Post on 10-Jun-2020
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UNICEF Ghana
Country Programme 2018-2022
Programme Strategy Note: Health and Nutrition
2017
1. Introduction
Ghana has seen improved overall survival rates, health and nutrition outcomes for children over the past
10 years, although gains have not been universal and gaps remain in care practices and access to health
and nutrition services. In the context of Ghana's well-established health system, accompanying policy
framework, middle-income status, and the Sustainable Development Goals (SDGs) especially Goals 2 and
3, UNICEF aims at focusing on health system strengthening in its new country programme (2018-2022).
Building on the achievements and lessons learned from the current country programme, this will involve
supporting the Government in improving capacities for data generation and planning; budgeting and
management; generating evidence of successful and cost-effective interventions that can be scaled up;
and strengthening the enabling environment with better care standards, protocols and guidelines as
well as cross-sectoral collaboration to improve uptake of services and provide an enabling environment
for care practices.
These elements were identified in a process in which government and civil society partners were
engaged during the validation of the Situation Analysis in September 2016. This was followed by more
detailed discussions on the proposed country programme for 2018-2022 during the Strategic Moment of
Reflection (SMR), which took place in October 2016 and was attended by government counterparts and
development partners, and subsequently in a more detailed discussion with high-level representatives
of the Ministry of Health and Ghana Health Service that took place in November 2016 (Sogakope).
The main government counterparts are the Ministry of Health and its agencies, the Ghana Health
Service with its Regional Health Directorates, and the Food and Drugs Authority on matters pertaining to
drugs and nutritional supplements; the Ministry of Trade and the Ministry of Gender and Social
Protection. A Health Sector Working Group of which UNICEF is a member comprises all donors and
development partners in the sector and meets regularly to deliberate on issues of the sector. A good
number of these donor and development partners were engaged during the process notably WHO, WFP,
USAID, DFID and JICA, and it is expected that UNICEF will collaborate closely with each of them during
the implementation of the new country programme. UNICEF will continue to engage and collaborate
with development partners in the Scaling-Up-Nutrition- Working group, Civil Society, Influencers, Private
Sector and the National Development Planning Commission on strategic and multisectoral issues
affecting nutrition. Ghana is in the process of decentralizing its health sector as part of the
Government s policy of strengthening local governance. Through this process, the subnational entities of
the Ghana Health Service - the district health services - will become departments of the District
Assemblies, which are the political wing of local government. The District Assemblies will be the key
government partners for health sector support during the implementation of the new country
programme.
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Expected milestones for the country programme period include: at the global level, the adoption of the
new UNICEF Strategic Plan, 2018-2021; the new UNICEF Global Gender Action Plan 2018-2021; at the
national level, the finalization and implementation of the Long-Term National Development Plan, 2018-
2057 and its 10 medium-term plans notably the Medium-Term Health Sector Development Plan 2018-
2021, and related efforts and forums related to the SDGs; and within the sector, the ongoing reviews of
several key policies, described below.
The programme also draws on the UNICEF Nutrition Strategy (2015) and the UNICEF 2016-2030 Health
Strategy, with the focus on critical unmet health needs related to maternal, newborn and child survival,
growth and development needs of children and adolescent health.
2. Prioritized issues and areas
The priority issues were identified through a methodical and meticulous process applying the five main
criteria of prioritization: criticality of the issue to the performance of the health and nutrition sector
from both the Government's and UNICEF perspectives; UNICEF s capacity and comparative advantage to
work on these issues as compared to other partners on the ground; UNICEF s capacity (human, financial,
knowledge and technology), knowledge and experience; and lessons learned from previous
programmes. The selection of issues also ensured alignment with Government's priorities in the sector
as elaborated in the National Health Sector Medium-Term Development Plan, National Nutrition Policy,
and other relevant policy and strategic documents. Review of available data, reports, and evaluation
documents was also undertaken prior to the selection of the priority issues. The analysis considered the
assumptions, preconditions and risks that could facilitate or hinder progress in addressing these issues.
A series of internal brainstorming sessions by the programme team applied a risk-informed causal
analysis to each issue, and the proposed outcome was presented and discussed with key government
implementing partners and NGOs, who provided feedback received. The following priority issues and
areas were identified.
2.1. High neonatal mortality
Using Demographic and Health Survey (DHS) data from 2008 and 2014, the situation analysis cited
reductions of 25 per cent in U5MR (from 80 to 60 per 1,000 live births) and 18 per cent in IMR (from 50
to 41 per 1000 live births) but only a marginal decline of 3 per cent in neonatal mortality (from 30 to 29
per 1000 live births), with the exception of the Northern Region, where neonatal mortality declined by
31 per cent, from 35 to 24 per 1,000 live births. This marginal decline was in spite of increased coverage
of antenatal and postnatal care and of improved skilled deliveries, which the 2014 DHS report attributed
to the free maternal care policy. Neonatal deaths now account for 71 per cent of infant deaths and 48
per cent of under-5 deaths; almost half of the deaths that occur in the first five years actually take place
within the first 28 days from birth. There is also a worrying trend of an increase in both neonatal and
infant mortality in urban areas. The risk of neonatal mortality is twice as high for babies born to teenage
mothers than for babies born to older mothers. The Government has developed a national newborn
health strategy which envisions to reduce neonatal mortality from 29 per 1,000 live births in 2014 to 21
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per 1,000 live births by 2021 and reduce institutional neonatal mortality rate by 35 per cent from it 2015
level of 5.3 per 1,000 live births. 1
2.2. High maternal mortality
Between 2000 and 2015, the MMR declined by 32 per cent (including institutional and home births),
although the MMR for 2015 was estimated to be as high as 319 per 100,000 live births.2 Maternal
deaths occurring in healthcare institutions are better recorded than those happening at home. The rate
of facility-based deliveries has been increasing, whereas institutional newborn and maternal deaths
remain persistently high (NMR of 6 per 1,000, MMR of 142 per 100,000 live births).1 The institutional
MMR differs significantly across the country with some regions seeing an increase in maternal deaths
between 2012 and 2015 (e.g., Ashanti, Eastern and Upper West Regions).3 Social norms such as
newborns being kept indoors until the seventh day and a culture of home delivery in some communities
compromise the demand for early maternal and newborn care from health facilities.
The situation analysis highlighted an increasing trend in number of pregnancy-related deaths among
adolescent girls, demonstrating starkly the risk associated with child-bearing at a very young age.
Children born to very young (teenage) mothers are at increased risk of sickness and death. Teenage
mothers are more likely to experience adverse pregnancy outcomes. In 2009 alone, 52 girls aged 12-14
years died due to pregnancy-related complications, with 917 live births, correlating to a MMR of 5,671
per 100,000 live births. In the 15-19 year age group, there were 228 pregnancy-related deaths with
40,307 successful births, correlating to a MMR of 485 per 100,000 live births.4 Teenage pregnancy is
common among girls with no education (1 in 4 such pregnancies), which is four times higher than among
girls with secondary or higher education (1 in 16)5.
2.3. Declining immunization coverage
Ghana has achieved major progress in immunization coverage in the last 20 years. However, recent DHS
data show a slight decrease in full vaccination coverage, from 79 per cent in 2008 to 77 per cent in 2014
with major differences across the regions: 76 per cent of children aged 12-23 months are fully
immunized in Greater Accra, and only 41 per cent in Northern region. The EPI6 attained a vaccination
coverage rate of 89.9 per cent in 20147 and has had notable success with regards to some childhood
diseases: neonatal tetanus elimination in Ghana in 2011; no reported case of polio since 2008; no
1 Ghana Ministry of Health - 2015 annual Holistic Assessment Report, July 2016.
2 Global Health Observatory accessed 10 October 2016 http://apps.who.int/gho/data/node.main.MATMORT?lang=en , cited in
the Situation Analysis. 3 Ghana Ministry of Health - 2014 annual Holistic Assessment Report, May 2015.
4 Census 2010 quoted in Participatory Development Associates (2013). Adolescents and Young People in Ghana (10 to 24 years)
A Situation Analysis, cited in the Situation Analysis. 5 Ghana Statistical Service, GDHS 2014
6 Ghana includes BCG and oral polio vaccine at birth; oral polio, pentavalent (five-in-one), rotavirus and pneumococcal vaccines
at six and ten weeks respectively; oral polio, pentavalent (five-in-one) and pneumococcal vaccines at 14 weeks. Yellow fever and
measles vaccines are given at 9 months, and a second dose of measles vaccine is given at 18 months. Source: Situation Analysis. 7 The third dose of the pentavalent vaccine is used as a proxy to determine coverage. Source: Situation Analysis.
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documented death due to measles since 2003; and a significant reduction in diarrhoea and pneumonia
in children.8 However, coverage has stagnated, with more than 1 in 10 children not being immunized.
The immunization programme faces numerous challenges to the expansion of its services, as identified
by a bottleneck analysis conducted by the Ghana Health Service in 2015. These include a lack of fully
trained health workers in all health centres, lack of resources for outreach activities (motorbikes, boats,
etc.), stock-outs of essential supplies and vaccines, negative staff attitude towards mothers and babies,
and a lack of commitment to full vaccination of children from hard-to-reach itinerant mothers.9 A more
pressing challenge is the lack of budget assigned to cover the EPI as external funding retracts. Currently
estimates are that over 100,000 children residing in peri-urban areas are not vaccinated, many of them
living in internal migrant households. Services are particularly weak in reaching mobile populations such
as market women who are available at home with their children only during the evening time.
The Ministry of Health and Ghana Health Service are working together to increase immunization
coverage to 95 per cent by addressing the above bottlenecks, notably by reducing vaccine and essential
supply stock-outs, beefing up cold chain storage capacity, strengthening human resource capacities
through in-service training (and standardizing training), mapping and micro-planning for effective
outreach, better tracking of children and follow-up on defaulters, as well as community mobilization to
increase demand and uptake. Efforts are also being made in the provision of appropriate transport
logistics for outreach service delivery.
Ghana's main funding partner for immunization has been GAVI, The Vaccine Alliance. In consideration of
Ghana s lower-middle-income country status, GAVI has informed the Government of its decision to
graduate Ghana from funding support starting in 2017 and to attain full graduation by end-2021. Key
areas for much attention in the new UNICEF country programme will be continuous engagement with
Government at high levels to ensure sustainable immunization financing for maintaining very high
immunisation coverage and continuous monitoring of the situation across the country.
