be published in UN
Development Business online and on the Bank’s external website within two weeks of receiving
IDA’s "no objection" to the recommendation of contract award. For goods, and non-consulting
services, the information to publish shall specify (i) name of each bidder who submitted a bid;
(ii) bid prices as read out at bid opening; (iii) name and evaluated prices of each bid that was
evaluated; (iv) name of bidders whose bids were rejected and the reasons for their rejection; and
(v) name of the winning bidder, and the price it offered, as well as the duration and summary
scope of the contract awarded. For Consultants, all consultants competing for an assignment
involving the submission of separate technical and financial proposals, irrespective of its
estimated contract value, should be informed of the result of the technical evaluation (number of
points that each firm received), before the opening of the financial proposals. Furthermore, the
65
following information must be published: (i) names of all consultants who submitted proposals;
(ii) technical points assigned to each consultant; (iii) evaluated prices of each consultant; (iv)
final point ranking of the consultants; and (v) name of the winning consultant and the price,
duration, and summary scope of the contract. The same information will be sent to all
consultants who have submitted proposals. The Borrower’s implementing agency will be
required to offer debriefings to unsuccessful bidders and consultants, should the individual firms
request such a debriefing.
72. NCB and other post review contracts shall be published in national gazette or on a widely
used website or electronic portal with free national and international access within two weeks of
the Borrower’s award decision and in the same format as in the preceding paragraph.
73. Fraud, Coercion and Corruption: All procurement entities as well as bidders and
service providers, i.e., suppliers, contractors, and consultants shall observe the highest standard
of ethics during the procurement and execution of contracts financed under the project in
accordance with paragraphs 1.16 and 1.17 of the Procurement Guidelines and paragraph 1.23 and
1.24 of the Consultants Guidelines, in addition to the relevant Articles of the Ghana Public
Procurement Laws which refer to corrupt practices.
Environmental and Social (including safeguards)
74. The project targets are clearly defined. Besides the defined targets – namely pregnant
women, mothers of children between ages zero and five and the children under five – there is an
inherent gender issue due to socio-cultural practices. The project will ensure that partners of
target women are considered as key players and therefore get more interested and involved in
implementation activities. The participation of partners beyond the financial support will boost
the morale of the women. Information, Education and Communication (IEC) of the project will
make conscious effort to target men including opinion leaders, chiefs and other males in
influential position in the targeted communities. Other targets will be family members in general,
mothers and mother in-laws of targeted women in particular.
75. Considering the importance of social and cultural beliefs and practices that influence
maternal and child care, and eventually nutrition and health outcomes, the project will pay
particular attention to existing communication strategies; existing communication strategies will
be reviewed and updated and new strategies will be pilot tested. These will include culturally
sensitive information and communication strategies and will include beliefs surrounding
initiation of breastfeeding and implication for the health of mother and baby. The attention given
to the role of communities, care givers and other key players in a collaborative way does not only
have the potential to make a positive impact but also has potential to ensure that all are involved
to achieved set targets for communal benefit in the short to the long run. Indeed the whole of
component 2 activities speak to the strong emphasis of positive social reflection of the project
activities.
76. The adoption of simple implementation strategies will encourage participation and
inclusiveness and engender ownership and sustainability through behavioral change. Such
changes will positively impact beneficiaries’ (individuals and communities) medium to long
66
term productivity beyond health and nutrition considerations. The project anticipates active
engagement of existing social capital and resources (institutions and skills) including NGOs,
traditional and religious bodies in the beneficiary communities. This is expected to improve
efficiency, encourage knowledge transfer and cost reduction, and most importantly reduce
possibility for competition and conflict. It is envisioned that this will improve understanding of
women’s role in health and eventually their status. A cornerstone of the project is community
mobilization whereby community committees will select community growth promoters and
monitor their activities and achievements.
77. The project did not trigger the involuntary resettlement policy, OP 4.12. This is due to the
nature of project activities none of which will require land acquisition that will contribute to
restriction of access, restriction of access to assets, and displacement.
