IMCI DOCUMENTATION: Experiences, Progress and Lessons Learnt

0 24 2 4 22 6 20 8 18 10 11 12 IMCI DOCUMENTATION: Experiences, Progress and Lessons Learnt Ghana, May 2004 Kyei-Faried S. For WHO Ghana Office

TABLE OF CONTENTS Section Page Table of Contents...1 List of Abbreviations.2 List of Annexes...3 List of tables 3 Acknowledgement.3 Executive summary..4 1 Introduction..5 2 Situation of Children and women...8 3 Introduction of the IMCI Strategy in the Country...10 4 Introduction of community IMCI...12 5 Capacity Development & Implementation of IMCI 13 6 Motivation of Community resource persons...13 7 Policies on IMCI 15 8 Programme reviews 16 9 Partnerships analysis and linkages 16 10 Changes and Impact Demonstrated...18 11 Sustainability and scaling up...20 12 Supervision mechanisms..22 13 Challenges, constraints and solutions.24 14 Best Practices and lessons learned...25 15 Lessons learned...25 16 Next steps, conclusions and recommendations...26 17 Conclusion.27 18 Recommendations..27 Annexes 28 1

LIST OF ABBREVIATIONS ANC AIDS AR ARI BCG C-IMCI CCGP CHO CBS CBA CBGP CD COMM CHPS CORP CHEST DA DHMT ER EPI FP GAR GES GHS GDHS HE-HA-HO HIV IDSR IMCI ITN NGO NR OPD OPV POW2 PRA PH QA RBM SWAp TL TA VR UER Antenatal clinic Acquired immune deficiency syndrome Ashanti Region Upper respiratory infection Tuberculosis vaccine Community component of integrated management of childhood illness Community child growth promoter Community health officer Community based surveillance Community based agent Community based growth promotion Community development Community Community health planning and service Community Resource person Community health education tool District Assembly District health management team Eastern Region Expanded programme on immunization Family planning Greater Accra Region Ghana Education service Ghana Health services Ghana demographic and health survey Healthier happier home Human immune deficiency virus Integrated diseases surveillance and response Integrated management of childhood illness Insecticide treated nurse Nongovernmental organization Northern Region Out patient Department Oral polio vaccine Programme of work (Phase2) Participatory rapid appraisal Public health Quality assurance Roll back malaria Sector wide approach Traditional leader Traditional authority Volta Region Upper East Region 2

LIST OF ANNEXES 1.01: List of key organizations and individuals contacted 11.01: Cost of IMCI Implementation 11.01: UNICEF IMCI Expenses 12.01: Key findings and recommendations of the clinical care review 16.01: Sample of IMCI strategic plan for Ghana, 2002-2006 18.01: Trend of Sector wide performance indicators, 2001-2003 A: IMCI Documentation: Ghana Summary Report LIST OF TABLES 2.01: Malnutrition rates in children under-5 years 2.02: ANC, delivery and HIV Seroprevalence rates 5.01: Coverage of IMCI case management implementation 5.02: Trained IMCI resource persons 6.01: CORPs trained in the pilot districts and their roles 9.01: List of stakeholders and their focus 12.01: Health workers followed up after training and districts supervised 12.02: QA: Results of health facilities charts review 3

Acknowledgements I wish to express my gratitude to WHO Ghana Office for its confidence in appointing me to undertake this first ever IMCI Documentation in Ghana. I am very much indebted to all the Pilot Districts Health Directors and their Teams, the Regional Health Directorates and the Development Partners for the useful information they provided and the time they spent with me during the interviews. I am also very grateful to all those, whose constructive comments and valuable inputs on the draft report have been used to make this report better, especially Dr. B.Manyame, the external consultant. Dr. Victor Ankrah, UNICEF Project Officer, Health, provided a lot of useful information when critically needed and I am grateful to him. I say Thank you to the external consultant whose support has been invaluable. Of special mention is Dr. Mrs. Isabella Sagoe-Moses, the Child Health Coordinator, Ghana Health Service, and the National Focal person fro IMCI whose regular contact with partners difficult to reach, provided considerable amount of the information required for the timely completion of the assignment. 4

