Evaluate_Attach_J.5_ProMPT_Final_Report_Amend_02.pdf

Final RepoRt

PRESIDENT’S MALARIA INITIATIVE

C e n t e r s f o r D i s e a s e C o n t r o l a n d P r e v e n t i o n

TM

ProMPT Ghana Promoting Malaria Prevention and Treatment, was made possible by the United States Agency for International Development (USAID) under Cooperative Agreement number

641-A-00-09-00010-00. The project team included prime recipient University Research Co., LLC (URC) and sub-recipients the Population Council and Malaria Consortium.

DISCLAIMER

The authors views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development of the United States Government.

Final RepoRt April 2009–March 2013

Table of Contents

Introduction

Major Achievements

Coordination & Collaboration

Implementation Approaches & Results

Malaria Prevention through LLIN Distribution Door-to-door Hang-up Campaigns Continuous Distribution

Malaria in Pregnancy and Case Management, Including HMM Integrated Malaria in Pregnancy and Case Management Specific Activities Relative to MIP/IPTp Home-based Management of Malaria

Community-Based Malaria Prevention and Control National Level Multi-Media BCC Engaging Civil Society Capacity Building for NGOs

Capacity Building of GHS and Health Systems Strengthening Supportive Supervision Framework

Challenges & Opportunities

Lessons Learned & Recommendations

Annexes

Annex 1. Performance Monitoring Plan

Annex 2. Success Stories

Annex 3. Technical Briefs & Reports

Annex 4. Job Aids and BCC Materials

ACT Artemisinin-based Combination Therapy ANC Antenatal Care CBA Community-based Agent CD Continuous/Routine Distribution [of LLINs] CHIM Centre for Health Information and Management CHV Community Health Volunteer CWC Child Welfare Clinic DHMT District Health Management Team DHIMS District Health Information Management System DHS Demographic and Health Survey GES Ghana Education Services GHS Ghana Health Services HH Household HIO Health Information Officer HMM Home-based Management of Malaria ICD Institutional Care Division [of Ghana Health Service] IPTp Intermittent Preventive Treatment of Pregnant Women ITN Insecticide-treated Net LLIN Long-lasting Insecticidal Net M&E Monitoring and Evaluation MICS Multiple Indicator Cluster Survey MIP Malaria in Pregnancy NGO Non-governmental Organization NMCP National Malaria Control Programme PMI President’s Malaria Initiative PPME Policy, Planning, Monitoring, and Evaluation Division (Ghana Health Services) ProMPT Promoting Malaria Prevention and Treatment RHMT Regional Health Management Team SHEP School Health Education Programme SP Sulfadoxine-Pyrimethamine UNICEF United Nations Children’s Fund URC University Research Co., LLC USAID United State Agency for International Development WHO World Health Organization

Acronyms

A community volunteer carries a bale of long-lasting insecticidal nets.

Final Report 1

Introduction

Promoting Malaria Prevention and Treatment (ProMPT) Ghana was a four-year (March 2009–March 2013)

United States Agency for International Development (USAID)-funded program under the President’s Malaria Initiative (PMI). It was implemented by University Research Co., LLC (URC) and its partners, the Malaria Consortium and the Population Council. ProMPT aimed to strengthen the capacity, effectiveness, and reach of Ghana’s National Malaria Control Programme (NMCP) and support the engagement of all key actors in malaria prevention and control, including health workers, nongovernmental organizations (NGOs), schools, communities and the private sector.

Initially scheduled to end on March 9, 2012, the ProMPT agreement was extended to March 31, 2013. In its first 12-months, ProMPT had a nationwide mandate. However, with the launch of PMI-supported malaria activities through two other USAID-funded family health programs in ProMPT’s second year, ProMPT activities shifted to focus on seven of Ghana’s ten regions: Ashanti, Brong Ahafo, Eastern, Northern, Upper East, Upper West and Volta. Nevertheless, the project continued to provide technical support to some activities in all ten regions.

ProMPT worked to reduce malaria morbidity and mortality by implementing proven interventions in prevention and treatment. These interventions were clustered in four components:

1. Prevention of malaria through use of long-lasting insecticidal nets (LLINs);

2. Management of malaria in pregnancy (MIP), including intermittent prevention treatment for pregnant women (IPTp) and diagnosis of malaria and treatment with artemisinin-based combination therapy (ACT), including community-based home management of malaria (HMM) delivered by community-based agents (CBAs);

3. Strengthening capacity to implement community-based malaria prevention and control activities through social mobilization, which combines behavior change communication (BCC) and community mobilization; and

4. Capacity building of Ghana Health Service (GHS) and NMCP and health systems strengthening for monitoring and evaluation (M&E).

Coordination and collaboration with international and national partners were part of all of these components.

The project used the conceptual framework in Figure 1 to guide the implementation of activities.

This report summarizes ProMPT’s achievements and results, discusses the strategies used, and presents lessons learned and implications for future activities.

