Integrated Management of Childhood Illness (IMCI)

Transcription

1 Integrated Management of Childhood Illness (IMCI) REVIEW OF INTRODUCTORY AND EARLY IMPLEMENATION PHASES - GHANA MINISTRY OF HEALTH MAY 2002

2 Table of Contents 1.0 INTRODUCTION: Background Characteristics of Ghana Health Status Organisation of the Health Sector ORGANISATION, PLANNING AND MANAGEMENT OF IMCI Preliminary Visit National IMCI Orientation Meeting IMCI National Planning Workshop Organisation and Management of IMCI at Central Level Policy support: IMCI and Health Sector Reforms Management Information System Central Level Support for Districts Organisation and Management of IMCI at District Level Interest of partners TRAINING Adaptation Process Training Activities Challenges Pre-service training Major Lessons Learnt and Way Forward HEALTH SYSTEM SUPPORT FOR IMCI Drug Supplies Basic equipment Actions taken facility support Referral Supervision Follow up Constraints and supports for implementing IMCI in facilities Documentation of Early Implementation Phase: COMPONENT 3: FAMILY AND COMMUNITY PRACTICES Formation of CIMCI sub-group Assessment of community based interventions Key Family Practices Selected for Intervention District orientations Adaptation of Feeding guidelines/local terms Development of CHEST-Kit Development of Child Health Records Development of an Improved Version of the IMCI Mothers Card Development of training manual for traditional healers Development of child health component for the CHPS curriculum Community Based Growth Promotion RBM Home-Based Care Communications Strategy Community IMCI Planning Meeting Future Plans...41 ANNEX...43 Page 2

3 1.0 INTRODUCTION: The IMCI strategy is a broad strategy developed by WHO in collaboration with UNICEF, and it aims at reducing childhood deaths, illness, and disability, and improving growth and development. It combines improved management of childhood illness with aspects of nutrition and immunisation in children below the age of five years. In 1998, Ghana adopted IMCI as one of the key strategies for reducing mortality in children less than five years of age. The rationale for this strategy is to reduce the high number of deaths in children below five years, majority of which occur in developing countries. It is estimated that 70% of all these deaths are due to acute respiratory infections (ARI), malaria, diarrhoea, measles and malnutrition. For many sick children, a single diagnosis may not be appropriate and hence the need for an integrated approach to the care of sick children. Research has also shown that more than fifty percent of deaths occur in the community and thus the strategy focuses on interventions at health facilities as well as in the community. The strategy focuses on three main components: Improvements in the case management skills of first level health staff Improvements in the health system required for effective management of childhood illness Improvements in family and community practices. There are three stages in Implementation of the strategy and these are: Introduction Phase Early Implementation Phase Expansion Phase The purpose of the Introductory Phase is to orient and train key Ministry of Health decision makers and staff to enable them make an informed decision on whether or not to adopt the IMCI strategy and if so to create a management and co-ordination group to see to the implementation. The early implementation phase is carried out to gain experience with IMCI planning and implementation through a well-defined set of activities within a limited geographic area. The experience explores how the IMCI strategy will fit into the overall planning system at both central and district levels, how to link with health sector reforms, how much it costs and how district capacity can be strengthened to implement IMCI activities. The focus of the expansion phase is to extend the geographical coverage and activities implemented in the early districts based on the experiences and lessons learnt in the early implementation phase. The introductory phase of IMCI implementation in Ghana began in 1998, when the strategy was adopted in the Child Health Policy and Strategy Document 1998/1999, as one of the key interventions for improving Case Management of Sick Children. The National Orientation Meeting was held in September 1999, and this was followed by the National Planning Meeting in November 1999.One of the outcomes of the National Planning meeting was a work plan for the early implementation Phase that began at the end of The strategy was implemented in four initial districts in order to build capacity, and learn lessons, which could be used in the expansion phase. Page 3

4 Collaboration between IMCI and Roll Back Malaria (RBM) started at the African Regional level in 1996, and has since expanded to operations at country level. In Ghana, there has been collaboration between the two programmes in Case Management training, home-based care, and Information, Education and Communication (IEC) among others. In November 2001, the Ministry of Health / Ghana Health Service took the RBM-IMCI partnership a step further by involving other programmes Expanded Programme on Immunisation and Integrated Disease Surveillance and Response (IDSR). The MOH/GHS in collaboration with WHO developed a proposal to integrate service provision, monitoring and evaluation of these interventions in 10 selected districts. These districts have therefore been designated as the districts of focus for the programme interventions in the IMCI, Malaria (RBM), EPI and IDSR. This report summarises the activities carried out in the introductory and early implementation phases of IMCI in Ghana. It is expected that the experiences and lessons documented during the first two phases will form the basis for the strategic plan for IMCI expansion in Ghana. 1.1 Background Characteristics of Ghana Ghana is situated in West Africa, and is bordered by Burkina Faso to the North, the Gulf of Guinea to the South, Togo to the East and Côte d Ivoire to the West. The country can be divided into three ecological zones. These comprise a coastal strip in the south, forest (middle) belt covering about a third of the country and a dry northern savannah covering about one half of the country in the north. Occupying a land area of about 283,500 square kilometres, it has a population of approximately 18.4 million according to the 2000 Census. In 1992 the constitution was reformed to bring multiparty democracy back to Ghana s political process. The country is divided into 10 regions and each region divided into a number of districts. There are a total of 110 districts in the country. The governance of the country is based on the three-tier system with National, Regional and District Level Administrations. Agriculture has dominated the economy of Ghana for sometime now. Up until 1990, it accounted for 70% of employment and represented 44% of GNP while Industry was 17% of GNP and Services 39% of GNP. Cocoa constituted the mainstay of the Ghana economy, accounting for about 70% of the total export earnings and about 10% of GDP. The mining sector, comprising gold, diamonds (industrial) bauxite and manganese contributed about 15% of the foreign exchange earnings while Timber contributes about 8%. The current GDP is estimated at $390 per capita. Page 4

