Performance and Appraisal Management of Square Pharmaceuticals

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					         Greater Accra Region
   2008 Review of Sector Performance




                          Vision
    Improved status and reduced inequalities in health
outcomes and health system responsiveness; and increased
  fairness in health financing for all people living in the
                   Greater Accra Region




                             1
FORWARD

This report is a summary appraisal of what the health sector in the Greater Accra region was
able to achieve in 2008 in the light of its vision and set objectives, as well as what it was not
able to achieve and why. We hope that this attempt to critically appraise our performance in
2008 will help us move further forward in 2009. It represents the work of the many health
sector workers in the Greater Accra region – public as well as those in the quasi government
and private sector who provided reports on the work they did to enable us incorporate it in this
report. We acknowledge with thanks the efforts of all the quasi-government and private
sector providers who collaborated with us in 2008 and look forward to expanded
collaborations in 2009.

In 2008, the regional health directorate started a process of half yearly and yearly review
meetings of all referral hospitals providing emergency obstetric care and newborn care in the
region as part of an effort to accelerate progress towards MDG 4 & 5. The regional health
directorate acknowledges with much appreciation the participation of non GHS hospitals in
the public and quasi-government sector namely: the Korle-Bu teaching hospital, the Military,
Police, Trust, Manna Mission, Christian Medical Centre, University (Legon) and Alpha Medical
Centre hospitals in these very engaging and informative meetings. Without this kind of
collaboration, the attainment of MDG 4 and 5 in the region cannot become a reality.

The main body of the report is an analytic summary overview of performance in relation to
sector objectives. The appendix provides detailed statistical tables. It is not possible to put in
one report all the details of work that has been done in the region in the course of 2008.
What has been done is to pull out highlights in relation to health sector objectives and targets
to give an idea of the situation of the health sector in Greater Accra in 2008. An attempt has
been made to keep a balance between detail and readability.

The districts, hospitals, and regional health directorate divisions have their individual detailed
annual reports available upon request if further detail is required beyond what has been
presented in this report.




Dr. Irene Akua Agyepong
Regional Director of Health Services
April 2009




                                                2
Contents 
FORWARD ..............................................................................................................................2 
TABLE OF CONTENTS ........................................................... Error! Bookmark not defined. 
MEMBERS OF THE REGIONAL HEALTH DIRECTORATE SENIOR MANAGEMENT TEAM
IN 2008 ....................................................................................................................................4 
MEMBERS OF THE REGIONAL HEALTH MANAGEMENT TEAM (2006) ..............................5 
LIST OF ABBREVIATIONS......................................................................................................7 
1. BACKGROUND ON THE GREATER ACCRA REGION ......................................................8 
2. FRAMEWORK FOR THE ANNUAL REVIEW OF SECTOR PERFORMANCE ....................9 
3. STRATEGIC OBJECTIVES AND KEY PRIORITIES SET FOR 2008 ................................11 
   3.1 Manage and Improve stewardship and governance.....................................................11 
   3.2 Manage and improve financing ....................................................................................11 
   3.3 Manage and Improve Resource Generation ................................................................11 
   3.4 Manage and Improve Service Provision.......................................................................12 
   3.5 Advocate for contextual factors and non health system determinants of health ...........13 
4. PERFORMANCE: STEWARDSHIP AND GOVERNANCE ................................................14 
   4.1 Procurement ................................................................................................................14 
      4.1.1 Non Medicine Consumables.................................................................................14 
      4.1.2 Medicines .............................................................................................................14 
   4.2 Audit ............................................................................................................................14 
   4.3 Collaboration and Partnerships with other providers....................................................15 
   4.4 Collaboration and Partnerships with other non health sectors .....................................17 
   4.5 Health Information Management and Research...........................................................18 
5. PERFORMANCE: FINANCING..........................................................................................20 
   5.1 Revenue ......................................................................................................................20 
   5.2 Expenditure..................................................................................................................23 
6. PERFORMANCE: RESOURCE GENERATION.................................................................25 
   6.1 Human Resource.........................................................................................................25 
   6.2 Transport ....................................................................... Error! Bookmark not defined. 
   6.3 Essential equipment, tools and supplies ........................ Error! Bookmark not defined. 
   6.4 Estates and Infrastructure............................................................................................27 
7. PERFORMANCE: SERVICE PROVISION.........................................................................29 
   7.1 Community Health and Planning Services (CHPS)......................................................29 
   7.2 Outpatients Clinical Care Access and Quality ..............................................................29 
   7.3 Referral and Inpatient clinical care access and quality.................................................31 
      7.3.1 Referral services...................................................................................................31 
      7.3.2 Inpatient Care .......................................................................................................32 
   7.4 Pharmaceuticals & Rational Use of Medicines.............................................................34 
   7.5 Reproductive and Child Health (MDG 4 & 5) ...............................................................35 
      7.5.1 Preventive and Primary Clinical Care Reproductive health...................................35 
      7.5.2 Supervised delivery ..............................................................................................37 
      7.5.3 Expanded Program on Immunization....................................................................42 
      7.5.4 Integrated Management of Childhood Illnesses (IMCI) .........................................44 
   7.6 Selected priority disease control programs ..................................................................44 
      7.6.1 Malaria..................................................................................................................44 
      7.6.2 Tuberculosis ........................................................... Error! Bookmark not defined. 
      7.6.3 HIV/AIDS .............................................................................................................45 
8. WAY FORWARD AND PRIORITIES FOR 2009 ................................................................46 
   8.1 Manage and Improve stewardship and governance.....................................................46 
   8.2 Manage and improve financing ....................................................................................46 
   8.3 Manage and Improve Resource Generation ................................................................46 
   8.4 Manage and Improve Service Provision.......................................................................47 




                                                                     3
MEMBERS OF THE REGIONAL HEALTH DIRECTORATE SENIOR MANAGEMENT TEAM
IN 2008


Dr. Irene A. Agyepong Amarteyfio   Regional Director of Health Services

Dr. Edward Antwi                   Deputy Director Public Health

Mr. A.Y. Boamah                    Deputy Director Administration

Mr. S. Amedzro                     Regional Accountant

Mr. J. Owusu-Agyeman               Deputy Director of Pharmaceutical Services
                                   (Acting Head Clinical Care Division)
Mrs Doris Kpongboe                 Deputy Director of Nursing Services

Mr. Y. Atuo                        Head Health Information Management




                                    4
MEMBERS OF THE REGIONAL HEALTH MANAGEMENT TEAM (2008)

            Name                             Title                     Place of Work
Dr. Irene Agyepong              RDHS                            RHD Accra
Dr. Edward Antwi                DD-PH                           RHD Accra
Mr. A.Y. Boamah                 DD-Admin                        RHD Accra
Mrs. Doris Kpongboe             DDNS                            RHD Accra
Mr. Owusu Agyeman               DDPS                            RHD Accra
Mr. Johannes Atuwo              Head, CHIM                      RHD Accra
Mrs Comfort Sylvia Addo         DDNS (Clinical)                 RHD Accra
Mrs. Mildred Ampadu-Mensah      DDNS (PH)                       RHD Accra
Mrs. Elsie Okoh                 HRM                             RHD Accra
Ms. Honesty Numetu              Head, Head Promotion            RHD Accra
Mr. Seth Amedzro                Regional. Accountant            RHD Accra
Mrs. Ruby Dovlo                 Regl. Nutri. Officer            RHD Accra
Mr. Agudey Sika-Nartey          Regl. Disease Control Officer   RHD Accra
Dr. John Yabani                 M.D.H.S., Accra                 MHD Accra
Dr. E. Mensah-Quainoo           MDHS, Tema                      Tema
Dr. Doris Arhin                 Ag. DDHS, Ga East               Abokobi
Dr. Evelyn Ansah                DDHS, Dangme West               Dodowa
Dr. Justice Hoffman             DDHS, Dangme East               Ada-Foah
Dr. Cynthia Kwakye              DDHS Ga West                    Amasaman
Dr. Letiticia Asomaning Wiafe   MDHS Ledzokuku-Krowor
Dr. Julius Dadebo               MDHS Ashiaman
Dr. Vera Opata                  MDHS Ga South
Mr. Ebenezer Asiamah            DDHS Dangme East
Dr. Charity Brako               Medical Supt.                   Tema Gen. Hosp.
Dr. Cynthia Sottie              Medical Supt.                   Achimota Hosp.
Dr. George Acquaye              Medical Supt.                   Ridge Hospital
Dr. Matilda Agyemang            Medical Supt.                   PML /Ga South district hosp.
Dr. P. Frimpong                 Medical Supt.                   La Gen. Hospital
Dr. Philip K. Narh              Medical Superintendent          D /E hospital
Mrs. E. Atta-Fynn               DDNS                            NTC, Korle-Bu
Mrs. Sarah Addo                 DDNS                            MTS, Korle-Bu
Mrs. Balchisu Iddrisu           DDNS                            Pantang NTC
Mr. Sam Ayitey                  Prin, SMLT                      SMLT, Korle-Bu
Mr. Nyame                       Prin, SOH                       SOH, Korle-Bu
Mrs. Mary Dampson               DDNS                            PHNS, Korle-Bu
Dr. Margaret Gyapong            Director DWHRC                  Dodowa
Mr. Kofi Asafo-Adjei            Transport Officer               RHD
Mr. Jonas Mantey                Reg. Procurement Officer        RHD
Mr. George Antwi                Principal Executive Officer     RHD


                                              5
            Name                Title                      Place of Work
Mr. F.L.B. Okwah    PTO, Leprosy                    RHD
Dr. Doris Arhin     Ag. Sub-Metro health director   Osu-Clottey
Dr. M. Brese        Ag. Sub-Metro health director   Ayawaso
Dr. E. Kumahor      Ag. Sub-Metro health director   Ablekuma
Dr. A. Babbington   Ag. Sub-Metro health director   Okai-koi
Dr. E. Onuaha       Ag. Sub-Metro health director   Ashiedu-Keteke
Dr. P. Frimpong     Ag. Sub-Metro health director   Kpeshie




                                 6
LIST OF ABBREVIATIONS

Abbreviation   Meaning
ADHA           Additional Duty Hours Allowance
AFP            Acute Flaccid Paralysis
AIDS           Acquired Immune Deficiency Syndrome
BCC            Behaviour Change Communication
BCG            Baccille Camille Guerin
CHAG           Christian Health Association of Ghana
CSM            Cerebrospinal Meningitis
DD-Admin       Deputy Director Administration
DDNS           Deputy Director Nursing Services
DDPH           Deputy Director Public Health
DDPS           Deputy Director Pharmaceutical Services
DPF            Donor Pooled Fund
DPT            Diphtheria, Pertussus, Tetanus
GHS            Ghana Health Service
GOG            Government of Ghana
HIV            Human Immuno Deficiency Virus
IDSR           Integrated Disease Surveillance and Response
IEC            Information, Education and Counselling
IGF            Internally Generated Funds
MOH            Ministry of Health
NID            National Immunization Days
OPV            Oral Polio Vaccine
PLWHA          Persons living with HIV and AIDS
PML            Princess Marie Louise hospital
PMTCT          Prevention of Mother to Child Transmission
RDHS           Regional Director of Health Services
RHD            Regional Health Directorate
SIA            Supplementary Immunization Activities
SNID           Sub National Immunization Days
STD            Sexually Transmitted Diseases
STI            Sexually Transmitted Infections
TB             Tuberculosis
VCT            Voluntary Counselling and Testing
WAPCAS         West African Project to Combat AIDS and STD




                                          7
1. BACKGROUND ON THE GREATER ACCRA REGION

The Greater Accra region is one of the ten administrative regions of Ghana. In 2008, 4 new
municipalities were established by further sub-dividing some already existing districts, making
the total number of districts in the region 10. The districts in the region in 2008 were:

     •   Accra Metropolis
     •   Tema Metropolis
     •   Ledokuku-Krowor Municipality (formerly part of Accra metro)
     •   Ashiaman Municipality (formerly part of Tema metro)
     •   Adenta Municipality (formerly part of Tema metro)
     •   Ga East municipality
     •   Ga West municipality
     •   Ga South municipality (formerly part of Ga West district)
     •   Dangme East district
     •   Dangme West district

Greater Accra had a population of 2,905,726 in the 2000 National population census and a
growth rate of 4.4% which is the highest in the country. The estimated 2008 midyear
population was 4,100,702. The total fertility rate in the region of 2.9 from the 2003 Ghana
demographic and health survey is the lowest in the country. The high population growth rate
in the region is thus a mixture of natural increase and high migration into the urban parts of
the region from all over the country. Observation suggests that a fair number of the migrants
are unskilled rural migrants moving into the city to look for non-existent jobs and ending up in
the pool of urban poor.

