early implementation 1

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Integrated Management

of Childhood Illness(IMCI)

REVIEW OF INTRODUCTORY

AND EARLY IMPLEMENATION

PHASES - GHANA

MINISTRY OF HEALTH

MAY 2002


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Table of Contents

1.0 INTRODUCTION:...............................................................................................................................................31.1 Background Characteristics of Ghana................... ........... ........... ........... .......... ........... ........... ........... ..........41.2 Health Status.....................................................................................................................................................5

1.3 Organisation of the Health Sector.....................................................................................................................62.0 ORGANISATION, PLANNING AND MANAGEMENT OF IMCI.................................................................11

2.1 Preliminary Visit.............................................................................................................................................112.2 National IMCI Orientation Meeting .............................................................................................................112.3 IMCI National Planning Workshop.......... ........... ........... ........... .......... ........... ........... ........... ......... .......... .......132.4 Organisation and Management of IMCI at Central Level...............................................................................152.5 Policy support:................................................................................................................................................162.6 IMCI and Health Sector Reforms ...................................................................................................................162.7 Management Information System...................................................................................................................162.8 Central Level Support for Districts.................................................................................................................172.9 Organisation and Management of IMCI at District Level ......... ........... ........... .......... ........... ........... .......... .....172.10 Interest of partners ........................................................................................................................................18

3.0 TRAINING.........................................................................................................................................................19

3.1 Adaptation Process .........................................................................................................................................193.2 Training Activities ..........................................................................................................................................213.3 Challenges.......................................................................................................................................................263.4 Pre-service training.........................................................................................................................................273.5 Major Lessons Learnt and Way Forward........................................................................................................27

4.0 HEALTH SYSTEM SUPPORT FOR IMCI.......................................................................................................294.1 Drug Supplies .................................................................................................................................................294.2 Basic equipment..............................................................................................................................................304.3 Actions taken facility support ........... .......... ........... ........... .......... ........... ........... .......... ........... .......... .......... .....304.4 Referral ...........................................................................................................................................................314.5 Supervision.....................................................................................................................................................314.6 Follow up........................................................................................................................................................324.7 Constraints and supports for implementing IMCI in facilities........................................................................344.8 Documentation of Early Implementation Phase: .......... ........... ........... ........... .......... ........... ........... ........... ......34

5.0 COMPONENT 3: FAMILY AND COMMUNITY PRACTICES .....................................................................355.1 Formation of CIMCI sub-group......................................................................................................................355.2 Assessment of community based interventions ........... .......... ........... ........... ........... ........... .......... ........... ........355.3 Key Family Practices Selected for Intervention..............................................................................................355.4 District orientations.........................................................................................................................................365.5 Adaptation of Feeding guidelines/local terms.................................................................................................365.6 Development of CHEST-Kit...........................................................................................................................365.7 Development of Child Health Records ........... .......... ........... ........... ........... ........... .......... ........... ........... ..........375.8 Development of an Improved Version of the IMCI Mothers Card.................................................................375.9 Development of training manual for traditional healers ........... .......... ........... ........... ........... ........... .......... ......375.10 Development of child health component for the CHPS curriculum .......... ........... .......... ........... ........... ........375.11 Community Based Growth Promotion..........................................................................................................375.12 RBM Home-Based Care Communications Strategy.....................................................................................38

5.13 Community IMCI Planning Meeting ........... ........... ........... .......... ........... ........... ........... ........... ........... ..........385.14 Future Plans ..................................................................................................................................................41

ANNEX ....................................................................................................................................................................43


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1.0 INTRODUCTION:

The IMCI strategy is a broad strategy developed by WHO in collaboration with UNICEF, andit aims at reducing childhood deaths, illness, and disability, and improving growth anddevelopment. It combines improved management of childhood illness with aspects of nutritionand immunisation in children below the age of five years. In 1998, Ghana adopted IMCI as oneof the key strategies for reducing mortality in children less than five years of age.

The rationale for this strategy is to reduce the high number of deaths in children below fiveyears, majority of which occur in developing countries. It is estimated that 70% of all thesedeaths are due to acute respiratory infections (ARI), malaria, diarrhoea, measles andmalnutrition. For many sick children, a single diagnosis may not be appropriate and hence theneed for an integrated approach to the care of sick children. Research has also shown that morethan fifty percent of deaths occur in the community and thus the strategy focuses oninterventions at health facilities as well as in the community.The strategy focuses on three main components:

Improvements in the case management skills of first level health staff Improvements in the health system required for effective management of childhood

illness Improvements in family and community practices.

There are three stages in Implementation of the strategy and these are: Introduction Phase Early Implementation Phase Expansion Phase

The purpose of the Introductory Phase is to orient and train key Ministry of Health decisionmakers and staff to enable them make an informed decision on whether or not to adopt the

IMCI strategy and if so to create a management and co-ordination group to see to theimplementation.The early implementation phase is carried out to gain experience with IMCIplanning and implementation through a well-defined set of activities within a limitedgeographic area. The experience explores how the IMCI strategy will fit into the overallplanning system at both central and district levels, how to link with health sector reforms, howmuch it costs and how district capacity can be strengthened to implement IMCI activities. Thefocus of the expansion phase is to extend the geographical coverage and activities implementedin the early districts based on the experiences and lessons learnt in the early implementationphase.

The introductory phase of IMCI implementation in Ghana began in 1998, when the strategy

was adopted in the Child Health Policy and Strategy Document 1998/1999, as one of the keyinterventions for improving Case Management of Sick Children. The National OrientationMeeting was held in September 1999, and this was followed by the National Planning Meetingin November 1999.One of the outcomes of the National Planning meeting was a work plan forthe early implementation Phase that began at the end of 1999. The strategy was implemented infour initial districts in order to build capacity, and learn lessons, which could be used in theexpansion phase.


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Collaboration between IMCI and Roll Back Malaria (RBM) started at the African Regionallevel in 1996, and has since expanded to operations at country level. In Ghana, there has beencollaboration between the two programmes in Case Management training, home-based care,and Information, Education and Communication (IEC) among others. In November 2001, theMinistry of Health / Ghana Health Service took the RBM-IMCI partnership a step further by

involving other programmes Expanded Programme on Immunisation and Integrated DiseaseSurveillance and Response (IDSR). The MOH/GHS in collaboration with WHO developed aproposal to integrate service provision, monitoring and evaluation of these interventions in 10selected districts. These districts have therefore been designated as the districts of focus for theprogramme interventions in the IMCI, Malaria (RBM), EPI and IDSR.

This report summarises the activities carried out in the introductory and early implementationphases of IMCI in Ghana. It is expected that the experiences and lessons documented duringthe first two phases will form the basis for the strategic plan for IMCI expansion in Ghana.

1.1Background Characteristics of GhanaGhana is situated in West Africa, and is bordered by Burkina Faso to the North, the Gulf ofGuinea to the South, Togo to the East and Cte dIvoire to the West. The country can bedivided into three ecological zones. These comprise a coastal strip in the south, forest (middle)belt covering about a third of the country and a dry northern savannah covering about one halfof the country in the north.

Occupying a land area of about 283,500 square kilometres, it has a population of approximately18.4 million according to the 2000 Census.

In 1992 the constitution was reformed to bring multiparty democracy back to Ghanas politicalprocess. The country is divided into 10 regions and each region divided into a number ofdistricts. There are a total of 110 districts in the country. The governance of the country isbased on the three-tier system with National, Regional and District Level Administrations.