5 1.2 Health Status The Ghana Demographic and Health Survey (GDHS 1998) estimated the following: Child Health Approximately half of all deaths in children under five occur during the first year of life. Infant mortality is 57 deaths per 1,000 births. The risk of neonatal deaths is 30 per 1,000 births and the risk of post-neonatal deaths is 27 per 1,000 births. There has been a 43 percent decline in under-five mortality in the last two decades. Mortality is consistently lower in urban than rural areas, and infant mortality is lowest in the Greater Accra Region and highest in the Upper East Region. As expected, mother s education displays a strong negative relationship with infant and child mortality, with children born to mothers with little or no education suffering the highest mortality. Immunisation The proportion of children fully immunised by age one has increased in the last five years from 43 percent in 1993 to 51 percent in Around nine in ten children received the BCG, and first dose of DPT and polio vaccines before age one. However, the coverage for the third dose of DPT and polio fell to 67 percent before age one. Sixty-one percent of children received the measles vaccine before age one and 39 percent have been vaccinated against yellow fever. One in four children received Vitamin A in the six months prior to the survey. Breastfeeding and Nutrition Breastfeeding is nearly universal in Ghana, and the median duration of breastfeeding is long (22 months). However, exclusive breastfeeding is relatively short and three in five children less than two months of age are given water, water-based liquids like juice, and other types of complementary food. The use of a bottle with a nipple is common, with 15 percent of children under 36 months using it, and bottle-feeding starting as early as 0 1 month. Under nutrition is significant in Ghana, with one in four Ghanaian children under five years of age stunted (short for their age), 10 percent wasted (thin for their age), and 25 percent underweight. In general, rural children, children residing in the three northern regions of Ghana (Northern, Upper West, and Upper East) and children of uneducated mothers are more likely to be stunted, wasted or underweight. Fertility Fertility in Ghana has declined rapidly over the last decade, from over 6 births per woman in the mid-eighties, to 4.6 births per woman during the last five years. Fertility has fallen recently in every age group, with fertility levels among women under age 35 declining by around 25 percent during the decade between the 1988 and 1998 surveys. Page 5

6 1.3 Organisation of the Health Sector The National Health Sector is made up of the Ministry of Health. The key players involved are Public Sector, Private Sector, Traditional Sector and other sectors. The Public Sector is made up of Ghana Health Service, Teaching Hospitals, Quasi Government Institutions and Statutory Bodies. The Private Sector is made up of Private for Profit, Mission-Based Providers, Non- Governmental Organisations, and Civil Society Organisations. The Traditional Sector is made up of Traditional Medicine Providers, Alternative Medicine and Faith Healers. Other Sectors include Education, Food and Agriculture, Works and Housing, Local Government and Rural Development, and Environment Science and technology. The second health sector five-year programme of work maintains the five strategic pillars of the previous (first) one and these are: Improving quality; Increasing access; Improving efficiency; Fostering partnerships; and Improving equity in financing healthcare. The Priority health interventions identified in the Programme of Work are: HIV/AIDS/STDs Malaria Tuberculosis Guinea Worm Poliomyelitis Reproductive, Maternal and Child Health - Scaling up IMCI is one of the key interventions Accidents and Emergencies Non-communicable diseases Oral Health and Eye Care Specialist services including psychiatry care (community, secondary and tertiary). There are a number of challenges in addressing these priority health needs effectively such as lack of health information, marginalizing of the poor and vulnerable, non-availability of appropriate job aids, inadequate involvement of non-government providers. The strategic objectives to address the priority health needs as stated in the POW are: Implement a package of priority health interventions (to address each of the diseases or health problems above IMCI is mentioned as an example of such package) Empower communities to improve their health and gain access to basic health care. Improve efficiency and effectiveness of health service provision. Institutionalise quality in all health facilities. Reorient secondary and tertiary health services to support primary care. Page 6

