Upper West Regional Health Services

2012 Annual Report

Dr. Alexis Nang-beifubah Regional Director of Health Services

March 2013 FOREWORD The 2012 Annual Health Sector Performance report captures information on key health sector strategies and specific interventions that were implemented during the year in line with the sector policies.

During the period under review the perennial shortage of critical staff such as midwives, medical assistants and doctors as well as poor health infrastructure still persisted. There was also the emergent problem of a prolong (5 months) delay in reimbursement of NHIS funds to health facilities bringing untold difficulties to management of hospitals and health centres that rely on IGF from the NHIS as their main source of income. The Regional Health Directorate and all BMCs also experienced erratic flow of funding from central government as well as a decline in donor support. Other issues of concern such as high infant and maternal deaths, inadequate monitoring and supervision, and weak clinical services also confronted the region in the year. The challenges in the detection and control of key epidemic prone diseases were also encountered.

Despite these challenges, the Regional Health Directorate adopted several innovative strategies that brought positive results in most of the key service delivery areas such as Reproductive and Child Health, Disease Surveillance and control and Clinical Care services. Most of the Sector wide Indicators in these service areas have improved as captured in our routine service data for 2012 as well as corroborated in national surveys as the Multiple Indicator Cluster Survey (MICS). 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 UNICEF, JICA, , UNFPA, Plan Ghana, World Vision etc.

This 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 report is arranged according to the main strategic objectives outlined by the Ministry of Health. The general health indices of the region are improving but not fast enough. It is my hope that this trend will continue through 2013 and beyond towards the achievements of MDG 4 & 5 by the target year of 2015 which is fast approaching. Thank you.

Dr. Alexis Nang-beifubah (RDHS –UWR)

i EXECUTIVE SUMMARY The 2012 Annual report of the Upper West Region covers all the key service delivery areas and in accordance with the five (5) strategic objectives of the Ghana Health Service. It enumerates the key activities undertaken during the year under the five (5) 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.

The region within the period under review had made some remarkable improvements in some of the sector-wide indicators; others however stagnated, whilst some actually declined. This is partly attributable to inadequate critical health personnel such as midwives and clinicians as well as erratic and inadequate flow of funding from routine funding sources such as GOG and donor support.

The region in the year 2012 witnessed a massive increase in the number functional CHPS zones from 114 in 2011 to 166 in 2012 representing 45.6% increase over the 2011 number. Functioning zones with compounds also increased from 104 to 114 in 2012. 82 Community Health Officers were also trained and deployed.

Antenatal registrants slightly improved from 23,943 in 2011 to 24,720 in the year under review. Total number of skilled deliveries conducted increased from 14,687 in 2011 to 15,389 in 2012. Total still births recorded reduced from 365 in 2011 to 334 in 2012 with a corresponding decrease in fresh still births from 127 in 2011 to 106 fresh still births in 2012. Post Natal registrants (PNC) marginally increased from 19,113 in 2011 to 19,199 in 2012 . The Region recorded 28 institutional maternal deaths out of a total of 15,212 live births (LB) for 2012. This is a drop from 29 deaths out of 14,322 LB in 2011 and 26 deaths out of 12,270 LB in 2010. This is due to the interventions put in place especially Community Ambulance and institutional arrangements to speed up attention and care for expectant mothers as well as telephone directory use.

Total number of clients accepting family planning decreased from 81,234 in 2011 to 79,021 in 2012. This was due to shortage of some of the family planning devices in the course of the year.

ii In the area of EPI number of eligible children receiving BCG increased from 23,596 in 2011 to 23,753 in 2012. Penta III coverage however, decreased from 22,403 in 2011 to 22,129 in 2012. Measles and yellow fever immunization also recorded a modest improvement in coverage with OPV3 recording a decline in coverage.

Tuberculosis (TB) cure rate declined marginally from 62.5% in 2011 to 62.3% in 2012. The Success rate on the other hand improved from 69.0% in 2011 to 75.4% in 2012. The HIV/AIDs programme was confronted with challenges of dwindling support in the area of logistics and funding. These led to general decline in most of the HIV/AIDs indicators. Total number of clients undergoing HIV/AIDs Testing and Counselling (HTC) declined from 8,921 in 2011 to 7,274 in 2012. There was also general decline in number of pregnant women tested for HIV from 24,407 in 2011 to 21,940 in 2012. With regards to Know Your Status (KYS) campaign there has been a general decline in coverage in all districts in the region due to inadequate number of trained counsellors as well as the drop in funding. With clinical care OPD attendance per capita stagnated at 1.1 and hospital admission rate declined marginally from 89.6/1000 population to 87.3/1000 population in 2012. The region recorded a slight fall in percentage bed occupancy from 72.6% in 2011 to 69.7% in 2012. It is very encouraging that the region has continued to record a gradual decline in the death rate and average length of stay in the hospitals from 2.1% to 2.0% and 3.2 to 3.1 days respectively from 2011 to 2012. The improvement in the clinical care indicators may be attributed to expansion in the coverage of NHIS which currently covers 95.6% of OPD cases in 2012 as against 94.3% in 2012. NHIS also accounted for 94.2% of inpatient cases in 2012 as against 77.6% in 2011.

The proportion of underweight declined from 14.4% in 2011 to 13.5%, in 2012. The proportion of children wasting also reduced from 7.8% in 2011 to 7.2% in 2011, whilst the proportion of children stunting also came down from 24.1% in 2011 to 22.3% in 2012.

Human resource availability and management continued to pose a serious challenge to quality health services delivery in the region. The region continued to grapple with inadequate numbers of critical staff especially, midwives, medical doctors, pharmacists and x-ray

iii technicians. The situation was compounded by large number of critical staff in all categories who are fast approaching their retirement age.

The region has faced real challenge in getting the full complement of critical staff to operationalize the five (5) new polyclinics that were completed and handed over to the GHS in 2012. We are however, grateful to the Cuban medical brigade that continued to complement our work force in all hospitals. The region is now adopting a strategy of prioritizing sponsorship for staff that opt to undergo further courses in the critical health care areas. The region was however, fortunate to experience an improvement in the enrolment into health training institutions from 986 in 2011 to 1,195 in 2012 with an accompanying improvement in the pass rate of students. It is the hope of the RHA that some of the human resource needs of the region shall be catered for when these students pass out from these schools successfully.

Internally Generated Funds (IGF) remains the primary source of funding to the region especially health facilities contributing about 84% of the total funds received in the year under review as against the previous year’s of 63.93%. The implementation of the National Health Insurance Scheme (NHIS) has seen consistent increase in the revenue generation by health facilities in the Region. In total terms, however, the contribution of the National Health Insurance decreased marginally by a percentage point in 2012.

Programme funding by the Health Partners ranked second after IGF accounting for only 15% of the total amount received for the year but have also declined consistently since 2009. Government of Ghana funding in terms of items 2 & 3 and Sector Budget Support (DPF) came third but also showed a sharp decrease in year 2012. The region continue to grapple with high indebtedness of health facilities to the Regional Medical Stores (RMS) standing currently at 48.25% in 2012 as against 57% in 2011. This is due to the failure of the National Health Insurance to reimburse the health facilities for over five months in arrears. This has the potential of adversely affecting the smooth running of the RMS if not checked. We recommend separate reimbursement of medicine from non-medicine. Management will be encouraged to work at improving their claims management.

iv TABLE OF CONTENT FOREWORD ...... i EXECUTIVE SUMMARY ...... ii LIST OF TABLES ...... ix LIST OF FIGURES ...... xi ACRONYMS & ABBREVIATIONS...... xii CHAPTER ONE - INTRODUCTION ...... 1 1.1 Profile of the Upper West Region ...... 1 1.2 Demographic characteristics ...... 1 1.3 Location and Population Density ...... 2 1.4 Topography and Water Bodies ...... 2 1.5 Climate ...... 3 1.6 Economic Activities and Migration ...... 3 1.7 Transport and communication ...... 3 1.8 Health Delivery System ...... 4 1.9 Main priorities for 2012...... 5 CHAPTER TWO – OBJECTIVE 1 ...... 6 Bridging the Equity gaps in access to health care and nutrition services and ensure sustainable financing arrangements that protect the poor...... 6 2. 1 Community-based Heath Planning and Services (CHPS) ...... 6 2.2 National Health Insurance Scheme ...... 7 CHAPTER THREE- OBJECTIVE 2 ...... 9 Strengthen Governance and Improve the Efficiency and Effectiveness of the Health System 9 3.1 Develop Capacity to Enhance the Performance of the National Health Systems ...... 9 3.1.1 Human Resources for Health ...... 9 3.1.2 Health Training Institutions ...... 11 3.1.3 Infrastructure for Health ...... 12 3.1.4 Equipment for Health ...... 14 3.1.5 Transport for Health ...... 15 3.1.6 Mechanical Technology Centre (MTC) ...... 16 3.1.7 Nangfang Motorbike Spare Parts ...... 17

v 3.2 Strengthen Inter-sector Collaboration Including Public-Private Partnership ...... 17 3.2.1 Collaboration for Health ...... 17 3.2.2 Collaboration with CHAG ...... 18 3.3. Strengthen Systems for Improving the Evidence Based for Policy and Operations ..... 19 3.3.1 Lot Quality Assurance (LQAS) Survey ...... 19 3.3.2 Health Information Management ...... 19 3.4 Strengthen systems for effective financial resources management ...... 21 3.4.1 Indebtedness to the Regional Medical Stores ...... 21 3.4.2 Financial Monitoring ...... 21 3.4.3 Internal Audit ...... 21 3.4.4 Revenue and Expenditure ...... 22 CHAPTER 4 - OBJECTIVE 3 ...... 24 Improve access to quality maternal, neonatal, child and adolescent health services...... 24 4.1 Reproductive and Child Health ...... 24 4.1.1 Antenatal Care Services ...... 24 4.1.2 Skilled Delivery ...... 25 4.1. 3 Maternal Mortality ...... 27 4.1.3 Postnatal Services ...... 29 4.1.4 Family Planning Services ...... 30 4.1.5 School Health Services ...... 30 4.1.6 Adolescent Health Services ...... 31 CHAPTER 5 - OBJECTIVE 4 ...... 33 Intensify prevention and control of communicable and non-communicable diseases and promote healthy lifestyles ...... 33 5.1 Disease Control ...... 33 5.1.1 Disease Surveillance ...... 33 5.1.2 Guinea Worm Eradication ...... 35 5.1.3 Tuberculosis Control...... 36 5.1.4 HIV/AIDS ...... 38 5.1.5 Leprosy Control Programme ...... 41 5.1.6 Malaria Control ...... 41

vi 5.2 Expanded Programme on Immunization (EPI) ...... 43 5.3. Nutrition Programme ...... 47 5.3.1 Growth Monitoring and Promotion (GMP) ...... 48 5.3.2 Prevalence of Underweight among children 0-23 Months in GMP ...... 49 5.3.4 Nutrition Surveillance System (NSS) ...... 53 5.3.5 Routine Maternal Vitamin A Supplementation ...... 55 5.4 Health Promotion...... 56 5.4.1 Communication for Development (C4D) Programme...... 56 5.4.2 Material Development on Maternal and Child Health ...... 57 CHAPTER 6 - OBJECTIVE 5 ...... 59 Improving Clinical care including Mental Health Services ...... 59 6.1 Activities carried out in 2012 ...... 59 6.2 Specialised Clinical Care Services ...... 59 6.2.1 General Eye Care Service ...... 59 6.2.2 Mental health care ...... 61 6.2.3 Physiotherapy Service ...... 62 6.2.4 Oral Health ...... 62 6.3 Service Statistics - OPD Attendance ...... 62 6.3.1 OPD attendance - 2012 ...... 62 6.3.2 Per capita OPD attendance by districts - 2012 ...... 63 6.3.3 Trend of per capita OPD attendance...... 64 6.3.4 Financial accessibility of OPD services by use of Health Insurance ...... 64 6.4. Inpatient statistics ...... 66 6.4.1 Inpatient performance by facilities - 2012 ...... 66 6.4.2 Trend of admission and institutional death rate 2005-2012 ...... 67 6.4.3 Admission rate – 2012 and regional trend 2005 - 2012 ...... 67 6.4.4 Bed utilisation 2012...... 68 6.4.5 Trend in bed statistics 2008- 2012 ...... 69 6.5. Inpatient and outpatient Morbidity ...... 69 6.5.1 Out Patient Morbidity – 2012 ...... 69 6.5.2 Inpatient morbidity ...... 70