Agriculture has dominated the economy of Ghana for sometime now. Up until 1990, itaccounted for 70% of employment and represented 44% of GNP while Industry was 17% ofGNP and Services 39% of GNP. Cocoa constituted the mainstay of the Ghana economy,accounting for about 70% of the total export earnings and about 10% of GDP. The miningsector, comprising gold, diamonds (industrial) bauxite and manganese contributed about 15%of the foreign exchange earnings while Timber contributes about 8%. The current GDP is

estimated at $390 per capita.


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1.2 Health Status

The Ghana Demographic and Health Survey (GDHS 1998) estimated the following:

Child HealthApproximately half of all deaths in children under five occur during the first year of life. Infantmortality is 57 deaths per 1,000 births. The risk of neonatal deaths is 30 per 1,000 births andthe risk of post-neonatal deaths is 27 per 1,000 births.There has been a 43 percent decline in under-five mortality in the last two decades. Mortalityis consistently lower in urban than rural areas, and infant mortality is lowest in the GreaterAccra Region and highest in the Upper East Region. As expected, mothers education displaysa strong negative relationship with infant and child mortality, with children born to motherswith little or no education suffering the highest mortality.

ImmunisationThe proportion of children fully immunised by age one has increased in the last five years from

43 percent in 1993 to 51 percent in 1998. Around nine in ten children received the BCG, andfirst dose of DPT and polio vaccines before age one. However, the coverage for the third doseof DPT and polio fell to 67 percent before age one. Sixty-one percent of children received themeasles vaccine before age one and 39 percent have been vaccinated against yellow fever. Onein four children received Vitamin A in the six months prior to the survey.

Breastfeeding and NutritionBreastfeeding is nearly universal in Ghana, and the median duration of breastfeeding is long(22 months). However, exclusive breastfeeding is relatively short and three in five childrenless than two months of age are given water, water-based liquids like juice, and other types of

complementary food. The use of a bottle with a nipple is common, with 15 percent of childrenunder 36 months using it, and bottle-feeding starting as early as 0 1 month.Under nutrition is significant in Ghana, with one in four Ghanaian children under five years ofage stunted (short for their age), 10 percent wasted (thin for their age), and 25 percentunderweight. In general, rural children, children residing in the three northern regions ofGhana (Northern, Upper West, and Upper East) and children of uneducated mothers are morelikely to be stunted, wasted or underweight.

FertilityFertility in Ghana has declined rapidly over the last decade, from over 6 births per woman in

the mid-eighties, to 4.6 births per woman during the last five years. Fertility has fallen recentlyin every age group, with fertility levels among women under age 35 declining by around 25percent during the decade between the 1988 and 1998 surveys.


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1.3 Organisation of the Health Sector

The National Health Sector is made up of the Ministry of Health. The key players involved arePublic Sector, Private Sector, Traditional Sector and other sectors.The Public Sector is made up of Ghana Health Service, Teaching Hospitals, Quasi GovernmentInstitutions and Statutory Bodies.The Private Sector is made up of Private for Profit, Mission-Based Providers, Non-Governmental Organisations, and Civil Society Organisations. The Traditional Sector is madeup of Traditional Medicine Providers, Alternative Medicine and Faith Healers. Other Sectorsinclude Education, Food and Agriculture, Works and Housing, Local Government and RuralDevelopment, and Environment Science and technology.

The second health sector five-year programme of work 2002-2006 maintains the five strategicpillars of the previous (first) one and these are:

Improving quality; Increasing access; Improving efficiency; Fostering partnerships; and Improving equity in financing healthcare.The Priority health interventions identified in the 2002 2006 Programme of Work are:

HIV/AIDS/STDs Malaria Tuberculosis Guinea Worm Poliomyelitis Reproductive, Maternal and Child Health - Scaling up IMCI is one of the keyinterventions Accidents and Emergencies Non-communicable diseases Oral Health and Eye Care Specialist services including psychiatry care (community, secondary and tertiary).There are a number of challenges in addressing these priority health needs effectively such aslack of health information, marginalizing of the poor and vulnerable, non-availability ofappropriate job aids, inadequate involvement of non-government providers.The strategic objectives to address the priority health needs as stated in the POW 2002-2006are:

Implement a package of priority health interventions (to address each of the diseases or healthproblems above IMCI is mentioned as an example of such package)Empower communities to improve their health and gain access to basic health care.Improve efficiency and effectiveness of health service provision.Institutionalise quality in all health facilities.Reorient secondary and tertiary health services to support primary care.


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There are a variety of providers in the public, private and informal sector involved in healthservices delivery in the country. The table below shows the providers at the different levels.This has been described as a pluralist health service.

Table: Providers at each level of the health delivery system

Type of ProviderLevel

Public Health Clinical MaternityCommunity VHW, VHC, CHN,

CHO, PCW, TBA,Wansam committees,private laboratories,condom outlets

Chemical sellers,pharmacy shops,traditional healers,CHOPrivate Midwives

TBA, CBD (FP), CHO,CHN

Sub district Health centre, MCHClinic, EnvironmentalHealth Officers

Health Centre,pharmacy shops,private clinics

Maternity homes,MCH clinics

District District Hospitals and Mission Hospitals

Regional Public HealthReference Laboratory Regional Hospital Regional Hospital

National Specialised Hospitals,Teaching Hospitals

Teaching Hospitals

The Health of the Nation, MoH, Ghana (2001)

Key:

Village Health Workers VHWVillage Health Committees VHCCommunity Health Nurses CHNCommunity Health Officers CHOCommunity Based Distributors - CBDTraditional Birth Attendants TBAMaternal and Child Health - MCHPrimary Care Workers - PCW

1.4 Justification for IMCI Implementation in the Country

(i) Child Health Policy

The Ministry of Health in its document Policy and Strategies for improving the health ofChildren Under-Five in Ghana(1999) adopted the WHO/UNICEF IMCI approach as one of

the interventions for improving the management of the sick and injured child.

It identified six health problems as being responsible for the majority of infant and childmorbidity and mortality: These problems, which represented at least 50 percent of all childadmissions in the country, are:

Pneumonia, Diarrhoea, Malaria,


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Measles, Malnutrition, and

Neonatal Causes.

Several sources of data show the levels of morbidity and mortality of children under five. In1992, a national sample of mothers estimated the mortality rate from neonatal tetanus to be2.2/1000 live births (MOH, Primary Health Care survey, 1992). MOH administrative datafrom 1997 estimated immunisation coverage as follows: BCG, 72 percent; DPT3, 60 percent;OPV, 61 percent, and measles, 58 percent. Of particular concern was the increase in thenumber of measles cases; 36,968 cases were reported in 1997. Measles, therefore, remained animportant cause of morbidity in the presence of a high prevalence of other common infectiousdiseases, malnutrition, and vitamin A deficiency.

Malnutrition is also a major health problem in Ghana. The Ghana Vitamin A SupplementationTrial in 1992 found that 65 percent of young children in northern Ghana had low serum retinol

levels. Preliminary data from a nation-wide anaemia survey (1996) indicated that 81 percent ofpre-school children had serum haemoglobin of less than 11g/dl. The Ghana DHS 1998estimated that 20 percent of children aged 3 to 35 months were stunted, 25 percent wereunderweight, and 13 percent were wasted (GDHS, 1998). Thirty-six percent of infants lessthan 4 months of age are exclusively breastfed (GHS 1998).

