Effectiveness of public health systems to support national rollout strategies in Ghana
By Michael A. Neequaye and Wilhelmina Okwabi
Wilhelmina Okwabi is Deputy Director of Nutrition of the Ghana Health Service (GHS), a position she has held for 2 years. Her previous positions include Programme Manager of Nutrition and HIV/AIDS, National Coordinator for Infant and Young Child Feeding, Assismstant Programme Manger (Supplementary Feeding Programme) and Nutrition Course Coordinator in a Rural Health Training School.
Michael A. Neequaye works with the Ghana Health Service as the National Programme Manager, Nutrition Rehabilitation, and the National Coordinator for the CMAM programme since 2007. Previously he was the Regional Nutrition Officer of the Ministry of Health in the Eastern region of Ghana before joining World Vision Ghana as the Project Manager for the Micronutrient and Health (MICAH) Project for 10 years.
The authors gratefully acknowledge the support of WHO, USAID/FANTA-2, and UNICEF in writing this article. The Nutrition Department would like to mention in particular the following people for their invaluable contributions and comments during the development of the article: Dr. Isabella Sagoe-Moses and Cynthia Obbu, Ghana Health Service (GHS), Reproductive and Child Health Department, Samuel Atuahene-Antwi GHS, Ga South Municipal Health Directorate, Akosua Kwakye, WHO/Ghana, Alice Nkoroi, USAID/FANTA-2, Catherine Adu-Asare, USAID/FANTA-2, Ernestina Agyapong, UNICEF/Ghana, Maina Muthee, UNICEF/Ghana. Special thanks also to the Director General, Director of Family Health and other Divisional and Departmental Directors of GHS for their support in the integration of CMAM into the health service delivery in Ghana. Last but not least, GHS wishes to thank all Directors and staff working in the 31 districts implementing CMAM in Ghana.
|CHIM||Centre for Health Information Management|
|CHO||Community health officer|
|CHN||Community Health Nurse|
|CHPS||Community Health Planning Services|
|CHVs||Community health volunteers|
|CMV||Combined Mineral and Vitamin mix|
|CSO||Civil society organisation|
|DHMT||District Health Management Team|
|FANTA2||Food and Nutrition Technical Assistance Project II|
|GDHS||Ghana Demographic and Health Survey|
|GHS||Ghana Health Service|
|GPRS II||Ghana Poverty Reduction Strategy II|
|GSGDA||Ghana Shared Growth and Development Agenda|
|HIMS||Health Information Management System|
|HSMTDP||Health Sector Medium Term Development Plan|
|ICD||Institutional Care Division|
|IMNCI||Integrated Management of. Neonatal and Childhood Illness|
|IYCN||Infant and Young Child Nutrition|
|MOH||Ministry of Health|
|MUAC||Mid Upper Arm Circumference|
|NACS||Nutrition Assessment Counselling and Support|
|NHI||National health insurance|
|NID||National Immunisation Day|
|NMCCSP||Nutrition Malaria Control for Child Survival Project|
|NRC||Nutrition Rehabilitation Centre|
|PLHIV||People living with HIV|
|RCH||Reproduction and Child Health|
|RHMT||Regional Health Management Team|
|RUTF||Ready to Use Therapeutic Food|
|SAM||Severe acute malnutrition|
|SAM ST||SAM Support Teams|
|SAM SU||SAM Service Unit|
|SAM TC||SAM Technical Committee|
|SBCC||Social Behaviour Change and Communication|
|SFP||Supplementary Feeding Programme|
|PPME||Policy Planning and Monitoring and Evaluation|
|TMPs||Traditional medicine practitioners|
Medical examination of a child with SAM
National nutrition and health situation
Like most developing countries, Ghana is faced with high rates of malnutrition. According to the Ghana Demographic and Health Survey (GDHS) 2008, 14% of children under five years are underweight, 28% are stunted and 9.0% wasted. Severe wasting is 2.0% with the highest proportion of severely wasted in the Upper West (3.9%), Eastern (3.7%) and Northern (3.4%) regions of the country (see Figure 1 for map of Ghana). In terms of micronutrient deficiencies, the prevalence of anaemia is very high among women of reproductive age (59%), pregnant women (70%) and lactating women (62%). It is equally high among children under-five at 78% with no improvement seen when compared to the 2003 GDHS. Encouragingly, infant mortality has dropped from 64/1000 live births (GDHS 20031) to 50/1000 live births (GDHS 20082) whilst under-five mortality has dropped from 111/1000 live births (GDHS 2003) to 80/1000 live births (GDHS 2008).
