Upper West Regional Health Services

2009 ANNUAL REPORT

Dr. Alexis Nang-beifubah Regional Director of Health Services

20 th February, 2010 FOREWORD The 2009 Annual Health Sector Performance report captures information on key health sector strategies and specific interventions that were implemented during the year. The year also marks the second full year in office of the new management. The health sector of the was confronted by many challenges in the 2009 service year particularly the perennial shortage of doctors during the absence of the doctors of the Cuban Medical Brigade. Other issues of concern were high infant and maternal deaths, inadequate monitoring and supervision, inadequate financial resources for service delivery including delays in the reimbursement of insurance claims to health facilities as well as weak clinical services. Despite these challenges, some modest achievements were made that were consistent with the trend showed in the 2008 Demographic and Health Survey (GDHS) report, the Multiple Indicator Cluster Survey (MICS) report and the routine service data for 2009. The modest achievements made can be attributed to our dedicated health staff, community based volunteers, local governments at all levels, the people of the Upper West region, our development partners such as JICA, UNICEF, UNFPA, Plan Ghana, World Vision etc. This concise easy to read report is to serve as an immediate source of information as well as a reference guide for researchers who are advised to contact the various units and BMCs for more details. The general health indices of the region are improving but not fast enough. It is my hope that this trend will continue through 2010 and beyond towards the achievements of MDG 4 & 5 by the target year of 2015.

Thank you

Dr. Alexis Nang-beifubah. Regional Director of Health Service

I EXECUTIVE SUMMARY The 2009 Annual report of the Upper West Region has been documented to reflect the key activities undertaken during the year under the four strategic objectives of the service and the outcomes as measured by the sector-wide indicators. It represents a summary of many processes and reports from all the BMCs.

In general terms, there were some remarkable improvements in most of the sector-wide indicators; however some indicators stagnated during the year. This is partly attributable to inadequate critical health personnel as well as inadequate funding for some priority interventions due to the global economic downturn which impacted negatively on funds inflow.

On healthy lifestyles and environment, the region intensified efforts to reach out to the general public with sensitization messages especially on healthy eating habits, physical exercise and environmental cleanliness. At almost all the levels of service delivery health talks and the importance of physical exercise featured very well. A keep fit club formed in the Wa Municipality contributed in a very large measure to the creation of awareness among the populace to adopt healthy lifestyles to enhance their health status. Additionally, a major anti-alcoholism campaign was launched to educate the public on the ill effects of alcohol consumption.

Functional CHPS zones increased from 64 to 85 representing 32.8% over the 2008 number. Family Planning acceptor rate increased from 52.7% in the year before to 55.9%. Penta III coverage however, stagnated almost at 90.0%. Although Tuberculosis (TB) cure rate improved from 27% to 37%, TB case detection declined from 20/100,000 in 2008 to 18/100,000 in 2009. OPD attendance per capita and hospital admission rate declined from 0.73 to 0.72 and 68/1000 to 65/1000 population in 2009 respectively whilst Under-5 Malaria Case Fatality Rate was 2.4%. The nutritional status of children under-5 years also

II suffered some decline. The proportion of underweight climbed from 19.5% to 23.2%, the proportion of children wasting increased from 12.6% to 19.3%, whilst the proportion of children stunting went up from 29.7% in 2008 to 30.3% in 2009. Antenatal Care coverage slightly improved from 91.1% in 2008 to 92.2% in the year under review. Skilled delivery increased from 42% in 2008 to 52% in 2009, Post Natal Care (PNC) marginally increased from 67.4% in 2008.to 67.5% in 2009. Consequently, Institutional Maternal Mortality worsened by increasing from 109/100,000 live births in 2008 to 312/100,000 live births in 2009. Institutional Infant Mortality (IMR) also deteriorated from 9/1000 live births in 2008 to 12/1000 live births in 2009. Institutional U5MR however remained stagnant at 2/1000 live births as was the case in 2008.

Human resource availability and management continues to pose a serious challenge to quality health services delivery in the region. The midwives situation is particularly serious as most of them are ageing. Even though the doctor to population ratio had improved towards the close of the year, doctor availability remained largely unstable and erratic throughout the year to the extent that some facilities had to resort to locum doctors for over six months.

Internally Generated Funds (IGF) is gradually becoming a major source of funding for service delivery in the region accounting for over 80.0% of the total funding in 2009. This is attributable to increased utilization of services as a result of the National Health Insurance scheme whose contribution to total IGF was 89.66% during the year under review. In terms of funds disbursement, it was generally erratic and untimely and as a result service provision in some areas suffered. Besides, only 63.65% of the region’s budget for the year was actually released.

III CONTENTS Page FOREWORD ...... I EXECUTIVE SUMMARY ...... II ACRONYMS & ABBREVIATIONS ...... VII 1.0 INTRODUCTION ...... 1 1.1 Regional Profile ...... 1 1.2 Political arrangements ...... 1 1.3 Management Structures and Systems ...... 1 1.4 Demographic characteristics ...... 2 1.5 Health Structures ...... 3 1.6 Structure of the Report ...... 4 KEY ACTIVITIES PERFORMED ...... 5 2.0 OBJECTIVE 1: HEALTHY LIFESTYLES AND ENVIRONMENT ...... 5 2.1 Health Promotion and Awareness Creation on Risk Factors ...... 5 3.0 OBJECTIVE 2: HEALTH, REPRODUCTION AND NUTRITION SERVICES ...... 6 3.1 Clinical Care with Emphasis on Maternal and Child Health Services ...... 6 3.2 Reduction of Malnutrition as a Public Health and Developmental Problem ...... 6 3.3 Survival, Growth and Development of all Children ...... 6 3.4 Disease surveillance, emergency preparedness and response ...... 7 3.5 Access to Quality Maternal Newborn and Reproductive Health Services ...... 8 3.6 Improve Quality of Clinical Care ...... 8 3.7 Physiotherapy services ...... 8 3.8 Oral Health ...... 9 3.9 Eye Care ...... 9 4.0 OBJECTIVE 3: GENERAL HEALTH SYSTEMS STRENGTHENING ...... 10 4.1 Information Technology to Improve Information Management and Service Delivery .10 4.2 HR Planning, Recruitment, Deployment, Retention and Management ...... 10 4.2.1 HR Planning ...... 10 4.2.2 Recruitment, Deployment and Retention ...... 11 4.3 Performance Management ...... 11 4.4 Infrastructure to Support Effective and Efficient Service Delivery ...... 11 4.5 Supplies and Equipment Management ...... 12 4.6 Transport Availability and Management ...... 13 4.7 Research and Development ...... 14 5.0 OBJECTIVE 4: GOVERNANCE, PARTNERSHIP AND SUSTAINABLE FINANCING ...... 15 5.1 Management Systems and Leadership Training ...... 15

IV 5.2 Gender and Equity ...... 16 5.3 Financing Mechanism and Financial Management Systems ...... 16 5.4 National Health Insurance Scheme ...... 17 5.5 Health Revenue and Expenditure ...... 18 5.6 Community-based Health Planning and Services ...... 20 5.6.1 The JICA Project ...... 20 5.6.2 Community Health Action Plans(CHAP) ...... 20 5.6.3 Facilitative Supervision ...... 21 5.6.4 Phase two of JICA Project ...... 21 ANNEXES ...... 22 Annex 1: Summary of Some Sector Wide Indicators ...... 22 Annex 2: Trend of Malaria in Children U5 Years from 2005-2009 ...... 22 Annex 3: Trend of functional CHPS compounds by District ...... 23 Annex 4: Status of CHPS Implementation 2009 ...... 23 Annex 5 : Trend of ANC coverage – 2005 -2009 ...... 24 Annex 6 : Trend of Skilled Delivery -2006 -2009 ...... 24 Annex 7 : Population Ratios for Doctors and Medical Assistants ...... 25 Annex 8: Population Ratios for Midwives and CHOs ...... 25 Annex 9: OPD Clients Distribution by Age Group and Insurance Status - 2009 ...... 26 Annex 10 : Bed Utilisation Statistics (% occupancy and ALOS) 2007 -2009 ...... 26 Annex 11: Bed Utilisation Statistics (Bed Turn Over & Turn Over Interval) 2007 -2009 ...... 27 Annex 12: Outpatient Attendance by Districts 2005 -2009 ...... 27 Annex 13: Outpatient Attendance per Capita by District 2005 - 2009 ...... 28 Annex 14: Inpatient Admissions by Hospital 2005 -2009 ...... 28 Annex 15: Hospital Admissions Rate per District 2005 - 2009 ...... 29 Annex 16: HIV Prevalence Among Pregnant Women Attending ANC by Dist 2008 - 2009 ....29 Annex 17: HIV Prevalence Among Pregnant Women by Age Group 2007 - 2009 ...... 30 Annex 18: Prevalence of Malaria per 100,000 populations 2005 - 2009 ...... 30 Annex 19: Tuberculosis Cases Detection Per 100,000 (2005 - 2009) ...... 31 Annex 20: Tuberculosis Cure Rate 2005 - 2009 ...... 31 Annex 21: Treatment Outcomes (NSP) 2006 - 2008 ...... 31 Annex 22: Expanded Programme on Immunization 2005 - 2009 ...... 32 Annex 23: Measles Immunization Coverage 2005 -2009 ...... 32 Annex 24: Penta 3 Immunization Coverage 2005 - 2009 ...... 33 Annex 25: OPV 3 Immunization Coverage 2005 - 2009 ...... 33 Annex 26: Tetanus Toxoids Immunization Coverage 2005 - 2009 ...... 34

