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IMCI DOCUMENTATION: Experiences, Progress and Lessons Learnt

Ghana, May 2004


Kyei-Faried S.

For WHO Ghana Office

TABLE OF CONTENTS
Section

Page
Table of Contents...1 List of Abbreviations.2 List of Annexes...3 List of tables3 Acknowledgement.3 Executive summary. .4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Introduction..5 Situation of Children and women...8 Introduction of the IMCI Strategy in the Country..........................10 Introduction of community IMCI...12 Capacity Development & Implementation of IMCI13 Motivation of Community resource persons..................13 Policies on IMCI15 Programme reviews16 Partnerships analysis and linkages16 Changes and Impact Demonstrated...18 Sustainability and scaling up...20 Supervision mechanisms..22 Challenges, constraints and solutions .24 Best Practices and lessons learned...25 Lessons learned...25 Next steps, conclusions and recommendations......................26 Conclusion.27 Recommendations..27 Annexes28

LIST OF ABBREVIATIONS
ANC AIDS AR ARI BCG C-IMCI CCGP CHO CBS CBA CBGP CD COMM CHPS CORP CHEST DA DHMT ER EPI FP GAR GES GHS GDHS HE-HA-HO HIV IDSR IMCI ITN NGO NR OPD OPV POW2 PRA PH QA RBM SWAp TL TA VR UER Antenatal clinic Acquired immune deficiency syndrome Ashanti Region Upper respiratory infection Tuberculosis vaccine Community component of integrated management of childhood illness Community child growth promoter Community health officer Community based surveillance Community based agent Community based growth promotion Community development Community Community health planning and service Community Resource person Community health education tool District Assembly District health management team Eastern Region Expanded programme on immunization Family planning Greater Accra Region Ghana Education service Ghana Health services Ghana demographic and health survey Healthier happier home Human immune deficiency virus Integrated diseases surveillance and response Integrated management of childhood illness Insecticide treated nurse Nongovernmental organization Northern Region Out patient Department Oral polio vaccine Programme of work (Phase2) Participatory rapid appraisal Public health Quality assurance Roll back malaria Sector wide approach Traditional leader Traditional authority Volta Region Upper East Region

LIST OF ANNEXES

1.01: 11.01: 11.01: 12.01: 16.01: 18.01: A:

List of key organizations and individuals contacted Cost of IMCI Implementation UNICEF IMCI Expenses Key findings and recommendations of the clinical care review Sample of IMCI strategic plan for Ghana, 2002-2006 Trend of Sector wide performance indicators, 2001-2003 IMCI Documentation: Ghana Summary Report

LIST OF TABLES

2.01: 2.02: 5.01: 5.02: 6.01: 9.01: 12.01: 12.02:

Malnutrition rates in children under-5 years ANC, delivery and HIV Seroprevalence rates Coverage of IMCI case management implementation Trained IMCI resource persons CORPs trained in the pilot districts and their roles List of stakeholders and their focus Health workers followed up after training and districts supervised QA: Results of health facilities charts review

Acknowledgements I wish to express my gratitude to WHO Ghana Office for its confidence in appointing me to undertake this first ever IMCI Documentation in Ghana. I am very much indebted to all the Pilot Districts Health Directors and their Teams, the Regional Health Directorates and the Development Partners for the useful information they provided and the time they spent with me during the interviews. I am also very grateful to all those, whose constructive comments and valuable inputs on the draft report have been used to make this report better, especially Dr. B.Manyame, the external consultant. Dr. Victor Ankrah, UNICEF Project Officer, Health, provided a lot of useful information when critically needed and I am grateful to him. I say Thank you to the external consultant whose support has been invaluable. Of special mention is Dr. Mrs. Isabella Sagoe-Moses, the Child Health Coordinator, Ghana Health Service, and the National Focal person fro IMCI whose regular contact with partners difficult to reach, provided considerable amount of the information required for the timely completion of the assignment.

EXECUTIVE SUMMARY
IMCI documentation was carried out in the months of April 2004 under the auspices of WHO. It covered 3 of the initial 4 pilot districts and at the national level. The Terms of Reference were to document the implementation of the IMCI strategy, the process of scaling and identify best practices in IMCI implementation. Using a documentation framework provided by WHO, data were gathered from the national level and the three IMCI pilot districts; Atwima District in the Ashanti Region, Tolon Kumbungu in the Northern region and Manya Krobo in the Eastern region. Contacts were made with the Ghana Health Service, BASICS, UNICEF and WHO. Key informant interviews were conducted and where necessary focus group discussions were held with the DHMTs. Reports, reporting forms and supervisory checklists were reviewed and in some cases data verification was done. Overview of the Situation of Children and Women: Ghana has 10 regions and 110 districts. The 2003 projected population is 21 million. The pilot districts have populations ranging from 144,000 to 262,000. Women in their child bearing age accounts for 23% of the population and children U5, 18%. There are 2,173 health facilities, 1207 doctors and 8123 nurses. The population doctor ratio is 20,500:1 and the population nurse ratio is 1800:1. The proportion of the population who can reach a health facility in 30 minutes is 58%.The 2003 OPD attendance was 1,0551,000 (OPD utilization per capita of 0.5). Child utilization as a proportion of total utilization was 15%. The total admissions were 598,774; the admission rate was 28.4/1000pop. Malaria, Diarrhoea, Anaemia, Cough or cold, and pneumonia are the 5 top childhood illnesses in all the districts with under five malaria case fatality rate of 1.5%. Children under five who sleep under ITN are 3.5%1. Percentage tracer drug availability is 70%. The national median HIV seroprevalence among pregnant women has risen from 3.4% in 2002 to 3.6% in 2003. Stunting is 26%, underweight 25% and wasting 10%. Measles coverage is 83.2% and pentavalent vaccine 76.4%. ANC registrants coverage is 91.9%3 at 2+ visits of 20% and 3% average visits per client. Supervised deliveries rate is 47.1%3. Infant mortality, child mortality and maternal mortality rates are respectively 64/1000, 111/1000 and 214/100000. Ghana started IMCI in 1998 and by 2000 all the districts had started. Currently, 33 Districts are implementing IMCI. Community IMCI is implemented in 38 districts and 145 subdistricts. Ghana has a child health policy and a programme of work (POW2) that give priority to IMCI. A national IMCI strategic plan has been drawn. There is IMCI national focal person and a working group and each pilot district has IMCI focal persons and teams with women constituting 57% to 100%. Implementation of IMCI is multisectoral and the stakeholders are part of steering, adaptation, implementation and planning committees. In 2000, C-IMCI implementation started. Almost all subdistricts in the pilot districts are on board. These districts have other community based programmes. At the onset, key household and family practices were gathered as part of the baseline studies that were used to adapt the generic WHO feeding recommendations. In addition the IMCI findings have been used to edit the CHEST Kit, Safemotherhood Communication Strategy, EPI Communication Strategy, and Anaemia Communication Strategy. Capacity for IMCI is being built at all levels though not sufficient. All the pilot districts have case management facilitators and C-IMCI facilitators. At the national level a total of 90 case management and 23 CBGP facilitators are documented. 127 first level staff have been trained in C-IMCI. CARE, PLAN, PCI and UNICEF are the key supporting agencies. Over 1322 community resource persons have been trained in the 3 pilot districts and are located in 104 subdistricts. Several motivational strategies are in place in all the districts to ensure continuous involvement of community members in C-IMCI and sustainability. The work of CBGPs is guided by policies and guidelines. The gender distribution of CORPS is determined by the gender literacy distribution in the community. Policies and guidelines are in place to support linkages of community activities with health care providers Several review processes were identified. At the National level the steering committee meets quarterly. Quarterly community durbars, sub-district, district and regional performance review meetings were taking place. Several partners are contributing to IMCI planning and implementation in different geographic locations. UNICEF support to the northern sector is pro-poor in focus. Free supervised deliveries, ANC and under five exemptions are in place in all ten regions. Programs are linked under the IMCI working

