Report of the field visit in Ghana

d/' WORLD I{EALTH ORGAMZATION ORGANISATION MONDT.ALE DE I-A SANTE ONCHOCERCIASIS CONTROL PROGRAMME TN WEST AFRJCA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFRIQTJE DE L'OUEST EXPERT ADVISORY COMMITTEE Sixteenth session Ouaeadougou. 5-9 June 1995 EACI6/INFIDOC.2 ENGLISH ONLY REPORT OF THE FIELD VISIT IN GHANA By Professor D.H. Molyneux (Chairman of the Expert Advisory Committee) \ Reporl of Professor D.lI. Molyneux on visit lo Gh:rua as lrield Visit to Onchocerciasis Controt Progranrme activiries as Chairnran of the Expcrl Advisory Conunittee The author arrived in Ghana on lst February 1995 and was nlet at the airport by the Executive Director of the National Onchocerciasis Control Cornmittee, Mr James Fosu, and Mr Sanrmy Sowah, Chief of Sector Tanrale. Activities cornmenced on 2nd February 1995. Executive sunrnrary The tield visit was most successful and all the initial objectives were achieved. The visit was excellently organised and given tlre large nunrbers of people involved the visitor was able to see the nrajority of the actors in the Oncho scene in Ghana including the Deputy Minister of Health and the Directors. At the technical level the tbllowing observations are nrade and the justification of any remarks and recorrrrnendations can be found in tlre text. The Onchocerciasis Chenrotherapy Research Centre in Holroe is an irnportant facility for clinical trials and has rnade a rnost significant contribution to evaluating compounds for Onchocerciasis chenrotherapy. The results of the high dose ivernrectin trials are currently being analysed and will be available shortly. Protocols for Anocarzine trials have beert agreed, the results of which will be available by the end of the year. Thereatier unless UMF 078 is ready for use in man an alternative use of the OCRC should be considered and this could be for undertaking malaria trials tbr TDR. Dr. Awaclzi would discuss this issue in Geneva in late February. The Bui focus has provoked interest as an explanation of the epidemiology is required given twenty years of vector control has been undertaken. It is considered that over this period constant reinvasion tiorn tlre Tano river basin has occurred. The area of the Tano river should be subjected to art epidenriological study as the area is a potentially key source of reirtvasiort tor a lnrge part of the programme area. The potential changes which nright occur to the area when the Bui dam is constructed must be evaluated and any constnrction associated control of nuisance flies undertaken must be charged to the danr site construction including rivers further south. The Asubende tbcus was visited and is under good control (conrbined larviciding and ivennectin). However, it is clear that this fbcus could have been included earlier in control activities. 2 3 4 I 5 The Government of Ghana rnust be compllrttented on its commitment to Onchocerciasis control via significant contributions to the National Onchocerciasis Secretariat which links to all relevant sectors frorn a Ministry of Finance base. The Government also provides significant support to national teams for ivermectin distribution which is predominantly undertaken in the Volta river valleys (Asukawkaw and Dayi river valleys, Bui, Asubende; Mole, Kulpawn and Sissili. However, additional activities in a non-OCP Oncho control environment based on ivermectin (or Amocarzine if appropriate) should be a priority if epidemiological studies in the Tano and adjacent rivers confirm that blinding Onchocerciasis transmitted by savanna flies is a problem which will seed the core area. Discussion on devolution focused around role of districts and district health management teams in integrating Onchocerciasis in their activities; and the priority level Onchocerciasis might assume in this context; the process of ivermectin distribution which might be ernployed and the need for a seminar for selected DMOs to inform them of the probleln local to their situation. The irnpact of decentralized budgetary control was anticipated to be an important issue particularly in the light of many pressing priorities. The difficulties for Oncho related thinking to assimilate itself into the new approaches of the reform of the health sector required an increased dialogue between OCP and the Ministry of Health policy and planning processes. 