2.4. Prevention of new HIV infection in children, scale-up of paediatric HIV treatment and care services
The overall prevalence of HIV is declining in Ghana. The 2014 National Sentinel Survey, released in
2015, revealed that Ghana has recorded a median antenatal HIV prevalence (i.e., prevalence of HIV-
positive status among pregnant women who sought the services of a clinic) of 1.8 per cent.10 Even so,
Ghana s HIV prevalence depicts a generalized epidemic with high prevalence pockets in Eastern Region
(3.6 per cent). A total of 34,557 children were living with HIV as of November 2014, and 2,407 new
child HIV infections were recorded in 2013, accounting for 31 per cent of all new infections. In 2014,
the total number of children aged 0-14 years in need of ART was projected to be 18,621. This makes
clear that the effective implementation of a comprehensive PMTCT scale-up plan would be an
8 Ghana Health Service, Family Health Division (2015), Annual Report 2014, cited in Situation Analysis. 9Ghana Health Service, (December 2015) EPI scale up for increasing immunization coverage of infants and young
children in Ghana: The BNA Approach, cited in Situation Analysis. 10 National Sentinel Survey (2014) cited in Situation Analysis.
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important method of curbing new incidence of HIV as well as improving the health outcomes of HIV-
infected mothers.11
A bottleneck analysis conducted by the Ghana Health Service identified the need to improve demand
and utilization, increase geographical accessibility and availability of services, and enhance the quality
of PMTCT and paediatric HIV care services. The Government has finalized its new National Strategic
Plan for HIV and STI (2016-2020) and has prioritized PMTCT as a major intervention for HIV/AIDS
response. A paediatric HIV acceleration plan has also been developed and provides an opportunity to
fast track the treatment of infected children. The roll-out of 'Option B plus' is considered a real
opportunity for virtual elimination of MTCT and keeping infected mothers alive. The Government has
also committed to full implementation of test and treat by 2018.
2.5. Malaria remains the first cause of morbidity in children under 5 years of age
The situation analysis also revealed persistently high rates of malaria in children aged 6-59 months,
particularly in rural areas, where the malaria parasite was found in 53 per cent of children (DHS 2014).
Rates are particularly high in the Northern and Upper West regions (60.6 and 62.3 per cent respectively
in 2014). Uptake of preventive measures remains low, with only 47 per cent of children under age 5
years sleeping under insecticide-treated nets, although up from 39 per cent in 2008.12 A review by the
Family Health Division of the Ghana Health Service found that measures to control malaria were
inadequate.13 UNICEF has not been active in malaria prevention given the presence and comparative
advantage of the Global Fund and DFID in this area.
2.6. Low access to healthcare and suboptimal quality of maternal and newborn healthcare
Antenatal care (ANC) coverage has increased at the institutional level and uptake of ANC services has
been improved through initiatives such as sustained awareness creation, the free maternal care policy
and continued training and deployment of midwives in the country. Consequently, 97.3 per cent of
pregnant women received institutional antenatal care, with rates of over 96 per cent for the first ANC
visit in every region except for Volta and Northern regions (94 and 92 per cent respectively).14 The data
show that wealth and education are not very significant factors in the uptake of antenatal care services
which may suggest that access is the critical factor and when available, women will take up antenatal
care. The 2014 DHS report indicates slight differences in ANC coverage with respect to wealth quintile
and level of education: 94 per cent (lowest quintile) versus 99.7 per cent (highest quintile) and 94.1 per
cent (no education) versus 99.9 per cent (secondary+ education). However, there are wide disparities
in the quality of ANC and type of skilled providers (doctor, nurse, midwife etc.). Among women in the
highest wealth quintile, 42.8 per cent receive ANC from a doctor and only 6.1 per cent of women in the
lowest quintile receive care from a doctor. Noteworthy is the high percentage (about 70 per cent) of
11 UNICEF Ghana, November 2014, Situational Analysis and Defining Strategic Action for Accelerating Paediatric HIV
Treatment, Care And Support In Ghana, cited in Situation Analysis. 12 DHS 2014, cited in Situation Analysis. 13 Ghana Health Service, Family Health Division (2015), Annual Report 2014, cited in Situation Analysis. 14
Ghana Statistical Service, GDHS 2014
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women with no education and among the lowest quintile who receive antenatal care from a
nurse/midwife.
In spite of these increasing trends in access to and utilization of antenatal and institutional delivery
healthcare services, Ghanaian mothers and newborns are yet to benefit from health-care services of
optimal quality. Several issues negatively affect the quality of maternal and newborn health care and
include low availability of up-to-date skilled health-care workers; non-institutionalization of quality of
care standards; unfriendly health-care environments; lack of essential health-care supplies (including
medicines) and equipment; a weak culture of accountability by care providers and their managers; and
negative staff attitudes towards service users (particularly adolescent girls and poorer households).15
On the user side, people's ignorance of their rights to health care of the best quality (including some
negative misconceptions), their incapacity to demand accountability either as individuals or
communities or civil society, compounded by low levels of education and poverty (all elements of their
vulnerability) make them accept and condone the poor quality health-care services they receive in
health facilities. Considering the comparatively higher cost of quality health care, it becomes clear that
the poor and/or uneducated are penalized two-fold as they are challenged by the cost of
transportation to distant health facilities that provide relatively better quality health care and the
relatively higher cost of care in such facilities.
Other key barriers to accessing health care are the inequitable distribution of health facilities and
services, with hard-to-reach areas underserved; weak leadership and lack of an accountability culture
and mechanisms at all levels; poor client tracking, resulting in lack of follow-up monitoring and care;
poor quality of care, as reflected in the high institutional maternal and neonatal mortality rates
mentioned under priority area 1; limited technical capacity within the sector for child- and gender-
responsive social and behaviour change communication on health and nutrition; low demand for
health and nutrition services by beneficiaries due to lack of knowledge and information; and reliance
on unorthodox health and nutrition services, which make users especially children and women
vulnerable to complications and death.
2.7. High child undernutrition
Food insecurity, inadequate feeding practices, lack of dietary diversity and low access to health
services are among the main causes of undernutrition in children.
Anaemia is the biggest nutritional problem the next country programme will need to focus on. It
especially affects young children, adolescent girls and women of reproductive age. Anaemia
prevalence in children dropped significantly from 77.9 per cent in 2008 to 65.7 per cent in 2014;
however, the rate is still well above 40 per cent, the WHO cut-off point for a severe public health
problem, meaning that two out of every three children in Ghana are anaemic. Anaemia rate in women
of child bearing age is at 42 per cent and the rate in adolescents aged 15-19 years was 48 per cent in
15 Participatory Development Associates (2013). Adolescents and Young People in Ghana (10 to 24 years) A Situation Analysis
identified the bias of health workers was said to hinge on whether a patient was wealthy or poor, male or female, able-bodied or
disabled through FGDs (2015), cited in Situation Analysis.
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2014 (DHS)
Stunting among children under five years of age has declined by one third since 2008, from 28 per cent
to 19 per cent in 2014 (in the Upper East region, stunting declined remarkably by over 50 per cent –
from 31.5 per cent in 2011 to 14.4 per cent in 2014). In the same period, wasting declined from 8.5 to 5
per cent and underweight from 14 to 11 per cent. The downward trend has been consistent among
both girls and boys, in urban and rural areas, and across all income and education levels. However, it is
worthy of note that despite the decline, there are still disparities, with children in the poorest
households being three times as likely to be stunted than children from the wealthiest households. A
slightly higher proportion of male (20 per cent) than female (17 per cent) children are stunted, and
stunting is greater among children in rural areas (22 per cent) than urban areas (15 per cent). By
region, stunting ranges from 10 per cent in Greater Accra to 33 per cent in the Northern Region.
Stunting is inversely correlated with wealth, with 25 per cent of children in the lowest two wealth
quintiles being stunted, as compared to 9 per cent of children in the highest quintile. These disparities
are also observed with respect to educational level and place of residence.
The observed progress is attributable to a variety of factors: overall reductions in poverty levels;
improvements in education levels; early identification and addressing of health and nutrition problems
in infants; improved capacity of frontline health staff on nutrition and having graduate level nutrition
officers in all 216 districts, However, the burden of stunting, wasting and underweight in children is
still high in rural areas and some regions and represent a significant number of children whose growth
and cognitive development are adversely affected for their lifetime, including their productivity in adult
life. A key area UNICEF needs to pay attention and provide leadership in collaboration with FAO, WHO
and academic institutions is on monitoring of complementary feeding indicators, so that the indicators
reflect actual trends in stunting consistent with the causality and action frameworks for stunting.
While progress in reducing undernutrition has been made, there is a growing problem of obesity among
adolescents and adults especially in urban areas. The rate of overweight and obesity in women has
increased significantly from 30 per cent in 2008 to 40 per cent in 2014. The rate in men is much lower at
16 per cent in 2014.
Overall the rate of exclusive breastfeeding has declined 11 percentage points from 63 per cent in 2008
to 52 per cent in 2014 partly as a result of reduced effort and investment in the promotion of exclusive
breastfeeding, weak enforcement and monitoring of the application of the International Code of
Marketing of Breastmilk Substitutes, and increased involvement of women in paid employment and
economic activities. In 2011, the rates had dropped to 46 per cent and rose again to 52 per cent in
2014 as a result of capacity building of staff working in maternity centres and child welfare clinics on
lactation management and the baby friendly hospital initiative.
The percentage of children aged 6-23 months fed with the recommended minimum dietary diversity
(4+ food groups) has also declined, from 47 per cent in 2011 to 28 per cent in 2014. Only 13 per cent of
children are fed a minimum acceptable diet according to infant and young child feeding
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recommendations.
2.8. Challenges facing the health and nutrition systems
A causality analysis of the health and nutrition systems revealed a number of reasons for the poor
performance of the system, including low rates of access to health-care services; the low quality of
health care; a poorly performing Health Management Information System (HMIS); limited access to
quality nutrition services, fortified foods and health and nutrition information; and low demand for
health-care and nutrition services. These causes were viewed through the three areas of enabling
environment, service supply and demand for service.
Enabling environment: the vast majority of health and nutrition programme intervention areas are
based on relevant policies and strategy documents that need regular revision and update to incorporate
latest developments and guidance from the global perspective. Limited investment in the HMIS has
resulted in weak application of information technology in the system, which translates into poor client
tracking for assurance of continuum of care and weak data production for decision-making, planning
and monitoring the effectiveness of interventions. Data generation, management and use in the sector
currently rely on manual processing with attendant weaknesses in terms of data quality, completeness
and timeliness. A well-conceived and established electronic data generation and management system
would help to address these issues as well as enable both the tracking of clients for service continuity
and assurance of effective intervention coverage, and periodic evaluations. With the impending
decentralization of the health sector, it is expected the district assembles will oversee health centres,
although they currently have very limited capacity for developing costed annual workplans, budgeting,
resource mobilization, oversight of implementation, monitoring, evaluation and accountability.