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

group. The Regional and District health management teams also work to link programme. Under the CHPS strategy, service delivery is integrated. There are demonstrable changes as a result of IMCI implementation that relate to service structure and organization, home and family practices, case management and distribution of health goods at community level. Scaling up of both IMCI and CHPS are planned and being executed. Districts are encouraged and pilot districts have budget lines for Malaria, diarrhea and nutritional control measures; some very explicit on IMCI and CBGP training and supervision. Curriculum revision and Pre-service training has started and is ongoing. The enabling factors for scaling up include partners commitment, Child Health Policy, CHPS draft policy, the priorities in the POW 2002-2007, the human resource, leadership and enthusiasm of health training institutions and the UNICEF best practice.. Supervision after follow up is decentralized to Regions and districts. All trained health workers have received follow up visit. A monitoring mechanism exists as part of PH support supervision to regions, districts and subdistricts within which IMCI supervision is integrated. IMCI implementation is confronted with a few problems and many challenges such as the increasing demand for scaling up, difficulty in getting facilitators released, high attrition rate among facilitators, delay in funds release and weak documentation. Measures to address some of these include encouraging local funding for community based activities, developing the full compliment of facilitators and decentralizing case management training to regions, introducing IMCI into pre-service training and increasing advocacy for increased resource mobilization. There are significant Best Practices. These include adopting different entry points for C-IMCI, decentralizing case management training, regional initiative to integrate IMCI classification into HIS, concentrating resources to underserved regions in C-IMCI (UNICEF), early involvement of regional level senior managers as facilitators and course directors and the use of local initiatives to motivate CORPs are among the best practices in place. Several lessons have been learnt, both in IMCI and in C-IMCI. They included the need to use a variety of practicing health workers as facilitators and practicing doctors as clinical instructors. Other lessons are that shortening the case management course for first level staff will compromise the quality and practice; linking up with other programmes helps in judicious use of scare resources; building on existing interventions make things work and identifying each partner s comparative strength is very important in moving things forward. Next steps and recommendations: The programme is to continue with the arrangements to expand to many districts, speed up the process of incorporating IMCI into pre-service training curricular and include private providers in IMCI case mgt among others. District assemblies should be encouraged to support C-IMCI initiatives. National and Regional fora should be created for IMCI experiences to be shared, including website as is available for CBGP. The documentation process should be adopted to be carried out at all levels. 6

1. Introduction 1.01 Introduction UNICEF and WHO developed the Integrated Management of Childhood Illnesses (IMCI) initiative in order to reduce childhood mortality, particularly for children under five years. It had been observed that in most developing countries, more than two thirds of deaths are due to five common conditions i.e. respiratory infections, malaria, diarrhea, malnutrition and measles. Each of these conditions has had a control programme targeted at it. However, these vertical programs have been criticized, not only for their duplication of resource use but also because patients rarely present with symptoms and signs of only one of these conditions at a time. Cough and fast breathing in a child may be caused by pneumonia, but it could also be due to severe anemia or malaria. A "very sick" child may be suffering from pneumonia, meningitis, septicemia or a combination of these conditions. The IMCI initiative aims to integrate the ways health workers look at children and manage the conditions that children present with at health facilities. It aims to prevent and reduce the number of cases of these illnesses and to improve the quality of care of children in the health services, while also involving parents, households and communities in the care of their children. It has three main components i.e. a) Improvement of the case management skills of health workers through the provision of locally adapted guidelines and training activities. b) Improvement in health systems required for effective case management of childhood illness, especially supplies of essential drugs. c) Improvement in family and community practices in relation to child health. These three components are complementary. They all need to be functioning well to fully benefit the child. Forty-four out of forty-six countries in the African Region (including Ghana) have adopted the IMCI strategy. As a way of encouraging evidence-based planning and implementation, WHO/AFRO, UNICEF/ESARO and BASICS II developed a framework for documenting experiences and best practices with IMCI implementation in the countries. Ghana is one of the first countries to use this documentation framework to document its experiences with IMCI implementation and best practices observed so far. The documentation was carried out in the months of March and April 2004, covering 3 of the initial 4 pilot districts. At the national level, attempt was made to obtain as much information as possible on all districts implementing IMCI. The terms of reference were to: 1. Document the implementation of the IMCI strategy 2. Document the process of scaling up of the IMCI strategy and identify best practices in IMCI implementation 1.02 Tasks The specific tasks were to: 1. Orient national officials on the documentation process to be followed. 2. Coordinate with MOH, WHO, UNICEF, and BASICS. 3. Consult with the international consultant on a regular basis to inform on progress. 4. Use the documentation framework (provided by WHO) to collect information from national and district levels through review of existing documents, key informant interview and focus group discussions. 5. Review national and district plans and approaches for the IMCI strategy, including costs and budgets. 6. Identify lessons learned and best practices. 7

