REVISED CMA III - Ministry of Health

GHANA HEALTH SECTOR
COMMON MANAGEMENT
ARRANGEMENTS FOR
IMPLEMENTATION OF THE SECTOR
MEDIUM-­‐TERM DEVELOPMENT
PLAN
REVISED DRAFT
OCTOBER 2012
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Table of Contents
Abbreviations and Acronyms ........................................................................................................................................... 3
1. Introduction ........................................................................................................................................................................ 5
2. Coordination and Dialogue ........................................................................................................................................... 8
3. Planning and Budgetting ............................................................................................................................................ 15
4. Performance Monitoring ............................................................................................................................................ 18
5. Disbursement and Financial Management ......................................................................................................... 23
6. Procurement and Logistics ........................................................................................................................................ 27
7. Audit .................................................................................................................................................................................... 29
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Abbreviations and Acronyms
BCA Basic Cooperation Agreement
BMC
CCM
CHAG
CIMU
CMA
CSOs
DHIMS
DPs
GAC
GFATM
G-­‐HAP
GHS
G-­‐JAS
GoG
HQ
IALC
ICCs
IGF
MDAs
MDBS
M&E
MOFEP
MOH
MoU
MTEF
Business Management Centre
Country Coordinating Mechanism of the Global Fund
Christian Health Association of Ghana
Capital Investment Management Unit of the Ministry of Health
Common Management Arrangement
Civil Society Organisations
District Health Information Management System
Development Partners
Ghana Aids Commission
Global Fund for AIDS, Tuberculosis and Malaria
Ghana Harmonisation Action Plan
Ghana Health Service
Ghana Joint Assistance Strategy
Government of Ghana
Headquarters
Inter-­‐Agency Leadership Committee
Inter-­‐Agency Coordinating Committees
Internally Generated Funds
Ministries, Departments and Agencies
Multi-­‐Donor Budget Support
Monitoring and Evaluation
Ministry of Finance and Economic Planning
Ministry of Health
Memorandum of Understanding
Medium Term Expenditure Framework
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NDPC
NGOs
NHIA
NHIF
OECD
PAF
PEPFAR
PFM
PIUs
POW
PPA
PBU
PPME
SBS
SMTDP
SWAp
SWG
TB
VFM
National Development Planning Commission
Non-­‐Governmental Organisations
National Health Insurance Authority
National Health Insurance Fund
Organisation for Economic Cooperation and Development
Performance Assessment Framework
US President’s Emergency Plan for AIDS Relief
Public Financial Management
Project Implementation Units
Programme of Work
Public Procurement Authority
Budget Unit of the Policy Planning, Monitoring and Evaluation Directorate
Policy Planning, Monitoring and Evaluation
Sector Budget Support
Sector Medium Term Development Plan
Sector Wide Approach
Sector Working Group
Tuberculosis
Value for Money
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1. Introduction
Background
This Common Management Arrangement sets out arrangements for effective collaboration and
coordination within the health sector. It describes interrelationships within the health sector and
partners at all levels. It is aimed at ensuring effective achievement of the sector program of work.
The CMA recognizes institutional legislation, mandates and roles of all sector partners, the
coordination and collaboration arrangements set out in the CMA aim to complement them. The
CMA is guided by the sector’s legislation, policies and procedures as well as key developments in
the international and national aid architecture as reflected in the following – the Ghana Health
Services and Teaching Hospitals Act 525, 1996; the National Health Insurance Act 650, 2003; the
Financial Administration Act 654, 2003; and Regulations 2004; the Accounting, Treasury and
Financial Rules and Regulations; the sector annual Planning Guidelines; the Paris Declaration on
Aid Effectiveness; the Accra Agenda for Action; the Ghana Aid Policy; the Ghana Harmonisation
Action Plan ( G-­‐HAP ); the Ghana Joint Assistance Strategy ( G-­‐JAS ) and the sector Aide Memoire.
The Common Management Arrangement III is different from CMA I and II because of the evolving
institutional reforms and decentralisation between MOH and its agencies; an increasing need to
involve a larger group of stakeholders such as the private sector and civil society in the sector
planning, implementation and monitoring processes; and changes in the way DPs work following
the signing of the Paris Declaration on Aid Effectiveness and development of the Ghana Joint
Assistance Strategy. CMA III also reflects the changing financing architecture of the health sector -­‐
the National Health Insurance Fund becoming a significant funding source; the shift to sector
budget support by the health partners rather than the Health Fund, and reduction in the Health
Fund relative to earmarked funds.
Under the guidance of the National Development Planning Commission (NDPC), the Ministry of
Health together with other MDAs is preparing a new Sector Medium Term Development Plan
2010-­‐2013 (SMTDP), which will replace the current 5-­‐year Programme of Work (POW III). The
SMTDP will be aligned with the overall National Medium-­‐Term Development Policy Framework
(2010-­‐2013) which has been developed with a view to improving the living standards of people
living in Ghana. While the SMTDP sets out the direction for the sector for the next four years in
terms of policy and key implementation strategies, the CMA focuses on the collaboration
arrangements which need to be in place in the sector for the policies outlined in the SMTDP to be
successfully implemented. CMA III will support implementation of the Sector Medium-­‐Term
Development Plan.
All stakeholders that support the sector with significant activities and resources will be expected
to comply with the arrangements set out in the CMA. On an annual basis, in line with the
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principles of mutual accountability, all sector partners will undergo a peer review to assess their
level of compliance with the CMA”s key principles. The review will be coordinated by the PPME
of MOH and the results will be presented at the first Business Meeting for the year. Sector
partners will be expected to take corrective measures to address any deviations identified in this
reviews. Compliance with the CMA will also be encouraged through dialogue.
