final report the retrospective evaluation of acsd: ghanathe retrospective evaluation of acsd: ghana...

ACCELERATING CHILD SURVIVAL AND DEVELOPMENT (ACSD)

Final Report The Retrospective Evaluation of ACSD:

Ghana

Submitted to UNICEF on 7 October 2008

Institute for International Programs Johns Hopkins Bloomberg School of Public Health

Baltimore, MD

ii IIP-JHU | Retrospective evaluation of ACSD in Ghana

Disclaimer: This report was prepared by IIP-JHU under contract with UNICEF. All photos were taken by members of the IIP-JHU evaluation team after requesting permission from those who were photographed. All text, data, photos and graphs should be cited with permission from the authors and UNICEF.

IIP-JHU | Retrospective evaluation of ACSD in Ghana iii

Summary Introduction UNICEF implemented the Accelerated Child Survival and Development (ACSD) project between 2001 and 2005 in 11 countries in Africa with support from Canadian CIDA. The aim of ACSD was to reduce mortality among children less than five years of age by working with governments and other partners to increase coverage with a set of proven interventions. In the “high-impact” countries of Benin, Ghana, Mali and Senegal, a total of 16 districts worked to deliver the full set of interventions grouped into three packages: “EPI+” including vaccinations, vitamin A supplementation and the use of insecticide-treated nets (ITNs) for the prevention of malaria; “IMCI+” including promotion of exclusive breastfeeding for six months, timely complementary feeding, use of iodized salt and improved and integrated management at the health facility and community levels of children suffering from pneumonia, malaria and diarrhea, including home-based ORS use, treatment of malaria, and treatment of pneumonia with antibiotics; and “ANC+” including intermittent preventive treatment of malaria with SP (Fansidar) for pregnant women (IPTp), tetanus immunization during pregnancy to prevent maternal and neonatal tetanus and supplementation with iron/folic acid during pregnancy and with vitamin A post-partum. An internal evaluation by UNICEF estimated through modeling that the levels of coverage achieved through ACSD were associated with about a 20 percent reduction in all-cause under-five mortality relative to comparison districts in participating districts in four “high-impact” countries. This retrospective evaluation was commissioned by UNICEF to confirm these findings and provide additional information that could be used in planning effective programs to reduce child mortality and achieve the 4th Millennium Development Goal (MDG-4) in poor countries in Africa.

The IIP evaluation team worked with ACSD managers at international and national levels to develop a generic ACSD framework that defined the pathways through which ACSD activities were expected to lead to reductions in child mortality and improvements in child nutritional status. The generic framework served as the “backbone” of the evaluation design. The country-specific evaluations also addressed equity across socioeconomic and ethnic groups, for urban-rural residence and for girl and boy children. At the request of UNICEF, the evaluation does not include an economic evaluation or a full assessment of the effects of ACSD on national policy.

Aim of the independent retrospective evaluation in Ghana The aim of the evaluation was to provide valid and timely evidence to child health planners and policy makers about the effectiveness of ACSD in reducing child mortality and improving child nutritional status in Ghana, as a part of the larger retrospective evaluation designed to inform future programs intended to reduce child mortality and accelerate progress toward MDG-4. Equity was also assessed.

Two questions served as a guide to the analysis and reporting of the evaluation findings:

a) Was ACSD implementation associated with improvements in coverage, nutrition and mortality over time?

b) If so, was progress in the ACSD districts faster than that observed for the national comparison area?

ACSD implementation in Ghana UNICEF-Ghana received approximately $3.8 million from Canadian CIDA to support ACSD activities in sixi

i These six districts subdivided into eight districts in 2005 during redistricting.

“high-impact” districts (HIDs) with a combined population of about one million located in the Upper East region, and two expansion regions (Upper West and Northern regions) between 2001 and 2004. ACSD was implemented at the regional, district and sub-district levels in partnership with the Ghana

iv IIP-JHU | Retrospective evaluation of ACSD in Ghana

Health Service (GHS) and other development partners. The GHS supported EPI+ and ANC+ activities after 2004 by incorporating them into routine health services. After a hiatus of about one year, other ACSD activities received continued support from UNICEF funds, DANIDA and the Government of the Netherlands. ACSD inputs and activities in the Ghana HIDs, comprised of the entirety of the Upper East region, focused on:

1) Providing essential drugs, supplies, equipment and other support for outreach and campaign activities. ACSD-Ghana: a) provided an estimated 814 bicycles, 18 motorcycles and one vehicle to the HIDs over the course of the project for outreach and supervision activities; b) equipped health facilities with 553 refrigerator units for cold chain; c) supported local and national campaigns for vaccination and vitamin A supplementation, as well as routine health-facility outreach activities; and d) supplied commodities including vitamin A supplements, antihelminths, ORS, antimalarials and ITNs and retreatment chemicals for the prevention of malaria.

2) Supporting distribution and retreatment of ITNs at various levels. Over 200,000 ITNs were distributed in the HIDs between 2002 and 2005 through health centers, community outreach and distribution systems and campaigns. ACSD supported retreatment efforts at the community and facility levels, as well as through campaigns starting in 2004. All health workers and volunteers involved in ITN distribution and retreatment received training.

3) Training and supervising of facility-based workers. Forty-eight clinicians and three regional staff received standard 11-day IMCI training in 2005.

4) Training, equipping and supervising community health workers. ACSD-Ghana provided support for the training and supervision of over 1900 community-based agents (CBAs) in 600 communities to deliver messages to promote infant feeding, careseeking and treatment of childhood illness and ITNs, and immunization. The CBAs received health kits containing chloroquine, ORS, and handwashing and educational materials. ASCD also provided training and educational materials to community-based mothers’ groups for the promotion of infant feeding practices.

5) Supporting facility and outreach activities for pregnant women. The ANC+ package of ACSD included support for tetanus toxoid supplemental immunization activities, as well as facility and community distribution of postnatal vitamin A. IPTp was introduced in 2004 and ACSD supported its regional scale-up.

Important barriers to full implementation of the ACSD implementation plan, as reported by program staff and reflected in project documentation, included: a) commodity insecurity, particularly stockouts of ITNs from late 2005 to late 2006; b) changes in the first-line antimalarial policy and the delayed authorization to distribute these drugs at the community level; and c) inadequate incentives and support and supervision systems for community-based workers.

Evaluation design and methods The IIP evaluation team worked with UNICEF-Ghana, the Government of Ghana and other partners to adapt the generic ACSD evaluation design to ACSD as implemented in Ghana. The intervention area was defined as the six HIDs located in the Upper East region. The comparison area was the remainder of Ghana excluding the urban areas of Greater Accra and Ashanti regions (Accra and Kumasi).

The primary data sources for estimates of intervention coverage were DHS surveys conducted in 1998-99 and 2003 at baseline, and a national MICS survey carried out in 2006 supplemented by a special extension of the MICS in the HIDs carried out in 2007. Information was collected and summarized in order to document ACSD intervention activities and contextual factors through key informant interviews, document reviews and field visits carried out as part of a mapping exercise by investigators at Kwame Nkrumah University of Science and Technology (KNUST). All results and interpretations were reviewed with representatives of the Government of Ghana and UNICEF-Ghana.

IIP-JHU | Retrospective evaluation of ACSD in Ghana v

Results In Ghana, coverage for most of the ACSD interventions improved over time in the HIDs and reached the target coverage levels set by ACSD. Indicators showing positive trends over time in the HIDs included vaccinations, vitamin A, ITNs, antibiotics for suspected pneumonia, timely initiation of breastfeeding, exclusive breastfeeding, antenatal care, IPTp and the presence of a skilled attendant at delivery. Indicators that were observed to stagnate or decline included case management of common childhood illnesses, tetanus toxoid vaccination and postnatal vitamin A. Utilization of ITNs, antibiotics for pneumonia, breastfeeding initiation, skilled delivery and IPTp for pregnant women increased significantly more in the HIDs than in the comparison area. Appropriate management of childhood fever and diarrhea decreased in the HIDs, while stagnating in the comparison area; the difference in trends was statistically significant. For coverage, the answers to the two primary evaluation questions are as follows:

(a) Coverage indicators related to vaccination, vitamin A, ITNs, feeding behaviors, antenatal care and skilled delivery improved over time in the HIDs and most reached the target coverage levels set by ACSD. Indicators of correct management of childhood illness declined over time.

(b) Comparison with the rest of the country showed mixed results. Coverage increased rapidly for a greater number of interventions in the HIDs than in the comparison area. On the other hand, coverage declined significantly more for interventions related to the case management of childhood illness in the HIDs than in the comparison area.

For nutritional status:

(a) The HIDs showed a reduction between 1998-9 and 2007 in the prevalence of stunting and underweight, but not in wasting. The largest decline in stunting occurred between 1998-9 and 2003, before sufficient time had elapsed for interventions supported by ACSD to have had an impact on nutrition

(b) Relative to the national comparison area, stunting declined faster in the HIDs in the period from 1998-9 to 2006-7. Most of this drop occurred before 2003, before ACSD inputs and activities could have contributed, but the decline was maintained and extended during the ACSD project period from 2003 onwards. Wasting declined significantly in the comparison area while remaining stable in the HIDs.

For mortality:

(a) There was a reduction of 20% in under-five mortality in the HIDs from before to after ACSD implementation, close to the ACSD goal of 25%. This trend was ascertained through the full birth history technique, and the reduction was close to reaching statistical significance (p=0.10).

(b) Data on under-five mortality trends in the comparison area were available from a different source than those for the intervention area, with data points available through 2003. Other analyses suggest that mortality levels remained stable at around 115 deaths per thousand live births. Although these results must be interpreted with caution, they do suggest that the drop in under-five mortality was greater in the HIDs than in the national comparison area.

The assessment of equity in coverage was limited to the period after ACSD implementation, because of limited sample sizes available from earlier periods. There were no inequalities in coverage based on the sex of the child, and few differences between urban and rural households. Results by socioeconomic level were mixed, with few inequalities for interventions delivered through campaign approaches (e.g., vaccinations, vitamin A supplementation and ITNs), moderate levels of inequality for diarrhea management and antenatal care visits, and large differences favoring wealthier households for the presence of a skilled attendant at delivery. Children in the poorest households were somewhat more likely to be stunted and to die before the age of five years than children in the least poor households. Ethnic diversity within and between the HIDs and comparison area precluded examination of inequities by

vi IIP-JHU | Retrospective evaluation of ACSD in Ghana

ethnic group membership. When HIDs were compared to the rest of the country, there was no evidence of differences in patterns of health inequalities.

Discussion and interpretation ACSD in Ghana focused available resources on filling gaps in EPI, distributing ITNs, expanding C-IMCI through community health workers and promoting antenatal care interventions. The highest coverage levels in the endline surveys in the HIDs were achieved for vaccinations, vitamin A supplementation to children, antenatal interventions (including IPTp and TT) and ITNs, and most of these interventions progressed faster in the HIDs than in the national comparison area. Exclusive breastfeeding also showed rapid increases in both the HIDs and the comparison area during the ACSD project period. Coverage levels for the correct case management of malaria and diarrhea were low and decreased in the HIDs from before to after ACSD. Taken together, the interventions showing large gains in coverage are likely to have had only limited impact on the main causes of death in Ghana (malaria, neonatal conditions, pneumonia, diarrhea and undernutrition) and hence are consistent with the 20 percent reduction in under-five mortality observed in the HIDs. Interpretation of these findings jointly by the IIP evaluation and Ghana team focused on the missed opportunities for saving further child lives through ACSD, including the need for: 1) greater emphasis on interventions to address child undernutrition; 2) more intensive efforts to change behaviors related to the management of childhood illnesses, skilled delivery and child feeding; 3) greater support and training for the community-based workers that were a key part of intervention delivery; and 4) increased commodity security to ensure adequate and continuous supply of essential commodities. The team also believed that stronger supervision and monitoring systems would have increased ACSD effectiveness. These results must be considered in light of the many international, bilateral and Ghanaian agencies that were active in the HIDs before and concurrent with the ACSD project. Special advantages and contributions of the ACSD project in this complex environment were defined by the implementation team as: 1) the program’s ability to concentrate on a package of effective interventions; 2) the provision of additional resources for commodities, equipment and human resources; 3) clearly stated targets; 4) the establishment of productive partnerships and synergies across institutions; and 5) achievement of strong commitment from the Government of Ghana and other donors. An important methodological issue for this and future evaluations is that the presence of other partners throughout Ghana makes it impossible to attribute observed changes to ACSD alone, and limits the validity of results based on comparisons between the HIDs and broader geographic areas.

In summary, the ACSD HIDs accelerated gains in coverage of several key interventions relative to gains in the rest of the country, despite the fact that the HIDs were among the poorest in Ghana and geographically remote. However, several key interventions for reducing the main causes of death in Ghana, showed little change and even some decreases in coverage. While stunting prevalence declined during the ACSD period, there was a similar decline in the remainder of the country from 2003 to 2006. In total, the changes in intervention coverage are consistent with the 20 percent reduction in under-five mortality observed in the HIDs, and compares with what appears to be little or no reduction in the rest of the Ghana.

IIP-JHU | Retrospective evaluation of ACSD in Ghana vii

Table of Contents

1. The external retrospective evaluation of ACSD in four countries ..................... 1 2. Evaluation methods ........................................................................................... 5 3. Characteristics of the “high-impact” districts and comparison area .................. 11

4. ACSD as implemented in Ghana ...................................................................... 21

5. Coverage and family practices .......................................................................... 29 6. Nutrition ............................................................................................................ 49 7. Mortality ............................................................................................................. 55 8. Equity of coverage, nutrition and mortality ...................................................... 61 9. Conclusions ...................................................................................................... 67

References ............................................................................................................... 71

Appendices

A. Description of Ghana and “high-impact” districts

B. Methodology for documentation of implementation activities and contextual factors

C. Documentation of implementation

D. Definition of key indicators

E. Survey Questions

F. Methodologies of surveys in Ghana 1998-2007

G. Tables presenting priority coverage indicators over time for ACSD “high-impact” districts

H. Tables presenting comparisons of priority coverage indicators over time in ACSD “high-impact” districts and the comparison area

I. Tables presenting 2007 MICS results for key coverage indicators in the ACSD “high-impact” districts by socio-demographic characteristics of the population

J. Additional tables for nutrition

K. Methodological challenges

L. References for the appendices

M. Mapping of partners’ activities in ACSD “high-impact” districts (Upper East region) and nationally

viii IIP-JHU | Retrospective evaluation of ACSD in Ghana

Acknowledgements

This evaluation could not have been conducted without full participation of the representatives from the Ministry of Health, the Ghana Health Services, the Ghana Statistical Service, UNICEF-Ghana and other development partners. We thank them for their commitment to child survival, as reflected in their willingness to share their time, as well as information and their personal opinions about the contributions and limitations of the ACSD project. We specifically would like to thank Eddie Addai and George Amofah from the Ministry of Health and Ghana Health Service who were strong supporters of the evaluation. Vida Abaseka provided valuable information on ACSD implementation; we are grateful to her and the Ghana Health Service team in Upper East region for their dedication and openness to our questions. The Ghana Statistical Service carried out surveys integral to this evaluation; we especially thank Faustina Ainguah and Rochester Appiah for their on-going efforts. Easmon Otupiri at KNUST Department of Community Medicine carried out the program mapping activities, essential to understanding the context in the Upper East region, as well as contributing to the data interpretation. UNICEF-Ghana staff were responsible for working with governments and partners to implement the ACSD project and collaborate in activities related to the independent retrospective evaluation and we thank them for their commitment to child survival and to the evaluation process as a means of improving program effectiveness. We would also like to express our appreciation to Dorothy Rozga, Yasmin Haque, Mark Young, Tamar Schrofer, Victor Ankrah, Bo Pedersen, Elias Massesa, George Fom Ameh, Augustine Botwe, Felicia Mahata and Joanne Greenfield. UNICEF-Ghana also provided financial support for the supplemental survey and advanced technical assistance from Macro, International. This support was essential, as without it there would have been few data to analyze. We would also like to thank UNICEF staff at regional and global levels for their efforts to provide us with documentation about ACSD and the values and conceptual frameworks that guided its implementation. Additionally, we would like to thank the members of the IIP-JHU for their insights and help throughout the evaluation, as well as Macro International and Trevor Croft for technical assistance. Lanie Morgan provided valuable assistance in the documentation of ACSD implementation and contextual factors. Finally, we thank the leadership of UNICEF and CIDA, for their continuing commitment to the importance of independent evaluations and their efforts to see that this work was completed.

IIP-JHU | Retrospective evaluation of ACSD in Ghana ix

Acronyms ACSD Accelerated Child Survival & Development Project

ACT Artemisinin combination therapy for use in treating fever/malaria.

ANC Antenatal care

ANC+ One of the ACSD intervention packages, consisting of antenatal care and the intermittent prevention of malaria during pregnancy (IPTp)

BASICS

Basic Support for Institutionalizing Child Survival, a project supported by the United States Agency for International Development.

BFHI

Baby Friendly Health Initiative

CBA Community Based Agent

CDC US Centers for Disease Control and Prevention

CHW Community health worker

CHO Community Health Officer

CHPS Community-based Health Planning and Services

CIDA Canadian International Development Agency

C-IMCI

Community component of Integrated Management of Childhood Illness

DANIDA

Danish International Development Agency

DFID Department for International Development, government of the United Kingdom

DHS Demographic and Health Surveys (DHS), supported by USAID.

DPT Diphtheria, Pertussis, Tetanus immunization

EPI Expanded Programme on Immunization

EPI+ One of the ACSD intervention packages, consisting of the full EPI schedule as well as the provision of vitamin A and deworming twice each year for children aged six to 59 months, and the provision of insecticide-treated nets for the prevention of malaria.

F-IMCI

Facility component of Integrated Management of Childhood Illness, which includes improving the skills of facility-based health workers as well as strengthening aspects of the health system needed to provide appropriate care for children less than five years of age.

GAVI Global Alliance for Vaccines and Immunizations

GHS Ghana Health Service

GoG

Government of Ghana

x IIP-JHU | Retrospective evaluation of ACSD in Ghana

GoN

Government of the Netherlands

GRCS Ghana Red Cross Society

GSS Ghana Statistical Service

Hib Haemophilus influenzae type b immunization

HIDs “High-impact” districts for ACSD implementation, defined as Bawku East, Bawku West, Bolgatanga, Bongo, Builsa, and Kasena-Nankana in the Upper East region in Ghana

IEC Information, Education and Communication

IHNS Integrated Health and Nutrition Survey in Northern, Upper East, and Upper West Regions of Ghana, 2002

IIP The Institute for International Programs at JHU

IMCI Integrated Management of Childhood Illness

IPTi Intermittent preventative treatment for malaria in infancy

IPTp Intermittent preventative treatment for malaria in pregnancy

ITN Insecticide-treated net

JHSPH The Johns Hopkins University Bloomberg School of Public Health

JICA Japan International Cooperation Agency

KNUST Kwame Nkrumah University of Science and Technology

LLITN Long-lasting insecticide-treated net

MBB Managing Budgets for Bottlenecks, a tool developed by UNICEF and the World Bank to support results-based planning for maternal, newborn and child survival in developing countries.

MDG Millennium Development Goal

MDG-4 The fourth millennium development goal, which aims to reduce mortality among children less than five years of age by two-thirds from levels in 1990.

MICS Multiple Indicator Cluster Survey designed by UNICEF

MOH Ministry of Health

NGO

Non-governmental organization

NHIS

National Health Insurance Scheme

NIDs National Immunization Days

ORS Oral Rehydration Salts, usually pre-packaged in a sachet

IIP-JHU | Retrospective evaluation of ACSD in Ghana xi

ORT Oral Rehydration Therapy, can be either pre-packaged in a sachet or prepared in the home

pp Percentage points

PMTCT Prevention of mother-to-child transmission of HIV

RHMT Regional Health management team

SP A combination of two drugs, sulfadoxine and pyrimethamine. This drug combination is commonly known as Fansidar.

SIA

Supplementary Immunization Activity

SWAp Sector-Wide Approach: World Bank

TBAs Traditional Birth Attendants

TT2 Two doses of Tetanus toxoid vaccine during pregnancy

UER

Upper East Region

UNICEF United Nations Children’s Fund

USAID

United States Agency for International Development

VCT

Voluntary Counseling and Testing

WHO World Health Organization

xii IIP-JHU | Retrospective evaluation of ACSD in Ghana

IIP-JHU | Retrospective evaluation of ACSD in Ghana 1

1. The external retrospective evaluation of ACSD in four countries

UNICEF implemented the Accelerated Child Survival and Development (ACSD) project between 2002 and 2005 in 11 countries in Africa with support from Canadian CIDA and other partners. The main objective was to use results-based planning techniques to increase coverage with three packages of high-impact interventions known to reduce child mortality (see Box 1). In Benin, Ghana, Mali and Senegal, 16 “high-impact” districts worked to deliver all three packages; in the remaining countries, the focus was on the “EPI+” package that included vaccination, Vitamin A and insecticide-treated nets (ITNs) for the prevention of malaria. Internal UNICEF evaluations in 2003 and 2004 showed increases in coverage for the EPI+ package in all countries; UNICEF modeled the associated reductions in mortality using the "Marginal Budgeting for Bottlenecks " (MBB) tool and estimated an overall mortality reduction of 20 percent in the “high-impact” districts in the four countries, relative to comparison districts.1 UNICEF and the evaluation team recognized the limitations of a retrospective evaluation, including the difficulties associated with reconstructing project assumptions and activities on a post hoc basis, and making the best possible use of available data and information despite their shortcomings. Readers are reminded to treat the results with caution.2 The aim of the evaluation is to provide valid and timely evidence to child health planners and policy makers about the effectiveness of ACSD Phase I in reducing child mortality and improving child nutritional status. The specific objectives are: 1. To evaluate the impact of ACSD on mortality and nutritional status among children under five.

2. To document the process and intermediate outcomes of ACSD and results-based planning as a basis for improved planning and implementation of child health programs.

3. To document the contextual factors necessary for effective implementation of efforts to reduce child mortality in order to be able to extrapolate evaluation findings to other settings.

4. To assess the process, outcomes and impact of ACSD and results-based planning on socio-economic, ethnic and gender inequities.

Achievement of these objectives should also expand regional and global capacity for large-scale effectiveness evaluations of strategies, programs and interventions designed to improve child health in low-income countries.

Box 1: ACSD High-Impact

Implementation Packages*

Immunization plus (EPI+) Routine immunization and periodic measles

catch-up and mop-up

Vitamin A supplementation bi-annually

Distribution and promotion of Insecticide Treated Nets for all children who are fully vaccinated as well as pregnant women, and re-dipping of bednets every six months

Improved management of pneumonia, malaria and diarrhea (IMCI+) Promotion of exclusive breastfeeding for six

months, timely complementary feeding

Improved and integrated management (at the health facility, community and family levels) of children suffering from ARI, malaria and diarrhea, including home-based ORS use, treatment of malaria with anti-malarial blisters, and treatment of ARI with antibiotic blisters

Promotion of household consumption of iodized salt

Antenatal Care (ANC+) Intermittent preventive treatment (IPT) of

malaria with SP (Fansidar) for pregnant women

Tetanus immunization during pregnancy to prevent maternal & neonatal tetanus

Supplementation with iron/folic acid during pregnancy and with vitamin A post-partum.

______ * UNICEF grouped these interventions into

paragraphs in different ways at various points during the project; we have adopted the grouping used in the final report from UNICEF to CIDA for the ACSD project in 2005.1


1.1 Evaluation design

Geographic focus: The global retrospective evaluation covers the four countries within which UNICEF defined districts as “high impact” for the ACSD project. Within each country, we focus on these “high-impact” districts (HIDs). Development of a generic impact model for ACSD: The first step in any evaluation is to define what those implementing the project expect to happen because of project activities. We developed an impact model that specifies the pathways through which UNICEF and implementing countries expected ACSD activities to result in reductions in child mortality.3 Figure 1 presents the generic ACSD impact model in two parts. Figure 1A shows the “top” of the framework describing expected ACSD inputs and processes from the point of introduction at national level in a country through the definition of the three packages of interventions recommended for accelerated implementation (see Box 1 for a description of the three packages). We derived the “top” of the framework from ACSD documentse.g.4 and discussions with ACSD implementers at all levels. Figure 1B shows the “bottom” of the framework, defining the pathways through which each of the three packages was expected to result in reductions in under-five mortality and improvements in the nutritional status of infants and young children. ACSD documents did not describe the pathways in the “bottom” of the model in detail, but made reference to other sources where the effects of the interventions are defined and quantified.5,6 For the internal evaluation,1 UNICEF utilized the estimates of effectiveness published in these sources and changes in intervention coverage as the basis for modeling the impact of ACSD on child mortality. A central tenet of the evaluation is that the coverage, family practices and impact reflected in the “bottom” of the framework cannot be attributed to ACSD alone. UNICEF and country partners designed ACSD to reinforce existing activities in child survival by the government of each country and its partners. Therefore, increases or decreases in coverage and mortality must be understood as the result of a combined implementation effort, tempered by contextual factors. A key challenge for the current evaluation is to arrive at a qualitative assessment of ACSD’s role as a part of this overall effort; quantified attribution of the results to ACSD alone is not warranted given the implementation approach. Definition of priority indicators for coverage and family practices. Priority coverage indicators address the prevalence of key family practices and intervention coverage for each of the elements defined in the “bottom” of the framework. Although some of these indicators reflect behaviors—such as exclusive breastfeeding and complementary feeding—rather than intervention coverage, these will be referred to as coverage indicators throughout the text. Appendix D defines the priority indicators of coverage utilized in the evaluation. Whenever possible, the ACSD priority coverage indicators are consistent with those supported by a consensus of United Nations (UN) agencies and multi- and bi-lateral partners for tracking progress toward MDG-4.7,8 Where no international consensus indicator exists, we contacted technical experts in the topical area to obtain advice on selection of a valid coverage indicator that could be calculated using the data available in Ghana. Definition of priority indicators of impact (nutrition and mortality). The main objective of the ACSD project was to reduce mortality among children less than five years of age. The primary impact indicator in the evaluation is the under-five mortality rate, expressed as the probability of dying between birth and exact age five years. Additional priority indicators include infant and child mortality. Some ACSD project documents described expected improvements in child nutritional status, reflecting the synergy between undernutrition and infectious disease.9 In Ghana, the regional management team in the HIDs specified ACSD targets to reduce undernutrition by 15 percent in three years and by 25 percent in five years,10 although specific indicators of undernutrition were not defined. Priority impact indicators include prevalence of stunting, wasting and underweight. Appendix D presents the detailed definitions of the priority indicators for mortality and nutritional status.


Improved nutritionReduced mortality

Immunization +

Vitamin A supplementation

DPT, Hib, measles vaccines

Insecticide treated nets

MeaslesPneumonia MalariaDiarrheaMeningitis / sepsis

Increased coverage

High attendance at facilities/outreach sessions;deployment at community level

Spillover effect (co-morbidity)

Reduced mortality? Improved nutrition?

Antenatal care +

Tetanus toxoidIPT for malaria Post-partum

Vitamin A

Neonatal tetanusPreterm delivery

Increased coverage

High attendance at facilities/outreach sessions

Iron/folic acid

Neural tube defects ?????

Reduced mortalityImproved nutrition

IMCI +

Pneumonia treatment

Breastfeeding promotionMalaria treatment

PneumoniaMalaria

Increased coverage

Deployment of interventions at community level

ORT

Diarrhea Other infections

Spillover effect (co-morbidity)

ACSD impact model:“Bottom” model showing interventions to impact

Figure 1B

“Top” model showing inputs and processes


Equity. As part of the evaluation, we examine inequity in coverage and impact indicators, including socio-economic status, sex of the child, place of residence (urban or rural) and ethnic groups. Documenting contextual factors. Contextual factors are defined as variables that can confound the association between the delivery of interventions and their health impact, or modify the effects of the approach.11 We documented contextual indicators in the HIDs and comparison area, including: (1) indicators of implementation-related contextual factors such as characteristics of the health system (e.g., utilization rates), child health policy, drug policy, and availability of drugs; and (2) indicators of impact-related contextual factors including baseline levels and patterns of child morbidity and mortality that can affect the potential magnitude of program impact.11 Economic evaluation. At the request of UNICEF, the evaluation does not include an economic component.


2. Evaluation Methods 2.1 Evaluation design Overall design.

The overall evaluation design was retrospective, drawing on existing population-based surveys with over-sampling of the MICS in the Upper East region, commissioned for the purpose of this evaluation. We re-analyzed pre-existing data sets whenever possible to ensure that the indicator definitions were correct and consistent. Preliminary results were reviewed in meetings of the evaluation team with representatives of the Ghana Health Service (GHS), the Ghana Ministry of Health (MOH), the Ghana statistical service (GSS) and the UNICEF country office in Accra, Ghana in July 2008. Coverage and family practice indicators.

We reanalyzed existing household survey data to calculate the ACSD priority coverage and family practice indicators. As described above, these indicators are consistent with those used internationally for monitoring progress toward the Millennium Development Goals7,8 and are presented in appendix D. Appendix E provides the specific survey questions used for the indicator calculations. Nutrition and mortality indicators.

We reanalyzed existing household surveys to calculate the priority nutrition indicators using the 2006 WHO Growth Standards.12 Appendix J and section 6 present more details on these methods. For calculation of priority mortality indicators, the evaluation team analyzed mortality retrospectively, using direct under-five mortality estimates based on full birth histories collected in the 2007 MICS supplemental survey in the HIDs. Estimates of under-five mortality in the comparison area were based on available direct and indirect estimates.

Intervention area.

The intervention area included the Upper East region (UER), selected for ACSD “high-impact” implementation. When ACSD was first implemented, the Upper East region comprised six districts: Bawku East, Bawku West, Bolgatanga, Bongo, Builsa, and Kasena-Nankana. In 2005, new health districts and boundaries were defined, these eight districts in Upper East region are: Bawku Municipality, Bolgatanga Municipality, Bongo, Builsa, Bawku West, Kasena-Nankana, Guru Tempane and Talensi Nabdam (Figure 3). Throughout the body of this report and appendices, we refer to the six “high-impact” districts (HIDs) defined at the inception of ACSD, unless otherwise noted. Comparison area.

The main comparison area is the remainder of Ghana excluding the urban areas of Greater Accra and Ashanti regions (Accra and Kumasi). We have excluded Accra and Kumasi because access to services and living conditions in these areas differ considerably from the predominantly rural HIDs. Intervention activities.

We documented the timing and scale of intervention activities using information collected from field visits to the HIDs, key informant interviews and document review, such as administrative and supervision reports and monitoring data. Equity.

To examine inequities, we performed analyses of selected intervention coverage and impact measures stratified by sub-groups of the population, including household assets (expressed in quintiles), sex of the child, place of residence (urban/rural) and ethnic group. Contextual factors.

We collected standard information on contextual factors, defined above, in order to assist in interpretation of the results and the potential contributions of ACSD. Certain elements, such as economic status, ethnicity and access to clean water were re-analyzed for HIDs and comparison areas using existing household survey data. Field visits to the HIDs, key informant interviews and


document review provided contextual information not available in existing surveys. A program mapping exercise, carried out by investigators at Kwame Nkrumah University of Science and Technology (KNUST), documented health and development activities in the HIDs and nationally between 1999 and 2007. Appendix B and M provide further details on the methods used to collect contextual factors. 2.2 Data sources and methods Tables 1a and 1b summarize the different types of information used in the evaluation. The 1998-9 and 2003 Demographic Health Surveys (DHS) and the 2006 Multiple Indicator Cluster Survey (MICS) with a supplemental survey in the Upper East region (HIDs) conducted in 2007 served as the primary data sources for estimates of intervention coverage and nutrition in the HIDs and comparison area. For estimation of the endline coverage and nutrition results in the HIDs, we utilized the Supplemental MICS 2007; the 2006 national MICS was utilized to provide endline estimates in the comparison area, excluding the HIDs and urban areas of Greater Accra and Ashanti regions. We did not merge the MICS 2006 data for the HIDs with the supplemental MICS 2007 data due to incompatible sampling strategies and the small sample size of the data in the HIDs (Upper East region) in the 2006 MICS. The 2007 supplemental MICS included a full-birth history module used to estimate child mortality both before and after ACSD implementation. The full-birth history method allows the calculation of period estimates of mortality ranging from the previous 12 months to 10 or more years in the past. No comparable data was available for the comparison area. Estimation of under-five mortality in the comparison area was based on indirect child mortality estimation as measured in the DHS 2003 and MICS 2006, and direct estimates from DHS 2003. Section 7 describes the mortality analysis methods in more detail. Other survey data were available, but given lesser prominence in the analyses because they did not fully meet the quality criteria established for the evaluation. These criteria were: 1) full data sets and documentation, including sampling weights, available to the evaluation team so that the data could be reanalyzed using the standard definitions for priority indicators; and 2) no more than 5 percent missing values on key socio-demographic variables (e.g., child age) or the variables needed to construct the priority indicators. We did not use data from the Integrated Health and Nutrition Survey (IHNS) 2002 and the CDC-ACSD 2003 survey in the primary analyses because they did not fulfill these criteria. However, we use these data to explore time trends between 1998-9 and 2006-7. Descriptions of the methodology and conduct of surveys used in the evaluation are presented in appendix F and full documentation of 2003 ACSD-CDC survey data quality issues is available upon request from IIP-JHU evaluation team. Table 1b presents sources of information used in the documentation of intervention activities and contextual factors. We collected information through: 1) review of documents, including administrative and monitoring reports; 2) key informant interviews; and 3) searches and review of published and grey literature. Technical staff at UNICEF-Ghana provided input and revisions throughout the process of documentation. Due to the retrospective nature of the evaluation, it was difficult to collect complete and standardized information on ACSD implementation activities and other health activities in the Upper East region. The collaborative nature of ACSD makes it difficult to distinguish which activities were: 1) carried out as part of the ACSD program, 2) carried out with only partial technical and/or financial support from the ACSD program, or 3) carried out by ACSD partners, but independent of the ACSD program. In some cases, the information presented in administrative reports was inconsistent; for example, annual reporting of the number of bednets treated varied slightly. Appendix C notes observed discrepancies in implementation reports.


Table 1a: Data sources for independent retrospective evaluation of ACSD in Ghana, population-based surveys.

TYPE OF DATA DESCRIPTION USE IN EVALUATION Population-based surveys that met inclusion criteria

DHS 1998/1999 Used to establish baseline levels of priority coverage and nutrition indicators in HIDs and comparison area.

: Nationally representative household survey conducted from November to February 1999.

DHS 2003

: Nationally representative household survey conducted from July to October 2003.

Used to estimate interim coverage and nutrition indicators in HIDs and comparison area.

MICS 2006 Used to estimate priority coverage and nutrition indicators in HIDs and comparison area.

: Nationally representative household survey conducted from August to November 2006.

MICS supplemental 2007

: Household survey in Northern, Upper West and Upper East region conducted from September to December 2007 with additional EA’s collected in February 2008.

Used to estimate endline coverage and nutrition indicators in HIDs. Used for retrospective estimation of mortality in HIDs.

Other population- based surveys

IHNS 2002: Reported in appendices, but given limited weight in analysis due to availability of a usable datafile.

The Integrated Health and Nutrition Survey in Northern, Upper East, and Upper West regions conducted from February to March 2002.

CDC-ACSD 2003

: Household survey of 2341 households in the Upper East region carried out from July to September 2003.

Reported, but given limited weight in analysis due to concerns about data quality.


Table 1b: Data sources for independent retrospective evaluation of ACSD in Ghana, routine data, administrative reports and key informant interviews.

TYPE OF DATA DESCRIPTION OF KEY DOCUMENTS USE IN EVALUATION Routine health information system data

Routine data collected through health facilities pertaining to intervention coverage, compiled at the local, regional and national levels.

Documentation of MOH and ACSD activities.

Administrative reports

Annual UNICEF reports: Three administrative reports from 2003 – 2005 detailing implementation and inputs; ACSD annual reports and presentations – Upper East region: Eight reports/presentations on ACSD progress 2004 - 2006, one EPI+ report 2004; Ghana Health Service: Upper East region Health Sector Annual Reviews: 2000 – 2006; Bawku West annual reports: five health sector update reports: 2004 – 2006; IMCI training/monitoring reports

Documentation of ACSD and partners’ activities.

: Nine documents prepared by the regional offices and KNUST.

Job aids and tools

Job aids and tools, such as visual aids and register books, used in the implementation of ACSD were collected and reviewed where possible.

Documentation of ACSD and partners’ activities.

Summary report

UNICEF Assessment of ACSD, 2004.

Documentation of ACSD activities.

Program mapping of development activities in UER and nationally

KNUST contracted to perform sub-study on partner activities in UER and nationally; (Appendix M presents the full methods and sources list).

Documentation of contextual factors.

Key informant interviews

Approximately 24 interviews at the national, regional and district level: see appendix B for summary.

Documentation of ACSD activities and contextual factors.

Working discussions

Field visit and discussions: November 2006; Review of preliminary results: July 2008.

Discussion and documentation of ACSD activities and contextual factors.


2.3 Analysis We employed the Habicht et al framework13 for real-life evaluations. Starting with an adequacy evaluation, we assessed whether trends in coverage indicators were moving in the expected direction, and whether goals were met. Next, we carried out a plausibility

evaluation, defined as a controlled, non-randomized study that assesses whether observed impact can be attributed to program implementation. ACSD in Ghana was a combination of separate interventions – vaccines, mosquito nets, vitamin A supplementation, etc – that are highly efficacious if delivered at optimal coverage. The evaluation did not assess the efficacy of these interventions, but instead focused on their impact when delivered under routine conditions. We carried out the analysis of coverage and nutrition in four steps, explained below. Section 7 describes the analysis of under-five mortality.

Step 1: Generating indicator levels for each survey in the analysis

Objective: To describe levels of priority indicators for coverage and nutrition in all surveys included in the analysis, overall and for specific subsets of children defined by age, sex, geographic location of the household, mothers’ education and socioeconomic status, where sample sizes permit. We applied standard indicator definitions to the reanalysis of all datasets to ensure the comparability of indicators over different surveys. For each indicator, only data for women and children with known responses for that indicator were included in the analyses; cases with missing or unknown data were excluded. The point estimates of indicators presented here may therefore differ slightly from those calculated using standard DHS and MICS tabulation programs, which do not exclude missing records from the analyses. Step 2: Comparing rates of change over time within each ACSD district (“time trends”).

Objective: To determine whether there are statistically significant differences in indicator levels within HIDs from before ACSD was implemented to after ACSD was implemented in ACSD areas, with a mid-point during the process of implementation where adequate data are available, overall and for specific subsets of children. This step refers to the adequacy evaluation. Step 3: Comparing rates of change between ACSD and non-ACSD districts within each country (“time trend with comparison”).

Objective: To determine whether there are statistically significant differences in the rates of change for indicator levels between the HIDs and comparison area where ACSD was not implemented (the comparison area is comprised of the rest of Ghana, excluding Accra, Kumasi and the HIDs), overall and for specific subsets of children. Step 4: Attributing improvements to ACSD and related child survival activities at country level.

Objective: To determine whether any statistically significant changes in indicator levels can be attributed to ACSD activities, including activities implemented by others in collaboration with ACSD and the national child survival plan, overall and for specific subsets of children. Steps 3 and 4 refer to the plausibility evaluation, assessing whether progress was greater in the ACSD than in the comparison area, and whether or not external factors can account for these differences. For all comparisons across time and geography, we initially calculated a simple chi-square statistic of difference. The simple chi-square statistic does not take into account the design effect of the survey, thus it under-estimates the variance. If no statistical differences were observed using the simple chi-square statistic, we assumed that none would be observed after the design effect was taken into consideration (adding to the variance) and that the groups were therefore not statistically different from one another. For comparisons with a significant chi-square, we calculated standard errors and 95 percent confidence intervals that take into account the survey design effect, using the Taylor Linearized Variance method. We used a “difference-in-differences” approach to compare whether the change in each indicator over time differed significantly between the HIDs and comparison area.


3. Characteristics of the “high-impact” districts and comparison area This section presents pertinent characteristics of Ghana as a whole and the HIDs and the comparison area. We emphasize differences between the HIDs and comparison area, as well as factors that have changed over the evaluation period to help guide the interpretation of evaluation results. Some of the quantitative results (table 2) presented here are based on our reanalyses of available survey data, because these provide the most recent information disaggregated by the HID and comparison area. Appendices A and M present additional information on the geographic, socio-demographic, economic, health and health service factors in Ghana and the UER. 3.1 The Ghana context

Ghana, located in West Africa, maintains three international boarders and a coast off the Gulf of Guinea (Figure 2). Togo is situated to the East, Cote d’Ivoire to the West, and Burkina Faso to the North and Northwest. Great Britain established a colony in 1874 known as the Gold Coast, and Ghana declared independence in 1957. The first president of Ghana, Dr. Kwame Nkrumah was overthrown in a military coup in 1966.17 A cession of military leaders ruled Ghana until Jerry Rawlings seized power in 1981 and gradually restored civilian rule, with the first free elections in 1992.17 The current president John Agyekum Kufor holds office in his second and final term ending in December 2008. Of Ghana’s estimated 23 million population, 38 percent are younger than 15 years old.18 The

estimated growth rate is currently 1.9 percent with a total fertility rate of 3.8 births per woman.19 In 2000, 41 percent of the population was urban.19 Well-endowed with natural resources, Ghana’s per capita output is twice that of neighboring West African countries. Despite prosperity relative to its neighbors, Ghana maintains a 5.7 billion (US$) debt, 26 percent of the Gross National Income. According to a new Ghana Living Standards Survey reported by the World Bank, poverty levels have dropped from 52 to 29 percent between 1992 and 2005. 3.2 Child health in Ghana Ghana had an estimated population of 3.2 million children under age five in 2006. The under-five mortality rate has stagnated at 120 per 1000 live births between 1990 and 2006, falling short of progress needed to achieve the two-thirds reduction from 1990 levels defined by the fourth Milliennium Goal (40 per 1000 live births). Box 2 shows the major causes of under-five deaths in Ghana in 2003 as reported by WHO14 Almost one-third of all under-five deaths occur in the neonatal period. Among these deaths, infections account for

Box 2:

Overview of child health in Ghana

Prevalence of undernutrition***

13Underweight (% mod + severe)

28Stunting (% mod + severe)

76Infant

120120Under-five

Mortality rates (per 1000 live births)**20061990

Diarrhea12%

Injuries3%

HIV/AIDS6%

Measles3%

Neonatal29%

Malaria27%

Pneumonia15% 33%

Causes of under-five deaths in Ghana*

Sources: *WHO, 200614; **SOWC15; ***MICS 200616

Figure 2: Map of Ghana and its neighbors


approximately one-third (32%) with the remainder attributed to preterm births (26%), asphyxia (23%), congenital (6%) tetanus (4%) and other causes (9%). Child undernutrition is also a problem in Ghana. In 2006, estimates using the new WHO growth standards indicated that 28 percent of children under five years of age were either moderately or severely stunted, 6 percent were wasted, and 13 percent were underweight.20 Appendix A includes the full profile of maternal, newborn and child health from the Countdown to 2015 2008 report.20 3.3 Selection of the ACSD “high-impact” districts in Ghana UNICEF and the Government of Ghana (GoG) selected the six districts in the Upper East region (UER) for “high-impact” implementation of ACSD. UER is one of the poorest regions in Ghana and had high levels of under-five mortality, contributing to its choice for implementation of the ACSD approach. UNICEF had been supporting activities in the Bawku West and Builsa districts in the UER since 1995; the ACSD “high-impact” districts (HIDs) included these two districts as well as the remaining four districts in the UER. Redistricting occurred in 2005 and the UER is now comprised eight districts (Figure 3). Key informants reported that other factors considered in the choice of the UER included: 1) political stability; 2) a strong regional health team; and 3) a passable road network, ensuring high accessibility to the entire region. 3.4 Socio-economic and demographic factors Figure 4 shows the incidence of poverty in the HIDs and the geographic comparison area as measured in the 2000 Housing and Population Census and the Ghana Living Standards Survey 4.21 The poorest districts are located in the northern areas of the country, with the six HIDs, noted in the call-out box, among the poorest in the country. Table 2 presents socio-demographic variables as measured in household surveys in 1998-9, 2003 and 2006-7 in the HIDs and comparison area. Based on our re-analyses of the DHS 1998-9, DHS 2003 and MICS 2006-7, households in the HIDs remained significantly poorer relative to the comparison area throughout the evaluation period (p<0.001), based on measures of household assets. The proportion of women with primary and higher education was significantly greater in the comparison area than the HIDs across all time points (p<0.001). In 1999 and 2003, almost two-thirds of women in the HIDs reported no schooling, decreasing to 58 percent of women without schooling in 2006-7. Similarly, female literacy was two times greater in the comparison area as compared to the HIDs in 1999 and 2003. The difference in literacy between the HIDs and comparison area narrowed in 2006-7, but was still statistically significant (p<0.001). The majority of households in the HIDs are of the Mole-Dagbani, Gruma and Grussi ethnic groups, while the comparison has much larger proportion of Akan, Ewe and Ga households (p<0.001). The apparent decline in the Gruma households in the 2003 DHS is thought to be due to different classifications of responses between surveys or the sampling error. 3.5 Environmental characteristics The HIDs fall into Ghana’s savannah zone, with the forest and coastal zones in the central and southern areas of the country. The HIDs experience much less rainfall than the central and southern areas of Ghana, with particular drought hazards between January and March in the HIDs.22 Accordingly, malaria transmission is seasonal in the HIDs, with highest transmission between June and October.23 Models predict that the length of annual malaria transmission is longer in the southern areas of the country, becoming more seasonal in the northern zones,24 although other models predict

Builsa

Kassena/Nankana Bongo

Bolgatanga M.