7 There are a variety of providers in the public, private and informal sector involved in health services delivery in the country. The table below shows the providers at the different levels. This has been described as a pluralist health service. Table: Providers at each level of the health delivery system Level Community Sub district District Regional National Type of Provider Public Health Clinical Maternity VHW, VHC, CHN, Chemical sellers, CHO, PCW, TBA, pharmacy shops, Wansam committees, traditional healers, private laboratories, CHO condom outlets Private Midwives Health centre, MCH Clinic, Environmental Health Officers Health Centre, pharmacy shops, private clinics District Hospitals and Mission Hospitals Public Health Regional Hospital Reference Laboratory The Health of the Nation, MoH, Ghana (2001) Key: Village Health Workers VHW Village Health Committees VHC Community Health Nurses CHN Community Health Officers CHO Community Based Distributors - CBD Traditional Birth Attendants TBA Maternal and Child Health - MCH Primary Care Workers - PCW Specialised Hospitals, Teaching Hospitals TBA, CBD (FP), CHO, CHN Maternity homes, MCH clinics Regional Hospital Teaching Hospitals 1.4 Justification for IMCI Implementation in the Country (i) Child Health Policy The Ministry of Health in its document Policy and Strategies for improving the health of Children Under-Five in Ghana (1999) adopted the WHO/UNICEF IMCI approach as one of the interventions for improving the management of the sick and injured child. It identified six health problems as being responsible for the majority of infant and child morbidity and mortality: These problems, which represented at least 50 percent of all child admissions in the country, are: Pneumonia, Diarrhoea, Malaria, Page 7

8 Measles, Malnutrition, and Neonatal Causes. Several sources of data show the levels of morbidity and mortality of children under five. In 1992, a national sample of mothers estimated the mortality rate from neonatal tetanus to be 2.2/1000 live births (MOH, Primary Health Care survey, 1992). MOH administrative data from 1997 estimated immunisation coverage as follows: BCG, 72 percent; DPT3, 60 percent; OPV, 61 percent, and measles, 58 percent. Of particular concern was the increase in the number of measles cases; 36,968 cases were reported in Measles, therefore, remained an important cause of morbidity in the presence of a high prevalence of other common infectious diseases, malnutrition, and vitamin A deficiency. Malnutrition is also a major health problem in Ghana. The Ghana Vitamin A Supplementation Trial in 1992 found that 65 percent of young children in northern Ghana had low serum retinol levels. Preliminary data from a nation-wide anaemia survey (1996) indicated that 81 percent of pre-school children had serum haemoglobin of less than 11g/dl. The Ghana DHS 1998 estimated that 20 percent of children aged 3 to 35 months were stunted, 25 percent were underweight, and 13 percent were wasted (GDHS, 1998). Thirty-six percent of infants less than 4 months of age are exclusively breastfed (GHS 1998). In order to address the six most important causes of morbidity and mortality for young children the Policy Document identified five key health sector areas which will be targeted: quality of services, access to services, availability of funds and their efficient use, participation in community, health program issues. Primary health care program development was still to be undertaken in the context of improved district-level capacity and autonomy for the planning, management, implementation, and monitoring of health care programs. There was an increasing recognition of the need to develop integrated infant and child health programs that address all of the most important health problems at the same time. One important element of improving primary health care for young children was to improving the management of sick children coming to first-level health facilities in the country. In order to develop programs to improve the quality of these services, the MOH in Ghana planned an assessment of the quality of care provided to sick children reporting to first level out patient health facilities. (ii) Health Facility Assessment The Health Facility Assessment was conducted in August 1998, in five districts, which are representative of the different ecological zones as well as rural urban distribution. A total number of 25 health facilities, both public and private were visited and observations conducted on 180 children. The distribution of ages of children observed ranged between 2 59 months with a mean of 22 months. In each of the facilities visited a health worker responsible for seeing sick children was observed as he/she managed a number of sick children and was interviewed at the end of the observations on their knowledge and practices. There were also exit interviews with caretakers Page 8

9 of the children observed. In addition, the health facility equipment, supports and drug supply were assessed. Category of HW Managing Sick Children at first level A total of 25 health workers were observed and interviewed. Forty four percent (44%) of health workers were medical assistants (professional nurses with additional training), twenty-eight of them were nurses, twenty percent (20%) doctors, and eight percent (18%) were community health nurses. This implies that either medical assistants or nurses managed sixty nine percent of all the children observed. Assessment of Sick Children The results from the study showed there was the need for improvement in clinical case management - in assessing, classification, treatment and counselling. None of the children observed were assessed for all four danger signs (child unable to drink, vomiting everything, lethargic/change in consciousness and convulsions), which are an indication of severe illness requiring hospital care. Only forty-three percent of children were fully assessed for all three main symptoms cough, diarrhoea and fever. Forty one percent of the assessment tasks were completed for sick children with fever, 35% of tasks completed for those with ARI and 18% completed for those with diarrhoea. None of the children had their nutritional status fully assessed. The most common assessment task completed for Nutrition was checking for pallor in 81% of the children. Seventeen percent of the children seen were weighed. Thirty-three percent of the children observed had their immunisation status assessed. Twenty two percent of children needing immunisation were vaccinated or referred appropriately for vaccination. Treatment and Counselling Most of the cases diagnosed as malaria (75%) were treated appropriately, that is as defined by the National Treatment Guidelines and the diagnosis made by the health worker. Between twothirds to three-quarters of the patients diagnosed as simple diarrhoea and Upper respiratory tract Infections, were given antibiotics inappropriately. The study also showed that counselling of patients was poorly done, and this was evident in the very low percentage (9%) of caretakers who knew how to administer the essential treatment at home. Health workers explained how to administer drugs to a third of the caretakers of the children seen, however demonstrations on administration and verification of comprehension was carried out in only 3 % and 6% of the caretakers respectively. Thirty-one percent of the caretakers were advised on when to return for follow up but none of them were able to give three signs of severity, which would imply their immediate return to the health facility. Facility Supports and Equipment The assessment of the facility equipment and supports indicated that most health facilities have essential drugs, equipment and supplies for managing sick children. Eighty-four percent of the health workers had received a supervisory visit in the last six months prior to the survey however checklists were not used, neither were actual Health Worker practices observed. There was also lack of job-aids, which could be used by the health workers. Page 9