2 ProMPT Ghana Promoting Malaria Prevention and Treatment

Figure 1. ProMPT’s Conceptual Framework

Contribute to the reduction of malaria by 50% among �vulnerable groups by reaching 85% of pregnant women and �children with key interventions and commodities

High Impact Malaria Prevention and Control Activities

Brought to Scale

ProMPT Key Interventions:

Long-lasting Insecticidal Nets

Diagnosis & Case Management of Malaria

Malaria in Pregnancy and Infants

ProMPT component one:

STRENGTHENING Health � System RESPONSE

• Monitoring and Evaluation

• Logistics/Delivery System

• Supportive Supervision

• Provider Competence

• Quality Services

• Institutionalized Processes

ProMPT component two:

STRENGTHENING �

Community RESPONSE

• Behavior Change Communication

• Non-governmental Organization/ Faith-based Organization Participation

• Community Involvement

In collaboration with:

MOH, GHS, NMCP, �

USAID, PMI, GFATM, �

Private Sector, � UNICEF, NfL

Final Report 3

Major Achievements

Mosquito Net Distribution

• Supported NMCP to distribute a total of over 12.5 million insecticide-treated nets (ITNs), engaging all major stakeholders and volunteers

• Directly supported the distribution of 6,349,361 ITNs in four regions, with US Government funds and provided technical support for five additional regions

• Tested continuous distribution of ITNs through school-based distribution in partnership with the Ghana Education Service, which enabled over 181,000 students and teachers to receive nets

• Developed effective national strategies (and documented results) for distribution and hang-up campaigns as well as for continuous distribution of nets

Malaria Case Management and Malaria in Pregnancy

• Led an initiative to train and provide training materials for more than 10,000 facility-based health workers in integrated malaria case management and MIP

• Collaborated with GHS to train and provide training materials for over 2,500 community health officers and community-based agents in community case management of malaria

Supportive Supervision

• Worked with master trainers from GHS to train 642 supervisory staff from seven regions and from GHS’s Institutional Care Division (ICD) in supportive supervision and provided grants to enable regions to effectively monitor, evaluate and continuously teach health workers to correctly manage malaria and MIP

• In collaboration with the ICD of GHS, supported regions to conduct supervisory visits to over 21,000 health workers from more than 2,000 health facilities

ProMPT and GHS staff coach a health facility worker on calculation of malaria data.

4 ProMPT Ghana Promoting Malaria Prevention and Treatment

Behavior Change Communication and Community-based Malaria Prevention and Control

• Co-sponsored, with GHS and the USAID|Behavior Change Support (USAID|BCS) project, a nationwide multi-media campaign promoting malaria prevention, through which more than 11,000 radio spots aired in 5 local languages

• With NMCP and other partners, finalized a national malaria BCC strategy and developed and distributed a package of print materials, including 20,000 sets of counseling cards, posters on benefits of sulfadoxine pyrimethamine (SP) and posters on the use of ACTs

• Reached 2,134,147 people, through 33 NGO grantees, with malaria prevention messages and activities

• Engaged 326 civil society organized groups (e.g., trade unions, faith-based organizations) in community-based malaria activities

• Oriented more than 4,500 opinion leaders, including traditional chiefs and queen mothers, clergy members, trade union leaders and media journalists, in mobilization against malaria

Health Systems Strengthening

• Strengthened NMCP capacity to monitor and evaluate the national malaria program (through a seconded M&E advisor), equipping NMCP to use statistical software and conduct evaluations of national malaria projects

• Supported the training of 45,970 health personnel in malaria treatment or prevention in 7 regions

• Collaborated with the Policy, Planning, Monitoring, and Evaluation (PPME) Unit of the GHS and the NMCP to strengthen the capacity of regional and district health information officers (HIOs) in malaria data management and to coach facility-level staff in 4 regions to improve the use of reporting tools and the calculation of key indicators reported to the District Health Information Management System (DHIMS)

• Trained over 1,300 facility-based health workers to use new consulting room registers to improve data quality and distributed 15,500 revised registers in 7 regions

• Facilitated malaria data review meetings for the exchange of best practices in malaria data management, resulting in increases in the quality and timeliness of district reporting

Final Report 5

Coordination & Collaboration

From its outset, ProMPT systematically encouraged all malaria partners (and others) to collaborate, and the project made concerted efforts to do so for each project component. NMCP served as the primary counterpart organization within the Government of Ghana, closely followed by many other GHS units, the Regional Health Directorates, and the Districts.

The LLIN hang-up campaigns were massive undertakings, involving multiple partners, each contributing various resources and expertise.

In all campaigns NMCP and the GHS (and its regional, district, and sub-district units) were the lead partners. USAID|PMI and its partners, including USAID|DELIVER, USAID|Focus Region Health Project, and USAID|BCS, also played key roles in many campaigns.

International partners such as the Department for International Development, United Kingdom; the World Health Organization (WHO); the United Nations Children’s Fund (UNICEF); Malaria No More (UK); the Global Fund to Fight AIDS, Tuberculosis and Malaria;

and NetsforLife® were additional partners. For each regional campaign, numerous other local and international partners contributed.

Planning and implementation of continuous distribution (CD) also involved coordination with several partners. USAID|NetWorks facilitated the write-up of the continuous/ routine distribution guidelines and the NetCALC computer modeling tool. The Regional Health Management Team (RHMT) and the District Health Management Teams (DHMTs) in Eastern Region were pivotal in the planning and execution of the health facility-based CD channels: antenatal care (ANC) and child welfare clinic (CWC). The regional management of GES, the various district education circuits, School Health Education Program (SHEP) Coordinators, and primary schools in the region also played critical roles in piloting the school-based LLIN distribution.