Talensi-Nabdam

BawkuWest Garu-

Tempane

Bawku Mun.

Builsa

Kassena/Nankana Bongo

Bolgatanga M.

Talensi-Nabdam

BawkuWest Garu-

Tempane

Bawku Mun.

Figure 3: Map of eight health districts, as of 2005, Upper East region, Ghana


similar transmission intensities and prevalence of parasitemia among children less than five years of age in the northern, central and southern areas of the country.25 Before and during ACSD implementation, resistance of malaria parasites to chloroquine grew.26-28 Evidence suggests that levels of chloroquine resistance differed by geographic region, with the highest chloroquine resistance in the south and the lowest resistance levels in the north of the country.29 The HIDs are significantly more rural than the comparison area (p<0.001), which excludes the major metropolitan areas of urban Greater Accra and Ashanti regions (table 2). The apparent decrease in rural residences between 1999 and 2003 is likely due to previously rural localities reclassified as “urban” (population greater than 5,000) after the 2000 census.21 The proportion of households with access to an improved water source was greater in the HIDs than the comparison in 1998-9 and 2006-7 (<0.001). In both areas, access to improved water sources significantly increased, with greater increases over time in the comparison area. Less than five percent of households in the HIDs reported access to improved sanitation facilities in 2003 and 2006-7. Access to improved sanitation was significantly greater in the comparison area (p<0.001), but still less than 15 percent in 2003 and 2006-7.

Our investigations did not reveal any natural disasters in the HIDs over the primary evaluation period. However, severe flooding took place in the northern regions of Upper East, Northern and Upper West in August to November 2007, prompting the government to declare a state of disaster. Data collection for the Supplemental MICS 2007 endline survey was on going at this time; we discuss the implications of the flooding on intervention coverage (section 5) under methodological challenges.

Figure 4:

Incidence of poverty in Ghana districts as measured by the 2000 Housing and Population Census and 1999 Ghana Living Standards Survey

Source: Coulombe, 200521


Table 2:

Selected characteristics of the “high-impact” districts and comparison area, as measured in the DHS 1998-9 and 2003, and MICS 2006-7, Ghana.

n* % n* % p n* % n* % p n* % n* % pWealth quintiles

Poorest 43% 17% 57% 13% 33% 7%Poorer 37% 22% 15% 20% 28% 8%

Poor 3% 16% 5% 21% 19% 19%Less poor 4% 25% 14% 24% 10% 31%

Least poor 14% 20% 8% 22% 10% 35%

Education among womenNone 74% 30% 72% 31% 58% 30%

Primary school 10% 20% 12% 22% 21% 22%Secondary school+ 16% 50% 16% 46% 21% 48%

Literacy among women 287 20% 3588 53% <0.001 309 14% 3853 37% <0.001 3257 27% 4141 41% <0.001

Ethnicity Akan(Asante, Akwapim,

Fante and Other Akan) 1% 58% 0.3% 52% 0.6% 47%Ewe 0.9% 18% 0.2% 15% 0.2% 15%

Gruma 29% 5% 1% 3% 28% 2%Mole Dagbani 43% 5% 41% 15% 45% 12%

Grussi 21% 2% 17% 1% 12% 1%Ga/Adangbe, Guan, Hausa,

Mande 2% 8% 2% 10% 8% 11%Other 3% 5% 38% 4% 7% 12%

Rural residence 271 89% 4615 79% <0.001 279 80% 4497 70% 0.11 3324 78% 4344 71% <0.001

Hygiene§ Improved water source 271 70% 4613 53% <0.001 277 66% 4490 61% 0.43 3316 83% 4297 72% <0.001

Improved sanitation n/a n/a 279 4% 4492 12% <0.001 3316 4% 4339 13%

¥Excluding urban Great Accra and Ashanti region and High Impact districts *Weighted § MDG definitions

INDICATORS

GEOGRAPHIC COMPARISONS¥

271 4615

1998/99 DHSHIGH IMPACT

DISTRICTS

<0.001

2003 DHSHIGH IMPACT

DISTRICTSGEOGRAPHIC

COMPARISONS¥

279 4497 <0.001 <0.0013324

HIGH IMPACT DISTRICTS

GEOGRAPHIC COMPARISONS¥

4344

288 3588 <0.001 310

4167 <0.001

3870 <0.001 3288 4167

2007 S. MICS 2006 MICS

<0.001

288 3588 <0.001 310 3868 <0.001 3288


3.6 Baseline health conditions Section 3.2 presents a profile of child health in Ghana as a whole, including the cause of death profile. Cause of death information is not available disaggregated by HIDs and comparison area. However, a vitamin A trial conducted in the Kassena-Nankana district (one of the six HIDs) in 1989 to 1991 found that children aged six to 59 months died from diarrhea (26%), malaria (23%), measles (19%), pneumonia (13%), malnutrition (8%).30 The proportionate causes of child mortality found in the study were slightly different than 2008 estimates for Ghana, likely due to decreases in measles deaths since 199131 and more HIV/AIDS deaths nationally and in later years. However, these findings suggest that the primary causes of death in the HIDs are similar to Ghana as a whole. We present and consider baseline levels of undernutrition and under-five mortality in sections six (nutrition) and seven (mortality). 3.7 Health service characteristics Availability of health services.

The health services of Ghana have been decentralized, with regions and districts having more autonomy than in the past. Since Alma-Ata in 1978, there has been a focus on development of primary health care at the sub-district level, mostly through the training of health providers and installation of health facilities.32 Table 3 presents the approximate coverage of all health facilities in the HIDs and comparison area in 2002 and 2007. According to the Ghana Health Service (GHS) annual reports,33 the HIDs had approximately one health facility per 15,500 population in 2002, with coverage increasing to approximately one facility per 10,000 population in 2007. In the comparison area, coverage was estimated at one facility per 12,000 population in 2002, and increased to one facility per 10,000 population in 2007. These differences and increases are difficult to interpret, as available measures included all public and private health facilities, maternity centers, as well as nutritional rehabilitation centers. Community-based Health Planning and Services (CHPS) compounds, discussed below, were not included in these estimates. The Community-based Health Planning and Services (CHPS), is an expansion of the primary health care concept, through community engagement and placement of community health officers (CHOs) to make primary health services more accessible. It began in the Kassena-Nankana district (one of the HIDs) as a research project in 1994,34-36 and has since been expanded to other communities in the HIDs. In the HIDs, the GHS in UER reported seven functioning compounds in 2002 and 82 functioning compounds in 2006. The catchment area for community health officer or CHPS compound is to be comprised of approximately 3000 individuals.37 The MOH planned to deploy 1570 community health officers (community health nurses) to various communities nation-wide by 2006; however, implementation is far behind schedule and only 258 CHPS compounds were reported to be functioning in the comparison area in 2006. Coverage of CHPS compounds in 2007 in the HIDs was much greater (approx 11,220 population per CHPS facility) than in the comparison area (58,000 population per CHPS compound).

Table 3: Coverage of health facilities and CHPS compounds in 2002 and 2006, Ghana.

YEAR INDICATOR HIDs (UER)

GHANA, EXCLUDING

ACCRA & HIDs* 2002 Population** 920,089 15,077,264 Hospitals 6 80 Total health facilities*** 59 1244 CHPS compounds 7 32

2007 Total health facilities*** 92 1425 CHPS compounds 82 258 *estimates exclude Greater Accra, but not urban Ashanti region **estimates from 2000 Housing and Population census ***Includes hospitals, clinics, health centers and maternity homes, as well as private facilities; 2002 estimates taken from the GHS 2002 annual report; 2007 estimates from the GHS annual report and website33


Changes in health policies.

A number changes in national policies influencing child health took place between 2000 and 2007. In 2002, Hib vaccination was introduced into national policy and included in routine EPI vaccination schedules. Due to growing chloroquine resistance, national policy changed to recommend ACTs as the first-line antimalarial drug in April 2004. ACTs became available in health facilities & CHPS compounds in late 2005; the community-based distribution of ACTs was not authorized until late 2007. The GoG introduced the National Health Insurance Scheme (NHIS) in 1998, but inadequate and slow reimbursement limited its effectiveness. The GoG passed a law concerning the NHIS in 2003 to support districts to set up mutual health insurance schemes and to initiate activities to recruit and register clients. The NHIS automatically covered children less than 18 years of age if parents have paid at least the minimum contribution. No estimates of NHIS coverage were available at the writing of this report, although the 2007 Supplemental MICS survey will provide estimates of coverage for the Northern, Upper East, Upper West and Central regions. 3.8 Other projects that may impact child health Child health partners and activities in the HIDs (UER).

As Belch states in his background document on Upper East region: “If signboards are held to constitute development, then Northern Ghana has no further need of it.38” A multitude of international and local development partners and NGOs implemented child survival, health and other development activities in the HIDs both before and during ACSD implementation. Table 4 provides a summary of the activities and approximate coverage of selected health projects in the HIDs from 1998 to 2007; appendix M provides further details. We documented major child health and nutrition activities in the HIDs during this period, given available data; this list should not be considered comprehensive of all child health activities in the HIDs. Many activities supported by partners in the HIDs focused efforts on child nutrition. The LINKAGES project, funded by USAID and carried out by Academy for Education Development (AED), provided support from 2000 to 2003 for activities to improve infant feeding practices in the northern regions, including the HIDs. This project trained a variety of actors and provided technical support to NGOs, the GHS, and UNICEF to implement packages to promote appropriate infant feeding, including early initiation of breastfeeding, exclusive breastfeeding and complementary feeding. There are approximately 30 supplementary feeding centers in the HIDs (Upper East region) which provide supplementary feeding for children and mothers through support from the World Food Program and impart educational messages about child nutrition and survival. Fifteen nutritional rehabilitation centers have also been established with support from churches, Catholic Relief Services (CRS) and World Vision International. With support from the American Red Cross, the Ghana Red Cross Society (GRCS) established over 60 mothers’ clubs in the Bawku East, Bawku West and Bolgatanga districts to promote child health and infant feeding, and provide home based management of fever and diarrhea in 1999. The mother’s clubs and health and nutrition promotion activities expanded over time, covering 200 communities in 2002, partially in collaboration with the LINKAGES project described above. Between 1999 and 2000, GRCS served an estimated 16,500 children under-five annually in the HIDs through these activities. Starting in 2003, GRCS collaborated with the UNICEF ACSD project to train and equip over 1800 community-based agents (CBAs) to carry out health promotion and community management of common illnesses. Section 4, “ACSD as implemented in Ghana” describes these activities in further detail.


Table 4:

PROGAM TYPE OF ACIVITYGEOGRAPHIC

COVERAGE

BEST ESTIMATE OF COVERAGE OR

INTENSITY TIMING

CRS

Trainings & community meetings for improved nutrition;

on-going support to feeding centers

Bongo district over 200 trained 2000-2002

1 hospital & 7 health centers; w ith outreach points

n/a

Reproductive health / skilled deliveries

Avg. 235 deliveries annually in 1998-2002; Avg. 1014 deliveries annually in 2004-2006

ANC Avg. of 7422 ANC visit annually 1999-2006

Child w elfare clinicsAvg. 21,045 children

served annually in 2001-2005

C-IMCI training 20 staff trained 200547 communities

(99) to 200 communities (01) in Baw ku West,

Baw ku East, Bolgatanga

~16,500 children served annually through mothers

clubs; training of mothers in mothers' clubs in CS interventions & infant

feeding

1999-2002

Training and support (bicycles & ,medicines) of

1820 w omen through ACSD project

2003-2005

Training and support of 9750 w omen

CHWs/volunteers2006

Message & materials development to promote BF, EBF, complementary feeding

Workshops w ith ~100 participants from radio

stations, GHS, CRS, GRCS, UNICEF

2000

Training of partners & providers in nutritional BCC

over 150 participants (health staff, NGOs, radio) 2000-2003

Training of trainers for mother-to-mother support groups for

nutrition BCCTraining of over 50 trainers 2001-2003

Formation of mother-to-mother support groups for improved

infant feeding & nutrition

Over 400 Mother-to-mother support groups formed & supported by CRS, GRCS,

GHS, UNICEF, ACDEP

2001-2003

Radio broadcasts 500 in UER, UWR & NR 2000-2003

Navrongo Health Research Center

Child and maternal health research

entire Kasena-Nankana district

Early trials on effectiveness of ITNs,

vitamin A; CHPS delivery strategy; malaria treatment

and prevention via antimalarials

1993-present

Nutrition rehabilitation ceters 4 communities in Bongo district

4 centers constructed constructed in 1996-9

Logistic/equipment support to district

Bongo district

Scales, vaccination, vitamin A, dew orming; See

Appendix L for details on inputs

1998 - 2007

Supplemental feeding to school children

Bongo district Approx. 2000 children served annually 1999-2003

Training on nutrition/breastfeeding Bongo district

Approx. 500 mothers trained annually 1999-2007

1998 to present

Diocesan Health and development programmes, in coordination with CRS

HBM of malaria & diarrhea; ARI recognition & referral; infant

feeding; immunization promotion

Ghana Red Cross, UER (with support from EU, AMCROSS & UNICEF) 900 communities

in UER

UER (& UWR & NR)

World Vision International Bongo Area Development Program

Six communities in Bongo, Builsa &

Kassena-Nankana

LINKAGES Project (USAID supported, AED as implementers)

Summary of selected child health and nutrition projects and activities outside of routine services in the HIDs from 1998-2007, Ghana


The Diocesan Health Services was active in the HIDs of Bongo, Builsa and Kassena-Nankana, with one hospital and seven health centers with outreach points. Through these services, approximately 7000 ANC visits took place annually and a skilled provider attended 1000 deliveries annually. Between 2001 and 2005, these services served approximately 21,000 children annually through child welfare clinics providing preventative services, such as vaccinations, and curative care. Also located in Kassena-Nankana district, the Navrongo Research Center conducted effectiveness trials on supplementation of children with vitamin A,30 use of insecticide treated bednets for children35 and pregnant women39 and the CHPS strategy for primary health care34-36 over the last decade. The Navrongo Center has continued to implement and conduct research around these and other interventions in the entirety of the Kassena-Nankana district.40 Other NGOs, among them Rural Help Integrated, Action Aid, and World Vision International, also conducted water and sanitation, reproductive and sexual health and community development projects throughout the period of 1999 to 2007. Additionally, CIDA, the World Bank and the GoG supported water and sanitation projects in over 1000 communities in the HIDs. Child health partners and activities in the rest of Ghana. We provide here a brief overview of the external investments in health activities taking place in the rest of Ghana (our comparison area) both before and after ACSD, appendix M provides detailed descriptions of these activities. Donor support for health and HIV/AIDS in Ghana totaled approximately US$150 million annually between 2003 and 2007, the majority in grants rather than through credit. USAID supported promotion and marketing of ITNs, initiatives to improve the quality of care, and community-based health & planning services (CHPS), as well and family planning and HIV/AIDS activities in the comparison area before and during ACSD implementation. These activities focused in 30 target districts in the southern and central regions of Western, Central, Volta, Greater Accra, Eastern, Ashanti & Brong-Ahafo and were carried out by partners including: Ghana sustainable change project; Population council; JHPIEGO; Quality Health Partners; Engender Health; Abt Associates; AED; CRS, Futures Group, DELIVER; Opportunities for Industrialization Centers International; and Netmark. USAID supported technical assistance and partner programming with annual budgets of approximately US$9-12 million. Approximately 50 percent of these funds supported child survival and 50 percent supported HIV/AIDS activities through 2002; in 2003 to present, approximately 30 percent of funds were targeted to child survival projects and 70 percent for HIV/AIDS. Japan International Cooperation Agency (JICA) provided support to EPI programs, GHS static and outreach services, and HIV/AIDS logistic support in the south of the country and nationally. The Global Fund to Fight Aids, Malaria and Tuberculosis (Global Fund) awarded the national MOH almost US$9 million for malaria control in 2003; another US$38 million grant to control malaria followed in 2005. Additionally, the Global Fund has granted approximately US$51 million for HIV/AIDS programming and US$24 million for tuberculosis programming to date, starting in 2003. The Global Alliance for Vaccines and Immunizations (GAVI) supported national vaccination initiatives with approximately US$5 million annually. The World Bank provided support of approximately US$35 million through 1998-2002 through the Sector-Wide Approach (SWAp) pooled health funding mechanism and provided over US$100 million for health programming in 2003 to 2007. The Danish International Development Agency (DANIDA) provided approximately US$10 million annually through the SWAp for health systems strengthening between 2003 and 2007. During this same period, the British government’s Department for International Development (DFID) provided over US$20 million annually for health at the national level. The World Health Organization (WHO)

The

also contributed to national pooled funding, as well as supporting health system strengthening and child health clinics (preventative and curative) in eight districts in the south and central Ghana.

Government of the Netherlands (GoN) provided approximately US$10 million annually in 2003 to 2005 for health nationally. In 2006 and 2007, the GoN increased their support to more than US$28 million annually. Part of this investment was in support of the GHS child health strategy, High Impact Rapid Delivery (HIRD), which is based closely on the ACSD approach. In addition to the GoN,


DANIDA supported the roll out of HIRD in the Northern, Upper West, Upper East and Central regions, with US$0.80 to US$1.4 million for HIRD provided to each of the four regions in 2006. In 2006, DFID donated US$11 million to UNICEF for the purchase and national distribution of almost two million long-lasting ITNs to children under-two through a national campaign at the end of 2006.


4. ACSD as implemented in Ghana This section provides an overview of the ACSD activities in the HIDs. We consider adaptation of the generic ACSD package, funding, results-based planning and the timeline of activities; the inputs and activities for each ACSD component are then briefly described. Appendix C includes further textual description of the intervention implementation and detailed timelines of ACSD activities. 4.1 Introduction and adaptation of the generic ACSD intervention package UNICEF introduced the ACSD approach to the Government of Ghana (GoG) in late 2001, followed by planning meetings with regional officials in the Upper East and Northern regions. According to key informants, UNICEF presented the generic ACSD framework to regional and district officials, assessed current levels of intervention coverage, set coverage targets and planned how to achieve the ACSD targets. As described above, various development partners—including UNICEF, the Ghana Red Cross Society, and Navrongo Health Research Center—in collaboration with the Ghana Health Services (GHS) had been supporting child survival activities in selected districts and communities of the UER for over a decade. Interventions such as immunization, vitamin A distribution, iron and folic acid supplementation for pregnant women, and the promotion of exclusive breastfeeding, complementary feeding, and iodized salt were well established before ACSD was introduced, albeit at less than ideal coverage levels. Before ACSD, some districts had started to implement the promotion and distribution of insecticide treated nets (ITNs), as well as community case management of diarrhea and malaria. ACSD drew on the experiences of these programs to package the ACSD strategy of interventions for region-wide scale-up. Additionally, the ACSD strategy supported the development training materials and scale up of C-IMCI volunteers and introduced IPTp, PMTCT, deworming and post-natal supplementation with vitamin A. The ACSD strategy was implemented at the regional, district and sub-district levels in partnership with the Ghana Health Service (GHS) and other development partners. 4.2 Funding UNICEF-Ghana received support of US$3.8 million through Canadian CIDA for implementation of ACSD, equivalent to approximately US$25 per child under-five years of age in the HIDs, as well as US0.7 million in resources from other donors from 2002 to 2004.ii

4.3 Results-based planning

The last transfer of CIDA funds was in 2003, and by the end of 2004, expenditure was 97 percent of the initial funds. At the end of the CIDA funds, the government continued in EPI+ and ANC+ through routine services. There was a lag in external support for activities for over one year, until the Government of the Netherlands and DANIDA provided significant funding for the northern regions to continue ACSD activities.

ACSD implementers chose the package of interventions to be implemented in the four “high-impact” countries based on evidence and cost-effectiveness. The ACSD strategy set specific targets for each package and UNICEF monitored results actively at the regional, district, sub-district and community level, in coordination with GHS implementers.10 Key informants noted that GHS implementers presented a report bi-annually to UNICEF to justify funds used for activities. We did not find evidence that ACSD in Ghana included performance contracts or other innovations linking results to specific incentives.

ii Assuming that all funds were spent in the HIDs. We were not able to disaggregate funding by implementation area, i.e. to identify support in the HIDs versus expansion areas. A review of ACSD conducted in 2004 estimated a US$1.9 million price-tag for ACSD implementation outside of routine GHS expenditures from 2001-2003,10 with an approximate expenditure of US$12.35 per child under-five over this period. UNICEF’s final report to CIDA estimated a per capita annual cost US$0.34 through all funding sources and per capita annual costs of US$0.29 through CIDA funding for children in the HIDs and expansion regions.


4.4 Time line of ACSD activities in the “high-impact” districts UNICEF introduced the ACSD strategy to the GoG in late 2001 and logistical support for EPI+ started in 2002, while ITN distribution and treatment programs kicked-off in early 2003. Figure 5 presents summary timeline for the start of selected interventions within the ACSD approach, as well as for household surveys. The C-IMCI program was scaled-up in all districts in late 2003 and ANC+ by early 2004. Table 5 and Appendix C provide additional information about the timing of specific activities. Figure 5: Time line of the accelerated implementation of selected ACSD interventions and surveys conducted to evaluate intervention coverage, 2001 - 2007, Ghana

Figure Key:

• Grey bars represent implementation before ACSD, colored bars implementation supported by ACSD • Spotted area represents ITN stock-outs • Bars represent districts in the following order: Builsa, Bawku East, Kasena-Nankana, Bolgatanga, Bawju

West, Bongo


Table 5: Start times for accelerated implementation of selected ACSD interventions in the ACSD “high-impact” districts of Ghana.

INTERVENTION PACKAGE APPROXIMATE START TIME IN HIDS (UPPER EAST REGION)

EPI+ Routine EPI on-going prior to ACSD; scale-up of EPI+ logistical support began in early 2002

ITNs

On-going before ACSD in Kassena-Nankana and Builsa districts; Started region-wide in second half of 2003

ANC+

2004: first Tetanus Toxoid - Supplementary Immunization Activity (SIA) campaigns; ACSD funded IPTp begins; postnatal vitamin A 2004: de-worming for pregnant women

F-IMCI 2004/2005: training of facility staff

C-IMCI

1st quarter 2003: Planning and budget meetings 2nd-4th quarter 2003: Training of trainers and CBA training sessions begin 2004: Sensitization workshops and full scale delivery

ITN stock-outs

2004 – 2005: Intermittent stock-out of retreatment chemicals (KO tablets) Late 2005 – 2006: Stock-out of ITN nets

Child Health Promotion Week (CHPW)

May 2004

4.5 Description of ACSD activities in the “high-impact” districts EPI+.

The EPI+ strategy in Ghana included: 1) routine immunization and periodic measles catch-up; 2) twice yearly vitamin A supplementation of children six to 59 months of age; and 3) twice yearly de-worming of children with anti-helminthic drugs. Distribution, promotion and retreatment of ITNs for children under-five was promoted as part of the IMCI+ package in Ghana; however, we present this intervention as part of EPI+ for consistency with overall ACSD documents.

Delivery of routine vaccination occurs at health centers and through outreach activities, as well as through National Immunization Days (NIDs), which occurred every quarter during the ACSD period. The ACSD strategy in the HIDs started with EPI+ in early 2002 with US$0.5million in USAID support.

Vaccination, vitamin A and de-worming

ACSD focused on developing and supporting strategies to improve defaulter tracing using community-based surveillance systems. CBA volunteers used a register to trace children due for vaccinations. Mop-up campaigns occurred after National Immunization Days (NIDs) to vaccinate “zero dose” children identified by polio vaccinators. Vitamin A supplementation of children six to 59 months of age started nationally in 1996. In 2004, NIDs incorporated de-worming, vitamin A supplementation and tetanus toxoid (TT) supplemental immunization activities (SIA) as part of the ACSD program. Many development partners contributed to vaccination activities and it is difficult to identify ACSD-specific contributions. UNICEF provided vehicles, motorcycles, bicycles and fuel for outreach and supervision activities linked to routine vaccination activities. In addition, UNICEF provided logistical


assistance to the health sector when required. For instance, UNICEF purchased polio vaccines to assist GHS in achieving the polio eradication goals. Table 6 summarizes available information, extracted from administrative and summary reports, about ACSD inputs intended to reinforce EPI+ activities. To provide rough guidance on the potential coverage of these activities, we present several of the indicators as ratios per 1,000 children under- one year of age or under-five years of age. Appendix C presents further description of EPI+ activities and timing, as well as quantitative monitoring data.

Table 6: Description of inputs related to the accelerated implementation of the EPI+ intervention package in the HIDs, Ghana.

DESCRIPTION OF ACTIVITY TIMING INTENSITY OF

ACTIVITY COVERAGE ESTIMATE

Provision of bicycles, motorcycles and vehicles for outreach activities

2002 – 2004 Estimated as 814 bicycles, 18 motorcycles and 1 truck for the district*

2002-2007 553 refrigerator units distributed to health facilities to support cold chain

Training of health agents in EPI provision, monitoring and surveillance

2002 – 2004 1522 CBA-surveillance volunteers trained

40 per 1000 children 0-11 months of age**

Vitamin A supplementation integrated in NIDs and CHPW

2004 54,803 vitamin A supplements

356 supplements per 1000 children under-five**

2005 Quantitative data not available

Integration of child de-worming into NID activities

2004 170,736 antihelminthic doses***

1110 doses per 1000 children under-five**

2005 177,553 antihelminthic doses***

1154 doses per 1000 children under-five**

EPI+ annual totals 2003 - 2006 Monitoring data available in Appendix C; Table C2

*Unknown for which ACSD program transportation was purchased; cumulative total uncertain; see Table C5 in Appendices for further information **Estimated population from 2004 projections: 153,799 under five children, 36,223 pregnant women & 38,450 children 0-11m

***Delivered through two campaigns in March and September

Sale of bed nets to target groups at health centers;

Insecticide-treated nets (ITNs). ACSD-supported distribution of ITNs began in the second half of 2003, the exact start of implementation varying by district. ITNs were distributed to the district offices, then to the volunteers and then to the communities. The ACSD strategy employed multiple approaches for bednet delivery and treatment:

Sale of bednets by commissioned volunteer sales agents accompany nurses on health outreach sessions;

Distribution and treatment by community-based agents (CBAs) trained in C-IMCI activities;

Campaigns for distribution and retreatment.

All volunteers, CBAs and nurses involved in the ITN program received training on bed net distribution and treatment. ITNs were sold at a reduced price to families with children under five and pregnant women through a chit (voucher) system. Initial insecticide treatment was provided with the net and included in the price.


However, as demand for ITNs increased, the subsidized nets were sold using the 20/80 rule. Target groups could purchase 80 percent of the ITNs for 5000 cedis (~US$0.50) and non-target groups could purchase the remaining 20 percent for 23,000 cedis (~US$2.30). Volunteers were responsible for advising customers at the time of purchase to retreat the net every six months, through the health centre or a volunteer. Retreatment cost 2000 cedis (~US$0.20) per net and the ITN volunteer agents received 1000 cedis (~US$0.10) per net sold or retreated. In May 2004, nets were retreated free of charge during national child health week. Reports indicated that although each ITN purchased came with an initial insecticide treatment kits, supply and stock-outs of insecticide for retreatment of existing nets was an on-going issue. A large number of ITNs were distributed through 2005 (table 7), although key informants reported, and monitoring data reflect, stock-outs of ITNs starting in late 2005. The GHS in the HIDs reported procuring ITNs through the Global Fund in 2006. In late 2006, two million long-lasting ITNs were distributed countrywide to children under-two during the national immunization and vitamin A campaign, with support from DFIF (~$US11 million) and UNICEF. The HIDs distributed almost 90,000 long-lasting ITNs during this campaign in late 2006. Table 7 summarizes available information, extracted from administrative and summary reports, about ACSD inputs intended to reinforce ITN activities. Once again, to consider the potential coverage of these activities, we present several of the indicators as ratios per 1,000 children under-five years, even though it is recognized that the ITNs may have been used by non-targeted members of the population. As a result, the coverage estimates below are likely overestimated. Appendix C presents further description of ITN activities and details on exact timing. Table 7: Description of inputs related to the distribution, promotion and treatment of ITNs in the ACSD “high-impact” districts of Ghana.

DESCRIPTION OF ACTIVITY TIMING

INTENSITY OF ACTIVITY

COVERAGE ESTIMATE

Distribution of ITN

2002 –2004

109,579 ITNs distributed for children under-five

712 ITNs per 1000 children under-five*

36,223 ITNs distributed to pregnant women

1000 ITNs per 1000 estimated pregnant women*

2005

132,270 ITNs distributed for children under-five


40,576 ITNs distributed to pregnant women

1120 ITNs per 1000 estimated pregnant women*

2006

93,832 long-lasting ITNs distributed**


Re-treatment campaigns

June 2003 – June 2004

Approximately 14,000 nets retreated

Approx. 82 nets retreated per 1000 nets estimated in the community

2005 25,034 nets retreated 103 nets retreated per 1000 nets estimated in the community

mid 2006 6,829 nets retreated 28 nets retreated per 1000 nets estimated in the community

Cumulative total of Mosquito nets provided by UNICEF

Reported 2006

287,850 ITNs distributed from 2002 to mid-2006 (not inclusive of national campaign LLITNs in late 2006) NB: Global Fund provided 80,000 ITNs in the HIDs, included in numbers above

*Estimated population from 2004 projections: 153,799 under five children, 36,223 pregnant women **includes long-lasting ITNs distributed through DFID-supported national campaign in late 2006


IMCI+.

The IMCI+ strategy in Ghana included: 1) integrated management of childhood malaria, diarrhea, and pneumonia at facility and community/household levels; 2) promotion of infant feeding practices, including exclusive breastfeeding and complementary feeding; and 3) promotion of improved hygiene and consumption of iodized salt. The IMCI+ strategy in Ghana also included distribution and promotion of ITNs, which are discussed above.

Promotion of appropriate infant feeding practices;

Community IMCI The UER has a strong history of community-based health volunteers and before ACSD, Ghana Red Cross, Catholic Relief Services, and others supported community volunteers and community integrated management of childhood illness (C-IMCI) on a small scale. ACSD built on and harmonized these experiences, implementing C-IMCI at a greater scale than before. Through a memorandum of understanding (MOU) UNICEF, Kwame Nkrumeh University of Science and Technology (KNUST), Ghana Red Cross and Ghana Health Services (GHS) collaboratively developed and supported a CBA training program, with almost 2000 community based agents (CBA) trained starting in the second half of 2003 to deliver services and educational messages in 600 communities. The volunteer CBAs received training to carry out following activities:

Provision of health education to mothers, including recognition and referral of childhood pneumonia;

Treatment of fever with pre-packed chloroquine, management of diarrhea with ORS;

Promotion of immunization and iodized salt;

Mobilization of communities for participation in de-worming, NIDs and other programs. The CBA volunteers were equipped with bicycles, educational materials and health kits containing chloroquine doses for children and infants, ORS sachets and handwashing materials, although key informants and document review revealed that not all CBAs received bicycles, educational materials or health kits. CBAs earn a small percentage of medicine sales, for example a CBA earns 100 cedis (US$~0.01) for every ORS sachet sold. Monitoring reports documented that CBAs focused on illness management and health education activities were sporadic or absent in many cases. CBAs treated more than 80,000 children with fever and more than 60,000 children with diarrhea between 2003 and 2006; CBAs referred less than 1000 children with pneumonia annually. In 2004, due to growing levels of antimalarial resistance, Ghana national policy changed the first-line antimalarial to artemisinin combination therapies (ACTs). CBAs retained chloroquine in their kits until the end of 2006, and received authorization and training to use ACTs only at the end of 2007. Appendix C presents detailed information about childhood illnesses treated and health education activities conducted at the community level as reported through routine monitoring systems. The KNUST team and the regional UNICEF office carried out monitoring and supervision of CBA activities, at times integrated into routine supervision by the Regional Health Management Team (RHMT). Key informants noted that integrated supervision was problematic at times: for example, sub-district supervisors are reluctant to carry out CBA supervision without additional funds for fuel. They also noted stronger supervision and monitoring of CBAs in CHPS zones where these activities were incorporated in the responsibilities of the community health officers (CHOs). In 2006, supervision teams found that out of 1366 CBAs visited, almost one-half had no bicycles, more than half (~60%) had no health kits and one-third did not have reporting forms. We did not find comprehensive information about retention of CBAs initially trained through ACSD; however, key informants in Bongo district noted that 60 percent of CBAs remained active in 2006. Facility-based IMCI Facility-based IMCI started after C-IMCI in the HIDs. In 2005, ACSD supported the standard IMCI training of 48 clinicians and three regional staff. The training-of-trainers at the regional level included sessions pertained to CBA supervision. In 2006, the IMCI monitoring team evaluated IMCI-trained prescribers and found high non-compliance with the IMCI objectives regarding assessment, diagnosis and supervision. Standard IMCI training for facility-based providers is on-going in the HIDs.


In addition to infant feeding promotion included in IMCI activities, UNICEF supported facilities to implement the Baby Friendly Health Initiative (BFHI) to promote appropriate infant feeding practices. In partnership with the Ghana Red Cross Society, ACSD also supported promotion of appropriate infant feeding practices by developing guidelines on exclusive breastfeeding, training mother-to-mother support groups and providing training materials. ACSD explicitly did not focus on nutritional rehabilitation.

Infant feeding practices.

Table 8 summarizes available information about ACSD inputs intended to reinforce IMCI activities. Again, to estimate rough coverage, we present selected inputs and activities as ratios per 1,000 children under-five years of age or ratios of CBAs supplied. Appendix C provides more description of IMCI+ activities and timing.

Table 8: Description of inputs related to the implementation of the IMCI+ intervention package in the ACSD “high-impact” districts of Ghana.

DESCRIPTION OF ACTIVITY TIMING

INTENSITY OF ACTIVITY

COVERAGE ESTIMATE

Facility-based agent (prescriber) training 2004 - 2006

72 prescribers & 10 clinicians trained in HIDs

1 IMCI-trained provider per 1000 children under- five

CBA training in C-IMCI 2003 - 2006 1982 CBAs trained in 600 communities

13 trained CBAs per 1000 children under-five*

C-IMCI CBA supplies

2003-2006 (cumulative

total)

Provision of 1400 health/medicine kits

706 kits per 1000 trained CBAs

Provision of 2022 reporting booklets

1020 booklets per 1000 trained CBAs

Provision of 746,100 doses of chloroquine

4851 doses chloroquine per 1000 children under-five*

Provision of 645,900 ORS sachets

4200 ORS sachets per 1000 children under-five*

Supervision 2004 - 2006 Supervision ongoing by regional teams, facility-based health staff and KNUST**

Monitoring 2004 - 2006 Monitoring of the number of cases with diarrhea,

fever and ARI seen and referred**

*Estimated population from 2004 projections: 153,799 under five children, 36,223 pregnant women & 38,450 children 0-11m **See further details in Appendix C, Table C2

ANC+.

ANC+ in Ghana was implemented with the aim of preventing maternal and neonatal tetanus and low birth weight due to malaria and severe anemia in pregnancy. The ANC+ strategy in Ghana included: 1) distribution and promotion of ITNs for pregnant women; 2) IPT for malaria with sulphadoxine pyremethamine; 3) tetanus toxoid immunization during pregnancy; 3) supplementation with iron and folic acid during pregnancy and vitamin A in the post-natal period; and 4) voluntary counseling and testing (VCT) for HIV/AIDs and prevention of mother to child transmission (PMTCT). The ANC+ strategy did not focus explicitly on delivery and neonatal care.10 The GHS provided ANC and delivery services, including supplementation with iron and folic acid and TT immunization, before ACSD. ACSD and other partners supplied support for the distribution and


promotion of ITNs for pregnant women; these activities are discussed above under the EPI+ component. ANC+ included support for TT immunization, with many women immunized during NIDs. The first round of TT supplementary immunization activities (SIA) took place in early 2004, with an estimated 46 percent coverage of the targeted population. Subsequent rounds of TT SIA achieved higher rates of coverage (table 9). IPTp was coupled with routine ANC services at facilities and promoted through radio spots. Bongo and Bawku East districts received Global Fund support for IPTp activities starting May 2004. In mid-2004, ACSD extended IPTp to the remaining four HIDs, with a training of trainers and district level training. Approximately 25,000 doses of SP were administered annually, although monitoring data show high drop out rates after first and second dose. Deworming for pregnant women and postnatal vitamin A supplementation began in mid-2004 through facilities. In 2005, TBAs and CBAs received training to distribute vitamin A in the postpartum period. Table 9 summarizes available information, extracted from administrative and summary reports, about ACSD inputs intended to reinforce ANC+ activities. Appendix C presents further description and exact timing of ANC+ activities.

Table 9: Description of inputs related to the implementation of the ANC+ intervention package in the ACSD “high-impact” districts of Ghana.

DESCRIPTION OF ACTIVITY TIMING INTENSITY OF ACTIVITY

COVERAGE ESTIMATE

TT SIA

2004 143,954 / 230,700 women targeted 62%**

2005 No data

2006 National EPI+ report for UER: TT2 – 78%**

IPT training 2004 May: Training of trainers June: District level training

IPT dosing

May –Dec 2004 35,257 doses of SP

IPT1:50%* IPT2:31%* IPT3:16%*

2004 - 2005 23,260 doses of SP

IPT1:30%* IPT2:21%* IPT3:13%*

2006 24,046 doses of SP

IPT1:30%* IPT2:22%* IPT3:15%*

Postnatal Vitamin A supplementation July – Dec 2004 5,973 vitamin A supplements

16%**

2005 2,217 vitamin A supplements 6%**

2006 10,351 vitamin A supplements

29%**

* as reported in ACSD monitoring reports, **coverage estimated based on target population from 2004 projections: 36,223 pregnant women


5. Coverage and family practices This section of the report presents the results for priority coverage and family practices indicators and their interpretation. Section 2 describes the methodology used for the analysis, and appendix D defines the priority coverage indicators. We present the results in graphical form for selected priority coverage indicators within each intervention package. Two graphs are presented for each package. The first shows time trends in indicator levels in the HIDs. Arrows in these graphs indicate the ACSD coverage targets as adapted for Ghana. We present data from the ACSD-CDC survey conducted in 2003 in shades of grey and without confidence limits because, as explained in the methods section, these estimates are of lesser quality and should be interpreted with caution. The second graph for each intervention component presents indicator levels in 1998-9 (baseline) and 2006-7 (endline), with an intermediate point in 2003 for the HIDs and comparison area. The number at the bottom of each bar in the graph is the percent coverage of the indicator and the black lines in these graphs represent the 95 percent confidence limits. We carried out differences-in-differences statistical tests for these comparisons and the results are presented in the text. Appendices G and H present the full results for HIDs and comparison groups. Tables in appendix I present coverage results from the 2007 Supplemental MICS survey in the HIDs by district, urban versus rural residence, socio-economic status and age of the child. Here we present only statistically significant results on differences in coverage by sub-populations. For certain indicators and sub-populations, the results should be interpreted with caution due to the small sample sizes for some cells. Chapter 8 includes further results in the context of equity. 5.1 Results EPI+.

Figure 6 shows the time trends in measles and DPT vaccinations and one dose vitamin A supplementation in the previous six months in the HIDs in Ghana, based on the two DHS, two MICS with an additional point estimate drawn from the ACSD survey carried out in mid-2003. Coverage levels for these three indicators increased significantly between 1998-9 and 2006-7 (p<0.001). The results suggest that gains in vaccination were gradual over the evaluation period, while gains in vitamin A supplementation mostly occurred between 1998-9 and 2003. All indicators were at or above their ACSD program targets of 80 percent coverage, indicated in the graph with an arrow.

Vaccinations and vitamin A supplementation.

Appendix tables I2 and I3 provide further information on coverage levels for vaccinations and vitamin A supplementation by sub-groups of the population in the HIDs in 2007. No significant differentials in sub-groups of the population were observed for vaccination. Vitamin A supplementation in the previous six months varied significantly (p<0.001) by district, with children in Kasena-Nankana having the highest coverage (96%) and children in Bongo the lowest coverage with vitamin A supplementation (74%). Coverage with vitamin A was marginally higher in urban areas compared to rural areas (p=0.07) and children aged six to 11 months were less likely to receive vitamin A than older children (p<0.001).


Figure 6

: Coverage levels for measles and DPT3 immunization and receipt of one vitamin A supplement in the preceding six months in the HIDs as measured in DHS (1998-9 and 2003), the ACSD survey (2003), and MICS (2006 and 2007), Ghana.

§ Estimate based on less than 100 children * Vitamin A coverage data only available for children 6-32 months in 2003 ACSD survey Note: Measles and DPT3 indicators are calculated based on MICS protocol, where the distribution of children reporting vaccination before 12m in vaccination card is applied to all other children reported as vaccinated.

Figure 7 shows coverage levels for vaccinations and vitamin A supplementation in the HIDs and the comparison area in 1999 and 2006-7, with a midpoint in 2003. Measles vaccine coverage increased significantly between 1998-9 and 2006-7 in both the HIDs and comparison area; the increase in the HIDs was not significantly different from gains in the comparison area. DPT3 coverage also increased in both areas, with greater increases in the HIDs (p<0.001). Vitamin A supplementation with one dose in the previous six months increased by 25 and 74 percentage points (pp) in the HIDs and comparison area, respectively. Increases in vitamin A coverage over time in both the HIDs and comparison areas were statistically significant (p <0.001). Baseline levels of vitamin A coverage were significantly less in the comparison area, and the increase in coverage in the comparison area was significantly greater relative to the increase in the HIDs (p<0.001).

68 6566

84

6876

8682

93 91

80

9590

60

73

0

20

40

60

80

100

Measlesimmunization

DPT3 immunization Vitamin Asupplementation

DHS 1998-9 ACSD 2003 DHS 2003 MICS 2006 Sup MICS 2007

§§§§§§

Cov

erag

e (%

)….

(one dose)

ACSD vaccination & vitamin A objective

*


Figure 7: Coverage levels for measles and DPT3 immunization and receipt of one vitamin A supplement in the preceding six months in HIDs and the comparison area as measured in DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.

