Integrated Childhood Management Illness by cgn16846

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									 Integrated Management
   of Childhood Illness
          (IMCI)



REVIEW OF INTRODUCTORY
AND EARLY IMPLEMENATION
    PHASES - GHANA




       MINISTRY OF HEALTH

            MAY 2002
                                                               Table of Contents

1.0 INTRODUCTION: ...............................................................................................................................................3
   1.1     Background Characteristics of Ghana.........................................................................................................4
   1.2 Health Status.....................................................................................................................................................5
   1.3 Organisation of the Health Sector.....................................................................................................................6
2.0 ORGANISATION, PLANNING AND MANAGEMENT OF IMCI.................................................................11
   2.1 Preliminary Visit.............................................................................................................................................11
   2.2 National IMCI– Orientation Meeting .............................................................................................................11
   2.3 IMCI National Planning Workshop ................................................................................................................13
   2.4 Organisation and Management of IMCI at Central Level...............................................................................15
   2.5 Policy support: ................................................................................................................................................16
   2.6 IMCI and Health Sector Reforms ...................................................................................................................16
   2.7 Management Information System...................................................................................................................16
   2.8 Central Level Support for Districts.................................................................................................................17
   2.9 Organisation and Management of IMCI at District Level ..............................................................................17
   2.10 Interest of partners ........................................................................................................................................18
3.0 TRAINING .........................................................................................................................................................19
   3.1 Adaptation Process .........................................................................................................................................19
   3.2 Training Activities ..........................................................................................................................................21
   3.3 Challenges.......................................................................................................................................................26
   3.4 Pre-service training .........................................................................................................................................27
   3.5 Major Lessons Learnt and Way Forward........................................................................................................27
4.0 HEALTH SYSTEM SUPPORT FOR IMCI.......................................................................................................29
   4.1 Drug Supplies .................................................................................................................................................29
   4.2 Basic equipment..............................................................................................................................................30
   4.3 Actions taken facility support .........................................................................................................................30
   4.4 Referral ...........................................................................................................................................................31
   4.5 Supervision .....................................................................................................................................................31
   4.6 Follow up ........................................................................................................................................................32
   4.7 Constraints and supports for implementing IMCI in facilities........................................................................34
   4.8 Documentation of Early Implementation Phase: ............................................................................................34
5.0 COMPONENT 3: FAMILY AND COMMUNITY PRACTICES .....................................................................35
   5.1 Formation of CIMCI sub-group......................................................................................................................35
   5.2 Assessment of community based interventions ..............................................................................................35
   5.3 Key Family Practices Selected for Intervention..............................................................................................35
   5.4 District orientations.........................................................................................................................................36
   5.5 Adaptation of Feeding guidelines/local terms.................................................................................................36
   5.6 Development of CHEST-Kit...........................................................................................................................36
   5.7 Development of Child Health Records ...........................................................................................................37
   5.8 Development of an Improved Version of the IMCI Mothers Card.................................................................37
   5.9 Development of training manual for traditional healers .................................................................................37
   5.10 Development of child health component for the CHPS curriculum .............................................................37
   5.11 Community Based Growth Promotion..........................................................................................................37
   5.12 RBM Home-Based Care Communications Strategy.....................................................................................38
   5.13 Community IMCI Planning Meeting ............................................................................................................38
   5.14 Future Plans ..................................................................................................................................................41
ANNEX ....................................................................................................................................................................43




                                                                               Page 2
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 1999. 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
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
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 1998. 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
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 2002-2006 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 2002 – 2006 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 2002-2006
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
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                  Type of Provider
                       Public Health             Clinical                 Maternity
Community              VHW, VHC, CHN,            Chemical sellers,        TBA, CBD (FP), CHO,
                       CHO, PCW, TBA,            pharmacy shops,          CHN
                       Wansam committees,        traditional healers,
                       private laboratories,     CHO
                       condom outlets            Private Midwives
Sub district           Health centre, MCH        Health Centre,           Maternity homes,
                       Clinic, Environmental     pharmacy shops,          MCH clinics
                       Health Officers           private clinics
District               District Hospitals and Mission Hospitals
Regional               Public Health             Regional Hospital        Regional Hospital
                       Reference Laboratory
National                                         Specialised Hospitals,   Teaching Hospitals
                                                 Teaching Hospitals
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


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
•   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 1997. 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
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 two-
thirds 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
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
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
   •   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
           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
           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
    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                                              PUBLIC                       POLICY                           HOSPITAL                            STORES
AL                    HUMAN                              HEALTH                       PLANNING,                        ADMIN.                  &          SUPPLIES
                                                                                      MONITORING &



       DEP.   DIRECTOR                    PUBLIC                                                             DEP.   DIRECTOR                     PUBLIC
       HEALTH                                                                                                HEALTH

                                                                                                  REPRODUCTI                   HEALTH                    NUTRITION
                                                                                                  VE & CHILD                   EDUCATIO                    UNIT



                                                                        SAFE                      CHILD                      FAMILY
                                                                        MOTHERHO                  HEALTH                     PLANNING



                                                                                                                                       ADOLESCENT
                                BREASTFEEDING                       SCHOOL HEALTH                     IMCI                             HEALTH
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 2002 – 2006 and in the
country’s Poverty Reduction Strategy Programme 2002-2004.
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 - 2002 – 2006
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 follow-
up 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.
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 2001. 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 2000. 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
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.

