Ghana: Evaluation of the bank assistance to the health sector, 1985-2004

Evaluation Team

This report was prepared by Albert-Enéas Gakusi, Principal Post-Evaluation Officer, Operations Evaluation Department (OPEV) and Messrs. Thomas O’Brien Kirk and David Royston Moore, external consultants, following their mission to Ghana in March 2005.

Objective

The objectives of the Health Sector evaluation are to: a) assess the relevance of funded activities through projects over the years 1985-2004; b) assess the effectiveness of Bank support to the Ghanaian health sector in improving health system delivery and access to health services; c) promote changes in health sector policies and institutional reforms; and d) identify lessons from experience over the period in order to strengthen Bank’s future policies and procedures and improve quality of Bank operations.

Main Lessons

• Lack of incentives in terms of accommodation and transportation makes it difficult to attract and retain qualified personnel in rural areas and to find a solution to human resources deficit and regional imbalances. In addition, installing medical equipment and constructing new or renovating hospital buildings may not necessarily lead to significant improved quality of services; if staff is not in place, the equipment does not work, power supply is erratic or unaffordable and the hospital cannot maintain equipment.

• Using medical doctors as administrative managers of a hospital, constitute a considerable opportunity cost for the health technical aspects in that they have better comparative advantages being medical doctors delivering the service for which they were trained - also due to the long time required to acquire medical competence.

• Participation in all cycles of project interventions improves effectiveness, yet despite the fact that the Bank’s development policies insist on dialogue and the beneficiaries’ participation in its interventions in Regional Member Countries, the realisation of projects pays lip service to participation. Thus, participation is not effective. This situation is supported by the behaviour of the beneficiaries towards maintenance problems, as they seem to be spectators in a process over which they have no control.

 

Main Recommendations

Recommendation(s) to the beneficiary:

• With the brain drain being one of the major challenges in the health sector, the Government of Ghana should step-up measures to provide staff accommodation and other incentives particularly for health personnel in rural areas, especially in under-privileged areas. It is also recommended that more hospital managers be trained in order to relieve doctors and other medical staff from administrative and managerial responsibilities.

• The Government should address the serious Human Resources problems in the health sector. The number of trained health staff leaving the country for positions abroad constitutes a big challenge for the Health Sector, and innovative solutions to the situation should be examined. A study to better document the problem and analyse the best approaches to solve it should be initiated, and should integrate ideas from the Health Sector personnel. The designing and planning of interventions should be based on a realistic assessment of local resources and include capacity development.

• The Government should ensure that the project managers effectively manage and implement projects in order to attain the desired objectives. It should ensure that Governmental investments in the Health Sector are accompanied by measures to ensure benefits and sustainability. In addition, regular maintenance of equipment and facilities should be organized to ensure optimal use within their normal life span, and the private sector should be utilised to improve maintenance.

• The Government of Ghana should ensure the implementation of the New Audit Service Act to present to Development Partners a solid framework for utilization of funding within the new international assistance instruments settings: Sector Wide Approach and budget support.

• The Government should enhance the country wide administrative capacity to collect information useful for monitoring and evaluating its development actions.

Recommendation(s) to the Bank:

• In Ghana, the process of implementing new intervention instruments, which provide predictable funding via the Government’s budget and reduces Government’s administrative burden, is well established with effective donor coordination under the Government’s leadership. The Bank should enter the Health Basket Fund in a manner suitable to the Bank’s procedures; this could be totally or partially by earmarked funds, which allows the tracing of fund utilization.

• It is recommended that the Bank should not keep task managers on the same project and/or in the same country for more than five years. In order to increase efficiency, efficacy and innovation in business practice, systematic rotation of task managers should be considered.

• The participatory process in designing, appraising, implementing and assessing project activities should be effective and involve all relevant stakeholders in every stage of the project cycle. The Bank should increase the quality of its appraisal process, as well as training of the personnel of the implementing agencies. It should also reduce the workload of the task managers. These recommendations could cut down the time lag in responding to beneficiaries’ requests.