For social mobilization and BCC, support to the National Malaria Communication Committee helped generate the harmonization of materials and messages and develop the National Malaria Behavior Change Communication Strategy. Partners in this effort included several GHS units, NMCP, UNICEF, WHO, Roll Back Malaria, USAID|BCS, Ghana Social Marketing Foundation, VOICES for a Malaria-free Future, World Vision Ghana, and a dozen Ghanaian NGOs. ProMPT and USAID|BCS created a joint implementation plan for the national malaria campaign under the “Good Life” umbrella. In another collaborative effort, ProMPT led the development and pre-testing of a pictorial fact sheet for LLIN campaign volunteers, involving seven partner organizations, including USAID|BCS and UNICEF; Malaria No More (UK) financed the printing. In every region, ProMPT worked with and supported a broad range of civil society organizations, including NGOs, organized groups, and faith-based organizations (FBOs).

ProMPT also collaborated with PMI/Centers for Disease Control and Prevention, WHO, NMCP, PPME/Centre for Health Information and Management (CHIM), regional and district HIOs and regional malaria focal persons to enhance the strengthening of routine systems throughout the project. The project also worked closely with health facility staff throughout the country during coaching visits and during trainings.

6 ProMPT Ghana Promoting Malaria Prevention and Treatment

Implementation Approaches & Results

MalaRia pReVention tHRoUGH llin DiStRiBUtion

In Ghana, use of ITNs, which have an insecticide incorporated into the netting fibers during manufacturing, is one of the main approaches to preventing malaria. By reducing contact between malaria-carrying mosquitoes and humans, the combination of high ownership and use of such nets reduces all-cause mortality in children under five by about 20% and malarial infections in children under five and pregnant women by up to 50%. The national strategic plan for malaria 2008–2015 sets several targets for ITN coverage by 2015, including having one ITN available per two persons by 2015;

100% of households (HHs) will own at least one ITN, and 85% of children under five years and pregnant women will sleep under an ITN.

The PMI targets align with national targets for net ownership and use. ProMPT supported the NMCP to achieve these goals. Table 1 summarizes the projects interventions and outputs relative to net distribution.

Table 1. Summary of Key Interventions and Outputs: Malaria Prevention through LLIN Distribution intervention output

Directly supporting door-to-door LLIN hang-up campaigns

6,349,361 LLINs hung in Northern, Eastern, Volta, and Ashanti Regions

Providing technical assistance for door-to-door hang-up campaigns

4,531,944 LLINs hung in Western, Central, Upper West, Upper East, and Brong Ahafo Regions

Applying the campaign model developed by NMCP and ProMPT in other campaigns

2,023,705 LLINs hung in Greater Accra Region

Pilot-testing CD of LLINs through primary schools

181,600 LLINs distributed to primary 2 and primary 6 pupils in 2,321 public and private schools in Eastern Region

Training in LLIN distribution, hang-up and/or promotion

33,430 people trained in 4 regions

Door-to-door Hang-up Campaigns The 2008 Ghana Demographic and Health Survey (GDHS) reported that only 32.6% of HHs owned at least one ITN. In addition, the 2008 HH Survey on ITNs, conducted by the USAID-funded NetMark project, found that almost 45% of ITNs owned were not hung and ready to use. The NMCP had adopted the use of LLINs as one of its primary malaria control interventions. Since 1998, untreated and treated nets had been available on a limited scale through distribution from fixed points, both in the public sector (for free or at subsidized prices) and in the private sector (for purchase).

In 2009, NMCP and ProMPT, in collaboration with the NetsforLife program, decided to try a new strategy, never used before on a large scale in Africa: a door-to-door delivery and hang-up campaign that used community volunteers. Just three years later, more than

12.5 million LLINs had been distributed in Ghana using this strategy.

The model developed with NMCP and supported by ProMPT is presented in Figure 2.

Final Report 7

Door-to-Door LLIN Distribution and Hang-Up Campaign in Ghana

Implementation

Evaluation

Social Mobilization

Household Registration

Debriefing on Lessons Learned

Advocacy with Leaders

Community Radio Announcements

Mobile Van Announcements

Data Validation by Supervisors

Sorting and Prepositioning of LLINs, Nails, and Rope

LLIN Hang-Up and Messages on Use

Training

Training of Registration Volunteers

Training of Logisticians

Orientation of Hang-Up Volunteers

Planning

District-Level Planning

Regional Harmonization of District Plans

Training of Supervisors and Trainers

National Planning Meetings

S ta ke ho ld er

E ng ag em en t

M o nito ring

Validation of LLIN Distribution

© 2012, University Research Co., LLC Design concept by Dr. Tankoano

Regional Planning Meeting

Figure 2. Door-to-Door LLIN Delivery and Hang-Up Campaign Model

Each campaign involved careful orchestration of multiple activities involving all levels of the health system, several other government sectors, donor and implementing agencies, civil society organizations, and volunteers.

At the central level, a national campaign committee oversaw planning; this committee and its subcommittees were replicated at the regional and district levels in coordination with the RHMT and DHMTs. A complex set of trainings ensured that supervisors, logisticians and volunteers had the knowledge and skills required to carry out their responsibilities.

Communities were tasked with recruiting and motivating volunteers for HH registration before LLIN distribution and the subsequent door-to-door hanging of nets. After a campaign, a validation exercise ascertained the number of LLINs distributed and hung. Campaign review meetings with stakeholders at the various levels discussed lessons learned and proposed solutions to identified problems.