78. The Project is classified as environment screening category C, meaning that it is expected
to have minimal or no adverse environmental impacts. The project activities are outreach
activities promoting pre- and post-natal care that include both clinic and home visits. While the
Project will not procure the inputs for any immunization, those outreach financed may be used as
a vehicle for immunization; therefore, the Environmental Assessment Policy OP4.01 is triggered
due to the potential for medical waste generation and need for proper management and disposal
of the waste. The kind of wastes to be generated under the project will be in the form of sharps
from the immunization program and long term family planning methods. There is a well-
developed national disposal program that is implemented for this sort of waste. All staff and part
time employees involved in the delivery of outreach will be given brief training and materials on
the waste disposal policy.
79. Additionally, it is important to highlight the fact that Ghana and the health sector have
experience regarding World Bank safeguards policies, instruments and compliance requirements
and also the sector has implemented projects that have dealt with management and disposal of
medical waste, hence not a new phenomenon. What this means is that the institutions to be
involved in the implementation of this project have the capacity to deal with the rather
manageable medical waste expected from the facilities to be supported under the project. The
Environmental Protection Agency (EPA) is very strong institutionally and technically to handle
environmental and social safeguards related issues and has collaborated well with the World
Bank over the years. In spite of this, implementing entities especially those at the district levels
will be trained in handling medical waste, management and disposal as is outlined in the existing
National Health Care Waste Management Policy, which has been reviewed by the Bank and
found to be good practice and to meet acceptable national standards. It is expected that the
identified minor impacts will be handled appropriately and effectively by the client and with the
guidance of the Bank's safeguards team.
Monitoring & Evaluation
80. The Project will include a comprehensive M&E system as part of the regular M&E
process for the entire health sector. The emphasis is on monitoring action-relevant information,
including data validation and proactive feedback mechanisms. The project has a set of outputs
that will be used to monitor progress towards the achievement of the project. There is a set of
67
intermediate indicators to measure the extent of progress on key deliverables of the project. The
project contribution to health outcomes is described by the PDOs. The project outputs will be
collected, collated, and reported by the implementing districts using the GHS reporting chain
(which is from sub districts through districts, regions to national level). The project outputs will
be included in the routine data reporting system. The project intermediate and PDO indicators
will be tracked and reported through surveys, the DHS, with the MICS during the mid-term of
the project and the DHIMS (GHS routine health management information system).
81. The eRegister database system designed during the NMCCSP will be expanded to cover
all the services delivered under the community services delivery platform. This system links with
the district health information management system-DHIMS (used to report health indicators by
the Ghana Health Service). The eRegister captures transactional data and will be used as the
primary source of verification of community level immunization, growth promotion, ANC and
PNC services.
82. At the level of individual households, the growth chart and the registers will serve as the
principal tool for data collection and monitoring for action to improve child growth and
development. Community volunteers will keep track of this information using community
registers, which are currently being integrated and simplified. In addition, there will be a
monthly validation of the data by the DHMT supported by NGOs and the Local Government for
the CPBF and a quarterly independent validation of the CPBF to enable transfer of funds.
83. Community volunteers, CHOs and sub-district focal persons will collect community
service data on children, pregnant women and mothers during service delivery. The information
in the community register will be entered into the centralized eRegister database, which will
aggregate the information and upload into the DHIMS software for reporting health indicators.
The DHIMS software is web enabled and the health indicators will be available to all
stakeholders with access permission to view reports. The eRegister system will reduce
duplication of data collection, ensuring that each service provider collects data on services that
he/she provides. All health service indicators are reported through the DHIMS.
84. For timely feedback and unbiased monitoring, other process monitoring systems
including operational research will be incorporated whenever necessary. With the use of the
eRegister, records of registration, ANC, delivery, PNC and each growth promotion sessions will
be available for both internal and external verification of the CPBF to validate data from the
CHPS zones prior to payment. Thus the health staff earning the reward will ensure that records
of visits and attendances, including service data are entered into the system. There will also be an
independent verification of the CPBF results by a third party engaged by the GHS. In addition to
the system described above, an internal verification of the CPBF results will be carried out by a
team consisting of district and sub-district health teams, District Assembly staff and NGOs
working in the districts.
85. The effectiveness of CPBF will be rigorously assessed using an impact evaluation design
where it is compared to simply providing district grants. Two special surveys (baseline and end
line) are planned to measure project outcomes. The evaluation study will be contracted out.