In order to address the six most important causes of morbidity and mortality for young childrenthe Policy Document identified five key health sector areas which will be targeted: quality ofservices, access to services, availability of funds and their efficient use, participation incommunity, health program issues. Primary health care program development was still to be

undertaken in the context of improved district-level capacity and autonomy for the planning,management, implementation, and monitoring of health care programs. There was anincreasing recognition of the need to develop integrated infant and child health programs thataddress all of the most important health problems at the same time. One important element ofimproving primary health care for young children was to improving the management of sickchildren coming to first-level health facilities in the country. In order to develop programs toimprove the quality of these services, the MOH in Ghana planned an assessment of the qualityof care provided to sick children reporting to first level out patient health facilities.

(ii) Health Facility AssessmentThe Health Facility Assessment was conducted in August 1998, in five districts, which arerepresentative of the different ecological zones as well as rural urban distribution. A totalnumber of 25 health facilities, both public and private were visited and observations conductedon 180 children. The distribution of ages of children observed ranged between 2 59 monthswith a mean of 22 months.

In each of the facilities visited a health worker responsible for seeing sick children wasobserved as he/she managed a number of sick children and was interviewed at the end of theobservations on their knowledge and practices. There were also exit interviews with caretakers


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of the children observed. In addition, the health facility equipment, supports and drug supplywere assessed.

Category of HW Managing Sick Children at first level

A total of 25 health workers were observed and interviewed. Forty four percent (44%) of healthworkers were medical assistants (professional nurses with additional training), twenty-eight ofthem were nurses, twenty percent (20%) doctors, and eight percent (18%) were communityhealth nurses. This implies that either medical assistants or nurses managed sixty nine percentof all the children observed.

Assessment of Sick ChildrenThe results from the study showed there was the need for improvement in clinical casemanagement - in assessing, classification, treatment and counselling. None of the childrenobserved were assessed for all four danger signs (child unable to drink, vomiting everything,lethargic/change in consciousness and convulsions), which are an indication of severe illness

requiring hospital care. Only forty-three percent of children were fully assessed for all threemain symptoms cough, diarrhoea and fever. Forty one percent of the assessment tasks werecompleted for sick children with fever, 35% of tasks completed for those with ARI and 18%completed for those with diarrhoea. None of the children had their nutritional status fullyassessed. The most common assessment task completed for Nutrition was checking for pallor in 81% of the children. Seventeen percent of the children seen were weighed. Thirty-threepercent of the children observed had their immunisation status assessed. Twenty two percent ofchildren needing immunisation were vaccinated or referred appropriately for vaccination.

Treatment and CounsellingMost of the cases diagnosed as malaria (75%) were treated appropriately, that is as defined bythe National Treatment Guidelines and the diagnosis made by the health worker. Between two-thirds to three-quarters of the patients diagnosed as simple diarrhoea and Upper respiratorytract Infections, were given antibiotics inappropriately.The study also showed that counselling of patients was poorly done, and this was evident in thevery low percentage (9%) of caretakers who knew how to administer the essential treatment athome. Health workers explained how to administer drugs to a third of the caretakers of thechildren seen, however demonstrations on administration and verification of comprehensionwas carried out in only 3 % and 6% of the caretakers respectively. Thirty-one percent of thecaretakers were advised on when to return for follow up but none of them were able to givethree signs of severity, which would imply their immediate return to the health facility.

Facility Supports and EquipmentThe assessment of the facility equipment and supports indicated that most health facilities haveessential drugs, equipment and supplies for managing sick children. Eighty-four percent of thehealth workers had received a supervisory visit in the last six months prior to the surveyhowever checklists were not used, neither were actual Health Worker practices observed. Therewas also lack of job-aids, which could be used by the health workers.


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


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2.0 ORGANISATION, PLANNING AND MANAGEMENT OF IMCI

2.1 Preliminary Visit

Following Ghanas participation in the IMCI inter-country orientation workshop organised by

WHO, in 1999 at Accra, the Ministry of Health decided to embark on the implementation ofIMCI.

A formal request was therefore made to WHO to conduct a preliminary visit. The purpose ofthe mission was to assess the feasibility of IMCI implementation in Ghana, and makerecommendations on actions to be undertaken and plan for the next steps. The interest in IMCIimplementation within the country, the status of programmes involved in IMCI, the healthsystem and its co-ordination, and interventions at community level were assessed during thevisit.

Conclusions made at the end of the visit were that Ghana had many assets to successfully

implement IMCI. Political will and partners interest was high. It was also indicated thatthe health system was likely to provide ground for a solid take off for IMCI. However, theimplementation of different programs needed some improvement by having policies, strategiesand guidelines officially adopted. IMCI strategy could be instrumental for theoperationalization of the Sector Wide Approach (SWAP) as it provides a concrete example ofthe Minimum Package of services that should be provided to children, in a rational, holistic andintegrated way, and have impact on the reduction of morbidity and mortality.

It was recommended that Program managers should finalise/develop policies, strategies andguidelines and have them officially adopted, the mechanisms for co-ordination and funding ofprograms must be analysed to ensure effective collaboration between the MOH and partners, aswell as the sustainability of programmes. It was also recommended that a National OrientationMeeting on IMCI be held.The decision to commence IMCI implementation was reinforced after the preliminary visit.

2.2 National IMCI Orientation Meeting

The National Orientation Workshop on IMCI was held from 13 to 15 September 1999 withsupport from a number of partners. Participants were drawn locally from the Ministry ofHealth, Ghana Education Service, Ghana National Commission on Children, partners likeUNICEF, USAID JICA, DFID, PLAN International, LINKAGES, John Hopkins University,European Union, BASICS and WHO-Ghana. WHO/AFRO provided technical support for the

meeting.

Objectives

The objectives of the meeting were: To ensure a common and sound understanding of IMCI by all decision-makers and

participants,

To ensure a common understanding of the implications of IMCI implementation forGhanas health care system and


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To affirm the commitment of Ghana and the countrys partners for the implementationof IMCI and the establishment of IMCI working group.

Method of workThese included presentations on the strategy, the process of implementation and the contextual

setting. Emphasis was given to the understanding of the concept and deliberating on theimplications this approach would have on the health care system. The Health FacilityAssessment, Drug and Care-seeking Behaviour surveys were used to depict the currentsituation and provided a base of evidence for the planning.

OutcomesThe Government of Ghana and its partners reaffirmed their commitment to IMCI. It wassuggested that although Health system reforms in Ghana were underway and a lot of successhad been registered already, there was a need to implement IMCI in a phased manner applyingsome guided flexibility for implementation within different contexts.

There was agreement on the initiation of the adaptation process for the guidelines andmaterials. Recommendations for adaptation were: To cover the leading causes of death at first level facilities To make the generic material consistent with national guidelines and policies To adapt the guidelines in a way that makes implementation feasible through the

current health system.