§ Estimate based on less than 100 children Note: Figures inside bar represent percentage coverage

Figure 8 shows the time trends in the use of ITNs in the HIDs in Ghana, based on the two DHS, two MICS with an additional point estimate drawn from the ACSD survey carried out in mid-2003. The 1998-9 DHS did not collect information pertaining to bednet use; thus, no comparable indicators for ITN use among children were available at baseline. However, if ITN use among children is assumed to be close to zero in 1998-9, there were significant increases between 1998-9 and 2007. In 2007, ITN use among children (58 pp) exceeded the ACSD target of 50 percent coverage. The MICS 2006 and supplemental MICS 2007 did not collect information about ITN use among pregnant women, precluding the examination of this indicator in our analyses.

Insecticide-treated bednets (ITNs).

§ § § §

32 IIP-JHU | Retrospective evaluation of ACSD in Ghana

Figure 8

2723

43

58

00

20

40

60

80

100

ITNs (child)


~0

Cov

erag

e (%

) ….

ACSD target (ITN child)50

: Coverage levels for insecticide-treated nets in the HIDs as measured in DHS (1998-9 and 2003), the ACSD survey (2003), and MICS (2006 and 2007), Ghana.

Appendix table I4 provides further information on coverage levels for ITNs in 2006-7 in the HIDs by district, urban/rural residence, child’s sex and age, and wealth quintile. ITN use among children was significantly higher in Builsa, Bongo and Talensi-Nabdam districts relative to the other districts (p<0.001). Higher proportions of children aged zero to 35 months slept under ITNs as compared to children aged 36 to 59 months (p<0.001) Figure 9 shows coverage levels of ITN use in the HIDs and the comparison area in 1999 and 2006-7, with a midpoint in 2003. The proportion of children sleeping under an ITN increased by approximately 58 pp in the HIDs and 24 pp in the comparison area, if coverage in 1998-9 is assumed to have been close to zero in both areas (both trends p<0.001). The rates of increase over time, between 1999-9 and 2006-7 and between 2003 and 2006-7, were significantly greater in the HIDs relative to the comparison area (p< 0.001).


Figure 9

23 3 58 240

20

40

60

80

100

ITN

Cov

era

ge (

%)

High-impact districts (UER)Comparison area

1998-9 2006-7

~+58

~+24

Absolute change in percentage points between 1998-9 and 2006-7

2003

§ §~0 ~0

: Coverage levels for insecticide-treated nets in HIDs and the comparison area as measured in DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.

Note: Figures inside bars represent percentage coverage

IMCI+.

The IMCI+ package includes case management and nutrition assessment and counseling, and the provision of locally adapted messages to improve family practices related to child survival. In this section, we focus on results related to the case management of childhood illness and child feeding practices.

Figure 10 shows time trends in the HIDs in the administration of any antimalarial for the management of childhood fever (presumed to be malaria in this highly endemic country), appropriate care-seeking for suspected pneumonia and oral rehydration therapy and continued feeding for diarrhea. The measurement of these indicators is based on reports by mothers of children who reported these illness symptoms in the two weeks prior to the survey. Additional data are available in appendix tables I5, I6 and I7. About three-fourths of mothers of febrile children reported giving their child an antimalarial at baseline, and this decreased significantly in 2007, with only about half receiving an antimalarial. However, in 2007 mothers reported that only nine percent of febrile children received artesunate-amodiaquine, the first line antimalarial in Ghana since 2004 (appendix table I6). Approximately one-half of children with probable pneumonia were taken to a health facility in both 1998-9 and 2007, with no significant change during this period. The proportion of children with diarrhea receiving oral rehydration therapy or increased liquids to prevent dehydration, along with continued feeding, decreased over time, from 39 percent in 1998-9 to 28 percent in 2007. Case-management indicators stagnated or declined over time; none of the ACSD case management coverage targets (indicated with arrows) were met by 2007.

Case management.


Figure 10

54

39

61

35 37

7166

32

67

0

30

53 50

28

78

0

20

40

60

80

100

Antimalarial treatment Careseeking forpneumonia

Oral rehydration andcontinued feeding


§§§ §§§§ §

Pro

porti

on o

f ill

child

ren

man

aged

for i

llnes

s (%

)...

Sam

ple

size

too

smal

l..

ACSD target (antimalarial & pneumonia)

ACSD taregt (oral rehydration & con't

feeding)50

: Coverage levels for case management indicators in the HIDs as measured in DHS (1998-9 and 2003), the ACSD survey (2003), and MICS (2006 and 2007), Ghana.

§ Estimate based on less than 100 children

Appendix I presents further details and analyses stratified by sub-population (where sample-sizes permit) for the management of fever and diarrhea, as well as careseeking for pneumonia, in 2007 in the HIDs. Treatment of febrile children with an antimalarial varied significantly by district (p<0.001); only 42 percent of febrile children living Garu-Tempane district received an antimalarial, while in Bolgatanga municipality 85 percent of febrile children received an antimalarial. Antimalarial coverage among urban children was higher than among their rural counterparts (p<0.01). Fifty-eight percent of boys received an antimalarial, while coverage among girl children was 48 percent (p=0.02). Girls were marginally more likely to be adequately managed for diarrhea than boys were (p=0.05). Sample sizes were too small to perform all stratified analyses for indicators related to careseeking for suspected pneumonia and diarrhea management.

Figure 11 presents coverage levels for the case management of childhood illness in the HIDs and the comparison area in 1999 and 2006-7, with a midpoint in 2003. Levels of treatment with any antimalarial for fever decreased significantly in the HIDs, while stagnating in the comparison area. The difference in the changes between 1998-9 and 2006-7 in the HIDs relative to the comparison area was statistically significant (p<0.001). However, if the indicator is defined as “treatment of fever with an effective and nationally recommended antimalarial” there was a precipitous drop in coverage in both the HIDs and the national comparison area, because chloroquine was no longer recommended at the end of the period, but use remained frequent (appendix table I6). Care seeking for pneumonia remained relatively stable in the HIDs, while increasing 14 pp in the comparison area and the difference-in-differences was significant (p=0.04). Correct home management practices for diarrhea decreased in the HIDs, while increasing


seven pp in the comparison area; the difference between the trends in the HIDs and comparison area was statistically significant (p<0.01).

Figure 11

: Coverage levels for case management indicators in HIDs and the comparison area as measured in DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.

§ Estimate based on less than 100 children Note: Figures inside bars represent percentage coverage

Figure 12 presents the use of antibiotics for suspected pneumonia among children aged 0-59 months in the HIDs and the comparison area in 1999 and 2006-7. Coverage with antibiotic treatment was low at baseline in the HIDs (2%), and increased to just over 50 percent in 2006-7. Use of antibiotics for suspected pneumonia also increased in the comparison area, although only by 15 pp. These results are inconsistent with the trends in careseeking for pneumonia presented in the previous graphs, which showed stagnation in the HIDs. Secondary analyses (appendix table I7) found that 12 percent of children with suspected pneumonia in the HIDs were taken for care at a private drug vendor in 2007, while no mother reported this behavior in the comparison area. Similarly, approximately 25 percent of mothers in the HIDs reported obtaining the antibiotic for their child’s pneumonia outside of an appropriate health facility, with 21 percent of antibiotics obtained at a drug shop and 4 percent obtained from drug peddlers. Antibiotic distribution at the community level is not authorized in Ghana through community-based distributors or drug peddlers.

78 54 3960 22 2371 66 3267 40 3853 50 2861 36 300

20

40

60

80

100

Antimalarial treatment Careseeking forpneumonia

Oral rehydration andcontinued feeding


1998-9 2006-7 1998-9 2006-7

-25

+1

-4

+14

-11

+7

Absolute change in percentage points btw. 1998-9 to 2006-7

1998-92003 20032003 2006-7

§ §§ § § §Prop

ortio

n of

ill c

hild

ren

man

aged

for

illne

ss

(%)


Figure 12

20 51 35

2

0

20

40

60

80

100

Antibiotic treatment for pneumonia

% o

f chi

ldre

n w

ith s

uspe

cted

pne

umon

ia re

ceiv

ing

antib

iotic

s..


1998-9 2006-7

+49

+15


§ §

§2

: Coverage levels for use of antibiotics for suspected childhood pneumonia in HIDs and the comparison area as measured in DHS in 1998-9 and MICS 2006-7, Ghana.

§ Estimate based on less than 100 children Note: Figures inside bars represent percentage coverage

IMCI+ in the context of ACSD also included promotion of appropriate infant and young child feeding practices (Box 1). Figure 13 shows the prevalence of selected feeding behaviors as reported by mothers of children less than one year of age at the time of the survey. Breastfeeding behaviors tend to be relatively stable over time, so apparent fluctuations should be interpreted with caution as they may reflect differences in how the questions were posed, the answers recorded or statistical error due to small sample sizes. The proportion of mothers reporting initiation of breastfeeding within one hour of birth increased significantly between 1998-9 and 2007 (p<0.001), with a large, unexplained fluctuation in the 2003 DHS. The prevalence of exclusive breastfeeding of infants less than six months steadily increased over time, from 28 percent of mothers reporting this practice in 1998-9 to 55 percent of mothers reporting this practice in the 2007 survey (p<0.01). This exceeded the ACSD objective of 50 percent coverage by five pp. Complementary feeding among children six to nine months of age remained stable between 2003, 2006 and 2007, with approximately half of children in this age group reported to have received complementary feeding and continued breastfeeding throughout the period. Sample sizes in the 1999-8 and 2003 DHS were too small to provide valid estimates of complementary feeding from these surveys. Prevalence of appropriate complementary feeding practices fell well short of the ACSD target of 90 percent. Mothers reported continued breastfeeding 84 percent of children aged 20-23 months in 2007 in the HIDs (appendix table G3); sufficient sample sizes were not available for baseline estimation of this indicator.

Feeding, including breastfeeding.


Figure 13


: Prevalence of infant feeding behaviors as reported by mothers in the HIDs as measured in DHS (1998-9 and 2003), the ACSD survey (2003), and MICS (2006 and 2007), Ghana.

Appendix table I8 shows the breakdown of breastfeeding practices by selected sub-groups of the population, where sample sizes permit. The proportion of rural mothers initiating breastfeeding within one hour of birth (54%) was marginally greater than that among their urban counterparts (42%); (p=0.05). The proportion of infants exclusively breastfed varied significantly by district, with over 70 percent exclusive breastfeeding in Kasena-Nankana, Bongo and Bolgatanga municipality districts and only 37 percent in Bawku municipality (p=0.02). Exclusive breastfeeding was more common among women residing in urban areas (p<0.01) and in wealthier households (p=0.01) than among women in rural and poorer households. Figure 14 shows the prevalence of infant feeding behaviors in the HIDs and the comparison area in 1999 and 2006-7, with a midpoint in 2003. Initiation of breastfeeding within one hour of birth significantly increased by 41 pp in the HIDs and increased only eight pp in the comparison area; the difference in the rates of change was significant (p<0.001). Exclusive breastfeeding up to six months of age increased by more than 20 pp in both the HIDs and the comparison area; the difference-in-differences was not significant. Complementary feeding of children six to nine months of age declined by 10 pp in the comparison area. Sufficient sample sizes were not available in the HIDs in 1998-9 or 2003, precluding a comparison in trends.

11 28

0

4539

50

85

43

0

42

56 5352 55 53

0

20

40

60

80

100

Initiation of breastfeeding within one hour of birth

Exclusive breastfeeding (< 6 months)

Breastfeeding plus complementary food

(6-9 months)


Pre

vale

nce

of b

ehav

ior a

s re

porte

d by

mot

hers

(%)..

.

Sam

ple

size

too

smal

l..

Sam

ple

size

too

smal

l..50

90

ACSD target (exclusive breastfeeding)

ACSD target (complementary feeding)


Figure 14

28 023 29 6785 4341 49 6452 55 5331 51 57

11

0

20

40

60

80

100

Initiation of breastfeeding withinone hour of birth

Exclusive breastfeeding Breastfeeding pluscomplementary food


1998-9 2006-7 1998-9 2006-7

+41

+8

+27

+22 -10


1998-92003 20032003 2006-7

§

§§ §

Pre

vela

nce

of

beh

avio

r as

rep

ort

ed b

y m

oth

er (

%).

..

Sam

ple

siz

e t

oo

sm

all

..

Sam

ple

siz

e t

oo

sm

all.

.

* *

(< 6 months)(6-9 months)

: Prevalence of infant feeding behaviors as reported by mothers in HIDs and the comparison area as measured in DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.

§ Estimate based on less than 100 children *Estimation based on unweighted data, no 95% confidence intervals presented Note: Figures inside bars represent percentage coverage

ANC+.

The ANC+ package as implemented in Ghana included interventions in both the antenatal and perinatal periods. In this section, we address coverage levels for antenatal interventions and interventions designed to improve maternal and neonatal health during delivery and the post-natal period.

Figure 15 shows the time trends in coverage of antenatal care in the HIDs. Further details are presented in appendices G, H and I. The proportion of women reporting four or more ANC attendances increased steadily by 17 pp over the evaluation period (p<0.001). The ACSD target of 80 percent coverage of four or more ANC visits was achieved. Intermittent presumptive treatment (IPTp) with two doses of SP for malaria during pregnancy was not measured in 1998-9, and coverage was only four percent in 2003, IPTp coverage increased dramatically between 2003 and 2006, with further increases between 2006 and 2007 (p<0.001). Approximately two-thirds of women reported IPTp, falling just short of the ACSD objective of 75 percent ITPp coverage. Tetanus toxoid (TT2) vaccination, consisting of two doses during pregnancy, remained stable, with approximately one-third of women not reporting two vaccinations during their previous pregnancy. However, in 2007 in the HIDs, 78 percent of women reported full neonatal protection from tetanus toxiod in their previous pregnancy, close to the ACSD target of 80 percent coverage. Comparable information about neonatal protection from tetanus toxoid was not collected in earlier surveys, precluding comparisons of this indicator over time.

Antenatal care.


Figure 15

64

0

63

74

5664

33

86

47

61

81

6763

40

20

40

60

80

100

Antenatal care IPTp with SP 2 TT doses


§§ § §

Cov

erag

e (%

)...

No

data

..

§§

§§

(4+ visits)

ACSD target (ANC 4+)

ACSD target (NN protection)

ACSD target (IPT) 75

80

No

data

..

: Coverage levels of antenatal indicators in the HIDs as measured in DHS (1998-9 and 2003), the ACSD survey (2003), and MICS (2006 and 2007), Ghana.

§ Estimate based on less than 100 women

Appendix I9 provides further information on coverage levels of antenatal care in the HIDs as measured in the 2007 Supplemental MICS. The proportion of women reporting four or more antenatal care visits varied somewhat by district (p=0.07), with highest levels in Kasena-Nankana district (94%) and the lowest in Garu-Tempane district (73%). Coverage of ANC interventions was inequitable in 2007 in the HIDs. Significantly more women in the wealthiest households reported four or more ANC visits (93%) as compared to those in the poorest households (75%); (p=0.02). Similar inequities were observed for two doses of tetanus toxiod during the previous pregnancy (p=0.06) and full neonatal protection (p=0.04).

Figure 16 shows reported antenatal care in the HIDs and the comparison area in 1999 and 2006-7, with a midpoint in 2003. The proportion of women reporting of four or more ANC attendances and IPTp with two doses of SP increased significantly in both the HIDs and comparison area (p<0.001). Receipt of two doses of tetanus toxoid vaccination during the previous pregnancy did not increase in the HIDs, while increasing 14 pp in the comparison area. Absolute pp increases were significantly greater in the HIDs for IPTp with SP than in the comparison area (p<0.001). The differences in changes over time between the HIDs and the comparison area for four ANC attendances and TT2 were not statistically significant.


Figure 16: Coverage levels of antenatal indicators in HIDs and the comparison area as measured in DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.

§ Estimate based on less than 100 women Note: Figures inside bars represent percentage coverage

Figure 17 shows trends in deliveries assisted by a skilled attendant and postnatal supplementation with vitamin A as reported by women giving birth within the 12 months before the survey. Assisted deliveries by trained workers included those attended by a doctor, nurse, midwife or auxiliary midwife. Additional data concerning these indicators are available in appendices G, H and I. Assistance at delivery by a skilled provider increased from 17 percent in 1998-9 to 40 percent in 2007 (p<0.001). However, more than half of women giving birth do not benefit from a skilled attendant at delivery and coverage levels fell far short of the initial ACSD target of 80 percent. Supplementation with vitamin A within 40 days after birth was high at baseline (72%) and declined over the period from 1998-9 to 2007 (p=0.01).

Skilled attendant at delivery and postnatal care.

Appendix table I10 presents the breakdown of skilled delivery and postnatal vitamin A supplementation in the HIDs by socio-demographic characteristics as measured in the 1007 Supplemental MICS. More than double the proportion of urban dwellers reported a skilled attendant at delivery (71%) than their rural counterparts (31%); (p<0.001). Coverage levels of skilled delivery were similar among women reporting no formal education or primary school; however, women with secondary or higher education were more likely to deliver with a skilled attendant (p<0.01). Women in the highest wealth quintile were more than three times as likely to have a delivery assisted by a skilled provider (77%) than women in the poorest households (23%); (p<0.001).

§ §

§

§


Figure 17

: Coverage levels of skilled attendant at delivery and postnatal vitamin A supplementation in the HIDs as measured in DHS (1998-9 and 2003), the ACSD survey (2003), and MICS (2006 and 2007), Ghana.

§ Estimate based on less than 100 women

Figure 18 shows coverage levels of skilled deliveries and postnatal supplementation with vitamin A as reported by women giving birth within the 12 months before the survey in the HIDs and the comparison area in 1999 and 2006-7, with a midpoint in 2003. Deliveries assisted by a skilled health provider increased by 23 pp in the HIDs and by 4 pp in the comparison area; the difference between the HIDs and comparison area in the rates of change was significant (p=0.01). Levels of postnatal supplementation with vitamin A decreased by 15 pp in the HIDs, while increasing by 25 pp in the comparison area (p<0.001).

17

72

27

18

4752

40

5751

4

0

20

40

60

80

100

Skilled attendant at delivery Postnatal vitamin A


§

§

§

Cov

erag

e (%

)...

§ §§


Figure 18

7238 2318 5835 3640 5742 48170

20

40

60

80

100

Skilled attendant at delivery Postnatal vitamin A


1998-9 2006-7 2006-7

+23

+4 +25


1998-92003 2003

§ § §

Cove

rage

(%)..

.

§

-15

: Coverage levels of skilled attendant at delivery and postnatal vitamin A supplementation in HIDs and the comparison area as measured in DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.

§ Estimate based on less than 100 women Note: Figures inside bars represent percentage coverage 5.3 Summary and interpretation of results

Table 10 summarizes the main results of the adequacy analyses of time trends in coverage in the HIDs. In table 10, we present indicators showing significant improvement between 1998-9 and 2007 in the HIDs in bold italics. Indicators showing positive trends over time in the HIDs included vaccinations, vitamin A, ITNs, antibiotics for suspected pneumonia, timely initiation of breastfeeding, exclusive breastfeeding, antenatal care, IPTp and skilled assistance at delivery. Indicators that were observed to stagnate or decline included case management of common childhood illnesses, tetanus toxoid vaccination and postnatal vitamin A. In the last column of table 10, we present the stated ACSD targets in Ghana in relation to the coverage levels measured in 2007. Many of the stated objectives were fully met or exceeded; however, management of diarrhea, complementary feeding and skilled delivery were 30 pp or more short of the stated ACSD targets for coverage.


Table 10: Summary of ACSD coverage results in HIDs as measured in DHS 1998-9 and 2003 and Supplemental MICS 2007, Ghana, as compared to initial ACSD objectives.

COVERAGE INDICATOR

BASELINE LEVEL IN 1999 DHS

(%)

MIDLINE LEVEL IN

2003 DHS (%)

ENDLINE LEVEL IN

2007 MICS (%)

CHANGE 1999 to

2007

P value

ACSD TARGET

(%)

ABSOLUTE DIFFERENCE

BETWEEN ENDLINE & OBJECTIVE

Measles vaccine 60 68 80 <0.001 80 0

DPT3 68 76 95 <0.001 80 +15 Vitamin A to child 65 86 90 <0.001 80 +10

ITN for child ~0 23 58 <0.001* 50 +8 Any antimalarial for fever 78 71 53 <0.001 50 +3 Careseeking for pneumonia 54 66 50 >0.10 50 0 Antibiotics for pneumonia 2 - 51 <0.001 50 +1 Oral rehydration for diarrhea 39 32 28 0.05 80 -52 Breastfeeding initiation 11 85 52 <0.001 n/a n/a Exclusive breastfeeding 28 43 55 <0.01 50 +5 Complementary feeding - - 53 - 90 -37 Antenatal care (4+ visits) 64 64 81 <0.001 80* +1 IPTp with 2+ SP ~0 4 67 <0.001* 75 -8 TT2 in pregnancy 63 33 63 >0.10 n/a n/a Full neonatal TT protection n/a n/a 78 n/a 80 -2 Skilled delivery 17 18 40 <0.001 80 -40 Postnatal vitamin A 72 58 57 0.01 n/a n/a

*Changes calculated assuming 0% coverage at baseline NOTE: Indicators in bold italics represent significant positive changes over time Table 11 summarizes the main results of the plausibility analysis, comparing time trends in coverage for HIDs and the comparison area. Estimates that showed a positive trend over time in HID that were significantly greater than the comparison area at p<0.05 are shown in bold italics. Vaccination, vitamin A supplementation for children aged 6-59 months, ITN utilization among children, antibiotics for pneumonia, exclusive breastfeeding, four or more antenatal care visits, and IPTp all improved by 10 pp or more in both HIDs and comparison area; ITNs, antibiotics for pneumonia, and IPTp increasing significantly more in the HIDs. Breastfeeding initiation and delivery assisted by a skilled worker improved by more than 10 pp in the HIDs, while increasing less than 10 pp in the comparison area. Two doses of tetanus toxoid during pregnancy, careseeking for suspected pneumonia and postpartum vitamin A stagnated (=/- 9pp) in the HIDs, while increased by more than 10 pp in the comparison area. Appropriate management of childhood fever and diarrhea decreased in the HIDs, while stagnating in the comparison area (difference in difference test were statistically significant). These results suggest that ACSD as implemented in the


HIDs in Ghana had a positive effect on levels of coverage for some of the interventions targeted for accelerated implementation.

Table 11: Summary of ACSD coverage results in HIDs and the comparison area as measured in as measured in DHS 1998-9 and 2003, MICS 2006 and Supplemental MICS 2007, Ghana.

COVERAGE INDICATOR AREA

BASELINE VALUE IN

1999-9 (%)

MIDLINE VALUE IN

2003 (%)

ABSOLUTE CHANGE (% POINTS)

DIFFERENCE IN

DIFFERENCES TEST (p LEVEL)

1998-9 to 2006-7

2003 to 2006-7

1998-9 to

2006/7

2003 to

2006-7

Measles vaccine HIDs 60 68 +20 +12 >0.10* >0.10* Comparison 60 67 +18 +11

DPT3 HIDs 68 76 +27 +19 0.001 <0.001 Comparison 65 76 +14 +3

Vitamin A to child HIDs 65 86 +25 +4 <0.001 0.01 Comparison 22 79 +74 +17

ITN for child** HIDs ~0 23 +58 +35 <0.001 <0.001 Comparison ~0 3 +24 +21 Any antimalarial for fever

HIDs 78 71 -25 -14 <0.001 >0.10 Comparison 60 67 +1 -6

Careseeking for pneumonia

HIDs 54 66 -4 -16 0.04 >0.10

Comparison 22 40 +14 -4 Antibiotics for pneumonia

HIDs 2 n/a +49 n/a <0.01 n/a Comparison 20 n/a +15 n/a Oral rehydration for diarrhea

HIDs 39 32 -11 -4 <0.01 >0.10 Comparison 23 38 +7 -8

Breastfeeding initiation

HIDs 11 85 +41 -33 <0.001 0.001 Comparison 23 41 +8 -10

Exclusive breastfeeding

HIDs 28 43 +27 +12 >0.10 >0.10 Comparison 29 49 +22 +2

Antenatal care (4+ visits)

HIDs 64 64 +17 +17 >0.10 >0.10 Comparison 55 58 +11 +8

IPTp with SP** HIDs ~0 4 ~+67 +63 <0.001 <0.001 Comparison ~0 1 ~+31 +30 Tetanus toxoid in pregnancy

HIDs 63 33 0 +30 0.12 0.04 Comparison 46 47 +14 +13

Skilled delivery HIDs 17 18 +23 +22 0.01 0.02 Comparison 38 35 +4 +7 Postnatal vitamin A

HIDs 72 58 -15 -1 <0.001 0.05 Comparison 23 36 +25 +12

*P value based on children 12-13 months of age ever receiving measles or DPT3 vaccination **Difference in end-line estimates only assuming 0% coverage at baseline in HIDs and comparison area. NOTE: Indicators in bold italics represent positive changes over time in HID that were significantly greater than the comparison area at p < 0.05

Coverage results: contributions and challenges of ACSD implementation.

Preliminary results were reviewed and discussed with a technical team from Ghana that included those directly involved in ACSD implementation and/or the collection and analysis of the data used in the evaluation. We have incorporated the interpretation of results based on discussions with the Ghana technical team and review coverage in the context of ACSD implementation by each ACSD component, as well as overall ACSD contributions and challenges associated with changes in coverage.


EPI+ACSD in Ghana had set targets to achieve 80 percent coverage for vaccination and vitamin A coverage and reached these goals; routine monitoring system data in the HIDs mirrored these trends. ACSD started with the EPI+ strategy, which focused primarily on preventative services delivered through campaigns and outreach. Key informants noted that ACSD’s key contributions in achieving the EPI+ targets included the supply of commodities and clear targets at the district level. Vaccination and vitamin A supplementation coverage increased in both HIDs and comparison area, although DPT3 increased more rapidly in the HIDs. The GHS and other development partners supported these activities in the comparison area, discussed in section 3 and below in contextual factors.

.

The promotion, distribution and re-treatment of ITNs were large components of the ACSD strategy in Ghana and elsewhere. Our results show large increases in coverage with ITNs between 1999 and 2006-7 in the HIDs, with fewer gains in coverage in the comparison area. ACSD supplied large quantities of ITNs early, with other donors such as the Global Fund also providing support for ITN interventions. Key informants reported widespread stock-outs in ITNs, starting in late 2005 and persisting until late 2006, although other partners, such as the Global Fund provided ITNs at this time. UNICEF, with substantial funding from DFID, supported a national campaign to distribute two million long-lasting ITNs in late 2006, with approximately 90,000 LLITNs distributed in the HIDs.

ACSD efforts included expanding coverage and strengthening existing community-based systems, primarily by training, equipping and supporting CBAs to treat childhood illness in the community in the HIDs. However, we found that case management practices for fever and diarrhea declined or stagnated in the HIDs. Administrative data from communities showed similar trends. Likewise, careseeking for pneumonia to an appropriate health provider did not increase, although antibiotic treatment for pneumonia increased. Secondary analyses revealed that this increase was at least partially driven by antibiotics from shops and drug peddlers. The government and partners scaled up C-IMCI before training facility-based staff in IMCI, which may have lessened the synergistic effect of the full IMCI package.

IMCI+.

Key informants and program documents noted important challenges to implementing the case management of fever. The GoG changed the first-line antimalarial policy to ACTs in 2004 due to high levels of resistance to chloroquine in Ghana. Although our indicator for treatment of fever appears to have declined marginally in the HIDs, this does not necessarily represent effective management of fever with the recommended first-line antimalarial. Only nine percent of caretakers reported that febrile children received an ACT in 2007 in the HIDs, and fewer than five percent did so in comparison area. Although health facilities and CHPS centers stocked ACTs in 2005, national policy did not allow ACTs at the community level (through CBAs) until 2007. CBAs retained chloroquine in their health kits until it was retired from the communities at the end of 2006. Roll out of ACTs in the community began just after collection of our endline data. At the end of 2004, CIDA funding was mostly depleted and this affected the constant supply of commodities, especially drugs for managing sick children. Many CBAs, who had previously focused on treating children with fever did not have antimalarials (chloroquine) and reportedly saw fewer sick children for fever, as well as diarrhea, and ARI referrals. Sporadic stock-outs of antimalarial drugs were also noted at facilities. Program implementers reported that gaps in supplies and the end of incentives for health workers (both facility-based and community-based) linked to the end of CIDA hampered the continuation of some ACSD activities. Key informants reported that the C-IMCI activities through CBAs were a great strength of ACSD, but challenging to sustain. Sufficient supervision and monitoring of the CBA system were reported as on-going issues. Incentives for CBAs were primarily limited to job aids and bicycles given at the beginning of implementation, and program implementers postulated that lack of on-going incentives and packages to increase CBA motivation limited the impact of C-IMCI activities, including community case management of child illnesses.


Infant and young child feeding practices improved somewhat in the HIDs over the course of the study period. Program implementers noted that there were strong nutritional interventions through other donors and NGOs in the HIDs in the early part of the decade, while ACSD focused more strongly on the EPI+, ANC+ and case management of illness components. Nutritional interventions did not receive much emphasis, and some key informants reported a lack of coordination between ACSD activities and regional nutrition activities.

Most ANC+ interventions increased over the period of evaluation. IPTp was introduced in 2004 in the HIDs and nationally, although coverage increased significantly more in the HIDs. This strategy was strongly supported by ACSD and the Global Fund in the HIDs. The proportion of women reporting a skilled attendant at delivery increased in the HIDs, but failed to reach the ACSD of 80 percent coverage. Key informants and documents cited explicitly that delivery care was not a focus of the ACSD approach in Ghana. Reported coverage with postnatal supplementation with vitamin A stagnated in the HIDs, while increasing in the comparison area. Measured levels of coverage were exceptionally high at baseline in the HIDs and we were not able to ascertain if this was due to statistical fluctuations or intervention coverage through previous projects.

ANC+.

Early in the program, ACSD reinforced and strongly supported outreach activities for vaccination, ITNs and ANC services. ACSD built partnerships and built on what exists; this strategy was often cited as the “value-added” aspect of ACSD. Across the mix of child survival interventions, ACSD was also noted as contributing to capacity building and technical support for program implementers and partners. Key informants recognized that enhanced monitoring was important part of ACSD, but also noted that monitoring was weak and became weaker after initial CIDA funds for ACSD were depleted.

Overall contributions and challenges of ACSD implementation.

Support for ACSD through Canadian CIDA ceased in 2005, with important gaps in sustained external funding as discussed above. Gaps and delays in funding were cross-cutting, affecting: 1) the constant supply of commodities such as antimalarials and ITNs; 2) continued supervision and motivation of CBAs; 3) insufficient resources for recurring costs such as motorbikes, fuel and incentives for health providers; and 4) delays in the development of health promotion materials for CBAs and radio spots. Despite these constraints, other partners, including the GHS continued to support the ACSD activities, with large infusions of support provided by the government of the Netherlands and DANIDA in 2006. Contextual factors.

The contextual factors considered in the evaluation were based on those proposed as relevant11 for child survival programs.11 Section 3 and appendices A and M provides a more comprehensive description of contextual factors. Given that the adequacy findings on coverage suggest that ACSD had positive effect on some indicators but not on others, the analysis of contextual factors here examines two questions to better interpret the results:

1. Were there any major disruptions in the HIDs or nationally that could explain why ACSD did not lead to a more marked effect on coverage levels?

2. Were there other activities outside of ACSD in the HIDs or nationally that could have led to increases in coverage in the HIDs?

To our knowledge, there were no natural disasters or other emergencies in the HIDs from 1998 to present that would have influenced the effect of ACSD on intervention coverage. Flooding occurred during data collection for the Supplemental MICS 2007, used for endline estimates. In order to assess the impact of the flooding on the population, as well as on the MICS survey, we developed an additional questionnaire module to assess household damage and migration due to the flooding. Twenty-eight percent of the households in the HIDs reported affects of the flood and 24 percent reported damage to the household structure. This emergency would not affect our coverage measures of interventions delivered well before the survey data collection, such as vaccination, vitamin A supplementation, ANC visits, delivery care, etc.

Major disruptions.


Disruptions due to the flooding may have negatively affected indicators related to management of childhood illness, which rely on a two-week recall period or use of ITNs, which pertain to the night before the survey. We performed secondary analyses to assess if household disruptions due to flooding may have affected these indicators. There were no significant differences in management of diarrhea or pneumonia or use of ITNs between households affected by the flood and those not affected. A significantly higher proportion of febrile children in flood-affected households received an antimalarial for fever (61%) than children in non-affected households (50%); (p=0.02). Key informants reported that the increase in malaria treatment in the flood areas was likely associated with an emergency procurement of ACTs funded through the European Commission’s Humanitarian Aid Office–the remaining non-flooded areas did not receive this additional funding. Coverage of case management interventions was also similar in the 2006 MICS, and it is unlikely that the flooding biased our coverage estimates.

As part of the evaluation, we documented other health and development project activities in the HIDs and comparison area between 1999 and 2006-7; section 3 and appendix M provide further details. A number of multilateral, bilateral, and non-governmental agencies, as well as Navrongo Health Research Center, implemented similar and complementary interventions targeting child health and nutrition before and during ACSD implementation. It is difficult to quantify the contributions and population coverage of these programs, but activities widely implemented and supported outside of ACSD included: 1) supplementation with vitamin A for children; 2) ITNs; 3) promotion and support of appropriate infant feeding practices; and 4) community case management for common childhood illnesses. Between 1998 and 2007, coverage of CHPS compounds, also focusing on preventative and primary health care, expanded more rapidly in the HIDs than in comparison area. We were not able to find measures of intervention coverage associated with the CHPS strategy, although the literature suggests that the implementation of this strategy in the Kassena-Nankana district led to greater declines in child mortality than routine services or routine services with community volunteers only.34,36,42

Other activities in HIDs and comparison area.

Thus, changes in intervention coverage in the HIDs cannot be attributed to ACSD alone and must be viewed in light of prior and concurrent activities of other partners in the health sector. Additionally, the GoN and DANIDA provided substantial financial support in 2006 and 2007 to the HIDs and other northern regions for the HIRD strategy, the national GHS continuation of the ACSD strategy. Many other development programs in the HIDs focused on education and literacy, agriculture, poverty reduction through micro-credit, and water and sanitation. We would not expect these projects to have a large short-term influence on coverage of maternal and child health interventions, because they do not directly address the interventions. As described in section 3 and appendix M, over the period of 1998 to 2007, Ghana benefited from massive investments in health at the national level. In the comparison area, USAID, WHO, and others supported child survival activities similar to those promoted by ACSD. Summarizing the presentation on contextual factors:

• No major humanitarian or natural crises were found that affected the coverage results;

• A multitude of maternal and child health activities were implemented by development partners in the HIDs, some in close collaboration with ACSD;

• The expansion of CHPS compounds may have differentially improved access for preventative and curative care in the HIDs;

• Development partners supported activities similar to those included in the ACSD package in the comparison area.

Methodological Challenges.

Here we present a very brief overview of methodological challenges encountered in the retrospective evaluation of ACSD in Ghana, noting how they may have affected the evaluation results related to coverage. Complementing this section, appendix K provides a more thorough review of methodological challenges, appendix F provides descriptions of surveys included in the evaluation, and appendix D and


E provide indicator definitions and a list of the questionnaire items supporting the measurement of the priority indicators in each survey. Many of the challenges encountered reflect the retrospective nature of the evaluation. The evaluation team was forced to rely existing data and information, even if imperfect.2. The 1998-9 and 2003 DHS had limited sample sizes for calculation of baseline coverage indicators in the HIDs, especially those indicators measured among small subgroups of the sample such as exclusive breastfeeding or careseeking for pneumonia. These small sample sizes affect the precision of point estimates and the statistical power to detect small differences over time. Collection of data occurred approximately one year apart for the Supplemental MICS 2007 (used for endline coverage estimates in the HIDs) and MICS 2006 (used for endline coverage estimates in the comparison area). We compared estimates of coverage between 2006 and 2007 in the HIDs to assess if the one-year time lag could have influenced our results. Most coverage indicators remained relatively stable in the HIDs between 2006 and 2007, and were not statistically significant. ITNs for children and IPTp were significantly greater in 2007 as compared to 2006 in the HIDs; coverage with any antimalarial for fever was significantly less in 2007. For these three indicators, we reran statistical tests using the 2006 MICS as our endline estimate to identify any possible bias introduced by using the 2007 MICS survey only in the HIDs. Statistical inferences were the same for trends over time and differences in changes over time in the HIDs and comparison area. The DHS and MICS use slightly different methodologies to collect data. DHS ask only biological mothers of young children about intervention coverage, while MICS questions caretakers of children, even if not biologically related, about intervention coverage. Appendices D and E note differences in the DHS and MICS questions used for indicator calculations; appendices F and K review the differences between the surveys. These differences were minimal and we would not expect them to affect the findings. The data available in the 1998-9 DHS did not allow for calculation of all priority indicators for the evaluation, which are identical to those used for monitoring progress toward the Millennium Development Goals (MDG).7,8 In the 1998-9 DHS, several essential questions were not included: use of bednets by children or pregnant women, timing of antimalarial administration for febrile children, SP taken as part of IPT for pregnant women, or full neonatal tetanus toxoid protection. For the evaluation of time trends between 1998-9 and 2006-7, we used indicator definitions that could be calculated from the 1998-9 data to ensure comparability with indicator estimates in 2006-7 (see appendices D and E). These proxy indicator definitions were less stringent than the priority indicator in all cases; coverage estimates from 2006-7 using the more stringent, MDG priority coverage indicators are presented in appendices G, H and I. Taken together, these methodological issues are not likely to influence the endline comparisons between the HIDs and national comparison area. Differences in the conduct of the survey, the DHS and MICS questionnaires and interviewers’ style of asking questions may have introduced some bias into the comparison of coverage levels between 1998-9, 2003 and 2006-7. However, these methodological challenges are not likely to change the main evaluation findings or conclusions in any substantial way.


6. Nutrition In this section, we describe the differences in nutritional status of young children between the HIDs (comprised of the UER) and comparison area; the latter includes the rest of the country with the exception of the HIDs and urban Greater Accra and Ashanti regions (Accra and Kumasi). Anthropometric data from the HIDs are available for the 1998-9 and 2003 DHS, and for the main MICS in 2006 and the supplementary MICS in 2007. The same surveys – except for the 2007 supplementary MICS – also provide data for the national comparison area. We used data from the 2006 MICS for the comparison area and from the 2007 supplemental MICS for the HIDs for the endline results. Section 2 explains the rationale in more detail. Three indicators of undernutrition prevalence were calculated from these surveys: prevalence of stunting (low length for age for children below 24 months; low height for children 24-59 months of age), wasting (low weight for length/height), and underweight (low weight for age). We used the minus two z-score cutoff based on the 2006 WHO Growth Standards,12 to identify children with moderate or severe undernutrition; for severe undernutrition we used the minus three z-scores cutoff. Mean z scores of the three indices were also calculated. Appendix J presents a schematic of the inclusion and exclusion criteria for children included in the analysis. We present results for all children less than five years of age. For stunting, results are also presented for children aged 24-59 months, the age group with the highest prevalence of this condition 43. Likewise, wasting results are described for children aged less than 24 months. Table 12 presents the numbers of children included in the analyses. Presentation of the results follows the approach used in the section on coverage indicators. First, the adequacy findings are presented (time trends in the HIDs), followed by the plausibility results (comparison between HIDs and the rest of the country). Appendix J presents full nutrition results for sub-groups in both areas. 6.1 Results Figure 19 shows that stunting decreased over time in the HIDs. Wasting and underweight remained relatively unchanged over time, with a peak observed in the 2003 DHS, possibly due to seasonality of surveys. Table 12 and Figure 20 show results for the HIDs as well as the comparison area, in the 1998-9, 2003 and 2006-7 surveys.


Figure 19:

14

25

42

27 3037

1823

35

1421

56

0

20

40

60

80

100

Stunting (24-59m) Wasting (0-23m) Underweight (0-59m)

DHS 1998-9 DHS 2003 MICS 2006 Sup MICS 2007

§§§ §§ §

Pre

vale

nce

of m

oder

ate

and

seve

re (%

)...

Time trends in stunting (children 24-59 months), wasting (children 0-23 months) and underweight (children 0-59 months) in the ACSD “high-impact” districts as measured in DHS and MICS in 1998-9, 2003 and 2006-7, Ghana.


Stunting.

From 1998-9 to 2006-7, there was a reduction of 21 percentage points (pp) for children 24-59 months in the HIDs (p<0.001), compared to a four pp decline in the comparison area. The decline in overall stunting (moderate or severe) in the HIDs was mostly due to the reduction in the prevalence of severe stunting, which fell from 26 to 10 percent. The reduction in the comparison area was from 17 to 13 percent. Mean height/length for age also improved more markedly in the HIDs than in the comparison area. Similar patterns were also observed when all under-five children were analyzed. Despite the small baseline sample size in the HIDs, the difference in difference tests showed that the decline in the HIDs was significantly greater than in the comparison area (p<0.001). Of the 21 pp reduction in stunting among children 24-59 months observed between 1998-9 and 2007 in the HIDs, the largest drop - of 14 pp - seems to have occurred between 1998-9 and 2003, before ACSD was fully implemented (p<0.01). The seven pp reduction between 2003 and 2007 was not significant (p>0.10). Nevertheless, the confidence intervals for these estimates are wide due to the small sample sizes.


Table 12:2006-7, Ghana.

Summary of anthropometry results in ACSD “high-impact” districts and comparison area as measured in DHS 1999, 2003 and MICS

n% /

mean95% CI / (SD) n

% / mean

CI / (SD) n

% / mean

95% CI / (SD) n

% / mean

95% CI / (SD) n

% / mean

95% CI / (SD) n

% / mean

95% CI / (SD) p p p p

Stunting (height for age)24-59 months

% stunted (< -2 SD) 56 50-63 41 38-45 42 28-56 47 44-50 35 32-38 37 33-40 <0.001 >0.10 0.04 <0.001% severely stunted (< -3 SD) 26 20-32 17 15-19 18 11-25 18 16-21 10 9-12 13 11-15 <0.001 <0.01 0.01 <0.01

mean Z score (sd) -2.1 (1.4) -1.8 (1.3) -1.8 (1.2) -1.9 (1.3) -1.6 (1.2) -1.6 (1.2) <0.001 0.08 <0.01 <0.0010-59 months

% stunted (< -2 SD) 44 38-49 32 30-35 36 29-44 39 37-41 29 27-31 31 29-33 <0.001 0.03 >0.10 <0.001% severely stunted (< -3 SD) 19 13-24 13 12-15 14 9-20 15 14-17 9 8-11 11 9-13 <0.001 0.03 0.05 <0.001

mean (sd) -1.6 (1.6) -1.4 (1.5) -1.4 (1.5) -1.6 (1.5) -1.3 (1.3) -1.3 (1.4) <0.001 >0.10 >0.10 <0.001Wasting (weight for height)0-23 months

% wasted (< -2 SD) 14 7-21 17 15-20 27 18-36 13 11-15 14 11-17 9 7-11 >0.10 <0.001 <0.001 0.01% severely wasted (< -3 SD) 5 0-10 4 3-6 10 3-18 4 2-5 4 3-6 2 1-4 >0.10 0.02 0.04 >0.10

mean (sd) -0.9 (1.3) -0.8 (1.3) -1.1 (1.4) -0.5 (1.4) -0.7 (1.3) -0.5 (1.2) >0.10 0.04 <0.001 >0.100-59 months

% wasted (< -2 SD) 8 4-12 11 9-12 13 7-18 8 6-9 8 7-10 6 5-7 >0.10 0.04 <0.001 0.02% severely wasted(< -3 SD) 3 1-5 2 2-3 4 1-7 2 1-2 2 1-3 2 0-2 >0.10 >0.10 0.03 >0.10

mean (sd) -0.6 (1.1) -0.5 (1.2) -0.7 (1.2) -0.2 (1.2) -0.5 (1.1) -0.2 (1.1) >0.10 >0.10 <0.001 >0.10

Underweight (weight for age)0-59 months

% underweight (< -2 SD) 25 21-30 22 20-24 30 21-38 20 18-22 21 19-23 15 13-17 0.03 <0.01 <0.001 <0.001

% severely underweight (< -3 SD) 7 5-9 6 5-8 9 6-13 5 4-6 5 4-6 4 3-5 0.10 <0.01 0.01 >0.10mean (sd) -1.3 (1.2) -1.1 (1.2) -1.4 (1.2) -1.0 (1.2) -1.1 (1.1) -0.9 (1.1) 0.02 <0.01 <0.001 0.03

2186

2121

1999 to 2007

2003 to 2007

1999 to 2007

Comparison: Change in

baseline to 2007

High impact districts: Change in

baseline to 2007 2006 MICS GEOGRAPHIC

COMPARISON¥2003 to

2007

1075

2603

2504

1385

2429

2007 Sup. MICSHIGH IMPACT

DISTRICTSGEOGRAPHIC

COMPARISON¥HIGH IMPACT

DISTRICTSGEOGRAPHIC

COMPARISON¥HIGH IMPACT

DISTRICTS

NUTRITIONAL INDICATOR

1998 DHS 2003 DHS

1138

2068

952

2230145 2317

2264

48 865

143 2277

1336

2192

2226137

955

90 1316

171

173

97

168

71

¥Comparison area comprised of Ghana national level, minus urban Greater Accra and Ashanti regions

Figure 20:

14 2541 17 2242 47 2035 14 2137 9 1556 27 30130

20

40

60

80

100

Stunting (24-59m) Wasting (0-23m) Underweight (0-59m)


1998-9 2006-7 1998-9 2006-7

-21

-4

0

-8 -7

Absolute change in percentage points between 1998-9 to 2006-7

1998-92003 20032003 2006-7

§

§

§ §Prev

alen

ce o

f mod

erat

e an

d se

vere

(%)..