Over recent years, the country has developed and implemented a number of strategies to combat malnutrition. Progress has been made, with an increase in exclusive breastfeeding rate among infants less than 6 months from 53% (DHS 2003) to 63% (DHS 2008). Progress has also been made towards the achievement of the MDG 1 target of halving underweight by 2015. The prevalence of underweight has reduced from 23% in 1993 to 14% in 2008, however, major challenges remain. There has been limited progress in reducing stunting (chronic malnutrition), the prevalence of which has fallen by only 6 percentage points since 1988. Ghana is among the 36 countries with a stunting prevalence above 20%3. Whilst levels of wasting have remained relatively constant, it is also of concern that the rate of overweight among children under five years is on the increase (from 1% in 1998 to 5% in 2008), indicating a dual burden of malnutrition.
Health and nutrition policies
The National Nutrition Policy is currently being drafted4. Prior to the development of the national nutrition policy, a strategic document ‘Imagine Ghana free of Malnutrition5’ was developed by a multi-sectoral group of stakeholders. The document set out strategic nutrition objectives and provided costing for implementing nutrition interventions to meet the set objectives. This document is currently being used as the basis for the nutrition policy, updating and aligning Ghana’s nutrition priorities to address under-nutrition using evidence-based nutrition interventions.
The Ghana Health Sector Medium Term Development Plan (HSMTDP) 2010–2013 and the Ghana Shared Growth and Development Agenda (GSGDA), which is a follow on document to the Ghana Poverty Reduction Strategy II (GPRS II), identify nutrition and food security as critical and cross-cutting issues in addressing overall human resource development. The GSGDA sets out policy objectives to address issues relating to nutrition and food security. Both aforementioned documents express particular concern regarding the persistent and high undernutrition rates among children, particularly male children in rural areas and in northern Ghana. The HSMTDP identifies the scale up of CMAM as an important intervention for helping to reduce under five mortality rates and also for improving the nutrition status of women and children.
Vulnerability to emergencies
The Comprehensive Food Security and Vulnerability Analysis conducted by the World Food Programme (WFP) in May 2009 showed that, although Ghana is generally less affected by food insecurity compared to other West African and sub-Saharan countries, about 1.2 million Ghanaians are food insecure. A further 2 million people are vulnerable and could experience food insecurity during adverse weather conditions, such as floods or droughts, and as a result of post-harvest losses. Although the prevalence of acute undernutrition is below emergency thresholds, nutritional challenges threaten Ghana’s overall social and economic development. There are regional variations in food security and undernutrition in the country. The Northern regions (Upper East, Upper West, and Northern) have a higher prevalence of underweight and wasting that are closely linked to food insecurity. Lack of access to food is also a determining factor for acute undernutrition in the coastal zone.
Organisation of the Ghana Health System (GHS)
The Ministry of Health (MOH) is the government ministry in Ghana that is responsible for the formulation of national health policies, resource mobilisation, and health service delivery regulation. The MOH has a number of agencies, including the Ghana Medical and Dental Council, the Pharmacy Council, Ghana Registered Nurses and Midwives, Alternative Medicine Council, Food and Drugs Board, Private Hospitals and Maternity Homes Board, National Health Insurance Secretariat, Ghana National Drugs Programme, teaching hospitals and the Ghana Health Service (GHS). See Figure 2 for an overview of the GHS structure.
The GHS is an autonomous body under the MOH, responsible for healthcare provision in accordance with MOH policies through public hospitals, health centres, and Community Health Planning Services (CHPS) compounds. The GHS provides in-service training and develops guidelines and plans for implementation of national health policies. Private and faith-based health facilities, such as mission hospitals, administer approximately 40% of healthcare services in the country. While independent, these facilities are bound by national MOH policies and GHS guidelines and are required to submit statistics and reports to the GHS.