10 The data obtained from the Health Facility Assessment 1998, as well as other information on the health status as indicated above, were then used as the basis for adopting IMCI implementation in the country, to address the gaps identified. Page 10

11 2.0 ORGANISATION, PLANNING AND MANAGEMENT OF IMCI 2.1 Preliminary Visit Following Ghana s participation in the IMCI inter-country orientation workshop organised by WHO, in 1999 at Accra, the Ministry of Health decided to embark on the implementation of IMCI. A formal request was therefore made to WHO to conduct a preliminary visit. The purpose of the mission was to assess the feasibility of IMCI implementation in Ghana, and make recommendations on actions to be undertaken and plan for the next steps. The interest in IMCI implementation within the country, the status of programmes involved in IMCI, the health system and its co-ordination, and interventions at community level were assessed during the visit. Conclusions made at the end of the visit were that Ghana had many assets to successfully implement IMCI. Political will and partners interest was high. It was also indicated that the health system was likely to provide ground for a solid take off for IMCI. However, the implementation of different programs needed some improvement by having policies, strategies and guidelines officially adopted. IMCI strategy could be instrumental for the operationalization of the Sector Wide Approach (SWAP) as it provides a concrete example of the Minimum Package of services that should be provided to children, in a rational, holistic and integrated way, and have impact on the reduction of morbidity and mortality. It was recommended that Program managers should finalise/develop policies, strategies and guidelines and have them officially adopted, the mechanisms for co-ordination and funding of programs must be analysed to ensure effective collaboration between the MOH and partners, as well as the sustainability of programmes. It was also recommended that a National Orientation Meeting on IMCI be held. The decision to commence IMCI implementation was reinforced after the preliminary visit. 2.2 National IMCI Orientation Meeting The National Orientation Workshop on IMCI was held from 13 to 15 September 1999 with support from a number of partners. Participants were drawn locally from the Ministry of Health, Ghana Education Service, Ghana National Commission on Children, partners like UNICEF, USAID JICA, DFID, PLAN International, LINKAGES, John Hopkins University, European Union, BASICS and WHO-Ghana. WHO/AFRO provided technical support for the meeting. Objectives The objectives of the meeting were: To ensure a common and sound understanding of IMCI by all decision-makers and participants, To ensure a common understanding of the implications of IMCI implementation for Ghana s health care system and Page 11

12 To affirm the commitment of Ghana and the country s partners for the implementation of IMCI and the establishment of IMCI working group. Method of work These included presentations on the strategy, the process of implementation and the contextual setting. Emphasis was given to the understanding of the concept and deliberating on the implications this approach would have on the health care system. The Health Facility Assessment, Drug and Care-seeking Behaviour surveys were used to depict the current situation and provided a base of evidence for the planning. Outcomes The Government of Ghana and its partners reaffirmed their commitment to IMCI. It was suggested that although Health system reforms in Ghana were underway and a lot of success had been registered already, there was a need to implement IMCI in a phased manner applying some guided flexibility for implementation within different contexts. There was agreement on the initiation of the adaptation process for the guidelines and materials. Recommendations for adaptation were: To cover the leading causes of death at first level facilities To make the generic material consistent with national guidelines and policies To adapt the guidelines in a way that makes implementation feasible through the current health system. A working group was to be formed after some consultations. Recommended members of the IMCI working group were o Staff of relevant technical programs (MCH, ARI, CDD, EPI, National Drugs Program etc) o Representatives of university departments o Paediatricians o Interested partners The following were recommendations from the workshop Co-ordination and participation of partners is crucial for the success of IMCI implementation. The MOH with support from WHO should ensure that the working group, key programs and stakeholders understand and are committed to IMCI. National, regional and district levels should conduct planning for IMCI implementation. The IMCI working group should review the WHO guidelines as a prerequisite for the introduction of IMCI at regional and district level Reviewing and revision of IMCI materials for adaptation by program managers in the light of the existing policies of the vertical programs. The IMCI working group should develop a strategy for the initial IMCI implementation and seek consensus among stakeholders before its implementation. The IMCI working group should review existing criteria for the selection of IMCI facilitators, develop a means of working effectively with regional and district teams to ensure that they are applied appropriately. Page 12