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Role of Partners
86. The project will benefit from technical assistance of the United Nations technical
agencies and will complement activities of other development partners. The World Health
organization (WHO), the United Nations Children’s Fund (UNICEF), the World Food Program
(WFP) and the Micronutrient Initiative (MI) will be providing technical assistance on policy and
strategy development including micronutrient deficiency control strategies as well as
procurement and distribution of vaccines. The World Bank will continue to support the
implementation of the CHPS and roll out the community-based growth promotion activities
nationwide. The other donors such as the Global Fund, the European Union (EU), the United
States Agency for International Development (USAID) and the United Kingdom Department for
International Development (DFID) on the other hand will continue to support procurement and
distribution of anti-malarial drugs and diagnostic test kits, equipment for service delivery in
facilities, support training of clinical staff and strengthen the regulatory system to ensure good
quality inputs for service delivery.
87. The European Union (EU) is providing substantial support through the Ghana
Millennium Acceleration Framework (MAF) in maternal and child health over the period of
2013 to 2017. UNICEF is supporting the three northern regions of Ghana in maternal, child
health and nutrition activities. The United States Agency for International Development
(USAID) is supporting a number of programs in maternal health and nutrition through the
Community Management of Acute Malnutrition project (CMAM). The World Food Program
(WFP) is implementing supplementary feeding program, community based fortification program
and IDD control program in the northern sector of the country. The World Health Organization
(WHO) is providing technical assistance and funds to build staff capacity in policy analysis and
nutrition surveillance. The Department for International Development (DFID) plan for the next
five years will focus on strengthening Community Mental Health, Food and Drugs Board to
address challenges of fake drugs, and the Health Facility and Regulatory Board. Support will
also be provided to the sector for service delivery using a performance based financing system.
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Annex 4 Operational Risk Assessment Framework (ORAF)
Ghana: Maternal and Child Health Improvement Project (P145792)
Project Stakeholder Risks
Stakeholder Risk Rating Low
Risk Description: Risk Management:
The RBF approach may be questioned at first, but
experience elsewhere has shown that such approaches are
welcomed and generate intended benefits, especially at the
front line level. In addition the different stakeholders
including the MoH, GHS, communities in project areas,
community volunteers, health workers, DHMT and
District Assemblies will see this as a another mechanism
to facilitate essentially the roll-out of proven interventions
so it should not be controversial.
There are multiple development partners and stakeholders
(e.g., multilateral and bilateral donors, UN agencies, and
non-governmental organizations) operating in the health
sector. Lack of proper coordination may lead to
duplication, confusing messages, and waste of resources.
All these stakeholders participated in the implementation of the NMCCSP and their
representatives are also part of the preparation process. Furthermore, there is a wide
range of information about the project activities already as a result of the
implementation of the previous project. There is general agreement on the
appropriateness of these interventions. Dissemination will be continued into the new
target communities ahead of implementation.
There will be exchange programs with countries that have experience in the
implementation of PBF that would contribute to building capacity in the Ghana health
sector.
Government policies, strategies and plans serve as the framework for donor and
stakeholder harmonization and program coordination. Government agencies, including
the Ministry of Finance, have established mechanisms to coordinate and align support
provided by donors and stakeholders. Under the proposed project, support would be
provided to strengthen the policy and institutional capacity of the health sector agencies
so that they could exercise effectively this vital stewardship function in the health sector.
Additionally, the regular coordination meetings with government and other development
partners would facilitate sharing of information and coordination of all efforts.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Both
01-Sep-2014
Implementing Agency (IA) Risks (including Fiduciary Risks)
Capacity Rating Low
Risk Description: Risk Management:
The project management team has adequate Intensify supervision and introduce mechanisms to allow direct community monitoring of service
70
experience and capacity to ensure quality
delivery of the project activities. However,
it has recorded slow progress resulting
from complex internal processes and
procedures. There may be issues with
delayed implementation, although the fact
that the activities have already been
implemented under the first project should
reduce the impact of this.
delivery to expedite implementation.
Resp: Bank Status: Not
Yet
Due
Stage: Imple
menta
tion
Recurrent:
Due
Date: Frequency
:
Governance Rating Low
Risk Description: Risk Management:
Coordination issues between MoH and GHS may cause
delays to project implementation.