vii 6.5.3 Burden of some selected non-communicable diseases ...... 71 CHAPTER 7 – REGIONAL INITIATIVES AND OTHER EVENTS ...... 73 7.1 Key Innovations and Best Practices ...... 73 7.2 Annual General Meetings (AGMs) of DDHS and AHSAG ...... 74 ANNEXES ...... 75 Annex 1: Trend of total OPD attendance by districts 2007 – 2012 ...... 75 Annex 2: Trend of OPD attendance per capita -2007 2012...... 75 Annex 3: OPD Morbidity Under Five years - 2012 ...... 75 Annex 4: OPD morbidity by gender (female only) all ages -2012 ...... 76 Annex 5: OPD morbidity all ages male & female -2012 ...... 76 Annex 6: Top ten causes of OPD morbidity 2010 -2012 ...... 77 Annex 7: Top ten causes of inpatient admissions 2010 - 2012 ...... 77 Annex 8 : Sector- Wide Indicators 2006 2013 ...... 78

viii LIST OF TABLES Table 1: Upper West Regional Population and Target Populations 2011 & 2012...... 2 Table 2: Summary of health facilities 2012 ...... 4 Table 3: Status of CHPS implementation, 2012 ...... 7 Table 4: Ratio of NHIS to Cash and Carry ...... 8 Table 5: Indebtedness of NHIS to health facilities ...... 8 Table 6: Critical Staff/Pop. Ratios 2012 ...... 11 Table 7: Student Population (2011-2012) ...... 11 Table 8: Student population in health training institutions 2012 ...... 12 Table 9: Students academic performance -Pass Rate 2010 -2012 ...... 12 Table 10: Age Blocks of Vehicles 2009 - 2012 ...... 15 Table 11: Age Blocks of Motorbikes 2009 -20012 ...... 15 Table 12: Driver Vehicle Ratio 2010 - 2012 ...... 16 Table 13: Trend of Workload at MTC -2008 -2012 ...... 16 Table 14: Ranking of Performance of Districts in Data Set Completeness -2012 ...... 20 Table 15: : Indebtedness of health facilities to RMS for 2010 – 2012 ...... 21 Table 16: Source of income (funding) , 2009-2012, UWR ...... 22 Table 17: Budget and funds availability 2009 – 2012 ...... 23 Table 18: Expenditure by source 2009 – 2012 ...... 23 Table 19: Number of ANC Registrants by Districts 2006 -2012 ...... 24 Table 20: Performance of IPT3 from 2006-2012 ...... 25 Table 21: Trend of Skilled delivery -2006 – 2012 ...... 26 Table 22: Number of Fresh Stillbirths Out of Total Stillbirths ...... 27 Table 23: Total Number of Institutional Maternal Deaths -2006 – 2012 ...... 27 Table 24: Maternal Mortality Ratio per 100,000 Live births -2006 -2012 ...... 28 Table 25: PNC Registrants 2006 – 2012 ...... 29 Table 26: Family Planning Acceptors -2006 -2012 ...... 30 Table 27: Number of School Children examined ...... 31 Table 28: Adolescent Health Counseling services ...... 32 Table 29:Suspected Measles cases and specimen collected 2009-2012...... 34 Table 30: Reported Suspected Cases of Yellow Fever and Samples taken with confirm cases ... 34 Table 31: AFP Cases from 2008-2012 Jan-Dec in UWR by Districts ...... 35 Table 32: Five Year Trend Analysis of Regional Performances Summary Compared ...... 37 Table 33: TB Case Detection by district for NSP - 2008 to 2012 ...... 37 Table 34: HTC by district – 2011 - 2012 ...... 39 Table 35: Know your status campaign by district /Facility- 2011-2012...... 39 Table 36: PMTCT Service Data, 2010-2012 UWR ...... 40 Table 37: Clients on HAART, year 2011 – 2012, UWR ...... 40 Table 38: Prevalence of HIV infection among blood donors by sex – 2010-2012 ...... 41 Table 39: Malaria cases put on ACT ...... 42

ix Table 40: Coverage of Long lasting insecticide nets (LLINs) ...... 42 Table 41: BCG Coverage by Districts 2006-2012, UWR ...... 43 Table 42: Penta 3 Coverage by District 2009-2012 ...... 44 Table 43: OPV 3 Coverage by District 2006-2012 ...... 44 Table 44: Measles Coverage by District 2006-2012 ...... 44 Table 45: YF Coverage by District 2006-2012 ...... 45 Table 46: TT2+ Coverage by Districts absolute figures Jan –Dec 2009 -2012 ...... 45 Table 47: Number of children immunized during the March 2012 NID ...... 46 Table 48: Meningococcal Meningitis Type A Coverage by Districts, UWR October 2012 ...... 47 Table 49: Summary of Achievement on key indicators ...... 48 Table 50: Trend of Admission of Severe Acute Malnourished (SAM) Cases 2010-2012 ...... 51 Table 51: Summary of Some Key Indicators Compared ...... 53 Table 52: Number and category of people orientated on Communication for Development .... 56 Table 53: Statistics on Eye Care Services 2006 – 2012 ...... 60 Table 54: Statistics on mental health care 2009 - 2012 ...... 61 Table 55: Summary of physiotherapy clients seen by specialist ...... 62 Table 56: OPD attendance by district 2012 ...... 63 Table 57: Per capita OPD attendance by districts – 2012 ...... 63 Table 58: Trend of per capita OPD attendance 2005 – 2012...... 64 Table 59: % of OPD clients accessing health care with NHIS by districts – 2012 ...... 65 Table 60: Trend of proportion of OPD clients accessing health care with NHIS 2006 – 2011 .... 66 Table 61: Admissions and Institutional death rate by facilities – 2012 ...... 67 Table 62: Trend of admission and institutional death rate 2005 – 2012 ...... 67 Table 63: Regional trend of admission rate - 2005 – 2012 ...... 67 Table 64: Bed statistics by facilities – 2012 ...... 68 Table 65: Trend of bed statistics 2006 – 2012 ...... 69 Table 66: Some selected non - communicable diseases: ...... 71 Table 67: Trend of some selected non-communicable diseases 2009 – 2012 ...... 71

x LIST OF FIGURES Figure 1: Map of Ghana Showing location of UWR & Map of Upper West Region showing road networks and health facilities ...... 1 Figure 2: Causes of Maternal Deaths ...... 28 Figure 3: Men A Cluster Coverage Results for the three Low performing districts ...... 47 Figure 4: CMAM Cure Rate 2010 -2012 ...... 52 Figure 5: CMAM Defaulter Rate, 2010 - 2012 ...... 52 Figure 6: CMAM Death Rate- 2012 ...... 52 Figure 7: CMAM Non-Recovery Rate 2010 - 2012 ...... 53 Figure 8: Initiation of Breastfeeding ...... 53 Figure 9: Consumption of Food groups by children 6-23 months, NSS November 2012 ...... 54 Figure 10: Training session for CHO’s on the use of flip chart before the field pre- testing ...... 58 Figure 11: Pre-Testing of Flip Chart with Opinion Leaders ...... 58 Figure 12: Per capita OPD attendance by districts – 2012 ...... 64 Figure 13: Insured & non-Insured by districts 2012 ...... 65 Figure 14: Percentage bed occupancy by facilities – 2012 ...... 68 Figure 15: Average length of stay by facilities – 2012 ...... 69

xi ACRONYMS & ABBREVIATIONS

A/A - Artesunate Amodiaquine ACT - Antersunate Combination Therapy AFP - Acute Flaccid Paralysis AGM - Annual General Meeting AHSAG - - Association of Health Service Administrators of Ghana ALOS - Average Length Of Stay ANC - Antenatal care ARI - Acute Respiratory Infection ART - Anti Retroviral Therapy ARVs - Anti-Retroviral Drugs BCG - Bacille Calmette Guérin (Tuberculosis Vaccine) BMCs - Budget Management Centres BMI - Body Mass Index C/S - Caesarean Section C4D - Communication for Development CBA - Community Based Agents CBGP - Community-based Growth Promoters Cd1 - Communicable Diseases Form 1 Cd2 - Communicable Diseases Form 2 CHAG - Christian Health Association of Ghana CHN - Community Health Nurse CHO - Community Health Officer CHPS - Community Based Health Planning and Services CHPW - Child Health Promotion Week CHV - Community Health Volunteers CMAM - Community-based Management of Severe Acute Malnutrition CMS - Central Medical Stores CPT - Co-trimoxazole CSM - Cerebrospinal Meningitis CWC - Child Welfare Clinic DA - District Assembly DDCC - Deputy Director for Clinical Care DDG - District Directors Group DDHS - District Director of Health Services DHA - District Health Administration DHMT - District Health Management Team DPF - Donor Pooled Fund DTC - Drug and Therapeutic committee ENT - Ear Nose and Throat EPI - Expanded Programme on Immunization EQA - External Quality Assurance FIDS - Faculty of Integrated Development Studies FM - Frequency Modulation FSV - Facilitative Supervision

xii FT - Field Technician GAM - Global Acute Malnutrition GES - Ghana Education Service GHS - Ghana Health Service GMP - Growth Monitoring and Promotion GOG - Government of Ghana GWP - Guinea Worm Programme HATS - Health Assistants Training School HBC - Home Base Care HIRD - High Impact Rapid Delivery HP - Health Promotion HTC - HIV Testing and Counselling ICD - Institutional Care Division IDSR - Intergraded Disease Surveillance and Response IGF - Internally Generated Funds IMCI - Integrated Management of Childhood Illness IPC - Interpersonnel Communication IUA - Infernal Audit Unit IYCF - Infant and Young Child Feeding JCC - Joint Co-ordinating Committee JICA - Japanese International Cooperation Agency KRHTS - Kintampo Rural Health Training School LDP - Leadership Development Programme LGS - Local Government Service LP - Lumber Puncture M/DAs - Municipal/District Assemblies MAF - Millennium Acceleration Framework MBs - Multibacillary MDGs - Millennium Development Goals MHD - Municipal Health Directorate MOH - Ministry of Health MOU - Memoradum of Understanding NACP - National Aids Control Programme NACS - National Assessment Counselling and Support NGOs - Non-Governmental Organisations NHI - National Health Insurance NHIS - National Health Insurance Scheme NIDs - National Immunization Days NMCCSP - Nutrition and Malaria Control for Child Survival Project NTD - Neglected Tropical Disease OI - Opportunistic Infections OPD - Out Patients Department OPV - Oral Polio Vaccine PBs - Paucibacillary PLHIV - People Living with Human Immune Virus PMTCT - Prevention of Mother to Child Transmission

xiii PNC - Post Natal Care PPM - Parts Per Million PPM - Planned Preventive Maintenance ProMPT - Promoting Malaria Prevention and Treatment QA - Quality Assurance QI - Quality Improvement RCC Regional Coordinating Council RGN - Registered General Nurse RHD - Regional Health Directorate RHMT - Regional Health Management Team RMS - Regional Medical Stores SAM - Severe Acute Malnutrition SBS - Sector Budget Support SDA - Seventh Day Adventist SFP - Supplementary Feeding Programme SIAs - Supplementary Immunization Activities SOPs - Standard Operating Procedures STIs - Sexually Transmitted Infections TB - Tuberculosis TBAs - Traditional Birth Attendants TOT - Trainers of Trainees UDS - University for Development Studies UNICEF - United Nations Children Fund UWR - Upper West Region VPD - Vaccine Preventable Disease WAP - Wa Polytechnic WFP - World Food Programme WHO - World Health Organisation WIFA - Women in Fertile Age YF - Yellow Fever

xiv CHAPTER ONE - INTRODUCTION

1.1 Profile of the Upper West Region The region in 2012 had two new administrative districts added to the existing nine (9) districts making the total eleven. The latest districts are Daffiama Bussie Issah and Nandom Districts. The old districts are Jirapa, Lambussie, Lawra, Nadowli, Sissala East, Sissala West, Wa East, Wa Municipal and Wa West. However, the Ghana Health Service report for the 2012 covers the performance of the old nine (9) districts.