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

information especially on the organization of activities, meetings and ways to verify some of the information. Some activities are done but not documented at higher level. It becomes difficult to accept such kind of information. Tolon Atwima Manya 1.04 Summary descriptions and observations on the documentation process Visits to GHS headquarters, UNICEF, WHO, the selected districts and some regional health directorates took place for the data collection process. Most of the required information was available especially where responsible officers were in place. However, it was observed that there was minimal or no document inventory at the various places visited. This made it particularly difficult to identify information sources. 1.05 Observations on filling in the framework, its usefulness, deficiencies, etc This was a very nice experience. Filling the framework makes one go through a series of literature/ documents/ reports. One benefit is being informed of the current situation on the subject. The collected information is particularly important for planning purposes and other use. It readily gives answers for example on important national indicators to whoever is in need. Such information could be shared on the Internet. 1.06 Problems encountered Some required information was not clear from the tool attached to the TOR. Extra effort had to be put in to obtain the additional information.(annex A) Some required information was not easily available in the form it was required. One had to take time to convert it to the required format. In addition to the short time allocated for the exercise, non-availability of different people at the national and district levels (due to different commitments) and lack of clarity of some items in the documentation tool caused some delays in the data collection process. 1.07 Recommendations to improve the documentation process There is need to sensitizing stakeholders at various levels to process data for use both locally as well as for higher levels. This could be done through the DDHSs and Regional and district review meetings. DDHSs could be oriented in this process so that it becomes easier for the District Health System to simplify the activity for the National levels. Future documentation is to give first priority to National level to be supplemented by validation visits to districts and regions selected by geographic zones or because of peculiarities. Institutional strengthening issues must also be well captured Financing sources, amounts and purpose must be obtained to track partner contributions 9

There may be need for orienting responsible people at the various levels (where applicable) on ways for updating the Documentation Framework on a yearly basis. 2. Situation of Children and Women 2.01 Overview: Administratively Ghana is divided into ten regions, 110 districts and --- villages. The Country has a 2003 projected population of 21 million, 3.4 million of whom are children under five years of age and 4.3 million women of childbearing age. There are 1207 doctors and 8123 nurses. Population doctor ratio is 20,500 to 1 and population nurse ratio is 1800:1. There are 2,173 health facilities excluding three teaching hospitals. The districts that were assessed have populations ranging from 144,000 to 262000. Women in their childbearing age account for 23% of the population and children under-5 years age constitute 18% of the population. 2.02 Health Situation of Children From the GDHS, infant mortality rate (IMR), child mortality rate (CMR) and maternal mortality rates (MMR) for 2003 are quoted to be 64/1000, 111/1000 and 214/100000 respectively. However, there were no consistent data sources for infant, child and maternal mortality rates at district level. For example, depending on the data source the IMR for Tolon district for 2003 ranged from 62 to 91 per 1000 live births. Malaria, Diarrhoea, Anaemia, Cough or cold, Pneumonia are the 5 top childhood illnesses in all the districts. At national level however, measles and malnutrition join ARI, malaria and diarrhoea as the top five causes of morbidity in children under five years age which are exactly the same as the IMCI target conditions. The 2003 OPD attendants were 10,551,000 and the OPD attendance per capita 0.5. The total admissions were 598,774 with an admission rate of 28.4/1000pop. Children under five who sleep under ITN are 3.5% 2. The under-five year malaria case fatality rate is 1.5%. The percentage tracer drug availability is 70% at national level. There were high levels as of malnutrition in all the districts, as shown in Table 1. Of particular concern are the very high levels of acute malnutrition (wasting), both at national level and at district level. In all these figures, Tolon, which falls in the Northern region, one of the 4 regions classified as deprived, has the worst values. Table 2.01 Malnutrition Rates in children under-5 years age: Ghana, 2003 Tolon Atwima Manya Krobo Ghana 1 Stunting 39.6 27.6% 23.6% 26% Underweight 38.1%% 24.7% 22.3% 25% Wasting 12.7% 9.2% 8.7% 10% EPI coverage in infants is quite high at BCG 92%, Measles 83.2%, pentavalent vaccine 76.4% and OPV 76% 1. 2.03 Maternal Health The proportion of pregnant women attending antenatal care (at least 2 visits) as recorded by the districts was over 100% in all the districts. This was attributed to double registration and inaccurate census figures for women in fertility age and hence the expected pregnancies. ANC registrant at national level was 87%. The 2+ visit statistic was not available at the district level though national report had this to be 20%. The average visit per client was 3. Supervised deliveries rate were similar in all the districts and were close to the national average of 68% (for deliveries by health workers and by TBAs. There were however wide 10