6. Finally the author is grateful for all the support, hospitality and company of OCP and national staff in a stimulating and useful rnission which it is hoped was of value to all parties. 2.2.19952 Visits to the WHO Representative's Oft'ice (Dr. Avokey, Epidemiologist), Ministry of Health to meet with Dr. K. Ahrned, Director of Public Health followed by meeting with Deputy Minister of Health, Mrs Margaret Clark-Kwesie, accompanied by Mr J. Fosu, Dr. Joseph Amankwa, National Onchocerciasis Coordinator and Mr S. Sowah, Sector Chief OCP, Tamale. Met Dr. S. Bugri, Head of Epiderniology, Ministry of Health. Attended and participated in rneeting of National Onchocerciasis Committee under Chairmanship of Dr. Kofi Ahmed, Vice Chairman Dr. M. Odei, Institute of Aquatic Biology. NOC attended by World Health Organization representative, Dr. B. Dando. Lunch with NOC p.m. Visit to National Eye Care Unit of Ministry of Heath. Activities, structure, training and resourcing of eye care in Chana explained by Dr. Marie Hagan. This introduced DHN{ to role of the NGO Sight savers in eye care in Ghana. Objectives of the Eye Care Unit are (i) Hunran Resource Development; (2) provide eye care coverage to as extensive area as possible; (3) organize training fbr ophthallnologists and eye nurses; (4) provide school eye care service, (5) organize cye cantps: (6) rrtonitor distribution of ophthalrnologists; (7) provide advice to Mrrtistry oll L'quiprllerlt. Discussion on Onclrocerciasis concentriltr'd on Dr. Hagan's work in Western Regiort where endernic oncho is a serious skin problenr. Dr. Hagan has participated in TDR Oncho skin disease progranlucs and trsed Rapicl r\ssessnrent ntetltod to evalrrate problents in tbrest l rf areas. Discussion with National Coordinator on iverrnectin distribtrtion rnodalities in areas outside OCP's nrandate; a valuatrle contact was established between Dr. Hagan and Dr. Amanknva. There is clearly concern over Onchocerciasis as a problem of public health significance outside OCP treatrnent area where it has been assunred only forest Oncho exists (e.g. Tano River Basin). Evening meeting with Dr. M. Wilson ex. TDR student frorn Noguchi Institute of Medical Research (NIMR), Mr D. Boagye, TDR sponsored PhD student and Dr. R. Cheke, visiting scientist from ODA NRI, Chatham, UK. Discussion on vector issues and research activities in Simulitul biology at NIMR in particular TDR sponsored prograrnme on blackfly identification and newly funded TDR research on deforestation and Simulium distribution. 3.2.1995. (a.m.) Meeting with Dr. A. Tinorgah, External Aid Coordinator, MOH. Topics discussed revolved around donor inputs to the Health Sector in Ghana; Quality Assurance studies to address service related issues, inrportance of rnalaria as a Government priority health issue and nlanagellrent and operationalisation oI nralaria action and links to devolution. Visit to MOH, Epiderniology Unit, Korle-Bu. Meeting with Dr. S. Bugri. Discussion on devolution diseases - Cuinea worrn and rnalaria. Dr. Bugri articulated concerns over reporting of rnalaria in context of nredical cards and diagnostic problems and recording at different levels. 50% of patients are given malaria treatment in addition to other drugs at Health Centres irrespective of what was on the treatrnent cards. Hence there is a need to improve prescribing practice in relation to diagnosis. Quality of laboratory diagnosis and likelihood of the availability of nricroscopical diagnosis at the expected levels was also an issue of concern. It was considered that Level B (health centre level) has inadequately supplied with nricroscopes. The role of the Pharrnacy Board in quality control of chloroquine was explained. Quality of chloroquine in private sector was also an issue. The question of chloroquine resistance was not discussed as chloroquine rernains tirst line drug. Dr. Bugri ernphasized the need to irnprove disease surveillance; he considered that mandatory diagnosis of nralaria (however nrade) should be included on patients records before prescription made out. This needs to be established as policy. Dr. Bugri considered that referral to next level was as low as 25% largely due to transport problems and hospitali ation costs. He estinrated that although Health Centres should have