A recent assessment of WASH in health facilities reported a lack of both proper access to water for both
washing and drinking and functional sanitation facilities for patients and staff; a lack of staff training on
infection prevention and control; and limited budgets for operation and maintenance of WASH facilities
and services.
Ghana established the Cross-Sectoral Planning Group (CSPG), a multi-stakeholder platform under the
National Development Planning Commission, to develop a comprehensive approach to reducing levels
of malnutrition. In 2016, the National Nutrition Policy, which seeks to reposition nutrition as a cross-
cutting issue and strengthen sectoral capacity for the effective delivery of these interventions, was
launched.
Ghana has revised its 2002 Food and Agricultural Sector Development Policy to involve the private
sector and farmer-based organizations in agricultural policy implementation; adopted the Nutrition
Strategic Plan 2015, adapting WHO guidelines on micronutrients; adopted the Essential Nutrition
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Actions Package16 and rolled out training to district-level providers; and developed the IYCF programme
and community management of acute malnutrition (CMAM) strategy.
Supply side challenges
Low prioritization of hard-to-reach areas in the provision of health facilities and services has led to an
inequitable distribution of health facilities, leaving populations in hard-to-reach areas with long
distances to travel to reach the nearest health facilities. Even with the recourse to an outreach service
delivery strategy for communities far from existing health facilities, insufficient transport logistics and
lack of funding at the operational level impede effective service delivery to remote populations.
A culture of low accountability significantly impacts the quality of care delivered, with weak monitoring
and supervision and a culture of poor clinical care and poor maintenance of equipment. Together with
insufficient commodities, equipment and infrastructure, the attitudes of health-care providers and non-
adherence to care protocols account for the low quality of institutional care.
Further causality analysis of the nutrition subsector points to key supply-side and demand-side issues.
Most child nutrition problems can be attributed to lack of knowledge on appropriate IYCF practices on
the part of caregivers. Health and nutrition service providers are supposed to address this through age-
appropriate and gender-responsive counselling, and support for and monitoring of child growth and
development. However, the capacity of service providers remains low as a result of inadequate pre-
service and on-the-job training for health workers; inadequate numbers and irrational distribution of
health workers; poor service organization; and limited supervision and monitoring. These problems in
turn stem from poor linkages between the faculties that provide pre-service training and the public
health and clinical care services that attend to children and caregivers, and who receive pre-service
trainees on internship; weak integration of nutrition services in antenatal and child welfare services; low
prioritization of nutrition in the health sector agenda; and inadequate budgetary allocations for nutrition
interventions. The market supply of nutrient-fortified foodstuffs by the food industry remains limited,
probably due to the public sector's lack of engagement with industry on the need for food fortification,
which itself can be traced back to a weak public sector leadership on nutrition and weak facilitation,
regulation and enforcement of quality and safety standards.
Demand side challenges
In spite of the National Health Insurance Scheme that addresses the financial barriers to health care,
demand for and utilization of most health services on the one hand, and for nutrition information,
services and fortified foods on the other, remains very weak due to limited knowledge and low
awareness among the population on health issues and the services available to address them, on
nutrient-rich foods, supplements and their benefits, and the cost factor. The health sector has not really
engaged the public on a regular and sustainable basis about health and nutrition deprivations, their
causes and available solutions to generate demand for and utilization of available services. This in itself
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Seven proven nutrition actions that improve the health of women, newborns, infants and young children within the first 1,000
days of life.
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is due to the sector's limited technical capacity in child, adolescent and gender-responsive social and
behaviour change communication on nutrition. These types of approaches have not been prioritized in
the health sector and consequently do not receive government funding. Virtually all social and
behaviour change communication interventions in the sector are donor-funded and programme specific.
With increasing trends of non-communicable diseases including obesity and overweight, social and
behaviour change communication deserves becoming a priority area of investment for the sector.
2.9. Financing of the health sector:
Ghana s lower-middle-income status is reshaping the donor landscape. Several bilateral development
partners, including GAVI, are exiting the sector and this trend will continue in the coming programme
period. The current programme period has already witnessed the exit of a number of donors from the
sector and the few still present are gradually scaling down the sizes of their funding portfolios. In
addition, support from the Global Fund to government efforts to combat HIV/AIDS, tuberculosis and
malaria is increasingly being tied to counterpart government funding, especially for commodities, in a
context where the Government is facing increasing fiscal challenges. This makes the funding outlook
very uncertain as to the sustainability of gains in the three disease areas and scale-up of ongoing
interventions in other priority programme areas.
Lessons learned:
The main lessons learned during the current country programme are that while the effectiveness of key
health and nutrition interventions was demonstrated, this was not followed up by systematic
documentation and the strategic engagement needed for scale-up. At the sectoral level, limited funding
for operational costs, including essential commodity supplies, negatively impacted overall performance
and the sustainability of gains made. Finally, upstream work was largely limited to issue-based policies
and frameworks, with less emphasis on implementation and sustainability at downstream level. Based
on these conclusions, UNICEF will adopt a systemic child-, adolescent- and gender-responsive approach
to addressing critical sectoral issues such as neonatal mortality, immunization, stunting, quality of care,
etc. The UNICEF health and nutrition programme will thus focus on system strengthening, capacity-
building and technical support for disaggregated data generation and evidence-building, promoting
equities, with limited, targeted service delivery whose scale will be determined by funding. This will be
accompanied by evidence-based advocacy on these areas and issues. UNICEF will work through the
monthly meetings of the Health Sector Working Group to raise issues with the Government and partners
and to propose options and solutions, culminating in the annual National Health Summit, which takes
place in April each year and is the forum for policy direction for the health and nutrition sector.
UNICEF’s comparative advantage lies in its in-country presence, characterized by high-level technical
expertise and deep understanding of Ghana's health and nutrition sector, backstopped by support from
the Regional Office, headquarters or other country offices and including access to the latest research
findings; its longstanding presence in the country, working at national and subnational levels and on the
ground to support government capacity strengthening in the design, planning, costing (budgeting),
implementation, monitoring and evaluation of health and nutrition interventions; and its credibility,
based on its experience as an impartial and trusted long-term partner. UNICEF remains a source of
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technical expertise and information on nutrition-specific programming for government and non-state
organizations. Above all, UNICEF brings to the health and nutrition sector its multisectoral approach and
ability to leverage synergies with other sectors, particularly WASH, social protection and social policy,
supported by cross-sectoral work on gender, monitoring and evaluation and communication for
development.
3. Theory of change
The health and nutrition programme aims to support Ghana in achieving SDG 3.2, "By 2030, end
preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce
neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low
as 25 per 1,000 live births ", with a particular focus on U5MR; and SDG 2.2, "By 2030, end all forms of
malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in
children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and
lactating women and older persons", with particular focus on the nutritional needs of under-5 children.
Conditions that must exist:
Improved quality of both preventive and curative health care for children, adolescents and women
of childbearing age
Children, adolescents, and women of reproductive age access and utilize high-quality nutrient-rich
foods, supplements and relevant services.
For the purpose of this document, the term "children" includes newborns, children under five years of
age and adolescents (especially adolescent girls), and "women" refers to women of child bearing age
with particular reference to the periods of pregnancy, delivery and post-partum.
UNICEF will contribute to the achievement of this impact result through two outcomes:
1. Health: By 2022, more children and women access and utilize quality health services
2. Nutrition: By 2022, more children, adolescent girls and women of childbearing age access and utilize
nutrition services, nutrient-rich foods and supplements to improve their well-being.
3.1 Health Outcome
The vision of change is that by 2022, more children under five years of age, particularly newborns and
infants, access and utilize preventive and curative healthcare of enhanced quality.
The theory of change is that:
if health facilities are geographically and financially accessible to the population irrespective of their
place of residence,
if these health-care facilities are adequately equipped and provided with essential commodities, are
adequately staffed with a qualified, competent, skilled and motivated health workforce,
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if the highest standards of quality of care are upheld in these facilities with their managers and care
providers being held accountable,
and the population is satisfied with the care and effectively demands and utilizes these services in a
timely manner,
then institutional maternal and neonatal mortality rates will decline, as will rates of stillbirth.
Conditions that must exist:
Inspired by the thematic goal of Ghana s current Health Sector Medium-Term Development Plan, To
improve access to quality, efficient and seamless health services that are gender and youth friendly and
responsive to the needs of people of all ages in all parts of the country , SDG 3, Ensure healthy lives and
promote well-being for all at all ages and UNICEF s vision in its Health Strategy 2016-2030, … a world
where no child dies from a preventable cause, and all children reach their full potential in health and
well-being , the achievement of the outcome will require the following conditions to be met:
Health facilities are equitably distributed and accessible both geographically and financially;
The health facilities are staffed with a competent (skilled), equitably distributed and motivated
workforce;
Quality of care standards are applied at all levels and for both preventive and curative care
services
Health-care providers and their managers are accountable for the quality of care provided.
The population readily demands and utilizes the health-care services available through different
delivery platforms (facility-based, outreach, etc.)
Assumptions and risks
It is our assumption that Government of Ghana will continue to prioritize newborn and child health and
will have resources to adequately fund newborn and child health interventions. It is also our expectation
that improvements in the quality of care, will attract more people to use health services and derive the
intended benefits, thus contributing to the achievement of the outcome and ultimately the impact.
Risks and mitigating measures
Risk Mitigating measures
Low donor investment in the sector in general
and on newborn and child health as current
trends show gradual but persistent declines in
donor funding for the sector and pullouts by
others
UNICEF will work with the Ministry of Health and
the Ghana Health Service to demonstrate
evidence-based and effective models and use the
results to engage and influence donors.
Fragmented donor-driven and supported
programmes.
UNICEF will work to strengthen partner
coordination under government leadership.
The theory of change for the programme component will focus therefore on the conditions and
pathways that lead to the achievement of this outcome result to which three identified output-level
results will contribute. Contributing to the attainment of these outputs will be activities to address the
bottlenecks and barriers identified in the causality analysis.
13
The theory of change that will lead to the attainment of the outcome follows from how each of the
three outputs will be achieved (conditions for this change and the pathways to those conditions).
3.1.1 Output 1: Enabling environment, leadership and Governance: By 2022, Ghana's health system has
the necessary management tools to support effective service delivery at national and subnational levels.
As a result of the public health sector's weak capacities, at national and subnational levels, for
performance-based planning, budgeting and funding of interventions and operations and in human
resources management, the sector's mobilization and allocation of resources and programme
implementation are ineffective and inefficient. The sector lacks a system for real-time management of
procurement and distribution of supplies to ensure their on-time availability at service delivery points.