group. The Regional and District health management teams also work to link programme. Under the CHPS strategy, service delivery is integrated. There are demonstrable changes as a result of IMCI implementation that relate to service structure and organization, home and family practices, case management and distribution of health goods at community level. Scaling up of both IMCI and CHPS are planned and being executed. Districts are encouraged and pilot districts have budget lines for Malaria, diarrhea and nutritional control measures; some very explicit on IMCI and CBGP training and supervision. Curriculum revision and Pre-service training has started and is ongoing. The enabling factors for scaling up include partners commitment, Child Health Policy, CHPS draft policy, the priorities in the POW 2002-2007, the human resource, leadership and enthusiasm of health training institutions and the UNICEF best practice.. Supervision after follow up is decentralized to Regions and districts. All trained health workers have received follow up visit. A monitoring mechanism exists as part of PH support supervision to regions, districts and subdistricts within which IMCI supervision is integrated. IMCI implementation is confronted with a few problems and many challenges such as the increasing demand for scaling up, difficulty in getting facilitators released, high attrition rate among facilitators, delay in funds release and weak documentation. Measures to address some of these include encouraging local funding for community based activities, developing the full compliment of facilitators and decentralizing case management training to regions, introducing IMCI into pre-service training and increasing advocacy for increased resource mobilization. There are significant Best Practices. These include adopting different entry points for C-IMCI, decentralizing case management training, regional initiative to integrate IMCI classification into HIS, concentrating resources to underserved regions in C-IMCI (UNICEF), early involvement of regional level senior managers as facilitators and course directors and the use of local initiatives to motivate CORPs are among the best practices in place. Several lessons have been learnt, both in IMCI and in C-IMCI. They included the need to use a variety of practicing health workers as facilitators and practicing doctors as clinical instructors. Other lessons are that shortening the case management course for first level staff will compromise the quality and practice; linking up with other programmes helps in judicious use of scare resources; building on existing interventions make things work and identifying each partners comparative strength is very important in moving things forward. Next steps and recommendations: The programme is to continue with the arrangements to expand to many districts, speed up the process of incorporating IMCI into pre-service training curricular and include private providers in IMCI case mgt among others. District assemblies should be encouraged to support C-IMCI initiatives. National and Regional fora should be created for IMCI experiences to be shared, including website as is available for CBGP. The documentation process should be adopted to be carried out at all levels.

1. Introduction 1.01 Introduction UNICEF and WHO developed the Integrated Management of Childhood Illnesses (IMCI) initiative in order to reduce childhood mortality, particularly for children under five years. It had been observed that in most developing countries, more than two thirds of deaths are due to five common conditions i.e. respiratory infections, malaria, diarrhea, malnutrition and measles. Each of these conditions has had a control programme targeted at it. However, these vertical programs have been criticized, not only for their duplication of resource use but also because patients rarely present with symptoms and signs of only one of these conditions at a time. Cough and fast breathing in a child may be caused by pneumonia, but it could also be due to severe anemia or malaria. A "very sick" child may be suffering from pneumonia, meningitis, septicemia or a combination of these conditions. The IMCI initiative aims to integrate the ways health workers look at children and manage the conditions that children present with at health facilities. It aims to prevent and reduce the number of cases of these illnesses and to improve the quality of care of children in the health services, while also involving parents, households and communities in the care of their children. It has three main components i.e. a) Improvement of the case management skills of health workers through the provision of locally adapted guidelines and training activities. b) Improvement in health systems required for effective case management of childhood illness, especially supplies of essential drugs. c) Improvement in family and community practices in relation to child health. These three components are complementary. They all need to be functioning well to fully benefit the child. Forty-four out of forty-six countries in the African Region (including Ghana) have adopted the IMCI strategy. As a way of encouraging evidence-based planning and implementation, WHO/AFRO, UNICEF/ESARO and BASICS II developed a framework for documenting experiences and best practices with IMCI implementation in the countries. Ghana is one of the first countries to use this documentation framework to document its experiences with IMCI implementation and best practices observed so far. The documentation was carried out in the months of March and April 2004, covering 3 of the initial 4 pilot districts. At the national level, attempt was made to obtain as much information as possible on all districts implementing IMCI. The terms of reference were to: 1. Document the implementation of the IMCI strategy 2. Document the process of scaling up of the IMCI strategy and identify best practices in IMCI implementation 1.02 Tasks The specific tasks were to: 1. Orient national officials on the documentation process to be followed. 2. Coordinate with MOH, WHO, UNICEF, and BASICS. 3. Consult with the international consultant on a regular basis to inform on progress. 4. Use the documentation framework (provided by WHO) to collect information from national and district levels through review of existing documents, key informant interview and focus group discussions. 5. Review national and district plans and approaches for the IMCI strategy, including costs and budgets. 6. Identify lessons learned and best practices.

1.03 Methodology In order not to take away precious health personnel from their busy schedules, a local consultant was hired to coordinate the documentation, analyze the information and write a report summarizing the information. An external consultant hired by WHO/AFRO, who was also coordinating a similar process that was being carried out in other countries at the same time, assisted him. The process that the local consultant went through can be summarized as follows: 1. Orient national officials on the documentation process to be followed. 2. Coordinate with MOH, WHO, UNICEF, and BASICS and other partners within the country. 3. Consult with the international consultant on a regular basis to inform on progress 4. Use the documentation framework (provided by WHO/AFRO and BASICS II to collect information from national and district levels through review of existing documents, key informant interview and focus group discussions, including visits to the districts. 5. Review national and district plans and approaches for the IMCI strategy, including costs and budgets. 6. Identify lessons learned and best practices. 7. Complete the Documentation Framework, for the national level as well as for each district visited 8. Write a report summarizing the information collected. Information from different areas was collected through various methods as follows; a. The National, Regional, International Organizations and District levels: At this level, the bulk of the information was collected through review of different documents. There were also in-depth interviews with the different stakeholders in an attempt to capture information needed in filling gaps experienced through document reviews.(Annex 1) b. Institutions: Visits to the different institutions were organized with prior information. Review of annual reports documents was done. In addition, Focus Group Discussions (FGDs) were held to find out their strengths, weaknesses and efforts to address the weaknesses as well as their recommendations in enhancing the sustainability as well as the scaling up of the IMCI strategy. In Regions where IMCI support visit had been conducted in 2003 on all those trained to assess progress in components 1 and 2, the findings were used. c. Hospitals and Front Line Health Facilities (FLHFs) At this level, there was need to learn clinicians feelings on the usefulness of the strategy, the way they were practicing the IMCI skills as well as the constraints/ problems they had encountered during practice. A minimum of one FGD was held at each health facility (HF) visited. Participants ranged from Medical Officers to Trained Nurses/ MCHA depending on the category of HF. Observation of clinicians when practicing the skills was also done. Observation was made on presence of the IMCI modules especially the chart booklet in place. d. HF clients: Client interviews were not conducted as part of the documentation process though observation of the treatment packages done as part of support visit shows that the desired treatments were being given as per IMCI classifications among those who had received the full 11-day course. e. Community members No patient satisfaction interviews were conducted though a review of the ten regional 2003 reports indicates that these surveys are frequently carried out. Information gathering within IMCI activities It is easier to collect information from the lower levels (though incomplete) since organization is better at such level. As you go up the hierarchy, it becomes difficult to get some

information especially on the organization of activities, meetings and ways to verify some of the information. Some activities are done but not documented at higher level. It becomes difficult to accept such kind of information.

Tolon

Manya Atwima

1.04 Summary descriptions and observations on the documentation process Visits to GHS headquarters, UNICEF, WHO, the selected districts and some regional health directorates took place for the data collection process. Most of the required information was available especially where responsible officers were in place. However, it was observed that there was minimal or no document inventory at the various places visited. This made it particularly difficult to identify information sources. 1.05 Observations on filling in the framework, its usefulness, deficiencies, etc This was a very nice experience. Filling the framework makes one go through a series of literature/ documents/ reports. One benefit is being informed of the current situation on the subject. The collected information is particularly important for planning purposes and other use. It readily gives answers for example on important national indicators to whoever is in need. Such information could be shared on the Internet. 1.06 Problems encountered Some required information was not clear from the tool attached to the TOR. Extra effort had to be put in to obtain the additional information.(Annex A) Some required information was not easily available in the form it was required. One had to take time to convert it to the required format. In addition to the short time allocated for the exercise, non-availability of different people at the national and district levels (due to different commitments) and lack of clarity of some items in the documentation tool caused some delays in the data collection process. 1.07 Recommendations to improve the documentation process There is need to sensitizing stakeholders at various levels to process data for use both locally as well as for higher levels. This could be done through the DDHSs and Regional and district review meetings. DDHSs could be oriented in this process so that it becomes easier for the District Health System to simplify the activity for the National levels. Future documentation is to give first priority to National level to be supplemented by validation visits to districts and regions selected by geographic zones or because of peculiarities. Institutional strengthening issues must also be well captured Financing sources, amounts and purpose must be obtained to track partner contributions

There may be need for orienting responsible people at the various levels (where applicable) on ways for updating the Documentation Framework on a yearly basis.