lnicroscopes only 25% did have. Discussion then focused on success of Guinea worm programme and its structure and functioning as Guinea wonn is a 'devolution disease'. The village volunteer workers (VVW) have had a key role in surveillance, health education, and data collection. The Unit had discussed with VVWs what additional roles they considered they could assume and what their terms and conditions would be. They did not wish to be responsible for selling or collecting money for drugs but would undertake surveillance and distribution. The use of VVWs for distribution of Vitamin A capsules was also being considered (in discussions with the Head of Nutrition Division). , The VVWs used in Guinea worm canrpaign were supported by district coordinators and regional/district level zonal coordinators were at level C. The district coordinators briefed the DHMT and hence played a role in coordination. The DMO appoints the district coordinators. 3 VVWs had a role to ensure protection of water sources if cases were present and, to ensure use of filters and as well as to maintain quality of filters. Referral of cases for worm extraction and occlusion bandaging of not yet emerged worms was responsibility of VVW. District Coordinators (DC) are usually technical officers with MFU or environmental health staff . "Tamale' oil was used to aid worms extraction (CuSo4, Neem extract and vegetable oil (Shea butter)). It was suggested the National Coordinator should discuss potential use of Guinea worm systems to investigate potential of VVW for Oncho surveillance and ivermectin distribution via DCs particularly as guinea worm eradication is in sight given low number of cases currently being reported. 3.2.1995. p.m.: Journey to Hohoe. Arrived circa 1600. An initial visit was made to Hohoe sub-sector of VCU. Met Mr Alex Adzah responsible for sub-sector. A helicopter refuelling point is located at the sub-sector office for rivers under treatment in the Dayi and Asukawkaw area. The area was infested with s. sanctipauli Dodji which has now been eradicated. Presently mainly S. domnosurn ss, S. yahense and S. squamosumare present due to nature of habitat. Currently fly catches are low (3 local capture points) and B.t. H-14 is insecticide currently used due to low dry season discharges with Abate applied in the rainy season. Visit to Onchocerciasis Chemotherapy Research Centre (OCRC) met with Director, Dr. K. Awadzi, Medical Officer, Dr. Opoku, and ophthalmologist, Dr. Addy. Visited facilities, wards, Iaboratories (histology, in vitro culture), offices. The facilities are excellent for clinical trial studies with all requisite back-up. There is a need to investigate if a replacement Coulter Counter is necessary as the existing one has broken down and is unlikely to be capable of repair. Dr. Awadzi is assisted by a team of 12 nurses who work on a 3 x 8h shift system. Currently patients attending were those being followed up following high dose ivermectin treatment. Discussions on initial results of single high dose 800pg/kg treatment were held and plan for future trials of Amocarzine now WHO ethical clearance has been obtained. DHM mentioned the possible use of Hohoe for TDR trials for chemotherapy of malaria. The OCRC is attached to the district hospital hence it is likely that patients would be available but Dr. Awadzi did not have data on malaria admissions. Dr. Awadzi will discuss during his forthcoming visit to Geneva the possibilities with Dr. P. Olliaro of TDR. The facilities at present are clearly well used and represent a considerable investment by the Government of Ghana, OCP and TDR via Macrofil funding. The future of OCRC following the next trials will clearly require close exarnination but if TDR are seeking a well managed, committed group, with excellent facilities tbr malaria trails Hohoe needs to be evaluated in more detail. Dr. Awadzi represents a cornrnitted, experienced physician who would be undoubtedly more than capable of organizing such trials but nray require to be given an opportunity to spend tinre with the other nralaria chentotherapy grortps funded by TDR as well as additional investrnent on equiprttertt. 