2014 ANNUAL REPORT NATIONAL MALARIA CONTROL PROGRAMME JANUARY 2015 ACRONYMS AND ABBREVIATIONS ACT Artemisinin-Based Combination Therapy ACSM Advocacy Communication and Social Mobilisation ADRs Adverse Drug Reactions AFRO WHO Africa Regional Office AGA Anglogold Ashanti AGAMal Anglogold Ashanti Malaria Control Program Ltd ANC Antenatal Clinic AQ Amodiaquine AS Artesunate AMDP Antimalarial Drug Policy AMFm Affordable Medicines Facility-Malaria AMTs Artemisinin monotherapies ANC Antenatal Care ARI Acute Respiratory Infection AS-AQ Artesunate +Amodiaquine AL Artermether-Lumefantrine CBAs Community-Based Agents CBO Community-Based Organization CCM Country Coordinating Mechanism CD Continuous Distribution CFR Case Fatality Rate CHAG Christian Health Association of Ghana CHIM Centre for Health Information Management CHO Community Health Officer CHPS Community Health Planning Services CFR Case-Fatality Rate 2 CHQ CLU Chloroquine Clinical Lab Unit CMS Central Medical Store DHMT District Health Management Team DDT Dichlorodiphenyltrichloroethane DFID Department for International Development (British) DHAP Dihydroartemisinin Piperaquine DHS Demographic and Health Survey DRGs Diagnosis Related Groups DSS Demographic Surveillance Systems EPA Environmental Protection Agency EPI Expanded Programme on Immunization ETF Early Treatment Failure FDA Food and Drugs AUTHORITY FDC Fixed-Dose Combination FHD Family Health Division FY Fiscal Year GFATM Global Fund to fight AIDs, Tuberculosis and Malaria GF Global Fund GHS Ghana Health Services GNDP Ghana National Drugs Programme GoG Government of Ghana G6PD Glucose-6-Phosphate Dehydrogenase Deficiency GSS Ghana Statistical Service HBC Home-Based Care HH Household HIO Health Information Officer HIS Health Information Systems 3 HIV Human Immunodeficiency Virus HIV/AIDS HMIS Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome Health Management Information Systems HMM Home Management of Malaria IDSR Integrated Disease Surveillance and Response IEC Information, Education and Communication IMCI Integrated Management of Childhood Illnesses IPT Intermittent Preventive Treatment IPTp Intermittent Preventive Treatment for Pregnant Women IPTi Intermittent Preventive Treatment for Infants IRS Indoor Residual Spraying ITN Insecticide-Treated Net LBW Low Birth Weight LCF Late Clinical Failure LLIN Long Lasting Insecticidal Net LPF Late Parasitological Failure MaVCOC Malaria Vector Control Oversight Committee MDGs Millennium Development Goals M&E Monitoring and Evaluation MICS Multiple Indicator Cluster Surveys MIP Malaria in Pregnancy MIS Malaria Indicator Survey MOFEP Ministry of Finance and Economic Planning MoH Ministry of Health MPR Malaria Programme Review NGO Non-Governmental Organization NHIA National Health Insurance Authority NHIF National Health Insurance Fund 4 NHIS National Health Insurance Scheme NMCC National Malaria Communication sub--Committee NMCP National Malaria Control Programme NMIMR Noguchi Memorial Institute for Medical Research OPD Out-Patients Department OIG Office of the Inspector General ORS Oral Rehydration Salt OTC Over-the-counter OTSS Outreach Training and Support Supervision PCR Polymerase Chain Reaction POW Programme of Work PPME Policy Planning Monitoring and Evaluation PR Principal Recipient PSD Procurement and Supply Division PSM Procurement and Supply Management Pf Plasmodium falciparum Pm Plasmodium malariae PMI The U.S. President’s Malaria Initiative Po Plasmodium Ovale PPQ Piperaquine PQ Primaquine PU Procurement Unit P.v Plasmodium vivax PW Pregnant Woman Q Quinine QA Quality Assurance QAACT Quality Assured Artemisinine-Based Combination Therapy 5 QC Quality Control Q+SP Quinine + Sulfadoxine–Pyrimethamine RBM Roll Back Malaria RCC Rolling Continuation Channel RDTs Rapid Diagnostic Tests RMS Regional Medical Store SCMP Supply Chain Master Plan SDP Service Delivery Point SMC Seasonal Malaria Chemoprevention SP Sulfadoxine-Pyrimethamine SWAP Sector – Wide Approach T3 Test Treat and Track TB Tuberculosis TF Total Treatment Failure UC Universal Coverage UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization WHOPES WHO Pesticide Evaluation Scheme 6 ACKNOWLEDGEMENT The National Malaria Control Programme wishes to express its gratitude to the following persons and institutions for their diverse support during the year under review: ADDRO Airtel Ghana. All health workers, public and private, who are working tirelessly to help control malaria in the country Anglogold Ashanti DFID GFATM (The Global Fund to fight HIV/AIDS, TB and Malaria) Humanities International Malaria Care Malaria Consortium, Malaria No More-UK Municipals/Metropolitan/Districts Assemblies, Networks Regional Coordinating Councils, Regional Health Directorates, Roll Back Malaria, The Country Coordinating Mechanism (CCM) UNICEF USAID (PMI, ProMPT, DELIVER, FOCUS & BCS), Vestergaard Frandsen Voices for Malaria free Future, WHO World Bank 7 EXECUTIVE SUMMARY Priority Areas Planned For 2014 The overall goal of the programme, to reduce the malaria morbidity and mortality by 75% (using 2012 as baseline) by the year 2020, continued to be pursued in 2014. The following areas were identified as some of the priorities for the year: Malaria Case Management under which we have Malaria in Pregnancy (MIP), Home Based Care and Diagnostics. The others include Procurement and Supply Management (PSM), and Research, Surveillance, Monitoring and Evaluation (RSM&E). Furthermore, other priority areas for the year 2014 included Advocacy, Communication and Social Mobilization (ACSM); Partnership, Planning and Resource Mobilization; National Policy and Regulatory Preparedness and Administration and Finance under which we have The New Funding Model. Activities carried out by the programme were based on these priority areas. Key Activities Undertaken During the Year 2014 Malaria case management is made up of Diagnosis and Treatment, Malaria in Pregnancy (MIP) and integrated Community Case Management (iCCM). Most of the planned activities under malaria case management were carried out except a few, some of which are the impact study on IPTp and research into reasons for drop-out in the view of increasing IPTp doses from three (3) to five (5), among others. Commodities such as RDTs, SPs, community registers, etc., were distributed under these activities. Categorized under Integrated Vector Control, by the Programme, are Continuous Distribution of LLINs and Continuous Distribution of LLINs. There is also the In-door Residual Spraying (IRS). Under the LLIN distribution are the continuous distribution of bed-nets in Child Welfare Clinics (CWCs) and Ante-Natal Care (ANCs) units of facilities where over 1.1 Million bednets were pushed to facilities, and over most of them were distributed to pregnant women and children under 5 years. There was also the school distribution under which over 1.3 Million bednets were distributed to school children in primaries 2 and 6 though all the ten regions of Ghana. Under the point distribution, over 2.9 Million bednets were distributed to households, using the coupon 8 system, in the Eastern (over 1.3 Million) and Volta regions (over 1.6 Million). There were a series of meetings held by the Malaria Vector Control Coordinating Committee MaVCOC, a multisectoral committee, membership of which comprises Insecticide Regulatory Bodies (FDB, EPA), Research Institutions (NMIMR, GAEC), other agencies (MOFA, MOH), Partners (PMI, WHO), Vector Control Implementing Bodies (AGA, Abt, VCC, Labiofam) and Commercial Partners (Vestergaard Frandsen and recently admitted, Bayer, Zoomlion and Calli Ghana) in the reporting year, among others. Under the New Funding Model, activities were planned including finalizing the Programmatic and Gap Analysis, the National Strategic Plan as well as the M&E Plan. External consultants were also brought in to conduct a joint assessment of the National Strategic Plan (NSP). There was Private Sector Copayment Mechanism (PSCM) under which the Copayment Task Force was formed and Task Force Meetings were also held. First Line Buyer Assessments were undertaken as well as Port of Entry Monitoring and FLB Spot Checks undertaken. A committee was formed to undertake Resource Mobilization, among others. Activities carried out under the Advocacy, Communication and Social Mobilization (ACSM) where the National Communication Strategy Review was initiated. Five strategies were developed for IPTp, Case Management including HBC, LLINs, SMC, and IRS. Bahaviour Change Communication (BCC) activities were carried out during the year as well as a number of materials including data tools, manuals, policy guidelines and other IE&C materials developed, printed and distributed to all regions. Activities were undertaken over the period under RSM&E including finalization of Revised Reporting tools Second Edition of Standard Operating Procedures for Health Information, Data Quality Audit, National Malaria Monitoring and Evaluation Plan 2014-2020 developed, Research Demographic and Health Survey (DHS 2014) participated in and a study on Feasibility and Acceptability of Use of RDTs within the Private Sector in Ghana planned and carried out in collaboration with the Dodowa Health Research Centre. 9 Presented in Table 0.1 below are a summary of some of the achievements chalked in the areas of Malaria Morbidity and Mortality in the Year 2014. Table 1: Malaria Morbidity and Mortality in the Year 2014 PATIENT CATEGORIES NUMBER REPORTED PROPORTION ATTRIBUTABLE TO MALARIA All OPD Cases 27,388,250 30.9% All suspected Malaria Cases 8,453,557 Pregnant Women 224,542 2.7%* Under 5 years 1,331,239 15.7%* All Admissions 1,536,003 27.9% OPD Admissions attributed to malaria. 429,940 ADMISSION Pregnant Women malaria cases 28,864 6.7%* Under 5 years malaria cases 207,913 48.4%* Total deaths 30,439 7.2% All malaria deaths 2,200 Pregnant Women malaria deaths 23 1%* Under 5 years malaria deaths 1,060 48.2%* DEATHS UNDER 5 MALARIA CASE FATALITY RATE 0.51 NB: * proportion of cases to total malaria cases There was a slight reduction in the number of OPD malaria cases put on ACT in 2014, representing a 5% decrease over the 2013 level. About thirty percent of all OPD cases were malaria, 73.5% of all OPD malaria cases were tested before being treated, 27.9% of all admission cases were malaria and about 7.2% of all deaths on admission were from malaria in the year under review. 10 TABLE OF CONTENTS ACRONYMS AND ABBREVIATIONS ..................................................................................... 2 ACKNOWLEDGEMENT ............................................................................................................ 7 EXECUTIVE SUMMARY .......................................................................................................... 8 LIST OF TABLES ...................................................................................................................... 14 LIST OF FIGURES .................................................................................................................... 16 CHAPTER ONE ......................................................................................................................... 17 1.0 INTRODUCTION .............................................................................................................. 17 1.1 PROGRAMME OBJECTIVES......................................................................................... 17 1.2 PRIORITY AREAS PLANNED FOR 2014 ...................................................................... 18 1.2.1 Malaria Case Management ................................................................................................ 18 1.2.2 Procurement and Supply Management (PSM) .................................................................. 19 1.2.3 Research, Surveillance, Monitoring and Evaluation (RSM&E) ........................................ 20 1.2.4 Advocacy, Communication and Social Mobilization (ACSM) ......................................... 20 1.2.5 Partnership, Planning and Resource Mobilization ............................................................. 21 1.2.6 Programme Management ................................................................................................... 21 CHAPTER TWO ........................................................................................................................ 23 2.0 ACTIVITIES UNDERTAKEN IN 2014 .............................................................................. 23 2.1 MALARIA CASE MANAGEMENT ............................................................................. 23 2.1.1 Diagnosis and Treatment ................................................................................................... 23 2.1.2 Malaria in Pregnancy (MIP) .............................................................................................. 24 2.1.3 Integrated Community Case Management/ Home-Based Care ........................................... 28 2.3.2 Integrated Vector Control .................................................................................................. 35 2.4 PARTNERSHIP AND COLLABORATION ................................................................... 43 2.4.1 Introduction ........................................................................................................................ 43 2.4.2 Ghana Private Sector Copayment Mechanism .................................................................. 43 2.4.3 Resource Mobilization ....................................................................................................... 45 2.4.4 Other Activities .................................................................................................................. 46 2.5 INTEGRATED SUPPORT SERVICES ........................................................................... 46 2.5.1 Advocacy, Communication (IE&C and BCC) and Social Mobilization (ACSM) .............. 46 11 BCC Campaign ............................................................................................................................. 47 2.6 RESEARCH, SURVEILLANCE, MONITORING AND EVALUATION (RSM&E) . 52 2.6.1 Routine Monitoring............................................................................................................ 52 2.6.2 Research ............................................................................................................................. 54 CHAPTER THREE .................................................................................................................... 57 3.0 PROGRESS, ACHIEVEMENTS AND CHALLENGES .................................................. 57 3.1 Introduction ........................................................................................................................ 57 3.2 Malaria Case Burden.......................................................................................................... 57 3.3 Intermittent Preventive Treatment in Pregnancy (IPTp) ................................................... 71 3.4 Financial Support .............................................................................................................. 75 3.5 Programme Management .................................................................................................. 77 3.6 Meetings and Conferences ................................................................................................. 79 3.7 Challenges ......................................................................................................................... 80 CHAPTER FOUR....................................................................................................................... 81 CONCLUSION AND THE WAY FORWARD ........................................................................ 81 4.1 SUMMARY OF OBJECTIVES AND KEY OUTCOME................................................................. 81 4.2 THE WAY FORWARD .................................................................................................... 84 4.3 ACTIVITIES PLANNED FOR 2015................................................................................. 85 4.3.1 Administration and Finance ............................................................................................... 85 4.3.2 National Policy and Regulatory Preparedness ................................................................... 