Figure 1: Map of Ghana Showing location of UWR & Map of Upper West Region showing road networks and health facilities

Accra

4

1.2 Demographic characteristics The projected population for 2012 based on the 2010 Population and Housing Census is 729,044. The Women in the Fertile Age (WIFA) which is 23.7% of the total populations is 172,783. The expected pregnancy and number of children under 1 year of age is estimated to constitute 2.7% of the population which is 19,684. There are 989 settlements. Table 1 shows the total and target populations of the various districts for 2011 and 2012.

1 Table 1: Upper West Regional Population and Target Populations 2011 & 2012 2011 2012

Expected Expected Pregnancies/ Pregnancies/ District Total Pop Children< 1yr WIFA Total Pop Children < 1yr WIFA Jirapa 90,082 2,432 21,349 91,793 2,478 21,755 Lambussie 52,635 1,421 12,475 53,635 1,448 12,712 Lawra 102,847 2,777 24,375 104,801 2,830 24,838 Nadowli 96,181 2,597 22,795 98,009 2,646 23,228 Sissala E. 57,602 1,555 13,652 58,696 1,585 13,911 Sissala W. 50,515 1,364 11,972 51,475 1,390 12,199 Wa East 73,443 1,983 17,406 74,839 2,021 17,737 Wa Muni 109,251 2,950 25,893 111,327 3,006 26,384 Wa West 82,894 2,238 19,646 84,469 2,281 20,019 Total 715,450 19,317 169,562 729,044 19,684 172,783

1.3 Location and Population Density The Upper West Region situated in the north-western part of Ghana lies between longitude 1 o 25’’ W and 2 o 45’’ and latitudes 9 o 30’’ N and 11 oN (Refer Figure 1). It is bordered to the south by the Northern region, to the north and West by Burkina Faso and to the east by the Upper East region. With an area of 18,476 km 2, the region’s population density stands at 40 persons per square kilometre. The Sissala East, Wa East and parts of the Nadowli districts (in the eastern parts of the region) have nucleated communities that are far apart, with a resultant population density of 13 persons per square kilometre. This implies that health staff have to travel over long distances in order to deliver health services including immunization to the people. There is an increasing phenomenon of nomadic Fulani herdsmen moving into the eastern part of the region from Burkina Faso and Niger. The health services have faced difficulties in determining the real population as well as tracking these nomads to provide both routine services and immunization during National Immunization Days (NIDs) against Polio and Supplementary Immunization Activities (SIAs) against Measles.

1.4 Topography and Water Bodies The landscape is generally flat and below 300m above sea level with a central plateau ranging between 1,000 and 1,150 ft. The low lying nature of the region opens up several communities to flooding during the rainy season. The Black Volta forms the western border of the region with Burkina Faso whilst the Kulpawn and Sissili which are tributaries of the White Volta also run through the eastern part of the region. 2 1.5 Climate The climate is tropical with an average minimum temperature of 22.6 oC and maximum of 40.0 oC. There is one rainy season from May- October with an intensity of 100-115 cm/annum with humidity ranging between 70- 90% but falling to 20% in the dry season. During this time from November to March, the cold dry and dusty wind, the harmattan, blows from the Northeast across the region. It is this period from November to March that the region is most prone to outbreaks of cerebrospinal meningitis.

1.6 Economic Activities and Migration Since the predominant activity is farming the long dry season means that many people are idle for so many months each year resulting in a lot of seasonal migration to the southern parts of the country especially to the Brong-Ahafo, Ashanti and Eastern regions. This form of migration has implications for public health in the region. The emergence of Galamsey (illegal mining activities) activities currently in Nadowli, Wa East, and Sissala East districts poses an increasing risk of respiratory related health problems as well as sexually transmitted diseases.

1.7 Transport and communication The region has the least kilometers of tarred roads in Ghana. Only three of the district capitals are linked to each other and to the regional capital courtesy parts of the Bamboi-Hamile trunk road. The bad nature of most of the roads during the rainy season also makes movement to some of the communities in the eastern part of the region very difficult. Telephone and fax facilities exist in all the districts. Mobile phone coverage to the entire region is about 90% but the eastern parts of the region have poor phone coverage. There is a small airstrip in the regional capital but this is rarely used, as there are no commercial flights. The predominant means of transport is by road using lorries, buses, motorcycles tricycles or bicycles and rarely donkey carts. The region prides itself with about seven (7) FM radio stations currently in operation that broadcast in English and in more than three local languages (Dagaare, Brifo, Sissala and Akan). Majority of the stations are situated in the regional capital namely, Progress, Radio Upper West, Fids, and Waps. The others are two – Nandom (FREED and Voice of Nandom) and RADFORD in Sissala East

3 1.8 Health Delivery System The Regional Health Management Team (RHMT) oversees the planning and implementation of health services in the region. Nine district health management teams planned and supervised health service delivery in 65 sub-districts and 166 CHPS compounds in 2012. There are a total of two hundred and fifty (250) health facilities providing various types of services in the region. These are three (3) district government hospitals, one (1) Regional hospital, two (2) CHAG Agency hospitals and three (3) private hospitals. The rest are sixty (65) health centres, 5 private clinics and one hundred and sixty six (166) CHPS Compounds (Refer Table 2). Three out of the nine districts in the region (Wa East, Wa West, and Lambussie) have no district or private hospital. The Gwollu Health Centre in Sissala West has been upgraded to a district hospital status. Table 2: Summary of health facilities 2012 District Health Other Maternity Regional District CHPS Clinic Hosp Centre Hospitals Home Hosp Total Jirapa 23 7 1 31 Lambussie 10 6 16 Lawra 20 1 1 10 1 33 Nadowli 42 1 13 1 57 Sissala E. 8 1 6 1 16 Sissala W. 9 4 13 Wa East 12 1 7 20 Wa Mun. 21 6 6 2 1 36 Wa West 21 6 1 28 Total 166 8 3 65 5 2 1 250

In the course of the year five (5) polyclinics were completed and handed over. They had not yet started operating by the close of the year (Refer page 12 for further details)

Health services such as clinical care, reproductive and child health, nutrition, immunization and other disease control services were delivered by the 9 district health management teams and 65 sub-district health management teams. These teams were supported by a community based health system of volunteers and service providers made up of 1,209 Traditional Birth Attendants, 1,850 community based surveillance volunteers, 3,520 Community Based Agents and 184 guinea worm volunteers who are providing various services in 3,557 demarcated areas

4 with supervision from sub district health staff. There are 861 outreach points for the provision of immunization and other services.

Since 2003, the region has, in line with the policy of the Ghana Health Service, been implementing the Community based Health Planning and Services (CHPS) strategy. This strategy is aimed at the provision of close to client/ door to door high impact rapid delivery (HIRD) and other health interventions to communities. These services are provided by designated Community Health Officers (CHO) supported by CHPS volunteers operating out of a building constructed and located in the community called a CHPS compound. The region has at the end of 2012 one hundred and sixty six (166) functional CHPS compounds out of 197 earmarked zones.

1.9 Main priorities for 2012. The main priorities of the region at the beginning of the year 2012 included the following: • Intensification of surveillance, disease investigation and response with reference to silent districts • Scale up Leadership Development Training to cover more health managers at all levels • Implementation of maternal death audit recommendations and start neonatal death audits • To improve the management of indebtedness in relation to the RMS & MTC • To improve Quality Assurance and rationale use of medicines. • Implementation of developed systems (FSV, CHAPs etc) • Improve financial resource management in the areas of timely resource allocation, routline audit inspection, ,review audit recommendations, zoned BMCs for internal auditing purposes. • Improving monitoring and supervision of service delivery at all levels

5 CHAPTER TWO – OBJECTIVE 1 Bridging the Equity gaps in access to health care and nutrition services and ensure sustainable financing arrangements that protect the poor.

2. 1 Community-based Heath Planning and Services (CHPS) The Community-based Health Planning and Services (CHPS) is aimed at improving geographical access to healthcare. This strategy is achieved through six major steps as; planning, community sensitization, compound construction, equipment supply, training and deployment of Community Health Officers and volunteer selection. The implementation of CHPS is varied from one region to the other especially the way in which communities are engaged for CHPS implementation. Community Health Action Plans (CHAPs) and Community Emergency Transport Systems are the strategies adopted by the region to engage for CHPS implementation.

The region has a target of One Hundred and Ninety Seven (197) CHPS zones that were targeted in 2006. Currently, there are suggestions to increase the target to 231 earmarked zones in the region. These suggestions are mainly as a result of the increase in the number of districts over the period. The creation of new districts necessitates further planning that lead to the creation of new zones.

In 2012 key activities carried out in relation to the CHPS implementation were; 1. Training and deployment of 82 Community Health Officers. (Total number trained from 2006 to date is 272) 2. Massive increase in the number of functioning CHPS zones from 114 to 166 and functioning zones with compounds also increased from 104 to 114 in 2012 (Refer Table 3) 3. Revision of the Facilitative Supervision (FSV) materials 4. Development of training materials for community engagement 5. Participated in the launching of CHPS compounds etc 6. Implementation of activities of the second fiscal year of the GHS/JICA Phase Two Project

CHPS implementation in the region is beset with a number of challenges such as poor security, water and electricity supply, high attrition of CHOs, and continuous demand of number of earmarked CHPS zones and, poor community participation

6 To promote the implementation of the CHPS in the years 2013 there is the need for timely implementation of the grant aid component of the JICA support to construct the 73 CHPS compounds. It is also necessary for districts to seek clearance from the Regional Director of Health Services before demarcating additional CHPS zones. There is also the need to identify frontline workers that have adequate number of years to work for CHO training Table 3: Status of CHPS implementation, 2012 No of No of No of CHN Sub- Earmarked Functional No with No with in CHPS District districts zones in 2006 zones CHOs compounds zones Jirapa 7 16 23 21 9 3 Lambussie 6 14 10 10 10 0 Lawra 10 26 20 18 16 3 Nadowli 13 34 43 20 17 25 Sissala East 6 18 8 8 9 4 Sissala West 4 15 9 10 9 0 Wa East 7 21 12 13 14 0 Wa Mun 6 22 21 17 15 7 Wa West 6 31 21 18 15 4 Total 65 197 166 135 114 46

2.2 National Health Insurance Scheme The National Health Insurance Scheme (NHIS) is the main policy to improve financial access to health care delivery in the country as well as the primary source of funding to the region for service provision. In 2012 NHIS accounting for 92% of total IGF during the period under review. A total amount of eleven million five hundred and fifty-two thousand six hundred and forty- seven Ghana Cedis forty-four pesewas (GH¢11,552,647.44) was generated from insured clients during the year under review as against eleven million seven hundred and fifty-four thousand two hundred and seventy-seven Ghana Cedis eighty-three Pesewas (GH¢ 11,754,277.83) mobilised in 2010 (Refer Table 4). This represents a marginal decrease of 1.72% as against the previous year increase of 28.46%. This is as result of delays in the reimbursement of claims. The high contribution of NHIS to the total IGF during the year is as a result of high enrolment of clients on to the various schemes at the districts level in the region. NHIS clients accounted for 95.6% of OPD attendance as compared to 94.3% in 2011 and 90.70% in 2010. Insured clients also accounted for 94.18% of all inpatient cases in 2012 as compared to the 77.6% in 2011.. NHIS is gradually wiping out the cash and carry for both OPD attendance and inpatient admissions. Table 4 depicts the relative contributions of the NHIS and the “Cash and Carry” to total IGF by facility levels.