2. Situation of Children and Women 2.01 Overview: Administratively Ghana is divided into ten regions, 110 districts and --- villages. The Country has a 2003 projected population of 21 million, 3.4 million of whom are children under five years of age and 4.3 million women of childbearing age. There are 1207 doctors and 8123 nurses. Population doctor ratio is 20,500 to 1 and population nurse ratio is 1800:1. There are 2,173 health facilities excluding three teaching hospitals. The districts that were assessed have populations ranging from 144,000 to 262000. Women in their childbearing age account for 23% of the population and children under-5 years age constitute 18% of the population. 2.02 Health Situation of Children

From the GDHS, infant mortality rate (IMR), child mortality rate (CMR) and maternal mortality rates (MMR) for 2003 are quoted to be 64/1000, 111/1000 and 214/100000 respectively. However, there were no consistent data sources for infant, child and maternal mortality rates at district level. For example, depending on the data source the IMR for Tolon district for 2003 ranged from 62 to 91 per 1000 live births. Malaria, Diarrhoea, Anaemia, Cough or cold, Pneumonia are the 5 top childhood illnesses in all the districts. At national level however, measles and malnutrition join ARI, malaria and diarrhoea as the top five causes of morbidity in children under five years age which are exactly the same as the IMCI target conditions. The 2003 OPD attendants were 10,551,000 and the OPD attendance per capita 0.5. The total admissions were 598,774 with an admission rate of 28.4/1000pop. Children under five who sleep under ITN are 3.5%2. The under-five year malaria case fatality rate is 1.5%. The percentage tracer drug availability is 70% at national level. There were high levels as of malnutrition in all the districts, as shown in Table 1. Of particular concern are the very high levels of acute malnutrition (wasting), both at national level and at district level. In all these figures, Tolon, which falls in the Northern region, one of the 4 regions classified as deprived, has the worst values. Table 2.01 Malnutrition Rates in children under-5 years age: Ghana, 2003 Tolon Atwima Manya Krobo Stunting 39.6 27.6% 23.6% Underweight 38.1%% 24.7% 22.3% Wasting 12.7% 9.2% 8.7% Ghana1 26% 25% 10%

EPI coverage in infants is quite high at BCG 92%, Measles 83.2%, pentavalent vaccine 76.4% and OPV 76%1. 2.03 Maternal Health

The proportion of pregnant women attending antenatal care (at least 2 visits) as recorded by the districts was over 100% in all the districts. This was attributed to double registration and inaccurate census figures for women in fertility age and hence the expected pregnancies. ANC registrant at national level was 87%. The 2+ visit statistic was not available at the district level though national report had this to be 20%. The average visit per client was 3. Supervised deliveries rate were similar in all the districts and were close to the national average of 68% (for deliveries by health workers and by TBAs. There were however wide

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variations in the deliveries conducted by trained health professionals (Skilled attendant rate). This ranged from 20.7% in Tolon to 72.8% in Atwima with a national rate of 47.1%. Compared to other parts of Africa, particularly Eastern and Southern Africa, the HIV seroprevalance rate among pregnant women is still relatively low in Ghana (Table 2), ranging from 3.6% and 7.6% in the pilot districts. The national median seroprevalance for 2003 is 3.6%. It is estimated that there are 200,000 AIDS orphans in Ghana3. Except in Atwima where the proportion of the population living within 5Km of a health facility was found to be 30.4%, this information was not readily available. The proportion of the population who take more than 30 minutes to reach a health facility was however found to range from 24% in Manya to 50% in Tolon with a national average of 48%4. The proportion of the population utilizing curative services ranged from 0.17% (Tolon) to 0.44 in Atwima with a national average of 0.50. Children account for a high proportion of OPD attendants in some districts. Child OPD utilization as a proportion of total utilization ranged from 7.7% in Atwima to 24.9% in Tolon with a national figure of 15%.

Table 2.02: ANC, Delivery and HIV Seroprevalence Rates, Ghana 2003 Indicator Tolon Atwima Manya Krobo Ghana ANC 2+ visits ? ? ? 20% ANC attendance DHS (Regions) 82.3% 94.2% 91.8% 91.9%1 Delivery by trained personnel (Regions)1 18.3% 59.9% 49.5% 47.1%1 Deliveries (TBA +HW) 77% 69% 72% 51.95% HIV Seroprevalence in ANC (Regions) 2.1% 4.7% 6.1% 3.6% (2003)3 NB: The validated figures for the districts are the mean values for the sites in that region. 3. Introduction of the IMCI Strategy in the Country: Components 1 and 2 Though Ghana started IMCI in 1998, with the initial capacity building, baseline studies and adaptation, it was not until 2000 when four pilot districts started components 1 and 2. The pilot districts were selected based on their close proximity to Accra, interest of region and district, involvement in health facility assessment and training site availability. Ghana has a child health policy6 and programmes of work7 that gives priority to IMCI. MOH 2003 POW Reproductive and Child Health Expected Output8: IMCI scaled up Improved access to essential obstetric care delivery in every district All district hospital provide adolescent friendly services

Following the experiences from the pilot districts, WHO in collaboration with Ghana Health Service and other stakeholders has drawn a national IMCI strategic plan9. The plan covers in-service and pre-service case management training, community IMCI using various child survival and development interventions, institutional strengthening, resource mobilization for IMCI, integrating IMCI into CHPS (CHPS is a community health planning and service strategy to provide comprehensive health care to the underserved at door mouth). At national level, an IMCI Focal person who is also the National Child Health Coordinator coordinates IMCI. There is IMCI working group with 16 members drawn from the Ghana Health Service (GHS) departments relevant to IMCI (Dir. PH, Dep. Dir RCH, ICD, EPI, HEU, RBM, NU, HRD, RCH, Private Sector Unit, etc), university departments, donors (e.g.

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USAID), UN agencies (UNICEF and WHO) and NGOs (e.g. BASICS). The working group is involved in IMCI performance assessment, monitoring and coordination. In addition to the working group, other stakeholders are brought on board to influence and agree on levels and focus of support and implementation. These stakeholders are part of one or more of the following committees: IMCI Steering committee made up of NGOs, Adaptation Committee and an Implementation and planning committee (for case mgt and Component 2). There is also a Coalition of NGOs for C-IMCI, which includes Red Cross, CRS, ADRIA, PCI, JHU, BASICS, PRIME II, and CARE and an Adaptation committee. Each district has an IMCI Focal person and an IMCI working group to coordinate IMCI activities and women form 57% to 100% of the district team involved with matters of IMCI. In Ashanti, region and Northern Region there are Regional IMCI Focal Persons. District Assemblies and Traditional authorities are also key players at district level, in addition to the GHS, NGOs (e.g. BASICS), UN agencies (UNICEF and WHO) and donors (e.g. USAID). Other government departments such as the Ghana Education service (GES), and community development (CD) are also involved. IMCI is included in the overall district health plan. Currently 47 Districts are implementing components 1 and 2.

List of Districts Involved in IMCI Case Management: 46


GREATER ACCRA Accra Metro Ga Dangbe West Dangbe East Tema Metro WESTERN Wasa Amanfi Wasa West Nzema East Takoradi ASHANTI Atwima Ejisu-Juaben Amansie West Asante Akim North Asante Akim South Btwe Atwma Kwanwoma Kumasi Offinso Adansi west Adansi East Sekyere west Sekyere East CENTRAL Gomoa Cape Coast VOLTA Ho Kejebi Hoehoe Ketu Jasikan EASTERN New Juaben Manya Krobo Fantiakwa Kwahu South Suhum Kraboa Coaltar UPPER EAST Bolga Sandema Bawku UPPER WET Wa BRONG AHAFO Techiman Kintampo Berekum NORTHERN Tolon Kunbungu Gushegu Karaga Yendi Savelugu Nantong Tamale

4.