2.10 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
3.0 TRAINING

3.1 Adaptation Process

The process of adaptation of IMCI training materials for use in Ghana was initiated in
November 1999. 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.

3.1.1 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

3.1.2 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.

3.1.3 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
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.

3.1.4 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


3.1.5 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
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.

3.2.1 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 2000. 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.

3.2.2 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

3.2.3 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
        Sequence of training activities

Date         Type             Venue       Funding    Objectives               Categories   Number
                                                                              of Worker    Trained
                                                                              Trained
Nov          Facilitation     Accra       WHO        Build Capacity           SHP          6
2000         Skills                                                           PO
Nov          National         Accra                  Train SHP from           SHP,         19
2000         Case                         WHO        MOH National and         PO,
             Management                              District level Train     HW
                                                     PO who will assist in
                                                     strengthening IMCI
                                                     implementation.
                                                     Identify potential
                                                     trainers
March        Facilitation     Accra       BASICS     Build Capacity        SHP             9
2001         Skills                                                        PO
 March       Regional         Kumasi      BASICS     Strengthen National SHP               21(includi
2001         Case                                    capacity              HW              ng 4
             Management                              Train SHP                             participant
                                                     Train HW                              s from the
                                                                                           Gambia
                                                                                           and Sierra
                                                                                           Leone
May          Supervisors      Accra       BASICS     Train National /         SHP          9
2001         Training                                Regional / District      PO
                                                     supervisors              HW
July         Regional         Koforidua   BASICS                                           23
2001         Case
             Management
Sept         Facilitation     Accra                                                        12
2001         Skills
 Nov         Regional         Tamale      WHO        Strengthen National      SHP          20
2001         Case                                    capacity                 HW
             Management                              Train SHP
                                                     Train HW
                                                     Prepare training sites
                                                     for expansion phase
Feb 2002 Supervisors          Accra       BASICS     Train district           SHP,         8
         Training                                    supervisors              HW
April    Regional             Kumasi      USAID      Train HW                 HW,          22
2002     Case                                        Train potential          SHP          including
         Management                                  facilitators                          2 Sierra
                                                                                           Leonians
April        Facilitation     Accra       USAID      Build Capacity for                    9
2002         Skills                                  IMCI training


                                                  Page 22
May         Regional          Koforidua    USAID                                           21
2002        Case                                                                           including
            Management                                                                     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        -      104
       Facilitation           -      38 (11 more awaiting training)
       Course Directors       -      5
       Clinical Instructors   -      7
       Follow-up              -      19



       3.2.4 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
IMCI Indicators of Quality of Training

Course                   Facilitator:    Total Course     Time (Hrs)         Participant:     Participant:    Completion of
                         Participant     Duration (Hrs)   spent for          Exposure Ratio   Patient Ratio   Modules
                         Ratio                            Clinical session
National CM              1:2.5           93               28                 1:69             1:24            All
Nov. 2000
Regional CM              1:2.5           93               28                 1:62             1:24            All
March 2001, Kumasi
Regional CM              1:4             93               28                 1:48             1:16            All
July 2001, Koforidua
Regional CM              1:3             93               28                 1:64             1:19            All
Nov. 2001, Tamale
Regional CM              1:3             93               28                 1:64             1:25            All
April 2002, Kumasi
Regional CM              1:3             93               28                                                  All
May 2002, Koforidua




                                                          Page 24
3.2.5 Records of Trained Health Workers at First level

District           Total No. Of          No. of IMCI              No. of Prescribers to be
                   Prescribers           Trained Prescribers      trained
Ga                 57                    13                       44

Tolon              35                    12                       23
Kumbumgu

Manya Krobo        46                    13                       33

Atwima             49                    20                       29

Total              187                   58                       129


Facilitators/Supervisors trained per region

Region/District      Facilitators Course Directors        Clinical Instructors       Supervisors
Greater Accra        6 (3)          0                     0                          5
Ga
Ashanti              13 (2)         2 (1)                 4                          6 (2)
Atwima
Eastern              7              1                     2                          4 (1)
Manya Krobo
Northern             6              1                     2                          4 (1)
Tolon Kumbungu
Head quarters/       3              1                     0                          3
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
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
3.4 Pre-service training

6 health staff from pre- service institutions have been trained in IMCI case management and 5
in facilitation skills. These have been very keen and have been assisting with trainings. 4 of
them are clinical instructors.