Purpose
The Common Management Arrangement sets out arrangements for effective collaboration and
coordination within the health sector. It describes interrelationships, roles and responsibilities
within the health sector and with partners at all levels. It is aimed at ensuring effective
achievement of the sector program of work. The CMA recognizes institutional legislation,
mandates and roles of all sector partners -­‐ the coordination and collaboration arrangements set
out in the CMA aim to complement them. The CMA is guided by the sector’s legislation, policies
and procedures as well as key developments in the international and national aid architecture as
reflected in the following – the Ghana Health Services and Teaching Hospitals Act 525, 1996; the
National Health Insurance Act 650, 2003; the Financial Administration Act 654, 2003; and
Regulations 2004; the Accounting, Treasury and Financial Rules and Regulations; the sector
Annual Planning Guidelines; the Paris Declaration on Aid Effectiveness; the Accra Agenda for
Action; the Ghana Aid Policy; the Ghana Harmonisation Action Plan (G-­‐HAP); the Ghana Joint
Assistance Strategy (G-­‐JAS) and the sector Aide Memoire.
All stakeholders that support the sector with significant activities and resources will be expected
to comply with the arrangements set out in the CMA. On an annual basis, in line with the
principles of mutual accountability, all sector partners will undergo a peer review to assess their
level of compliance with its key principles. The review will be coordinated by the PPME of MOH
and the results will be presented at the first Business Meeting for the year. Sector partners will be
expected to take corrective measures to address any deviations identified in these reviews.
Compliance with the CMA will also be encouraged through dialogue.
Objectives
The CMA III is structured into six sections, each corresponding to a core collaboration process or
theme, each with broad objectives as follows:
• Coordination and Dialogue. The key objectives are to provide a framework to ensure that
arrangements for coordination and dialogue in the sector facilitate effective
implementation of the sector program and achievement of the sector objectives. It is also
to provide for a stronger role of the private sector and civil society in sector planning,
implementation and monitoring.
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• Planning and Budgeting
The key objectives are to manage the rapidly changing funding environment in the sector
and to integrate all resources into sector planning and management processes and ensure
that all parties commit to an indicative resource framework in line with MOH timelines.
• Performance Monitoring
Objectives include clarifying and improving reporting and communication lines within the
sector and among agencies; improving linkages between sector data sources;
operationalising arrangements for performance agreements with service providers; and
improving on the efficiency and effectiveness of the sector’s review processes.
• Disbursement and Financial Management
Key objectives include strengthening the policy dialogue between MOH and its agencies,
MOFEP and DPs to ensure sufficient GOG budgetary allocations; to promote the
participation of the private sector and civil society in health sector financial management
and oversight; and to maximize compliance with the agreed rules and procedures by the
use of dialogue through the existing structures.
• Procurement and Logistics
The primary objective in this area is to intensify collaboration between DPs and the MOH
and its agencies to use national systems under the Public Procurement Act (Act 663) for
procurement activities wherever possible to ensure availability of health commodities.
• Audit
In line with the overall sector objective of improved transparency and accountability at all
levels, the specific objectives in this area include continued promotion of use of a common
audit system for all sources of funds, continued improvement in scope, coverage, and
quality standards, and institutionalizing responses to audit recommendations through the
Audit Recommendation Implementation Committees and the Business Meetings.
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2. Coordination and Dialogue
Background
The institutional responsibilities and relationships in the health sector are guided by the Civil
Service Act 327; the Ghana Health Services and Teaching Hospitals Act 525, 1996; the National
Health Insurance Act 650, 2003 and the Ministry of Health Organisational Manual 1998. Other
relevant responsibilities and relationships are defined in the Government of Ghana Aid Policy;
the MoU on Earmarked Funds; the Sector Budget Support (SBS) Framework Memorandum; and
the Terms of Reference for the Health, HIV & AIDS Sector Group. The Ministry of Health will agree
other bilateral relationships with sector partners as relevant e.g. the MoU with CHAG.
A number of emerging challenges have been identified in the health sector’s institutional
arrangements and coordination during and since CMA II. They include:
• Weak coordination and collaboration between the Ministry, its agencies and partners.
• Complexity and increasing fragmentation of the sector with different funding modalities.
• Weak institutional arrangements for performance agreements with service providers.
• Lack of structures for and ineffectiveness of inter-­‐sectoral collaboration.
• Weak engagement with the private sector and civil society.
CMA III will provide a framework to enable key sector stakeholders to address the challenges and
ensure that institutional arrangements and coordination in the sector facilitate effective
implementation of the sector program and achievement of the sector objectives.
Health Sector Partners
The key sector partners identified under the CMA III are listed below and are hereinafter referred
to in the CMA as ‘key sector partners’
• The Ministry of Health.
• The Ghana Health Service.
• Teaching Hospitals and Specialised Institutions.
• Regulatory Bodies – the Medical and Dental Council; Nurses and Midwives Council;
Pharmacy Council; Food and Drugs Board; Private Hospitals and Maternity Homes Board;
Traditional Medicine Practice Council (work on a regulatory body for Laboratories and
other Allied Services is in progress; the list of regulatory bodies will be updated in an
addendum as needed).
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• The National Health Insurance Authority/District Mutual Health Insurance Schemes.
• Other Public Sector Implementing Agencies – Quasi-­‐Government Institutions.
• Christian Health Association of Ghana.
• Non-­‐Government Providers – Private Sector and NGOs, including Traditional Providers.
• The Ministry of Finance and Economic Planning, and other MDAs; the Parliamentary
Select Committee on Health; and the National Development Planning Commission.
• Metropolitan, Municipal and District Assemblies.
• Development Partners.
• Civil Society.
• The HIV/AIDS Sub-­‐Sector led by the Ghana Aids Commission, as defined in the June2008
Terms of Reference for the Health, HIV and AIDS Sector Group.
• Any other current/new bodies or stakeholders as identified by the Ministry of Health.