Introduction of Community IMCI (Component 3)

Though there had been several child survival initiatives in the different districts, it was not until 2000 that actual C-IMCI implementation started. The Ministry undertook several interventions in an attempt to develop this component. Among the main activities carried out were: Selection of key practices for implementation Identification of successful community programmes and interventions Review of materials that deal with child health and Identification of key community level stakeholders. As part of the process to introduce C-IMCI, an assessment of on-going community based child health programmes were carried out and the following were considered. a. Home management of Fevers b. Baby friendly initiatives with mother support groups c. Community based growth monitoring and d. VHC, CBS and VHW activities.

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Based on these practices, The UNICEF IMCIplus support to Upper east region has taken on board home management of diarrhoea and fever, promotion of breastfeeding and hygiene and malaria prevention using ITNs as part of c-IMCI. Community-based volunteers, mostly members of Red Mother Clubs, dispense pre-packed antimalaria drugs and ORS. The EPI component of the programme (Immunizationplus) also adds on deworming, vitamin-A supplementation and defaulter tracing to the package of strengthening outreach services. All the 3 districts have other community based programmes taking place. These include a)Community based surveillance system (CBS) that tracks diseases, births and deaths, gives advise on sanitation, treats diarrhea and malaria and refers cases b) Community Health Planning and Service (CHPS) in which a health worker is assigned to and lives among a group of communities, carries out house-to-house visits, gives prompt care to the sick and provides PH activities. c)FP Community Based Distributor of modern contraceptive methods (d) HIV/AIDS Community Based Organizations (e) School children deworming, (f) First aid training for teachers, (g) Supply of hand washing facilities to schools h) Insecticide treated bed nets (ITN) sales (i) vitamin-A supplementation (j) Home based treatment of malaria and diarrhea and (k) Use of Daddy Clubs and mother support groups to support behavioural change. In the pilot districts, community IMCI has basically been growth promotion except in Tolon where additional components have been added to make it IMCIplus . Initially each district started with 2 sub-districts but currently all the 5 sub-districts in Tolon, all 6 in Manya and 6 of 8 in Atwima are participating. The selection of initial sub-districts was left to the district to decide. In Atwima, the criterion was nearness to District capital to facilitate supervision, whereas in Manya-Krobo it was fairness so that there was one each from the Upper and Lower Manya areas of the district. In Tolon, it was based on high incidence of communicable diseases such as measles.Within the sub-district, initial communities were selected based on poor access, irregular use of child welfare clinics, or high infant death reports. C-IMCI baseline studies on family practices were conducted in Ajumako Eyan Esiam (Central region), Atwima District (Ashanti Region), Birim South District (Eastern region), Ga district (Greater Accra) and East Mamprusi (Upper East region). Among the key findings were: Delayed initiation of breastfeeding and discarding colostrum. Absence of exclusive breastfeeding. Breastfeeding fewer than 10 times a day Incorrect positioning and attachment Complaints of inadequate breast milk Early introduction of complementary food and Use of feeding bottle. .The Key Family Practices selected for use are: 1) Exclusive breastfeeding from birth to 6 months and continuing till the child is 2 years 2) Nutrient rich complimentary feeding from 6 months while continuing breastfeeding till the child is 2 years 3) Full immunization before 1st birthday 4) Adequate amount of micronutrients (Vit-A, Iodate and iron) 5) Sleeping under ITN 6) Use of safe drinking water 7) Good hygiene and sanitation practice 8) Adequate care for pregnant women and promotion of spacing

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The following key practices during sickness were also adopted: a. More food before and after illness b. Continuing feeding and more fluids during illness c. Appropriate home treatment of infections and injuries d. Following H/workers advice on treatment, follow up and referral and e. Recognizing when child needs further care and seeking appropriate care. The findings have been used to edit the Child Health Record (formerly road to Health Card) and the CHEST Kit (Community Health Education Strategy Tool Kit) which uses PLA to influence family and household practices and decisions to improve child health. There are aspects of the Safe Motherhood Communication strategy, which had selected sections influenced extensively by IMCI key family practices. The national EPI unit in 2003 finalized its five-year EPI communication strategy to be put to use in 2004. The First draft of Anaemia communication strategy is ready. In all these, the selected key practices had influence. Other communication strategies used extensively are the newspapers, radio, TV, internet, post, reports, telephone, fax and visits (observations). At national level, 33 of the 110 districts are implementing aspects of c-IMCI.

5. Capacity Development & Implementation of IMCI In Ghana, 46 Districts are implementing the case management component of IMCI while 38 districts and 119+ sub-districts are implementing the Community IMCI component. The Table below shows the coverage in IMCI case management: Table 5.01 Coverage of IMCI Case Management Implementation, Ghana REGION Districts IMPLEMENTING DISTRICTS % IMPLEMENTING GAR 5 5 100 ASH 18 12 67 VR 12 5 42 CR 12 2 17 BA 13 3 23 UER 6 3 50 NR 13 5 38 ER 15 5 33 WR 11 4 36 UWR 5 0 0 NATIONAL 110 44 40 5.1 Facilitators for IMCI and C-IMCI Capacity for IMCI is being built at all levels and is still not sufficient. All the pilot districts have case management facilitators and C-IMCI facilitators. At the national level, there are 71 facilitators for case management. There are several facilitators for C-IMCI. These include 23 CBGP facilitators made up of those in the three pilot districts and four World Bank assisted areas focal persons and 6 focal persons from Project Concern. The rest are facilitators addressing home management of fevers and others under CARE, PLAN, PCI and UNICEF projects. Given the fact that case management training at the district level may not be possible because of the limited number of cases, the district considered sub-district facilitators adequate if there was even one facilitator in that sub-district.

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Table 5.02: Trained MCI Resource Persons Region Facilitators Course Clinical Directors Instructors Greater Accra 6 0 0 Ashanti 13 2 4 Eastern 7 1 2 Northern 6 1 3 Head Quarters 3 1 0 Total 35 5 9

Supervisors Total 5 6 4 4 3 22 11 25 14 14 7 71

5.2 Community resource persons (CORPs) A total of 127 first level staff have been trained in C-IMCI and over 1322 community resource persons in the 3 pilot districts (286 by BASICS in growth promotion) and 1036 under the UNICEF project in Northern and Upper east regions in home management of fevers, diarrhea and ARI in 104 subdistricts10. There are other similar resource persons trained under the PLAN, CARE and PCI projects. 6. Motivation of CORPs Among the motivational approaches used to retain CORPs are: Bicycles, ID cards for VIP treatment when sick, assistance at funerals of deceased relatives with free transportation of the body from the morgue if died in H/facility (in Manya Krobo); commission from ITN/iodated salt sales and token amount at community durbars. Allowances are also given during refresher training sessions. In Tolon, UNICEF has provided seven bicycles that will be given out as incentive. In Atwima end of year awards and negotiation with the District Assembly (DA) to obtain soft loans for CCGPs are additional incentive strategies. Table 6.01: CORPs Trained in the Pilot Districts and Their Roles. Table 3 Tolon Atwima Manya Krobo 91 (76% 109 (43.1% 86 (Women Number of women. women due to =34.9% due to community Trained by low female low female resource BASICS literacy) illiteracy). persons trained Trained by (& percent who UNICEF-1036 are women) and BASICS286. Their specific Weighing Weighing, Weighing and roles in the charting Charting Charting community Counseling Counseling Counseling Referral Referral Referral NID NID volunteers volunteers, Vitamin-A Nutritional supplementa surveillance tion Iodated salt Assist mother sales support ITN sales groups. Home treatment of fever and diarrhea Deworming

Ghana Not readily available

Breastfeeding support Growth promotion Care of sick children Counseling, Micronutrient supplementati on ITN sales, referral, Advocacy, sensitization

15

Table 3

Tolon Hygiene and sanitation education

Atwima

Manya Krobo

Ghana

7. Policies on IMCI 7.01: Policies governing work of community-based workers: The work of the CORPs is guided by Guidelines. These are applied at the district level. To be selected as a CORP, the person must be resident, literate, credible; must be willing to be a volunteer and have time to do CCGP every month. A CORP is to be a female (preferably) and must treat a sick child only if trained. The proportion of women CORPS was low 34% at Tolon where female literacy is low. Community health Officers (CHOs) resident in CHPS (community health planning and service) zones are mandated by Policy to supervise the work of CORPs. The work of the CORPs is guided by Guidelines. These are applied at the district level. To be selected as a CORP, the person must be resident, literate, credible; must be willing to be a volunteer and have time to do CCGP every month. A CORP is to be a female (preferably) and must treat a sick child only if trained. The proportion of women CORPS was low 34% at Tolon where female literacy is low. Community health Officers (CHOs) resident in CHPS (community health planning and service) zones are mandated by Policy to supervise the work of CORPs.

