UPPER EAST REGIONAL HEALTH ADMINISTRATION

Transcription

1 ANNUAL REPORT, 2004 UPPER EAST REGIONAL HEALTH ADMINISTRATION GHANA HEALTH SERVICE MARCH 2005 i

2 TABLE OF CONTENTS List Of Tables...iii Table Of Figures... vii Executive Summary... ix Chapter One Introduction Vision Profile Of Region Major Concerns At The Beginning Of The Year Policy Thrust Priorities Summary Of Key Activities Chapter Two Service Delivery Public Health Integrated Disease Surveillance And Response (IDSR) Epidemic Prone Disease Control Of Other Priority Diseases Non-Communicable Diseases Reproductive And Child Health (RCH) Chapter Three Clinical Care Key Activities Carried Out Chapter Four Special Initiatives To Increase Access Accelerated Child Survival And Development (ACSD) National Health Insurance Community Health Planning And Services (CHPS) Food Assisted Child Survival (FACS) Integrated Disease Surveillance And Response (IDSR) Strategy Intermittent Preventive Treatment Of Malaria In Pregnancy (IPT-SP) Communication Network Chapter Five Support Services Estates Equipment Management Transport Regional Medical Stores Chapter Six Human Resource Development And Management Human Resource Management In-Service Training Chapter Seven : 1. Collaboration Chapter Eight Health Training Institutions ii

3 8.1. Bolgatanga Nurses Training College : Presbyterian Nurses Training College, Bawku : Midwifery Training School, Bolgatanga Navrongo Community Health Nursing Training School Chapter Nine Financial Management Finance Internal Audit Chapter Ten Summary Of Key Achievements Chapter Eleven Outlook For Annexes LIST OF TAB Table 1: Target Populations... 3 Table 2: Health Status Indicators... 4 Table 3: Summary Of Ownership Of Major Health Facilities... 4 Table 4: Timely And Completeness Of CD1 Returns By Districts Table 5: Five-Year Trend Summary Of CD1 (Weekly) From Districts Table 6: Timely Submission Of CD2 (Monthly) By Districts Table 7: Summary Of CD2 Report Performance By Districts Table 8: AFP Surveillance Performance Table 9: Performance Of AFP Surveillance Table 10: Five Year Trend Of Epidemic Prone Diseases Table 11: Five Year Trend Of Incidence Of Reported Cases Of Meningitis Table 12: Case Fatality Rates Of Meningitis By Districts Jan- Dec Table 13: Analysis Of Causes And Deaths Of Reported Cases Of Meningitis Table 14: Case Fatality Rates Of Meningitis Table 15: Containment By District, Table 16: Trend Of Guinea Worm Cases By Districts Table 17: Insecticide Treated Nets (ITN) Distribution By Districts Table 18: Malaria, OPD, Admissions And Deaths Table 19: Trend Of U 5 Malaria Case Fatality Rates , UER Table 20: Summary Of Performance Table 21: TB By Category: Table 22: Case Load Table 23: VCT Centres Table 24: PMTCT Sites Table 25: Case Load By Districts Table 26: Distribution Of Cases By Age Group By Districts Table 27: Trend Of Prevalence Rate (Per 10,000 Population) By Districts Table 28: Treatment Coverage, Surgeries And Clinical Cases Treated, iii

4 Table 29: Results Of Epidemiological Survey Of Villages Sissili And White Volta Table 30: Programme Coverage Table 31: Health Education And Rations For Pregnant And Lactating Women Table 32: Outcomes Of Admissions To Rehabilitation Centres Table 33: Vitamin A Supplementation: Trend Of Performance By Districts Table 34: Results Sentinel Market Survey: Iodated Salt Utilisation Table 35a: Type Of Psychiatric Conditions Seen By Districts Table 35b: Cases Load By Districts Table 36: Summary Of Performance In Reproductive Health Table 37: CYP Coverage Table 38: Trend Of ANC Coverage By Districts Table 39: Supervised Deliveries By Districts Table 40: Postnatal Care By Districts Table 41: IPT-P Coverage By District Table 42: Summary Of VCT/PMTCT Performance In Bolga And Bawku Hospitals Table 43: Timeliness And Completeness Of EPI Reports By District, Table 44: EPI Performance, Table 45: 2004 Antigen Drop Out Rate Table 46: 2004 Results NID Campaigns Table 47: School Health Coverage Table 48: Results Of U5 De-Worming By Districts Table 49: Results Of School De-Worming By Districts Table 50: Summary Of Childhood Diseases (Admissions) Regional Table 51: Trend Of Case Fatality Rates Of Common Childhood Diseases Table 52: Summary Of Health Facilities Table 53: Bed Complements Of Hospitals Table 54: Clinical Conferences: Performance Of Hospitals Table 55: Compliance On Guidelines And Standard On The Management Of Malaria And Diarrhoea In Children Under Five Years Table 56: Client Satisfaction Survey Table 57: Summary For The Upper East Region (All Institutions) Table 58: Regional Hospital, Bolga Table 60: Summary Of District Hospitals Table 61: Summary Of Mission Hospital (Bawku) Table 62: Trend Of Ten Top Causes Of Opd Attendance Table 63: Top Ten Diseases Seen At The OPD, 2004, Regional Summary And District Contributions Table 64: Trend Of Ten Top Causes Of Admission, UER Table 65: Top Ten Causes Of Admissions, 2004, Regional Summary And District Contributions Table 66: Trend Of Ten Top Causes Of Death, UER Table 67: Top Ten Causes Of Deaths, 2004, Regional Summary And District Contributions Table 68: Institution Maternal Death Audits Table 69: Institutional Maternal Death Ratio Table 70: Intra-Regional Outreach Services iv

5 Table 71: External Specialists Services Table 72: Ownership Of Laboratories Table 73: Essential Investigations Table 74: Trend Of Results Of Epi Coverage Survey, UER Table 75: ITN Promotion Table 78: Status Of Chps By Districts Table 79: Internal Projects Table 80: Vehicles Table 81: Motorcycles Table 82: Running & Maintenance Cost (Actual) Table 83: 4 -Wheel Vehicles Table 84: Motorcycle Table 85: Number And Types Of Vehicle Table 86: Makes Of Motorcycles Table 87: Make Of Vehicles Table 88: Accidents Table 89: The List Of Auctioned Vehicles Table 90: Drugs Table 91: Non-Drugs Table 92: Non-Drug Consumables Table 93: Purchases From (Non Drugs) Table 94: Financial Statement Table 95: Expenditure Summary Table 96: Payments Summary Table 97: Summary Of Institutional Indebtedness Table 98:Financial Drugs Table 100: Clinical Medical Officers Table 101a: Distribution Of Nursing Staff, UER, Table 101b: Professional Nurses Table 102: Auxiliary Nurses Table 103: Staff Recruitment Table 104: Promotions Table 105: Wastage Table 106: Implementation Of IST Carried Out At The RHD Table 107: Implementation Rate Of IST At Regional And District Levels In Table 108: Planned/Executed IST Programs By BMCS Table 109: Categories Of Staff Receiving SIST In Table 110: Cost Of In-Service Training Table 111: Trend Of Cost Of IST Table 112: List Of Some Collaborators/Partners Table 113: Financial Statement Table 114: Student Recruitment And Performance (Licensure Exams) Table 115: Population Of Students: Table 116: Below is the Performance Of Students Between Table 117: Finances-DPF Table 118: GOG Admin v

6 Table 119: GOG Service Table 119: Cash Flow Statements Performance Review - Finance Unit Table 120.: Cash Outflows By SOF Table 121: Consolidated Statement Of Revenue And Expenditure By BMC Table 122: Summary Of Exemption Reimbursements Table 123: Funds For Free Maternal Deliveries (July 2003-December 2004) Table 124: Consolidated Statement Of Assets And Liabilities vi

7 TABLE OF FIGURES Fig 1 Map Of Upper East Region... 2 Fig 2 Spot Map Of Health Institutions, Upper East Region, Fig 3: Ownership Of Health Institutions, UER, Fig 5: Trend Of Attack Rates Of Meningitis Fig 6: Trend Of Annual Incidence Of Meningitis Fig 7: Case Fatality Rates Of Meningitis By Districts Fig 8: Five-Year Trend Of Incidence Of Measles Fig 9: Reported Cases (Imported) Of Guinea Worm, Fig 10: Malaria Disease Burden; Malaria Morbidity And Mortality Fig 11: U5 Malaria Cases Fatality Rates By Hospitals, Fig 12: Trend Of U5 Malaria C/F Rates Fig 13: District Treatment Results Fig 14: Cummulative HIV Cases, , Upper East Fig 15: Age And Sex Distribution Of Cases Fig 16: Trend Of Sero-Prevalence By Sentinel Sites Fig 17: Leprosy Elimination: Trend Of Performance By Districts Fig 18: Comparing Well Nourished And Under Weight Children Fig 19: Level Of Stunting And Wasting Among Children Fig 20: Nutritional Status Of Lactating Women Fig 21: Trend Of F/P Performance Fig 22: Trend Of ANC Coverage Fig 23: Trend Of Institutional Supervised Delivery Coverage Fig 24: PNC Performance By Districts Fig 25: Trend Of PNC Coverage Fig 26: Trend Of Safe Motherhood Performance Indicators Fig 27: IPT-P Coverage (3 rd Dose) By Districts Fig 28: EPI Performance, Fig 29: EPI Performance By Districts: PENTA 3 And Measles, Fig 30: Trend Of EPI Performance, Fig 31: EPI Drop Out, BCG-Measles Fig 32: EPI Drop Out Rate, PENTA 1-PENTA Fig 33: Trend Of Institutional Maternal Deaths Fig 34: Institutional Maternal Mortality Ratio Fig 35: Major Causes Of Institutional Maternal Deaths Fig 36:Direct Causes Of Institutional Deaths Fig 37: Trend Of Still Birth Rates Fig 38: Still Birth Rate By Districts In Fig 39: Age Groups Of All Nurses, UER, As At December Fig 40: Age-Groups Of Clinical Nurses, UER, As At December Fig 41: Age-Group Of Public/Community Nurses, UER, As At December Fig 42: Trend Of IST Implementation Rate Fig 43: Category Of Staffs Receiving SIST In Fig 44: Type And Cost Of Trainings vii

8 Fig 45: Trend Of Exemptions Claims Fig 46: Proportion Of Exemptions Claims By Category Fig 47: Cost Per Head Of Exemptions Category Fig 48: Trend Of ADHA Claims viii

9 EXECUTIVE SUMMARY The 2004 Annual Performance Report is the output of the annual review process. The process involved peer reviews in all District Health Administrations, Hospitals and Training Institutions and finally the Regional Performance Hearing which brought together all the BMCs in the region, representatives of the Regional Coordinating Council, Municipal and District Assemblies, NGOs in health, UN Agencies and observer team from Ghana Health Service and Ministry of Health (GHS/MOH) Headquarters. Activities implemented during the year were aimed at addressing the seven strategic objectives of the Second Five Year Programme of Work ( ) and the key concerns or issues identified during the 2003 performance review. These concerns include the following: Poor geographical and financial access to quality health services Serious shortfalls in health professionals High disease burden Stagnating and poor quality public health interventions Low utilisation of clinical services, high maternal death rate, weak management of hospitals. Numerous uncompleted capital projects, poor state of residential and office accommodation including hospitals and health centres Slow scaling up of special initiatives aimed at improving access and quality of health services. These include: CHPS, MHOs, IDSR, ACSD, FACS, SFP, IPT-P, VCT/PMTCT e.t.c. Weak partnership and community participation in health service planning, implementation, monitoring and evaluation. Below are the key achievements during the year: Infant and Child Mortality: There was dramatic improvement infant and child mortality indicators as shown by the 2003 DHS. Infant mortality reduced by 59.8% (from 82 to 33 per 1,000 Live Births) between 1998 and Similarly child mortality reduced by 49% (155 to 79 per 1,000 Live Births between the same period. Expanded Progarmme on Immunisation-Plus (EPI) The following were achieved for the various antigens: Measles = 88.2% Penta 3 = 86.9% OPV3 = 87.1%. Penta1 Penta 3 Drop Out Rate = 11%. Four rounds of NIDs with coverage of over 100% No wild polio isolated from any child ix

10 Significant reductions in the incidence of EPI Target Diseases, for example 39 cases of measles were reported with no deaths in 2004 as against 62 cases in 2003, representing a reduction of about 37.1%. Vitamin A Supplementation: Coverage was about 85.9% De-worming: Under five years coverage was 94.6% and School Children 82.0% Malaria:- The under five malaria case fatality rate reduced from 3.2% in 2003 to 2.5% (21.9% reduction). The ITN distribution was stepped up through support from UNICEF in the Accelerated Child Survival Development programme. A total of 123,034 ITNs were sold to parents for children under five years, giving a coverage of 80% and 36,223 to pregnant, representing 94.2% coverage. Efforts are being made to promote their use. Intermittent Preventive Treatment of malaria in Pregnancy (IPT) was rolled out to all districts in the region by the close of the last quarter of the year. Disease Surveillance: - Training in Integrated Disease Surveillance and Response strategy was carried out in all districts. Timeliness and Completeness of reporting of the weekly and monthly reports of Communicable Diseases improved. Timeliness of weekly reporting (CD1) improved from 77.9% in 2003 to 92% in 2004 and completeness was 100.0% as in Completeness for monthly reports (CD2) equally improved from 98.6% in 2003 to 100% in Timeliness showed dramatic improvement 55.6% in 2003 to 80.6% in AFP Surveillance: Indicators of AFP surveillance equally showed improved. Non Polio AFP rate was 2/100,000 children below 15 years against target of more than 1/100,000 and 88.9% of the stools were collected within 14 days (target (80%). No wild polio was isolated. Epidemics: The region had a major Epidemic Meningococcal Disease epidemic in 1996/1997. However, yearly focal outbreaks continue to occur in some sub-district. The following focal outbreaks were rapidly contained: Epidemic Meningococcal Disease (EMD) in Kassena Nankana East (Late Dec.2003-Mid Jan. 2004) Anthrax at Kassena Nankana District: April 2004 Measles and Anthrax at Bugri-Kuka and Worikambo respectively in Bawku East. May 2004 Rabies at Gagbiri in Garu (Now Garu Tempane district). July 2004 Suspected Yellow Fever in Bawku West district, July (Laboratory result proved case not to be Y/F) Guinea worm: - No indigenous case was seen during the year. The region reported its last indigenous case in Since then all reported cases have been imported from either Northern or Brong- Ahafo regions. A total of 17 imported cases were seen in 2004 as against 23 in All were contained. Leprosy:- Leprosy elimination target of 1 case per 10,000 population was achieved : 1.34 cases/10,000 in 2001, 0.92 case /10,000 population in 2002 and 0.64 case/10,000 x

11 population in 2003 and 0.81/10,000 However, two districts, namely Bolgatanga and Bongo did not achieve the elimination target (1.26/10,000 for Bolgatanga and 1.34/10,000 population for Bongo District) Tuberculosis Key performance indicators dropped in 2004 compared to Cure rate was 76.3% in 2004 against 69.6% in 2003 Case Detection rate was 33.3% in 2004 against 35.0% in 2003 Defaulter rate was 14.4% in 2004 against achievement of 6% in Onchocerciasis:- No recrudescence detected and Ivermectin combined with Abendazole distribution by community members was carried out with a coverage of 66.4%. Lymphatic Filariasis: A coverage of 66.4% was achieved for mass treatment with Ivermectin and Albendazole. A coverage was 63% in About 80 million cedis was made available for institutions for hydrocoele surgeries. Soil-Transmitted Helminthiasis. A mass de-worming of under five year olds and school children was undertaken during the year. The coverage treatment was 94.2% for under fives and 82.0% for school children. HIV/AIDS: - A total of 318 cases reported in 2004 against 339 cases in 2003; this represents a decrease of about 6.2%. As in previous years many health personnel were trained in counselling, prevention and control. STI/partner notification counselling is ongoing; visits were made in search of commercial sex workers in hotels and drinking bars. The two PMTCT centres in Bolgatanga and Bawku hospitals reported a total 11,565 ANC registrants out of which 282 were counselled and tested; 13 were positive, given a prevalence of 4.6%. Mothers and their babies were put Nivaripin. All the six hospitals have VCT centres. A total of 448 clients were tested following counselling out of these 62 were positive, given a prevalence rate of 13.8%. Plans are advanced for rehabilitation works and refurbishment of the VCT centres in all hospitals in the region. Reproductive Health: Modest achievements were made in the following areas ANC was 102 % in 2004 against 101.2% in 2003 Average visits were 3.4 against 3.3 in 2003 Supervised Delivery (Institutional) was 31.9% in 2004 against 23.9% in The following Performance indicators however dropped in 2004 compared to 2003 PNC was 48.4% against 50.2% in 2003 Family Planning 19.3% in 2004 against 22.5% in There were also 47 maternal deaths and maternal mortality ratio of 398/100,000 Live Births in 2004 as against 42 and 248/100,000 Live Births in Clinical Care There was modest improvement in service utilisation in 2004 over xi