V Annex 27: Yellow Fever Immunization Coverage 2005 - 2009 ...... 34 Annex 28 : AFP Non – Polio Rate ...... 35 Annex 29: Post Natal Care Coverage 2005 -2009 ...... 35 Annex 30:Family Planning Acceptor Coverage 2005 - 2009 ...... 36 Annex 31: Institutional Maternal Mortality Ratio 2007 - 2009 ...... 36 Annex 32: Top Ten Causes of OPD Attendance 2007 - 2009 ...... 37 Annex 33: Top Ten Causes of Admission 2007 - 2009 ...... 38 Annex 34: Top Ten Causes of Inpatient Mortality 2007 - 2009 ...... 38

LIST OF TABLES Table 1: Pop. of UWR Projected from 2000 Census population (GR-1.7%) ...... 2 Table 2: Health Facilities per District ...... 3 Table 3 : Comparative Procurement Values from CMS and the Private Sector ...... 13 Table 4 : Sources of Funds - 2009 ...... 16 Table 5 : Ratio of NHIS to Cash And Carry ...... 17 Table 6: Budget and Funds Availability 2006 – 2009 ...... 19 Table 7:Revenue Trends 2006 – 2009 ...... 19 Table 8:Expenditure by Source of Funds ...... 19

VI ACRONYMS & ABBREVIATIONS AFP - Acute Flaccid Paralysis ANC - Antenatal care ART - Anti Retroviral Therapy BCG - Bacille Calmette Guérin (Tuberculosis Vaccine) BMCs - Budget Management Centres CBGP - Community-based Growth Promoters CHN - Community Health Nurse CHO - Community Health Officer CHPS - Community Based Health Planning and Services CHPW - Child Health Promotion Week CMAM - Community-based Management of Acute Malnutrition CMS - Central Medical Stores CT - Counselling & Testing DDHS - District Director of Health Services DHA - District Health Administration DPF - Donor Pooled Fund EPI - Expanded Programme on Immunization FSV - Facilitative Supervision FT - Field Technician GHS - Ghana Health Service GMP - Growth Monitoring and Promotion GOG - Government of Ghana HIRD - High Impact Rapid Delivery HRP - Human Resource Planning ICT - Information and Communication Technology IGF - Internally Generated Funds JICA - Japanese International Cooperation Agency LAN - Local Area Network MDGs - Millennium Development Goals MHD - Municipal Health Directorate NACP - National Aids Control Programme NGOs - Non-Governmental Organisations NHI - National Health Insurance NHIS - National Health Insurance Scheme

VII NMCCSP - Nutrition and Malaria Control for Child Survival Project OPD - Out Patients Department OPV - Oral Polio Vaccine PMTCT - Prevention of Mother to Child Transmission PPMs - Planned Preventive Maintenance RCC - Regional Co-ordinating Council RHD - Regional Health Directorate RHMT - Regional Health Management Team RMS - Regional Medical Stores RQAT - Regional Quality Assurance Team SAM - Severe Acute Malnutrition SFP - Supplementary Feeding Programme UN - United Nations UNICEF - United Nations International Children’s Emergency Fund W/A - Weight-for-age WFP - World Food Programme BMI - Body Mass Index DHMT - District Health Management Team GIMPA - Ghana Institute of Management & Public Administration

VIII 1.0 INTRODUCTION

1.1 Regional Profile he Upper West Region is situated in the North-Western part of the country Tand borders the Northern Region to the south, Upper East Region to the north-east, Republic of La Cote D’Ivoire to the West and Burkina Faso to the north.

Presently it has nine (9) political districts from the previous 8 with the splitting of the Jirapa/ District into two. The Lambussie-Karni District which is the latest addition has taken off but requires a lot of support both in infrastructure and other resources to be able to function more effectively. This is not to say that the other relatively older Districts are any better in terms of adequate infrastructure and other resources.

1.2 Political arrangements At the apex of the political/administrative arrangement is the Regional Co- ordinating Council (RCC) whose basic role is to co-ordinate, harmonise monitor and evaluate the activities of District Assemblies as well as Government departments in the region. The Regional Co-ordinating Council is made up of the Regional Minister as head with all District Chief Executives and Presiding Members of District Assemblies, two representatives of the Regional House of Chiefs, a representative of the National Development Planning Commission, as members. Regional heads of decentralized departments are ex-officio members of the Regional Co-ordinating Council. The region has an urban council in Wa and four town councils (Jirapa, , Tumu and ) and 47 Area Councils. In addition there are 618 unit committees in the region

1.3 Management Structures and Systems The following management structures have been established for the effective management of health services at the various levels: a Regional Health Committee responsible for advising the Regional Director on the running of the regional health service, district health committees, core and extended management teams at the regional, district and hospital levels, community health committees at the community levels, standing committees and taskforces. The

1 systems used include co-ordinated planning mechanisms, quarterly and annual performance reviews, peer review mechanisms, durbars, open days and staff performance management systems.

All these management systems play key roles in the effective and efficient running of health services as well as good governance and general participation from the regional level right down to the community level.

1.4 Demographic characteristics The projected population for 2009 based on the year 2000 Population and Housing Census using a growth rate of 1.7% is 671,043. There are 989 settlements. Table 1 shows the total projected populations of the various districts from 2007 to 2009. The region covers a total land area of 18,476 km 2, with a population density of 32 persons per square kilometre. The Sissala district has the lowest population density of 11 persons per square kilometre, whilst Lawra district has the highest of 94 persons per square kilometre. This low population density means cost of health delivery per capita is high due to long travelling distances to reach the population. The bad nature of roads and the poor road network in some districts makes movement even more difficult. Illiteracy rate is high. It is estimated that only about 29.9% of the adult population of the region are literate (GLSS, 2008).

Table 1: Pop. of UWR Projected from 2000 Census population (GR-1.7%) District 2007 Projection 2008 Projection 2009 Projection Jirapa 108,962 110,814 63,549 Lambussie - - 49,149 Lawra 98,487 100,161 101,864 93,076 94,658 96,267 Sissala East 50,916 51,782 52,662 Sissala West 45,227 45,996 46,778 Wa East 55,900 56,162 63,645 Wa Municipality 112,049 114,513 116,229 Wa West 84,180 85,741 80,900 UWR 648,797 659,827 671,043

2 1.5 Health Structures The Regional Health Management Team (RHMT) comprises of four main units: Public Health, Clinical Care, Health Administration and Support Services and the Office of the Regional Director. The four units are responsible for strategic planning, resource mobilization and distribution, training, technical support, monitoring and evaluation of service delivery in the districts.

There are nine district health services managed by District Health Management Teams. The nine districts are further demarcated into sixty-five {65) sub-districts, one hundred and ninety-seven (197) CHPS zones with eighty-five being functional. Table 2 below shows the various health facilities per district.

Table 2: Health Facilities per District

District

Hospitals Health Centres Clinics Centre RCH CHPs Private Maternity Homes Clinics Private Private Hospitals Total Jirapa 1 7 0 0 8 0 0 0 16 Lambussie 0 6 0 0 9 1 1 0 17

Lawra 2 8 0 2 9 0 0 0 21 Nadowli 1 12 0 0 14 0 0 1 27

Sissala East 1 6 0 0 6 1 0 0 14

Sissala West 0 4 0 0 7 0 0 0 11 Wa East 0 6 1 0 8 0 0 0 14

Wa Municipal 1 6 3 0 12 1 3 2 28

Wa West 0 6 0 0 12 1 0 0 18

Reg Total 6 61 4 2 85 4 4 3 166 There are also at least 885 Traditional Birth Attendants, 1,165 community based surveillance volunteers and 184 guinea worm volunteers who are providing services in the communities with supervision from sub district health staff. Community participation in health delivery is facilitated at all levels through the community representation on various health committees at Regional, District and Sub district levels.