7 Table 4: Ratio of NHIS to Cash and Carry 2010 2011 2012 BMC Cash & Carry NHIS Cash & Carry NHIS Cash & Carry NHIS 257,104.93 1,890,403.95 254,823.72 1,896,457.43 2,132,705.06 299,008.52 Regional Hosp (11.97%) (88.03%) (11.85) (88.15) (87.70) (22.30) 487,903.75 4,112,998.23 396,726.80 7,126,700.23 6,721,349.65 492,816.46 District Hosp (10.6%) (89.4%) (5.27) (94.73) (93.17) (6.83) 186,621.29 3,140,748.27 175,788.43 2,723,025.90 2,698,592.73 155,815.55 Sub-Districts (5.61%) (94.39%) (6.06) (93.94) (94.54( (5.46) 931,629.97 9,144,150.45 827,338.95 11,746,183.56 11,552,647.44 947,640.53 Total (9.25%) (90.75%) (6.58) (93.42) (92.42) (7.58)

It is to be noted however that delays in submission of claims to Schemes for reimbursement, increase in patient attendance resulting in overcrowding, long waiting time and complaints of poor health attitudes of heath staff continues to confront the implementation of the National Health Insurance Scheme. Overdue delays in the reimbursement of health facilities for services rendered to insured clients continue to affect the ability of health facilities to procure medicines and other materials. This situation if not dealt with expeditiously will ultimately affect quality of health care provision by health facilities and also its ability to repay their debts owed to the Regional Medical Stores. For the year under review the indebtedness of the various Schemes to the health facilities in the region stood at six million, seven hundred and seventy-nine thousand seven hundred fifty-six Ghana cedis eighty-four pesewas (GH¢6,779,756.84) as compared to previous year’s amount of five million, four hundred and forty-one thousand five hundred and twenty-four Ghana cedis ninety-six pesewas (GH¢5,441,524.96) representing an increase of 24.60 resulting in 2.4% fall in the previous year’s 27% increase (Refer Table 5)

Table 5: Indebtedness of NHIS to health facilities Levels 2009 2010 2011 2012 Regional Hospital 1,505,835.00 553,115.45 833,518.87 1,074,610.81 District Hospitals 1,406,347.82 2,435,359.30 3,198,683.43 4,196,898.43 Sub-districts 642,856.67 1,221,022.31 1,409,322.66 1,508,247.60 Total 3,555,039.49 4,209,497.06 5,441,524.96 6,779,756.84

8 CHAPTER THREE- OBJECTIVE 2 Strengthen Governance and Improve the Efficiency and Effectiveness of the Health System 3.1 Develop Capacity to Enhance the Performance of the National Health Systems 3.1.1 Human Resources for Health

As in the few past years, the region continued to grapple with inadequate critical health professionals including Medical Doctors, Medical Assistants, Midwives and Pharmacy Technicians even though progressively the total staff strength keeps increasing. During the year under review, inadequacy of Personnel officers and other administrative staff have also become a significant need due to the expansion in the facilities.

Within the period a total of one hundred and eighty-seven (187) health professionals trained in the region were allocated to all the nine districts and facilities including CHAG institutions. These professionals comprised seventy nine (79) Community Health Nurses (CHNs), eighty six (86) Enrolled Nurses (EN) and twenty two (22) Registered General Nurses (RGNs). Also, three (3) Registered Mental Health Nurses (RMNs) and four (4) Internal Audit Agency (IUA) staff posted to the region reported for duties except two (2) of the latter category. Likewise, two (2) out of the four (4) Medical Officers posted to the region actually reported and assumed permanent duties. These new additions brought the total regional staff strength to 2,208 compared to the staff strengths of 1,945 and 2,129 in the years 2010 and 2011 respectively. On staff attrition, a total of eleven (11) deaths, thirty three (33) retirements, and two (2) resignations were recorded during the period.

During the year under review a total of twenty eight (28) in-service training activities were undertaken in the region to build the capacities of staff in various areas of health delivery. These areas comprised Public Health, Disease Control, and Nutrition etc. A total of over four hundred and eighty (480) staff participated in these trainings.

On staff developments a total of seventy eight (78) serving staff were granted study leave to pursue various academic programmes related to their professions. The programmes ranged from certificate to diploma and post-basic through first degree. About 90% of the programmes were related to the nursing profession. Specifically, the programmes included Public Health, Post Basic Midwifery, Bsc. Nurse Anaesthesia, Diploma in Registered Midwifery, Nutrition, Oral Health, Physician Assistant, Ophthalmic Nursing etc.

The Leadership Development Programme (LDP) which was introduced to the region in March 2012 with the aim of empowering employees of the Service with analytical and problem solving

9 skills came to a successful conclusion in October 2013. All the DHAs and Hospitals that participated successfully implemented a project each in their respective stations using the problem-identification skills acquired during the training.

In terms of promotions, no staff was promoted in the year under review. This was primarily due to the absence of promotion guidelines which usually came from the Human Resource Development Division of the Ghana Health Service. But it is significant to indicate that a total of ninety four (94) staff within the interviewable grades were promoted in 2011 as against eighty four (84) in 2010. Two hundred and sixty four (264) category D and E personnel were also promoted in 2011 based on the prescribed promotion guidelines.

Performance appraisals were also conducted for all District Directors of Health Services, Deputy Directors, Programme Coordinators and other Senior Managers. The exercise took place at all levels of the service delivery system for other categories of health staff. Weaknesses identified were addressed through appropriate capacity enhancing activities to strengthen competencies and skills such as on-the-job training and workshops.

And as part of strategies to attract and retain critical health personnel, the service made some proposals to the Regional Coordinating Council (RCC) for consideration and approval for implementation. When approved it is expected that both Ghana Health Service (GHS) and the Local Government Service (LGS) comprising Municipal/District Assemblies (M/DAs) would have a role to play in terms of collaborating to provide both monetary and non-monetary incentives such as salary top-ups and accommodation to attract and retain these health personnel the region is so much in dire need of. In addition, the “locum” system whereby doctors are hired by health facilities to make up for the absence of resident medical officers was also intensely deployed to address the gaps in service delivery. However, it is significant to state that this approach is rather very expensive and is actually having a toll on the finances of hospitals which are also saddled with the challenge of non-payment of health insurance claims for very long periods.

Another measure adopted to address the issue of service gaps is the use of medical outreach programmes. In this regard, teams of medical personnel were arranged from the Teaching Hospitals as well as abroad to visit specific facilities in the region to provide both general and specialist services such as plastic and eye surgeries. Indeed, the eye care outreach programme is being run on a regular basis by visiting ophthalmologists.

Staff distribution in the region can be described as near equitable. The real issue has to do with

10 availability in adequate numbers of some of the professionals especially midwives, Most of the sub-district facilities do not have midwives and the few available are also getting to their retirement.

The doctor/pop ratio (Refer Table 6) keeps worsening by the year due largely to unwillingness of doctors to accept postings to the region. Nonetheless, the presence of the Cuban doctors made an important difference. The number of MAs has seen a steady increase over the years. This is partly attributable to a deliberate policy of the region to encourage serving staff to undertake the Physician Assistant programme as a post-basic course.

Table 6: Critical Staff/Pop. Ratios 2008 - 2012 Category 2008 2009 2010 2011 2012 No. of Ghanaian Doctors 13 13 15 14 12 Doctor: Pop Ratio 1:50,756 1:51,619 1:46,807 1:51,104 1: 60 ,753 No. of Nurses 787 934 966 1,333 1,250 Nurse: Pop Ratio 1:838 1:718 1:727 1: 53 7 1:5 83 No of Medical Assistants 16 15 20 23 26

3.1.2 Health Training Institutions In all, there are 7 training schools in the Upper West Region. These include 1 CHN Training School, 2 HATS, 3 Post-Basic and 1 RGN training school. Table 7: Student Population (2011-2012) School Type Location 2011 student Pop 2012 student Pop Nursing Training College Diploma Jirapa 204 208 Midwifery Training School Diploma Jirapa 113 133 Midwifery Training School Certificate Jirapa 132 71 Midwifery Training School Certificate Nandom 55 53 Midwifery Training School Certificate Tumu 15 38 Community Health Nursing Certificate Jirapa 192 297 Health Assistants Certificate Wa 130 141 Health Assistants Certificate Lawra 148 254 TOTAL 989 1,195

There has been a steady growth in the enrollment and the pass rates of trainees (Refer Tables 7, 8 & 9). This is encouraging as the yawning gap in health professionals is most likely going to be bridged in the foreseeable future.

11 Table 8: Student population in health training institutions 2012 Name of school 1st Years 2nd Year 3rd Year Total Wa HATS 69 72 141 JNTC 79 46 83 208 JMTC (RM) 60 30 43 133 JMTC (PBM) 42 29 71 JCHNTS 101 88 108 297 Lawra HATS 185 69 254 NMTS 29 24 53 TMTS 15 23 38 Total 580 381 234 1,195

Table 9: Students academic performance -Pass Rate 2010 -2012 INSTITUTION 2010 2011 2012 WA HATS 61% 70% 70% JNTC 64% 56.90% 37.60% JMTC Nil 35.50% 42.90% JCHNTS 60% 96.60% 89.80% LAW HATS Nil Nil 62% NMTS Nil Nil Awaiting TMTS Nil Nil Nil

The challenges facing the training schools include, Inadequate infrastructure in terms of hostel and staff accommodation as well as office infrastructure , Inadequate staffing, poor funding and non availability of skills laboratory

3.1.3 Infrastructure for Health The efforts of the RHD to expand access to health through infrastructural development continues to be a topmost priority for the region in the year under review. Five (5) Polyclinics which commenced in 2011 were completed in 2012 and handed over to the GHS. These are located at Ko and Babile in the Lawra District, Lambussie in the Lambussie Karnie District, Hain in the Jirapa District and Wechau in the Wa West District

Again, Four (4) of the eight (8) CHPS compounds initiated by Ghana Health Service (GHS) at the beginning of the year were completed. A new pediatrics ward which began in the Nadowli District Hospital in 2011 through the collaborative efforts of JICA and the then Nadowli District Assembly has been completed and put to use in 2012.

Besides, expansion and remodeling works in Gurungu, Vieri, Eggu and Charikpong health centre and Kohou CHPS compound in the Lambussie sub-district which started in the year under review are also on-going. A lecture hall for students in the Jirapa Midwifery training School (with financial support from the Japanese Government) also commenced in the year under

12 review and is currently at the roofing stage.

The Regional Health Directorate Library witnessed some face-lifting thanks to the Leadership Development Programme (LDP) that was introduced early in the year. Now the library has been successfully converted into a conference hall with a seating capacity of fifty (50) persons. And can serve as venue for certain types of conferences to serve cost.

Residential accommodation for staff is still a critical issue in the region (especially for the hospitals and health centres) resulting in a good number of critical health personnel living outside their facilities in rented premises.. The few accommodation facilities available are not well maintained due to lack of funds with their electrical wiring and plumbing systems severely deteriorated. The non-payment of health insurance claims to the facilities by the NHIA has compounded the problem. To improve the accommodation situation the region made efforts in 2010 to reactivate abandoned residential projects most of which are over 60% complete this efforts however, failed to yield the desired results. Although all the relevant information was forwarded to headquarters (GHS) payments were not made to the contractors to enable them return to site. Some of these projects include the 4-units 2-bedrooms residential projects started in 2005 as part of the then Director General’s special initiative in the Wa Municipality, Wa East, Sissala East, and Larwa districts. The region shall continue to lobby headquarters for their completion.