The Family Health Division under the GHS has three departments: Reproductive and Child Health, Nutrition, and Health Promotion. The Nutrition Department assigns Programme Officers for the various nutrition programmes such as Infant and Young Child Nutrition (IYCN), Nutrition Malaria Control for Child Survival Project (NMCCSP), Micronutrient Control Programme, which covers vitamin A, iron deficiency anaemia, iodine deficiency disorders and food fortification, Nutrition Rehabilitation, which includes CMAM and Nutrition Assessment Counselling and Support (NACS) for PLHIV, and the Supplementary Feeding Programme (SFP) in Northern Ghana. At the regional and district levels, there are assigned nutrition officers, while at the subdistrict levels a health manager (Physician Assistant or Public Health Nurse) oversees nutrition activities along with other health activities.
Health services delivery
There are three semi-autonomous referral teaching hospitals, one each in the northern, central and southern parts of the country. There are ten regions of Ghana, divided into 170 districts, and each region has a regional referral hospital. All districts are expected to have a district hospital, which serves as the first referral level. However, some of the newly created districts have upgraded health facilities rather than hospitals, due to variations in levels of staffing and equipment. Districts are further divided into sub-districts, which have health centres headed by Physician Assistants and staffed with clinical and public health nurses and other auxiliary staff. Some of the larger urban health centres, referred to as polyclinics, are staffed with physicians in addition to the personnel mentioned above. Additionally, there are 42 Nutrition Rehabilitation Centres (NRCs) that were established to manage malnutrition prior to the introduction of CMAM. Ten of the NRCs provide residential nutrition care. NRCs tend to be clustered in more urban areas. Administratively, the GHS is managed at the regional and district level by health directorates.
Beyond the sub-district level, community level health services are provided through different mechanisms. Two of the more developed mechanisms include child welfare outreach points (run from health centres) and CHPS zones. The CHPS zones comprise communities of 3,000 to 4,500 people (generally two to five villages), to which a community health officer6 (CHO) is assigned to provide primary health care services from the CHPS compound (the nurse’s home and office, built by the community) and through frequent home visits. The CHO is supported by a number of community health volunteers (CHVs) selected by a community health committee, comprised of village leaders, women’s and youth groups, traditional birth attendants and others.
Across the different levels of service delivery, health staffing is generally adequate with exceptions in newly formed districts. The Northern regions also tend to have fewer physicians and nurses compared to the southern and central parts of the country because these regions are less developed.
CMAM integration and scale up in Ghana
Introduction of CMAM
CMAM was first introduced in Ghana in June 2007 at a workshop organised by the GHS in collaboration with UNICEF, WHO and USAID for selected health care providers throughout the country. See Table 1 for an outline of key events in the development of CMAM in Ghana. Prior to 2007, the GHS had addressed the needs of children with severe acute malnutrition (SAM) in paediatric wards or NRCs, which provided nutrition counselling and foods cooked using locally available ingredients. However, these NRCs did not follow the WHO 1999 treatment protocol for the management of SAM7 or provide any specialised therapeutic foods for children with SAM.
|Table 1: Key events timeline|
|June 2007||- Workshop organised to introduce CMAM into Ghana.|
|December 2007||- Severe Acute Malnutrition Technical Committee (SAM TC) formed to plan and coordinate the integration of CMAM into the health delivery system.|
|March 2008||- Sensitisation of regional and district health directorates on CMAM in Central and Greater Accra regions where learning sites were selected.|
|April 2008||- Training for health staff in the learning sites on outpatient and inpatient care.
- Training of volunteers in community outreach.
- Initial outpatient care facilities established in the learning sites of Ashiedu Keteke (2) and Agona Districts (7).
|July 2008||- Field testing of the generic community outreach module conducted in Ghana. This is part of the FANTA, VALID, UNICEF, Concern Worldwide and other partners CMAM training modules developed in 2008.|
|March 2009||- CMAM activities scaled up within the learning sites to provide district-wide coverage in Agona West Municipality and Agona East District.|
|May 2009||- Field test of the global CMAM costing tool.|
|July 2009||- Conducted a CMAM training of trainers workshop for regional health staff from Phase 1 regions (Northern, Upper East, Upper West, Central and Greater Accra).|
|August 2009||- Conducted the first expanded WHO training of facilitators and clinicians workshop on the management of SAM in inpatient care. The expanded WHO training included the management of SAM in the context of CMAM.|
|January 2010||- Initiated the review and adaptation of the generic CMAM training materials developed by FANTA, VALID, UNICEF, Concern Worldwide and other partners in 2008 to the Ghana context. This included recent global developments and best practice in the management of SAM.