. -4

Prevalence of stunting, wasting and underweight, and absolute change in percentage points in the HIDs and comparison area as measured in DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.


Wasting.

Time trends in wasting should be interpreted with caution because of small sample sizes in the HIDs that are reflected in the wide confidence intervals. For children under 24 months, the prevalence of wasting declined between 1998-9 and 2006-7 by eight pp in the national comparison, but there was no decline in the HIDs. This difference was statistically significant (p=0.03) in favor of the comparison area. There was a marked peak in prevalence in 2003 in the HIDs, but this estimate is based on only 48 children. Trends in severe wasting and in mean weight-for-length showed similar patterns. No significant differences were observed between the time trends in intervention and comparison area for the period 2003 to 2006-7. Underweight.

The analyses of underweight included all under-five children. Using the 1998-9 baseline, there was a decline of four pp in the HIDs and seven pp in the comparison area. As for wasting, underweight prevalence showed a peak in 2003 in the HIDs, but not in the comparison area. After this peak, prevalence declined by nine pp in the HIDs and by five pp in the comparison area. Trends in severe underweight and in mean weight-for-age showed similar patterns. The difference-in-differences tests were not significant for the 1998-9/2006-7 period or for the 2003/2006-7 period.


5.3 Summary and interpretation of results Summary.

Stunting.According to national surveys, the prevalence of stunting in under-five children in the comparison area increased between 1998-9 and 2003 and declined between 2003 and 200616,44 The decline between 2003 and 2006 is probably related to overall socioeconomic progress and improvements in health care and coverage of preventive interventions as described in section 3. Stunting is primarily influenced by dietary quality and quantity, as well as by the incidence and severity of infections. Coverage of interventions for preventing infections, such as ITNs and vitamin A, increased substantially in the HIDs and comparison area. There are insufficient data to assess time trends in complementary feeding, so that these cannot be related to changes in stunting prevalence.

Our results suggest that there was a substantial decline in stunting prevalence in HIDs between 1998-9 and 2003, compared to absence of a decline in the comparison area during the same period. After 2003, the reductions in stunting prevalence were maintained and improved upon, although the rates of decline appear to have been similar in HIDs and comparison area. Wasting.From 1998-9 to 2006, the prevalence of wasting among children less than five years of age has steadily declined in Ghana as a whole, from 10 percent in 1998-9 to 5.4 percent in 2006.16,44 Our results show an apparent increase in the prevalence of wasting in the HIDs, but not in the comparison area, between 1998-9 and 2003, followed by a reduction of the same magnitude. Looking at the whole period, from 1998-9 to 2006-7, there was a reduction by almost half in the prevalence of wasting in the comparison area that was significantly different from the lack of progress observed in the HIDs.

Underweight.For Ghana as a whole, the prevalence of underweight has shown similar trends as wasting, declining from 25 percent in 1998-9 to 18 percent in 2006.16,44 We observed these declining trends in both HIDs and the comparison area, with no significant differences between the two.

Cross-cutting implementation and contextual factors.

Here we review factors that may affect the comparisons described above.

Poverty is associated with stunting (see section 8 on equity for further discussion) and as discussed in section 3, the HIDs were significantly poorer than comparison area. Thus, our stunting results could be affected by this imbalance of poverty. We used direct standardization to estimate the stunting prevalence in HIDs in 2007, had these areas presented a similar wealth distribution to that in the comparison area. The standardized prevalence in 2007 in the HIDs became 31 percent, compared to the crude prevalence of 35 percent in HIDs and of 37 percent in the comparison area. The small number of children available in the earlier surveys in the HIDs does not allow breakdown by socioeconomic position, but because the HIDs are historically poorer than the rest of the country, the time trends are unlikely to be affected.

Socio-economic status.

Understanding of the role of nutritional interventions requires a discussion of the timing of growth faltering. The active process of stunting, or growth faltering, occurs up to the age of 24 months, and thereafter prevalence remains constant up to five years of age. The most sensitive indicator, therefore, is the prevalence of stunting among children age 24-59 months, who are already fully “stunted.” However, for ACSD to have an impact on stunting, children should be exposed to it during their first two years of life when active faltering, or stunting, is occurring. For this reason, there is a lag between the time of the intervention and the time when an impact on height-for-age can be measured. Most of the reduction in stunting in the HIDs appears to have happened between 1998-9 and 2003 (figure 19), which means that whatever caused this reduction must have happened at least a couple of years before the 2003 survey. Implementation of ACSD started in 2002, thus ACSD activities cannot explain this reduction. Interviews

Presence of other nutritional interventions or programs in the HIDs.


with key informants and review of documentation showed that strong nutritional interventions (presented in section 3), such as the establishment and support of feeding and nutritional rehabilitation centers and the LINKAGES project which focused exclusively on infant feeding practices,45 were present in the HIDs before the launch of ACSD. These activities are a possible explanation for the marked reduction in stunting prior to 2003.

We investigated reasons for the apparent increase in wasting prevalence in HIDs between 1998-9 and 2003. Unlike stunting, changes in wasting can occur soon after a change in causal factors, because it usually reflects acute weight loss. A potential cause of sharp increases in wasting is food shortage, but our interviews with key informants and reviews of the documentation did not indicate that this was the case. It is possible that the apparent increase in wasting is due to statistical fluctuation given the small sample size of fewer than 50 children in the HIDs in 2003.

Natural occurrences.

Summing up, after consideration of other factors, there was still no evidence of a differential impact of ACSD on any of the three nutritional indicators studied. As will be discussed below (section 9 on conclusions), this is consistent with the finding on coverage of interventions with a potential impact on nutrition.


7. Mortality This section reports on changes in child mortality in the HIDs and mortality trends in the comparison area. The methods used to estimate mortality for the results presented in this section differ from those used for coverage and nutrition analyses. The methods also differ by HIDs and comparison area due to data availability. Below we provide a brief review of the analyses used for mortality estimation for the HIDs and comparison area separately. Mortality estimation in the HIDs.

We used the full birth history data collected in the 2007 Supplemental MICS to estimate child mortality in the HIDs both before (baseline) and after ACSD became operational (endline). There are two reasons why we elected to use the 2007 survey as the basis for estimating mortality throughout the evaluation period. First, the use of a full birth history allows the calculation of period estimates of mortality from the previous year to 10 or more years in the past because a child’s birth and/or death is very significant to the mother and generally can be recalled reliably. Second, using a single survey to estimate mortality for the two periods – baseline and endline – builds on the correlation between periods arising from use of the same sample of households. This usually reduces the sampling error of the difference in mortality between the two periods, enabling smaller differences to be measured more precisely. Third, this method reduces the impact of non-sampling errors since there is generally more consistency of non-sampling errors within a survey than between surveys. Whether one or more surveys are used to estimate mortality, larger sample sizes are associated with more precise estimates of mortality. Thus, we want to maximize the sample size by selecting longer time periods for mortality estimation. These periods need to be consistent with ACSD implementation and the baseline period should not extend far into the past, as this would result in a higher mortality estimate before initiation of ACSD in contexts where mortality levels are declining over time. We calculated mortality for two periods of the same length, 3½ calendar years each, before and after ACSD implementation in the HIDs. As shown in Figure 21, based on the documentation of ACSD implementation, we defined the baseline period as July 1998 to December 2001, and the full implementation period as January 2004 to July 2007, with a phase-in period in between baseline and full implementation.


Figure 21:

2007

2004

2005

2006

2001

2002

2003

2000

1999

YEAR (from full birth history)

A. BASELINE: before implementation ACSD Jul 1998-Dec 2001

C. ENDLINE- Full implementation ACSDJan 2004-Jul 2007

B. PHASE-IN: start of ACSD interventions Jan 2002-Dec 2003 Compare U5MR

Time periods used in mortality analysis1998

A. BASELINE: No ACSD implementation: start of period chosen for symmetry with period C

B. PHASE-IN: Start reinforcement of EPI & cold chain; donation of vehicles, motos & refrigerators; ITNs Vitamin A; reinforcement of ANC activities

C. ENDLINE = EPI + ITNs; Vitamin A; ANC; CHW training & deployment; Facility IMCI

ACSD implementation time periods in Ghana for the retrospective mortality analysis using full-birth history data, based on documentation of ACSD implementation.

The under-five mortality rate (U5MR) is our priority indicator for measuring changes in mortality in the HIDs, because the primary goal of the ACSD project was to reduce it by 25 percent by the end of 2006.46 One benefit of using U5MR relative to other measures of child mortality (see Box 3) is that it provides the largest sample size and is less sensitive to errors in reporting age than infant or neonatal mortality. Although we present findings for specific age groups within 0 to 59 months, we have considered U5MR as the primary indicator of mortality impact. Mortality estimation in the comparison area.

In Ghana, there is no single recent household survey with a full birth history to generate comparable direct child mortality estimates for the comparison area (defined as the rest of Ghana minus the HIDs, and urban Greater Accra and Ashanti regions). The most recent national survey in Ghana with a full birth history is the 2003 DHS. The 2006 Ghana MICS used the Brass-type questions on children even born and children surviving. These questions only provide indirect estimates of child mortality, which cover a period of up to 15 years before the survey. Thus, we use the available data from both the 2003 DHS and 2006 MICS to estimate and project trends in the under-five mortality rate for the

Box 3: Measures of child mortality

(expressed as deaths per 1,000 live births) Neonatal mortality (NN)

The probability of dying between birth and the first month of life

Post-neonatal mortality

The probability of dying between the exact age of one month and the exact age of one year

Infant mortality (IMR) The probability of dying between birth and exact age one year

Child mortality (CMR) The probability of dying between exact ages one and five years

Under-five mortality (U5MR)

The probability of dying between birth and exact age five years


comparison area. We focus on U5MR since this is most robust indicator of child mortality, as described above. Yearly direct mortality estimates were calculated from the DHS 2003 and then averaged over a two-year period. The indirect estimates of under-five mortality (from DHS 2003 and MICS 2006) had their most recent two points excluded. The most recent point is always excluded by demographers as being too inaccurate, and the second most recent is recognized as often being biased, usually to higher levels of mortality. We then fit a trend line to all the available data points to estimate increases or declines in mortality in the comparison area, described further in section 7.1. 7.1 Results Figure 22 presents the annual direct mortality estimates of U5MR in the HIDs from 1997 to 2007, as well as the estimated mortality trend in the comparison area. Mortality over the last 10 years is declining in the HIDs (95% confidence intervals shown in dashed, red lines). The U5MR in the comparison area is estimated to have stagnated over the last 10 years, although trends from 2004 forward are projected from available data (shown in blue dashed bar) and should be interpreted with great caution.

Figure 22:

Annual estimates of under-five mortality rates in the HIDs as measured in the 2007 Supplemental MICS and estimated levels of mortality in the comparison area, 1997-2007, Ghana.

Note: Projected mortality in comparison area shown in dashed blue bar HIDs. Table 13 presents several age-specific mortality rates in the periods before ACSD implementation and after full implementation, as well as the absolute reduction over time expressed as deaths per thousand births. We present the 95 percent confidence limits for these estimates, as well as the p-value for comparisons of estimate between baseline and endline.

0

20

40

60

80

100

120

140

160

180

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007Year

U5M

R (

deat

hs p

er 1

000

birt

hs)

High-impact High-impact - 95% confidence bounds

National comparison - estimated National comparison - projected


Table 13:

Absolute difference p value

Priority IndicatorUnder-five mortality (5q0) 106.7 86.2 20.6 0.1

95% CI (87.9 - 125.6) (72.2 -100.1) (-4.3 to 45.5)Age-specific indicatorsNeonatal mortality (NN) 38.4 26.3 12.1 0.07

95% CI (28.5 - 48.4) (17.8 - 34.8) (-1.3 to 25.5)

Postneonatal mortality (PNN) 20.4 26.9 -6.4 >0.1095% CI (13.9 - 27.0) (18.2 - 35.6) (-17.8 to 5.0)

Infant mortality (1q0) 58.9 53.2 5.7 >0.1095% CI (47.5 - 70.2) (41.4 - 64.9) (-12.0 to 23.4)

Child mortality (4q1) 50.9 34.9 16 0.0595% CI (37.3 - 64.4) (26.7 - 43.0) (-0.2 to 32.2)

ACSD

Pha

se-in

per

iod

HIGH IMPACT ZONES

MORTALITY MEASURESA. JUL 1998 -

DEC 2001C. JAN 2004 -

JUL 2007

DIFFERENCE IN BASELINE AND ENDLINE (A minus C)

Mortality rates by time period and changes between baseline and endline periods in the HIDs, Ghana.

The U5MR decreased over time in the HIDs, from 106.7 in the period of July 1999 to December 2001 to 86.2 in the period of January 2004 to July 2007, representing a decline in UM5R of approximately 20 percent. This decline in U5MR just failed to reach statistical significance (p=0.10). Neonatal and child mortality showed the fastest relative declines (32% and 31%, respectively, with p levels of 0.07 and 0.05), while infant mortality decreased by 9.7 percent (p>0.10). Postneonatal mortality was observed to increase, although this change was not statistically significant (p>0.10). Comparison area.

As described above, no comparable data was available for the comparison area. Figure 23 presents the trend line as estimated from available direct and indirect mortality estimates. The U5MR remained approximately constant between 1994 and 2003 at 115 deaths per 1000 live births. We can project this estimate forward to 2006 to cover the ACSD period; however, the uncertainty of this projection increases as it gets further from 2003. Nevertheless, these estimates based on available data suggest that U5MR has been constant in the comparison area for much of the period of the ACSD, but with considerable uncertainty in the period since 2004.


Figure 23:

Estimated and projected under-five mortality rate in the comparison area as measured using indirect and direct mortality estimates from DHS 2003, and indirect estimates from MICS 2006, Ghana.

7.2 Summary and interpretation of results Based on these findings, the U5MR in the HIDs implementing ACSD in Ghana declined by 20 percent in the period from 1998 to 2007—from 107 to 86 per 1,000 live births (p=0.10). Based on available data, the U5MR was estimated to stagnate at approximately 115 per 1000 live births through 2003 in the comparison area where ACSD was not implemented. Cross-cutting implementation and contextual factors.

We considered the implementation and contextual factors that might have offset the impact of ACSD, with special attention to factors that would have influenced the HIDs and comparison area differentially. As presented in section 3, we observed that the HIDs were significantly poorer than the comparison area. Available data suggested higher rates of mortality in the less poor comparison area and mortality in the HIDs did not show a strong social gradient (see next section), thus it is difficult to assess how socio-economic status might affect our estimates of mortality. As discussed in section 3 and previous results sections, many child health and nutrition activities took place outside of routine services in the HIDs before and during ACSD. These activities, in addition to other development activities, such as improvements in water and sanitation, most likely contributed significantly to the observed declines in mortality. Evidence reported in the literature suggests that the CHPS strategy as implemented in the Kassena-Nankana district (one of the HIDs) led to declines in child mortality.34,36,42 Coverage of CHPS in the HIDs greatly expanded over the evaluation period, although with lower population coverage than in the original experiment conducted by the Navrongo Health Research Center taking place in Kassena-Nankana district.

0

20

40

60

80

100

120

140

160

1990 1992 1994 1996 1998 2000 2002 2004 2006Year

U5M

R (d

eath

s pe

r 100

0 bi

rths)

DHS 2003 direct DHS 2003 indirect

MICS 2006 indirect Linear trend

Excluding women aged 20-24 yrs data in trend line


Thus, as noted above, the observed declines in mortality in the HIDs must be interpreted as a result of broad efforts to improve child survival and health in these areas. Despite large-scale health programming in the southern and central regions of the country and substantial investments in health at the national level, available data suggest that mortality in the comparison area stagnated. Methodological Challenges.

There are important methodological issues that may have affected the results of this retrospective estimation of the effect of ACSD on under-five mortality. Appendix K provides a complement to this section with a more detailed discussion of these issues.

Our primary methodological limitation is the lack of comparable data in the comparison area. We were not able to estimate mortality, using direct estimates from the full birth history, for the same time periods in the comparison area as in the HIDs. We estimated mortality trends in the comparison area using all available data (direct estimates from the DHS 2003 and indirect estimates from the MICS 2006 and DHS 2003) to assess trends. Although this provides an estimate of mortality trends, it is a composite, based on different surveys and different methodological assumptions in the calculation of mortality. Additionally, these surveys only provide data that refer to mortality experiences up to 2004; the overall trend was projected to 2007, but with the large uncertainty associated with any projection. The incomparability of the data and methodologies between the two areas also precludes statistical comparisons of changes in mortality between the two areas. More appropriate comparison data would consist of direct estimation of mortality through full-birth histories collected in the neighboring districts in the Northern and Upper West regions during the Supplemental MICS 2007—the same survey and methodology used for estimation in the HIDs. In spite of numerous attempts, we were unable to obtain such data in a timely fashion.

Mortality data in comparison area.

A second methodological challenge was the definition of the “before” and “after” periods of ACSD implementation. Documentation of implementation is difficult in a retrospective evaluation, and is based by necessity on records maintained for other purposes and the subjective recall of project implementers. The two periods defined for the purpose of this evaluation were discussed and agreed to with in-country teams composed of ACSD implementers and national counterparts, and we believe that they accurately distinguish between periods before ACSD was implemented and periods during which ACSD was “fully implemented” in the views of those responsible.

Definition of the “before” and “after” periods of ACSD

In summary, despite these methodological challenges, there is sufficient evidence to conclude that that there was a reduction in child mortality in the HIDs from before to after ACSD was implemented, that just failed to reach statistical significance. The 20 percent reduction in U5MR between the two periods comes close to the reduction goal for the ACSD project of 25 percent by the end of 2006. At the same time, available data suggest that U5MR has stagnated in the comparison area, at least through 2004. In our conclusions, we discuss how these findings relate to the results on coverage and nutrition.


8. Equity of coverage, nutrition and mortality In addition to evaluating the impact of ACSD implementation on indicators of coverage, undernutrition and mortality, it is also important to assess whether or not the strategy helped reduce inequities in health. In this chapter, we describe within-population inequalities according to socioeconomic position, place of residence and sex, separately for the HIDs and for the comparison area. Socioeconomic position was categorized according to wealth quintiles, obtained from an index based on ownership of household assets and building characteristics (described in Appendix D). The definition of urban or rural residence was based on survey classification, derived from the 2000 Ghana Housing and population census. The sample size available in 1998-9 and 2003 DHS for the calculation of baseline indicators in the HIDs was small. Because equity analyses require breakdown of these already small samples into two to five subgroups, it was not advisable to carry these out for the coverage and nutrition data. Given the over-sampling of the HIDs at endline in the Supplemental MICS in 2007, it was possible to carry out equity analyses for the post-implementation period. Our analyses, therefore, will be restricted to documenting how inequalities differ between the two areas after ACSD implementation. We also attempted to investigate ethnic group inequalities, but except for the Mole-Dagbani ethnicity, no other group accounted for more than 10 percent of the sample in both the HIDs and comparison area, and thus it was not possible to compare ethnic inequalities across areas. Families in the HIDs were markedly poorer than those in the national comparison area (see figure 4 and table 2 in section 3). For example, only nine percent of the under-five children belonged to the wealthiest quintile based on the national sample). The small sample size in the upper quintiles in the HIDs should be borne in mind when interpreting the results. Appendix I presents the breakdown of all coverage indicators according to sex and wealth quintiles within the HIDs zones in 2007. Due to the imbalance in the number of children in each wealth quintile in the HIDs when the combined samples were used, the analyses in appendix I relied on a different asset index, based exclusively on the HID sample in order to produce quintiles with approximately equal number of children. The results in Appendix I, therefore, may differ from those presented in this chapter. In this section, we present results for both the HID and comparison area, but restrict the results to six coverage indicators representing the different components of ACSD. These include EPI+ (measles vaccine, ITNs for children and vitamin A to children), IMCI+ (diarrhea management / ORT) and ANC+ (three or more antenatal visits, skilled attendant at delivery). We also carried out equity analyses for the two main indicators of impact: stunting among children aged 24-59 months and under-five mortality rate. Socioeconomic inequalities.

These results are summarized in figures 24a-h and in table 14. The table presents two summary measures of inequality. The slope index shows the absolute difference between top and bottom of the wealth scale, based on a regression approach the uses data from all quintiles rather than just the two extreme groups. For example for skilled delivery in the HIDs, the index of 65.6 indicates that this is the difference in percentage points (pp) in the coverage between the richest and poorest children. Table 14 also presents the concentration index that summarizes the overall amount of inequity in the population. Concentration indices take values between minus one and one. A value of zero indicates that the outcome is equitably distributed across all wealth groups. A negative value indicates disproportionate concentration of the health variable among the poor, for example in the case of disease or malnutrition, where the poor are more likely to be affected. A positive value indicates that the poor are getting less than would be expected had the distribution been equitable, as often occurs for preventive and curative interventions.iii

iii More information available at: (

http://siteresources.worldbank.org/INTPAH/Resources/Publications/Quantitative-Techniques/ health_eq_tn07.pdf)

http://siteresources.worldbank.org/INTPAH/Resources/Publications/Quantitative-Techniques/%20health_eq_tn07.pdf�

http://siteresources.worldbank.org/INTPAH/Resources/Publications/Quantitative-Techniques/%20health_eq_tn07.pdf�


Figure 24a-h:

Socioeconomic inequalities, showing breakdown by wealth quintiles of selected indicators in “high-impact” zones and comparison area, Ghana, 2006-7.


Table 14: Summary indices of socioeconomic inequalities for selected indicators in HIDs and comparison area, Ghana, 2006-7.

INDICATOR

SLOPE INDEX OF INEQUALITY CONCENTRATION INDEX

HIDs Comparison

Area HIDs Comparison

Area Measles coverage -0.6 2.8 -0.001 0.004 Vitamin A (children) 1.0 1.1 0.005 0.008 ITNs (children) -0.5 -0.3 0.000 -0.058 Diarrhea Management* 13.6 13.7 0.077 0.089 ANC (3 visits) 13.5 22.4 0.031 0.049 Skilled delivery 65.6 60.2 0.254 0.230 Stunting -5.1 -11.1 -0.070 -0.129 Underfive mortality -18.8 N/A -0.037 N/A

* ORS, recommended home fluids, or increased fluids with continued feeding There were virtually no inequities for indicators such as measles vaccination, vitamin A and ITNs, which were promoted using campaign and community outreach approaches. In contrast, poor children presented lower coverage levels than their better-off peers for diarrhea management, antenatal and delivery care. The largest gaps refer to skilled attendance at delivery. There was only one significant difference between HIDs and the comparison area in terms of equity in coverage – in the latter, ITN coverage was slightly higher among the poor than among the rich, whereas in the HIDs there was no inequality (p=0.02). To better understand the equity gap in diarrhea management, we carried out additional analyses of children who received ORS packets from a provider. Inequities were even sharper, with seven percent coverage in the poorest quintile and 42 percent in the better-off. This is in agreement with the finding that interventions requiring contact with a provider – ANC, skilled delivery, etc – tend to be more inequitable than those delivered through community channels. In terms of stunting and mortality (Figures 24g-h) the slopes are in the opposite direction than for most coverage indicators, that is, levels are higher among the poor than the rich. The summary indices (table 14) take a negative sign under these conditions. The degree of inequality in stunting was lower in the HIDs than in the comparison area, but this was not statistically significant. For mortality, data on equity are available only for the HIDs, because of the limitations of the data collected in the comparison area (see section 7). For this reason, the quintiles used for the mortality analyses are based on the asset distribution in the HIDs only rather than the joint distribution of assets in HIDs and comparison area. Use of the joint distribution, with very small numbers of HIDs children in the better-off quintiles, would not allow precise estimation of mortality rates for these groups. Our results show that children in the poorest quintile had mortality levels that were substantially greater than those in all other quintiles (Figure 24-h). This pattern is uncommon at high mortality levels such as that observed in the HIDs; when mortality is high, such as observed in Ghana, the better-off quintile usually stands out from the other quintiles with markedly lower mortality levels. Summing up, the analyses of socioeconomic inequalities show remarkably small gaps between rich and poor for interventions delivered through campaigns and outreach, but there are substantial inequities for those that depend on health services. Appropriate management of diarrhea, which is mostly indicative of family practices, also showed inequities. Inequalities in stunting prevalence are lower in the HIDs, but it is difficult to attribute this finding to ACSD given the lack of differential effect on inequities in coverage indicators.


Gender inequalities.

Table 15 presents data on possible inequities in terms of gender. There is no evidence of a preferential treatment for boys, either in the HIDs or in the comparison area. Gender inequalities were not analyzed for antenatal or delivery care, when the sex of the baby was yet to be known (assuming a low frequency of pregnancy ultrasound). For the impact indicators (table 15), stunting prevalence was similar in both sexes, but mortality was higher for boys than for girls, as is the case in most places in the world, although this difference was not statistically significant.

Table 15: Selected coverage, nutrition and mortality indicators for boys and girls in the HIDs and comparison area, Ghana, 2006-7.

COVERAGE or NUTRITIONAL INDICATOR AREA

2006 MICS and 2007 SUPPLEMENTAL MICS

TOTAL MALE FEMALE

% n % n p Any measles Innoculation (12-23m)

HIDs 98% 98% 187 99% 208 >0.10

Comparison 96% 95% 274 98% 276 0.07

ITN use for under five children

HIDs 58% 57% 1119 58% 1137 >0.10

Comparison 24% 24% 1364 23% 1304 >0.10

Vitamin A supplementation of children (6-59m)

HIDs 90% 90% 991 90% 984 >0.10

Comparison 96% 96% 1217 96% 1151 >0.10

ORT for diarrhea HIDs 28% 23% 183 34% 174 0.05

Comparison 30% 33% 231 27% 173 >0.10

Moderate & severe stunting (24-59m)

HIDs* 35% 37% 671 32% 665 0.08

Comparison 37% 37% 730 35% 654 >0.10

MORTALITY AREA U5MR U5MR Births U5MR Births p Under-five mortality HIDs 86.2 93.8 834 77.6 858 >0.10

Urban-rural inequalities.

Urban residents accounted for 11 percent of the HID sample and 21 percent of the comparison area. Urban women showed higher coverage of skilled attendance at birth and urban children had lower prevalence of stunting in both the HIDs and comparison area (table 16). In contrast, rural children in the comparison area were significantly more likely to sleep under an ITN. There were no significant urban/rural differentials for under-five mortality rates, nor for coverage with the remaining interventions (measles vaccine, vitamin A, diarrhea managment and ANC). There is no evidence that ACSD implementation affected urban/rural differentials. In summary, the analyses of inequalities by socioeconomic position, gender and urban/rural residence did not provide evidence that ACSD implementation contributed to improving equity in Ghana.


Table 16: Selected coverage, nutrition and mortality indicators for urban and rural areas in the HIDs and comparison area, Ghana, 2006-7.

COVERAGE or NUTRITIONAL INDICATOR AREA

2006 MICS and 2007 SUPPLEMENTAL MICS

TOTAL URBAN RURAL

% n % n p Any measles Innoculation (12-23m)

HIDs 98% 99% 87 98% 309 >0.10

Comparison* 96% 97% 110 96% 439 >0.10 ITN use for under five children

HIDs 58% 53% 418 59% 1838 >0.10

Comparison* 24% 17% 586 25% 2083 0.01 Vitamin A supplementation of children (6-59m)

HIDs 90% 93% 368 89% 1607 0.07

Comparison* 96% 97% 511 96% 1857 >0.10

ORT for diarrhea

HIDs 28% 32% 58 27% 299 >0.10

Comparison 30% 36% 86 29% 319 >0.10 Skilled birth attendant: doctor or nurse/midwife

HIDs* 40% 71% 94 33% 392 <0.001

Comparison* 42% 61% 114 37% 419 <0.001

3+ visits ANC care

HIDs 89% 94% 94 88% 385 >0.10

Comparison* 80% 88% 113 77% 419 0.09

Moderate & severe stunting (24-59m)

HIDs* 35% 27% 228 36% 1108 0.03

Comparison* 36% 23% 333 41% 1052 <0.001

MORTALITY AREA U5MR U5MR Births U5MR Births p Under-five mortality HIDs 86.2 83.6 329 86.4 1363 >0.10


9. Conclusions In this section, we summarize the findings of the evaluation, addressing two separate questions:

a. Was ACSD implementation associated with improvements in coverage, nutrition and mortality over time?

b. If so, was progress in the ACSD districts faster than observed for the rest of the country? As described in section 2 (methods), there was no true baseline survey in the HIDs and comparison area that met the quality criteria for coverage and nutritional data. Implementation of ACSD started in mid 2002, and therefore the 1998-9 DHS was too early for a baseline, and the 2003 DHS survey a bit too late. It is important to keep this issue in mind when interpreting the evaluation results. Figure 25 summarizes these trends in the HIDs and comparison area during the period from 1998-9 to 2006-7. The horizontal axis shows the change in coverage in the HIDs and the vertical axis the corresponding changes in the comparison area. All dots are on the right side of the y-axis, that is, the indicators showed an increase in the comparison area (although not all of these increases were statistically significant). Most dots are also above the x-axis, meaning that the indicators increased in the HIDs. A few interventions, mainly related to case management, showed some degree of decline in the HIDs.

Figure 25:

-40

-20

0

20

40

60

80-40 -20 0 20 40 60 80

Absolute percentage change in coverageComparison area

Abs

olut

e pe

rcen

tage

cha

nge

in c

over

age

HID

s

IPTp

ITN (child)

Vitamin A (child)

Vitamin A (postnatal)

EBF

AM for fever

BF within 1 hr

Skilled deliveryDPT3

ANC4+ Measles

ORT & feeding

Careseeking pneumonia

TT2

Antibiotics for pneumonia

ANC+ interventions EPI+ interventions Case managementInfant feedingKey:

Summary of absolute changes between 1998-9 and 2006-7 in coverage and family practices in “high-impact” districts and comparison area, Ghana.

When the indicator increased (or decreased) to a similar extent in both areas, the points are close to the diagonal. Indicators that are above the diagonal showed better performance in HIDs than in comparison


area. The reverse is true for those below the diagonal. A larger number of indicators improved faster in the HIDs than in the comparison area than the reverse, but key indicators of case-management tended to increase faster in the latter areas, except for antibiotics for pneumonia. A caveat of the results shown in Figure 25 is that they do not reflect baseline levels. For example, vitamin A to the child shows a larger increase in the comparison area than in the HIDS, but it started out from baseline levels of 65 percent in the HIDs and 22 percent in the comparison area, so that the scope for improvement was much greater in the latter. Relative to the two questions posed at the beginning of the chapter, the answers for coverage indicators are:

(a) Most coverage indicators improved over time in the HIDs and reached the target coverage levels set by ACSD, although declines were observed for case management indicators.

(b) Comparison with the rest of the country showed mixed results, although more indicators showed faster increase in the HIDs than in the comparison area.

Turning to nutritional status, the answers to the two basic questions are:

(c) The HIDs showed a reduction between 1998-9 and 2007 in underweight and stunting prevalence, but not in wasting.

(d) Over the period from 1998-9 to 2006-7, stunting declined significantly faster in HIDs than in the comparison area. Because of the time lag between the implementation of ACSD-promoted nutritional interventions and the detection of an impact on stunting, it is unlikely that ACSD can account for much of the observed reduction in this indicator. Wasting, on the other hand, declined significantly in the comparison area while remaining stable in the HIDs.

Reducing under-five mortality by 25 percent by 2006 was the primary goal of the ACSD strategy. Our analyses showed that:

(c) There was a reduction of 20 percent in under-five mortality in the HIDs, close to the ACSD goal of 25 percent. This trend was ascertained through the full birth history technique, and the reduction was close to reaching statistical significance (p=0.10).

(d) Data on under-five mortality trends in the comparison area were available from a different source than those for the intervention area, with an endpoint in 2004. Other analyses suggest that mortality levels remained stable at around 115 deaths per thousand live births, in contrast to the 20 percent reduction by 2007 in the HIDs. The different endpoints and analytical techniques used in the two time series preclude a more accurate comparison.

Because of the small sample sizes in the HIDs at baseline, analyses of inequalities in coverage and nutrition indicators were limited to comparisons at the end of the study period. Our conclusions are:

(a) Only small socioeconomic inequalities were observed for interventions delivered through campaign approaches such as vaccination, vitamin A and ITNs. Diarrhea management, four or more ANC visits, stunting and mortality showed intermediate magnitudes of inequalities, whereas large rich-poor gaps were observed for skilled delivery care. Inequalities between boys and girls were virtually non-existent. Urban-rural inequalities were small, except for skilled attendance at delivery and for stunting.

(b) When HIDs were compared to the rest of the country, there was no evidence of differences in patterns of health inequalities for intervention and coverage indicators.

The retrospective nature of the evaluation imposed a number of important constraints that may have affected our findings. These include the fact that no true baseline data were available, as discussed above. Secondly, the available “near-baseline” samples were very small in the HIDs, precluding the precise measurement of coverage and nutrition indicators. Third, the methods and timelines for mortality assessment were different in the two areas being compared. Finally, HIDs were markedly poorer than the rest of the country, so that comparability is affected; a more appropriate comparison area would consist of neighboring districts in the Northern and Upper West regions, but in spite of numerous attempts we were


unable to obtain such data in a timely fashion. The joint interpretation of findings on coverage, nutrition and mortality in the HIDs is limited by the different time spans for the coverage and nutrition indicators (1998-9 to 2006-7) and for mortality estimation (1998-2001 to 2004-2007). The main causes of under-five deaths in Ghana in 2003 were malaria (33%), neonatal causes (29%), pneumonia (15%) and diarrhea (12%). The highest coverage levels in the endline surveys in the HIDs were achieved for vaccinations, vitamin A supplementation to children, antenatal interventions (including IPTp and TT) and ITNs. Exclusive breastfeeding also showed large increases. One would expect these interventions to have a greater impact on deaths due to malaria, neonatal causes and diarrhea. None of these preventive interventions, except for HiB vaccine and exclusive breastfeeding, would be expected to affect pneumonia deaths. Reported careseeking for pneumonia stagnated while antibiotics for pneumonia significantly increased. Further analyses showed that over one-fourth of the reported antibiotics came from drug shops and itinerant vendors, making it difficult to interpret the impact of this practice. Key informants reported that mothers might have chosen to go to drug vendors when community-based workers encouraged mothers to seek care for cases of childhood pneumonia. Case-management interventions against malaria and diarrhea showed low and declining coverage levels in the HIDs. Taken together interventions showing large gains in coverage had only limited impact on the main causes of death, and hence are compatible with a moderate decline in mortality levels, similar to the 20 percent reduction observed in the HIDs. When contrasting trends in the ACSD and comparison area, it is important to consider that a large number of international, bilateral and Ghanaian agencies have been operating in both areas, before as well as during the study period. The sections on background characteristics and implementation (sections 3 and 4) show that many of the interventions promoted by ACSD had been actively implemented by other agencies, some well before ACSD was formally launched in 2002, and others in collaboration with ACSD. These included, but were not limited to; the Navrongo Health Research Center (vitamin A, ITNs and CHPS strategy), Ghana Red Cross Society (mother-to-mother support groups and community activities), World Food Program feeding programs, the LINKAGES project (infant feeding interventions), World Vision and CRS (nutritional rehabilitation centers and education), CHPS centers (access to primary health care), etc. The coverage of the CHPS strategy, posting community nurses to improve preventative and curative primary health care, expanded greatly in the HIDs over the ACSD implementation period. ACSD worked with many of these partners to achieve further increases in coverage. Building upon what exists is a key ACSD strategy, and although this makes strong programmatic sense, it renders it difficult if not impossible to attribute specific coverage gains to ACSD per se. Thus, the results must be interpreted in light of combined efforts to improve child survival in the region. The Ghana implementation team noted on various occasions several key ACSD contributions, including: 1) the program’s ability to concentrate on a package of effective interventions; 2) additional resources for commodities, equipment and human resources; 3) clearly stated targets; 4) establishment of productive partnerships and synergies across institutions; and 5) achievement of strong commitment from the GoG, GHS and other donors. The Ghana team also noted key lessons learned from the ACSD experience and recommendations for future child health programming, shown in box 4. At the same time, other development partners, including UNICEF, provided massive investments in the rest of Ghana, again making it difficult to ascertain the additional impact of ACSD by comparing the HIDs with other geographical regions.


The findings reported above should not detract from the fact that remarkably high and equitable levels of coverage with key child survival interventions were achieved in the HIDs, and that ACSD coverage goals were met for a majority of these indicators, in a region of extreme poverty when compared to the rest of the country. Stunting prevalence declined markedly over time, although much of the improvement seems to have occurred prior to ACSD implementation, likely associated with strong nutrition programs present in the HIDs for a number of years. Under-five mortality also showed a 20 percent reduction, which just failed to reach statistical significance. The fact that gains in intervention coverage were greater in the HIDs than in the comparison area lends plausibility to the hypothesis that some part of the mortality reduction found in the HIDs may be attributed to activities linked to ACSD.

Box 4: The way forward: Lessons learned in ACSD Ghana according to national

counterparts 1. The ACSD strategy did not focus strongly on interventions to improve child undernutrition

New ACSD-like programs need a “nutrition-plus” component to ensure that efforts and resources are devoted specifically to nutritional interventions.

2. Community-based activities, including training and supporting CHWs, were an integral, but challenging component of ACSD

More attention needs to be given to the motivation of community-based agents and their supervisors at the sub-district level Support for adequate supervision, monitoring and incentives and an uninterrupted supply of commodities will be essential to sustain adequate levels of motivation and quality

3. Gains for behaviors related to management of childhood illness, skilled assistance at delivery, and nutritional practices were less than expected Changing behaviors is complicated and time consuming. More efforts and resources should be devoted to behavior-change strategies, especially face-to-face counseling and mother’s support groups

4. Supervision and monitoring system are often weak and untimely, particularly at the sub-district and community levels. Problems, such as stock-outs of ORS and antimalarials, were picked up by the current system, but only after persisting for long periods.

Importance needs to be given to supervision and M & E systems, developing systems that function in real time.

5. Increased supply of commodities was a contribution of ACSD; however, stock-outs of essential commodities associated with weak supply management, gaps in funding and changes to national policies hindered potential gains in intervention coverage.

Ensuring an adequate and continuous supply of essential commodities will strengthen future program efforts;

Commodity security should be included in program planning and monitoring; alternative approaches should be explored to strengthen commodity security.

6. ACSD was integrated into the planning processes at the regional level; it now needs to be better integrated into the national and district-level planning processes

7. Government ownership of the program was an on-going issue; the program is still often viewed as an externally driven project outside of the routine health services.

8. External evaluation results can be used to improve new ACSD-like programs ACSD successes should provide an impetus for scale-up of similar packages and new interventions; Introduction of interventions should be done incrementally with early review; Evaluation results should convey a sense of urgency of all that remains to be done, especially for

nutrition and case management of childhood illness


References 1. UNICEF. Accelerating child survival and development: A results-based approach in high under-5

mortality areas. Final Report to CIDA. New York, 2005.

2. Bryce, J., Gilroy, K., Black, R.E., Jones, G. & Victora, C.G. A Retrospective Evaluation of the Accelerated Child Survival and Development Project in West Africa; Inception Report. Baltimore, MD, Johns Hopkins University Institute for International Programs, 2007.

3. Bryce, J., Victora, C.G., Habicht, J.P., Black, R.E. & Scherpbier, R.W. Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness. Health Policy Plan. 20 Suppl 1: i5-i17 (2005).

4. UNICEF. Accelerating early child survival and development in high under-five mortality areas in the context of health reform and poverty reduction: a results-based approach. UNICEF funding proposal (2002-2003). New York, 2002.

5. Darmstadt, G.L., Bhutta, Z.A., Cousens, S., Adam, T., Walker, N. & de Bernis, L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 365 (9463): 977-88 (2005).

6. Jones, G., Steketee, R.W., Black, R.E., Bhutta, Z.A. & Morris, S.S. How many child deaths can we prevent this year? Lancet. 362 (9377): 65-71 (2003).

7. Bryce, J., Terreri, N., Victora, C.G., Mason, E., Daelmans, B., Bhutta, Z.A. et al. Countdown to 2015: tracking intervention coverage for child survival. Lancet. 368 (9541): 1067-76 (2006).

8. UNICEF. UNICEF/WHO Meeting on Child Survival Survey-based Indicators. Summary List of Child Survival Indicators. New York, 2004. Available at www.childinfo.org.

9. Bryce, J., Boschi-Pinto, C., Shibuya, K. & Black, R.E. WHO estimates of the causes of death in children. Lancet. 365 (9465): 1147-52 (2005).

10. Efem, I., Jehu-Appiah, C., Anemana, S.D., Addai, E., Awittor, E. & Ankrah, V. Report of the review of the Accelerated Child Survival and Development Programme in the Upper East region of Ghana, November 2004. Accra, Ghana, UNICEF, Ghana, 2004.

11. Victora, C.G., Schellenberg, J.A., Huicho, L., Amaral, J., El Arifeen, S., Pariyo, G. et al. Context matters: interpreting impact findings in child survival evaluations. Health Policy Plan. 20 Suppl 1: i18-i31 (2005).

12. W H O Multicentre Growth Reference Study Group & de Onis, M. WHO Child Growth Standards based on length/height, weight and age. Acta Paediatr. 95 (s450): 76-85 (2006).

13. Habicht, J.P., Victora, C.G. & Vaughan, J.P. Evaluation designs for adequacy, plausibility and probability of public health programme performance and impact. Int J Epidemiol. 28 (1): 10-8 (1999).

14. WHO. World Health Statistics. Geneva, 2007.

15. UNICEF. State of the World's Children 2008. New York, UNICEF, 2007.

16. GSS & UNICEF. Multiple Indicator Cluster Survey, Ghana 2006. Accra, Ghana, Ghana Statistical Service and UNICEF-Ghana, 2006.

http://www.childinfo.org/�


17. Berry, L. Ghana : a country study, 3rd ed ed. Washington, D.C. , Federal Research Division, Library of Congress 1994, pp. 382.

18. U.S. Census Bureau. International Data Base - Country Summary: Ghana, 2008.

19. Ghana Statistical Service (GSS) and Macro International Inc (MI). Ghana Demographic and Health Survey 2003. Calverton, Maryland, GSS and MI, 2003.