85 4.3.3 Partnership, Planning and Resource Mobilization ............................................................. 85 4.3.4 Malaria Case Management ................................................................................................ 85 4.3.5 Malaria in Pregnancy ......................................................................................................... 86 4.3.6 Integrated Community Case Management (iCCM) ........................................................... 86 4.3.7 Diagnostics......................................................................................................................... 86 4.3.8 Vector Control ................................................................................................................... 87 4.3.9 Vector Control Coordinating Meetings ............................................................................. 87 4.3.10 Indoor Residual Spraying .................................................................................................. 87 4.3.11 Procurement and Supply Management (PSM) .................................................................. 88 4.3.12 Research, Surveillance, Monitoring and Evaluation.......................................................... 88 12 4.3.12 Advocacy, Communication And Social Mobilization (ACSM) ........................................ 88 13 LIST OF TABLES Table 1: Malaria Morbidity and Mortality in the Year 2014 ....................................................... 10 Table 2: Summary of Trainings Conducted on Malaria Case Management and Outputs ............ 24 Table 3: Sulphadoxine-Pyrimethamine Supplied and Distributed in 2014 .................................. 25 Table 4: SP Distributed in 2014 .................................................................................................... 25 Table 5: SP Distribution by Region .............................................................................................. 26 Table 6: Planned Activities and Achievements ............................................................................ 26 Table 7: CBAs Trained by Sub-Districts ...................................................................................... 30 Table 8: iCCM Logistics Distributed to Regions ......................................................................... 31 Table 9: Allocation of RDTs to Districts Implementing HBC/iCCM Activities.......................... 32 Table 10: Artesunate Amodiaquine Distributed to Regions for iCCM from Global Fund in 2014 ....................................................................................................................................................... 32 Table 11: Distribution of World Vision Donated ACTs ............................................................... 32 Table 12: Breakdown of 2014 LLINs Distributed through Schools in the Regions ..................... 36 Table 13: Private Sector Copayment Mechanism (PSCM) and Resource Mobilization ............. 45 Table 14: Allocation of Data Tools, IE&C Materials and Policy Guidelines .............................. 49 Table 15: Indicators and Sites Selected for Data Quality Audit. .................................................. 53 Table 16: In-patients Malaria Deaths, 2000-2014 ........................................................................ 68 Table 17: Key Results from Health Facilities and Surveys, 2000-2014 ....................................... 74 Table 18: Funding Sources ........................................................................................................... 75 Table 19: Table Showing Transfer to Purchase Malaria Drugs and Commodities ...................... 75 Table 20: Table Showing NMCP Budget and Expenditure in 2014. All amounts are US$(National level and partners, excluding GoG) ....................................................................... 76 Table 21: International Conferences Attended by Technical Staff in 2014.................................. 79 Table 22: Summary of objectives and key results for 2014.......................................................... 81 14 15 LIST OF FIGURES Figure 1: Nets Distribution in Primary School and Teachers’ Orientation Prior to the Distribution ....................................................................................................................................................... 36 Figure 2: Orientation of Health Workers in the Ashanti Region .................................................. 39 Figure 3: Implementation Guideline Developed and Distribution in Progress at a Static Point .. 40 Figure 4: World Malaria day, April 25th 2014, celebration at Wa, Upper West Region ............. 51 Figure 5: Malaria Cases per 1000 Population, 2010-2014 ........................................................... 58 Figure 6: OPD Malaria Cases from 2010 to 2014 ....................................................................... 59 Figure 7: Number of OPD Malaria Cases in 2014 by Region ...................................................... 60 Figure 8: Proportion of OPD Cases Attributable To Malaria From 2006 To 2014 ...................... 61 Figure 9: Proportion of OPD Cases Attributable to Malaria in 2014 ........................................... 61 Figure 10: Proportion of OPD Malaria Cases Tested, 2010- 2014 ............................................... 62 Figure 11: Proportion of OPD Malaria Cases Tested by Regions, 2011-2014. ............................ 63 Figure 12: Test Positivity Rates for RDT and Microscopy in 2014 ............................................. 64 Figure 13: Malaria Prevalence from 2014 GDHS ........................................................................ 64 Figure 14: Proportion of OPD Malaria Cases Put on ACTs, 2011-2014...................................... 65 Figure 15: Proportion of OPD Malaria Cases Put on ACTs by Regions in 2014 and 2014 ......... 66 Figure 16: Ranked Order of Inpatients Malaria Cases in 2014 by Regions ................................. 67 Figure 17: Inpatient Malaria Deaths, 2010-2014 .......................................................................... 69 Figure 18: Inpatient Malaria Deaths by Region in 2014.............................................................. 70 Figure 19: Case Fatality Rate by Region for 2013 and 2014 ........................................................ 71 Figure 20: Proportion of Pregnant Women who took up IPTp from 2006-2013.......................... 72 Figure 21: IPTp Uptake in 2014 by Pregnant Women ................................................................. 73 Figure 22: NMCP Budget and Expenditure in 2014 ..................................................................... 77 16 CHAPTER ONE 1.0 INTRODUCTION Malaria control in Ghana is a priority development issue as malaria affects all ages and all sectors of the economy, it is therefore integrated at all levels of the health system. It relies on the health sector policy based on the participation and empowerment of the community according to the national health policy. Research data has shown changing malaria epidemiology in the country (MICS, 2011) and this has meant that control efforts are targeted to achieve maximum impact. Again, the need for countries to look inwards for financial, material and human resources in the fight against malaria has meant the reorganization of some management structures to achieve more functional efficiency and effectiveness. This chapter therefore focuses on; National Policy and Regulation, Case Management as a core and priority intervention, Surveillance, Monitoring and evaluation for improved data for decision making, improved and more efficient finance and administration systems and procedures to ensure better accountability and transparency, Partnerships, Planning and Resource Mobilization for financial sustainability and Advocay, Communication and Social Mobilization to create awareness, drive uptake of interventions and to improve implementation outcomes. 1.1 PROGRAMME OBJECTIVES The overall programme goal is to reduce the malaria morbidity and mortality by 75% (using 2012 as baseline) by the year 2020. The specific objectives were to protect at least 80% of the population with effective malaria prevention interventions by 2020, to provide parasitological diagnosis to all suspected malaria cases and provide prompt and effective treatment to 100% of confirmed malaria cases by 2020, to strengthen and maintain the capacity for programme management, partnership and coordination to achieve malaria programmatic objectives at all levels of the health care system by 2020, to strengthen the systems for surveillance and M&E in order to ensure timely availability of quality, consistent and relevant malaria data at all levels by 2020, and to increase awareness and knowledge of the entire population on malaria prevention and control so as to improve uptake and correct use of all interventions by 2020. 17 1.2 PRIORITY AREAS PLANNED FOR 2014 In 2014, Malaria Case Management was prioritized with a focus on universal diagnosis of all cases in all ages before treatment and improving uptake of SP for prevention of malaria in pregnancy to at least three doses and a maximum of five doses (policy is till delivery). Evidence for decision making meant that data collection and analyses was prioritized A good procurement and logistics management ensure malaria product quality and expands access to planned interventions therefore Procurement and Supply Management (PSM) is prioritized at all times Malaria Case Management. Health Facility Case Management (public and private), Malaria in Pregnancy, Home Based Care (now Integrated Community Case Management, iCCM) and Diagnostics are the major areas of focus under case management. 1.2.1 Malaria Case Management Comprising Malaria Case Management are Malaria in Pregnancy, Home Based Care (Integrated Community Case Management, iCCM) and Diagnostics. 1.2.1.1 Facility-based Case Management The planned activities under facility case management included; • Pre-service training for health training institutions • Training of staff of public health facilities • Revision of policy guidelines, charts and Job Aides • Quality Assurance of Diagnostics and treatment • Monitoring and supportive supervision • Collaboration with key Partners such as Quasi Government agencies and Private sector 1.2.1.2 Malaria in Pregnancy (MIP) Activities planned to be covered under Malaria in Pregnancy for 2014 included conducting bottleneck analysis and operations research to identify reasons for drop-out of IPTp and outcome of IPTp, develop strategy to improve uptake of IPT, OTSS on MIP, allocation of SP to regions and conduct pre-service training for health workers. 18 1.2.1.3 Home Based Care Under Home Based Care, activities planned for 2014 included conducting supervisory visits to CDDs by CHOs, conducting quarterly review meeting for CDDs, OTSS for HBC, developing and implementing HBC uptake improvement plan and distribution of HBC logistics. The rest are advocating for funding for ARI, Diarrhoea products and paracetamol, allocating and distributing ACTs for HBC implementation, advocating for financing IE&C activities for HBC, revision of HBC manuals, inventory cards and reporting tools, aligning and coordinating all HBC activities in the country. 1.2.1.1 Diagnosis Activities planned in 2014 for Diagnostics, included conducting RDT training for new health recruits, conducting supervisory visits for laboratories in the 3 highly endemic regions (Northern, Upper East and Upper West), undertaking regional level training for laboratory technicians, reviewing diagnostics policy documents (on RDT and Microscopy), assisting the Clinical Lab Unit (CLU) in updating and providing the lab OTSS and in developing a microscopist PT programme. The rest are conducting lessons learned workshop for regional-level laboratory OTSS supervisors, conducting MDRT TOT for regional -level laboratory OTSS supervisors, redesigning, printing and distributing malaria laboratory registers, obtaining WHO validation of the Ghana National Archives for Malaria Slides (NAMS) and developing a national-level expert microscopist accreditation programme. 1.2.2 Procurement and Supply Management (PSM) Many activities were planned for 2014 under Procurement and Supply Management with the aim of ensuring the regular uninterrupted supply of all malaria commodities. Key among which are tracking Voluntray Pooled Procurement shipments and deliveries as well as providing feedback to storage points, carrying out monitoring and supportive supervision of service delivery points, following up on the implementation of the Supply Chain Master plan and undertaking monitoring visits to the Central Medical Stores and selected Regional Medical Stores to advise on the management of malaria commodities. Others included reviewing reports generated by the Early Warning System and activating response where applicable, coordinating the compilation of consumption data from service providers. 19 1.2.3 Research, Surveillance, Monitoring and Evaluation (RSM&E) Key activities planned for 2014 included finalizing and printing SOPs for data management in all health facilities in the country, conducting data coalition meetings with the private sector, conducting consensus meetings on the harmonized forms from working groups, conducting training sessions on the revised SOP on data verification at the Regional and district level as well as providing orientation for service providers on the harmonized forms. Research Other activities planned for 2014 include Operations Research (IRS+LLINs vrs LLINs comparative study), providing technical support for the Demographic and Health Survey (DHS) and production of periodic reports. Others include repeating the Anaemia & Parasitemia studies in Wa West District (of the Upper West Region), Obuasi (in the Ashanti Region) and Adansi South District (of the Ashanti Region). Furthermore, other activities such as publication of quarterly bulletin, production of half year report and annual reports and completing the research on assessing the feasibility of expanding the use of RDTs within the private sector were also planned for 2014 under the RSM&E. Monitoring and Evaluation Other activities include conducting quarterly data review meetings as well as quarterly regional data quality audits for the regions, rolling out DQAs at district levels, undertaking public and private sector supervisory visits in each of the 10 regions, supporting the hosting of the DHIMS2 server and reporting on the Dashboard for CCM, PUDR for the Global Fund and Situation Room for WHO, among others Others also include conducting stakeholder engagements on the private sector, monitoring antimalarial drug efficacy at 10 sentinel sites around the country (including sentinel sites for Malaria Parasite Testing in additional districts). 1.2.4 Advocacy, Communication and Social Mobilization (ACSM) Among activities planned for ACSM include providing support for NGOs advocacy and sensitizing communities on IPT, launching the AGAMal Documentary on IRS, conducting BCC campaign through the use of posters, TV, radio, community information alerts and all interventions as well as undertaking joint IRS/HBC radio sensitization programs in AGAMal Districts. Others include conducting Malaria Day advocacy which includes the commemoration of the 2014 World Malaria Day, undertaking intensive IE&C to promote compliance, use and improve provider confidence in the use of RDTs (Posters, Radio [Adverts and talk shows], TV, Print media, etc.) 20 and providing support for Product champions to promote the use of RDTs and increase provider confidence in the use of RDTs, printing of harmonized data collection forms for compilation of malaria data from health facilities and printing of revised SOPs and data utilization manual for health facilities. Furthermore, other activities were also planned under ACSM. These included the printing of source documents for data capture; drug analysis book/dispensing tally booklets, CRR, laboratory register, OPD tally book, ANC register, designing, setting up and printing of IPT training manuals, Strategic Plan, and Case Management Manuals and M&E Data tools. Others included developing and printing of laminated job aids on preparation of thick and thin film for laboratories in the country, developing and printing daily malaria laboratory log book for all facilities in the country, developing and printing materials for education on SMC and reviewing of the National Communication Strategy. Finally, the orientation of Health Promotion focal persons printing of RDT policy guidelines, malaria microscopy and RDT job aids and Malaria Microscopy policy guidelines were other activities which were planned for 2014 under ACSM. 1.2.5 Partnership, Planning and Resource Mobilization Activities geared towards forging partnership with NGOs, the private sector, etc., were planned under Partnership, Planning and Resource Mobilization for 2014. These included conducting supervisory visits to the private sector, conducting First Line Buyer Assessments of the private sector, conducting Price & Availability Survey of the private sector and conducting Port of Entry and Cohort Event Monitoring. Also planned for the year under review was the formation of a Copayment Task Force and conducting Copayment Task Force Meetings. An end-of-year review meeting with NGOs was also planned. 