- Initiated the review and adaptation of the generic WHO training materials for inpatient manage ment of SAM in the context of CMAM in Ghana.
|May 2010||- Scale up of CMAM started in the Phase 1 regions (Upper West, Upper East, Northern, Greater Accra and Central).|
|Feb 2010||- The SAM TC approved the Interim National Guidelines for CMAM and Job Aids.|
|August 2010||- Review of the integration of CMAM services into the health system.|
|January 2011||- Consolidated feedback from the regions and districts implementing CMAM on the Ghana adapted CMAM training materials.
- Consolidated the feedback from clinicians and other trainers on the adapted Ghana inpatient care training materials.
|January 2011||- Conducted regional SAM STs refresher training and annual planning workshop.|
|January 2011 to date (Aug 2011)||- Ongoing scale up of CMAM within Phase 1 scale up regions.|
Following recommendations from the June 2007 workshop, the MOH/GHS adopted the CMAM approach for the management of SAM with the establishment of learning sites in two districts, Ashiedu-Keteke sub-metropolitan area (Greater Accra region) and Agona District (Central region) in April 2008. The learning sites were later expanded to Ga South district in March 2009. These learning sites provided accessible practical experience and an opportunity to refine the strategy for the scaling-up of CMAM in phases.
Integration and scale up of CMAM
CMAM integration and scale up within Ghana has been planned in a two-phased approach. Phase 1 targeted five regions: Upper West, Upper East, Northern, Central and Greater Accra. The second phase will target the five remaining regions of Western, Eastern, Volta, Ashanti and Brong-Ahafo, which is expected to start in 2012.
The Phase 1 scale-up of CMAM began in 2010, with a limited number of districts and a gradual expansion to additional districts in 2011. CMAM scale-up activities have specifically focused on strengthening the capacities of the GHS and nutrition partners and developing competencies for sustainable, quality services for the management of SAM. An enabling environment for CMAM was created and competencies strengthened in partnership with UNICEF, WHO, USAID, the USAID-funded Food and Nutrition Technical Assistance Project II (FANTA-2), national training institutions, and other partners in health and nutrition.
In Ghana, the operational strategy for CMAM is managed by the SAM Technical Committee (SAM TC) at the national level. At the regional level, support teams working under the regional health director oversee the roll-out of CMAM within their regions.
CMAM services and supplies were made accessible in a sustainable manner, in order that quality services could be provided to children with SAM. To ensure quality service provision, each region initiated CMAM in one or two districts with a limited number of outpatient and inpatient sites. These facilities acted as learning sites for the region, with services then gradually scaling-up to the rest of the districts in the region. Decisions to expand CMAM to new districts were based on the quality of service delivery at the learning sites, the availability of qualified technical personnel to provide technical support and the availability of resources and supplies to ensure continuous service delivery in all new districts.
A five-year National Scale up Strategy is currently being developed. It is expected that the National Strategy for CMAM will be discussed and endorsed in a national workshop.
The MOH/GHS is responsible for the overall coordination of CMAM services, creating an enabling environment and providing CMAM services. The MOH/GHS health care providers manage SAM cases in outpatient and inpatient care and collaborate with health volunteers to conduct community outreach activities. Other GHS human resources at managerial and auxiliary levels support CMAM services as part of existing routine health services. MOH/GHS national, regional and district technical officers are responsible for building the capacity of the implementing health care providers.
The GHS is also responsible for distributing and storing CMAM supplies through the existing GHS logistics system. The GHS also provides routine medication (antibiotics and malaria prophylaxis) free to children with SAM in some facilities.
Partners currently supporting the integration and scale-up of CMAM in Ghana are USAID, USAID/FANTA-2, UNICEF and WHO. The partners provide technical assistance that includes facilitating the development of guidelines, training materials, monitoring, reporting and quality improvement tools, and supporting the review of the learning sites that inform design of the CMAM services. UNICEF and USAID also procure CMAM supplies for the government and provide financial support to the GHS to conduct trainings and other capacity building activities.
Implementation of CMAM in Ghana
Follow up visit on a SAM child to prevent defaulting
Enabling environment for CMAM
The MOH/GHS has taken the lead role in the integration of CMAM into the national health system. In December 2007, the GHS established the SAM TC to coordinate and oversee implementation and integration of CMAM activities into the service delivery system at all levels in Ghana. The SAM TC is chaired by the GHS Nutrition department and is composed of a range of representatives, including other GHS Departments, Institutional Care Division (ICD), Child Health, Policy Planning and Monitoring and Evaluation (PPME), Korle-Bu Teaching Hospital (representing the academic institutions), and partners (UNICEF, WHO, USAID and FANTA-2).
