CHA 2009 C0NFERENCE HELD IN KAMPALA UGANADA CHAG HRH STAUDY REPORT PRESENTED BY PHILIBERT KANKYE BERNARD C. BOTWE.

CHA 2009 C0NFERENCE HELD CHA 2009 C0NFERENCE HELD IN KAMPALA UGANADA IN KAMPALA UGANADA

CHAG HRH STAUDY REPORT CHAG HRH STAUDY REPORT PRESENTED PRESENTED

BYBY

PHILIBERT KANKYEPHILIBERT KANKYE

BERNARD C. BOTWEBERNARD C. BOTWE

TITLE OF STUDYTITLE OF STUDY• An Assessment of the Impact of An Assessment of the Impact of

Government Human Resources for Government Human Resources for Health (HRH) Policies on Network Health (HRH) Policies on Network Members of the Christian Health Members of the Christian Health Association of GhanaAssociation of Ghana

• February 2008February 2008

• Philibert Kankye, CHAGPhilibert Kankye, CHAG• Peter Yeboah, CHAGPeter Yeboah, CHAG• Bernard C. Botwe, CHAGBernard C. Botwe, CHAG

OUTLINE OF PRESENTATIONOUTLINE OF PRESENTATION

• INTRODUCTIONINTRODUCTION• BACKGROUND OF STUDYBACKGROUND OF STUDY• PROBLEM STATEMENTPROBLEM STATEMENT• STUDY OBJECTIVESSTUDY OBJECTIVES• METHODOLOGYMETHODOLOGY• POLICY OBJECTIVESPOLICY OBJECTIVES• POLICIES AND STRATEGIESPOLICIES AND STRATEGIES• POLICY IMPLEMENTATIONPOLICY IMPLEMENTATION• FINDINGSFINDINGS• CONCLUSIONSCONCLUSIONS• RECOMMENDATIONSRECOMMENDATIONS• LESSONSLESSONS• NEXT STEPSNEXT STEPS

INTRODUCTIONINTRODUCTION• The Ministry of Health (MOH) and Christian Health The Ministry of Health (MOH) and Christian Health

Association of Ghana (CHAG) have maintained Association of Ghana (CHAG) have maintained operational relationships since the establishment of operational relationships since the establishment of CHAG in 1967 CHAG in 1967

• In 1975 the government commissioned Adibo In 1975 the government commissioned Adibo Committee to study the role of mission health facilities Committee to study the role of mission health facilities in Ghana. in Ghana.

• The Committee recommended that Government The Committee recommended that Government should sun-vent CHAG Facilities to enable them to pay should sun-vent CHAG Facilities to enable them to pay salaries.salaries.

• This recommendation led to a strengthened This recommendation led to a strengthened relationship between the government and CHAG. relationship between the government and CHAG.

INTRODUCTION CONT.INTRODUCTION CONT.• This relationship was further evidenced This relationship was further evidenced

in the signing of a Memorandum of in the signing of a Memorandum of Understanding (MOU) and Understanding (MOU) and Administrative Instructions (AI) in Administrative Instructions (AI) in 2003. The objectives of which are: 2003. The objectives of which are:

– To provide a framework to formalize the To provide a framework to formalize the working arrangement between the parties working arrangement between the parties

– To ensure accountability and transparency To ensure accountability and transparency in the working relationship.in the working relationship.

INTRODUCTION CONT.INTRODUCTION CONT.

• In the MOU,In the MOU,

• CHAG agreed to adopt the HRH policies CHAG agreed to adopt the HRH policies outlined by the MOH and to submit its outlined by the MOH and to submit its human resource needs to the MOH for human resource needs to the MOH for support. support.

• For its part, For its part,

• the MOH agreed to facilitate the equitable the MOH agreed to facilitate the equitable distribution of health professionals among distribution of health professionals among its agencies including CHAG.its agencies including CHAG.

INTRODUCTION CONT.INTRODUCTION CONT.• Health professionals from training Health professionals from training

institutions shall be proportionately institutions shall be proportionately allocated to CHAG institutions through allocated to CHAG institutions through negotiation or based on needs.negotiation or based on needs.

• Staff placement and deployment in Staff placement and deployment in CHAG institutions shall be in CHAG institutions shall be in accordance with MOH guidelines and accordance with MOH guidelines and norms.norms.

• CHAG training institutions shall CHAG training institutions shall receive support from the MOH like all receive support from the MOH like all MOH training institutions.MOH training institutions.

