National Onchocerciasis Committees, fifteenth meeting, Ouagadougou, 28-30 May 1991: Ghana

WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LASANTE ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFRTQUE DE L'OUEST NATIONAL ONCHOCERCIASIS COMMITTEES NOC15.4 Fiflteenth meeting ENGLISE g]ILy Ouagadougou. 28-30 May 1991 GHANA GHANA I'10C15.4 A. PROGRESS REPORT ON DEVOLUTION 1. The Devolution Programme is pJ-anned to operate within the goals of the National Health Services. This is to maximize the total healthy life of the Ghanaian people, with the objectives of achieving basic primary health care for all by the year 2000 and effectively attacking the heal-th problems that contribute to deaths and disabilities afflicting Ghanaians by the year 2000. 2. Ghana's Devolution PLan combines the control 0f Onchocerciasis with the eradication of yaws and guinea worm, and the control of leprosy. The control of these di-seases is being integrated into the national progralnme for disease control in the g'eneral framework of Primary Health Care. 3. The Government's policy objectives for these diseases are: onchoeert:i asi s: i. To prevent a recrudescence of the disease in ii. To safeg'uard the achievement of the Control Yaws: i. To update information on the prevalence of country ii. To eradicate the disease from the country by the end of 1995 Leprosy: i. To update iniormation on the prevalence of leprosy in the country ii. To reduce incidence of the disease Guinea Worm: i. To determine the extent of Guinea Ghana ii. To eradicate Guinea worm from the 1993 the OCP zorLe Programme. yaws in the worm infestation in country by the end of aL 4. The Ghana Pl-an f or devol-ution was presented to the Joint Programme committee of the oncho contror progranime tn Decemberr 1990. since then, copies of the report have been produccd and widely circulated among: members of Government for their study. This was necessary for two reasons: i. To secure Government approval of the programme for financing; and ii. To give political backing to its implementation. Formal- approval of the devolution plan was received on 16th May 1991 5. Meanwhile the strengthening of the health infrastructure and institutions is being implemented through the Public Investment Programme. New Heal-th Centres/posts are being buiIt, among which are Fumbisi, Kubore, Mankarig.u and yagaba Health Centres. The MOH will provide laboratory facilities for alI Service Delivery Points (sDPs). Already, the training of Laboratory Assistants has started in order to produce laboratory personnel to serve at the health centre leve1. In addition, ophthalmic nurs3s and technicians in entomology and parasitology are being trained tn local institutions. 6. The Devolution Implementation Committee which meets regularly as a Sub-committee of the National oncho Commi.ttee hils drawn up plans for launching the Devolution Programme in the lattor part of June, this year. The launchingwill be done by very senior members of g'overnment and is aimed at giving the devolution prograrnme publicity and political impetus. It will be followed by the reactivation of RegionaI, District and Village Oncho Committees which have already beenlformed but which have become dormant. 7 - In the meantime, Medical Assistants in charge of leveL B stations in the progralnme are receivi.ngr traininq in the use of Ivermectin., So far, all medical assistants in the Northern Region have been trained and supplied with rvermectin for passive atreatment of oncho. patients. Training in the Upper East and west Regions will be completed in June 1991 8. A major component of the devolution plan is in the area of public information, education and communication. There already exist structures at the di.strict and community levels for effective information, education and communication (rEC. ) These invorvehealth workers as well- as collaborators from the g'overnment sectors such as the Ministry of rnformation, Ministry of Education, Ministry of Mobilization, The Committees for the Defence of the Revolution, Thirty First December women,s Movement, The press andOther NGOS. 9. Training modules for Guinea worm and Leprosy have beenprepared and are ready for printing. Those for onchocerciasis and yaws are in preparation. 