They have shown interest in incorporating IMCI into their training curricula and recently
attended a pre-service dissemination meeting organised by WHO/AFRO.

3.5 Major Lessons Learnt and Way Forward

3.5.1 Major Lessons Learnt
       • Involving senior staff at the regional level facilitated implementation
       • The course is appropriate for the target group.
       • Shortening the course for first level health workers will result in compromising the
          quality and hence not much change in practice.
       • A short course may however be appropriate for senior level personnel with
          extensive medical training.
       • Training country level personnel in adaptation process facilitates adaptation.
       • Training other workers at the facility e.g. Dispensers and Nutrition officers can
          facilitate actual practice.
       • Medical Assistants and nurses can be good facilitators when trained
       • Doctors in clinical practice serve as the best Clinical Instructors
       • Building Regional and District capacity is critical for scaling up. For both training
          and follow-up training can be done with minimal national involvement.
       • Regional level training can cater for the districts and ensure quality.
       • So far, facilitators’ training has occurred at the national level to ensure quality.
       • It is essential to train large numbers of facilitators to maintain an available pool
          when needed.
       • Case management training is very expensive, between 17,000 to 18,000 US
          dollars. It will be difficult for regions/districts to bear the entire cost.
       • The method of teaching used in the course ensures acquisition of essential skills
          for management of sick children.


Specific Changes Needed
Further discussions and consensus on pre-referral for Malaria and Quinine dosages should be
initiated and the issues resolved.




                                          Page 27
3.5.2 Selected Activities for Expansion Phase
1.     Selected tutors from Pre-service institutions should be trained in IMCI.
2.     Orient staff at Nurses and Midwives Councils, HRD, CHNTS and Medical and Dental
       Council in IMCI pre-service.
3.     Drug management and dispensing counselling training should be provided for
       dispensing assistants and technicians.
4.     Incorporate IMCI into training curricular of pre-service schools
5.     Upgrade skills of referral level staff and adopt WHO guidelines for the purpose.
6.     Inclusion of private providers in IMCI implementation. Need to find modalities for
       training them.
7.     Conduct planning meeting to look at cheaper alternatives for conducting 11-day case
       management.
8.     Adapt abridged course for senior level personnel.




                                         Page 28
4.0 HEALTH SYSTEM SUPPORT FOR IMCI

4.1 Drug Supplies

4.1.1 Policy
Government drug policy provides for the compilation of an essential drug list, EDL, which is
basically for the public sector although private sector is encouraged to use it. All drugs needed
for IMCI implementation are on the Essential drug list. The main challenge however is that
EDL categorisation of drugs puts some of the key IMCI drugs into groups that majority of
frontline workers are not supposed to prescribe or stock in their facilities. Drugs such as
amoxycillin suspension, chloramphenicol injection, quinine injection, sulfadoxine-
pyrimethamine, Nalidixic acid that are in the Level B2 and C category are not to be handled
by health centres without a doctor. More than 60 percent of the facilities in the 4
implementing districts fall within this category of “health centres without a doctor” and are
therefore prohibited by the policy from prescribing these drugs. In addition in some health
facilities even though a facility is allowed to stock all the IMCI drugs some first level health
workers working in that facility are not allowed by law to prescribe certain drugs. For
instance Community Health Nurses (CHN), one category of frontline health workers, are not
supposed to prescribe antibiotics and quinine. A number of IMCI-trained prescribers in the 4
IMCI implementing districts are neither doctors nor medical assistants and therefore fall in
this category.

4.1.2 Drug procurement and distribution
The country operates a well-established system for the distribution of drugs. Public sector
facilities have been directed to procure drugs from government medical stores, as the first
source but where a drug or group of drugs in the EDL is not available in the government-
owned stores the policy allows facilities to procure from privately owned pharmacy shops.
The private sector, including the mission, are not bound by policy to purchase drugs from the
government owned stores however the private-not for profit facilities are encouraged to buy
drugs from government. All of the health facilities in the IMCI implementing districts
procure their drugs from the medical stores. The first level health facilities (i.e., health
centres) procure their drugs from district medical stores or where there are no district medical
stores from regional medical stores. The regional medical stores in turn procure their drugs
from the central medical stores at national level. They buy from elsewhere if not available.

4.1.3 Availability of drugs and other supplies
Reports from facility support/follow up visits indicate that first-line oral drugs are available in
all the implementing health facilities. Second line drugs, vitamin A, and pre-referral drugs
were not available in most health facilities. Most facilities did not have Quinine, Nalidixic
acid, Gentamycin, Fansidar, and IM chloramphenicol. These facilities did not have the drugs
most probably because the National Drug Policy bars their facilities from stocking these
drugs.