3 1.6 Structure of the Report The 2009 report is structured around the four main health sector thematic areas. These are:

1. Healthy lifestyles and environment:- This area considers broadly Health Promotion and Awareness Creation on risk factors; Nutrition Services and Food Safety; Environmental and Occupational Health and Safety; Healthy lifestyles and Behaviours 2. Health, Reproduction and Nutrition Services:- This looks basically at Clinical care with emphasis on access to Quality Maternal and Child Health Services: Reduction of Malnutrition as a Public Health and Developmental Problem; Survival, Growth and Development of all Children; Disease surveillance, emergency preparedness and response; 3. General Health System Strengthening; This section is concerned with: Information Technology to improve Information Management and Service delivery; Human Resource Planning, Recruitment, Retention and Management; Infrastructure to Support Effective and Efficient Service Delivery; Supplies of Medicines and Non-medicine Consumable and Equipment Management; Transport Availability and Management; Research and Development 4. Partnership and Sustainable Development: This section analyses: Management Systems and scale-up leadership training; Gender and Equity; Financing Mechanism and Financial Management Systems; National Health Insurance Scheme; Health Expenditure

The report also provides a three-year trend of the sector –wide health indicators to show how the region fared and indicated the way forward.

The facts and figures are attached at the end of the report as appendixes.

4 KEY ACTIVITIES PERFORMED

2.0 OBJECTIVE 1: HEALTHY LIFESTYLES AND ENVIRONMENT During the year under review, a number of activities were carried out under the regenerative health and nutrition strategy to promote healthy lifestyles and environmental practices.

2.1 Health Promotion and Awareness Creation on Risk Factors The key health promotion messages focused on healthy eating habits and exercise. Alcoholism has become a growing concern in the region and a Stakeholders’ discussions was held on it following the dissemination of research findings conducted by a local NGO known as Rural Action Aid Programme. In addition, there was intense education on the benefits of eating natural foods such as moringa, having adequate rest and use of water therapy among others. Medical screening exercises were also organized for health staff and the general public during every occasion. With regard to physical exercises, keep fit clubs were formed in all the districts to promote physical exercises whilst weekly health walks were organized for health staff and the general public especially in Wa. The year under review also saw a renewed effort at creating increased awareness on environmental cleanliness and ensuring occupational health and safety. Zoomlion Ghana Ltd which is a waste management company is a key partner to Ghana Health Service in providing waste management services to some health facilities in the region particularly the regional hospital. A number of activities were also carried out to enhance occupational health and safety. Health staffs were reoriented on infection prevention and waste management

5 3.0 OBJECTIVE 2: HEALTH, REPRODUCTION AND NUTRITION SERVICES

3.1 Clinical Care with Emphasis on Maternal and Child Health Services During the year under review, the region adopted strategies to improve maternal and child health. The capacity of institutions were also strengthened to implement recommendations of maternal and infant death audit committees. All the forty- three (43) facility and four (4) community maternal deaths reported were audited and the implementation of recommendations is in progress. There has also been gradual increase in skilled deliveries over the three year period (2007 -2009) increasing from 33% in 2007 to 42.2% in 2008 to 51.6% in 2009.

3.2 Reduction of Malnutrition as a Public Health and Developmental Problem Micro-nutrient deficiencies, especially vitamin A, iron and iodine remain a huge public health challenge in the region. Poor dietary consumption and inadequate education among others contribute to this problem. Various interventions including dietary diversification through nutrition education, supplementation and food fortification are currently being implemented at various levels to improve the situation in the region. Weight-for-age (W/A) is the main indicator used to monitor malnutrition during Growth Monitoring and Promotion (GMP) sessions. There was an increasing trend of underweight for the three year period (2007 – 2009) in Jirapa, Nadowli, and Sissala West districts. On the other hand, Lawra and Sissala East and Wa West districts made reductions in the prevalence of underweight. The overall regional prevalence rate of children 0-23 months underweight reduced by 2.3% (from 26.4% to 24.1%).

3.3 Survival, Growth and Development of all Children A joint nutrition and malaria control for child survival project (NMCCSP) is being implemented in all districts in the region. Baseline data were collected in May 2009 from four districts namely Lawra, Jirapa, Wa Municipal and Lambussie Karni. Activities of this programme are not going on as expected mainly due to

6 delay in the release of funds and other logistics from Accra. At the close of year only three districts received funding and have trained community-based growth promoters making a total 5 districts in the region currently on the programme.

World Bank supported the NMCCSP with transport –(vehicles and motorbikes) and weighing scales.

3.4 Disease surveillance, emergency preparedness and response The Region used passive and active systems of surveillance at the both the health facility and community levels supported by Community Based Surveillance Volunteers who reported suspected cases and events from their communities for follow-ups by their respective Sub-district staff. The achievements recorded by the region during the year under review were as follows; • Polio surveillance stool adequacy was 64%. The region reported 12 suspected cases against a target of 6 cases - thus giving us a non polio AFP rate of 4.8 • 18 suspected cases of measles were reported. Samples were collected on all the cases for investigation. All the results were negative for measles IgM but one sample sent from the tested positive for rubella IgM. • 60.4% of suspected meningitis cases had lumbar puncture conducted to confirm their diagnosis. The region recorded 86 cases of meningitis with 9 deaths in 2009. This gives a case fatality rate of 10.5% • Blood specimens were collected from 10 patients who had symptoms of jaundice for investigation for yellow fever. All these specimen tested negative for yellow fever

The unit among other things investigated cases of food poisoning in which a family of four (three children and their mother) died due to organophosphate poisoning of the food they ate. These deaths occurred in the Nandom hospital. Health staff and selected population groups were sensitized on the H1N1 pandemic.

7 3.5 Access to Quality Maternal Newborn and Reproductive Health Services During the period under review, training for midwives in life - saving skills was enhanced. Thirty-two (32) midwives were trained in Safe motherhood clinical skills and another twenty-eight (28) given a refresher. Twenty-four (24) midwives from the districts and hospitals were also trained in neonatal resuscitation care. District hospitals also implemented the Kangaroo Mother Care programme. The strategy is a skin-to-skin care given to low birth weight and pre-term babies with the aim of reducing neonatal mortality. A total of six hundred and ninety-five (695) pre term and Low Birth Weight neonates benefited in the care. Out of this number seventy-three (73) died giving a mortality rate of 10.5%.

There was an improvement in the number of clients counselled especially pregnant women as part of antenatal services in all the districts and the region as a whole with the main purpose of improving the quality of life for the HIV exposed infants . Currently all the six (6) hospitals are providing ART services with three hundred and ninety-four (394) clients benefiting. A total of 13,121 clients were counselled in 2009 out of which 12,366 were tested. 701 tested positive.

3.6 Improve Quality of Clinical Care The regional Clinical Care Unit carried out the following activities; dissemination of wrong site surgery guidelines and referral policy guidelines to health facilities. Regional training on the National Policy on referrals and quarterly facilitative supervision on referrals were carried out in all the district hospitals. Other activities carried out include; Institutional training in Infection Prevention and Control in three hospitals (Regional hospital, Tumu and Nandom). During the period under review the Regional Quality Assurance Team (RQAT) trained and inaugurated the Quality Assurance Team in Tumu hospital. The Team also took part in mortality conferences and maternal death audits.

3.7 Physiotherapy services The regional hospital is the only facility providing physiotherapy services in the region. The facility embarked on; radio talk shows, counselling on healthy lifestyle and treatment of some disease conditions using physiotherapy. There

8 has been improvement in client attendance from 85 in 2008 to 272 in 2009. Total revisits also improved from 372 in 2008 to 1095 in 2009. However service in 2008 covered only September to December because there was no Physiotherapist at that time. The unit also received donation from an American Philanthropic Organization – Joni and Friends Wheels for the World - comprising wheel chairs, walkers, clutches and walking sticks for the physically challenged which were distributed to over 300 clients.

3.8 Oral Health The Regional Hospital is the only facility with a dental clinic in the region although services are also provided by the Community Health Nurses during school health services in all the nine (9) districts in the region. There has been gradual increase in the number of cases seen at the dental clinic in the Regional Hospital over the past three year period compared; from 1,464 in 2007 to 1,781 in 2008 to 2,063 in 2009. Services at the facility include; tooth extraction, filling, scaling and polishing, wiring, root canal and minor surgery

3.9 Eye Care The Regional Hospital in Wa serves as the referral hospital for all eye cases in the region. Four (4) district hospitals namely; Nadowli, Jirapa, Lawra and Tumu have satellite clinics for eye care services. During the year under review, the Regional Hospital eye unit carried out community outreach services of which 6,743 people were screened. Out of the number screened, 56 were diagnosed with cataracts of which only 39 reported for surgery. Seven hundred and twenty- one (721) were also diagnosed with conjunctivitis and managed. The regional ophthalmologist was transferred out of the region in November 2009 as such cases that need specialist care are referred. To address the shortfall the region is planning to engage specialists for quarterly outreach services with support from the Swiss Red Cross.