10. rt is the Government's policy that the District in line with the PHC strategy, will be the unit for the implementation of the Devolution prog'ramme, basing the health care delivery on a 3 tier structure ie, Level_ A (the community) Level B ( the health centre/health post ) LeveL C (the district) The district is managed by a District Health Management ream which is headed by a District Medical officer. The health centre operates within a "catchrnent area" of 10 kir-ometres radius or more. Thehealth workers at the health centre wirr- manag.e devolution activities jointly with the community health workers in al_l the communities that falI within their catchment area. are Traditional Birth Attendants (ATBs )and community clinic Attendants (ccAs) These community health workers are supported by Government and Non-Government organizations including revorutionary organs. For the Devol-ution rmplementation, the community members are bein,-r trained to be ableto identify rand report the presence of biting fr_ies and theirbreeding sites as well as any person with clinicar- chang.es tassociated with onchocerciasis, yaws, leprosy and guinea worm for examination and treatment. Such report is sent to level B health personnel who are aLso receiving the necessary training to be able to examine pati,ents who attend clinics. They will- also conduct surveys to determine the presence of devolution diseases. At the district leveI. the district health personnel who ar€t reguired for the devoLution activities include: 1. District Medical Officer ii. District Public Heal-th Of f icer iii. District communicabLe disease control officer iv. District Environmental Health Officer v. District Health Education Officer At the Regionar Lever, medical specialist wilr give technical support to the level C or district Level- personneL in carrying out their devolution activities . There will be a team of special-ists who wilL visit the districts to monitor the prog'rammes through assessment of plan mechanism at a1l, l-eveLs of the programme activities to ensure that thqe institutional arrangements that have been put in place is satisfactorily implemented. B. tr HEALTH EDUCATION ACTIVITIES IN THE NORTHERN AND UPPER REGIONS L1'. Health Education activities of the Oncho Freed Zone areas of the Northern and Upper Regions are currentl-y concerned with the training of heal-th personnel in effective communication ski11s, family planning expanded prog'ramme and immunization, Diarrhoea, aids, onchocerciasis,Yaws, Leprosy and Guinea worm. The health education officers as much as possible use the integrated programme approach to co-ordinate al-1 Primary Health Care activities with most Government institutions and departments as well- as some Non- Governmental Organi zations . L2. Methodol-ogies used by the off icers to get the messag:e across to the public are through lectures, group discussions, drama, songs, radio, video and firm shows. rt has been observed that the method of the use of songs and drama has been a very effective one in carrying across the health messag'es to the public. Local singing g'roups are used for such cases. The GBC,/URA radio station in Bolgatanga has also been fuI1y utilized for sending health messages to the public. Discussions, debates, songs and drama are played back to the public. 13. The community l-eaders such as chief s, assembly men, teachers, members of the cDRs and members of the district,/vLrlages Oncho Committees have been useful in organrzing the people for the health education session campaigns. with regards to the implementation of the devolution p1an, intensive health education campaigns have so far been extended to areas in the WaLewale, Builsa and Tumu District which have been among the worst affected Oncho areas. L4- The objectives of intensifying the health education campaigns in these areas are: i. To disseminate as much as possible the methods and efforts being made by the NationaL Government and the ocp to maintain the achievements of the prog:ramme) 6ii. To get the communities completely i-nvolved in the control of the devolution diseases and the socio economic development of their own areas. iii. To bring the awareness of the people to the symptoms of the devolution diseases and the need for medical attention iv. To change the conception of the people regarding the cause of the diseases in order to remove any superstitional beliefs and taboos from the minds of the people. v. To enable the medical teams to get the maximum co- operation of the people particularly in the use of the drugs that are being introduced. Health fnfrastructrrrF There are twenty-four di_stricts in list of District Capital and popula 1E1J. BeLow is a the Devolution area tion: DTSTRTCT UPPER EAST REGTON CAPITAL POPULATION NO. VILLAGES 1. 2. 3. 4. 5. 6. Bawku VJest Bawku East Frafra Bongo Kassena N. Bui lsa Bawku Zabi 11a Bolgatanga Bongo Navrongo Sandema t7g,L7O 62 | ooo 166,300 67,ooo 135,400 79 t0oo 342 80 250 E'JZ L36 91 Total 628 | 0oo 951 t. 2. 3. 4. 5. Sissila Lawra Jirapa L. Nadawli Wa UPPER WEST REGTON Tumu Lawra Jirapa Nadawl-i Wa 59,900 72 , goo 92,900 89,300 135,300 98 160 185 728 138 Total- 439,300 134 DISTRICT NORTHERN REGION CAPITAL POPULATIONl VILLAGES 1. East Mamprusi 2. West Mamprusi 3. Chereponi Sapoda 4 . Gushi ega,/Karaga 5. Savelug'a Nanton 6. Talon Kumbungu 7. East Dagomba 8. West Dag'omba 9. West Gonja 10. East Gonja 11. Zabzugu L2. Nanumba 13. Bole Gambaga Wa.l-ewaLe Saboba Gushi eg.r Savelug'u Tal-on Yendi Tamale Damongo Salaga Sabzugu Bimbi l-a Bole L27,800 73,too 62 , OOO o5,000 92,300 89,700 7 0 ,6OO 150,100 63,400 123,000 60,300 91,100 85,900 377 94 234 J/.] 