variations in the deliveries conducted by trained health professionals (Skilled attendant rate). This ranged from 20.7% in Tolon to 72.8% in Atwima with a national rate of 47.1%. Compared to other parts of Africa, particularly Eastern and Southern Africa, the HIV seroprevalance rate among pregnant women is still relatively low in Ghana (Table 2), ranging from 3.6% and 7.6% in the pilot districts. The national median seroprevalance for 2003 is 3.6%. It is estimated that there are 200,000 AIDS orphans in Ghana 3. Except in Atwima where the proportion of the population living within 5Km of a health facility was found to be 30.4%, this information was not readily available. The proportion of the population who take more than 30 minutes to reach a health facility was however found to range from 24% in Manya to 50% in Tolon with a national average of 48% 4. The proportion of the population utilizing curative services ranged from 0.17% (Tolon) to 0.44 in Atwima with a national average of 0.50. Children account for a high proportion of OPD attendants in some districts. Child OPD utilization as a proportion of total utilization ranged from 7.7% in Atwima to 24.9% in Tolon with a national figure of 15%. Table 2.02: ANC, Delivery and HIV Seroprevalence Rates, Ghana 2003 Indicator Tolon Atwima Manya Krobo Ghana ANC 2+ visits??? 20% ANC attendance DHS (Regions) 82.3% 94.2% 91.8% 91.9% 1 Delivery by trained personnel (Regions) 1 18.3% 59.9% 49.5% 47.1% 1 Deliveries (TBA +HW) 77% 69% 72% 51.9 5 % HIV Seroprevalence in ANC (Regions) 2.1% 4.7% 6.1% 3.6% (2003) 3 NB: The validated figures for the districts are the mean values for the sites in that region. 3. Introduction of the IMCI Strategy in the Country: Components 1 and 2 Though Ghana started IMCI in 1998, with the initial capacity building, baseline studies and adaptation, it was not until 2000 when four pilot districts started components 1 and 2. The pilot districts were selected based on their close proximity to Accra, interest of region and district, involvement in health facility assessment and training site availability. Ghana has a child health policy 6 and programmes of work 7 that gives priority to IMCI. MOH 2003 POW Reproductive and Child Health Expected Output 8 : IMCI scaled up Improved access to essential obstetric care delivery in every district All district hospital provide adolescent friendly services Following the experiences from the pilot districts, WHO in collaboration with Ghana Health Service and other stakeholders has drawn a national IMCI strategic plan 9. The plan covers in-service and pre-service case management training, community IMCI using various child survival and development interventions, institutional strengthening, resource mobilization for IMCI, integrating IMCI into CHPS (CHPS is a community health planning and service strategy to provide comprehensive health care to the underserved at door mouth). At national level, an IMCI Focal person who is also the National Child Health Coordinator coordinates IMCI. There is IMCI working group with 16 members drawn from the Ghana Health Service (GHS) departments relevant to IMCI (Dir. PH, Dep. Dir RCH, ICD, EPI, HEU, RBM, NU, HRD, RCH, Private Sector Unit, etc), university departments, donors (e.g. 11

USAID), UN agencies (UNICEF and WHO) and NGOs (e.g. BASICS). The working group is involved in IMCI performance assessment, monitoring and coordination. In addition to the working group, other stakeholders are brought on board to influence and agree on levels and focus of support and implementation. These stakeholders are part of one or more of the following committees: IMCI Steering committee made up of NGOs, Adaptation Committee and an Implementation and planning committee (for case mgt and Component 2). There is also a Coalition of NGOs for C-IMCI, which includes Red Cross, CRS, ADRIA, PCI, JHU, BASICS, PRIME II, and CARE and an Adaptation committee. Each district has an IMCI Focal person and an IMCI working group to coordinate IMCI activities and women form 57% to 100% of the district team involved with matters of IMCI. In Ashanti, region and Northern Region there are Regional IMCI Focal Persons. District Assemblies and Traditional authorities are also key players at district level, in addition to the GHS, NGOs (e.g. BASICS), UN agencies (UNICEF and WHO) and donors (e.g. USAID). Other government departments such as the Ghana Education service (GES), and community development (CD) are also involved. IMCI is included in the overall district health plan. Currently 47 Districts are implementing components 1 and 2. List of Districts Involved in IMCI Case Management: 46 GREATER ACCRA Accra Metro Ga Dangbe West Dangbe East Tema Metro WESTERN Wasa Amanfi Wasa West Nzema East Takoradi ASHANTI Atwima Ejisu-Juaben Amansie West Asante Akim North Asante Akim South B twe Atwma Kwanwoma Kumasi Offinso Adansi west Adansi East Sekyere west Sekyere East CENTRAL Gomoa Cape Coast VOLTA Ho Kejebi Hoehoe Ketu Jasikan EASTERN New Juaben Manya Krobo Fantiakwa Kwahu South Suhum Kraboa Coaltar UPPER EAST Bolga Sandema Bawku UPPER WET Wa BRONG AHAFO Techiman Kintampo Berekum NORTHERN Tolon Kunbungu Gushegu Karaga Yendi Savelugu Nantong Tamale 4. Introduction of Community IMCI (Component 3) Though there had been several child survival initiatives in the different districts, it was not until 2000 that actual C-IMCI implementation started. The Ministry undertook several interventions in an attempt to develop this component. Among the main activities carried out were: Selection of key practices for implementation Identification of successful community programmes and interventions Review of materials that deal with child health and Identification of key community level stakeholders. As part of the process to introduce C-IMCI, an assessment of on-going community based child health programmes were carried out and the following were considered. a. Home management of Fevers b. Baby friendly initiatives with mother support groups c. Community based growth monitoring and d. VHC, CBS and VHW activities. 12