1.2.6 Programme Management The key activities planned under Programme Management were the New GF Funding Model, submission of the Concept Note, conducting Financial Monitoring to public facilities, participating in International Conferences and workshops (such as WARN, among others), participating in Coordination meetings ( MIACC, various committees), conducting an End-of-term review meeting at the national level, conducting Regional Malaria Review Meetings. 21 1.2.6.1 The New Funding Model Activities planned under the New Funding Model included finalizing Programmatic and Financial Gap Analysis, the National Strategic Plan (NSP) and Monitoring and Evaluation (M&E) Plan. Completing the New Funding Model Concept Note template, submitting the Concept Note to CCM and following up for its approval and on-ward submission of to the GF and further following up the TRP review of the Concept Not and feedback to country were the other of the key activities of ensuring a successful Concept Note in 2014. 22 CHAPTER TWO 2.0 ACTIVITIES UNDERTAKEN IN 2014 2.1 MALARIA CASE MANAGEMENT Under Malaria Case Management is Diagnosis and Treatment, Malaria in Pregnancy (MIP) and Home Based Care/ Integrated Community Case management 2.1.1 Diagnosis and Treatment The Programme continued to pursue the Test, Treat and Track (T3) strategy to ensure all suspected malaria cases are tested either microscopically or by using Rapid Diagnostic Test (RDT) kits in conformity with WHO’s recommendation to test all malaria cases before treatment. During the year under review, a number of capacity building activities aimed at improving malaria case management for that matter diagnosis were carried out. These included the following: 2.1.1.1 Training of Over the Counter Medicine Sellers (OTCMs) In its bid to expand access to malaria diagnosis and treatment in the private sector (community pharmacies, private facilities) and sensitize health care providers on the adherence to the T3 strategy, the Programme in collaboration with Pharmacy Council with funding from USAID carried out RDT training for 8,920 Over the Counter Medicine Sellers (OTCMs) throughout the country. 2.1.1.2 In-service training of Public Health Workers Other capacity building and sensitization activities aimed at maximizing efforts towards the T3 strategy were held for various categories of health care providers at all levels of health care delivery including, community, district, regional and teaching hospitals. This involved diverse professional categories such as doctors, nurses, pharmacists, Malaria focal Persons, Nurses, Midwives, Medical Doctors, Lab Technicians, Health Information Officers (HIO), Community Health Nurses (CHNs), Pharmacy Technicians, Over the Counter Medicine Sellers (OTMS) and some tutors from Health Training Institutions. In all, a total of 17,733 health care providers were trained.  Training of Tutors of Health Training Institutions 23 Trainings were extended to some health training institutions such as Nurses and Midwifes Training Schools (NMTS) and Medical/Allied Health training institutions where tutors were trained in malaria case management. The process of incorporating the updates on malaria has begun with the Nurses and midwives Council. The table below shows the category of professionals trained in malaria diagnosis and treatment Table 2: Summary of Trainings Conducted on Malaria Case Management and Outputs Training Level Number trained Categories 14 Regional trainings/3 Teaching hospitals 1,176 Pharmacists, Prescribers, Malaria focal Persons, Staff Nurses Regional Symposia(Greater Accra & Ashanti Regions) 518 Medical Doctors District trainings 5237 Prescribers, Pharmacists, Nurses, Midwives, Lab Technicians, HIO, Pharm Technicians Nationwide Training in 10 Regions 1,788 Pharmacists Nationwide Training in 10 Regions 8920 Over the Counter Medicine Sellers (OTMS)Tutors Nurses and Midwives Training Schools/KRTC 94 2.1.2 Malaria in Pregnancy (MIP) Pregnant women by virtue of their physiological status remain one of the most vulnerable groups to malaria. Malaria has a debilitating effect on pregnancy and birth outcomes. The National Malaria Control Programme therefore considers malaria in pregnancy as priority. During the year, a total of 19,873,570 tablets of SP were procured (tables 2.2&2.3) and a total of 2,301,000 tablets distributed to the 10 regions and 3Teaching Hospitals, namely, Korle Bu, Komfo Anokye and Tamale Teaching hospitals as in the table below: 24 Table 3: Sulphadoxine-Pyrimethamine Supplied and Distributed in 2014 Date Organisation Received from Quantity Received 1 16/01/2014 Ernest Chemist 522,900 2 20/02/2014 Remedica 1,800,000 3 10/03/2014 Remedica 4 03/04/2014 5 Table 4: SP Distributed in 2014 1st Actual Region Allocation 2nd Actual Allocation Total Western 50,250 171,330 221,580 Central 46,650 158,610 205,260 GAR 77,625 281,130 358,755 2,131,200 Volta 44,850 152,520 197,370 Ernest Chemist 161,400 Eastern 55,800 190,110 245,910 03/04/2014 Remedica 570,660 Ashanti 98,250 333,360 431,610 6 08/05/2014 Ernest Chemist 308,700 BAR 48,900 166,590 215,490 7 14/05/2014 Ernest Chemist 214,200 Northern 50,475 177,480 227,955 8 09/06/2014 Ernest Chemist 1,600,200 Upper East 22,050 74,280 96,330 9 30/06/2014 Guilin Pharma 2,700,000 Upper West 14,850 49,140 63,990 10 14/08/2014 Remedica 2,764,320 Armed Forces 5,250 9,990 15,240 11 14/08/2014 Remedica 3,927,000 KBTH 3,000 4,980 7,980 12 27/08/2014 Ernest Chemist 413,700 KATH 4,050 6,000 10,050 13 17/11/2014 Remedica 2,764,290 TTH 0 3,480 3,480 TOTAL 522,000 1,779,000 2,301,000 TOTAL 19,878,570 25 Table 5: SP Distribution by Region QUANTITY DISTRIBUTED Western 221,580 Central 205,260 GAR 358,755 Volta 197,370 Eastern 245,910 Ashanti 431,610 BAR 215,490 Northern 227,955 Upper East 96,330 Upper West 63,990 Armed Forces 15,240 KBTH 7,980 KATH 10,050 TTH 3,480 TOTALS 2,301,000 *Total quantity of SP procured in 2014 was 19,878,570 REGIONS/INSTITUTIONS Table 6: Planned Activities and Achievements Planned Activities Number Number Comments planned carried out Carry out impact study on IPTp 1 0 Funds not available Research to determine reasons for drop out in the view of increasing IPTp doses to 5 1 0 Funds not available. Objective will be integrated into the Impact Study in 2015 MiP working group meetings 4 3/4 Funds are not available Review of Malaria in Pregnancy Guidelines 1 1 Guidelines completed and ready for printing Malaria in Pregnancy Working Group (RBM) International Working Group on Malaria in Pregnancy (MIP) initiative of Roll Back Malaria (RBM) initiative with Headquarters in Geneva was held in Ghana from the 15th-17th July 2014 and 26 Ghana gave a presentation on: “Collaboration between Reproductive Health and Malaria Control to Improve Outcomes for MIP”. In the presentation it was indicated that the incidence of deaths from Malaria in Pregnancy has reduced. However, routine data indicated that not much change has been seen in the rate of low birth weights (LBWs) in babies and anaemia levels in pregnant women. JHPIEGO with input from National Malaria Control Programme (NMCP) also gave a presentation during the meeting on “Linking Communities with Health Facilities to Improve MIP Coverages under CHPS” in their STARCHiP Programme in the Western Region. In the presentation they indicated that the use of CHNs in hard to reach areas have improved and this to some extent has improved coverage of IPTp. Activities of Ghana’s Malaria in Pregnancy Working Group During the year under review, three (3) meetings were held by the local Malaria in Pregnancy Working Group. The group met to review and finalize the MIP Guidelines and other document and tools. Changes in the Guidelines included: Increasing IPTp dosing based on WHO recommendations from 3 to 7 doses to be taken monthly from 16 weeks till delivery from the initial 5 Ghana had agreed. This change became necessary after deliberations from the MIP working groups; both international and local. The artwork is about completed, however funds for printing were not available and therefore document was not printed. Maternal Health Record and all relevant docs and registers have also created spaces up to 5+doses CHALLENGES Supply chain issues: Although SP was available and distributed, most districts were not collecting the drugs from the regions due to lack of logistics such as fuel. Districts/ regions also indicated that they had not been made aware of the availability of SP. Lack of Dissemination of New Guidelines: 27 Health workers have been trained on the new guidelines but information of the change from 3 doses to 5 and then to 7 has not been adequately disseminated because the revised Malaria in Pregnancy Guidelines could not be printed. The lesson learnt was that when drugs have been out of stock for some time and there is a restoration of supply, an intensive awareness campaign has to be carried out because health workers continue to believe that the drugs are unavailable. 2.1.3 Integrated Community Case Management/ Home-Based Care Target for 2014 Number of uncomplicated malaria cases among under 5 years children treated with ACT by community based agents (CBAs): 129,179 Actual Attained: 105,631 Aligning all Regions/ Stakeholders Involved in HBC/iCCM The programme realized that a number of organisations were implementing one form of iCCM in parts of the country and decided to put measures in place to aligning all of them interventions across the country. A good number of them have been contacted and are part of the iCCM coordinating committee except for Millenium Village Project (MVP) SADA region. There is also increased collaboration and better alignment of between UNICEF-supported regions and other regions. However data generated by these other stakeholders is not put on the DHIMS2 platform. Some of these stakeholders are as follows: • Ghana Community Health Worker (CHW) Programme • Plan Ghana • Millennium Village Project (Bonsaaso and SADA in Builsa) • UNICEF • STARCHiP Programme of JHPIEGO With respect to data generated from UNICEF-supported regions, in exception of Northern region, Upper West and East have been submitting data. 28 A good number of stakeholders implementing some form of iCCM are represented on the committee. These are: Starchip (JHPIEGO), PPME, 1 Million CHW Programme, Plan Ghana, Millennium Village Project (Bonsaaso) and UNICEF. Attempts has been made to engage the Milleennium Village Project (SADA in Builsa) but this has not been successful. Other organisations working under President’s Malaria Initiative (PMI) USAID work with the NMCP to implement their activities. International Meeting on iCCM An international meeting on iCCM was held in Ghana 3rd-6th March 2014. Over 300 persons were present from all over the world and different organisations. Main issues discussed included the following: – iCCM across the world includes different package of services – Calibre of staff rendering iCCM services differed across countries with some countries using the equivalent of Community Health Nurses for implementing the intervention. – Some countries paid staff to implement the intervention while others made use of volunteers. It seemed that countries were using paid staff were doing better – Innovation in the implementation such as the use of mobile technology for generating and transmitting data – Demand creation (using BCC activities mainly) – Acceptance of incorporation of iCCM activities into GF support A road map of activities was drawn at the conference with one of the activities being the invitation of a consultant to give Technical Assistance in the costing of iCCM intervention. The costed intervention was incorporated into the Concept Note that was developed. This was carried out between the months of May and June 2014. The consultant returned during the Concept Note development to ensure that the intervention was adequately incorporated. Refresher Training Programme During the year under review, Guidelines, Manual and tools were revised. There was therefore the need to carry out refresher trainings beginning from the national level. A National facilitators’ workshop was therefore held in Dodowa to: – Make inputs on the Implementation guidelines and manual and also 29 – Revise and standardise presentations, incorporating the new information This was followed by a National training of trainers’ workshop in Kumasi from the 20-22 May, 2014. In all 65 persons were trained. This time about 6 persons per region were invited and included the regional malaria focal persons, the CHPS coordinator, deputy director, clinical care, deputy director, public health, regional nutrition officer, regional officer in charge of Reproductive Health. This training has yielded a team-building spirit; especially with the involvement of the CHPS coordinator. This is because it was emphasised at the meeting that iCCM is under CHPS and therefore the CHO has oversight responsibility. Regional trainings have also been held in 6 regions with support from MalariaCare and ADDRO (for Upper East). These regions are: Upper East, Upper West, Brong Ahafo, Ashanti, Volta and Eastern Regions. Some district CBA trainings have also been carried out. These are in Ashanti and Eastern Regions (8 in Ashanti and 7 in Eastern) ADDRO has also carried out refresher trainings in Upper East and in some sub-districts in districts across the country as shown in the table below: Table 7: CBAs Trained by Sub-Districts # of # CHV/ Communities CBA Region District Sub-district Upper East Bawku West Sapeliga 29 58 Upper East Builsa North Chuchuliga 18 36 Northern Karaga Zandua 26 50 Ashanti Bosome Freho Nsuaem 12 24 Western Sefwi-Wiawso Anyabirim 25 50 Eastern Akwapim South Pakro 19 38 Upper West Nadowli Nanville 12 24 141 280 TOTAL 30 Other regional/ district level trainings will be held in the year 2015 with the support of organizations such as Systems for Health; who have jurisdiction over Northern, Western, Greater Accra and Central Regions. LOGISTICS/DRUGS DISTRIBUTED FOR ICCM IN 2014 Table 8: iCCM Logistics Distributed to Regions ITEMS COMMUNITY REGISTER COUNSELING CARD CHO SUMMARY FORM DVD(IMCI) FACILITATORS GUIDE IMPLEMENTATIO N GUIDE W GA BA UE UW TOTA VR AR R ER CR R R NR R R L 20 45 25 15 20 0 0 250 0 0 100 350 0 150 150 2,250 10 10 10 10 0 0 100 0 0 100 100 50 50 50 950 10 20 10 10 0 0 100 0 0 100 100 50 50 50 950 5 10 10 5 5 - 10 10 10 - - 30 20 10 5 10 5 5 5 10 31 65 30 10 10 5 5 5 105 Table 9: Allocation of RDTs to Districts Implementing HBC/iCCM Activities World Vision International donated ArtesunateRegions Total Test Kits Allocated to Region Cartons of 800 pieces 46,400 65,600 62,400 52,800 52,800 56,000 8,800 34,400 40,000 80,800 500,000 58 82 78 66 66 70 11 43 50 101 625 Amodiaquine tablets 3+3 and 6+6 to the NMCP. This was used given to regions, which had relatively high uptake with respect to iCCM. Central Ashanti Eastern Brong Ahafo Western Volta Greater Accra Upper West Upper East Northern Total Below is a table of beneficiary regions/ districts: Table 11: Distribution of World Vision Donated ACTs Table 10: Artesunate Amodiaquine Distributed to Regions for iCCM from Global Fund in 2014 REGION ART.AMOD. TABLET ART.AMOD. TABLET (25/75mg) (50/135mg) under one yr 1-5yrs (Sanofi Aventis) (Sanofi Aventis) DISTRICTS Ashanti Eastern BAR Western Volta GAR UWR UER 22 20 19 18 18 3 10 13 42,000 32,000 38,000 28,000 30,000 6,000 20,000 26,000 136,500 104,000 123,500 91,000 97,500 19,500 65,000 84,500 Northern 26 26,000 169,000 Central TOTAL 7 149 14,000 262,000 45,500 936,000 32 Strengthening the CHPS Concept As part of the Director-General’s vision to consolidate community level activities under CHPS, attempts have been made to strengthen CHPS including their supervisory work in iCCM. Some of these activities include:  Developing a curriculum for CHO/CHNs: A preliminary draft of the curriculum was put together in August 2014 and stakeholders from Human Resource Division of Ghana Health Service, Family Health Division and Nurses and Midwives Council participated in the workshop.  