9 4.0 OBJECTIVE 3: GENERAL HEALTH SYSTEMS STRENGTHENING

4.1 Information Technology to Improve Information Management and Service Delivery The region has made strides in the introduction of ICT in its day to day management to improve service delivery. Aside the procurement of additional computers to facilitate information management, a lot of external hard drives have also been acquired to back up data storage. The RHD was connected to the internet. The Regional Hospital also undertook some ICT projects in the period under review. All the service points at the Hospital had been networked to enhance effective and efficient service delivery and also to reduce drastically the waiting time of clients. Efforts would be made to ensure that the other 5 hospitals are also networked. The region will organize and update its information and regularly upload them onto the GHS websites for easy access by interested persons and organizations. Procurement of Anti-virus is a challenge to the region.

4.2 HR Planning, Recruitment, Deployment, Retention and Management Human Resource Management in the region still faces a major challenge. The region still does not have access to certain specialized services such as dentistry and lately eye care. The region basically relies on outreach services to cater for the specialized services not available in the region e.g. ENT, Eye and Psychiatry.

Other key areas of concern include: • Negative Staff Attitude • Inadequate numbers of key personnel • Increase staff attrition through retirements, death, staff proceeding on further studies and inter-regional posting • Acute staff accommodation shortage • Staff performance management • Ageing staff especially midwives

4.2.1 HR Planning The region held important meetings with key stakeholders in a bid to address the shortage of critical staff. There were meetings with Principals of the Health Training Institutions in the region as well as with the Honourable Regional Minister and his District Chief Executives. Some of the key issues discussed were how to improve the facilities in the training institutions to be able to admit more students and also ensure

10 quality training of the students. The following were some of the key issues raised • District Assemblies are to liaise with their respective District Health Administrations to determine the critical staff requirements for appropriate support • Assemblies to be more involved in the provision of accommodation for personnel posted to their respective districts

4.2.2 Recruitment, Deployment and Retention The Region embarked on a number of recruitment drives to resource the various facilities. Interviews were conducted for newly qualified health professionals who opted to serve in the region based on the national quota for the various categories. However, not all vacancies were filled and it is of significance to note that none of the 10 vacancies declared for midwives were filled. The region also secured the services of an Obstetrician Gynaecologist and two medical officers who honoured the posting out of the fifteen. All new recruits were orientated and deployed in the various facilities to enhance service delivery.

4.3 Performance Management Performance management as well as health and safety of staff were some of the key priority areas for the region during the year. As a measure to ensure the health and safety of staff, routine medical screenings were carried out for staff at the various BMCs to identify dangerous health conditions early enough for management. This practice is to be institutionalized in all facilities.

All Supervisors were also tasked to carry out performance appraisal for their subordinates. This was done twice and though the target of 100% was not achieved, it is refreshing to note that supervisors have attached a lot of importance to the practice and the region hopes to strengthen the appraisal system to ensure improved performance.

4.4 Infrastructure to Support Effective and Efficient Service Delivery Health infrastructure in the region equally faces a lot of challenges. There are still inadequate CHPS Compounds and offices as well as residential accommodation to support effective service delivery. Most of the health facilities also require some urgent renovations. However, the following activities were carried out to strengthen and improve the existing infrastructure in the region:

11 • Comprehensive assets registers were prepared and updated for some Hospitals and Directorates in the region. • Six (6) staff quarters within the Wa Municipality were renovated. • A security post was constructed at the Regional Health Directorate to ensure effective security for staff and property • Updates were conducted on all developmental projects. • Discussions were held with the Regional Coordinating Council on some suspended development projects for GHS in a bid to get them completed. • The region received support from NACP/Global Fund for refurbishments of twelve (12) sites for PMTCT. Out of the twelve (12) proposed sites, eight (8) are completed and works on the other four (4) sites are in progress. • The region has also secured legal title to land acquired for the construction of the new regional hospital.

4.5 Supplies and Equipment Management Some procurement was made in the area of office equipments to enhance administration. The region is also grateful to JICA for supporting the various DHAs and the Regional CHPS Unit with laptop computers, printers and external hard drives (comprising 10 laptops, 10 printers and 10 external hard drives). EPI also supported the region with 6 solar fridges and 66 solar batteries to enhance service delivery. Various PPMs on office and clinical equipment as well as needs assessment for clinical equipment were carried out during the year. The level of medicines supply has been quite remarkable throughout the year. As a measure of ensuring continuous availability of essential medicines and other non- medicine consumables at user points, the region procured drugs from other identified and reliable suppliers through open and competitive tender. This was because not all the essential medicines and non medicine consumables were available at the Central Medical Stores. The table below shows the comparative procurement values from the CMS and the open market during the year. There are plans to start schedule delivery this year.

12 Table 3 : Comparative Procurement Values from CMS and the Private Sector

Level of 2009

Procurement Drugs % of Total Non- Drugs % of Total

CMS 359,711.78 34.52 56,575.17 30.57

Open Market 682,200.03 65.48 128,512.31 69.43

Total 1,042,004.03 100 185,087.48 100 There was also a lot of effort to recover most of the debts owed the Regional Medical Stores to ensure that its operations are sustained. Equal efforts were made to redeem the RMS indebtedness to the CMS. There is much improvement with regards to the performance of non-medicine consumables as compared to the net deficit last year, i.e. net loss of GH¢17,586.15 to net profit of GH¢156,207.85. This improvement could be attributed to the following: o Increased stocking of fast moving items o Less pressure on the account From the statement, RMS is solvent enough to pay its creditors. Sales, payments and indebtedness increased from GH¢678,806.16 to GH¢1,376,459.29 for drugs representing more than 100%. Non –drugs consumables also increased from GH¢180,780.79 to GH¢ 419,417.40 representing over 200% for the year under review.

Payments to RMS in percentage terms decreased from 85% in 2008 to 77.4% in 2009 whilst indebtedness increased from 24.9% in 2008 to 38.3% in 2009. For non-medicine payments declined from 80.69% to 53.53% whilst indebtedness rose from 19.30% to 46.47% over the period.

Management would strengthen its debt recovery mechanisms to ensure that the RMS remains viable to provide the essential role of stocking essential medicine and non- medicine consumables to cater for the needs of the region.

4.6 Transport Availability and Management The region took delivery of 12 new vehicles and 334 new motorbikes to augment its fleet. The total fleet as at the end of the year stood at 77 vehicles and 478 motorbikes. The vehicles and motorbikes were mostly distributed to the District Health Directorates and the Sub-districts. The Hospitals are however confronted with inadequate transport for service delivery. Two trainings were conducted for all GHS drivers in the region on

13 defensive driving skills. Similar trainings were organized for all motor riders especially for the safe use of the Nafang motorcycles. The region carried out regular PPM especially for motorbikes to prolong the lifespan of the motorbikes and also ensured that all riders acquired riders’ license. An auction was also carried out to dispose of unserviceable vehicles and motorbikes. In all 27 vehicles and 151 motorbikes were auctioned. Two accidents were recorded involving 1 pick-up and 1 Ambulance. The two vehicles have since been repaired and are back on road. The region however faces a couple of challenges in managing its transport resources. The lack of genuine spare parts and the bad roads contribute significantly to the frequent breakdown and high cost of maintenance of vehicles and motorbikes. The inaccessible nature of the roads especially during the rainy season sometimes makes it extremely difficult to provide the needed services to some catchment areas. The region is working around the clock to improve and recapitalize the Mechanical Technology Center to cater adequately for the maintenance of the vehicles while lobbying the various stakeholders to improve the condition of the roads to ensure easy access. Security and proper use of vehicles and motorbikes will be enforced this year.

4.7 Research and Development The region embarked on one major research activity to determine the performance levels of frontline staff mainly community health nurses and midwives in the attainment of the MDGs 4 & 5. - the category of staffs we believe could provide the package of interventions as contained in the HIRD approach to essential service delivery. Though the region has had an appreciable number of these frontline staff especially community health nurses and field technicians, it is observed that there was not a corresponding increase in the coverage of services such as EPI, disease surveillance and nutrition. It was suggested that this basically was as a result of the individual CHNs and FTs not being well oriented to appreciate what level of performance is expected from each of them to make an impact both in coverage and quality of services rendered. The objective of the study was therefore 1. To determine the levels of knowledge and practice of community health nurses and field technicians in relation to their job descriptions. 2. To identify specific factors hampering the delivery of HIRD services by CHNs and FTs 3. To evaluate the utilization of the log books in monitoring service delivery performance at the community and sub-district level

14 4. To make recommendations to district and regional health authorities on ways of improving service delivery by CHNs and FTs.