UNICEF will support the sector to develop and demonstrate: integrated planning and budgeting tools; a
performance-based budgeting model; a functional human resources management information system
and a task-shifting policy; tools and procedures for technical, managerial and social accountability; and
an in-built system for staff capacity development at all levels. It also envisions support for establishing
sustainable financing mechanisms for essential commodities, and a system that provides real-time
information on procurement and management of supplies. If these objectives are met, then the Ministry
of Health, the Ghana Health Service and other relevant agencies will be better able to effectively plan,
budget, fundraise, manage the supply chain and implement, monitor and account for high-impact,
gender-responsive interventions for newborns, children, adolescents and women of childbearing age.
The following conditions will have to be in place for this output result to be achieved:
Political will to embark on relevant performance-based programming.
UNICEF capacity required to effectively engage the Ministry of Health and the Ghana Health
Service at the policy level and support specific and relevant strategic interventions;
UNICEF pathways to be developed:
UNICEF will implement sustained, evidence-based policy dialogue on improving the efficiency and
effectiveness of key expenditures in the health sector through:
Sector budget expenditure analysis;
Development of integrated planning and budgeting tools and their demonstration in selected
districts;
Support for the establishment of sustainable financing mechanisms for essential commodities;
Support for establishment of a performance-based management system at national and
subnational levels.
Design and development of a functional human resources management information system
(HRMIS) that captures all relevant information on staff for their effective management and
deployment.
Support the implementation of a task-shifting policy with training of staff to take on additional
duties for scale-up of high-impact maternal, newborn, child and adolescent health interventions.
14
Development of tools and procedures for technical, managerial and social accountability on
quality of care and financial management.
Design, testing and adoption of a computerized (web-based) procurement and supply
management system platform covering all health facilities and health-care commodities.
Development and utilization of tools for supply chain management (forecasting, quantification,
planning, procurement and distribution), and ensuring "last mile" availability of essential
commodities; and
Putting in place an emergency preparedness and response framework that takes into account
age, gender, location and other vulnerabilities faced by children, adolescents and women.
To improve the enabling environment, UNICEF will build on its comparative advantage as a trusted long-
standing partner of the Ministry of Health to network and advocate at the highest levels for the
development of the tools needed to strengthen functioning, accessibility, inclusiveness and
accountability of the health system. High-level advocacy will be backed up by technical support and
capacity-building to support the Government in developing and testing tools and systems to improve
integrated planning, human resources management and financing for, procurement and distribution of
essential health-care commodities, all with the aim of strengthening the capacity and accountability of
the health system to provide quality and needs-based care for all, with a focus on high-impact
interventions to improve health outcomes. Activities will include provision of expertise through qualified
consultants and support for training, capacity-building and documentation. UNICEF will collaborate with
other key development partners in the sector notably WHO, USAID, JHPIEGO, to support the Ministry of
Health and Ghana Health Service, and embark on targeted advocacy with the Ministry of Finance and
the parliamentary select committee on health for sector funding allocation and legislative action on
relevant regulatory documents as and when necessary.
3.1.2 Output 2. Quality of care: Evidenced-based tools and strategies are in place for delivery of
quality care for all.
Ghana has witnessed remarkable trends in access and utilization of antenatal care and institutional
delivery by pregnant women. Nonetheless, pregnancy outcomes have remained poor in terms of high
institutional maternal and neonatal deaths and high stillbirth rates, all of which point to deficiencies in
the quality of the care they receive. Reversing these negative outcomes require that the health care
received by pregnant women meets the highest standards of quality.
For this to happen, the following conditions will have to be met:
Evidence-based standards of quality of care are in place, understood, adopted and applied;
Political will to invest in improvement of quality of care, including accountability;
Functional social protection measures are in place to ensure equity in access to quality care for the
vulnerable, including adolescent girls during pregnancy and HIV-infected children and pregnant
women.
Intersectoral collaboration on WASH in health-care facilities as an essential component of quality of
care
The NHIA has the resources to pay health-care service providers in a timely manner;
15
The NHIA institutionalizes quality of care standards and criteria in contracts with service providers
(credentialing)
The Health Facilities Regulatory Agency implements quality of care standards and criteria in health
facility accreditation
UNICEF pathways to be developed:
UNICEF will support the system to strengthen its capacity to deliver maternal and newborn care of
optimal quality through:
Continuous advocacy in favour of institutionalization of quality of care standards
Setting of standards and criteria for quality of care for maternal, newborn and child care including
age and gender-responsiveness of care for specific issues and diseases;
Development of costed service delivery strategy for hard-to-reach and most deprived populations;
Development and testing of model for integrated service delivery at the operational level;
Update of pre-service training curricula, development of teaching aids and training of tutors of
health professional training schools/colleges on quality of care standards and related guidelines;
Demonstration of the integration of PMTCT and paediatric HIV into maternal, newborn and child
health services.
Application by the National Health Insurance Scheme (NHIS) of quality of care standards and criteria
in their accreditation of health-care facilities to ensure quality assurance and accountability.
Strengthening the health system s capacity to market health and nutrition services through child
and gender responsive behavior change communication on health and nutrition.
To support the health system in improving quality of care, UNICEF will focus on advocacy and technical
support through evidence-generation; provision of expert consultants to support the system develop
tools, conduct training, documentation, monitoring and evaluation; networking and participation in
working groups and other forums; and targeted service delivery for immunization and other high-impact
interventions. An equity lens will be applied in ensuring that districts with the highest disease burden
are prioritized and that healthcare provision reflects the age and gender specific needs and interests of
the population. UNICEF will also advocate for quality healthcare affordability via an NHIS that
reimburses care providers in a timely manner.
Partners will include the UN system, Delivering as one; DFID, JICA, Global Fund, the World Bank, GAVI;
training institutions (Ghana College of Physicians and Surgeons and Ghana College of Nurses and
Midwives); regulatory bodies (Medical and Dental Council, Nurses and Midwifery Council, Pharmacy
Council, etc.).
3.1.3 Output 3: Data, health information, community engagement, and research: Quality
disaggregated data from routine monitoring system is available and knowledge is generated on the
survival challenges of older children (6-10 years) and adolescents.
Conditions that must exist:
A real-time data collection system in place that enables health service client tracking and is linked to
the district health management information system;
Health-care staff dispose of capacity and will to collect disaggregated data
Government is committed to research about the needs of older children and adolescents
16
UNICEF pathways to be developed:
UNICEF will support the system to strengthen its capacity to collect high-quality, complete and timely
disaggregated data through:
Design, testing and adoption of an electronic system for collection and tracking of health-care client
information which is synchronized with the district health management information system;
Strengthening the capacities of health-care providers and managers for disaggregated data
collection and information management;
Research to fill data gaps on emerging issues - adolescents, especially adolescent girls, children 6-10
years, stigma on HIV and uptake of PMTCT services;
Various health scorecards will be publicized as part of community engagement and social
accountability.
UNICEF support for improved data and research will primarily take the form of technical support and
provision of expertise to strengthen information management capacities, including for analysis of data
using age and gender lenses, and using the data to continuously improve quality of care. Linkages with
social protection will be explored through potential interface between the health system and LEAP and
engagement of LEAP beneficiaries, especially pregnant women and children under two years of age.
Advocacy will include efforts to publicize health scorecards through community engagement and to
increase the social accountability of the health system to its beneficiaries by ensuring representation of
diverse voices, especially of the most vulnerable groups. UNICEF partners will include JICA, USAID, World
Bank; research institutions, academia, local government, and the Department of Social Welfare.
3.2 Nutrition
The vision of change of the nutrition component is that by 2022, the Government of Ghana, through
its relevant ministries, departments, agencies, and working with civil society and the private sector,
will ensure that more children (0-59 months), adolescent girls (10-19 years) and women of
childbearing age (15-49 years) access and utilize services, nutrient-rich foods and supplements for
prevention and treatment of malnutrition.
This vision is in line with the country s Health Sector Medium-Term Development Plan, improvements
in access to quality Maternal and Child Nutrition services , SDG 1, End hunger, achieve food security
and improved nutrition and promote sustainable agriculture , the UNICEF nutrition strategy and the
World Health Assembly targets on nutrition. UNICEF s work to support government and other
stakeholders in achieving the outcome will rely on a number of conditions being met.
Conditions that must exist:
High-quality, nutrient-rich foods and micronutrient supplements are available and affordable for all
socio-economic and cultural strata of the population;
The food industry is engaged and commits to relevant food fortification;
Caregivers and the population at large know and apply appropriate infant and young child feeding
practices;
17
Health-care facilities have skilled and motivated staff who provide quality nutrition services and
care;
A regulatory framework on newborn, infant and child nutrition is in place and enforced;
Government prioritizes nutrition among its development sectors and sufficiently funds its
interventions;
Earmarked funding is available for the provision of essential nutrition commodities and service
delivery;
UNICEF has the capacity required to effectively engage the health and other relevant sectors at the
policy level.
Pathways to achieve this outcome
In order to achieve this outcome, UNICEF will count on the efforts of other nutrition sector and
nutrition-sensitive stakeholders while focusing on its areas of comparative advantage. It is critical that
the Government positions nutrition high on its development agenda and sufficiently funds its
interventions. The agricultural sector would have to increase the amount of locally grown nutrient-rich
foods for the population and the education sector would teach young people about good child feeding
practices before they have children. With proper government engagement, the private sector,
particularly the food industry, would market affordable nutrient-rich foods and supplements to increase
their availability. UNICEF will support the Government to strengthen the nutrition regulatory framework,
taking into account the most recent evidence, international frameworks and WHO guidelines and
recommendations; build the capacity of health-care workers to educate child caregivers and family
members visiting health facilities and via other means, on appropriate infant and young child feeding
practices. UNICEF will work with influencers, communities and communication stakeholders to address
social norms that are negatively affecting infant and young children feeding. UNICEF will support the
establishment and implementation in health-care facilities of standards of quality of nutrition care for
infants and young children.
Assumptions and risks
The outcome is based on the assumption that there will not be no major food insecurity crisis, but if one
were to occur, UNICEF would work with other partners to address it. It is also assumed that if nutrient-
rich foods are made available and affordable, and the populace (caregivers) are educated on
appropriate infant and young child feeding practices, they will be willing to adopt these practices.
Risks and mitigating measures
Risk Mitigating measures
Government might not invest
sufficiently on nutrition
UNICEF will work with other partners to advocate strongly
using a nutrition investment case, with Government to
prioritize and sufficiently fund nutrition sector interventions
Donors not interested in funding
nutrition sector interventions
UNICEF will engage donors with the same investment case
to advocate for their engagement and funding for the sector
Nutrition services not integrated into
maternal, newborn and child health
UNICEF will support the health sector develop and
implement a service integration model that ensures
18
services inclusion of health and nutrition into an integrated package
Poor coordination of partners around
nutrition
UNICEF will advocate for and work with other partners to set
up a functional nutrition sector coordination platform.