Internship for CHNs/CHOs: CHNs/CHOs were given one week Internship to build their capacity for all their roles (including their supervisory role in iCCM). The internship program was useful in improving their skills however participants complained that the duration was limited and so could not complete the iCCM fieldwork. CBA Onsite Training Supportive Supervision The iCCM intervention has been fraught with a number of challenges; one of which is the weak supervision at all levels. It was therefore thought that an OTSS exercise carried out on CBA would improve output and quality of work. An OTSS tool was therefore developed using available supervision checklists. This tool was piloted in five (5) districts in the Ashanti Region. The tool was found to be: • Easy to administer • Acceptable by both CBAs and CHOs • Helpful CBAs to recap of what was learnt in the trainings Findings from OTSS indicated that: • CBAs doing well in assessing children • Some CBAs concentrate only on fever and do not assess for ARI and diarrhoea • RDT: It was difficult for some CBAs to pick blood sample using the pippette • CBAs have difficulty in assessing respiratory rate • Handwashing: CBAs were also not washing their hands before seeing to a patient 33 • Verbal referral was a common practice and CBAs were not using the referral form because health workers at facilities disregarded them. • Some CBAs prescribed amoxyl, ORS and Zinc • Concerns of treating older children: some CBAs were treating older children cases above them • Record keeping was a challenge. CBAs were giving medication without recording. Registers had not been filled • Pregnant women and neonatal care assessment: CBAs have not been trained • Trained and untrained CBAs in the districts were found in the districts because of the high attrition rate CHOs also expressed concern about the need for motorbikes to carry out a successful OTSS exercise. CHALLENGES Challenges faced under the integrated Community Case Management include • Supply chain challenges: drugs/logistics are allocated but regions delay in collecting them from the national level. When eventually the logistics arrive at the regional the districts also do not go and pick sometimes because they have not been made aware of the availability of stocks. • Inability to meet targets in terms of number of persons treated in the community – One of the reasons is that many stakeholders are generating data but this is not being reported on the DHIMS2 platform • Continued lack of ARI and diarrhoea products; which affects the whole intervention implementation • Dichotomy in leadership because allocation of drugs has to be divided (ACTs signed by NMCP and ARI and diarrhoea drugs sent for signing at Family Health Division(FHD) and it takes months to get the letter to be signed) 34 2.3.1.4 Seasonal Malaria Chemoprevention (SMC) Participated in training of regional and districts SMC facilitators training in Wa in the Upper West Region which took place on the 4th of June 2014. A total of 74 regional and districts health staff were trained. Facilitators included the Regional Deputy Director of Public Health, Dr. Kofi Issah, a regional Deliver rep and 4 others from the NMCP. A pretest was conducted to assess knowledge on SMC before presentations were made. Pharmacist Dan Ekwan from Nawdoli District moderated the training. Presentation made comprised SMC Implementation Process, Pharmacovigilance, Logistics Management, Communication (BCC/Social Mobilization) and data/monitoring forms. 2.3.2 Integrated Vector Control Considered under Vector Control are the point and continuous Distribution of LLINs and In-Door Residual Spraying (IRS). 2.3.2.1 Continuous Distribution (CD) of LLINs The Universal Coverage of LLIN distribution was adopted by Ghana in 2009 and the country embarked on a nationwide door-to-door LLINs mass distribution and hang- up campaigns from 2010 to 2012. The mass campaigns as a catch up strategy was aimed at making up for the low LLINs access in the household to reach Universal Coverage. The country’s definition of the Universal Coverage was one LLIN to 2 people in the household. Three main channels were adopted by the country through a computer generated model to distribute LLINs free to various population groups to make sure Universal Coverage reached was maintained and sustained. The channels adopted are the Ante Natal Clinic (ANC) to pregnant women attending ANC for the first time (Registrants), the Child Welfare Clinics (CWC) to children 18 months to 36 months due for measles booster and Primary Schools to pupils in primaries 2 and 6. 2.3.2.2 Basic Schools based Continuous Distribution The 2014 nationwide school distribution of LLINs to both the public and private schools was conducted from the 24th of March to April 4th before schools went on their terminal holidays and 35 before the rains. This activity was led by NetWorks Ghana, a USAID funded project in close collaboration with the NMCP and closely implemented it with the School Health Education Program (SHEP) unit of the Ghana Education Service (GES). About one million four hundred pieces of LLINs were distributed to pupils in primaries two (2) and six (6) in all public and private schools in all the ten regions; and pupils were educated on the use and care of the nets before the distribution. A total of 1,500 circuit supervisors (CS) and D-SHEP coordinators were trained in the 10 regions prior to the distribution. Figure 1: Nets Distribution in Primary School and Teachers’ Orientation Prior to the Distribution Over twenty one thousand public and private primary schools were reached. Table 1 gives the breakdown of nets distributed to the regions. Table 12: Breakdown of 2014 LLINs Distributed through Schools in the Regions Region Ashanti Brong Ahafo Central Eastern Greater Accra Northern Upper East No. of Circuits in District 220 163 122 180 118 182 87 36 Total no. of Primary SCHs 4,050 2,239 2,212 2,200 2,496 2,254 846 LLIN Distributed 253,215 143,532 135,609 139529 153,373 160,183 72,918 Upper West Volta Western Grand Total 70 153 129 1,424 560 1,918 2,271 21,046 49,805 112,979 152,525 1,373,670 As part of pre-distribution activities planning meetings were organized for each region’s District Directors of Education, SHEP Coordinators and the Regional Education Officers. The participants were taken through the school based LLIN distribution mechanism which forms an integral part of the National Continuous Distribution strategy. A one day training of trainers’ (TOT) workshops were organized for all District SHEP coordinators and all the Circuit Supervisors to equip them with the needed knowledge on the school based LLIN distribution. The trainees were also taken through the various levels of record keeping and the tools to be used. The Circuit Supervisors trained were charged with the responsibility of organizing circuit level orientations for primary school head teachers and school based SHEP coordinators in their individual circuits. The school head teachers and the school based SHEP coordinators briefed teachers in their various schools especially the primaries 2 and 6 teachers on malaria and the modalities of the school based LLIN distribution. The class teachers in turn educated the primaries 2 and 6 pupils before nets were given to them on the effects of malaria on their performance and health; and also educated them on the use of LLINs in the prevention of malaria, how to hang the LLINs in their homes and how to take very good care of their LLINs to obtain the full benefit of them. There was active monitoring during the distribution and recommendations made included intensification of messages on the nets use and care to the pupils, appeal to partners to give more nets to also give to all teachers and involvement of PTAs in advocacy. It was also noted that the embossment of the telephone numbers of NMCP on the net packaging helped in curbing the sale of nets to pupils as pupils, siblings and parents called the office to report such activities. Presentation of Jerseys to Primary Schools 37 The National Malaria Control Programme was represented by Aba Baffoe-Wilmot at a ceremony at the Sege cluster of schools in the Greater Accra Region on the 22nd of May 2014 where sets of soccer jerseys were presented to schools from Akplabanya and Goi in the Ada West District. An address was made on behalf of the programme at the ceremony. Receiving the jerseys from the Deputy Mission Director of USAID was the Deputy Director General of the Ghana Education Service (GES). USAID NetWorks Ghana Project formally presented the jerseys to GES to acknowledge and reward the effort of deserving schools that engaged and educated their communities through various art forms including drama and songs to ‘Drive Malaria Away for Good Life’. Two schools in each circuit across the country that excelled in the exercise would each receive a set of soccer jerseys. 2.3.2.3 Health Facility based Continuous Distribution Onsite orientation for the implementation of Health Facility (HF) LLINs distribution took place in the remaining five regions, namely Upper West, Ashanti, Brong Ahafo, Northern and the Greater Accra regions from January to June 2014. Health workers at ANCs and the CWCs were taken through the documentation using documentation guide lines made available to them. Service providers were made to bring out their registers, books and forms used for documentation and physically pointed out to them where they are to fill in the information on LLINs to be given out. They were also taken through messages to be given to their clients on nets. All health facilities in the country implemented the health facility distribution of LLINs to clients who qualified to receive. The initial 5 regions (Eastern, Volta, Central, Western and Upper East) which started implementation in 2013 should have pulled their nets during the early part of the year but could no. Therefore about 1,155,100 nets were pushed to all regions again during the latter part of 2014 for the HF distribution. 38 Figure 2: Orientation of Health Workers in the Ashanti Region 2.3.2.4 POINT DISTRIBUTION CAMPAIGNS The Ministry of Health through National Malaria Control Programme/Ghana Health service and partnering organizations, organized mass LLIN Point Distribution campaigns in Eastern and Volta regions in November 2014 where a total of 2,991,281 nets (VR=1,373,993 & ER=1,617,288) were distributed. Issuance of coupons to households which had been used to redeem nets on the day of distribution at static points took place before the distribution exercise. This followed the 2010 to 2012 door-to-door distribution and hang-up campaign where over 12 million nets were distributed and hanged and through which the country attained the Universal Coverage. The point distribution was a replacement campaign to sustain and maintain the coverage achieved. Partners which supported NMCP/GHS in the 2014 point distribution campaigns were Nets for Life/ADDRO which supported with printing of coupons and monitoring; PMI-DELIVER which supported with vehicles and personnel for monitoring and JHU-ESMI supported with technical support plus monitoring. Post distribution validation took place in the two regions in December 2014 and analysis is in progress. 39 Figure 3: Implementation Guideline Developed and Distribution in Progress at a Static Point 2.3.2.5 MaVCOC Meetings and Insecticide Resistance Monitoring MaVCOC a multi-sectoral committee, membership of which comprises Insecticide Regulatory Bodies (FDB, EPA), Research Institutions (NMIMR, GAEC), other agencies (MOFA, MOH), Partners (PMI, WHO), Vector Control Implementing Bodies (AGA, Abt, VCC, Labiofam) and Commercial Partners (Vestergaard Frandsen and recently admitted, Bayer, Zoomlion and Calli Ghana) held its four meetings in March, July, August and December during the year. MaVCOC also held a special meeting with Inesfly Company Ltd to discuss its insecticidal paint as one of its insecticide resistance monitoring activities. Monitoring took place in the 20 insecticide resistance monitoring sites by National Insecticide Resistance Monitoring Partnership (NIRMOP) secretariat. Thirteen out of the 20 sites were found to be doing well with special commendation to personnel manning the sites at Upper West, Western and the Greater Accra regions. A number implementation challenges including fuel cost, availability of rooms at districts to operate, inadequate support from Regional Directors, health workers expectation of higher remuneration, unavailability of larvae for tests, attrition of health personnel managing sites, lackadaisical attitude of health workers and delay in reporting were observed. 40 Partners Vector Control activities Vector Control activities were undertaken in 2014 by PMI/ABT, Anglogold Ashanti Malaria Control Programme, Labiofam and ESMI. Indoor Residual Spraying were undertaken in 4 districts in the Northern region by PMI/ABT and 15 districts in Ashanti, Upper East, Northern, Western and Central regions by AGAMal. A total of 1,702,638 structures were sprayed between the two institutions with a population coverage of 97% and structural coverage of 93% and 83.8% for AGAMal and PMI/ABT respectively. PMI/ABT undertook capacity building for 153, 106 and 16 in IRS operation, M&E and Applied Entomology respectively. Entomological studies to access different parameters like species composition, distribution, biting rate, parity, indoor resting density, susceptibility test and decay rate among others have been accessed by the two institutions. Workshop was conducted for some NMCP staff by PMI/ABT to take them through IRS tools used over the years with the intention of eventually handing them over to the NMCP. A desk was established at the Ministry of Health for Labiofam for larval source management. Larviciding continued in the capitals towns of Greater Accra, Ashanti and the Brong Ahafo regions. M&E staff at NMCP met with the Epidemiologist of Labiofam on how to conform to data collected by the institution. ESMI’s private sector involvement in LLINs distribution was held back due to fraud detected in an East African country also being supported by DFID. 2.3.2.6 Dissemination Meetings ESMI Stakeholders Workshop E-Enhanced Social Marketing Initiative project (ESMI) Demand and Communication workshop for stakeholders and supported by John Hopkins Center for Communication/MEDA/ Malaria Consortium/DFID was held on the 18 and 19th of June 2014 at the Airport Wes Hotel. In attendance were a number of communication agencies in Accra, agents of net manufacturers, NMCP and Health Promotion Department personnel and Ghana Education Service officers. Stakeholders were taken through what ESMI is and where it is coming from i.e. from the e-coupon pilot. Participants made gainful inputs into demand and communication strategy needed for success of the project. 41 LLINs Continuous Distribution End Line Survey Meeting on the Eastern Region LLINs CD pilot dissemination was held at the Alisa Hotel on the 27/06/14 with very revealing findings; also presented at the meeting were findings of the e-coupon pilot at Koforidua also in the Eastern Region and outdoor sleeping in two communities in the northern regions. 2.3.8.1 The New Funding Model Activities planned under the New Funding Model included finalizing Programmatic and Financial Gap Analysis and finalizing the development of the National Strategic Plan (NSP) and Monitoring and Evaluation (M&E) costed plan as well as joint assessment of the National Strategic Plan (NSP) by external consultants. 