4.2.1995. a.m.: Further discussions u,ith sub-sector and OCRC. Return to Accra via Akosombo. Dr. Amankwa, National Coordinator discussed with Dr. Opoku local iurangements for iverrnectin distribution in the area by the National Teams. i+ 5.2.1995. a.ru. Detailed discussion with National Coordinator, Dr. Joseph Anrankwa, on devolution issues. In particular organiprtion of health service at central, regional and district levels. The potential role of districts in organigation of devolution diseases related activities. Possibilities to be investigated should be the use of the Guinea worm eradication programme VVWs in ivernrectin distribution, and the organisational role of DMOs in initiating discussions with DHMTs (Level C) and the use of the District Coordinator of Guinea worm programme in organiation of iverrnectin distribution. The possibility of role of sub-district health teams at Level B in context of Medical Assistants role in malaria rnicroscopy was an additional issue. The decentralization process which has taken place in Ghana giving budgetary responsibility to districts ernphasiies the irnportance of DHMT through its relations with DMO and its links to sub-district teanls presents an excellent opportunity for investigating the way devolution can be achieved. This may be through the Guinea worm programme, Medical Field Unit staff and leprosy workers (either of whom may also have role as Guinea worm coordinators depending on district). Lunch with fellow EAC mernber, Dr. Y. Aboagye-Atta, accompanied by colleagues. Discussions involved proposed developnrent of Bui dam and potential impact of such a developrnent on Onchocerciasis particular the change in vector populations. It was suggested construction will need blackfly nuisance corrtrol whlch could be sub-contracted at commercial cost to OCP. This would alleviate necessity for continued OCP funded vector control in key areas. Mr Fosu undertook to investigate the current situation regarding dam construction with appropriate governnrent departnrents in view of possibility inrpact on planning for final phase of OCP (1998-2002). Monday,6.2.1995 a.m. Courtesy call on Dr. Asarnoa Baah, Director, Policy Planning and Evaluation and Dr. D. Dovlo, Director Hurnan Resource Developrnent. Arranged meeting on Thursday, 2 p.rn.. Travel via Kumasi to Techinran. Meeting with Chief of sub-sector of Kintalnpo - Mr Mohammed A. Adants. Discussion of entornological and control situation in the area. Rivers treated apart from Black Volta are R. Subin, Tain and Tombe (all with Bt.at present) all these rivers were treated at the start of programlne. Black Volta is currently being treated with Pyraclofos. Rivers south of Black Volta have an oncho prevalence of up to 60Vo whereas north of Black Volta prevalence is circa li-l1Vo The likely analysis of this is that continual treatment of Black Volta has reduced but not cornpletely elirninated transmission north of the river whereas the area south of the river is being invaded from further south (Tano basin) where there is no vector control as it is outside the Programme area. The nature of the O. volvulus strains in the area south of the Black Volta are likely to be mixed forest/savanna but this needs clarifying. Major fly populations are savanna/so/sq. Ivermectin distribution south of Black Volta is being undertaken by four national teams and treatment is on a quarterly basis (salary paid by Government of Ghana; per diem and running costs by OCP). The population of the area is around 26,000. Long term strategy for this critical area needs considering as the Black Volta is being invaded from areas to the south outside the Programme area but because of treatment of Black Volta over many years much of the migration has stopped. The other potential factors in this area is the proposed construction of the Bui dam which may have a significant impact on the pattern of transmission and cytospecies distribution. The construction site will require nuisance control which should not be the responsibility of OCP. OCP could be sub-contracted to provide advice on treatment which would extend to rivers further south. 