Ghana general data The disease remains one of the major causes of death; and it tops the list of outpatient attendance in many hospitals and clinics. According to Ghana Health Service 2010 report, 5,041,025 malaria cases were recorded across the country the previous year, representing more than 60 percent of all out-patient cases. Ghana update Zack 28 July “Managers of the National Malaria Control Programme have not honoured a promise to grant me interview. I have had to travel to Accra from my Kumasibase on three occasions; spending at least 2-days on each occasion without success to speak to officials. This disrupted my program to visit and speak to a user hospital in a rural area in the Central region of Ghana before I travel to Eastern region. I had a chat with secretary to the Programmes Manager who assured me of a favourable response between now and tomorrow. They are currently meeting at an undisclosed area till Friday. I am visiting the Central region on Saturday. Hopefully, I will send something on Sunday. I asked for a week's off from office but it elapsed because of the back-and-forth response from the NMCP office.” Ghana update first week of August: trip Zack to Volta region General data: Malaria patients on the programme who live in inaccessible areas of the Ashanti, Eastern, Upper East and Volta Regions, end up with malaria complications in the absence of drugs. Twenty-one thousand, 979 people tested positive of malaria (WHEN, THIS YEAR? OR BETWEEN 2012 AND 2014?) Nine thousand, 912 malaria patients, made up of 5,688 aged above 5-years and 4,224 below were admitted at the Hohoe Municipal Hospital between 2012 and 2014. One hundred and twenty-six deaths, comprising 102 above 5-patients with 24 infants below 5 were recorded between 2012 and 2014. One hundred and twenty-one pregnant women has in the past 2 and half years tested positive for the disease with more than half, 479 being recorded in 2014 alone. Children and pregnant women who have no access to health facilities are likely to develop complications while Community-Based Agents idle about. (ISSUE OF VOLUNTEERS, BUT WHAT ARE THEY GOING TO DO WITHOUT DRUGS) Interview Dr Felix Doe, Municipal Health Director, Hohoe, Volta “We use to run out of drugs and sometimes too they don’t give us all the drugs. They supply only some of the drugs. I quite remember when we started the program; they brought only some of the drugs. We didn’t have ORS for treating diarrhea. We didn’t have paracetamol for the fevers.” Dr Doe wants implementation of the Malaria Control Programme reviewed from what he describes as ‘being dumped from the top to subordinates’ to address some of the lapses. “We are supposed to own it but because it’s a vertical program, that ownership is not fully there. It’s like you sit somewhere and somebody dumps something on you, and then you go and distribute and that’s all. But we are supposed to own the malaria control program, okay? And look at our program and make it part and parcel of day- to -day activities so that it becomes part of our CHIPS strategy, so that community health nurses who are in the CHIPS zones will see it as part of their activities. Not that we wait, a time comes ,and say okay, now, instructions come from Accra; this is what we are doing now then we all join hands and do it and that’s it. We have to own the program. That is how it’s supposed to be actually, but if you look at the way things are going, it’s actually not like that”. “Obviously, if the drugs are not there and the people are not working, we are likely to see more malaria complicated cases if those people are not working at that level”, Dr. Doe emphasized. Later he says: ‘’I’m not sure the programme(National Malaria Control Programme) will be happy to hear this; that we run out of drugs “. He has no idea what went into the programme. “I am not aware because the proposal that they wrote that the money came, we are not privy to the proposal so we don’t know what and what is in the proposal. Only that when the fund comes, they say now we are doing this”. Interview Forty-five year old Faustina Sarbah lives at Fudome Lomnava with her 9 kids and her husband. Like many residents in out-of-reach areas, Faustina who lost one of her kids to malaria has depends on malaria treatment though she has no idea of what causes. According to her, malaria is caused by too much work on the farmfatigue. (Did CBA’s not tell her or is she in denial?) Interview volunteer community-based agent Richard Nenyo Nenyo dispenses Artesunate Amordaiquine in Lomnava (population 400) where at least 4 people contract malaria every week. At the time of this interview, Nenyo has only two packs of amordaquine tablets left. Knowing he won’t be able to deal with many more cases, he has organized a ‘house-search’ to inspect residents’ rooms to check if they have mounted the treated insecticide nets. He wants residual spraying done here as a one-stop treatment for malaria. “I think it would be good because all the people (already) have the mosquito nets so when you come with the spraying, I will like it.” Interview Edith Boke, contact person for the NMCP in the region Edith Boke is the Focal Person for Malaria Control Prgoramme in the area. She denies that malaria deaths could be due to lack of drugs. “I don’t think it is due to lack of drugs because sometimes the volunteers are in the communities. And this home-based concept has ruled-out that the communities where we have our health facilities do not practice home-based care. (Is she saying that the home-based programme works because it works?) “What I suspect is that is either these cases are not coming from communities where the home-based care is going on. Because it’s not all the communities in the municipality where we have the Home-based care going on. So if you want to know where these deaths occurred, then we still have to go back to the hospital and