13 The IMCI working group should work with relevant units and initiatives involved in communications like the chest kit to incorporate IMCI messages into training materials for CHWs. Follow up of trained health workers should be carried out by existing supervisors at district level, those who conduct follow up should be trained in both IMCI and supervision techniques. The IMCI working group should continue to advocate for the availability of essential IMCI drugs at the appropriate levels of the health systems where workers will be trained. Upon request, IMCI/AFRO in collaboration with other partners should provide technical assistance to the working group to undertake the adaptation of IMCI guidelines and development of strategy for implementation. Feeding Adaptation should involve going out to the field to test the feasibility and review the checklist. The study has to be done separately in the different geographical zones. Cost must be considered. The head of nutrition unit must be consulted for the nutrient value of food to get recommendation for the food box. It is gratifying to note that all recommendations made have been pursued. 2.3 IMCI National Planning Workshop One of the outcomes of the National IMCI Orientation Meeting in September 1999 was the formation of the IMCI Working Group. The IMCI National Planning Workshop was held 4 5 November 1999 as the first meeting of the Working Group. The Objectives of the meeting were: To develop a shared understanding of IMCI and its implications among IMCI Working group members To develop a shared understanding of the roles and responsibilities of the working Group To develop a National Plan for the Early Implementation phase of IMCI in the country. To initiate the adaptation process. Outcomes The IMCI Working Group was inaugurated and formally presented with terms of reference. The three sub groups Implementation/Planning, Adaptation and Community were also formed. The Adaptation subgroup was reconstituted into 3 subgroups based on the different adaptations that needed to be considered Clinical Guidelines, Feeding guidelines and local terms sub groups. Selection of Early Implementation Districts: In order to select the districts or regions, some considerations were made these include: o The accessibility to Accra as implementation requires close collaboration with staff from the headquarters, o Interest of Region or district to implement IMCI, o Participation in Health Facility Assessment, Page 13

14 o Availability of training sites which will provide adequate number of patients for both outpatient and in-patient practical. Using the criteria above, the following districts were selected: Site Region Geographical zone Ga Greater Accra Region South Atwima Ashanti Region Central Manya Krobo Eastern Region East Tolon Kumbungu (Later) Northern Region North Tolon Kumbungu Northern Region was added as a fourth district later in the process of implementation, due to the high level of under 5 mortality in the northern sector. Modalities for planning and conducting Regional/District Orientation Meetings were agreed upon. Discussions on improving the health system were held and some major decisions made as follows o The need to assess the supervisory system and suggest ways of improving the system. o The need to ensure availability of IMCI drugs at district level. o The need to improve the referral system and also equip referral centres to provide better care. A draft plan for the early implementation phase was developed, which was to be presented to partners for their commitment to funding. Page 14

15 2.4 Organisation and Management of IMCI at Central Level The diagram below summarises the organisational structure and how the IMCI unit fits into the structure within the Ghana health Service. DIRECTOR-GENERAL INSTITUTION AL HUMAN PUBLIC HEALTH POLICY PLANNING, MONITORING & HOSPITAL ADMIN. & STORES SUPPLIES DEP. DIRECTOR PUBLIC HEALTH DEP. DIRECTOR PUBLIC HEALTH REPRODUCTI VE & CHILD HEALTH EDUCATIO NUTRITION UNIT SAFE MOTHERHO CHILD HEALTH FAMILY PLANNING BREASTFEEDING SCHOOL HEALTH IMCI ADOLESCENT HEALTH

16 The Child Health Co-ordinator is the IMCI Focal Person within the Ghana Health Service at the central level. The Co-ordinator has in addition oversight responsibilities for Breastfeeding and School Health. The School Health Co-ordinator supports the IMCI focal person. There is no office space for the Child Health Co-ordinator and the available secretarial support is shared with all other programmes within the RCH unit. IMCI Working Group - Terms of Reference To advise on all technical matters pertaining to planning implementation and evaluation of IMCI activities in the country. To identify sources of funding and resource co-ordination while working with donor agencies involved in health activities. To develop a strategic framework which outlines the processes to mainstream the IMCI strategy. Facilitate the co-ordination of related programmes and groups for successful implementation. The working group has authority to enact decisions affecting implementation. 2.5 Policy support: IMCI strategy is the one of key interventions in the Child Health Policy and Strategy Document as well as the MOH s 5-Year Programme of Work and in the country s Poverty Reduction Strategy Programme IMCI as a concept and approach for addressing childhood diseases has been presented at a number of fora to health authorities at various levels National, Regional and District. In the Early Implementation districts, dissemination was done widely to involve the sub district and community levels as well as Local Government authorities. The Programme Managers EPI/CDD, Malaria, as well as the head of the Nutrition Unit form part of IMCI working group and have ensured that the IMCI strategy is in harmony with their programme policies. 2.6 IMCI and Health Sector Reforms IMCI is one of the priority interventions identified under the second POW since the health sector embarked on reforms. Some districts have incorporated IMCI into the Medium Term Expenditure Framework and annual work plans. Districts have funded some IMCI activities such as Community Sensitisation Meetings held within their districts. Funding for majority of IMCI activities is at national level and funds have come mainly from the Earmarked funds, a component of the three funding arrangements under the HSR. A few activities especially meetings of Working Group and Sub Group have been funded with GOG funds. Districts and regions have also contributed to preparatory activities and followup visits. 2.7 Management Information System There is a need to harmonise the classifications of RBM, IMCI and existing classifications. New Forms developed by IDRS to collect data have been discussed with both IMCI and RBM to ensure that all relevant areas are covered.