7.02: Policies supporting linkages of community activities with health care providers. There are several policy thrusts that support linkages between the health sector and the community activities. TBA and CORP training manuals are prepared by the GHS within the context of its strategic direction. Examples are the CBG counselling cards, the TBA training manuals, RBM manuals for training chemical sellers. The GHS 5-year programme of work stresses partnership in the provision of services and identifies CHPS as one strategy to carry health care to the door step of the underserved with the participation of CORPs.11 8. Programme Reviews Several review processes were identified. Quarterly community durbars, sub-district, district and regional performance review meetings were taking place. At the National level the steering Committee meets quarterly and the last was in February 2004. The GHS has a performance review guideline, which has CHPS as a key indicator, suggesting a strong commitment to community based service delivery.12 9. Partnerships analysis and linkages 9,01 Partners in IMCI Several partners are contributing to making IMCI work in Ghana though they have different areas of focus. These are GHS, WHO, UNICEF, USAID, BASICS, PLAN Int., LINKAGES, GRC, WVI, PRIME II, JHU, ADRA, CARE Int., Project Concern Int. (PCI) and Africare. The partners play the following roles: Table 9.01: List of Stakeholders and Areas of Focus STAKEHOLDER FOCUS BASICS, PLAN, CARE, ADRA, PCI: Community IMCI training and support CARE, USAID, WHO, UNICEF: Case management PRIME II: Institutional strengthening (logistics support) UNICEF : Institutional Strengthening, logistics support (pre-packed chloroquin, ORS), Community IMCI training and support and Supply of manuals.

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Traditional Leaders, the Ghana education Service, district assemblies are important partners in all the districts, particularly for community activities. There are also other partners specific to different districts such as New Energy, Amaasachina, Bible church of Africa (BCA), Global 2000, Ghana Danish Comm. Project (GDCP) in Tolon and the alliance (Transport Union) and Information Service Dept. in Manya-Krobo. Partners also complement roles at district level as exemplified by Tolon below: PARTNER Roles played by Partners in Tolon district, Ghana UNICEF: Case management training, Provision of communication gadgets, motorbikes and bicycles and support for CBGP training and outreach. DA: Assembly members assist in volunteers selection, help settle disputes Global 2000: Support provision of water and sanitation and help organize durbars BCDP: Public education, deworming and provision of soak-away sanitary pits. New Energy: Provision of household toilet facilities and hand dug wells. Amaasachina: Hygiene education, emergency readiness, health fund for referral WVI: Mother support groups
NB: The overlaps make MAPS presentation Complex OR Many!

The partners have different geographic coverage. JHU operates at the national level UNICEF: National and Regional: UER, NR; BASICS: National and Regional: ASR, GAR, ER, NR- 4 districts PCI: Regional: WR-2 districts; in all LINKAGES: Regional: NR, UER, UWR, CR, VR, ER; GRC: Regional: NR, UER, GAR; PLAN Int: Regional: ER, CR, VR; AFRICARE: Regional: VR; CARE: Regional: ASR; WVI: NR;

UER UWR

NR

BAR

VR

ASR WR CR

ER GAR

9.02 Linkages among partners are ensured through IMCI working group; C-IMCI Subgroup; Partners (review) meetings; NGO Coalition for C-IMCI; Partners review meeting (WB, WHO, DANIDA etc meets with GHS and MOH monthly.

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There are pro-poor ppolicies to ensure access to underserved communities. The 3 Northern Regions and Central region with poor social, economic and health indices have been considered deprived and therefore receive additional resources for health. These regions are given government of Ghana Funds to exempt payment for supervised deliveries. In other regions, including the deprived, exemption systems exist for children under-5, the aged and the pregnant woman for basic services. The proposed NHI is also expected to use a means test to identify the core poor for support in premium payment. 9.03 Partnership Analysis and Linkages The partners supporting c-IMCI are GHS, BASICS, WHO, USAID, UNICEF, PCI, World Bank. The partners have different level of involvement in c-IMCI planning, implementation, training, support and monitoring. GHS, BASICS and UNICEF (especially in UER and NR) are fully involved at all stages. Since training and development of materials could be cash driven, GHS national level and the multilateral organizations feature prominently at the planning and development stage. Implementation, support and supervision are generally decentralized by GHS to the district level and it is at this stage that district assemblies and Ghana education service come in. At each level, the partners sit, discuss and agree on what is to be done and assign responsibilities and allocate cost. For example, during district orientation WHO gives a certain amount and UNICEF tops up or USAID gives funds for IMCI facilitators training and GHS tops up, or BASICS pays for technical assistance and counseling cards development and UNICEF prints.

9.04 Programs are linked under the IMCI working group. EPI advised on immunization sessions of assess and classify part of case management and what must be done if a child has missed immunization. Recommendation for the use of ITN and adoption of Chloroquine as the 1st line drug and quinine as a pre-referral drug were based on RBM recommendations. At the MOH-GHS-Partners review meeting held in April 2004, RBM promoted the replacement of Chloroquine with a combination drug and the IMCI working group will be considering the implications of this for home management of fevers. The PPME unit will be looking at the cost implication for the poor and the effects on the exemption fund and national health insurance premium etc. The IMCI Focal person and the IMCI working group are assisted by various arms of government to co-ordinate their activities. For example, the District Coordinating Director (DCD) calls Heads of Departments meeting, the District Chief Executive convenes DA meetings (chaired by Presiding Officer) and the District Director of Health, GHS, convenes performance review meetings. To strengthen the partnership between IMCI and RBM, the two, with assistance from WHO have acquired a joint office at the National level. Following a joint review of activities by the two programmes, the following were agreed upon as activities that will be integrated in RBM ten selected districts: evaluation of progress, constraints and challenges identification, exploring options for integration and joint planning to achieve common objectives13.

RBM Targets 2003: Improving Management at HH Level Increase from 22% to 32% the proportion of children with fever receiving correct home treatment

At the community level, sub-district health workers link the CBS, TBAs, GW Vols., and CCGPs and community durbars bring them together. Community leaders, assembly members and Unit committee members bring NGO activities together.