A working group was to be formed after some consultations. Recommendedmembers of the IMCI working group were

o Staff of relevant technical programs (MCH, ARI, CDD, EPI, National DrugsProgram etc)

oRepresentatives of university departments

o Paediatricianso Interested partners

The following were recommendations from the workshop Co-ordination and participation of partners is crucial for the success of IMCI

implementation. The MOH with support from WHO should ensure that the working group, key

programs and stakeholders understand and are committed to IMCI. National, regional and district levels should conduct planning for IMCI

implementation. The IMCI working group should review the WHO guidelines as a prerequisite for

the introduction of IMCI at regional and district level Reviewing and revision of IMCI materials for adaptation by program managers in

the light of the existing policies of the vertical programs. The IMCI working group should develop a strategy for the initial IMCI

implementation and seek consensus among stakeholders before its implementation. The IMCI working group should review existing criteria for the selection of IMCI

facilitators, develop a means of working effectively with regional and district teamsto ensure that they are applied appropriately.


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The IMCI working group should work with relevant units and initiatives involved incommunications like the chest kit to incorporate IMCI messages into trainingmaterials for CHWs.

Follow up of trained health workers should be carried out by existing supervisors atdistrict level, those who conduct follow up should be trained in both IMCI and

supervision techniques. The IMCI working group should continue to advocate for the availability of

essential IMCI drugs at the appropriate levels of the health systems where workerswill be trained.

Upon request, IMCI/AFRO in collaboration with other partners should providetechnical assistance to the working group to undertake the adaptation of IMCIguidelines and development of strategy for implementation.

Feeding Adaptation should involve going out to the field to test the feasibility andreview the checklist. The study has to be done separately in the differentgeographical zones. Cost must be considered. The head of nutrition unit must beconsulted for the nutrient value of food to get recommendation for the food box.

It is gratifying to note that all recommendations made have been pursued.

2.3 IMCI National Planning Workshop

One of the outcomes of the National IMCI Orientation Meeting in September 1999 was theformation of the IMCI Working Group. The IMCI National Planning Workshop was held 4 5November 1999 as the first meeting of the Working Group.

The Objectives of the meeting were: To develop a shared understanding of IMCI and its implications among IMCI Working

group members To develop a shared understanding of the roles and responsibilities of the working

Group To develop a National Plan for the Early Implementation phase of IMCI in the country. To initiate the adaptation process.

Outcomes The IMCI Working Group was inaugurated and formally presented with terms of

reference. The three sub groups Implementation/Planning, Adaptation andCommunity were also formed. The Adaptation subgroup was reconstituted into 3subgroups based on the different adaptations that needed to be considered Clinical

Guidelines, Feeding guidelines and local terms sub groups.

Selection of Early Implementation Districts: In order to select the districts or regions,some considerations were made these include:

o The accessibility to Accra as implementation requires close collaboration withstaff from the headquarters,

o Interest of Region or district to implement IMCI,o Participation in Health Facility Assessment,


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o Availability of training sites which will provide adequate number of patients forboth outpatient and in-patient practical.

Using the criteria above, the following districts were selected:

Site Region Geographical zone

Ga Greater Accra Region SouthAtwima Ashanti Region CentralManya Krobo Eastern Region EastTolon Kumbungu (Later) Northern Region North

Tolon Kumbungu Northern Region was added as a fourth district later in the process ofimplementation, due to the high level of under 5 mortality in the northern sector.

Modalities for planning and conducting Regional/District Orientation Meetings wereagreed upon.

Discussions on improving the health system were held and some major decisions madeas follows

o The need to assess the supervisory system and suggest ways of improving thesystem.

o The need to ensure availability of IMCI drugs at district level.o The need to improve the referral system and also equip referral centres to

provide better care. A draft plan for the early implementation phase was developed, which was to be

presented to partners for their commitment to funding.


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2.4 Organisation and Management of IMCI at Central LevelThe diagram below summarises the organisational structure and how the IMCI unit fits into the structure within the

DIRECTOR-GENERAL

INSTITUTION

AL HUMANPUBLIC

HEALTH

POLICY

PLANNING,HOSP

ADM

DEP. DIRECTOR PUBLIC DEP. DIR

REPRODUCTI

SAFE CHILD F

IMCIBREASTFEEDING

SCHOOL HEALTH


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The Child Health Co-ordinator is the IMCI Focal Person within the Ghana Health Service atthe central level. The Co-ordinator has in addition oversight responsibilities for Breastfeedingand School Health. The School Health Co-ordinator supports the IMCI focal person. There isno office space for the Child Health Co-ordinator and the available secretarial support isshared with all other programmes within the RCH unit.

IMCI Working Group - Terms of Reference To advise on all technical matters pertaining to planning implementation and

evaluation of IMCI activities in the country. To identify sources of funding and resource co-ordination while working with donor

agencies involved in health activities. To develop a strategic framework which outlines the processes to mainstream the

IMCI strategy. Facilitate the co-ordination of related programmes and groups for successful

implementation.The working group has authority to enact decisions affecting implementation.

2.5 Policy support:

IMCI strategy is the one of key interventions in the Child Health Policy and StrategyDocument as well as the MOHs 5-Year Programme of Work 2002 2006 and in thecountrys Poverty Reduction Strategy Programme 2002-2004.IMCI as a concept and approach for addressing childhood diseases has been presented at anumber of fora to health authorities at various levels National, Regional and District. In theEarly Implementation districts, dissemination was done widely to involve the sub district andcommunity levels as well as Local Government authorities. The Programme ManagersEPI/CDD, Malaria, as well as the head of the Nutrition Unit form part of IMCI working groupand have ensured that the IMCI strategy is in harmony with their programme policies.

2.6 IMCI and Health Sector Reforms

IMCI is one of the priority interventions identified under the second POW - 2002 2006since the health sector embarked on reforms. Some districts have incorporated IMCI into theMedium Term Expenditure Framework and annual work plans. Districts have funded someIMCI activities such as Community Sensitisation Meetings held within their districts.Funding for majority of IMCI activities is at national level and funds have come mainly fromthe Earmarked funds, a component of the three funding arrangements under the HSR. Afew activities especially meetings of Working Group and Sub Group have been funded withGOG funds. Districts and regions have also contributed to preparatory activities and follow-up visits.

2.7 Management Information System

There is a need to harmonise the classifications of RBM, IMCI and existing classifications.New Forms developed by IDRS to collect data have been discussed with both IMCI and RBMto ensure that all relevant areas are covered.


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2.8 Central Level Support for Districts

The Districts selected for early implementation met most of the criteria, the exception beingavailability of suitable training sites at district level. As a result trainings were conducted atregional level rather than at district level.

District Orientation and Planning Meetings were held in all four early implementationdistricts in the latter part of 2000 and early 2001. These meetings brought together Regional,District and Sub district health staff as well as partners from the other Ministries, Departmentsand Agencies, Non governmental Organisations and Community Representatives. Duringthese meetings, key MoH staff from the neighbouring Regions not implementing IMCI wereto participate. These meetings oriented the Districts on the IMCI strategy and supported themto plan for its implementation. All the District Directors were trained in the First NationalCase Management Training as part of the Orientation process. Subsequently other members ofthe District Health Management team were trained in Case Management as well assupervision.

After Orientation meetings in each district, the Districts were again brought together for anOrientation in Community IMCI in March 2000. In August 2001, districts were againbrought for dissemination of the framework for implementation of CIMCI and planning ofdistrict plans for CIMCI. All the districts went further to conduct orientation meetings foropinion leaders and other stakeholder in their communities.

The MoH has identified seven additional districts for expansion of IMCI strategy incollaboration with RBM, IDSR, and EPI programmes as discussed in the introduction. Thesedistricts as well as others targeted for expansion by the MoH in collaboration with UNICEFand other partners were brought together for an Orientation and Planning meeting whichfocused on all four programme areas. These district teams are expected to carry outorientation meetings in their respective districts.