20. Bryce, J., Requejo, J. & 2008_Countdown_Working_Group. Tracking progress in maternal, newborn, and child survival: the 2008 report. (avilable at http://www.countdown2015mnch.org). New York, UNICEF, 2008.

21. Coulombe, H. Ghana Census-based Poverty Map: District and Sub-District level Results, Ghana Statistical Service and Department for International Development, UK, 2005.

22. FAO. Gateway to Land and Water Resources, Ghana obtained from: http://www.fao.org/ag/agl/swlwpnr/reports/y_sf/z_gh/gh.htm#overview, accessed 10 August 2008., 2004.

23. Appawu, M., Owusu-Agyei, S., Dadzie, S., Asoala, V., Anto, F., Koram, K. et al. Malaria transmission dynamics at a site in northern Ghana proposed for testing malaria vaccines. Trop Med Int Health. 9 (1): 164-70 (2004).

24. Kleinschmidt, I., Omumbo, J., Briet, O., van de Giesen, N., Sogoba, N., Mensah, N.K. et al. An empirical malaria distribution map for West Africa. Trop Med Int Health. 6 (10): 779-86 (2001).

25. Gemperli, A., Sogoba, N., Fondjo, E., Mabaso, M., Bagayoko, M., Briet, O.J. et al. Mapping malaria transmission in West and Central Africa. Trop Med Int Health. 11 (7): 1032-46 (2006).

26. Landgraf, B., Kollaritsch, H., Wiedermann, G. & Wernsdorfer, W.H. Plasmodium falciparum: susceptibility in vitro and in vivo to chloroquine and sulfadoxine-pyrimethamine in Ghanaian schoolchildren. Trans R Soc Trop Med Hyg. 88 (4): 440-2 (1994).

27. Ehrhardt, S., Mockenhaupt, F.P., Agana-Nsiire, P., Mathieu, A., Anemana, S.D., Stark, K. et al. Efficacy of chloroquine in the treatment of uncomplicated, Plasmodium falciparum malaria in northern Ghana. Ann Trop Med Parasitol. 96 (3): 239-47 (2002).

28. Koram, K.A., Abuaku, B., Duah, N. & Quashie, N. Comparative efficacy of antimalarial drugs including ACTs in the treatment of uncomplicated malaria among children under 5 years in Ghana. Acta Trop. 95 (3): 194-203 (2005).

29. Afari, E.A., Akanmori, B.D., Nakano, T. & Ofori-Adjei, D. Plasmodium falciparum: sensitivity to chloroquine in vivo in three ecological zones in Ghana. Trans R Soc Trop Med Hyg. 86 (3): 231-2 (1992).

30. Vitamin A supplementation in northern Ghana: effects on clinic attendances, hospital admissions, and child mortality. Ghana VAST Study Team. Lancet. 342 (8862): 7-12 (1993).

31. Otten, M., Kezaala, R., Fall, A., Masresha, B., Martin, R., Cairns, L. et al. Public-health impact of accelerated measles control in the WHO African Region 2000-03. Lancet. 366 (9488): 832-9 (2005).

32. Bossert, T.J. & Beauvais, J.C. Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space. Health Policy Plan. 17 (1): 14-31 (2002).

http://www.countdown2015mnch.org)/�

http://www.fao.org/ag/agl/swlwpnr/reports/y_sf/z_gh/gh.htm#overview�


33. Ghana_Health_Service. Regional Detailed Health Statistics, obtained from: http://www.ghanahealthservice.org, accessed 7 August 2008., 2008.

34. Binka, F.N., Bawah, A.A., Phillips, J.F., Hodgson, A., Adjuik, M. & MacLeod, B. Rapid achievement of the child survival millennium development goal: evidence from the Navrongo experiment in Northern Ghana. Trop Med Int Health. 12 (5): 578-83 (2007).

35. Binka, F.N., Kubaje, A., Adjuik, M., Williams, L.A., Lengeler, C., Maude, G.H. et al. Impact of permethrin impregnated bednets on child mortality in Kassena-Nankana district, Ghana: a randomized controlled trial. Trop Med Int Health. 1 (2): 147-54 (1996).

36. Phillips, J.F., Bawah, A.A. & Binka, F.N. Accelerating reproductive and child health programme impact with community-based services: the Navrongo experiment in Ghana. Bull World Health Organ. 84 (12): 949-55 (2006).

37. Nyonator, F.K., Awoonor-Williams, J.K., Phillips, J.F., Jones, T.C. & Miller, R.A. The Ghana community-based health planning and services initiative for scaling up service delivery innovation. Health Policy Plan. 20 (1): 25-34 (2005).

38. Belch, R. Working paper: background conditions in the Upper East region, Northern Ghana, 2005. A background document for the Land Conservation and Smallholder Rehabilitation Project (LACOSREP) - Phase II Evaluation. Wa, Ghana, International Fund for Agricultural Development, 2006.

39. Browne, E.N., Maude, G.H. & Binka, F.N. The impact of insecticide-treated bednets on malaria and anaemia in pregnancy in Kassena-Nankana district, Ghana: a randomized controlled trial. Trop Med Int Health. 6 (9): 667-76 (2001).

40. Binka, F.N., Hodgson, A., Adjuik, M. & Smith, T. Mortality in a seven-and-a-half-year follow-up of a trial of insecticide-treated mosquito nets in Ghana. Trans R Soc Trop Med Hyg. 96 (6): 597-9 (2002).

41. UNICEF. Stratégies accélérées de survie et du développement du jeune enfant (SASDE) au Mali: Un recherche opérationnelle mise en œuvre dans le cadre du PRODESS dans six cercle de démonstration. Bamako, Mali, 2005.

42. Pence, B.W., Nyarko, P., Phillips, J.F. & Debpuur, C. The effect of community nurses and health volunteers on child mortality: the Navrongo Community Health and Family Planning Project. Scand J Public Health. 35 (6): 599-608 (2007).

43. Shrimpton, R., Victora, C.G., Onis, M., Lima, R.C., Blossner, M. & Clugston, G. World wide timing of growth faltering: implications for nutritional interventions. Pediatrics. 107 (5): E75 (2001).

44. GSS, NMIMR & ORC_Macro. Ghana Demographic and Health Survey 2003. Calverton, Maryland, Ghana Statistical Service (GSS), Noguchi Memorial Institute for Medical Research (NMIMR), and ORC Macro, 2004.

45. AED. LINKAGES Project Ghana: Final Report (1997-2004). Washington, DC, Academy for Educational Development 2004.

46. UNICEF. Accelerating early child survival and development in high under-five mortality areas in the context of health reform and poverty reduction: a results-based approach. UNICEF proposal to Canadian CIDA. New York, 2002.

http://www.ghanahealthservice.org/�

ACCELERATING CHILD SURVIVAL AND DEVELOPMENT (ACSD)

Final Report

The Retrospective Evaluation of ACSD: Ghana

APPENDICES

Submitted to UNICEF Headquarters on 7 October 2008

Institute for International Programs Johns Hopkins Bloomberg School of Public Health

Baltimore, MD

A. Description of Ghana and “high-impact” districts

B. Methodology for documentation of implementation activities and contextual factors

C. Documentation of implementation

D. Definition of key indicators

E. Survey Questions

F. Methodologies of surveys in Ghana 1998-2007

G. Tables presenting priority coverage indicators over time for ACSD high-impact districts

H. Tables presenting comparisons of priority coverage indicators over time in ACSD high-impact districts and the comparison area

I. Tables presenting 2007 MICS results for key coverage indicators in the ACSD high-impact districts by socio-demographic characteristics of the population

J. Additional tables for nutrition

K. Methodological challenges

L. References for the appendices

M. Mapping of partners’ activities in “High-impact” districts (Upper East region) and nationally

APPENDIX A Description of Ghana and “high-impact” districts

Geography Ghana, located in West Africa, maintains three international boarders and a coast off the Gulf of Guinea. Togo is situated to the East, Cote d’Ivoire to the West, and Burkina Faso to the North and Northwest. Formerly known as the Gold Coast, Ghana achieved independence from Great Britain in 1957. Ghana’s 23,383,000(2) people are distributed over 238,500 km, with their capital in Accra. Divided into 10 political regions, 17% of the population resides in the three northern regions (Upper West, Upper East, and Northern Regions), which along with Brong Ahafo region comprise Ghana’s Savannah ecologic zone.(3) Greater Accra and part of Central Region encompass the Coastal zone, while Ashanti, Volta, Western and Eastern Regions are predominantly in the Forest zone.(4)

Population Of Ghana’s 23,383,000 people, 38% are younger than 15 years old.(2) In 2000, 47% of households were in urban areas, but given the higher average number of people per household in rural areas, an estimate 41% of the population is urban.(5) However, some regions, like the Upper East Region, host as much as 87% of the population in rural areas.(3) The overall male-female ratio is 100.2:100, but distribution is unequal with more women living in rural areas than men. The estimated growth rate is currently 1.9% with a total fertility rate of 3.8 births per woman.(5)

Fig A1: Ecological map of Ghana Fig A2: Map of Ghana showing the regions

A2 IIP-JHU | Retrospective evaluation of ACSD in Ghana

Diversity typifies Ghana’s population with more than 50 languages and dialects spoken throughout the country. According to the 2000 Census, Akans comprise 45.3% of the population, Mole-Dagbon 15.2%, Ewe 11.7%, Ga-Dangme 7.3%, and less than 5% each of Guan, Gurma, Mande-Busanga and others. In terms of religion, approximately 69% are Christian, 15-30% Muslim, and the other faiths include traditional African religions and Judaism. Economy Well endowed with natural resources, Ghana’s per capita output is twice that of neighboring West African countries. In 2005 and 2006, the Gross Domestic Product grew at a rate of 6%. The domestic economy is based on subsistence agriculture, while gold, timber and cocoa earn most foreign exchange. Even though 60% of the labor force is involved in agriculture, it only contributes 34% of the GDP. The services industry, employing 25% of the labor force, supplies 41% of the GDP.(6, 7)

Despite prosperity relative to its neighbors, Ghana maintains a 5.7 billion (US$) debt, 26% of the Gross National Income. In 2001, the unemployment rate rested at 20% with no recent updates. According to a 2003 Poverty Profile, roughly 40% of Ghanaians live below the poverty line (900,000 cedis), and 27% are in extreme poverty (less than 700,000 cedis). However, rural areas suffer the brunt of poverty with an average of 55% below the poverty line.(8) The northern savannah regions are most affected with 70-88% of households in poverty.(3) Table A1: Percentage of Population below Poverty Lines(8) National Average Rural Average Urban Average Poverty (>900,000 c) 39.5% 54.6% 23%

Absolute poverty

(>700,000) 26.6% 40.7% 14.2%

Education Fifty-eight percent of Ghanaians 15 years or older are literate. Literacy among youth (15-24 years) is higher, but the gender disparity continues with rates of 76% for males and 66% for females. The primary school net enrololment ratio, the number of school-aged children enrolled divided by the number of school-aged children in the population, is 69-70% for boys and girls. The gross enrollment ratio, which includes children outside the age-appropriate limits, is 93-94%, suggesting that children older than official primary school-aged enroll as well.(9) Similar to the poverty trends, the 3 northern regions have the lowest adult literacy rate at 24%.(3) Health Primary health program expansion since 1978 has reduced childhood mortality rates. Additional sub-district health facilities and trained personnel, along with the Expanded Programme on Immunization (EPI) initiated in 1976, have contributed to health gains that now provide Ghanaians with an average life expectancy of 59 years.(9) Additionally, health reforms in early 1990s focused on an achieved reduction in early childhood mortality. However, progress plateaued by 2003. Table 3 provides a 1998-2003 comparison of various health indicators. Of particular concern, the infant mortality rate (IMR) rose from 57 deaths of infants less than 12 months per 1,000 live births in 1998 to 63 deaths per 1,000 as measured in the 2003 DHS. The Upper West and Northern Regions were estimated to have the highest infant and child mortality rates in the 10 years previous to the 2003 DHS. Rising vaccination coverage and health care seeking behavior prompted the Ghanaian Ministry of Health to investigate explanations for the mortality stagnation. The Upper East Region was identified as an anomaly to the trend, and their child survival interventions are currently being explored.

IIP-JHU | Retrospective evaluation of ACSD in Ghana A3

UPPER EAST REGION Given the disparities observed among health, education and economic indicators, the Upper East Region (UER) has become one of the focal points for collaborative programs and intervention projects. Geography Located in the north-eastern corner of Ghana, UER shares international borders with Burkina Faso and Togo, along with internal borders with Upper West Region and Northern Region. Cross-border movement is common and gives way to difficulties in disease surveillance and control. UER is divided into 8 districts, each autonomous regarding planning, budgeting and implementation of projects. Bolgatana is the Region’s capital. Overall, there are 911 communities both dispersed and sometimes overlapping. Of the Region’s 1017 km of road, 69% is considered motorable. Unlike the Ghana’s southern regions, UER has 2 seasons instead of 4, with particular drought hazards between January and March.

Population According to the 2000 census, 4.8% of Ghanaians live in UER, which represents only 3.7% of the country’s landmass. Despite a higher than average population density, 87% of the population is rural. The 2006 estimated population was almost 983,000, up from 920,000 in 2000. The growth rate is 1.1%, below the national average. 56.3% of males and 49% of females are 0-19 years old. The proportions reflect an excess of adult females compared to national averages. Out-migration of men is the predominant explanation. (10) Ethnically, 74.5% are Mole-Dagbon, 8.5% Grusi, 6.2% Mande-Busanga, and 3.2% Gurma. The Region’s main languages are Gurune, Kusal, Kasem, Buili and Bisa. 46% of the population practices traditional religions, 28% Christianity, and 23% Islam. Economy UER is has the highest percent of the population living below the poverty among Ghana’s 10 Regions. 88% earn less than 900,000 cedis annually. According to the Ghana Living Standards Survey, poverty worsened between 1992 and 1999 in UER. Over 80% of the economically active population engages in agriculture, predominantly grains and cattle. Only one industry, a cotton ginnery, is active. Education UER also has the highest level of illiteracy in the country. Seventy-eight percent of adults 15 years or older are not literate in either English or a Ghanaian language. The disparity between male and female literacy is most exaggerated in UER as well. The Region supports 449 primary schools, 177 junior secondary schools, and 23 senior secondary schools, but 71.8% over the population 6 years and older have never attended school. More males than females have attended school, 35.3% versus 23.6%

Fig A3: District Map of UER


respectively of the 6 years and older population; however the proportion varies by district. 34% of children 7-14 years work full-time, over half of which are boys. (7) Table A2: Educational Attainment for Those Who Ever Attended School Education Level Attained

Percent of >6 years old population who have attended school and attained given educational level

Primary 48.1% Middle/JSS 20.8% Secondary/SSS 12.5% Vocational/Technical 4.2% Post-secondary 4.5% Health UER’s health situation presents an interesting mix of improvements and declines. In 1998, DHS information indicated that UER had the highest early childhood mortality rates in Ghana, as shown in Table 3. However, by the 2003 DHS, UER reduced both infant and under-5 mortality rates were estimated to have dramatically decreased, despite the lack of progress in neighboring regions. However, many other health indicators remained above national averages, such as the percent of malnourished children. UER mothers actually received less antenatal care (ANC) in 2003, while the percentage of professionally assisted births rose. However, the majority of UER deliveries were still unattended professionally, at slightly over half the national average. In comparison with Upper West Region and Northern Region, which have basically similar populations in terms of culture, socio-economic conditions, health determinants and human resource difficulties, the Upper East Region far exceeded mortality rate expectations.

Sentinel site data indicated that 44%

of UER’s mortality burden was attributed to deaths of children younger than 5 years old. The primary under-5 mortality contributors were: malaria, anaemia, diarrhoea, malnutrition, acute respiratory infections, measles and neonatal complications. Child survival interventions, such as the Integrated Management of Childhood Illnesses, may be related to UER’s deviant results. Several organizations have supported projects in the Region; such as the Dioscesan Health Service (1998-2006), Ghana Red Cross Society (1999-2006), World Vision International (1996-2007), Community Water and Sanitation Agency (1973-2005), US Agency for International Development (1998-2007), Japanese International Cooperation Agency (2003-2007), World Health Organization (2003-2007), Opportunities Industrialization Centres International (2003-2006), and Danish International Development Agency (2003-2007).(10)

Source: FAO Gateway to Land and Water Resources, Ghana(1)

Fig A4: Average annual rainfall in Ghana


APPENDIX B Methodology for implementation of ACSD activities and contextual factors

Various techniques were employed to collect information retrospectively about the implementation of ACSD activities and contextual factors in the “high-impact” zones. Much information was gathered from colleagues at the UNICEF-Ghana field office, who have been collaborating on the retrospective evaluation throughout the process. Field visits, key informant interviews and working meetings to review of the preliminary coverage results all provided information pertaining to details of ACSD implementation and contextual factors. Details of these discussions are provided in table B1. During these encounters, the JHU evaluation team requested any documents providing more details on ACSD and other partner’s activities.


Tabl

e B

1. D

escr

iptio

n of

fiel

d vi

sits

, key

info

rman

t int

ervi

ews,

and

wor

k se

ssio

ns c

arrie

d ou

t to

docu

men

t AC

SD

impl

emen

tatio

n ac

tiviti

es a

nd

cont

extu

al fa

ctor

s

DA

TE

DES

CR

IPTI

ON

P

AR

TIC

IPA

NTS

TO

PIC

S C

OV

ERED

EV

ALU

ATI

ON

TE

AM

P

AR

TIC

IPA

NTS

Fiel

d Vi

sits

Nov

200

6

To c

olle

ct

info

rmat

ion

abou

t G

hana

’s e

xper

ienc

e w

ith A

CSD

, and

av

aila

ble

data

on

the

proc

ess,

out

com

es

and

pote

ntia

l im

pact

of

ACS

D in

Gha

na.

UN

CEF,

MO

H, D

anid

a/D

FID

, di

stric

t an

d re

gion

al

repr

esen

tativ

es

Area

s of

foc

us:

(i) im

pres

sion

s of

ACS

D-G

hana

ii)

chal

leng

es f

or

the

eval

uatio

n; a

nd (

iii)

com

mun

icat

ions

fro

m t

hose

im

plem

entin

g th

e pr

ogra

m.

The

obje

ctiv

e of

the

vis

it w

as t

o be

gin

the

lear

ning

pro

cess

and

iden

tify

prom

isin

g av

enue

s fo

r fu

rthe

r do

cum

enta

tion

and

anal

ysis

Ful

l doc

umen

tatio

n av

aila

ble

upon

req

uest

Jenn

ifer

Bryc

e,

Robe

rt B

lack

, G

aret

h Jo

nes

and

Kate

Gilr

oy

Aug

& Se

pt 2

007

Trai

ning

and

su

perv

isio

n of

sur

vey

team

s

UN

ICEF

, GSS

, Mac

ro a

nd

MIC

S in

terv

iew

er t

eam

s

Prov

ided

tec

hnic

al a

ssis

tanc

e du

ring

inte

rvie

wer

tea

m t

rain

ing

for

the

2007

sup

plem

enta

l MIC

S su

rvey

. Pr

ovid

ed o

n-si

te

supe

rvis

ion

of in

terv

iew

er t

eam

and

fee

dbac

k to

UN

ICEF

and

G

SS. F

ull d

ocum

enta

tion

avai

labl

e up

on r

eque

st

Kate

Gilr

oy a

nd

Eliz

abet

h H

azel

Jan

2008

Rev

iew

of

data

pr

oces

sing

U

NIC

EF, G

SS a

nd H

arva

rd

Scho

ol o

f Pu

blic

Hea

lth

Prov

ided

logi

stic

al a

ssis

tanc

e du

ring

data

pro

cess

ing;

per

form

ed

a co

mpr

ehen

sive

rev

iew

of da

ta q

ualit

y; p

rovi

ded

feed

back

to

UN

ICEF

and

GSS

. Ful

l doc

umen

tatio

n av

aila

ble

upon

req

uest

Gar

eth

Jone

s an

d El

izab

eth

Haz

el

Key

info

rman

t in

terv

iew

s /

disc

uss

ion

s

Mee

ting

G

hana

MO

H

Dis

cuss

ion

of A

CSD

and

mor

talit

y ra

tes

in G

hana

& U

ER

Gar

eth

Jone

s ,

Kate

Gilr

oy

Mee

ting

GH

S –

Publ

ic H

ealth

Div

. D

iscu

ssio

n of

ACS

D

Gar

eth

Jone

s,

Kate

Gilr

oy

16 –

17

Nov

, 20

06

M

eetin

g G

hana

Sta

tistic

al S

ervi

ce

Dis

cuss

ion

of M

ICS

2006

– im

plem

enta

tion,

pro

cess

ing

and

prog

ress

; ot

her

avai

labl

e da

ta s

ourc

es

Gar

eth

Jone

s,

Kate

Gilr

oy


DA

TE

DES

CR

IPTI

ON

P

AR

TIC

IPA

NTS

TO

PIC

S C

OV

ERED

EV

ALU

ATI

ON

TE

AM

P

AR

TIC

IPA

NTS

Info

rmal

dis

cuss

ion

Gha

na S

tatis

tical

Ser

vice

Po

vert

y m

aps

of G

hana

& o

ther

Wes

t Af

rica

coun

trie

s Ka

te G

ilroy

Mee

ting

/ in

form

al

disc

ussi

on

UN

ICEF

Pr

esen

tatio

n of

the

eva

luat

ion

over

view

; ge

nera

l dis

cuss

ion

of

ACSD

Jenn

ifer

Bryc

e,

Robe

rt B

lack

, G

aret

h Jo

nes,

Ka

te G

ilroy

16 –

17

Nov

, 20

06

Mee

ting

/ in

terv

iew

G

HS

– Re

prod

uctiv

e &

chi

ld

heal

th u

nit

Dis

cuss

ion

of im

plem

enta

tion

of A

CSD

, IM

CI;

disc

ussi

on o

f na

tiona

l pol

icie

s re

: CC

M, I

MCI

, etc

Jenn

ifer

Bryc

e,

Robe

rt B

lack

, G

aret

h Jo

nes,

Ka

te G

ilroy

Mtg

G

HS

– Bo

ngo

Dis

tric

t O

ffic

es

Dis

cuss

ion

of A

CSD

in B

ongo

dis

tric

t; F

ollo

w u

p w

ith C

Sam

ata

Azab

a, G

Alc

olba

, & A

Any

inat

o fo

r do

cum

ents

con

cern

ing

impl

emen

tatio

n of

ACS

D a

nd a

nnua

l rep

orts

Jenn

ifer

Bryc

e,

Robe

rt B

lack

, G

aret

h Jo

nes,

Ka

te G

ilroy

Site

vis

it to

hea

lth

cent

re

GH

S –

Bong

o di

stric

t,

Zork

or f

acili

ty

Des

crip

tion

of C

HO

s an

d CB

As r

oles

in o

utre

ach

and

heal

th

prom

otio

n; d

escr

iptio

n of

pro

mot

ion

of c

hild

birt

h at

hea

lth

faci

lity;

rev

iew

of

kit

boxe

s

Jenn

ifer

Bryc

e,

Robe

rt B

lack

, G

aret

h Jo

nes,

Ka

te G

ilroy

Site

vis

it to

CH

PS

cent

er

GH

S –

Bong

o di

stric

t,

Kodo

ro C

HPS

fac

ility

Des

crip

tion

of C

HPS

cen

tre

and

wor

k of

CH

O in

com

mun

ity;

revi

ew o

f CH

PS r

egis

ters

and

rec

ords

; re

view

of

CHPS

cen

tre

supp

lies

Jenn

ifer

Bryc

e,

Robe

rt B

lack

, G

aret

h Jo

nes,

Ka

te G

ilroy

Site

vis

it to

N

avro

ngo

Nav

rong

o he

alth

res

earc

h ce

nter

Des

crip

tion

of r

esea

rch

proj

ects

pas

t an

d pr

esen

t ca

rrie

d ou

t at

N

avro

ngo;

des

crip

tion

of D

SS;

disc

ussi

on o

f m

appi

ng e

xerc

ise

of

UER

Jenn

ifer

Bryc

e,

Robe

rt B

lack

, G

aret

h Jo

nes,

Ka

te G

ilroy

20-2

4 N

ov.

2006

Mtg

with

dis

tric

t G

HS

– Ba

wku

Wes

t di

stric

t of

fices

D

iscu

ssio

n of

ACS

D in

Baw

ku W

est

dis

tric

t; in

clud

ing

nutr

ition

al

cent

ers

and

ITN

S

Jenn

ifer

Bryc

e,

Gar

eth

Jone

s,

Kate

Gilr

oy


DA

TE

DES

CR

IPTI

ON

P

AR

TIC

IPA

NTS

TO

PIC

S C

OV

ERED

EV

ALU

ATI

ON

TE

AM

P

AR

TIC

IPA

NTS

Site

vis

it to

hea

lth

cent

er

GH

S –

Baw

ku W

est

– Sa

pelli

ga h

ealth

cen

ter

Des

crip

tion

of C

HO

s an

d CB

As r

oles

in o

utre

ach

and

heal

th

prom

otio

n; D

escr

iptio

n of

ant

enat

al s

ervi

ces;

rev

iew

of

heal

th

cent

er r

egis

ter;

rev

iew

of

CBAs

mon

itorin

g no

tebo

oks

Jenn

ifer

Bryc

e,

Gar

eth

Jone

s,

Kate

Gilr

oy

F-U

mtg

s; c

olle

ctio

n of

key

docs

G

HS

– U

pper

Eas

t Re

gion

al

offic

e

Dis

cuss

ions

of

avai

labl

e da

ta &

ann

ual r

epor

ts a

nd c

olle

ctio

n of

da

ta/r

epor

ts;

dis

cuss

ions

of

com

mun

icat

ions

str

ateg

ies

and

colle

ctio

n of

mat

eria

ls;

disc

ussi

ons

of t

rain

ing

& m

onito

ring

of

CBAs

; co

llect

ion

of p

ertin

ent

docu

men

ts

Jenn

ifer

Bryc

e,

Kate

Gilr

oy

Follo

w-u

p m

tg

Nav

rong

o he

alth

res

earc

h ce

nter

D

iscu

ssio

n of

map

ping

act

ivity

and

ava

ilabi

lity

of

prot

ocol

/que

stio

nnai

re/d

ata

Gar

eth

Jone

s

Dis

cuss

ion

UN

ICEF

D

iscu

ssio

n of

ACS

D im

plem

enta

tion

and

prog

ress

ion;

cha

lleng

es,

etc

Jenn

ifer

Bryc

e,

Gar

eth

Jone

s,

Kate

Gilr

oy

Deb

riefin

g of

site

vi

sit

UN

ICEF

In

form

al p

rese

ntat

ion

of p

relim

inar

y fin

ding

s/pe

rcep

tions

fro

m

site

vis

it; D

iscu

ssio

n of

suc

cess

es &

cha

lleng

es

Jenn

ifer

Bryc

e,

Gar

eth

Jone

s,

Kate

Gilr

oy

Info

rmal

dis

cuss

ion

UN

ICEF

D

iscu

ssio

n of

MIC

S 20

06 s

urve

y an

d po

ssib

ility

of

furt

her

sam

plin

g in

UER

, UW

R &

Nor

ther

n Reg

ion

(als

o on

24-

11-2

006)

G

aret

h Jo

nes

Deb

riefin

g of

site

vi

sit

UN

ICEF

In

form

al p

rese

ntat

ion

of p

relim

inar

y fin

ding

s/pe

rcep

tions

fro

m

site

vis

it; D

iscu

ssio

n of

suc

cess

es &

cha

lleng

es

Jenn

ifer

Bryc

e,

Gar

eth

Jone

s,

Kate

Gilr

oy

20-2

4 N

ov.

2006

Info

rmal

dis

cuss

ion

UN

ICEF

Id

entif

icat

ion

of d

ocum

ents

with

UN

ICEF

inpu

ts &

tim

elin

e fo

r AC

SD

Jenn

ifer

Bryc

e,

Kate

Gilr

oy


DA

TE

DES

CR

IPTI

ON

P

AR

TIC

IPA

NTS

TO

PIC

S C

OV

ERED

EV

ALU

ATI

ON

TE

AM

P

AR

TIC

IPA

NTS

Info

rmal

dis

cuss

ion

UN

ICEF

G

ener

al t

imel

ine

of im

plem

enta

tion;

col

lect

ion

of f

urth

er

docu

men

tatio

n an

d da

ta s

ourc

es

Kate

Gilr

oy

Info

rmal

dis

cuss

ion

UN

ICEF

Co

llect

ion

and

disc

ussi

on o

f fu

rthe

r da

ta s

ourc

es a

vaila

ble;

id

entif

icat

ion

of m

ico-

data

file

s G

aret

h, K

ate

Mtg

IN

-DEP

TH

Dis

cuss

ion

of m

appi

ng e

xerc

ise

proj

ect

for

UER

G

aret

h

20-2

4 N

ov.

2006

Info

rmal

dis

cuss

ion

KNU

ST

Dis

cuss

ion

of t

rain

ing

and

mon

itorin

g of

CBA

s; c

olle

ctio

n of

pe

rtin

ent

KNU

ST d

ocum

enta

tion

Kate

Wor

k se

ssio

ns to

revi

ew a

nd in

terp

ret p

relim

inar

y re

sults

July

200

8 P

rese

ntat

ion

of

prel

imin

ary

resu

lts

GH

S, M

OH

, KN

US

T<

UN

ICE

F, G

SS

Fu

ll re

view

of c

over

age,

nut

ritio

n an

d m

orta

lity

prel

imin

ary

resu

lts

TBD


APPENDIX C Documentation of ACSD implementation activities

UNICEF-ACSD, consolidating the efforts of previous programs, presented a package of cost effective intervention and a strategy of service delivery for scale-up region-wide(11). UNICEF acted as the facilitator with partner support and the Ghana Health Service (GHS) implemented the interventions at the regional, district and sub-district levels(11). The UER has a strong history of community-based health volunteers. UNICEF-ACSD utilized this resource for intervention delivery: developing a community health curriculum and recruiting and training Community Based Agents (CBAs)(11). De-worming, PMTCT and IPTp programs were introduced as part of ACSD(11).

The ACSD implementation activities are described in more detail here, expanding on the information provided in the main body of the report. Timelines of implementation activities for each ACSD component are presented in tabular format with brief explanatory text. In order to estimate the magnitude of implementation, the population projection for adults, children and infants in 2004 was used to standardize and provide a coverage estimate. Delivery of ITNs In late 2002, distribution of ACSD ITNs began in the Upper East region (table C1). The start of implementation was variable by district, some districts adopted ITN delivery before the overall ACSD program(11). Bed nets were distributed to the district offices, then to the volunteers and then to the communities(11). Multiple strategies of community delivery were used:

1. ITN sale of nets to target groups at health centers 2. Volunteer sales agents accompany nurses on health outreach session

to sale nets while the nurses work 3. Community based agents (CBA) trained in management of childhood

illnesses began distributing and retreating ITNs(11). 4. Retreatment and distribution campaigns

All volunteers, CBAs and nurses involved in the ITN program have been trained on ITN distribution and retreatment (11). Treated bed nets were sold at a reduced price to families with children under five and pregnant women through a chit (voucher) system(11). However as demand for nets increased, the subsidized nets were sold using the 20/80 rule(11). Eighty percent of the nets are sold to the target groups for 5000 cedis and the remaining 20% are sold to anyone for 23,000 cedis(11). At the time of purchase, the customers are advised by the volunteers to retreat every six months, through the health centre or a volunteer(11). Retreatment cost is 2000 cedis per net and the ITN volunteer agents receive a 1000 cedis per net sold or retreated(11). From November 2002 to September 2004, volunteers in UER sold 156,510 out of 236,500 (66%) ITN nets received (Table C1). In the UER, a reported 36,223 ITN nets were distributed for an estimated 38,450 (94%) pregnant women and 109,579 ITN nets distributed for an estimated 144,187 (76%) under five children (Table C1). Distribution occurred at ANC, PNC, CWS and delivery service points (12). At the end of 2004, 100% coverage is reported for children under five and pregnant women(13). The first household retreatment campaign occurred in May of 2003 (11) and the second retreatment campaign was planned for April of 2004(12). The retreatment campaign in 2004 was delayed until June, leading to concerns that the campaign occurred too late in the rainy season(12). Retreatment was also integrated into Child Health Week in May of 2004(11, 12). The campaigns that occurred during 2003 and the 2004 Child Health week were free of charge(11). After Child Health week in 2004, the nets were retreated for 2000 cedis(11). During this second retreatment exercise, there was poor turnout as cost was a barrier for many people(14). Also there were limited chemicals for retreatment(11). The cumulative outputs from these campaigns are listed in Table C1. By mid-2004, depending on the source 12,000 – 13,000 nets were retreated out of an estimated 169,965 nets in the community, approximately 10 percent (table C1).


ITN distribution and retreatment activities continued into 2005. By December 2005, most of the districts had stock-outs of ITN nets, except for Bongo and Bawku Municipal districts funded through the Global Fund and Roll back Malaria(15). Therefore only modest gains in cumulative ITN distribution for pregnant women and under five children are reported since 2004 (table C1). Ghana submitted a proposal to UNICEF for addition bed nets in 2005 (15). In order to estimate the number of bed nets required, Ghana completed a bed net inventory that was integrated into the filariasis treatment campaigns(15). Retreatment of bed nets in 2005 was planned for the spring but then delayed until Child Health Promotion Week(15). There are also several accounts of first and second quarter funds delayed until later in the year(16, 17) although ITN distribution was reportedly ongoing (15). At the end of the year approximately 25,000 were retreated out of an estimated 244,000 nets in the community (Table C1). Retreatment levels are still relatively low (25%) however the Upper East region received approximately 40,000 KO tablets to help with retreatment activities(17). The proposal for UNICEF was for one billion, one millions cedis for additional nets(18). At the first quarter of 2006, the region had 40,000 KO tablets but no nets to distribute(18). Instead the region procured nets from the Global Fund to distribute while awaiting the UNICEF nets(18). The Global Fund nets were significantly more expensive at 20,000 cedis compared to the UNICEF nets which were sold for 5,000 cedis(19). Retreatment campaigns began during Child Health Promotion Week and continued for several months in order to address the issue of low retreatment levels (18). At this point, CBA-IMCI volunteers are the primary mechanism for retreatment campaigns(19). The mid-2006 totals for bed net distribution and retreatment are quite low compared to earlier years (Table C1). However as Ghana moves towards exclusive use of long-lasting ITN nets, the retreatment campaigns will become less important(11).


Tabl

e C

1: O

verv

iew

of I

TN d

istri

butio

n an

d re

treat

men

t in

the

Upp

er E

ast r

egio

n, 2

002-

2006

Year

M

onth

s A

ctiv

ity

Are

aIn

tens

ity

Not

es

Jan-

Mar

A

pr-J

un

Jul-S

ept

Oct

-Dec

N

ov: b

egan

dis

tribu

tion

of

ITN

s(11

, 20)

R

egio

nal

K

ick-

off d

ate

2002

Ann

ual T

otal

/ U

nspe

cifie

d

Jan-

Mar

Apr

-Jun

M

ay-J

uly:

firs

t ret

reat

men

t of

ITN

(11,

20)

C

umul

ativ

e IT

N d

istri

butio

n lis

ted

unde

r se

cond

retre

atm

ent,

May

-Jun

e 20

04

Jul-S

ept

Oct

-Dec

2003

Ann

ual T

otal

/ U

nspe

cifie

d

Jan-

Mar

May

: Hea

lth W

eek(

11, 1

2)

IT

N re

treat

men

t int

egra

ted

into

Chi

ld H

ealth

W

eek

activ

ities

(12)

Apr

-Jun

Ju

ne: s

econ

d re

treat

men

t of

ITN

(12)

12,0

12 re

-trea

ted

out o

f est

imat

ed 1

69,9

65

nets

in th

e co

mm

unity

(12)

13

,766

re-tr

eate

d (1

4)

13,

353

retre

ated

(20)

▪ Cum

ulat

ive

nets

retre

ated

sin

ce J

une

2003

▪ D

iffer

ent t

otal

s re

porte

d by

sou

rce

109,

579

/ 153

,799

1 und

er-fi

ve c

hild

ren

targ

eted

Jul-S

ept

Cum

ulat

ive

ITN

Dis

tribu

tion

from

200

2 to

Sep

t. 20

04 (1

2)

(Dec

. 200

4) (2

0)

Reg

iona

l

36,2

23 /

36,2

231 p

regn

ant w

omen

targ

eted

▪ Rec

eive

d: 2

36,5

00 IT

N; T

otal

sal

es:

156,

510

ITN

Oct

-Dec

144,

187

/ 153

,799

1 und

er-fi

ve c

hild

ren

targ

eted

2004

Ann

ual T

otal

/ U

nspe

cifie

d A

nnua

l ITN

Dis

tribu

tion(

13)

Reg

iona

l 38

,450

/ 36

,223

1 pre

gnan

t wom

en ta

rget

ed


Year

M

onth

s A

ctiv

ity

Are

aIn

tens

ity

Not

es

Jan-

Mar

Apr

-Jun

M

ay: C

hild

Hea

lth W

eek

(16)

Reg

iona

l

2503

4 re

treat

ed o

ut o

f an

estim

ated

244

,000

ne

ts in

the

com

mun

ity(1

6)

25,8

12 re

treat

ed in

ear

ly M

ay b

efor

e th

e ra

iny

seas

on (1

7)

▪ Diff

eren

t tot

als

repo

rted

by s

ourc

e

Jul-S

ept

Oct

-Dec

13

2,27

0 / 1

53,7

991 u

nder

-five

chi

ldre

n ta

rget

edC

umul

ativ

e IT

N D

istri

butio

n fro

m 2

002

to D

ec. 2

005

(13,

15

) R

egio

nal

40,5

76 /

36,2

231 p

regn

ant w

omen

targ

eted

▪ Rec

eive

d: 2

36,5

00 IT

N; T

otal

sal

es:

184,

069

ITN

2005

Ann

ual T

otal

/ U

nspe

cifie

d

ITN

sal

es a

gent

trai

ned(

21)

Reg

iona

l 6

84 p

er 1

90,0

221 p

regn

ant w

omen

and

ch

ildre

n un

der f

ive

Jan-

Mar

Apr

-Jun

M

id y

ear r

epor

t: IT

N

retre

atm

ent(1

3)

Reg

iona

l 40

,000

KO

tabl

ets

have

bee

n de

liver

ed in

200

5

5,48

9 / 1

53,7

991 u

nder

-five

chi

ldre

n ta

rget

ed

2,

541

/ 36,

2231 p

regn

ant w

omen

targ

eted

Jul-S

ept

Mid

yea

r rep

ort:

bed

net

dist

ribut

ion

and

retre

atm

ent(1

3, 1

8)

Reg

iona

l 6,

829

retre

ated

out

of a

n es

timat

ed 2

44,0

00

nets

in th

e co

mm

unity

▪ U

sed

2005

est

imat

ed fo

r num

ber o

f ne

ts in

com

mun

ity

Oct

-Dec

2006

Ann

ual T

otal

/ U

nspe

cifie

d

1

– E

stim

ated

pop

ulat

ion

from

200

4 pr

ojec

tions

(22)

: 15

3,79

9 un

der f

ive

child

ren,

36,

223

preg

nant

wom

en &

38,

450

child

ren

0-11

m ;

807

,447

adu

lts a

nd c

hild

ren

>5y


EPI+ The strengthening of the preexisting EPI+ program involved many partners and it is difficult to decipher the exact UNICEF contribution(23). UNICEF-ACSD mostly focused on developing strategies to improve defaulter tracing (11). Using community based surveillance systems, the CBA volunteers used a register to trace children due for vaccinations(11). Mop-up campaigns occurred after National Immunization Days (NID) to vaccinate “zero dose” children identified by polio vaccinators during the NID(11). UNICEF also worked through GHS, District Assemblies and the BESFA and BUCO rural banks to allocate funds for the purchase of iodized salt to women in microcredit groups in the Builsa and Bawku East districts(12). In 2003, monitoring data shows 45% BCG, 38% measles and 35% Penta3 coverage for an estimated 23,207 children under five targeted (Table C2). Concerns during implementation of EPI+ in 2003 include: poor quality of district-level EPI data, continuing high levels of wastage and defaulting, incomplete or late EPI form submissions and irregular submission of Cold Chain inventory reports(23). Vitamin A campaigns were initiated during the 2004 Child Health Promotion Week(24). Monitoring data from 2004 shows an estimated 44% of children 6-11m and 27% of children 12-59m received vitamin A(25). In 2004, two campaigns for de-worming children under five and pregnant women occurred during the NID in March and September, resulting in very high coverage for the target populations (12). Four rounds of NID occurred in the Upper East region in February, March, October and November (26). The monitoring data from the first quarter of 2004 shows large gains compared with 2003: 36% BCG, 30% Measles and 31% for Penta3 (Table C2). The NID campaigns are successful; polio coverage is above 100% and no wild-type polio has been detected since September 2003(14). However the issue is still adherence to immunization schedule: initial contact with EPI+ is high, but continuation is poor, effecting the quality of vaccination (14). Intermittent shortages of measles vaccine were reported in BW district(12, 26) In addition to campaigns, the Upper East regional office also provided cold chain equipment, logistical assistance and monthly or quarterly feedback at the district level (23). UNICEF contributed to these efforts along with other partners. The issues identified at the end of the year by the UNICEF for the EPI+ programs are late release of funds, inadequate incentives for volunteers, inadequate information of immunization schedule and inadequate monitoring and supervision(14). In 2005, the NID continued, four rounds in February, April, November and December(27). UNICEF procured 26.2 millions doses of OPV to assist the GHS in polio eradication efforts(17). The EPI+ program received adequate quantities of routine vaccines: MOH and GAVI purchased all vaccine using UNICEF procurement services(17). All districts in the Upper East region have a community-based registration system in place: 992+ CBS volunteers have been trained in all 8 districts and deployed with community registers(17). Four districts in the UER have functional defaulter tracing and outreach services(17). The CBS volunteers received defaulter tracing refresher training and conducted a market immunization and defaulter tracing exercise, results on Table C2 (16) (27). In addition to the defaulter tracing training and exercises, Bawku West district reported strong EPI+ activity for 2005: routine monthly static and outreach immunizations, quarterly mop-up immunizations and training of Health Staff on increasing immunization coverage at sub-district levels (27). A GHS National EPI report shows high coverage for the UER at the end of 2005 (Table C2). Continuing measles shortages is reported for the BW district(19). No Vitamin A coverage data for this year although continued distribution. De-worming campaigns for children under five continued with very high coverage rates, almost 100% (Table C2). In 2006, an EPI survey completed in four districts, shows defaulter tracing and mop-up campaigns need to be strengthened(18). Defaulter tracing exercises are to be done monthly, but some districts are not in compliance(19). A GHS National EPI report shows high coverage for the UER at the end of 2006 (Table C2). There was no quarterly mop-up of iodization campaign although market supplementation occurred (Table C2).