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10. Changes and Impact Demonstrated 10.01 Health Worker skills improvements There is generally improved case management as reported in district reports and from follow up reports14. They are now offering better choice of treatment, referrals are more appropriate and the stocks of pre-referral drugs have improved. In Ashanti Region, forty-five IMCI case managers were assessed early this year. Analysis of the findings shows that 95.6% had ORS for Diarrhoea management, 91.1% had a weighing scale and did weigh every child and 91.1% had thermometer and checked each childs temperature. 10.02 Improvements in the Health system There are major systemic changes taking place in Ghana. Scaling up of IMCI is a priority intervention in the 2004 GHS Programme of work (POW). The current child health record card has been revised and contains feeding recommendations and instructions for the sick child, which changes the outlook for childcare at child welfare clinics and consulting rooms. Frontline health workers now can administer drugs previously left for doctors to prescribe. Despite the fact that the Drug Policy in Ghana Has not been changed to permit health centres to stock some 2nd line and pre-referral drugs, 42.2% of the IMCI practicing facilities evaluated had Quinine injection and 45.5% had Gentamycin and chloramphenicol injections. In 51.1% of cases, Tabs. Fansidar was available. Attempts are currently underway to revise the Drug Policy to make it possible for prereferral and 2nd line drugs to be available to health centres, CHOs and clinics. The health system now permits community level case management. The new CHPS policy, though does not mention IMCI and C-IMCI, which appears to be a big oversight, it outlines Basic Package of Services by the CHO that further empowers health workers to work with communities as case finders, care givers and counselors, care supporters, case referral and disease control workers15. 6.03 Improvements at household and community level Community register review conducted by BASICS in CBGP implementation districts and communities have demonstrable results form the intervention. As high as 96% of the children under-2 years participate the programme. Whereas the proportion of children 12-24months with low weight for age remained at 40% from 2002 to 2003, that of children 0-11months reduced from 16% to 14%. Missing data were as high as 22% thus making comparative analysis unrealistic. Proportion of children with adequate weight gain increased from 48% (2002) to 67% (2003). It is reported, there were many reported deaths in the communities, but with the CBGP program they (Atwima) are beginning to see fewer reported deaths.16. In all 6 deaths were reported in the 19 communities with total registered children of 1098 in the three districts In Tolon district, the proportion of babies on exclusive breastfeeding has increased from 1% in 1999 to 73% in 2003. Feeding practices in general, such as better positioning and attachment, introduction of snacks, have been observed to improve and the use of CBGP has increased. Use of iodated salt has also improved. Community members now record cases of diseases such as measles, polio etc. and record deaths. Breastfeeding practices have improved considerably in Linkages areas of work >50% (Northern region), there is improvement in home based care of children with fever (He-ha-ho feedback reports), better home management of diarrhea and families now feed children 3x with snacks. The use of CBGP for growth promotion17 and support within mothers support groups has been well accepted. 16.6% under five years have been dewormed In Atwima, the C-IMCI implementing districts register average growth promotion visits of 82.9%. Malnutrition rate (underweight) in children under five years has reduced from about 10% (2000) to 3.9% (in 2003). The proportion of children with adequate weight gain has increased from initial value of 40% to 54% (2003). Families now feed children 3 times a day with snacks and mothers assist others through support groups. Infants less than 6 months exclusively breastfeeding has moved from 0% to 36% in CBGP communities.

19

Preliminary results of UNICEF 2003 coverage survey in the UER has shown increase in ITN use by children and pregnant women, from 2001 baseline of 1-4% to 27%18. To date the programme has distributed 250,000 ITNs in nine districts. Mass bednet retreatment has taken place in 6 districts with 60.9% ITNs in compounds re-treated19. (The Chart below shows ITN use by Region with UNICEF assisted UER and NR registering the highest values)1.
% Children <5Yrs using ITN By Region (DHS), Ghana, 2003
25.0

20.7 20.0

15.0 Percentage 10.0 7.2 5.0 3.5 2.2 1.0 0.0 ER AR BAR UWR UER National Immunization coverage has increase to 70% and NR vitamin-A supplementation coverage is now Region 80%. The programme has covered 99,233 (71.2%) Children < 5 years covered and 33,340 % Children <5Yrs using ITN (100%) pregnant women. WR CR GAR VR 0.7 1.1 0.3 1.2 2.1 1.9

It was not easy to obtain changes in under-5 mortality due to IMCI introduction. 11. Sustainability and Scaling up 11.01 Scaling up both IMCI and CHPS These are planned and being executed. Plans for scaling up are in place. C-IMCI strategy and communication strategy are in place. Districts are being encouraged to plan and budget for IMCI. In Ashanti region for example all 18 districts have been asked to budget to introduce CBGP into two communities in two subdistricts. In-service case mgt expansion training has started and Pre-service training has already taken place in the Kintampo Rural Health Training school. The IMCI scale up objectives are to build capacity in all 10 regions for case management, build up capacity in pre-service institutions for IMCI teaching, strengthen the capacity of the private sector to implement IMCI case management and to initiate C-IMCI activities in all regions.20 Both the full (11 days) and abridge (6days) training modules shall be used. The underlying assumptions include multiple funding sources, enhanced regional capacity and district and regional ownership. SCALING UP IMCI: Expected Outputs Each of the ten regions will have the full compliment of case management trainers. 700 health staff from all regions and pre-service institutions will be trained in case management (80 Districts will have at least one practitioner) Adequate capacity will be built in all general and community health nursing training schools to start IMCi teaching by October 2004. Ghana Registered Midwives association (GRMA) will have IMCI trained facilitators to serve the group At least one district in each of the ten regions will have CBGP and Community-based fever treatment in at least 5 deprived communities Within the 2002-2006 strategic plan, all the components have been targeted. The following objectives have been set: 11.01.1 COMPONENT 1 The following targets have been set to be achieved by 2006.

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At least one health worker trained in 60% of first level health institutions in all districts 80% of prescribers prescribe antimalaria drugs correctly 60% of health workers correctly assess children for all general danger signs 80% of health workers assess correctly for cough, fever and diarrhea 80% of children reporting to health facilities have their immunization and nutrition assessed and 50% of caregivers or reporting children know the 3 rules of home care-extra fluids, continue feeding and when to return. A number of strategies and Activities have been defined. They include training (in-service and pre-service0, Supporting activities (training sites preparation, training of facilitators and materials development), private sector participation and follow-up after training. 11.01.2 COMPONENT 2 Under componenet-2, the following activities have been defined: Review of Drug Policy on pre-referral and 2nd line drugs (including the shift from Chloquine to multidrug malaria treatment) to ensure 100% drug availability. Advocacy for drug pre-packing to improve compliance Training health workers on the new Child Health Record and Procurement and distribution of mothers counseling cards to facilities. 11.01.3 COMPONENT 3 Two community interventions are being promoted under C-IMCI: CBGP and community management of sick children. These have been chosen because they have been proven effective in addressing the problems of under-fives in Ghana. The main objectives are to: Create the appropriate policy environment to support and stimulate commitment Promote practices that promote growth and development (EBF, Use of CHEST Kit, Micronutrient, formal education, appropriate complimentary feeding) Promote family and community practices that prevent disease (ITN, Sanitation, Hygiene, immunization, safe drinking water) Promote appropriate home care for sick children and Promote appropriate care seeking behaviour outside household. 11.02 Enabling Factors The enabling factors for scaling up include partners commitment and support, GHS Child Health Policy, the priorities in the POW 2002-2007; Human resource base at regional and district levels; leadership and enthusiasm of Health training institution. Some Regions have already been asked to prepare for three training sessions in 2004 with funds already sent. The Regions and districts have GOG Service and Donor Funds, which part they are encourage to apply to IMCI expansion. The scaling up of CHIPS and RBM will compliment IMCI scale up. CHPS will get services to the underserved deprived areas, make basic resources available and stimulate joint actions with communities. RBM will provide ITNs, improve sanitation and lead home management of fevers. It will also strengthen the referral level to deal with severe and complicated malaria. At community level, some of the enabling factors include the demand from communities working with NGOs to continue with the activities, and the success stories from implementing communities spur other communities to also start activities 11.03 Measures to ensure sustainability In Ghana, IMCI was included in the budget in 2003 though other resources are decentralized. All the pilot districts have Budget lines for Malaria, diarrhea and Nutritional control measures, which also contribute to IMCI. Some resources are already available to support IMCI such as the focal persons for IMCI at all levels, regular source of funding both from government and donors including the Global