2.9 Organisation and Management of IMCI at District Level

All three components of IMCI form part of the district plans of the early implementationdistricts as well as districts targeted for expansion.District Health teams in the early implementation districts have been involved in supervisionand work at ensuring adequate support for health workers to practice IMCI Case Managementin the facilities.

Reports from follow up visits were shared with the heads of the facilities visited and theDistrict health teams and they were to follow up certain actions to be taken. There wereimprovements in the facility supports noticed when facilities were visited for the second time,indicating some action had been taken. The Facilities/districts provided logistics and otherfacility supports, as well as reorganised the case management tasks in the facilities.

District/District Assembly funds were used for sensitisation and community activities withinthe districts.


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Although the aim was to build capacity in all four early implementation districts/Regions, tocarry out IMCI case Management training, only one region is capable presently of carryingout training without National support. The Ashanti Region has a Pool of Regional/Districtstaff trained in IMCI facilitation and able to implement training and follow up without central

support. There is some capacity in the other regions and districts however this is not the fullcomplement of facilitators/course director/clinical instructor needed to carry out training.There is however adequate capacity to conduct supervision in all four districts.

2.10 Interest of partners

Since the introduction of IMCI into Ghana, several partners have expressed interest insupporting its implementation in the Country. WHO, UNICEF, USAID and BASICS II havebeen the major partners working with and supporting the Ministry in implementing all threecomponents of IMCI. In addition to the financial support, these agencies provide the MOHwith technical and administrative assistance in implementing activities. There are others whohave also shown very keen interest, supporting in various activities particularly Community

IMCI.Some serve on the Community IMCI and other sub groupsThese are listed below:Plan InternationalLINKAGESGhana Red CrossWorld Vision InternationalPRIME IIJohns Hopkins UniversityAdventist Relief AgencyProject Concern InternationalCare InternationalAfricareProject ConcernThe funding provided by each of these agencies in implementing IMCI is shown in Annex.The results of follow up and supervision have not yet been made available to partners as anadvocacy tool for generating more support. It is expected that this report will serve as such atool to engage more partners.There are some bilateral agencies such as DFID, GTZ, JICA, the European Union and othersthat may be considered as potential partners.


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3.0 TRAINING

3.1 Adaptation Process

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

November 1999. The adaptation process was facilitated by two Ministry of Health officialstrained as adaptation consultants at a workshop organised by WHO/AFRO in Harare,Zimbabwe. There was therefore no need for external technical support. The adaptationprocess was further facilitated by the presence in the country of six health workers alreadytrained in IMCI case management. One of these had extensive experience with IMCIimplementation in another country.

3.1.1 Adaptation Sub-group membershipAll relevant divisions, programmes and units of the Ministry of health as well as somedevelopmental partners were represented on the Adaptation sub-group that undertook theprocess. There were representatives from

Malaria Control Programme

Expanded Programme on Immunisation/CDD Institutional Care Division Reproductive and Child Health Essential Drugs Programme Paediatrician from the Teaching Hospital Nutrition Unit Health Education Unit WHO, UNICEF and USAID Representatives from the Initial Districts

3.1.2 List of reference material used in adaptation WHO Adaptation Guidelines Treatment Guidelines for Middle Level Health Providers MOH, Ghana Management of common infections in Ghana Prof. J. O. O. Commey Malaria A training guide for primary health care in Ghana, MOH Essential Drugs list Ghana Objectives, strategies, targets and implementation guidelines for PH interventions in

Ghana Community Health Education Skills Tool (CHEST) kit - MOH, Ghana

In addition to the above, there were consultations with researchers within the country as wellas with external experts on specific issues.

3.1.3 Local Terms Adaptation/Identification of feeding recommendationsLocal terms adaptation were done for 3 of the initial districts. The 4th, Tolon Kumbungudistrict was not included at the time since it was only selected later. Local terms wereidentified for main symptoms; general danger signs and signs for when to returnimmediately. A local consultant was appointed and the WHO protocols were used for thisprocess.WHO protocols were also used to determine appropriate feeding recommendations for variousage groups after a survey that was conducted in areas representative of the ecological zones of


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the country. Technical support for the feeding adaptation was provided by the BASICS IIProject.The Linkages Project, Ghana undertook the process for the Northern sector of the country,using local facilitators who had previously been trained through their involvement in theprocess for the rest southern sector of the country.

At various stages, materials produced were circulated among other stakeholders andcomments made were incorporated. The process was completed within 8 months after which ameeting was held to build consensus among a larger group of stakeholders.

3.1.4 National IMCI Consensus Building WorkshopIn August 2000, 9 months after initiating the adaptation process in Ghana, a consensusmeeting was held to address the following objectives:

To build consensus among all stakeholders on adapted IMCI guidelines. To ensure consistency of adaptations with national policies. To share technical background information justifying the proposed adaptations and

To obtain support from all stakeholders for the use of the IMCI guidelines.The various adaptations, which had been made to the generic IMCI guidelines, were presentedto a forum of stakeholders from the Ministry of health, training institutions, hospitals, regions,districts as well as researchers and developmental partners. Consensus was built on therecommended adaptations.

Main outcomes of consensus MeetingAfter thorough discussion of the adaptations made by the sub-group the following changeswere made.

In view of the prevalence of G6PD deficiency in the Ghanaian setting as well as therisk of Stevens-Johnsons syndrome, the first-line antibiotic for the treatment ofpneumonia and acute ear infection was changed from Cotrimoxazole to Amoxycillin.

Incorporation of the Hepatitis B vaccine into the materials since plans were faradvanced for its inclusion in the immunisation schedule for Ghanaian children

3.1.5 Appropriateness of Adapted materialsThe adapted materials have been used in various training courses and have been found to beappropriate to the Ghanaian setting. Health workers find them very useful on return to theirfacilities since they cover a majority of the conditions encountered.

A few corrections were suggested after the first four case management courses. These havebeen incorporated into the material.

Lately, questions have been raised about the need to include treatment for malaria in the sickyoung infant algorithm. It may be necessary to discuss this further.

It has been detected that the Roll Back Malaria programmes pre-referral treatment formalaria is different from what is used in IMCI. This will need to be clarified. The dosage ofquinine used by the two programmes also needs to be synchronised.


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3.1.6 Need for adaptations for other regions/districtsIdentification of local terms will be needed for some districts/regions as they initiate IMCIimplementation. On account of the multiplicity of languages spoken in the country, it wasimpossible to do this adaptation for the whole country. National expertise exists in the form ofhealth workers of initial districts who were trained during the adaptation for their own

districts. They can assist new districts in conducting similar surveys.

3.2 Training Activities

During the period of adaptation, health workers were given opportunities to be trained outside the country. This contributed immensely to the adaptation as well as building capacity forconducting the first training in the country.

3.2.1 Participants trained outside GhanaCase management - 10Facilitation skills - 6

Adaptation - 2Follow-up - 1

The first IMCI training in Ghana was held in November 2000. It comprised facilitatorstraining, which was immediately followed by a case-management course. Since then variousother training sessions have been conducted, as shown below.