check or check through the records and know where they came from and then we can conclude what happened.” ON TRYING TO GET INFO FROM THE NATIONAL MALARIA CONTROL PROGRAMME Efforts to reach the National Malaria Control Programme for response has proved futile as officials keep on avoiding interviews. A member of the programme’s communication team, Eunice Adjei, who acts as a liaison officer for journalists and the program, will not give out the name of the Program Manager after several interview appointments went hanging. She reveals details of the budget cannot be given out. According to her, what has been advertised on Global Fund website are the only data the fund wants to be put out. Update 29 September: Zack sent a letter to the Regional Health Directorate asking for statistics on malaria. He reports: “Interestingly, the director told me fetching me the data is “not an emergency” for the office. “ Data Kumasi 27 October General data Kumasi is the second largest town in Ghana. It is the capital of the Ashanti region. Despite claims by health officials, this region leads in malaria admissions, with more pregnant women contracting the disease (than anywhere else?). Out of a total of 42, 940 malaria patients admitted nationwide, 93,015 were recorded in Ashanti Region which also has the second highest pregnancy malaria--related cases. (THIS MUST BE A MISTAKE OR TYPO SINCE 93 015 IS MORE THAT 42940). With 29, 772, recorded cases the region comes behind Western Region. At least, 9 per cent of over 700,000 malaria patients who visited health facilities across the region were admitted in 2014 alone. But over the last 12 months, the Ashanti Region has received the highest consignment of insecticide- treated nets and drugs distributed by the National Malaria Control Programme. Out of 1, 373, 670 Long Lasting Insecticide Treated nets were distributed to primary schools nationwide, 4,050 schools in 220 circuits in the region received 253, 215 nets, representing about 20 per cent. Besides, the region took delivery of 178,500 cartons of 25/75 mg and 50/135 mg of Artesunate Amodiaquine supplied in 2014 by the Global Fund to districts which are implementing Home-Based Care for children under 5 years. So what is going wrong? Despite claims by Dr. Adomako-Boateng, deputy Regional Director in Charge of Clinical Services, that the Malaria Control Programme has never run short of drugs in the region, the 2014 national report acknowledges supply chain challenges (BUT THESE ARE GENERAL FINDINGS NATIONALLY, NOT ABOUT ASHANTI?). “Drugs and logistics are allocated but the regions delay in collecting them from the national level and when eventually the logistics arrive at the region, the districts also do not go and pick them. Sometimes, they have not been made aware of the availability of stocks”(Page 34) The National Malaria Control Programme admits ‘bureaucratic and artificial impediments’ hamper the smooth running of the programme, which sometimes delay allocation of drugs. “Dichotomy in leadership because allocation of drugs has to be divided (Artemisinin-Based Combination Therapies) signed by the National Malaria Control Programme and Acute Respiratory Infection and dirrahoea drugs sent for signing at Family Health Division and it takes months to get the letter to be signed”( 2014 National Malaria Control Programme Report. Page 34) Officials of the National Malaria Control Programme are patting themselves on the back for seeing a drop in the number of reported malaria cases at Out-Patient Departments OPD). The number of OPD malaria cases increased consistently (from 2010 to 2013, in the four years preceding the reporting period). However, 2014 saw a sharp drop from about 11 million cases in 2013 to 8.4 million cases with the proportion of OPD cases attributable to malaria dropping from 43.7% in 2013 to 30.9% in 2014. Institutional deaths due to malaria are also said to have declined. Officials attribute this to improved management of malaria cases. The commendation, however, comes as presumptive diagnosis and (presumptive?) treatment persist in health facilities across the country, especially, in the Ashanti Region. Even though the current policy is to test all suspected malaria cases before treatment (to avoid increasing resistance?), there are instances where many people who test negative for malaria are treated , putting data gathered at the health facilities into disrepute. Ironically, no care-giver has been punished for this professional misconduct in the past 3-years in the Ashanti and other regions. Dr. Fred Adomako-Boateng says his outfit must first deal with this cancer. “There is this challenge that I want to bring about. When people think they have malaria or the prescriber is thinking that based on this clinical signs and symptoms this person is having malaria, this person is sent to the lab; lab comes as negative and still the person is treated for malaria. All these things will go to the OPD morbidity statistics so it will give you that idea. So what we are saying is that the true burden of malaria is still not known”, he stated. This means there is no accurate data and statistics to represent the true state of malaria in the region. According to the 2014 National Malaria Control Programme report, Ashanti Region recorded 190 in-patient deaths. Vice President of NGOs in Malaria, Stephen Oracca-Tetteh, however, believes the figure could be higher. “I doubt it. That's why I'm saying that data collection in Ghana is a problem. It's a big issue so, virtually, I doubt it. It could be a bit higher but this figure I believe is coming from the facilities. So what about other facilities which were not covered? This is where the bone of contention, almighty question mark is. I believe it could be more than this”. Mr. Oracca-Tetteh is unhappy at the way Ghana’s National Malaria Control Programme has ‘hijacked’ programs meant to fight