INTRODUCTION CONT.INTRODUCTION CONT.

• The MOH shall provide fellowships to The MOH shall provide fellowships to CHAG in line with the approved CHAG in line with the approved Human Resource plans and budgets Human Resource plans and budgets

BACKGROUND OF STUDYBACKGROUND OF STUDY

• In 2002, the MOH launched an HRH In 2002, the MOH launched an HRH policy intended to facilitate the policy intended to facilitate the development and retention of a development and retention of a highly trained and motivated highly trained and motivated workforce with skills appropriate to workforce with skills appropriate to implement the health sector’s implement the health sector’s Program of Work (POW). Program of Work (POW).

BACKGROUND OF STUDY BACKGROUND OF STUDY CONT.CONT.

• Christian Health Association of Ghana Christian Health Association of Ghana (CHAG), in the broader scheme of (CHAG), in the broader scheme of things, subscribed to both the HRH things, subscribed to both the HRH policy and the five-year POW as policy and the five-year POW as covenant in the Memorandum of covenant in the Memorandum of Understanding (MOU) and Understanding (MOU) and Administrative Instructions (AI).Administrative Instructions (AI).

• The implementation of the policy The implementation of the policy reached its final year in 2006.reached its final year in 2006.

BACKGROUND OF STUDY BACKGROUND OF STUDY CONT.CONT.

• As a major stakeholder in the health sector, As a major stakeholder in the health sector, CHAG conducted this study to assess the CHAG conducted this study to assess the extent to which the policy impacted the extent to which the policy impacted the health service delivery of its network health service delivery of its network members. members.

• The outcome of the study will be used to The outcome of the study will be used to guide the development of future HR policy guide the development of future HR policy options and to strengthen CHAG’s capacity options and to strengthen CHAG’s capacity to remain a key partner in the health to remain a key partner in the health service delivery throughout the country.service delivery throughout the country.

PROBLEM STATEMENTPROBLEM STATEMENT

• The health sector reform initiatives in The health sector reform initiatives in Ghana recognized HRH as the most Ghana recognized HRH as the most crucial aspect of the delivery of crucial aspect of the delivery of efficient and cost effective health careefficient and cost effective health care

• The reforms also addressed the issue The reforms also addressed the issue of increased participation of private of increased participation of private providers in health care delivery from providers in health care delivery from 35% to 50% by 2010, 35% to 50% by 2010,

PROBLEMPROBLEM STATEMENT STATEMENT• The operations of CHAG network members The operations of CHAG network members

continue to be affected by the HRH policy continue to be affected by the HRH policy direction of the MOH and its implementing direction of the MOH and its implementing agency, Ghana Health Service (GHS).agency, Ghana Health Service (GHS).

• HR inequities still exist between GHS and HR inequities still exist between GHS and CHAG member institutions at all levels. CHAG member institutions at all levels.

This phenomenon is further compounded by This phenomenon is further compounded by a number of factors.a number of factors.

Internal brain drain:Internal brain drain: • CHAG staff continue to resign their post to CHAG staff continue to resign their post to

join GHS. join GHS. Uneven staff distribution:Uneven staff distribution:

Newly qualified and existing skilled Newly qualified and existing skilled professionals are also distributed to the professionals are also distributed to the disadvantage of the CHAG member disadvantage of the CHAG member institutionsinstitutions

PROBLEM STATEMENTPROBLEM STATEMENT

Career development:Career development: • the exclusion of CHAG network members where the exclusion of CHAG network members where

opportunities do exist.opportunities do exist.

Policy implementation gaps:Policy implementation gaps: • CHAG in its policy document, CHAG continues to be CHAG in its policy document, CHAG continues to be

adversely affected by implementation structures and adversely affected by implementation structures and processes. processes.

Latent competition:Latent competition: Underlying the above developments is the seemingly hostile Underlying the above developments is the seemingly hostile attitude of public health professionals toward those in attitude of public health professionals toward those in private sector, especially CHAG.private sector, especially CHAG.

There are serious challenges and inequality gaps in HRH that There are serious challenges and inequality gaps in HRH that work against CHAG.work against CHAG.

STUDY OBJECTIVESSTUDY OBJECTIVES

• To assess MOH HRH policy/program To assess MOH HRH policy/program implementation and impact on implementation and impact on CHAG’s HR capacity.CHAG’s HR capacity.

• To provide HR policy options to To provide HR policy options to strengthen CHAG’s capacity to strengthen CHAG’s capacity to engage the MOH, stakeholders and engage the MOH, stakeholders and other partners in HR development and other partners in HR development and maintenance.maintenance.