12 OPD Per capita was 0.6 in 2004 compared to 0.59 in 2003 Bed Occupancy was 49.7% in 2004 as against 48.2% in 2003 Death rate was 3.4% in 2004 as against 3.6% in 2003, a reduction of 5.6%. 91.5% of all maternal deaths were audited. Health Infrastructure: Physical infrastructure received considerable attention during the year. Twelve (12) projects were approved under our capital investment plan. Technical and financial evaluations were carried out and all awarded to deserving contractors. Works are various stages of completion. The Regional Health Directorate carried out the following: Major rehabilitation/renovations on five (5) senior staff bungalows including Boys quarters. Renovations works at three (2) Health Centres Fumbisi and Kulungugu and minor repair works at Paga Health Centres. Construction of four (4) Community Health Compounds (CHCs) throughout the region. Installation five solar invertor systems for CHO Compounds Procurement of medical equipment: Ten (10) Delivery Beds and ten (10) Blood Pressure Motorola communication equipment installed in three districts (Kassena Nankana, Bolgatanga and Bawku West) bringing the total f districts with equipment to four. Transport: The region procured fifteen (15) motorbikes and received twelve others from motorbikes from HQ. For the first time, an HND graduate was posted to the region as a substantive Regional Transport Officer Drugs and Non-Drug Consumables: Drugs: Tracer Drug Availability was 94.1% in 2004 compared 92.2% in Networth as at 31 st December 2004 was 1,950,253, Non-Drugs: Availability was 89% in 2004 as against 86% in 2003 Networth as 31 st December 2004 was 118,000, Finances: There was improvement in timeliness of financial releases from HQ in 2004 compared On the whole, Cash inflows was higher than expected, for example, Billion was realised in yr 2002, Billion in 2003 and Billion in 2004, these translated in percentages are an increase of 24.2% in 2003 over 2002 and an xii

13 increase of 30.0% in 2004 over All BMCs were reimbursed their exemptions claims The outlook or focus for the year 2005 in the following: 1. Improve geographical access to quality health services Scaling up CHPS Increasing primary health care outreach services Improve Specialist Outreach Services Staff training Strengthening collaboration with communities, private health service providers (for profit and Not for profit including quasi-government) Provision of essential drugs and supplies and equipment 2. Improve financial access Operationalisation of Mutual Health Insurance Schemes in all districts and Municipalities in the region Strengthening the implementation of the exemptions schemes for the poor and vulnerable 3. Public Health Sustain the modest gains made in some public health programmes (surveillance, containment of epidemics, disease control and reproductive and child health) Strengthen the implementation of Child Survival Initiatives: ACSD and FACS, SFP etc Mainstreaming Adolescent Health; orientation and dissemination Adolescent Reproductive Health Policy. Strengthen Safe motherhood, Essential and Emergency Obstetric Care (Improve care of newborn, improved management of labour and pueperium, improved maternal death audits) Scale up and improve quality of IPT-P, VCT/ PMTCT for HIV, including management of STIs) The control of Malaria, TB, HIV/AIDS, Soil transmitted helminthiasis, Lymphatic Filariasis and Onchocerciasis The Eradication of Guinea Worm Disease and Polio. Elimination of Leprosy and Maternal Neonatal Tetanus Health Promotion Strengthen Nutrition Interventions: a. Exclusive Breastfeeding b. Complementary Feeding c. Supplementary Feeding, d. Micronutrient deficiency Control,(Vitamin A, Iodine, Iron, Folic Acid) 4. Clinical Care Strengthen Management of Emergencies and Trauma; Strengthen Quality Assurance xiii

14 QA committees Drug and Therapeutic Committees, Infection Prevention Committees, Maternal Audits, Referrals, Tracer Drug Availability and Non-Drug Consumables Clinical conferences Patients Charter Code of Ethics Code of Conduct and Disciplinary Procedures Specialist Outreach Services Patients satisfaction surveys Training in: Rational drug use Standards of pharmaceutical care Standard treatment Guidelines Strengthen Hospital Improvement Management. 5. Human resource development and management Training o In-Service, o Expanding intake of Community Health Nurses Training School o Scaling up Health Aides Training o Enrol Nurses training to started this year Monitoring and supervision Staff motivation, attraction and retention Staff re-distribution to needy areas 6. Health Infrastructure and support services Completion of all on-going projects Rehabilitation of Existing structures Construction of CHPS Compounds Provision of Residential Accommodation Continue upgrading of three district hospitals:- Zebilla, Bongo and Sandema Procure radio communication equipment for the two remaining districts:- Bongo and Builsa districts. 7. Strengthening Health Information Management System Training xiv

15 Use of information for planning and implementation Monitoring and supervision 8. Financial Management in Budget Management Centres Training in ATF rules/ FAAR, BPEMS, new Procurement Act, Internal Audit Agency Act Internal Control mechanisms Timeliness and completeness of financial reports Prompt response to audit reports Improving Exemptions implementation IGF 9. Improving monitoring and supervision Facilitative supervision On the spot coaching and on-the-job training. 10. Collaboration Strengthening linkages with District Assemblies & decentralised departments Collaboration with NGOs in health Collaboration with communities Strengthen partnership with private Mission and Private for-profit service providers Collaborate with quasi-government service providers Strengthen Regional, District and Institutional Health Committees to support health service delivery xv

16 CHAPTER ONE 1.0 INTRODUCTION This report is a summary of the policy thrust, priorities, key activities, achievements and constraints in 2004 and outlook in Similar to the previous year, this report is the output of the annual review process. The process involved dissemination of guidelines to all Budget and Management Centres (BMCs), peer review process in all District Health Administrations, Hospitals and Training Institutions and the finally the Regional Performance Hearing which brought together all the BMCs in the region, representatives of the Regional Coordinating Council, Municipal and District Assemblies, NGOs in health, UN Agencies and observer team from Ghana Health Service and Ministry of Health (GHS/MOH) Headquarters VISION The Vision of the Ghana Health Service is A society in which preventable diseases and avoidable deaths are kept to the barest minimum and everywhere every citizen has access to quality driven, results oriented, close-to-client focused and affordable health service by a well motivated workforce. Within the context of the GHS Shared Vision, we look forward to a future Regional Health Service with competent, committed and motivated health teams providing quality, affordable and client-focused services, which empower individuals, households and communities to take individual and collective responsibilities for their own health and development PROFILE OF REGION. The Upper East Region is located in the north-eastern corner of the country between longitude 0 and 1 West and latitudes N and 11 N. It has two international boundaries; namely Burkina Faso to the north and the Republic of Togo to the East. Peoples of these three countries share so much in common: language, socio-cultural and belief systems. There is intense cross border movement of people, goods and services at these borders. The challenges of disease surveillance and control in particular and health service delivery in general arising out of this geo-physical and social cultural associations cannot be over-emphasised. Surface area of the region is 8,842 sq.km (about 3.7% of the country). Rainfall short and scanty ( mm p.a) and long dry season with dry harmattan winds and hot periods 40 o C. Population from 2000 census is 920,089 (this about 4.8% of total population of country) Growth rate 1.1% Projected Population for 2004 is 961,246. Density 108 people/sq.km, range and compare national average of 77 Population is largely rural (87%). 1

17 Settlement pattern is highly dispersed in 911 communities Portable water coverage is about 66% in 2002 (national 44%), range 39 (Bolga 96%-Bawku West) Five main languages are spoken in the region (Gurune, Kusal, Kasem, Buili and Bisa Map of Upper East Region Burkina Faso Upper West Region Kassena-Nankani Builsa SANDEMA NAVRONGO BONGO BOLGA Bongo Bolgatanga ZEBILLA Bawku West BAWKU Bawku East Togo Northern Region Capital Towns District Bawku East Bawku West Bolgatanga Bongo Builsa Kassena-Nankani N Kilometers W E S Fig 1 Map of Upper East Region 2

18 Table 1: Target Populations GHANA HEALTH SERVICE, UPPER EAST REGION 2004 Total Population, Target Populations, and Sq. Km per Dist. BAWKU BAWKU BOLGA BONGO BUILSA KASSENA REGION TARGET POP. EAST WEST NANKANA TOTAL Children 0-11 months & Exp Pregnancy (4%) 12,868 3,368 9,562 3,255 3,150 6,247 38,450 Children 0-59 months (16%) 51,471 13,474 38,248 13,019 12,600 24, ,799 WIFA (24%) 77,206 20,211 57,372 19,529 18,899 37, ,699 TOTAL POP. 321,691 84, ,050 81,369 78, , ,246 Square Km per District 2,067 1,009 1, ,205 1,658 8,842 Pop/Sq. Km DISTRICT NO OF COMMUNITIES NO. OF SUB-DISTRICTS BAWKU EAST BAWKU WEST BOLGATANGA BONGO 53 6 BUILSA KASSENA/NANKANA Administration Region is divided into 6 administrative districts and 42 health sub-districts. Two new districts were created towards end of the year. These are Talensi-Nabdam from Bolgatanga Municipal, and Garu-Tempane from Bawku East Municipal, bringing the number of districts to eight in the Region.. The region lies within the Meningitis Belt of Africa. This belt is made up 21 countries with a population of 250 million in the age group 2-29 years. This is the most vulnerable group with respect to CSM epidemics. Focal outbreaks and sometimes very widespread and devastating epidemics are commonplace events in the region each year. The Region also lies within the Savana blinding onchocerciasis belt of West Africa. Before the inception of OCP, blinding rates from onchocerciasis were as high as 10% in some communities. Even though the disease is practically controlled, the flies still pose serious nuisance to farming communities along the fertile river basins. In addition to mass distribution of ivermectin to communities with residual infections, we are also conducting active epidemiological surveillance for early detection of any recrudescence of the disease. Economic Activities Compounds are surrounded by relatively small farmlands. Crops grown year in and year out on these small farmlands include cereals (millet and guinea corn), groundnuts and onions. Rice and tomatoes are cultivated on both small and large scale using two irrigation 3

19 schemes (Tono and Vea Dams) and about 400 smallholder dams and dugouts. Animal rearing is also a major occupation of the rural population. Table 2: Health Status Indicators Indicator Regional Performance National Infant Mortality Rate (per (DHS, 2003) 1,000 LB) U5 Mortality Rate (DHS, 2003) Maternal Mortality Ratio (NHRC, 1992) 214 (DHS, 1993) Total Fertility Rate (DHS, 2003) U5 underweight 32% 22% (DHS, 2003) Table 3: Summary of Ownership of Major Health Facilities Govt Mission Type of Institution Total Institutions Institutions Private Inst Regional Hospital District Hospitals Health Centres Clinics

20 5 Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ Ñ KN DIST BUILSA DIST BOLGA DIST BAWKU WEST BAW KU EAST BONGO DIST Dist Boundary Bawku East Bawku West Bolgatanga Bongo Builsa Kassena-Nankani Roads Type of Institution Ñ Reg Hospital Ñ District Hospital Ñ Health Centre Ñ Clinic Uedata.shp Kilometers N Spot Map of Health Institutions, Upper East Region, 2004 Fig 2 Spot Map of Health Institutions, Upper East Region, 2004 $ $ $ $ $ $ $ $ $ $ $ $ BONGO DIST BAW KU EAST BAWKU WEST BOLGA DIST BUILSA DIST KN DIST District Bawku East Bawku West Bolga Bongo Builsa Kassena/Nankana Type of Ownership Gov't Inst $ Mission Inst N Ow nership of Health Institutions, UER, 2004 Fig 3: Ownership of Health Institutions, UER, 2004

21 1.3. MAJOR CONCERNS AT THE BEGINNING OF THE YEAR 1. Poor geographical and Financial Access Geographical Access Population within 8km H/F is about 61% CHPS: Scaling Up facing serious challenges o Slow pace of construction of Community Health Compounds (CHSs) o Logistics including motorbikes o Inadequate numbers and Commitment of staff Dispersed settlements pattern of population/communities Poor road network Referral systems poor Seasonal floods with many riverine communities inaccessible during the wet season Poor communication network; no telephones network in some districts Financial Access The region is the poorest among the ten regions of the country with about 88.2% population leave below poverty line as shown below Incidence of Poverty by Regions (1999, GLSS) Percent below Poverty line UER UWR NR CR ER VR BAR Region AR WR GAR NATIONAL Fig 4: Incidence of Poverty by Regions (1999, GLSS) 6

22 Difficulties in Implementing the Exemptions: Lack of uniformity in implementation Inadequate funding and late release of funds Delay and irregular release of funds Abuses by some patients and health personnel Difficulty in identifying paupers and declaration of wrong ages Poor public awareness Poor staff attitude towards clients/patients Operationalization of NHIS Poor coordination Start up funding - inadequate Low awareness among both service providers and the general public Readiness of Health facilities 2: Human Resource for Health Inadequate numbers of health personnel of all grades Serious shortfalls of numbers of health professionals and specialists. Mal-distribution Difficulty in retaining products of the health training schools (4) in the region, Refusal of postings High attrition rate of health professionals due to Push and Pull Factors Ageing health professionals 3: High Disease Burden Malaria: Highest Cause of morbidity and mortality 40-50% OPD 25-50% Institutional admissions 10-40% Hospital Deaths Frequent due to Epidemic prone diseases: CSM epidemics (1983/84, 1991, 1996/7), Yellow Fever in 1996, Anthrax almost yearly, Cholera (1991, 1998) TB: Low case detection and cure rates and high defaulter rates HIV/AIDS: Rising incidence: Stigmatisation of PLWHAs Environmental/water-related diseases Guinea Worm Onchocerciasis ( Blackspots and possibility of recrudescence Lymphatic Filariasis Schistosomiasis and Soil-transmitted heminthiasis Rising Incidence of Non-Communicable Diseases: CVD including hypertension Diabetes, Bronchial Asthma Substance abuse and other mental illnesses RTAs 7

23 High incidence of: Protein Energy Malnutrition (PEM) Iodine Deficiency Diseases (IDD) Vitamin A Deficiency (VAD) Anaemia (Children and Pregnant Women) 4. Public Health Interventions Stagnating public health service coverage Poor Essential Obstetric Care Low supervised delivery and PNC coverage Weak involvement of males in Safe Motherhood programme Poor quality of public health service (e.g. high EPI drop out rates, high TB defaulter rates etc Poor social mobilization strategies Weak and inappropriate communication strategies 5: Clinical Care Poor internal management of health facilities Low utilisation of clinical services (OPD per capita, Bed occupancy etc) High institutional maternal deaths Poor quality of maternal death audits and clinical conferences Weak management of emergencies, especially obstetric emergencies and RTA Poor and non-functional QA systems in health facilities Poor specialist outreach services Indequate and obsolete equipment 6: Health Infrastructure and Capital Investment Numerous uncompleted capital projects Health facilities and residential accommodation in serious state of disrepair Inadequate staff accommodation Bongo, Sandema and Zebilla hosipitals are yet to be upgraded to District Hospital status Bawku Hospital needed urgent rehabilitation and refurbishment. The infrastructure of the Regional Hospital do not befit the status of secondary referral centre Inadequate equipment Most of the available equipment are obsolete or outdated or broken down 7: Scaling Up of Special Initiatives CHPS Community Health Planning and Service ACSD-IMCI P-Plus, EPI-Plus and ANC-Plus IDSR Integrated Disease Surveillance and response Supplementary Feeding Programme and Nutrition Rehabilitation Centres 8

24 8: Weak Management of Health Services Poor supervision at all levels Weak human resource, financial, transport, logistics management all levels Weak health Information Management systems 9: Partnership and Community Participation Weak collaboration with District Assemblies and Health related MDAs Poor co-ordination of activities of NGOs in health High level poverty militate against community participation Beliefs and socio-cultural practices affecting health-seeking behaviour 10: Coordination Poor Planning and Coordination of programmes between Regions and National Programme Managers / Coordinators. 11: Cash flow: Late release of funds from Headquarters to meet implementation dead lines. Short falls in cash flow against the approved budget 1.4. POLICY THRUST The strategic objectives outlined in the 5 Year POW II The pro-poor agenda as outlined in the GPRS and the Framework of Health response to the GPRS. The regional agenda or priorities set for 2004 following the performance review Strategic priorities recommended from the Health Summit The Details are: Increasing geographical and financial access to health care Improving quality of health care Improving efficiency Improve collaboration and partnership Increasing financial resources for health service delivery Bridging equity gaps in access to quality services Ensuring financial arrangements that protect the poor. Priority health interventions (priority diseases and health interventions etc.) 1.5. PRIORITIES 1. Improving Geographical and Financial Access Rolling out CHPS Strengthening outreach services (including specialists outreach services) Streamlining implementation of the exemptions policy Facilitate and prepare facilities/staff for the NHIS 9

25 Collaboration with other health service providers (quasi-, private, traditional), District Assemblies and decentralised departments to improve access to quality health services 2. Surveillance and Disease Control Strengthening surveillance systems for early detection, prevention and containment of epidemics (EMD, YF, Cholera, Anthrax etc) Rolling out IDSR Improving strategies and building capacity to eradicate, eliminate and control priority diseases;- Eradication: Guinea worm and Polio Elimination: Neonatal tetanus, Leprosy and Lymphatic filariasis Control: Malaria, TB, HIV/AIDS, Soil transmitted helminthiasis Emerging non-communicable diseases (Diabetes, Hypertension etc) Oral health Primary Eye Care Mental Health 3. Reproductive and Child Health Strengthening reproductive and Child Health Initiatives Safe Motherhood including strengthening essential and emergency obstetric care (EOC) Strengthening and Scaling up Child survival Initiatives (NIDS, SIAs, ACSD, FACS, SPF, Nutrition Surveillance, Vit A and Iodated Salt programme etc) Mainstreaming Adolescent Health Strengthening the School health programme 4. Improving Clinical Care Improving management of emergencies and trauma Improving Quality Assurance Systems in health facilities Improving Performance management in hospitals Specialist Outreach Services (Intra and inter-regional and district) Improve laboratory and diagnostic services 5. Improving Human Resource Management Pre, post and In-Service Training Programme Expansion of intake and quota of health training institutions Motivation/Incentives to attract and retain health professionals Advocacy for support by Assemblies, NGOs. Ensuring equitable distribution of available human resource for health 6. Improving Support Services Estates (Physical infrastructure) including Completion of uncompleted projects Rehabilitation of existing staff accommodation and offices 10