Three outputs have been identified as necessary to contribute to the attainment of the outcome.
3.2.1 Output 1: Enabling environment: National Nutrition Policy and frameworks are aligned with
international standards and monitored annually.
Addressing the nutrition problem in Ghana requires an interplay between several different sectors with
diverse but synergistic contributions in terms of policies and strategies, and their implementation at
various levels. Currently, there are numerous gaps in policies, regulations and guidance and some of the
available ones are either obsolete or not aligned with most recent international standards and
recommendations. UNICEF, working in collaboration with other UN agencies and bilateral partners,
intends to support the nutrition-relevant sectors to develop/update strategic documents and secure
funding for essential nutrition commodities, while supporting the Government to engage the private
food industry and set up and enforce accountability systems for nutrition service delivery in the health
sector. UNICEF will support capacity strengthening for government nutrition sector workers to provide
quality high-impact nutrition services for newborns, children, adolescents, especially adolescent girls
and women of reproductive age.
Conditions that must exist:
Government commitment to create an enabling environment for the coordination of nutrition
action across sectors in the country
Structures responsible for coordinating nutrition action across sectors in the country have
appropriate technical capacity
UNICEF has the capacity to provide technical assistance and to rally other major stakeholders
around the nutrition problem
Financing for nutrition programmes, especially essential and life-saving supplies
UNICEF pathways to be developed:
UNICEF will support the Government to strengthen its capacity to enable, lead and regulate the
country s nutrition situation through:
Revision/updating and implementation of nutrition-relevant strategic documents notably
regulations on breastfeeding; regulations and standards on food fortification; CMAM guidelines
and the IYCF policy, based on identified relevant social norms;
Adoption by Government of improved maternity protection measures;
Putting in place of sustainable financing mechanisms for essential nutrition commodities;
Engagement of the private sector on options for food fortification, including how to address
anaemia through a gender-sensitive supplementation programme; using nutrient rich family foods
and wheat fortification with more effective forms of iron;
19
Working with UNICEF Supply Division on standards of food fortification and qualifying supplies as
needed;
Setting up and rendering effectively functional, accountability framework and structures led by
local governments, in partnership with the Ministry of Health and CSOs, with clearly defined roles,
responsibilities and performance indicators;
UNICEF will undertake high-level advocacy and provide technical expertise and assistance to update
nutrition regulations and standards, engaging WHO, ILO (for maternity protection measures) and
partners in the Scaling-Up Nutrition (SUN) movement. UNICEF will also advocate with parliamentarians,
policymakers, implementing partners and development partners (WFP, WHO, USAID and other SUN
development partners,) about the need for sustainable financing for essential nutrition commodities,
coupled with technical assistance in forecasting and costing commodities. UNICEF will advocate and
support the development of a strategy for domestic financing of essential nutrition commodities
involving the private sector, government food standard authorities and SUN business partners. Support
for an accountability framework, with clear roles and responsibilities for all actors, will take the form of
capacity-building (training of partners and key stakeholders), technical assistance and
advocacy/convening of partners to review enforcement and performance.
3.2.2 Output 2: Health service providers have improved capacity to deliver quality nutrition services at
national and sub-national level
Conditions that must exist:
High political and administrative levels recognize nutrition as an important development issue
The nutrition programmes in the country are adequately funded
UNICEF is able to provide technical assistance for capacity-building of government and civil society
stakeholders
UNICEF pathways to be developed:
UNICEF will support the Government to strengthen its capacity to ensure that more mothers, newborns,
children and adolescent girls access and utilize high quality nutrient-rich foods, supplements and
relevant services through:
Strengthening the evidence base to inform policies, advocacy, plans, strategies and programmatic
adjustments and scale-up, specifically with regard to supplements for women of child-bearing age
and adolescents, combined infant nutrition/health/WASH interventions and use of multiple
micronutrient powders in malaria-endemic areas;
Development of a costed implementation strategy for nutrition interventions such as multiple
micronutrient supplementation for children, adolescent girls and women of child-bearing age; etc.
Integration of guidelines on micronutrients, breastfeeding, CMAM, IYCF, etc. into pre-service and
in-service training curricula for health service providers, and enforcement of their teaching and
examination;
Revision and integration of quality standards and criteria on implementation guidelines for IYCF
and micronutrient supplementation into the quality of care framework;
20
Demonstration and documentation of the application of the guidelines in selected districts, backed
up by real-time client satisfaction surveys;
UNICEF will support the generation of evidence on interventions to reduce stunting and anaemia among
vulnerable groups, complemented by advocacy to scale up effective strategies, requisite capacity-
building and resource mobilization. Linkages with LEAP, which is being implemented nationwide, will be
explored, particularly to ensure that women and children benefiting from the cash-transfer are also
accessing nutrition services including micronutrient supplements. UNICEF will provide technical and
financial support for studies and research to strengthen the evidence base, specifically to establish clear
age and gender sensitive indicators and baselines and information systems for monitoring progress.
Training and other capacity-building activities will be undertaken in three districts, and targeted
commodity support (micronutrients and other strategic supplies) will be provided, depending on the
availability of resources. UNICEF will engage government and SUN partners during implementation and
scale-up to other districts.
3.2.3 Output 3: Stronger capacity among public and private sector and civil society actors to promote
nutritional wellbeing of children, adolescents and women.
Conditions that must exist:
Clear knowledge of social norm determinants of feeding practices for women, newborns, children
and adolescent girls;
Commitment and audacity of Government and civil society organizations to address social norms
UNICEF is able to provide requisite technical expertise to develop a strategy to address identified
social norms that are negatively affecting access to and utilization of nutrient-rich foods.
UNICEF pathways to be developed:
UNICEF will support the Government to address the social cultural factors and norms that are negatively
impacting nutrition and child health through:
Development, on the basis of social research findings, of guidelines and a social and behaviour
change communication strategy for changing misconceptions on health and nutrition;
Implementation of the costed strategy to address the impact of social cultural factors and norms
Setting up a system for tracking of behaviour change;
The primary strategies will be C4D and social and behaviour change communication, developed through
partnerships with local and international institutions with expertise on social norms. UNICEF will provide
technical assistance to develop an approach for addressing social-cultural factors and norms around
health and nutrition, bringing together stakeholders and influential change agents to develop guidelines
and tools, support training for key implementing partners and the development and implementation of
a tracking system. Partnerships with development partners will be strengthened to support
implementation of social and behaviour change communication strategies.
21
3.3 Major assumptions, risks and mitigating measures for the nutrition and health outcomes
Important assumptions underlying the proposed programme are that there will be ownership by the
new national Government and local authorities, as reflected in the strategic documents under
preparation (Ghana Shared Growth and Development Agenda, Medium Term Health and Nutrition
Strategic Plans, 2018 -2021); and that the health sector decentralization process will continue as
planned. UNICEF will continue to advocate strongly for the system-strengthening approach as key to
improving newborn, child, adolescent and maternal health and nutrition outcomes, and will work with
sector partners as the decentralization process continues.
Given Ghana's middle-income status and related changes in the donor environment, it is critical that the
Government fulfills its commitments to support public health interventions including procurement of
vaccines, nutrition supplements and other essential commodities. This is especially important during the
period 2017-2021 when GAVI support for the immunization programme will be phased out and during
which other donors such as the Global Fund are instituting a counterpart funding arrangement against
their funding support. The accompanying risk is that the Ministry of Health, beyond the payment of
salaries, will not have funds for the implementation of the initiatives this programme intends to support,
thereby jeopardizing further progress on key programme intervention outcomes and even reversing
some of the gains. UNICEF will work with the Government to identify potential funding mechanisms
including the Vaccine Independence Initiative revolving fund mechanism. Similarly, the programme
approach assumes that the Government will have the capacity to scale up the initiatives proposed via
evidence generation and demonstration. UNICEF and partners will work closely with the Government on
the development of these initiatives to ensure they are realistic and cost-effective.
Another assumption is that caregivers and medical staff will accept task shifting and be willing to change
their behaviour towards health service clients, and that these clients in turn are willing to change their
own beliefs and cultures. Specific to nutrition, it is assumed that the NHIS will fulfil its commitment to
incorporate breastfeeding criteria in assessing the quality of health care provided in health facilities.
There is a risk that rapid urbanization will negatively affect breastfeeding practices, especially exclusive
breastfeeding, which is much higher in rural areas. In all instances, stakeholders will be involved in every
step from the onset of the change processes, to ensure their buy-in.
It is also assumed that the Government will be able to avail itself of the financial resources and the
political will to adopt, apply at scale all the tools developed as well as the accountability mechanisms
demonstrated, that revised pre-service curricula will be effectively taught and examined, and the
different strategic documents and implementation models will be fully implemented.
Progress in the health sector could be derailed by major emergencies such as cholera outbreaks or
epidemics such as Ebola and Zika virus. UNICEF will advocate with government and other stakeholders
for the strengthening of the country s emergency preparedness and response mechanism with set-aside
22
government funding. Meanwhile, and internally, UNICEF will in case of emergency, and in consultation
with government, embark on either fund reprogramming or leveraging or both, to meet immediate
emergency needs.
4. Results structure and framework
The results structure and framework presents the hierarchy of results to which the health and nutrition
programme component aims to contribute. The highest level result is the impact (lasting positive change
in the lives of newborns, children, adolescents and women of childbearing age). The programme has
identified two outcomes that will contribute to the attainment of this projected impact but which on
their own are not enough to cover all the issues that affect the survival, growth and development of
these target populations. It is expected that actions of other stakeholders on other causes of under-five
morbidity and mortality will complement those of UNICEF to enhance the health and survival of children
under five years of age.
Impact: By 2022 Ghana s under-five mortality rate is reduced from 60 in 2014 to 45 (based on Ghana s
SDG 3.2 UFMR target).
4.1 Health Outcome: The vision of the health component of the programme is that by 2022, more
children under five years of age, particularly newborns and infants access and utilize preventive and
curative healthcare of enhanced quality.
4.1.1 Output 1: Enabling environment, leadership and Governance: By 2022, Ghana health system has
the necessary management tools to support effective service delivery at national and subnational
levels.
4.1.2 Output 2. Quality of care: Evidenced-based tools and strategies are in place for delivery of
quality care for all.
4.1.3 Output 3: Data, health information, community engagement, and research: Quality
disaggregated data from routine monitoring system is available and knowledge is generated on
survival challenges of older children (6-10 years) and adolescents.
4.2 Nutrition Outcome: The vision of the Nutrition component of the programme is that by 2022, the
Government of Ghana, through its relevant ministries, departments, agencies, and working with the civil
society and private sector, will ensure that more children (0-59 months), adolescent girls (10-19 years)
and women of childbearing age (15-49 years) access and utilize services, nutrient-rich foods and
supplements for prevention and treatment of malnutrition.