As a result health workers do not make requisitions for them. Probably they do not feel
confident enough to use drugs that they have not previously handled. The few who requested



                                             Page 29
were supplied and are using them. Talking to regional/district pharmacists, they are willing to
supply all drugs when requisitions are made.

4.1.4 Drug management
Capacity to manage drug supplies.
Qualified pharmacist with the requisite expertise to manage drug supplies efficiently man
district hospital pharmacies. Health centres also have dispensing assistants, who have had
some training and are able to manage drug supplies, however a number of health facilities
(hospitals, health centres and clinics) lack staff in these two basic category of pharmacy staff
for their dispensary. Small one-man stations keep a little dispensary manned the by same
Health worker who attends to patients.

4.2 Basic equipment
All the health facilities have basic equipment for storage, record-keeping and stock
management. Drugs are kept in cabinets or in dry places on shelves where necessary, one or
two facilities I visited had drugs in boxes – no shelve. The situation was rectified by the
DHMT after reporting and stores/shelves provided for the sole purpose of storing drugs and
few other medical items. These stores have ledgers and tally cards that are well kept. What is
lacking is good forecasting and timely ordering of appropriate drugs based on patient flow.
This leads to stock-outs for some key drugs. The reason for this may be due to inadequate
capacity or high workload. Some do not keep tally cards up to date.
Some facilities do not have the required equipment particularly weighing scale.

4.2.1 ORT Corners
The ORT corners of 23% of health facilities were non-existent or non-functioning. Some had
the utensils but not in use. Some lay out corners but do not use.

4.2.2 Immunisations
Some of the routine childhood vaccines were not available at the time of visit. This probably
stems from the fact that vaccine ledgers were not kept up to date in order to monitor vaccine
stock levels. In a few facilities the cold chain systems were not functioning optimally due to
problems associated with electricity and or faulty refrigerators


4.3 Actions taken facility support

Following the first round of follow-up and facility visits the national working group discussed
the findings from the visits and initiated action to correct the situation. These include
reporting problems on cold chain equipment with EPI to prioritise needy facilities in their
distribution.
In addition to the above corrective measures taken by the national IMCI working group,
management in all the health facilities and their district health management teams have
rectified some of the anomalies in their health facilities. For example 90% of health facilities
now have all the first line IMCI drugs.




                                            Page 30
4.4 Referral

The average distance from a health centre to a referral facility (usually a district hospital) is
variable for the different health facilities/districts.

Factors that hindered caretakers from going to a referral facility were lack of adequate funds
and or transport. Some times the caretakers did not have confidence in quality of service in
the referral centre or feared attitude of Health workers at higher level. Some fear getting lost
in big centres where no special arrangement for exits for attending to referred cases.
It is not clear how health workers managed children who needed referral but could not go.

4.5 Supervision

4.5.1 Incorporating IMCI into Routine Supervision

A review of Facility based Supervision was conducted in August 2001 in the four districts to
Review current supervisory practices,
Identify barriers to effective supervision
Plan a strategy for improving supervisory practices, including a supervision workshop.

The findings from the assessment were as follows:
Positive findings
Supervisory teams are in place, and schedule routine visits, and make the majority of visits.
Facilities had been visited between 3 and 6 times in the previous 12 months. Standard
checklists that combine administrative and technical information are used. The importance of
solving problems is recognised and a number of activities are undertaken routinely to address
problems.

Gaps identified
Observations of clinical practice are not conducted,
Quality of care is not assessed nor do supervisory activities focus on improving health worker
practice
Checklists can be duplicative and include unnecessary information. The quality of feedback
and problem solving conducted immediately with health staff is variable.
The majority of district supervisors have no clinical training, and have not received
supervisory skills training
Supervisors are often unavailable due to other competing responsibilities.

Actions taken to address gaps
Following the assessment, a workshop was held for eighteen district supervisors and some
programme managers and members of the IMCI Working Group to address some of the gaps
identified.
Revising standard checklists to be more focused on program needs and problem solving.
Adding IMCI clinical observation using a simple checklist to routine supervisory activities.




                                            Page 31
Scheduling supervision so that an IMCI trained supervisor is included on each team to
conduct clinical observations at least twice a year.
Better organising how supervision is conducted at facilities.
Training all supervisory staff in skills to improve feedback and problem solving, and
equipping them to train other supervisors in their districts.

4.6 Follow up

Follow up is an integral component of IMCI case-management. WHO recommends that
trained health workers be followed up within 4-6 weeks of training. The objectives of the
follow-up are:
Reinforce IMCI skills and help health workers transfer them to their work in Facilities
Identify and help solve problems faced by health workers in managing cases
Gather information on performance of health workers and conditions that influence
performance in order to improve implementation of IMCI.

4.6.1 Training of supervisors
A National training of supervisors was held in May 2001 and a second training held in
February 2002. Most of the supervisors had been trained previously in facilitation skills. The
trained supervisors then carried out follow up visits to the trained health workers within their
districts or regions. The first batch of follow up visits conducted was done with support from
the National level and a number of partners. Subsequently follow visits were conducted by
district supervisors.