It also important to point out that the issue of uncompleted structures would worsen if steps are not taken to ensure the continuation of projects such as the Administration Block in Nandom Hospital which began in 2011. The project reached lintel level in early 2012 and since then nothing has been added. A similar project - An administration Block which started over eight years ago in Jirapa Hospital is yet to be completed. However, the suspended maternity block in Nandom Hospital which is about 90% complete has been handed over to the hospital authorities to enable it to be completed with internally generated funds (IGF) and other sources.

Inadequate office space is also hampering efficient service delivery in the region. Wa Municipal Health Directorate including five other districts especially those created within the last seven years do not have office accommodation. Even though a structure was started several years ago to provide office accommodation for the Wa MHD it is still at the foundation level. In 2010 this structure was amongst the many that were reactivated and recommended to headquarters for completion but no progress has been recorded in that regard since then. The state of the storage facilities for health commodities at the district and sub-district level need expansion in view of the ever-increasing utilization of health services mainly due to the

13 introduction of the NHIS and population increase. Indeed, the storerooms in most facilities can no longer hold sufficient commodities for service delivery beyond a one-month period. This compels the facilities to visit the Regional Medical Stores (RMS) more frequently with its attendant high administrative costs. A comprehensive warehouse assessment is therefore required to determine their true state and improve the situation.

3.1.4 Equipment for Health During the year under consideration there was an injection of one hundred and twenty five (125) adult hospital beds into eight health facilities – six public and two private. Four hospitals also received four blood bank fridges from the United Nations Population Fund (UNFPA). In addition, assorted medical equipment including suction machines, autoclaves gas cylinders, trays etc were distributed to selected districts and facilities namely: the Regional Hospital, Lawra District Hospital, Wa West District and Wa Municipality. Apart from these, Lawra Hospital and Nandom District Hospitals also received modern digital print out SPN X-ray Machines. Generally, the equipment situation in the facilities is relatively better but there is still room for improvement as some equipment such as anaesthetic machines, ECG machines, autoclaves in some hospitals etc need o be replaced altogether. At the Health Centre level some type of instruments for service delivery such as obstetric sets, boilers etc are inadequate and therefore need to be revamped.

The cold chain equipment in the region are very old and therefore break down quite frequently. Most of the solar batteries and fridges need replacement and routine and emergency maintenance systems are not strong and efficient enough to deal with the situation. This situation was due to the absence of a revolving fund to support routine visits by the regional equipment team to the districts for both planned and emergency maintenance activities. Hydrometers are also urgently needed in all the facilities for the purpose of measuring the strength of acid in the batteries as part of the PPM system.

In general, Planned Preventive Maintenance (PPM) is a challenge at all levels due basically to inadequate budgetary allocations. In most institutions budgetary provisions were hardly made for equipment maintenance. There is also the challenge of lack of reliable database for accurate assessment of the true equipment situation in the region due to the failure of BMCs to regularly update their Assets registers. It is the plan of the RHD to update the skills of BMCs on keeping of asset registers in 2013. Besides, equipment maintenance personnel are also inadequate with most facilities without any to attend to basic equipment maintenance issues. It was therefore in light of this that in the region in 2010 organized a workshop to train equipment maintenance focal persons for the districts on

14 basic equipment maintenance activities. Unfortunately, the necessary funding and logistics support appeared not to be forthcoming. Region will take steps to encourage M/DDHSs to accept and implement the maintenance focal person concept to improve the culture of maintenance at all levels as a stop-gap measure while efforts are made to increase the numbers.

As part of efforts by government to stem the severe power outages and fluctuations prevailing in the country in the year under review, the Ministry of Health initiated a project to supply electric generating sets and transformers to health institutions. Consequently, two facilities namely Nadowli and Nandom Hospitals received a standby generating set each. In addition, Nadowli Hospital, the Regional Medical Stores and the Regional Walk-In Cold Room also received three transformers of various capacities to ensure stable and good electric current voltage to run the medical equipment. To improve equipment maintenance the region is considering taking action to dispose of all the TP Radios that are broken down and can no longer functioning, establishing revolving fund for equipment maintenance and lobby the EPI programme to replace all spoilt solar batteries and fridges in health facilities.

3.1.5 Transport for Health The transport situation was generally good during the year under review. There was an increase by eight (8) in the number of vehicular fleet. The total number of vehicles in the green and yellow zones was very good compared to the number in the red zone (Refer Table 10). However, the average fleet age increased from 4.7 years in 2011 to 5.2 years in the year under review.

Table 10: Age Blocks of Vehicles 2009 – 2012 Zone Age 2009 2010 2011 2012 Green 1-5yrs 31 48 61 47 Yellow 6-9yrs 38 39 37 55 Red 10yrs & above 15 15 17 21 Total 84 102 115 123 Similarly, the motorbikes position in the region during the year was also very satisfactory. The number of motorbikes that crossed over into the red zone was twelve (12). There was no motorbike received during the year. The average age of the bikes also increased from 3.7 years in 2011 to 4.1years. (Refer Table 11)

Table 11: Age Blocks of Motorbikes 2009 -20012 ZONE AGE 2009 2010 2011 2012 Green 1-3yrs 254 348 265 339 Yellow 4-5yrs 149 159 159 164 Red 6yrs & above 75 75 75 87 Total 478 582 599 599

15

The driver: vehicle ratio which was 1:3 in 2011 remained the same in the year under review (Refer Table 12). Though the total number of drivers increased by twelve (12) in the year the increase in the number of drivers was neutralized by the corresponding increase in the vehicular fleet.

Table 12: Driver Vehicle Ratio 2010 - 2012 No Description 2010 2011 2012 1 Number of Drivers (permanent +volunteers 39 35 47 2 Number of Vehicles 102 113 123 3 Driver/Vehicle ratio 1:2.6 1:3 1:3

Road Traffic Accident (RTA) In the course of the year under review two Road Traffic Accidents (RTAs) involving Service vehicles were recorded one of them fatal. And even though the vehicles suffered some damages they have both been repaired and brought back on road. The affected vehicles were a Toyota Hillux Double Cabin Pick Up and an Ambulance.

3.1.6 Mechanical Technology Centre (MTC) The Mechanical Technology Centre (MTC) continues to be one of the most preferred workshops in the region for individuals and corporate bodies. The clientele of the workshop can be categorized into three groups namely; Individuals, MoH/GHS Agencies and other Statutory Agencies. During the year under review another state agency – the National Health Insurance Authority (NHIA) signed a Memorandum of Understanding (MoU) with the Regional Health Administration (RHA) to have its vehicles in the region maintained and serviced at the workshop. Since its establishment the workload at the workshop has been growing steadily over the years. Ttable 13 shows the trend of workload over the past five years:

Table 13: Trend of Workload at MTC -2008 -2012 YEARS 2008 2009 2010 2011 2012 NO OF JOBS 277 361 376 504 527

The facility also witnessed some level of refurbishment during the year. The offices were repainted, furniture, television set and a computer provided. The RHA also signed a Memorandum of Understanding (MoU) with the Edern Security Services Ltd for the provision of twenty four (24hr) security for the workshop. Indeed, this arrangement has improved the security situation with no cases of theft or pilfering recorded since its inception. Also one mechanic and an electrician from the workshop participated in a workshop organized by GHS headquarters to equip them with knowledge and skills to maintain the VWT5 ambulance

16 vehicles supplied to the regions.

For the total of five hundred and twenty seven (527) jobs done by the workshop during the year under review, the sum of thirty two thousand two hundred and fifty eight Ghana Cedis forty two pesewas (GH¢32,258.42) was generated. Of this amount, only fourteen thousand six hundred and seventy five Ghana Cedis forty six pesewas (GH¢14,675.46) was paid representing 45.49%. And of the total sum unpaid – seventeen thousand five hundred and eighty two Ghana Cedis ninety six pesewas (GH¢17,582.96) the MOH/GHS Agencies alone accounted for about 74.50%. It is therefore clear that there is a challenge with settlement of debts as far as the GHS institutions are concerned.

3.1.7 Nangfang Motorbike Spare Parts In the year 2011 GHS headquarters supplied a quantity of nangfang motorbike spare parts worth almost eighty thousand Ghana Cedis (GH¢80,000.00) to the regional workshop. The idea was to allocate or sell these spare parts to the Ghana Health Service institutions and use the proceeds generated as Seed Capital to establish a revolving fund for the workshop. The purpose of the revolving fund was to enable the workshop purchase and stock vehicles’ consumables for efficient and effective service provision. Unfortunately, only four districts have so far paid for the parts. This development is therefore hampering efforts at stocking spare parts at the workshop. The other difficulties faced by the workshop include unwillingness of health institutions to pay their service bills and lack of full complement of the requisite tools to provide certain services. The Regional Health Administration (RHA) intends to set up a debt collection team to visit the districts twice a year and also to implement a “cash and carry” system for GHS institutions if feasible as strategies to overcome the challenges.

3.2 Strengthen Inter-sector Collaboration Including Public-Private Partnership

3.2.1 Collaboration for Health The regional health service collaborated with the local government system (District Assemblies) for the provision of health infrastructure including CHPS compounds, Hospital Wards, Residential Accommodation for critical staff especially doctors, drilling of boreholes for CHPS compounds and Health Centres and extension of electricity to rural clinics. The DHAs also have some collaborative relationships with NGOs for health at the district level notably World Vision – Ghana, Plan Ghana and World Food Programme (WFP) etc. In addition, the service collaborated with communities (CHVs) during mass immunizations and other decentralized departments such as Agric for food fortification, Environmental Health for carcass inspection, Ghana Education Service (GES) for school health services delivery. Collaboration with private

17 and mission hospitals and clinics however needs to be strengthened to improve information sharing and in order to be able to account for the true burden of disease in the region.

It is to be emphasized that the key health partners who are actually driving health service delivery in the region are UNICEF, UNFPA, JICA etc. Over the years these organizations have injected enormous resources into the region to help roll out important health interventions which are contributing in a very large measure to the reduction in malnutrition, improving maternal and child health and bridging equity gaps in health service provision.

An NGO desk which was set up by the Regional Health Directorate to coordinate the activities of traditional herbal medicine practitioners (TMP) in the region collaborated effectively with stakeholders. The desk registered 960 Traditional Medicine Practitioners and twenty five (25) local NGOs in health. Through the NGO desk the region carried out registration of some of the products of the TMP and issued authorization for adverts to be played on radio and other media. The GHS received great support and cooperation from media houses in this regard.

3.2.2 Collaboration with CHAG The period under review experienced difficulties in collaboration with CHAG as a separate agency. This took the form of struggle for ownership of health facilities by the latter without the requisite legal documentation, changing of signatories to accounts hitherto jointly owned and unilateral illegal taking over and occupation of a polyclinic built on a church land before it was legally handed over.

These problems arose as a direct misunderstanding of the relationship between the two agencies of the Ministry of Health (MOH). A high level delegation visited the region to initiate a process of signing a local MOU between the two to streamline local level operations. Midway, however, the committee abandoned the assignment and was subsequently dissolved with no results.

As at the close of the year tensions were still running high fueled by emotions from the church affecting service delivery. The National Executive of CHAG has taken the challenge to assist in the drafting and signing of MOUs to facilitate collaboration as has been done easily in the Upper East Region involving eight churches.

Meanwhile MOH stakeholders e.g. SDA, UDS etc are getting on board in the health service delivery area.