4.2.1 Output 1: National Nutrition policy and frameworks are aligned with international standards and
monitored annually.
4.2.2 Output 2: Health service providers have improved capacity to deliver quality nutrition services at
national and sub-national levels.
23
4.2.3 Output 3: By 2022, stronger capacity among public and private sector and civil society actors to
promote nutritional wellbeing of children, adolescents and women.
5. Aligning results, strategies and required resources
Outcome 1 Health: By 2022, more children and women access and utilize quality
health services
Total 5 years
RR OR/E
Staff and
Technical
Assistance
L4 (RR) Chief of Section $ 975,000
GS6 (RR) PA $ 75,000
GS5 (OR) PA Tamale $ 62,500
Temporary Assignment (OR) $300,000
Health Specialist NOC (OR) Accra $260,000
Health & Nutrition Specialist NOC (RR) Tamale $260,000
Health Specialist NOC (RR) Accra $260,000
Total Posts Health Outcome $ 1,570,000 $ 622,500
Output 1: By 2022, Ghana health system has the necessary management tools to support
effective service delivery at national and subnational levels
Total 5 years
RR OR/E
Staff and
Technical
Assistance
Accra: Health Specialist NOC (RR) $ 260,000
Tamale: Health and Nutrition Specialist NOC (RR) $ 260,000
L4 (RR) Chief of Section $ 325,000
GS5 (OR) PA Tamale $ 62,500
GS6 (RR) PA $25,000
Strategies Grouping of related activities
Policy Dialogue
and Advocacy
Strategy/Policy formulation, convening meetings, organizing
workshops, study tours, partnership building, media communication,
resource mobilization, budget exercises, legal framework.
$ 185,000
24
Systems
strengthening.
Sector budget analysis; integrated planning and budgeting tools,
sustainable financing mechanisms for essential commodities;
performance-based management at national and subnational levels;
functional human resources management information system
(HRMIS); task-shifting policy; tools and procedures for accountability
on quality of care and financial management; computerized (web-
based) procurement and supply management platform; tools for
supply chain management; emergency preparedness and response
framework
$ 500,000 $ 2,000,000
Total Posts Output 1 (Health) $ 870,000 $ 62,500
Total Non-Posts Output 1 (Health) $ 685,000 $ 2,000,000
TOTAL Output 1 (HEALTH) $ 1,555,000 $ 2,062,500
Output 2: Quality of care: Evidenced-based tools and strategies are in place for delivery
of quality care for all
Total 5 years
RR OR/E
Staff and
Technical
Assistance
Health Specialist NOC (OR) Accra $ 260,000
Health Specialist NOC (RR) Accra
Health & Nutrition Specialist NOC (RR) Tamale $ 130,000
L4 (RR) Chief of Section $325,000
GS6 (RR) PA $25,000
Strategies Grouping of related activities
Policy Dialogue
and Advocacy
Advocacy for institutionalization of quality of care standards;
Formulation of standards and criteria for quality of care for maternal,
newborn and child care and resource mobilization for
implementation.
$200,000 $300,000
Institution-
building
(organizational)
Development of costed service delivery strategy for hard-to-reach
and most deprived populations and model for integrated service
delivery at the operational level; Update pre-service training
curricula, development of teaching aids and training of tutors of
health professional training schools/colleges on quality of care
standards and related guidelines; Demonstration of integration of
PMTCT and paediatric HIV into maternal, newborn and child health
services. Application by the National Health Insurance Scheme (NHIS)
of quality of care standards and criteria in their healthcare facilities
accreditation.
$ 300,000 $800,000
Service Delivery Procurement/distribution of supplies and equipment;
logistics/transportation, warehousing, infrastructure, direct
assistance/cash grants, monitoring, innovations, programme
technical capacity building, demonstration of model for integrated
service delivery.
$655,000 $8,700,000
Capacity
development
Development of materials/training aids, IEC materials, workshops,
social mobilization/community empowerment, C4D, networks,
Strengthening the health system s capacity to market health and
nutrition services.
$200,000 $350,000
Total Posts Output 2 (Health) $480,000 $260,000
25
Total Non-Posts Output 2 (Health) $ 1,355,000 $10,150,000
Total Output 2 (HEALTH) $ 1,835,000 $10,410,000
Output 3: Data, health information, community engagement, and research: Quality
disaggregated data from routine monitoring system is available and knowledge is
generated on survival challenges of older children (6-10 years) and adolescents.
Total 5 years
RR OR/E
Staff and
Technical
Assistance
L4 (RR) Chief of Section $325,000
Temporary Assignment (OR) $300,000
Health & Nutrition Specialist NOC (RR) Tamale $ -
GS6 PA (RR) $ 25,000
Strategies Grouping of related activities
Policy Dialogue
and Advocacy
Strategy/Policy formulation, convening meetings, organizing
workshops, study tours, south/south cooperation, partnership
building, resource mobilization, budget exercises, legal framework.
$50,000 $50,000
Institution-
building
(organizational)
Design, testing/adoption of electronic client information system
synchronized with district health management information system;
development of plans/micro-plans, institutional mechanisms/tools,
guidelines, protocols/standards, coordination; oversight
strengthening, resourcing and budgeting, governance.
$ 100,000 $ 500,000
Service Delivery Procurement/distribution of equipment; data infrastructure, direct
assistance/cash grants, monitoring, innovations.
$ - $300,000
Capacity
development
(community)
Build capacities of health-care providers and managers for
disaggregated data collection and information management.
$ - $ 250,000
Evidence
generation
Situation analysis, research, studies and surveys to fill data gaps on
emerging issues - children 6-10 years and adolescents, stigma on HIV
and PMTCT, evaluation, assessments, generation of profiles,
knowledge management, innovative approaches.
$ 150,000 $ 600,000
Total Posts Output 3 (Health) $ 350,000 $ 300,000
Total Non-Posts Output 3 (Health) $ 300,000 $ 1,700,000
Total Output 3 (Health) $ 650,000 $ 2,000,000
Total Posts Outcome 1 (Health) $ 1,700,000 $ 622,500
Total Non-Posts Outcome 1 (Health) $ 2,340,000 $ 13,850,000
TOTAL OUTCOME 1 (HEALTH) $ 4,040,000 $ 14,472,500
Outcome 2 Nutrition: More children, adolescent girls and women of childbearing age access and utilize nutrition services,
nutrient-rich foods and supplements to improve their well-being
RR OR/E
Staff and
Technical
Assistance
L4 Chief of Section $ 325,000
L4 (RR) Nutrition Specialist $ 1,300,000
GS6 (RR) PA $ 75,000
26
GS5 (OR) PA Tamale $ 62,500
Health & Nutrition Specialist NOC (RR) Tamale
Nutrition Officer NOB (OR) Tamale $ 245,000
Nutrition Officer NOB (OR) Accra $ 245,000
Total Posts Nutrition Outcome $ 1,700,000 $ 552,500
Output 1: National Nutrition policy and frameworks are aligned with international
standards and monitored annually. Total 5 years
RR OR/E
Staff and
Technical
Assistance
L4 (RR) Nutrition Specialist $ 500,000
GS6 (RR) PA $ 75,000
GS5 (OR) PA Tamale $ 62,500
Health & Nutrition Specialist NOC (RR) Tamale
Strategy Grouping of related activities
Policy Dialogue
and Advocacy
Nutrition-relevant Strategy/Policy formulation/update, maternity
protection, standards of food fortification, Private sector engagement
on options for food fortification, convening meetings, organizing
workshops, study tours, south/south cooperation, partnership
building, media communication, sustainable financing mechanisms
for essential commodities and resource mobilization, legal
framework, accountability frameworks and structures.
$ 300,000 $ 1,500,000
Total Posts Output 1 (Nutrition) $ 575,000 $ 62,500
Total Non-Posts Output1 (Nutrition) $ 300,000 $ 1,500,000
TOTAL Output 1 (Nutrition) $ 875,000 $ 1,562,500
Output 2: Health service providers have improved capacity to deliver quality nutrition
services at national and sub-national levels. Total 5 years
RR OR/E
Staff and
Technical
Assistance
NOB Nutrition Officer (OR) Tamale $ 122,500
L4 (RR) Chief of Section $-
L4 (RR) Nutrition Specialist $ 400,000
Strategy Grouping of related activities
Policy Dialogue
and Advocacy
Strategy/Policy formulation, convening meetings, organizing
workshops, study tours, south/south cooperation, partnership
building, media communication, resource mobilization, budget
exercises, legal framework.
$100,000 $ 100,000
Institution-
building
(organizational)
Development of plans/micro-plans, institutional mechanisms/tools,
guidelines, protocols/standards, coordination; oversight
strengthening, management information systems, resourcing and
budgeting, governance.
$300,000 $ 500,000
Service Delivery Procurement/distribution of supplies and equipment;
logistics/transportation, warehousing, infrastructure, direct
assistance/cash grants, monitoring, innovations.
$ 800,000 $ 10,467,500
Capacity
development
(community)
Development of materials/training aids, IEC materials, workshops,
social mobilization/community empowerment, C4D, networks
$ 200,000 $ 545,000
27
Total Posts Output 2 (Nutrition) $ 400,000 $ 122,500
Total Non-Posts Output 2 (Nutrition) $ 1,400,000 $ 11,612,500
TOTAL Output 2 (Nutrition) $ 1,800,000 $ 11,735,500
Output 3: By 2022, stronger capacity among public and private sector and civil society
actors to promote nutritional wellbeing of children, adolescents and women. Total 5 years
RR OR/E
Staff and
Technical
Assistance
L4 (RR) Nutrition Specialist $ 400,000
NOB (OR) Nutrition Officer Accra $ 245,000
NOB (OR) Nutrition Officer Tamale $ 122,500
Strategy Description
Policy Dialogue
and Advocacy
Strategy/Policy formulation, convening meetings, organizing
workshops, study tours, south/south cooperation, partnership
building, media communication, resource mobilization, budget
exercises, legal framework.
$ 30,000 $ 200,000
Institution-
building
(organizational)
Development of communication plans/micro-plans, institutional
mechanisms/tools, guidelines and a costed strategy for changing
social norms and misconceptions on IYCF and SAM,
protocols/standards, coordination; oversight strengthening,
management information systems - for tracking of interventions to
change social norms; resourcing and budgeting, governance.
$ 30,000 $ 150,000
Service Delivery Procurement/distribution of supplies and equipment;
logistics/transportation, warehousing, infrastructure, direct
assistance/cash grants, monitoring, innovations. Implementation of
the costed strategy to address the impact of social norms on
newborn, child, adolescent (especially adolescent girls') and maternal
nutrition.