Clear definition of roles and responsibilities of the stakeholders will be developed and
written into the operational manuals. Monitoring of performance of these roles will be
strengthened.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Both
Risk Management:
The project will address these risks by (i) incorporating quality measures as an integral
part of the process of determining payouts to the CHPS zone; (ii) the team closely
monitoring the procurement processes; (iii) establishing strong internal and external
verification systems to ensure that records are authentic; and establishing a grievance
redressal system to respond to community needs appropriately.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Bank In Progress Implementation
Project Risks
Design Rating Moderate
Risk Description: Risk Management:
The project is designed to roll out pilot
activities of previous Bank supported
projects and introduce result-based
financing approach to enhance quality
performance and utilization of health
services.
Capacity building and awareness creation have been programmed for so staff are well trained before
implementation. Learning events, exchange visits and video conferences will be organized so key
stakeholders are knowledgeable and confident of implementation processes.
Resp: Both Status: In
Progres
s
Stage: Both Recurrent:
Due
Date: Frequency
:
71
Applying CPBF is a new approach that the
client is unfamiliar with. In addition, the
project will have an added complexity
combining supply- and demand-side
performance-based contracts and financing.
In addition PBF mechanism has not been
tested in Ghana.
Social and Environmental Rating Low
Risk Description:
The project falls under Bank Social
Safeguards policy category C. However the
environmental assessment policy is
triggered to ensure that medical waste,
primarily in the form of sharps from the
immunization program and long term
family planning methods, is properly
managed and disposed according to the
national disposal program.
Risk Management:
All staff and part time employees involved in the delivery of outreach will be given brief training and
materials on the waste disposal policy.
Resp: Both Status: Not
Yet
Due
Stage: Imple
menta
tion
Recurrent:
Due
Date: Frequency
:
Risk Management:
A safeguard specialist will be part of the task team to ensure compliance and follow consistently follow
up on medical waste management. This may entail minor and irreversible environmental and social
impacts that can be effectively managed. The project will therefore require the development of a
resettlement policy framework, an environmental and social management framework and a medical
waste disposal plan.
Resp: Both Status: Not
Yet
Due
Stage: Imple
menta
tion
Recurrent:
Due
Date:
01-Sep-2014 Frequency
:
Program and Donor Rating Low
Risk Description: Risk Management:
The project is designed to include
supplemental funding from the Health
Results Innovation Trust Fund (HRITF)
financed by Norway and DFID. The
HRITF funds will finance result-based
financing approach to complement quality
assurance measures introduced by
Government.
The HRITF Grant has been approved and project team has begun coordination with and will continue
to work collaboratively with the HRITF Team to ensure compliance during implementation with the
processes that are well established and are expected to be quite straightforward.
Resp: Bank Status: Not
Yet
Due
Stage: Both Recurrent
:
Due
Date:
Frequency
:
72
Delivery Monitoring and
Sustainability Rating Low
Risk Description: Risk Management:
Monitoring: Several issues related to data
collection, verification and use pose
moderate risk to the project achieving its
PDO: (i) the community-based monitoring,
the PHC monitoring, and the HMIS are not
yet fully aligned; (ii) the temptation to
inflate results and the need for reliable
verification and counter-verification of
results (making payments service providers
and community volunteers for achieved
results may be an incentive to inflate the
figures); (iii) the increasing workload that
comes with monitoring and reporting; and
(iv) limited capacity in monitoring and
reporting at the local level (illiteracy is a
major problem in the villages).
The Nutrition and Malaria Control for Child Survival project (NMCCSP) has built substantial capacity
in 77 districts and this is available for use under the new project. An eRegister was also introduced and
capacity built for its use. The project will also include a technical assistance component which will
provide additional capacity especially for the RBF monitoring and verification of results.
Resp: Both Status: Not
Yet
Due
Stage: Both Recurrent:
Due
Date: Frequency
:
Overall Risk
Overall Implementation Risk: Rating Moderate
Risk Description:
Implementation risk is rated moderate. While the introduction of the RBF is new to Ghana, these activities represent a relatively small portion of the
entire project activities. Interest in RBF is high in Ghana, and international experience can be tapped to address any remaining issues.
73
Annex 5: Implementation Support Plan
Strategy and Approach for Implementation Support
1. The Implementation Support Plan (ISP) focuses on mitigating the risks identified in the
ORAF, and aims at making implementation support to the client more flexible and efficient. It
also seeks to provide the technical advice necessary to facilitate achievement of the PDO (linked
to results/outcomes identified in the result framework), as well as identify the minimum
requirements to meet the Bank’s fiduciary obligations.
