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Field Article Effectiveness of public health systems to support national rollout strategies in Ghana By Michael A. Neequaye and Wilhelmina Okwabi Wilhelmina Okwabi is Deputy Director of Nutrition of the Ghana Health Service (GHS), a position she has held for 2 years. Her previous positions include Programme Manager of Nutrition and HIV/AIDS, National Coordinator for Infant and Young Child Feeding, Assismstant Programme Manger (Supplementary Feeding Programme) and Nutrition Course Coordinator in a Rural Health Training School. Michael A. Neequaye works with the Ghana Health Service as the National Programme Manager, Nutrition Rehabilitation, and the National Coordinator for the CMAM programme since 2007. Previously he was the Regional Nutrition Officer of the Ministry of Health in the Eastern region of Ghana before joining World Vision Ghana as the Project Manager for the Micronutrient and Health (MICAH) Project for 10 years. Acronyms: CHIM CHO CHN CHPS CHVs CMV CSO DHMT FANTA2 GDHS GHS GPRS II GSGDA HIMS HSMTDP ICD IMNCI IYCN 21 Centre for Health Information Management Community health officer Community Health Nurse Community Health Planning Services Community health volunteers Combined Mineral and Vitamin mix Civil society organisation District Health Management Team Food and Nutrition Technical Assistance Project II Ghana Demographic and Health Survey Ghana Health Service Ghana Poverty Reduction Strategy II Ghana Shared Growth and Development Agenda Health Information Management System Health Sector Medium Term Development Plan Institutional Care Division Integrated Management of. Neonatal and Childhood Illness Infant and Young Child Nutrition MOH MUAC NACS NHI NID NMCCSP NRC PLHIV RCH RHMT RUTF SAM SAM ST SAM SU SAM TC SBCC SFP PPME TMPs Medical examination of a child with SAM The authors gratefully acknowledge the support of WHO, USAID/FANTA-2, and UNICEF in writing this article. The Nutrition Department would like to mention in particular the following people for their invaluable contributions and comments during the development of the article: Dr. Isabella Sagoe-Moses and Cynthia Obbu, Ghana Health Service (GHS), Reproductive and Child Health Department, Samuel Atuahene-Antwi GHS, Ga South Municipal Health Directorate, Akosua Kwakye, WHO/Ghana, Alice Nkoroi, USAID/FANTA-2, Catherine Adu-Asare, USAID/FANTA-2, Ernestina Agyapong, UNICEF/Ghana, Maina Muthee, UNICEF/Ghana. Special thanks also to the Director General, Director of Family Health and other Divisional and Departmental Directors of GHS for their support in the integration of CMAM into the health service delivery in Ghana. Last but not least, GHS wishes to thank all Directors and staff working in the 31 districts implementing CMAM in Ghana. Ministry of Health Mid Upper Arm Circumference Nutrition Assessment Counselling and Support National health insurance National Immunisation Day Nutrition Malaria Control for Child Survival Project Nutrition Rehabilitation Centre People living with HIV Reproduction and Child Health Regional Health Management Team Ready to Use Therapeutic Food Severe acute malnutrition SAM Support Teams SAM Service Unit SAM Technical Committee Social Behaviour Change and Communication Supplementary Feeding Programme Policy Planning and Monitoring and Evaluation Traditional medicine practitioners MOH, Ghana Background National nutrition and health situation Like most developing countries, Ghana is faced with high rates of malnutrition. According to the Ghana Demographic and Health Survey (GDHS) 2008, 14% of children under five years are underweight, 28% are stunted and 9.0% wasted. Severe wasting is 2.0% with the highest proportion of severely wasted in the Upper West (3.9%), Eastern (3.7%) and Northern (3.4%) regions of the country (see Figure 1 for map of Ghana). In terms of micronutrient deficiencies, the prevalence of anaemia is very high among women of reproductive age (59%), pregnant women (70%) and lactating women (62%). It is equally high among children under-five at 78% with no improvement seen when compared to the 2003 GDHS. Encouragingly, infant mortality has dropped from 64/1000 live births (GDHS 2003 1 ) to 50/1000 live births (GDHS 2008 2 ) whilst under-five mortality has dropped from 111/1000 live births (GDHS 2003) to 80/1000 live births (GDHS 