21

fund for Malaria control. Staff are highly committed and facilitators and training manuals are available. For the first time GHS has come out with its POW, separate from that of MOH. It is in this document that IMCI is made a priority. This is very positive for the future. Partners made inputs into the IMCI strategic plan developed for Ghana (Draft); this increases its acceptability. The following resources were available in 2002 and it is believed that this commitment will remain:21 2002 EXPENSES TOTAL/$ TOTAL/$ Comp-1 Comp-2 Comp-3 2002 2003 WHO 540,000,000 0 0 BASICS 404,500,000 54,000,000 271,000,000 UNICEF 534,000,000 37,600,000 10,000,000 $198101 USAID 268,000,000 1,311,800,000 131,180 See also Annexes 11.01 and 11.02. It was not possible to extract the expected total cost from the WHO and UNICEF interventions up to the end of the strategic plan period. Government of Ghanas direct contribution (GOG Service and GOG Administration) was not readily obvious. 12. Supervision Mechanisms An integrated checklist has been developed to assist with supervision and is administered quarterly. It is augmented by follow-up reports from the regions and RCH biennial meetings. Different forms of integrated checklists are also available in the districts. For example, in Manya-Krobo, the observation checklist has been clipped to the district monitoring checklist whereas in Atwima the IMCI checklist has been added to the district checklist. Supervision is the responsibility of the IMCI Focal Person aided by the Working Group both at national level and at district level. The frequency of supervision varies from quarterly in Tolon district, to once a year in Atwima district and at national level. In Ghana, supervision after follow up is decentralized to Regions and districts. All those trained in IMCI have had their follow up visit as shown in the following Table. Supervision of the districts by the regional level is also regular. Table 12.01: Health Workers Followed Up After Training and Districts Supervised Tolon Atwima Manya Krobo Health workers followed up after 16 23 23 training (16/16) = 100% (23/23) =100 (23/23) = 100% Districts supervised by regional 8 12 None level in past 6 months (8/10) = 80% (12/12) =100% A monitoring mechanism exists as part of PH support supervision to regions, districts and sub-districts within which IMCI supervision is integrated. All the districts, which were assessed, have integrated checklists for supervision, though in Atwima there is also an IMCI checklist. In Tolon the checklist includes checking for availability of 1st line drugs and prereferral drugs, that there are IMCI trained staff in facility, for ORT corner etc and it is administered by any district supervisor (whether IMCI-trained or not). There are also quarterly support visits in which IMCI facilitators join in to do IMCI-specific observation with the standard IMCI checklist. The routine reports also cover area such as malaria and diarrhea cases, immunization coverage, morbidity and mortality by age etc. In Manya Krobo the standard IMCI case management and observation checklists are attached to the district integrated-checklist, which is used by the IMCI Focal person only. Though the DHD members are Sub-district Parents and provide routine support, they however do not use the IMCI standard checklist. In this district, the community system appeared not to be well

22

supervised and hence could not provide need mortality rates as could easily be obtained in other districts in the same region. There are periodic quality (QA) assessments by Regions that look at drugs per prescription, prescriptions with antibiotics and tracer drugs availability which drugs include IMCI recommended drugs. The Chart below shows tracer drugs availability as reported in the regional annual reports (Blank Regions had no report).
% Tracer drugs Availability By Region, Ghana 2003.
120

100

95 89

98 92 91

98 92.1 93

80 Percentage

60

40

20

0 0 WR CR GAR VR ER AR Region % Tracer drugs Availability BAR NR UWR UER National

There are however problems with the quality of services in the facilities in the Country as shown in the table below. Table 12.02: QA: Results of Health Facility Charts Reviews22
INSTITUTION Number of Charts Examined Patient Details Clinical Clerking Treatment Nursing Records Filing, Storage

Standards of Documentation: - Percentage Satisfactory KBTH 30 KATH 30 Ridge Regional Hospital Koforidua Regional Hospital Nkawkaw Holy Family Hospital Kwahu District Hospital La Polyclinic, Accra 10 Manhiya Polyclinic/ Hospital, Kumasi 10 70 0 55 30 60 40 15 0 50 30 15 15 20 10 55 66 20 50 30 100 50 50 25 70 90 75 60 50 60 15 15 15 0 10 10 10 10 15 15 55 100 100 25 15

23

INSTITUTION Mankranso Polyclinic/Hospital Bomso Private Clinic/Hospital Mamprobi Polyclinic, Accra

Number of Charts Examined 10 5 10

Patient Details

Clinical Clerking

Treatment

Nursing Records

Filing, Storage

0* 30 10

60 60 10

70 100 50

0 0 0

30 50 10

Periodic meetings are conducted to share lessons in the use of the checklist and its integration into the mainstream checklist. In Atwima, lessons learnt in integrating IMCI checklist into routine support visit has been prepared in PowerPoint and shared at district and regional quarterly review meetings. Among the issues captured from the slides are: Positive Findings The CHECKLIST: was easy to understand and use. is systematic Puts the Supervisor on track in supervising. allows for real observation to be done STAFF & INSTITUTION The health workers were systematic in the assessment They asked about immunization Classifications were generally correct Medications were appropriate for the classification Problems CHECKLIST It is time consuming if it is integrated into the routine support visit. The checklist uses diagnosis instead of classification. STAFF AND INSTITUTION The staff did not ask about all the symptoms More concentration is required on the part of the supervisor Conversion tables to improve compatibility between IMCI classification and the National health Information system exists in Ashanti Region and includes IMCI, RBM and IDSR. The national reporting forms are currently being revised to take into account the needs of IMCI. Performance review is a major component of the MOH/GHS programmes of work. Early this year there were Clinical care, Maternal mortality, information, monitoring and evaluation and POW reviews (See References and Annex 12.01). There are several review processes to monitor IMCI implementation. Quarterly community durbars, sub-district, district and regional performance review meetings were taking place. At the National level the steering Committee meets quarterly and the last was in February 2004. The GHS has a performance review guideline, which has CHPS as key indicators, suggesting a strong commitment to community based service delivery.23 13. Challenges, constraints and solutions 13.01 CAPACITY BUILDING The training has so far taken place in Regional and Teaching hospitals to be able to observe most of the classifications. Given the multiple roles of these hospitals, especially the Teaching hospitals, delays occur and frequent rescheduling of training does occur. This can be addressed if the training could be organized in District hospitals. Arrangements could then be made for trainees to see cases such as mastoididtis, convulsing now and unconscious

24

children at later dates. Difficulty in getting the time of facilitators has also been observed. Building regional full compliment of facilitators, clinical instructors and course directors as has been done in Ashanti is one best way to address this problem. Delays in funds release and limited financial resourcefulness at district level presents a big challenge. If donors could sustain their commitment and GHS/MOH could transfer more resources to the lower level, IMCI and CIMCI in particular could be locally funded without undue reliance on IMCI headquarters to source for funds. Advocacy for increased resource mobilization poses a challenge, especially at the district level where Health sector has minimal influence on the Common Fund proportion for health. Refractory problems have been observed in 10% of IMCI case management trainees, which affect training progress. GHS may need to provide a facility that will address the health care needs of its workers. Some National level programme mangers trained in IMCI have not been able to facilitate because of their busy schedule. The benefits to be derived if for example EPI, RBM and CHPS are facilitating at IMCI training will be immense; every effort should be made by the IMCI coordinator to be part of training or support visit. 13.02 INSTITUTIONAL STRENGTHENING The change in drug policy to make the use of pre-referral and 2nd line drugs available at health centres and clinics remains to be addressed. This is being addressed in the IMCI strategic plan. Integrating IDSR, IMCI and RBM output indicators into the national morbidity and mortality reporting forms has not taken full effect though it is slated for action probably in 2004. The list of sectorwide (SWAP) indicators upon which the health sectors performance is assessed has no indicator on IMCI (Annex 18.01). 13.03 COMMMUNITY IMCI There have been widespread delays and shortages in INT delivery. UNICEF has therefore made a bulk purchase order of ITNS and insecticides that are expected to address this problem at the UNICEF supported areas. Working with Mobil Fuel stations, ITN Voucher system is being introduced in selected areas in Ghana for women attending ANC for a certain number of times to qualify for collection. CBGP supervision presents a challenge. It has been observed during growth promotion session that supervisors (Nurses) are not involved in the weighing activities; they only observe and wait for their turn to vaccinate the children. This explains the over 20% gaps observed during the review of the CBGP registers. Documentary evidence of some C-IMCI activities supported by partners are not made available to local Ghana health Service managers, thus making follow up action difficult. Encouraging local funding for community-based activities is worth doing but challenging, District assemblies can be very supportive in C-IMCI (with the HIPC and Poverty Alleviation Funds) if were briefed. 14 Best Practices Among the best practices are the IMCIplus strategy carried out in the Northern and Upper east regions. It is pro-poor, relevant and works through local structures. The programme focused on interventions that community members could implement (ITN sales, treatment of fever and diarrhea, deworming and INT retreatment). UNICEF worked with Red Cross mother Clubs, thus putting women at the forefront. GHS was a key partner and is involved at all levels at all times. Early involvement of Regional Level senior managers as facilitators and course directors is another leadership best practice. In Ashanti region the Deputy Director Public Health (SMO-PH) and a Senior Nurse at the Training Unit were trained as facilitators and

25

Course Directors. Since their training, the region has supported training in Eastern region and Northern regions. The region is the first to undertake IMCI expansion training which is evidenced by the number of districts implementing case management. It is the only region that has incorporated IMCI classifications into the morbidity/mortality reporting Forms. It is also the Region that has reviewed the performance of its IMCI practitioners without financial support from outside the region. These regional level resource persons organized the First case management training for Tutors in health training schools in the Country and the First pre-service training of Medical Assistant Trainees.