It is the most densely populated region in the country in part because it contains the city of
Accra, the capital of Ghana. Its population density from the 2000 census was 1,019 persons
per square kilometre. It is the only region in the country where the rural urban ratio is
reversed. Eighty eight percent (88%) of its population lives in localities defined as urban
(population five thousand or more) and only 12 percent live in small rural communities. Many
of its urban localities are very large with population running into tens of thousands.

It is clear from population census data that the population growth in the region is most rapid in
the suburbs and slums surrounding the Accra metropolis that are located in the Tema
Municipality and the Ga East and West districts. The Ga district (East and West combined)
population increased by 2000 to approximately 4 times what it was in 1984. It is the fastest
growing district in the region. Next fastest growing is the Tema municipality. Its population in
2000 was 2.6 times what it was in 1984. The Accra metropolitan population increased to 1.7
times what it was in 1984, and the Dangme East population increased to approximately 1.3
times what it was in 1984.




                                               8
2. FRAMEWORK FOR THE ANNUAL REVIEW OF SECTOR PERFORMANCE

The framework for assessment of the performance of health systems that was used for the
world health report 20001 is used for the Greater Accra region 2008 review of sector
performance



                         FINANCING



                                                                         CONTEXTUAL
                                                                         FACTORS EXTERNAL
                       STEWARDSHIP                                       TO THE HEALTH
                                                                         SYSTEM THAT
                                                                         INFLUENCE
                                                                         PERMFORMANCE OF
                                                                         HEALTH SYSTEMS
                                                                         FUNCTIONS e.g.
    RESOURCE                                                             Judicial systems.
    GENERATION                               PROVISION
                                                                         General attributes of
                                                                         governance systems, etc




       BASIC FUNCTIONS OF HEALTH SYSTEMS
     (HEALTH SYSTEMS INPUTS AND PROCESSES)




    SUCCESS OR FAILURE IN ATTAINMENT
    OF HEALTH SYSTEM GOALS (OUTPUTS)
    • Level & distribution of Health
    • Level and distribution of Responsiveness
    • Fairness in financing




     DETERMINANTS OF HEALTH SYSTEM GOAL ATTAINMENT
     CONTROLLED BY SYSTEMS OUTSIDE THE HEALTH
     SYSTEM.
     E.g. Education, water, sanitation, traffic regulatory systems




1
 Murray C.J.L. & Frenk J. (2000) A Framework for assessing the performance of health
systems. Bulletin of the World Health Organization, 78 (6)
WHO (2000) The World Health Report 2000. Health Systems: Improving Performance.


                                              9
The framework of the 2000 world health report defines a health system as “the resources,
actors and institutions related to the financing, regulation and provision of health actions”;
where a health action is defined as “any set of activities whose primary intent is to improve or
maintain health.” Adopting this definition therefore: a health system is
         “The resources, actors and institutions related to the financing, regulation and
         provision of activities whose primary intent is to improve or maintain health”
The framework distinguishes between two types of goals of health systems – intrinsic and
extrinsic. Intrinsic goals are goals that are desired as a good in and off themselves. An
increase in the level of achievement on an intrinsic goal is valued in and of itself, regardless of
whether it increases levels of achievement on other valued goals or not. Extrinsic goals on
the other hand, are goals that are desired only to the extent that they increase the attainment
of one or more of the intrinsic goals of health systems. The first intrinsic health system goal,
which is also the defining goal of health systems, is to improve the health of the population in
terms of the average level of population health as well as reduction in health distribution
inequalities. The other two intrinsic goals are to improve the responsiveness of the health
system to the legitimate expectations of the population again in terms of the average level as
well as reduction inequalities; and to improve fairness in financial contributions.

The extent, to which the intrinsic goals of a health system are achieved or not achieved, will
be the extent to which the health systems can be considered to have succeeded or failed.
Achievements of the intrinsic goals of a health system are influenced by the performance of
the four basic health system functions of stewardship, financing, resource generation and
service provision. These four basic functions can also be regarded as the inputs and
processes of a health system while the intrinsic goals are the outputs. The ability of a health
system to perform optimally on these four basic functions, or inputs and processes is
influenced by factors external to the health system that nevertheless influence the
performance of these functions. For example the general quality of stewardship and
governance in a given context can affect the quality of stewardship and governance in the
health system.

Finally, performance in other systems whose outputs influence performance in the health
system needs to be taken into account. For example, levels of literacy, especially female
literacy; access to safe water and adequate sanitation, are all known to influence health.

Performance is a relative concept (Murray and Frenk 2000) and in evaluating performance of
health systems, goal attainment has to be related to what could be attained in terms of worst
and best case scenarios. Goal attainment must also be related to inputs. Worst and best
case scenarios will vary depending on the level of inputs or resources available to support
performance.




                                                10
3. STRATEGIC OBJECTIVES AND KEY PRIORITIES SET FOR 2008


3.1 Manage and Improve stewardship and governance

This objective is related to the thematic area of the Ghana health sector third program of work
labeled governance and financing.

Priorities in the Greater Accra region for 2008 were:

    1. To improve adherence to the procurement law and transparent and fair procurement
       procedures at all levels
    2. To strengthen internal audit systems and reduce audit queries to zero in all BMC
    3. To strengthen partnerships and collaborations with non public sector providers and
       coordination of all provider efforts in the region to achieve intrinsic health goals
    4. To strengthen health information management systems and operations research in
       the region and the use of the information they generate for monitoring and evaluation
    5. Improve the quality, completeness, timeliness of submission of routine HMIS data
       and its use for monitoring and evaluation at all levels
    6. Improve planning and budgeting and linking of resource allocation to programs,
       targets and outputs at all levels


3.2 Manage and improve financing

This objective is also related to the thematic area of the Ghana health sector program of work
labeled governance and financing.

Priorities in the region were:
    1. To improve the efficiency of use of government and donor funds,
    2. To improve the fairness in its distribution and allocation within the region and
    3. To support the efficient functioning and management of the national health insurance
         scheme to the extent possible as providers; and also
    4. To encourage the general public to enroll in the national health insurance scheme.


3.3 Manage and Improve Resource Generation

Specific objectives were:

    1. Improve the availability and the maintenance of physical infrastructure in the region
       and reducing inequalities in distribution and therefore in geographic access to
       physical infrastructure in the region. Specifically look for financing and continue
       advocacy for:
          a. CHPS compounds in rural areas
          b. Ga East hospital in Madina
          c. Development of a maternity wing, theatre and extra wards for Achimota
               hospital
          d. Upgrading of Weija communicable diseases centre to Ga South district
               hospital
          e. The Dangme West district hospital OPD block that was completed before the
               project was abandoned to become functional
          f. Completion of the Dangme West district hospital
          g. New infrastructure and renovations of old infrastructure (where feasible) for
               regional hospital (Ridge)
          h. Housemen’s flats for Ridge, PML, La and Tema General hospital
          i. Staff accommodation to attract staff to difficult areas (Dangme East, Dangme
               West, Ga West)
          j. Infrastructure for La General hospital to reduce congestion
          k. Completion of stalled Maamobi polyclinic theatre and other infrastructure
               development
          l. Completion of regional health directorate permanent office block


                                              11
            m. Permanent DHMT office blocks districts without (Dangme East, Ga East,
               Accra Metro, 4 new districts)
            n. Renovation for districts whose DHMT blocks have major problems (Ga West)


    2. Improve the availability, distribution and management of human resource in the
       region
    3. Improve the availability, distribution and management of essential equipment, tools
       and supplies in the region and reduce the incidence of stock outs and non availability
       of essential logistics, equipment and supplies at all levels including the RMS
    4. Improve the availability, management and use of transport in the region


3.4 Manage and Improve Service Provision

This is related to the thematic areas of the Ghana health sector third program of work labelled
reproductive health and nutrition, aspects of health systems strengthening and regenerative
health and nutrition.

Specific objectives were:

    1. Improve referral services organization, procedures and staff attitudes
          a. Ensure that the standard referral notes are in use at all public sector service
              points
          b. Introduce the standard referral notes to the private sector
          c. Introduce a standard referral feedback booklet and ensure its use
          d. Convey an inter-stakeholder forum involving public and quasi-government
              (Military and Police hospital) referral hospitals and the Korle-Bu teaching
              hospital to develop agreements and strategies to resolve the problem of
              rejection and tossing of referred patients sometimes with fatal outcomes
          e. Disseminate and update the directory of public and private health providers in
              the Greater Accra region, location, contact and services they offer
          f. Hold at least one regional QA conference
          g. Organize best QA awards
          h. Make sure that all remaining district and sub-district level GHS institutions in
              the region (hospitals, polyclinics, health centres) who have not received QA
              training are trained in 2008 and all GHS institutions in the region have
              functional QA teams


    2. Strengthening selected priority interventions and programs
           a. Malaria. Priorities included:
                    i. Sustain current household ITN availability to children under five of
                       80% or more in all districts and sub-metros except Ashiedu-Keteke
                       and Okai-koi
                   ii. Devise and implement strategies to ensure Ashiedu-Keteke and
                       Okai-koi also attain 80%
                  iii. Continue public education to ensure actual and sustained use of the
                       nets for the children
                  iv. Start monitoring net availability and use by pregnant women
                   v. Manage policy change from chloroquine as first line drug to
                       artesunate-amodiaquine combination as first line drug including
                       management of Adverse Drug Events and reporting
                  vi. Improve clinical case management
           b. Tuberculosis. Priority intervention areas included:
                    i. Sustain and improve public private partnerships in all districts
                   ii. Maintain and improve control program implementation in all districts
                       including case reporting and detection
                  iii. Maintain and improve current high cure rates and low defaulter rates
           i. HIV/AIDS. Priority interventions areas included:
                    i. Health education and community partnerships