The table below shows the number of supervisors available in each Region/district.

Table: Supervisors per Region/District

   Region / District                              Number of Supervisors
   Greater Accra/Ga District                      5
   Eastern /Manya Krobo                           4 (1)
   Ashanti /Atwima                                4 (2)
   Northern /Tolon Kumbungu                       4 (1)
 (1) – NA available


The country since it began IMCI implementation has not been able to meet the target of
conducting follow up visits within 4- 6 weeks of IMCI Case Management Training. Follow
up visits were conducted eight – twelve weeks after Case Management training.
During follow up visits, health workers were observed as they performed case management
tasks and given feed back. The caretaker was interviewed at the end of the observation and
the outcome also used in providing feedback to the health worker. The facility supports were
reviewed and staffs of the facility were brought together at the end of the visit to provide
feedback of the review and discuss improvements in the health facility. A summary report
was left at the facility, one at the District and the third submitted to the National level after
each training. There were actions to be taken at the different levels and reports indicated these
actions. Follow up reports were discussed during IMCI Working Group meetings and with the


                                            Page 32
other Programme Managers to identify the possible solutions to the problems identified at
each level.
A total of 40 first level health workers have been followed up and the findings from the
follow up visit are summarised below.

Table: health Workers followed up per district
   District                     Number Trained      No Followed up    Percentage
                                                                      followed up
   Ga District                    13                6                 46%
   Manya Krobo                    13                10                77%
   Atwima                         15                13                87%
   Tolon Kumbungu                 12                11                85%

Findings from follow up visits
Health worker practices            Percentage (%)
Correctly assessed general         71
danger signs
HW Correctly assessing for         81
three main symptoms Cough,
diarrhoea, fever
Correctly checked weight for       81
age
Correctly checked                  91
immunisation.
Give immunisation according to     93
schedule
Correctly prescribed anti-         80
malarial for malaria
Advised on home care               30

Assess and counsel on feeding      58

Caretaker knowledge

Correct knowledge on antibiotic    78
or anti-malarial

Knows 3 rules of home care         32




                                          Page 33
Available Facility Supports

Functioning ORT Corners             77

Cold Chain equipment                77

Vaccine                             83

IMCI Drugs – First line             90



4.7 Constraints and supports for implementing IMCI in facilities

The job descriptions of staff of first level health facilities are generally not available and do
not usually determine roles of the various staff. The current organisation of work in health
facilities does not allow every trained Health Worker to perform all IMCI tasks. Generally the
prescribers who maybe medical assistants or nurses were responsible for assessing,
classifying and treating the children seen. Other staff did some aspects of assessment such as
weighing of children and taking of temperatures. It was generally found that there was
pressure on Health Workers and they were unable to carry out all IMCI tasks. The feeding
assessment and counselling on feeding was not usually carried out in facilities with high
patient load. In such facilities, the most feasible option was for the feeding assessment and
counselling to be carried out by nutrition officers or community or public health nurses. The
trained health workers were asked to share the counselling cards with such workers for this
purpose. In certain facilities, the dispensary staff administers the drugs and was responsible
for counselling of patients on the drugs. It may be necessary to provide trained health workers
with some materials/job aids, which can be used by such staff, who carry out some aspects of
the IMCI Case management tasks.

4.7.1Other signs indicating IMCI was implemented
The trained Health Workers in a number of facilities disseminated information on IMCI to
their colleagues. Some health workers knew about general danger signs, the need for
counselling on drugs as well as counselling on when to return although they had not
undergone the 11-day course. This was to help them pick out children who needed urgent
attention by the trained Health Workers. The first dose of the drugs was also given in some
facilities and this was done by the dispensary assistant/technician, where the trained health
worker was too busy to do so.

4.8 Documentation of Early Implementation Phase:

The Child Health Co-ordinator was responsible for documenting most of the activities carried
out in the early implementation phase. Other partners such as WHO, UNICEF and BASICS
supported this activity.
In addition, the various sub-groups were responsible for the activities they carried out and
these were submitted to the IMCI focal person.




                                            Page 34
5.0 COMPONENT 3: FAMILY AND COMMUNITY PRACTICES

Community IMCI is all activities aimed at introducing, reinforcing and sustaining family and
community practices that will improve child health.

5.1 Formation of CIMCI sub-group

In Ghana the MOH decided that all three components of IMCI should be implemented
together.
To ensure the incorporation of community IMCI activities into the overall IMCI framework, a
community sub-group has been formed with membership from:
• Ministry of Health
    • Health Education Unit
    • Nutrition Unit
    • Reproductive and Child Health Unit
• USAID
• BASICS
• UNICEF
• WHO
• John Hopkins University (Centre for Communication Programs),
• Ghana Red Cross and
• PLAN International.