5 The suggestion that ivermectin distribution could be administered by the National Volunteer foroe Was discussed. Mr Fosu would investigate the possibilities that this might be initiated. He would also discuss progress on the time scale of construction of the Bui dam. Forest Onchocerciasis treatment was discussed which is an increasing problem - NOS has discussed with different NGOs the possibility of giving responsibility of a different NGO to each region. Western Region has been attributed to Sight Savers; Brong-Ahafo to Seventh Day Adventists and, Assemblies of God (Passive). Lions CIub and Friends of Oncho are also interested in other regions. Ghana presents a particularly opportune environment for investigating a range of different ivermectin delivery systems. These could be via existing health personnel at lrvels A and B, who have assumed responsibility for Guinea worm control activities at these levels, via VCU teams until the programme ends, or via leprosy and EPI workers. The National Coordinator as a DMO is in a strong position to evaluate all these options in the context of the different epidemiological situations which exist in Ghana. These can be summarized as (1) forest Oncho; (2) mixed forest and savanna; (3) areas controlled and where vector control has stopped due to acceptable .epidemiological situation; (iv) extension areas in South F^st (Volu region) where ongoing VC and ivermectin distribution is being undertaken; (5) villages in the original area where situation is not yet acceptable but where VC and ivermectin distribution are continuing (Mole, Kulpawa, Sissili, Pru, Asubende). These areas are being regularly treated by OCP and National Teams; (6) interface villages south of the Black Volta where dbeit in a relatively small area despite treatment of the Tain, Tombe and Subin since 1975 the prevalence reading is high. This it is suggested is due to (1) migration of flies from Tano basin which is uncontrolled; (2) migration of population from forest areas. It would be trseful to know the strains of O. volvulns found in these populations. This epidemiological picture suggests that the southern boundary of OCP in the West of Ghana was not sufficiently far south compared with neighbouring Cote d'Ivoire. The Bui area would be ideally suited to Macrofilaricidal distribution if and when one becomes available. It may be appropriate to estimate the cost of this given the logistic experience of treatment schedules in Ecuador and the need for medical supervision. 7.2.1995. L€ft Techiman for field at 0600 via Wenchi to Bui. Visiting catching point at Akanyakrom on Black Volta; Bui Camp to visit rural clinic; Bui dam site and villages south of Bui (Sobie, Banda Ahinkro, Gboo). These villages together with others in the area are treated by four national teams four times each year in view of high prevalence and high level of migration. Accompanied by sub-sector chief of Kintampo (Mohammed Adams), Medical Assistant from Bui Camp and Hassan (Technical Officer, member of sub-district HMT) who reports to DMO and is responsible for cold chain and statistics. Visited site of proposed Bui dam. Return to Techiman. Discussions with Drs. Amankwa and Boatin on devolution in context of malaria and Guinea worm progran'rtnes and local epidemiology of onchocerciasis in Bui. E.2.1995. kft for Kintampo to refuel at Sub-sector office. Drove east towards Asubende focus on Kintampo/Prang road which is adjacent to focus on River Pru. The area is treated annually by four national teams following early trials of ivermectin in Asubende in 1987. 6 Visited catchillg poirtt u'lterc V('U tcunr ll'orrr Krrrtarrrptl sub-scctor w,erc ilrst:rllcd. I:cw tlies were caught conlparecl with Black Volt:i calches orr thc ltreviorrs day btrt larvae easily found at breeding site. Still ten blind irr Asubende village including chief. The area could have been included earlier in the Prograrnrne as clearly it is an area of blinding savanna Oncho. Both ivermectin distribution and vector control is ongoing. Four national teams treated Asubende focus (46villages) in l0 days in early Novenrber 1994. The prevalence is around 38.5Vo but CMFLs have fallen drarnatically to allnost zero as a result of ivennectin. The blind, however, are still working; a "Young" rnother with 3 children; blind rnen fishing, collecting thatch and rnaking charcoal. Leti Asubende via Prang ancl Ateburu reaching Accia ar 1900. 