                                              12
                   ii. Improving access to functional Voluntary Counselling and Testing
                       centres
                  iii. Prevention of maternal to child transmission
                  iv. Improving access to ART
           j. Diseases with epidemic potential (Cholera) – Continue Community education
              and advocacy on water and sanitation
           k. Chronic Diseases prevention and management. Priorities included:
                    i. Improve public and health worker awareness on diabetes and
                       hypertension as increasing chronic disease problems and major
                       cause of morbidity and mortality in adults
                   ii. Develop public educational program on health lifestyles (diet and
                       exercise) for diabetes and hypertension prevention and management
                  iii. Improve case detection and management of diabetes and
                       hypertension
           l. Child Health –
                    i. Strengthen IMCI implementation monitoring.
                   ii. Integrate the IMCI and the ETAT (Emergency Triage Assessment
                       and Treatment) programs
                  iii. Look for funds to train at least 50% of prescribers in all institutions in
                       IMCI and ETAT
                  iv. Maintain and increase the current over 80% EPI coverage in all
                       districts and improve routine reporting.
           b. Reproductive Health
                    i. Increase uptake of services specifically: Increase the % of
                       supervised deliveries & Reduce maternal mortality. Target is to
                       reduce by half the current institutional maternal mortality ratios
                   ii. Improved accuracy and completeness of reporting and better
                       integration of immunization data from CDC unit and RCH unit
                  iii. Strengthen Adolescent Reproductive health program
                  iv. Continue the implementation of the regional maternal and neonatal
                       mortality reduction program started in 2005 specifically: Sustain the
                       process of ensuring 100% maternal death audits and use of the
                       information, Repeat the inventory of essential delivery and neonatal
                       resuscitation equipment to see if institutions are filling in the gaps, In
                       service training for all remaining serving midwives (Accra Metro, Ga
                       West, Dangme West, Dangme East) in essential maternal and
                       neonatal life saving skills


   3. Nutrition
               a. Develop and seek funding for a program to target under five nutritional
                  education and improvement programs to the worst performing areas in
                  terms of stunting and underweight in the November 2005 survey
                  (Asheidu-Keteke and Dangme East)
               b. Improve public education and awareness on Anaemia and micronutrient
                  deficiency disorders and their prevention
               c. Improve detection and management of anaemia and micronutrient
                  deficiency disorders as well as prevention programs (antenatal use,
                  vitamin A supplementation etc)


3.5 Advocate for contextual factors and non health system determinants of health

To strengthen collaboration and partnerships and advocacy targeted towards other non health
sectors whose work impacts on health

Advocate for and promote healthy lifestyles and environment




                                              13
4. PERFORMANCE: STEWARDSHIP AND GOVERNANCE

4.1 Procurement
There has been a marked improvement in Procurement Planning at the region when
compared to the previous year. For the first time the region was able to draw a composite
Procurement Plan that is linked to our budget to ensure judicious use of financial resources.
We have observed, however, that some facilities are still not implementing the PPA (Act 663)
as expected.


4.1.1 Non Medicine Consumables
The total value of procurement of non-medicine consumables for the year 2008 was GH¢
1,816,300. Of this only GH¢ 176,870 i.e. 10% was from the CMS. The remaining 90% of non
medicine consumables (GH¢ 1,639,430) were procured from the open market by competitive
tendering. Purchases from the open market continue to outpace purchases from the Central
Medical Stores because the CMS is not able to meet the needs of the region.

The Regional Medical Stores continue to provide credit facilities to distressed facilities. Some
of the debt owed to the facilities in unpaid NHIS bills was therefore held by the RMS. Of the
total sales of GHC 2,340,940 made by the Regional Medical Stores to facilities, GHC 801,467
i.e. 35% remained unpaid at the end of the year. The ability of the RMS to remain functional
and provide a credit to facilities in distress will depend to a large extent on the ability of
facilities owing the RMS to settle their indebtedness.

The procurement unit launched three major tenders to procure the under-listed items to
improve patient care in the region.

        Essential Medicines

        Non Drugs Consumables

        Patient folders

        Detergents and Disinfectants

To ensure that suppliers adhered to the Public Procurement Act 663 the Procurement Unit
Organized Pre Tender Meeting to Suppliers bidding for Jobs .This led to the improvement in
presentation of Tenders by suppliers. This also increase Bidder participation in our in Tenders


4.1.2 Medicines
The total value of procurement of medicines for the year 2008 was GH¢ 3,826,612.12. Of this
only GH¢ 263,278.57 i.e. 7% was procured from the Central Medical Stores (CMS). As in the
case of non medicine consumables, this was because the CMS was unable to meet the
needs of the region. The remaining 93% of medicine procurement (GH¢ 3,563,333.55) was
from the open market by competitive tendering.

Of the total medicines with value GH¢ 2,102,273.11 purchased from the RMS by institutions,
GH¢ 1,480,873.5 i.e. 71% had been fully paid by 31st December 2008. The RMS therefore
held indebtedness of GH¢ 621,399.61 at 31st December 2008. This represents 29% of total
sales. As for non medicine consumables, the major excuse given by institutions for non
payment of bills was that they in turn were owed money by the NHIS.


4.2 Audit
The regional internal audit unit became functional in 2008 with the transfer of staff from GHS
HQ to the region to establish a regional unit. The unit still does not have enough staff, and
several BMC are covered by the same staff. The approach taken therefore was to conduct

                                              14
routine internal audit inspections on a rotational basis. In the course of the year 12 BMC out
of the 72 in the region had one routine internal audit completed or initiated. Four audits were
completed and a final report produced before the end of the year. The 12 BMC were:
         Old Ningo health center
         Ridge hospital
         Tema General hospital
         Regional Medical Stores
         Maamobi polyclinic
         Adabraka polyclinic
         Mamprobi polyclinic
         Dansoman health centre
         PML hospital
         Achimota hospital
         Madina polyclinic – Kekele park site (Maternity)
         Madina polyclinic – New Road site (General OPD)

Findings at different BMC showing areas of weakness in internal controls and financial
management that need to be improved included:
        Sometimes not accounting properly for IGF revenue at Ningo HC
        Missing medicine and non medicine consumables at RMS
        Non maintenance of procurement register at Adabraka polyclinic
        Entity tender committee doubling as tender evaluation committee at PML hospital and
        tenderers and their representatives not being invited to tender openings at the same
        hospital
        Late submission of health insurance claims at Adabraka polyclinic
        Delayed reimbursement of health insurance claims at almost all BMC


4.3 Collaboration and Partnerships with other providers
Apart from the public sector providers who fall under the umbrella of the GHS, service
provision is also carried out by private self financing and private not for profit (mainly mission
and NGO clinics and hospitals) providers. Effective collaboration and partnerships with these
other providers is an important part of effective stewardship of the health sector in the region
to be able to attain the health sector goals. Similarly important are effective coordination
arrangements to pull together the work of public, quasi-government and private sector
providers to achieve this common goal.

All districts in the region have been making efforts to map out all licensed providers in their
area of coverage – whether public, private or quasi-government, to link up with them,
collaborate with them and capture and document data on the services they are providing and
clients served to provide a better picture of what is happening in the region.

All facilities in the region that we have been able to capture by our mapping efforts by type
(public, private, quasi-government) and by district of location are summarized in the attached
tables in excel. The tables also summarizes which proportion of public and quasi-government
providers are actively collaborating with the public sector and what proportion are submitting
their data for inclusion in regional reports and analysis. Some of this data is summarized in
the figure below..

Most of the private self financing sector in the region consists of small clinics providing
predominantly ambulatory primary care. There are however a few hospitals. In 2008, in our
data capture we did not clearly separate out the few private self financing hospitals from the
many primary care clinics. In 2009, this separation will be a major part of our efforts.

The data clearly shows the importance of the private self financing sector in the region. Of
the 414 private clinics and hospitals in the region, 409 are private self financing. This makes
82% of all licensed formal sector facilities in the Greater Accra region private self financing.
Forty five percent of these private self financing clinics are located in the Accra metro. The
rest are scattered over all the other districts in the region, with the exception of Dangme East
which has no private clinics. This reflects the tendency of private clinics to locate in urban
and peri-urban areas. Dangme East remains completely rural. Even though Dangme West is



                                                15
completely rural also, the periphery bordering the Tema metropolis is rapidly urbanizing and
the district is attracting some private providers.

Only 5 of the private clinics in the region were mission/NGO owned. These mission clinics by
location and ownership are:

        •    Alpha Medical Centre in Madina, Ga East (Church of Penecost hospital)
        •    St. Andrews Clinic in Kordiabe, Dangme West (Catholic clinic)
        •    Manna Mission Hospital in Ledzokuku Krowor (Charismatic mission hospital)
        •    Faith Mission hospital in Okai-Koi (Charismatic mission hospital)
        •    Lighthouse Mission hospital in Okai-Koi (Charismatic mission hospital)

Of the 15 quasi-government clinics and hospitals in the region, 10 were located in the Accra
metropolis. These clinics and hospitals by location and government agency are:

    •       Ayawaso sub-metro
                o 37 Military hospital (Ministry of Defence)
                o University hospital, Legon (Ministry of Education)
    •       Okai-Koi sub-metro
                o Cocoa clinic
                o Police Depot clinic (Ministry of the Interior
    •       La Sub-metro
                o Police Hospital (Ministry of the Interior)
                o Military Camp clinic
                o Airport Clinic (Civil Aviation)
    •       Ashiedu Keteke sub-metro
                o Fire service medical centre
                o Ghana post clinic
    •       Osu-Clottey sub-metro
                o The Trust Hospital (Social Security and National Insurance Trust)
    •       Tema Metro
                o Michel Camp clinic
                o Naval base clinic
                o GAPOHA clinic
    •       Ga East Municipal
                o Ghana Atomic energy clinic
    •       Dangme West district
                o Afienya Youth Leadership training school clinic




                                                16
        Facilities by ownership, district &
                  reporting status
        500                                                                                                      497
        450
        400
        350
        300
        250
                                                                                                      217
        200
        150
        100     89    87          100                                  93 9592                            90          87
                            74                                     71                          83
                                                                                                80
               57 43    55
         50          38    27 35 17 18                           41      43  39                                        33
                                                          80    17    15                                    21
          0                                                                                    6
               GaS        GaE    GaW           Ade        D/E    D/W           Ash    Tema     L/K        Acc     Reg

               Total no.         %private & quasi                         %private & quasi reporting




The extent of private and quasi-government sector data capture is highest in Ledzokuku
Krowor and Dangme West. It is lowest in Accra metro and Adenta municipality. The extent of
private sector data capture reflects to a large extent the efforts being made by the various
district and sub-metro management teams. High performing teams need to be encouraged to
maintain and improve performance and low performing teams encouraged to make more
effort and catch up with their better performing colleagues.



        Facilities by ownership, district &
         reporting status – Accra Metro
         250
                                                                                                           217
         200

         150

         100                         96                              96              94            9190          90
                                                     74         76
                     68                                   64                    66
          50
                22        27    23        27                                                                          21
                                                19
                                                                          11              8   11
           0
                OsuC            OkaiK           AshK            Aya                 Able       La          Accra

               Total no          % private & quasi                    % private & quasi reporting




4.4 Collaboration and Partnerships with other non health sectors

This is an area in which the sector is still not making the level of desired progress in advocacy
and collaboration to address the non heath sector related factors that affect health. Much
more effort is needed. Clear guidelines for intervention as well as reporting need to be
developed by the region to guide the districts.