18 3.3. Strengthen Systems for Improving the Evidence Based for Policy and Operations

3.3.1 Lot Quality Assurance (LQAS) Survey A survey aimed at achieving the under listed objectives was also conducted in selected districts of the region using the Lot Quality Assurance Sampling (LQAS) methodology. The overall purpose of the survey was two-fold namely; for decision making and reporting. In relation to decision making it was expected that it would aid district authorities to refine programme strategies and guide the allocation of resources at the district and sub-district levels. And for reporting, it would aid DHMT members to prepare reports based on evidence. The specific objectives were as follows: • To estimate district average coverage for key outcome indicators of the HIRD interventions • To identify Supervision Areas (SAs) that perform below the district average coverage to prioritize accordingly. • To assess whether or not the HIRD interventions were producing the expected results in each target district and identify priority outcome indicators. At the end of the survey, service areas under the HIRD programme which did not perform well such as PNC, 4+ ANC visits, skilled delivery are now made targets for better allocation of resources and strategies to improve performance. It is imperative to indicate that this project was the collaborative effort of the Navrongo Health Research Centre, the Upper West Regional Health Services, and the London School of Hygiene and Tropical Medicine in the United Kingdom. Indeed, the LQAS was found to be an effective tool for the management of health programmes and interventions. It has therefore been recommended for adoption by districts and other health institutions as a means of focusing resources properly and using the correct strategies to overcome the deficiencies in service performance.

3.3.2 Health Information Management The District Health Information Management System (DHIMS2) is the key tool or data management software in the region for capturing and analyzing most health data as it pertains in other regions. The Regional Health Information Unit at the Regional Health Directorate is responsible for improving data quality, accuracy, completeness and timeliness of reporting. To ensure the realization of these indicators, the Unit has institutionalized quarterly and monthly data validation meetings at the regional and district levels respectively. During the period under review the region benefited from trainings in DHIMS2 sponsored by the Policy Planning Monitoring and Evaluation Division (PPME) of the Ghana Health Service (GHS). Those trainings included:

19 • Dhims2 software utilization for core District Health Management Team (DHMT) staff who are directly involved in data entry. • Training for Systems Administrators at the district and regional levels • Dhims2 appreciation and navigation in the respective reports for district and regional level health managers. • To make Dhims2 training more effective PPME supported the DHMTs and the RHIU with one modem each. Regarding supervision, the RHIU undertook two joint quarterly support visits to the districts in collaboration with PPME. The main objective of the visit was to assess the administrative, logistics and management challenges confronting the implementation of the dhims2 in the respective districts. As a way of motivating the districts to take data completeness seriously, the RHIU ranked them on this indicator and their respective performance is shown in Table 14. Table 14: Ranking of Performance of Districts in Data Set Completeness -2012 Average Completeness (All District # of Dataset Dataset) Ranking Jirapa 32 90.86 1st Nadowli 39 89.59 2nd Lambussie/Karni 26 87.72 3rd Sissala West 36 72.28 4th Wa East 29 63.23 5th Wa West 32 62.25 6th Wa Municipal 43 61.08 7th Lawra 49 47.82 8th Sissala East 48 44.61 9th

It is significant to explain that the Wa Municipal, Lawra and Sissala East Districts are at the bottom because the hospitals in the districts were not able to enter clinical data in the areas of laboratory, theatre, pharmacy, blood organizer returns and others as required. The Regional Health Directorate (RHD) has planned a training schedule to train these defaulting units to enable them start data entry and reporting in 2013. In terms of ICT infrastructure, almost all offices at the Regional Health Directorate have at least a desktop computer or a laptop and their requisite accessories. The districts equally have adequate numbers of computers to facilitate information processing at that level. The following challenges are hampering information management in the region: • Continuous uninterrupted internet connectivity is a challenge in most districts. • There is no software programmes for the management of health commodities and human resources. • Inadequate Health Information Officers • Unwillingness of some programmes to switch on to the dhims2 20 • Lack of co-operation from private health facilities in submitting reports on services they provide to the public • Data security e.g. anti-virus etc

3.4 Strengthen systems for effective financial resources management 3.4.1 Indebtedness to the Regional Medical Stores The indebtedness of the hospitals and the health centres to the Regional Medical Stores (RMS) has reduced from 57% in 2011 to 48.25% in 2012. This is is still high due the failure of the National Health Insurance to reimburse the health facilities for over five months in arrears. This has the potential of adversely affecting the smooth running of the RMS if not checked. Table 15 shows the indebtedness of various health facilities to the Regional Medical Stores. Table 15: : Indebtedness of health facilities to RMS for 2010 – 2012 Year Product Regional Hosp District Hosp Sub-districts Others Total Medicine 152,039.26 72,410.67 264,371.47 3,991.73 492,813.13 Non -med 172,675.56 152,853.52 169,642.96 4,166.06 499,338.10 2010 Total 324,714.82 225,264.19 434,014.43 8,157.79 992,151.23 Medicine 230,521.50 85,825.66 358,538.79 21,229.25 696,115.20 Non -med 367,147.77 263,767.34 229,165.35 9,917.85 869,998.31 2011 Total 597,669.27 349,593.00 587,704.14 31,147.10 1,566,113.51 Medicine 505,968.61 303,310.12 670,332.13 34,912.70 1,514,523.56 Non -med 169,710.11 308,365.75 236,017.09 16,603.24 730,696.19 2012 Total 675,678.72 611,675.87 906,349.22 51,515.94 2,245,219.75

Debts collection exercise was undertaken during the year under review in an effort to reduce the indebtedness of these health facilities to the RMS in order to make it more viable.

3.4.2 Financial Monitoring Financial Monitoring Unit (FMU) of the Regional Health Directorate as part of efforts to maintain financial discipline and reliable financial reporting undertook financial monitoring and supervision to all the BMCs in the region and also validated their financial reports quarterly. Through these visits lapses detected in financial returns are corrected without delay and staff given on-the-job capacity building to improve their performance.

3.4.3 Internal Audit As part of efforts to ensuring good governance practice in the region, the Regional Internal Audit Unit deployed Internal Auditors to the districts to ensure that the relevant financial laws, rules, regulations, policies and procedures are complied with. The Unit in the year under review coordinated the responses to external audit queries by BMCs to follow-up on them to ensure that recommendations are implemented and also provided appropriate advice where

21 necessary. The Unit covered 57% of auditees for the year as against 32% last year, principally due to the zoning of the region. Efforts are being made to reduce audit queries on all sources of funding to the barest minimum.

3.4.4 Revenue and Expenditure Table 16 depicts a three-year trend of the relative shares of the main sources of funds to the region.

Table 16: Source of income (funding) , 2009-2012, UWR

Year Amount/ Source of funding % Share GOG Item 2 GOG Item 3 DPF IGF Programmes Total Amount 166,224.98 211,481.15 114,451.00 9,441,555.58 5,654,231.16 15,587,943.87 2009 % Share 1.07 1.37 0.73 60.56 36.27 100 Amount 172,103.21 128,279.87 207,316.06 10,857,921.21 5,629,256.98 16,994,877.33 2010 % Share 1.01 0.76 1.23 63.89 33.12 100 Amount 241,331.89 137,712.72 270,224.13 13,986,807.76 5,364,261.95 20,000,338.45 2011 % Share 1.2 0.7 1.35 69.93 26.82 100 Amount 107,799.55 - 60,871.50 14,398,706.06 2,575,396.63 17,142,773.74 2012 % Share 0.63 - 0.36 84 15 100

Internally Generated Funds (IGF) continues to dominate as the key source of financing health service delivery in the region. Of the total figure of seventeen million one hundred and forty- two thousand seven hundred and seventy-three Ghana Cedis seventy-four pesewas (GH¢17,142,773.74) mobilised during the period under review, IGF contributed 84% as depicted in Table 16. Funding from Health Partners ranked next to IGF accounting for 15% of the total. This is however a decrease from 26.8% the previous year. Generally, funding from Health Partners as compared to the total resource envelope has seen a steady decline since 2009.

With regard to expenditure, the sum of fifteen million eight hundred and fifty-seven thousand and thirty-nine Ghana Cedis twenty-two pesewas (GH¢15,857,039.22 ) was spent to provide health services. This expenditure is 4.70% lower as compared to last year’s expenditure of sixteen million six hundred and thirty-nine thousand one hundred and nine Ghana Cedis seventy-eight pesewas (GH¢16,639,109.78) (Refer Table 18). IGF and Programme expenditures continue to constitute the largest during the year under review representing 86.43% and 11.55% respectively. However, apart from IGF expenditure that saw an increase of 19.81%, all others decreased as compared to last year figures. There was no expenditure on GOG 3 as no

22 funds was received for this purpose from the central government during the year under review. In general terms, total expenditure decreased from an amount of GH¢16,639,109.78 to 15,857,039.22representing a decrease of 4.70% for the year under review. Table 18 shows the relative share of expenditures by source.

Table 17: Budget and funds availability 2009 – 2012 Year Annual Budget Yearly Releases GOG/DPF IGF Program funds Total % of budget released

2009 21,835,061.00 492,157.13 9,441,555.58 3,764,231.16 13,897,943.87 63.65

2010 24,789,457.20 507,699.14 10,857,921.21 5,629,256.98 16,994,877.33 68.56

2011 28,564,760.32 649,268.02 13,986,807.76 5,364,261.95 20,000,338.45 70.02

2012 29,822,875.54 168,671.05 14,398,706.06 2,575,396.63 17,142,773.74 57.48

Table 17 compares the annual budgets with actual releases. It is apparent that actual financial releases relative to the annual budgets have been on the increase except in 2012 which showed a sharp dip from 70.02% to 57.48%. This situation arose out of the fact that both government and health partners funding declined during the year under review, thus affecting the total resource envelope.

Table 18: Expenditure by source 2009 – 2012 Year Amount/ GOG Item 2 GOG Item 3 DPF IGF Programmes Total Share Amount 164,721.46 165,470.12 70,721.36 6,926,632.79 3,306,925.24 10,634,470.97 2009 % Share 1.55 1.56 0.67 65.13 31.1 100 Amount 131,506.16 126,405.87 139,002.99 5,900,893.35 4,378,789.82 10,676,598.19 2010 % Share 1.23 1.18 1.31 55.27 41.01 100

2011 Amount 296,683.57 123,147.19 168,575.24 11,084,890.47 4,965,814.31 16,639,109.78 % Share 1.78 0.74 1.01 66.62 29.85 100 Amount 121,382.84 - 197,480.78 13,705,453.16 1,830,710.44 15,857,039.22 2012 % Share 0.77 - 1.25 86.43 11.55 100

23 CHAPTER 4 - OBJECTIVE 3 Improve access to quality maternal, neonatal, child and adolescent health services.

4.1 Reproductive and Child Health Concerns at the beginning of the year bordered on issues with regards to (1) the 2010 population and housing estimates (2) poor data management (3) shortage of some family planning devices (Pills and Norigynon) (4) high maternal and child mortality and (5) inadequate numbers of midwives As part of interventions to address the concerns a number of interventions were carried out inclusive of (1) orientation for all District Public Health Nurses (DPHN) on updates of selected RCH indicators (2) conduct of regular data validation review meetings with DPHNs and District Health Information officers (DHIs) and (3) implementation of integrated supportive supervisory visits to the districts.