$ 250,000 $ 1,000,000
Capacity
development
(community)
Development of materials/training aids, IEC materials, workshops,
social mobilization/community empowerment, C4D, networks.
$ 40,000 $ 300,000
Evidence
generation
Situation Analysis, research, studies, surveys, evaluation,
assessments, generation of profiles, knowledge management,
innovative approaches.
$ 35,000 $ 212,500
Total Posts Output 3 (Nutrition) $ 400,000 $ 367,500
Total Non-Posts Output 3 (Nutrition) $ 385,000 $ 1,862,500
TOTAL Output 3 (Nutrition) $ 785,000 $ 2,230,000
Total Posts (Nutrition) $ 1,375,000 $552,500
Total Non-Posts (Nutrition) $ 2,085,000 $ 14,975,000
TOTAL OUTCOME 2 (NUTRITION) $ 3,460,000 $ 15,527,500
Total All Posts (Health & Nutrition) $ 3,075,000 $ 1,175,000
Total Non-Posts (Health & Nutrition) $ 4,425,000 $ 28,825,000
TOTAL OUTCOME 1 & 2 (Health & Nutrition) $ 7,500,000 $ 30,000,000
28
6. Monitoring achievement of outputs and UNICEF's contribution to outcomes
Progress towards the achievement of planned results will be monitored using the indicators defined in
the attached results and resources framework, including UNICEF s contribution to the achievement of
outcome-level results. The health and nutrition programme can rely on a well-established, rich
administrative data source, the District Health Information Management System (DHIMS) for monitoring
programme progress. UNICEF will continue to work with Ghana Health Service and Ministry of Health to
expand the accessibility and reporting frequency of DHIMS to further increase its utility for programme
monitoring.
Besides these routine administrative data sources, implementing partner-generated information and
regular survey data will be used to track progress and assess UNICEF s contribution. Special-purpose
data collection efforts will be undertaken only where no other data source exists, to reduce the data
collection and reporting burden placed on government and other implementing partners.
Partner-generated data on programme implementation progress, mainly from Ghana Health Service,
follows the results frameworks that are agreed with the respective partners and are derived from the
country programme results and resources matrix. Since 2015, UNICEF Ghana has deployed an electronic
programme performance monitoring tool, TrackME , to harmonize the collection, analysis and reporting
of this data from a wide range of partners, and to ensure that the programme logic between activity
implementation and achievement of outputs can be tested and validated with programme data on an
ongoing basis.
In choosing output indicators and activity trackers (low-level tracer indicators captured in TrackME), the
health and nutrition programme will focus on monitoring potential bottlenecks and barriers to the
achievement of results, in line with UNICEF s organizational approach to strengthening the equity-focus
of its programmes. Data collection is organized to capture information disaggregated by sex, location,
and other relevant dimensions as relevant. The programme will regularly and proactively reach out to
UNICEF s global, regional and country-specific knowledge sharing networks and resource persons, and
participate in other existing communities of practice, to apply lessons learnt and good practice
approaches in monitoring progress in Ghana and to deploy innovative tools that support progress
monitoring and real-time data collection where appropriate.
Outcome indicators, as indicated in the results and resources framework, will be measured using regular
national surveys, special surveys and suitable routine data systems whenever possible. Ghana has a
strong record of conducting the Multiple Indicator Cluster Survey (MICS), Demographic and Health
Survey (DHS) and Ghana Living Standards Survey (GLSS) at reliable intervals. UNICEF Ghana has
supported the Ghana MICS 2006, 2011 and is supporting MICS 2017, and has a close working
relationship with the Ghana Statistical Service to be able to adapt other surveys to capture relevant data
pertaining to the situation of children and women and lend themselves to impact monitoring, and to
provide data on SDG indicators that are household survey-based.
29
Ghana s health and nutrition sector benefits from additional, comprehensive surveys that cover a wide
range of outcome indicators relevant to the UNICEF programme, including maternal health and malaria
indicator surveys. Given the stagnating high prevalence of anaemia in Ghana, UNICEF will commission an
evaluation of micronutrient interventions in Ghana in 2020, four years after the large-scale
micronutrient survey undertaken in 2016. The evaluation will shape UNICEF Ghana s strategic direction
in focusing on interventions that are most effective in reducing anaemia prevalence.
To foster shared accountability, government and non-governmental partners are actively involved in
monitoring progress against planned results, collecting and analyzing data with UNICEF. Joint review
meetings will be held at least annually, to take stock of programme progress, assess any relevant
changes in context and environment, and decide on strategic shifts and changes in programme design
that may be necessary.
At the end of 2018 and early 2019, UNICEF Ghana will evaluate the maternal and newborn quality of
care improvement initiative and conduct an end-of-project evaluation of the WASH in health facilities
intervention. Both will contribute to organizational learning, donor accountability, and inform future
programming.
30
Annex 1a: Theory of change – Visual
Fragmented
donor-driven
programmes
Risks Assumptions
Outcome Outputs
Conditions Barriers and bottlenecks to
be addressed (identified Pathways to
change/strategie
s
Legend:
2018 -
2022
Theory
of
Change
U
NIC
EF
GH
AN
A
PA
RT
NE
RSH
IPS
Poor client tracking Limited capacity of government on child &
gender responsive communication Limited availability & accessibility to
quality health care
Disadvantaged, wealth and
geographical disparities
Weak leadership and lack of
accountability systems
Low demand for
health services
Change
Evidenced-based tools and strategies are in place
for delivery of quality care for all
Ghana health system has the necessary management
tools to support effective service delivery at national
and subnational levels
Quality disaggregated data from routine monitoring system
is available and knowledge is generated on the survival
challenges of older children (6-10 years) and adolescents
High-level advocacy, technical support and capacity-
building to support develop and test tools and systems
to improve integrated planning & budgeting, human
resources management, social accountability, budget
analysis and financing mechanisms, supply chain
a age e t (i cludi g e suri g last ile availability of essential commodities); as well as
equity-based gender sensitive emergency
preparedness and response frameworks
Advocacy, technical support and evidence-generation to support
development of tools & costed strategies, curricula update and
documentation on quality of care for health services; targeted
service delivery for immunization and other high-impact
interventions; demonstration of integration of PMTCT and
paediatric HIV into maternal, newborn and child health services;
and capacity building for child and gender responsive behavior
change communication on health and nutrition services
System strengthening for enhanced data collection and
information management capacities; evidence
generation to fill data gaps on emerging issues -
adolescents, especially adolescent girls, children 6-10
years, stigma on HIV and uptake of PMTCT services;
and advocacy to publicize health scorecards for
community engagement and social accountability
Caregivers & healthcare providers accept task shifting
and change their behaviour towards health service
clients, and clients also change their own beliefs and
Government remains committed to health
system goals, allocate sufficient resources &
has capacity to scale up initiatives
Government procures
vaccines & other essential
healthcare commodities
By 2022, more children and women access and utilize quality health services
Health facilities are equitably
distributed and accessible -
both geographically and
financially
Health facilities are staffed
with competent (skilled),
equitably distributed and
motivated health workforce
Healthcare providers
and managers are
accountable for the
quality of care provided
Quality of care standards are
applied at all levels and for
both preventive and curative
care services
The population
demands and utilizes
available healthcare
services
Health
Change
Reduction in under-five mortality rate
Low donor
investment in
health sector
31
Annex 1b: Theory of change – Visual
Fragmente
d nutrition
programm
Low donor
investment
in nutrition
sector
2018 -
2022
Theory
of
Change
UN
ICE
F G
HA
NA
P
AR
TN
ER
SH
IPS
Risks Assumptions Outcome Outputs Conditions Barriers and bottlenecks to be
addressed (identified issues) Pathways to
change/strategies
Legend:
Inadequate knowledge of
appropriate IYCF
practices
Limited capacity of government
on child & gender-responsive
communication
Limited access to quality
nutrition services, fortified foods
and nutrition information
Disadvantaged, wealth
and geographical
disparities
Low prioritization of
nutrition in the health
sector agenda
Low demand for
nutrition services
Health service providers have improved capacity to deliver
quality nutrition services at national and sub-national level
National Nutrition Policy and frameworks are aligned
with international standards and monitored annually
Stronger capacity among public and private sector
and civil society actors to promote nutritional
wellbeing of children, adolescents and women
High-level advocacy, technical support and capacity
building support for update of nutrition regulations,
standards, guidelines & policies, set up accountability
framework and adopt improved maternity protection
measures; engaging private sector and other partners in
developing strategies for domestic financing of essential
nutrition commodities and options for food fortification;
and technical assistance in forecasting and costing
commodities
Evidence generation to inform policies, advocacy, plans,
strategies and programmes; system strengthening on
development of strategy for micronutrient supplementation for
adolescent girls, integration of guidelines on micronutrients,
breastfeeding, CMAM, IYCF, etc. into pre-service and in-
service training curricula; revision & integration of quality
standards and criteria on implementation guidelines for IYCF
and micronutrient supplementation into quality of care
framework; and targeted service delivery in selected districts
Build key partnerships and technical assistance to
develop costed strategy/guidelines for promoting
recommended feeding behaviours, addressing social
norms, a tracking system to monitor implementation
and change processes; capacity building for key
implementing partners; partnerships with SUN
members on implementation of social and behaviour
change communication strategies
Caregivers & medical staff accept task shifting
& change their behaviour towards health
service clients, and that clients also change
their own beliefs and cultures
Government remains committed to
nutrition sector goals, allocate
sufficient resources
More children, adolescent girls and women of childbearing age access and utilize nutrition services, nutrient-rich foods and
supplements to improve their well-being
Change
Nutrition
Change
High quality nutrient-rich foods and
supplements are available and
affordable for all socio-economic and cultural strata of the population
Caregivers & the population
know and apply appropriate
infant and young child
feeding practices
Regulatory framework
on newborn, infant and
child nutrition in place
and enforced
Healthcare facilities have
skilled & motivated staff
who provide quality
nutrition services & care
The food industry is
engaged and commits to
relevant food fortification standards
Reduction in under-five mortality rate and all surviving
Government procures
nutrition supplements &
other essential commodities
NHIA incorporates
breastfeeding criteria to
health care facility
credentialling
Weak integration of nutrition
services in antenatal & child
welfare services
32
Annex 2: Detailed Results and Resources Framework – Health and Nutrition
Programme of cooperation between the Government of Ghana and UNICEF, 2018 – 2022
Key Results Key progress indicators, Baselines [B]
and Targets [T]
Means of
verification
Major partners,
partnership
frameworks
Indicative resources (millions of
US$)
RR OR Total
Convention on the Rights of the Child: (relevant articles of the convention)
National priority: (related Millennium Development Goals or other internationally recognized goals)
UNDAF outcome involving UNICEF: (copied verbatim from UNDAF)
Outcome indicator measuring change that includes UNICEF contribution (UNDAF outcome indicator, copied verbatim from UNDAF)
Related UNICEF Strategic Plan outcome(s): (from Health Strategy 2016-2030)
VISION: A Ghana where no child dies from a preventable cause and all children reach their full potential in health and well-being.