15 Lessons learned 15.01 Components 1 and 2 Involving senior staff at the Regional level facilitates implementation. The case management course has been found to be appropriate for the front line health workers. In Ashanti region where, selected health workers were trained in Introduction to IMCI, General Danger Signs and Fever (up to counsel the mother) with the aim to phase out the 11-day training, it was observed when evaluated that the two day training was not intensive enough to give proper understanding. Again, the health workers who received abridged case management training in the same region with support from CARE have been found to limit understanding especially if they are not supported frequently. Shortening the course for 1st level staff therefore appears to compromise the quality and hence minimal change in practice. To get senior manager on board IMCI, an abridged training module has been prepared and is in use as a sensitization and advocacy tool. Trainees with this module have demonstrated broad understanding of the principles. It appears this approach is appropriate for senior managers. In the scheme of things, doctors have led many health interventions in Ghana, especially in GHS. It has however been observed in IMCI case management training that Medical Assistants and Nurses can be good facilitators if trained. It has also been observed that Doctors in clinical practice (especially if they are paediatrician lecturers), serve better as Clinical instructors as compared to non-practicing doctors as they demonstrate considerable competence in instructor-student relationships. Training country level personnel in adaptation facilitated the adaptation process in Ghana. The teaching method is appropriate as it ensures that essential skills are acquired. The cost of case management training (17,000-18,000$) is considered very high by the national level, thus making local funding (regions and districts) impossible without addition resource inflow. Given the cost of in-service training and its effect on routine activities, pre-service training is essential for sustainability. 15.02 Component 3

From the UNICEF supported projects, it has been observed that earmarked funding can be an effective means in accelerating expansion of cost effective interventions. In addition, there are sufficient potential partners on the ground with skills and organization to contribute to accelerating expansion of high impact programmes. Building on existing interventions make things work e.g. Building home based care on mother support groups and Red Cross mothers clubs. Identifying each partners comparative strength is very important (e.g. documentation and printing for UNICEF and Allowances for USAID)

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Linking up with other programmes helps in judicious use of scare resources (e.g. Nut Unit brought CBGP and taken up by IMCI, He-ha-ho initiated by RBM and taken up by IMCI). Recognition of CORPs by health professionals and working with them (e.g. H/workers referring mothers to them) serves as a motivation to keep them working. Building regional and district capacity is critical for scaling up (Training, F/up and monitoring). Mobilization of additional resources is necessary to ensure rapid expansion. CBGP and home management of fevers are powerful entry points for C-IMCI as they can take up ITN distribution, counseling hygiene education and births and deaths registry. The healthy happier home (Heha-ho) radio drama programme has been found very attractive to community members as they enjoy the drama and follow the discussions.

16. Next Steps Given the progress made in the last three years, IMCI implementation has a very bright future, in all the components (See Annex 16.01). 16.01 COMPONENT ONE Pre-Service Training: IMCI will be part of the curriculum of all health training institutions, including Medical schools. This will institutionalise the concepts of case management and reduce the cost and burden of in-service training. A lot of progress is being made in this direction and there is every reason to believe that this will work. Private Sector Involvement: Nurses and Midwives Council and Medical and Dental Council key persons shall be trained and the full compliment of facilitators shall be built among the Ghana Registered Midwives Association membership for their internal IMCI training. 16.02 COMPONENT TWO Essential Drugs Available: Without pre-referral and 2nd line drugs at the facility level and prepacked drugs at the community level, IMCI implementation will suffer. All effort is being made GHS, working with Pharmacy Council, to revise the current national drug policy. Dispensing Technicians and Assistants shall be trained in drug management and dispensing counseling. 16.03 COMPONENT THREE Home Care of sick Children: From the lessons learnt from Ejisu-Juaben home management pilot study and the UNICEF IMCIplus support, home management will be replicated in other Regions and scaled up. It addresses diarrhoea, malaria, intestinal worms and micronutrient supplementation. The EPIplus component addresses immunization and uses community members for defaulter tracing. This programme has all the strengths in partnership and linkages that ensures ownership and sustainability of. CBGP: Community based growth promotion will also be pursued to address malnutrition. Malaria and diarrhoea control, micronutrient supplementation and may run on its back in some places. 17. Conclusion The IMCI concept has been embraced very well in the pilot districts with rapid onset of expansion. Cascading the expansion process to the level where it will be institutionalized will depend on the ability of the programme to attract financial resources. If the Ministry of Health, Ghana Health Service at all levels, partners and the District Assemblies could demonstrate renewed commitment and support, the health of children will see a major transformation in Ghana. 18. Recommendations Ghana Health Service should continue to work with Agencies and Organizations to widen the coverage of C-IMCI. Attempt should be made to look at cheaper alternatives to IMCI case

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management training. There is the need to define IMCI output indicators to measure the performance of the three components. At least one IMCI output indicator should be defined in the sector wide (SWAp) list of indicators (See Annex 18.01). Ghana Health Service may need to look at the BASICS Register review recommendations for further discussion and implementation. CBGP supervision will need a critical look if the quality and effectiveness of the intervention is to be realized. IMCI-specific quarterly review meetings is to be instituted to in all districts implementing to sustain interest as recommended in the facilitative support visit report of Ashanti Region24.

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ANNEX A: IMCI DOCUMENTATION- GHANA SUMMARY REPORT

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REFERENCES

Ghana Statistical Service, DHS, 2003 Preliminary report Ghana Statistical Service, DHS, 2003 Preliminary report 3 MOH, HIV/AIDS in Ghana, NACP (Advocacy PP presentation, AIM 2001) 4 CWIQs 2003, Ghana Core Welfare Indicators Survey summary report. 5 GHS, CHIM 2003 Statistical Report 6 MOH, Policies and Strategies for Improving the Health of Children Under-Five in Ghana, 1999 7 MOH, Second five-year programme of work, 2002-2006 8 MOH, The Ghana Health Sector Annual Programme of Work 2003 9 WHO, IMCI Strategic Plan for Ghana, 2002-2006 10 RDHS, UER, Presentation at Senior Managers review Meeting, Miklin Hotel Accra, April 2003 11 GHS The 2004 Agenda, Policies and priorities for the year 12 GHS SWAP performance review guidelines, 2003 13 GHS, National Malaria Control Programme, Ghana, annual report (Draft) 2003 14 Discussion and reports from IMCI National Programme Coordinatos 15 GHS, Community-Based Health Planning and Services: National Policy and strategic Plan of Implementation, 2004 16 BASICS-GHS. Growth Promotion Register Review, Ghana, November 2002December 2003 17 Reports from District directors of Tolon, Atwima and Manya and their IMCI Team members 18 UNICEF Gh. Under five Mortality Reduction in Northern and Upper east Regions (Accelerated approach to Child survival and Development, ACSD): Overview 19 UNICEF Gh. Under five Mortality Reduction in Northern and Upper east Regions (Accelerated approach to Child survival and Development, ACSD): An Overview, Feb 2004 20 GHS, IMCI. Scaling Up IMCI-2004 21 MOH, IMCI Review of early introduction and implementation phases-Ghana, 2002 22 MOH. Ghana Clinical Care Service Review Vol.1 Main report, 2004 23 GHS SWAP performance review guidelines, 2003 24 RHD Ashanti, GHS. Report on Facilitative Support visits conducted on IMCI and RBM Trained Personnel, 2003
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