METHODOLOGYMETHODOLOGY

• Document Reviews - from published Document Reviews - from published and unpublished sources. and unpublished sources.

• Primary data was collected with the Primary data was collected with the use of questionnaires, interviews and use of questionnaires, interviews and focus group discussions with key focus group discussions with key informants.informants.

GOVERNMENT HRH POLICY GOVERNMENT HRH POLICY OBJECTIVESOBJECTIVESThe objectives of the HRH policy are:The objectives of the HRH policy are:

• To provide a strategic basis for human resource To provide a strategic basis for human resource development, deployment and compensationdevelopment, deployment and compensation

• To ensure coherence between national/MOH policies To ensure coherence between national/MOH policies and HR policies and strategiesand HR policies and strategies

• To ensure improved performance of the health sector To ensure improved performance of the health sector workforceworkforce

• To depict the extent and impact of the brain drain on To depict the extent and impact of the brain drain on the health sector and the country as a whole, and the health sector and the country as a whole, and strategies to mitigate these effects.strategies to mitigate these effects.

HRH POLICIES AND HRH POLICIES AND STRATEGIESSTRATEGIES• Policy 1: Policy 1: The MOH will ensure high The MOH will ensure high

quality training for all categories of quality training for all categories of staff. Strategies include:staff. Strategies include:

• Continuing to train increasing numbers Continuing to train increasing numbers of high quality professionalsof high quality professionals

• Restructuring training programsRestructuring training programs• Coordinating in-service training Coordinating in-service training

programsprograms• Coordinating fellowships to ensure that Coordinating fellowships to ensure that

awards are based on national needs, awards are based on national needs, and to ensure equity in the distribution and to ensure equity in the distribution of awards.of awards.

Policy 2: Policy 2: The MOH will ensure The MOH will ensure equitable distribution of health equitable distribution of health professionals to benefit deprived professionals to benefit deprived areas.areas.Strategies:Strategies:• Paying rural allowance (30% and Paying rural allowance (30% and

50% of basic salary to doctors and 50% of basic salary to doctors and other staff respectively) to rural area other staff respectively) to rural area health staffhealth staff

• Providing staff with viable housing Providing staff with viable housing ownership schemesownership schemes

• Encouraging mission/NGO hospitals Encouraging mission/NGO hospitals to run more satellite clinics in the to run more satellite clinics in the rural areas where they operate.rural areas where they operate.

Policy 3:Policy 3: The MOH will ensure The MOH will ensure

retention of trained staff.retention of trained staff.

StrategiesStrategies::• Providing career development avenues by increasing Providing career development avenues by increasing

opportunities for further training, attendance of opportunities for further training, attendance of conferences and updates; providing access to conferences and updates; providing access to fellowships for eligible staff of all categories at all fellowships for eligible staff of all categories at all levels; and encouraging, supporting and recognizing levels; and encouraging, supporting and recognizing essential non-clinical programs.essential non-clinical programs.

• Reviewing salaries of all health staff by consolidating Reviewing salaries of all health staff by consolidating basic salaries and ADHA [Additional Duty Hours basic salaries and ADHA [Additional Duty Hours Allowance] with an appropriate top-upAllowance] with an appropriate top-up

• Providing non-salary incentives by providing saloon Providing non-salary incentives by providing saloon cars/year for health staff; and providing housing cars/year for health staff; and providing housing units/year to health sector workers.units/year to health sector workers.

Policy 4: Policy 4: The MOH will ensure The MOH will ensure efficiency in human resource efficiency in human resource management.management. • Developing and implementing a continuous Developing and implementing a continuous

performance management system to replace the performance management system to replace the current appraisal systemcurrent appraisal system

• Decentralizing HR management to teaching Decentralizing HR management to teaching hospitals, regional and district directorate levels hospitals, regional and district directorate levels with clear lines of responsibility and authoritywith clear lines of responsibility and authority

• Promoting interview at agency level except for Promoting interview at agency level except for very senior staffvery senior staff

• Training and employing a new cadre of staff as Training and employing a new cadre of staff as health care assistants to take care of non-health care assistants to take care of non-technical dutiestechnical duties

• Training and employing nurse prescribers and Training and employing nurse prescribers and dispensary technologists.dispensary technologists.