The SAM Service Unit (SAM SU), which is a core team of the SAM TC, is housed in the GHS/Nutrition Department and receives technical and financial support from USAID, FANTA-2, UNICEF and WHO. It is responsible for providing day-to-day technical guidance, coordination and advocacy for CMAM.
At the regional level, SAM Support Teams (SAM STs) were established in January 2010. Their role is to plan and coordinate CMAM implementation within the region and provide technical support to the districts and facilities. The regional SAM STs comprise of GHS staff specifically the Regional Nutrition Officer, Regional Public Health Nurse, Regional Disease Control Officer, Regional Clinical Care Officer (from the ICD) and an appointed clinician/ paediatrician trained and experienced in inpatient care. The Regional SAM STs report to the Regional Health Director.
Integration and scale-up of CMAM is a key component of nutrition in the HSMTDP 2010–2013. The SAM TC prepares national annual CMAM work plans and also supports the regions to prepare region-specific CMAM scale up plans. These work plans are then integrated into the overall regional and national GHS annual work plans in line with the health sector plan. The nutrition policy under development will include policy guidance on implementation and scale up of CMAM in Ghana.
The MOH/GHS has developed and disseminated the Interim National Guidelines for CMAM in Ghana that are widely used within the implementing regions. CMAM has also been integrated into the new IMNCI (Integrated Management of. Neonatal and Childhood Illness) chart booklet and training materials. In addition, the WHO pocket booklet is currently being updated to reflect Ghanaspecific adaptations and will provide guidance to clinicians on the management of SAM in the hospitals.
Competencies for CMAM
In order to integrate and scale-up CMAM in Ghana, it has been necessary to conduct inservice training for health care providers to improve their knowledge and skills in recent global developments and best practices in the management of SAM. Since 2008, the SAM SU and regional SAM STs have spent considerable time conducting training to build the capacity of health care providers at the national, regional, district and facility levels. Training has also been provided to CHVs on active case search, follow up and referral of SAM cases. To date, approximately 1,473 health care providers and 6,555 CHVs have been trained on the management of SAM. Table 2 provides details of health care providers and CHVs trained since initiation of CMAM in Ghana.
|Table 2: Number of health care providers and community volunteers trained (as of August 2011)|
|Region||Number trained in outpatient care (OPC)*||Number trained in inpatient care (IPC)||Community Health Volunteers (CHV)|
|Upper East Region||156||37||304|
|Upper West Region||190||28||1816|
|National Level Trainers||23||25||-|
*District nutrition officers, disease control officer, CHN (Community Health Nurse)/CHO trained on CMAM provide training to community volunteers
In addition to in-service training, the SAM SU and regional SAM STs provide continuous supportive mentoring and supervision to the DHMT and facilities implementing CMAM. Interns from tertiary institutions assigned to the Nutrition Department and within the implementing districts receive training and orientation to provide support in the management of SAM cases. Medical and Dietetics students from the University of Ghana on rotation at Princess Marie Louise (PML) Children’s Hospital (one of the learning sites) are also orientated and participate in the management of SAM.
Access to CMAM services
Appetite test being conducted
In 2008, CMAM service provision started in limited learning sites with one district in each of two regions, Central and Greater Accra. In 2009, new learning sites were set up in Ga South District of Greater Accra region to provide a learning experience within a peri-urban setting. Gradual expansion to other facilities within these districts and expansion to new districts in 2009 increased access to services.
In 2010, the SAM TC and SAM SU initiated Phase 1 scale up within Central, Northern, Greater Accra, Upper East and Upper West Regions (See Table 3). Each region followed the same process of implementing a limited number of outpatient and inpatient care sites in one or two districts, which served as learning sites, before gradually scaling up to other districts. Selection of initial districts was based on prevalence of malnutrition, availability of staff and geographical accessibility.
CMAM services are provided within existing MOH/GHS service delivery structures. Health facilities providing outpatient care include hospitals, polyclinics, health centres, community clinics, CHPS and community outreach points. Inpatient care services are provided solely in hospitals.
|Table 3: Summary of health facilities implementing CMAM (as of August 2011)|
|Region||Total number of districts||Number of districts implementing CMAM||Total number of facilities in implementing districts||Total number of outpatient care facilities||Total number of hospitals in implementing districts||Total number of inpatient care facilities|
* Staff in one hospital in Ashanti (a phase 2 region) was trained because of the high case load.