2008). Over recent years, the country has developed and implemented a number of strategies to combat malnutrition. Progress has been made, with an increase in exclusive breastfeeding rate among infants less than 6 months from 53% (DHS 2003) to 63% (DHS 2008). Progress has also been made towards the achievement of the MDG 1 target of halving underweight by 2015. The prevalence of underweight has reduced from 23% in 1993 to 14% in 2008, however, major challenges remain. There has been limited progress in reducing stunting (chronic malnutrition), the prevalence of which has fallen by only 6 percentage points since 1988. Ghana is among the 36 countries with a stunting prevalence above 20% 3 . Whilst levels of wasting have remained relatively constant, it is also of concern that the rate of overweight among children under five years is on the increase (from 1% in 1998 to 5% in 2008), indicating a dual burden of malnutrition. 1 Ghana Demographic and Health Survey, 2003 2 Ghana Demographic and Health Survey, 2008 3 Black et al, 2008. Maternal and Child Undernutrition 1. Maternal and child undernutrition: global and regional exposures and health consequences. Figure 1: Administrative map of Ghana Group 1 region: Upper West, Upper East, Northern, Central and Greater Accra Group 2 region: Western, Eastern, Volta, Ashanti and Brong Ahafo
Field Article Health and nutrition policies The National Nutrition Policy is currently being drafted 4 . Prior to the development of the national nutrition policy, a strategic document ‘Imagine Ghana free of Malnutrition 5 ’ was developed by a multi-sectoral group of stakeholders. The document set out strategic nutrition objectives and provided costing for implementing nutrition interventions to meet the set objectives. This document is currently being used as the basis for the nutrition policy, updating and aligning Ghana’s nutrition priorities to address under-nutrition using evidence-based nutrition interventions. The Ghana Health Sector Medium Term Development Plan (HSMTDP) 2010–2013 and the Ghana Shared Growth and Development Agenda (GSGDA), which is a follow on document to the Ghana Poverty Reduction Strategy II (GPRS II), identify nutrition and food security as critical and cross-cutting issues in addressing overall human resource development. The GSGDA sets out policy objectives to address issues relating to nutrition and food security. Both aforementioned documents express particular concern regarding the persistent and high undernutrition rates among children, particularly male children in rural areas and in northern Ghana. The HSMTDP identifies the scale up of CMAM as an important intervention for helping to reduce under five mortality rates and also for improving the nutrition status of women and children. Vulnerability to emergencies The Comprehensive Food Security and Vulnerability Analysis conducted by the World Food Programme (WFP) in May 2009 showed that, although Ghana is generally less affected by food insecurity compared to other West African and sub-Saharan countries, about 1.2 million Ghanaians are food insecure. A further 2 million people are vulnerable and could experience food insecurity during adverse weather conditions, such as floods or droughts, and as a result of post-harvest losses. Although the prevalence of acute undernutrition is below emergency thresholds, nutritional challenges threaten Ghana’s overall social and economic development. There are regional variations in food security and undernutrition in the country. The Northern regions (Upper East, Upper West, and Northern) have a higher prevalence of underweight and wasting that are closely linked to food insecurity. Lack of access to food is also a determining factor for acute undernutrition in the coastal zone. Organisation of the Ghana Health System (GHS) The Ministry of Health (MOH) is the government ministry in Ghana that is responsible for the formulation of national health policies, resource mobilisation, and health service delivery regulation. The MOH has a number of agencies, including the Ghana Medical and Dental Council, the Pharmacy Council, Ghana Registered Nurses and Midwives, Alternative Medicine Council, Food and Drugs Board, Private Hospitals and Maternity Homes Board, National Health Insurance Secretariat, Ghana National Drugs Programme, teaching hospitals and the Ghana