Sector Dialogue Structures
The Ministry of Health provides overall leadership and direction to the health sector; coordinates
implementation of the SMTDP to ensure achievement of sector objectives; and facilitates
engagement with health sector partners at all levels. The Ministry will facilitate quality policy and
technical dialogue with health sector partners and stakeholders through the following structures:
1. The Inter-­‐Agency Leadership Committee (IALC).
2. The Sector Working Group (SWG).
3. Business Meetings.
4. Annual Health Summit.
5. Decentralised Level Dialogue.
The Inter-­‐Agency Leadership Committee
The primary purpose of the Inter-­‐Agency Leadership Committee (IALC) is to institutionalize a
key leadership structure across MOH and its Agencies. The Committee fosters health sector unity
through collaboratively determining priorities, discussing issues, sharing strategic ideas,
examining results to date, shaping policy, and strengthening overall strategic direction. The
Committee works together as health leaders and partner Agencies of the MOH to contribute to
and meet health sector goals and outcomes as laid out in the Health Policy, Programmes of Work
and complementary Aide Memoire.
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The Inter-­‐Agency Leadership Committee convenes four times a year (quarterly) for ongoing
governance planning, strategic decision making, and performance oversight, and to discuss
current pressing issues. The Committee members develop a shared agenda and periodically
evaluate the agenda structure to ensure that there is an emphasis on cross cutting areas best
addressed through collaboration of health sector leadership.
Core membership of the Committee comprises the Minister of Health, the Deputy Ministers,
the Heads of Agencies, and the Chief Director. Other stakeholders (i.e. training and research
institutions, development partners, civil society, the private sector, other Ministries, Agency
board members, health sector specialists etc) are invited as participants on an ad hoc basis when
asked to speak to particular agenda items or support any committee member to make decisions
on a specific agenda item. The PPME of MOH is responsible for coordinating agendas and meeting
materials, and attends each meeting.
The Minister of Health is the standing chairperson; where the Minister is unavailable to act as
chairperson a Deputy Minister may stand in. The Chief Director is responsible for oversight of the
agenda and works with the PPME to coordinate the meeting schedules and agenda.
Sector Working Group Meetings
Health is influenced by many factors outside the direct control of the MOH. Progress in health
sector objectives depends on how effectively the Ministry engages with its partners. The Sector
Working Group provides the forum to achieve effective engagement with all health sector
partners. The objectives of Sector Working Group meetings are to:
• Conduct a coordinated, coherent and quality policy dialogue among health sector
stakeholders.
• Provide input to formulation of sector policies, strategies and programs and to ensure
coherence with the national development plan.
• Participate actively in decision-­‐making on the direction of policies and strategies
concerning health.
• Monitor implementation of the sector program and commitments made by different
stakeholders to the realization of the objectives of the health policy and strategic
framework.
• Monitor resource allocation and utilisation, and integration of external assistance into the
overall sector financing plan.
• Improve the harmonization and alignment of DPs towards Government budget, priorities,
systems and procedures; and
• Share information and views and if necessary, agree on sector operational issues.
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Sector Working Group Meetings will be designed and convened by the PPME Directorate in
consultation with sector partners including the Development Partner Lead. Working group
meetings are expected to be attended by all key sector partners at senior management and
technical staff level. The outputs from Sector Working Group meetings will be collated by the
PPME of MOH to feed into the Inter-­‐Agency Leadership Committee meetings. Outputs from the
other dialogue structures – Inter-­‐Agency Coordinating Committees, Business Meetings, Health
Summits and decentralized level dialogue will also be collated by the Sector Working Group
through the PPME, to the IALC. For maximum efficiency outputs from the Inter-­‐Agency
Coordinating Committees will also feed directly to the IALC but the Working Group will be kept
informed and updated.
Sector Working Group Meetings are held monthly at the Ministry of Health and chaired by the
Chief Director of the Ministry. If necessary, the Ministry of Health may decide to convene
additional sector group meetings. The agenda for Working Group meetings will be broad and will
reflect relevant issues in the health sector with an objective to improving health outcomes. Inter-­‐
Sectoral collaboration at the national and decentralised levels will also be strengthened through
participation in each other’s relevant activities including sector reviews.
Inter-­‐Agency Coordinating Committees
The Inter-­‐Agency Coordinating Committees (ICCs) provide the platform for discussing technical
issues on specific themes/diseases. To ensure their effectiveness:
• The Ministry of Health will agree with stakeholders on which ICC’s will be in operation at
any point in time – the aim will be to ensure that groups cover all relevant themes and/or
diseases while maintaining a manageable number of groups.
• Sector agencies and partners engaged in or interested in a particular theme/disease
will participate in that group.
• The structures for meetings – the Chair; frequency; format; location; planned outputs; will
be agreed by participants.
• Outputs from ICC meetings will feed into the monthly Sector Working Group meetings -­‐
short reports will be prepared and presented at the SWG meeting.
The Global Fund Country Coordinating Mechanism (CCM) will work closely with the Inter-­‐
Agency Coordinating Committees on its three focal diseases – HIV/AIDS; TB and Malaria, and its
program managers will participate actively in the relevant ICCs and the Sector Working Group.
The CCM will also be broadened to include all relevant agencies and stakeholders, including the
NHIA and Chairs of relevant groups on its three thematic areas.
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Business Meetings
Business meetings take place three times a year. One of them is in conjunction with the April
health summit and the two others are in August and November. Business meetings are attended
by the key sector partners at senior management and technical level, and are chaired by the
Ministries of Health and MOFEP. Business Meetings are open and other interested stakeholders
can attend as observers. Business Meetings focus on:
• Stakeholder commitments to implementation of the sector program.
• Current policy issues relevant to the sector.
• Budget updates and disbursement schedules of Government and Development Partners.