GOAL End preventable maternal, newborn and child deaths and promote the health and development of all children.
Impact indicators: U5 mortality rate, infant mortality rate, neonatal mortality rate, Stunting, SAM rate, Anaemia rate in U5 children, adolescent
girls and women of reproductive age.
HEALTH
OUTCOME 1. By 2022, more
children and women access
and utilize quality health
services
* includes newborns, children
under five and adolescents
especially adolescent girls, and
women of child-bearing age
focusing on pregnancy, delivery
and post-partum.
**In Ghana the Ministry of
Health utilizes these indicators
as a proxy to assess quality of
care
1. Percentage of women who had a
pregnancy in the five years preceding
the survey with at least four ANC
visits.
B: 87% (2014)
T: 90%
DHS, MICS Government (MoH,
GHS, NHIA, FDA,
HeFRA), CHAG
UN Agencies (WHO,
UNFPA, UNAIDS, WFP)
Development Partners
(DFID, USAID, JICA,
KOICA, EU, Canada)
Civil Society (Coalition
of NGOs)
4.0 14.5 18.5
2. Institutional neonatal mortality
rate**
B: 3.8 per 1000 live births (2016)
T: 2.5 per 1000 live births
DHIMS
33
3. Institutional maternal mortality
ratio**
B: 151.1 per 100,000 live births
(2016)
T: 120 per 100,000 live births
DHIMS
4. Stillbirth rate**
B: 1.7 per 1000 live births (2016)
T: 1.0 per 1000 live births
DHIMS
OUTPUT 1. Ghana health
system has the necessary
management tools to support
effective service delivery at
national and subnational
levels.
1.1 Existence of a functioning real-
time commodity management
system
B: Partial system covering few health
facilities and few commodities
T: Functional national system
covering all essential health
commodities
Reports from
Stores, Supplies
and Drugs
Management
(SSDM) of GHS
Government (MoH,
GHS, NHIA, FDA,
HeFRA), CHAG
UN Agencies (WHO,
UNFPA, UNAIDS, WFP)
Development Partners
(DFID, USAID, JICA,
KOICA, EU, Canada)
Civil Society (Coalition
of NGOs)
Private Corporate
Sector
1.5 2.1 3.6
1.2 Existence of an integrated
programme-based planning and
budgeting tool for national and
subnational levels
B: No standardised tool for
programme-based planning and
budgeting for all levels of Health
Service delivery
T: Standardised tool for programme-
based planning and budgeting for all
levels available
Reports from
the Policy,
Planning,
Monitoring and
Evaluation
Division
(PPMED) of GHS
34
OUTPUT 2. Evidenced-based
tools and strategies are in
place for the delivery of
quality care for all.
2.1 Existence of a validated maternal
and newborn quality of care model
for scale-up
B: A quality of care model being
piloted in 24 healthcare facilities in 4
districts
T: A validated quality of Care model
available
Reports from
the Family
Health Division
(FHD) of GHS
Government (MoH,
GHS, NHIA, FDA,
HeFRA), CHAG
UN Agencies (WHO,
UNFPA, UNAIDS, WFP)
Development Partners
(DFID, USAID, JICA,
KOICA, EU, Canada)
Civil Society (Coalition
of NGOs)
Private Corporate
Sector
1.8 10.4 12.2
2.2 Existence of an accountability
framework for quality healthcare
delivery
B: No accountability framework for
quality of healthcare services
T: Accountability framework for
quality of healthcare services available
Reports from
the Policy,
Planning ,
Monitoring and
Evaluation
Division
(PPMED) of
Ministry of
Health
OUTPUT 3. Quality
disaggregated data from
routine monitoring system is
available and knowledge is
generated on survival
challenges of older children (6-
3.1 Existence of a national web-based
patient management platform linked
with DHIMS
B: No nationally endorsed web-based
patient management platform
Reports from
the Policy,
Planning ,
Monitoring and
Evaluation
Division
(PPMED) of
Government (MoH,
GHS, NHIA, FDA,
HeFRA), CHAG
UN Agencies (WHO,
UNFPA, UNAIDS, WFP)
0.7 2.0 2.7
35
11 years) and adolescents
T: National web-based patient
management platform available
Ministry of
Health
Development Partners
(DFID, USAID, JICA,
KOICA, EU, Canada)
Civil Society (Coalition
of NGOs)
Private Corporate
Sector
3.2 Electronic patient management
system is available
B: No nationally endorsed system
currently in place
T: At least one district implements
the national web-based patient
management system (linked to
indicator 3.1)
District
monitoring
reports
3.3 Number of UNICEF funded
research/studies on issues around
survival and thrive for children (6-10)
and adolescents (11-19) especially
adolescent girls.
B: 0 research/studies in the 2012-
2017 CP Cycle
Children: 0
Adolescents: 0
T: 2 research/studies in the 2018-2022
CP cycle on:
Children: 1
Adolescents: 1
Research
reports/UNICEF
IMEP 2018-2022
36
3.4 Social accountability forums
consistently organized on Maternal,
Neonatal, Child, Adolescent Health
(MNCAH) issues at national level and
regional levels
B: Social accountability forums on
MNCAH issues are not organized
T: 10
National level: 5 (At least 1 per year
from 2018)
Regional level: 5 (At least 1 per year in
a UNICEF focused region)
Forum reports
at national and
regional levels
Impact indicators: U5 mortality rate, infant mortality rate, neonatal mortality rate, Stunting, SAM rate, Anaemia rate in U5 children, adolescent
girls and women of reproductive age.
NUTRITION
OUTCOME. More children,
adolescent girls and women of
childbearing age access and
utilize nutrition services,
nutrient-rich foods and
supplements to improve their
well-being
1. Children aged 0-23 months old
who were put to the breast within
one hour of birth
B: 55.6% (2014)
T: 70% (2022)
DHS Government (MoH,
GHS, NHIA, FDA,
HeFRA; MoFA, MoTI),
CHAG, NDPC
UN Agencies (WHO,
UNFPA, UNAIDS, WFP,
FAO)
Development Partners
(DFID, USAID, JICA,
KOICA, EU, Canada)
Civil Society (Coalition
of NGOs)
3.5 15.5 19.0
2. Percentage of children 6-8 months
old who are fed with iron-rich foods
B: 21.6% (2014)
T: 40%
DHS
37
3. Percentage of girls 10-19 years
taking iron supplement
B: 0%
T: 80%
Baseline and
end-line
evaluation
surveys
Private Corporate
Sector
4. Number of adolescent girls
reached with IFA supplementation
with UNICEF support (modified SP
Indicator)
B: 0
T: 285,000 girls in 4 regions
DHIMS
OUTPUT 1 (ENABLING
ENVIRONMENT). National
Nutrition policy and
frameworks are aligned with
international standards and
monitored annually
1.1. Existence of revised regulations
on breastfeeding in line with
international standards
B: Ghana Breastfeeding promotion
regulations, 2000
T: Updated regulations on Ghana
Breastfeeding promotion available
MoH Reports Government (MoH,
GHS, NHIA, FDA,
HeFRA), CHAG,
NDPC
Parliament
UN Agencies (WHO,
UNFPA, UNAIDS, WFP,
ILO)
Development Partners
(DFID, USAID, JICA,
KOICA, EU, Canada)
Civil Society (Coalition
of NGOs)
Private Corporate
0.9 1.6 2.5
1.2. Existence of key guidelines on
Micronutrient Supplementation for
children 6-23 months, adolescent
girls and women of reproductive age
B: Draft MNP Guidelines (children 6-
23mo) and IFA guidelines
Draft IFA Guidelines (adolescent girls
and women of reproductive age)
Guidelines
document
38
T: MNP Guidelines (children 6-23mo)
IFA Guidelines (adolescent girls and
women of reproductive age)
Sector
1.3. Existence of revised guidelines
on Food Fortification
B: 2007 operational guidelines on
food fortification
T: Updated operational guidelines on
food fortification available
Guidelines
document
1.4 Existence of revised guidelines on
breastfeeding and Complementary
Feeding
B: IYCF strategy 2007, Lactation
management training guidelines 2016
T: Updated IYCF strategy and
guidelines on breastfeeding and
complementary feeding available
Guidelines
document
OUTPUT 2 (SERVICE DELIVERY
& QUALITY). Health service
providers have improved
capacity to deliver quality
nutrition services at national
and sub-national level.
2.1. Proportion of districts in
targeted regions implementing IFA
Supplementation for adolescent girls
B: 0
T: 100% (91 districts)
UNICEF Annual
Reports
Government (MoH,
GHS, NHIA, FDA,
HeFRA), CHAG
UN Agencies (WHO,
UNFPA, UNAIDS, WFP)
Development Partners
1.8 11.7 13.5
39
2.2. Proportion of health facilities in
targeted districts with at least two
staff trained to provide essential
nutrition services (counselling on
maternal nutrition, IYCF, CMAM,
micronutrients) as per national
standards
B: 50%
T: 80 %
UNICEF Annual
Reports
( USAID, JICA, KOICA,
Canada)
Civil Society (Coalition
of NGOs)
Private Corporate
Sector (Food
Processing Companies)
2.3. Proportion of health facilities in
targeted districts that benefited from
at least three supportive supervision
visits on nutrition services in the past
year
B: 50%
T: 80%
UNICEF Annual
Reports
OUTPUT 3 (DEMAND
GENERATION). Stronger
capacity among public and
private sector and civil society
actors to promote nutritional
wellbeing of children,
adolescents and women.
3.1. Existence of a multisectoral SBCC
strategy on nutrition
B: None
T: Yes
Strategy
Document
Government (MoH,
GHS, NHIA, FDA,
HeFRA), CHAG
UN Agencies (WHO,
UNFPA, UNAIDS, WFP)
Development Partners
(DFID, USAID, JICA,
KOICA, EU, Canada)
Civil Society (Coalition
of NGOs)
0.8 2.2 3.0
3.2. Proportion of districts in target
regions implementing the SBCC strategy
on nutrition with UNICEF support
B: None
T: 100%
UNICEF Annual
Reports
40
Private Corporate
Sector 3.3. Number of studies, evaluations,
researches produced by UNICEF to
increase the evidence base in relation
to social and behaviour change in
infant and young child feeding and
iron supplementation target areas
B: 0
T: 2
Country Office
IMEP
Total Health and Nutrition 7.5 30.0 37.5
41