Tabl

e C

2: T

imel

ine

of im

plem

enta

tion

of E

PI+

act

iviti

es in

the

Upp

er E

ast r

egio

n, 2

002

- 200

6

Year

M

onth

s A

ctiv

ity

Ant

igen

Are

a In

tens

ity

Not

es

Jan-

Mar

Ja

n: A

CS

D E

PI+

act

iviti

es

begi

n (1

1)

Col

d ch

ain

expa

nsio

n

Incr

ease

dem

and

for E

PI s

ervi

ces

▪ USA

ID 0

.5 m

illion

USD

gra

nt (2

8)

Apr

-Jun

Jul-S

ept

O

ct-D

ec

20

02

Annu

al T

otal

/ U

nspe

cifie

d

Jan-

Mar

Apr

-Jun

Jul-S

ept

O

ct-D

ec

B

CG

: 104

62 /

38,4

501 ta

rget

ed

Mea

sles

: 873

5 / 3

8,45

01 targ

eted

2003

Annu

al

Tota

l /U

nspe

cifie

d C

umul

ativ

e im

mun

izat

ion

for 2

003(

20)

BC

G,

Mea

sles

, D

PT3

Reg

iona

l (di

stric

t le

vel a

vaila

ble)

D

PT:

817

7 / 3

8,45

01 targ

eted

Mar

ch:

Firs

t ro

und

of d

e-w

orm

ing(

12, 1

4)

NID

: A

ntih

elm

inth

R

egio

nal (

dist

rict

leve

l ava

ilabl

e)

177,

533

/ 153

,799

1 de-

wor

med

BC

G: 8

357

/ 38,

4501 ta

rget

ed

Mea

sles

: 703

7 / 3

8,45

01 targ

eted

Ja

n-M

ar

EP

I+ fi

rst q

uarte

r to

tals

(20)

BC

G,

Mea

sles

, D

PT3

Reg

iona

l (di

stric

t le

vel a

vaila

ble)

D

PT:

711

/ 38

,450

1 targ

eted

▪ Firs

t qua

rter E

PI+

resu

lts fo

r 200

4 m

uch

high

er th

an 2

003

annu

al re

sults

Apr

-Jun

M

ay: C

hild

Hea

lth

Pro

mot

ion

Wee

k(25

) V

itam

in A

R

egio

nal (

dist

rict

leve

l ava

ilabl

e)

54,8

03 /

153,

7991 ta

rget

ed

Jul-S

ept

Oct

-Dec

O

ct:

seco

nd r

ound

of

de-

wor

min

g (1

2, 1

4)

NID

: A

ntih

elm

inth

R

egio

nal (

dist

rict

leve

l ava

ilabl

e)

170,

736

/ 153

,799

1 de-

wor

med

Mea

sles

: 33,

927/

38,

4501 ta

rget

ed

Pen

ta3:

33,

395/

38,

4501 ta

rget

ed

2004

N

atio

nal

Imm

uniz

atio

n D

ays

(NID

)(14)

N

atio

nal

B

CG

: 41,

528/

38,

4501 ta

rget

ed


Year

M

onth

s A

ctiv

ity

Ant

igen

Are

a In

tens

ity

Not

es

Jan-

Mar

Apr-J

un

Chi

ld H

ealth

Wee

k(27

)

Onl

y fo

und

in d

istri

ct re

port

Jul-S

ept

Oct

-Dec

A

nnua

l tot

al d

e-w

orm

ing

for u

nder

five

s(15

) A

ntih

elm

inth

R

egio

nal (

dist

rict

leve

l ava

ilabl

e)

177,

553

/ 153

,799

1 targ

eted

▪ S

ince

Oct

200

4

BC

G

BC

G: 1

140

/ 38,

4501 ta

rget

ed

Pen

ta3

Pen

ta3:

107

4 / 3

8,45

01 targ

eted

OP

V3

OP

V3:

105

2 / 3

8,45

01 targ

eted

M

easl

es

Mea

sles

: 150

3 / 3

8,45

01 targ

eted

E

PI+

ann

ual t

otal

s(15

)

Yel

low

feve

r

Reg

iona

l (di

stric

t le

vel a

vaila

ble)

Yel

low

feve

r: 15

09 /3

8,45

01 targ

eted

▪ M

arke

t im

mun

izat

ion

and

defa

ulte

rtra

cing

2005

Ann

ual r

egio

nal s

umm

ary

of E

PI

activ

ities

(24)

Nat

iona

l U

ER

: BC

G: 1

11%

P

enta

3: 9

6%

Mea

sles

: 90%

G

HS

EP

I rep

ort

Jan-

Mar

Apr

-Jun

Jul-S

ept

Iodi

zed

salt(

13)

Iodi

zed

salt

Su

pple

men

ted

100

bags

of

sa

lt in

B

olga

mar

ket

▪ No

mop

-up

cam

paig

n he

ld d

urin

g th

is q

uarte

r O

ct-D

ec

Ann

ual r

egio

nal s

umm

ary

of E

PI

activ

ities

(24)

N

atio

nal

UE

R: B

CG

: 111

%

Pen

ta3:

93%

M

easl

es: 9

6%

GH

S E

PI r

epor

t

20

06

Annu

al T

otal

/U

nspe

cifie

d

1 –

Est

imat

ed p

opul

atio

n fro

m 2

004

proj

ectio

ns(2

2) :

153,

799

unde

r fiv

e ch

ildre

n, 3

6,22

3 pr

egna

nt w

omen

& 3

8,45

0 ch

ildre

n 0-

11m

; 8

07,4

47 a

dults

and

chi

ldre

n >5

y


IMCI Before ACSD, IMCI interventions were implemented on a smaller scale by partners such as Ghana Red Cross and Catholic Relief Services (11). ACSD pulled together the experiences of these pilot programs and presented a common framework for scale-up region-wide(11). Community IMCI was implemented in 2003 however the majority of community based agents (CBA) did not begin service until 2004(11). The C-IMCI model utilizes trained CBAs on a voluntary basis to provide the following services: appropriate infant feeding practices(12), health education to mothers, fever treatment with pre-packed chloroquine, diarrheal treatment with ORS, recognition and referral of ARI, promote immunization and iodized salt and mobilize the community for participation in de-worming, NIDs and other programs(11). UNICEF collaborated with KNUST, Ghana Red Cross and Ghana Health Services to develop a CBA training program. CBA volunteers were equipped with bicycles, educational materials and health kits containing Kinaquine junior and infant (chloroquine), ORS sachets and hand washing material(11). In order to continue motivation and commitment, the CBA volunteers earn a percentage of sales(11). For instance, a CBA earns 100 cedis on every ORS sachet sold(11). Based on past experience in the regions with volunteers, female volunteers are preferred over men(11). Monitoring and supervision was carried out by the KNUST team and the regional office(12). However the most of the time it is integrated into routine supervision with Regional Health Management Team (RHMT) members(12). However there are issues with integration, sub-district supervisors are reluctant to carry out CBA supervision without additional funds for fuel, for instance(29). In the first half of 2003, IMCI scale-up activities and CBA volunteer recruitment took place (Table C3). CBA volunteers were trained at the district and regional level and also at KNUST Community Health Department of the School of Medical Science (11). The first CBA training session occurred from May-June 2003, in which 1039 or 1118 (depending on the source) volunteers were trained (Table C3). Training of Trainers (TOT) sessions are reported in July 2003 at the sub-district level (Table C3). Additional volunteer training sessions occurred in July and November and December of 2003 in all districts although there is no record on the number of volunteer trained (20). The number of children seen and referred for illness for 2003 is reported in Table C3. In March of 2004, an additional 744 CBAs were trained bring the total to 1780 or 1892, depending on the source (Table C3). The first two quarters of 2004 show poor supervision of CBAs at the district and sub-district level (12). In June 2004, KNUST conducted CBA supervisory visits, covering one-third of the sub-districts in the region in one month (30). KNUST visited the CBAs and the households that had accessed services from the CBAs. Some of the results were promising: there was an itinerary and plans for continued supervisory visits, CBAs are undertaking follow-up visits for illness treatment and CIMCI implementation has strong community support(30). However supervision is weak, CBA coverage is inadequate and distribution of inputs is incomplete and behind schedule(30). For childhood illnesses, the KNUST team found that mothers are accessing CBAs too late (more than 24 hours after onset of symptoms) and many adults are consuming the drugs meant for children(30). Also it was found that CBAs focused more on drug treatment than the health education messages(30). Finally KNUST noted that many areas in the region will be inaccessible to CBAs during the rainy season. KNUST participated in CBA training in October of 2004, training approximately 100 CBAs in the Bolga and BE districts(31, 32). Also in October, UNICEF held a TOT session for 30 extension field staff from GHS, Department of Community Development and Environmental Health of Sanitation Unit (33). The TOT session focused on ACSD activities so that the leaders could return their communities and train representatives to disseminate the information(33). Later in November, the 30 participants in this TOT exercise trained a total of 300 representatives on the ACSD objectives. The purpose of these workshops was to strengthen the capacity of community members on ACSD activities and promote the use CBAs (33) In November, UNICEF conducted an ACSD sensitization workshop for 36 political authorities including council chairpersons, opinion leaders, assembly-persons, market queens and political representatives(33). Another component of CIMCI is training of clinicians. UNICEF reported 5 clinicians were trained in the CIMCI module although it is difficult finding trainers in the UER(14).


In October, KNUST undertook another CBA supervisory visit this time focusing on CBAs to discuss the implementation process; this was the fourth such supervision exercise since May of 2004 (32). KNUST found that many of the CBAs had not received refresher training since their initial training, 11 months ago and weak supervision continues to be an issue. However many of the supervisors had been introduced to various M&E tools. The quality of training differed by district, Bolga had the most well organized training and Bawku the poorest(32). Also at the district level, there is a lack of the computer literacy for proper data processing, analysis and interpretation. KNUST found CBAs continuing to emphasis drug treatment over health education and had difficultly filling out paperwork. The number of children seen and referred for illness for 2004 is reported in Table C3. In 2004, health education sessions were only taking place in three districts: Bawku West, Bolga and Bongo. The number of adults and adolescent children receiving health education from CBAs is shown on Table C3. As of 2004, five district hospitals have been designated as Baby Friendly as part of the Baby Friendly Health Initiative Facilities (BFHI). UNICEF- ACSD supports BFHI by developing guidelines on exclusive breastfeeding, training Mother to Mother Support Groups (MtMSG) and providing training materials. A district report from Bawku West offers more details on BFHI training: meeting with midwives and sub district leaders on BFHI, 20 health staff trained on lactation management and complementary feeding and 100 TBAs trained on exclusive breast-feeding(26). In 2005, UNICEF continued clinical staff training exercises, 48 prescribers and 3 regional staff were trained in the UER, 20 RHMT and NGO partners sensitized to CIMCI, 20 district level TOT sessions and sub-district TOT and CBA training(16, 17). At there end of the year, UNICEF reports a total of 1780 CBAs providing CIMCI servicing 922 communities(17). Other reports state 1810 CBAs trained(16) and 1892 total trained(29). Throughout 2005, KNUST and the regional staff supervised the CBAs. Sub-district supervision was found to continue to weak and there is an inadequate supply of logistics such as kits, training materials and bicycles(15). There was also an issue with expired Kinaquine(16). There are been some CBA drop-out: either the CBAs left, found other jobs or the women got married(16). Replacement of CBA staff affecting CBA supervision and new staff claim they are not trained in CIMCI(19). The number of children seen and referred for illness for 2005 is reported in Table C3. In 2005, health education sessions were only taking place in three districts: Bawku West, Bolga and Bongo. The number of adults and adolescent children receiving health education from CBAs is shown on Table C3. BFHI activities continued; UNICEF focused on exclusive breastfeeding training and 16 health facilities were assessed and 15 qualified as Baby Friendly(16). In mid 2006, TOT sessions are continued with 10 clinicians and 3 regional focal persons participating(13). In October, 24 prescribers were trained(34). The monitoring team evaluated trained prescribers and found high non-compliance with the ACSD objectives (13) Monitoring and supervision of CBAs are ongoing but not to expectation(13). In 2006, a total of 1982 CBAs are reported (19). The regional team conducted supervision visits to 1366 of the 1982 CBAs in the region. The team found poor supervision at the district and sub-district level for instance many supervisors were not inquiring about ACSD activities during their supervisory visits. In some districts the supervisors did not know where their volunteers were or even how many CBAs were in their jurisdiction. The CBAs complained of missing or irregularly paid commissions and lack of mobility due to broken bicycles(19). The regional team also found poor integration of ACSD activities into routine services(19).


Tabl

e C

3: T

imel

ine

of im

plem

enta

tion

of IM

CI+

act

iviti

es in

the

Upp

er E

ast r

egio

n, 2

002

- 200

6

Year

Mon

ths

Act

ivity

A

rea

Sour

ce

Inte

nsity

N

otes

Jan-

Mar

P

lann

ing

mee

ting(

20)

Reg

iona

l

▪ “A

ctio

n pl

an &

bud

get I

MC

I sca

le u

p m

eetin

g w

ith K

NU

ST

Hom

e M

anag

emen

t of M

alar

ia: F

eb

2003

”

Com

mun

ity e

ntry

and

vo

lunt

eer r

ecru

itmen

t (2

0) (1

1)

Reg

iona

l

▪ R

epor

ted

prog

ram

kic

k-of

f dat

e

Apr

-Jun

M

ay-J

une:

vol

unte

er

train

ing

(29)

R

egio

nal

IMC

I M

onito

ring

repo

rt

1118

trai

ned

per 1

53,7

991

Und

er-fi

ve c

hild

ren

▪ D

iffer

ent n

umbe

r rep

orte

d th

an e

lsew

here

July

: TO

T fo

r sub

-dis

trict

s be

gin(

20)

Jul-S

ept

July

: vol

unte

er

train

ing(

20)

▪ N

o da

ta o

n nu

mbe

r of v

olun

teer

s tra

ined

Oct

-Dec

N

ov/D

ec: v

olun

teer

tra

inin

g (2

0)

▪ No

data

on

num

ber o

f vol

unte

ers

train

ed

Com

mun

ity v

olun

teer

tra

inin

g(12

, 14)

R

egio

nal

UN

ICE

F A

nnua

l rev

iew

10

39 tr

aine

d pe

r 153

,799

1 U

nder

-five

chi

ldre

n ▪ D

iffer

ent n

umbe

r rep

orte

d th

an e

lsew

here

Mal

aria

: 50,

760

case

s pe

r 153

,799

1 U

nder

-five

chi

ldre

n ; 9

70 re

ferre

d D

iarrh

oea:

21,

444

case

s pe

r 15

3,79

91 U

nder

-five

chi

ldre

n ; 2

68 re

ferre

d

2003 Ann

ual T

otal

/ U

nspe

cifie

d R

esul

ts o

f com

mun

ity

heal

th v

olun

teer

s:

treat

men

t and

refe

rrals

(1

3)

Reg

iona

l

AR

I: 54

9 ca

ses

per 1

53,7

991

Und

er-fi

ve c

hild

ren

;all

refe

rred


Year

Mon

ths

Act

ivity

A

rea

Sour

ce

Inte

nsity

N

otes

Jan-

Mar

Q

uarte

rly s

uper

visi

on

repo

rt(12

)

▪ Poo

r sup

ervi

sion

from

dis

trict

to s

ub-d

istri

ct

leve

l for

the

first

two

quar

ters

Apr

-Jun

Ju

ne: K

NU

ST

CB

A

supe

rvis

ory

visi

ts(3

0)

Reg

iona

l K

NU

ST

repo

rt

Jul-S

ept

July

: rec

eive

d Ki

naqu

ine

prep

acks

(20)

25 -3

1st O

ct: K

NU

ST

CBA

trai

ning

(31,

32)

B

olga

, BE

KN

US

T re

port

~100

CB

As

in v

ario

us s

ub-d

istri

cts

26-2

9th O

ct: T

OT

for

gene

ral A

CS

D

activ

ities

(33)

Reg

iona

l, he

ld in

Ta

mal

e

Trai

ning

br

iefin

g re

port

30 e

xten

sion

fiel

d st

aff

▪ Fro

m G

HS

, Dep

t. of

Com

mun

ity D

evel

opm

ent

& E

nviro

nmen

tal H

ealth

of S

anita

tion

Uni

t

Oct

: : K

NU

ST C

BA

su

perv

isor

y vi

sits

(32)

R

egio

nal

KNU

ST re

port

2nd N

ov: S

ensi

tizat

ion

exer

cise

for p

oliti

cal

auth

oriti

es(3

3)

Reg

iona

l Tr

aini

ng

brie

fing

repo

rt 36

lead

ers

parti

cipa

ted

Oct

-Dec

25-2

6th N

ov: C

omm

unity

re

pres

enta

tive

wor

ksho

ps(3

3)

Reg

iona

l, he

ld in

va

rious

lo

catio

ns

Trai

ning

br

iefin

g re

port

300

parti

cipa

nts

▪ C

omm

unity

repr

esen

tativ

es w

ere

train

ed o

n A

CS

D o

bjec

tives

by

30 T

OT

mem

bers

trai

ned

in

Aug

2004

CBA

vol

unte

er tr

aini

ng

(14)

(13)

(25)

(29)

R

egio

nal

10

36 (2

003)

+ 7

44 (2

004)

= 1

780

cum

ulat

ive

train

ed p

er 1

53,7

991

Und

er-fi

ve c

hild

ren

▪ Cum

ulat

ive

CB

As

repo

rted

train

ed

▪ 111

8 al

so re

porte

d tra

ined

in 2

003

IMC

I Clin

ical

Tra

inin

g (1

4)

Reg

iona

l

5 cl

inic

ians

trai

ned

per 1

53,7

991

Und

er-fi

ve c

hild

ren

Mal

aria

: 14,

003

case

s pe

r 153

,799

1 U

nder

-five

chi

ldre

n D

iarrh

oea:

21,

444

case

s pe

r 15

3,79

91 U

nder

-five

chi

ldre

n

Res

ults

of c

omm

unity

he

alth

vol

unte

ers:

tre

atm

ent a

nd re

ferra

ls

(12)

Reg

iona

l (d

istri

ct

avai

labl

e)

AR

I: 54

9 ca

ses

per 1

53,7

991

Und

er-fi

ve c

hild

ren

▪ Slig

htly

diff

eren

t (sm

alle

r) nu

mbe

rs in

ann

ual

repo

rt(25

) and

in a

200

6 br

ief r

esum

e(13

)

2004 Ann

ual T

otal

/ U

nspe

cifie

d

Res

ults

of c

omm

unity

he

alth

vol

unte

ers:

hea

lth

Baw

ku

Wes

t,

D

iarrh

oea/

sani

tatio

n: 8

895

per

807,

4471

pop

ulat

ion

over

5y

▪ Num

ber o

f adu

lts a

nd a

dole

scen

t chi

ldre

n re

ceiv

ed h

ealth

edu

catio

n fro

m c

omm

unity

hea

lth


Year

Mon

ths

Act

ivity

A

rea

Sour

ce

Inte

nsity

N

otes

Infa

nt fe

edin

g: 4

665

per 8

07,4

471

po

pula

tion

over

5y

Imm

uniz

atio

n: 6

688

per 8

07,4

471

po

pula

tion

over

5y

Mal

aria

: 815

8 pe

r 807

,447

1

popu

latio

n ov

er 5

y A

RI:

1643

per

807

,447

1 p

opul

atio

n ov

er 5

y

Bab

y Fr

iend

ly H

ealth

In

itiat

ive

(BFH

I) fa

cilit

ies

Reg

iona

l

5 he

alth

inst

itutio

ns q

ualif

y fo

r BFH

I; 3

dist

rict h

ospi

tals

and

18

heal

th

cent

res

to fo

llow

.

D

atab

ase

for c

omm

unity

ba

sed

volu

ntee

rs a

nd

mid

wiv

es (3

5)

Reg

iona

l (d

istri

ct

avai

labl

e)

Volu

ntee

r da

taba

se

TBA:

495

per

36,

2231

pre

gnan

t w

omen

C

BA

-age

nts:

189

2 pe

r 153

,799

1 U

nder

-five

chi

ldre

n C

BA

-sur

veill

ance

: 152

2 pe

r 153

,799

1

Und

er-fi

ve c

hild

ren

ITN

vol

unte

ers:

684

per

153

,799

1 U

nder

-five

chi

ldre

n M

idw

ives

: 173

per

36,

2231

pre

gnan

t w

omen

▪ Num

ber o

f diff

eren

t hea

lth v

olun

teer

s, m

ore

to

be tr

aine

d.

▪ Lis

ts d

iffer

ent n

umbe

r of C

BA

s =

1892

Jan-

Mar

Apr

-Jun

Jul-S

ept

Oct

-Dec

O

ct: T

rain

ing

for

pres

crib

ers

(14,

16,

17)

R

egio

nal

48

pre

scrib

ers

train

ed p

er 1

53,7

991

Und

er-fi

ve c

hild

ren;

3 re

gion

al s

taff

tra

ined

Mal

aria

: 20,

189

case

s pe

r 153

,799

1 U

nder

-five

chi

ldre

n ; 1

,556

refe

rred

D

iarrh

oea:

11,

839

case

s pe

r 15

3,79

91 U

nder

-five

chi

ldre

n ; 9

68 re

ferre

d

2005

Res

ults

of c

omm

unity

he

alth

vol

unte

ers:

tre

atm

ent a

nd re

ferra

ls

(15)

Reg

iona

l

AR

I: 94

4 ca

ses

per 1

53,7

991

Und

er-fi

ve c

hild

ren

; 94

4 re

ferre

d


Year

Mon

ths

Act

ivity

A

rea

Sour

ce

Inte

nsity

N

otes

Dia

rrhoe

a/sa

nita

tion:

24,

401

per

807,

4471

pop

ulat

ion

over

5y

Infa

nt fe

edin

g: 2

4,14

0 pe

r 807

,447

1

popu

latio

n ov

er 5

y Im

mun

izat

ion:

23,

447

per 8

07,4

471

po

pula

tion

over

5y

Mal

aria

: 21,

319

per 8

07,4

471

po

pula

tion

over

5y

Res

ults

of c

omm

unity

he

alth

vol

unte

ers:

hea

lth

educ

atio

n(15

)

Baw

ku

Wes

t, B

olga

, Bo

ngo

AR

I: 7,

068

per 8

07,4

471

pop

ulat

ion

over

5y

▪ Stro

nges

t lev

el o

f hea

lth e

duca

tion

in B

awku

W

est

▪ No

educ

atio

n re

porte

d in

oth

er d

istri

cts

Jan-

Mar

Apr

-Jun

M

idye

ar re

port:

IMC

I ca

se m

anag

emen

t TO

T tra

inin

g(13

)

Not

sp

ecifi

ed

10

clin

icia

ns p

er 1

53,7

991

Und

er-fi

ve c

hild

ren;

3 re

gion

al fo

cal

pers

ons

Mal

aria

: 10,

377

case

s pe

r 153

,799

1 U

nder

-five

chi

ldre

n ;

513

refe

rred

Dia

rrhoe

a: 9

.897

cas

es p

er 1

53,7

991

Und

er-fi

ve c

hild

ren

; 172

refe

rred

Jul-S

ept

Mid

yea

r rep

ort:

resu

lts o

f co

mm

unity

hea

lth

volu

ntee

rs: t

reat

men

t and

re

ferra

ls(1

3)

Reg

iona

l

AR

I: 16

6 ca

ses

per 1

53,7

991

Und

er-fi

ve c

hild

ren

; all

refe

rred

Oct

-Dec

M

id y

ear r

epor

t: IM

CI+

(1

3)

Not

sp

ecifi

ed

24

pre

scrib

ers

train

ed p

er 1

53,7

991

Und

er-fi

ve c

hild

ren

▪ Nov

21st

trai

ning

dat

e, in

add

ition

to 4

8 tra

ined

in

Oct

200

5 (3

4)

2006 S

uper

visi

on re

port(

19)

Reg

iona

l (b

y di

stric

t av

aila

ble)

Mee

ting

repo

rt &

IMC

I su

perv

isor

y re

port

1366

met

by

supe

rvis

ion

team

out

19

82 C

BAs

train

ed

▪ 642

/136

6 w

ith n

o bi

cycl

es

▪ 816

/136

6 ha

d no

kits

▪ 4

60/1

366

had

no re

porti

ng fo

rmat

s

1

– E

stim

ated

pop

ulat

ion

from

200

4 pr

ojec

tions

(22)

: 15

3,79

9 un

der f

ive

child

ren,

36,

223

preg

nant

wom

en &

38,

450

child

ren

0-11

m;

807,

447

adul

ts a

nd c

hild

ren

>5


ANC+

ANC services, known as the IPT package, were offered through the Antenatal clinics to pregnant women. The IPT package includes Vitamin A supplements, Iron and folic acid supplements, antihelminths and IPT of malaria with sulphadoxine pyremethamine. Two districts were supported by the Global Fund starting May 2004: Bongo and Bawku East(11). In June 2004, ACSD extended IPT to the remaining four districts(11). Tetanus Toxoid immunization of pregnant women is also included, but as part of the EPI+ program and many of the immunizations were done during NIDs(23). UNICEF supported TT immunization along with other partners(23). In May 2004, a National TOT for IPT activities took place in all six UER districts(20) . District level IPT training occurred in June 2004(11). Also this year sensitization activities took place in ANC clinics by services provider(20). TT immunization was scaled up to all districts, the first round of TT supplementary immunization activities (SIA) took place in early 2004 with 46% coverage of the target population (Table C4). The second round of TT SIA occurred later in the year with an estimated 62% coverage(23). The third round of TT SIA only covered two districts with 73-95% estimated coverage (Table C4). Distribution of postnatal vitamin A and SP to pregnant women began mid-2004, with service through ANC delivery centres(12). Annual postnatal vitamin, SP and de-worming coverage for 2004 can be seen in Table C4. UNICEF-ACSD completed a market immunization and defaulter tracing exercise for EPI+ antigens, TT was included in the exercise (Table C4). Bawku West district reported iron deficiency and anaemia control training for midwives and other health workers (Table C4). In 2005, de-worming activities were scaled up in Bawku West. Annual de-worming rates for the region are reported in Table C4. BW reported three rounds of TT SIA in 2005 and even though we found no other evidence of TT SIA in other UER districts, it is assumed that it was ongoing because TT coverage is estimated at 76% for the UER in 2005(24). Data in postpartum vitamin A distribution is variable during 2005, but up to 2217 women were dosed (Table C4). SP distribution continued with no reported side effects (Table C4) although there are high drop-out rates after first and second dose(15). Use of SP by pregnant women was promoted through radio health education discussions(16). TBAs and CBAs were trained on distribution of postpartum Vit A (16) The 2006 annual monitoring data for vitamin A, SP, de-worming and TT are reported in Table C4.


Tabl

e C

4: T

imel

ine

of im

plem

enta

tion

of A

NC

+ ac

tiviti

es in

the

Upp

er E

ast r

egio

n, 2

002

– 20

06

Year

M

onth

s A

ctiv

ity

Are

a In

tens

ity

Not

es

Jan-

Mar

A

pr-J

un

Jul-S

ept

Oct

-Dec

20

02

Ann

ual T

otal

/ U

nspe

cifie

d

Jan-

Mar

A

pr-J

un

Jul-S

ept

PM

TCT

sens

itiza

tion

activ

ities

(20)

▪ N

o da

ta o

n sc

ale

of

sens

itiza

tion

activ

ities

Oct

-Dec

2003

Ann

ual T

otal

/ U

nspe

cifie

d

Jan-

Mar

TT

SIA

roun

d 1(

23)

Reg

iona

l 10

5,87

9 / 2

30,7

00 ta

rget

ed w

omen

May

: AC

SD

fund

ed

IPT

begi

ns w

ith T

OT

train

ing

(11,

20)

(25)

BW

, Bol

, B

uil,

KN

▪ No

data

on

num

ber o

f TO

T pa

rtici

pant

s

Apr

-Jun

7

– 12

Jun

e: D

istri

ct

IPT

train

ing(

20)

MW

, CH

N d

oing

AN

C, C

HO

??

July

: Pos

tnat

al

vita

min

A

supp

lem

enta

tion

begi

ns(1

2) (2

5)

Jul-S

ept

De-

wor

min

g of

pr

egna

nt w

omen

be

gan(

12)

2004

Oct

-Dec

P

ost n

atal

Vita

min

A

supp

lem

enta

tion

(12)

Reg

iona

l (d

istri

ct

avai

labl

e)

1st d

ose:

5,9

73 /

36,

2231 p

regn

ant w

omen

targ

eted

2nd

dos

e: 7

,320

/ 36

,223

1 pre

gnan

t wom

en ta

rget

ed

▪ J

uly-

Dec

200

4


Year

M

onth

s A

ctiv

ity

Are

a In

tens

ity

Not

es

IPT

for p

regn

ant

wom

en (1

2)

Reg

iona

l (d

istri

ct

avai

labl

e)

IPT1

: 18,

197

/ 36,

2231 p

regn

ant w

omen

targ

eted

IP

T2: 1

1,11

5 / 3

6,22

31 pre

gnan

t wom

en ta

rget

ed

IPT3

: 5,9

45 /

36,2

231 p

regn

ant w

omen

targ

eted

▪ M

ay –

Dec

200

4

TT S

IA ro

und

2 (2

3)

Reg

iona

l 14

3,95

4 / 2

30,7

00 ta

rget

ed w

omen

TT S

IA ro

und

3 (2

3)

Bolg

a an

d Bu

ilsa

only

B

ol: 5

4,30

7 / 5

7,37

2 ta

rget

ed w

omen

B

uil:

13,8

16 /

18,8

99 ta

rget

ed w

omen

Dew

orm

ing

of

preg

nant

wom

en(1

2)

Reg

iona

l (d

istri

ct

avai

labl

e)

7320

/ 36

,223

1 pre

gnan

t wom

en ta

rget

ed

No

dew

orm

ing

in B

awku

W

est(1

2) (2

6)

Res

ults

of m

arke

t im

mun

izat

ion,

TT

for

preg

nant

wom

en

Bol

ga,

Buils

a 31

2 /6

708

preg

nant

wom

en ta

rget

ed

A

nnua

l Tot

al/

Uns

peci

fied

Iron

Def

icie

ncy

Ana

emia

con

trol

Trai

ning

(26)

B

W

Twen

ty n

ine

mid

wiv

es a

nd C

HN

s tra

ined

out

of

5190

1

preg

nant

wom

en ta

rget

ed

Trai

ning

on

iron

defic

ienc

y an

d an

aem

ia c

ontro

l in

preg

nanc

y.

Jan-

Mar

Ja

n: d

ewor

min

g of

pr

egna

nt w

omen

be

gan

in B

W(2

7)

BW

Apr

-Jun

Th

ree

roun

ds o

f TT

SIA

cov

erag

e

BW

Reg

iona

l: N

o da

tes

or

num

bers

spe

cifie

d (1

4)

BW

: 20th

-24th

Jun

e 20

05

Jul-S

ept

Oct

-Dec

Ann

ual t

otal

po

stpa

rtum

Vita

min

A

(15)

Baw

ku,

Baw

ku W

est

(oth

er

dist

ricts

are

ni

l)

1st d

ose:

645

/ 36,

2231 p

regn

ant w

omen

targ

eted

2nd

dos

e: 6

45/ 3

6,22

31 pre

gnan

t wom

en ta

rget

ed

2217

rece

ived

PP

Vit

A b

ut

num

ber o

f dos

e no

t sp

ecifi

ed. (

16)

1649

repo

rted

in 2

006

Brie

f R

esum

e (1

3)

2005

Ann

ual T

otal

/ U

nspe

cifie

d

Ann

ual t

otal

for I

PT

sinc

e M

ay 2

004(

15,

16)

Reg

iona

l, di

stric

t av

aila

ble

1st: 1

0700

/ 36

,223

1 pre

gnan

t wom

en ta

rget

ed

2nd: 7

717

/ 36,

2231 p

regn

ant w

omen

targ

eted

3rd

: 484

3/ 3

6,22

31 pre

gnan

t wom

en ta

rget

ed


Year

M

onth

s A

ctiv

ity

Are

a In

tens

ity

Not

es

Ann

ual t

otal

D

ewor

min

g fo

r pr

egna

nt w

omen

(15)

Reg

iona

l, di

stric

t av

aila

ble

6711

/ 36

,223

1 pre

gnan

t wom

en ta

rget

ed

5,93

7 re

porte

d in

200

6 B

rief

resu

me

repo

rt (1

3)

Jan-

Mar

Mid

yea

r rep

ort:

IPT

tota

ls (1

3)

Reg

iona

l IP

T1: 1

0,69

8 / 3

6,22

31 pre

gnan

t wom

en ta

rget

ed

IPT2

: 7,7

93 /

36,2

231 p

regn

ant w

omen

targ

eted

IP

T3: 5

,555

/ 36

,223

1 pre

gnan

t wom

en ta

rget

ed

Mid

yea

r rep

ort:

Pos

tpar

tum

vita

min

A

tota

ls (1

3)

Reg

iona

l 6,

019

/ 36,

2231 p

regn

ant w

omen

targ

eted

A

pr-J

un

Mid

yea

r rep

ort:

dew

orm

ing

of

preg

nant

wom

en

tota

ls (1

3)

Reg

iona

l 5,

051

/ 36,

2231 p

regn

ant w

omen

targ

eted

Jul-S

ept

Oct

-Dec

2006

Ann

ual T

otal

/ U

nspe

cifie

d

Ann

ual r

egio

nal

sum

mar

y of

EP

I ac

tiviti

es(2

4)

GH

S E

PI

repo

rt U

ER

: TT2

– 7

8% (2

4)

1 –

Est

imat

ed p

opul

atio

n fro

m 2

004

proj

ectio

ns(2

2) :

153,

799

unde

r fiv

e ch

ildre

n, 3

6,22

3 pr

egna

nt w

omen

& 3

8,45

0 ch

ildre

n 0-

11m

; 80

7,44

7 ad

ults

and

chi

ldre

n >5

y


Table C5: Summary of inputs of supplies and logistics for the ACSD program, UER

Date Supplies Number Notes Year 1 Motor bikes (20) 12 42 motor bikes

planned/requested Year 1 Pickup truck (20) 1 June 2003 Kinaquin prepacks

(20)

January 2004 Kit boxes(20) 300 January 2004 Bicycles (20) 216 May 2004 Bicycles (20) 300

Bicycles (16) 800 Reported in 2005 60 60 60 60

FIMCI training manuals: (16) Introduction Assess and class sick child Identify treatment Assessment chart Counsel to mother

60

Reported in 2005. Missing the “Treat the child” and “Management of sick infant 1 wk to 2 m” manuals

Bicycles (19) 814 Reported in 2006 Kit boxes (19) 1,400 Reported in 2006 Motor bikes (19) 6 Reported in 2006 Reporting booklets (19)

2,022 Reported in 2006

Breast feeding posters (19)


Kinaquine junior (19) 645,900 Reported in 2006 Kinaquine infant (19) 100,200 Reported in 2006 ORS (19) 645,900 Reported in 2006 Facility training manuals (19)

420 Reported in 2006

Mosquito nets from UNICEF (19)

287,850 Reported in 2006 Global Fund provided 80,000 nets

Mosquito nets from revolving fund (19)


KO tablets (19) 287,850 Reported in 2006

No date given

Scales mother/child (19)

20 Reported in 2006


AP

PEN

DIX

D

Def

init

ion

of

prio

rity

cov

erag

e an

d fa

mily

pra

ctic

e in

dica

tors

for

th

e ev

alu

atio

n o

f A

CSD

Ta

ble

D1:

Def

initi

on o

f prio

rity

indi

cato

rs a

nd p

roto

cols

for m

issi

ng d

ata

NO

. A

CSD

TA

RG

ET

IND

ICA

TOR

S D

ATA

FILE

N

UM

ERA

TOR

D

OM

INA

TOR

¹ ²

PRO

TOC

OL

FOR

M

ISSI

NG

/UN

KN

OW

N D

ATA

EPI+

1 M

easl

es

imm

uniz

atio

n co

vera

ge §

Per

cent

age

of c

hild

ren

aged

12

-23

mon

ths

who

rece

ived

m

easl

es v

acci

ne b

efor

e fir

st

birth

day

Chi

ld

Elig

ible

chi

ldre

n re

ceiv

ed

mea

sles

inoc

ulat

ion

befo

re 1

2 m

onth

s of

age

; acc

ordi

ng to

im

mun

izat

ion

card

, mot

her's

re

port

or re

ceip

t of

vacc

inat

ion

durin

g na

tiona

l ca

mpa

ign3

All

child

ren

12-2

3m,

still

aliv

e, in

clud

e M

B

IMP

UTE

TIM

ING

1: M

issi

ng c

ard

or

vacc

inat

ion

on c

ard:

use

mot

her's

re

port

& im

pute

tim

ing

with

dis

tribu

tion

of k

now

n va

ccin

atio

n da

tes

2 D

PT3

im

mun

izat

ion

cove

rage

§

Per

cent

age

of c

hild

ren

aged

12

-23

mon

ths

who

rece

ived

3

dose

s of

DP

T va

ccin

e be

fore

firs

t birt

hday

.

Chi

ld

Elig

ible

chi

ldre

n re

ceiv

ed

DP

T3 b

efor

e 12

mon

ths

of

age;

acc

ordi

ng to

im

mun

izat

ion

card

or m

othe

r's

repo

rt3

All

child

ren

12-2

3m,

still

aliv

e, in

clud

e M

B

IMP

UTE

TIM

ING

2: M

issi

ng/in

valid

da

te o

n ca

rd: i

mpu

te ti

min

g w

ith

dist

ribut

ion

of k

now

n va

ccin

atio

n da

tes

3 H

ib3

imm

uniz

atio

n co

vera

ge §

Per

cent

age

of c

hild

ren

aged

12

-23

mon

ths

rece

ived

full

(3x

dose

s) H

IB v

acci

natio

n be

fore

firs

t birt

hday

.

Chi

ld

Elig

ible

chi

ldre

n re

ceiv

ed H

ib3

befo

re 1

2 m

onth

s of

age

; ac

cord

ing

to im

mun

izat

ion

card

All

child

ren

12-2

3m,

still

aliv

e, in

clud

e M

B

EX

CLU

DE

CA

SE

S: U

nkno

wn/

mis

sing

m

othe

r's re

port

and

no c

ard

data

4 C

over

age

of

vita

min

A in

last

6

mon

ths

§

Per

cent

age

of c

hild

ren

6 -

59m

who

rece

ived

at l

east

on

e hi

gh d

ose

vita

min

A

supp

lem

ent w

ithin

the

last

6

mon

ths

Chi

ld

Elig

ible

chi

ldre

n re

ceiv

ing

vita

min

A in

pre

viou

s 6m

ac

cord

ing

to m

othe

r's re

port

or im

mun

izat

ion

card

All

child

ren

6-59

m, s

till

aliv

e, in

clud

e M

B

EX

CLU

DE

CA

SE

S: M

issi

ng m

othe

r's

repo

rt an

d no

ent

ry o

n va

ccin

atio

n ca

rd

§ In

tern

atio

nal C

onse

nsus

Cov

erag

e In

dica

tor

¹ MB

=Mul

tiple

birt

h: in

clud

e al

l mul

tiple

birt

h ch

ildre

n

² CD

C 2

003

- due

to d

ata

qual

ity is

sues

, all

child

ren

with

val

id d

ata

for i

ndic

ator

var

iabl

es w

ere

incl

uded

3 To

est

imat

e th

e ch

ildre

n w

ithou

t a c

ard

to h

ave

rec'

d va

ccin

e be

fore

12m

of a

ge, t

he p

ropo

rtion

of v

acci

natio

ns g

iven

in th

e fir

st y

ear i

s as

sum

ed to

be

the

sam

e as

the

prop

ortio

n of

chi

ldre

n w

ith a

n im

mun

izat

ion

card

who

rec'

d th

e va

ccin

e be

fore

12m

of a

ge (M

ICS

man

ual)


NO

. A

CSD

TA

RG

ET

IND

ICA

TOR

S D

ATA

FILE

N

UM

ERA

TOR

D

OM

INA

TOR

¹ ²

PRO

TOC

OL

FOR

M

ISSI

NG

/UN

KN

OW

N D

ATA

IMC

I+

5 C

ase

man

agem

ent

mal

aria

(effe

ctiv

e)

Per

cent

age

of c

hild

ren

aged

0-5

9 m

onth

s w

ith

feve

r rec

eivi

ng a

ppro

pria

te

antim

alar

ial d

rugs

Chi

ld

Elig

ible

chi

ldre

n re

ceiv

ed

appr

opria

te a

ntim

alar

ial

med

icat

ion

acco

rdin

g to

na

tiona

l pol

icy

in p

revi

ous

two

wee

ks

Chi

ldre

n (0

-59)

with

re

porte

d fe

ver i

n pr

evio

us tw

o w

eeks

, in

clud

e M

B, e

xclu

de

dece

ased

EX

CLU

DE

CA

SE

S: R

epor

ted

treat

men

t of

chi

ld b

ut m

issi

ng fo

r spe

cific

m

edic

atio

ns u

sed

6 C

ase

man

agem

ent

mal

aria

-pr

ogra

mm

atic

(p

rogr

amm

atic

)

Per

cent

age

of c

hild

ren

aged

0-5

9 m

onth

s w

ith

feve

r rec

eivi

ng a

ny

antim

alar

ial d

rugs

Chi

ld

Elig

ible

chi

ldre

n re

ceiv

ed a

ny

antim

alar

ial m

edic

atio

n du

ring

illne

ss in

pre

viou

s tw

o w

eeks

Chi

ldre

n (0

-59)

with

re

porte

d fe

ver i

n pr

evio

us tw

o w

eeks

, in

clud

e M

B, e

xclu

de

dece

ased

EX

CLU

DE

CA

SE

S: R

epor

ted

treat

men

t of

chi

ld b

ut m

issi

ng fo

r spe

cific

m

edic

atio

ns u

sed

7 C

are

seek

ing

pneu

mon

ia §

Per

cent

age

of c

hild

ren

aged

0-5

9 m

onth

s w

ith

susp

ecte

d pn

eum

onia

ta

ken

to a

n ap

prop

riate

he

alth

car

e fa

cilit

y.