                                                                               17
4.5 Health Information Management and Research
The routine health management information system in the Greater Accra region is similar to
that for the health sector and the GHS across the country. Data on clients and services is
collected from service points and community outreach points on virtually all services and
products in the health sector and collated at each level upwards. There remain problems of
accuracy, completeness and timeliness of this data.

The region uses special surveys and research to complete the information from the routine
system. It has a directorate of health information management and research under the office
of the regional director of health services. Each year, the Greater Accra regional health
directorate organizes a simple multiple indicator cluster survey using the EPI cluster sampling
method to collect data on selected indictors to support its situational assessment of sector
performance and strategic planning for the way forward. It also carries out other operational
surveys as indicated.

Capacity is still being built in the research unit and it currently only has one full time officer.
He obtained a scholarship for a master in biostatistics and epidemiology at the University of
Cape Town and is currently on study leave. Since he had to leave in early January 2009, it
has affected the region’s ability to provide cleaned multiple indicator survey data for 2008 as
has happened in previous years. There is a need to build more capacity in this unit. When
surveys need to be done, he is supported by other staff in the region. There is also a pool of
trained interviewers in the region who are employed temporality to assist.

The region continues to have difficulties related to the quality, completeness and timeliness of
compilation and submission of routine health management information system data. Part of
the problem is related to the lack of appreciation at the lower levels of the importance of the
data being collected. Middle level managers also do not always fully understand how to
analyse the data, the indicators and their meaning and the importance of the use of the data
in monitoring, evaluation and planning. A major problem that also constrains the routine
health management information system is the quality of the staff in the biostatistics units at
district and hospital levels. Some of the older staff were employed long ago with very basic
education and have risen through the ranks to seniority based on years of service with no
accompanying skills testing, upgrading and training. The newer crop of biostatistics technical
officers being employed have been trained to at least the level on a Higher National Diploma.
However they are still not the majority of biostatistics staff. More vigorous central measures
are needed to drastically increase the numbers of qualified biostatistics technical officers in
the health sector.

There remain continuing problems with the quality of routine health management information
system data capture in the region as well as the capacity of the regional biostatistics unit to
track and reconcile inconsistencies in data. The split of old districts into new districts in part
accounts for some of the discrepancies between the regional and district data in 2008. The
regional unit was unable to organize itself effectively and realign its systems to accurately
capture separated data from old and new districts. The districts themselves appeared to be
more successful in separating out the data for their own local analysis and use. The districts
must be congratulated on this effort.

In compiling the final regional annual report, as much as possible, discrepancies in data were
passed back to the districts to revisit the data and clarify what the final numbers should be.
The data that has been sent back and forth between the office of the RDHS and the districts
for cleaning is presented as the ‘districts data’. The data as recorded at the regional
biostatistics unit is recorded as the regional biostatistics unit data. As much as possible
efforts were made to reconcile the differences in the two. Sometimes howeer it was not
possible in the end becausae the regional biostatistics unit data had already been submitted
using the DHIMS database onward to the national office and is what will reflect in the national
reports. To improve transparency in reporting and the accuracy of the regional report – where
ever there are discrepancies between the reports provided by the regional biostatistics unit
from compiling routine reports received in the course of the year, and those provided by the
districts as the final edited data for the year; we report both sets of data. In addition, we also



                                                18
show the level of difference between the two reports. We consider that the ‘district’ data is
the more accurate data set given the backwards and forwards cross checking process.

The differences in the two sets of data i.e. ‘district annual review’ data and ‘regional
biostatistics unit data’ tends to cancel out and become very small when the data is
aggregated for the region. This supports the observation that part of the discrepancies
problem are difficulties especially in the routine reports received at the regional office in
separating out cross border data, and also in weakness in ability to continuously cross check
discrepancies and sort them out with the districts as the monthly reports that are aggregated
to form the annual reports are received. Sometimes districts submit a report that has not been
cleaned to the regional biostatistics unit in order to meet monthly reporting deadlines. After
submission of the report, they may clean the data, but do not provide the feedback to the
regional office. The regional office also appears not to follow up to check on these cleanups
and align its data. Within the districts also the same problems can occur where district
biostatistics units do not cross check reports submitted from peripheral units.




                                               19
5. PERFORMANCE: FINANCING

The sources of revenue for financing the public sector in the region are:
       Government of Ghana general tax and other revenue mainly as
           o Salaries
           o Flexible funding for recurrent expenditure in the form of the administration
                and the service budget lines (GOG administration and GOG service)
       Internally generated funds from:
           o Out of pocket payments by client at point of service use (IGF) for non insured
                clients
           o Insurance claim reimbursements for insured clients
       Donor Pooled Fund (DPF) – also referred to as the health fund (HF)
       Program and earmarked funding from development and other partners
       Exemptions reimbursement funds from Government of Ghana consolidated or
       general tax revenue fund

Some receipts and expenditure specifically related to vertical program funds from some
development partners and NGO in cash or kind e.g. construction of a building, donation of a
vehicle etc go direct to the district and the regional health directorate is unable to capture
these in its monitoring of regional financing. GOG Administration to the districts also goes
directly to the district treasuries and is not captured by the Regional health directorate. The
amounts of GOG administration are however extremely small and even if captured would not
make much difference to the data presented

5.1 Revenue

In 2008, total financial resources available for recurrent expenditure for the region as a whole
increased slightly over the levels of the preceding year. Most of the increase in 2008 as in
2007 was due to increases in IGF as the figure below shows.



         Receipts for service delivery by
          item (2004 – 2008) in GH¢
              30000000


              25000000


              20000000


          GHc 15000000


              10000000


               5000000


                     0
                           Salary         IGF        Programs          DPF        GOG       Exempt

                  2004   12747777.1    6627321.66    989360.89     1615536.49   409679.17   210050.57
                  2005   16382399.52   9130760.07    1649350.96    2081476.15   490336.6    222838.19
                  2006   27857612.37   12117740.38   1423503.96    1056413.29   439822.27   292733.21
                  2007   28346577.81   15622605.29   3269104.49     80907.65    517332.36    212551
                  2008   28757267.68   26362895.98    3750656          4319     984011.26   871207.66




The halt in the continual annual steep rises in personnel emoluments was maintained and the
rise in personnel emoluments was marginal. The Donor Pooled Fund is now effectively and
completely dead.



                                                                  20
Earmarked program funds in 2008 rose very marginally over 2007 levels. As in previous
years, program and earmarked funds encompassed a myriad of different line items including:

          EPI/NID/Disease Control program funds,
          Family Planning /Voluntary /Safe contraception
          Guinea worm program
          National AIDS control program (Global Fund)
          National TB program (Global Fund)
          Malaria control program (Global Fund)
          USAID – CHPS TA, Quality Health Partners (QHP – formerly Engender health)

Some of the earmarked and program funds simply pass through the region as a transit route
to the district being supported and no fund management is carried out at the regional level
other than passing on the funds to the districts. Others are for programs such as region wide
training programs and monitoring managed by the regional health directorate. Though efforts
are made at the regional office to keep track of all funding in the region, the office was also
aware that there were some cases where funds were sent directly to the districts. Such funds
may not all have been captured in the summary on program funds since if the region is not
aware of the transfers; its financial monitoring team is unable to capture and add the data to
the regional analysis.

In 2008, GOG non salary funding (administration and service) rose very slightly over 2007
levels. The level of rise is essentially insignificant. It was not enough to make a major impact
on the sector in the region.

IGF which continued to rise is flexible. Some of the rise was from insured patients and some
of the rise was from user fee paying patients. The rise from insured patients is a good sign
since the NHIS funding mechanism is fairer than out of pocket payments at point of service
use. The figure below shows the percentage of the IGF that come from insured clients.




            % IGF from insured clients
          60

          50                                                           49.9

          40
      %




          30                                           28.8

          20

          10                           12


           0          0.4
                   2005             2006             2007           2008




It was almost 50% of the IGF and the trends over time show that it is an increasing proportion
of IGF. This is a good sign. However the fact that 50% of IGF is from out of pocket fees at
point of service use shows that there is still more work to do to improve fairness in financing.
IGF from out of pocket fees is the most inequitable and least pooled source of sector
financing. The ability to generate IGF is related to the wealth – and therefore ability to pay out

                                                21
of pocket fees at point of service use – of the population in which the community is located. It
is also related to the type of facility and infrastructure available. Thus a district hospital with a
laboratory will generate more than a health centre without a laboratory.


The figure below shows the percent categories to the total revenue for running public sector
health services in the region in over time. It shows the continued rise in the importance of
IGF, the stabilization of expenditures on personnel emoluments, disappearance of DPF, fairly
stable program funding, continued low GOG funding for recurrent non salary expenditure and
the continued small and falling amounts of exemptions funding.



           Contribution of different items to total
                  receipts 2004 – 2008
           80

           60

      %    40

           20

            0
                      Salary         IGF          Program         DPF      GOG     Exempt
           2004        56.4          29.3           4.4            7.1     1.8      0.9
           2005        54.7          30.5           5.5            6.9     1.6      0.7
           2006        64.5          28.1           3.3            2.4         1    0.7
           2007        59            32.5           6.9            0.2     1.1      0.4
           2008        47.4          43.4           6.2            0       1.6      1.4




          Trends in non salary, non IGF receipts
                      2004 – 2008
                  8

                  6

                  4

                  2

                  0
                              2004          2005            2006         2007      2008
          Program              4.4          5.5             3.3          6.9       6.2
          DPF                  7.1          6.9             2.4          0.2        0
          GOG                  1.8          1.6              1           1.1       1.6
          Exempt               0.9          0.7             0.7          0.4       1.4




                                                             22
       Trends in salary & IGF contribution to total
                 receipts 2004 – 2008
      70
                                                64.5
      60                                                    59
                  56.4          54.7
      50
                                                                          47.4
                                                                          43.4
      40
      30                        30.5                        32.5
                  29.3                          28.1
      20
      10
       0
              2004           2005          2006          2007          2008

                                       Salary      IGF




Insurance is (in theory at least) a more equitable way of financing the health sector than out of
pocket payments at point of service use. It is hoped that as more and more people get
insured, especially in deprived areas, and the percentage of IGF generated from insured
clients increases the equity in the health system financing will improve somewhat.

The current funding situation is not optimal especially at the health system management
levels i.e. regional and district health directorates; and also in the parts of the region with
poorer populations. Of the different categories of funding to the region, only IGF, DPF and
GOG are flexible and provide room for adjusting financing to the visions, plans and strategies
for the region. As already explained, salaries are centralized and fixed, program and
earmarked funding is similarly tied as is exemptions money.

Unfortunately, it is the flexible funding that enables the region and districts to carry out plans
and programs developed in response to the situational analysis and needs in the region that
is reducing. Though IGF, which is flexible is increasing as already mentioned, IGF is mainly
available to institutions that provide clinical /institutional care. Moreover, out of pocket
payments at point of service use is essentially a regressive tax and IGF is a relatively
inequitable source of financing. Bigger hospitals in better resourced areas generate more
than smaller institutions in poorer areas. The district and regional health administrations who
generate little or no IGF are particularly challenged along with the small institutions serving
poorer communities.