26 Collaboration with RCC/DAs for accommodation Improving communication network Transport: Carry out regular PPM Equipment: Repair and acquisition of new equipment Procurement: Adherence to procurement procedures and plans 7. Scaling Up Special Initiatives Community-based Health Planning and Services (CHPS) NHIS:- Mutual Health Organisations Accelerated Child Survival and Development Programme (ACSD) Supplementary Feeding Centres Food Assisted Child Survival programme (FACS) Intermittent Preventive Treatment of Malaria in Pregnancy (IPT-P) Integrated Disease Surveillance and Response (IDSR) 8. Building Management Capacity of BMCs: Facilitative Supervision Human Resource management and development Financial management Compliance with ATF, FAA, IAA rules and regulation Internal Controls Capacity building of district financial and non-financial managers Ensure prompt financial reporting for decision making Estate/transport/equipment Health Information Management Improve quality of data collection at all levels Build capacity for in-depth analysis of data for decision making Expand scope of data collection and analysis at all levels to service providers 9. Promoting Partnerships for Health Active involvement of other MDAs, NGOs, Civil society and communities in planning, implementation and evaluation of health services SUMMARY OF KEY ACTIVITIES The following key activities were undertaken 1. General Monitoring and facilitative supervisory visits and feedback on key findings and decisions at all levels Technical and management meetings at all levels (weekly, monthly quarterly etc) Regional, District and Facility In-House Health Committee meetings Review of 2003 Performance Drawing of MTEF Need Based Plans and Budgets 11

27 Drawing/distribution of guidelines and standards End of year Awards for deserving staff Celebration of first Anniversary of the GHS launch. 2. Improving Access Community Health Planning and Services (CHPS) Strategic, programatic, CHO and Volunteer training and placement of CHOs at completed zones Construction of CHPS Compounds Procurement of logistics including motorbikes for CHOs, Mutual Health Insurance Scheme Set up and strengthened Regional Health Team Sensitisation (Health workers and general public) Training of health service providers Monitoring and supervision of schemes throughout the region Outreach services Inter and Intra regional conduct of outreach services and specialist services to the region Exemptions Public education on exemptions facilities carried out Claims submitted by BMCs, validated by the Regional Team and payments made 3. Surveillance and Disease Control Roll out training on IDSR Training of Community Based Surveillance Volunteers(CBSV) Conduct of core and support functions of surveillance AFP surveillance (Active and passive) District Peer Review of AFP Surveilance Case based-investigation of epidemic prone diseases Outbreak/epidemic containments Control of priority diseases: Malaria, Tuberculosis, HIV/AIDS, Guinea worm, LF, Onchocerciasis, Schistosomiasis and soil-transmitted helminthes etc Malaria Training in case management Rolling out IPT-P training in all districts Distribution and promotion of ITNs Environmental Sanitation Clean-up campaign by Assemblies etc. Public education 12

28 Tuberculosis Monitoring and supervision of DOTs centres Half year review meetings of Districts and Institutional coordinators Provision of drugs and logistics to centres Refresher training for DOTS centres staff Quality Control of TB microscopy Quarterly Cohort analysis HIV/AIDS Implementation of VCT/PMTCT in five hospitals Training of Nurses and Midwives in STI Training of health staff on VCT/PMTCT Sensitization of opinion leaders and chiefs and the general public Support PLWHA meetings and income generating activities Conduct of 2004 sero-surveillance survey Lymphatic Filariasis (LF) Albendazole and Ivermectin drug combination mass distribution Free Hydrocoelectomy Onchocerciasis Active epidemiological surveys Public education Schistosomiasis and Soil-transmitted Helmintheses Urinary and Intestinal Schistosomiasis Hookworm, round worms etc 4. Reproductive and Child Health Reproductive Health Services Routine ANC, PNC, FP Conduct of safe deliveries including assisted and C/S Training and conduct of Maternal Death Audits Emergency obstetric care Training in Safe Motherhood Clinical Skills and Health Education Training of TBA supervisors Training and distribution of SP for IPT-P programme in all districts Post-partum Vit A Supplementation VCT/PMTCT Special STI Clinics Child Survival activities: Scaling Up ACSD EPI Plus Routine Immunisation 13

29 NIDs Measles SIAs Vitamin A Supplementation Mass De-worming (pre-school) IMCI Plus Treatment, distribution and promotion of ITNs Training in Management of children with malaria, diarrhoea, ARI in health facilities and homes Promotion Breastfeeding, complementary feeding, growth monitoring Promotion of the use of Iodated salt School Health Registration and Screening of school children De-worming of school children Health education talks Nutrition Nutrition surveillance (Growth monitoring etc.) Monitoring and supervision of supplementary feeding centres Monitoring and supervision of nutrition rehabilitation centres Training in anaemia control and prevention Provision of micro-nutrients Nutrition education 5. Health Promotion Public education on epidemic prone diseases Launching of Special Days Community Durbars 6. Quality Assurance / Clinical Services Provision of 24 hour OPD services Provision of out and in patient care Management of emergencies Conduct of client satisfaction surveys Maternal death audits and mortality conferences Training in infection prevention and control Survey of compliance of treatment guidelines Specialist Clinical Care Outreach services 7. Human resources Development and Management Pre service training of Nurses (4 training schools), Laboratory Assistants and Health Aides In-service training: Structured and Remedial training of all categories of all staff Post Basic / Post Graduate training for various cadres of health workers 14

30 Promotion and upgrading of health staff Staff posting and re-distribution Motivation / Incentives (awards, ADHA, deprived area allowances) Maintenance of staff accommodation, cars on hire purchase, maintenance allowance etc. 8. Support Services Estate Completion of uncompleted projects Rehabilitation of Residential and Office accommodation Upgrading of health facilities Construction of CHPS compounds Transport management Fleet management PPM and repairs Interview and recruitment of drivers Auction of unserviceable vehicles Procurement and distribution of motorbikes and bicycles Equipment Management Inventory taking PPM Cold Chain Procurement of Medical Equipments, Computers and Accessories Stores and Supplies Management Procurement and distribution of drugs and non-drugs consumables Drug quality monitoring Stock taking 9. Financial Management Training on financial management for non-finance managers Conducted Regional financial validation of all BMCs Sensitization of RHMT and DHMT members on the FA Act, the procurement Act and the IAA Act Monitoring and supervision of all BMCs in the region Routine Audit inspection Special Audit inspection Pre-inspection of procurements Facilitation of audit query responses 15

31 CHAPTER TWO 2.0. SERVICE DELIVERY 2.1. PUBLIC HEALTH Integrated Disease Surveillance and Response (IDSR) The roll out training plan of IDSR was successfully carried out in all six districts. A total of 239 health workers were trained from all six districts. The course content included the core functions of surveillance: Case detection or identification Recording and reporting Analysis and interpretation of data Case investigation Response/action Provision of feedback Evaluation and improvement of the system. Timeliness and Completeness of Surveillance Reports. Table 4: Timely and Completeness of CD1 returns by Districts Districts Reporti ng sites Expe cted Timel y receiv ed 2003 Timel y receiv ed 2004 % Time ly 2003 % Time ly 2004 %Complete ness 2003 Bawku East Bawku West Bolga Bongo Builsa KND Region %Completene ss 2004 Over 90% of CD 1 reports were timely received in 2004 as against 77.9% in The target of 80% was achieved by all districts in

32 Table 5: Five-Year Trend Summary of CD1 (Weekly) from Districts Year Timeliness Completeness Significant improvement in terms both timelines and completeness of reporting was made during the year under review. Table 6: Timely Submission of CD2 (monthly) by Districts Districts Reporti ng sites Expec ted Timel y receiv ed 2003 Time ly receiv ed 2004 % Time ly 2003 % Time ly 2004 Complete ness 2003 % Bawku East Bawku West Bolga Bongo Builsa KND Region Completen ess 2004 % Table 7: Summary of CD2 report performance by Districts Year Timeliness Completeness Timeliness and completeness of CD2 reports were 80.6% and 100% respectively in 2004 as against 55.6% and 97.2% in Only two districts, namely Bawku West (66.7%) and Kassena Nankana (75%) did not achieve the recommended target of at least 80%. 17

33 AFP Surveillance: The table below shows AFP surveillance performance during the year. Table 8: AFP Surveillance Performance District Expected AFP Reported 2 stools within 14days Bawku East Bawku West Bolgatanga Bongo Builsa KND Region days Followup Nine (9) cases against the expected 4 were seen. However Builsa district was silent during the whole year. Table 9: Performance of AFP surveillance District Expected Reported 2 Stool specimens with 14 days of onset % Non polio AFP rate Outcome Bawku E Discarded Bawku Discarded W Bolga Discarded Bongo * Builsa KND Discarded Region *One discarded while one is pending Summary of Achievements. All planned visits (quarterly) were carried out. IDSR roll out training carried out in all districts AFP Surveillance targets (stool specimen with 14 days, non-polio AFP rate) achieved 18

34 Standard case definitions (SCD) were widely used, suspected cases followed up promptly and data analysis done at most levels Epidemic Prone Disease Focal Disease Outbreaks. Six different outbreaks were reported during the year 2004 in three districts. All were thoroughly investigated and rapidly contained. They included: Epidemic Meningococcal Disease (EMD) in Kassena Nankana East (Late Dec.2003-Mid Jan. 2004) Anthrax at Kassena Nankana District:- April 2004 Measles and Anthrax at Bugri-Kuka and Worikambo respectively in Bawku East. May 2004 Rabies at Gagbiri in Garu (Bawku East district) - July 2004 Suspected Yellow Fever in Bawku West district - July (Laboratory result proved case not to be Yellow Fever) Table 10: Five year Trend of Epidemic Prone Diseases Disease Meningitis Cholera Yellow Fever Measles Anthrax (1 death) Wild Polio MENINGITIS/CSM-EMD Meningitis especially meningitis caused by Neisseria meningococcal meningitides (Epidemic Meningococcal Disease- EMD) is a major cause of serious epidemics in the region. Major epidemics occur in 8-10 year cycles; the last major epidemic was in 1996/7. Yearly focal outbreaks occur each year. The area of frequent outbreaks is enclave involving three contiguous sub-districts in three adjacent districts, namely Kassena-Nankana East in Kassena Nankana District, Sumburugu in Bolgatanga District and Zorkor in Bongo district. The emergence of epidemics since 2001 caused by sero-type W135 in neighbouring Burkina Faso poses serious challenge to our surveillance and containment preparedness. The current vaccine is effective against sero-types A & C. The vaccine against W135 is 19

35 expensive and not readily available. Thus the mainstay of prevention and control of W135 is early detection and effective case management. Table 11: Five year Trend of incidence of reported cases of Meningitis Year Pop Cases Attack Rate (100,000 pop) , , , , , Trend of Attack Rates of Meningitis AR (per 100,000 Pop) Attack Rate Threshold Year Fig 5: Trend of Attack Rates of Meningitis Annual Attack rates of per 100,000 occur during epidemic periods in Meningitis Belt of Africa. In 2001, 2002 and 2004 there were focal outbreaks and thus rates of over 50/100,000 were reported. Trend of Annual Incidence of Meningitis No. Cases /7 Epidemic Year Fig 6: Trend of Annual Incidence of Meningitis 20

36 Table 12: Case Fatality Rates of Meningitis by Districts Jan- Dec 2004 Districts Cases Deaths Case Fatality Rates % Bawku East Bawku West Bolgatanga Bongo Builsa KND Region Case fatality rates were unacceptably high in three districts (Builsa, Bawku East and Bawku West). Kassena Nankana District however recorded the lowest (far below the acceptable rate of 10%) despite the focal outbreak experienced in one of its sub-districts. Case Fatality Rates of Meningitis by Districts C/R (%) C/R Threshold Bawku East Bawku West Bolga Bongo Builsa KND Region District Fig 7: Case Fatality Rates of Meningitis by Districts With the exception of Kassena Nankana District, case fatality rates exceeded the acceptable level of 10% for EMD. Most of the deaths might be due to Streptococcal pneumonia. Meningitis due to Strept. Pneumonia has been shown to be more virulent than the other causative agents of meningitis. 21

37 Table 13: Analysis of causes and deaths of reported cases of Meningitis. Districts Nm Type A Strep P Nm Type W135 H. Inf C D C D C D C D Bawku East Bawku West Bolgatanga Bongo Builsa KND REGION Three hundred and four cases (304) lumbar puncher (CSF taken) out of the five hundred and fourteen cases (514) during year; this gives rate of 59.1%. One case of Nm Type W135 was isolated from Bolgatanga Table 14: Case Fatality Rates of Meningitis Causative Agent Cases Deaths Case Fatality Rate (%) Nm Type A Nm Type W Strep. Pnuemonia Haemaphilus Influenza Streptococcal Pneumonia continues to be a significant cause of meningitis (about 17% of cases) with very high cases fatality rate (27.6%) in the region. Most cases are seen during the cold period of the dry season and most patients are brought in unconscious state. MEASLES The incidence of measles continued to decline since the introduction of measles Supplementary Immunisation exercise (SIAs) 22

38 Five-Year Trend of Incidence of Measles 2000 No. Cases SIAS Year Fig 8: Five-Year Trend of Incidence of Measles The supplementary immunisation exercises since 2002 have in deed paid off as shown by the reduction in annual incidence of measles. All cases seen were investigated and blood specimens taken to Nogouchi for confirmation. Out of the 27 specimens that were submitted to Nogouchi, 13 (48.1%) were positive for measles. ANTHRAX Yearly outbreaks of Anthrax continue to be a challenge. The excellent collaboration between us and staff of the Vertinary Division of Ministry of Food and Agriculture contributes significantly to early containment of outbreaks of Anthrax in the region. YELLOW FEVER One suspected case was promptly investigated and found not to be Yellow Fever. Case based investigations of all suspected cases were vigorously conducted. ACHIEVEMENTS 1. Focal outbreaks of the following were rapidly contained Epidemic meningococcal Disease (EMD or CSM) in Kassena Nankana East Subdistrict Measles in Bugri-Kuka sub-district of Bawku East District Anthrax in Kassena Nankana and Bawku East District Rabies in Bawku East District 23

39 2. IDSR Roll out training successfully carried out in all districts Priorities for 2005 (Surveillance and Control of Epidemics) Organise IDRS training for the rest of facility staff that were not trained. Strengthen collaboration with partners ( MOFA, PHR, WHO, NSU, LABORATORY UNIT, GBC,) Support districts to do case review, data analysis and interpretation and use of data for decision-making. Hold regular quarter review meetings with district staff Strengthen capacity building of districts in surveillance activities Strengthen monitoring and supervision to districts Prompt districts on 60 days follow up including clinician reports Organise data management training for district surveillance officers. Collate, analyse and send regular feedback of surveillance reports all levels Give Technical support to low performing districts Train district officers on report writing Control of Other Priority Diseases GUINEA WORM Guinea worm cases seen over the past five years in the region have been imported from the Northern and Brong-Ahafo Regions Key activities included surveillance (by both health personnel and volunteers), containment/management of cases, community sensitisation and education and retraining of volunteers. Active case search was carried out in February, March, October and November Supervision of volunteers in all communities and follow up to communities that reported cases was carried out. Table 15: Containment by District, 2004 District No. Cases Number of cases meeting International Standards for Intensified Case Management Case Containment Intensified case Containment No. % No. % No. % Bawku East Bawku West Bolga Bongo Builsa KND Total

40 A total of 17 cases were reported from all districts except Bawku West. All were contained. Table 16: Trend of Guinea Worm Cases By Districts District Bawku East Bawku West Bolga Bongo Builsa KND Total Reported Cases (Imported) of Guinea Worm: Cases Year Fig 9: Reported Cases (Imported) of Guinea Worm, Achievements Maintained zero indigenous cases Capacity built for both health staff and village volunteers Dialogue and collaboration with District Assemblies and Community Water and Sanitation Agency for Safe Water Supply Priorities For 2005 Maintain zero non-indigenous cases for the region Encourage DDHS to provide funding for guinea worm programme Support districts to carry out effective supervision Intensify educational activities in all communities reporting cases Strengthen collaboration with District Assemblies, CWSA and GWCL and other Agencies. 25

41 MALARIA As stated earlier key activities carried out were training of health workers in case management, distribution and promotion of ITNs, re-treatment of ITNs, public education and environmental sanitation campaigns in collaboration with Municipal and District Assemblies. IPT-P implementation also fully took off in all six districts during the year. The dosing of pregnant women with SP was preceded by training. Funding was supported by UNICEF and Global Fund in four and two districts respectively. Table 17: Insecticide Treated Nets (ITN) Distribution By Districts District Children U 5 Pregnant Women Qty Dist Coverage (%) Qty Dist Coverage (%) Bawku East 27, , Bawku West 18, , Bolgatanga 34, , Bongo 15, , Builsa 11, , KND 15, , REGION 123, , Table 18: MALARIA, OPD, ADMISSIONS AND DEATHS Year OPD Attendance (% of total) Admissions (% of total) Deaths (% of total) Except OPD attendances, proportion of admissions and deaths from malaria has been on the increase since In 2004, malaria accounted for 54% of all OPD attendances, 35.2% of all admissions and 20.9% of all deaths. Except for OPD attendances, these figures represent increases in 2004 against

42 Malaria Disease Burden: Malaria Morbidity and Mortality Proportion (%) of Total Cases OPD Attendance Admissions Deaths Year Fig 10: Malaria Disease Burden; Malaria Morbidity and Mortality 27