the disease in the country. He wants to see bureaucracies surrounding Malaria control activities broken. “Like I am saying, this calls for a holistic intervention. Most of the time, programs which come up where from the word go you don't involve the main stakeholders. I mean those on the ground at the community level. It becomes a problem for a successful intervention of such programs”. General observation Many district and sub-district heads appear not to be so much involved in the decision- making for malaria control activities. On bed nets Farmers in some communities use the insecticide treated nets, among other activities, to fence fencing of seed nursery fields and backyard gardens. For some young men, it is the ‘net’ behind the goal-posts on football pitches. Others use it for fishing. Many find them more useful on the farms. The practice is widespread at Asante-Bekwai and Ankaase in the Bekwai Municipality, Hemang in the Amansie District, Krobo, Kofiase in the Mampong Municipality as well as Kwanfinfini in the Atwima Mponua District. The majority of the farmers who received the nets have refused to sleep under them as they find them more ‘useful’ on their farms. More than two- thirds of them have visited the hospital in the last three weeks for malaria. Some of the victims have no idea about the cause or symptoms of malaria. Certainly, three mosquito nets are not enough for a family of 8. At Hemang, for instance, Opanin Osei Yaw, a farmer, lives with his family of seven, in a semi-detached mud house. He prefers to use one of the four mosquito nets he received from the National Malaria Control Programme to fence an oil-palm nursery because the seedlings are high demand here. He tells me that though the community benefitted from a residual spraying scheme; it has not been done for the past one year. His 2-year old grandson, Kwaku, has rashes all over his body. Osei Yaw attributes it to mosquito bites. Kwaku was discharged two days ago from the Jacobu Government Hospital where he had been treated for malaria. According to Opanin Osei, many residents at Hemang have been suffering from the disease. Mostly, they spend several hours outside their rooms, exposing themselves to mosquito bites. Some pregnant women at Fudome in the Volta Region, have refused to sleep under the insecticide- treated bed net because of what they say is discomfort. Some women rather keep the nets under their pillow. Enyonam Tsigah of Fudome is three months pregnant, and she refuses to use the net, though her 2-year old child has been receiving measles immunization. (WHY?) Twenty-one year old Samuel Nyarko, an apprentice mechanic, is watering his oilpalm nursery at Hemang. He looks forward to making a fortune from the activity, riding on the back of high demand for oil-palm seedlings.He hopes to make Gh900.00 (about 215 Euros) from the sale of the seedlings. Unlike Opanin Osei? Nyarko has no idea about the cause or prevention of malaria. It would arguably help a lot if all people exposed to malaria would be informed about prevention, testing and treatment. But you cannot blame them if they aren’t: out of Gh1, 624,205.54 budgeted for communication in the period; only Gh 315,683.8 was spent, leaving a whooping variance of Gh 1,308,521.63. Simultaneously, nets are diverted from free distribution and sold on the open market. A man in his 40s who had come to buy goats at Hemang explains how his friend [he refused to name] sold some of the treated nets his four children brought them from school where they had received them for free. For the father, it was opportunity for business so he seized the nets, sold them to make money to buy food for the family. (IF THE KIDS GOT THEM IN SCHOOL, THEY WOULD HAVE BEEN TOLD WHAT IT WAS FOR. THAT FATHER CANNOT PLEAD IGNORANCE. IS FOOD A HIGHER PRIORITY?) “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 parents and children called the office to report such activities”.[ 2014 National Malaria Control Programme Report Chapter 2, 2.3.2.2) Officials of the Ashanti Regional Health Directorate will not discount the use of treated nets for farming and other agricultural purposes, among other uses. Interview Stephen Oracca-Tetteh, NGO Health Vice Chairman of the Non-Governmental Organizations in Malaria, Stephen Oracca-Tetteh, a board member of Coalition of NGOs in Health, has been working on the field, helping fight malaria, especially, in rural Ghana. He has witnessed the rate at which donor-items are abused. “It's a reality on the ground. I have also been going round to those communities and it's interesting that the Ghanaian attitude you know, it’s so bad. Look at the donor money which has been used in purchasing these bed nets to prevent malaria. The Ghanaian has also decided to use it for otherwise. It’s serious. This is why sometimes I also believe that when things are free, people don't value it”. he lamented. For him, district assemblies and health directorates should collaborate to propose sanctions for people who divert items from donor support for personal gains. “If the assemblies can come out with some by-laws that people who are using these mosquito nets for farming, for agricultural purposes should be made to face some sanctions. I think it will deter them from using the nets so that it would be used for its purposes that are intended.” Some pregnant women also refuse to sleep in the treated net, citing discomfort among their reasons. Such refusal is common at Fudome, Kpeme,Hohoe, both in the Volta Region; and Akate in the Manya Krobo District in the Eastern Region, Asante Mampong in the Ashanti region. Typical of them, pregnant women in outof-reach communities like Fudome Lomnava, Abledze, Dzorkpe, Tonglo, Agumatsa , Aktafu, Mangotsi Kope near Likpe, Korpe who have no knowledge of the causes of malaria and their children spends long hours in the night outside their rooms only to suffer mosquito bites.