Based on these practices, The UNICEF IMCIplus support to Upper east region has taken on board home management of diarrhoea and fever, promotion of breastfeeding and hygiene and malaria prevention using ITNs as part of c-imci. Community-based volunteers, mostly members of Red Mother Clubs, dispense pre-packed antimalaria drugs and ORS. The EPI component of the programme (Immunizationplus) also adds on deworming, vitamin-a supplementation and defaulter tracing to the package of strengthening outreach services. All the 3 districts have other community based programmes taking place. These include a)community based surveillance system (CBS) that tracks diseases, births and deaths, gives advise on sanitation, treats diarrhea and malaria and refers cases b) Community Health Planning and Service (CHPS) in which a health worker is assigned to and lives among a group of communities, carries out house-to-house visits, gives prompt care to the sick and provides PH activities. c)fp Community Based Distributor of modern contraceptive methods (d) HIV/AIDS Community Based Organizations (e) School children deworming, (f) First aid training for teachers, (g) Supply of hand washing facilities to schools h) Insecticide treated bed nets (ITN) sales (i) vitamin-a supplementation (j) Home based treatment of malaria and diarrhea and (k) Use of Daddy Clubs and mother support groups to support behavioural change. In the pilot districts, community IMCI has basically been growth promotion except in Tolon where additional components have been added to make it IMCIplus. Initially each district started with 2 sub-districts but currently all the 5 sub-districts in Tolon, all 6 in Manya and 6 of 8 in Atwima are participating. The selection of initial sub-districts was left to the district to decide. In Atwima, the criterion was nearness to District capital to facilitate supervision, whereas in Manya-Krobo it was fairness so that there was one each from the Upper and Lower Manya areas of the district. In Tolon, it was based on high incidence of communicable diseases such as measles.within the sub-district, initial communities were selected based on poor access, irregular use of child welfare clinics, or high infant death reports. C-IMCI baseline studies on family practices were conducted in Ajumako Eyan Esiam (Central region), Atwima District (Ashanti Region), Birim South District (Eastern region), Ga district (Greater Accra) and East Mamprusi (Upper East region). Among the key findings were: Delayed initiation of breastfeeding and discarding colostrum. Absence of exclusive breastfeeding. Breastfeeding fewer than 10 times a day Incorrect positioning and attachment Complaints of inadequate breast milk Early introduction of complementary food and Use of feeding bottle..the Key Family Practices selected for use are: 1) Exclusive breastfeeding from birth to 6 months and continuing till the child is 2 years 2) Nutrient rich complimentary feeding from 6 months while continuing breastfeeding till the child is 2 years 3) Full immunization before 1 st birthday 4) Adequate amount of micronutrients (Vit-A, Iodate and iron) 5) Sleeping under ITN 6) Use of safe drinking water 7) Good hygiene and sanitation practice 8) Adequate care for pregnant women and promotion of spacing 13