3.2.2 Training SitesAppropriate training sites have been identified and tested in all the four regions of the selecteddistricts. Regional level training sites were used instead of district sites for the followingreasonsThe presence of regional training co-ordinators, experienced in organising training for districtstaff. With the exception of Greater Accra region, all regional training co-ordinators havebeen trained in case-management as well as facilitation. The one in Ashanti region has alsobeen trained as course director.Adequate case and variety load for both out patient and in-patient practice (not the case inmost district health facilities)Only 1 of the initial districts (Atua) has a district hospital with in-patient facilities for sickchildren.- The presence of appropriate classroom and other facilities at regional level

3.2.3 National Training ConductedThe early phase was mainly used to build capacity for scaling up. Efforts were initially madeto select participants who could be trained as facilitators to assist with future training in theirown and other regions.

Training organised at various sites covered participants selected from all the four initialdistricts. This was thought to be a better method for 2 reasonsTo cover all 4 districts simultaneouslyTo avoid drawing away too many health workers at a time from any particular district for theentire 2-week period.


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Sequence of training activities

Date Type Venue Funding Objectives Categoriesof Worker

Trained

NumberTrained

Nov2000

FacilitationSkills

Accra WHO Build Capacity SHPPO

6

Nov2000

NationalCaseManagement

AccraWHO

Train SHP fromMOH National andDistrict level TrainPO who will assist instrengthening IMCIimplementation.Identify potentialtrainers

SHP,PO,HW

19

March2001 FacilitationSkills Accra BASICS Build Capacity SHPPO 9

March2001

RegionalCaseManagement

Kumasi BASICS Strengthen NationalcapacityTrain SHPTrain HW

SHPHW

21(including 4participants from theGambiaand SierraLeone

May2001

SupervisorsTraining

Accra BASICS Train National /Regional / District

supervisors

SHPPO

HW

9

July2001


Koforidua BASICS 23

Sept2001

FacilitationSkills

Accra 12

Nov2001


Tamale WHO Strengthen NationalcapacityTrain SHPTrain HWPrepare training sites

for expansion phase

SHPHW

20

Feb 2002 SupervisorsTraining

Accra BASICS Train districtsupervisors

SHP,HW

8

April2002


Kumasi USAID Train HWTrain potentialfacilitators

HW,SHP

22including2 SierraLeonians

April2002

FacilitationSkills

Accra USAID Build Capacity forIMCI training

9


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May2002


Koforidua USAID 21including4 SierraLeonians

KeySHP senior health ProfessionalsNPM - National Programme ManagersPO Programme Officers of Partner agenciesHW Health Workers

Totals for various categories of training (including those trained outside)

Case management - 104Facilitation - 38 (11 more awaiting training)Course Directors - 5

Clinical Instructors - 7Follow-up - 19

3.2.4 Quality of IMCI Case management training course

WHO guidelines for conduction standard case management indicates the following:

90 hours of training (excluding period for tea break and lunch)30% of the time should be used for hands on skills

Facilitator: Participant ratio of 1:4Participant: patient ratio of 1:20Participant: exposure ratio of 1:40

The table on the next page shows the characteristics of case management training coursesconducted during the early use phase.


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IMCI Indicators of Quality of Training

Course Facilitator:ParticipantRatio

Total CourseDuration (Hrs)

Time (Hrs)spent forClinical session

Participant:Exposure Ratio

PartiPatie

National CMNov. 2000

1:2.5 93 28 1:69 1:24

Regional CMMarch 2001, Kumasi

1:2.5 93 28 1:62 1:24

Regional CMJuly 2001, Koforidua

1:4 93 28 1:48 1:16

Regional CMNov. 2001, Tamale

1:3 93 28 1:64 1:19

Regional CMApril 2002, Kumasi

1:3 93 28 1:64 1:25

Regional CM

May 2002, Koforidua

1:3 93 28


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3.2.5 Records of Trained Health Workers at First level

District Total No. OfPrescribers

No. of IMCITrained Prescribers

No. of Prescribers to betrained

Ga

TolonKumbumgu

Manya Krobo

Atwima

57

35

46

49

13

12

13

20

44

23

33

29

Total 187 58 129

Facilitators/Supervisors trained per region

Region/District Facilitators Course Directors Clinical Instructors Supervisors

Greater AccraGa

6 (3) 0 0 5

AshantiAtwima

13 (2) 2 (1) 4 6 (2)

EasternManya Krobo

7 1 2 4 (1)

NorthernTolon Kumbungu

6 1 2 4 (1)

Head quarters/Partners

3 1 0 3

- ( ) Not available to contribute to implementation.

Number trained in new Districts

Ashanti - Ejisu 3 Offinso - 1Adansi West 1 Sekyere East - 1Anansie West Sekyere West - 1Asante Akim North 2


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3.3 Challenges

As expected, not all recommended signs and classifications were seen by participants duringtraining. The following were consistently missed at all training:1 week up to 2 months - Grunting, Convulsion, Severe dehydration, Blood in stool

2months up to 5 years - Deep extensive mouth ulcers, Mastoiditis

Refractory problems were detected in 10% of participants attending the case managementtraining. This made it difficult for them to reach the materials. The opportunity was taken torefer them to the optician. After they had acquired reading glasses they picked up and wereable to complete the course without problem.

Some participants reported late for the case management course. This gave extra work tofacilitators who had to work with them at night and early mornings to assist them to catch up.The situation was worse with foreign participants who sometimes arrived as late as theevening of the third day.

Some who were invited for training did not report in spite of several reminders. They did notsend the replacement therefore places remained vacant

Despite extra assistance from facilitators a few participants found it difficult to follow thetraining. This was so with 2 participants. It was suggested that they be attached to betterperforming participants for 2 weeks after the course in order to improve their understanding.

Facilitators were sometimes difficult to come by due to commitment to other activities as wellas inadequate motivation. Varying rates among partners sometimes led to dissatisfactionamong facilitators.

High attrition rate among facilitators they either moved to join other organisations or wenton to further their studies. Others who were trained never availed themselves to facilitate dueto conflicting interests.

Delays in release of funds for some trainings made organisation extremely difficult.

Co-ordination of IMCI and other training and implementation

Staff from other programmes have been involved in organising orientation meetings forimplementing districts e.g. Nutrition unit, IDSR and RBMSome IMCI facilitators also facilitate trainings for the RBM programme. Some programmemanagers have been trained in IMCI but have not been used in facilitating courses because oftheir busy schedule. It has not been possible to involve staff from other programmes forsimilar reasons.

IMCI training has been co-ordinated with training in Breastfeeding. Some staff fromimplementing districts were trained in the Breastfeeding Counsellors course in order to act asreferral points for mother who are identified with problems by IMCI trained personnel.


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3.4 Pre-service training

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

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

3.5 Major Lessons Learnt and Way Forward

3.5.1 Major Lessons Learnt

Involving senior staff at the regional level facilitated implementation

The course is appropriate for the target group. Shortening the course for first level health workers will result in compromising the

quality and hence not much change in practice.

A short course may however be appropriate for senior level personnel withextensive medical training.

Training country level personnel in adaptation process facilitates adaptation. Training other workers at the facility e.g. Dispensers and Nutrition officers can

facilitate actual practice.

Medical Assistants and nurses can be good facilitators when trained Doctors in clinical practice serve as the best Clinical Instructors Building Regional and District capacity is critical for scaling up. For both training

and follow-up training can be done with minimal national involvement. Regional level training can cater for the districts and ensure quality. So far, facilitators training has occurred at the national level to ensure quality. It is essential to train large numbers of facilitators to maintain an available pool

when needed.