The business meeting during the April health summit will assess the sector Performance
Assessment Framework (PAF) to feed into the MDBS dialogue. The second business meeting in
August will review the sector’s progress from the beginning of the year to date and provide an
opportunity to table new issues. The business meeting in November shall be devoted to planning
and budgeting. The meeting will discuss and agree on health sector plans and associated budget
for the ensuing year. It will also agree on indicators for the PAF based on the sector program that
was presented and discussed.
An Aide Memoire will be signed by the Ministry of Health and representatives of Development
Partners that records the decisions taken during the business meeting. Follow-­‐up committees
will be established at the end of each meeting to work with the PPME of MOH to ensure
implementation of recommendations from Aide Memoire. The PPME will report back to the next
business meeting on progress with implementation of each action and, if any action is
outstanding, the agency/ies responsible for implementation, their plan and timeline for action.
Health Summit
The Health summit takes place once a year in April. All key sector partners and health sector
stakeholders will participate in the health summit. Summits are implemented as follows:
The Health Summit provides the forum to discuss the results of the annual sector performance
review (including the assessment of the sector performance appraisal framework).
• Based on the health sector program monitoring framework, a holistic assessment of sector
performance will be conducted on an annual basis to feed into reviews at the sector and
national level.
• The content of summit will be prepared by a designated committee of representatives
from the Ministry of Health and its agencies, NHIA, civil society and DPs.
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• Reports and presentations from the summit will be made public on the Ministry of Health
website.
Decentralised Level Dialogue
The Ministry of Health in conjunction with the Ghana Health Service will coordinate sector
dialogue at the decentralized level until such a time that the District Assemblies assume
responsibility for coordination and planning of district health services through their respective
health directorates. The structures for engagement at the decentralized level will be
strengthened and modalities will be put in place to ensure that outputs from the dialogue feed
into the dialogue at the national level. In the short-­‐term, District Health Directors will coordinate
all the sector players and engagement at the district level and report to the District Assembly.
Engagement at the decentralized level will include:
• Quarterly stakeholder meetings at the district level involving all contributors to district
health services, together with representatives from the District Assembly. All service
providers will provide quarterly information on agreed indicators and the district health
management teams will coordinate and consolidate the information. Progress on
performance will be discussed and reasons for non-­‐performance analysed
• GHS will hold annual district, regional and national fora for all managers of the different
levels and commissioned health facilities to discuss strategic and operational issues
• Bi-­‐annual regional meetings will be held to strengthen regional collaboration.
Engagement with the Private Sector and Civil Society
The Ministry of Health has set up a Private Sector Unit under the PPME Directorate and
developed a Private Health Sector Policy with broad policy objectives to facilitate participation of
the private sector in health service provision and to establish a framework for partnership and
collaboration between the private and public health sectors. To achieve this:
• The private sector and civil society will be involved in policy development, planning,
implementation, reviews, monitoring and evaluation of health sector activities at all levels
– national, regional, district and sub-­‐district.
• The Ministry will implement strategies for reaching out to private sector and civil society,
to make them aware of the various dialogue platforms and to ensure their participation in
relevant ones
• The Ministry will engage collectively with the private sector and civil society through the
emerging coalition of private health sector bodies and the Coalition of NGOs in the Health
Sector, and with the various bodies based on their respective strengths – communication,
training, advocacy etc.
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• The Ministry and its agencies will issue policy guidelines to agencies for contracting with
private providers as necessary, with the mandatory involvement of the appropriate
statutory bodies.
• NGOs will be engaged in the implementation framework of the MOH and different
agencies. Efforts will be made to ensure that health sector funds are available to support
NGO/CSO projects and participation at all levels.
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3. Planning and Budgeting
The health sector program is based on the concept of a Sector Wide Approach (SWAp), with
comprehensive planning, programming, budgeting and reporting for the sector encompassing all
sources of funding (Treasury, Internally Generated Funds, NHIF, SBS and Earmarked Funds). The
objectives in planning and budgeting include to manage the rapidly changing funding
environment in the sector, with earmarked the dominant funding modality and fragmentation as
a whole increasing; and to integrate all resources into sector planning and management
processes and ensure that all parties commit to an indicative resource framework in line with
MOH timelines.
The Planning and Budgeting Process
All formal agreements between the Ministry of Health and its agencies will be adhered to. The
Ministry of Health will ensure that the resource allocation principles and process address the
changing organisational framework and funding structure of the sector. The key activities in the
planning and budgeting process are as follows:
• There will be a sector dialogue with agencies, the NHIA and partners to agree on priorities
for the budget year from the health sector program; one of the monthly Sector Working
Group meetings will be dedicated to this.
• Budget guidelines for the sector will be drawn based on the guidelines from MOFEP, with
ceilings for agencies -­‐ resource allocation principles and guidelines will be used to
determine the amount of resources to allocate to the Agencies.
• Agencies will prepare their respective annual work plans and budgets based on the
guidelines and agreed priorities and ceilings; together with procurement plans and cash
flow forecasts for collation at the national level.
• The MOH will sign annual service agreements with the various provider agencies.
The Budget Committee
The Ministry of Health’s Budget Committee is made up of representatives from all the Agencies
and Authorities. The Budget Committee will meet quarterly and will:
• Develop the framework, guidelines, tools and timetable for planning and budgeting.
• Project the resource envelope for the health sector and oversee mobilization of internal
and external resources.
• Review the criteria for resource allocation to Agencies.
• Attend the budget hearing with the Ministry of Finance.
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• Review budget performance and report to the Minister of Health.
• Review and formulate the strategic plans based on the policies of Government.
• Review department’s revenue collecting activities.
• Allocate resources based on objective, outputs and activities.
• Coordinate and consolidate the budget.
• Monitor and evaluate budget performance.
• Report in accordance with regulations.
Agencies have also established in-­‐house budget committees that report to the MOH Budget
Committee and share minutes of their committee meetings as a form of feedback.