43 Table 19: Trend of U 5 Malaria Case Fatality Rates , UER Hospital Adm Deaths C/F Adm Deaths C/F Adm Deaths C/F Adm Deaths C/F Bawku 1, , , , Zebilla Bolga Regional Bongo Sendema S Navrongo , , , Total 3, , , , Only Zebilla Hospital in Bawku West District achieved the national target case fatality rate of 1.2%. The facilities with the worst performance were the Bolgatanga Regional Hospital (4.8%) and Navrongo Hospital (3.4%) U 5 Malaria Case Fatality Rates by Hospitals, 2004 C/F (%) Bawku Zebilla Bolga RH Bongo Sandema Hospital Navrongo Total C/F TARGET Fig 11: U5 Malaria Cases Fatality Rates by Hospitals,

44 Trend of U5 Malaria C/F Rate 10 C/F (%) C/F Target Year Fig 12: Trend of U5 Malaria C/F Rates Case Fatality rates reduced by about 21.8% in 2004 over C/F rates for the previous three years (2001 to 2003) were essentially the same. TUBERCULOSIS Concerns at the beginning of the year included the following: Low case detection rate Low cure rates Weak capacity at district and sub district levels In adequate microscopic centres Targets for 2004 Increase treatment success rate from 65% to 75% Increase case detection rate from 35% to 40% < 10% defaulter rate Key Activities Quarterly support visits to DOTS and Microscopic centres Refresher training for 35 health workers at DOTS centres. Five of the six districts also carried out DOTS training Two review meetings held for District and Institutional TB Coordinators. Worked out cohort analysis for 2003 case holding Lab supplies replenished Q/A: Slides picked for blinded rechecking for quality improvement Drugs &logistics collected three times Survey on HIV prevalence in among TB patients on going 29

45 Fig 13: District Treatment Results Table 20: Summary of Performance Indicator Target (%) Cure Rate Case detection Defaulter Rate < Table 21: TB by Category: Year CATEGORY SM+ Rel SM- EP. TB TOTAL % REL CDR

46 Achievements Case Detection Overall Case Detection (Finding) rate was 33.0% against the Regional and National Targets of 40% and 70% respectively. However, Bolgatanga Municipality achieved case detection rate of 63.8%. There was a drop of 5.7% in performance in 2004 (33%) against 2003 (35%). Cure Rate Again, the target of 85% for cure rate was not achieved. Cure rate achieved was 67.3%; this was also lower (3.3% reduction) in 204 against 2003 achievement of 69.6% Challenges Poor performance in 2004 as against previous year Low cure and case detection rates and high defaulter rate Weak capacity at district and sub-district levels Poor community sensitisation Inadequate microscopic centres Outlook for 2005 Strengthen microscopy at both public and private health facilities Start additional DOTS centres at strategic areas Strengthen capacity at both district and DOTS centres Strengthen supervision Pilot Community-based DOTS in two Districts Intensify public education BURULI ULCER Buruli ulcer is: Closely linked to TB Cases in region often traced to the south TB drugs used for management Case management is strictly by DOTS Activities Carried Out Surveillance Treatment using DOTS TOT training for doctor 31

47 Table 22: Case Load District Bawku East Bawku West Bolgatanga Bongo Builsa KND Total Outlook for 2005 Surveillance and continuous case management Public education One medical officer to participate surgery training HIV/AIDS Key Challenges and concerns High level of knowledge not translated into behavioral change How to overcome certain customary practices that fuel the Epidemic e.g widowhood marriages Stigmatization and discrimination still high Link between institutional and community -base care absent Care and support for PLWHA & OVC inadequate Access to ARV not available in region Limited VCT/PMTCT Centres Main Priorities for 2004 Foster collaboration/partnership for community education and sensitization Support formation of PLWHA associations Scale up VCT/PMTCT centres Management of STIs Build criteria for accreditation to access ARV Summary Key Activities/Achievements VCT/PMTCT on going in Bolgatanga Regional Hospital and Bawku Hospitals 24 midwives trained in STI Symdromic Management/introduction to VCT/PMTCT Special STI Clinics in Bolgatanga Regional Hospital and Bawku Hospital Supported 3 PLWHA meetings and income generation Carried out refresher training of 42 nurses on VCT/PMTCT at Bawku Hospital VCT services being kick-started in 3 hospitals. 32

48 Conducted 2004 HIV sero-survey at four sites Partnership for education and sensitization of House of Chiefs &civil society Radio discussions Navrongo Health Research Centre started research protocol on VCT using Lay Counselors in Kassena Nankana Districts with financial support from Ghana AIDS Commission Fig 14: Cummulative HIV Cases, , Upper East A total of 308 cases were seen in 2004 against 339 in This represents a reduction of 9.1% in the number of reported. Age and Sex Distribution of Cases NOT STATED AGE GROUP MALE FEMALE 33

49 Fig 15: Age and Sex Distribution of Cases Over 90% of cases are in the age group years. Females especially in the younger age group are still marginally more affected than males. Trend of Sero-Prevalence by Sentinel Site 6 5 HIV PREVALENCE (%) BAWKU M BOLGA M NAVRONGO YEAR Fig 16: Trend of Sero-Prevalence by Sentinel Sites The region has four sentinel sites; the fourth one, Wiaga representing a rural site was added in The 2004 results were pending at the time compilation of this report. Results of the original three sites are shown above. The Sero-prevalence for Bolgatanga site has been on the increase since Sites at Navrongo and Bawku reported marginal reductions in 2003 as against Blood Screening A total of 5,905 blood donors were screened for HIV. Out of this 151 were positive, giving a prevalence of 2.6%. In 2003, the prevalence among blood donors was 2.7% 34

50 Table 23: VCT Centres District No. No. Prev No. No. Prev Tested Positive Tested Positive Bawku East Bawku West Bolgatanga Bongo Builsa KND Total Table 24: PMTCT SITES Site ANC Regist No No Positive Prev. Counselled Reg. 3, Hospital Bawku Hosp Total 11, Outlook for 2005 Establish 3 more VCT/PMTCT centres Create enabling environment for VCT/PMTCT Increase access to ARV by establishing ARV treatment centre in the region. Staff trainings to implement ART Continue trainings in STI syndromic management Provide technical and co-ordination/partnership role in HIV/AIDS education Strengthen support visits Initiate review meetings with partners and all stakeholders. Link up with NGO/CBO to improve Community Based Care LEPROSY Goal: To sustain elimination target of less than 1/10,000 populations Key Activities Supported Bolga and Bongo Districts to achieve elimination target 35

51 Focused on disability prevention through intensification of awareness creation, case search and case management Capacity building through training for both health workers and community based agents Carried out supervision Held quarterly review meetings Table 25: Case Load by Districts District/ Municipal Brought forward New cases Other additions Total cases Cured RFT/ ODD B/F to 2005 Bawku Bawku West Bolgatanga Bongo Builsa KND Region TABLE 26: Distribution of Cases by Age group by Districts District/Municipal 0 14yrs 15+ Total Bawku Bawku west Bolgatanga Bongo Builsa KND Total A significant number of cases, 17.8% were children below 15 years with most cases (14.7%) from Bongo district and the rest from Bolgatanga. 36

52 Table 27: Trend of Prevalence Rate (per 10,000 population) by districts District Bawku Bawku West Bolgatanga Bongo Builsa KND Region Even though the region as whole achieved the elimination target for the past two years, two districts, namely Bolgatanga and Bongo did not at the close of the year achieve the elimination target. Leprosy Elimination: Trend of Performance by Districts PREV (Per 10,000 Pop) B/EAST B/WEST BONGO BOLGA BUILSA KND REGION PREV TARGET DISTRICT Fig 17: Leprosy Elimination: Trend of Performance by Districts Achievements Elimination target sustained at 0.8 per 10,000 population Support visits were successfully carried out Nerve function assessment was done on all new cases Bongo and Bolga Health Directorate were supported in areas of training and case search activities Review meetings were held District leprosy drugs were available throughout the year 37

53 Outlook for 2004 Provision of anti leprosy drugs Conduct quarterly monitoring and supervision Hold quarterly technical review meetings Increase campaigns/awareness in communities Identify endemic communities and organised volunteers for active case search Submit monthly returns, quarterly written reports and annual reports Intensify collaboration especially at the community level and NGOs Talks on leprosy in various languages on URA Radio FM station LYMPHATIC FILARIASIS Lymphatic Filariasis is a debilitating disease. It is hyperdemic in the region. Control involves the interruption of transmission with annual distribution of Ivermectin and Albendazole. In addition surgical removal of hydrocoels is also aimed at reducing disease morbidity. Table 28: Treatment coverage, surgeries and clinical cases treated, District Registered Pop No. Treated % Hydrocelectomies Elephantiasis Bawku East 353, , , Bawku West 95,028 63, Bolga 215, , Bongo 86,151 59, Builsa 76,492 57, KND 145,748 92, Region 972, , ,299 3,333 ONCHOCERCIASIS The strategy is to interrupt transmission through annual distribution of Ivermectin and Albendazole where Onchocerciaisis and Lymphatic filariasis co-exist and epidemiological surveillance for the early detection of recrudescence. Public education is being undertaken on the nuisance effect of the vector fly. As shown above, a coverage of 66.4% for mass distribution of ivermectin and Albendazone during the reporting period. 38

54 Table 29: Results of epidemiological survey of villages Sissili and White Volta Community Name No. exam No. Positive % Nakong KND Kayoro W KND Achanga B/West Tilli B/West Widnaba B/West Denugu Bawku E Total 1, Five (5) people from two of the six selected communities were positive for microfilarial of Onchocerca volvulus. The prevalence is within acceptable levels. NUTRITION Key Activities Vitamin A supplementation of children 6-59 months and post partum Trained health staff (214) on Anaemia control in pregnancy Conducted training (15 attendants) on Therapeutic dietary management for nutrition rehabilitation centre attendants, Monitored activities of the supplementary feeding programme in 36 feeding centres Monitored activities of the Community Based Nutrition Food Security Project (CBNFSP) in Bongo District Promoted exclusive breast feeding through Baby Friendly Hospital Initiative (BFHI) Promotion the use of iodised salt through surveys, dissemination of results and education. Supplementary Feeding Centres They are 36 in five districts and are under the support of the World Food Programme (WFP). Major activities that took place at the centres within the period include -Daily provision of meals to children 0-5 years (pre-school activities), -Monthly growth monitoring of the children and women (lactating) -Nutrition/ Health Education. Data collected is used to calculate the following: Weight for height (wasting or acute malnutrition) Height for age (stunting or chronic malnutrition) Weight for age (underweight both acute & chronic malnutrition) Body Mass Index (BMI), that is, Weight (kg) / Height (m) ² of lactating mothers. 39

55 Table 30: Programme Coverage District Children Mothers Pregnant Women Lactating B/East B/West Bolgatanga Bongo KND TOTAL Comparing Well Nourished and UnderWeight Children % Bongo Bolga Baw ku East Kassena Nankana Baw ku West Districts Well Nourished Under Weight Fig 18: Comparing Well Nourished and Under Weight Children 40

56 A significant number of the children were found to be underweight as shown in graph above. Level of Stunting and Wasting Among Chn % Bongo Bolgatanga Baw ku East Kassena Nankana Baw ku West Districts Stunted Children Wasted Children Fig 19: Level of Stunting and Wasting Among Children About 29% and 16% of all children were stunted and wasted respectively. The bulk of the malnourished children came from Bolgatanga Municipality. Proportion of the malnourished children who were stunted ranged from 4% in Kassena Nankana District to as high as 65% in Bolgatanga. Wasting ranged from 4% in Kassena Nankana and Bawku West districts to 36% in Bolgatanga. Table 31: Health Education and Rations for Pregnant and Lactating Women District No. Centres H/E Sessions Pregnant-Lactating women No. Received Dry Ration/Month No. at H/E sessions per month B/East B/West Bolgatanga Bongo KND TOTAL (92%) 41

57 Fig 20: Nutritional Status of lactating Women Nutrition Rehabilitation Centres Eight (8) nutrition rehabilitation centres are being supported by World Food Programme (WFP) in the Region (3 in Bawku East, 1 each in Bolgatanga, Bongo, Kassena Nankana, Bawku West, and Builsa Districts. Table 32: Outcomes of admissions to Rehabilitation Centres. District No. Centres Adm Deaths Marasmus Kwashiokor Marasmic- Kwashiokor B/East B/West Bolga Bongo Builsa KND TOTAL Most of the cases admitted were marasmus (84%) and the overall case fatality rate was 2.5%. 42

58 Community Based Nutrition And Food Security Project (CBNFSP) The project is being piloted in four districts in the country. These are: Bongo (Upper Region), Kadjebi (Volta Region), Commenda Edina Aguafo Abrem (Central Region), and Sefwi Wiawso (Western Region). The aimed at testing strategies, models and implementation process that will help build capacities of District Assemblies and communities to enable them identify the causes of malnutrition and help remove these causes and improve upon food security at the household and community levels. Achievements Scaled up to cover up 10 communities Training of 62 Community Based Volunteers in the selected communities Vitamin A Table 33: Vitamin A Supplementation: Trend of Performance by Districts District Cov % (May) Cov % (Nov) Cov % (May) Cov %(Dec) Cov % (Nov) B/East B/West Bolgatanga Bongo Builsa KND REGION One round of was carried out in The coverage for the round was also much lower than previous years coverage. Iodated Salt Table 34: Results Sentinel Market Survey: Iodated Salt Utilisation District Concentration of Iodine (PPM) 0 ppm < 30 ppm 30 ppm B/East (n = 300) 268 (89.3%) 291 (97%) 9 (3.0%) B/West (n= 300) 280 (93.3%) 286 (95.3%) 14 (4.7%) Bongo (n= 300) 243 (78.6%) 293 (94.8%) 16 (5.2%) Builsa (n= 294) 122 (41.5%) 273 (92.9%) 21 (7.1%) The proportion of samples that contained adequate iodine (passed Iodated Salt Test) from the four district Markey surveys ranged from 3 7.1%. This is indeed very grave despite 43

59 the fact a lot of education is on going and most importantly a Law on Iodated Salt had been passed. Outlook for 2005 Intensify monitoring and supervision of nutrition activities at the district level. Prepare and designate at least 8 hospital facilities as baby-friendly and revitalize already existing facilities. Assess activities of already existing facilities Support form and train Mother-to-Mother support groups Advocacy on exclusive breast feeding and appropriate complementary feeding Conduct twice mass vitamin A supplementation of children 6 59 months Conduct sentinel market salt survey Strengthen advocacy on iodised salt usage through radio discussions COMMUNITY PSYCHIATRY Objectives To increase geographical assess to the Mental Health Service To sensitise the public about the effects of drug abuse Key Activities Clinical services at static points Outreach services Mental Health Promotion Talks Home visits Defaulter tracing Counseling Supportive supervision Referrals Training and meeting Table 35a: Type of Psychiatric Conditions seen by Districts Condition B/East B/West Bolga Bongo Builsa KND Total Psychosis Epilepsy Neurosis Subs. Abuse Headaches Others Total About 56.4% of the cases seen were epileptics with about 65% from Bawku East. The next most common cases were headaches with about 96% from Bongo district and the remaining 4% from Builsa district. 44

60 Table 35b: Cases Load by Districts Condition % Change: 2003 and 2004 Psychosis % Epilepsy % Neurosis % Subs % Abuse Headaches % Others % Total % There were increases in psychotics (32%), Substance Abuse (52%) and headaches (110%). As stated earlier almost all cases were reported from Bongo district. However there were reductions in numbers of Neurotics (44%) and Epileptics (33%) Non-Communicable Diseases Concerns Little data on Non-Communicable Diseases Lack of awareness by the public on risk factors that lead to NCD No support for NCDs Strategic Objectives Improve the capacity of health staff to promote healthy life style among general public Increase advocacy for non-communicable diseases Encourage hospitals to establish Non-communicable disease centres Activities Passive surveillance on NCDs Management of NCDs Achievements There were 3,372 cases of hypertension cases 135 with other heart diseases 6,164 rheumatic & joint cases 2,186 accident cases All accounted for 2.5% of new attendants 45

61 Outlook for 2004 Improve data collection for NCDs Lobby for the appointment of a designated officer at all levels Create awareness on risk factors that lead to NCDs Encourage the celebration of NCD-Days Lobby with Regional hospital to revive diabetic and hypertension clinics Encourage BMC heads to budget for NCD activities Encourage monthly health walks Reproductive and Child Health (RCH) Goal: The main goal is to reduce maternal and child morbidity and mortality rates. Objectives To improve coverage and quality of RCH Services. To make reproductive health services accessible and affordable to all. To improve the quality of service delivery through capacity building. Collaborate with other health related agencies improving RH services. Priorities in 2004 Encourage Essential Obstetric Care. Improve newborn care Increase skilled delivery coverage. Improve maternal audit system IPT Introduction Increasing baby friendly facilities in the region. Scaling up of Community -IMCI and training of prescribers in Clinical IMCI Targets Increase F/P Acceptors Rate from 22% to 25% Ensure ANC coverage reaches 95%. Improve on 4 ANC visits Increase skilled deliveries from 23.9% to 50%. Ensure EPI coverage of Penta 3 and measles reaches 85%. Reduce under 5 malaria case fatality rate from 1.5 to 1.2% 46