42 2.4 PARTNERSHIP AND COLLABORATION 2.4.1 Introduction The NMCP works in partnership and in collaboration with local and international private organisations as well as Non-Governmental Organizations and this continued in the year under review. In the year under review, the Private Sector Copayment Mechanism (PSCM) of the Programme undertook activities under two main themes. These are Private Sector Copayment Mechanism under which the Copayment Task Force was formed and Task Force Meetings were also held. First Line Buyer Assessments were undertaken as well as Port of Entry Monitoring and FLB Spot Checks undertaken. 2.4.2 Ghana Private Sector Copayment Mechanism The year 2014 marked the beginning of the implementation of the Private Sector Copayment Mechanism (PSCM). This replaced the Affordable Medicines Facility for Malaria (AMFm) Initiative which was implemented from 2010-2013. It had three core elements which was similar to that of AMFm: 1) Price negotiations 2) Subsidy provided directly to manufacturers 3) Supporting interventions PSCM implementation required the setting up of a Copayment Mechanism Task force and the public advertisement, evaluation and selection of private sector ACT importers as First Line Buyers (FLBs). The Global Fund issued an Operational Policy Note (OPN) to guide the process of the implementation of the PSCM to participating countries on 16th January 2014 and on the 19th of February the PSCM Task Force was inaugurated. The Task Force was established to advice the MOH/NMCP in the implementation of the PSCM and to lead the process for the transparent advertisement for and selection of FLBs. 43 The Task force was constituted by the CCM and mandated to work closely with the NMCP. Specifically; The Task Force was given the responsibility to advice and support the MOH/GHS/NMCP on critical strategic and policy matters related to the PSCM and in arriving at implementation strategies that will help to achieve the objectives of the PSCM. The Task Force reports directly to the CCM and consults with other committees as appropriate in developing its recommendations and advice to the MOH/GHS/NMCP. . Advertisement, Assessment and Slection of First Line Buyers: The Ghana Health Service procurement unit led the advertisement and evaluation process for the FLBs. Advertisements to solicit applications were placed in March and extended in April 2014 in the Daily Graphic and Ghanaian Times. Twenty One (21) firms applied and after the evaluation fifteen (15) were successful. These successful firms were officially informed by the Ministry of Health. Port of Entry Monitoring: The NMCP with support from partners; Food and Drugs Authority and Pharmacy Council, GHS PPME conducted Port of Entry monitoring of green leaf ACTs to ascertain whether they were being smuggled out of the country in order to develop mechanisms to check such leakage. However, the monitoring at all sites showed that medicines in general and ACTs are not moving across the borders at least not though the official ports of entry and return. The ports monitored were: Aflao, Elubo and Paga It was difficult to determine if diversion could have been through any of the many unofficial routes Again, the NMCP in collaboration with the FDA developed a tool and used it to conduct Spot Checks on the warehouses of all FLBs. To ascertain: • Warehouse conditions of storage of ACTs as a quality assurance measure • Most Warehouses were satisfactory • Required improvements communicated to FLBs 44 The Pharmacy Council on behalf of the GHS/ NMCP conducted a Price and Availability Survey in September-October 2014. Three Price and Availability surveys were planned for the year under review, one for each quarter beginning from the second quarter to the last. However, only one was conducted because of reprogramming of funds. Results showed that in most outlets the prices though have increased from GH¢ 1.50p they are still approximately equivalent to US$1. • That is approximately GH¢3.50 & 4.00 • There were a few that had prices as high as GH¢ 6.00 • Approximately eleven million (11,000,000) treatments were approved and delivered in country under the PSCM in 2014. DFID provided malaria Rapid Diagnostic Test kits for deployment in the private health sector. The NMCP then collaborated with USAID –SHOPS Project to review the training Manual for Over the Counter Medicines Sellers – OTCMS (formerly Licensed Chemical Sellers). Subsequently the OTCMS were trained (9000) in how to conduct the malaria rapid diagnostic test in their shops/outlets and supplied with RDTs provided by DFID. A monitoring system including a monitoring form was developed by the partners in order to keep track of the RDTs and their use in these private retail outlets. 2.4.3 Resource Mobilization A Resource Mobilization and Financial Sustainability sub Committee was inaugurated in September 2014. The Committee met more than three times after inauguration because of the urgency of the activities they had to perform. The sub Committee worked with the NMCP and other partners with support from DFID to develop a draft Resource Mobilization and Financial Sustainability Plan. The draft Plan is yet to go through review and printing. Table 3.1 below shows the proportion of activities that were undertaken as against those earmarked for the year under review: Table 13: Private Sector Copayment Mechanism (PSCM) and Resource Mobilization PSCM ACTIVITY EXPECTED 45 ACHIEVED Formation of Task Force 1/1 1/1 Task Force Meetings 4/4 2/4 First Line Buyer Assessments 1/1 1/1 Port of Entry Monitoring 1/1 1/1 Operational Research 2/2 2/2 Price and Availability 3/4 1/4 RESOURCE MOBILIZATION ACTIVITY EXPECTED ACHIEVED RM Sub Committee Meetings 3/4 3/4 RM Plan Drafting Workshop 1/1 1/1 Epi Profile/Knowledge Gaps Workshop 1/1 1/1 2.4.4 Other Activities Among other activities undertaken under the PSCM were the review of Over the Counter Medicine Sellers Manual, national training of more than 9000 OTCMS on RDTs held, RDTs deployed in OTCMS shops, Epidemiological Profile and subsequent knowledge Gaps workshop held, support given to Marketing Activities, among others. 2.5 INTEGRATED SUPPORT SERVICES 2.5.1 Advocacy, Communication (IE&C and BCC) and Social Mobilization (ACSM) Behaviour Change Communication and Advocacy in Ghana is implemented in line with the National Malaria Strategic Plan and National communication strategy. Communication plays a vital role in changing/improving knowledge, creating positive attitudes and improving practice of desired health behaviours. The focus of ACSM for malaria prevention and treatment is to ensure correct and consistent use of LLINs; appropriate treatment seeking behavior for malaria; compliance with the correct treatment regimen as enshrined in the Strategic Plan; improving community participation in indoor residual spraying (IRS) campaigns; and encouraging pregnant women to seek antenatal clinic services and comply with national recommendations for treatment of malaria in pregnancy. 46 The following were activities implemented in line with the national objectives: 1. National Communication Strategy Review The national communication strategy is in the process of being reviewed. Following the various policy recommendations by WHO, the strategy is being revised to reflect the new and current policies as reflected in the revised National Strategic Plan. A stakeholder’s workshop was held from 7th to 12th of April, 2014 to review the strategy. Five strategies have been developed for IPTp, Case Management including HBC, LLINs, SMC, and IRS. Strategies for Malaria Vaccines and Environmental Management are yet to be developed. A consultant has been engaged to write out the strategies. 2.5.1.1 BCC/IEC BCC Campaign Bahaviour Change Communication (BCC) activities carried out during the year included - television advertising which focused on Test, Treat and Track (T3) and was aired on 5 selected stations in English Language. In all a total of 402 spots were aired. - radio commercial focusing on malaria confirmation and treatment with Treatment completion and compliance. This was placed on 18 selected radio stations across the country in English and 7 other local languages. A total of 23,967 spots were aired. 47 2.5.1.2 IE&C 1. Development and Printing of Materials During the year under review, a number of materials including data tools, manuals, policy guidelines and other IE&C materials were developed, printed and distributed to all regions. Below were the materials: Manuals and Data Tools              ACT data tools-6,000 Guideline for malaria case Management-10,000 Anti-malarials Drug Policy-7,000 ANC Register - 6,000 Midwife Form A-6,000 Monthly morbidity returns Form6,000 Monthly morbidity tally form-10,000 IRS SOPs- 300 IMCI Flow chart poster-12,000 Case Management flow chart-20,000 Implementation Guidelines for LLIN point Distribution -300 Coupons for point Distribution (Eastern and Volta)-32,000 2015 Calendar -5000 T-Shrirts   48 SMC Tshirts-5,000 2014 WMD Tshirts-3,500 Table 14: Allocation of Data Tools, IE&C Materials and Policy Guidelines ALLOCATION OF MALARIA MATERILAS AND GUIDELINES Monthly Monthly Flow Chart OPD IMCI OPD Medical for malaria Morbidity OPD Management morbidity Lab diagnosis returns Register Guideline returns Register &Treatment Tally form sheet 2800 1200 700 1350 500 1000 ANC Register Monthly Midwife Return ( Form A) Total per Region 750 750 10750 NO REGION Guideline for case mgt of malaria 1 ASH 1700 2 BA 800 1500 1300 650 1100 350 800 650 650 7800 3 CR 700 1200 1000 500 900 250 700 500 500 6250 4 ER 1500 3000 1800 800 1400 300 1100 800 800 11500 5 GAR 1500 2500 800 800 1250 500 950 700 700 9700 6 NR 700 1500 1500 500 900 200 700 500 500 7000 7 UE 650 1200 1000 400 750 200 650 400 400 5650 8 UW 500 1000 900 350 550 150 500 350 350 4650 9 VR 800 1500 1200 650 900 300 800 650 650 7450 10 WR NMCP / Partners / NGOs TOTAL 800 1500 1200 650 900 250 800 700 700 7500 350 2300 100 0 0 0 0 0 0 2750 10000 20000 12000 6000 10000 3000 8000 6000 6000 81000 11 49 2.5.1.3 SOCIAL /COMMUNITY MOBILIZATION Social/Community mobilization (community participation or engagement) is an ongoing activity aimed at sensitizing the community members to accept and participate in health interventions put in place to control diseases, in this case malaria. Some community activities were implemented through NGOs, Community Based Agents (CBAs), health personnel, etc. They were empowered with funds to undertake community level sensitization through durbars, traditional & opinion leaders’ orientations, market, churches/mosques one-on- one and group education. NGOs as well did house to house education of women on the need to attend Antenatal Clinics as early as they notice they are pregnant. 2.5.1.4 2014 WORLD MALARIA DAY COMMEMORATION Ghana joined the rest of the world to commemorate the World Malaria Day on the 25th of April, 2014.The World Malaria Day was instituted by the World Health Organization (WHO) member states in 2007 as an occasion to highlight the need for continued investment and sustained political commitment for malaria prevention and control globally. The day was marked in Ghana in Wa in the Upper West Region where the Seasonal Malaria Chemoprevention (SMC) is to be rolled out. The global theme for this year was: “Invest in the future; Defeat Malaria” and Ghana adopted the same theme for the commemoration. The day was used to launch the SMC and also showcase the achievements chalked in the malaria prevention and control by National Malaria Control Programme (NMCP) in partnership with Global Fund, WHO, the United States Agency for International Development (USAID), UK Department for International Development and UNICEF among others. In attendance were the Deputy Upper West Regional Minister, Mr. Abu Kabiabata Kasangbata who gave the keynote address and launched the SMC, women groups, the hearing impaired group, schools, the RCC, directors from all regions, MCEs/DCE s and the general public. Side attraction included the mounting of the largest bed net in the world measuring 12m width x 16m length x 7m in height; malaria screening by Clodix and Fio Healthcare sign interpretation of 50 addresses for the benefit of the hearing impaired and presentation of awards to reps schools who won the malaria quiz competition. Figure 4: World Malaria day, April 25th 2014, celebration at Wa, Upper West Region Pre-2014 World Malaria Day activities had included a press briefing at the Civil Servant’s Hall on the 16/06/14 chaired by the Deputy Director General, Dr Gloria Quansah-Asare, where Mr. James Frimpong made a presentation on the Theme, Invest in the Future, Defeat Malaria” and another press briefing on the 23rd of April in Wa for the press in the Upper West Region. 2.5.1.5 WORLD HEALTH DAY World Health which annually falls on the 7th of April was commemorated by Ghana on the 12th of April 2014 at the premises of the Ghana Health Service. The theme was ‘Vector-borne diseases’ and the slogan was ‘Small bite, Big threat’. Vector borne diseases account for 17% of the estimated global burden of all infectious diseases. Global trade, rapid international travel, and environmental changes such as climate change and urbanization are causing vectors and vectorborne diseases to spread beyond borders. In attendance were the Hon Minister of Health, WHO Country Representative, health directors including the Director General Ghana Health Service, members of the Ghana Pharmaceutical Society and the Tema Station Market traders. Key note address was given by the Minister of Health and the function chaired by Dr Erasmus Agongo of the GHS. 51 Address on vector borne diseases, yellow fever, dengue, Chagas disease, leishmaniasis, lymphatic filariasis, Trypanosomiasis and onchocerciasis were given by the programme manager of Neglected Tropical Diseases, Dr Birutum. A detailed presentation on Malaria, singled out as an important vector-borne disease in the country was given by Aba Baffoe-Wilmot. The general public was screened for Lymphatic Filariasis by NTD officers and on malaria by Clodix and Fio In-cooperated. 2.6 RESEARCH, SURVEILLANCE, MONITORING AND EVALUATION (RSM&E) 2.6.1 Routine Monitoring Among activities undertaken over the period under RSM&E are finalization of Revised Reporting tools Second Edition of Standard Operating Procedures for Health Information, Data Quality Audit, National Malaria Monitoring and Evaluation Plan 2014-2020 developed, Research Demographic and Health Survey (DHS 2014) participated in and a study on Feasibility and Acceptability of Use of RDTs within the Private Sector in Ghana planned. 2.6.1.1 Finalization of Revised Reporting tools To improve surveillance and monitoring of malaria control interventions in health facilities, the revision of malaria reporting tools were finalized during the first quarter of 2014. The tools were also printed and distributed to all health facilities. The reporting tools and registers distributed include; Monthly OPD Morbidity Return, Monthly OPD Morbidity Sheet, Monthly Returns for Anti-Malaria, Midwife Form A and ANC Register. 2.6.1.2 Second Edition of Standard Operating Procedures for Health Information In addition, the Standard Operating Procedures (SOPs) for health information in Ghana Health Service which contains definitions of all malaria variables and indicators, timeliness and completeness of reporting was revised. The purpose of the SOP is to improve on quality of information that is needed for making critical health decisions. Training on the revised SOP was conducted for data managers in the health service. Copy of SOP can be downloaded from the resource section of DHIMS. 52 2.6.1.3 Data Quality Audit In the last quarter of the year, NMCP in collaboration with Swiss Tropical and Public Health Institute conducted data quality audit in health facilities and schools in the country. The purpose of this Data Quality Audit (DQA) was to verify the accuracy of reported data and to assess the quality of the data recording and reporting system, in relation to the current Global Fund grant. The following are summary preliminary findings from the audit;  The recording and reporting system for indicators is well defined and basically robust.  The implementation of the recording system has been found to be challenging in several sites. The provision of ACTs is not being properly recorded  Data Validation Meetings held but still significant discrepancies. Encourage OTSS and monitoring at the facility level and District Director Endorsement  There is no record of how discrepancies were resolved both paper-based and DHIMS.  