Case management training is very expensive, between 17,000 to 18,000 USdollars. It will be difficult for regions/districts to bear the entire cost.

The method of teaching used in the course ensures acquisition of essential skillsfor management of sick children.

Specific Changes NeededFurther discussions and consensus on pre-referral for Malaria and Quinine dosages should beinitiated and the issues resolved.


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3.5.2 Selected Activities for Expansion Phase1. Selected tutors from Pre-service institutions should be trained in IMCI.2. Orient staff at Nurses and Midwives Councils, HRD, CHNTS and Medical and Dental

Council in IMCI pre-service.3. Drug management and dispensing counselling training should be provided for

dispensing assistants and technicians.4. Incorporate IMCI into training curricular of pre-service schools5. Upgrade skills of referral level staff and adopt WHO guidelines for the purpose.6. Inclusion of private providers in IMCI implementation. Need to find modalities for

training them.7. Conduct planning meeting to look at cheaper alternatives for conducting 11-day case

management.8. Adapt abridged course for senior level personnel.


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4.0 HEALTH SYSTEM SUPPORT FOR IMCI

4.1 Drug Supplies

4.1.1 PolicyGovernment drug policy provides for the compilation of an essential drug list, EDL, which isbasically for the public sector although private sector is encouraged to use it. All drugs neededfor IMCI implementation are on the Essential drug list. The main challenge however is thatEDL categorisation of drugs puts some of the key IMCI drugs into groups that majority offrontline workers are not supposed to prescribe or stock in their facilities. Drugs such asamoxycillin suspension, chloramphenicol injection, quinine injection, sulfadoxine-pyrimethamine, Nalidixic acid that are in the Level B2 and C category are not to be handledby health centres without a doctor. More than 60 percent of the facilities in the 4implementing districts fall within this category of health centres without a doctor and are

therefore prohibited by the policy from prescribing these drugs. In addition in some healthfacilities even though a facility is allowed to stock all the IMCI drugs some first level healthworkers working in that facility are not allowed by law to prescribe certain drugs. Forinstance Community Health Nurses (CHN), one category of frontline health workers, are notsupposed to prescribe antibiotics and quinine. A number of IMCI-trained prescribers in the 4IMCI implementing districts are neither doctors nor medical assistants and therefore fall inthis category.

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

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

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


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

4.1.4 Drug managementCapacity to manage drug supplies.

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

4.2 Basic equipment

All the health facilities have basic equipment for storage, record-keeping and stockmanagement. Drugs are kept in cabinets or in dry places on shelves where necessary, one ortwo facilities I visited had drugs in boxes no shelve. The situation was rectified by the

DHMT after reporting and stores/shelves provided for the sole purpose of storing drugs andfew other medical items. These stores have ledgers and tally cards that are well kept. What islacking is good forecasting and timely ordering of appropriate drugs based on patient flow.This leads to stock-outs for some key drugs. The reason for this may be due to inadequatecapacity or high workload. Some do not keep tally cards up to date.Some facilities do not have the required equipment particularly weighing scale.

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

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

4.3 Actions taken facility support

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


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4.4 Referral

The average distance from a health centre to a referral facility (usually a district hospital) is

variable for the different health facilities/districts.

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

4.5 Supervision

4.5.1 Incorporating IMCI into Routine Supervision

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

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

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

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


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

4.6 Follow up

Follow up is an integral component of IMCI case-management. WHO recommends thattrained health workers be followed up within 4-6 weeks of training. The objectives of thefollow-up are:Reinforce IMCI skills and help health workers transfer them to their work in FacilitiesIdentify and help solve problems faced by health workers in managing casesGather information on performance of health workers and conditions that influenceperformance in order to improve implementation of IMCI.

4.6.1 Training of supervisorsA National training of supervisors was held in May 2001 and a second training held inFebruary 2002. Most of the supervisors had been trained previously in facilitation skills. Thetrained supervisors then carried out follow up visits to the trained health workers within theirdistricts or regions. The first batch of follow up visits conducted was done with support fromthe National level and a number of partners. Subsequently follow visits were conducted bydistrict supervisors.

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

Table: Supervisors per Region/District

Region / District Number of Supervisors

Greater Accra/Ga District 5

Eastern /Manya Krobo 4 (1)

Ashanti /Atwima 4 (2)

Northern /Tolon Kumbungu 4 (1)

(1) NA available

The country since it began IMCI implementation has not been able to meet the target ofconducting follow up visits within 4- 6 weeks of IMCI Case Management Training. Follow

up visits were conducted eight twelve weeks after Case Management training.During follow up visits, health workers were observed as they performed case managementtasks and given feed back. The caretaker was interviewed at the end of the observation andthe outcome also used in providing feedback to the health worker. The facility supports werereviewed and staffs of the facility were brought together at the end of the visit to providefeedback of the review and discuss improvements in the health facility. A summary reportwas left at the facility, one at the District and the third submitted to the National level aftereach training. There were actions to be taken at the different levels and reports indicated theseactions. Follow up reports were discussed during IMCI Working Group meetings and with the


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

Table: health Workers followed up per districtDistrict Number Trained No Followed up Percentagefollowed up

Ga District 13 6 46%

Manya Krobo 13 10 77%

Atwima 15 13 87%

Tolon Kumbungu 12 11 85%

Findings from follow up visits

Health worker practices Percentage (%)

Correctly assessed general

danger signs

71

HW Correctly assessing forthree main symptoms Cough,diarrhoea, fever

81

Correctly checked weight forage

81

Correctly checkedimmunisation.

91

Give immunisation according toschedule

93

Correctly prescribed anti-

malarial for malaria

80

Advised on home care 30

Assess and counsel on feeding 58

Caretaker knowledge

Correct knowledge on antibioticor anti-malarial

78

Knows 3 rules of home care 32


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Available Facility Supports

Functioning ORT Corners 77

Cold Chain equipment 77

Vaccine 83

IMCI Drugs First line 90

4.7 Constraints and supports for implementing IMCI in facilities

The job descriptions of staff of first level health facilities are generally not available and donot usually determine roles of the various staff. The current organisation of work in health

facilities does not allow every trained Health Worker to perform all IMCI tasks. Generally theprescribers who maybe medical assistants or nurses were responsible for assessing,classifying and treating the children seen. Other staff did some aspects of assessment such asweighing of children and taking of temperatures. It was generally found that there waspressure on Health Workers and they were unable to carry out all IMCI tasks. The feedingassessment and counselling on feeding was not usually carried out in facilities with highpatient load. In such facilities, the most feasible option was for the feeding assessment andcounselling to be carried out by nutrition officers or community or public health nurses. Thetrained health workers were asked to share the counselling cards with such workers for thispurpose. In certain facilities, the dispensary staff administers the drugs and was responsiblefor counselling of patients on the drugs. It may be necessary to provide trained health workers

with some materials/job aids, which can be used by such staff, who carry out some aspects ofthe IMCI Case management tasks.

4.7.1Other signs indicating IMCI was implementedThe trained Health Workers in a number of facilities disseminated information on IMCI totheir colleagues. Some health workers knew about general danger signs, the need forcounselling on drugs as well as counselling on when to return although they had notundergone the 11-day course. This was to help them pick out children who needed urgentattention by the trained Health Workers. The first dose of the drugs was also given in somefacilities and this was done by the dispensary assistant/technician, where the trained healthworker was too busy to do so.