The study revealed that most of the frontline staff had adequate knowledge of their job description. However about 50% needed some level of prompting to remind them of activities they had to carry out. Again, though most of these staff have heard about the HIRD strategy, not many actually appreciated what the strategy stood for. Based on the study, logbooks have been introduced to track the services of these frontline service providers. Orientation sessions would be held to expose the frontline providers to the tenets of the HIRD strategy. Managers at all levels have also been tasked to be more involved and interested in the performance of these staff to serve as a motivation and encouragement.

5.0 OBJECTIVE 4: GOVERNANCE, PARTNERSHIP AND SUSTAINABLE FINANCING

5.1 Management Systems and Leadership Training To strengthen leadership across all levels of management, the region facilitated leadership capacity building for senior and junior staff. Six senior staff (mostly management team members) from the DHAs and Hospitals were supported to attend a short course in Health Administration and Management (HAM) at GIMPA in Accra. One District Director of Health Services (DDHS) also attended a Leadership Development Course at the University of Ghana, Legon. Locally, refresher training was organized for RHMT, DHMT, and Sub-district staff in Facilitative Supervision (FSV) as a way of strengthening monitoring and supervision at all levels of the health delivery system. Community Health Officers were also retrained to enhance their capacity for effective CHPS implementation at the community level. A Regional Annual Work Plan based on key priorities was developed to guide programmes implementation, whilst a Facilitative Supervision Manual was modified to make it more relevant to programme or service needs.

All the management structures at the regional, district and facility levels were functional throughout the year. Even though the Regional and District Health Committees were dissolved in the early part of the year, the region continued to tap the wise counsel of

15 these bodies pending their reconstitution due to her peculiar circumstances.

5.2 Gender and Equity Gender planning and mainstreaming are global strategies adopted to promote gender equality. Even though the Upper West Region has not developed any known strategy to foster gender mainstreaming, most of its health activities with reference to access to health care, quality of care, reproductive and adolescent health needs are gender sensitive. The advocacy role the service in the region played for District Assemblies to support the training of midwives and Community Health Nurses was to ensure that women in the reproductive age group as well as rural populations were adequately served. In addition, the budgeting process and allocation of resources is reflective of the needs of all population sub-groups in the region.

5.3 Financing Mechanism and Financial Management Systems Financing of health services in the region comes from three main sources namely; Government of Ghana (GOG), Development Partners including the United Nations Agencies and Internally Generated Funds (IGF) derived largely from the NHIS. The contribution of GOG (recurrent expenditure) to the overall financing of health services in the region is fast decreasing whilst IGF which is driven by NHIS is fast assuming a dominant role. Funds (earmarked) from UN Agencies and other Development Partners are normally provided based on collaborative initiatives with the regional health services. The table below shows the relative shares of the various sources of funding to the service in the region.

Table 4 : Sources of Funds - 2009 Source Amount %Share GOG/DPF (Recurrent) 492,157.13 4.30% IGF 9,441,555.58 82.50% Donors 1,511,191.04 13.20% Total 11,444,903.75 100%

The Region relies on the Financial Monitoring Team located at the Regional Health Directorate for capacity development at the district level as far as financial management

16 is concerned. This team is responsible for supporting districts in their financial management processes including validation of financial information for routine reporting. During the year the team visited all the BMCs at least once to validate their financial data.

The Regional Internal Audit Division visited and coordinated all audit responses from the BMCs. Out of fourteen (14) BMCs targeted for the year, nine (9) were visited and the team used the opportunity to sensitize facility managers especially finance staff on the functions of the Audit Implementation Committees. The team collated and reviewed BMCs’ responses to external audit queries and educated managers and finance staff on current developments within the auditing system and on emerging issues. In addition, audit hearings were conducted for BMCs. However, the Unit has the potential to improve its operations if a separate budget line is created to finance its activities since funding from the general resource envelop of the region has several competing demands.

5.4 National Health Insurance Scheme National Health Insurance is steadily becoming the main source of recurrent budget of the region contributing about 89.66% to total IGF. This represents an increase of 8.66% over the previous year where it accounted for 81.0% of total IGF. In terms of OPD utilization, the NHIS was responsible for 86.70% of OPD attendance compared to 72.0% in the previous year. For admissions, the NHIS accounted for 88.69% as against 79.05% in 2008. The table below depicts the relative contributions of NHI and the “Cash and Carry” to total IGF by facility levels.

Table 5 : Ratio of NHIS to Cash And Carry BMC Cash & NHIS Total %Cash & %NHIS Carry Carry Regional 270,973.27 1,731,463.33 2,002,441.60 13.53 86.47 Hospital District 231,632.76 2,421,804.23 2,653,436.99 8.73 91.27 Hospital Sub-Districts 170,402.47 1,682,149.99 1,852,552.46 9.2 90.8 Total 673,013.50 5,835,417.55 6,508,431.05 10.34 89.66

In general, more females access health services using the NHIS than males. At the

17 outpatient department (OPD) females accounted for 56.37%, whilst accounting for 58.45% of admissions among the insured group.

Barring any unexpected developments in the operations of the NHIS, its increasing role as far as utilization and revenue mobilization are concerned would continue until out of pocket payment for health care becomes virtually non-existent or insignificant. The region is looking forward to that situation.

It is however, significant to note that processing of NHI claims is a factor that adversely affected service delivery in all health facilities in the region. Delays in the processing of the claims were both from the provider as well as from the NHIS side. On average re- imbursement of claims to health facilities by the NHIS took four to five months. Out of a total of nine million, two hundred and forty-four thousand four hundred and fifty-seven Ghana Cedis sixty-four pesewas (GH¢9,244,457.64) claims submitted to the NHIS, five million six hundred and thirty two thousand three hundred and forty-four Ghana Cedis thirty seven pesewas (GH¢5,632,344.37) was reimbursed giving a rate of 60.9%. Therefore, the negative effects of these delays on the delivery of quality care, could be eliminated through the policy of 40% upfront payment of claims to the health facilities and more through and purposeful claims preparations..

5.5 Health Revenue and Expenditure Internally Generated Funds (IGF) (“cash and carry” + NHIS claims) continues to constitute the largest source recurrent health expenditure in the region accounting for over 65.0%. This is followed by programme funds which represented over 31.0%. The share of GOG (recurrent expenditure) in the overall health expenditure is dwindling and accounted for just a little over 3.0%, whilst DPF is virtually being phased out. The table below shows the proportions of the various receipts and expenditures by source.

18 Table 6: Budget and Funds Availability 2006 – 2009 Year Annual Budget Yearly Releases GOG/DPF IGF Program Total % of Budget Funds Released 2006 6,245,668.98 728,247.76 1,183,631.00 710,003 2,621,881.76 42.0 2007 7,807,086.22 529,226.83 1,794,018.99 988,970.71 3,312,216.53 42.4 2008 15,880,872.75 350,448.29 6,138,511.43 1,775,159.40 8,264,119.12 52.0 2009 21,835,061.00 492,157.13 9,441,555.58 3,764,231.16 13,697,943.87 62.7

The trend in revenue mobilization over the past four years has been increasing except in 2007 where a drop was recorded. In 2009, total funding to the service in the region was significantly more in comparison with the year 2008. A total sum of thirteen million, six hundred and ninety-seven thousand nine hundred and forty-three Ghana Cedis eighty seven pesewas (13,697,943.87) was mobilized for service delivery in the region and out of this IGF share was 68.93% . There were no funds for investment in 2008 and 2009. The table below depicts the revenue trend for the past four years.

Table 7:Revenue Trends 2006 – 2009

FUND TYPE 2006 2007 2008 2009

GOG/DPF 728,247.76 529,226.83 350,448.29 492,157.13

PROG 710,003.00 988,970.71 1,775,159.40 3,764,231.16

IGF 1,183,631.00 1,794,018.24 6,138,511.43 9,441,555.58

INVESTMENT 293,354.90 80,903.00 0 0

TOTAL 2,915,236.66 3,393,118.78 8,264,119.12 13,697,943.87

Table 8:Expenditure by Source of Funds Source Amount Spent % Of Total Expenditure GOG 330,191.58 3.1% DPF 70,721.36 0.67% IGF 6,926,632.79 65.13% PROGRAMMES 3,306,925.24 31.1% GRAND TOTAL 10,634,470.97 100% Receipts relative to the total annual budgets from 2006 to 2009 were 41.98%, 42.43%, 52.04% and 63.65% respectively.

19 5.6 Community-based Health Planning and Services The region continued to progress gradually in the implementation of CHPS. Activities carried out in 2009 included meetings/durbars, CHO development, Facilitative supervision to all districts, launching of 22 CHPS compounds and the holding of Regional CHPS forum and final evaluation of the JICA project held in Accra.