Last but not least, the fact that IGF is the major source of recurrent financing for institutions in
the region combined with the small amounts of exemption funds explains the reluctance of
institutions to grant exemptions that may never be reimbursed. If institutions are to strictly
enforce the exemptions policy under the current circumstances of unreliable refunds, many of
them will collapse.



5.2 Expenditure

The figure below shows expenditure in the region as a percentage of receipts year by year
over the period 2004 - 2008. As can be seen the region continues to spend over 90% of
funding received.



                                                  23
     Proportion of public sector receipts
       expended by item 2004-2008
                   6
                   5
                   4
                   3
                   2
                   1
                   0    Salary   IGF    Prog   DPF     GOG    Exempt   Total
                 2004    0.97    0.88   0.77   0.93    0.95     1      0.93
                 2005    0.99    0.92   0.73   0.99    1.08    3.54    0.97
                 2006     1      0.99   1.11   1.12    0.96    1.97    1.01
                 2007     1      0.82   0.81   3.91    0.99    5.16    0.95
                 2008     1      0.83   0.89           0.99    0.75    0.92




DPF is not included in this diagram because it will distort the figures. Even though no DPF
was received in 2008, our records showed a DPF expenditure of GHc 95,175.72. A little over
half this amount (GHC 49,894.29) was expenditure from the training schools. It appears they
had been holding back unspent balances on DPF from previous years which they spent in
2008. The RHD also finally paid DENG an amount of GHc 28,523.15 which was outstanding
DPF money that had not been paid in the year it was transferred. The other balances spent
were spread over some of the institutions and district health directorates.




                                                      24
6. PERFORMANCE: RESOURCE GENERATION



6.1 Human Resource

Table 6-1 in the appendix summarizes staff distribution in the region in 2008.

Figure below shows the trends in total public sector staff in the region and the public sector
staff to population ratio in the region. Unfortunately information on the staff in the private
sector though improving remains incomplete and can not be presented. However as an
example of the importance of continuing to improve the capture of this data – especially in the
highly urbanized areas with a well developed private sector; in the Ledzokuku Krowor
municipality even though there was only one doctor employed full time in the public sector,
there were 14 in the private sector employed in the Manna Mission hospital and other private
sector facilities in the municipality. The difficulties in estimating who is doing what are to an
extent compounded by the fact that many professional staff in the public sector also provide
services in the private sector. In some cases it is informally known that private sector
hospitals and maternity homes are actually owned by public sector physicians and midwifes.



      HR Numbers – Trends in total staff
           and Pop: Staff in GAR
     7000
     6000                                                             5996
     5000
                                                        4525
     4000                            4172
                     3583
     3000
     2000
     1000            1006            902                868           684
         0
                  2005            2006                2007         2008

                                   Total staff    Pop/staff




There was an increase in the total number of staff in the region as figure … shows, and the
population per staff fell slightly but probably not significantly. However the increase in
numbers hides a problem with staff skill mix. Though highly trained professional staff such as
doctors, nurses, laboratory technologists, pharmacists etc are urgently needed, the staff that
contributed most to the rise were semi /unskilled staff in the form of health assistants and
health extension workers coming out of the short term (6 months) youth employment training.
The sector needs to take a critical look at the numbers and types of staff it is using resources
to train in relation to the actual needs.

Thus despite the increases, the region still lacks adequate professional and technical staff to
cope with the increasing ambulatory and inpatient clinical care workload especially with the
introduction of the National Health Insurance Scheme. This is shown clearly in the data on
population to doctor ratios in the graph below.




                                                 25
        Population : Doctor Ratios in the
             Public Sector (GHS)
            350000
            300000
            250000
            200000
            150000
            100000
             50000
                   0     Accra    Tema     GaW      GaE      D/W       D/E     GaS       Ash      Ade    LedK     Reg

                 2005    18370    20939   106057    86159    60033    57740                                       23250
                 2006    19351    17255   110724 134926      41783    30141                                       22941
                 2007    13677    14261   115596    46954    43621    25173                                       16931
                 2008    33640    10457    49504    49020    27324    65702    94904    96299    135148 322792    25710




The new municipalities (Ledzokuku-Krowor, Adenta, Ashiaman and Ga South) have very little
public sector infrastructure and this reflects in the fact that they have so few doctors in the
public sector. The private sector made up some of the gap as the data presented earlier on
private sector facilities (4.3). Unfortunately, data was not available on full time staff by type in
the private sector. However in Ledzokuku-Krowor where the data was available, for the one
full time doctor in the public sector (the Municipal director); there were 13 full time doctors in
the private sector. GMA data suggests that altogether, the private sector in Greater Accra
has about 100 - 200 full time doctors (some are retired but still working). Work still needs to
be done to accurately map out the doctors in active practice in the region whether in the
public or private sector. Many doctors also work in both the public and the private sector
because of locums.

In relation to nurses, the gaps are less marked than for doctors but there are still distortions
and the new districts with fewer facilities also have higher numbers of people per nurse.



         Population : Nurse Ratios in the
              Public Sector (GHS)
             7000
             6000
             5000
             4000
             3000
             2000
             1000
                 0     Accra     Tema     GaW      GaE      D/W      D/E      GaS      Ash      Aden    LedK     Reg

                2005    1432     1217     2540     4103     1429     1698                                        1503
                2006    1686     1165     2531     2388     1319     1566                                        1580
                2007    1526     1131     2191     2408     1378     939                                         1484
                2008    1975     738      1980     2280     1339     1510     1849     3210     6436    3843     2432




                                                                              26
It must be noted that people move around the region for care, and so the data district by
district needs to be interpreted with caution. Some of the population in the underserved
districts is using the human resource in the better served districts.

However the fact that numbers of population per doctor and per nurse has risen on the
average despite a fall in overall number of population per staff in the health sector is a cause
for concerning. We are not paying attention to skills in increasing staff numbers.

The difficulties in improving equity in staffing are related to the fact that the GHS in the region
has an absolute staff shortage in terms of numbers as well as skill mix. The minimum
regional GHS staff numbers required to provide efficient and effective service remains higher
than the current staff available. The number of professional staff such as doctors, nurses,
pharmacists and other technical staff is still very inadequate to support the provision of
effective and efficient health care delivery especially in the peripheral districts. Thus if great
care is not taken, in trying to improve inequity in one district by moving more staff there,
inequity is increased in another district because it never had enough to start with. Secondly
infrastructure availability in terms of facilities to work from as well as accommodation in the
most deprived districts as far as availability of health services is concerned such as Dangme
East, Dangme West, Ga East and Ga West also limits ability to move staff there. Last but not
least, personnel posted to some deprived districts like the Damgme East District either refuse
to report or are reluctant to accept the challenge of serving in the district.



6.2 Estates and Infrastructure

Capital projects in the region being constructed with GOG funding all remained stalled in 2008
as in previous years because of non availability of GOG investment funding for the region.
Below is the list of started but halted capital projects in the region

    1. Construction of Regional Health Directorate Offices.

    2. Renovation of Prampram Health Centre

    3. Construction of Residential Units at Dangme East Hospital

    4. Construction of Bortiano Health Centre

    5. Construction of Administration Block and Theatre at Ussher Polyclinic

    6. Rehabilitation of PML Hospital

    7. Upgrading of polyclinics (Kaneshie, Maamobi, Mamprobi)

These projects have stalled due to lack of GOG funds from headquarters to continue.


Projects that were completed in 2008 – from funding sources other than GOG were:

    8. Construction of Dodowa Health Research Centre Offices from Internally Generated
       funds at the research centre

    9. Renovation of the Regional Medical stores with support from benevolent drug
       companies

    10. Upgrading of Amasaman H/C to district hospital status with OPEC funds

    11. Upgrading of Dufour CHPS compound to H/C with OPEC funds

    12. Upgrading of Dodowa H/C to Dist Hospital by completion of the abandoned district
        hospital structure with NACP funding for the ART unit and IGF for the other work


                                                27
Some lands belonging to the GHS in the Region continue to be under threat of encroachment.
Notable among them are Nima, Madina, Abelemkpe and the Teshie Opec Clinics. For the
Nima Clinic, legal protection of the land has been obtained, what is required now is the
physical protection i.e. construction of fence wall.

General property management was an on-going activity in the region. Districts carried out
embossment of their properties. Asset Registers were opened in all facilities to ensure that
properties are well managed. This also facilitated the replacement of broken down fittings and
equipment.




                                             28
7. PERFORMANCE: SERVICE PROVISION

7.1 Community Health and Planning Services (CHPS)
In line with national policy, CHPS is the strategy for improving primary care access in the
region. CHPS is defined as “a process of strategic planning and implementation of Primary
health care activities within a community with the full involvement and participation of the
community members. It is a process that emphasizes preventive health care and education
through effective communication and community mobilization. It involves:
     • A situational analysis of health care delivery within a given community
     • Community consultation on health needs and prioritization of such needs
     • Identifying and mobilizing resources both within and outside the community
     • Designing a culturally appropriate service delivery package
     • Providing health and family planning services with community members, on an
         individual and household basis
     • Conducting early diagnosis and treatment of common ailments and timely referral of
         serious cases”2

As in previous years, very little progress was made with CHPS implementation because of the
resource constraints in the health sector and the situation of CHPS implementation in 2008
remained much the same as in previous years.

7.2 Outpatients Clinical Care Access and Quality

OPD visits per capita continued to increase, but the increases between 2007 and 2008 were
not as steep as between 2006 and 2007. This is summarized in the figure below. Public as
well as private sector facilities reporting data are all put together in this chart.



           Trends in OPD per capita visits
     0.7
     0.6
                                                                       0.573
     0.5                                                    0.52

     0.4          0.39         0.4             0.39
     0.3
     0.2                                                               0.198
                                                            0.173
     0.1
                                               0.047
       0                       0.0185
              2004          2005         2006             2007      2008

                                     Insured      Total




There was wide variation in per capita OPD attendance across the districts. It reflects in part
the extent of private sector data capture but also reflects utilization. The detailed data is
provided in table 7-1. The detail is shown in the figure below.




2
  Quoted from Community Based Health Planning and Services (CHPS) Implementation
Steps and Milestones. Adapted from earlier write ups on CHPS – Dr. Frank Nyonator,
Director PPMED, GHS

                                                 29
             OPD attendance per capita by
                    district in 2008
       Adt       0.02
        LK               0.18
       G/S                0.22
      G/W                              0.49
       Acc                              0.52
       Ash                                     0.66
       G/E                                     0.67
       D/E                                        0.73
      D/W                                            0.8
     Tema                                                                 1.35
             0          0.2      0.4     0.6        0.8         1   1.2   1.4    1.6
                                               per capita OPD




The region continued to monitor the quality of OPD care in GHS facilities as part of rational
use of medicines monitoring using % temperature recorded, weight recorded and blood
pressure recorded as indicated. As the charts below from health centers, polyclinics and
hospital OPD in the region shows, the institutions are continuing to maintain the high
performance of previous years. The exception is Ridge hospital which is under performing
and needs to put in more effort in 2009.




                                                          30
7.3 Referral and Inpatient clinical care access and quality


7.3.1 Referral services

Inadequate numbers of emergency as well as ward beds in the big referral hospitals (Korle-
Bu, Military, Ridge, La, Tema and Police) in the region continued to be a problem. There
were still cases of clients moving round in a taxi or private car from hospital to hospital looking
for a bed. The national ambulance service now insists that the receiving hospital confirms the
availability of a bed before it accepts to transport a patient there. This is because of repeated
experiences of ambulances moving round the metropolis from hospital to hospital with a
critically ill patient looking for an emergency bed.