5.2 Assessment of community based interventions

With technical assistance from the Basics II project, an assessment of on going community
interventions was also conducted from July 24 to 12th August 2000. This was done to
document successful community-based child health activities, being supported by both
Government (MOH) and NGOs in the country. Some successful activities found included the
following:
• Home Based Treatment of Fevers (HBTF) project at Ejisu, Gomoa and Wa;
• the Ghana Red Cross (GRC) mothers clubs;
• Mother Support Groups (MSG) - Baby Friendly Hospitals Initiative (BFHI);
• Freedom From Hunger’s (FFH) credit with education programmes for mothers,
• Community Based Growth Monitoring at Ejisu and
• PLAN International’s VHC and VHW activities in child health.

5.3 Key Family Practices Selected for Intervention
IMCI orientation meetings were held for policy makers and key health personnel of the MOH
at the national level as well health partners in Accra. At these meetings all three components
of IMCI were discussed as well as the implications for implementation at the district level.
Key family practices selected for intervention in Community IMCI include:

1. Exclusive breastfeeding from birth up to 6 months and continue until the child is 2 years




                                           Page 35
2. Energy and nutrient rich complementary feeding from 6 months while continuing
breastfeeding into the second year of life.
3. Ensure children receive adequate amounts of micronutrients (vitamin A, iron, and iodine)
4. Ensure children are fully immunised before their first birthday
5. Ensure children sleep under insecticide-treated bed nets
6. Ensure children have safe drinking water
7. Ensure the child receives formal education
8. Practice of good sanitation including safe disposal of waste

9. Practice of good hygiene including hand-washing with soap (after defecation, before
preparing meals and before feeding children), and the use of clean utensils for feeding
10. Ensure that every pregnant woman receives adequate care and promote child spacing.

Key practices for sick children are:
1. Continue to feed and give more fluids when a child is sick
2. Give a child more food before and after illness
3. Appropriate home treatment for injuries and infections
4. Follow health worker advice on treatment, follow up and referral
5. Recognise when child needs further care and seek appropriate care.

5.4 District orientations

Similar orientation meetings were also held in all the four IMCI early implementation districts
between September 2000 and February 2001. Participants brought together included health
staff from the districts, regional level health staff, NGOs in the districts and policy makers in
the local government authorities. Districts were asked to develop work plans to implantation
of IMCI, looking at key areas like who is to be trained, support for trained staff, availability of
drugs and supplies recommended for IMCI, supervision and referral systems etc.

5.5 Adaptation of Feeding guidelines/local terms

An initial assessment of feeding practices of infants and young children was conducted using
the Trials of Improved Practices (TIPs) methodology. This was done in the Manya Krobo
district in the Eastern region, Ga district in the Greater- Accra region, Atwima in the Ashanti
region and Tolon-Kumbungu in the Northern region. The results of TIPS were used to adapt
the generic IMCI food box and the IMCI counsel the mother module.

5.6 Development of CHEST-Kit

A draft Community Health Education Skills Tools (CHEST) Kit was developed by the HEU
and the MOH. This is to assist Community Health Nurses (CHN’s) deliver accurate
information to promote preventive measures e.g. Immunisation, use of ORS, provide timely
referrals to other service providers and generally act as health advocates in their communities.
During the review of the CHEST-Kit, a team with knowledge in IMCI reviewed the child
health section of the kit and incorporated IMCI into the kit. The revised CHEST-Kit has been
produced and in order to promote the use of the Kit, USAID provided funds to train health
workers in the early IMCI implementation districts as well as other districts in the country.



                                            Page 36
5.7 Development of Child Health Records

The IMCI team also reviewed and helped revised the old Road to Health cards. IMCI has
therefore been incorporated into the new Child health Records, which will be used by mothers
for all children less than five years to any of the child health services. Messages on the IMCI
mothers card have also been incorporated into the new Child health Records to ensure
sustainability.




5.8 Development of an Improved Version of the IMCI Mothers Card

An improved version of the IMCI mother’s card to be used by health workers to counsel
mothers has been developed and field-tested with the assistance of an expert in health
education. These materials are currently being printed by UNICEF.

5.9 Development of training manual for traditional healers

 The traditional Medicine Directorate of the MOH put together a draft manual for traditional
medicine practitioners in the country in 1999. Two members of the IMCI working group
participated in the workshop to review the draft document and addressed the gaps that were
identified to conform to IMCI guidelines in the country.

5.10 Development of child health component for the CHPS curriculum

CHPS is a strategy for health care delivery system to provide cost effective health services to
individuals and households in communities through engaging the communities in the planning
and delivery of the service. The curriculum developed for the Community Health Officers
(CHOs) was found to have no information on child health. To help address this, the IMCI
team was tasked to help review and develop a child health training module for the CHOs.