Various communities in collaboration with the Regional Health Directorate have introduced the Community Emergency Transport system to cater for the emergency transport needs of communities where Ambulance services are not readily available. In this system, community members contribute an agreed sum to a common fund and private transport providers are contracted to provide services when the need arise. These providers are paid from the fund and the beneficiary community member given sometime to reimburse the fund. The strategy seems to be working very well and other communities are encouraged to adopt it.

5.6.1 The JICA Project The implementation of the JICA project started in 2006, with an overall objective of improving the health status of people living in the Upper West Region, through scaling up of the CHPS strategy. Within the time frame of the project from 2006 to 2010, JICA supported in various areas including capacity building of health staff, provision of medical equipment, development of manuals, promotion of community participation through Community Health Action Plans (CHAPs) and Facilitative Supervision (FSV). The project finally ended on 19 th January 2010 with a dissemination workshop in Accra.

The project was considered a huge success having contributed to the increase of the number of CHPS from 24 in 2006 to 84amongst others. However, some challenges were identified. These include slow pace of compound construction which was not included in the project design and inaccessible roads to CHPS zones.

5.6.2 Community Health Action Plans(CHAP) CHAP is a road map which guides community members on what they want to do and how to do it towards solving their health issues. CHAP provides the platform for participatory planning, implementation and evaluation of community health initiatives. As

20 a strategy of sustaining the achievements. Some CHPS zones were supported to develop action plans in order to maintain the gains made or improve upon them. These plans are reviewed and updated periodically. CHAP has caught up in other communities in other districts as an integral part of CHPS.

5.6.3 Facilitative Supervision It is an approach of supervision that emphasizes mentoring, joint problem solving, and two way communication between the supervisor and those being supervised. These visits were to provide technical support to improve quality of services. Some of the visits were jointly carried out by the regional and district teams. The visits provided an opportunity to interact with staff and also assess their performance with reference to the performance standards agreed upon at the beginning of the year.

Reviews were held monthly/quarterly to give feedback to CHOs and their supervisors and issues identified in the course of implementing action plans. At the regional level supervision was carried out to all nine districts and verbal feedback given at the district level immediately after supervision and written feedback distributed to districts later.

5.6.4 Phase two of JICA Project Following the successful completion of the first phase of the project a proposal was submitted to the Japanese government for a second one to consolidate the gains. In this pro[posal the challenge identified were incorporated – e.g construction of CHPS compounds. The proposal was approved and activities have already began to roll out the second phase.

21 ANNEXES

Annex 1: Summary of Some Sector Wide Indicators 2009 Performance Indicator Target 2007 2008 2009 Institutional MMR/100,000 Live Births 100 156 109 240 Institutional IMR/1,000 Live Births 6 9 9 Institutional U5MR/1,000 Children 0-59 months 1 2 2 ANC Coverage 98 91.1 91.1 92.2 % skilled delivery 50 33 42.2 51.6 PNC coverage 75 73.1 67.4 67.5 Family Planning Acceptor Rate 60 73.1 52.7 55.9 Penta3 coverage 90 94 90.2 90.8 Measles coverage 90 98 98.2 91.8 OPD attendance per capita 1 0.7 0.73 0.72 Hospital Admissions rate 57 67.6 65.2 % Underweight 26 19.5 23.2 % Wasting 11.9 12.6 19.3 % Stunting 26.4 29.7 30.3

Annex 2: Trend of Malaria in Children U5 Years from 2005-2009

22 Annex 3: Trend of functional CHPS compounds by District

Annex 4: Status of CHPS Implementation 2009

District Zones Op CHPS Pop Cov. by Pop % by dist. Earmarked zones CHPS Jirapa 18 8 15,318 24.1 Lambussie* 15 9 18,389 37.4 Lawra 22 9 18,001 18 Nadowli 34 14 34,521 30.6 Sissala East 18 6 18,097 34.4 Sissala West 15 7 15,521 12.4 Wa Mun. 24 12 27,726 24.2 Wa East 24 8 19,731 24.9 Wa West 31 12 16,353 22.6 Region *201 85 183,657 27.1 *Was part of the then Jirapa-Lambussie Districts

23 Annex 5 : Trend of ANC coverage – 2005 -2009

District 2005 2006 2007 2008 2009 Jirapa 78.3 73.9 89.9 84.4 93.9

Lambussie* 0.0 83.3

Lawra 69.3 68.4 72.3 69.2 71.4

Nadowli 87.3 88.6 100.8 90.1 101.7

Sissala East 77.7 95.9 102.1 98.1 98.5

Sissala West 72.2 79.7 88.4 79.0 78.2 Wa East 115.6 99.0 129.6 121.3 92.0

Wa municipal 110.9 74.5 101.8 106.4 105.2 Wa West 78.5 77.3 99.3 88.5 96.8 Regional 86.1 90.3 96.3 91.1 92.2 *Was part of the then Jirapa-Lambussie Districts

Annex 6 : Trend of Skilled Delivery -2006 -2009 District 2006 2007 2008 2009 Jirapa 31.0 42 70.8 64 Lambussie* 38 Lawra 28.3 37 43.5 49 Nadowli 30.4 36 37.1 45 Sissala East 27.4 23 26.2 29 Sissala West 14.4 18 15.6 20 Wa East 8.6 10 11.9 70 Wa municipal 54.5 56 65.0 74 Wa West 13.9 12 28.4 47 Regional 28.8 33 42.2 51.6 *Was part of the then Jirapa-Lambussie Districts

24

Annex 7 : Population Ratios for Doctors and Medical Assistants Doctor Pop. Ratio MA Pop. Ratio District 2008 2009 2008 2009 JIRAPA 1: 62,487 1: 63,549 1: 12,497 1: 15,887 LAMBUSSIE 0 0 1: 48,327 1: 49,149 LAWRA 1: 100,162 1: 50,932 1: 20,032 1: 20,373 NADOWLI 1: 94,657 1: 96,267 1: 94,657 1: 48,134 SISSALA EAST 1: 52,782 1: 52,662 1: 26,391 1: 26,331 SISSALA WEST 0 0 1: 45,996 1: 46,778 WA EAST 0 0 0 0 WA MUNICIPAL 1:22,520 1:29,057 1:112,599 0 WA WEST 0 0 0 0 TOTAL 1: 73,289 1:74,560 1: 41,225 1: 44,736

Annex 8: Population Ratios for Midwives and CHOs

Midwife Pop. Ratio CHO Pop. Ratio District 2008 2009 2008 2009 JIRAPA 1: 1,644 1: 4,237 1: 5,207 1: 4,237 LAMBUSSIE 1: 6,904 1: 7,021 1: 4,833 1: 4,915 LAWRA 1: 3,130 1: 3,183 1: 14,309 1: 12,733 NADOWLI 1: 4,303 1: 6,876 1: 4,116 1: 6,876 SISSALA EAST 1: 4,399 1: 4,389 1:5,278 1: 5,851 SISSALA WEST 1:9,199 1: 11,695 1: 22,998 1: 5,198 WA EAST 1: 6,317 1: 7,956 1: 4,373 1: 5,786 WA MUNICIPAL 1: 6,256 1: 1,970 1: 2,298 1: 5,283 WA WEST 1: 21,436 1: 20,225 1: 3,728 1: 3,517 TOTAL 1: 4,487 1: 4,329 1: 4,427 1: 5,546

25 Annex 9: OPD Clients Distribution by Age Group and Insurance Status - 2009

Annex 10 : Bed Utilisation Statistics (% occupancy and ALOS) 2007 -2009

Percentage occupancy Average Length of Stay District 2007 2008 2009 2007 2008 2009 Jirapa Hospital 42 60 64 4 3.1 3.8 Lawra Hospital 33 45 57.3 2 2.4 3.2 Nadowli Hospital 39 47 56.3 5 2.5 2.8 Nandom Hospital* 60 62 70.6 3 4.6 5.1 Tumu Hospital 70 61 50.4 5 3.6 2.9 Regional Hospital 66 65 60.3 3 3.1 2.9

Regional 48 60 62.1 4 3.3 3.5 *Due to visiting Neurosurgeon & Orthopaedic Surgeon

26

Annex 11: Bed Utilisation Statistics (Bed Turn Over & Turn Over Interval) 2007 - 2009 District Turnover Per bed Turnover Interval

