Ministry of Health, Ghana HEALTH SECTOR 5 YEAR PROGRAMME OF WORK 2002 - 2006

1. Ministry of Health, Ghana HEALTH SECTOR 5 YEAR PROGRAMME OF WORK 2002 - 2006 Independent Review of POW-2006 March/April 2007

2. TORs • Broad ánd narrow: sector-wide ‘audit’ ánd in-depth analyses on MDG (4/5) issues. • Briefing: focus was needed on HOW to achieve MDGs, rather than identification of (largely known) problems • Governance and finance prominently in TORs • Broad ánd narrow led to diverging expectations – relevant for shaping future sector review process.

3. Review: Independent. • Team members • Observations and views discussed and reconciled during frequent internal team-meetings • The team bears collective responsibility for findings and opinions; these cannot be attributed to team members’ organisations, their sponsors or to the Ministry of Health.

4. Team

5. Methods • Bilateral Interviews: MOH, MOF, Politicians, public and private service providers, DPs, … • Focus groups on MDG technical areas • Review of documents • Review of PP presentations from 6 regions • Observations during technical performance hearings • Field visits (GAR, VR, WR) • Internal team discussions on feedback (debrief; draft rep.)

6. POW 2006 – Covered (+) / not covered (-)

7. Status draft report • Pressure cooking… no thorough editing of entire report during mission • Provoked useful commentaries and reveiled factual omissions, diverging opinions, diverging expectations • Final report: after Summit…to be used for ongoing constructive debate on ways forward

8. Constraints • Availability of aggregated / formal data not optimal, due to P&C cycle of MOH/GHS • Availability of team members varied • TORs vs. availability of time • Collective and individual TORs

9. Outline presentation findings / views • Sector Performance / indicators • Achieving MDG’s and results ‘06 • Technical aspects • Systems focus • Governance focus • Health financing • Review process • Areas for research / TA • Key messages

12. Overall sector performance – the team’s impression (1) There is progress, despite recent difficulties in health financing (?), ánd there is stagnationServices:Specific programmes / reproductive health: progressClinical care: low utilisation, low efficiencyHealth status: IMR / MMR: stagnation?Malnutrition: improvement? HIV prev.: small decrease?

13. Overall sector performance – the team’s impression (2) CAVE - Interpretation of sector-wide indicators not straightforward: • Outcome data: not enough data to show trends; sources not comparable • Service outputs: irregularities in data collection • Some indicators not appropriate (budget vs expenditure; 1st visits ANC?; institutional based mortality?; ..)

14. Reaching MDG 4 – child health Key achievements 2006 • EPI – coverages maintained / VAS • HIRD and comm. based growth promotion (CBGP) pilots (UER; VR) • Nutrition: • improvements in wasting, but not in stunting. CAVE: geographic variance • Advocacy for ‘Ghana Free of…’ • Equipment… • GHS strategy for fortification

15. Reaching MDG 4: FOCUS • Newborn care • Community-based delivery of evidence-based interventions (preventative and treatment) • Malaria (ITN; case-management) • Diarrhoea (ORT; …) • Pneumonia (antibiotics..) • Nutrition (EBF,Compl. feeding, micronutrients) • Immunizations • Coverage of <5yos with key CH interventions • Targeting un-reached and high risk

16. Reaching MDG 4:INVEST • Short term • HIRD, IMCI at community level • Increase CHPS zones to scale-up HIRD and IMCI • Common nutrition communication strategy • Essential newborn care, including resuscitation • Mapping for coverage and mobilization of community resources • Standards of care in district hospitals for severe infections • Medium term • IMCI at all health centers • Pre-service training in IMCI, Essential newborn care • Quality “recognition”/accreditation of facilities, providers

17. Scaling up Child Health DeliveryKey Message: Maximize coverage through community-based delivery How? • Build on strengths of existing programs (EPI, Malaria) • Use existing community-based workers like Surveillance Officers, CHPS Nurses to deliver selected CH interventions • Micro-planning/mapping at district and sub-district levels • Mobilize existing local organizations to deliver core preventive and selected curative interventions • Districts measure, report, use coverage results for local accountability (DAs) as well as improving care

18. 1st visit ANC high, but … drop-out rates Slight increase of % deliveries assisted by skilled personnel Reaching MDG 5 – maternal / repr. healthAchievements 2006

19. Population based maternal mortality ratio

20. MDG5: Population based maternal mortality ratio: key considerations for the futureKey message: We need data on trends How? • Surveys every 5 years • Link studies (upcoming opportunities: National maternal mortality and abortion care survey 2007, DHS 2008, Census 2010) • Aim to get national estimate, and disaggregate e.g. by poverty, residence and education (already possible from DHS) • Use demographic surveillance sites • In between 5 year surveys, collect institutional maternal mortality ratios through HMIS and link these with explanatory trends through maternal audit