5.11 Community Based Growth Promotion

Community Based Growth Promotion (CBGP) has been identified as one of the key
interventions to improving key behaviours and family practices and is being used as the entry
point for the implementation of community IMCI. The Nutrition Unit (NU) of the MOH has
been the key organisation to this programme. The unit has initiated the formation of a task
force with representatives from the NU, Reproductive and Child Health (RCH) unit, Health
Education Unit (HEU), WHO, LINKAGES, BASICS, and UNICEF to review and develop
materials for the growth promotion programme.

The task force has developed the following draft materials, which are yet to be pre-tested:
Community Growth Promotion manual for community child growth promoters
Training guide
Trainer of Trainers guide
Counselling cards
A guide to planning CBGP


                                           Page 37
Brochure on Growth Promotion

An initial orientation and sensitisation meeting was held for all the four IMCI early
implementation districts. District and sub-district health workers as well as some members of
the health and social services sub-committee of the District assemblies were the targets for the
orientation meetings. Following these activities, 8 selected communities from all the four
districts have been sensitised on the CBGP. Together with the communities guidelines for
selection of community volunteers has been developed and communities have been tasked to
develop community action plans with the assistance of district health teams.

5.12 RBM Home-Based Care Communications Strategy

Home-based care of malaria presents an enormous opportunity to reduce childhood morbidity
and mortality in Ghana. The home-based care communications strategy outlines an approach
to improve home treatment of malaria in children and early referral of severe cases by
providing information to mothers as the primary caretakers, training chemical sellers, and
advocating for support from policy-makers.

The home-based care communication campaign will use a multi-channel approach, with a
combination of various communication channels mutually reinforcing each other. The
approach encompasses:
Community and regional level communication activities to change social norms influencing
care for the child’s health within the home and community;
A national level media campaign strategy to address and empower mothers regarding home-
based care of malaria has been developed and has the following components:
• A child health theme or symbol to unify this and other child health interventions.
• Enhancement of chemical sellers ability to inform and provide a full course of
    chloroquine to caretakers through interpersonal communication and counseling skills
    training and provision of provider and client support materials;
• Advocacy and media initiatives that contribute to a more conducive environment for
    home-based care of malaria.
Currently a radio serial programme called “He Ha Ho” standing for Healthier; Happier Home
is being aired on the national radio station in 5 Ghanaian languages and English. The first part
of the series will run weekly for 26 weeks, after which it will be reviewed for another set of
messages to run for another 26 weeks. Topics on Malaria, ARI, Diarrhoea disease,
malnutrition and measles have been selected for discussion on the 30 minutes radio
programme.
Copies of the serial programme has been made available to all the 10 regional health
administrations to be duplicated and sent to all health facilities. The expectations are that
these radio cassettes would be played at child welfare clinics, outpatient departments etc.

5.13 Community IMCI Planning Meeting

To agree on community interventions within the early IMCI implementation districts, a five-
day planning workshop was organised in August 2001 in Accra. Participants of this workshop
included representatives from the DHMT, district assembly, SMO-PHs from the four regions




                                           Page 38
of IMCI early implementation, policy makers from the central MOH, private providers and
partners.

 The objectives of the workshop were:
To orient key national, regional and district level personnel on the WHO recommended steps
for implementation of community IMCI.
To share experience of CIMCI implementation from other countries.
Draw up district plans for CIMCI implementation.
Draw up a national plan for CIMCI implementation.




                                         Page 39
Flow Chart to illustrate sequence of events

                        C-IMCI Subgroup formed


                     ADAPTATION OF FEEDING
                    GUIDELINES & LOCAL TERMS



                                                          SURVEY OF EXISTING
                                                            INTERVENTIONS

               C-IMCI Orientation meeting for National,
               Regional & District MOH staff, Partners,
                    NGO’s & other Stakeholders




                KEY BEHAVIOURS & PRACTICES IDENTIFIED,
                    AGREEMENT ON KEY PLAYERS AT
                 COMMUNITY LEVEL, INTERVENTIONS TO
                         PROMOTE BARRIERS