Technical: Implementation support will include: (a) progress on objectives (b) fine tune
strategies where required (c) drawing lessons from the implementation for wider
applicability.
Procurement. Implementation support will include: (a) leveraging the existing
arrangements in the MoH and GHS; (b) providing additional staff and training as needed;
(c) reviewing procurement documents and providing timely feedback to the
implementing agencies; (e) providing detailed guidance on the Bank’s Procurement
Guidelines to the implementing Agencies (IAs); and (f) monitoring procurement progress
against the detailed Procurement Plan.
Financial management. Implementation support will include: (a) reviewing of the
country’s financial management system, including but not limited to, accounting,
reporting and internal controls; (b) leveraging the existing IAs; (c) hiring additional staff
and providing training as needed to the IAs; and (d) reviewing submitted reports and
providing timely feedback to the IAs.
Environmental and Social Safeguards. The Bank team will supervise the
implementation of the agreed Environmental and Social Management Frameworks and
Plans and provide guidance to IAs and government.
Other Issues. Sector level risks will be addressed through policy dialogue with the
governments’ Ministries and Regulatory Authorities.
2. Implementation Support Plan. While this is a repeater project and Ghana health sector
has adequate experience in implementing World Bank Projects, and despite the Bank’s own
experience in preparing similar projects, the nationwide scope of and innovations in the project
will require fairly intensive supervision, especially during the first two years of implementation.
The Bank team members will be based either in Washington DC, or in Country Offices, and will
be available to provide timely, efficient and effective implementation support to the clients.
Formal supervision and field visits will be carried out at least 2 times annually. These will be
complemented with monthly video conferences to discuss project progress. Detailed inputs from
the Bank team are outlined below:
Technical, Policy and legal/Regulatory inputs. Technical, policy and legal/regulatory
related inputs will be required to review bid documents to ensure fair competition, sound
technical specifications and standards, and confirmation that activities are in line with
Government’s health sector strategies.
74
Fiduciary requirements and inputs. Training will be provided by the Bank’s financial
management and procurement specialists as needed. The Bank team will also help
identify capacity building needs to strengthen financial management capacity and to
improve procurement management efficiency. Financial management and the
procurement specialists will be based in the country office to provide timely support.
Formal supervision of financial management and procurement will be carried out semi-
annually.
Safeguards. Inputs from environment and social development specialists will be
provided as needed.
Operation. The Task Team will provide day-to-day supervision of all operational
aspects, as well as coordination with the clients and among Bank team members.
Relevant specialists will be identified as needed.
Implementation Support Plan
Table 12 Implementation Support Plan
Time Focus Skills Needed Resource
Estimate (US$)
Partner Role
First twelve
months
CPBF
Operationalization,
Impact evaluation
design, capacity
building for the
various areas
Communication
Strategy for
Community health and
nutrition
Procurement of
external verification
and impact evaluation
agency
RBF Specialist,
Impact Evaluation
Specialist,
Nutrition
Specialist, Health
Specialist,
Pharmaceutical
Specialist,
Communication
Specialist, FMS,
Procurement
Specialist
Governance
Specialist
290,000 (IDA
+HRITF SPN)
50,000 HRITF
Preparation Fund
Civil Society
including NGOs
support
implementation and
advocacy
Development
Partners for
leveraging
resources
12-48 months Implementation
support
Same as above 150,000 Yr 1
240,000 Yrs 2 and
3
Civil Society and
NGOs
Other
75
Skills Mix Required
Skills Needed Number of Staff Weeks Number of Trips Comments
Task team leader 10 SWs annually Fields trips as
required.
Country office based
Procurement 5 SWs annually Fields trips as
required.
Country office based
FM Specialist 5 SWs annually Fields trips as
required.
Country office based
Social Development
Specialist
2 SW annually Fields trip as
required.
Country Office based
Nutrition Specialist 5 SW annually Fields trip as
required
DC based
Environment specialist 1 SW annually Field trip as
required.
Country office based
Legal Specialist 1 SW annually Field trip as
required
DC based
Health Specialist
5 SWs annually Fields trips as
required.
DC based
M&E Specialist 4 SW annually Fields trips as
required
Country office based
RBF Specialist
8 SW annually Fields trips as
required.
DC based
Pharmaceutical
Specialist
3 SW annually Fields trips as
required.
DC based
Economist 4 SW annually Fields trip as
required.