200 200 268 T4L L48 318 L47 29L 310 Total- L,754,000 3169 Grand total 2 ,222 , ooo/4825 'Ghana 1984 Census report ;";;rl Northern UPPer west UPPer East -: c P T G P T G P rG P T G 'I' V Hospit. ;--;;--r; -;;;---;- r -; ----; ; -; - -;--;-- ' H.Centre 76 79 11 3 1'4 Z - 2 2 Z H.Posts 29L lgt ZZ 22 10 - 10 Lt 10 2L Cl-inics 139 - 59 198 4 1'3 - 13 - M.Homes tol - to7 L 7 8 - z z P.Clinics707033zZ G = Government P = Private T = Total the regions has been in' :::';::::"'"?";":', :T":1?: ;1"='''"n"'"oli"'"" rechni c i ans and Technologist ' with the new system of cash and carry ' Ghana plans to train more dispensingassistantstotakeoverdrugsmanagementatthehealth Posts and health centres level" 10 NORTHERN 13 13 13 u/wEST 5 5 s U,/EAST 6 6 6 AJ 5 6 13 6 13 5 6 13 5 TZ iJ 5 IJ J 6 1J ( 6 13 trJ 6 24.AL=2424242+ 24 2+ 24 24TOTAL 2L Abbreviations M.O. = Medical Officer MA = Medical Assistant DPHN = District PubLic Health Nurse DCDCO District Communicable Diseases Control 0fficer DEHO = District Environmental Health Officer CHN = Community Health Nurse AEHO = Assistant Environmental Health Officer Find attached cletails of heal-th facilities for the core areas PROGRESS REPORT ON DEVOLUTION. GHANA 1.0 INSTITUTIONAL FRAMEWORK. 1.1 In Ghana, the head of the National Oncho. Secretariat has been appolnted the Coordinator for the Devolution. L.2 Regarding setting up of national team, Ghana has a Devlolution Implementation Committee with a Public Health Physician as its chairman. It is a multi-sectoral committee made up of representatives from: Minisury of Finance and Economic Planning; National Oncho. Secretariat; , ^Ministry of Information; )Ministry of Education; Ministry of Health: Health Education, Epi Unit, Directorate; Institute of Aquatic Biology; Environmentatl Protection Council ; Private Sector:Public Health Physician. 1.3 Ghana's NOC has been in existence since the inception of the Control Program in Ghana, with NOS as its secretariat. NOC functions under the auspices of the Ministry of Finance and Economic Planning. It is an active committee and meets regularly once a month. Its sub-committee, the Devolution Implementation Commiutee, reports devolutlon activities to the NOC. 2.0 ACTIVITIES. 2.L Epideniological evaluation of the Oncho. program under the Devolution has noc yet started at the national level. However, evaluation of Guinea worm, one of the devolution diseases, has been done. General epidemiological evaluation will be carried out in due course. 2.2 Regarding the distribution of Ivermectin, Ghana received an initial consignment of ten thousand ivermectin tablets which was distributed to health institutions in both the core program area and the forest oncho. areas. Recently, another consignmentt of 6,000 tablets received from OCP has been distributed to health facilities in the core program areea for passive treatment of oncho. patients. The core area covers the 3 regions in the North, namely, Northern, Upper East and Upper West. Besides, OCP collaborates with MOH to undertake periodic mass treatment in the southern extension areas. Incidentally, the Ivermectin clinical trials formerly based in Tamale in the -2- Northern region of Ghana, has moved to Hohoe in the southern extension area. 2.3 Training is categorLzed into broad areas: (i) In-service training of service providers. MOH has been providing in-service training for the District Health Managementt personnel to enable them carry out health promotion programs and prevention of communicable diseases. (ii) Formal training of professional staff, namely:(a) entomologists;(b) parasitologists and(c) epidemiologists. In this area, GOG has some candidates undergoing training in overseas institutions. In addition, interviews have been conducted and cadidates selected to train in those specialties. Ghana will seek sponsorship fron bilateral and other agencies in support of their trainlng.. 3. Resources made available. 3.1 Each region in the Oncho. freed zone has been provided with a senior Public Health Physician to be responsible for communicable disease control including onchocerciasis. In addition, a health education officer has also been provided. These will collaborate with personnel from other government sectors such as ministries of Information, Education, Community development, etc. At the district level, there is the District Health Management Team each made up of five professionals, namely: DistricL Medical Officer (DMO), District Public Health Nurse (DPHN), District Communicable Diseases Control Officer (DCDCO), District Environmental Health Officer (DEHO), District Health Education Officer (DHEO). The above health management team will also collaborate with the district level personnel of the mentioned line ministries. as well as NGOs, organs of the revolution (CDRs, 31st December women's group etc.) The critical area of manpower shortage in the oncho area has been in the grades of Medical Officers, Laboratory Technicians and Technologists. With the new system of cash and carry, Ghana plans to train more dispensing assistants to take over drugs management at the health posEs and health centre levels. 