Health Service (GHS). See Figure 2 for an overview of the GHS structure. The GHS is an autonomous body under the MOH, responsible for healthcare provision in accordance with MOH policies through public Figure 2: Ghana Health Services organisation structure Family Health Division Reproductive and Child Health Department Health Promotion Department Nutrition Department Public Health Division Disease control Department Disease Survillance Department Policy, Planning, monitoring and evaluation Policy Department Planning and Budgeting Department Health Administration and support services Clinical engineering Department Estate Management Department Transport Management Department hospitals, health centres, and Community Health Planning Services (CHPS) compounds. The GHS provides in-service training and develops guidelines and plans for implementation of national health policies. Private and faith-based health facilities, such as mission hospitals, administer approximately 40% of healthcare services in the country. While independent, these facilities are bound by national MOH policies and GHS guidelines and are required to submit statistics and reports to the GHS. The Family Health Division under the GHS has three departments: Reproductive and Child Health, Nutrition, and Health Promotion. The Nutrition Department assigns Programme Officers for the various nutrition programmes such as Infant and Young Child Nutrition (IYCN), Nutrition Malaria Control for Child Survival Project (NMCCSP), Micronutrient Control Programme, which covers vitamin A, iron deficiency anaemia, iodine deficiency disorders and food fortification, Nutrition Rehabilitation, which includes CMAM and Nutrition Assessment Counselling and Support (NACS) for PLHIV, and the Supplementary Feeding Programme (SFP) in Northern Ghana. At the regional and district levels, there are assigned nutrition officers, while at the subdistrict levels a health manager (Physician Assistant or Public Health Nurse) oversees nutrition activities along with other health activities. Health services delivery There are three semi-autonomous referral teaching hospitals, one each in the northern, central and southern parts of the country. There are ten regions of Ghana, divided into 170 districts, and each region has a regional referral hospital. All districts are expected to have a district hospital, which serves as the first referral level. However, some of the newly created districts have upgraded health facilities rather than hospitals, due to variations in levels of staffing and equipment. Districts are further divided into sub-districts, which have health centres headed by Physician Assistants and staffed with clinical and public health nurses and other auxiliary staff. Some of the larger urban health centres, referred to as polyclinics, are staffed with physicians in addition to the personnel mentioned above. Additionally, there are 42 Nutrition Rehabilitation Centres (NRCs) that were established to manage malnutrition prior to the introduction of CMAM. Ten of the Director General Deputy Director General Human Resource General Administration Department Institutional Care Internal Audit Finance Research and Development Supplies Stores and Drug Management Office of Director General NRCs provide residential nutrition care. NRCs tend to be clustered in more urban areas. Administratively, the GHS is managed at the regional and district level by health directorates. Beyond the sub-district level, community level health services are provided through different mechanisms. Two of the more developed mechanisms include child welfare outreach points (run from health centres) and CHPS zones. The CHPS zones comprise communities of 3,000 to 4,500 people (generally two to five villages), to which a community health officer 6 (CHO) is assigned to provide primary health care services from the CHPS compound (the nurse’s home and office, built by the community) and through frequent home visits. The CHO is supported by a number of community health volunteers (CHVs) selected by a community health committee, comprised of village leaders, women’s and youth groups, traditional birth attendants and others. Across the different levels of service delivery, health staffing is generally adequate with exceptions in newly formed districts. The Northern regions also tend to have fewer physicians