Chi

ld

Elig

ible

chi

ldre

n w

ere

seen

at

appr

opria

te h

ealth

car

e fa

cilit

y:

excl

udin

g ph

arm

acy

and

othe

r dr

ug v

endo

rs

Chi

ldre

n (0

-59)

with

: D

HS:

cou

gh A

ND

la

bore

d br

eath

ing

M

ICS:

cou

gh, l

abor

ed

brea

thin

g an

d ch

est

cong

estio

n in

pre

viou

s tw

o w

eeks

, in

clud

e M

B, e

xclu

de

dece

ased

EX

CLU

DE

CA

SE

S: R

epor

ted

treat

men

t of

chi

ld b

ut m

issi

ng fo

r spe

cific

loca

tion

of tr

eatm

ent

8 A

ntib

iotic

trea

tmen

t of

pne

umon

ia

Per

cent

age

of c

hild

ren

aged

0-5

9 m

onth

s w

ith

susp

ecte

d pn

eum

onia

re

ceiv

ing

antib

iotic

s

Chi

ld

Elig

ible

chi

ldre

n gi

ven

antib

iotic

s

Chi

ldre

n (0

-59)

with

: D

HS:

cou

gh A

ND

la

bore

d br

eath

ing

M

ICS:

cou

gh, l

abor

ed

brea

thin

g an

d ch

est

cong

estio

n in

pre

viou

s tw

o w

eeks

, in

clud

e M

B, e

xclu

de

dece

ased

EX

CLU

DE

CA

SE

S: R

epor

ted

treat

men

t of

chi

ld b

ut m

issi

ng fo

r spe

cific

m

edic

atio

ns u

sed


NO

. A

CSD

TA

RG

ET

IND

ICA

TOR

S D

ATA

FILE

N

UM

ERA

TOR

D

OM

INA

TOR

¹ ²

PRO

TOC

OL

FOR

M

ISSI

NG

/UN

KN

OW

N D

ATA

IMC

I+

OR

S/R

HF/

incr

ease

d flu

ids

for c

hild

ren

with

dia

rrho

ea +

co

ntin

ued

feed

ing

§

Per

cent

age

of c

hild

ren

aged

0-5

9 m

onth

s w

ith

diar

rhoe

a re

ceiv

ing

OR

S

OR

RH

F O

R in

crea

sed

fluid

s A

ND

con

tinue

d fe

edin

g

EX

CLU

DE

CA

SE

S 1

: Rep

orte

d tre

atm

ent o

f chi

ld b

ut m

issi

ng fo

r OR

S,

RH

F an

d IF

and

pos

itive

/mis

sing

for

cont

inue

d fe

edin

g

OR

S

OR

S p

acke

ts

OR

T/R

HF

reco

mm

ende

d ho

me

fluid

s

Incr

ease

d flu

ids

(IF)

Rec

'd m

ore

(MIC

S)

9

Con

tinue

d fe

edin

g

Rec

'd s

omew

hat l

ess,

ab

out t

he s

ame

or m

ore

(MIC

S)

Chi

ld

Elig

ible

chi

ldre

n re

ceiv

ed

OR

S, R

HF

or in

crea

sed

fluid

s A

ND

con

tinue

d fe

edin

g

Chi

ldre

n (0

-59)

with

re

porte

d di

arrh

oea

in

prev

ious

two

wee

ks,

incl

ude

MB

, exc

lude

de

ceas

ed

EX

CLU

DE

CA

SE

S 2

: Rep

orte

d tre

atm

ent o

f chi

ld b

ut p

ositi

ve/m

issi

ng

for O

RS

, RH

F or

IF a

nd m

issi

ng fo

r co

ntin

ued

feed

ing

§ In

tern

atio

nal C

onse

nsus

Cov

erag

e In

dica

tor

¹ MB

=Mul

tiple

birt

h: in

clud

e al

l mul

tiple

birt

h ch

ildre

n

² CD

C 2

003

- due

to d

ata

qual

ity is

sues

, all

child

ren

with

val

id d

ata

for i

ndic

ator

var

iabl

es w

ere

incl

uded


NO

. A

CSD

TA

RG

ET

IND

ICA

TOR

S D

ATA

FILE

N

UM

ERA

TOR

D

OM

INA

TOR

¹ ²

PRO

TOC

OL

FOR

M

ISSI

NG

/UN

KN

OW

N D

ATA

IMC

I+

10

Tim

ely

initi

atio

n of

bre

astfe

edin

g §

Per

cent

age

of n

ewbo

rns

put t

o th

e br

east

with

in

one

hour

of b

irth;

mos

t re

cent

live

birt

h pr

evio

us

12m

Wom

en

Wom

en in

itiat

ed b

reas

tfeed

ing

with

in th

e fir

st h

our a

fter

deliv

ery

Wom

en w

ith a

birt

h in

pr

evio

us 1

2m

EX

CLU

DE

CA

SE

S: R

epor

ted

ever

br

east

feed

ing,

but

mis

sing

tim

ing

of in

itiat

ion

EX

CLU

DE

CA

SE

S 1

: Mis

sing

for a

ll fe

edin

g va

riabl

es A

ND

pos

itive

/mis

sing

for s

till

brea

stfe

edin

g

11

Exc

lusi

ve

brea

stfe

edin

g th

roug

h 6

mon

ths

(0-5

m) §

Per

cent

age

of in

fant

s ag

ed 0

-5 m

onth

s w

ho

are

excl

usiv

ely

brea

stfe

d

Chi

ld

Elig

ible

chi

ldre

n st

ill

brea

stfe

edin

g an

d di

d no

t re

ceiv

e an

y liq

uids

or f

oods

in

prev

ious

24h

Chi

ldre

n (0

-5m

):

DH

S: m

ost r

ecen

tly

born

(inc

lude

onl

y on

e M

B) s

till a

live

& li

ving

w

ith m

om.

MIC

S: C

hild

(0-5

) with

co

mpl

eted

qu

estio

nnai

re

EX

CLU

DE

CA

SE

S 2

: Neg

ativ

e/ m

issi

ng fo

r all

feed

ing

varia

bles

AN

D m

issi

ng fo

r stil

l br

east

feed

ing

EX

CLU

DE

CA

SE

S 1

: Mis

sing

for a

ll fe

edin

g va

riabl

es A

ND

pos

itive

/mis

sing

for s

till

brea

stfe

edin

g

12

Bre

astfe

edin

g an

d co

mpl

emen

tary

fe

edin

g (6

-9

mon

ths)

§

Per

cent

age

of in

fant

s ag

ed 6

-9 m

onth

s w

ho

are

brea

stfe

d an

d re

ceiv

e co

mpl

emen

tary

fo

od (s

olid

or s

emis

olid

fo

ods)

Chi

ld

Elig

ible

chi

ldre

n st

ill

brea

stfe

edin

g an

d re

ceiv

ed

solid

/sem

isol

id fo

ods

in th

e pr

evio

us 2

4hr

Chi

ldre

n (6

-9m

):

DH

S: m

ost r

ecen

tly

born

(inc

lude

onl

y on

e M

B) s

till a

live

& li

ving

w

ith m

om.

MIC

S: C

hild

(6-9

) with

co

mpl

eted

qu

estio

nnai

re.

EX

CLU

DE

CA

SE

S 2

: Pos

itive

/mis

sing

for a

ll fe

edin

g va

riabl

es A

ND

mis

sing

for s

till

brea

stfe

edin

g

13

Con

tinue

d br

east

feed

ing

(20-

23 m

onth

s)

§

Per

cent

age

of c

hild

ren

aged

20-

23 m

onth

s w

ho

are

curr

ently

br

east

feed

ing

Chi

ld

Elig

ible

chi

ldre

n st

ill

brea

stfe

edin

g

Chi

ldre

n (2

0-23

m):

D

HS:

mos

t rec

ently

bo

rn (i

nclu

de o

nly

one

MB

) stil

l aliv

e &

livi

ng

with

mom

. M

ICS:

Chi

ld (2

0-23

) w

ith c

ompl

eted

qu

estio

nnai

re

EX

CLU

DE

CA

SE

S: M

issi

ng fo

r stil

l br

east

feed

ing

14

Con

sum

ptio

n of

io

dize

d sa

lt

Per

cent

age

of

hous

ehol

ds c

onsu

min

g io

dize

d sa

lt: e

xclu

de H

H

with

no

salt

HH

A

ll H

H w

ith c

ompl

eted

su

rvey

s an

d sa

lt av

aila

ble

for t

estin

g

EX

CLU

DE

CA

SE

S: M

issi

ng s

alt t

est a

nd H

H

with

no

salt

15

Con

sum

ptio

n of

io

dize

d sa

lt

Per

cent

age

of

hous

ehol

ds c

onsu

min

g io

dize

d sa

lt: in

clud

e H

H

with

no

salt

HH

Elig

ible

HH

has

sal

t with

>=

15pp

m io

dine

A

ll H

H w

ith c

ompl

eted

su

rvey

s

EX

CLU

DE

CA

SE

S: M

issi

ng s

alt t

est

§ In

tern

atio

nal C

onse

nsus

Cov

erag

e In

dica

tor

¹ MB

=Mul

tiple

birt

h: in

clud

e al

l mul

tiple

birt

h ch

ildre

n

² CD

C 2

003

- due

to d

ata

qual

ity is

sues

, all

child

ren

with

val

id d

ata

for i

ndic

ator

var

iabl

es w

ere

incl

uded


NO

. A

CSD

TA

RG

ET

IND

ICA

TOR

S D

ATA

FILE

N

UM

ERA

TOR

D

OM

INA

TOR

¹ ²

PRO

TOC

OL

FOR

M

ISSI

NG

/UN

KN

OW

N D

ATA

ITN

s

16

Use

of b

edne

ts b

y pr

egna

nt w

omen

Per

cent

age

of p

regn

ant

wom

en s

leep

ing

unde

r any

m

osqu

ito n

et la

st n

ight

W

oman

E

ligib

le p

regn

ant w

oman

sle

pt

unde

r a m

osqu

ito n

et la

st n

ight

A

ll el

igib

le p

regn

ant

wom

en

EX

CLU

DE

CA

SE

S: U

nkno

wn/

mis

sing

fo

r sle

pt u

nder

a b

ed n

et la

st n

ight

17

Effe

ctiv

e us

e of

be

dnet

s by

ch

ildre

n <

5yr §

Per

cent

age

of c

hild

ren

aged

0-

59 m

onth

s sl

eepi

ng u

nder

an

inse

ctic

ide

treat

ed

mos

quito

net

(Use

trt'd

<=1

2 m

onth

s du

e to

hea

ping

at

12m

)

Wom

an

Elig

ible

chi

ld s

lept

und

er a

n IT

N m

osqu

ito n

et la

st n

ight

A

ll ch

ildre

n un

der f

ive,

st

ill li

ving

EX

CLU

DE

CA

SE

S 1

: Mis

sing

ITN

dat

a

(a

) Net

obt

aine

d <=

12m

prio

r AN

D

mis

sing

if tr

eate

d w

hen

obta

ined

(b

)Tre

ated

net

obt

aine

d A

ND

mis

sing

m

onth

s ag

o ob

tain

ed (

c) T

reat

ed th

e ne

t afte

r obt

aini

ng b

ut m

issi

ng m

onth

s ag

o tre

ated

Effe

ctiv

e us

e of

be

dnet

s by

pr

egna

nt w

omen

W

oman

EX

CLU

DE

CA

SE

S 2

: Unk

now

n/m

issi

ng

for a

,b &

c a

nd

posi

tive/

mis

sing

/unk

now

n fo

r sle

pt u

nder

a

net l

ast n

ight

18

Per

cent

age

of p

regn

ant

wom

en s

leep

ing

unde

r an

inse

ctic

ide

treat

ed m

osqu

ito

net l

ast n

ight

(Use

trt'd

<=1

2 m

onth

s du

e to

hea

ping

at

12m

)

Elig

ible

pre

gnan

t wom

an s

lept

un

der a

n IT

N m

osqu

ito n

et la

st

nigh

t

All

elig

ible

pre

gnan

t w

omen

E

XC

LUD

E C

AS

ES

3: P

ositi

ve/m

issi

ng

for a

, b &

c A

ND

unk

now

n/m

issi

ng fo

r sl

ept u

nder

a b

ed n

et la

st n

ight

§ In

tern

atio

nal C

onse

nsus

Cov

erag

e In

dica

tor

¹ MB

=Mul

tiple

birt

h: in

clud

e al

l mul

tiple

birt

h ch

ildre

n

² CD

C 2

003

- due

to d

ata

qual

ity is

sues

, all

child

ren

with

val

id d

ata

for i

ndic

ator

var

iabl

es w

ere

incl

uded


NO

. A

CSD

TA

RG

ET

IND

ICA

TOR

S D

ATA

FILE

N

UM

ERA

TOR

D

OM

INA

TOR

¹ ²

PRO

TOC

OL

FOR

M

ISSI

NG

/UN

KN

OW

N D

ATA

AN

C+

Mos

t rec

ent l

ive

birt

h w

ithin

pre

viou

s 12

m

19

4+

pren

atal

vis

its,

train

ed h

ealth

ca

re w

orke

r

Per

cent

age

of p

regn

ant

wom

en w

ho re

port

at le

ast 4

pr

enat

al v

isits

to a

ski

lled

heal

th w

orke

r: do

ctor

, nu

rse/

mid

wife

or a

uxili

ary

mid

wife

Wom

en

Elig

ible

wom

en re

ceiv

ed 4

+ pr

enat

al c

are

visi

ts w

ith a

tra

ined

hea

lth c

are

wor

ker

EX

CLU

DE

CA

SE

S: U

nkno

wn/

mis

sing

for

num

ber p

rena

tal v

isits

AN

D p

ositi

ve/m

issi

ng

for s

kille

d H

CW

20

Inte

rmitt

ent

mal

aria

tre

atm

ents

in

preg

nanc

y

Per

cent

age

of p

regn

ant

wom

en r

ecei

ving

inte

rmitt

ent

prev

enta

tive

treat

men

t for

m

alar

ia d

urin

g p

regn

ancy

Wom

en

Elig

ible

wom

en re

ceiv

ed a

t le

ast t

wo

dose

s of

SP

dur

ing

the

preg

nanc

y

EX

CLU

DE

CA

SE

S: R

ecei

ved

med

icin

e du

ring

preg

nanc

y fo

r mal

aria

but

unk

now

n.

mis

sing

type

of m

edic

ine

21

TT2

cove

rage

du

ring

preg

nanc

y §

Per

cent

age

of n

ewbo

rns

prot

ecte

d ag

ains

t tet

anus

: M

othe

r rec

'd a

t lea

st 2

dos

es

of T

T du

ring

preg

nanc

y

Wom

en

Elig

ible

wom

en re

ceiv

ed a

t le

ast t

wo

dose

s of

teta

nus

toxo

id d

urin

g th

e pr

egna

ncy

EX

CLU

DE

CA

SE

S: U

nkno

wn/

mis

sing

if

rece

ived

TT

or re

ceiv

ed T

T bu

t unk

now

n do

sage

22

Full

TT c

over

age

Per

cent

age

of n

ewbo

rns

prot

ecte

d ag

ains

t tet

anus

: M

othe

r rec

’d im

mun

ity

thro

ugh

inje

ctio

ns p

revi

ous

to

preg

nanc

y

Wom

en

Elig

ible

wom

en re

ceiv

ed a

ny

of th

e fo

llow

ing:

▪ 2

+ do

es d

urin

g pr

egna

ncy

▪ 1 d

ose

durin

g pr

egna

ncy

+

a

ny d

oses

bef

ore

preg

nanc

y ▪ 2

+ do

ses

prio

r, th

e m

ost

rec

ent 3

yea

rs b

efor

e

pre

gnan

cy

▪ 3+

dose

s pr

ior,

the

mos

t r

ecen

t 5 y

ears

bef

ore

p

regn

ancy

▪ 4

+ do

ses

prio

r, th

e m

ost

rec

ent 1

0 ye

ars

befo

re

pre

gnan

cy

▪ 5+

lifet

ime

dose

s

EX

CLU

DE

CA

SE

S: U

nkno

wn/

mis

sing

if

rece

ived

TT

or re

ceiv

ed T

T bu

t unk

now

n do

sage

or d

ate

of m

ost r

ecen

t inj

ectio

n

23

Pre

gnan

t wom

en

take

3 m

onth

s iro

n su

pple

men

ts

Per

cent

age

of p

regn

ant

wom

en re

ceiv

ing

3 m

onth

s of

iro

n su

pple

men

tatio

n.

Wom

en

Elig

ible

wom

en re

ceiv

ed ir

on

supp

lem

enta

tion

daily

for a

t le

ast 9

0 da

ys

EX

CLU

DE

CA

SE

S: U

nkno

wn/

mis

sing

if

rece

ived

iron

or r

ecei

ved

iron

but f

or u

nkno

wn

time

perio

d

24

Ski

lled

atte

ndan

t at

del

iver

y §

Per

cent

age

of b

irths

at

tend

ed b

y sk

illed

hea

lth

wor

ker:

doct

or, n

urse

/mid

wife

or

aux

iliar

y m

idw

ife

Wom

en

Elig

ible

wom

en d

eliv

ered

with

a

train

ed h

ealth

car

e w

orke

r.

All

elig

ible

wom

en w

ith

a pr

egna

ncy

resu

lting

in

a li

ve b

irth

in th

e pr

evio

us 1

2m

EX

CLU

DE

CA

SE

S: U

nkno

wn/

mis

sing

dat

a fo

r birt

h at

tend

ant


NO

. A

CSD

TA

RG

ET

IND

ICA

TOR

S D

ATA

FILE

N

UM

ERA

TOR

D

OM

INA

TOR

¹ ²

PRO

TOC

OL

FOR

M

ISSI

NG

/UN

KN

OW

N D

ATA

AN

C+

Mos

t rec

ent l

ive

birt

h w

ithin

pre

viou

s 12

m

(a) E

ligib

le w

omen

del

iver

ed a

t an

inst

itutio

nal f

acili

ty (n

on-

dom

estic

)

EX

CLU

DE

CA

SE

S 1

: Unk

now

n/m

issi

ng p

lace

of

del

iver

y an

d no

dat

a fo

r pos

tnat

al c

are

25

Pos

tnat

al v

isit

with

in 3

day

s of

de

liver

y, tr

aine

d he

alth

wor

ker

Per

cent

age

of n

ewbo

rns

rece

ivin

g a

post

nata

l vis

it by

a

train

ed w

orke

r (do

ctor

, nu

rse/

mid

wife

or a

uxili

ary

mid

wife

) with

in 3

day

s of

de

liver

y.

Wom

en

(b) E

ligib

le w

omen

who

de

liver

ed d

omes

tical

ly

rece

ived

at l

east

one

pos

tnat

al

chec

kup

with

in 3

day

s of

de

liver

y w

ith a

trai

ned

heal

th

care

wor

ker

EX

CLU

DE

CA

SE

S 2

: Non

-inst

itutio

nal

deliv

ery

and

posi

tive/

mis

sing

ski

lled

HC

W

and

posi

tive/

mis

sing

rece

ived

pos

tnat

al c

are

26

Pos

tnat

al

supp

lem

enta

tion

with

Vita

min

A §

Per

cent

age

of w

omen

re

ceiv

ing

vita

min

A

supp

lem

enta

tion

with

in 2

m

onth

s of

birt

h

Wom

en

Elig

ible

wom

en re

ceiv

ed

vita

min

A s

uppl

emen

tatio

n w

ithin

2 m

onth

s of

del

iver

y

All

elig

ible

wom

en w

ith

a pr

egna

ncy

resu

lting

in

a li

ve b

irth

in th

e pr

evio

us 1

2m

EX

CLU

DE

CA

SE

S: U

nkno

wn/

mis

sing

if

rece

ived

vita

min

A

§ In

tern

atio

nal C

onse

nsus

Cov

erag

e In

dica

tor

¹ MB

=Mul

tiple

birt

h: in

clud

e al

l mul

tiple

birt

h ch

ildre

n

² CD

C 2

003

- due

to d

ata

qual

ity is

sues

, all

child

ren

with

val

id d

ata

for i

ndic

ator

var

iabl

es w

ere

incl

uded


Tabl

e D

2: D

efin

ition

of p

riorit

y im

pact

indi

cato

rs

NO

. IN

DIC

ATO

RS

DA

TAFI

LE

NU

MER

ATO

R

DO

MIN

ATO

R§

PRO

TOC

OL

FOR

EXC

LUSI

ON

O

F C

ASE

S§

1 S

tunt

ing

(low

hei

ght f

or

age)

am

ong

child

ren

24-

59 m

onth

s of

age

* H

ouse

hold

Mod

erat

e an

d Se

vere

: C

hild

ren

with

<-2

z s

core

s fo

r hei

ght f

or a

ge b

ased

on

the

2006

WH

O g

row

th

curv

es(3

6)

Seve

re: C

hild

ren

with

<-3

z

scor

es fo

r hei

ght f

or a

ge

base

d on

the

2006

WH

O

grow

th c

urve

s(36

)

Chi

ldre

n ag

ed

24-5

9 m

onth

s w

ho:

1.

Hav

e a

repo

rted

(non

-m

issi

ng) b

irth

mon

th &

yea

r 2.

H

ave

a va

lid (

non-

mis

sing

) an

thro

pom

etric

mea

sure

3.

S

lept

in th

e ho

use

the

nigh

t be

fore

the

surv

ey

Cas

es w

ith im

prob

able

val

ues

for

heig

ht-fo

r-ag

e ar

e ex

clud

ed fr

om

anal

ysis

; im

prob

able

def

ined

as

+/- 4

sta

ndar

d de

viat

ions

of Z

sc

ore

rela

tive

to th

e ov

eral

l m

edia

n Z

scor

e va

lue

from

the

crud

e da

tafil

e

2 W

astin

g (w

eigh

t for

he

ight

) am

ong

child

ren

0-23

mon

ths

of a

ge*

Hou

seho

ld

Mod

erat

e an

d Se

vere

: C

hild

ren

with

<-2

z s

core

s fo

r wei

ght f

or h

eigh

t bas

ed

on th

e 20

06 W

HO

gro

wth

cu

rves

(36)

Se

vere

: Chi

ldre

n w

ith <

-3 z

sc

ores

for w

eigh

t for

he

ight

bas

ed o

n th

e 20

06

WH

O g

row

th c

urve

s(36

)

Chi

ldre

n ag

ed 0

-23

mon

ths

who

: 1.

H

ave

a va

lid (

non-

mis

sing

) an

thro

pom

etric

mea

sure

2.

S

lept

in th

e ho

use

the

nigh

t be

fore

the

surv

ey

Cas

es w

ith im

prob

able

val

ues

for

wei

ght-f

or-h

eigh

t are

exc

lude

d fro

m a

naly

sis;

impr

obab

le

defin

ed a

s +/

- 4 s

tand

ard

devi

atio

ns o

f Z s

core

rela

tive

to

the

over

all m

edia

n Z

scor

e va

lue

from

the

crud

e da

tafil

e

3 U

nder

wei

ght (

wei

ght f

or

age)

for c

hild

ren

0-59

m

onth

s of

age

* H

ouse

hold

Mod

erat

e an

d Se

vere

: C

hild

ren

with

<-2

z s

core

s fo

r wei

ght f

or a

ge b

ased

on

the

2006

WH

O g

row

th

curv

es(3

6)

Seve

re: C

hild

ren

with

<-3

z

scor

es fo

r wei

ght f

or a

ge

base

d on

the

2006

WH

O

grow

th c

urve

s(36

)

Chi

ldre

n ag

ed 0

-59

mon

ths

who

: 1.

H

ave

a re

porte

d (n

on-

mis

sing

) birt

h m

onth

& y

ear

2.

Hav

e a

valid

(no

n-m

issi

ng)

anth

ropo

met

ric m

easu

re

3.

Sle

pt in

the

hous

e th

e ni

ght

befo

re th

e su

rvey

Cas

es w

ith im

prob

able

val

ues

for

wei

ght-f

or-a

ge a

re e

xclu

ded

from

an

alys

is; i

mpr

obab

le d

efin

ed a

s +/

- 4 s

tand

ard

devi

atio

ns o

f Z

scor

e re

lativ

e to

the

over

all

med

ian

Z sc

ore

valu

e fro

m th

e cr

ude

data

file

4 U

nder

-five

mor

talit

y ra

te

Birt

h hi

stor

y ex

tract

ed

from

w

omen

’s

file

The

prob

abilit

y of

dy

ing

betw

een

birth

an

d ex

act

age

five

year

s

Expr

esse

d as

100

0 liv

e bi

rths

N/A


Tabl

e D

3: D

efin

ition

of c

onte

xtua

l var

iabl

es u

sed

in th

e A

CS

D e

valu

atio

n C

ON

TEXT

UA

L VA

RIA

BLE

SO

UR

CE

OF

DEF

INIT

ION

D

ESC

RIP

TIO

N O

F D

EFIN

ITIO

N

Wea

lth q

uint

iles

DH

S s

tand

ard

calc

ulat

ion

of w

ealth

qui

ntile

s (h

ttp://

ww

w.c

hild

info

.org

/mic

s/m

ics3

/doc

s/D

HS

%20

Wea

lth%

20In

dex%

20(D

HS

%20

Com

para

tive%

20R

epor

ts).p

df)

All

hous

ehol

d as

sets

and

util

ities

are

dic

hoto

miz

ed in

to in

dica

tor v

aria

bles

. P

rinci

ple

com

pone

nts

anal

ysis

is p

erfo

rmed

usi

ng a

ll th

e in

dica

tor v

aria

bles

to

stan

dard

ize

the

wei

ghts

of t

he v

aria

bles

usi

ng th

e fir

st p

rinci

ple

fact

or.

Eac

h ho

useh

old

is th

en a

ssig

ned

a w

eigh

ted

inde

x va

lue,

bas

ed o

n its

repo

rted

asse

ts

and

utili

ties.

Hou

seho

lds

are

then

div

ided

into

qui

ntile

s ba

sed

on th

eir i

ndex

va

lue.

Fo

r the

cal

cula

tion

of w

ealth

qui

ntile

s fo

r the

AC

SD

eva

luat

ion,

the

urba

n ar

eas

of A

shan

ti an

d G

reat

Acc

ra re

gion

are

rem

oved

and

the

indi

ces

calc

ulat

ed fo

r ho

useh

olds

in th

e H

IDs

and

com

paris

on a

rea

only

.

Impr

oved

Wat

er

Sou

rce

MD

G w

ater

and

san

itatio

n de

finiti

ons

(http

://w

ww

.uni

cef.o

rg/w

es/m

dgre

port/

defin

itio

n.ph

p)

Uni

mpr

oved

drin

king

wat

er s

ourc

es in

clud

e: 1

) Unp

rote

cted

wel

l, 2)

U

npro

tect

ed s

prin

g, 3

) Riv

ers

or p

onds

, 4) v

endo

r pro

vide

d w

ater

, 5) B

ottle

d w

ater

, 6) T

anke

r tru

ck w

ater

Impr

oved

S

anita

tion

Faci

litie

s

MD

G w

ater

and

san

itatio

n de

finiti

ons

(http

://w

ww

.uni

cef.o

rg/w

es/m

dgre

port/

defin

itio

n.ph

p)

Impr

oved

san

itatio

n fa

cilit

ies

incl

ude:

1)

Con

nect

ion

to a

pub

lic s

ewer

, 2)

Con

nect

ion

to a

sep

tic s

yste

m,

3) P

our-

flush

latri

ne,

4) S

impl

e pi

t lat

rine,

5)

Ven

tilat

ed im

prov

ed p

it la

trine

.

.

U

nim

prov

ed s

anita

tion

faci

litie

s in

clud

e:

1) P

ublic

or s

hare

d la

trine

, 2)

Ope

n pi

t lat

rine,

3)

Buc

ket l

atrin

e.


APPENDIX E Survey questions used in the calculation of coverage indicators

DHS Questionnaire DHS Questionnaire ACSD Questionnaire MICS Questionnaire1998/99 2003 2003 2006 & 2007/08

EPI+

1 Measles immunization coverage

Have vaccination card (q443); Measles innoc. on card (q444); Rec'd other

vaccines (q446); Mom report of measles innoc (q447G)

Have vaccination card (q458); Measles innoc. on card (q460); Rec'd other vaccines (q462); Mom

report of measles innoc (q463G)

Have vaccination card (q404); Measles innoc. on card (q405); Rec'd other vaccines (q407); Mom

report of measles innoc (q414)

Have vaccination card (IM1); Measles innoc. on card (IM6);

Rec'd other vaccines (IM10); Mom report of measles innoc (IM17); rec'd vaccine during campaign

(IM19)

2 DPT3 immunization coverage

Have vaccination card (q443); DPT3 on card (q444); Rec'd other

vaccines (q446); Mom report of DPT(q447E); number of

doses(q447F)


vaccines (q462); Mom report of DPT(q463E);

number of doses(q463F)


vaccines (q407); Mom report of DPT(q412);

number of doses(q413)

Have vaccination card (IM1); DPT3 on card (IM5C); Rec'd other

vaccines (IM10); Mom report of DPT(IM15); number of

doses(IM16)

3 Hib3 immunization coverage N/A N/A N/A Have vaccination card (IM1); Hib3

innoc. on card (IM5C)

4 Coverage of vitamin A in last 6 months

Have vaccination card (q458); Mother's report

(q448)

Have vaccination card (q458); VitA on card (q460);

Mother's report (q457)

Have vaccination card (q404); VitA on card (q405);

Mother's report (q403)

Have vaccination card (IM1); VitA on card (IM8a/b); Mother's report

(VA1,VA2)

IMCI+

5 Case management malaria (effective)

Had fever(q449); gave meds (q449A); what meds (q449B)

Had fever(q466); gave meds (q473); what meds (q474)

Had fever(q515); gave meds (q517); what meds (q518); prescribed meds (q523); what meds prescribed(q524)

Had fever(ML1); gave meds (ML3/ML5); what meds (ML4/ML7)

6Case management malaria-programmatic (programmatic)

N/AHad fever(q466); gave meds (q473); what meds (q474)

Had fever(q515); gave meds (q517); what meds (q518); prescribed meds (q523); what meds prescribed(q524)

Had fever(ML1); gave meds (ML3/ML5); what meds (ML4/ML7)

7 Care seeking pneumonia

Suspected pneum. (q450 & q451); consulted for treatment (q452); where consulted (q453)



Suspected pneum. (CA5, CA6, CA7); consulted for treatment (CA8); where consulted (CA9)

8 Antibiotic treatment of pneumonia

Suspected pneum. (q450 & q451); consulted for treatment (q451A); where consulted (q451B)

N/A


Suspected pneum. (CA5, CA6, CA7); consulted for treatment (CA8); where consulted (CA9)

ORS/RHF/increased fluids for children with diarrhoea + continued feeding

Had diarrhea (q454) Had diarrhea (q475) Had diarrhea (q501) Had diarrhea (CA1)

ORS ORS (q461) ORS (q478a) ORS (q506a) ORS (CA2a)

ORT/RHF RHF (q461) RHF (q478b) RHF (q506b) RHF (CA2b)

Increased fluids (IF) Increased fluids (q457) Increased fluids (q476) Increased fluids (q504) Increased fluids (CA3)

Continued feeding Continued feeding (q458) Continued feeding (q477) Continued feeding (q505) Continued feeding (CA4)

NO. ACSD TARGET

9


DHS Questionnaire DHS Questionnaire ACSD Questionnaire MICS Questionnaire1998/99 2003 2003 2006 & 2007/08

10 Timely initiation of breastfeeding

Ever breastfed (q427); Timing of BF initiation (q425)



Ever breastfed (MN12); Timing of BF initiation (MN13)

11

13Continued breastfeeding (20-23 months)

Still breasfeeding (q447) Still breasfeeding (q445) Still breasfeeding (q326) Still breasfeeding (BF2)

14 Consumption of iodized salt

15 Consumption of iodized salt

ITNs

ANC+

19 4+ prenatal visits, skilled HCW

Prenatal care and who did you consult (q407); Number of visits (q409)

Prenatal care (q407); Number of visits (q409)

Prenatal care (q303);who did you consult (q304); Number of visits (q306)

Prenatal care and who did you consult (MN2); Number of visits (MN2bb)

20Intermittent malaria treatments in pregnancy

N/A Took meds for malaria (q421); Which meds (q422)

Took meds for malaria (q223); Which meds (q224)

Took meds for malaria (MN6A); Which meds (MN6B)

21 TT2 coverage during pregnancy

Rec'd TT (q410); number of doses (q411)



Rec'd TT (TT2); number of doses (TT3)

22Pregnant women take 3 months iron supplements

N/A Rec'd iron (q417); Number of days took iron (q418)

Rec'd iron (q313); Number of days took iron (q314) N/A

23 Skilled attendant at delivery Assisted with birth (q414) Assisted with birth (q426) Assisted with birth (q320) Assisted with birth (MN7)

Location of delivery (q427); Rec'd postnatal care if non-institutional delivery (q429)

Days after delivery rec'd care (q430); who performed care (q431)

25Postnatal supplementation with Vitamin A

Rec'd vitamin A (q417G) Rec'd vitamin A (q433) Rec'd vitamin A (q322) Rec'd vitamin A (MN1)

N/A24Postnatal visit within 3 days of delivery, skilled HCW

Days after delivery rec'd care (q417B); who performed care (q417C)

N/A

Still breasfeeding (q326); liquids/food in last 24h (q331b-g)

Still breasfeeding (q326); food in last 24h (q331g)

Child slept under net last night (q465C); How long ago was net obtained (q465E); Was a treated net obtained (q465F); Was the net ever treated(q465G); How long ago treated (q465H)

Still breasfeeding (q447); liquids & foods in last 24h (q434)

Iodized salt (q35) Iodized salt (q29)

Still breasfeeding (q445); liquids in last 24h (q492a-e); food in last 24h (q493a-j)

Iodized salt (q35)

Still breasfeeding (q445); food in last 24h (q493a-j)

Child slept under net last night (H32D); How long ago was net obtained (H31); Was a treated net obtained (H31b); Was the net ever treated(H32A); How long ago treated (H32B)

N/A

Still breasfeeding (q447); liquids & foods in last 24h (q434)

18

Exclusive breastfeeding through 6 months (0-5m)

12Breastfeeding and complementary feeding (6-9 months)

17Effective use of bednets by children < 5yr

ACSD TARGET

Still breasfeeding (BF2); liquids/foods(BF3)

Still breasfeeding (BF2); liquids/foods(BF3)

Salt tested for iodization (SL1)

Child slept under net last night (ML10); How long ago was net obtained (ML11); Brand of net (ML12); Was a treated net obtained (ML13); Was the net ever treated(ML14); How long ago treated (ML14)

N/AEffective use of

bednets by pregnant women

N/A N/A

Currently pregnant (q226); How long ago was net obtained (H31); Was a treated net obtained (H31b); Was the net ever treated(H32A); How long ago treated (H32B)


APPENDIX F Methodology and implementation of household surveys in Ghana 1998 to 2008

The methodologies and implementation of households surveys re-analyzed for the ACSD retrospective evaluation are presented in table F1. Less documentation of the methods and implementation was available for the ACSD 2003 survey. This survey is presented in the body of the report, but should be interpreted with caution due to questions about the data quality and the exact methodologies utilized. A full report describing data quality issues in the ACSD 2003 survey is available on request from the JHU evaluation team.


Tabl

e F1

: Met

hodo

logy

and

impl

emen

tatio

n of

hou

seho

ld s

urve

ys in

Gha

na 1

998

to 2

008

pres

ente

d in

the

AC

SD

eva

luat

ion

repo

rt

Gha

na

Surv

ey C

ompo

nent

D

HS

1998

-99

A

CSD

200

3 D

HS

2003

M

ICS

2006

M

ICS

su

pple

men

tary

20

07

Geo

grap

hic

Cov

erag

e N

atio

nal

Upp

er E

ast

Reg

ion

Nat

iona

l N

atio

nal

Upp

er E

ast R

egio

n (a

lso

data

ava

ilabl

e in

N

orth

ern

and

Upp

er

Wes

t reg

ions

)

Impl

emen

ting

Age

ncy

(& T

A)

Gha

na S

tatis

tical

S

ervi

ces

& D

HS

, M

acro

Inte

rnat

iona

l

Nav

rong

o H

ealth

Res

earc

h Ce

ntre

, TA

(C

DC

– A

tlant

a &

U

NIC

EF)

Gha

na S

tatis

tical

S

ervi

ces

& D

HS

, M

acro

Inte

rnat

iona

l

Gha

na S

tatis

tical

S

ervi

ces

and

Min

istry

of H

ealth

w

ith U

NIC

EF;

TA

(PE

PFA

R, M

acro

&

Gha

na A

IDS

C

omm

issi

on)

Gha

na S

tatis

tical

S

ervi

ces

and

UN

ICE

F;

TA (M

acro

and

JH

SP

H)

Dat

afile

av

aila

ble

for

rean

alys

is

Yes

Y

es

Yes

Y

es

Yes

G

ener

al

Surv

ey

docu

men

t-at

ion

avai

labl

e

Sam

plin

g m

etho

ds /

size

; Sam

plin

g fra

me/

se

lect

ion/

wei

ghts

; R

evis

ed

ques

tionn

aire

; Tr

aini

ng m

anua

l; In

terv

iew

er m

anua

l; S

uper

viso

r man

ual;

D

ataf

ile fo

r ana

lysi

s;

Rep

ort o

f dat

a an

alys

es

Engl

ish

ques

tionn

aire

s;

Dat

afile

for a

naly

sis

Sam

plin

g m

etho

ds /

size

; Sam

plin

g fra

me/

se

lect

ion/

wei

ghts

; R

evis

ed

ques

tionn

aire

; Tr

aini

ng m

anua

l; In

terv

iew

er m

anua

l; S

uper

viso

r man

ual;

D

ataf

ile fo

r ana

lysi

s;

Rep

ort o

f dat

a an

alys

es

Sam

plin

g m

etho

ds

/ siz

e; S

ampl

ing

fram

e/

sele

ctio

n/w

eigh

ts;

Rev

ised

qu

estio

nnai

re;

Trai

ning

man

ual;

Inte

rvie

wer

m

anua

l; S

uper

viso

r m

anua

l; D

ataf

ile

for a

naly

sis;

R

epor

t of d

ata

anal

yses

Sam

plin

g m

etho

ds /

size

; Sa

mpl

ing

fram

e/

sele

ctio

n/w

eigh

ts;

Rev

ised

que

stio

nnai

re

Trai

ning

man

ual;

Inte

rvie

wer

man

ual;

Sup

ervi

sory

fiel

d re

port;

D

ataf

ile fo

r ana

lysi

s


Gha

na

Surv

ey C

ompo

nent

D

HS

1998

-99

A

CSD

200

3 D

HS

2003

M

ICS

2006

M

ICS

su

pple

men

tary

20

07

Stra

tific

atio

n &

sam

plin

g of

cl

uste

rs

2 st

age

sam

plin

g st

ratif

ied

by re

gion

&

urba

n/ru

ral;

clus

ters

ch

osen

from

198

4 ce

nsus

; ove

rsam

plin

g in

UE

, UW

& N

orth

ern

regi

ons

2 st

age

sam

plin

g de

sign

; Unk

now

n st

ratif

icat

ion

2 st

age

sam

plin

g,

clus

ters

sel

ectio

n st

ratif

ied

by re

gion

an

d ur

ban/

rura

l; cl

uste

rs c

hose

n fro

m

2000

cen

sus;

ov

ersa

mpl

ing

in U

E,

UW

, Nor

ther

n &

B

rong

Aha

fo re

gion

s

2 st

age

sam

plin

g,

clus

ters

sel

ectio

n st

ratif

ied

by re

gion

an

d ur

ban/

rura

l; cl

uste

rs c

hose

n fro

m G

hana

Liv

ing

Sta

ndar

ds S

urve

y 5;

ove

rsam

plin

g in

U

E, U

W &

N

orth

ern

regi

ons

2 st

age

sam

plin

g

stra

tifie

d by

dis

trict

&

urba

n/ru

ral

Num

ber o

f cl

uste

rs

400

83

412

300

HID

: 173

Num

ber o

f ho

useh

olds

pe

r clu

ster

20 in

the

UE

, UW

and

N

orth

ern

regi

ons;

15

in a

ll ot

her r

egio

ns

Unk

now

n

20 in

the

UE

, UW

&

Bro

ng A

hafo

; 16

in

Nor

ther

n an

d 15

in a

ll ot

her r

egio

ns

25 in

rura

l UE

, U

W &

Nor

ther

n;

20 in

all

othe

r HH

s 20

Map

ping

/ lis

ting

Com

plet

e lis

ting

in

EA

s w

ith <

500

HH

s;

parti

al li

stin

g in

larg

er

EA

s. A

ugus

t –

Oct

ober

199

8

Unk

now

n C

ompl

ete

HH

list

ing;

M

ay –

Jun

e 20

03

Com

plet

e lis

ting

in

May

– J

uly

2005

; so

me

re-li

sted

ea

rly 2

006

List

ing

of s

elec

ted

HH

on

ly; t

echn

ical

team

re

com

men

ded

stan

dard

, fu

ll lis

ting

Sam

plin

g &

en

umer

atio

n

Hou

seho

ld

sele

ctio

n

Don

e by

Mac

ro fr

om

hous

ehol

d lis

ting

befo

re s

urve

y fie

ld

wor

k

Unk

now

n

Don

e by

Mac

ro fr

om

hous

ehol

d lis

ting

befo

re s

urve

y fie

ld

wor

k po

int)

Don

e by

GS

S

from

hou

seho

ld

listin

g be

fore

su

rvey

fiel

d w

ork

Don

e by

GS

S fr

om

hous

ehol

d lis

ting

thro

ugho

ut p

erio

d of

su

rvey

fiel

d w

ork


Gha

na

Surv

ey C

ompo

nent

D

HS

1998

-99

A

CSD

200

3 D

HS

2003

M

ICS

2006

M

ICS

su

pple

men

tary

20

07

Lang

uage

of

ques

tionn

aire

A

kan,

Ga,

Eng

lish,

E

we,

Hau

sa, a

nd

Dag

bani

En

glis

h A

kan,

Ga,

Eng

lish,

E

we,

Nze

ma,

and

D

agba

ni

Engl

ish

En

glis

h

Que

stio

nn-

aire

s us

ed

Hou

seho

ld, w

omen

's

[Men

's]

Hou

seho

ld,

wom

en's

H

ouse

hold

, wom

en's

[M

en's

]

Hou

seho

ld,

wom

en's

and

U

nder

-five

[Men

's]

Hou

seho

ld, w

omen

's a

nd

Und

er-fi

ve [M

en's

]

Mod

ules

in

clud

ed in

w

omen

's/c

hild

qu

estio

nnai

re

Soc

iode

mog

raph

ic

Info

; Rep

rodu

ctio

n;

Con

trace

ptio

n;

Pre

gnan

cies

, AN

C, &

br

east

feed

ing;

Im

mun

izat

ion

and

Hea

lth; M

arria

ge;

Ferti

lity

Pre

fere

nces

; H

usba

nd/P

artn

er’s

Ba

ckgr

ound

and

W

omen

’s W

ork;

AID

S;

Hei

ght a

nd W

eigh

t

Soc

iode

mog

raph

ic

Info

; Rep

rodu

ctio

n;

Con

trace

ptio

n;

Pre

gnan

cies

, AN

C,

& b

reas

tfeed

ing;

Im

mun

zatio

n; C

hild

illn

ess

and

care

; H

ygie

ne, m

arita

l st

atus

, wor

k of

w

omen

Soc

iode

mog

raph

ic

Info

; Rep

rodu

ctio

n;

Con

trace

ptio

n;

Pre

gnan

cies

, AN

C, &

br

east

feed

ing;

Im

mun

izat

ion

and

Hea

lth; M

arria

ge a

nd

sexu

al a

ctiv

ity;

Ferti

lity

Pre

fere

nces

; H

usba

nd’s

Ba

ckgr

ound

and

W

omen

’s W

ork;

A

IDS

& S

TDs;

SE

S In

fo ;

child

m

orta

lity;

Mat

erna

l an

d N

ewbo

rn

Hea

lth; M

arria

ge

and

Uni

on;

Sec

urity

of

Tenu

re;

Con

trace

ptio

n;

Dom

estic

V

iole

nce;

Fem

ale

Gen

ital M

utila

tion;

S

exua

l Beh

avio

ur;

HIV

Kno

wle

dge;

B

irth

Reg

istra

tion

and

Early

Le

arni

ng; C

hild

D

evel

opm

ent;

Vita

min

A;

Bre

astfe

edin

g;

Car

e of

Illn

ess;

M

alar

ia;

Imm

uniz

atio

n;

Ant

hrop

omet

ry

Soc

iode

mog

raph

ic In

fo ;

child

mor

talit

y; T

etan

us

Toxo

id; M

ater

nal a

nd

New

born

Hea

lth;

Mar

riage

and

Uni

on;

Sec

urity

of T

enur

e;

Con

trace

ptio

n; D

omes

tic

Vio

lenc

e; H

IV/A

IDS

; N

atio

nal H

ealth

In

sura

nce;

Birt

h R

egis

tratio

n an

d Ea

rly

Lear

ning

; Chi

ld

Edu

catio

n; V

itam

in A

; B

reas

tfeed

ing;

Car

e of

Ill

ness

; Mal

aria

; Im

mun

izat

ion;

A

nthr

opom

etry

Fu

ll bi

rth h

isto

ry w

as

adde

d to

wom

en’s

que

st.

& Fl

oodi

ng m

odul

e w

as

adde

d to

HH

que

st.

Que

stio

nn-

aire

s

Pre-

test

/ pi

lot

Pre

test

of a

ll qu

estio

nnai

res

in S

ept

1998

; the

5 lo

cal

lang

uage

s w

ere

pret

este

d.

Unk

now

n

Pre

test

of a

ll qu

estio

nnai

res

in

urba

n &

rura

l are

as

5-7

May

200

3 in

all

5 lo

cal l

angu

ages

; A

lso

pret

este

d A

IDS

m

odul

e

Pre

test

ed in

G

reat

er A

ccra

re

gion

in 2

urb

an

and

2 ru

ral E

As

in

June

200

6

Pre

test

ed in

per

i-urb

an

Kum

asi


Gha

na

Surv

ey C

ompo

nent

D

HS

1998

-99

A

CSD

200

3 D

HS

2003

M

ICS

2006

M

ICS

su

pple

men

tary

20

07

Man

uals

St

anda

rd D

HS

guid

es

Unk

now

n St

anda

rd D

HS

guid

es

Sta

ndar

d M

ICS

gu

ides

In

terv

iew

er m

anua

l

Logi

stic

s &

tim

ing

3

wee

k pe

riod,

Oct

-N

ov 1

998.