The following key practices during sickness were also adopted: a. More food before and after illness b. Continuing feeding and more fluids during illness c. Appropriate home treatment of infections and injuries d. Following H/workers advice on treatment, follow up and referral and e. Recognizing when child needs further care and seeking appropriate care. The findings have been used to edit the Child Health Record (formerly road to Health Card) and the CHEST Kit (Community Health Education Strategy Tool Kit) which uses PLA to influence family and household practices and decisions to improve child health. There are aspects of the Safe Motherhood Communication strategy, which had selected sections influenced extensively by IMCI key family practices. The national EPI unit in 2003 finalized its five-year EPI communication strategy to be put to use in 2004. The First draft of Anaemia communication strategy is ready. In all these, the selected key practices had influence. Other communication strategies used extensively are the newspapers, radio, TV, internet, post, reports, telephone, fax and visits (observations). At national level, 33 of the 110 districts are implementing aspects of c-imci. 5. Capacity Development & Implementation of IMCI In Ghana, 46 Districts are implementing the case management component of IMCI while 38 districts and 119+ sub-districts are implementing the Community IMCI component. The Table below shows the coverage in IMCI case management: Table 5.01 Coverage of IMCI Case Management Implementation, Ghana REGION Districts IMPLEMENTING DISTRICTS % IMPLEMENTING GAR 5 5 100 ASH 18 12 67 VR 12 5 42 CR 12 2 17 BA 13 3 23 UER 6 3 50 NR 13 5 38 ER 15 5 33 WR 11 4 36 UWR 5 0 0 NATIONAL 110 44 40 5.1 Facilitators for IMCI and C-IMCI Capacity for IMCI is being built at all levels and is still not sufficient. All the pilot districts have case management facilitators and C-IMCI facilitators. At the national level, there are 71 facilitators for case management. There are several facilitators for C-IMCI. These include 23 CBGP facilitators made up of those in the three pilot districts and four World Bank assisted areas focal persons and 6 focal persons from Project Concern. The rest are facilitators addressing home management of fevers and others under CARE, PLAN, PCI and UNICEF projects. Given the fact that case management training at the district level may not be possible because of the limited number of cases, the district considered sub-district facilitators adequate if there was even one facilitator in that sub-district. 14

Table 5.02: Trained MCI Resource Persons Region Facilitators Course Directors Clinical Instructors Supervisors Total Greater Accra 6 0 0 5 11 Ashanti 13 2 4 6 25 Eastern 7 1 2 4 14 Northern 6 1 3 4 14 Head Quarters 3 1 0 3 7 Total 35 5 9 22 71 5.2 Community resource persons (CORPs) A total of 127 first level staff have been trained in C-IMCI and over 1322 community resource persons in the 3 pilot districts (286 by BASICS in growth promotion) and 1036 under the UNICEF project in Northern and Upper east regions in home management of fevers, diarrhea and ARI in 104 subdistricts 10. There are other similar resource persons trained under the PLAN, CARE and PCI projects. 6. Motivation of CORPs Among the motivational approaches used to retain CORPs are: Bicycles, ID cards for VIP treatment when sick, assistance at funerals of deceased relatives with free transportation of the body from the morgue if died in H/facility (in Manya Krobo); commission from ITN/iodated salt sales and token amount at community durbars. Allowances are also given during refresher training sessions. In Tolon, UNICEF has provided seven bicycles that will be given out as incentive. In Atwima end of year awards and negotiation with the District Assembly (DA) to obtain soft loans for CCGPs are additional incentive strategies. Table 6.01: CORPs Trained in the Pilot Districts and Their Roles. Table 3 Tolon Atwima Manya Krobo Ghana Number of community resource persons trained (& percent who are women) 86 (Women =34.9% due to low female illiteracy). Trained by UNICEF-1036 and BASICS- 91 (76% women. Trained by BASICS 109 (43.1% women due to low female literacy) Not readily available Their specific roles in the community 286. Weighing and charting Counseling Referral NID volunteers, Nutritional surveillance Iodated salt sales ITN sales Home treatment of fever and diarrhea Deworming Weighing, Charting Counseling Referral NID volunteers Vitamin-A supplementa tion Assist mother support groups. Weighing Charting Counseling Referral Breastfeeding support Growth promotion Care of sick children Counseling, Micronutrient supplementati on ITN sales, referral, Advocacy, sensitization 15

