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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;

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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.

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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.

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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

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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