17 2.8 Central Level Support for Districts The Districts selected for early implementation met most of the criteria, the exception being availability of suitable training sites at district level. As a result trainings were conducted at regional level rather than at district level. District Orientation and Planning Meetings were held in all four early implementation districts in the latter part of 2000 and early These meetings brought together Regional, District and Sub district health staff as well as partners from the other Ministries, Departments and Agencies, Non governmental Organisations and Community Representatives. During these meetings, key MoH staff from the neighbouring Regions not implementing IMCI were to participate. These meetings oriented the Districts on the IMCI strategy and supported them to plan for its implementation. All the District Directors were trained in the First National Case Management Training as part of the Orientation process. Subsequently other members of the District Health Management team were trained in Case Management as well as supervision. After Orientation meetings in each district, the Districts were again brought together for an Orientation in Community IMCI in March In August 2001, districts were again brought for dissemination of the framework for implementation of CIMCI and planning of district plans for CIMCI. All the districts went further to conduct orientation meetings for opinion leaders and other stakeholder in their communities. The MoH has identified seven additional districts for expansion of IMCI strategy in collaboration with RBM, IDSR, and EPI programmes as discussed in the introduction. These districts as well as others targeted for expansion by the MoH in collaboration with UNICEF and other partners were brought together for an Orientation and Planning meeting which focused on all four programme areas. These district teams are expected to carry out orientation meetings in their respective districts. 2.9 Organisation and Management of IMCI at District Level All three components of IMCI form part of the district plans of the early implementation districts as well as districts targeted for expansion. District Health teams in the early implementation districts have been involved in supervision and work at ensuring adequate support for health workers to practice IMCI Case Management in the facilities. Reports from follow up visits were shared with the heads of the facilities visited and the District health teams and they were to follow up certain actions to be taken. There were improvements in the facility supports noticed when facilities were visited for the second time, indicating some action had been taken. The Facilities/districts provided logistics and other facility supports, as well as reorganised the case management tasks in the facilities. District/District Assembly funds were used for sensitisation and community activities within the districts. Page 17

18 Although the aim was to build capacity in all four early implementation districts/regions, to carry out IMCI case Management training, only one region is capable presently of carrying out training without National support. The Ashanti Region has a Pool of Regional/District staff trained in IMCI facilitation and able to implement training and follow up without central support. There is some capacity in the other regions and districts however this is not the full complement of facilitators/course director/clinical instructor needed to carry out training. There is however adequate capacity to conduct supervision in all four districts Interest of partners Since the introduction of IMCI into Ghana, several partners have expressed interest in supporting its implementation in the Country. WHO, UNICEF, USAID and BASICS II have been the major partners working with and supporting the Ministry in implementing all three components of IMCI. In addition to the financial support, these agencies provide the MOH with technical and administrative assistance in implementing activities. There are others who have also shown very keen interest, supporting in various activities particularly Community IMCI. Some serve on the Community IMCI and other sub groups These are listed below: Plan International LINKAGES Ghana Red Cross World Vision International PRIME II Johns Hopkins University Adventist Relief Agency Project Concern International Care International Africare Project Concern The funding provided by each of these agencies in implementing IMCI is shown in Annex. The results of follow up and supervision have not yet been made available to partners as an advocacy tool for generating more support. It is expected that this report will serve as such a tool to engage more partners. There are some bilateral agencies such as DFID, GTZ, JICA, the European Union and others that may be considered as potential partners. Page 18