CHVs, Community Health Nurses (CHNs) and CHOs undertake the community outreach component of CMAM. Existing volunteers used for other public health outreach activities, such as National Immunisation Days (NIDs), vitamin A supplementation, community surveillance and guinea worm eradication, are being used for CMAM community assessment and mobilisation. This ensures the efficient use of volunteers and takes advantage of additional motivation as these volunteers are given an incentive package to support the NIDs. The volunteers generally support one community each, although some support two or three communities if they are relatively close to each other.
CHVs screen children at the household level by measuring Mid Upper Arm Circumference (MUAC) and checking for oedema. They refer SAM cases to the nearest health facility. Active case finding of children with SAM is also conducted during the child welfare clinics (usually once per month) and during child health weeks. In communities where there are CHPS zones/compounds, the CHVs work in close collaboration with the CHOs.
Some strong links have been established between identification of SAM and other public health programmes. For example, assessment of MUAC and oedema has been incorporated into the World Bank supported NMCCSP (Nutrition and Malaria Control for Child Survival Project) training modules. Additionally, the Ghana IMNCI has adopted the new algorithm, which uses MUAC, bilateral pitting oedema and appetite test to diagnose SAM with and without medical complications. The IMNCI chart booklet and training materials also provide guidance on how children with SAM without medical complications should be managed in outpatient care, and explains how to refer children with SAM with medical complications to inpatient facilities.
There is a linkage also between HIV services and CMAM. Children with SAM who fail to thrive are referred for further investigation, which includes HIV testing and counselling and referral to HIV services if necessary. Children with HIV who are severely malnourished are also treated using the national CMAM protocols.
Access to CMAM supplies
UNICEF procures and provides anthropometric equipment, Ready to Use Therapeutic Food (RUTF), therapeutic milk (F-75, F-100), Rehydration Solution for Malnutrition (ReSoMal) and Combined Mineral and Vitamin mix (CMV) for the programme. USAID is also procuring RUTF, F-75 and F-100 to support two regions and has committed funds for procuring CMAM supplies to support scale up in 2012.
The RUTF and equipment are stored at the National MOH/GHS warehouse. The supplies are then requested by facilities at national, regional and district level and distributed through the existing GHS supply chain system. Stock reporting has been incorporated into the weekly tally sheets and monthly reports to systematise and improve stock control and reduce the risk of ‘stock-outs’ due to delayed requests for re-supply. Health care providers have been trained to use the system, whereby they report on inventory levels on a monthly basis and make requests to the DHD for supplies when they reach a minimum stock level.
Quality of CMAM services
Standardised treatment protocols and job aids have been developed and are being used at all CMAM operational districts, facilities and communities. Adherence to the protocols is high, although there are variations between individuals and facilities. Experience to date has indicated that the main determinants of good adherence to standardised treatment protocols are the intensity of supervision and support received during the initial two to three months of setting up inpatient and outpatient care facilities from the national SAM SU and regional SAM STs, and the level of training received by the implementers.
The national SAM SU and regional SAM STs provide monthly and quarterly supportive supervision to the regions, districts and facilities. The DHMT also carries out weekly/bi-weekly supportive supervision. The focus of the support and supervision is on adherence to CMAM protocols, admission procedures, use of the action protocol, the quality of screening and assessment of malnutrition using MUAC tapes, testing for bilateral pitting oedema, and the quality of individual and service data recording and reporting. The quality of the management of SAM is high partly due to this intensive supportive supervision.
The CMAM monitoring tools for care include outpatient care treatment cards, tally sheets, client registers and reporting forms, bin cards or tally sheets for supplies, supervision checklists for regional and district levels. There is generally good record keeping and reporting by the service providers. CMAM service performance is reviewed monthly at all levels: sub-metropolitan area, municipality, district, regional and national levels. CMAM data are currently managed by the nutrition officers and not yet integrated into the Health Information Management System (HIMS). Discussions are ongoing with the Centre for Health Information Management (CHIM) to review existing nutrition indicators in the system to also include CMAM indicators. CMAM data are collated at the district level and the data are then sent to the regional level where they are entered into an Excel database before being submitted to the national GHS/Nutrition Department.