DC based
Communications
Specialist
4 SW annually Fields trips as
required.
Country office based
Governance Specialist 3 SW annually Fields trips as
required.
Country office based
Impact Evaluation
Specialist
4 SW annually Fields trips as
required.
DC based
Partners
Name Institution/Country Role
Afisah Zakaria Ministry of Health, Ghana
Health Service
Oversight
Dan Osei Ghana Health Service Project Coordinator
76
Annex 6: Financial and Economic Analysis
1. There is strong economic rationale for investing in maternal and child health and
nutrition in Ghana. 8 While evidence from the Multiple Indicator Cluster Survey (2011)
shows improvement over time in access to and utilization of essential maternal and child
health services, nutrition supplements, and related health outcomes, regional, urban-rural,
and socio-economic disparities remain considerable. For example, while the national average
for under-five mortality rate has reduced to 82 per 1,000 live births, this masks a wide
variation between the lowest of 56 in the Greater Accra region to the highest of 124 in the
Northern region. With respect to maternal care utilization, only 37 percent of women benefit
from skilled delivery in the Northern Region, 20 percentage points below the national
average of 57 percent. Likewise, wide inequalities exist in seeking antenatal care (ANC) and
the knowledge of and access to modern contraception methods. The reduction in malnutrition
rates over time has been encouraging. Yet, on average, 1 in 5 children in Ghana remain
stunted and nearly 1 in 3 in the Northern Region (MICS 2011).
2. Despite increased attention to maternal mortality and the availability of proven,
high-impact interventions to address poor maternal health, health systems and current
financial commitments for maternal and reproductive health may not be sufficient to
achieve the MDG Goals 4 and 5, which focus on maternal and child mortality. Maternal
and child health services constitute an integrated continuum of care that delivers essential
services and interventions to women who face particular risk arising from reproduction and
pregnancy, their infants at critical points, and to children in their first 5 years of age. The
continuum of MCH care is fundamental to development, which is reflected in Millennium
Development Goals (MDGs) 4 (reducing under-five child mortality by two-thirds between
1990 and 2015) and 5 (reducing maternal mortality by three quarters between 1990 and 2015
and achieving universal access to reproductive health by 2015). Globally, nearly 10 million
women per year who survived childbirth suffer from pregnancy related injuries, infections,
diseases and disabilities, often with lifelong consequences. Research has shown that 80% of
these deaths could be averted if women had access to essential maternity and basic health
care services. As part of the service continuum, reproductive health, including family
planning, saves infant lives by spacing planned births and limiting unintended births. Family
planning also saves maternal lives by reducing exposure to the risks of pregnancy and
childbirth, including recourse to unsafe abortion, one of the main causes of deaths among
young women.
3. Maternal mortality has a significant negative impact on economic growth through
various pathways, including its effect on the size of the labor force and adverse effect on
human capital formation, and hence, levels of GDP. As mothers play a prominent role in
8 There are minor differences in the data cited below and that in the main text due to different sources.
77
production of household food, their premature death may have a negative effect on children’s
nutritional status which, in turn, can affect their physical and cognitive development.
4. Maternal and childhood nutrition has substantial effect on economic growth, as
underscored in the Copenhagen Consensus (2012), and this is particularly relevant for
Ghana where nutrition is at the heart of economic development and poverty reduction
efforts. Better nutrition increases productivity and thus economic growth through increased
labor supply. The productivity losses by malnutrition occur through three pathways: direct
loss of physical productivity, indirect loss from loss in schooling and poor cognitive
development, and losses from high use of health care resources. Based on very high cost-
effectiveness ratios, the Copenhagen Consensus concluded that out of 30 potential
development investments, interventions to reduce under nutrition in preschoolers is the best
way to advance global welfare.
5. To address these challenges and improve the availability and accessibility to good
quality maternal and child health and nutrition services, the project proposes to use
simultaneous and reinforcing supply and demand side mechanisms, including (i)
strengthening the community-based delivery platform; and (ii) introducing provider
incentives through community performance-based financing (CPBF). The interventions
financed by the project target resources to low-performing areas and the most vulnerable
segments of society, young children, adolescents, and women of reproductive age, especially
pregnant women. This targeting aims to contribute to reducing both health outcome and
poverty differentials in the country.