21. Make the health centre the anchor institution for normal deliveries Address cultural barriers to access Improve clinical quality In health centres for basic care In hospitals focus on delivery complications, abortion and neonatal resuscitation And: … measure! Reaching MDG 5: FOCUS

22. Reaching MDG 5: INVEST Short term: • Clinical quality in – and effective coverage of - hospitals • Measurement of MMR Medium term: • Health centre strengthening / coverage • Human resource capacity development • Equipment and supplies

23. CHPS: potential for maternal mortality reduction • CHPS can: • provide family planning services • increase AN/PN coverage (especially for hardest to reach) • reduce anaemia before delivery • promote institutional delivery • For maternal survival, CHPS has less ability to: • Improve quality of delivery care in the community • Deal effectively with emergencies • Childhood interventions are different from maternal survival ones, one strategy cannot always fulfil the needs of both

24. MDG6 achievements POW-06 • TB cure rates; integration of TB control in BHS; community DOTs; (detection rates lagging behind) • Pro-active malaria control programme (scaling up IPT/ITN; IEC; implementation new policies) • HIV/AIDS: POW06 activities followed up; VCT growing; 341 PMTCT centres; 46 hospitals with ART

25. Achieving MDGs – systems focus • BHS / District health care / institutional care; coverage; access; referral; .. • HRH • HMIS • Support services: proc., cap., equip..

26. Systems focus - BHS • Indicators on institutional care: stagnating. West-African picture – low utilisation of BHS; inefficiencies in use of hospital care. • CHPS roll-out: still slow. Focus: • Implement hospital strategy (03) • Implement GHS referral policy (06) • ‘Map’ and target pockets of under-coverage, including urban pockets • Resources: top-priority = district and sub-district levels to achieve health gains

27. BHS (ctd) Focus: • Integration of vertical programmes at the district level: win-win • Flexible and adequate admin. and service budgets (2&3)

28. Systems focus - Human Resources for Health The workforce expansion needs to be fine-tuned: • Target on health needs • Go for cost-effective new cadres To assure quality of new health graduates: • Manage pressure on training infrastructure, and expand practical training sites • Be selective in the cadre mix (for example, cadres with impact on MDG 4,5)

29. Systems Focus - HR Management Decentralizing HRM is desirable. Potential to contain payroll inflation But: • Careful planning required • Establish skills and systems first at regional level Improvement in workers pay is stabilizing staff retention. Challenge: • fashion incentives that encourage redistribution and improved productivity of the workforce • and: ensure adequate recurrent and flexible budgets for routine work

30. Systems Focus - HR management skills and leadership Performing managers will drive the performance of their staff: • There are best practices in some regions on accountability of managers for service results. Expand to all agencies and BMCs • Review management systems and performance: • Training/assigning of BMC heads • Develop management competencies and skills development • Ensure robustness of management support systems (e.g. HMIS) • Create effective incentives that motivates managers to perform

31. HMIS • Foundations are in place • And …good track record in Ghana on ‘data collection for decision making’ (reprod. Health – 90s) • But: use of data for local decision making still insufficient. • Opportunities: simple data analysis at sub-districts, inclusion data from private providers, target setting for SLAs, … • Specific review adequate: HMIS essential for building confidence and strategic planning

32. Equipment / transport • Basic equipment: problematic • Transport: aged fleet • CAVE: (next POW) investments needed for district health

33. GOVERNANCE A.Rendering the MoH more effective in its collaboration with its Agencies B.Constructive interventions for strengthening accountability mechanisms.

34. A. EFFECTIVE COLLABORATION • Ministry intends to centralize Health Sector Vision by meeting all Agency Heads quarterly. • Suggestion: develop a Universal Agreement/Code of Conduct that would promote responsible decision making. • MoH - being the key change driver – to maintain a strong leadership corps to ensure that behaviours are aligned with set expectations under the Vision.

35. Universal Agreement/Code of Conduct Heads of Agencies will resolve to work together to: • Preserve and improve the relationship between the MoH andthe Agencies • Promote the principles of good governance and accountability • Foster confidence and trust of the wider society in Health Sector operations and activities. • Collaborate to serve the needs of the Ghanaian public

36. Engaging Leadership Competencies • Ministry to extend dialogue to Government and to orient policy/decision makers on the centralised Vision and programmes in order to enrich the top-down staff selection process. • Where gaps in capacity are identified, MoH to consider engaging quasi-public/private sector experts on secondment to operate as a practical stop-gap measure while in-house persons with the right competencies and to whom the specific job skills will eventually be transferred, are sought to play the substantive role.