Policy 5: Policy 5: The MOH will foster close The MOH will foster close partnerships with other MDAs, private and partnerships with other MDAs, private and nongovernmental providers to improve nongovernmental providers to improve

access to health care.access to health care. StrategiesStrategies

• Encouraging and supporting Encouraging and supporting legitimate institutions to train health legitimate institutions to train health professionalsprofessionals

• Providing human resourcesProviding human resources

• Providing interest-free vehicles for Providing interest-free vehicles for institutional use.institutional use.

POLICY IMPLEMENTATIONPOLICY IMPLEMENTATION

• The MOH developed the policy to run The MOH developed the policy to run concurrently with the second five-concurrently with the second five-year POW, spanning 2002-2006. year POW, spanning 2002-2006.

• There was, however, no action planThere was, however, no action plan

• No system of monitoring and No system of monitoring and evaluation to guide the evaluation to guide the implementation. implementation.

• Nevertheless, the policy was Nevertheless, the policy was implemented somehow implemented somehow

ACHIEVEMNTSACHIEVEMNTS• There were minimal achievements in the There were minimal achievements in the

implementation of the HR policy. implementation of the HR policy. • These include the following:These include the following:

• Training of health professionals:Training of health professionals: • There has been significant expansion of all existing There has been significant expansion of all existing

health training institutions to accommodate increase health training institutions to accommodate increase intake of students.intake of students.

• Twenty-eight new training institutions were set upTwenty-eight new training institutions were set up

• 21 of these by the MOH, six by the private sector and 21 of these by the MOH, six by the private sector and one by CHAG. one by CHAG.

• These new training institutions include the Ghana These new training institutions include the Ghana College of Physicians and Surgeons College of Physicians and Surgeons

ACHIEVEMENTS CONT.ACHIEVEMENTS CONT.

• New programs for direct entry into New programs for direct entry into midwifery, health assistants (clinical) midwifery, health assistants (clinical) and a diploma in community health and a diploma in community health nursing were introduced. This period nursing were introduced. This period of expansion resulted in an increase of expansion resulted in an increase of 50% in admissions into the Health of 50% in admissions into the Health Training Institutions and a 20% Training Institutions and a 20% increase in intake into all the increase in intake into all the universities.universities.

ACHIEVEMENTS CONT.ACHIEVEMENTS CONT.

• HR retention measures.HR retention measures. A number of A number of schemes were simultaneously implemented schemes were simultaneously implemented with the ultimate objective of curbing the with the ultimate objective of curbing the brain drain. These include:brain drain. These include:

• Vehicle Hire Purchase scheme (VHPSVehicle Hire Purchase scheme (VHPS): ): This scheme was instituted to provide This scheme was instituted to provide affordable private ownership of vehicles for affordable private ownership of vehicles for Health Staff by monthly deductions over a Health Staff by monthly deductions over a longer period of timelonger period of time. . Thus, the scheme led Thus, the scheme led to the procurement and distribution of 1,082 to the procurement and distribution of 1,082 saloon cars for health workers at all levels saloon cars for health workers at all levels and for categories of staff.and for categories of staff.

ACHIEVEMENTS CONT.ACHIEVEMENTS CONT.• Additional Duty Hours Allowance (ADHAAdditional Duty Hours Allowance (ADHA):):

Subsequent to Health Workers agitations for better Subsequent to Health Workers agitations for better remuneration packages, the MOH instituted the ADHA remuneration packages, the MOH instituted the ADHA policy in 1999 with 3 objectives:policy in 1999 with 3 objectives:

• To recognize and remunerate health workers for any To recognize and remunerate health workers for any hours performed over and above the normal 8 hour per hours performed over and above the normal 8 hour per day or 40 hours per week respectively. day or 40 hours per week respectively.

• To ensure a 24-hour cover by all health delivery points To ensure a 24-hour cover by all health delivery points in the country. in the country.

• To motivate health workers for higher performance. To motivate health workers for higher performance. This was expected to restore and sustain public This was expected to restore and sustain public confidence in the health sector’s capacity for quality confidence in the health sector’s capacity for quality health service delivery.The massive enhancement of health service delivery.The massive enhancement of salaries of health workers with the consolidation of salaries of health workers with the consolidation of ADHA into the basic salary with a top-upADHA into the basic salary with a top-up

ACHIEVEMENTS CONT.ACHIEVEMENTS CONT.