U

nkno

wn

102

inte

rvie

wer

s, 2

3 nu

rses

& 1

2 da

ta

entry

ope

rato

rs;

6-27

Jul

y 20

03

80 in

terv

iew

ers

and

10 d

ata

entry

op

erat

ors:

17–

31t

July

, 200

6

Two

wee

ks in

Aug

-Sep

t 20

07; T

A by

Mac

ro &

JH

SP

H

Trai

ning

co

nten

t

Stan

dard

DH

S tra

inin

g.

Two

day

train

ing

on

anth

ropo

met

ric

mea

sure

men

t.

Unk

now

n

Stan

dard

DH

S tra

inin

g in

clud

ing

anth

ro. m

easu

res.

N

urse

s tra

ined

in

bloo

d co

llect

ion

for

anem

ia a

nd A

IDS

Inte

rvie

win

g te

chni

ques

, di

scus

sion

of t

he

ques

tionn

aire

s,

and

moc

k in

terv

iew

s am

ong

train

ees

Inte

rvie

win

g te

chni

ques

, di

scus

sion

of t

he

ques

tionn

aire

s, a

nd m

ock

inte

rvie

ws

amon

g tra

inee

s

Trai

ning

Prac

tice

surv

ey a

dmin

in

fiel

d

Stan

dard

DH

S tra

inin

g.

U

nkno

wn

Stan

dard

DH

S tra

inin

g.

3 da

ys c

ondu

ctin

g in

terv

iew

s in

16

urba

n &

rura

l EA

s

2 da

ys c

ondu

cted

in p

eri-

urba

n Ku

mas

i

Surv

ey te

am

com

posi

tion

1 su

perv

isor

(1

3/14

wer

e m

ale)

1

field

edi

tor

(mal

e or

fem

ale)

3

inte

rvie

wer

s (m

ale

or fe

mal

e)

1 dr

iver

(mal

e)

Unk

now

n 1

supe

rvis

or; 1

edi

tor;

1 nu

rse;

4

inte

rvie

wer

s; 1

driv

er

1 su

perv

isor

; 1

field

edi

tor;

4 in

terv

iew

ers;

1

driv

er

1 su

perv

isor

; 1 fi

eld

edito

r; 4

inte

rvie

wer

s; 1

dr

iver

Num

ber o

f te

ams

14 te

ams

Unk

now

n 15

team

s

9 te

ams

4

team

s in

HID

s

Surv

ey s

tart

-up

M

id N

ovem

ber 1

998

July

200

3 La

te J

uly

2003

A

ugus

t 200

6

Sep

tem

ber,

2008

Fiel

d or

gani

zatio

n / w

ork

Perio

d of

fiel

d w

ork

Nov

– F

eb 1

999

July

– S

ept 2

003

Late

Jul

y –

late

O

ctob

er, 2

003

3 m

onth

per

iod

Sept

– D

ec 2

007

Follo

w-u

p w

ith a

few

ad

ditio

nal c

lust

ers

in F

eb-

Mar

ch 2

008


Gha

na

Surv

ey C

ompo

nent

D

HS

1998

-99

A

CSD

200

3 D

HS

2003

M

ICS

2006

M

ICS

su

pple

men

tary

20

07

Obs

erva

tion

of in

terv

iew

s

Unk

now

n U

nkno

wn

Unk

now

n U

nkno

wn

Yes

Supe

rvis

ion

Tech

nica

l te

am

supe

rvis

ion

Unk

now

n U

nkno

wn

10 re

gion

al

stat

istic

ians

act

ed a

s co

ordi

nato

rs a

nd

GSS

coo

rdin

ated

and

su

perv

ised

fiel

dwor

k

Unk

now

n St

art-u

p su

perv

isio

n do

ne

by G

SS

, Mac

ro, &

IIP

-JH

U te

am fo

r 1 w

eek

Editi

ng o

f qu

estio

nn-

aire

s Fi

eld

edito

rs

Offi

ce e

dito

rs a

t GS

S

Unk

now

n Fi

eld

edito

rs

Offi

ce e

dito

rs a

t GS

S

Fiel

d ed

itors

O

ffice

edi

tors

at

GS

S

Sim

ilar t

o M

ICS

200

6

Dat

a en

try

proc

edur

es

The

data

wer

e th

en

ente

red

and

edite

d us

ing

mic

roco

mpu

ters

and

th

e In

tegr

ated

Sys

tem

fo

r Sur

vey

Ana

lysi

s (IS

SA

) pro

gram

me

deve

lope

d fo

r DH

S s

urve

ys.

Unk

now

n

Dat

a pr

oces

sing

co

ncur

rent

with

fie

ldw

ork;

12

data

en

try o

pera

tors

; do

uble

ent

ry a

nd

cons

iste

ncy

chec

king

Dat

a pr

oces

sing

co

ncur

rent

with

fie

ldw

ork;

10

dat

a en

try o

pera

tors

w

ith 2

dat

a en

try

supe

rvis

ors

& 4

se

cond

ary

edito

rs;

doub

le e

ntry

and

co

nsis

tenc

y ch

ecki

ng

Sim

ilar t

o M

ICS

200

6

Qua

lity

cont

rol l

oop

Unk

now

n U

nkno

wn

Dat

a pr

oces

sing

co

ncur

rent

with

fie

ldw

ork;

feed

back

se

nt to

fiel

d te

ams

Dat

a pr

oces

sing

co

ncur

rent

with

fie

ldw

ork;

fe

edba

ck s

ent t

o fie

ld te

ams

Sim

ilar t

o M

ICS

200

6

Dat

a ed

iting

D

ata

edite

d/cl

eane

d fo

r int

erna

l co

nsis

tenc

y by

GS

S

Unk

now

n

Dat

a ed

ited/

clea

ned

for i

nter

nal

cons

iste

ncy

by G

SS

us

ing

CSP

ro

Dat

a ed

ited/

clea

ned

for

inte

rnal

co

nsis

tenc

y by

G

SS

usi

ng C

SP

ro

Sim

ilar t

o M

ICS

200

6, T

A

(Tre

vor C

roft

& G

aret

h Jo

nes)

Fina

lizat

ion

of

data

C

ompl

eted

mid

-Mar

ch

1999

by

GS

S

File

s tra

nsfe

rred

to

SP

SS

& S

tata

for

anal

ysis

Com

plet

ed m

id-

Dec

embe

r 200

3 by

G

SS

Com

plet

ed

Nov

embe

r 200

6 by

GS

S

Upp

er E

ast r

egio

n co

mpl

eted

ear

ly J

une

2008

Dat

a pr

oces

sing

Impu

tatio

n of

bi

rth

date

s D

one

acco

rdin

g to

D

HS

sta

ndar

d M

issi

ng b

irth

mon

th

impu

ted

to “6

” D

one

acco

rdin

g to

D

HS

sta

ndar

d D

one

acco

rdin

g to

st

anda

rd M

ICS

Tr

evor

Cro

ft, c

onsu

ltant


Gha

na

Surv

ey C

ompo

nent

D

HS

1998

-99

A

CSD

200

3 D

HS

2003

M

ICS

2006

M

ICS

su

pple

men

tary

20

07

Sour

ces:

DH

S 1

998

repo

rt(37

)

File

s tra

nsfe

rred

from

UN

ICE

F;

disc

ussi

on w

ith

How

ard

Gol

dber

g

DH

S 2

003

repo

rt(38

) G

hana

MIC

S 2

006

repo

rt; a

vaila

ble

from

UN

ICE

fF

Fiel

d vi

sits

; key

in

form

ants


AP

PEN

DIX

G

Ta

bles

pre

sen

tin

g pr

iori

ty in

dica

tors

ove

r ti

me

for

AC

SD “

hig

h im

pact

” di

stri

cts

Ta

ble

G1.

EP

I+ a

nd IT

N c

over

age

indi

cato

rs o

ver t

ime

in th

e “h

igh

impa

ct” d

istri

cts,

Gha

na (w

eigh

ted)

n%

mis

s(%

)95

%

CI

n%

n%

mis

s(%

)95

%

CI

n%

mis

s(%

)n

%m

iss(

%)

95%

C

In

%m

iss(

%)

95%

C

IEP

I+P

erce

ntag

e of

chi

ldre

n ag

ed 1

2-23

mon

ths

who

ar

e im

mun

ized

aga

inst

m

easl

es38

601

50 -

7059

3968

059

- 77

276

7317

3082

078

- 85

396

800.

979

- 82

Per

cent

age

of c

hild

ren

aged

12-

23 m

onth

s w

ho

rece

ived

3 d

oses

of D

PT

vacc

ine

3868

058

- 78

6439

760

65 -

8732

366

730

931.

488

- 98

397

950.

793

- 97

Per

cent

age

of c

hild

ren

aged

12-

23 m

onth

s w

ho

are

imm

uniz

ed a

gain

st H

ib30

662

53 -

79P

erce

ntag

e of

chi

ldre

n 6

- 59

who

rece

ived

at l

east

on

e hi

gh d

ose

vita

min

A

supp

lem

ent w

ithin

the

last

6

mon

ths

155

652

59 -

7178

185

861

75 -

9765

684

37

131

912

87 -

9419

7590

2.8

8 -

92

ITN

s2

Per

cent

age

of c

hild

ren

aged

0-5

9 m

onth

s sl

eepi

ng

unde

r an

inse

ctic

ide

treat

ed m

osqu

ito n

et (I

TN)

5³

230

230.

416

- 30

1394

27 4

614

443

134

- 52

2256

580.

554

- 61

Per

cent

age

of p

regn

ant

wom

en s

leep

ing

unde

r an

inse

ctic

ide

treat

ed

mos

quito

net

(ITN

) 1

31[3

2]0

n/a

166

26 4

0

N/A

N/A

2003

DH

S20

03 A

CSD

-CD

C

Indi

cato

rs*

No

Dat

a

N/A

sam

e as

DP

T

1998

/199

9 D

HS

N/A

MIC

S 20

0620

02

IHN

S1

No

Dat

a

No

Dat

aN

o D

ata

MIC

S 20

07 S

u ppl

.

*A

ll va

ccin

atio

n in

dica

tors

cal

cula

ted

base

d on

MIC

S p

roto

cols

(whe

re d

istri

butio

n of

chi

ldre

n re

porte

d va

ccin

atio

n be

fore

12m

in c

ard

s ap

plie

d to

all

child

ren

repo

rted

as v

acci

nate

d).

(1) I

HN

S d

ata

not a

vaila

ble;

indi

cato

rs fr

om IH

NS

200

2 su

rvey

repo

rt

(2

) ITN

= In

sect

icid

e tre

ated

net

def

ined

as

treat

ed w

ithin

12

mon

ths

befo

re th

e su

rvey

or l

ong-

last

ing

net.

(3) O

nly

avai

labl

e fo

r chi

ldre

n 6-

32 m

onth

s of

age

(4) I

nclu

des

bedn

ets

treat

ed in

pre

viou

s 6

mon

ths

only

(pre

viou

s 12

m n

ot a

vaila

ble

in d

ata )


Tabl

e G

2. Il

lnes

s ca

se m

anag

emen

t ind

icat

ors

over

tim

e in

the

“hig

h im

pact

” dis

trict

s, G

hana

(wei

ghte

d)

n%

Mis

s(%

)95

%

CI

n%

n%

Mis

s(%

)95

%

CI

n%

Mis

s(%

)n

%M

iss(

%)

95%

C

In

%M

iss(

%)

95%

C

IPe

rcen

tage

of c

hild

ren

aged

0-5

9 m

onth

s w

ith

feve

r rec

eivi

ng a

ntim

alar

ial

drug

s2

6078

068

- 89

3944

710

54 -

8736

761

0.3

3867

3.6

58 -

7655

453

1.6

48 -

58

Perc

enta

ge o

f chi

ldre

n ag

ed 0

-59

mon

ths

with

fe

ver r

ecei

ving

app

ropr

iate

an

timal

aria

l dru

gs3

4466

047

- 84

367

590.

338

0.3

3.6

0 - 0

.855

49

1.6

6 - 1

2

Gha

na a

ntim

alar

ial p

olic

y

Perc

enta

ge o

f chi

ldre

n ag

ed 0

-59

mon

ths

with

su

spec

ted

pneu

mon

ia

take

n to

an

appr

opria

te

heal

th p

rovi

der

3254

236

- 72

5329

[66]

0n/

a20

635

020

n/a

4n/

an/

a14

550

40

41

- 58

Perc

enta

ge o

f chi

ldre

n ag

ed 0

-59

mon

ths

with

su

spec

ted

pneu

mon

ia

treat

ed w

ith a

ntib

iotic

s

322

00

- 520

n/a 4

n/a

n/a

136

51 4

641

- 60

Perc

enta

ge o

f chi

ldre

n ag

ed 0

-59

mon

ths

with

di

arrh

oea

rece

ivin

g O

RS,

R

HF

or in

crea

sed

fluid

s an

d co

ntin

ued

feed

ing

3539

228

- 49

2443

320

18 -

4643

137

131

301

20 -

4035

728

0.9

24 -

33

ACT

2007

MIC

S su

ppl

1998

/199

9 D

HS

2002

IH

NS1

2003

DH

S20

03 A

CSD

-C

DC

chlo

roqu

ine

chlo

roqu

ine

No

data

IMC

I cas

e m

anag

emen

t in

dica

tors

2006

MIC

S

chlo

roqu

ine

chlo

roqu

ine

ACT

(sin

ce 2

004)

No

data

No

data

[U

NW

EIG

HTE

D: B

AS

ED

ON

CA

SE

S 2

5-49

] [N

/A: R

ES

ULT

S N

OT

SH

OW

N; B

AS

ED

ON

>24

CA

SE

S]

(1)

IHN

S D

ATA

NO

T A

VA

ILA

BLE

; IN

DIC

ATO

RS

FR

OM

IHN

S 2

002

SU

RV

EY

RE

PO

RT

(

2) A

NY

AN

TIM

ALA

RIA

L M

ED

ICA

TIO

N

(3) I

NC

LUD

ED

TR

EA

TME

NT

WIT

H A

PP

RO

PR

IATE

AN

TIM

ALA

RIA

L A

CC

OR

DIN

G T

O N

ATI

ON

AL

PO

LIC

Y

(4)

MIC

S D

EFI

NIT

ION

OF

PN

EU

MO

NIA

DIF

FER

EN

T FR

OM

DH

S (S

EE

AP

P.D

)


Tabl

e G

3. F

eedi

ng b

ehav

iour

indi

cato

rs o

ver t

ime

in th

e “h

igh

impa

ct” d

istri

cts,

Gha

na (w

eigh

ted)

Indi

cato

rsn

%m

iss(

%)

95%

CI

n%

n%

mis

s(%

)95

%

CI

n%

mis

s(%

)n

%m

iss(

%)

95%

C

In

%m

iss(

%)

95%

C

IPe

rcen

tage

of

new

born

s pu

t to

the

brea

st w

ithin

one

ho

ur o

f birt

h39

110

3-19

4585

073

- 97

328

452

2842

029

-55

484

520.

847

- 56

Perc

enta

ge o

f in

fant

s ag

ed 0

-5

mon

ths

who

are

ex

clus

ivel

y br

east

fed

39[2

8]3

n/a

3328

[43]

0n/

a16

839

332

[56]

0n/

a25

855

046

- 64

Perc

enta

ge o

f in

fant

s ag

ed 6

-9

mon

ths

who

are

br

east

fed

and

rece

ive

com

plem

enta

ry fo

od19

n/a

n/a

n/a

18n/

an/

an/

a94

505

30[5

3]0

n/a

159

530

42 -

63

Perc

enta

ge o

f ch

ildre

n ag

ed 2

0-23

m

onth

s w

ho a

re

curr

ently

br

east

feed

ing

13n/

an/

an/

a21

n/a

n/a

n/a

9382

825

[92]

0n/

a12

584

077

- 92

2006

MIC

S²20

07 M

ICS

supp

l²20

03 D

HS

2003

AC

SD-

CD

C19

98/1

999

DH

S20

02

IHN

S¹

[U

NW

EIG

HTE

D: B

AS

ED

ON

CA

SE

S 2

5-49

] [N

/A: R

ES

ULT

S N

OT

SH

OW

N; B

AS

ED

ON

>24

CA

SE

S]

(1)

IHN

S D

ATA

NO

T A

VA

ILA

BLE

; IN

DIC

ATO

RS

FR

OM

IHN

S 2

002

(2) M

ICS

200

6: N

O F

ULL

BIR

TH H

ISTO

RY; U

NA

BLE

TO

CA

LCU

LATE

BR

EA

STF

EE

DIN

G IN

DIC

ATO

RS

AS

DH

S (S

EE

AP

P.D

)


Tabl

e G

4: A

nten

atal

and

pos

tnat

al c

are

over

tim

e am

ong

wom

en w

ith a

live

birt

h in

the

prev

ious

12

mon

th fo

r “hi

gh im

pact

” dis

trict

s,

Gha

na (w

eigh

ted)

Indi

cato

rsn

%m

iss(

%)

95%

CI

n%

n%

mis

s(%

)95

%

CI

n%

mis

s(%

)n

%m

iss(

%)

95%

C

In

%m

iss(

%)

95%

CI

Per

cent

age

of p

regn

ant w

omen

who

re

port

at le

ast 3

pre

nata

l vis

its to

a

skille

d he

alth

wor

ker³

3974

166

-82

4578

058

-98

326

822

2891

085

-98

478

892

86-9

2P

erce

ntag

e of

pre

gnan

t wom

en w

ho

repo

rt at

leas

t 4 p

rena

tal v

isits

to a

sk

illed

heal

th w

orke

r³39

641

52 -

7545

640

50 -

7832

674

228

860

77 -

9547

881

277

- 85

Per

cent

age

of p

regn

ant w

omen

re

ceiv

ing

inte

rmitt

ent p

reve

ntat

ive

treat

men

t for

mal

aria

dur

ing

pre

gnan

cy

in p

revi

ous

year

(any

SP)

454

00-

1031

85

523

5416

40-

6848

082

278

-86

Per

cent

age

of p

regn

ant w

omen

re

ceiv

ing

inte

rmitt

ent p

reve

ntat

ive

treat

men

t for

mal

aria

dur

ing

pre

gnan

cy

in p

revi

ous

year

(2+

dose

s)45

40

0-10

2347

1637

- 57

479

672

61-7

2P

erce

ntag

e of

new

born

s pr

otec

ted

agai

nst t

etan

us (2

+ do

ses

TT d

urin

g pr

egna

ncy)

3963

046

-79

4545

330

19-

4732

056

428

611

48-

7448

463

157

-68

Per

cent

age

of n

ewbo

rns

fully

pro

tect

ed

agai

nst t

etan

us

322

744

2875

064

- 86

482

781

73 -

82P

erce

ntag

e of

pre

gnan

t wom

en

rece

ivin

g 3

mon

ths

of ir

on

supp

lem

enta

tion.

81

4452

240

-65

281

1016

Per

cent

age

of b

irths

atte

nded

by

skille

d he

alth

wor

ker ³

3917

17-

2747

4518

010

-30

332

27<1

2847

033

-61

485

401

35-4

6P

erce

ntag

e of

new

born

s re

ceiv

ing

a po

stna

tal v

isit

by a

ski

lled

heal

th w

orke

r w

ithin

3 d

ays

of d

eliv

ery

² ³

3919

010

-27

4520

05-

34P

erce

ntag

e of

wom

en r

ecei

ving

vita

min

A

sup

plem

enta

tion

with

in 2

mon

ths

of

birth

39

720

61-8

345

580

47-7

033

251

<128

521

41-

6248

157

151

-62

No

data

2003

DH

S19

98/1

999

DH

S20

02

IHN

S¹

No

data

on

# of

day

s

No

data

No

data

No

data

No

data

No

data

2003

AC

SD-

CD

C

No

data

No

data

No

data

2006

MIC

S20

07 M

ICS

supp

l

(1

) IH

NS

DA

TA N

OT

AV

AIL

AB

LE; I

ND

ICA

TOR

S F

RO

M IH

NS

200

2 S

UR

VE

Y R

EP

OR

T

(2) W

OM

EN

WIT

H IN

STI

TUTI

ON

AL

DE

LIV

ER

IES

AS

SU

ME

D T

O H

AV

E A

PP

RO

PR

IATE

PO

STN

ATA

L C

AR

E

(3) S

KIL

LED

HE

ALT

H W

OR

KE

R D

EFI

NE

D A

S D

OC

TOR

, NU

RSE

/MID

WIF

E O

R A

UXI

LLIA

RY

MID

WIF

E


AP

PEN

DIX

H

Tabl

es p

rese

nti

ng

com

pari

son

s of

pri

orit

y in

dica

tors

ove

r ti

me

in A

CSD

“h

igh

impa

ct”

dist

rict

s an

d th

e co

mpa

riso

n a

rea

Tabl

e H

1. E

PI+

and

ITN

cov

erag

e in

dica

tors

ove

r tim

e in

“hig

h im

pact

” dis

trict

s an

d co

mpa

rison

are

as, G

hana

(wei

ghte

d)

U E R 2n

%n

%M

iss

(%)

95%

CI

n%

n%

Mis

s (%

)95

% C

In

%n

%M

iss(

%)

95%

CI

EPI+

*Pe

rcen

tage

of c

hild

ren

aged

12-

23

mon

ths

who

are

imm

unize

d ag

ains

t m

easl

es38

6051

160

155

- 64

3968

536

670.

564

- 71

396

8054

978

1.1

76 -

79

Perc

enta

ge o

f chi

ldre

n ag

ed 1

2-23

m

onth

s wh

o re

ceiv

ed 3

dos

es o

f DP

T va

ccin

e38

6851

565

160

- 70

3976

537

760.

373

- 80

397

9554

579

1.8

78 -

81

Perc

enta

ge o

f chi

ldre

n ag

ed 1

2-23

m

onth

s wh

o ar

e im

mun

ized

agai

nst

Hib

555

500

44 -

56

Perc

enta

ge o

f chi

ldre

n 6

- 59

who

rece

ived

at l

east

one

hig

h do

se

vitam

in A

sup

plem

ent w

ithin

the

last

6

mon

ths

155

6520

9922

317

- 26

185

8622

7179

277

- 81

1975

9023

6896

195

- 97

ITN

¹

Perc

enta

ge o

f chi

ldre

n ag

ed 0

-59

mon

ths

slee

ping

und

er a

n in

sect

icid

e tre

ated

mos

quito

net

(IT

N)

230

2327

653

0.4

2 - 4

2256

5826

6824

0.9

21 -

26

Perc

enta

ge o

f pre

gnan

t wom

en

slee

ping

und

er a

n in

sect

icid

e tre

ated

mos

quito

net

(ITN

) 31

[32]

328

20.

10.

5 - 4

No D

ata

No D

ata

No D

ata

No D

ata

No D

ata

No D

ata

No D

ata

No D

ata

No D

ata

No

Dat

asa

me

as D

PT

Indi

cato

rs

1998

/199

9 DH

S

HID

Com

paris

on a

rea

¥

2006

MIC

S/ 2

007

MIC

S su

ppl.

HID

2007

M

ICS

supp

lCo

mpa

rison

are

a ¥

2006

MIC

S

2003

DHS

HID

Com

paris

on a

rea

¥

[U

NW

EIG

HTE

D: B

AS

ED

ON

CA

SE

S 2

5-49

] [N

/A: R

ES

ULT

S N

OT

SH

OW

N; B

AS

ED

ON

>24

CA

SE

S]

¥ C

OM

PA

RIS

ON

AR

EA

IS G

HA

NA

– N

ATI

ON

AL

LEV

EL,

EX

CLU

DIN

G T

HE

HID

S A

ND

UR

BA

N A

RE

AS

OF

THE

GR

EA

TER

AC

CR

A A

ND

AS

HA

NTI

RE

GIO

NS

(1) I

TN =

INS

EC

TIC

IDE

TR

EA

TED

NE

T D

EFI

NE

D A

S T

RE

ATE

D W

ITH

IN 1

2 M

ON

THS

BE

FOR

E T

HE

SU

RV

EY

OR

LO

NG

-LA

STI

NG

NE

T.


Ta

ble

H2.

Cas

e m

anag

emen

t ind

icat

ors

over

tim

e in

“hig

h im

pact

” dis

trict

s an

d co

mpa

rison

are

as, G

hana

(wei

ghte

d)

n%

n%

Mis

s(%

)95

% C

In

%n

%M

iss(

%)

95%

CI

n%

n%

Mis

s(%

)95

% C

I

Perc

enta

ge o

f chi

ldre

n ag

ed 0

-59

mon

ths

with

feve

r rec

eivi

ng

antim

alar

ial d

rugs

(pro

gram

)¹60

7863

760

055

- 64

4471

518

676

62 -

7255

453

602

612.

555

- 68

Chi

ldre

n 0-

59m

with

feve

r in

prev

ious

2 w

eeks

, rec

'd

appr

opria

te a

ntim

alar

ial

treat

men

t (ef

fect

ive)

²44

6651

864

660

- 68

554

960

03

2.8

1 - 5

Gha

na a

ntim

alar

ial p

olic

y

Perc

enta

ge o

f chi

ldre

n ag

ed 0

-59

mon

ths

with

sus

pect

ed

pneu

mon

ia ta

ken

to a

n ap

prop

riate

hea

lth p

rovi

der

3254

336

220

17 -

2629

[66]

276

401.

133

- 47

145

50 ³

158

36 ³

028

- 44

Perc

enta

ge o

f chi

ldre

n ag

ed 0

-59

mon

ths

with

sus

pect

ed

pneu

mon

ia tr

eate

d w

ith

antib

iotic

s

322

318

205

15 -

2513

651

³14

635

³7

27 -

43

Perc

enta

ge o

f chi

ldre

n ag

ed 0

-59

mon

ths

with

dia

rrho

ea re

ceiv

ing

OR

S, R

HF

or in

crea

sed

fluid

s an

d co

ntin

ued

feed

ing

3539

430

231

18 -

2843

3239

638

0.7

33 -

4335

728

405

301.

225

- 35

No

Dat

a N

o D

ata

chlo

roqu

ine

chlo

roqu

ine

AC

TAC

Tch

loro

quin

ech

loro

quin

e

Com

paris

on a

rea

¥

No

Dat

aN

o D

ata

IMC

I cas

e m

anag

emen

t in

dica

tors

1998

/199

9 D

HS

2006

MIC

S/ 2

007

MIC

S su

ppl.

HID

Com

paris

on a

rea

¥

HID

20

07 M

ICS

supp

lC

ompa

rison

are

a ¥

2006

MIC

S

2003

DH

S

HID

¥

CO

MP

AR

ISO

N A

RE

A IS

GH

AN

A –

NA

TIO

NA

L LE

VE

L, E

XC

LUD

ING

TH

E U

ER

AN

D U

RB

AN

AR

EA

S O

F G

RE

ATE

R A

CC

RA

AN

D A

SH

AN

TI R

EG

ION

S

(1) A

NY

AN

TIM

ALA

RIA

L M

ED

ICA

TIO

N

(2

) IN

CLU

DE

D T

RE

ATM

EN

T W

ITH

AP

PR

OP

RIA

TE A

NTI

MA

LAR

IAL

AC

CO

RD

ING

TO

NA

TIO

NA

L P

OLI

CY

(

3) M

ICS

DE

FIN

ITIO

N O

F P

NE

UM

ON

IA D

IFFE

RE

NT

FRO

M D

HS

(SE

E A

PP.D

)


, Tab

le H

3. F

eedi

ng b

ehav

iour

indi

cato

rs o

ver t

ime

in “h

igh

impa

ct” d

istri

cts

and

com

paris

on a

reas

, Gha

na (w

eigh

ted)

n%

n%

Mis

s(%

)95

%

CI

n%

n%

Mis

s(%

)95

%

CI

n%

n%

Mis

s(%

)95

% C

I

Per

cent

age

of n

ewbo

rns

put t

o th

e br

east

with

in o

ne h

our o

f birt

h39

1150

923

0.1

19 -

2745

8556

641

037

- 45

484

5252

731

1.1

26 -

35

Per

cent

age

of in

fant

s ag

ed 0

-5

mon

ths

who

are

exc

lusi

vely

br

east

fed

39[2

8]23

529

023

- 36

28[4

3]24

049

0.6

42 -

5625

855

297

510.

244

- 58

Per

cent

age

of in

fant

s ag

ed 6

-9

mon

ths

who

are

bre

astfe

d an

d re

ceiv

e co

mpl

emen

tary

food

19n/

a19

067

160

- 74

18n/

a18

864

0.3

55 -

7215

953

180

570.

749

- 65

Per

cent

age

of c

hild

ren

aged

20-

23 m

onth

s w

ho a

re c

urre

ntly

br

east

feed

ing

13n/

a16

561

054

- 68

21n/

a13

171

162

- 80

125

8418

360

051

- 68

Per

cent

age

of h

ouse

hold

s co

nsum

ing

iodi

zed

salt

(>=1

5ppm

)27

36

4441

211.

419

- 23

3314

1243

1127

0.8

24 -

31

Per

cent

age

of h

ouse

hold

s co

nsum

ing

iodi

zed

salt

(>=1

5ppm

)(e

xclu

de H

H w

ith n

o sa

lt)

4027

27 -

302

28

No

data

No

data

3222

1227

056

0616

2926

- 33

IMC

I fee

ding

beh

avio

r in

dica

tors

1998

/199

9 D

HS

2006

MIC

S/ 2

007

MIC

S su

ppl.

¹

HID

Com

paris

on a

rea

¥H

ID 2

007

MIC

S su

ppl

Com

paris

on a

rea

¥

20

06 M

ICS

7

2003

DH

S

HID

Com

paris

on a

rea

¥

259

641

2323

920

- 25

[U

NW

EIG

HTE

D: B

AS

ED

ON

CA

SE

S 2

5-49

] [N

/A: R

ES

ULT

S N

OT

SH

OW

N; B

AS

ED

ON

>24

CA

SE

S]

¥ C

OM

PA

RIS

ON

AR

EA

IS G

HA

NA

– N

ATI

ON

AL

LEV

EL,

EX

CLU

DIN

G T

HE

UE

R A

ND

TH

E M

AJO

R M

ETR

OP

OLI

TAN

AR

EA

S O

F A

CC

RA

AN

D K

UM

AS

I

(1) M

ICS

200

6: N

O F

ULL

BIR

TH H

ISTO

RY; U

NA

BLE

TO

CA

LCU

LATE

BR

EA

STF

EE

DIN

G IN

DIC

ATO

RS

AS

DH

S (S

EE

AP

P.D

)


Tabl

e H

4: A

nten

atal

del

iver

y an

d po

stna

tal c

are

indi

cato

rs o

ver t

ime

in “h

igh

impa

ct” d

istri

cts

and

com

paris

on a

reas

, Gha

na (w

eigh

ted)

n%

n%

Mis

s(%

)95

%

CI

n%

n%

Mis

s(%

)95

% C

In

%n

%M

iss(

%)

95%

CI

Perc

enta

ge o

f pre

gnan

t wom

en w

ho re

port

at le

ast 3

pre

nata

l vis

its to

a s

kille

d he

alth

w

orke

r ²39

7450

566

161

- 70

4578

552

762

72 -

8047

889

532

800.

376

- 84

Perc

enta

ge o

f pre

gnan

t wom

en w

ho re

port

at le

ast 4

pre

nata

l vis

its to

a s

kille

d he

alth

w

orke

r ²39

6450

555

150

- 59

4564

552

582

54 -

6347

881

532

660.

361

- 71

Perc

enta

ge o

f pre

gnan

t wom

en r

ecei

ving

in

term

itten

t pre

vent

ativ

e tre

atm

ent f

or

mal

aria

dur

ing

pre

gnan

cy in

pre

viou

s ye

ar

(any

SP

)45

454

21

40

- 248

082

500

436

37 -

48

Perc

enta

ge o

f pre

gnan

t wom

en r

ecei

ving

in

term

itten

t pre

vent

ativ

e tre

atm

ent f

or

mal

aria

dur

ing

pre

gnan

cy in

pre

viou

s ye

ar

(2+

SP)

454

542

14

0 - 1

479

6750

031

6 2

6 -

37

Perc

enta

ge o

f new

born

s pr

otec

ted

agai

nst

teta

nus

(2+

dose

s TT

dur

ing

preg

nanc

y)39

6350

546

0.7

41 -

5145

3356

247

0.6

43 -

5148

463

531

600.

555

- 65

Perc

enta

ge o

f new

born

s fu

lly p

rote

cted

ag

ains

t tet

anus

48

278

529

751

70 -

79

Perc

enta

ge o

f pre

gnan

t wom

en re

ceiv

ing

3 m

onth

s of

iron

sup

plem

enta

tion.

44

5250

633

1129

- 38

Perc

enta

ge o

f birt

hs a

ttend

ed b

y sk

illed

heal

th w

orke

r ²39

1750

838

0.2

33 -

4345

1856

635

030

- 40

485

4053

342

036

- 48

Perc

enta

ge o

f new

born

s re

ceiv

ing

a po

stna

tal v

isit

by a

ski

lled

heal

th w

orke

r w

ithin

3 d

ays

of d

eliv

ery¹

²39

1950

838

0.1

33 -

4245

2066

435

0.4

31 -

40

Perc

enta

ge o

f wom

en r

ecei

ving

vita

min

A

supp

lem

enta

tion

with

in 2

mon

ths

of b

irth

3972

509

230

19 -

2745

5856

636

032

- 40

481

5753

148

0.5

43 -

53

ANC

, ass

iste

d de

liver

y an

d po

stna

tal c

are

indi

cato

rs

HID

HID

200

7 M

ICS

supp

lC

ompa

rison

are

a ¥

1998

/199

9 D

HS

2006

MIC

S/ 2

007

MIC

S su

ppl.

Com

paris

on a

rea

¥

2006

MIC

S

2003

DH

S

HID

Com

paris

on a

rea

¥

No

data

No

data

No

data

No

data

No

data

No

data

No

data

No

data

No

data

No

data

No

data

No

data

No

data

No

data

¥

CO

MP

AR

ISO

N A

RE

A IS

GH

AN

A –

NA

TIO

NA

L LE

VE

L, E

XC

LUD

ING

TH

E U

ER

AN

D T

HE

MA

JOR

ME

TRO

PO

LITA

N A

RE

AS

OF

AC

CR

A A

ND

KU

MA

SI

(1)W

omen

with

inst

itutio

nal d

eliv

erie

s as

sum

ed to

hav

e ap

prop

riate

pos

tnat

al c

are

(2)

Ski

lled

heal

th w

orke

r def

ined

as

Doc

tor,

nurs

e/m

idw

ife o

r aux

illia

ry m

idw

ife


App

endi

x I

Tabl

es p

rese

nti

ng

20

07

-8 r

esu

lts

for

key

indi

cato

rs in

th

e H

IDs

by s

ocio

-dem

ogra

phic

ch

arac

teri

stic

s of

th

e po

pula

tion

Ta

ble

I1: D

escr

iptio

n of

hou

seho

lds,

elig

ible

wom

en a

nd c

hild

ren

unde

r fiv

e su

pple

men

tal M

ICS

200

7-8

in th

e “h

igh

impa

ct” d

istri

cts,

G

hana

Perc

ent

Tota

l Hou

seho

lds

Perc

ent

Tota

l Wom

enPe

rcen

tTo

tal C

hild

ren

Dis

tric

ts

Dis

tric

ts

Dis

tric

ts

Buils

a12

%39

01

11%

378

113

%29

5Ka

sena

-Nan

kana

17%

567

215

%48

72

12%

272

Bong

o6%

184

35%

171

35%

103

Bolg

atan

ga M

unic

ipal

ity12

%39

54

12%

406

49%

199

Baw

ku W

est

10%

319

510

%31

75

10%

226

Baw

ku M

unic

ipal

ity21

%71

26

24%

798

626

%59

1Ta

lens

i-Nab

dam

10%

344

79%

294

79%

206

Gar

u-Te

mpa

ne12

%41

28

13%

437

817

%37

7R

esid

ence

Res

iden

ceR

esid

ence

Urb

an22

%74

4U

rban

23%

771

Urb

an19

%42

0R

ural

78%

2580

Rur

al77

%25

17R

ural

81%

1848

Mon

ths

sinc

e la

st b

irth

Sex

<12

1548

8M

ale

49%

1122

<24

2891

4Fe

mal

e51

%11

46C

urre

ntly

pre

gnan

tYe

s7%

229

Not

sur

e0.

1%3

Educ

atio

nN

one

58%

1911

Prim

ary

21%

702

Seco

ndar

y +

21%

674

Tota

l33

24To

tal

3288

Tota

l22

68

Tab

le I1

a: H

ouse

hold

s in

terv

iew

ed

Tabl

e I1

b: E

ligib

le w

omen

with

com

plet

e in

terv

iew

sTa

ble

I1c:

Und

er fi

ve C

hild

ren

with

co

mpl

ete

inte

rvie

ws


Tabl

e I2

: Vac

cina

tion

by s

ocio

-dem

ogra

phic

cha

ract

eris

tics

in “h

igh-

impa

ct” d

istri

cts,

Gha

na 2

007-

8

Dis

tric

ts

Bui

lsa

88%

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Kas

ena-

Nan

kana

87%

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Bon

go87

%n/

an/

an/

an/

an/

an/

an/

an/

aB

olga

tang

a M

unic

ipal

ity85

%n/

an/

an/

an/

an/

an/

an/

an/

aB

awku

Wes

t80

%n/

an/

an/

an/

an/

an/

an/

an/

aB

awku

Mun

icip

ality

77%

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Tal

ensi

-Nab

dam

84%

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Gar

u-T

empa

ne88

%n/

an/

an/

an/

an/

an/

an/

an/

aR

esid

ence

Urb

an83

%99

%77

%77

%87

99%

99%

9887

Rur

al84

%98

%83

%81

%30

995

%99

%94

310

Sex

Mal

e84

%98

%84

%82

%18

797

%98

%95

188

Fem

ale

84%

99%

80%

79%

208

95%

99%

9420

9W

ealt

h in

dex

quin

tile

sP

oore

st85

%99

%80

%79

%75

92%

97%

8977

283

%97

%73

%71

%72

92%

100%

9272

386

%99

%87

%86

%85

99%

100%

9984

482

%97

%89

%86

%79

98%

98%

9579

Leas

t Poo

r83

%99

%78

%78

%85

99%

100%

9985

Tota

l84

%98

%82

%80

%39

696

%99

%95

397

Ch

ildre

n 1

2-23

mo

nth

s o

f ag

e va

ccin

ated

ag

ain

st m

eals

es a

nd

DP

T

Inno

cula

ted

agai

nst m

easl

es

Inno

cula

ted

agai

nst D

PT

%

with

E

PI c

ard

- S

een

Rec

'd

vacc

ine

(%)

vacc

ine

befo

re 1

2m

(%)

² A

CS

D in

dica

tor:

mul

tiply

the

perc

ent o

f chi

ldre

n th

at r

ecei

ved

vacc

inat

ion

befo

re fi

rst b

irthd

ay, a

ccor

ding

to im

mun

izat

ion

card

, by

the

tota

l pe

rcen

tage

of c

hild

ren

vacc

inat

ed, a

ccor

ding

to c

ard

or m

othe

r’s r

epor

t.

AC

SD

in

dic

ato

r (%

)²

Num

ber

of

child

ren

12-

23m

¹

¹ C

hild

ren

12-2

3 m

onth

s of

age

, stil

l aliv

e w

ith n

on-m

issi

ng d

ata

for

indi

cato

r ca

lcul

atio

n: w

eigh

ted

AC

SD

in

dica

tor

(%)²

Num

ber

of

child

ren

12-

23m

¹

Rec

'd

vacc

ine

(%)

vacc

ine

befo

re 1

2m

(%)


Tabl

e I3

: Vita

min

A s

uppl

emen

tatio

n (o

ne-d

ose)

in p

revi

ous

6 m

onth

s by

soc

io-d

emog

raph

ic c

hara

cter

istic

s in

“hig

h-im

pact

” dis

trict

s,

Gha

na 2

007-

8

Dis

tric

ts

Buils

a88

%26

0K

ase

na-N

anka

na96

%23

2B

ongo

74%

87

Bolg

ata

nga M

unic

ipalit

y91

%17

5B

aw

ku W

est

96%

198

Baw

ku M

unic

ipalit

y93

%51

5T

ale

nsi

-Nabd

am

89%

176

Garu

-Tem

pane

83%

332

Res

iden

ceU

rban

93%

368

Rura

l89

%16

07

Sex

Male

90%

991

Fem

ale

90%

984

Ag

e in

mo

nth

s6-

1172

%22

112-

2390

%39

524-

3592

%46

036-

4791

%46

048-

5994

%43

9W

ealt

h in

dex

qu

inti

les

Poo

rest

90%

375

288

%38

93

91%

417

488

%41

7Le

ast

Poor

93%

377

Tot

al

90%

1975

¹ C

hild

ren 6

-59 m

onth

s of

age

, st

ill a

live

with

non-

mis

sing d

ata

for

indic

ato

r ca

lcula

tion:

weig

hte

d

Ch

ildre

n 6

-59

mo

nth

s o

f ag

e re

ceiv

ing

on

e d

ose

vi

tam

in A

su

pp

lem

enta

tio

n in

th

e p

revi

ou

s 6

mo

nth

s

Vit

amin

A

sup

ple

men

tati

on

(%

)

Num

ber

of

child

ren

6-5

9 m

ont

hs

of

age

¹


Tabl

e I4

: Util

izat

ion

of b

edne

ts b

y ch

ildre

n ag

ed 0

-59

mon

ths

by s

ocio

-dem

ogra

phic

cha

ract

eris

tics

in “h

igh-

impa

ct” d

istri

cts,

Gha

na

2007

-8

Sle

pt u

nder

m

osqu

ito n

et la

st

nigh

t (%

)

Sle

pt u

nder

an

ever

-tre

ated

mos

quito

net

la

st n

ight

(%)

Slep

t und

er a

n IT

N* l

ast n

ight

(%

)D

istr

icts

B

uils

a78

%76

%72

%29

4K

asen

a-N

anka

na59

%58

%54

%26

8B

ongo

76%

76%

76%

102

Bol

gata

nga

Mun

icip

ality

71%

71%

65%

196

Baw

ku W

est

58%

58%

56%

225

Baw

ku M

unic

ipal

ity47

%47

%45

%58

9Ta

lens

i-Nab

dam

77%

76%

72%

205

Gar

u-Te

mpa

ne55

%54

%53

%37

6R

esid

ence

Urb

an55

%55

%53

%41

8R

ural

62%

62%

59%

1838

Sex

Mal

e61

%60

%57

%11

19Fe

mal

e61

%61

%58

%11

37Ag

e in

mon

ths

0-11

65%

64%

62%

483

12-2

370

%69

%67

%39

924

-35

67%

66%

63%

463

36-4

754

%53

%49

%50

748

-59

51%

50%

48%

405

Wea

lth in

dex

quin

tiles Poo

rest

61%

60%

56%

434

261

%60

%58

%45

23

61%

61%

58%

473

462

%61

%57

%46

9Le

ast p

oor

61%

61%

59%

428

Tota

l61

%61

%58

%22

56

² Tot

al c

hild

ren

unde

r fiv

e w

ho s

lept

in H

H la

st n

ight

, with

non

-mis

sing

dat

a fo

r ind

icat

or c

alcu

latio

n:

wei

ghte

d

Chi

ldre

n ag

ed 0

-59

mon

ths

slee

ping

und

er a

mos

quito

net

, a tr

eate

d ne

t or a

n IT

N¹ t

he n

ight

pre

cedi

ng th

e su

rvey Pe

rcen

tage

of c

hild

ren

who

: N

umbe

r of

child

ren

0-59

m

onth

s of

ag

e²

¹ ITN

=Mos

quito

net

trea

ted

with

inse

ctic

ide

in th

e pr

evio

us 1

2 m

onth

s, o

r a lo

ng-la

stin

g ne

t