62 Reproductive Health Table 36: Summary of Performance in Reproductive Health INDICATORS TARGET FOR 2004 ANC 95% (98.6%) (101.2%) (102.0%) Average Visit TT2 + 90% 26,696 (71%) (67.5%) (66.4%) 3 rd Trimester 15% 8621 (22.9%) 7756 (20.3%) 7129 (18.2%) Teenage Preg. <10% 5726 (15.2%) 5994 (15.2%) 6098 (15.5%) Over 35yrs <10% 4643 (12.3%) 4606 (12.1%) 4681 (11.9%) Parity 4+ <20% (28.2%) (28.2%) (27.5%) Supervised Dels 58% 8254 (21.9%) 9094 (23.9%) (31.9%) MMR 53 (340/100,000) 42 (248/100,000) 47 (398/100,000) Still Births 398 (2.5%) 370 (2.2%) 468 (3.8%) PNC 90% (48.1%) (50.2%) (48.4%) F/P 25% 19.80% 22.50% 19.30% FAMILY PLANNING Trend of F/P Performance 30 Cov (%) FAMILY PLANNING PERFORMANCE 0 Fig 21: Trend of F/P Performance COV TARGET Year COV TARGET For the reporting year, the coverage for F/P was 19.3% as against 22% for last year. The target of 25% was also not achieved. 47

63 Couple Years of Protection (CYP) The most preferred method is still Depo Provera followed by Norplant Implants and Male Condoms. The two areas of lower performance were female and oral contraceptives. Table 37: CYP COVERAGE METHOD CYP-2002 CYP-2003 CYP-2004 REMARKS Norigynon Increased Female condoms Decreased Male Condom Increased Orals Decreased Spermicides Increased Depo Provera Increased IUCD Increased Norplant Increased Vasectomy Same Female Sterilisation Decreased Total Improved Short Term Method = Long Term Method = Total = 26,548.1 ANTE-NATAL SERVICES The Antenatal service coverage for the last three years has been high. The region and all districts exceeded the set target. The challenge has been and continue to be the number of visits, parity of four and over, and teenage pregnancy among others. Most pregnant women report during the 2 nd and 3 rd trimesters (ref table 36) Inadequate and poor quality equipment, namely Blood Pressure apparatus and HB reagents at the peripheral service delivery points (outreach, community clinics) also continue to be major constraints. 48

64 Table 38: Trend of ANC Coverage by Districts DISTRICT 2002 % 2003 % 2004 % Bawku East Bawku West Bolgatanga Bongo Builsa KND REGION Ante-natal coverage continued to be very high. All districts except Bolgatanga achieved coverage of over 95%. Trend of ANC Coverage Cov (%) Cov Target Year Fig 22: Trend of ANC Coverage MATERNAL DELIVERY SERVICES Essential Obstetric Care The following is a breakdown of essential obstetric care coverage in the region during the year: Number of facilities conducting deliveries -55 Number of facilities with blood banks -6 Number of C/S done -397 C/S Rate -3.2% Number of vacuum deliveries -246 Number of forceps deliveries -0 Number of facilities with basic EOC -38 Number of facilities offering CEOC -5 49

65 Five of the six hospitals offer Comprehensive Obstetric Care. The C/S rate is unacceptably low. Recommended rate is 15% (WHO). SUPERVISED DELIVERIES The free maternal delivery package started in July A systematic training of midwives in Life Saving Clinical skills supported by UNFPA has been on course since At the close of 2004, over 30 midwives went through the training. TBA supervisors (28) were trained during the year. Institutional Supervised Delivery Coverage was still far below target as shown below: Table 39: SUPERVISED DELIVERIES BY DISTRICTS DISTRICT No % No % No % Bawku East Bawku West Bolgatanga Bongo Builsa KND REGION There was however an improvement, about 33.5% increase, in 2004 performance against This could largely be due to the free maternal delivery package introduced in July Trend of Institutional Supervised Delivery Coverage Cov (%) Year Cov. Target Fig 23: Trend of Institutional Supervised Delivery Coverage 50

66 TBA DELIVERIES TBAs delivered a total of 7,305; this gives a coverage of 19.0% (7305/38,450). POST NATAL CARE Post-Natal Service coverage also continues to be very poor as shown below Table 40: Postnatal Care By Districts DISTRICT No % No % No % Bawku East Bawku West Bolgatanga Bongo Builsa KND REGION PNC Performance by Districts 100 Cov (%) 50 COV. TARGET 0 B/E B/W BOL BON BUIL KND COV TARGET District Fig 24: PNC Performance by Districts 51

67 Trend of PNC Coverage Cov (%) Year Cov Target Fig 25: Trend of PNC Coverage The target of 58% was not achieved. Three districts, namely Bawku West, Bongo and Builsa exceeded PNC set target. Performance of Bawku West and Bongo districts was particularly very encouraging. Trend of Safe Motherhood Performance Indicators Coverage (%) Year ANC SUP. DEL PNC F/P Fig 26: Trend of Safe Motherhood Performance Indicators POST ABORTION CARE Reporting was very poor. Only 151 were registered for PAC during the year under review 52

68 Intermittent Preventive Treatment Of Malaria In Pregnancy (IPT-P) Intermittent Preventive Treatment of malaria in pregnant women using sulphadoxine pyramethamine, started around June 2004 in the region. Two districts namely Bongo and Bawku East are being supported through the Global Fund; UNICEF supports the remaining districts. The drop out rate from first to the third dose is very high. This is partly due to late reporting (second and third trimester) during Ante-natal period. Table 41: IPT-P COVERAGE BY DISTRICT DISTRICT 1 ST DOSE 2 ND DOSE 3 RD DOSE Dewormer Bawku East Bawku West Bolgatanga Bongo Builsa KND REGION IPT-P Coverage (3rd Dose) by Districts Coverage (%) B/East B/West Bolgat Bongo Builsa KND Region District Fig 27: IPT-P Coverage (3 rd Dose) by Districts VCT/PMTCT Two sites namely Bolga Regional Hospital and Bawku Presby. Hospital began the provision of VCT/PMTCT services for Ante-natal clients. The Navrongo Health Research Centre started VCT as pilot project. Lay counsellors and health workers were trained at three sites in the district. 53

69 Table 42: Summary of VCT/PMTCT Performance in Bolga and Bawku Hospitals. No. Reg. No. Pre- NO. No. No. No. ANC test Tested Positive Administered Opting clients counselled for HIV. Niverapine for C/S Reg Hosp. Bawku Hosp. Total Child Health Expanded Programme on Immunization. (EPI) Major Concerns The major concerns at the beginning of the year were: Sustaining gains of the previous year Low and stagnating service coverage Poor quality of EPI data Late submission f reports Collaboration with GES, NGOs, Organizations, and other health related organisations. High drop out and wastage rates Low TT coverage for pregnant women and MNT campaigns (TT SIAs). Irregular and later submission of Cold Chain inventory by districts and region. Activities Carried Out Routine immunization, defaulter tracing and mop-up exercises Conducted EPI coverage survey for year 2003 in all six district Provided cold chain equipments and Vaccine / logistics to districts. Provided feedback to districts on monthly and quarterly basis. Supported districts conduct four (4) successful NIDs and Tetanus Supplementary Immunization Activities. Training district health personnel on EPI policy issues and other activities. Carried out Child Health Week activities. Provided districts with monitoring indicators (charts) and copies of reporting forms. 54

70 Achievements: Table 43: Timeliness and Completeness of EPI Reports by District, 2004 DISTRICT Expected Returns No.Rec d Timely % Timely Total No. Received % Complete Bawku East Bawku West Bolgatanga Builsa KND Region Only Bawku East and Builsa districts achieved the minimum target of 90% for both timeliness and completeness of report. However, all districts achieved 100% completeness of reporting. Table 44: EPI Performance, Target Pop Chn 0-11months No. Imm Achievement Target for 2004 (National) Antigen 4% total Pop (%) BCG 38,450 41, Measles 38, Penta 3 38, OPV3 38, YF 38, TT2+ 38,

71 EPI Performance, COV (%) BCG MEASLES PENTA 3 OPV3 YF TT2+ COV Target-Nat ANTIGEN Fig 28: EPI Performance, 2004 Except two antigens, namely Yellow fever and TT2, targets for all EPI antigens were achieved. EPI PERFORMANCE BY DISTRICTS: PENTA 3 AND MEASLES, 2004 COV. (%) PENTA 3 MEASLES TARGET BE BW BOLGA BON BUILSA KN DISTRICT Fig 29: EPI Performance by Districts: PENTA 3 and Measles, 2004 The Graph above shows Penta3 and Measles coverage by districts for year All districts except Kassena Nankana achieved the national target. 56

72 Fig 30: Trend of EPI Performance, Targets for measles and Penta 3 were achieved in 2002 and The 2004 performance was also an improvement over that of 2003; however, performance stagnated over the three year period. Table 45: 2004 ANTIGEN DROP OUT RATE BCG-Measles OPV 1-OPV 3 Penta 1-Penta 3 DISTRICT TARGET No % No % No % BE 12, BW 3, Bolga 9, Bongo 3, Builsa 3, KND 6, Region 38, EPI DROP OUT: BCG-MEASLES RATE (%) B/EAST B/WEST BOLGA BONGO BUILSA DISTRICT KND REGION DOR TARGET Fig 31: EPI Drop Out, BCG-Measles 57

73 Drop out rates for Bawku East and Bawku West Districts were unacceptably high. Bongo district recorded a negative rate (-2%). EPI DROP OUT RATE: PENTA 1 - PENT 3 RATE 9%) DOR TARGET B/EAST B/WEST BOLGA BONGO BUILSA KND REGION DISTRICT Fig 32: EPI Drop OUT Rate, PENTA 1-PENTA 3 Again Bawku East and West District recorded rates above the recommended target of 10%. Table 46: 2004 Results NID Campaigns. Feb Mar Oct Nov No % No % No % No % BE 101, , , , BW 28, , , , Bolga 71, , , , Bongo 31, , , , Builsa 21, , , , KND 38, , , , Region 291, , , , Coverage for U5 for NID was generally very high (99 106%) for all the four rounds during the year. EXCLUSIVE BREASTFEEDING Out of mother /infant pairs discharged, (92.1%) were exclusively breastfeeding. Only 5 facilities have been designated as Baby Friendly since Efforts at designating other facilities as Baby Friendly in the region were pursued throughout the year. Three District hospitals, namely Bongo, Zebila and Bawku Presbyterian and five health centers have been earmarked for designation as Baby Friendly by close of

74 In the three hospitals, guidelines on Exclusive Breastfeeding (EBF) (Policies) have been developed. Proposal on training and refresher training for Facilitators of Mother-To- Mother Support Groups and health staffs have been written Adolescent Health The Adolescent Health Services have been subsumed under the general RCH services in the region. The orientation on the National Adolescent Health Policy could not come on during the year. The Ghana Red Cross Society, Rural Help Integrated, a Bolgatanga based NGO have trained and formed adolescent peer educators on HIV/AIDS and Female Genital Mutilation. Navrongo Health Research Centre is also implementing a pilot project on Adolescent Sexual Reproductive Health in two communities and six schools in Kassena Nankana District. Adolescents seen at ANC during the year were 6098 (15.5%) of the total ANC registrants. Adolescents who died during delivery were 6 (12.8%) out of the 47 maternal deaths. Seventy (70) reported at the STI and 30 at the F/P clinics respectively School Health Table 47: School Health Coverage Year No. Enrolled No. Exam. % Exam There was a drop in the proportion of children examined in 2004 as against Out of 843 schools, health teams visited and delivered at least three health talks to 354 (42.0%) schools. Mass Anti-helminthiasis (de-worming) programme Under Five Year De-worming: The Region planned to de-worm children under five years twice within the year. This was successfully carried out. The first and second rounds were integrated into March and October NIDs with coverage of 102.3% and 94.6% respectively. Basic School Children De-worming. This was also carried out with a regional coverage of 82%. 59

75 Pregnant Women De-worming of pregnant women started this September but as at the time of reporting districts had not sent in their information. Table 48: Results of U5 De-worming by Districts DISTRICT TARGET NO. OF CHN. DEWORMED 1 ST RUOND % CHILDREN DEWORMWED No. OF CHN. DEWORMED 2 ND ROUND % OF CHILDREN DEWORMED. Bawku East 56,555 54, , Bawku West 16,579 17, , Bolgatanga 42,641 49, , Bongo 17,737 16, , Builsa 11,698 12, , Kassena- Nankana Regional Total 28,357 27, , , , , Table 49: Results of School de-worming by Districts. No. Chn % De-wormed No. Chn De-wormed DISTRICT enrolled Bawku East 48,912 31, Bawku W Est 11,961 8, Bolga 49,099 46, Bongo 20,305 18, Builsa 15,096 11, Kassena-Nankana 28,543 22, Regional Total 173, , Table 50: Summary Of Childhood Diseases (Admissions) Regional REGION UNDER FIVE YEARS U-5 YR CASES DEATHS CFR MALARIA ANAEMIA DIARRHOEA ARI MEASLES MALNUTRITION Case fatality rate from malnutrition is unacceptably high. Rates due to anaemia and diarrhoea are also very high. 60

76 Table 51: Trend of Case Fatality Rates of Common Childhood Diseases MALARIA ANAEMIA DIARRHOEA ARI MEASLES MALNUTRITION Except Measles and Malaria, case fatality rates from the other common childhood illnesses got worse. No under five deaths from measles since Case fatality rates from malaria significantly reduced (21.9%) between 2003 and

77 3.0. CLINICAL CARE CHAPTER THREE Clinical care is an integral component of priority health service intervention package in the region. Clinical services are offered in hospitals, health centres and clinics and community based outreach health services including CHOs in the the CHPS programme and Community Based Agents (CBAs) in Community IMCI. The table below shows major health facilities and ownership in the region. Table 52: Summary of Health Facilities Govt Mission Type of Institution Total Institutions Institutions Private Inst Regional Hospital District Hospitals Health Centres Clinics Table 53: Bed Complements of Hospitals Hospital Bed Complement Bolgatanga Regional 189 Bawku Presbyterian 250 Zebilla 70 Bongo 38 Navrongo 140 Sandema 74 Bawku Presbyterian Hospitals provide services for a third of population of the region (about 350,000 people) including patients from neighbouring Togo and Burkina Faso. It is therefore not surprising that its bed complement is greater than Bolgatanga Regional Hospital. The three relatively smaller district hospitals, namely Zebilla, Bongo and Sandema are still being upgraded to the status of district hospitals which are expected to serve as primary referral centres in districts. Specialised Units: The Bolgatanga Regional Hospital and Bawku Presbyterian Hospital also provide specialist services as shown below: 62

78 Bolgatanga Regional Hospital ENT ( with ENT Specialist) Dental (Dental Surgeon) Eye Clinic (run by eye technicians Diet therapy (with Dietician) STI Clinic (with public health Nurse in-charge) Physiotherapy (no physiotherapist) Bawku Presbyterian Hospital Ophthalmology (with two Ophthalmologists) Orthopaedics Audiology STI Physiotherapy 3.1. Key Activities carried out The following are among key activities carried out in health institutions during the year: Routine Out and In-patient Care 24 hour OPD services Emergency care (obstetric and accidents Specialist clinical outreach services- intra and inter regional Implementation of quality assurance activities (waste management, infection prevention, client/patient satisfaction surveys, establishment of information/complaints desks Conducted maternal death audits Clinical conferences Quarterly support visits of Clinical Care Unit to health facilities In-service training of clinical staffs (maternal mortality audits, infection prevention, quality assurance, National Health Insurance etc) Summary of performance Table 54: Clinical Conferences: Performance of Hospitals Facility/Indicators Target No held Percentage held Bolgatanga Regional Hospital 12 NIL 0 Bawku Hospital War Memorial Hospital Sandema Hospital Zebilla Hospital Bongo Hospital 12 Nil 0 63

79 No Clinical conferences were held in two hospitals (Bolgatanga Regional and Bongo Hospitals). Table 55: Compliance on guidelines and standard on the management of malaria and diarrhoea in Children under five years. Hospital Weight Taken Temperature Taken Diagnosed Written Oral Chloroquine Given Correct Dosage Bolga Regional Hospital Bawku Hospital Navrongo Hospital Injection Chloroquine Given Sandema Hospital Zebilla Hospital Bongo Hospital REGIONAL Documentation continued to be a challenge. Diagnosis of about 8.9% of malaria cases was not written. Over 30% of cases of malaria in the under five old were not given correct dosage of ant-malaria. Table 56: Client Satisfaction Survey No. carried out Cov (%) Facilty/Indicator Target Region Hosp Bawku Hosp War Mem. Hosp Sandema Hosp Zebilla Hosp Bongo Hosp Total The quarterly patient satisfaction surveys were not carried out by hospital managers as shown in table

80 Health Service Utilisation. Table 57: Summary for the Upper East Region (All Institutions) Indicator Remarks OPD attendance 480, , , , % Increase Admissions 33,508 37,118 39,164 41, % Increase Bed Occupancy % Increase Bed Turnover % Increase OPD per capita % Increase Admission rate % Increase Deaths % Increase Death Rate % Decrease In all there was some modest improvement in health service utilisation in 2004 as against Table 58: Regional Hospital, Bolga Indicator Remarks OPD attendance 61,341 68,937 63,207 63, % Increase Admissions 6,604 7,489 7,053 7, % Increase Bed Occupancy % Increase Bed Turnover % Increase OPD per capita No Change Admission rate % Increase Deaths % Decrease Death Rate % Decrease 65

81 Table 60: Summary of District Hospitals Indicator Remarks OPD attendance 142, , , , % Increase Admissions 26,904 29,629 30,911 32, % Increase Bed Occupancy % Increase Bed Turnover % Increase OPD per capita % Increase Admission rate % Increase Deaths % Decrease Death Rate % Decrease Table 61: Summary of Mission Hospital (Bawku) Indicator Remarks OPD attendance 79, ,464 92,822 99, % Increase Admissions 15,721 16,996 17,079 18, % Increase Bed Occupancy % Decrease Bed Turnover % Increase OPD per capita % Increase Admission rate % Increase Deaths % Increase Death Rate % Decrease 66