• Deprived Area Incentives Allowance (DAIA): Deprived Area Incentives Allowance (DAIA): • The DAIAThe DAIA was intended to target critical health staff was intended to target critical health staff

(Doctors, Nurses/Midwives, Pharmacists) working in (Doctors, Nurses/Midwives, Pharmacists) working in disadvantaged and underprivileged areas of the disadvantaged and underprivileged areas of the country. The designation of deprived area status country. The designation of deprived area status was the exclusive responsibility of the Ministry of was the exclusive responsibility of the Ministry of Local Government that had the added duty of Local Government that had the added duty of administering the DAIA to eligible health staff.administering the DAIA to eligible health staff.

• Deployment strategyDeployment strategy: : • A ministerial committee for posting of health A ministerial committee for posting of health

professionals was formed to ensure the equitable professionals was formed to ensure the equitable distribution of staff among providers including distribution of staff among providers including CHAG. Also, a number of policy guidelines were CHAG. Also, a number of policy guidelines were developed to guide the management of the developed to guide the management of the existing stock of staff at all levels.existing stock of staff at all levels.

FINDINGSFINDINGS• POSITIVE IMPACTPOSITIVE IMPACT

• High staff retention ratesHigh staff retention rates

• Increased workforce productivity in-Increased workforce productivity in-spite of low staff numbersspite of low staff numbers

• Increased motivation as a result of Increased motivation as a result of enhanced salariesenhanced salaries

• Increased professional and technical Increased professional and technical skills for service deliveryskills for service delivery

FINDINGS CONT.FINDINGS CONT.

• POSITIVE IMPACT POSITIVE IMPACT

• Increased infrastructural investment Increased infrastructural investment in nursing training schoolsin nursing training schools

• Increased production of nurses to fill Increased production of nurses to fill the vacancies the vacancies

• and increase in the ratio of and increase in the ratio of professional to nonprofessional professional to nonprofessional nursing staff in hospitals.nursing staff in hospitals.

FINDINGS CONT.FINDINGS CONT.

• ADVERSE IMPACTADVERSE IMPACT

• Perverse incentivesPerverse incentives to overstay at to overstay at workplace due to pecuniary gains workplace due to pecuniary gains other than service delivery to other than service delivery to patients. patients.

• Low morale of some staff due to Low morale of some staff due to inequitable allocation of the HR inequitable allocation of the HR incentive packagesincentive packages

• enabled its staff to receive more enabled its staff to receive more money.money.

FINDINGS CONT.FINDINGS CONT.

• ADVERSE IMPACTADVERSE IMPACT

• Apathy in the case of some staff who Apathy in the case of some staff who felt marginalized.felt marginalized.

• Internal migration of CHAG staff to Internal migration of CHAG staff to GHS due its relaxed implementation GHS due its relaxed implementation of the ADHA, whichof the ADHA, which

CONCLUSIONSCONCLUSIONS

• QUOTES FROM RESPONDENTSQUOTES FROM RESPONDENTS

• ““It tended to lower morale because It tended to lower morale because of the inequities in quantum size of the inequities in quantum size between what CHAG staff got and between what CHAG staff got and staff in Ghana Health Service.staff in Ghana Health Service.” ”

• ““It bred mistrust, enmity as a result It bred mistrust, enmity as a result of its inbuilt exclusionist principle at of its inbuilt exclusionist principle at the facility level initially.”the facility level initially.”

CONCLUSIONS CONT.CONCLUSIONS CONT.

• ““The policy came to kill the spirit The policy came to kill the spirit of sacrifice in the mission of sacrifice in the mission institutions and we are now institutions and we are now struggling to resuscitate it.” struggling to resuscitate it.”

•came “came “to disturb the peace in the to disturb the peace in the mission hospital environment.”mission hospital environment.”

RECOMMENDATIONSRECOMMENDATIONS• CHAG should develop a common HRH CHAG should develop a common HRH

strategy for adoption by all members.strategy for adoption by all members.

• CHAG should adopt an HR transfer policy CHAG should adopt an HR transfer policy that will institutionalize or facilitate staff that will institutionalize or facilitate staff transfers and deployment amongst CMIs transfers and deployment amongst CMIs and across denominational lines. This and across denominational lines. This would ensure equitable allocation and would ensure equitable allocation and rational utilization of scarce human rational utilization of scarce human resources within the CHAG fraternity.resources within the CHAG fraternity.

• CHAG should develop a separate CHAG should develop a separate incentive package for its network incentive package for its network members that will be equitable and members that will be equitable and linked to performance.linked to performance.

RECOMMENDATIONS CONT.RECOMMENDATIONS CONT.