19 3.0 TRAINING 3.1 Adaptation Process The process of adaptation of IMCI training materials for use in Ghana was initiated in November The adaptation process was facilitated by two Ministry of Health officials trained as adaptation consultants at a workshop organised by WHO/AFRO in Harare, Zimbabwe. There was therefore no need for external technical support. The adaptation process was further facilitated by the presence in the country of six health workers already trained in IMCI case management. One of these had extensive experience with IMCI implementation in another country Adaptation Sub-group membership All relevant divisions, programmes and units of the Ministry of health as well as some developmental partners were represented on the Adaptation sub-group that undertook the process. There were representatives from Malaria Control Programme Expanded Programme on Immunisation/CDD Institutional Care Division Reproductive and Child Health Essential Drugs Programme Paediatrician from the Teaching Hospital Nutrition Unit Health Education Unit WHO, UNICEF and USAID Representatives from the Initial Districts List of reference material used in adaptation WHO Adaptation Guidelines Treatment Guidelines for Middle Level Health Providers MOH, Ghana Management of common infections in Ghana Prof. J. O. O. Commey Malaria A training guide for primary health care in Ghana, MOH Essential Drugs list Ghana Objectives, strategies, targets and implementation guidelines for PH interventions in Ghana Community Health Education Skills Tool (CHEST) kit - MOH, Ghana In addition to the above, there were consultations with researchers within the country as well as with external experts on specific issues Local Terms Adaptation/Identification of feeding recommendations Local terms adaptation were done for 3 of the initial districts. The 4th, Tolon Kumbungu district was not included at the time since it was only selected later. Local terms were identified for main symptoms; general danger signs and signs for when to return immediately. A local consultant was appointed and the WHO protocols were used for this process. WHO protocols were also used to determine appropriate feeding recommendations for various age groups after a survey that was conducted in areas representative of the ecological zones of Page 19

20 the country. Technical support for the feeding adaptation was provided by the BASICS II Project. The Linkages Project, Ghana undertook the process for the Northern sector of the country, using local facilitators who had previously been trained through their involvement in the process for the rest southern sector of the country. At various stages, materials produced were circulated among other stakeholders and comments made were incorporated. The process was completed within 8 months after which a meeting was held to build consensus among a larger group of stakeholders National IMCI Consensus Building Workshop In August 2000, 9 months after initiating the adaptation process in Ghana, a consensus meeting was held to address the following objectives: To build consensus among all stakeholders on adapted IMCI guidelines. To ensure consistency of adaptations with national policies. To share technical background information justifying the proposed adaptations and To obtain support from all stakeholders for the use of the IMCI guidelines. The various adaptations, which had been made to the generic IMCI guidelines, were presented to a forum of stakeholders from the Ministry of health, training institutions, hospitals, regions, districts as well as researchers and developmental partners. Consensus was built on the recommended adaptations. Main outcomes of consensus Meeting After thorough discussion of the adaptations made by the sub-group the following changes were made. In view of the prevalence of G6PD deficiency in the Ghanaian setting as well as the risk of Stevens-Johnson s syndrome, the first-line antibiotic for the treatment of pneumonia and acute ear infection was changed from Cotrimoxazole to Amoxycillin. Incorporation of the Hepatitis B vaccine into the materials since plans were far advanced for its inclusion in the immunisation schedule for Ghanaian children Appropriateness of Adapted materials The adapted materials have been used in various training courses and have been found to be appropriate to the Ghanaian setting. Health workers find them very useful on return to their facilities since they cover a majority of the conditions encountered. A few corrections were suggested after the first four case management courses. These have been incorporated into the material. Lately, questions have been raised about the need to include treatment for malaria in the sick young infant algorithm. It may be necessary to discuss this further. It has been detected that the Roll Back Malaria programme s pre-referral treatment for malaria is different from what is used in IMCI. This will need to be clarified. The dosage of quinine used by the two programmes also needs to be synchronised. Page 20

21 3.1.6 Need for adaptations for other regions/districts Identification of local terms will be needed for some districts/regions as they initiate IMCI implementation. On account of the multiplicity of languages spoken in the country, it was impossible to do this adaptation for the whole country. National expertise exists in the form of health workers of initial districts who were trained during the adaptation for their own districts. They can assist new districts in conducting similar surveys. 3.2 Training Activities During the period of adaptation, health workers were given opportunities to be trained out side the country. This contributed immensely to the adaptation as well as building capacity for conducting the first training in the country Participants trained outside Ghana Case management - 10 Facilitation skills - 6 Adaptation - 2 Follow-up - 1 The first IMCI training in Ghana was held in November It comprised facilitators training, which was immediately followed by a case-management course. Since then various other training sessions have been conducted, as shown below Training Sites Appropriate training sites have been identified and tested in all the four regions of the selected districts. Regional level training sites were used instead of district sites for the following reasons The presence of regional training co-ordinators, experienced in organising training for district staff. With the exception of Greater Accra region, all regional training co-ordinators have been trained in case-management as well as facilitation. The one in Ashanti region has also been trained as course director. Adequate case and variety load for both out patient and in-patient practice (not the case in most district health facilities) Only 1 of the initial districts (Atua) has a district hospital with in-patient facilities for sick children. - The presence of appropriate classroom and other facilities at regional level National Training Conducted The early phase was mainly used to build capacity for scaling up. Efforts were initially made to select participants who could be trained as facilitators to assist with future training in their own and other regions. Training organised at various sites covered participants selected from all the four initial districts. This was thought to be a better method for 2 reasons To cover all 4 districts simultaneously To avoid drawing away too many health workers at a time from any particular district for the entire 2-week period. Page 21