                                                31
7.3.2 Inpatient Care

The region made progress in its efforts to address the lack of district level hospitals in the
periphery surrounding the Accra Tema metropolitan areas and rural Greater Accra.
Amasaman hospital is now fully functional as a district hospital. The OPEC funded new ward
was completed by the end of 2008 and it is expected to be handed over for use in 2009. The
uncompleted Dodowa hospital building was completed with the support of the National AIDS
control program. Accra Metro assisted equipping of the theatre by donating some of the
unused theater equipment from the abandoned polyclinic upgrading project. Efforts are
continuing to find a full time obstetrician for the hospital so that it can start providing
emergency obstetric care in 2009. Bed state indicator data is summarized in table 7-2.
Figure 17 shows selected bed state indicators by the GHS hospitals in 2008.



          Selected bed state indicators by
           public sector hospital in 2008
           120
                  104
                 104
           100                                                               96
                                       91
                           83                                         86                 84
            80                        77
                            69                                                            68
            60                                   59        62

            40                                              38                    41

                                                  22                   24
            20
                                                   9.8                  13         8.5
                     3.7        4.4        3.1                  5.9                           4.5
             0
                 Ridge     Tema        La        PML       Achim D/East Amasa Total

                            % occupancy           Turnover/bed             ALOS




The data clearly shows the continuing pressure on the regional hospital, Ridge which
continued to have over 100% bed occupancy, with the highest turnover per bed in the region
and the shortest average length of stay (ALOS). The hospital continued to have patients
being nursed on benches and trolleys at the OPD waiting a bed, and floor and bench cases in
the maternity. Its negative turnover interval of -0.15 indicates the presence of the floor, trolley
and bench cases. Ridge hospital has now become efficient to the point of inefficiency
because of the lack of resources to expand the infrastructure to meet the increasing demand.
There is an urgent need for new infrastructure at Ridge hospital but all advocacy efforts have
so far not yielded any results because of the health sector budget constraints.

The Amasaman district hospital had the next highest percentage bed occupancy at 96%.
This is a combination of the fact that it has a high obstetric case load, with only 6 obstetric
and gynecology beds, combined with a high Buruli ulcer case load with 35 Buruli ulcer beds.
The Buruli ulcer cases tend to have long stays in hospital because of the nature of their
condition. The average length of stay (ALOS) for Buruli ulcer patients was 244 days with a
turnover per bed of 1, as compared to 1.2 days ALOS with a turnover per bed of 275 for the
obstetrics and gynecology clients. The handing over of the OPEC funded ward so the non
Buruli ulcer beds at Amasaman district hospital can increase is urgent.

The only public sector hospitals in the region whose bed occupancy have not exceeded 80%
are the La General hospital (which at 77% bed occupancy is almost there) and the Achimota
hospital with 62% bed occupancy and the PML hospital with 59% bed occupancy. The high


                                                      32
turnover interval of 6.88 in PML reflects the fact that the hospital takes care of malnutrition
cases who tend to have long admission periods. It is close to the turnover interval of 7.18 for
Buruli ulcer cases in Amasaman district hospital.

Overall the total of 840 public sector (GHS) hospital beds in the region had an 84% bed
occupancy, ALOS of 4.5 days and a turnover interval of less than a day (0.86) indicating very
efficient public sector inpatient bed use in the region. It also confirms the need to increase
hospital bed availability in the region. Examination of trends in percentage bed occupancy by
hospital shows that the general trend is upwards.




      Percentage Bed Occupancy by
                Hospital
                          120
                          100
      % occupancy




                           80
                           60
                           40
                           20
                             0       2000      2001    2002    2003     2004         2005          2006          2007      2008
                     Ridge           72        77      80      81       85           83.2          89            102.3     104
                     Achimota        31        39      46      54       47           52.3          44            45.1      62
                     Tema            86        72      73      64       54           49.2          42            70.8      83
                     PML             46        42      42      42       46           43.9          51            49.5      59
                     La                                        83       70           55.4          42.8          82.4      77
                     D/E                                                             49.8          54            58.6      86
                     Amasa                                                                                                 96




                    Turnover per bed by Hospital
                           150

                           100
      %




                             50

                                 0     1999     2000   2001   2002    2003     2004         2005        2006       2007     2008
                      Ridge               26     35     28     32      34       31           47           62        76.9    104
                      Achimota            39     46     61     75      80       80           88           77        70.5     38
                      Tema                38     46     40     46      42       36          38.8          42        48.4     69
                      PML                 22     30     22     24      25       29           27           35        37.9     22
                      La                                      104     112       79          66.3          48.3      59.6     91
                      D/E                                                       18          39.1          37        37.3     24




Ridge, Tema and La hospitals continued to show rising turnover per bed supporting the


                                                                        33
observation from other bed state indicators of continuing maximization of use of available
beds. Achimota, Dangme East and PML showed declining turnover per bed. There will be a
need to take a close look at the efficiency of bed use in these hospitals.

The pressure on the beds in the big GHS referral hospitals with multiple specialist referral
services i.e. Ridge, Tema and La explains in part the continuing phenomenon of critical ill
patients needing emergency referral care having difficulty in finding a bed and moving round
the metropolis in an ambulance or taxi or private car looking for a hospital which will take
them in. Qualitative reports of these problems have declined following the decision to nurse
and provide first aid on a bench or a trolley rather than have the case moving round the
metropolis in a vehicle without any provision of emergency care. The problems have
however not declined completely and there are still reports of cases moving from hospital to
hospital – public as well as quasi government, looking for a bed. There are a few big private
hospitals in the region. However they generally do not accept cases who cannot pay since
they are completely self financing. Since many people cannot afford major hospitalization
costs in a private hospital, the bulk of the referral problem is borne by the public sector and
quasi-government hospitals. They are obliged by their public nature to accept clients – even if
as currently happens – no one eventually pays the bill. The non GHS big referral hospitals in
the region – namely Korle-Bu, Military and Police all complain of similar problems of stress on
their beds. The region unfortunately has not been capturing their bed state indicators. This is
an effort that will be made in 2009 not only to give a complete picture of the situation, but also
to enable effective advocacy on behalf of those hospitals as well.


7.4 Pharmaceuticals & Rational Use of Medicines




                                               34
7.5 Reproductive and Child Health (MDG 4 & 5)


7.5.1 Preventive and Primary Clinical Care Reproductive health

The limitations of the routine health management information system data have already been
presented in section 4.5.
Table 7-3 summarizes health service coverage by district in 2008 based on regional
biostatistics unit data and as passed on to HQ to meet reporting deadlines. Table 7-4
suummarizes the data following cross checks with the districts. Figure 22 summarizes the
data as reported to the regional biostatistics unit and passed on to HQ, figure 23 summarizes
the data following cross checks with the districts and figure 24 shows the discrepancies
between the data sets. The discrepancies are generally small, but there are a few that are
large enough to be a cause for concerning. Improving data quality will be a major focus of
effort in 2009.

Public and private sector provider service delivery data is captured together for antenatal
care, supervised delivery and post natal services coverage. Districts showing over 100%
ANC coverage may be because of clients crossing district borders for service, and may also
be related to double counting – where women register as a first attendant on different
occasions.




                                             35
Reproductive Services Coverage by district 2008 based on
    edited data provided by districts for annual report

          140
          120
          100
          80
      %
          60
          40
          20
           0
                 Acc Tma GE      GW    GS   DE    DW Led Ade Ash Tot
          AN     90   124   69   60    96   89    105    88   3       88    89
          Del    60   73    32   27    34   31    60     13   3       42    49
          PN     67   47    22   27    37   38    67     15   3       31    50




Reproductive Services Coverage by district 2008
   based on Regional Biostatistics unit data

          150



          100

      %

           50



            0
                 Acc Tma GE      GW    GS   DE     DW Led Ade Ash Tot
           AN    91   144   69   139   49    90    105    9       3    48    83
           Del   67    82   32   31    37    54    60     8       3    42    53
           PN    68    57   22   48    19    37    65     6       3    13    49




                                                  36
     Comparison of level of discrepancy between cross checked
       district and regional biostatistics unit 2008 ANC data

                  150

                  100

                    50

                      0

                   -50

                 -100     Acc   Tma   GE   GW    GS   DE    DW    Led   Ade   Ash   Tot
             Dis dta(1)   90    124   69   60    96   89    105   88     3    88    89
             Reg dta(2)   91    144   69   139   49   89    105    9     3    48    83
             Diff (1-2)   -1    -20   0    -79   47   0      0    79     0    40     6




Ga West was split into Ga West and Ga South at the end of 2007; and the regional office set
up separate health administrations at the beginning of 2008. The large discrepancy between
the regional biostatistics unit data and the edited data from the districts for the annual report is
probably due to the fact that in the routine reports rushed to the regional office to meet
reporting deadlines, cross border data was not carefully sorted out. It was more carefully
sorted out in the later data after queries from the regional office to recheck the data and
reconcile differences. Similarly, Tema was split into Tema, Ashiaman and Adenta.



7.5.2 Supervised delivery

Table 7-5 presents cross checked data from the districts on supervised deliveries. Like other
reproductive health services delivery indicators, supervised delivery rates in the Greater
Accra region show a continued stagnation and remained stead as in previous years at 40 plus
or minus 5%. The persisting low supervised delivery rate is a concern within the region. It is
important to note that the average low rate masks variations, with some delivery units
overwhelmed with large numbers of cases, and other delivery units under utilized. The
delivery units that tend to be most overwhelmed are those in the hospitals where emergency
obstetric care is available such as Tema General, Ridge, La etc. Casual observation
suggests that women perceive that there is a certain level of unpredictability as to whether
they will be referred or not if they go to a smaller delivery unit with only midwives. If a hospital
is near enough therefore, it appears that women who have made up their mind to use a
skilled attendant preferential go to these larger units thereby creating the overcrowding there
and the underutilization in the smaller units. In the end sometimes this defeats their desired
objective of high quality care since the overwhelmed larger units can no longer give optimal
individual attention to clients.

The region has been actively involved over the last 5 years in a strategy to provide a district
level hospital with emergency obstetric services in every district and to also upgrade the
quality of the emergency referral system and the confidence in the system. The focus is to
urgently need to build /expand, equip and staff the smaller peripheral hospitals (where there is
no hospital find a suitably large health centre and upgrade it) so that they can take some of
the load of Ridge and the other congested central hospitals that provide emergency obstetric
care. This is the focus of the regions short and medium term agenda.




