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Table 2: Number of health care providers and community volunteers trained
(as of August 2011)
Region
Number trained in Number trained in
outpatient care (OPC)* inpatient care (IPC)
Community Health
Volunteers (CHV)
Greater Accra 330 38 515
Central Region 294 79 579
Upper East Region 156 37 304
Upper West Region 190 28 1816
Northern Region 213 83 3641
National Level Trainers 23 25 -
Total 1183 290 6555
*District nutrition officers, disease control officer, CHN (Community Health Nurse)/CHO trained on CMAM
provide training to community volunteers
MOH, Ghana
Follow up visit on a SAM child to
prevent defaulting
(Integrated Management of. Neonatal and
Childhood Illness) chart booklet and training
materials. In addition, the WHO pocket booklet
is currently being updated to reflect Ghanaspecific
adaptations and will provide guidance
to clinicians on the management of SAM in the
hospitals.
Competencies for CMAM
In order to integrate and scale-up CMAM in
Ghana, it has been necessary to conduct inservice
training for health care providers to
improve their knowledge and skills in recent
global developments and best practices in the
management of SAM. Since 2008, the SAM SU
and regional SAM STs have spent considerable
time conducting training to build the capacity
of health care providers at the national,
regional, district and facility levels. Training
has also been provided to CHVs on active case
search, follow up and referral of SAM cases. To
date, approximately 1,473 health care providers
and 6,555 CHVs have been trained on the
management of SAM. Table 2 provides details
of health care providers and CHVs trained
since initiation of CMAM in Ghana.
Appetite test being conducted
In addition to in-service training, the SAM
SU and regional SAM STs provide continuous
supportive mentoring and supervision to the
DHMT and facilities implementing CMAM.
Interns from tertiary institutions assigned to the
Nutrition Department and within the implementing
districts receive training and
orientation to provide support in the management
of SAM cases. Medical and Dietetics
students from the University of Ghana on rotation
at Princess Marie Louise (PML) Children’s
Hospital (one of the learning sites) are also
orientated and participate in the management
of SAM.
Access to CMAM services
In 2008, CMAM service provision started in
limited learning sites with one district in each of
two regions, Central and Greater Accra. In 2009,
new learning sites were set up in Ga South
District of Greater Accra region to provide a
learning experience within a peri-urban setting.
Gradual expansion to other facilities within
these districts and expansion to new districts in
2009 increased access to services.
In 2010, the SAM TC and SAM SU initiated
Phase 1 scale up within Central, Northern,
Greater Accra, Upper East and Upper West
Regions (See Table 3). Each region followed the
same process of implementing a limited
number of outpatient and inpatient care sites in
one or two districts, which served as learning
sites, before gradually scaling up to other
districts. Selection of initial districts was based
on prevalence of malnutrition, availability of
staff and geographical accessibility.
CMAM services are provided within existing
MOH/GHS service delivery structures.
Health facilities providing outpatient care
include hospitals, polyclinics, health centres,
community clinics, CHPS and community
outreach points. Inpatient care services are
provided solely in hospitals.
CHVs, Community Health Nurses (CHNs)
and CHOs undertake the community outreach
component of CMAM. Existing volunteers used
for other public health outreach activities, such
as National Immunisation Days (NIDs), vitamin
A supplementation, community
surveillance and guinea worm eradication, are
being used for CMAM community assessment
and mobilisation. This ensures the efficient use
of volunteers and takes advantage of additional
motivation as these volunteers are given an
incentive package to support the NIDs. The
volunteers generally support one community
each, although some support two or three
communities if they are relatively close to each
other.
CHVs screen children at the household level
by measuring Mid Upper Arm Circumference
(MUAC) and checking for oedema. They refer
SAM cases to the nearest health facility. Active
case finding of children with SAM is also
conducted during the child welfare clinics
(usually once per month) and during child
health weeks. In communities where there are
CHPS zones/compounds, the CHVs work in
close collaboration with the CHOs.
Some strong links have been established
between identification of SAM and other public
health programmes. For example, assessment
of MUAC and oedema has been incorporated
into the World Bank supported NMCCSP
(Nutrition and Malaria Control for Child
Survival Project) training modules.
Additionally, the Ghana IMNCI has adopted
the new algorithm, which uses MUAC, bilateral
pitting oedema and appetite test to diagnose
SAM with and without medical complications.
The IMNCI chart booklet and training materials
also provide guidance on how children with
SAM without medical complications should be
managed in outpatient care, and explains how
to refer children with SAM with medical
complications to inpatient facilities.
There is a linkage also between HIV services
and CMAM. Children with SAM who fail to
thrive are referred for further investigation,
which includes HIV testing and counselling
and referral to HIV services if necessary.
MOH, Ghana
Table 3: Summary of health facilities implementing CMAM (as of August 2011)
Region
Total
number of
districts
Number of
districts implementing
CMAM
Total number of
facilities in
implementing
districts
Total number
of outpatient
care facilities
Total number
of hospitals in
implementing
districts
Central 17 7 71 71 9 8
Greater Accra 10 6 62 62 7 4
Northern 20 8 78 78 12 9
Upper West 9 6 119 119 6 4
Upper East 9 4 73 73 3 4
Ashanti* - - - - - 1
Total 65 31 403 403 37 30
* Staff in one hospital in Ashanti (a phase 2 region) was trained because of the high case load.
Total number
of inpatient
care facilities
24