82 Table 62: Trend of Ten Top Causes of OPD Attendance No. DISEASES 2001 DISEASES 2002 DISEASES 2003 DISEASES 2004 No. % No. % No % No % 1 Malaria 206, Malaria 272, Malaria 257, Malaria 267, Upper Resp. Tract 2 Infection 29,119 Upper Resp. Tract 7.3 Infection 36, Other ARI 32, Other ARI (Acute Respirato 38, Diseases of Skin & 3 Ulcer 18,593 Diseases of Skin & 4.7 Ulcer 22, Diarrhoeal Diseases 22, Diarrhoea Diseases 21, Diarrhoea Diseases 12, Diarrhoea Diseases 20, Skin Diseases & Ulcers 19, Skin Diseases & Ulcers 20, Acute Eye Infection 9, Pneumonia 11, Acute Eye Infections 11, Acute Eye Infection 11, Pneumonia 8, Acute Eye Infection 10, Pneumonia 8, Pneumonia 9, Rheumatism & Joint 7 Pains 8, Anaemia 8, Anaemia 7, Typhoid Fever (TYPHOID) 6, Preg. & Related 8 Complications 7, Intestinal Worm 7, Rheumatism & Joint Pains 6, Anaemia 6, Intestinal Worm 6,984 Preg. & Related 1.8 Complications 6, Intestinal Worms 6, Rheumatism & Joint Pains 6, Anaemia 6,659 Rheumatism & Joint 1.7 Pains 5, Preg Related Comps 5, Pregnancy and Related Com 6, All Other Diseases 82, All Other Diseases 83, All Other Diseases 86, All Other Diseases 95, Total 397, Total 484, Total 465, TOTAL NEW CASES 489,

83 Table 63: Top Ten Diseases seen at the OPD, 2004, Regional Summary and District Contributions No. Regional BE BW BOLGA BONGO BUILSA KND Diseases No. % No. % No. % No. % No. % No. % No. % 1 Malaria 267, , , , , , , Other ARI (Acute Respiratory Infection 38, , , , , , Diarrhoea Diseases 21, , , , , , , Skin Diseases & Ulcers 20, , , , , , Acute Eye Infection 11, , , , Pneumonia 9, , , Typhoid Fever (TYPHOID) 6, , , , Anaemia 6, , , Rheumatism & Joint Pains 6, , , Pregnancy and Related Complication 6, , TOTAL NEW CASES 489, , , , , , ,

84 Table 64: Trend of Ten Top Causes of Admission, UER No DISEASES No. % DISEASES No. % DISEASES No. % DISEASES No % 1 Malaria 9, Malaria 11, Malaria 12, Malaria 14, Anaemia 3, Anaemia 3, Anaemia 3, Preg related compl 3, Pneumonia 1, Pneumonia 2, Pregnancy Related 3, Anaemia 3, Complications Other Diarrhoea 1, Preg. & Related 1, Typhoid Fever 1, Pneumonia 1, Diseases Complications Preg. & Related 5 Complications Typhoid Fever 1, Pneumonia 1, Typhoid fever 1, Upper Resp. Track 6 Infection Other Diarrhoea Diseases 1, Other Diarrhoeal Diseases 1, Other Diarrhoeal dis 1, Hernia Upper Resp. Track Cataract ARTI 1, Infection 8 RTA Meningitis RTA Cataract 1, Cataract Cataract Acute Respiratory RTA 1, Infections 10 Meningitis Hernia Hernia Hernia Others 12, Others 12, Others 13, Others 10, Total 33, Total 37, Total 39, Total 41,

85 Table 65: Top Ten Causes of Admissions, 2004, Regional Summary and District Contributions No. Region Bawku East Bawku West Bolga Bongo Builsa KND Diseases No. % No. % No. % No. % No. % No. % No. % 1 Malaria 14, , , , , Preg related compl 3, , Anaemia 3, , Pneumonia 1, Typhoid fever 1, , Other Diarrhoeal dis 1, ARTI 1, Cataract 1, , RTA 1, Hernia Total New Cases 41, , , , , ,

86 Table 66: Trend of Ten Top Causes Of Death, UER No DISEASES No. % DISEASES No. % DISEASES No. % DISEASES No. % 1 Malaria Malaria Malaria Malaria Anaemia Anaemia Anaemia Anaemia Pneumonia Pneumonia Meningitis Pneumonia Meningitis Meningitis Pneumonia Septicaemia Other Diarrhoea Diseases Septicaemia Typhoid Fever Meningitis Hepatitis Typhoid Fever Septicaemia Tuberculosis Malnutrition Other Diarrhoea Tuberculosis Typhoid fever Diseases 8 Septicaemia Hepatitis Other Diarrhoeal Hepatitis Diseases 9 Typhoid Fever Malnutrition Hepatitis AIDS RTA Tuberculosis RTA Other Diarrhoeal Diseases 11 All other diseases All other diseases All other diseases All other diseases Total 1, Total 1, Total 1, Total 1,

87 Table 67: Top Ten Causes of Deaths, 2004, Regional Summary and District Contributions Region Bawku East Bawku West Bolga Bongo Builsa KND Diseases No % No. % No. % No. % No. % No. % No. % 1 Malaria Anaemia Pneumonia Septicaemia Meningitis Tuberculosis Typhoid fever Hepatitis AIDS Other Diarrhoeal Diseases Total No. of Deaths 1,

88 MATERNAL MORTALITY AND FOETAL WASTAGE Institutional Maternal Mortality Ratio continues be of major public health concern. A total of 47 women lost their lives in our institutions. Out of this 41 (91.5%) were audited. Table 68: Institution Maternal Death Audits Name of Hospital No. Deaths No. Audited % Audited Bolga Regional Hosp % Bawku Presby Zebilla Bongo Navrongo Sandema Total Table 69: Institutional Maternal Death Ratio Name of Hospital No. Maternal Deaths No. Live Births Maternal Mortality Ratio (Per 100,000 LB) Bolga Regional Hosp Bawku Presby Zebilla Bongo Navrongo Sandema Total The maternal mortality ratios in Bolgatanga Regional Hospital and Sandema Hospital were unacceptably too high Trend of Institutional Maternal Deaths No. Deaths Year Fig 33: Trend of Institutional Maternal Deaths 73

89 Institutional Maternal Mortality Ratio MMR (per 100,000) Bolga Hosp Bawku Hosp Zebilla Hosp Bongo Hosp Navrongo Hosp Sandema Hosp Hospitals Regional Hospitals Fig 34: Institutional Maternal Mortality Ratio Maternal Mortality Ratio in Bolgatanga Regional Hospital (670.4/100,000 LB) and Sandema Hospital (634.9/100,000 LB) were well above the regional average Major Causes of Institutional Maternal Deaths Sepsis 24% 5% 7% 10% 2% 7% 25% 20% Haemorrhage Ruptured Uterus Abortion Anaemia Hepatitis SCD Others Fig 35: Major Causes of Institutional Maternal Deaths Haemorrhage and sepsis account for almost 50% of all the maternal deaths. Direct Causes of Institutional Maternal Deaths 27% 14% 9% 5% 45% Sepsis PPH Ruptured Uterus APH Abortion Fig 36:Direct Causes of Institutional Deaths The two major direct causes of deaths are sepsis, 45%, and haemorrhage (APH and PPH) 36%. The two account for about 81% of all the maternal deaths. 74

90 STILL BIRTHS. Still birth rates have been unacceptably high. The year under review with a rate of 3.8% (468/12,272 ) was worse than the previous two years (see graph below). Trend of Still Birth Rates SB Rate (%) Year Fig 37: Trend of Still Birth Rates Still birth rate is on a sharp rise. There was a dramatic increase of about 72.7% in Still Birth Rate in 2004 compared to Records indicate that over 50% of the Still Births were fresh SBs. Still Birth Rate by Districts in 2004 RATE (%) District Region B/E B/W BOLGA BONGO BUILSA KND DISTRICT Fig 38: Still Birth Rate by Districts in 2004 Rates in Bawku East, Bawku West and Bolgatanga districts were well above the regional rate. The lowest (1.3%) was in Bongo district. 75

91 SPECIALIST OUTREACH SERVICES Table 70: Intra-Regional Outreach Services Specialist Service No. Visits Patients Ophthalmologists - 4,837 Orthopaedics 2 86 Psychiatry Table 71: External Specialists Services Specialist Services No. of Visits No. of Clients Dermatologist Psychiatrist Christian Mission (Surgical) LABORATORY SERVICES Table 72: Ownership of Laboratories District Public Private Public Private Bolgatanga Bawku East Bawku West Kassena Nankana Builsa Bongo Total

92 Table 73: ESSENTIAL INVESTIGATIONS Investigation No Pos % No Pos % HIV (Donors) 5, , HIV (Patients) HIV (VCT) HIV (PMTCT) HBsAg (Donors) 6, Jaundice Patients 1, CSF Haemoglobin 26, , Blood transfusion 7, , Blood Film for malaria parasite 18,375 13, ,731 12, The prevalence of HIV and HBsAg among blood donors was 2.6% and 12.2% respectively. Constrains (Lab) Serious shortfalls in numbers of technical staff; three technicians and one Technologist suddenly left for school during the year A number of key health centres are still lacking Laboratory services. Large number of broken down microscopes. Way Forward (Laboratory services) Strengthen the Quality Assurance system to improve on the quality of results Strengthen the supervision of Laboratories including private Labaratory. Open two new Laboratories in Talensi-Nabdam district and Kassena Nankana East Health Centre Provide in-service training for Laboratory Assistants on basic Laboratory procedures. Navrongo Health Research Centre contacted to do PCR on all CSF specimens in the region. Arrange for the servicing of all microscopes in the region at a central point. 77

93 Summary of Achievements- Clinical care Guidelines and procedures for referrals developed and disseminated. Reconstitution of Quality Assurance teams in the 6 districts and hospitals. Training of staff on Quality Assurance (War Memorial, Zebilla Hospital and Bawku West Hospital) Establishment of Information/Complaints Maternal Death Audits: 91.5% of the 47 maternal deaths were audited. Marginal increases in service utilisation (OPD Per capita, Bed Occupancy etc (ref tables above) Clinical Conferences held in some facilities Outlook for Strengthening Hospital Management 2. Capacity building through IST 3. Continue orientation of Patient Charter and Code of Conduct 4. Training/Orientation Clinical Care Unit to support clinical care services 5. Strengthen Quality Assurance systems 6. Strengthen specialist outreach visits 7. Accident and emergency care - capacity building 8. Support facilities in their readiness for successful NHIS implementation 9. Improve quality and ensure that all facilities conduct audits to all maternal deaths 10. Monthly clinical conferences to be held in all hospitals 11. Partnership with private sector 12. Establish collaboration between traditional and orthodox medicine 13. Research;- Quarterly Client/patient satisfaction surveys to be conducted in all hospitals 14. Develop and disseminate guidelines and standards for clinical services 78

94 CHAPTER FOUR 4.0. SPECIAL INITIATIVES TO INCREASE ACCESS 4.1. ACCELERATED CHILD SURVIVAL AND DEVELOPMENT (ACSD) ACSD is a four country UNICEF-CIDA supported child survival initiative. The countries are: Ghana, Mali, Senegal and Benin. Criteria for selection of countries: Targets districts located in rural areas of countries with high U5MR (>200) or in most disadvantaged regions of countries with lower U5MR. These districts are termed High Impact Districts. Goal Goal is to achieve and demonstrate a reduction of under-five mortality by: 15% (on average) in the intervention districts after 3 years of full implementation of the full intervention packages and operational strategies and 25% after 5 years of full implementation in the programme districts Timeline: Implementation began during the last quarter of 2002 in the Upper East Region Covers all 6 districts in Upper East and 13 in Northern Regions It is to complement and accelerate child survival activities in these districts OVERALL STRATEGIES 1. Health Centre Based Strategy Integrated delivery of all priority interventions to 25-50% of population with access to HC.(<5km) Community based strategy for IMCI+ (home based prevention and care) for 50-75% of population without access to HC 2. Outreach Strategy For example, three monthly delivery of EPI+ and ANC services to 50-75% of population without access to HC (>5km.) 3. Support Strategies Social mobilization & communication to improve service use and family care A results based approach to financing service delivery including performance-based incentives (monetary or in kind),performance contracting with community groups, CBOs, health staff etc. 79

95 Community based monitoring & micro-planning to increase effective coverage and empower communities Package of Interventions, Strategies and Activities EPI PLUS: Objective To prevent immunizable diseases, Vitamin A deficiency and Intestinal parasites: Strategies: 1. Immunization: Routine, mop-up and defaulter tracing 2. Twice yearly Vitamin A Supplementation 3. Distribution of ITNs to under five year 4. Twice yearly deworming through provision of anti-helminthic drugs (under five and school aged children) Activities Micro-planning Routine immunization,mop ups and defaulter tracking. Distribution, treatment and re-treatment of ITNs to to pregnant women/children < 5 years through ANC, PNC, CHOs, CWC and CBAs Deworming of under-five integrated into NID Deworming of school aged children through School Health Programme Vit. A supplementation IMCI PLUS Objective To prevent and care for pneumonia, diarrhoea, malaria and malnutrition Strategies 1. Distribution and promotion of use ITNS for under fives 2. Promotion of exclusive breastfeeding for six months and timely complementary feeding, 3. Promotion of hygiene 4. Promotion of household consumption of iodised salt 5. Improved and Integrated Management at the health centre and family levels of children with malaria, pneumonia and Diarrhoea (Community- IMCI). Activities Capacity building: Training of Sub-districts, Families and Community Based Agents to manage: Malaria, Diarrhoea, ARI at home and to give health education messages on: Iodated Salt Sanitation Exclusive Breastfeeding. 80

96 ANC PLUS: Objective To prevent maternal and neonatal tetanus and low birth weight resulting from malaria and severe anaemia in pregnancy as well as mother to child transmission of HIV/AIDS Strategies 1. Distribution and promotion of use of ITNs to pregnant women 2. TT immunization 3. Intermittent preventive treatment of malaria in pregnancy (IPT-P) 4. Iron/Folic Acid supplementation during pregnancy and Vitamin A post-natal. 5. Promotion of VCT& PMTCT Activities ITN distributed at ANC, CWCs and Community levels TT 2: Immunization TT SIAs conducted IPT-P TOT training, training of health workers and distribution of SP at ANC Achievements EPI Plus Routine immunization and tracking of defaulter supported by trained Community based Surveillance Volunteers on course One round Vitamin A Supplementary undertaken with coverage of 85.9% Twice yearly de-worming of children under five with coverage of 102.3% and 94.6%. Once round of de-worming of basic school children with coverage of 82% Table 74: Trend of Results of EPI Coverage Survey, UER Antigen Year of Survey BCG with Card DPT3 with Card OPV3 with Card Measles with Card Fully Immunised by age 52 weeks IMCI Plus Training of sub-district health workers and about 1,600 Community based Agents carried out for Community IMCI. CBAs have been supplied with bicycles and boxes with chloquine and ORS for the management of malaria and diarrhea. CBAs are also referring cases of ARI and complicated malaria and diarrhea; health education, promotion of exclusive breastfeeding, iodated salt and ITNs are also being carried out by CBAs. 81

97 ANC Plus Table 75: ITN Promotion District ITN Districbution Coverage Chn < 5 yrs Pregnant women Chn < 5 yrs Pregnant women BAWKU EAST 27,668 13, BAWKU WEST 18,437 5, BOLGA 34,900 3, BONGO 15,211 4, BUILSA 11,334 3, KASSENA- 15,484 5, NANKANA TOTAL 109,579 36, TT SIAs Two rounds were conducted with coverage of 46% and 62% respectively in four silent districts. IPT-P Training was rolled out in all districts and active distribution SP began during the year Post Partum Vitamin A Mass treatment also began in all districts at PNC and Child Welfare clinics VCT/PMTCT All hospitals began providing VCT services. Two hospitals also began counselling and screening of pregnant women and administration of Niverapine to positive mothers and their babies NATIONAL HEALTH INSURANCE In 2003 the Parliament of the Republic of Ghana passed the National Health Insurance Act 650 to introduce a National Insurance Scheme that aims to improve financial access to quality of basic health care services in Ghana through the establishment of mandatory district level mutual health organizations. In Upper East Region, realising the existence of a number of solidarity groups which in a way already contribute to their welfare other than health care, the need to take advantage and pursue the regions objective of establishing Mutual Health Scheme became a matter of course. Key Activities Formation and training of Regional Task Force Appointment of a permanent Regional Coordinator Provision of office, computer and accessories for the Regional Coordinator Formation and training of District Task Force Regular briefing of the Regional Coordinating Council and District assemblies and their Roles in the establishment of the Schemes Monitoring and supervision of processes of schemes establishments Community Education in creating Public Awareness 82

98 A five member Task Force Team was sent from the Region for a TOT training in Accra. Training of Health Staff by taskforce: A total of 1,092 different categories of health staff were given orientation in NHIS. Table 77: Implementation Status Checklist For District Wide MHO DIC1 Constitution CHIC 'Scheme Manager'' District Contact person/coordinator Stakeholders Meeting Sensitisation Campaign Formed Training Drafted Disseminated Office Secured Formed Bolga BE BW Bongo Builsa KND Trained Governing Body Officers Recruited Officers Trained Reg. Logistics Procured/ Training of Collectors Launching Hsehold/Dues Collection Picture/ID Cards/ Contract/Data Entry Implementation of Benefits/Monitoring Annual General Meeting Outlook for Orientation/training of rest of health workers 2. Training of student nurses (Bawku, Bolga, Navrongo nursing training institutions) 3. Monthly review meetings with Facility Focal Persons, and Scheme Managers. 4. Under take a Study Tour to a functional MHO Scheme 5. Assist health workers and other civil servants register with their District Wide MHOs 6. Radio discussion Intensive radio publication on National Health Insurance Scheme in English, Bissa, Buli, Gurune, Kasim and Kusal at the two FM stations in the region 7. Surveys Conducting of client satisfaction survey in the health facilities 8. Undertake quarterly assessment of District Wide Mutual Health Insurance Scheme 9. Monitoring and supervision conduct monthly visits to all district and health facilities to assist them in their National Health Insurance activities COMMUNITY HEALTH PLANNING AND SERVICES (CHPS) CHPS is a process of sector-wide health system change and development that aims to provide accessible primary health care to all communities of Ghana. It is a national programme for reorienting and relocating primary health care from sub-district health centres to convenient community locations. It is a Close-to Client health service 83