3.2 Infrastructure Hospitals 15 Health Centres 53 There are also both government and private clinics as well as maternity homes where ivermectin treatmenL can be carried out. Meanwhile, the strengthening of the health infrastructure and institutions is belng implemented through the Public Investment Programme. Under NOS' budgetary allocation. two new health centres have beeng built at Ftrmbisi and Kubore. New ones are planned for Mankarigu, Yagaba and Soo localities. Ihe l.[OH will provide laboratory facilities for aI1 service delivery points. Apart from the health facllities that exist and are being put in place in the oncho controlled areas, the GOG is undertaking extensive infrastructural development to open uP an initial plannin9 area whieh forms a quadrant around Fumbisi, Yagaba, Soo and Mankarigu, comprising about 22,00O hectares of fertile land selected for an integrated human settlement programe to be f inanced by UNDP. Ghana Government's contribution towards the project includes construction of a total of 93 km of feeder roads to facilitate free flow of farm inputs and farm produce all year round. Two bridges are being built over the Sissili River and Wiasi and the Kulpawn river near Yagaba to break the inaccessibility of the area which has earned it a nick-name "overseas arearr. 3.3 Logistics. There are 24 districts in the devolution area. The GOG has provided four-wheeled vehicles to l-5 of the 24 districts. The remaining 35t are yet to be considered. For the 53 government health centres in the oncho. controlled area, 200 rnopeds have been provided for outreach work. 4.0 Integration of devolution activities. Ghana's Devolution Plan combines the control of onchocerciasis with the eradication of yaws and guinea worm, and the control of leprosy. As pointed out on p.7 of Ghana's Devolution Plan presented at the last JPC conference in Conakry, the economic reason for this combi-nation was is based on considerations of compatibility and cost-effectiveness. The nature of integration ls seen in the following operatlons: (a) System of data collection for purposes of surveillance ls common to all the devoluti-on diseases and indeed to all communicable diseases. (b) Examination for all the 4 listed diseases (Onchor ]aws, leprosy and guinea worm) will be by simple clinical inspection of the skin by health services personnel. (c) Common health education structures exist for all diseases including the 4 devolution ones. (d) Treatment for oncho and other devolution disease patients will be carried out by the existing primary health care structures. 5.0 NGOs (i) Global 2000 for Guinea worm disease eradication. (ii) Amici de leprosy programme provides all suPPort for Ghana's leprosy control prograrune. (iii) Mi-ssion Hospitals provide both material and personnel support. They undertake health progranmes in specific geographical areas of the country. (iv) Royal Commonwealth Society for the PrevenEion of Blindness is planning studies in the forest oncho. areas with promise of material support through Ghana Society for the Blind. (v) Adventist Development Rehabilitation Agency (ADRA) plans to participate in the ivermectin distribution. (vi) Lions Club of Ghana will also collaboratte in the ivermectin distribution. 5.0 Search for Financing. Donor representatives in Ghana have been invited to the formal -5- launching of Ghana's devolution plan by the end of June, L99L. Appeal for support w111 be made. Meanwhile, the International and Economic Relations Division(IERD) of the Ministry of Finance and Economlc Planning, whose director is the chairman of NOC, has been requested to formally seek donor assistance for the financing of the devolution plan. 7.0 Dlfficulties encountered and solutions envisaged. Mauerial development for training of health service personnel and for public education and information has been time-consuming since the team has other duties. Nevertheless, training modules for guinea worm and leprosy have been prepared and are ready for printing. Those for onchocerci-asis and yaws are in preparation. 8.0 Specific questions. 8.1 Establishment of Monitoring Team. On page 19 of Ghana's devolution plan states that " a monitoring team would be set up jointly by the National Oncho. Secretariat (NOS) and the Ministry of Health. The team will consist of four persons made up of two social scientists and two public health specialists. The team will visist the districts, monitoring the Programne through the assessment of the plans and mechanisms at all levels of the prograrnme activities to ensure that the institutional arrangements that have been put in place are satisfactorily implemented. Their rePort should be available by the end of April every year. Ghana's first report in this regard will be available by April, L992, eat1-y enough for the 15th NOC meeting.