37. Strengthen MoH Control Over Technical Matters • Perception that MOH is ‘weak’ vis-a-vis the Agencies over which it must have oversight. MOH currently relies on GHS as chief Technical Advisor • MoH may establish a Technical Unit and engage persons equipped with a range of skills and understanding to analyse technical issues. Must have the ability to challenge and/or support technical matters brought before MOH by the Agencies. (eg. Teaching Hospitals have specifically requested a special desk at Ministry that would be responsible for regulating, monitoring, etc.)

38. B. STRENGTHENING ACCOUNTABILITY MECHANISMS • Performance Agreements • Reports/Feedback & M&E/Internal Control • External Pressure and Support

39. Performance Agreements • Mixed success. Have been described as too blanket and not easy to decentralize down to BMC level. • Perhaps a more Participative Peer Review system must be explored with mechanisms tailored for all levels: • More supportive Performance Measurement • Process is shared and more consultative. • Skills transfer advantages would evolve from the ‘share your experiences while learning about my job’ approach. • Participants are more eager to make time to engage in a shared Performance Review cycle and would tend to see it more as a performance enhancement tool, rather than a sanctions-oriented process.

40. Reports/Feedback & M&E Challenges for routine reporting: • Reporting at the Ministry of Health is generally considered weak. Funding Agencies such as Government itself and its DPs are eager to see allocation and impact of funding, milestones and the budget attached to these. • Prescribed sanctions for not submitting reports on time? • Human Resource constraints and basic educational and skills limitations within the BMCs. • Problem with routine reporting is also the result of poor quality information

41. Feedback, Monitoring & Evaluation, Internal Control • Health Summits and Review Meetings not considered adequate by persons interviewed. Regular vertical feedback is critical for improving quality of reporting. • Both horizontal & vertical feedback is enhanced by a robust Monitoring and Evaluation system. • Health Administrators to exert bottom-up pressure by demanding feedback from decision-makers. • Weak Internal Audit capacity at District/sub-District level. Collaboration with Internal Audit Agency in revisiting internal audit system is desirable.

42. External Pressure and Support Parliamentary Select Committee • Reinforce the Parliamentary Select Committee as an accountability tool and strengthen its capacity to exercise constitutional mandates in respect of the Health Sector. Ministry of Finance and Economic Planning • Build rapport with the Ministry of Finance by establishing permanent in-house linkages within the Ministry and at the MoFEP level. Working with its intra-Ministerial counterpart, the Officer-in-charge of Health Sector Affairs at Budget Support level, would liaise with MoH, MoFEP, Development Partners and Parliament in making the case and lobbying for increased budget support for Health. Thereby there is pressure on Health Sector Agencies to demonstrate more accountability.

43. Governance focus - Key Issues • Clarifying the core business of MOH and its agencies, including NHIS • Strengthening partnerships and facilitating interrelationships – private sector, DPs, CSOs, agencies, MDAs, etc. • Improving accountability for policy results & performance: • of agencies to MOH • MOH to sector stakeholders

44. Governance - some steps… • Revise the review process and strengthen local ownership • Conduct institutional assessments/ analysis of roles of sector agencies, partners and MOH • Strengthen corporate M&E capacity & processes • Establish structured business relationships and agreed procedures with partners

45. Financing the health sector in 2006 (1) Caveats • Financial data was preliminary – update needed! • NHIS expenditure is not included in the totals. NHIS not included in current totals • No regional disaggregation available during review

46. Financing the health sector in 2006 (2)

47. Financing the health sector in 2006 (3) Was 2006 a difficult year? • Overall expenditure down by 25%? (to $14.3 per capita in total) • Sector in deficit overall • Balance of funds fell by half (indicates borrowing and drawing down reserves) • GoG increased as share of total (but partly because of fall in other sources – only 4% real growth) • GoG expenditure on health as % of total GoG expenditure was 8% (compared with 14% in 2005) • IGF up less than expected (11% - equivalent to inflation)

48. Financing the health sector in 2006 (4) - DPs • Health Fund fell by 59% - due to MDBS and earmarking • Earmarked funds also fell by 50% (is this a reporting error?) • Aid modalities increasingly fragmented • Poor predictability • Funds which do not contribute to PoW may squeeze out other resources (e.g. GoG)

49. Financing the health sector in 2006 (5) Expenditure patterns • PE up 8%; services up 11%; cap investment down by 16%; admin down by 3% • BMCs roughly on target for PoW II shares, though HQ high and district level below • Exemptions funding down from 8% to 3% of total expenditure • Low and erratic disbursement of GoG services and HF • Increase in earmarked funding (vs flexible)

50. Financing the health sector in 2006 (6) NHIS • Coverage rising, though still only 19% of population with cards • Although 60% of members are ‘exempt’, registered ‘indigents’ have fallen from 4% of population (2005) to 0.7% in 2006 • Concerns about financial sustainability (ILO cash-flow projections) • Need for public & provider education