22 Sequence of training activities Date Type Venue Funding Objectives Categories of Worker Trained Nov Facilitation Accra WHO Build Capacity SHP 2000 Nov 2000 March 2001 March 2001 May 2001 July 2001 Sept 2001 Nov 2001 Skills National Case Management Facilitation Skills Regional Case Management Supervisors Training Regional Case Management Facilitation Skills Regional Case Management Feb 2002 Supervisors Training April Regional 2002 Case Management April 2002 Facilitation Skills Accra WHO Train SHP from MOH National and District level Train PO who will assist in strengthening IMCI implementation. Identify potential trainers PO SHP, PO, HW Accra BASICS Build Capacity SHP PO Kumasi BASICS Strengthen National SHP capacity HW Train SHP Train HW Accra BASICS Train National / Regional / District supervisors SHP PO HW Koforidua BASICS 23 Accra 12 Tamale WHO Strengthen National capacity Train SHP Train HW Prepare training sites for expansion phase Accra BASICS Train district supervisors Kumasi USAID Train HW Train potential facilitators Accra USAID Build Capacity for IMCI training SHP HW SHP, HW HW, SHP Number Trained (includi ng 4 participant s from the Gambia and Sierra Leone including 2 Sierra Leonians 9 Page 22

23 May 2002 Regional Case Management Koforidua USAID 21 including 4 Sierra Leonians Key SHP senior health Professionals NPM - National Programme Managers PO Programme Officers of Partner agencies HW Health Workers Totals for various categories of training (including those trained outside) Case management Facilitation - 38 (11 more awaiting training) Course Directors - 5 Clinical Instructors - 7 Follow-up Quality of IMCI Case management training course WHO guidelines for conduction standard case management indicates the following: 90 hours of training (excluding period for tea break and lunch) 30% of the time should be used for hands on skills Facilitator: Participant ratio of 1:4 Participant: patient ratio of 1:20 Participant: exposure ratio of 1:40 The table on the next page shows the characteristics of case management training courses conducted during the early use phase. Page 23

24 IMCI Indicators of Quality of Training Course National CM Nov Regional CM March 2001, Kumasi Regional CM July 2001, Koforidua Regional CM Nov. 2001, Tamale Regional CM April 2002, Kumasi Regional CM May 2002, Koforidua Facilitator: Participant Ratio Total Course Duration (Hrs) Time (Hrs) spent for Clinical session Participant: Exposure Ratio Participant: Patient Ratio 1: :69 1:24 All 1: :62 1:24 All 1: :48 1:16 All 1: :64 1:19 All 1: :64 1:25 All 1: All Completion of Modules Page 24

25 3.2.5 Records of Trained Health Workers at First level District Ga Total No. Of Prescribers 57 No. of IMCI Trained Prescribers 13 No. of Prescribers to be trained 44 Tolon Kumbumgu Manya Krobo Atwima Total Facilitators/Supervisors trained per region Region/District Facilitators Course Directors Clinical Instructors Supervisors Greater Accra 6 (3) Ga Ashanti 13 (2) 2 (1) 4 6 (2) Atwima Eastern (1) Manya Krobo Northern (1) Tolon Kumbungu Head quarters/ Partners ( ) Not available to contribute to implementation. Number trained in new Districts Ashanti - Ejisu 3 Offinso - 1 Adansi West 1 Sekyere East - 1 Anansie West Sekyere West - 1 Asante Akim North 2 Page 25

26 3.3 Challenges As expected, not all recommended signs and classifications were seen by participants during training. The following were consistently missed at all training: 1 week up to 2 months - Grunting, Convulsion, Severe dehydration, Blood in stool 2months up to 5 years - Deep extensive mouth ulcers, Mastoiditis Refractory problems were detected in 10% of participants attending the case management training. This made it difficult for them to reach the materials. The opportunity was taken to refer them to the optician. After they had acquired reading glasses they picked up and were able to complete the course without problem. Some participants reported late for the case management course. This gave extra work to facilitators who had to work with them at night and early mornings to assist them to catch up. The situation was worse with foreign participants who sometimes arrived as late as the evening of the third day. Some who were invited for training did not report in spite of several reminders. They did not send the replacement therefore places remained vacant Despite extra assistance from facilitators a few participants found it difficult to follow the training. This was so with 2 participants. It was suggested that they be attached to better performing participants for 2 weeks after the course in order to improve their understanding. Facilitators were sometimes difficult to come by due to commitment to other activities as well as inadequate motivation. Varying rates among partners sometimes led to dissatisfaction among facilitators. High attrition rate among facilitators they either moved to join other organisations or went on to further their studies. Others who were trained never availed themselves to facilitate due to conflicting interests. Delays in release of funds for some trainings made organisation extremely difficult. Co-ordination of IMCI and other training and implementation Staff from other programmes have been involved in organising orientation meetings for implementing districts e.g. Nutrition unit, IDSR and RBM Some IMCI facilitators also facilitate trainings for the RBM programme. Some programme managers have been trained in IMCI but have not been used in facilitating courses because of their busy schedule. It has not been possible to involve staff from other programmes for similar reasons. IMCI training has been co-ordinated with training in Breastfeeding. Some staff from implementing districts were trained in the Breastfeeding Counsellors course in order to act as referral points for mother who are identified with problems by IMCI trained personnel. Page 26