Social mobilization activities served as the channel for both advocacy and information to communities to gain their commitment to support the campaigns and to practice the behaviors needed to sustain protection from mosquito bites. ProMPT’s social mobilization team worked closely with RHMTs and DHMTs, Malaria Focal Persons and other key stakeholders to enable them as malaria prevention advocates, who in turn worked with other officials, to gain the endorsement of community opinion leaders and stakeholders.

As a result, community leaders provided space to store the nets and other logistics, mobilized community members to support volunteers through various means, and in some instances paid for more “gong gong” beatings to increase awareness of the distribution and hang-up.

Other channels, such as mobile information vans and radio spots, announced the need to register a HH in advance to receive the correct number of nets and later reminded people to be at home on the day of the hang-up.

An outcome evaluation of door-to-door distribution and hang-up pilot campaign in the Northern Region found substantial increases in LLIN ownership, retention and use.

This evidence substantiated that door-to-door distribution of LLINs with hang-up support by local volunteers was an effective means of increasing LLIN use in the Northern Region. It also gave partners confidence in the approach and led to their commitment to replicate the strategy. Other evidence showed that people remembered the messages they heard about malaria. Of the HHs that received BCC messages, 81.0% had at least one member who slept under an ITN the previous night, whereas only 72.8% of HHs that did not receive messages had at least one member who slept under an ITN the previous night.

The difference was statistically significant (p=0.034).

8 ProMPT Ghana Promoting Malaria Prevention and Treatment

A community volunteer, with one of the pregnant women that he urged to go for malaria preventing antenatal care services.

Final Report 9

With this success, NMCP and partners embarked on carrying out the first LLIN campaign for universal coverage (defined as one ITN available per two people) by 2013. The campaign, held in the Eastern Region, resulted in the distribution of 1,142,110 nets. The Volta Region campaign followed, with 1,069,741 distributed. The lessons learned from these campaigns helped to further refine the model for subsequent door-to-door distribution and hang-up campaigns and helped to ensure the equitable distribution of LLINs.

Distribution in urban versus more rural environments: The next campaign, in the Ashanti Region, presented challenges that were not present in previous campaigns, challenges that derived from having a large, diverse metropolitan area, the regional capital of Kumasi. To address these challenges, implementation focused first on the 26 districts classified as rural; Kumasi Metro area was the final focal area. A strategy specific to each type of urban and peri-urban sub-population was developed and used for HH registration and distribution. ProMPT allocated additional time and resources to enable NMCP, the RHMT and the Kumasi Metro management team to complete the registration, distribution and hang-up. For example, a special collaboration among ProMPT, the Peace Corps and Ghanaian NGOs devised new approaches to reach Kayayei, a population of low-wage, seasonal migrant workers, who often live on the streets or in improvised dwellings. The experiences suggested that practices for reaching this vulnerable group, such as using trusted members of the group to register LLIN recipients and extend distribution hours into the evening, could be useful for other hard-to-reach populations. A total of 1,887,737 LLINs were distributed in Ashanti Region.

Table 2. Selected Indicators of Net Coverage and Use Before and After the May 2010 Campaign, Northern Region indicator

Before campaign

(n=928)* after campaign

(n=809) % increase

HHs with at least one ITN 53.5% 82.1% 53.5%

HHs with more than one ITN 26.2% 55.1% 110.3%

Children under 5 who slept under an ITN the previous night

31.8% 52.0% 63.5%

* Data are from the Ghana Demographic and Health Survey 2008.

Allocating LLINs for Equity Universal coverage—one net for every two people—is a goal, and the number is used for planning and evaluation purposes.

To ensure that all people are covered by LLINs at night, the campaigns allocate nets according to the number of sleeping places in a HH. The allocation takes into account LLINs found in a HH, but not yet hung. After volunteers hang the LLINs (both the new ones and those found in the home during registration), every sleeping place is covered by a net. This increases the likelihood that those who have less power, particularly children and women, are not denied access to this life-saving intervention.

10 ProMPT Ghana Promoting Malaria Prevention and Treatment

Institutionalization: Campaigns in Brong Ahafo, Central, Upper East, Upper West, and Western Regions, benefited from ProMPT’s technical support in the regional campaign planning meetings, training of community health volunteers (CHVs) to register HHs (HHs), and data validation and compilation. By the July 2012 “top-up” campaign in the Northern Region (to distribute additional nets to people not reached by the targeted campaign in 2010), NMCP and its regional counterparts had developed the requisite skills and capacity to lead the implementation of such campaigns, while ProMPT played a background role with technical support. Highlights of this campaign include strong partnerships with community leaders and district

ProMPT and Peace Corps Collaborate to Bring LLINs to

Vulnerable Populations

Kumasi, the capital of the Ashanti Region, is a large city of

1.5 million residents; it has several urban subpopulations that required specially tailored approaches to ensure that they receive LLINs. The Kayayei are a distinct population of low-wage workers who make their living by carrying goods on their heads, or by means of trolleys, or by selling small items in the markets. The Kayayei typically sleep in large groups within make-shift temporary shacks, underneath storefront verandas, or even outside without overhead cover. Similarly, many migrant workers frequent Kumasi for intermittent work opportunities. Like the Kayayei, these migrant workers also sleep in groups in improvised shelters.

Although Kayayei and street dwellers are especially at risk of suffering from severe malaria, registration of and hanging LLINs for them was not routine, particularly as these groups do not reside in HHs. Peace Corps volunteers, ProMPT and local NGOs combined efforts to ensure that these often overlooked and forgotten groups were reached. Almost 27,000 members of this vulnerable population were registered, and 4,300 LLINs were distributed to sleeping groups through NGO facilities.

