Ex-post Evaluation

1 Background of the Project

Enhancing the competence of health workers through In-service training (IST) is one of the key and priority areas for improving the of health status of the people in Ghana. However, IST was not properly structured and were organised on ad hoc basis. The training programmes were not harmonised and properly co-coordinated and were restricted to certain cadres of health workers. To correct these anomalies the Government of Ghana entered into a five-year agreement with the Japan International Co-operation Agency (JICA) in 1997 to implement the Health In-Service Training (HIST) Project with the aim of evolving a new IST system to streamline IST programs.

2 Project Overview

The five-year project was implemented on pilot basis in three regions; namely Volta, Western and Brong Ahafo. The Human Resource Development Division (HRDD) of the Ministry of Health (MOH) with Technical Assistance from JICA implemented the project. In May,2002 the project was extended for another year to cover the seven remaining regions in the country. The extension of the project was based on the successes and achievement from the initial pilot phase. The main purpose of the extension was to build the capacity of all the ten regions to develop and provide in-service training for all categories of health workers in the country.

(1) Overall Goal:

The overall goal of the project was to establish and implement Structured In-Service Training (SIST) system in the three focusing regions which is applicable nationwide

(2) Project Purpose

The establishment and implementation of a core/essential system for SIST system in the three focusing regions which is applicable nationwide.

(3) Outputs

a) Needs of IST identified in the three focusing regions.

b) IST information system established in the three focusing regions which is applicable nation wide

c) IST Logbook introduced in the three focusing regions.

d) IST course classification established in the three focusing regions

e) IST environment settings of Regional Training Centres (RTC) in the three focusing regions fulfilled to the set level of function

f) Financial guidelines made available and utilised in the three focusing regions at regional level

g) Monitoring and evaluation framework established and implemented in the three focusing regions

h) Involvement of Reproductive Health component in the IST system

*The Project ended on 31st May, 2002 and was extended for a year. Overall goal, Project Purpose and Outputs mentioned above were only for 3 pilot regions and were the plan before the extension.

(4) Inputs (at the time of Project Termination)

Japanese side:

Ghana side:

3-1 Summary of Evaluation Results

(1) Impact

With the expansion of SIST from the three focusing regions to the other seven regions, SIST has been institutionalised within the Ghana Health Service. This is also reflected in the revision of the IST Policy to include guidelines and new procedures for IST.

Sensitisation and awareness of the importance of IST created by the project coupled with the introduction of the logbook and its linkage to promotional interviews has led to increased demand for IST by health workers. Health workers are now more conscious and willing to attend training programs. Inadequate funding to meet this demand for carrying out trainings has led some facilities to institute what is referred to as study day where a group of health workers are brought together weekly within the facility and taken through some topics by resource persons for a short period of time. A particular topic could be treated for about a month. In-Service training takes one to two weeks depending on the course and participants would require accommodation and per diem, which becomes costly. Study day was developed to reduce the expense.

Training needs assessment has been institutionalised at all levels of GHS i.e. national, regional, district, sub-district and facility levels. This is done through staff appraisal, observation, interactions with staff i.e. at meetings, etc. It is heart warming to note that almost all facilities, districts and regions visited had a training plan. The priority areas of the region/district also influence Regional/district plans.

Majority of clients interviewed at the RCH units of the various facilities reported that they had noticed some improvements in services particularly in the area of care, friendliness and education/counselling. Majority also indicated that they were satisfied with the services they received. Program heads reported that a recent client satisfaction survey organised indicated that there had been some improvements in the quality of service provided by health workers.

(2) Sustainability

Project Outcomes :To a large extent the outcomes of the project are being sustained. This is reflected in the fact that almost all the project outcome such as the RTC, logbooks, TIS, monitoring tools, reporting formats, training curricula are still widely used in the GHS

Institutional Capacity :The GHS has the capacity to maintain gains accrued during the project period particularly in the area of personnel to co-ordinate and facilitate IST; however there are inadequate trained staff in the management of the TIS and the financial analysis software. Although some equipments supplied by JICA were broken and repaired or replaced by new ones, provision of training equipments in the three focusing regions has improved the capacity of the service in organising IST. Though not adequate, other non-pilot regions have purchased basic training equipments such as LCDs and projectors and refurbished their conference hall to enhance training programs.