and nurses compared to the southern and central parts of the country because these regions are less developed. CMAM integration and scale up in Ghana Introduction of CMAM CMAM was first introduced in Ghana in June 2007 at a workshop organised by the GHS in collaboration with UNICEF, WHO and USAID for selected health care providers throughout the country. See Table 1 for an outline of key events in the development of CMAM in Ghana. Prior to 2007, the GHS had addressed the needs of children with severe acute malnutrition (SAM) in paediatric wards or NRCs, which provided nutrition counselling and foods cooked using locally available ingredients. However, these NRCs did not follow the WHO 1999 treatment protocol for the management of SAM 7 or provide any specialised therapeutic foods for children with SAM. 4 As at November 2011. 5 ‘Imagine Ghana Free of Malnutrition’, NMCCSP Programme supported by the World Bank 6 A Community Health Officer is a Community Health Nurse or Midwife who receives additional training, upgrading his/her skills to manage a CHPS zone. 7 WHO. 1999. Management of severe malnutrition: A manual for physicians and other senior health workers. 22
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<strong>Field</strong> Article<br />
Effectiveness <strong>of</strong> public health<br />
systems to support national<br />
rollout strategies in Ghana<br />
By Michael A. Neequaye and Wilhelmina Okwabi<br />
Wilhelmina Okwabi is Deputy<br />
Director <strong>of</strong> Nutrition <strong>of</strong> the<br />
Ghana Health Service (GHS), a<br />
position she has held for 2 years.<br />
Her previous positions include<br />
Programme Manager <strong>of</strong><br />
Nutrition and HIV/AIDS, National Coordinator for<br />
Infant and Young Child Feeding, Assismstant<br />
Programme Manger (Supplementary Feeding<br />
Programme) and Nutrition Course Coordinator in<br />
a Rural Health Training School.<br />
Michael A. Neequaye works with<br />
the Ghana Health Service as the<br />
National Programme Manager,<br />
Nutrition Rehabilitation, and the<br />
National Coordinator for the<br />
CMAM programme since 2007.<br />
Previously he was the Regional Nutrition Officer<br />
<strong>of</strong> the Ministry <strong>of</strong> Health in the Eastern region <strong>of</strong><br />
Ghana before joining World Vision Ghana as the<br />
Project Manager for the Micronutrient and<br />
Health (MICAH) Project for 10 years.<br />
Acronyms:<br />
CHIM<br />
CHO<br />
CHN<br />
CHPS<br />
CHVs<br />
CMV<br />
CSO<br />
DHMT<br />
FANTA2<br />
GDHS<br />
GHS<br />
GPRS II<br />
GSGDA<br />
HIMS<br />
HSMTDP<br />
ICD<br />
IMNCI<br />
IYCN<br />
21<br />
Centre for Health Information<br />
Management<br />
Community health <strong>of</strong>ficer<br />
Community Health Nurse<br />
Community Health Planning Services<br />
Community health volunteers<br />
Combined Mineral and Vitamin mix<br />
Civil society organisation<br />
District Health Management Team<br />
Food and Nutrition Technical Assistance<br />
Project II<br />
Ghana Demographic and Health Survey<br />
Ghana Health Service<br />
Ghana Poverty Reduction Strategy II<br />
Ghana Shared Growth and Development<br />
Agenda<br />
Health Information Management System<br />
Health Sector Medium Term Development<br />
Plan<br />
Institutional Care Division<br />
Integrated Management <strong>of</strong>. Neonatal and<br />
Childhood Illness<br />
Infant and Young Child Nutrition<br />
MOH<br />
MUAC<br />
NACS<br />
NHI<br />
NID<br />
NMCCSP<br />
NRC<br />
PLHIV<br />
RCH<br />
RHMT<br />
RUTF<br />
SAM<br />
SAM ST<br />
SAM SU<br />
SAM TC<br />
SBCC<br />
SFP<br />
PPME<br />
TMPs<br />
Medical<br />
examination<br />
<strong>of</strong> a child<br />
with SAM<br />
The authors gratefully acknowledge the<br />
support <strong>of</strong> WHO, USAID/FANTA-2, and UNICEF in<br />
writing <strong>this</strong> article. The Nutrition Department<br />
would like to mention in particular the following<br />
people for their invaluable contributions<br />
and comments during the development <strong>of</strong> the<br />
article: Dr. Isabella Sagoe-Moses and Cynthia<br />
Obbu, Ghana Health Service (GHS),<br />
Reproductive and Child Health Department,<br />
Samuel Atuahene-Antwi GHS, Ga South<br />
Municipal Health Directorate, Akosua Kwakye,<br />