Recording of the provision of LLINs in different types of documents (including the standard source documents)  Lack of guidelines on how to complete the source documents or the reporting formats (however, reporting is done consistently)  LLINs distributed among pregnant women reported in two different forms (risk of double counting) The regions and services delivery sites audited as well as indicators selected for 2014 data quality audit as indicated in the table below. Table 15: Indicators and Sites Selected for Data Quality Audit. Indicator Region Districts AAK Number of reported uncomplicated malaria cases Central (both suspected and confirmed) treated with Artemisinin Combination Therapy (ACT) at health facilities Northern Cape Coast Nanumba North 53 Service Delivery Sites Abakrampa Health Centre Ayeldu CHPS Zone Amosima CHPS Zone Central Regional Hospital Efutu Health Centre Cape Coast Metropolitan Hospital Bimbilla District Hospital Makayili Health Centre Zabzugu AAK Central Total number of Long Lasting Insecticidal Nets (LLINs) distributed to pupils, pregnant women and children under five years Cape Coast Nanumba South Northern Zabzugu Chamba Health Centre Kukpaligu Health Centre Zabzugu District Hospital Kuntumbiyili CHPS Abakrampa Health Centre Ayeldu CHPS Zone Abura Dunkwa Methodist B School Central Regional Hospital Efutu Health Centre St. Monic Angelic School Lungi CHPS Wulensi Health Centre Saba DA Primary School Kukpaligu Health Centre Zabzugu District Hospital Rajia Primary School The final DQA report will be submitted in 2015. 2.6.1.4 National Malaria Monitoring and Evaluation Plan 2014-2020 National Malaria M&E Plan was developed and Finalized alongside the development of National Malaria Strategic Plan 2014-2020. The current M&E Plan improves on weakness of the previous system and lessons strategies 2.6.2 Research Key among research activities that were conducted in the year under review are participation in the Demographic and Health Survey (DHS 2014) and Feasibility and Acceptability of Use of RDTs within the Private Sector in Ghana There were also Operational Research on RDTs, Price and Availability Surveys. 2.6.2.1 Demographic and Health Survey (DHS 2014) Research continues to be an integral part of malaria control activities in Ghana. The major research undertaken or partaken in by NMCP was the Demographic and Health Survey (DHS 2014) undertaken by Ghana Statistical Service. This was undertaken support from USAID, MEASURE DHS, UNICEF and UNFPA. In addition to data collected in previous DHS research, data on malaria parasite prevalence, based on rapid diagnostic testing (RDTs) and microscopy, are 54 incorporated as part of the new components in the DHS 2014. These data provide a unique nationwide snapshot of peak-season malaria point-prevalence in children aged 6-59 months. The NMCP sponsored the Malaria component of the survey, partook in the review of questionnaire, training of field workers (interviewers and biomarkers) and undertook monitoring of field data collection activities nation-wide. Data management and report writing is underway. 2.6.2.2 Feasibility and Acceptability of Use of RDTs within the Private Sector in Ghana There is currently little or no strategy for promoting diagnosis in private pharmacies and LCS in Ghana despite the fact that the majority of patients, about 60% (SPS, 2008) seek malaria treatment from these outlets. As such, many people are receiving anti-malarials from private shops without the benefit of parasitological testing. For this reason, the NMCP and Dodowa Health Research Centre undertook an operational research to examine the feasibility of expanding RDT use in pharmacies and License Chemical shops. This study which examined the role of rapid diagnostic tests for malaria for the targeting of ACTs at community level aims at assessing the feasibility and acceptability of expanding RDT use among chemical sellers (LCS) in rural, urban and peri-urban settings in Ghana. Results from the study shows that,  It is possible to introduce RDTs into chemical shops and easy to train chemical sellers to carry out the tests. Community members welcomed the test and the testing was acceptable to chemical sellers.  Chemical sellers can carry out the test safely and accurately and they generally adhere strictly to the guidelines for carrying out tests and what to do with test negative patients.  Chemical sellers largely referred test negative patients unless patients absolutely refused to go to the health facility.  Providing RDTs in the private retail sector significantly reduced dispensing of antimalarials by chemical sellers to patients with fever who tested negative by RDT, did not reduce dispensing of antimalarials to those who tested positive and appeared safe. RDTs should be considered for the informal private sector. 55 2.6.2.3 Malaria Vaccine The Malaria Vaccines Technical Working Group was set up in 2009 by the Director General of the Ghana Health Services on a decision making framework to introduce a future malaria vaccine as soon as endorsed by WHO. This process has been supported by a collaboration between PATH/MVI, WHO and the MOH to identify gaps in information required and the necessary systems and processes to put in place to inform country decision on adopting the most advanced malaria vaccine under trials (the RTS,S) should it be recommended by WHO. Ghana is one of the countries hosting two trial sites in Agogo and Kintampo. Last year a technical working group stakeholders’ meeting for Central and West Africa was held in Ghana from 24th to 26th June. This meeting was to map policy decision making processes at country-level, identify needs and gaps in country level RTS,S decision making ,share and update priority activities and technical assistance needs for malaria vaccine decision making and to promote sharing of TWG experience in West and Central Africa. The meeting was chaired by Prof. Isabella Quakyi, chairperson of the Ghana TWG. At the opening, Dr. Magda Robalo, the World Health Organization (WHO) representative in Ghana, delivered WHO’s perspective on key factors in the decision to adopt the RTS,S vaccine such as the safety, protective efficacy, added public health value, impact on severe malaria, product presentation, cost and sustainable financing among others and indicated WHO’s interest in continuing the discussion beyond this meeting. The Malaria Control Program Manager, Dr Constance Bart-Plange gave a progress update on the Ghana TWG as well as the next steps. The results of 18-month follow up clinical trial of the RTS,S was shared as well as planning around vaccine implementation communications and recent experience of new vaccine introduction and discuss implications for evidence-based decision making at country levels. 56 CHAPTER THREE 3.0 PROGRESS, ACHIEVEMENTS AND CHALLENGES 3.1 Introduction Over the reporting period, the number of health facilities reporting in the DHIMs2 also increased in 2013, from over 5000 to 6869 facilities in 2014. Similar to what pertained in 2013, the increase in the number of facilities such as CHPS compounds, as well as private service providers submitting reports on their services led to an increase in the volume of information but made it difficult to compare and show trends among these facilities since the number of facilities reporting are not the same, However since it is still one nation comparison of figures across the years for the entire nation was possible. In the four years preceding the reporting period, the number of OPD malaria cases increased consistently (from 2010 to 2013). However, 2014 saw a sharp drop from about 11 million cases in 2013 to 8.4 million cases (Fig. 6) with the proportion of OPD cases attributable to malaria dropping from 43.7% in 2013 to 30.9% in 2014 (Fig. 8). It is important to note that, clinical or presumptive diagnosis and treatment still persist even though the current policy is to test all suspected malaria cases before treatment though it’s improved in 2014. There continues to be a general decline however in institutional deaths due to malaria. This could be attributable to improved management in malaria cases. 3.2 Malaria Case Burden 3.2.1 Outpatient Malaria Cases In 2014, the country recorded about 8.4 million cases of OPD malaria, which is a decline over the 11.4 million cases recorded in 2013, representing about 23.6% decrease. This translates into approximately 23,299 cases seen per day in 2014 in all health facilities, compared to an average of approximately 30,300 of such cases seen each day in the country’s health facilities in 2013. Whereas the OPD malaria cases per 1000 population in 2013 was 340, there was a drop to about 253 per 1000 population in 2014 for the country (Fig. 5). Malaria parasite prevalence also declined marginally from 27.5% in 2011 to 26.7% in 2014 (Table 17). 57 NUMBER CASES PER 1000 POPULATION MALARIA CASES PER 1000 POPULATION (2010-2014) 400.0 350.0 340.3 300.0 310.4 277.3 250.0 200.0 150.0 156.1 164.4 100.0 50.0 0.0 2010 2011 2012 2013 2014 YEAR Figure 5: Malaria Cases per 1000 Population, 2010-2014 In 2014, the total number of OPD malaria cases reported in health facilities in the country (8,453,557)was generally lower than that in 2013 (11,059,393) and that runs through eight out of the ten regions (Fig. 6). 58 OPD Malaria Cases from 2010-2014 12000000 10678387 9718894 10000000 Number of OPD Malaria Cases 11059393 8453557 8147011 8000000 6000000 4000000 2000000 0 2010 2011 2012 2013 2014 Year Figure 6: OPD Malaria Cases from 2010 to 2014 Upper West region recorded the least number of OPD malaria cases (374,851) followed by Upper East region (398,311). (Fig.7). The Brong Ahafo (1,243,886) Volta (903,419) and Western (800,177) regions reported highest malaria cases in 2014. 59 Number of OPD Malaria Cases in 2014 by Region 1400 Number of cases in 1000s 1200 1000 800 600 400 200 0 Upper West Greater Northern Accra Central Volta Ashanti Region Upper East Eastern Brong Ahafo Western Figure 7: Number of OPD Malaria Cases in 2014 by Region The proportion of total OPD cases attributable to malaria saw a decrease from 43.7% in 2013 to 30.9% in 2014, (See Fig. 8 below). On regional basis, Greater Accra recorded the least proportion of 22.0%, implying that 22% of all OPD cases recorded in health facilities in the Greater Accra Region in 2014 were as a result of malaria. However, Upper West region (50.7%), followed closely by the Upper East region (36.5%) which is also closely followed by the Northern region (36.1) were the three worst performing regions as far as proportion of OPD cases attributable to malaria is concerned (Fig. 9). 60 PERCENT PROPORTION OF OPD CASES ATTRIBUTABLE TO MALARIA, 2006-2014 50 45 40 35 30 25 20 15 10 5 0 38.65 38.4 33.7 31.7 40.28 38.93 43.7 32.5 30.9 2006 2007 2008 2009 2010 2011 2012 2013 2014 YEAR Figure 8: Proportion of OPD Cases Attributable To Malaria From 2006 To 2014 Proportion of OPD Cases Attributable to Malaria in 2014 60.0 50.7 50.0 Percent 40.0 32.1 36.1 33.4 35.7 29.9 27.1 30.0 36.5 22.7 22.0 20.0 10.0 0.0 Ashanti Brong Ahafo Central Eastern Greater Accra Northern Upper East Region Figure 9: Proportion of OPD Cases Attributable to Malaria in 2014 61 Upper West Volta Western There was a rise in the proportion of OPD malaria cases which were tested by microscopy or RDT from 48% in 2013 to 73.5% in 2014, representing a 53% increase over the 2013 figure. This performance happens to be the best over the past four years (Figure 10). Proportion of OPD Malaria Cases Tested By Microscopy and RDT, 20102014 80 73.5 70 Percent 60 50 48 45.2 40 37.9 30 31 20 10 0 2010 2011 2012 2013 2014 Year Figure 10: Proportion of OPD Malaria Cases Tested, 2010- 2014 The focus of the country programme has been the pursuance of the Test, Treat and Track policy. However, not all the suspected cases in all facilities were tested in the year under review and that is not peculiar to year 2014. The proportion of malaria cases targeted to have been parasitically tested in 2014 was 70% and the country achieved 73.5%, a little above the national target for the year (Figure 11 below). However the proportion of malaria cases parasitically tested in 2014 by the regions varied. In the same figure, all the 10 regions in the country, except the Northern, Volta and Western regions, achieved this target. All the regions and the nation as a whole performed in 2014 better than in the three years before 2014. 62 PROPORTION OF OPD MALARIA CASES TESTED (MICROSCOPY & RDT) BY REGIONS FROM 2011 - 2014 100.0 90.0 80.0 70.0 PERCENT 60.0 50.0 40.0 30.0 20.0 10.0 0.0 ASHAN BRONG CENTR EASTER TI AHAFO AL N GREAT NORTH UPPER UPPER WESTE NATIO ER VOLTA ERN EAST WEST RN NAL ACCRA 2011 41.4 60.7 54.8 47.2 35.8 33.5 46.5 34.4 37.3 37.2 42.9 2012 31.7 27.8 42.6 45.2 60.4 34.1 49.4 27.8 39.5 30.3 38.9 2013 50.4 52.2 70.6 56.5 51.0 37.3 68.8 55.2 49.7 45.8 53.7 2014 74.7 71.1 81.0 83.7 94.2 44.3 83.5 93.9 64.2 64.6 73.5 TARGET (2014) 70.0 70.0 70.0 70.0 70.0 70.0 70.0 70.0 70.0 70.0 70.0 Figure 11: Proportion of OPD Malaria Cases Tested by Regions, 2011-2014. Service providers continue to accept the need to test before treatment. In 2014, the malaria test positivity rate for both RDTs and microscopy nationally were 61.8% and 48.8% respectively and collectively, it was 55.5% in 2014 which was lower than 66% in 2013. The Greater Accra region continues to have the lowest test positivity rate of 24.3% (Fig. 12). Meanwhile, results from 2014 Ghana Demographic and Health Survey (GDHS) indicates a national parasite prevalence rate of 36.4% and 26.7% for RDT and microscopy respectively. Figure 13 shows malaria prevalence among children age 6-59 months by regions. 63 Test Positivity Rate by RDT and Microscope, 2014 80.0 70.0 61.8 Percent 60.0 48.8 50.0 40.0 30.0 20.0 10.0 0.0 Ashanti Brong Ahafo Central Eastern Greater Northern Upper Accra East Upper West Volta Western Ghana Region Test Positivity (RDT) Test Positivity (Microscopy) Figure 12: Test Positivity Rates for RDT and Microscopy in 2014 Malaria Prevalence in 2014 70 60 50 Percent 40 30 20 10 0 RDT Microscopy Western Central Greater Accra Volta Eastern Ashanti Brong Northern Upper East Upper West National 42.6 48.7 11.8 36.6 40.3 20.6 44.1 60.6 22.7 62.3 36.4 39 37.9 11.2 25.2 29.5 16.6 26.5 40 11.7 37.8 26.7 (Source: GDHS 2014) Figure 13: Malaria Prevalence from 2014 GDHS 64 The use of ACTs to treat uncomplicated malaria cases was adopted in 2004. Since then it has been of interest to track its use in both public and private health sectors. The proportion of OPD malaria cases treated with an ACTs has been increasing. PROPORTION OF OPD MALARIA CASES CASES PUT ON ACTs, 2011-2014 100.0 90.0 86.2 82.3 80.0 Percent 70.0 60.0 57.5 50.0 40.0 39.6 30.0 20.0 10.0 0.0 2011 2012 2013 2014 Year Figure 14: Proportion of OPD Malaria Cases Put on ACTs, 2011-2014 There had been consistent increase in the proportion of OPD malaria cases put on ACTs from 39.6% in 2011 to 86.3% in 2013; in 2014, there was a slight drop from 86.2% in 2013 to 82.3% in 2014. 65 Proportion of OPD Malaria Cases Put on ACTs by Region in 2014 Proportion of OPD Malaria Cases 120 100 86.3 82.3 80 60 2013 40 2014 20 0 Region Figure 15: Proportion of OPD Malaria Cases Put on ACTs by Regions in 2014 and 2014 The Eastern region treated the largest proportion (96.9%) of all suspected malaria cases with ACTs, followed by the Volta region (88.8%) while the greater Accra region was the least (68.2%) in 2014. 3.2.2 Malaria in Pregnancy Among pregnant women, malaria cases recorded at OPD in 2014 was 197,017 as against 217,000 in 2013. The 2014 figure represents a reduction of 9.2% over the 2013 recorded number of malaria cases among pregnant women. The top three regions with the highest number of malaria in pregnancy cases in 2014 were the Western region (30,892 cases), followed closely by the Ashanti region (29,772 cases) and the Volta region (23,445 cases). The region with the least number of malaria in pregnancy cases happens to have been the Upper East Region (11,024 cases). 