                       DISTRICT PLANNING WORKSHOP




             ORIENTATION OF KEY PLAYERS AT DISTRICT LEVEL




               IMPLEMENTATION OF SELECTED ACTIVITIES AT
                           DISTRICT LEVEL




                                              Page 40
5.14 Future Plans

The need to develop a child health curriculum for community workers
Apart from traditional medical practitioners other community-based agents identified include
community-based distributors (CBD’s), community based surveillance volunteers (CBS),
traditional birth attendants (TBA’s) etc. To improve the skills of these volunteers in the
management of sick children, the need for a national training curriculum has been identified
by all partners and the MOH. A consultant has therefore been contracted by the Basics II
project to work with the IMCI working group and partners to produce such a material for
volunteers.
Expand CBGP activities from original 16 to as many as possible communities in the early
IMCI implementation districts and also introduce this activity in many communities in the
new IMCI and World Bank districts (Komenda-Edina- Eguafo- Ebirem, Kadjebi and Bongo
districts).
Train community volunteers (surveillance volunteers, community-based distributors, etc) in
IMCI using the developed CIMCI curriculum in all districts implementing IMCI.
Enhance integrated communication activities to improve recognition of danger signs and to
prompt care seeking.
Encourage other public/private partnerships to ensure availability and demand for ITMs at the
community level.
Enhance role of NGOs in planning, implementing and evaluating CIMCI approaches.
Improve prescribing practices, counselling skills and referral practices of chemical sellers.
Enhance DHMT capacity to strengthen existing community structures i.e. Mother support
groups, surveillance volunteers, community based distributors etc.
Strengthen linkages between health facilities and communities through improved outreach,
inter-personal communication.
Increase advocacy with donors and MOH partners to invest in Community health activities.
Conduct operations research to document effectiveness and impact of innovative community
based approaches.
Strengthen inter-agency partnerships to scale up CIMCI activities




                                          Page 41
Acronyms
MOH        -   Ministry of Health
CBGP       -   Community Based Growth Promotion
GDHS       -   Ghana Demographic and Health Survey
CHW        -   Child Health Worker(s)
EPI        -   Expanded Programme on Immunisation
NGO        -   Non-Governmental Organisation




                          Page 42
          ANNEX

                  COST OF IMCI ACTIVITIES IN GHANA, 1998 THROUGH MAY 2002



LEVEL OF          ACTIVITY                              COST (¢)             SOURCE OF FUNDING
ACTIVITY
Component 1: Improving Health workers skills

Central               National level                    25,024,000
                      orientation/planning meetings
                      for initial districts                                            WHO

                      Adaptation (including local
                      terms study and TIPS)             6,606,900
                                                                                     UNICEF

                      Consensus building workshop       19,357,000
                                                                                       WHO
                      Editing of training materials     33,648,000

                                                                                       BASICS
                      Purchase of photocopier,          67,218,400
                      Cartridges & Toner for            +3,873,816
                      material production &              5,340,000                          WHO
                      stationery

                      Purchase of LCD Projector
                                                        33,434,000
                                                                                            WHO
                      Purchase of Laptop for NPO-
                      IMCI                                  21,161,000
                                                                                            WHO

                      *Purchase of 5 TV sets and
                      video deck for IMCI               -                         WHO/UNICEF


                      First In-country facilitators
                      and Case management               **
                      training                          106,096,500
                                                                                            WHO


          * Purchased directly by WHO and UNICEF.
          ** Does not include per diem and transport expenses of 6 external facilitators.



                                                      Page 43
           *Printing of 450 sets of wall
           charts, of 1,500 sets of
           mothers counselling cards,
           and of Child Health records.        505,400,000                UNICEF



           2nd National IMCI facilitator’s
           and case management
           training.                           126,004,400              BASICS



            3rd Case Management
           training                            175,633,200
                                                                         BASICS


           4th Case Management training
                                                  148,000,000             WHO


           Two supervisors training
                                               39,435,900       BASICS



           Development of counselling
           cards                                  29,789,420
                                                                BASICS

           16) Final printing of 250 sets
Central    of Training Modules and so          54,000,000       WHO
           sets of Facilitator’s Guide

Central    3rd Facilitators training           27,361,050       USAID

           Part of each Expansion phase        22,421,000       UNICEF
           activities
            District orientation meeting

Regional     17) 2 Case management
           training                            240,672,900      USAID

LEVEL OF   ACTIVITY                            COST (¢)         SOURCE OF FUNDING


                                             Page 44
ACTIVITY
District          District Orientation meetings

                  Atwima                          20,884,600    WHO


                  Manya Krobo                     15,226,50
                                                                WHO

                  Tolon                           11,513,828
                                                                WHO
                  Ga                              -

                  Follow-up of trained health 9,024,000         BASICS/UNICEF/WHO
                  workers (2)

IMCI Component 2: Improving Health Systems.

Central            1) Sub-group meetings          1697,200
                                                                UNICEF

                   2) Workshop on
                     Integrated supervision
                                                  53,969,400
                                                                BASICS
                   Development and           35,932,500         UNICEF
                   printing of new Child
                   Health Records.
IMCI Component 3: Improving family and Community Practices
                   National level            28,506,775
Central            orientation/plann-ing for
                   community IMCI                               BASICS
                   District Planning for
Central            community IMCI
                                             65,466,300         BASICS

                     3. Child Health
                   Promotion Strategy             10,066,000    UNICEF
                   workshop
                   Development of
                   community Growth
                   promotion training             46,466,300    BASICS
                   manuals and Guide



                   Baseline survey                127,455,500   BASICS


                                                  Page 45
           Community Sensitisation
District   – Growth Promotion        3,280,000   BASICS




                                     Page 46

								
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