WHO/Ghana, Alice Nkoroi, USAID/FANTA-2,<br />
Catherine Adu-Asare, USAID/FANTA-2, Ernestina<br />
Agyapong, UNICEF/Ghana, Maina Muthee,<br />
UNICEF/Ghana. Special thanks also to the<br />
Director General, Director <strong>of</strong> Family Health and<br />
other Divisional and Departmental Directors <strong>of</strong><br />
GHS for their support in the integration <strong>of</strong><br />
CMAM into the health service delivery in Ghana.<br />
Last but not least, GHS wishes to thank all<br />
Directors and staff working in the 31 districts<br />
implementing CMAM in Ghana.<br />
Ministry <strong>of</strong> Health<br />
Mid Upper Arm Circumference<br />
Nutrition Assessment Counselling and<br />
Support<br />
National health insurance<br />
National Immunisation Day<br />
Nutrition Malaria Control for Child<br />
Survival Project<br />
Nutrition Rehabilitation Centre<br />
People living with HIV<br />
Reproduction and Child Health<br />
Regional Health Management Team<br />
Ready to Use Therapeutic Food<br />
Severe acute malnutrition<br />
SAM Support Teams<br />
SAM Service Unit<br />
SAM Technical Committee<br />
Social Behaviour Change and<br />
Communication<br />
Supplementary Feeding Programme<br />
Policy Planning and Monitoring and<br />
Evaluation<br />
Traditional medicine practitioners<br />
MOH, Ghana<br />
Background<br />
National nutrition and health situation<br />
Like most developing countries, Ghana is<br />
faced with high rates <strong>of</strong> malnutrition.<br />
According to the Ghana Demographic and<br />
Health Survey (GDHS) 2008, 14% <strong>of</strong> children<br />
under five years are underweight, 28% are<br />
stunted and 9.0% wasted. Severe wasting is<br />
2.0% with the highest proportion <strong>of</strong> severely<br />
wasted in the Upper West (3.9%), Eastern<br />
(3.7%) and Northern (3.4%) regions <strong>of</strong> the<br />
country (see Figure 1 for map <strong>of</strong> Ghana). In<br />
terms <strong>of</strong> micronutrient deficiencies, the prevalence<br />
<strong>of</strong> anaemia is very high among women<br />
<strong>of</strong> reproductive age (59%), pregnant women<br />
(70%) and lactating women (62%). It is equally<br />
high among children under-five at 78% with<br />
no improvement seen when compared to the<br />
2003 GDHS. Encouragingly, infant mortality<br />
has dropped from 64/1000 live births (GDHS<br />
2003 1 ) to 50/1000 live births (GDHS 2008 2 )<br />
whilst under-five mortality has dropped from<br />
111/1000 live births (GDHS 2003) to 80/1000<br />
live births (GDHS 2008).<br />
Over recent years, the country has developed<br />
and implemented a number <strong>of</strong> strategies<br />
to combat malnutrition. Progress has been<br />
made, with an increase in exclusive breastfeeding<br />
rate among infants less than 6 months<br />
from 53% (DHS 2003) to 63% (DHS 2008).<br />
Progress has also been made towards the<br />
achievement <strong>of</strong> the MDG 1 target <strong>of</strong> halving<br />
underweight by 2015. The prevalence <strong>of</strong><br />
underweight has reduced from 23% in 1993 to<br />
14% in 2008, however, major challenges<br />
remain. There has been limited progress in<br />
reducing stunting (chronic malnutrition), the<br />
prevalence <strong>of</strong> which has fallen by only 6<br />
percentage points since 1988. Ghana is among<br />
the 36 countries with a stunting prevalence<br />
above 20% 3 . Whilst levels <strong>of</strong> wasting have<br />
remained relatively constant, it is also <strong>of</strong><br />
concern that the rate <strong>of</strong> overweight among<br />
children under five years is on the increase<br />
(from 1% in 1998 to 5% in 2008), indicating a<br />
dual burden <strong>of</strong> malnutrition.<br />
1<br />
Ghana Demographic and Health Survey, 2003<br />
2<br />
Ghana Demographic and Health Survey, 2008<br />
3<br />
Black et al, 2008. Maternal and Child Undernutrition 1.<br />
Maternal and child undernutrition: global and regional<br />
exposures and health consequences.<br />
Figure 1: Administrative map <strong>of</strong> Ghana<br />
Group 1 region: Upper West, Upper East, Northern,<br />
Central and Greater Accra<br />
Group 2 region: Western, Eastern, Volta, Ashanti and<br />
Brong Ahafo
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