2007 2008 2009 2007 2008 2009 Jirapa Hospital 37 68 61.1 6 2.3 2.2

Lawra Hospital 51 64 65.1 16 3.3 2.4

Nadowli Hospital 49 64 72.9 5 3.3 2.2

Nandom Hospital 44 46 50.1 2 3.3 2.1

Tumu Hospital 56 58 64.2 2 -0.6 2.8

Regional Hospital 71 76 75.7 2 1.7 1.9

Regional 48 63 64.0 3 2.0 2.2

Annex 12: Outpatient Attendance by Districts 2005 -2009 District 2005 2006 2007 2008 2009 Jirapa 71,380 58,062 81,977 91,433 58,214 Lambussie* - 28,604 Lawra 58,408 48,120 83,354 106,938 97,509 Nadowli 45,934 46,292 52,188 73,781 76,234 Sissala East 23,854 30,853 43,556 61,197 52,569 Sissala West 10,893 8,363 13,392 19,053 18,161 Wa East 25,736 12,462 18,547 20,051 21,916 Wa municipal 56,432 67,168 133,911 84,589 108,776 Wa West 18,856 19,179 29,673 22,318 22,530 Regional 311,493 290,499 456,598 479,630 484,513 *Was part of the then Jirapa-Lambussie Districts

27

Annex 13: Outpatient Attendance per Capita by District 2005 - 2009

District 2005 2006 2007 2008 2009 Jirapa 0.68 0.54 0.75 0.83 0.92 Lambussie* 0.00 0.58 Lawra 0.61 0.50 0.85 1.07 0.96 Nadowli 0.51 0.51 0.56 0.78 0.79 Sissala East 0.48 0.62 0.86 1.16 1.00 Sissala West 0.25 0.19 0.30 0.41 0.39 Wa East 0.34 0.15 0.34 0.35 0.34 Wa municipal 0.52 0.61 1.19 0.75 0.94 Wa West 0.32 0.35 0.35 0.26 0.28 Regional 0.50 0.46 0.70 0.73 0.72 *Was part of the then Jirapa-Lambussie Districts

Annex 14: Inpatient Admissions by Hospital 2005 -2009 District 2005 2006 2007 2008 2009 Jirapa Hospital 6,108 5,169 6,910 8,077 7,814 Lawra Hospital 3,322 2,559 3,440 4,716 4,751 Nandom Hospital 7,530 5,289 7,171 8,603 9,027 Nadowli Hospital 2,459 2,537 2,848 4,066 2,944 Tumu Hospital 2,774 2,273 2,944 3,852 4,617 Regional Hospital 7,530 11,992 13,639 15,318 14,632 Regional 29,723 29,819 36,956 44,632 43,785

28

Annex 15: Hospital Admissions Rate per District 2005 - 2009

District 2005 2006 2007 2008 2009 Jirapa 58 48 63 73 123 Lambussie 0 0 0 0 0 Lawra 114 81 108 133 135 Nadowli 27 28 31 43 31 Sissala East 50 45 58 73 88 Sissala West 0 0 0 0 0 Wa East 0 0 0 0 0 Wa municipal 73 109 122 136 126 Wa West 0 0 0 0 0 Regional 47 47 57 68 65

Annex 16: HIV Prevalence Among Pregnant Women Attending ANC by Dist 2008 - 2009 District 2008 2009 Jirapa 1.1 0.5 Lambussie 0.8 0.6 Lawra 1.5 2.0 Nadowli 1.6 1.0 Sissala East 0.8 0.6 Sissala West 0.9 0.5 Wa East 0.5 0.5 Wa municipal 2.1 1.1 Wa West 1.3 0.5 Regional 1.5 1.0

29 Annex 17: HIV Prevalence Among Pregnant Women by Age Group 2007 - 2009 District 2007 2008 2009 10 – 14yrs 0.0 0.0 2.3 15 – 19 yrs 0.5 0.5 1.1 20 – 24 yrs 1.6 1.6 1.0 25 – 29 yrs 2.2 3.2 1.2 30 – 34 yrs 2.2 2.2 1.0 35 – 39 yrs 1.5 1.5 0.8 40 – 44 yrs 2.6 2.6 0.7 45 – 49 yrs 2.0 2.0 2.9 50+ 0.0 0.0 0.3 Source: UWR Monthly PMTCT Report

Annex 18: Prevalence of Malaria per 100,000 populations 2005 - 2009 District 2005 2006 2007 2008 2009 Jirapa 25,030 22,150 29,531 51,950 56,921 Lambussie - - - - 27,425 Lawra 40,264 21,071 31,515 33,827 32,239 Nadowli 29,972 21,398 26,382 34,347 31,295 Sissala East 12,132 10,243 14,740 54,174 53,488 Sissala West - 8,977 13,443 22,943 16,497 Wa East 18,983 7,707 10,552 17,523 16,851 Wa municipal 15,723 20,548 26,533 27,228 42,308 Wa West 12,974 18,305 24,274 14,615 30,239 Regional 21,964 17,542 23,662 32,428 34,702 Source: UWR Monthly OPD Morbidity Returns

30 Annex 19: Tuberculosis Cases Detection Per 100,000 (2005 - 2009) District 2005 2006 2007 2008 2009 Jirapa 21 21 23 15 19 Lambussie* 0 0 0 0 2 Lawra 37 30 34 35 25 Nadowli 8 11 6 7 17 Sissala East 2 2 8 6 6 Sissala West 0 0 2 0 4 Wa East 0 0 2 14 3 Wa municipal 70 43 43 60 38 Wa West 0 0 14 14 16 Regional 22 17 20 20 18 *Was part of the then Jirapa-Lambussie Districts

Annex 20: Tuberculosis Cure Rate 2005 - 2009 District 2005 2006 2007 2008 2009 Jirapa 50 50 54 28 24 Lambussie* 0 0 0 0 0 Lawra 129 110 81 300 45 Nadowli 38 35 0 18 71 Sissala East 100 80 0 60 57 Sissala West 0 0 0 0 100 Wa East 0 0 0 67 0 Wa municipal 0 58 60 0 31 Wa West 0 0 0 8 8 Regional 47 63 58 27 37 *Was part of the then Jirapa-Lambussie Districts

Annex 21: Treatment Outcomes (NSP) 2006 - 2008 Outcome 2006 % 2007 % 2008* % Cured 62 55 70 60 47 30.9 completed 34 30 54 42 23 15.1 Died 17 15 35 20 13 8.5 Defaulted 12 10 8 6 7 4.6 Failed 1 0.9 2 0.6 2 1.3 Trans. Out 12 10 2 1 3 1.9

31 Annex 22: Expanded Programme on Immunization 2005 - 2009 District BCG 2005 2006 2007 2008 2009 JIRAPA 90.5 96.2 104.9 95.6 105.5 LAMBUSSIE * - 90.6 LAWRA 81.4 99.0 102.4 97.1 89.9 NADOWLI 88.5 106.3 95.6 88.7 81.7 SISSALA EAST 99.9 101.2 92.2 94.2 97.7 SISSALA WEST 118.1 107.4 119.9 112.6 96.9 WA EAST 131.0 82.1 83.3 146.9 110.4 WA MUNICIPAL 82.1 139.3 126.9 147.4 155.1 WA WEST 89.3 155.8 162.6 94.6 94.9 TOTAL 101.6 110.0 109.0 109.0 105.2 *Was part of the then Jirapa-Lambussie Districts

Annex 23: Measles Immunization Coverage 2005 -2009 District 2005 2006 2007 2008 2009 Jirapa 86.4 85.1 86.0 87.0 82.2 Lambussie * - 88.0 Lawra 81.1 89.3 84.2 85.7 75.2 Nadowli 81.2 106.6 88.8 93.4 74.8 Sissala East 88.9 92.8 86.1 88.8 90.4 Sissala West 105.0 87.0 106.7 102.9 83.3 Wa East 110.9 75.5 85.8 148.9 104.8 Wa municipal 54.1 128.3 106.6 104.5 119.7 Wa West 71.2 147.7 164.2 93.9 98.1 Regional 84.2 101.1 98.0 98.2 91.8 *Was part of the then Jirapa-Lambussie Districts

32 Annex 24: Penta 3 Immunization Coverage 2005 - 2009

District 2005 2006 2007 2008 2009 Jirapa 81.5 80.2 88.5 88.0 84.3 Lambussie* - 83.1 Lawra 72.9 76.2 82.1 75.8 74.6 Nadowli 87.4 91.9 83.2 82.9 81.8 Sissala East 90.0 94.7 90.8 89.9 88.3 Sissala West 100.2 89.9 94.2 88.7 88.6 Wa East 135.2 71.5 79.1 146.4 109.4 Wa municipal 57.4 110.0 99.6 93.9 108.4 Wa West 76.1 142.0 157.2 92.4 94.3 Regional 87.8 92.4 94.0 92.2 90.8 *Was part of the then Jirapa-Lambussie Districts

Annex 25: OPV 3 Immunization Coverage 2005 - 2009

District 2005 2006 2007 2008 2009

Jirapa 81.5 80.1 87.5 88.0 84.3

Lambussie* - - - 83.1 Lawra 72.8 76.2 79.8 75.8 74.6 Nadowli 88.8 91.3 82.8 86.8 81.8