As many as 20 to 30 Kayayei may sleep in wooden market stalls, after the market closes for the day. This sleeping place has an LLIN. Photo: David Kalpachian, Peace Corps

Figure 3. Number of LLINs Distributed and Dates of Regional Campaigns

WESTERN

NORTHERN

UPPER

WEST

UPPER EAST

BRONG

AHAFO

CENTRAL

VOLTA

GREATER ACCRA

EASTERN

ASHANTI

Feb–Mar 2012

368,537

Feb–Mar 2012

July

1,069,741

1,142,110

1,882,737

Dec 2010 & May 2011

Dec 2011

Nov 2011 1,329,819

1,031,932

2,023,705

Top up in 2012 1,882,737

Total with May 2010

Apr 2011 598,368

May 2012 1,203,288

ProMPT direct implementation support

ProMPT technical support only

No direct ProMPT involvement

Final Report 11 assemblies and a process of deciding volunteer motivation prior to the campaign. It was led by the Regional Coordinating Council, which provides intersectoral coordination to government activities. The map shows ProMPT’s support toward achieving universal LLIN coverage in Ghana.

Continuous Distribution The NMCP, with ProMPT support, developed a comprehensive CD system to sustain progress achieved through the distribution/ hang-up campaigns. CD ensures that everyone needing an LLIN after a campaign ends (newborns, migrants and people missed by the campaign and HHs with nets that need replacing) will have access to LLINs.

Two ProMPT-supported activities played key roles in developing the strategy: 1) a study tour to Kenya for GHS technical officers to learn about different approaches to CD and

2) use of the NetCALC tool, developed by ProMPT partner, The Malaria Consortium, to simulate the viability of the mix of channels and the quantity of nets needed to sustain the net coverage. In addition, ProMPT provided technical support to NMCP to review the CD guidelines and build consensus around the roles and responsibilities of piloting CD in Eastern and Volta Regions.

School distribution pilot in Eastern Region:

In August–September 2012, ProMPT, in collaboration with the Regional and District Education Officers of the Ghana Education Service (GES) trained 213 District School Health Education Program (SHEP) Coordinators and Circuit Supervisors as trainers to conduct and manage the circuit-level orientations and primary school-based LLIN distribution. These trainers trained 4,642 head teachers and school SHEP Coordinators from all 2,321 public and private primary schools in Eastern Region. During the campaign, schools distributed approximately 181,600 LLINs to primary 2 and primary 6 (P2 and P6) pupils in Eastern Region.

The key steps in the school-based distribution pilot are described in Table 3.

The collaborative efforts of LLIN campaigns resulted in substantial increases in LLIN ownership and use as demonstrated in Figures 4, 5 and 6. The largest differences are in Volta, Eastern, and Northern Regions, where campaigns were completed prior to the data collection for the Multiple Indicator Cluster Survey (MICS) in 2011.

While the 2011 MICS data show that the ambitious national targets (100% of HH owning nets and 85% of children and pregnant women sleeping under nets) have yet to be met, substantial progress has been made.

Because the job is unfinished, NMCP and GHS, with support from development partners, will need to continue efforts to strengthen and institutionalize support to increase and maintain LLIN ownership and use.

Key Channels of the CD Pilot CD maintains the focus on protecting the population groups most vulnerable to malaria by using distribution channels where pregnant women and young children are routinely found:

• ANC,

• Routine expanded program on immunization,

• Child Health Promotion Week, and

• School-based distribution (Eastern Region).

12 ProMPT Ghana Promoting Malaria Prevention and Treatment

Table 3. Steps for Distributing LLINs at Primary Schools

National Planning and Consensus Meetings

GHS (through the NMCP) actively engaged donors, development partners, health and education authorities, and the private sector in building consensus on the school-based LLIN distribution strategy and in developing an implementation process.

Regional Orientation and Planning Meetings

Regional orientation and planning meetings brought together regional and district education officers and SHEP Coordinators to be oriented on the CD implementation process and timeline.

Training of Trainers Workshops for District SHEP Coordinators and

GES Circuit Supervisors

Training of Trainers Workshops for District SHEP Coordinators and GES Circuit Supervisors equipped them to educate other teachers on the key facts related to malaria prevention and LLIN care and use, and school distribution. Micro-plans included information on the number of schools and enrollment figures for grades P2 and P6 (the beneficiaries of LLINs to be distributed).

Training of Primary School Head Teachers and SHEP Coordinators

At the circuit level, each circuit supervisor, supported by the district SHEP and the private school coordinator, organized a training session for all head teachers and school-based SHEP coordinators. The session addressed key malaria prevention messages and explained the process for distribution.

Orientation of Primary School Teachers

Trainers oriented primary school teachers on the rationale for the selection of the target classes and on key malaria prevention facts.

Distribution of LLINs to Pupils in Grades

P2 and P6

On the day(s) of distribution, each class teacher educated the pupils on the use and care of LLINs using laminated posters, developed and printed by ProMPT, as a teaching aid. Every class member received an LLIN.

Social Mobilization through School Drama and Radio

Eight schools, two urban and two rural, in each of two districts in Eastern Region piloted school dramas to engage students in using LLINs. The entire primary school population watched skits developed and performed by students to sensitize that population on the availability of and the need to consistently sleep under an LLIN to prevent malaria. Community radio stations also informed beneficiaries and their families about CD, and GHS staff and the SHEP Coordinators participated in weekly radio panel discussions to interact with listeners through phone call-ins.