66 3.2.3 Malaria Admissions Admissions for malaria increased from 428,000 in 2012 to 451,000 in 2013 and further decreased to 429,940 in 2014, translating into 1,177 admissions per day. In 2013, there were approximately 1,235 malaria admissions a day. Among children under five years, 207,913 admitted due to malaria in Ghana in 2014. Of that number, 42,741 (representing 20.6% of the total number of cases nationwide) occurred in the Ashanti region, followed by 41,123 (19.8%) in the Northern region. The least number of 5,908 (2.8%) occurred in the Greater Accra region. On regional distribution of admissions due to malaria in 2014, Ashanti regions turned out to have had the highest number of admissions (93,015) followed by the Northern and Brong Ahafo regions with 72,728 and 65,040 admissions respectively. The Upper West (19,838), Greater Accra (16,971) and the Upper East (14,140) regions were the regions with the lowest numbers of malaria admissions, in descending order, in 2014 (Fig. 16). Ranked Order of Inpatient Malaria Cases, 2014 100 93.015 Number of Malaria Admissions (1000) 90 80 72.728 70 65.04 60 49.376 50 44.979 40 29.408 30 24.445 20 19.838 16.971 14.14 10 0 Ashanti Northern Brong Ahafo Western Volta Eastern Region Figure 16: Ranked Order of Inpatients Malaria Cases in 2014 by Regions 67 Central Upper West Greater Accra Upper East 3.2.4 Malaria-Related Deaths The total number of deaths attributable to malaria in 2014 was 2,200 representing a reduction of about 26% to the 2013 figure. Out of these malaria deaths, 1,060 occurred among children-under5-years in 2014, compared to 1,348 in 2013, Table 3.1. The trend of in-patient malaria deaths from year 2000 to 2014 is presented in Table 16.and a section of it in Figure 17 showing a decreasing number of malaria deaths over the period, despite the fact that total deaths on admission has been on the increase from 2011. It is also observed that in the nine years preceeding the year under review, malaria related deaths in children-under-five years were less than that in persons five-years-and-above. Table 16: In-patients Malaria Deaths, 2000-2014 In-patient Malaria Deaths - 2000 – 2014 Years 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 In-patient malaria Death 6,054 4,158 4,274 3,571 2,734 5,948 4,434 4,579 3,760 3,352 3,882 3,197 2,799 2,985 2,200 < 5 malaria Deaths 3,952 2,717 2,914 2,195 1,380 2,026 973 1,241 1,697 1,505 1,812 1,539 1,129 1,348 1,060 5years and Above malaria Deaths 2,102 1,441 1,360 1,376 1,354 3,922 3,461 3,338 2,063 1,847 2,070 1,658 1670 1,637 1,140 It is also worth noting that the country has been recording a systematic reduction in the proportion of death due to malaria, as recorded at the In-Patient Departments of facilities in the country, and that there was a sharp reduction in the proportion of deaths attributable to malaria in 2014 (6.6%) compared to the 2013 figure of 12.5% (Fig. 17). 68 PROPORTION OF INPATIENT DEATHS ATTRIBUTABLE TO MALARIA, 2010-2014 Proportion of Deaths 25 20 19.5 18.1 15 12.6 12.5 10 7.2 5 0 2010 2011 2012 Year 2013 2014 Figure 17: Inpatient Malaria Deaths, 2010-2014 At the regional level, the Northern region recorded the highest number of deaths due to malaria (672) followed by the Central region (281) while the Eastern region recorded the lowest number of deaths due to malaria (77) in 2014 (Fig. 18). 69 Inpatient Malaria Deaths, 2014 800 672 700 Number of malaria Deaths 600 500 400 281 300 200 190 255 219 172 143 77 100 103 88 0 Ashanti Brong Ahafo Central Eastern Greater Northern Upper Accra East Region Upper West Volta Western Figure 18: Inpatient Malaria Deaths by Region in 2014 There was a reduction in the Case Fatality Rate recorded from about 0.6 in 2013 to less than 0.51 in 2014, Figure 19. This is reflected in all the ten regions. The Greater Accra region (0.52), followed by the Upper West region (0.44) and the Upper East region (0.40) were the regions which recorded the highest reduction in the CFR in 2014 over their respective 2013 figures of 0.92, 0.76 and 0.69. 70 Under Five Case Fatality Rate by Region, 2013-2014 1.20 1.11 1.07 1.00 0.92 0.86 Percent 0.80 0.75 0.69 0.58 0.60 0.43 0.40 0.76 0.70 0.46 0.32 0.52 0.51 0.42 0.69 0.42 0.35 0.40 0.44 0.51 2013 CFR 2014 CFR 0.18 0.20 0.00 Region Figure 19: Case Fatality Rate by Region for 2013 and 2014 3.3 Intermittent Preventive Treatment in Pregnancy (IPTp) The use of Sulphadoxine Pyrimethamine for preventing malaria during pregnancy is one of the interventions being pursued by the country under Intermittent Preventive Treatment of malaria in pregnancy (IPTp). In 2014 a total of 960,745 pregnant women were registered, out of which 519,916 (54.1%) received IPT1 compared to 560,306 (63.6%) who received IPT1 in 2013. This represents a reduction in IPTp1 uptake in 2014 over the 2013 figure. For IPT2 the figures were 372,331 (38.7%) in 2014 compared to 468,437 (53.2 %) in 2013 and for IPTp3, 236,392 (24.6%) were recorded in 2014 compared to 342,192 (38.9%) in 2013. The general uptake of IPTp plummeted further in the year under review. This represents the second year running when IPTp hit a downward path since 2012. 71 In the year under review, IPTp4 and IPTp5 were introduced. 39,882 pregnant women (4.2%) took up IPTp4 and over 11,270 (1.2%) took up IPTp5. The trend for the years is shown Figure 20 below. IPTp Uptake from 2006 to 2014 90 80 70 80.5 65.8 62.2 Percent 60 30 80.8 67.1 63.0 69.2 49.5 49.1 63.6 53.1 44.4 41.9 70.7 IPTp1 58.3 54.9 50 40 82.8 38.9 37.6 41.7 35.9 53.2 54.1 38.8 38.7 IPTp2 IPTp3 IPTp4 25.6 24.6 20 IPTp5 10 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 Figure 20: Proportion of Pregnant Women who took up IPTp from 2006-2013 Contrary to the reduction in IPTp from health facility reports over the past few years, result from population surveys conducted between 2011 and 2014 indicates increase from 64.4% (MICS 2011) and 67.5% (2014 GDHS) as shown in Table 17. 72 IPTp Uptake in 2014 80.0 70.0 Percent 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Ashanti Brong Ahafo Central Eastern Greater Northern Upper Accra East Upper West Volta Western Ghana Region IPT 1 IPT 2 IPT 3 IPT4 IPT5 Figure 21: IPTp Uptake in 2014 by Pregnant Women Regarding the regional distribution of IPTp uptake in 2014, the Upper East region was the region with the highest proportion of pregnant women taking up IPTp1, IPTp2, IPTp3, IPTp4 and IPTp5 and that happens to have been above the national figures, as can be seen in Figure 3.16 . The Upper West region recorded the lowest figures in IPTp uptake in 2014 (Fig. 21). 73 Table 17: Key Results from Health Facilities and Surveys, 2000-2014 Health Facility Report Indicators/Years Deaths Associated with Malaria Under five Malaria Case Fatality Rate (From Malaria Admissions) Indicators/Years LLINs/ITNs Percentage of Households with at least one insecticide treated nets (LLINs). Proportion of children under 5 sleeping under insecticide treated nets (LLINs). Proportion of Pregnant women slept under ITN(LLINs) the previous night IPTp (SP) Proportion of Women who received at least2 doses of SP/Fansidar during their last pregnancy. 2015 Targets - 6054 3197 2799 2985 2200 1.0% 14.4% 1.2% 0.6% 0.6% 0.5% 2015 Targets 2000 2003 GDHS 2011 2012 Survey Results 2008 2011 GDHS MICS 2013 2012* KAP BY SPH 2014 Remarks 2014 GDHS 80% 5.2% 32.6% 48.9% 97.7% 68.3% 80% 4.0% 53.9% 39.0% 77.6% 58.8% 80% 2.7% 50.4% 32.6% 59.7% 54.6% 80% 0.80% 43.7% 64.4% 75% - 27.50 % Malaria Parasite Prevalence Parasite Prevalence (among 6 to 59month) 74 - About 65% reduction in malaria deaths by 2014 over 96% reduction in under-five malaria CFR by 2014 Remarks Two third of all households in the country are protected from malaria Now 3 out of every 5 children under 5 years sleep under LLINs More than half of Pregnant Women Sleep under LLINs 67.50% Two third of all Pregnant women in the country are protected from malaria during pregnancy. 26.7 Over 60% drop in parasite prevalence by 2014 3.4 Financial Support The Malaria control efforts’ in the country is supported by the government and local and international partners. The Global Fund continues to be the major international funding agent supplementing the Government of Ghana in the fight against malaria in the country. Other funding agents include; PMI/USAID, UNICEF, WHO, DFID, etc. in the year under review. As at 1st January, 2014, balance on account stood at US$1,522,950.00 However, during the year, an amount of US$6,240,964.11 was received from the Global fund. This was also followed with three direct transfers for the payment of commodities as shown in detail below. In addition to the above, the programme also received funds from the following institutions for some ear marked activities. Table 18: Funding Sources Institution name GUILIN Purpose Support for ToT for case management Lab technicians WHO Support for MIP / iCCM/Concept Note Development working Group Meeting Support for review of communication strategic plan and MIP panning meeting UNICEF ZOOMLION DFID GLOBAL FUND GOV(Country level) Support for MAVCOC meeting Operationalisation of malaria parasite prevalence sentinel sites, technical support for resources mobilization and engagement of epidemiologist. Accelerating Access to Prevention, Treatment, and Home Based Care for Malaria and Increasing the Access to Affordable ACTs in the Private Sector Staff Salaries and other associated HR costs, Infrastructure, Equipments Table 19: Table Showing Transfer to Purchase Malaria Drugs and Commodities Date Commodity September 2014 ACTs 145,435.50 October 2014 RDTs 5,584,070.77 75 Amount disbursed (USD) November 2014 ACTs 253,050.73 Table 20: Table Showing NMCP Budget and Expenditure in 2014. All amounts are US$(National level and partners, excluding GoG) cost category Budget 703,306.61 616,075.76 Variance 87,230.85 0 0 0.00 98,437.00 61,265.54 20,270,007.9 3 5,584,070.77 31,902,460.4 8 398,486.23 37,171.46 14,685,937.1 6 31,503,974.2 5 5,632,241.95 1,494,302.20 4,137,939.75 366,927.54 355,768.95 11,158.59 Communication 1,624,205.54 315,683.8 1,308,521.63 Monitoring and Evaluation 1,914,213.55 770,570.93 486,117.62 Planning and Administration 1,932,949.89 1,681,432.02 251,517.87 28,962.63 12,727.93 16,234.70 Other 2,686,804.09 85,595.57 Total 64,952,156. 00 11,323,738. 70 2,601,208.52 53,628,417. 30 Human Resources Technical Assistance Training Health Products health and Health Equipments Medicines and Pharmaceutical Products Procurement and Supply Management cost Infrastructure and Other equipments Overheads 76 Expenditure 2014 NMCP Budget and Expenditure Other Overheads Planning and Administration Cost Category Monitoring and Evaluation Communication Infrastructure and Other equipments Procurement and Supply Management cost Medicines and Pharmaceutical Products Health Products health and Health Equipments Training Technical Assistance Human Resources 0.00 10,000.00 20,000.00 30,000.00 Amount (1000),USD Expenditure Budget Figure 22: NMCP Budget and Expenditure in 2014 3.5 Programme Management 3.5.1 Planning, Administration and Programme Management The multi sectoral approach to malaria control activities necessitates that a number of planning meetings are held among stakeholders in order to develop an appropriate and acceptable work plan for each calendar year. During the year a number of planning meetings were held, notable among them was a series of meetings held between the Programme, the Global Fund, external and internal resource persons including members from the Malaria Inter-Agency Coordinating Committee (MICC) to sort out issues related to the Grant signing. In March 2014, following the announcement of Ghana’s allocation, the Country Coordinating Mechanism (CCM) met and approved the Global Fund’s proposed disease split. Discussions around Willingness to Pay, and development of overall and disease specific roadmaps and disease New Funding Model (NFM) roadmap development were also commenced. The Country 77 Coordinating Mechanism (CCM) formally began its identification of key constituencies and planned to ensure their involvement in the process of Concept Note development. The Concept Note development process, which started in May 2014, commenced with a meeting of stakeholders, including CCM members and other relevant parties, to discuss high-level priorities for funding. Reselection of the 2 existing Principal Recipients (rated A2 and B1), taking into account the agreed priorities, was agreed by consensus at a meeting on 15 May 2014. The writing team then produced 4 iterations of the Concept Note between May and July 2014, each of which was sent to CCM members and other relevant parties for review and comments. In total, 4 meetings of the CCM and other stakeholders were held over said period, prior to the submission of the concept note. The writing team also attended several workshops to assist with the development of the Concept Note (including mock TRP workshops in Kenya and Uganda, iCCM conference in Ghana). The finalization of the current National Strategic Plan (NSP) also went through programmestakeholder engagement during which the draft plan was shared for inputs. The document went through a process of joint assessment (JANS) and review by various external and internal resource persons including WHO consultants. There were also other planning meetings that were conducted between the Programme and the USPMI implementing partners, USAID, WHO, UNICEF and other partners towards the implementation of integrated vector control activities. Under Resource Mobilization (RM), Sub Committee Meetings and RM Plan Drafting Workshop were held, and a draft RM Plan was DEVELOPED. An Epidemiological Profile and RBM Knowledge Gaps Workshop were also held. As part of the planning process, the Programme Manager participated in the GHS Directors’ Weekly meetings as well as that of the Public Health Directorate. Some members of staff represented the Programme on a number of Planning Committees including that of Expanded Program on Immunization (EPI), World Health Day, World Malaria Day and Weekly Public Health Technical meetings. 78 At the Programme level, weekly staff meetings were held to review programme activities. 3.6 Meetings and Conferences Capacity building and staff development is a major component for effective programme implementation. To this end, management supported some technical staff to attend meetings, workshops, conferences, and short courses / trainings during the period under review. Table 21: International Conferences Attended by Technical Staff in 2014 Main Purpose / Venue /Date Names of Participants Dr. Constance Bart Plange Mr. James Frimpong  Meeting to Formulate policies on malaria vectors. In Geneva.  ESAC3: member of committee that evaluates researches on innovations for Malaria vector control. Meeting in Geneva  RBM Board meeting, member of Task Force that evaluated RBM Board. In Geneva  Meeting to Review Global Malaria Strategic Plan for 2015-2020 in Harare  ASTMH. In New Orleans.   Economics of malaria in London. February 26th : Integration of traditional Medicine into Malaria Control Ouagadougou, Burkina Faso  March 7th workshop on LMIS Ouagadougou , Burkina Faso  March 25th : Communication Strategy for Malaria vaccine - Dakar, Senegal  June 1st to 10th Science of Eradication of Malaria workshop Basil, Switzerland  June 24th to July 29th Workshop on Deployment of Artesunate Injection Shanghai, China 79 Dr. Felicia Amo Sakyi  November 22nd to 29th WARN meeting Niamey, Niger  Workshop on innovative approaches to safety monitoring held from 7-9th October 2014 at WHO-UNAIDS building in Geneva  Workshop on peer review of National Malaria Strategic plan held at Sarova Stanely Hotel in Nairobi, Kenya from 11-14th March 2014. Dr. Constance BartPlange/Mr. Francis Ocloo  Conference to validate the Strategic Plan For the Elimination of Malaria in ECOWAS organized by WAHO at ERATA Hotel in Accra from 29th – 30th May, 2014 3.7 Challenges Among the challenges faced by the Programme in the activitites carried out in the reporting year are; • Sale of RDT to clients in some facilities resulting in refusal by clients to undergo test before treatment • Poor documentation of RDT supplies and use • Inadequate supplies of case management guidelines to training health institutions and teaching hospitals • Delay in collection and allocation of malaria commodities to districts and facilities leading to artificial stock outs of malaria commodities such as RDT and SP. • Inadequate coordination of NHIA with NMCP in addressing diagnosis and management of uncomplicated and severe malaria • Persistent reliance on clinical diagnosis only (i.e. treatment without testing or adherence to test result) by some prescribers resulting in over use of ACTs. • Limited supervision at subnational levels. 