99 delivery. Process relies on active community participation in planning, resource mobilisation, construction of compounds, service delivery and programme oversight Goal To reduce health inequalities and promote equity of health outcomes by removing geographic barriers to health care. All six districts of the region carried out situational analysis, drew strategic plans and coverage plans for scaling up CHPS. Districts are various stages of the implementation stage, namely training and placement of Community Health Officers and Volunteers at the various zones. A number of Community Health Compounds were constructed with funds from the approved capital investment plan for the region for the year, deprivation funds for the region and HIPC/District and Municipal Assembly Common Fund. The region took delivery of twelve (12) motorbikes from Headquarters and procured additional fifteen (15) for CHOs throughout the region. Human Resource: The pioneers of the Community Health Nurses Training School, numbering 45, wrote their final examinations during the last quarter of the year. The construction of Hostel for the students is also completed. Permanent classrooms would be constructed in The human for CHPS programme, hopefully should not a major challenge to the implementation of the programme in the next few years. Table 78: Status of CHPS by Districts District/Municipal No Zones No Functional Zones Estimated Pop in Functional Zones Coverage (pop) % Bawku East , Bawku West , Bolgatanga , Bongo , Builsa , KND , Total , Challenges The following continue to be among major challenges facing the implementation of the CHPS programme in the region: High level of poverty Scattered rural settlement pattern Low rate of construction of Community Health Compounds Poor support by some District Assemblies Inadequate transport (motor bikes and Bicycles very few and over-aged) Inadequate logistics (Fridges, solar set-up, examination equipment etc.) Low staff motivation Poor commitment of some Health Managers. 84

100 Outlook for Completion of the Hostel and Classrooms for the Day Community Health School at Navrongo Provision of adequate logistics. Intensify efforts at resource mobilisation (from MDAs) Strengthen collaboration and advocacy for the construction of CHCs and provision of resources for CHPS. Revision of CHPS plans and re-zoning in the light of the creation of addition two new districts. Intensification of supervision Motivation and attractive incentive packages for CHOs 4.4. FOOD ASSISTED CHILD SURVIVAL (FACS) This initiative is being supported by CRS in two districts. The initiative started in Bongo and is being extended to Bawku West District. FACS in Bongo District 35 communities (OP) supported by CRS under this project. Volunteers are trained in each community to assist in 1. Growth Monitoring 2. Immunization 3. Health Education and 4. Food distribution Material Support One Toyota Hilux Pickup 7 Yamaha Motor bikes to support FACS and CHPS program 23 bicycles Building materials for feeding centres. Bawku West District Baseline survey was conducted and results disseminated. Health workers have been trained in community entry skills Selection of beneficiary communities in progress 4.5. INTEGRATED DISEASE SURVEILLANCE AND RESPONSE (IDSR) STRATEGY. Roll out training was conducted in all districts for good number of health personnel. The exercise will continue in INTERMITTENT PREVENTIVE TREATMENT OF MALARIA IN PREGNANCY (IPT-SP). Two districts namely Bongo and Bawku East are among the Global Fund beneficiary districts for rolling out IPT-P. We secured funding from UNICEF under ACSD programme to carry out training and implementation of the programme in the remaining districts. Thus, except in three sub-districts in the Kassena Nankana 85

101 District where drug trial studies are ongoing, all six districts began implementation during the year COMMUNICATION NETWORK. Attempts at improving communication network in the region to facilitate referrals finally got a major boost during the year. At the close of 2003, only Bawku East District had communication equipment installed at the various health facilities. During the year three districts, namely Kassena Nankana, Bolgatanga and Bawku West had Motorala Equipment installed in all health centres and some CHPS compounds. Efforts are being made to get the two remaining districts (Bongo and Builsa) and District Hospitals and District Health Administrations networked. 86

102 5.0 SUPPORT SERVICES 5.1. ESTATES CHAPTER FIVE The Upper East Region is one of the most deprived regions in the country in terms of health infrastructure. Staff accommodation and health facilities amongst others are woefully inadequate and in deplorable state. Objectives for 2004 Ensure that all approved projects are procured and executed Construction of Community Health Compounds under the CHPS Programme for CHOs in selected communities in the region Rehabilitation of staff residential accommodation Monitor and support districts in health estates activities Carry out preventive maintenance programmes in the region Carry out site visits to project sites Attend all site meetings Co-ordinate all health estates activities Procurement of 2004 Civil Works (Capital Investment) The region under the 2004 civil works programme received approval for the procurement and execution of eleven (12) projects for The projects are: Rehabilitation of Sandema District Hospital Construction of Mortuary at Zebilla District Hospital Rehabilitation of War Memorial Hospital Completion of Works at CHNTS, Navrongo Completion of Health Centre at Bongo-Soe Completion of Health Centre at Kologo Completion of Health Centre at Sapeliga Completion of fence wall at Navrongo Hospital Rehabilitation of Chiana Health Centre Construction of 2No. CHPS Facilities with Borehole installation at selected areas Upgrading of Bolgatanga Regional Hospital BADEA Project Expansion of hostel and classrooms of Nurses Training College at Bawku Status of Projects All projects have been awarded and civil works are at various stages implementation. Rehabilitation of Bolgatanga Regional Hospital The Bolgatanga Regional Hospital Rehabilitation works funded by BADEA suffered a delay in the execution due to litigation by Land owners over compensation for land. In addition funds were also not released timely to pay the contractors. 87

103 Internal Rehabilitation/Construction Works. The following were undertaken by the Regional Health Directorate during the year: Table 79: Internal Projects Project Location % Completion of works 1. Construction of CHPS facility Bachongsa, Builsa District Construction of CHPS facility Bokko, Bongo District Construction of CHPS facility Bansi, Bawku East Municipality Construction of CHPS facility Agusi, Bolgatanga Municipality Installation of small Solar, Invertor 100 system to five CHPS Compounds At Selected CHPS Compounds 6. Rehabilitation 1No. 3-Bedroom 100 bungalow and boys Medical Village, Soe, Bolga 7. Rehabilitation of bungalow with Boys quarters ( No. 12 Medical Village, Soe, Bolga Rehabilitation Bung. For Municipal Health Director, Bawku Bawku East Renovation of Bungalow for Medical 100 Supt, Sandema Hospital Sandema, Builsa District 10. Rehabilitation Bungalow at GWCL for 80 senior officers Bolgatanga Japan Embassy Counter Value Funding The following projects were awarded during the last quarter of the year with funds from Japan Embassy. 1. Rehabilitation of Fumbisi Health Centre staff accommodation 2. Rehabilitation of Paga Health Centre staff accommodation 3. Rehabilitation of Kulungugu Health Centre staff accommodation 4. Procurement of weighing scales and Blood Pressure apparatus for four districts (Bawku East, Bolgatanga, Kassena Nankana and Builsa Districts) 5. Rehabilitation/expansion of Supplementary Feeding Centres in the four districts. Construction of Community Initiated Clinics (CICs) Construction of community initiated clinics under the support UNFPA has been ongoing in two Districts since Projects are: Wagliga in the Bongo District and Uasi in the Builsa District. Projects are stages of completion. Modification Of Incinerators. Work on the modification of incinerators has been completed in the four (4) Districts and two (2) Municipalities of the Upper East Region. The incinerators have since been put to use by the various facilities. 88

104 Acquisition of Landed Properties.. The Regional Health Directorate continued its collaboration with the Land Valuation Board and other departments on the proper acquisition of the Regional Hospital and other landed properties of the Ghana Health Service in the Region. Training A team of artisans from the various hospitals in the Region were sent to Kumasi for a two-week training under the sponsorship of DANIDA/EMU. Carried out training in Environmental sanitation and minor maintenance for unit in-charges in Bawku East District/Hospital. User training for incinerator operators 6 supervisors and 6 operators. Suspended Projects Works on the under listed projects which were awarded under the capital investment plan have been suspended since 2000 due unavailability of funds: 1. Construction of DMO s Bungalow at Zebilla 2. Construction of Maternity Unit at Fumbisi Health Centre 3. Completion of RHMT office/in-service Training Complex at Bolgatanga 4. Completion of Workshop at Bolgatanga Constraints/Challenges Suspension of work on many projects Regional priority projects not approved at HQ Lack of maintenance culture. Absence of adequate and qualified artisans in estates. Un-availability of adequate funds for the rehabilitation of staff accommodation and other facilities. Outlook for 2005 Funds to be made available for the completion of all uncompleted project. Intensify awareness creation on preventive maintenance culture to all health workers. To recruit more qualified artisans to take up the challenging task Funds should be made available for the renovation of existing staff accommodation and other facilities and to provide additional residential accommodation for staff 5.2. EQUIPMENT MANAGEMENT Equipment situation in the Region has not been the best. They are not adequate, broken down and obsolete. For many years there has not been a trained equipment manager to carry out basic maintenance of the available equipment. Replacement has been poor 5.3. TRANSPORT Transport exists primarily to provide spatial mobility for staff to deliver services to the population and ensure timely positioning of health logistics for effectiveness and efficiency of health provision. 89

105 The strategic intent of transport is not just to provide vehicles, but also to ensure that high availability and reliability of transport resources translate into improved health outputs. Drivers Situation Vehicle/Driver Ratio = No. of Vehicles = 62 = 1.8 : 1 No. of Drivers 34 There were 23 drivers as at November This gave a vehicle: driver ratio of 2.7:1. In December, however, 13 drivers were recruited and still awaiting financial clearance. Wastage: 1. Study Leave = 1 2. Two drivers were redeployed to the Regional Hospital as labourers following their recalcitrant drinking habits. Summary of Key Fleet Performance Indicators Table 80: Vehicles No of 4 wheel vehicles Total no of vehicles reported % No of vehicles Reported Total KM % Ava il % Util KM/L Maintenan ce cost/km Average Running Cost/km , Total No. of Motorc ycles. Fuel Cost 1,220,000, Maintenance Cost 2,714,400, Total Running Cost 3,934,400, Table 81: Motorcycles Total No. of Motors reported Total KM Travelled % Avail % Util % No of Bikes Report ed KM/L Maintenance Cost/ KM Average Runnin g Cost ,930, Fuel Cost 727,705, Maintenance Cost 3,497,700, Table 82: Running & Maintenance Cost (Actual) RUNNING COST MAINTENANCE COST TOTAL 1,530,679,729 1,432,433,817 2,963,133,546 90

106 Fleet Inventory- By Age Block Table 83: 4 -Wheel Vehicles AGE No. Percentage Colour Code Green 1-5 year year Amber 10 year and over Red TOTAL Table 84: Motorcycle. AGE NO. Percentage Colour Code 1-3 years Green 4-5 years Amber 6 years and above Red TOTAL Table 85: Number And Types Of Vehicle Motorcycle Saloon Pickup Station Wagon Ambulance Haulage Truck Water Tanker Bus Communication van Table 86: Makes of Motorcycles NO. MAKE NUMBER % QUOTA 1 Yamaha Jialing TOTAL

107 Table 87: Make Of Vehicles No. MAKE NUMBER % QUOTA 1 Toyota Mazda Nissan Kia Ford Mitsubitsi Isuzu Renault Land Rover TOTAL Table 88: Accidents RHD, Bawku DHMT STATION TYPE OF VEHICLE REG NO. INJURY/DEATH East Toyota Hilux 2.8D Mazda 2900 P/up GV 45 T GV 335 U Driver sustained neck injury. Passenger sustained chest injury Knocked down a pedestrian. Victim died about a couple a weeks after he was hospitalized at KATH, Kumasi Bawku DHMT East Yamaha AG 100 GV 441 T GV 689 U - RHD Yamaha AG 100 GT 6011 F Builsa DHMT Yamaha AG 100 GV 696 V 92

108 Auctioned Vehicles Table 89: The list of Auctioned Vehicles S/NO REG. NUMBER GV8851C GV2540D GV7202C GV7046C GV 7059 C GV 1841 D GV 7171 C GV 7061 C GV 7065 C GV 7139 C GV 1938 D GV 1940 D GT 4535 F MAKE/TYPE Nissan Patrol pick-up Mitsubishi D/C Pick-up Suzuki Jeep Nissan Cabstar Pick-up Nissan D/C P/Up Mitsubishi Canter P/Up Toyota Hilux D/C P/Up Toyota Hilux D/C P/Up Toyota Hilux D/C P/Up Toyota Hilux D/C P/Up Toyota Hiace Bus Kia Besta Ambulance Dodge Cheverolet Ambulance CHASSIS NO VSKPG260U SJ MBH URGD FE434E-A52285 LN LN LN LN LH KNFTPB152MS IGCHD34JOFF Motorcycle GV 1936 D GV 1933 D GV 1934 D GV 3258 D GV 3399 D UE 330 A GV 3438 C GV 3951 C GV 1937 D GV1935 D GV 7134 C GV 7136 C GV 7133 C GV 7135 C GV 1760 C GV 7096 C GV 7095 C GV 7102 C Suzuki 100 Suzuki 100 Honda 70 Yamaha 100 Yamaha Yamaha Yamaha Yamaha Yamaha Yamaha Yamaha Yamaha Yamaha Yamaha Yamaha Yamaha Yamaha Yamaha A A CDYO HA HA HA HA GY GY TT TT TT TT TT Challenges/constraints Staff attrition Lack of Adequate Maintenance (including PLANS) 93

109 Districts failure to send reports High Vehicle: Driver Ratio Lack of adequate capacity at Regional Mechanical Workshop (Human & Infrastructure) Theft of Motorcycles Outlook for 2005 Improving the Transport Office Working visit to BMCs Training for TOs and drivers Monitoring and supervision to BMCs Appeal to management to recruit more drivers Capacity building at the RMW 5.4. REGIONAL MEDICAL STORES. The Upper East Regional Medical Store (RMS) is situated at Zuarungu, about five kilometres from the Bolgatanga Township. It is the Regional warehouse for the storage of all public sector health commodities; Drugs, Non-drug medical consumables, medical equipment and other logistics required for the provision of health care services in the region. The Medical Stores has a large capacity for the storage of health commodities made up of: Four stores for the drugs section Four stores for the non-drug medical consumables and equipment A store for the nutrition division A large receiving and dispatch bay. Four offices housing; the head of the medical stores, the supply officer, an accounts unit and a security unit. The building is fenced with a security wall and a transit accommodation unit is provided. Presently the building is in a high state of disrepair. Objectives/Targets: Against the backdrop of the achievements and challenges revealed during the review of the performance of the regional medical stores at the end of 2003 the following objectives were set for the year under review: To ensure timely quarterly procurement and distribution of health commodities. To increase tracer drug availability from 96% to 98% by the end of the year To increase the percentage availability of essential non-drug consumables and equipment to 80% by the end of the year To reduce institutional indebtedness to the RMS to 5% of total sales by the end of the year To increase support and monitoring visits to health facilities to 24 visits by the end of the year To ensure the removal and appropriate disposal of all expired and unserviceable health commodities by the end of the year

110 To ensure complete and accurate documentation of all store records and to generate reliable information for management. Strategies: Strategies included: Monthly stocktaking and updating of stock records to identify store items close to expiry and those that require reorder. Regular analysis of requisitions of health facilities to identify request that could not be filled due to non-availability at the medical stores for inclusion in medical stores requirements. Timely execution of planned quarterly procurements as presented in the 2004 annual procurement and action plan. Ensure that the Regional Inspection team inspects all procured items before taking them into the stores. Ensure sound stock management and accounting via on-the-job training. Conduct regular staff meetings and deliberate on issues affecting the RMS. Monitoring and support visits to health facilities. Activities: Some of the major activities carried out are as follows:- 1. Quarterly procurement of drugs and non-drug consumables 2. Quarterly stocktaking were carried out and data used to prepare quarterly reports. 3. Disposal of unserviceable medical equipment and proceeds paid into the rehabilitation accounts. 4. Paid supervisory visits to the BMCs. 5. Participated in other Regional Health Management activities. 6. Meetings were held on every Tuesday to inform staff about policy issues arising from Regional Health Management Team meetings. Achievement and Challenges Procurement: Regional Medical Stores was able to carried out two procurements activities for the non-drugs and five activities for drug. Procurements were from the Central Medical stores and the open market as the table below shows. Table 90: DRUGS Value of purchase No. Source Percentage 1 CMS, Tema 561,808, Open Market 1,374,107, Purchases expenses (Fuel/Allowance 25,790, ,961,705,