Development Partners
DPs will provide inputs to support sector planning and budgeting and communicate consensus
position to Government through a Sector Lead validated by Heads of Cooperation. DPs will:
• Improve harmonisation and alignment to GoG budget, priorities, systems and procedures
and improve predictability of funds.
• Increase the proportion of funds channeled through Government planning, budgeting and
procurement systems as the systems are strengthened and integrate more
earmarked/direct funds into Government budgets and the Health Fund.
• Facilitate joint analytical work and increase information-­‐sharing.
• Strengthen division of labour by encouraging leads in focus areas based on knowledge and
experience – focal leads will be required to ensure effective sharing of information on
their area.
• Follow the guidelines and procedures for allowances and per diems as agreed between
Heads of Cooperation and the Ministry of Finance.
Funding
All Development Partners will ensure that they provide funding in line with international and
national aid effectiveness principles and commitments. DPs also commit to increase the use of
country systems in aid delivery.
DPs providing Sector Budget Support will:
• Ensure prompt transfer of funds to the national treasury through the Ministry of Finance
and inform the Ministry of Health once funds are transferred.
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• Monitor to ensure that funds received by GoG are transferred promptly to the Ministry of
Health and on to the agencies at all levels.
• Promote accountability for service delivery.
• Participate actively in the MDBS policy dialogue and monitoring process through the
Performance Assessment Framework.
The expectation is that other DPs will participate in the Sector Budget Support arrangement over
time. The inclusion of additional DPs will be confirmed by an exchange of letters between the
signatory participants to the SBS MoU.
DPs providing earmarked funding will:
• Ensure that earmarked funds contribute to filling gaps in priorities identified in the sector
program.
• Provide to the Ministry of Health an estimate of earmarked funds that would be available
as part of the sector planning and budgeting process.
• Submit comprehensive quarterly reports to the MOH – the Chief Director, copied to the
Financial Controller, Director of PPME and Head of Budget, detailing commitments,
disbursements and utilisation of all earmarked resources for the period.
DPs providing earmarked funds are also encouraged to contribute to the flexible funding through
the Health Fund.
Non-­‐OECD donors (Brazil, China, Korea, India etc.) providing resources to the sector will
endeavour to:
• Ensure better integration of their activities into the sector planning process.
• Work with MOH to improve planning of recurrent expenditure to support their capital
investments in the sector.
• Ensure that their support does not divert energy and resources from the core sector
program.
• Participate in the sector planning and review processes through their in-­‐country
representatives.
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4. Performance Monitoring
Background
Monitoring and evaluation involves a systematic process of collecting, analyzing and using data
to improve programme management, guide resource allocation and support learning and
decision-­‐making. A Health Information Management Strategic Plan has been developed with the
aim of improving access to health information, improving the quality of health information, and
supporting decision making.
The sector has developed a robust data management system, the District Health Information
Management System (DHIMS). The DHIMS is a health data repository with simplified reporting
forms using standardised entries and automated calculations. It generates performance summary
statements for any level or facility and provides a powerful tool to inform decision-­‐ making at all
levels. The sector has integrated the public health information system (the Health Service System
Database) at regional and district level into the DHIMS and will link it with the NHIA information
system to establish a single repository and monitoring framework.
Health Information Officer Positions have been established at regional and district level and over
half of the positions have been filled, the plan is to deploy staff to all the 170 districts.
To continue strengthening sector M&E the key sector partners will:
• Clarify and improve reporting and communication lines within the sector and among
agencies to facilitate sector monitoring.
• Improve linkages between sector data sources.
• Improve on the efficiency and effectiveness of the sector’s review processes.
Performance Management
• A performance agreement will be signed between agencies and the Minister of Health and
between Directors and the Heads of Agencies to promote accountability and strengthen
the decentralisation process and instill a performance management culture in the sector.
• At the decentralized level plans will be tied to the performance management system –
targets will be negotiated with the decentralized levels; districts will be required to
ensure that the plans they formulate will enable them meet those targets. The indicators
at the district level will be derived from the national level indicators.
• The performance appraisal system will be implemented at the level of individuals, teams
and Agencies.
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Data Management
• Information flow in the DHIMS will be improved in all directions and at all levels and will
be linked with the NHIS information system.
• Sector partners commit to using and strengthening the DHIMS.
• The MOH will continue to strengthen the capacity of districts in verification and validation
of data and in utilization of results for monitoring, evaluation and planning.
Monitoring
MOH, Management teams and Councils will be responsible for monitoring the implementation of
the sector program. Monitoring will involve:
• Quarterly collection and assessment of the performance of the different components of
the sector program to determine whether activities are being implemented as planned,
milestones are being achieved and outputs are being delivered.
• Tracking of progress towards the sector goals and objectives.
• Joint monitoring and support visits to undertake monitoring and provide technical
support to Agencies to improve performance in areas where performance is not optimal.
Review
• Ministry of Health and its partners will commission an annual review of the performance
of the sector against the objectives and targets of the PAF and the sector program, with
each review focusing on specific agreed areas.
• Every second year, an independent team of external consultants will perform the review.
Other years, an internal team from the Ministry of Health and its Agencies will perform the
review.
• The sector review will be part of a wider process of annual assessment of progress in the
health sector, and will be preceded by BMC performance reviews, district and regional
performance hearings, and Agency, development partner and technical reviews.
• All sector partners will submit documentation in time for the annual sector review.
• The review will formulate recommendations to strengthen the implementation of the
sector program.
• The report of the annual sector review team will be presented and discussed at the April
Health Summit.
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Holistic Assessment of Progress
The holistic assessment of performance in the health sector is a structured methodology to assess
the quantity, quality and speed of progress in achieving the objectives of the programme of work.