4.1.1 Antenatal Care Services Generally, there was a significant increase in ANC coverage from 23,943 in 2011 to 24,720 in 2012. There has been a steady increase in ANC registrants in the past three years. The total ANC registrants recorded in 2007 (25,005) was the highest attained in the past seven years. There has been district variations in performance with the some district recording more registrants in 2012 than in 2011 (Lambussie, Nadowli, Sissala East and Wa Municipal while the others recorded lower figures. ( Refer Table 19) Table 19: Number of ANC Registrants by Districts 2006 -2012 District 2006 2007 2008 2009 2010 2011 2012 Jirapa 3,166 3,925 3,452 2,388 2,192 2,442 2,433 Lambussie ** 1,637 1,453 1,417 1,535 Lawra 2,651 2,850 2,788 2,908 2,510 2,709 2,619 Nadowli 3,244 3,988 4,095 3,618 2,856 2,891 3,054 Sis. East 1,921 2,101 2,111 2,075 1,835 2,102 2,227 Sis. West 1,463 1,599 1,350 1,464 1,494 1,630 1,576 Wa East 2,569 2,656 2,383 2,366 2,376 2,636 2,595 Wa Muni. 4,346 4,587 4,861 4,893 4,639 5,116 5,714 Wa West 2,872 3,298 2,731 2,775 2,652 3,000 2,967 Reg. Total 22 ,232 25 ,004 23 ,771 24,124 22,007 23 ,943 24,720 **Lambussie District was created in 2009

There were a lot of strategies put in place such as ANC classes in Wa Municipal, using

24 community volunteers to register pregnant women in the communities on monthly basis and offering ANC services at outreach points. Such measures would need to be intensified and replicated in districts that are not practicing them.

Barriers militating against effective coverage of ANC include difficulties in the household decision making process where there is lack of support for women from husbands who happen to be the main decision makers. In addition there are cultural beliefs that a woman is not supposed to disclose her pregnancy at the early stage or else she would lose it. Other barriers include poor documentation and the inadequate numbers of midwives in the region.

IPT3 coverage for ANC mothers The regional performance in IPT has improved in 2012 as compared with 2011. A total of 11,708 antenatal mothers received IPT3 in the period under review as compared to 9,431 in 2011. There was also higher coverage for IPT1 and IPT in 2012 as compared with 2011 IPT3 (Refer Table 20). The region experienced shortage of IPT in the course of the year and also some pregnant women report for service late and are not able to receive the full course before delivery. There is also a problem with documentation. The region is putting in strategies to address these problems in 2013. Table 20: Performance of IPT3 from 2006-2012 Year IPT1 IPT2 IPT3 2006 16,384 12,678 9,047 2007 13,496 10,399 7,661 2008 18,668 15,820 12,512 2009 17,832 15,826 13,202 2010 16,541 14,242 11,302 2011 17,538 13,465 9,431 2012 17,793 15,567 11,708

4.1.2 Skilled Delivery Table 21 summarizes the trend of skilled delivery over the past seven years. The table indicates an increasing trend from 2006-2009 and a drop in 2010. However, it started increasing again in 2011 and 2012. The year under review had many of the districts performing above 2011 except Lambussie, Lawra and Wa West which performed a little below 2011. Generally, the region performed better in the year 2012 with a total skilled delivery of 15,389 as compared to 14,687

25 in 2011 and 11,676 in 2010 respectively. However, there is still the need to train more midwives and intensify education to improve upon skilled delivery in the Region. Table 21: Trend of Skilled delivery -2006 – 2012 District 2006 2007 2008 2009 2010 2011 2012 Jirapa 1,329 1,834 3,137 1,622 1,695 1,860 2,042 Lambussie 0 0 0 755 767 766 737 Lawra 1,095 1,460 1,744 2,012 2,037 2,575 2,444 Nadowli 1,113 1,334 1,405 1,747 1,682 2,044 2,173 Sissala East 549 471 543 605 652 1,028 1,052 Sissala West 256 325 287 373 409 584 675 Wa East 285 221 409 1,775 362 565 628 Wa Municipal 2,406 2,544 2,963 3,450 3,458 4,258 4,695 Wa West 302 399 638 1,637 614 1007 943 Reg Total 7,335 8,588 11,126 13,976 11,676 14,687 15,389

The education and motivation given to TBAs coupled with other interventions such as Video shows on the importance of skilled delivery, fines in most of the communities in the region, male advocacy in the communities, the use of ANC register to identify women at 36 weeks of gestation among others contributed to the increase in skilled delivery. Some districts also took the initiative to attach CHNs to the maternity ward to practically equip them with knowledge in deliveries. Some barriers to improving skilled deliveries include inadequate midwives to run the facilities, cultural beliefs (eg cultural belief that only unfaithful women deliver at health facilities) and the nomadic Fulanis who are part of our population who prefer delivering at home

Still Births The region recorded a total number of 334 stillbirths out of the total number of 15,389 skilled deliveries. Of this, 106 were fresh stillbirths, the rest were macerated. The number of stillbirths has reduced from 365 in 2011 to 334 in 2012 though 2010 recorded the least stillbirths (310) in the Region from 2009 to 2012 (Refer Table 22).

26 Table 22: Number of Fresh Stillbirths Out of Total Stillbirths 2009 2010 2011 2012 District Total SB Fresh Total SB Fresh Total SB Fresh Total SB Fresh Jirapa 44 10 31 12 40 16 41 19 Lambussie 2 1 4 3 4 1 2 1 Lawra 40 21 42 14 46 21 50 9 Nadowli 36 32 14 5 17 9 11 5 Sissala E 25 14 23 11 17 12 20 9 Sissala W 3 0 6 3 9 5 6 3 Wa East 17 17 4 4 7 2 9 8 Wa Mun 183 63 165 39 180 56 181 47 Wa West 6 3 21 14 45 5 14 5 Reg Total 356 161 310 105 365 127 334 106

4.1. 3 Maternal Mortality The Region recorded 28 institutional maternal deaths out of a total of 15,212 live births (LB) for 2012. This is a drop from 29 deaths out of 14,322 LB in 2011 and 26 deaths out of 12,270 LB in 2010. There is however the need to intensify education on maternal health and to put in measures such as training more midwives and oreintating community health nurses/community health officers on safe motherhood activities. These among others will help curb the issue of maternal mortality in order to meet the MDG 5 by 2015. (Refer Table 23 for the trend of maternal deaths in the region)

Table 23: Total Number of Institutional Maternal Deaths -2006 – 2012 District 2006 2007 2008 2009 2010 2011 2012 Jirapa 2 5 4 7 1 6 6 Lamb ussie 0 0 0 0 0 0 0 Lawra 3 10 5 6 3 6 1 Nadowli 1 1 2 1 3 2 0 Sissala E 1 3 3 5 4 1 2 Sissala W 0 0 0 0 0 1 0 Wa East 1 0 0 0 0 1 1 WaMun 9 9 8 24 15 11 18 Wa W 4 1 0 0 0 1 0 REGION 21 29 22 43 26 29 28 Maternal Mortality Ratio (Institutional) Maternal Mortality Ratio in the Region as at 2012 is 182deaths/100,000LB (Refer Table 24). There is a reduction in the trend from 2009 to 2012 even though there is an improvement in the performance of skilled delivery in 2012. This is an achievement above the 185 deaths per 100,000 live births of MDG5 by 2015. There is also the need to improve the emergency response systems in the hospitals especially the Regional Hospital

27 Table 24 : Maternal Mortality Ratio per 100,000 Live births -2006 -2012 Year 2006 2007 2008 2009 2010 2011 2012 Total maternal deaths 13 29 22 43 26 29 28 MMR 120 160 120 316 212 202 182

Maternal Mortality Audit Maternal death Audit is a priority policy in the region. As such all the maternal deaths that occurred in 2012 just as in the previous years had been audited. Usually the facilities where deaths occur audit these deaths at their level, then a regional audit forum organised for these districts to present their cases for others to share their experiences and also for others to learn. In 2012 however, after the facilities audit, the reg ional audits could not be organised for all the districts in any of the quarters . However individual districts with cases were invited to the region together with the Deputy Director of Public Health and the Regional Public Health Nurse (DDNS-PH) and other staff supported them to come out with action points for their districts to minimise future occurrences.

The major causes of maternal deaths for 2012 can be classified into direct and indirect causes. The direct causes include Haemorrhage (19%) Sepsis (19 %) unsafe abortion(5%), eclampsia (5) and ruptured uterus (5%). The indirect causes were renal failure (10%), malaria (9%), intestinal obstruction (9%) and sickle cell crisis (5%) . (Refer Figure 2) Figure 2: Causes of Maternal Deaths Sickle cell crisis Malaria 5% 9% Unsafe abortion Severe Anaemia 5% 14%

Renal failure Sepsis Intestinal 10% 19% Abstruction 9% Raptured Eclampsia uterus 5% Haemorrage 5% 19%

Plans for 2013 The regional Health Directorate plan ned to continue with interventions and initiatives targeted at reducing maternal d eaths by (1) intensify maternal death audit and the implement ation of

28 the maternal the death audit recommendations (2) Ensure quarterly monitoring of Zonal leaders to ensure that maternal death audit recommendations are complied with (3) Continue to train midwives on safe motherhood clinical skills (4) Conduct regular on-site coaching of midwives (5) Continue to carry out health education on the importance of facility delivery and acceptance of family planning in communities.

4.1.3 Postnatal Services This is the period from the end of delivery to six (6) weeks after delivery. Postnatal care is aimed at maintaining the physical and psychological well being of the mother and child. The essential components of postnatal care are; screening for detection and treatment or referral of complications in mother and child, health education and counselling and family planning motivation. The three main routine visits carried out were: the first is within 2 days of delivery, second visit is within 6 to 7 days of delivery and the third visit, 6 weeks after delivery. The utilization of the services is improving due to the change ideas the Project fives Alive together with facilities introduced. Particularly the second and third visits, mothers that do not turn up are followed and provided with the services. The regional performance has increased from 19,113 in 2011 to 19,199 in 2012 (Refer Table 25. Three districts Sissala East, Wa East and Wa Municipal performed better in 2012 than in 2011 while others recorded a reduction in coverage. There is the need to intensify home visits and outreach services in all the districts to address the issue of cultural barrier and to increase postnatal coverage in the region particularly first postnatal services. Table 25: PNC Registrants 2006 – 2012 District 2006 2007 2008 2009 2010 2011 2012 Jirapa 2,737 3,148 2,708 2,122 2,433 2,091 2,269 Lambussie 0 0 0 1,340 1,028 901 863 Lawra 2,327 3,939 2,503 2,406 2,102 2,888 2,498 Nadowli 2,274 3,729 1,986 2,217 2,255 2,459 2,424 Sissala East 886 2,037 1,187 1,275 1,194 1,508 1,677 Sissala West 1,300 1,809 1,127 1,203 1,094 1,205 1,165 Wa East 1,725 2,309 1,714 1,828 1,755 1,381 1,449 Wa Mun 2,405 4,504 3,892 4,021 3,881 4,896 5,128 Wa West 1,551 3,372 1,741 1,910 1,798 1,784 1,786 Reg Total 16,458 18,195 16,684 18,322 17,540 19,113 19,199

29 In order to improve on PNC services the region intends to intensify the Project Fives Alive change ideas in all the districts by (1) linking clients to CHOs/CBAs especially in hard to reach areas (HTRA) and (2) intensify family planning counselling and services to PNC mothers.

4.1.4 Family Planning Services Family Planning services include methods and practices to space births, limit family size and prevent unwanted pregnancies. Family Planning services also serve as a link to other reproductive health services such as prevention and management of STI including HIV/AIDS. All individuals and couples are eligible for family planning services; unfortunately, the services could be termed as women planning since men are not interested and do not also support their partners to practice. Educating men on the importance of family planning and the various methods available will be the target for 2013.