9.2.1995. Discussion at Sclrool of Public llealth, University of Ghana, Legon with Director, Professor S. Ofosu-Anraah (ex. Professor of Paediatrics, Community Medicine, ex- Dean of Medical School) and Dr. Nana A. Enyinrayew (Coordinator) re mission on Oncho devolution, developntent of School of Public Health, policies on clisease control. .l Nqguchi l\{enrorinl Institule for Medical Reselrch Professor F. Nkrurnalt was absent; nret Acting Director, Dr. Ankrah (Chernical Pathology). Met with Dr. Mike Wilson (ex-TDR) and Dr. D. Boakye (TDR fellow) both working on Sirrlllilrrr biology, genctics, distribution, insecticicle rcsistance mechanisrns and identification usirtg ntolecular nrethods. This group has TDR and Wellcome Trust funding with ntortey tbr a study on defbrestation in relation to blackfly clistribution in Ghana. Discussions were held on possible projects to be unclertaken by the Naguchi group. There was an interest in larviciding in Gharra (Tano river) to prevent reinvasion of C6te d'lvoire as it was felt this was the refuge of S. .ranc'tiltuuli. Dr. Wilson and Mr Boakye are well trained Simulium workers with excellent knowledge of West Africa Oncho environrnent and will form an irnportant critical nrass for research in Ghana. p.nr. Discussions with Mirristry of Healtlr, Dr. Asanroa-Baah, Director, Policy, Planning and Evaluation and Dr. D. Dovlo, Hurnan Resource Developntent. An intensive and fruitful discussion on linkages between Onchocerciasis clevolution and existing and developing health systeqs in Ghana. The irnportarrce of Onchocerciasis related activities being part of the District Healtlr Managerttent Teanr's responsitrility was stressecl. The decentralizetion of responsibility to DHMTs and DMOs is now operational both in tenns of managing health problems but also financially. OCP rnust address this issue in a Ghana specific context as it is clear that other OCP countries will not have nroved far down this route. The particular problems posed by vertical progranures, however justified, must be taken into account when devolution is being discussed in the context of any Health Sector Refbnn which are ongoing as any elnphasis on verticality which devolution plans thernselves irnpose is not cotnpatible with decentralization policies. In Ghana tlre central health policy of decentralization to districts must be taken into accol.u'lt in the context of the role of DHMTs and the local priorities as budgets are now devolved. In addition it was ernphasiz:d OCP must recogniz': that it ntust address the issues of iverrnectin distribution within the context of country drug distribution, purchasing and supply systents. 7 The issues of the validity of the devolution plan docurnent was raised by the discussants in the light of the changes in district level organiuation. The mechanism by which malaria control could be effectively implernented in the district context was discussed given again historic emphasis on verticality with which malaria control has hitherto been associated. The discussion was particularly valuable in highlighting issues which require attention not only in the context of devolution but also in areas of health sector reform and policy. OCP should perhaps open up greater dialogue with the Ghana Ministry of Health on such policy and human resource issues as they can certainly allow generalizations to be tested which will become applicable to other OCP countries. This is relevant as the World Bank seeks to implement health sector reform policies in line with WDR and "Better Health in Africa" documentsrand WHO/AFRO promotes increased disease control and surveillance (MDC). It is not clear how best the approaches of the different parties can be reconciled at the district level or its equivalent which will increasingly be focus of priority setting and budgetary control. The following issues emerge for consideration (l) the role of NCOs in ivermectin distribution (and their linkage to DHMTs); (2) the irnpact of health insurance systems (and possible exemption tiorn it); (3) the linkage of OCP as a programme which involves both health and other developrnent sectors (and of necessity is vertical because of its intervention strategy and geographic size) to the decentraliiation process which imposes a pre-requisite on OCP to examine the potential irnpact of the above issues on devolution. A further issue raised was the need tbr countries to have specitic cornnrunicable disease control policies. This topic needs further discussion but is relevant to WHO/AFRO's interests and in the context of the above points. 27 February 1995 I