111 Table 91: NON-DRUGS Value of purchase No. Source Percentage 1 CMS, Tema 318,983, ,136, ,527, Open Market 47,623, ,525, Purchases expenses (Fuel/Allowance 366,606,186 Nil Nil 732,053, From the procurement data provided from the above, both drugs and non-drugs recorded the higher purchases from the open market than from the Central Medial Stores. This was due to the fact that the Central Medical Stores was under going major rehabilitation and could not therefore meet the region s requirements fully. The projected procurement budget for non-drug was 813,742,832 and for drugs 1,969,869,423. Actual procurement for non-drugs for the year came to 732,053,050 forming 89% utilization. For drugs actual procurement for the year under review came to 1,935,951,670 also forming 98.3% utilization. This indicates our projected procurement is in line with our activities. The procurement activities during the year under review resulted in 89% for tracing drugs availability and 98% tracing drugs availability. Targets tracing availability for both non-drugs (80% and drugs 96%) have been reasonable achieved. Warehousing Despites the high state of disrepair of the Regional Medical Stores building, stores items were kept in a good state desired for used. Tally cards, stores ledger and other stores records were available regularly updated with records of daily receipt and issues. These were confirmed by the various auditors we received during the year. Regular quarterly stocktaking beside the monthly stock checks was also carried out for purposes of reconciliation and preparing of quarterly report. Distribution The Regional Medical Stores received requisition from public and private institution in the region. This were processed and filled out in accordance with the cash and carry system. To a large extend most requisition were fully filled. Non-availability certificates were however issued to institutions in the event of stock outs. Financial Management There is an accounts office, which received all cheques and keeps all basic records within the Regional Medical Stores. But the major cashbooks are under the supervision of the Regional Accountant. Financial performance and other performance target achievement over the past threeyear are presented in the tables below. 96

112 Table 92: NON-DRUG CONSUMABLES DESCRIPTION AS AT 31/21/02 AS AT 31/12/03 AS AT 31/12/04 Bank balance 226,582, ,571,896 1,199,930,236 Value of stock 851,497, ,375,314 1,062,790,643 Institutional indebtedness 758,575, ,801, ,955,522 Sub-total 1,836,655,206 1,992,748,462 2,515,676,402 Indebtedness to Suppliers 199,914, ,459, ,760,689 Net worth 1,636,740,687 1,671,289,641 1,996,915,712 % Tracer Non-Drug availability 79% 86% 89% Table 93: Purchases From (Non Drugs) Purchases 366,606, ,136, ,053,050 Sales 766,890, ,554, ,636,591 Payment 430,622, ,761,310 1,177,394,436 Cost recovery % 56% 65% 105% Expenses Nil Nil Nil Newt profit 43,062,273 66,376, ,000,000 Annual projected purchases 813,742, ,742, ,742,832 Utilization % 45% 49% 89% Table 94: Financial Statement 1/1/2004 Balance 468,571,896 1/1/04-31/12/04 payment 1,177,394,436 Less expenditure 433,545,000 Balance 1,212,421,332 % Procurement from Central Medical Stores and other agencies is = 89% Table 95: Expenditure Summary Non-Drug consumables 215,975, OPD/ID cards 208,470, ATF books 9,100, TOTAL 433,545,

113 Table 96: Payments Summary Jan - March 324,918,825 April - June 242,540,841 July - September 299,526,945 October - December 310,407,827 TOTAL 1,177,394,438 Table 97: Summary of Institutional Indebtedness Consumables 119,632,878 OPD/ID Folders 138,728,652 ATF books 44,388,300 Yamaha parts 10,205,692 TOTAL 312,955,522 Table 98:Financial DRUGS DESCRIPTION AS AT 31/21/02 AS AT 31/12/03 AS AT 31/12/04 Bank balance 537,425, ,709, ,666, Value of stock 538,424, ,106, ,061, Institutional indebtedness 337,415, ,481, , Sub-total 1,413,265, ,742,297, ,872,597, Indebtedness to Suppliers 239,028, ,392, ,344, Net worth 1,174,236, ,407,905, ,950,253, % Tracer Drugs availability Growth between: ,668, Growth between : ,347, Challenges/Constraint Although the year 2004 has witness the number of achievement at the Regional Medical Stores, the were other difficulties en-counted as stated below 1. As stated earlier the Regional Medical Stores is in a serious state of disrepair: Leaking roofs Crack wall and pillars Routing ceiling Poor air conditioning Weak and shaky shelves 2. Lack of regular stock bulletin from Central Medical stores makes us enable to know what is available and at what prices at the Central Medical Stores to facilitate our procurement activities. 98

114 3. There is also the failure of health facilities to present their requirements in advance to enable the Regional Medical Stores meet their needs. Outlook for 2005 To increase drug availability from 94 to 98 percentage. To increase non-drug availability from 80 to 90 percentage To institute schedule door-to-door delivery. To organiser two In-service training for health commodities manager 99

115 CHAPTER SIX 6.0. HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT 6.1. HUMAN RESOURCE MANAGEMENT Introduction: The objectives of the Human Resource Development and Management include the following: To recruit and select suitable job candidates To equip employees with the competences required for current and future jobs To help GHS to design and implement systems and strategies for utilizing employee potential To design and implement systems and strategies for rewarding and motivating employees Challenges at the beginning of the Year Serious shortfalls of numbers of health professionals and specialists. Mal-distribution Difficulty in retaining products of the health training schools (4) in the region, Refusal of postings High attrition rate of health professionals due to Push and Pull Factors Ageing health professionals Manpower Levels The region had 1,742 staff as at 31/12/04 as against 1, 624 as at 31/12/03; this gives an increase of 1.1%. Table 99: Staff Strength by BMC BMC As at 31/12/03 31/12/04 Regional Health Directorate Regional Hospital Midwifery Training School Nurses Training College Builsa DHMT Kassena-Nankana DHMT Sandema Hospital War Memorial Hospital Health Research Centre Bolgatanga MHD Bawku West DHMT Zebilla Hospital Bongo DHMT Bongo Hospital

116 Bawku East MHD Bawku Hospital Nurses Training College Bawku Cuban Medical Brigade CHNTS Navrongo 7 8 Total MEDICAL OFFICERS Table 100: Clinical Medical Officers Hospital No. at post Catchment Pop Doc:Pop Ratio Bolga Regional 6 239,050 1: 39,841 Bawku Hospital 5 (2 are 321,691 1: 64,338 Ophthalmologists) Zebilla Hospital 1 84,212 1: 84,212 Bongo Hospital 1 81,369 1: 81,369 Navrongo Hospital 2 156,178 1: 78,089 Sandema Hospital 1 78,747 1: 78,747 Total ,246 1: 60,078 Medical Officers in Administration RHDS = 1 SMO-PH = 1 DDHS = 4 Total = 6 Total No. Medical Officers = 22 Doctor: Population Ratio : 1: 43,693 Medical Officers at Navrongo Health Research Centre = 10 Cuban Medical Brigade =

117 NURSES Table 101a: DISTRIBUTION OF NURSING STAFF, UER, 2004 BAWKU EAST BAWKU WEST BOLGA Preby Hosp Zebilla Hosp Reg Hosp RHA DHA BONGO BUILSA KND Bongo Sande ma Hosp DHA Hosp DHA War Mem Hosp GRADE DHA DHA DHA TOTAL Professionals DDNS PNO SNO NO SN MIDWIVES Sub-total Auxilliary EN CHN Sub-total Total Wastage Table 101b: Professional Nurses GRADE NUMBER DDNS 8 PNO 24 SNO 38 NO 50 SN 107 MW 160 Total 387 Table 102: Auxiliary Nurses CATEGORY NUMBER EN 110 CHN 90 Total 200 Grand Total (Nurse) = 587 % Professional= 65.9% Nurse: Population Ratio: 1: 1,638 The total number of nurses at the close of 2003 was 662. The figure of 587 in 2004 represents a reduction of 11.3%. 102

118 AGE-GROUPS OF ALL NURSES, UER, AS AT DECEMBER NUMBER AGE GROUP Fig 39: Age Groups of All Nurses, UER, As At December 2004 Majority of the nurse (59.1%) are in the age bracket years and over 14% have reached their voluntary to compulsory retirement, 55 and 60 years respectively. Age-groups of Clinical Nurses, UER, As At December Number Age Fig 40: Age-Groups of Clinical Nurses, UER, As At December

119 Age-groups of Public/Community Nurses, UER, As At December Number Age 2 Fig 41: Age-Group of Public/Community Nurses, UER, As At December 2004 Majority the public/community Health Nurses however fall in the age group years with peaks in age groups and years. NURSES WASTAGE Leave with Pay 93 Leave Without Pay 2 Vacation of Post 1 Death 2 Total 98 Table 103: Staff Recruitment CATEGORY AS AT 31/12/03 AS AT 31/12/04 Medical Doctors 1 0 Dispensing Technicians 1 10 Technical Officer (CDC) 1 6 Technical Officer (Information) 0 2 Community Health Nurse Hospital Orderly 6 0 Asst. Nutrition Officer 0 1 Technical Officer (Nut.) 1 0 Technical Officer (Lab.) 1 2 Field Technician 1 0 Watchman

120 Contract Appointment 0 8 Total Last year s recruitment represents about 97%. This mainly came from Dispensing Technicians, Technical Officers (Disease Control) and Community Health Nurses. Table 104: Promotions CATEGORY AS AT 31/12/04 AS AT 31/12/04 Medical Doctors 1 1 Professional Nurses Auxiliary Nurses Technical Officers 6 27 Pharmacy 7 0 Others Conversions 0 10 Total Promotions in 2004 exceeded that of 2003 by about 21%. Table 105: Wastage TYPE OF WASTAGE AS AT 31/12/03 AS AT 31/12/04 Retirement 8 7 Transfer Death 3 9 Vacation of Post 4 8 TOTAL Staff wastage in 2004 was very high, exceeding that of 2003 by about 57.7%. Outlook for Preparation of Human Resource Annual plans to determine gaps/excesses to be ready by beginning of 2nd quarter of the year 2. Financial clearance for appointments at regional level to be sought by end of 2nd quarter (i.e. 1st half) 3. Management to assist prepare Regional postings and transfers policy for implementation by August Prepare staff promotion list and schedule for 2005 by September Procure and distribute staff performance appraisal forms and conduct appraisal for all staff (at least 60%) by June Upgrade skills of Managers on performance appraisals by April ending 105

121 7. Coordinate the development of Disengagement Plan, list disengaged staff, notify them and liaise with IST Coordinator to organise a workshop for them by December To liaise with HRDD to have Records Management streamlined in the region by end of June To coordinate the development of selection criteria, select interview panel, conduct selection interview and orientate/admit staff and students into the Ghana Health Service 6.2. IN-SERVICE TRAINING Introduction: Developing human resource in the Ghana Health Service is one of the strategies of improving quality of care to patients, clients and the general populace as captured in the strategic pillars in the sectors five years program of work (POW). In addition to providing needed incentives to motivate, retain and attract qualified staff into the service, emphasis is placed on the development of skills, knowledge and attitude of health care providers through In-service training. In-service training (IST) is aimed at providing systematic continuing education which is linked up with the delivery and practice of quality care. The IST unit in the region has been established in line with the sector s policy of developing human resource through continuing education. Its other functions include planning, organizing, implementing and evaluating IST activities in the region. Objectives for 2004 Taking into consideration the performance and challenges of the unit in 2003, the following objectives were set for 2004: 1. To increase the implementation rate of IST from 53.8% in 2003 to 60% by the end of December, To strengthen TIS in districts and institutions through quarterly support visits 3. To press for the construction of the office complex of the IST unit. 4. To gradually equip the IST unit Program Areas There are three main programme areas under IST namely, Public health, Clinical Care and Management. Some of the courses under these programme areas include the following: 1. Public Health Reproductive Health. Disease Surveillance/Control. Child Health Nutrition 2. Clinical Care Case Management. Nursing Care Practice. 106

122 Diagnostic Services. 3. Management Financial Management Quality Assurance. Resource Planning and Management. Training Management and design ACTIVITIES Regional level Public Health: Structured IST:- Integrated SRH Counseling Integrated Management of Childhood Illnesses (IMCI) Norplant insertion and removal Prevention of mother to child transmission of HIV and voluntary counseling and testing Therapeutic Dietary Management Child Health (ACSD) Disease Control/Surveillance Public Health: Remedial Integrated Disease Surveillance and Response (IDSR) (3 training) Intermittent preventive treatment (4 trainings) Enhanced disease surveillance DOTS (3 trainings) Lymphatic Filariasis Control Refresher on Norplant insertion and Removal STD syndromic management Malaria Case Management (5 trainings) Clinical Care : Structured Safe Motherhood clinical Identification and management of acute Psychiatric patients in the community Clinical: Remedial Infection Prevention Pre and post operative management Ward management Malaria case management (4 trainings) Management: Structured Financial management for non accounting staff Training Management and Design for IST Coordinators Facilitative supervision Management: Remedial:- Environmental sanitation and building maintenance General Administrative practices Administrative practices and procedures 107

123 Table 106: Implementation of IST Carried Out at the RHD Program Area Type of IST Structured Remedial Public Health Clinical Management Total Total From the table above, a total of 25 IST courses were carried out in the Public Health, 8 in Clinical, and 8 in Management areas, showing a skew towards Public Health. District Level Public Health :Structured:- CHO Technical Trainings, total = 4 Public Health: Remedial ACSD (2 trainings) IDSR, Cold Chain Management, Epidemic Preparedness (2) IPT Maternal and Neonatal Tetanus (MNT) Lactation Management and Behaviour change communication TOT for community-based surveillances trainers TB Management and Control Anaemia Control in Pregnancy Clinical Care: Structured Quality Assurance ( 2 trainings) Clinical: Remedial Home-based management of malaria Guidelines for the Clinical use Blood and Blood products Infection Prevention Ward Management Management: Structured Teaching Methodology Management: Remedial Client employee relationship Staff performance appraisal 108

124 Table 107: Implementation rate of IST at Regional and District levels in 2004 Type of Training Regional Districts Total Structured Remedial Total Total IST Planned Implementation Rate 91.1% 41.9% For the year 2004, a total of 119 In-Service trainings were planned throughout the region. Out of this number, 74 were executed giving an implementation rate of 62.2%. Of the 74 In-Service trainings (I.S.T) 12 Sructured and 29 Remedial trainings were caaried out by the Regional Health Directorate. The rest of the trainings were carried out at the District Health Administrations and Hospitals.The region has thus archieved its target of 60% implementation rate for Table below shows the number of trainings planned and number carried out by various BMCs Table 108: Planned/Executed IST Programs by BMCs No. BMC No. Planned No. Executed % 1 Reg. Health Directorate Regional Hospital Municipal Health 3 Directorate - Bolga War Memorial Hospital KND Builsa DHA Sandema Hospital Bawku West District Zebilla Hosital % Municipal Health 10 Directorate - Bawku East Bawku Hospital Bongo From the table above, Bawku Hospital recorded the highest IST implementation rate of 125%. Sandema Hospital also recorded 100% while the Regional Health Directorate recorded 94.6%, Regional Hospital recorded 75%, Zebilla Hospital 60%. The rest of the BMCs ranged between zero and 36%. 109

125 TREND OF IST IMPLEMTNATION RATE PERCENTAGE YEAR Fig 42: Trend of IST Implementation Rate There has been a gradual increase in the Trend of Implementation of IST rate in the Region from 33.3% in 2002 to 62.2% in This is as a result of the regular monitoring and supervisory activities of the unit to all districts/institutions Table 109: Categories of Staff Receiving SIST in 2004 Category No. % Operational definition of category Clinical % All Doctors, Nurses, MAs, M/wives providing Clinical Services Managers % Sub-dist. Heads DDHs etc+ PH Personnel % All Public & CHNs, DCOs, Nut Officers etc % 328 health staff received Structured In-Service Training (SIST). 103 (44.40%) Public Health personnel, 45 (65.2%) Managers and 180 (35.0%) Clinical staff as shown in the above table. These are the most important indicators of IST in the health sector in line with the IST policy. 110

126 Categories of Staff Receiving SIST in 2004 Percentage Staff Fig 43: Category of Staffs Receiving SIST In 2004 Clinical Managers PH Personnel Table 110: Cost of In-Service Training Type of Training No. Total Cost % Structured ,969, Remedial ,809, Total Cost 74 1,153,500, The total cost of I.S.T.in 2004 was 1,153,500,000. Of this figure 540,969,500 (46.9%) was spent on SIST, and 612,809,500 (53.3%) on remedials as shown above. The cost of IST is higher in Remedials because of the high number of remedial trainings done. Table 111: Trend of cost of IST Type of Training Structured 564,523, ,692, ,969,500 Remedial 293,847, ,909, ,809,500 Total 858,370, ,601,750 1,153,500,000 The cost of IST rose from Nine hundred-sixty million, six hundred and three thousand, seven hundred and fifty-three ( 960,601,750) cedis in 2003 to One billion, twenty-six million, seven hundred thousand ( 1,077,893,000) cedis with an increase of about Sixty-six million, ninety-six thousand, two hundred and forty-seven ( 117,291,250) cedis in

127 9 0 0,0 0 0, ,0 0 0, ,6 9 2, ,0 0 0, ,0 0 0, ,5 2 3, ,8 0 1, ,8 9 6, ,0 0 0, ,0 0 0, ,0 0 0, ,9 0 9, ,8 4 7, ,0 0 0, ,0 0 0, S tr u c tu r e d R e m e d i a l Fig 44: Type and Cost of Trainings Other Activities Training Plans/Activities of the Unit At the beginning of the year, the Unit drew training plans and activities in line with the regional plans. 45 training activities were planned and 37 (94.6%) of these were executed. The unit also planned and coordinated a number of regional meetings and conferences throughout the year (2004) Training of Co-ordinators / Focal Persons All the Training Co-ordinators and Focal Persons were trained in Training Management and Design. This programme was organised by Regional Health Directorate Training Unit. The objectives were: To review current training and management problems Develop a framework for determining institutional training priorities To identify district priorities and mobilise resources for smooth implementation and evaluation of IST 112