The primary objective of the assessment is to provide a brief but well-­‐informed, balanced and
transparent assessment of the sector’s performance and factors that are likely to have influenced
this performance. The assessment is based on indicators and milestones in the PoW and is
presented and discussed at the April Health Summit and negotiated and agreed upon by the
Ministry of Health and partners at the subsequent business meeting. The outcome serves as input
into the MDBS PAF.
Responsibilities for Monitoring and Evaluation
This section describes the main responsibilities for performance monitoring in the health sector.
All key sector partners, whether specifically identified or not, are expected to comply with the
relevant procedures for performance monitoring as defined by the Ministry of Health. All sector
agencies and partners will submit quarterly, half year and annual reports to the Ministry of
Health in accordance with stipulated guidelines and timelines.
The Ministry of Health
• MOH has primary responsibility for monitoring of all executing agencies.
• The Ministry will define performance areas and negotiate performance targets with all
executing agencies that will include sanctions for non-­‐performance.
• The ministry will be responsible for coordinating and organizing the annual review
process and ensuring that resulting Aide Memoire are prepared, disseminated and follow
up activities undertaken.
• The Ministry will collaborate with the Ghana Statistical Service and other relevant
agencies in the design of national surveys.
The Ghana Health Service
• The GHS will clarify responsibilities and define service delivery standards and identify key
achievement targets through a process of negotiation starting with BMCs at the district
level. Service providers will include private providers and other NGOs in health.
• The GHS will review service targets within the context of the overall national targets.
• GHS will facilitate performance hearings at the district, regional and national levels to feed
into district and regional reports. GHS will ensure Local Government participation in
performance hearings at the district level. GHS HQ will ensure that guidelines for
organizing information for performance hearings and the conduct of the sessions are
developed, reviewed and disseminated.
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• Quarterly, bi-­‐annual and annual reports from the regions will be collated and presented in
national reports.
• At the end of every year, the GHS will provide a technical report to the Ministry of Health
on primary and secondary health service provision in the country. The report will cover
the private, NGO and CSO sector and key components of the sector program and the
annual business plan of the service.
• The GHS will continue to strengthen the capacity of districts in verification and validation
of data and in utilization of results for monitoring, evaluation and planning.
• GHS will take steps to ensure a closer link between the financial reporting and service
delivery information to enable better performance assessment.
• The GHS will perform any other roles as defined by the Ministry of Health.
Teaching Hospitals and Specialised Institutions
The teaching hospitals and specialized institutions will:
• Provide annual and biannual reports on performance in the context of the overall sector
programme based on reports from the various divisions (BMCs) annual business plans
and will derive from the sector-­‐wide indicators.
• Maintain data on human resource; key activities and finance.
• Provide annual and half-­‐yearly reports based on the framework defined by the MOH.
• Perform any other roles as defined by the Ministry of Health.
Regulatory Bodies
• Statutory Bodies will be engaged in technical performance monitoring.
• The bodies will develop annual PoW in collaboration with the different agencies and
sector players under them and will report on progress within the framework, with a focus
on regulation within the sector.
• Separate reports will be produced on the different categories – public/private/NGOs. An
aggregated report showing comparisons in performance among the different categories
will be produced annually to support decision making.
• Statutory Bodies will provide quarterly, half yearly and annual reports based on the
framework defined by the MOH.
• Perform any other roles as defined by the Ministry of Health.
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Private Sector/NGOs
The private sector, both for and not for profit, will provide a set of defined data based on sector-­‐
wide and other indicators to the Ghana Health Service at the different levels. The respective
statutory bodies will develop monitoring tools to assist in measuring the performance of the
private/NGO sector.
Development Partners
Development Partners will:
• Work with GoG to monitor performance of the sector through the annual health sector
reviews and holistic assessment of progress based on sector-­‐wide indicators. Biennially,
DPs will field experts in the sector reviews to ensure a high level of technical participation
and an independent element.
• Provide inputs to support cross-­‐sectoral issues; the harmonisation action plan; annual
reviews; the MDBS PAF etc.
• Harmonise missions -­‐ establish and regularly update an annual mission calendar;
schedule missions to feed into sector reviews; develop joint missions/work programs for
missions; observe mission-­‐free periods; engage sector leads in missions; ensure briefing
and debriefing on missions; share mission reports with GoG and DPs.
• Play a key role in the review of indicators for assessing sectoral and interagency
performance.
• Participate in the negotiation of performance levels and targets of the sector and take
active part in the performance hearings of individual agencies and selected BMCs based
on an annual agreed schedule.
Civil Society
The role of civil society in monitoring the performance of the sector will be encouraged and
accommodated and civil society will be an integral part of the sector review processes. Civil
society will be challenged to play its watchdog role effectively.
Research
The key sector partners will work together to define the research agenda for the sector. All
agencies will undertake research relevant to the improvement of their functions. Technical
research of a cross agency nature or primarily based on public health principles will be
undertaken on behalf of all agencies by the Ghana Health Service and disseminated through
national scientific sessions and a country research bulletin. All research institutions will be
required to provide non-­‐patented information to the Directorate of Research, Statistics and
Information Management of the MOH and this will be made available across country. The
Ministry of Health will produce an annual Health Statistics Information Bulletin.
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5. Disbursement and Financial Management
Government of Ghana Funds
The main issues to be addressed are:
• Under-­‐funding of actual releases as compared with budget allocations.
• Delayed budget releases from MOFEP to MOH, and the subsequent ripple effect of delays
in disbursements through the various levels to the service provider facilities, which are
impacting quality of services.
The key sector partners agree:
1. To strengthen the policy dialogue between MOH and its agencies, MOFEP and DPs to
ensure sufficient GOG budgetary allocations for the health sector in general, and for
primary health and prevention activities in particular.
2. To promote the participation of the private sector and civil society in health sector
financial management and oversight, by increasing the level of their engagement through
mechanisms such as the CCM, Business Meetings, etc.