80 CHAPTER FOUR CONCLUSION AND THE WAY FORWARD 4.1 Summary of objectives and key outcome Table 22 summarizes objectives, key indicators and achievement in 2014. Table 22: Summary of objectives and key results for 2014 Goal/Objectives Indicator Description Goal: To reduce the malaria morbidity and mortality burden by 75% (using 2012 as baseline) by the year 2020 Parasitemia prevalence: children aged 6– 59 months with malaria infection (by microscopy) (percentage) Objective 1: To protect at least 80% of the population with effective malaria prevention interventions by 2020 Under five Case fatality rate All-cause under 5 mortality rate Confirmed malaria cases (microscopy and RDT) per 1000 population per year Baseline (if applicable) Value Year 27.5% 2011 Year of Target Actual Result (%) % achievement 2014 Intended Target (%) 24.5 26.7 91.0 0.6% 82/1000 LB 186 2012 2011 2013 2014 2014 2014 0.55 70/1000 LB 166 0.51 60/1000 LB 138 107.3 114.3 116.9 Percentage of pregnant women on Intermittent preventive treatment (at least two doses of SP) according to national policy Percentage of Households with at least one insecticide treated nets (LLINs). 64.4% 2011 2014 65.5% 67.50% 103.1 33.7% 2011 2014 66.0% 68.30% 103.5 Percentage of children under 5 years old who slept under an insecticide-treated net the previous night 39.0% 2011 2014 53.0% 58.8% 110.9 81 Objective 2: To provide parasitological diagnosis to all suspected malaria cases and provide prompt and effective treatment to 100% of confirmed malaria cases by 2020 Objective 3: To strengthen and maintain the capacity for programmer management, partnership and coordination to achieve malaria programmatic objectives at all levels of the health care system by 2020 Objective 4: To strengthen the systems for surveillance and M&E in order to ensure Percentage of pregnant women who slept under an insecticide-treated net the previous night 32.6% 2011 2014 48.0% 54.6% 113.8 Number and percentage of structures in targeted districts sprayed by indoor residual spraying in the last 12 months Percentage of reported suspected malaria cases that received a parasitological test( RDTs or microscopy) 98.5% (43993 7/446752) 2012 2014 85% (2168183/25 50804) 90.5% 106.5 (2886513/3188 838) 37.9% 2012 2014 70.0 74.3% 106.1 Percentage of reported uncomplicated malaria cases (both suspected and confirmed) treated with ACT at health facilities. Number and percentage of uncomplicated malaria cases (tested positive) treated with ACT at health facilities. Number of uncomplicated malaria cases among under 5 year children treated with ACT by community based health workers (CBA). Number of service providers from targeted public and private health facilities given refresher training on malaria control (case management etc.) 83% 2012 2014 90.0 82.6 91.8 100% 2012 2014 100% (3086102) 100% (3515912) 100.0 747615 2012 2014 129179 105631 81.8 23250 2011 2014 24000 17733 73.9 Number of meetings held by MICC and its subcommittee/working groups 21 2012 2014 21 19 90.5 Number of Districts with functional M&E unit with data quality improvement teams. 10 2012 2014 100 150 150.0 82 timely availability of quality, consistent and relevant malaria data at all levels by 2020 Objective 5: To increase awareness and knowledge of the entire population on malaria prevention and control so as to improve uptake and correct use of all interventions by 2020 Percentage (%) of health facilities submitting timely and complete reports( on malaria ) to regional level Promotion of research that informs the programmer in terms of policy and operational issues 13.2% 2012 2014 65.0% 78.0% 120.0 2 2012 2014 6 2 33.3 Number of sentinel sites established and functioning for epidemiological and insecticide monitoring 21 2011 2014 26 30 115.4 Quantities of ACSM materials(Manuals, posters, radio/TV spots, etc.) produced 12000 2012 2014 30000 50500 168.3 Percentage of people who know the cause of, symptoms of, treatment for or preventive measures 96% 2011 2014 96.70% N/A N/A Number of mass media spots promoting key messages on malaria case management 6533 2011 2014 21052 24369 115.8 83 4.2 THE WAY FORWARD 1. Monitoring and Supportive supervision • Undertake quarterly supportive supervisory visit to all regions • Harmonize OTSS check-list/monitoring tool of Malaria Care and NMCP on case management. • Develop observation chart to monitor cases of severe malaria at referral points • Conduct biannual Outreach Training and Supportive supervision for health workers at all levels 2. Capacity building and development of guideline and Job Aides • Build capacity on malaria case management for Formal Traditional Medicine practitioners and Providers in Private and Quasi government health facilities • Build capacity for malaria case management for Tutors in health training institutions (Medical and Allied schools) • Organize 2-day meeting with Facilitators from all regions on Malaria Case Management • Build infrastructure and capacity for management of severe malaria at referral points • Support the finalization of MIP, ICCM and Lab Diagnostics guidelines and job aides revision • Collaborate with Guilin to finalize Job Aide for Artesunate injection use • Collaborate with training institutions to update curriculum and arrange for pre-service training opportunities in all medical and allied schools for update in MCM 3. Innovations • Create 3 Task Teams: Procurement/transportation of drugs and logistics; Training and Monitoring and evaluation of SMC implementation and ACSM activities to facilitate full implementation of Seasonal Malaria Chemoprevention • Strengthen T3 initiative at all levels of care during Health Professional body meeting • Facilitate the discussion with NHIA on diagnosis of severe malaria and decoupling of laboratory service and other service delivery • Launch Case Management guidelines in addition to other policy documents 84 4.3 ACTIVITIES PLANNED FOR 2015 4.3.1 Administration and Finance Planned for 2015 under Administration and Finance are NMCP End of year review and planning meetings, conducing Financial Monitoring on public facilities, conducting Coordination meetings ( MIACC, various committees), conducting End of term review meeting at the national level, Participating in regional annual review meetings, producing half year report and annual reports and conducting internal and external audits. 4.3.2 National Policy and Regulatory Preparedness Under National Policy and Regulatory Preparedness for 2015, the programme has planned to conduct cohort event monitoring studies to assess safety and quality of ACTs and Work with the Task Force to prevent leakages of co-paid ACTs. 4.3.3 Partnership, Planning and Resource Mobilization The Programme has planned, in 2015, Finalization of Resource Mobilization (RM) Plan with RM Sub Committee and other stakeholders, lobbying the Presidency to get the President to make a firm commitment to assign domestic funds to malaria control activities, meeting with the Parliamentary Select Committee on Health and Finance on the need to get Cabinet and the Presidency to act on getting domestic financing for malaria activities and also for Parliamentarians to advocate at various for a/avenues to get funding to support malaria control activities in their constituencies and setting up a Malaria Fund with the support of professional Fundraisers and Event Organizers to support NMCP and its partners. 4.3.4 Malaria Case Management Under Malaria Case Management, in 2015, the Programme has planned to conduct Case management trainings for Tutors in pre-service health institutions, conduct Case Management for severe malaria cases at Referral points, conduct a meeting with Providers in Quasi government health Facilities, conduct Private sector health facility supervisory visits half yearly, conduct On-Site Training and supportive supervision (OTSS) half yearly in public health facilities, and conduct training for Providers in Private and Quasi Government on case management. Other activities planned for 2015 under Malaria Case Management are developing observation chart to monitor cases of severe malaria at referral points, providing CMEs for physicians, pharmacists and nurses, collaborating with Partners 85 to develop job Aide for Injection Artesunate use in health facilities, revising monitoring tools/OTSS to capture emergency response and management of complications due to severe malaria, conducting a 2-day facilitators training on malaria case management/emergency response and organizing meetings with providers from Quasi government facilities. The rest are to Collaborate with training institutions to update curriculum and arrange for pre-service training opportunities in all medical and allied schools for update in MCM and Coordinate with NHIA to address concerns raised on issues of diagnosis and treatment of malaria. 4.3.5 Malaria in Pregnancy The Programme has planned, in 2015 under Malaria in Pregnancy, to conduct OTSS on MIP (as part of Case Management), Stakeholders’ meeting on Folic Acid Formulation, Quarterly text messaging, phone calls and monitoring data, IPTp assessment study/operation research to identify reasons for drop out of IPTp and outcome of IPTp, Quarterly MIP Working Group Meeting, Develop Job Aid for MIP and Conduct in-service training for health workers. 4.3.6 Integrated Community Case Management (iCCM) In 2015, the Programme has planned under ICCM to Roll out of CBA OTSS across the country, hold sessions of Refresher training for CHOs, hold CBAs peer review meetings (half yearly), post Quarterly text message/call reminders to disseminate information, Revise the quantification of iCCM products to serve as advocacy tools (for both local and international partners), advocate for funds for printing of HBC manuals and reporting tools and hold Quarterly iCCM coordinating committee meetings. 4.3.7 Diagnostics Sentinel sites studies for Parasite prevalence tracking, Conduct MDRT TOT for regional -level laboratory OTSS supervisors, Conduct MDRT in each region for district -level laboratory OTSS supervisors -level laboratory OTSS supervisors, Conduct Malaria Diagnostic Refresher Training for facilities, Conduct lessons learned workshop for regional-level laboratory OTSS supervisors, Hold inservice training for lab assistants and Development of GHS quality assurance plan and standard protocol for RDTs are some of the activities planned by the Programme under Diagnostics for 2015. The rest are to implement the laboratory quality assurance protocol, Complete the WHO NAMS validation process and Work with laboratory training institutions to update malaria diagnostics preservice training based on revised national guidelines for malaria diagnosis and treatment. 86 4.3.8 Vector Control Under Vector Control for 2015, the Programme has planned to Work with laboratory training institutions to update malaria diagnostics pre-service training based on revised national guidelines for malaria diagnosis and treatment, distribute LLINs through point distribution in WR; regional informative meeting, volunteer& health worker trainings, distribution exercise, distribute LLINs through point distribution in CR; regional informative meeting, volunteer& health worker trainings, distribution exercise, distribute LLINs through point distribution in AR; regional informative meeting, volunteer& health worker trainings and distribute LLINs through point distribution in Non-IRS districts in NR; regional informative meeting, volunteer& health worker trainings, distribution exercise. Also planned for 2015 under Vector Control are to distribute LLINs through point distribution in UER; regional informative meeting, volunteer& health worker trainings, distribution exercise, distribute (to be determined) LLINs through point distribution in rural GAR; regional informative meeting, volunteer& health worker trainings, distribution exercise, Monitoring and supervision of LLIN Point distribution in all implementing regions and Conduct Post Point Distribution validation in BAR, WR, CR, AR, some districts in NR, UER and GAR. The rest are to Distribute LLINs through ANCs & CWCs in all regions and to monitor and supervise distribution of LLINs through ANC and CWCs. 4.3.9 Vector Control Coordinating Meetings Under Vector Control Coordinating Meetings, the NMCP plans to hold quarterly MAVCOC meetings, coordinate and monitor insecticide resistance management sentinel sites activities, Review the IVM Policy and conduct Insecticide Resistance Monitoring through sentinel sites. 4.3.10 Indoor Residual Spraying In 2015 under Indoor Residual Spraying, the NMCP plans to monitor IRS activities in Northern Region (Abt-IRS) and Upper West Regions (AGAMAL), review susceptibility reports to inform the selection of appropriate insecticide for IRS spraying in consultation with partners (MOH/NMCP, AGAMAL and PMI), facilitate Entomology training for GHS/NMCP technicians including participation from partners, conduct Entomological surveillance at all established sites (Both AGAMAL, and PMI/ABT sentinel sites including Bunpkurugu Yunyo) and conduct post-IRS evaluation workshop/meeting. 87 4.3.11 Procurement and Supply Management (PSM) Under PSM, the Ptogramme plans to Procure for continuous distribution and LLINs mass campaign, Procurement And Supply Management (Psm), Procure RDTs, pursue Private sector co-payment mechanism, Support Integration and Harmonization of LMIS and conduct Physical Stock checks at central and regional medical stores in 2015. 4.3.12 Research, Surveillance, Monitoring and Evaluation The NMCP, under Research, Surveillance, Monitoring and Evaluation in 2015, plans to conduct Surveillance, Monitoring and Evaluation Technical Working Group Meetings (quarterly), produce periodic reports, report on the PUDR for the Global Fund (GF), the Dashboard for the CCM, RBM Roadmap Updates, and WMR for the WHO. Others are produce reports to other partner and stakeholders, develop and produce of Malaria Bulletins and conduct On-site Training and Supportive Supervision (OTSS). Also planned for 2015 to be conducted under Research, Surveillance, Monitoring and Evaluation are Public and Private supervisory visits, support the GSS with the DHS report writing, Documentation of Best Practices, Conduct routine data quality audits, Conduct Periodic Data Review (in 10 Regions) Semi-annual seminars to disseminate research findings and investigate factors that influence adherance to test results and treatment policy. Other activities planned under RSM&E for 2015 are to conduct a Research into repellants, coils and other products reducing vector human contact, investigate the Threat of surface mining and artisan mining on malaria control, Identify reasons for low uptake of HBC, Stratify of malaria endemicity to cover districts and Develop national and district specific thresholds for malaria surveillance. 4.3.12 Advocacy, Communication And Social Mobilization (ACSM) One key are of the Programme’s activities for 2015 is Advocacy, Communication and Social Mobilization and under this, has planned to conduct Malaria day advocacy; including commemoration of world malaria day, conduct Quarterly Communication Sub Committee meetings, produce and air both TV and Radio adverts on LLINs and ACTs, Liaise with Health Promotion to undertake intensive BCC to promote test treat and track : compliance, use and improve provider confidence in the use of RDTs and SP ( TV Adverts), develop and print material for education on SMC and finalize ,design, print and deserminate National Communication Strategy. Others are to Support for NGOs advocacy and sensitise community on IPT for the coalition of NGOs in malaria, Train and orientate journalists 88 including newsroom editors on malaria control interventions, Review malaria educational materials on malaria interventions in line with current communication strategies(ITNs, SMC, SP, ACTS, RDTs, ICCM), Print MIP Guidelines, Print Mass LLIN Point Distribution Campaign Coupons for Brong Ahafo, Western, Central, Ashanti, Northern Region, Upper East and Greater Accra Regions, Design & Print disseminate IMCI Documents and educational Materials and Revise, Print and disseminate material for education on SMC. The rest are to develop and print malaria microscopy job aids, develop and print daily malaria log book for all facilities, print IPT Guidelines, National Strategic plan & M&E Plan, develop materials for community mobilsation on iCCM and print iCCM tools (when funds available). 89