Reporting

Records of the distribution at each school were sent to the circuit supervisors, who compiled the data from all the schools and submitted the information to the district SHEP. The district SHEP compiled all district data and submitted that information to the regional SHEP Coordinator. Circuit supervisors used data from schools to determine that all P2 and P6 children had received their LLINs. Any identified shortages were quickly reported, and additional nets sent to ensure total coverage. The Regional Deputy Director of Public Health shared the data with the NMCP, which used it to evaluate the campaign and inform future planning for CD.

Final Report 13

Figure 4. Trends in Ownership of ITNs: Percent of HHs with at Least One ITN by Region, Ghana 2011

Figure 5. Proportion of Children under Five Who Slept under an ITN the Previous Night, by Region, 2006–2011

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% Western

Upper East

31 32

Northern*

Brong Ahafo

Ashanti

Eastern*

Volta*

Greater Accra

Central

Upper West

MICS 2006

GDHS 2008

MICS 2011

* Campaigns completed prior to data collection

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% Western

Upper East

Northern*

Brong Ahafo

Ashanti

Eastern*

Volta*

Greater Accra

Central

Upper West

MICS 2006

GDHS 2008

MICS 2011

* Campaigns completed prior to data collection

14 ProMPT Ghana Promoting Malaria Prevention and Treatment

Figure 6. Proportion of Pregnant Women Who Slept under an ITN the Previous Night, by Type of Locale

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0% Urban

GDHS 2008

MICS 2011

Rural

Total

MalaRia in pReGnanCY anD CaSe ManaGeMent, inClUDinG HMM

The MIP interventions focused on

1) increasing uptake of intermittent preventive treatment of malaria during pregnancy (IPTp) at ANC, particularly the second and third doses of SP; 2) ensuring prompt and effective treatment of malaria cases that occur during pregnancy; and 3) promoting the regular use of LLINs among pregnant women. Case management content focused on 1) confirming a diagnosis of malaria through a rapid diagnostic test (RDT) or microscopy, 2) treating malaria through correct dosing of ACT, and 3) monitoring malaria cases to ensure improvement or referral for worsening cases.

For home-based management of malaria (HMM), ProMPT supported NMCP to develop strategies for effective implementation of HMM and to train trainers, community health officers/nurses and CBAs in community-based management of malaria. The interventions and outputs of activities supporting MIP and case management are in Table 4.

Integrated Malaria in Pregnancy and Case Management ProMPT adopted an integrated approach to MIP and case management, which was based on NMCP’s national malaria strategic plan for 2008–2015. In addition, ProMPT implemented NMCP’s recently revised MIP and malaria case management guidelines. The project worked with NMCP to train regional trainers who in turn trained district trainers, enabling large-scale and cadre-specific training countrywide. This resulted in a total of 10,045 health professionals receiving training in case management of malaria with ACTs, IPTp, and lab and microscopy.

Malaria in Pregnancy and Case Management Strategy To help Ghana reach its goal of a 75% reduction in malaria morbidity and mortality by 2015, ProMPT supported GHS to carry out a wide-ranging set of interventions aimed at improving supply, demand and management of MIP and malaria case management services. ProMPT’s strategy, developed with NMCP, was to ensure that potential users, their families and community leaders understood malaria treatment and prevention and that health providers knew how to accurately diagnose and treat malaria, how to administer SP to pregnant women and how to integrate these skills and services into the health delivery system.

Final Report 15

Table 4. Summary of Key Interventions and Outputs: MIP and Case Management intervention output

Training of facility-based health workers in MIP and case management

• 10,045 health workers trained nationwide

Reprinting and distribution of national guidelines and training manuals on MIP and case management

• Reproduced 11,800 copies of three sets of manuals in partnership with Improving Malaria Diagnostics (IMaD) and Jhpiego

Developing and distributing two job aids on IPTp and RDTs

Introduction of supportive supervision system through regional grants and technical support to supervisory teams

• 642 supervisory staff trained from the national, regional and district levels

• 21,586 health workers from 2,003 facilities received at least 1 supervisory visit

Mobilize communities to increase demand for MIP, case management and HMM

• 11,000 radio spots aired in 7 regions

• Community volunteers from 33 NGOs reached more than 2,134,147 people with information about early recognition of malaria symptoms and the need for treatment as well as the importance of IPTp

Support introduction of HMM • 2,526 community health officers and CBAs trained in HMM

• Produced and distributed educational materials, including 10,000 copies of new counseling card on home-based care, 10,000 copies of wall chart for CBAs and 30,000 copies of poster encouraging community members to seek CBA services

• Regional and national review meetings held on HMM strategy implementation and lessons learned

After completion of health worker training in MIP and case management, ProMPT and GHS shifted their attention to capacity building for the supervision of malaria services. To start this process, ProMPT trained 35 skilled regional and district supervisors from the seven regions to build GHS’s capacity in supportive supervision and create a pool of supportive supervision trainers. They worked alongside ProMPT’s expert trainers to train 625 regional and district supervisors in supportive supervision to enable them to provide hands-on guidance in MIP and case management to recently trained health workers at their respective facilities. ProMPT also trained 17 ICD (national level) staff to provide

16 ProMPT Ghana Promoting Malaria Prevention and Treatment

The nurse educates a pregnant woman about benefits of malaria prevention.