3. To strengthen internal collaboration within MOH and to build capacity to obtain full and
timely releases of funds from MOFEP.
4. To provide funding support for the full and immediate implementation of the Sector PFM
Strengthening Plan (October 2009 revision), including identification of priorities for quick
wins, and regular monitoring/supervision meetings of the PFM Working Group. Priorities
should include synchronising formats for the Annual Budgets and Financial Statements
within the framework defined by GOG’s broader PFM reforms, and facing up to the
challenges with validation and consolidation of financial information in different
computerised systems.
5. To improve the quality and completeness of the present quarterly Financial Statements,
and to improve compliance with requirements for monthly financial reporting and
feedback under the Financial Administration Regulations.
6. To maximize compliance with the agreed rules and procedures by the use of dialogue
through the existing structures, beginning with cautionary reminders and graduating to
dialogue at the Heads of Cooperation and Heads of Mission levels, and moving up to the
Government to Government level if necessary.
7. To review the agreed rules and procedures for financial management from time to time to
reflect changes in the external environment, with particular reference to new laws; new
GOG policies on decentralization and other issues; new international agreements; changes
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in DPs’ governments and/or policies, changes in sector structures or systems and
emergence of new types of sector partners.
Sector Budget Support Funds
Sector Budget Support is the MOH’s preferred modality for external support to its SMTDP. The
SBS Framework Memorandum of February 2008 sets out the key principles underlying the
provision of SBS, which intends to align signatory DPs’ policies and procedures to GoG priorities.
It also intends to improve policy dialogue among all stakeholders in the health sector, minimise
transaction costs, increase the predictability of funding by signatory DPs, reduce tied aid,
promote accountability for service delivery, and improve harmonisation of support provided by
signatory DPs. In implementing the SBS, signatories are committed to focus on results, using the
Performance Assessment Framework (PAF) to measure progress towards achieving the sector
development goals and the annual targets.
SBS is not yet fully integrated into the health sector financial management system. In particular, it
is currently reported and tracked separately from GOG funds in planning and financial reporting,
and is subject to the same bureaucratic mode of access as GOG Item 3 funds, with each individual
drawdown having to be applied for and justified. Under this CMA, key sector partners agree in
respect of Sector Budget Support:
1. To ensure that MOH, MOFEP and SBS DPs collaborate to minimise delays in disbursement
of SBS funds from MOFEP to the sector, by clarifying justification procedures and setting
targets for timeliness in disbursement by both SBS DPs and MOFEP.
2. To agree mechanisms for monitoring performance and enforcing sanctions for non-­‐
compliance.
3. To prepare and submit to MOFEP a plan for integrating SBS funds into GOG funds in
expenditure management at the earliest possible date, while maintaining the reporting of
separate sources of funds for accountability purposes.
Health Fund/Donor Pooled Fund
In spite of the reduced level of its utilisation at present, it is agreed that there is value in retaining
the Health Fund as a mechanism for new partners who may find merit in using a disbursement
mechanism that enables them to disburse directly to the health sector, rather than through
MOFEP as is the case with SBS. The objectives stated above for SBS also apply to the Health Fund,
with the proviso that in the case of Health Fund DPs the role of MOFEP in disbursement and
financial management is minimised or eliminated altogether. The scope of eligible expenditures
from the Health Fund may need to be reviewed, to bring it into line with the scope of SBS eligible
expenditures.
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Earmarked Funds
While stating clearly the Government of Ghana’s preference for SBS as the modality for external
support, the signatories also recognise the importance of setting out clear roles and
responsibilities for the provision and management of earmarked funds, and for ensuring that all
stakeholders adhere to these.
The key sector partners therefore state the following objectives for the disbursement and
financial management of earmarked funds, both those channelled through MOH and its agencies,
and those which are disbursed direct by the donor to pay for goods and services:
1. MOH will bring on board all new and emerging partners, to increase harmonisation and
alignment in accordance with the Accra Agenda for Action and also to improve
information on earmarked funding flows for better capture in sector plans, budgets and
financial reports.
2. All partners, as part of the broader programme of PFM strengthening, will communicate
budget commitments for each year in accordance with the Budget preparation cycle of
GOG (usually by June of the preceding year) in the agreed format.
3. MOH in consultation with its agencies, MOFEP and DPs, will develop a mutual
accountability system for monitoring performance of both GOG institutions and
earmarked funding partners, including measures for graduated sanctions in cases of non-­compliance.
The following further guidelines are agreed upon, to facilitate the disbursement and financial
management of earmarked funds:
1. Partners will work with the Ministry of Health in ensuring the verification and visibility of
earmarked funds, both those channelled through MOH and its agencies and those which
are disbursed direct by the donor, copies of bank statements showing the relevant
transactions will be forwarded by both the disbursing party and the recipient account
holder, to the MOH and GHS 1 not later than 30 days after the end of the calendar month in
which the transfer(s) took place.
2. Disbursement of earmarked funds implemented by NGO/CSO’s will be paid directly by the
DP to the concerned implementing organization, and will be reported on by the disbursing
party as per the preceding section. Items requiring donor direct expenditure
(procurement of goods and services where the development partner can clearly obtain
1 These should be addressed to (1) The Chief Director of the Ministry of Health, copied to the
Director of Finance MOH and the Director of Policy Planning Monitoring and Evaluation MOH;
and (2) The Director General, Ghana Health Service, copied to the Director of Finance GHS
and the Director of Policy Planning Monitoring and Evaluation GHS.
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substantially greater Value for Money (VFM) as well as better quality assurances and
guarantees than government) will be identified as part of the annual consultation process
with partners or form part of the multi-­‐year Basic Cooperation Agreement (BCA)
regarding the utilization of a DP’s earmarked funds.