CMAM service performance
Table 4 and Figure 3 provide a summary of the total number of children who were managed and some service performance indicators (from inception to August 2011).
|Table 4: Summary of CMAM performance data (to August 2011)|
|Region||Total admissions||Total discharges||Cured||Died||Defaulter||Non-recovered|
Cure rate: Overall, 71% of children were discharged cured, which is below the recommended Sphere target of >75%. The cure rate was offset by the high default explained below.
Death rate: Overall, 2% of children died, which is an acceptable rate for the management of SAM and below the Sphere standard of <10%. Many of the children who died had presented to the health facility at a very late stage or refused referral to the inpatient care for social reasons.
Default rate: The number of children who defaulted treatment was high (21%) and above the recommended Sphere standards of <15%. The high default rate can be explained by:
- Caregivers default treatment as soon as the child starts to improve. RUTF is quite effective and children will start to show significant improvement in the third week. The health workers are urged to provide intensive counselling to caregivers to ensure that children continue to come for treatment until they are fully recovered.
- Cases where children are coming from neighbouring districts that do not have CMAM established. As soon as the child starts to show improvement, the mothers discontinue treatment. It is assumed as scale up continues and there is more access to CMAM services, the default rate will decrease.
- Seasonal migration of caregivers of children with SAM already receiving treatment, especially during planting and harvest seasons.
Non-recovery rate: Overall, 1% of children were discharged as non-recovered. Average length of stay (LoS) and average daily weight gain: A total of 515 cards of children discharged as cured were used to analyse the average length of stay and weight gain. The average length of stay was 60 days and weight gain reported at 6.0 g/kg/day.
Promising practices (successes)
The following are notable promising practices and successes in the Ghanaian experience of rolling out CMAM:
Consensus building prior to rolling out CMAM between development partners (WHO, UNICEF, USAID), and the GHS was the key factor that enabled the principal stakeholders to become active members of the SAM TC. The good coordination established prior to roll out facilitated access to the funding required to hire sufficient external technical expertise and to purchase supplies. Selection of learning districts from regions already supported by partners made funding more easily accessible for CMAM.
The decision by the GHS to request external and in-country technical support at the planning stage allowed the existing national expertise to quickly gain confidence and to ensure the implementation of good practices from the start. It also facilitated the process of adapting guidelines and training materials to the Ghanaian context.
Exposure of the CMAM Coordinator to the experience of CMAM scale-up in other countries was key to building confidence in CMAM. This enabled effective advocacy for CMAM within the GHS Nutrition Department at the national level, District Health Management Teams (DHMTs) and Regional Health Management Teams (RHMTs).
The lead role taken by the GHS during the planning and implementation resulted in the rapid uptake of services at all levels (national-, regional- and district-level structures), which facilitated the institutionalisation of CMAM.
The establishment of a SAM TC as a forum for guidance and coordination of CMAM implementation and scale-up was an important step in a number of ways. It helped to speed up the understanding of CMAM, the development of interim guidelines and the strengthening of national competencies.
The learning site approach to implementing CMAM generated lessons learned and promising practices informed the process of scale-up.
The integration of CMAM outpatient care into the Reproduction and Child Health (RCH) service package, which mostly includes preventive activities, was very successful. The public health teams responsible for delivery were highly motivated by the rapid clinical improvement of children with SAM.
The approach of training most CHNs at the learning sites, as opposed to training only two or three CMAM focal people, enhanced team work and support for the programme. It maximised the chances of continuity of care and helped to convince implementers that CMAM is a government-owned intervention with a longterm perspective that requires the involvement of all health care providers.
Ensuring intensive and close monitoring and mentoring of implementers by adopting frequent supportive supervisory visits at initiation of services was a successful approach. It contributed to good quality service provision and also proved to be an effective motivator for staff implementing the programme.
MUAC measurement of a child with SAM in Nyakrom hospital, Ghana
Distribution of RUTF during the start of the programme used the same channels as other health supplies (employing the same transport and warehouse). This reinforced GHS ownership, minimised perceptions of the intervention as ‘vertical’ and increased the likelihood of the distribution system being sustained.
The CMAM programme did not select new volunteers, but used the same CHVs as for other health programmes. This minimised the risk of volunteers requesting a special motivation scheme and enhanced the integration of active SAM case finding with their activities.