6. Community-based service delivery has been attracting considerable policy attention
in low-income countries as an instrument that could bridge some of the health care
access and outcome gaps that unduly and adversely affect many of the poor and
vulnerable. Community- and family-based approaches have been identified in the
demographic and public health literature as one of the key factors promoting improvements
in health even under very poor economic conditions. Different mechanisms have been
suggested as driving forces behind the impact of community-based approaches, including
behavioral change communication, easy access to primary care, and engagement and
empowerment of communities in health campaigns and actions. As to empirical evidence, the
2013 Lancet Series on Maternal and Child Nutrition notes that community-based nutrition
programs can more than double the rate of initiation of breastfeeding within 1 hour of birth.
Further, a review of 82 studies found that community-based health or nutrition workers
improved rates of exclusive breastfeeding by 2.78 times in contrast with usual care. The 2011
statistics in Ghana for this indicator (on average, below 50%) suggests that the community-
based approach has plenty of space to boost exclusive breastfeeding rates. Beyond the public
health literature, recent theoretical and empirical research in economics has been focusing on
the broader effects of community-based approaches, including effects on schooling and labor
78
market participation. For example, community-based health interventions may give families
access to technologies that were previously too expensive or unknown (e.g. birth control,
nutrition practices). In the long run behavior changes in these areas may increase the return to
investment in human capital and attachment to the labor market, leading to broader economic
effects.
7. The community-based approach is expected to generate additional benefits as it can
help shift the focus from traditionally supply-side heavy interventions toward the
demand side, with the objective to balance incentives that target the providers and the
consumers. Proponents of community-based approaches hold that the strength of this
platform is rooted in the use of social capital, mutual trust, and peer monitoring, which
reduce transaction costs. The central attributes of community-based mechanisms include
decision-making at the local level, proximity to membership, personal acquaintance of the
members, empowerment of members by participatory design, autonomous management, and
lower-cost management due to reduced agency problems and transaction costs. These
attributes aim to foster service desirability and affordability, which are critical for utilization,
sustainability, and scale-up.
8. Performance-based financing (PBF) is an intervention that is gaining significant
momentum as a solution to poor performance and the health worker crisis in low-
income countries, particularly in Africa. Results indicate that PBF can play a role in
increasing the productivity of health workers and have positive effects on health service
utilization. However – given the novelty, heterogeneity, and context-specificity of PBF – to
date the evidence base has been limited. It is suggested that few studies have attempted to
isolate the effects of PBF from increased resources. Evidence is especially limited in the
context of community-based PBF. Therefore, providing economic arguments on
effectiveness and cost-effectiveness requires primary research. To contribute to the global
knowledge base in this area, and in line with the objectives of the HRITF program, the
project is subject to an impact evaluation, which aims to gather evidence on the effectiveness,
cost-effectiveness, and equity implications of the intervention.
9. The project will play an important role in reducing dramatically the maternal
mortality and child mortality, and subsequently have a significant positive impact on
the health system in Ghana. The project inputs in tandem with supporting the demand side
and Results-Based Financing (RBF) program would create incentives (i) for health workers
and volunteers to increase quality of health services, improve their productivity and increase
resources utilization pertaining to targeted activities (Maternal & Child Health and Nutrition
services); and (ii) for users to seek and better use MCH & Nutrition services. As explained
above, RBF becomes a good way to improve both accessibility and availability of good
quality services. Like the case of Rwanda and Burundi, this positive situation has a rapid
79
impact on the decline of maternal and child mortality. As illustrated in the table below, due to
the Project Development Objectives (PDO), Maternal Mortality will decrease by 56.1%
(versus 20.5% in case of status quo) and Under 5 Mortality will decline by 44.5% (versus
27.9% in case of status quo).
Table 13 Maternal Mortality and Under-five Mortality: Comparison between the Project
Scenario and the Status Quo
2012 2018 -
Status quo
2018 - Project
Scenario
Reduction in Maternal Mortality 20.5% 56.1%
Reduction in Under Five Mortality 27.9% 44.5%
Maternal Mortality Ratio at the end of the Project
(per 100,000 Live Births)
319.4 242.7 133.9
Under Five Mortality Rate at the end of the Project 61.6% 41.6% 32%
10. Reduction of maternal and child mortality due to the activities financed by the
project would save more lives than the status quo. The difference between the two
scenarios is closed to 32,000 lives saved (as shown in the table below) or US$171M in terms
of monetary value. The total cost of the project two main components ("Community-Based
MCH and Nutrition Interventions " and "Institutional Strengthening Capacity Building")
reaches US$73M. Thus, the benefit-to-cost ratio obtained is equal to 2.3 (171/73). In other
words US$1 invested in the project provides benefits equivalent to US$2.3. This ratio, which
can be considered quite high, means that for every US$2,300 invested in this project, Ghana
would save one mother or child life.