Table 3 Tolon Atwima Manya Krobo Ghana Hygiene and sanitation education 7. Policies on IMCI 7.01: Policies governing work of community-based workers: The work of the CORPs is guided by Guidelines. These are applied at the district level. To be selected as a CORP, the person must be resident, literate, credible; must be willing to be a volunteer and have time to do CCGP every month. A CORP is to be a female (preferably) and must treat a sick child only if trained. The proportion of women CORPS was low 34% at Tolon where female literacy is low. Community health Officers (CHOs) resident in CHPS (community health planning and service) zones are mandated by Policy to supervise the work of CORPs. The work of the CORPs is guided by Guidelines. These are applied at the district level. To be selected as a CORP, the person must be resident, literate, credible; must be willing to be a volunteer and have time to do CCGP every month. A CORP is to be a female (preferably) and must treat a sick child only if trained. The proportion of women CORPS was low 34% at Tolon where female literacy is low. Community health Officers (CHOs) resident in CHPS (community health planning and service) zones are mandated by Policy to supervise the work of CORPs. 7.02: Policies supporting linkages of community activities with health care providers. There are several policy thrusts that support linkages between the health sector and the community activities. TBA and CORP training manuals are prepared by the GHS within the context of its strategic direction. Examples are the CBG counselling cards, the TBA training manuals, RBM manuals for training chemical sellers. The GHS 5-year programme of work stresses partnership in the provision of services and identifies CHPS as one strategy to carry health care to the door step of the underserved with the participation of CORPs. 11 8. Programme Reviews Several review processes were identified. Quarterly community durbars, sub-district, district and regional performance review meetings were taking place. At the National level the steering Committee meets quarterly and the last was in February 2004. The GHS has a performance review guideline, which has CHPS as a key indicator, suggesting a strong commitment to community based service delivery. 12 9. Partnerships analysis and linkages 9,01 Partners in IMCI Several partners are contributing to making IMCI work in Ghana though they have different areas of focus. These are GHS, WHO, UNICEF, USAID, BASICS, PLAN Int., LINKAGES, GRC, WVI, PRIME II, JHU, ADRA, CARE Int., Project Concern Int. (PCI) and Africare. The partners play the following roles: Table 9.01: List of Stakeholders and Areas of Focus STAKEHOLDER FOCUS BASICS, PLAN, CARE, ADRA, PCI: Community IMCI training and support CARE, USAID, WHO, UNICEF: Case management PRIME II: UNICEF : Institutional strengthening (logistics support) Institutional Strengthening, logistics support (pre-packed chloroquin, ORS), Community IMCI training and support and Supply of manuals. 16

Traditional Leaders, the Ghana education Service, district assemblies are important partners in all the districts, particularly for community activities. There are also other partners specific to different districts such as New Energy, Amaasachina, Bible church of Africa (BCA), Global 2000, Ghana Danish Comm. Project (GDCP) in Tolon and the alliance (Transport Union) and Information Service Dept. in Manya-Krobo. Partners also complement roles at district level as exemplified by Tolon below: PARTNER Roles played by Partners in Tolon district, Ghana UNICEF: Case management training, Provision of communication gadgets, motorbikes and bicycles and support for CBGP training and outreach. DA: Assembly members assist in volunteers selection, help settle disputes Global 2000: Support provision of water and sanitation and help organize durbars BCDP: Public education, deworming and provision of soak-away sanitary pits. New Energy: Provision of household toilet facilities and hand dug wells. Amaasachina: Hygiene education, emergency readiness, health fund for referral WVI: Mother support groups NB: The overlaps make MAPS presentation Complex OR Many! The partners have different geographic coverage. JHU operates at the national level UNICEF: National and Regional: UER, NR; BASICS: National and Regional: ASR, GAR, ER, NR- 4 districts PCI: Regional: WR-2 districts; in all LINKAGES: Regional: NR, UER, UWR, CR, VR, ER; GRC: Regional: NR, UER, GAR; PLAN Int: Regional: ER, CR, VR; AFRICARE: Regional: VR; CARE: Regional: ASR; WVI: NR; UWR UER NR BAR VR ASR ER WR CR GAR 9.02 Linkages among partners are ensured through IMCI working group; C-IMCI Subgroup; Partners (review) meetings; NGO Coalition for C-IMCI; Partners review meeting (WB, WHO, DANIDA etc meets with GHS and MOH monthly. 17

There are pro-poor ppolicies to ensure access to underserved communities. The 3 Northern Regions and Central region with poor social, economic and health indices have been considered deprived and therefore receive additional resources for health. These regions are given government of Ghana Funds to exempt payment for supervised deliveries. In other regions, including the deprived, exemption systems exist for children under-5, the aged and the pregnant woman for basic services. The proposed NHI is also expected to use a means test to identify the core poor for support in premium payment. 9.03 Partnership Analysis and Linkages The partners supporting c-imci are GHS, BASICS, WHO, USAID, UNICEF, PCI, World Bank. The partners have different level of involvement in c-imci planning, implementation, training, support and monitoring. GHS, BASICS and UNICEF (especially in UER and NR) are fully involved at all stages. Since training and development of materials could be cash driven, GHS national level and the multilateral organizations feature prominently at the planning and development stage. Implementation, support and supervision are generally decentralized by GHS to the district level and it is at this stage that district assemblies and Ghana education service come in. At each level, the partners sit, discuss and agree on what is to be done and assign responsibilities and allocate cost. For example, during district orientation WHO gives a certain amount and UNICEF tops up or USAID gives funds for IMCI facilitators training and GHS tops up, or BASICS pays for technical assistance and counseling cards development and UNICEF prints. 9.04 Programs are linked under the IMCI working group. EPI advised on immunization sessions of assess and classify part of case management and what must be done if a child has missed immunization. Recommendation for the use of ITN and adoption of Chloroquine as the 1 st line drug and quinine as a pre-referral drug were based on RBM recommendations. At the MOH-GHS-Partners review meeting held in April 2004, RBM promoted the replacement of Chloroquine with a combination drug and the IMCI working group will be considering the implications of this for home management of fevers. The PPME unit will be looking at the cost implication for the poor and the effects on the exemption fund and national health insurance premium etc. The IMCI Focal person and the IMCI working group are assisted by various arms of government to co-ordinate their activities. For example, the District Coordinating Director (DCD) calls Heads of Departments meeting, the District Chief Executive convenes DA meetings (chaired by Presiding Officer) and the District Director of Health, GHS, convenes performance review meetings. To strengthen the partnership between IMCI and RBM, the two, with assistance from WHO have acquired a joint office at the National level. Following a joint review of activities by the two programmes, the following were agreed upon as activities that will be integrated in RBM ten selected districts: evaluation of progress, constraints and challenges identification, exploring options for integration and joint planning to achieve common objectives 13. RBM Targets 2003: Improving Management at HH Level Increase from 22% to 32% the proportion of children with fever receiving correct home treatment At the community level, sub-district health workers link the CBS, TBAs, GW Vols., and CCGPs and community durbars bring them together. Community leaders, assembly members and Unit committee members bring NGO activities together. 18