3. MOH and its agencies undertake to ensure that all earmarked funding transactions are
captured, consolidated and reported in its Financial Statements.
4. MOH, in consultation with its agencies, MOFEP and DPs, to develop clear guidelines for
defining and verifying direct donor expenditure on Missions, Overheads and Technical
Assistance, not later than the end of December 2010. These guidelines will then be used
each year by all earmarked funding partners for budget preparation and expenditure
reporting purposes, and may be reviewed as and when necessary to ensure their
continued relevance.
5. This system will be implemented with effect from January 2011, and its implementation
will be reported on annually at the Health Summit following the completion of the prior
year’s Financial Statement.
Internally Generated Funds (IGF)
The following guidelines are agreed for the disbursement and financial management of Internally
Generated Funds:
1. To review the NHIS tariff structure as agreed.
2. To implement relevant activities under the PFM Strengthening Plan, including clarifying
format, frequency of reporting mechanisms, and strengthening capacity.
3. To increase the percentage of claims that are paid within 30 days (baseline and target to
be decided).
4. To improve claims management from a paper-­‐based to an electronic-­‐based system.
5. To improve the skills in health insurance administration for staff working for the MOH,
NHIA, DMHISs, scheme operators and the providers needed to secure the financial
sustainability of the health insurance system.
6. To introduce capitation and other alternative provider payment mechanisms for
reimbursing primary health care providers.
7. To improve the capture of IGF received from non-­‐insured clients.
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6. Procurement and Logistics
The Final Draft Aid Policy of the Government of Ghana states that “Following the Joint Venture on
Procurement review, Ghana’s procurement system is said to be operating at an “above average”
level 2 . Nonetheless, DPs’ use of both GoG PFM and procurement systems has declined between
2005 and 2007, with DPs failing to respond to improvements in the reliability of these systems.
With the improvement of the PFM systems in Ghana, the Government is committed to dialoguing
with Development Partners to harmonize their systems with that of Ghana for mutual benefits.
Continuing use of Project Implementation Units (PIUs) and separate financial and procurement
arrangements by DPs undermine capacity development, increase transaction costs and hamper
Government ownership”.
The primary objective of the Government of Ghana in the area of procurement is therefore to
intensify collaboration between DPs and the MOH and its agencies in order to ensure the use of
national systems under the Public Procurement Act (Act 663) for procurement activities
wherever possible.
The key sector partners therefore agree that:
• As part of the annual budget preparation process, all funding signatories will provide
details of their procurement plans by November 1st of each preceding year, to enable
MOH to prepare a consolidated annual procurement plan, based on the agreed Sector
Medium Term Development Plan and including inputs from the district, regional; and
national levels of the Ministry and its agencies, for approval by all stakeholders not later
than December 31st.
• For SBS, MOH and its Agencies will perform all procurement in accordance with national
procurement rules, guidelines and procedures.
• MOH and its agencies will collaborate with the Public Procurement Authority (PPA) in
training different cadres of staff in the use of the PPA Manual, and in monitoring the
implementation of the national procurement rules, guidelines and procedures.
• As an input to GoG’s planned review of Act 663, MOH will request amendment(s) to take
cognizance of the special needs of the health sector.
• MOH, NHIA, and GHS and other service providers will collaborate to harmonise the
Standard Treatment Guidelines, Essential Medicines List and the DRG, to improve cost
containment and to ensure that facilities are not unjustly refused reimbursement for
services and drugs. MOH will ensure effective coordination of this process.
2 PD survey, 2008
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• Where capital investments are centrally procured, MOH headquarters shall be responsible
for policy development, options appraisal of capital programmes, resource mobilization,
approval of the capital plans and procurement.
• Procurement at the decentralized level will follow the provisions of Act 663.
• Where the funder’s rules do not permit the use of Ghana’s national systems, a second
option is the use of the “Partnership outsourcing” scheme, under which MOH and an
appointed Procurement Agent will jointly manage procurement under the agreed Sector
Medium Term Development Plan. However MOH will lead the selection and management
of the Procurement Agent, and will retain the overall control of the process by deciding
the sector’s procurement needs, specifications, quantity, timing, authorisation of
payments and effective management of the appointed Procurement Agent.
• As a third and least preferred option, items requiring donor direct expenditure will be
identified as part of the annual consultation process with partners or form part of the
multi-­‐year Basic Cooperation Agreement (BCA) regarding the utilization of a DP’s
earmarked funds. This will apply to procurement of works, goods and services where the
development partner can clearly obtain substantially greater Value for Money (VFM) as
well as better quality assurances and guarantees than Government, or where the funding
partner’s rules prohibit the use of national systems or Partnership outsourcing schemes.
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7. Audit
In line with the overall sector objective of improved transparency and accountability at all levels
through the continued promotion of use of a common audit system for all sources of funds, it is
agreed that:
• External audit will continue to be carried annually under the overall direction and
guidance of the Auditor General. The scope and coverage of the audit will be reviewed
annually, in order to ensure that all sources of funds continue to be covered.
• Quality standards and sample sizes will continue to be determined by the MOH, and a
formal audit opinion will be given on the financial statements and internal controls by
both the Auditor General and the independent audit team.
• Responses to audit recommendations are institutionalized through the Audit
Recommendation Implementation Committees, and reported on at the Business Meetings,
and all partners will continue their efforts to ensure that appropriate sanctions for non-­compliance
are agreed and implemented.
• No singular partner may undertake separate audit for purposes other than those
necessary for clarification of direct fund use. This may only be done as supplementary
where the existing audit report had not captured this adequately.
• The existing auditing system will continue to include the control on allocation,
requisitioning, disbursement and reporting of earmarked funds channeled through the
central accounts of the MOH/GHS.
• Co-­‐sourcing arrangements for internal audit will be encouraged wherever feasible, to
improve audit coverage and enhance value from audit.
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