Table 14 Project Benefits: comparison between the status quo and the project scenario
Status quo Project Scenario Differences/Benefits
Maternal Mortality Ratio at the end
of the Project (per 100,000 Live
Births)
242.7 133.9
Under Five Mortality Rate at the end
of the Project
41.6% 32%
Mothers lives saved 1,695 4,965 3,269
Child lives saved 44,286 72,854 28,569
Total lives saved 45,981 77,819 31,838
Benefits (value of the lives saved),
US$
171,176,011
80
11. Working with the public sector through this project is economically justified since:
(i) there will be a focus on high impact and cost effective interventions which are a public
good, enabling better use of the finite resources; (ii) the presence of positive externalities
produced by consumption or production of goods and services that would otherwise not have
been consumed; (iii) addressing market failures arising from imbalance between the
knowledge of the supplier and the knowledge available to the consumer (information
asymmetry); and, (iv) providing financial risk protection to those who would otherwise have
been prone to financial shocks due to ill health.
12. The leadership of the World Bank in the preparation and implementation of
previous complex and similar projects in the health sector is acknowledged, and this
has led to a request for further assistance. The value added of the World Bank in this
regard is its in-depth knowledge of the health sector and the interventions to be implemented
under the MCHIP, as well as its extensive experience in Results-based Financing (RBF) in
Africa and other Continents, which will be critical in successfully implementing the RBF
activities. Moreover, Word Bank technical support under the project (or in parallel) will
significantly contribute to the success of such a program.
K w a h u P l a t e a u
A
k wa
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- To
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Ra
ng
es
Mount AfadjatoMount Afadjato(880 m) (880 m)
U P P E R W E S TU P P E R W E S T
B R O N G - A H A F O B R O N G - A H A F O
A S H A N T IA S H A N T I
W E S T E R NW E S T E R N
C E N T R A LC E N T R A L
E A S T E R NE A S T E R N
V O L T A V O L T A
U P P E R E A S TU P P E R E A S T
N O R T H E R NN O R T H E R N
GREATERGREATERACCRAACCRATemaTema
WinnebaWinneba
EnchiEnchi
KadeKade
PresteaPrestea
Twifo PrasoTwifo Praso
TarkwaTarkwa
OdaOdaDunkwaDunkwa
KpanduKpandu
KrokosueKrokosue
DiasoDiaso
BibianiBibiani
GoasoGoaso
TechimanTechiman
YejiYeji
KwadwokuromKwadwokurom
DambaiDambai
NakpayiliNakpayili
YendiYendi
GushieguGushiegu
WalewaleWalewale
WalewaleTumuWalewaleTumu
NakpanduriNakpanduri
HamaleHamale
BoleBole
SawlaSawla
FufulsuFufulsu
AtebubuAtebubu
JemaJema
KintampoKintampo
MakongoMakongo
SalagaSalaga
AgogoAgogo
BerekumBerekum
NavrongoNavrongo
ObuasiObuasi
HoHo
WaWa
KumasiKumasi
TamaleTamale
SunyaniSunyani
KoforiduaKoforidua
BolgatangaBolgatanga
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Newtown
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Black Volta
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LakeVolta
To Porto-Novo
To Abomey
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To Djougou
To Dapaong
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To Bobo-
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To Bouna
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K w a h u P l a t e a u
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- To
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Mount Afadjato(880 m)
6° N
8° N
10° N
6° N
8° N
10° N
2° W
2° E
0°
2° W 2° E0°
GHANA
0 20 40 60
0 20 40 60 Miles
80 Kilometers
IBRD 33411
SEPTEMBER 2004
GHANASELECTED CITIES AND TOWNS
REGION CAPITALS
NATIONAL CAPITAL
RIVERS
MAIN ROADS
RAILROADS
REGION BOUNDARIES
INTERNATIONAL BOUNDARIES
This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, o r any endo r s emen t o r a c c e p t a n c e o f s u c h boundaries.