                                                           37
In the short term given the current financial constraints and the urgency of the problem, the
possibilities for doing this at reasonably lower cost while looking for the money for more
ambitious intervention have been:

    1. DODOWA – DANGME WEST DISTRICT: The infrastructure for the Dodowa district
       hospital phase I project (OPD and minor theatre) that was started by the MOH in the
       early nineties and had been abandoned and going to waste from disuse was picked
       up by the National Aids Control Program (NACP) upon an appeal from the district and
       the region to complete. The interest of the NACP was to be able to have a district
       hospital level centre for provision of ART. However they did not mind that in
       achieving this objective, it would also become possible to have a district hospital
       providing emergency obstetric care. The infrastructure work is completed, and
       equipment from donated by Accra metro and other places in the region with functional
       equipment they were not using. Dodowa health centre is now Dodowa district
       hospital and can begin to function almost immediately as a district referral centre for
       emergency obstetric care if at least one doctor with general surgical including
       obstetrics and gynecology skills or an obstetrician can be found to join the general
       practice doctor currently there. An appeal has been made to the Ghana Health
       Service /MOH for one such doctor. These appeals can be difficult given that
       relatively Greater Accra is better off in terms of staff than the rest of Ghana; despite
       its absolute shortage and therefore critical need for professional staff. Dodowa
       hospital also needs at least 2 nurse anesthetists. Given the desperate shortage of
       anesthetist – both doctor and nurse – in the health system; and the limited number of
       training schools (2) producing only a handful of trainees each year, the region is also
       starting a nurse anesthesia training program in October 2009 at the Ridge hospital.
       Kybele USA has been working with the regional team and has provided technical
       support for curriculum development and also donated books, training aids etc. They
       have also undertaken to provide periodic trainer /facilitator support when the school
       starts with its first batch in October 2009. Dodowa hospital, like several other
       facilities in the region that need anesthetists, but cannot find any in the system is
       planning to sponsor 2 nurses to the program. This is a medium term effort since it will
       take 18 months for them to graduate (April 2011). In the interim the hospital is
       exploring where to find at least one nurse anesthetist – even if it has to be on a locum
       basis. The implication is that the hospital may not be able to run full scale 24 hour
       emergency obstetric services if the only anesthetist it can find is a part time /locum. It
       is also planning to send a few nurses for on the job training as theater nurses in
       Tema General hospital

    2. TEMA POLYCLINIC – TEMA METRO: The infrastructure for the Tema polyclinic
       emergency obstetric theatre is completed. There were some gaps in the equipment
       availability which efforts are being made to fill by identifying functional but unused
       equipment in other institutions. Tema polyclinic can also start functioning almost
       immediately if we can get at least one O&G doctor for them and one other MO to
       assist. They have already trained 2 nurse anesthetists that they sponsored for
       training in the Kumasi program. Pending the start of theater services at the polyclinic,
       the two nurse anesthetists have been working at the General hospital to keep their
       skills current and help fill the gaps elsewhere in the health system. However it is
       agreed and understood that as soon as the polyclinic is ready to function they will
       move. Tema Polyclinic is also sending at least 2 nurses for on the job training as
       theater nurses in Tema General.

    3. AMASAMAN DISTRICT HOSPITAL – GA WEST MUNICIPAL: The transition of
       Amasaman from health centre to district hospital providing emergency obstetric care
       was completed in 2007 but with only 6 emergency obstetric beds. The OPEC funded
       construction of a new ward was completed in December 2008. Amasman has their
       new ward now and should be able to handle even more emergency obstetric cases.
       There are some issues around accommodation for the doctors there and enough
       doctors to take on an increasing load that needs to be addressed. It will not be easy
       – but we are trying to attract some doctors out of the teaching hospital to the
       periphery. The teaching hospital also has staffing gaps, but it is relatively much
       better supplied than the periphery. Moreover, strengthening the periphery will reduce


                                               38
    their current burden of cases from the periphery who travel all the way there because
    there is no where else.

4. USSHER POLYCLINIC /GOVT MATERNITY HOME – ACCRA METRO: Ussher
   needed only about GHC 30,000 (approximately US$ 25,000) or so to complete its
   theater when the work was abandoned. Completing the abandoned project is also a
   relatively low cost way of immediately expanding peripheral emergency obstetric
   services and taking the pressure off the regional and other big hospitals that are
   currently very congested, compromising quality and access. Ussher is exploring the
   possibility of completing the project with its own internally generated funds – but also
   continuing to seek support from HQ. There would also be the need to make
   arrangements for an obstetrician and nurse anesthetist. Ussher is planning to
   sponsor at least 2 nurses to the Ridge nurse anesthesia training program.

5. MAAMOBI AND KANESHIE POLYCLINICS – ACCRA METRO: Completing the
   abandoned infrastructure expansion at Maamobi and Kaneshie polyclinics would also
   expand peripheral emergency obstetric services. However the phase at which the
   projects were abandoned is such that this is not an initiative the region can struggle to
   find a way to carry out despite the absence of central funding. Appeals have to
   continue to be made to the centre to complete the projects.




Maternal health programs coverage
       100

        80

        60
  %




        40

        20

         0
              2001    2002   2003    2004    2005     2006   2007   2008
        ANC                           79         83    77     77     83
        Del                          46,4        49    57     48     53
        TBA                                            4      5      3
        PNC                           41         48    45     49     49




                                            39
       Comparison of level of discrepancy between district and
       regional biostatistics unit 2008 supervised delivery data

                 100
                   80
                   60
                   40
                   20
                     0
                  -20
                  -40    Acc   Tma   GE   GW   GS   DE        DW   Led   Ade   Ash   Tot
            Dis dta(1)   60    73    32   27   34   31        60   13     3    42    49
            Reg dta(2)   67    82    32   31   37   54        60    8     3    42    53
            Diff (1-2)   -7    -9    0    -4   -3   -23       0     5     0     0    -4




It is unclear why the regional records show so many more supervised deliveries in Dangme
East than the edited district data does. This is a problem that will have to be resolved with
further discussion and investigation with the district.

Dangme West seems to be the district with the fewest inconsistencies between routine
monthly reports submitted to the regional biostatistics unit and final annual reports based on
cross checked data.


Essential equipment, tools and supplies

The results of the regional survey of availability of essential equipment, tools and supplies for
safe supervised delivery as well as resuscitation of the new born are summarized in the
tables in the appendix. The situation has greatly improved since the region started
awareness raising in 2005 about the need to have the full complement of equipment, as well
as periodic surveys and checks of equipment availability.

Maternal Mortality
The quasi-government and private sector are well developed in the Greater Accra region, and
any intervention that will have an impact on maternal mortality in the region must take their
role into account and support and strengthen them. The region started a process of half
yearly and annual maternal survival meetings with the Korle-Bu Teaching hospital, the quasi-
government referral hospitals (Military and Police hospital, The Trust hospital) as well as
private sector referral hospitals (Alpha Medical Centre, Manna mission hospital, Christian
medical centre). The process will continue in 2009 and the efforts to bring on board on
hospitals – whether public or private – providing emergency obstetric care in the region. The
joint meetings are improving collaboration and dialogue between the hospitals with a theatre
and providing emergency obstetric care in the region to improve maternal survival. Figure 27
summarizes data from hospitals providing EOC in the region – whether GHS, teaching
hospital, quasi-government or private, that are now part of the network. Table 7-5 in the
appendix provides more detail.




                                                         40
       IMM Ratio and C/S rates 2008 by
          Hospitals providing EOC
        900
        800             814
        700
        600
        500
        400 394                                386                                      413
                                  355                              363
        300                             278
        200                                                  157
                                                     127
        100
                  32         40    31    21     22    10      25    20       14    14    16
             0                                                              0     0
                 Ridge K'Bu Military Police Legon Trust       La   Tema Alpha Amas       D/E

                                   IMM ratio/100,000LB        C/S rate (%)




Annual time series data is only available to the regional health directorate for the public sector
hospitals (GHS and Korle-Bu). All the public sector hospitals providing emergency obstetric
care in the region showed drops in institutional maternal mortality ratio as shown in figure 28
below. For the Ridge hospital and the Dangme East district hospital, 2008 is the third year in
a row registering a drop. Apart from the efforts all hospitals are making to improve quality of
emergency obstetric care, the presence of a second doctor in Dangme East district hospital is
also helping with the pressure that was there from having only one doctor.



         Institutional Maternal Deaths
            per 100,000 live births
      2000

      1500

      1000

       500

         0
                    Ridge               Tema           La                D/E            K'Bu
       2004            715              666            177               1010           791
       2005            451              667            157               1456           951
       2006            626              498            189               1282           882
       2007            540              518            186               967            1019
       2008            379              363            157               413            814




During the review presentation discussions, all the referral hospitals listed challenges in
common including:
    • Skilled human resource scarcity,
    • inadequate infrastructure, tools and supplies,
    • inadequate technical support and peer review


                                                             41
    • Heavy workloads,
Korle-Bu Teaching hospital maternity appears to be further challenged by some management
problems related to an over centralized management structure such that simple tasks e.g.
replacement of simple items such as non working sphygmomaneters can take weeks. It may
be useful for Korle-Bu hospital management to consider some kind of managerial re-
organization within the hospital to give the obstetrics unit more decentralized and greater
administrative autonomy for rapid essential managerial decision making.

To reduce maternal mortality, all hospitals providing emergency obstetric care in the region
whether public or private need to be supported to address their challenges. Not enough
attention is being given to the fact consistently revealed by the mortality audits from all
hospitals in the region that many women who died were very good antenatal clinic attendants.
Indeed your risk of dying if you happen to need emergency obstetric care does not appear to
be closely correlated with antenatal clinic attendance. The emphasis on primary prevention
needs to continue, but improved quality of emergency obstetric care is critical if the health
MDG are to be attained. The referral hospitals and the staff who work there need to be
adequately supported.

There was a rise in the total number of recorded maternal deaths in the region, despite the fall
in the public sector institutional maternal mortality ratios. This is because data capture on
maternal deaths in the region improved greatly. All these hospitals are located in Accra metro
– hence all the rise due to better data capture is reflected in Accra metro.



              Reported Maternal Deaths
                    (Data only represents institutions who reported rather than all deaths)



           200

           150

           100

            50

             0
                  1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
         Accra    21      24         55       86        86        83          85        87    109   137
         Tema     13      38         36       26        34        31          39        27    31    28
         Others    0       0          0        0         0         1          1         4      3     4
         Total    34      63         91       112       120       115        125       118    143   169




7.5.3 Expanded Program on Immunization

The were slight increases in EPI coverage as shown by the absolute numbers of children
immunized by antigen increased on all antigens (figure 30) and the percentage coverage
illustrated by Penta 3 coverage (figure 31)




                                                                42
                      Trends in Total Numbers of
                         Children Immunized
                      160000
                      140000
                      120000
      Nos immunized


                      100000
                       80000
                       60000
                       40000
                       20000
                                0
                                     1999     2000       2001    2002     2003       2004      2005     2006     2007   2008
                      BCG           75638    83937       89493   88210   106847 102963 118348 110745 115785 133559
                      DPT/Penta3 65978       75142       68044   91029   83928       82225     95502    98473   106549 119665
                      OPV3          65289    75850       70474   90500   82639       81798     95055    97569   105873 122861
                      Measles       62764    74529       75334   97148   87303       88800     96068    99151   108739 120431




     Penta 3 routine coverage by district
              Jan – Dec 2008
                            120

                            100

                             80

                      % 60

                             40

                             20

                                0   Acc     Led   Tema Ashia Aden        GaE     GaW    GaS      DE      DW     Reg
                             2007   64.2          61.8                   67.8    85.7            78.7   87.9    67.8
                             2008   65      56    110       85    41     64      75      107      76     83     73
                             2009




The region however failed to make 80% coverage, and more work will be needed in 2009 to
make 80% coverage. The above 100% coverage seen in some districts (Tema and Ga South
probably reflects errors in attribution of data to a particular district because the issues still
being settled around which data gets sent to which district following the split of Tema into
Tema, Adenta and Ashiaman; and Ga West into Ga Wes and Ga South. The low recorded
EPI coverage in Adenta and Ashiman is probably in part therefore accounted for by the over
high coverage in Tema from which they were split. The same phenomenon is observed in
Ledzokuku Krowor municipality and La sub-metro. La has an EPI coverage of over 100%
while Ledzokuku Krowor has rather low coverage. Ledzokuku Krowor was split from La and it
is very possible that some children belonging to Ledzokuku Krowor have had their data
captured under La sub-metro.