Final Report 17 coaching to the supervisors and to monitor the implementation of supportive supervision by the regions and districts.

The training culminated in the launch of grants to the regions to enable regional and district supervisors to carry out supportive supervision visits with health workers. These visits enabled supervisors to coach staff not only to improve the clinical quality of MIP and case management, but also to address broader, facility-level issues related to the quality of care. As supportive supervision fosters multidisciplinary team work, the visits allowed supervisors and facility staff to identify gaps and propose changes in areas such as internal processes on drug/supply requisitions, hygiene issues (such as having client wash rooms available) and referral systems. Furthermore, the visits helped strengthen the dialogue between districts and health facilities to identify and address issues faced by the facilities.

ProMPT worked with the regions to successfully complete two rounds of supportive supervision.

Across both rounds, 21,586 health workers from 2,003 health facilities received at least one supervisory visit: 99.4% of health facilities with a worker trained in MIP/case management received at least one visit. Figure 7 sets out the steps undertaken to introduce supportive supervision for MIP/case management.

Supportive supervision regional review meetings conducted midway through the process (organized by ProMPT and facilitated by regional health teams) also gave supervision teams an opportunity to share experiences and receive additional guidance on how to improve planning for and the implementation of supportive supervision.

Specific Malaria in Pregnancy/ Intermittent Preventive Treatment in Pregnancy Joint coaching visits to health facilities conducted with regional and district health officers highlighted inconsistencies and a

The supervision has helped us, especially on IPTp monitoring and how to chart monthly.

Facility Head, CHPS Compound in Upper East Region, February 2013 lack of understanding of the calculation of IPTp coverage, particularly related to the denominator. To address this, a job aid reminding providers and records staff how to calculate the IPTp coverage rate was

IPTp job aid from health facility in Eastern Region

18 ProMPT Ghana Promoting Malaria Prevention and Treatment

Supportive Supervision in Districts

• ProMPT provided grants to seven Regional Health Directorates to implement supportive supervision in two rounds. Round one was conducted in five regions, and round two was conducted in six regions.

• Trained supervisors from the district health teams supervised health facilities to identify and resolve barriers to good quality malaria services.

• Where feasible, supervisors worked with facilities to develop action plans to address key issues related to malaria case management and MIP.

Technical Assistance for Supportive Supervision

• Teams composed of ProMPT, ICD, and Regional Health Directorate staff provided coaching to support and monitor supportive supervision at the district level.

• The teams visited 97 districts in round one and 62 districts in round two.

• In round two, ICD took the lead in conducting monitoring and coaching visits and focused on districts most in need of support.

Review Meetings

• Midway through round one, ProMPT supported the regions to hold supportive supervision review meetings on lessons learned to date and to make midcourse corrections to the process.

• Meetings focused on helping supervision teams plan for supportive supervision and provide constructive feedback to health facilities.

Assessment

• To obtain facility feedback on their experience, facility heads completed post-supervisory questionnaires.

• In round one, 81% of respondents indicated a very high level of satisfaction with the first supportive supervision visit.

Across both rounds of grants, approximately 21,000 health workers from 2,000 facilities received a supervisory visit.

ProMPT and GHS trained 642 supervisory staff from seven regions in supportive techniques.

Mnemonic Devices for Steps in Supportive Supervision

Figure 7. ProMPT/GHS Supportive Supervision Process

Many supervisors found it challenging to internalize all of the recommended steps in planning for and carrying out supportive supervision. At the review meetings, ProMPT shared mnemonic devices with the attendees to help them remember the essential elements of supportive supervision.

Before the supervision visit – TICL:

• Form a supervision team with the requisite skills

and expectations of the visit in advance so they can prepare.

• Confirm your visit with the facility a few days before arrival.

• Make sure logistics are in place, such a means of transport and any materials or commodities needed by the facility.

During the supervision – COLA:

• Upon arrival, perform the appropriate courtesies

health facility.

• Ask questions about progress made, challenges the facility is facing, and/or anything that is unclear.

Before departing the facility – FAN:

• Provide constructive feedback; discuss the positive things observed and potential areas for improvement.

• Develop action plans or review progress on existing action plans.

• Define next steps and responsibilities for implementation of action items; discuss the time of the next visit and/or follow-up phone call.

Final Report 19

Figure 8. Percentage of Women Receiving at Least Two Doses of IPTp, by Type of Locale, 2008 and 2011

80%

70%

60%

50%

40%

30%

20%

10%

0% Urban

GDHS 2008

MICS 2011

Rural

Total

Figure 9. Percentage of Women Receiving IPTp2, Sub-Saharan Africa

0% 10% 20% 30% 40% 50% 60% 70%

Namibia 2009

Nigeria 2010

Guinea-Bissau 2010

Madagascar 2011

DRC 2010

Tanzania 2010

Kenya 2010

Uganda 2009

Liberia 2009

Malawi 2010

Senegal 2009

Ghana 2011

Zambia 2010

MICS 2011

WHO World Malaria Report 2011 developed in collaboration with NMCP, ICD and district staff. The job aid was distributed to facilities offering IPTp in all seven regions.

It enabled health workers to track the number of women receiving IPTp1, IPTp2 and IPTp3 each month; determine the number of women eligible for each dose (the denominator);

and plot the results monthly on a bar or line graph. The job aid enabled plotting to be done by hand and posted on the facility wall. In addition to tracking progress, helped serve as a reminder of the importance of IPTp to staff and patients.