Sissala East 90.0 95.8 92.6 89.9 88.3 Sissala West 100.9 88.6 94.2 88.7 88.6 Wa East 135.2 71.5 81.3 146.4 108.6

Wa municipal 57.4 110.0 99.3 95.2 108.4 Wa West 76.1 142.0 158.2 92.3 94.3 Regional 87.9 92.3 94.0 93.0 90.7 *Was part of the then Jirapa-Lambussie Districts

33 Annex 26: Tetanus Toxoids Immunization Coverage 2005 - 2009

District 2005 2006 2007 2008 2009

Jirapa 55.9 58.0 71.0 55 88

Lambussie* - - - 39 63

Lawra 66.9 66.2 70.2 47 68 Nadowli 66.4 41.8 73.3 81 78

Sissala East 89.0 76.8 59.3 89 75 Sissala West 66.3 46.8 55.0 82 58

Wa East 37.5 37.2 48.7 47 74

Wa municipal 24.7 37.1 58.9 45 81 Wa West 32.6 69.7 108.6 56 71 Regional 51.3 52.3 67.0 59 74 *Was part of the then Jirapa-Lambussie Districts

Annex 27: Yellow Fever Immunization Coverage 2005 - 2009

District 2005 2006 2007 2008 2009 Jirapa 93.4 84.6 85.5 87.0 82.2

Lambussie* - - - - 88.0

Lawra 89.0 88.8 84.2 85.7 75.2 Nadowli 85.4 89.8 88.2 93.4 74.8

Sissala East 99.0 86.4 84.3 88.8 90.4

Sissala West 118.6 81.3 106.9 102.9 83.3 Wa East 140.9 75.5 85.0 148.9 104.8

Wa municipal 56.2 124.9 106.2 104.5 119.7 Wa West 74.2 137.6 161.4 93.9 98.1 Regional 92.9 96.2 97.0 98.2 91.8 *Was part of the then Jirapa-Lambussie Districts

34 Annex 28 : AFP Non – Polio Rate District 2005 2006 2007 2008 2009

Jirapa 4 4 6 4 -

Lambussie* - - - - 9

Lawra 2 4 6 - - Nadowli 5 5 - 2 2

Sissala East 4 - - - 4 Sissala West - - - - 9 Wa East - - - 11 13

Wa municipal 2 2 2 - 4 Wa West - - - 7 5 Regional 2 2 2 3 4 *Was part of the then Jirapa-Lambussie Districts

Annex 29: Post Natal Care Coverage 2005 -2009

District 2005 2006 2007 2008 2009 Jirapa 69.4 62.3 72.2 66.8 83.5

Lambussie* 0.0 68.2

Lawra 68.2 55.8 72.3 63.2 59.0

Nadowli 60.2 59.6 69.3 57.4 56.8

Sissala East 76.6 57.8 78.7 57.3 49.4 Sissala West 99.5 74.9 78.3 66.7 64.3

Wa East 102.2 79.3 94.3 75.4 69.4

Wa municipal 98.9 62.0 75.1 86.9 86.5 Wa West 49.7 35.1 56.5 59.9 62.7 Regional 62.0 54.3 73.1 67.4 67.5 *Was part of the then Jirapa-Lambussie Districts

35 Annex 30:Family Planning Acceptor Coverage 2005 - 2009

District 2005 2006 2007 2008 2009

Jirapa 37.1 39.6 50.5 49.8 53.3

Lambussie* 35.0

Lawra 39.3 43.1 63.8 63.0 67.6

Nadowli 49.4 60.3 75.6 55.6 51.5

Sissala East 34.2 46.2 71.6 50.8 56.9 Sissala West 50.7 29.3 32.1 33.1 37.5 Wa East 38.1 24.1 36.4 40.9 45.6

Wa municipal 110.2 79.5 296.9 66.1 79.6 Wa West 19.9 27.0 42.1 43.6 45.0 Regional 53.9 54.3 97.0 52.7 55.9 *Was part of the then Jirapa-Lambussie Districts

Annex 31: Institutional Maternal Mortality Ratio 2007 - 2009 District 2007 2008 2009 Maternal MMR Maternal MMR Maternal MMR deaths deaths deaths Jirapa 5 147 4 142 7 444

Lambussie* 0 0 0 0 0 0 Lawra 10 402 4 135 6 287 Nadowli 1 42 2 93 1 56 Sissala East 3 174 3 218 5 862 Sissala West 0 0 0 0 0 0 Wa East 0 0 0 0 0 0 Wa municipal 9 238 6 143 24 738 Wa West 1 57 0 0 0 0 Regional 29 156 19 109 43 240 *Was part of the then Jirapa-Lambussie Districts

36 Annex 32: Top Ten Causes of OPD Attendance 2007 - 2009 Disease Disease Condition No. % Condition No. % Disease No. % of Total

Malaria 172,906 38 Malaria 208,309 44 Malaria 227,703 57.1

ARI 58,907 13 ARI 29,494 6 Other ARI(Acute 45,272 11.4 Skin Diseases & Skin Diseases & Skin Diseases & Ulcers 46,008 10 Ulcers 17,511 4 Ulcers 20,281 5.1 Acute Eye Acute Eye Acute Eye infection 22,486 5 infection 11,494 2 infection 15,451 3.9 Diarrhoea Diarrhoea Diarrhoea Diseases 21,437 5 Diseases 10,537 2 Diseases 13,790 3.5 Rheumatism Rheumatism Hypertension 16,883 4 and Joint 6,767 1 and Joint 6,852 1.7 Acute Ear Pneumonia 14,851 3 Pneumonia 5,132 1 infection 5,813 1.5 Rheumatism Acute Ear and Joint 14,112 3 infection 4,878 1 Pneumonia 5,139 1.3 Acute Ear infection 9,124 2 Hypertension 4,174 1 Hypertension 4,945 1.2 Road Traffic Intestinal Accidents 9,061 2 worms 3,976 1 Home Accidents 4,864 1.2 176,382 All Others 70,764 15 All Others 37 All Others 48,344 12.1

Total 456,539 100 Total 478,654 100 TOTAL 398,454 100.0

37 Annex 33: Top Ten Causes of Admission 2007 - 2009 2007 2008 2009 Disease Disease Disease Condition No % Condition No % Condition No. % Malaria 11,779 31.9 Malaria 16,927 37.93 Malaria 12,226 46.3 Anaemia 1,278 3.5 Anaemia 1,567 3.51 Anaemia 1,363 5.2 Hypertension 1,234 3.3 Hypertension 1358 3.04 RTA 1,225 4.6 Pneumonia 985 2.7 Pneumonia 888 1.99 Snake Bite 735 2.8 Hernia 984 2.7 Diarrhoea 380 0.85 Hernia 727 2.8 Accidents 967 2.6 Hernia 353 0.79 Pneumonia 643 2.4

Preg. Rel. Comp 918 2.5 Hydrocele 323 0.72 Hypertension 363 1.4 Abdominal Caesarian Section 902 2.4 Snake bite 320 0.72 Pains 324 1.2

Snake Bite 758 2.1 Typhoid Fever 315 0.71 Asthma 316 1.2 Gynaec. Disorders 629 1.7 RTA 281 0.63 Gastroenteritis 306 1.2 All Others 16,522 44.7 All Others 21,920 0.71 All Others 8,169 30.9

Total 36,956 100 Total 44,632 100 Total 26,397 100.0 Annex 34: Top Ten Causes of Inpatient Mortality 2007 - 2009 2007 2008 2009 Condition No of % of Condition No of % of Condition No of % of Cases Total Cases Total Cases Total Malaria 193 20.7 Malaria 291 28 Malaria 160 30.2

Anaemia 40 4.3 Anaemia 93 9 Anaemia 45 8.5 Pneumonia 30 3.2 Pneumonia 84 8 Pneumonia 34 6.4

Hepatitis 25 2.7 Typhoid 48 5 Hepatitis 25 4.7

Aids 22 2.4 Hypertension 38 4 Hypertension 16 3.0 Diarrhoeal Hypertension 19 2 Dx 33 3 Dehydration 9 1.7

Tuberculosis 12 1.3 Aids 29 3 Snake Bite 9 1.7 Abdominal Septicaemia 12 1.3 Hepatitis 26 2 Pains 8 1.5

Meningitis 13 1.4 Meningitis 11 1 Hypoglycaemia 8 1.5 Hernia 10 1.1 Convulsion 11 1 Tuberculosis 8 1.5

All Others 555 59.6 All Others 394 37 All Others 208 39.2

Total 931 100 Total 1,057 100 Total 530 100.0

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