                                                                                43
7.5.4 Integrated Management of Childhood Illnesses (IMCI)
Extensive training of staff in IMCI was conducted in 2008. A total of 175 prescribers in the
region have now been trained in IMCI. Most of the training was financed by the institutions
from IGF because there were no other funds available. Where HIRD funds were available
they were also used to support the training.  



7.6 Selected priority disease control programs


7.6.1 Malaria

There continues to be a problem of very low confirmation of malaria diagnosis. Most cases
reported as malaria are best labelled “febrile illness presumed malaria”. Only 5.7% of cases
diagnosed as malaria were confirmed (see figure 31 below).



             Reported against confirmed
                   malaria cases
                700000
                600000
                500000
                400000
                300000
                200000
                100000
                       0
                            <5yrs      >5yrs        Preg       Total
           Total reported   155587    458909        7682      620816
           Confirmed         9915      20435        1730       35324
           Not confirmed    145672    438474        5952      585492




Thus even though overall there were more reported cases of malaria in 2008 that in previous
years, it is uncertain how much of this was a real rise in cases and how much of it was a rise
in diagnosis (see figure 32 below).

Much work also still remains to be done to improve the quality and completeness of routine
data reporting.




                                               44
               Reported Malaria Cases
            700000
            600000
            500000
            400000
       No




            300000
            200000
            100000
                  0
                       2003        2004   2005         2006      2007        2008
              Total   399261   396360     449720      436987   624218      620816
              < 5 yrs 104510   115205     128454      85655                133387
              5 yrs + 293465   304578     353500      219195               466591




7.6.2 HIV/AIDS
 Within the Greater Accra region, sentinel sites for monitoring HIV sero-prevalence data are
located in Korle-bu teaching hospital, Adabraka and Maamobi polyclinics, and since 2005 the
Dangme East district hospital at Ada.

The seventeen ART sites in the region in 2008 were as follows:

District          ART sites

                  Public                              Quasi Government         Private

Accra Metro       Korle-Bu Teaching hospital          The Trust Hospital       Odorna clinic

                  Ridge hospital                      Police Hospital          Holy Trinity clinic

                  La General Hospital                 37 Military Hospital     Nyaho medical centre

                  Kaneshie Polyclinic                                          Akai house clinic

Tema Metro        Tema General Hospital               Port Medical Centre      Narh Bita Hospital

                  Tema Polyclinic

Dangme West       Dodowa polyclinic

Dangme East       Dangme East district hospital




                                                 45
8. WAY FORWARD AND PRIORITIES FOR 2009

The way forward and priorities for 2009 remain similar to those of 2008 because many of the
targets set in 2008 could not be met because of financial constraints. However to set
objectives limited to assured funding is to effectively do almost nothing. It is better to continue
to set objectives and targets that will make a difference and look for the resources.


8.1 Manage and Improve stewardship and governance

This objective is related to the thematic area of the Ghana health sector third program of work
labeled governance and financing. Priorities in the Greater Accra region for 2009 are:

    1. To continue to improve adherence to the procurement law and transparent and fair
       procurement procedures at all levels
    2. To continue to strengthen internal audit systems and reduce audit queries to zero in
       all BMC
    3. To strengthen partnerships and collaborations with non public sector providers and
       coordination of all provider efforts in the region to achieve intrinsic health goals
    4. To strengthen collaboration and partnerships and advocacy targeted towards other
       non health sectors whose work impacts on health
    5. To strengthen health information management systems and operations research in
       the region and the use of the information they generate for monitoring and evaluation
    6. Improve the quality, completeness, timeliness of submission of routine HMIS data
       and its use for monitoring and evaluation at all levels
    7. Improve planning and budgeting and linking of resource allocation to programs,
       targets and outputs at all levels


8.2 Manage and improve financing

This objective is also related to the thematic area of the Ghana health sector program of work
labeled governance and financing.

Priorities in the region for 2009 are:
    1. To improve the efficiency of use of government and donor funds,
    2. To improve the fairness in its distribution and allocation within the region and
    3. To support the efficient functioning and management of the national health insurance
         scheme to the extent possible as providers; and also
    4. To encourage the general public to enroll in the national health insurance scheme.


8.3 Manage and Improve Resource Generation

Specific objectives for 2009 are:

    1. Improve the availability and the maintenance of physical infrastructure in the region
       and reducing inequalities in distribution and therefore in geographic access to
       physical infrastructure in the region. Specifically look for financing and continue
       advocacy for:
          a. CHPS compounds in rural areas
          b. Ga East hospital in Madina
          c. Development of a maternity wing, theatre and extra wards for Achimota
               hospital
          d. Upgrading of Ga South district hospital infrastructure
          e. Completion of the abandoned Dodowa (Dangme West) district hospital
          f. New infrastructure and renovations of old infrastructure (where feasible) for
               regional hospital (Ridge)
          g. Housemen’s flats for Ridge, PML, La and Tema General hospital



                                                46
            h. Staff accommodation to attract staff to difficult areas (Dangme East, Dangme
               West, Ga West)
            i. Infrastructure for La General hospital to reduce congestion
            j. Completion of stalled Maamobi polyclinic theatre and other infrastructure
               development; Kaneshie polyclinic, Mamprobi polyclinic and Usser polyclinic
               stalled projects
            k. Completion of regional health directorate permanent office block
            l. Permanent DHMT office blocks districts without (Dangme East, Ga East,
               Accra Metro, 4 new districts)
            m. Renovation for districts whose DHMT blocks have major problems (Ga West)


    2. Improve the availability, distribution and management of human resource in the
       region
           a. Look for staffing (at least one obstetrician, nurse anaesthetist, theatre nurses,
               general clinical nurses and one MO) to make the Dodowa hospital OPD block
               that has been completed with support from NACP to become fully functional
               and provide emergency obstetric services
           b. Look for staff (at least one obstetrician, theatres, general clinical nurses and
               one MO) to become fully functional and provide emergency obstetric services
           c. More staff for the Tema General hospital obstetrics and gynaecology unit
           d. More staff for the Ridge hospital obstetrics and gynaecology unit
           e. Continue to support the development of the nurse anaesthesia program in
               Ridge hospital so that by 2011 it will be turning out graduates to fill in the
               needs in the region and in other regions of Ghana
    3. Improve the availability, distribution and management of essential equipment, tools
       and supplies in the region and reduce the incidence of stock outs and non availability
       of essential logistics, equipment and supplies at all levels including the RMS
    4. Improve the availability, management and use of transport in the region


8.4 Manage and Improve Service Provision

This is related to the thematic areas of the Ghana health sector third program of work labelled
reproductive health and nutrition, aspects of health systems strengthening and regenerative
health and nutrition.

Specific objectives are:

    1. Improve referral services organization, procedures and staff attitudes
          a. Ensure that the standard referral notes are in use at all public sector service
              points
          b. Introduce the standard referral notes to the private sector
          c. Introduce a standard referral feedback booklet and ensure its use
          d. Convey an inter-stakeholder forum involving public and quasi-government
              (Military and Police hospital) referral hospitals and the Korle-Bu teaching
              hospital to develop agreements and strategies to resolve the problem of
              rejection and tossing of referred patients sometimes with fatal outcomes
          e. Disseminate and update the directory of public and private health providers in
              the Greater Accra region, location, contact and services they offer
          f. Hold at least one regional QA conference
          g. Organize best QA awards
          h. Make sure that all remaining district and sub-district level GHS institutions in
              the region (hospitals, polyclinics, health centres) who have not received QA
              training are trained in 2009 and all GHS institutions in the region have
              functional QA teams


    2. Strengthening selected priority interventions and programs
           a. Malaria. Priorities included:
                   i. Continue public education to ensure actual and sustained use of the
                      nets for the children


                                              47
               ii. Start monitoring net availability and use by pregnant women
              iii. Manage policy change from chloroquine as first line drug to
                   artesunate-amodiaquine combination as first line drug including
                   management of Adverse Drug Events and reporting
              iv. Improve clinical case management
       b. Tuberculosis. Priority intervention areas included:
                i. Sustain and improve public private partnerships in all districts
               ii. Maintain and improve control program implementation in all districts
                   including case reporting and detection
              iii. Maintain and improve current high cure rates and low defaulter rates
       c. HIV/AIDS. Priority interventions areas included:
                i. Health education and community partnerships
               ii. Improving access to functional Voluntary Counselling and Testing
                   centres
              iii. Prevention of maternal to child transmission
              iv. Improving access to ART
       d. Diseases with epidemic potential (Cholera) – Continue Community education
          and advocacy on water and sanitation
       e. Chronic Diseases prevention and management. Priorities included:
                i. Improve public and health worker awareness on diabetes and
                   hypertension as increasing chronic disease problems and major
                   cause of morbidity and mortality in adults
               ii. Develop public educational program on health lifestyles (diet and
                   exercise) for diabetes and hypertension prevention and management
              iii. Improve case detection and management of diabetes and
                   hypertension
       f. Child Health –
                i. Strengthen IMCI implementation monitoring.
               ii. Integrate the IMCI and the ETAT (Emergency Triage Assessment
                   and Treatment) programs
              iii. Look for funds to complete IMCI train and attain level of at least 80%
                   of prescribers in all institutions trained in in IMCI and applying it
              iv. Attain and maintain a minimum of 80% EPI coverage in all districts
                   and improve routine reporting.
       c. Reproductive Health
                i. Increase uptake of services specifically: Increase the % of
                   supervised deliveries & Reduce maternal mortality. Target is to
                   reduce by half the current institutional maternal mortality ratios
               ii. Improved accuracy and completeness of reporting and better
                   integration of immunization data from CDC unit and RCH unit
              iii. Strengthen Adolescent Reproductive health program
              iv. Continue the implementation of the regional maternal and neonatal
                   mortality reduction program started in 2005 specifically: Sustain the
                   process of ensuring 100% maternal death audits and use of the
                   information, Repeat the inventory of essential delivery and neonatal
                   resuscitation equipment to see if institutions are filling in the gaps, In
                   service training for all remaining serving midwives (Accra Metro, Ga
                   West, Dangme West, Dangme East) in essential maternal and
                   neonatal life saving skills
               v. Ensure 100% use of partograph and training and supervision of staff
                   in interpretation and use of the partograph for decision making


3. Nutrition
            d. Develop and seek funding for a program to target under five nutritional
               education and improvement programs to the worst performing areas in
               terms of stunting and underweight in the November 2005 survey
               (Asheidu-Keteke and Dangme East)
            e. Improve public education and awareness on Anaemia and micronutrient
               deficiency disorders and their prevention




                                          48
           f.   Improve detection and management of anaemia and micronutrient
                deficiency disorders as well as prevention programs (antenatal use,
                vitamin A supplementation etc)

4. Advocate for and promote healthy lifestyles and env




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