• CHAG Staff that return from further CHAG Staff that return from further training and who do not fit well in their training and who do not fit well in their old places of work should be deployed old places of work should be deployed within the CHAG instead of losing them within the CHAG instead of losing them to either Ghana Health Service or other to either Ghana Health Service or other organizations.organizations.

• CHAs should analyze the impact of CHAs should analyze the impact of government HR policies on thier staff, government HR policies on thier staff, evolve own HR strategies and evolve own HR strategies and implementation plans, and gather and implementation plans, and gather and use evidence for engagement with their use evidence for engagement with their Ministries of Health.Ministries of Health.

LESSIONS FOR CHAGLESSIONS FOR CHAG• CHAG was unable to maximize the CHAG was unable to maximize the

opportunities created by the MOH’s HRH opportunities created by the MOH’s HRH policy for lack of effective participation.policy for lack of effective participation.

• CHAG’s commitment to the MOU in CHAG’s commitment to the MOU in relation to HR made it possible for CHAG relation to HR made it possible for CHAG network members to benefit from the network members to benefit from the policy, especially with regardspolicy, especially with regards– the equitable distribution of the newly trained the equitable distribution of the newly trained

health professionalshealth professionals– incentive packages to motivate and the ability incentive packages to motivate and the ability

to retain health staff to retain health staff – the infrastructural expansion of their nurses’ the infrastructural expansion of their nurses’

training colleges training colleges

LESSIONS FOR CHAG CONT.LESSIONS FOR CHAG CONT.

• Improved relationship between CHAG Improved relationship between CHAG and the MOH in the area of HR and the MOH in the area of HR productionproduction

• CHAG needs to develop its own HR CHAG needs to develop its own HR policy and strategy document that policy and strategy document that would feed into the national policy would feed into the national policy and strategic document in future and strategic document in future

LESSIONS FOR CHAsLESSIONS FOR CHAs• The experience of CHAG indicates that The experience of CHAG indicates that • Government HR policies directly affect Government HR policies directly affect

Christian Health Associations in Africa (CHAs). Christian Health Associations in Africa (CHAs).

• There is perennial problem of inequitable There is perennial problem of inequitable allocation of resources to the disfavour of allocation of resources to the disfavour of CHAs.CHAs.

• Staff working with CHAs often feel Staff working with CHAs often feel marginalized when their counterparts in marginalized when their counterparts in government receive preferential treatments, government receive preferential treatments, incentives and advantages that are not incentives and advantages that are not readily available at CHAs facilities. readily available at CHAs facilities.

LESSIONS FOR CHAsLESSIONS FOR CHAs

• Given the insightful preliminary findings Given the insightful preliminary findings of this study, CHAs are highly of this study, CHAs are highly encouraged to conduct a similar study encouraged to conduct a similar study into the impact of government policies into the impact of government policies on their network members. It would on their network members. It would enable them to identify key issues enable them to identify key issues around which they engage their around which they engage their respective Ministries of Health in a respective Ministries of Health in a constructive dialogue to find pragmatic constructive dialogue to find pragmatic solutions to HR challenges in their solutions to HR challenges in their countries and throughout Africa. countries and throughout Africa.

ACKNOWLEDGEMENTACKNOWLEDGEMENT• CHAG is very grateful to the following:CHAG is very grateful to the following:

– Charles Franzen, andCharles Franzen, and– Craig Hafner, of IMA World Health,Craig Hafner, of IMA World Health,

for failitaing the funding of the research; for failitaing the funding of the research;

– Capacity Project andCapacity Project and– USAID for financing the studyUSAID for financing the study

– The heads of CHAG Institutions for participating The heads of CHAG Institutions for participating in the rearchin the rearch

– The staff of CHAG Secretariat for assisting in The staff of CHAG Secretariat for assisting in the retrieval of relevant documentsthe retrieval of relevant documents

ACKNOWLEDGEMENTACKNOWLEDGEMENT

• BIG THANKS TO MIKE OF THE CHA BIG THANKS TO MIKE OF THE CHA PLATFORM FOR HELPING ME OUT PLATFORM FOR HELPING ME OUT LAST NIGHT.LAST NIGHT.

• THIS PRESENTATION WOULD NOT THIS PRESENTATION WOULD NOT HAVE BEEN POSSIBLE WITHOUT HIMHAVE BEEN POSSIBLE WITHOUT HIM

• THE END!!!THE END!!!

• THANKSTHANKS

• YE DA MO ASEYE DA MO ASE

• BARKA YAGABARKA YAGA

• ASANTE SANAASANTE SANA

• MERCIMERCI