Since most job aids were disseminated before or during supportive supervision, supervisors could help improve the uniformity of data collection by ensuring that all facilities in their jurisdiction used the correct numerators and denominators. In addition, supervisors helped facilities address situations that caused gaps in IPTp coverage by helping staff determine whether a pregnant woman was due for an IPTp dose during an ANC visit and remember to provide SP when indicated.

Ghana experienced a significant increase in the nationwide coverage of IPTp2 during the three-year period 2008–2011 (Figure 8).

The “total” level of coverage places Ghana among the highest in sub-Saharan Africa (Figure 9). The impressive growth from 46% to 65% brought Ghana closer to its target of 85% coverage of IPTp2. ProMPT’s work, carried out in collaboration with GHS and civil society, likely played a substantial role in these increases.

20 ProMPT Ghana Promoting Malaria Prevention and Treatment

Home-based Management of Malaria Throughout the project, ProMPT worked with NMCP to implement strategies to improve prompt treatment of uncomplicated malaria at the community level. ProMPT assisted with the development of implementation plans and helped lead a committee that oversaw the implementation of the malaria component of home-based care (or HMM) (In Ghana home-based care is essentially integrated community case management and covers childhood pneumonia, diarrhea, malnutrition and malaria.). To resolve bottlenecks in NMCP’s implementation of HMM, ProMPT actively participated in a nationwide review of HMM implementation in 2012. The review indicated that inadequate drug supplies, limited supervision and some misunderstandings of the HMM strategy as the main problems facing HMM implementation. Appropriate deployment and supervision of volunteers was a major constraint. ProMPT advocated for the resolution of these issues, and NMCP agreed to reduce by 70% the number of communities targeted for HMM until its fundamental elements could be better developed and implemented.

ProMPT also assisted NMCP with technical and financial support for the training of trainers at the national, regional and district levels. The project supported refresher training and supervision on HMM for 308 community health officers in 23 districts in the Ashanti, Eastern, Volta and Brong Ahafo regions. It also printed and disseminated numerous educational materials through government and NGO partners.

ProMPT redirected its efforts to support only “year-one” HMM districts (the first group of districts slated for HMM), rather than expand its support to the second group originally scheduled to begin in the second year of HMM implementation. The redirected efforts

1) included refresher trainings, consensus meetings and continuous coaching with regional and district malaria focal persons and 2) ensured that ProMPT-supported HMM activities in the 23 districts across four regions continued despite the challenges. In addition, ProMPT’s support to NGOs in HMM districts ensured that communities knew of the HMM services and that DHMTs learned about HMM challenges during regular NGO/DHMT meetings.

CoMMUnitY-BaSeD MalaRia pReVention anD ContRol

ProMPT’s community-based malaria prevention and control efforts worked to 1) increase demand for malaria interventions and 2) establish use of these interventions that would be sustained as a social norm, boosting community support and links to services. Social mobilization engaged many segments of society in embracing the goal of improving prevention and treatment of malaria, simultaneously strengthening the quality of health services and stimulating the public’s participation in both using and improving those services. Adapted from the definition used by UNICEF, social mobilization engaged a range of players in related and complementary efforts. It accounted for people’s needs; adopted the principle of community involvement; and empowered individuals, families, groups, and institutions for sustained action.

Activities used a mix of approaches— partnerships, capacity building, training, face-to-face interactions, mass media, special events, and traditional methods of communication—that lead to the sustained adoption of preventive and treatment behaviors: nightly sleeping under LLINs; rapid recognition of and action in cases of fever or other malaria symptoms; adherence to ACT; and early attendance at ANC and adherence to IPTp. ProMPT also leveraged the diversity of people, cultures, and social networks in Ghana through organized civil society groups and government structures, taking advantage of the opportunities they presented to influence the attitudes and behaviors of different social segments. Table 5 summarizes the interventions and outputs of ProMPT’s efforts relative to community-based prevention and control.

Final Report 21

Table 5. Summary of Key Interventions and Outputs: Community-based Malaria Prevention and Control

Development/dissemination of National Malaria Behavior Change Communication Strategy

• Strategy launched by the Minister of Health on World Malaria Day 2010

• 2,500 copies of strategy distributed to partners and stakeholders

Production and distribution of a package of malaria materials for health workers and community volunteers

• 20,000 sets of 7 counseling cards/job aids on LLINs, MIP and HMM

• 50,000 leaflets on LLINs

• 20,000 posters on benefits of SP

• 20,000 posters on ACT

• 4,274 radio spots aired nationwide on 23 radio stations

• 4,027 radio spots rebroadcast on 14 stations

• 1,796 spots, announcements, jingles, panel discussions and live presenter mentions aired on 21 community radio stations on MIP and LLIN use

Support joint “Good Life” malaria campaign with USAID|BCS

• Jointly developed strategy, media messages and materials;

technical input and review by ProMPT

• National campaign launched; music icon Nana Boro unveiled as LLIN Ambassador

• Materials produced and distributed:

– 50,000 posters on LLINs

– 20,000 large stickers

– 50,000 bumper stickers

– 100,000 leaflets on LLIN hanging and care

– 2,284 radio spots aired on 14 radio stations

Capacity development for NGOs and FBOs in community mobilization for malaria prevention…