Financial Capacity :Inadequate financial support has been the major challenge/constraint for program planners at the district, regional and national level. IST programmes within the service are heavily dependent on donor funding. The evaluation revealed that since the end of JICA TA, the service has not received support from any donor in the areas where JICA provided support. Donor funds have always been geared towards organizing training programs for staff but not in developing/establishing systems like JICA did. Inadequate government budget allocation to the health sector in general translates into inadequate allocation to IST.

3-2 Factors that have promoted project

Sensitisation and awareness about the importance of IST created by the project.

The level of commitment of institution/facility heads to IST influences the budget allocation to IST at the Institution or facility

The availability of the Donor Pull Fund, Internally Generated Fund and other professional bodies has empowered the GHS though not adequately to train health workers

One of the key political agenda of the current government is Human Resource Development. Public Institutions including GHS are expected to take staff development seriously. In this regard IST within GHS is given the necessary recognition and support at all levels.

3-3 Factor that have inhibited project

Financial constraints have been the major factor inhibiting IST.

Most of the institutions and facilities lack the requisite number of staff to work with. The participation of staff in structured IST which is expected to span over three days robs facilities off the services of the participating staff as a result pressure is brought to bare on the few who are left to work. In a situation like this quality of services provided could be compromised.

3-4 Conclusions

To a large extent the project overall goal has been achieved. SIST has been institutionalised within the Ghana Health Service. The project has contributed to the improved institutional capacity of the implementing agency. Existing IST culture, donor funding as well as awareness of IST created by the project have influenced the achievement of the project goal. Projects outcomes have been maintained and this is reflected in the fact that the Ministry of Health has adopted the TIS, logbooks, reporting forms and the training curricula provided by the project. Plans are in place to review these outcomes. The capacity of the counterpart organisation to maintain gains accrued by the project is suspect due to inadequate budget allocation to IST. Availability of donor funding for training is however re-assuring.

3-5 Recommendations

Training of more personnel in the management of the TIS and the financial analysis software is critical for the sustenance of the system in GHS.

Given that other units undertake training programs without the knowledge of the National and Regional Training Co-ordinators defeats efforts at keeping a comprehensive and complete training information system on the GHS. Future intervention should therefore aim at strengthening co-ordination of training programs within the Service.

Decentralisation of the implementation of training programs is laudable, however structures should be put in place to ensure proper co-ordination of programs and also to ensure that the quality of training is not compromised. This could be done through strengthened monitoring and supervision, which is currently lacking.

The super goal of the HIST project is to improve quality of health care services and health status. Findings of the study however revealed that lack of logistics/tools/equipments prevents health workers from fully utilising the knowledge and skills they acquire from training programs to improve health care services. Future support should aim at making such provision to ensure that the ultimate goal of the project is fully achieved

The desire for managers of health services to ensure sustainable integration of IST at all levels is very encouraging. However it requires more resources to undertake the integration in order to meet the increasing demand for IST among Health workers.

Recognition of IST for rewarding health workers in the form of promotions provides the necessary motivation for health workers at all levels to take IST seriously. To further minimize the non-submission of IST forms by certain categories of health workers especially the paramedics, the recognition of IST for promotion should be accepted by other health professional bodies.

The current system whereby Regional Training Centers are being rented out to other organisations for use is commendable and it presents an opportunity for the Centres to build on that potential to generate local income to sustain IST

The presence of IST coordinators and Focal Persons facilitates the proper management of the IST system. However, the desire to control resources by some Unit/Programme Heads undermine the role and authority of IST coordinators/Focal Persons

3-6 Lesson learned

It is generally accepted that IST should be sustained at all levels. But to give meaning to sustaining IST it requires institutional capacity in the form of personnel, financial resources and equipments at all levels. Therefore for the sustainability of project achievements, the project implementation strategy should include capacity development of human resources, resource mobilization and maintenance of equipment as an institutional capacity development.

Continuous reliance on donor funding hampers sustainability of IST at all levels and also compromises the laudable idea of fairness and equal opportunities for all health workers to attend IST. It is therefore important to develop strategies to minimise over reliance on donors for IST. Hence, the project implementation strategy should take good notice of not hindering the existing good practices.