Mother-to-mother sensitisation was used successfully, based on the ideas of ‘positive deviance’ whereby mothers/caregivers of recovering children are encouraged to sensitise caregivers of malnourished children to the existence and effectiveness of CMAM.
The CHNs initiated the use of new information technology (SMS messages and telephones) to communicate with the CHVs prompting them to conduct follow-up activities. This helped to increase the proportion of defaulters who returned.
At the district level, collaboration between managers of different interventions within the DHMT ensured the integration of trainings and sensitisation meetings. For example, resources for the National TB programme and NIDs were used to sensitise community workers on CMAM and/or provide refresher training to community volunteers. This kind of synergy optimised the output of the programme, ensuring that more communities were sensitised and more volunteers trained than the available CMAM budget allowed.
Despite the successes of CMAM implementation, some challenges and/or weaknesses have been identified (either through the CMAM review or through internal review) that need to be addressed:
- There is a lack of funding to support scale up to all the Phase 2 regions.
- Community mobilisation did not specifically target the traditional medicine practitioners (TMPs). As such, children with SAM who are taken to these informal providers first, due to the belief that SAM is a spiritual problem (‘evil eye/curse’), are not identified and referred.
- The defaulter rate is high. This is because some of SAM cases come from districts that have not initiated CMAM, making followup difficult once clients go back to their districts of origin.
- It has been observed that volunteer fatigue sets in after a while, particularly in the urban areas. There is a need to find ways of sustaining the enthusiasm and commitment of volunteers.
- Not all SAM cases being managed at the outpatient care facilities receive routine medication. This is because although treatment is supposed to be free to children under-five years, some health facilities are not able to provide free treatment to the children who are not registrants of the national health insurance (NHI) scheme.
- Initial attempts to produce RUTF in-country failed after management issues with the selected company led to the inability of the company to meet conditions for start up.
Risks to scaling up
At present, there are a number of risks to the scale up of CMAM in Ghana. Although regional and district SAM STs help to reduce the workload of the national SAM SU, as CMAM expands nationally, the SAM SU will not have sufficient staff to successfully manage this phase of scale up. Inadequate funding for training, mentoring and supervision is a constraint, especially in Phase 2 regions that are not the focus of development partners. This will require continuous advocacy for resource mobilisation to support the scale up. Ensuring adequate and sustained availability of CMAM supplies (RUTF, F-75, F-100) remains a challenge. The high quality of CMAM service might be compromised if initial supportive supervision is not maintained during Phase 2 scale up.
The next steps for CMAM activities in Ghana are to:
- Develop a five-year CMAM scale-up strategy (2012–2016).
- Integrate CMAM into pre-service training curricula for medical, nutrition, dietetics and nursing students.
- Conduct a coverage survey to determine the extent of SAM within the community, the current access and uptake of CMAM services and the barriers to access and uptake that exist.
- Include CMAM supplies, especially RUTF and CMV, into the national essential medicines list and hence the NHI drug list.
- Develop linkages between CMAM and informal health systems such as the TMPs.
- Conduct a capacity assessment to identify and prioritise the introduction of CMAM activities within Phase 2 regions (Western, Eastern, Volta, Ashanti and Brong-Ahafo).
- Strengthen Social Behaviour Change and Communication (SBCC) for CMAM and link with IYCN, using quality improvement tools and systems at the community level.
- Facilitate the involvement of civil society organisations (CSOs) to strengthen the community outreach component of CMAM.
- Continue to advocate for national production of RUTF.
For more information, contact: Mr Michael Neequaye, email: firstname.lastname@example.org
Ghana Health Service: http://www.ghanahealthservice.org/
1Ghana Demographic and Health Survey, 2003
2Ghana Demographic and Health Survey, 2008
3Black et al, 2008. Maternal and Child Undernutrition 1. Maternal and child undernutrition: global and regional exposures and health consequences.
4As at November 2011.
5‘Imagine Ghana Free of Malnutrition’, NMCCSP Programme supported by the World Bank
6A Community Health Officer is a Community Health Nurse or Midwife who receives additional training, upgrading his/her skills to manage a CHPS zone.
7WHO. 1999. Management of severe malnutrition: A manual for physicians and other senior health workers.
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Reference this page
Michael A. Neequaye and Wilhelmina Okwabi (2012). Effectiveness of public health systems to support national rollout strategies in Ghana. Field Exchange 43: Government experiences of CMAM scale up, July 2012. p21. www.ennonline.net/fex/43/effectiveness