10. Changes and Impact Demonstrated 10.01 Health Worker skills improvements There is generally improved case management as reported in district reports and from follow up reports 14. They are now offering better choice of treatment, referrals are more appropriate and the stocks of pre-referral drugs have improved. In Ashanti Region, forty-five IMCI case managers were assessed early this year. Analysis of the findings shows that 95.6% had ORS for Diarrhoea management, 91.1% had a weighing scale and did weigh every child and 91.1% had thermometer and checked each child s temperature. 10.02 Improvements in the Health system There are major systemic changes taking place in Ghana. Scaling up of IMCI is a priority intervention in the 2004 GHS Programme of work (POW). The current child health record card has been revised and contains feeding recommendations and instructions for the sick child, which changes the outlook for childcare at child welfare clinics and consulting rooms. Frontline health workers now can administer drugs previously left for doctors to prescribe. Despite the fact that the Drug Policy in Ghana Has not been changed to permit health centres to stock some 2 nd line and pre-referral drugs, 42.2% of the IMCI practicing facilities evaluated had Quinine injection and 45.5% had Gentamycin and chloramphenicol injections. In 51.1% of cases, Tabs. Fansidar was available. Attempts are currently underway to revise the Drug Policy to make it possible for prereferral and 2 nd line drugs to be available to health centres, CHOs and clinics. The health system now permits community level case management. The new CHPS policy, though does not mention IMCI and C-IMCI, which appears to be a big oversight, it outlines Basic Package of Services by the CHO that further empowers health workers to work with communities as case finders, care givers and counselors, care supporters, case referral and disease control workers 15. 6.03 Improvements at household and community level Community register review conducted by BASICS in CBGP implementation districts and communities have demonstrable results form the intervention. As high as 96% of the children under-2 years participate the programme. Whereas the proportion of children 12-24months with low weight for age remained at 40% from 2002 to 2003, that of children 0-11months reduced from 16% to 14%. Missing data were as high as 22% thus making comparative analysis unrealistic. Proportion of children with adequate weight gain increased from 48% (2002) to 67% (2003). It is reported, there were many reported deaths in the communities, but with the CBGP program they (Atwima) are beginning to see fewer reported deaths. 16. In all 6 deaths were reported in the 19 communities with total registered children of 1098 in the three districts In Tolon district, the proportion of babies on exclusive breastfeeding has increased from 1% in 1999 to 73% in 2003. Feeding practices in general, such as better positioning and attachment, introduction of snacks, have been observed to improve and the use of CBGP has increased. Use of iodated salt has also improved. Community members now record cases of diseases such as measles, polio etc. and record deaths. Breastfeeding practices have improved considerably in Linkages areas of work >50% (Northern region), there is improvement in home based care of children with fever (He-ha-ho feedback reports), better home management of diarrhea and families now feed children 3x with snacks. The use of CBGP for growth promotion 17 and support within mothers support groups has been well accepted. 16.6% under five years have been dewormed In Atwima, the C-IMCI implementing districts register average growth promotion visits of 82.9%. Malnutrition rate (underweight) in children under five years has reduced from about 10% (2000) to 3.9% (in 2003). The proportion of children with adequate weight gain has increased from initial value of 40% to 54% (2003). Families now feed children 3 times a day with snacks and mothers assist others through support groups. Infants less than 6 months exclusively breastfeeding has moved from 0% to 36% in CBGP communities. 19