4.8 Documentation of Early Implementation Phase:

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


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5.0 COMPONENT 3: FAMILY AND COMMUNITY PRACTICES

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

5.1 Formation of CIMCI sub-group

In Ghana the MOH decided that all three components of IMCI should be implementedtogether.To ensure the incorporation of community IMCI activities into the overall IMCI framework, acommunity sub-group has been formed with membership from:

Ministry of Health Health Education Unit Nutrition Unit Reproductive and Child Health Unit

USAID BASICS UNICEF WHO John Hopkins University (Centre for Communication Programs), Ghana Red Cross and PLAN International.5.2 Assessment of community based interventions

With technical assistance from the Basics II project, an assessment of on going community

interventions was also conducted from July 24 to 12th August 2000. This was done todocument successful community-based child health activities, being supported by bothGovernment (MOH) and NGOs in the country. Some successful activities found included thefollowing:

Home Based Treatment of Fevers (HBTF) project at Ejisu, Gomoa and Wa; the Ghana Red Cross (GRC) mothers clubs; Mother Support Groups (MSG) - Baby Friendly Hospitals Initiative (BFHI); Freedom From Hungers (FFH) credit with education programmes for mothers, Community Based Growth Monitoring at Ejisu and PLAN Internationals VHC and VHW activities in child health.5.3 Key Family Practices Selected for Intervention

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

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


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2. Energy and nutrient rich complementary feeding from 6 months while continuingbreastfeeding into the second year of life.3. Ensure children receive adequate amounts of micronutrients (vitamin A, iron, and iodine)4. Ensure children are fully immunised before their first birthday5. Ensure children sleep under insecticide-treated bed nets

6. Ensure children have safe drinking water7. Ensure the child receives formal education8. Practice of good sanitation including safe disposal of waste

9. Practice of good hygiene including hand-washing with soap (after defecation, beforepreparing meals and before feeding children), and the use of clean utensils for feeding10. Ensure that every pregnant woman receives adequate care and promote child spacing.

Key practices for sick children are:1. Continue to feed and give more fluids when a child is sick2. Give a child more food before and after illness

3. Appropriate home treatment for injuries and infections4. Follow health worker advice on treatment, follow up and referral5. Recognise when child needs further care and seek appropriate care.

5.4 District orientations

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

5.5 Adaptation of Feeding guidelines/local terms

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

5.6 Development of CHEST-Kit

A draft Community Health Education Skills Tools (CHEST) Kit was developed by the HEUand the MOH. This is to assist Community Health Nurses (CHNs) deliver accurateinformation to promote preventive measures e.g. Immunisation, use of ORS, provide timelyreferrals to other service providers and generally act as health advocates in their communities.During the review of the CHEST-Kit, a team with knowledge in IMCI reviewed the childhealth section of the kit and incorporated IMCI into the kit. The revised CHEST-Kit has beenproduced and in order to promote the use of the Kit, USAID provided funds to train healthworkers in the early IMCI implementation districts as well as other districts in the country.


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5.7 Development of Child Health Records

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

5.8 Development of an Improved Version of the IMCI Mothers Card

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

5.9 Development of training manual for traditional healers

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

5.10 Development of child health component for the CHPS curriculum

CHPS is a strategy for health care delivery system to provide cost effective health services toindividuals and households in communities through engaging the communities in the planning

and delivery of the service. The curriculum developed for the Community Health Officers(CHOs) was found to have no information on child health. To help address this, the IMCIteam was tasked to help review and develop a child health training module for the CHOs.

5.11 Community Based Growth Promotion

Community Based Growth Promotion (CBGP) has been identified as one of the keyinterventions to improving key behaviours and family practices and is being used as the entrypoint for the implementation of community IMCI. The Nutrition Unit (NU) of the MOH hasbeen the key organisation to this programme. The unit has initiated the formation of a taskforce with representatives from the NU, Reproductive and Child Health (RCH) unit, Health

Education Unit (HEU), WHO, LINKAGES, BASICS, and UNICEF to review and developmaterials for the growth promotion programme.

The task force has developed the following draft materials, which are yet to be pre-tested:Community Growth Promotion manual for community child growth promotersTraining guideTrainer of Trainers guideCounselling cardsA guide to planning CBGP


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Brochure on Growth Promotion

An initial orientation and sensitisation meeting was held for all the four IMCI earlyimplementation districts. District and sub-district health workers as well as some members ofthe health and social services sub-committee of the District assemblies were the targets for the

orientation meetings. Following these activities, 8 selected communities from all the fourdistricts have been sensitised on the CBGP. Together with the communities guidelines forselection of community volunteers has been developed and communities have been tasked todevelop community action plans with the assistance of district health teams.

5.12 RBM Home-Based Care Communications Strategy

Home-based care of malaria presents an enormous opportunity to reduce childhood morbidityand mortality in Ghana. The home-based care communications strategy outlines an approachto improve home treatment of malaria in children and early referral of severe cases byproviding information to mothers as the primary caretakers, training chemical sellers, and

advocating for support from policy-makers.

The home-based care communication campaign will use a multi-channel approach, with acombination of various communication channels mutually reinforcing each other. Theapproach encompasses:Community and regional level communication activities to change social norms influencingcare for the childs health within the home and community;A national level media campaign strategy to address and empower mothers regarding home-based care of malaria has been developed and has the following components:

A child health theme or symbol to unify this and other child health interventions. Enhancement of chemical sellers ability to inform and provide a full course of

chloroquine to caretakers through interpersonal communication and counseling skillstraining and provision of provider and client support materials;

Advocacy and media initiatives that contribute to a more conducive environment forhome-based care of malaria.

Currently a radio serial programme called He Ha Ho standing for Healthier; Happier Homeis being aired on the national radio station in 5 Ghanaian languages and English. The first partof the series will run weekly for 26 weeks, after which it will be reviewed for another set ofmessages to run for another 26 weeks. Topics on Malaria, ARI, Diarrhoea disease,malnutrition and measles have been selected for discussion on the 30 minutes radioprogramme.Copies of the serial programme has been made available to all the 10 regional health

administrations to be duplicated and sent to all health facilities. The expectations are thatthese radio cassettes would be played at child welfare clinics, outpatient departments etc.

5.13 Community IMCI Planning Meeting

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


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of IMCI early implementation, policy makers from the central MOH, private providers andpartners.

The objectives of the workshop were:To orient key national, regional and district level personnel on the WHO recommended steps

for implementation of community IMCI.To share experience of CIMCI implementation from other countries.Draw up district plans for CIMCI implementation.Draw up a national plan for CIMCI implementation.


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Flow Chart to illustrate sequence of events

C-IMCI Subgroup formed

ADAPTATION OF FEEDINGGUIDELINES & LOCAL TERMS

SURVEY OF EXISTINGINTERVENTIONS

C-IMCI Orientation meeting for National,Regional & District MOH staff, Partners,

NGOs & other Stakeholders

KEY BEHAVIOURS & PRACTICES IDENTIFIED,AGREEMENT ON KEY PLAYERS AT

COMMUNITY LEVEL, INTERVENTIONS TOPROMOTE BARRIERS

DISTRICT PLANNING WORKSHOP

ORIENTATION OF KEY PLAYERS AT DISTRICT LEVEL

IMPLEMENTATION OF SELECTED ACTIVITIES AT

early implementation 1

Documents