The total number of family planning acceptors decreased from 81,284 in 2011 to 79,021 in 2012. Though the regional figure indicates a fall two districts (Jirapa and Lawra ) performed better in 2012 as compared to 2011 (Refer Table 26) The low acceptor coverage in 2012 for most districts may be explained by the shortage of some of the family planning devices in the course of the year. This is becoming a norm and needs to be addressed firmly at GHS Head Quarters (HQ)

Table 26: Family Planning Acceptors -2006 -2012 DISTRICT 2006 2007 2008 2009 2010 2011 2012 Jirapa 8,710 11,521 9,460 7,095 6,932 8,598 8,921 Lamb 0 0 4,554 4,131 3,729 3,967 3,427 Lawra 7,468 13,148 15,671 15,519 11,520 11,059 12,055 Nadowli 10,497 13,328 14,014 11,941 10,646 10,304 12,058 Sissala E 3,979 7,090 7,869 7,177 9,270 9,325 7,058 Sissala W 2,502 3,061 3,832 4,184 4,013 4,285 3,999 Wa East 3,207 4,326 6,287 6,143 6,441 5,816 5,701 Wa Mun 21,245 72,004 19,778 22,194 18,039 19,142 19,034 Wa W 5,163 7,733 9,689 8,976 8,280 8,738 6,768 TOTAL 62,771 132,211 91,154 87,360 78,870 81,234 79,021

4.1.5 School Health Services School health services over the years have been a challenge in almost all the districts. Some

30 schools are not visited at all whilst others are visited several times. Every school is supposed to be visited at least once a year for examination of school children. Where other health services are provided in subsequent visits other than the examination should be considered as special visits and a narrative reports written to cover them. Also, if an examination visit is conducted and not all the children were examined, the follow up visits should not be counted again. The information needed is the number of schools visited and not the number of times the schools are visited. But because districts count visits and not schools, they tend to have over hundred percent schools visited. The number of children examined dropped from 101,292 in 2011 to 90,877 in 2012 (Refer Table 27). More attention still needs to be focused on school health services since common conditions such as ring worm, skin infection etc. are still high among school children in the region . Table 27: Number of School Children examined District 2006 2007 2008 2009 2010 2011 2012 Jirapa 7,118 7,224 6,864 2,062 4,140 14,843 14,891 Lambussie 0 0 4,471 5,198 12,846 6,488 9,794 Lawra 10,841 21,672 43,293 17,628 11,786 13,776 10,355 Nadowli 4,568 7,218 13,937 17,952 8,763 6,595 9,115 Sis. East 2,285 3,485 3,694 4,062 5,733 8,662 4,970 Sis. West 2,987 5,428 4,568 3,822 6,182 6,235 5,123 Wa East 5,281 6,694 12,772 22,532 10,693 6,522 10,362 WaMun 5,987 17,840 10,162 14,856 35,862 23,901 18,871 Wa West 4,810 3,522 4,663 11,649 18,168 14,270 7,391 Region 727,69 73,083 104,424 99,761 114,173 101,292 90,872

4.1.6 Adolescent Health Services All the districts provide adolescent health counselling to the adolescents in various areas of their health including STI management, HIV/AIDS, family planning education, mental health, substance abuse, sexual abuse, nutrition among others. Table 28 shows some of the counselling services that were rendered.

The challenge is that few districts reported monthly in the year under review. Others still report quarterly as it used to be while some too did not report at all. Plans are in place to orientate District Public Health Nurses on the reporting format such that they can also take sub-districts and CHPS levels staff through for adequate reporting.

31 Table 28: Adolescent Health Counseling services Sissala Sissala Wa Wa Wa Topic Jirapa Lamb. Lawra Nadowli E W East Mun. West Total Sexuality 0 0 2 669 12 36 660 4,428 0 5,801 STI Mgt 0 0 10 355 59 85 626 3,403 0 4,572 HIV/ AIDs 0 0 184 265 116 146 827 3,295 0 4,835 FP edu. 0 0 0 880 87 113 904 3,647 0 5,631 Nutrition 0 0 0 381 12 43 580 2,938 0 2,811 Sexual Abuse 0 0 21 0 16 0 251 2,243 0 1,531 Psychological Abuse 0 0 248 0 0 0 138 89 0 475 Mental Health 0 0 19 0 21 0 98 132 0 270 Substance Abuse 0 0 80 327 0 0 188 1,265 0 1,860 Healthy living 0 0 77 285 22 23 204 2,145 0 2,756

32 CHAPTER 5 - OBJECTIVE 4 Intensify prevention and control of communicable and non-communicable diseases and promote healthy lifestyles 5.1 Disease Control 5.1.1 Disease Surveillance The year 2012 started with plans to investigate 100% of all reported epidemic prone diseases, to help reduce morbidity and mortality due to vaccine preventable diseases, to maintain a polio free status in the region and to maintain zero mortality for measles Surveillance Activities The region embarked on several surveillance activities at all levels in the year under review. These include AFP active case search during the Polio NIDs and MenAfricVac campaigns; contained measles outbreak in Lambussie, Sporadic meningitis during the season, Human Anthrax in Lambussie, and Human Rabies in Wa Municipal; monitored CSM thresholds through the year and supported Sissala East and Lawra districts during their sporadic meningitis outbreak. The region conducted four quarterly monitoring and supervisory visit to all the nine districts; collected blood specimen from reported 24 Jaundice (Suspected Yellow fever) cases and sent to Accra for yellow fever laboratory confirmation – All the 24 samples tested negative for yellow fever IgM; blood specimen were also collected from reported 93 suspected measles cases and sent to Accra Noguchi for measles IgM investigation – In all 18 samples tested positive for measles IgM and when the negative samples were tested for rubella IgM 11 came out positive for rubella IgM The region recorded three (3) cases of rabies with one (1) death within the Wa municipality and two (2) Human Anthrax cases with one (1) death in the Lambussie district. All the districts attained 100% completeness in surveillance reports submitted to the regional level. Generally, timeliness of reporting has also improved compared to the previous year. All the districts attained above 90% timeliness with four districts achieving 100% timeliness in the years 2012.

Meningitis Total lumber puncture performance rate for the year 2012 improved drastically to 95.8% as compared to the previous two years. Out of the 166 cases in 2012 LP was done for 159. The LP

33 performance rate for 2010 was 67.1%. That is, out of the total of 471 cases, 316 cases had their LP done to isolate the type of organism that was causing the problem for effective treatment in 2010. There was an improvement in 2011 – 91.8% LP done i.e. 179 cases out of the total 195 cases recorded in 2011. Suspected measles cases and specimen collected from 2009 to 2012 and reported suspected cases of measles and Yellow Fever are shown in Tables 29 and 30. Districts with zero figures were silent for those periods, thus they did not record any case. But those with zero in the confirm columns did not have any of their cases positive for yellow fever IgM. Table 29:Suspected Measles cases and specimen collected 2009-2012 2009 2010 2011 2012 District Cases Samples Cases Samples Cases Samples Cases Samples Jirapa 3 3 1 1 5 5 6 6 Lambussie 2 2 0 0 0 0 38 38 Lawra 5 5 2 2 1 1 5 5 Nadowli 0 0 2 2 4 4 6 6 S. East 1 1 0 0 3 3 2 2 S. West 0 0 0 0 1 1 5 5 Wa East 0 0 0 0 3 3 3 3 Wa Mun 3 3 13 13 22 22 21 21 Wa West 4 4 4 4 0 0 7 7 Total 18 18 22 22 44 44 93 93

Table 30: Reported Suspected Cases of Yellow Fever and Samples taken with confirm cases District 2009 2010 2011 2012 Cases Samples Cases Samples Cases Samples Confirm Cases Samples Jirapa 0 0 11 11 9 9 1 3 3 Lambussie 0 0 1 1 9 9 0 1 1 Lawra 0 0 0 0 10 10 1 6 6 Nadowli 0 0 1 1 23 23 1 4 4 S. East 0 0 0 0 3 3 0 1 1 S. West 0 0 0 0 4 4 0 0 0 Wa East 0 0 0 0 13(28) 41 4 4 4 Wa Mun 2 2 2 2 29 29 0 3 3 Wa West 5 5 1 1 21 1 2 2 Total 7 7 16 16 121 149 8 24 24

For Acute Flaccid Paralysis (AFP), fourteen (14) cases were reported in 2012 as against Sixteen (16) cases in 2011. In all 6 cases so far have not yet had their 60 days follow-up conducted and reports sent to the national level. AFP cases recorded for the years 2007 to 2012 are as shown 34 in Table 31. District with zero figures did not record cases for those years although effort were made looking for them.

Table 31: AFP Cases from 2008-2012 Jan-Dec in UWR by Districts District 2007 2008 2009 2010 2011 2012 Cases Cases Cases Cases Cases cases Jirapa 3 2 0 5 3 2 Lambussie 0 1 2 3 2 1 Lawra 3 0 0 2 1 1 Nadowli 0 1 1 0 1 2 S. East 0 0 1 0 2 0 S. West 0 0 2 0 1 2 Wa East 0 3 4 1 3 5 Wa Municipal 1 0 2 1 2 1 Wa West 0 3 2 0 1 0 Total 7 10 14 12 16 14

There has also not been any documented death due to measles in Upper West and Ghana since 2003. The region shall continue strengthening surveillance and monitoring activities and ensure standard surveillance case definitions are available and used in all facilities

5.1.2 Guinea Worm Eradication Ghana has succeeded in breaking indigenous transmission of guinea worm disease. Eight (8) cases were recorded at the end of May 2010 in the northern region of Ghana. Since then not a single case has been reported anywhere in the country. This is a clear indication that we are in the pre-certification phase which demands a very sensitive surveillance including proper documentation at all levels. As part of securing certification as Guinea Worm free country, several activities were carried out in the region. There has been a continuous radio spots/ discussions at the two local FM stations to inform the populace about the need to report any suspicious swelling or hanging worm seen, and the Cash Reward instituted for any report leading to a hanging worm. Two Certification teams (National and International) visited the Region and commended the region for maintaining a strong surveillance system and encouraged health workers to intensify awareness creation on the cash reward for GW. A Cross border meeting was successfully organised with our Burkinabe counterparts to discuss interventions for a strong surveillance

35 between the two countries. Finally, Regional and District Guinea Worm Communication Task force teams were formed and inaugurated in all nine districts. One regional Communication meeting was held. The Regional Taskforce visited all districts to familiarise themselves with district task force activities. Within the year fourteen (14) Suspected Guinea worm cases were investigated in Wa Municipal, Nadowli, Wa West, Sissala West and Wa East districts but they were all found not to be guinea worm disease.

Integrated Disease Surveillance and Response (IDSR) After two years of the implementation of the new IDSR in the region, surveillance has improved tremendously at all the levels. Suspected case detection and reporting has also improved as compared to the previous years. Some districts and Sub districts identified focal persons to supervise the Community Based Surveillance Volunteers and submit their reports timely to the next level. Surveillance is maintained by the CBS Volunteers and Disease Control personnel in the sub districts and supported by the District and Regional teams. Integrated Case searches were conducted in three districts, namely; Wa West and Nadowli districts and Wa Municipal. No case of Guinea Worm was seen; however the exercise yielded some leprosy cases including Yaws and other skin infections which were put on treatment. The region intends to roll-out IDSR training to all districts in 2013.

5.1.3 Tuberculosis Control The objective of the Tuberculosis Control Programme is to decrease morbidity and mortality due to tuberculosis. This is to be attained through universal case detection of existing cases at any time but with population basis, detecting at least 106 cases per every 100,000 population and to cure 85% and less than 5% defaulter rate. The strategies used by the region included implementation of SOPs for case detection with particular focus on facility-based case detection, capacity to diagnose, manage cases, provision of drugs, logistics and sensitization to increase awareness about tuberculosis. The actual TB cases detected increased from 204 in 2008 to 316 in 2012 and the NSP TB cases detected also increased from 128 in 2008 to 169 in 2012. Refer Table 32. Wa Municipal recorded the highest number of cases (69) in 2012 and Lambussie and Sissala East districts recorded the lowest (4 each) – (Refer Table 33).

36 Table 32: Five Year Trend Analysis of Regional Performances Summary Compared Actual TB cases Total NSP TB cases Cure rate (%) Success rate (%) Year detected. (All forms) detected 2008 204 128 34 74 2009 230 144 53 69 2010 270 152 57 76 2011 283 167 62.5 69 2012 31 6 169 62.3 75.4

Table 33: TB Case Detection by district for NSP - 2008 to 2012 District 2008 2009 2010 2011 2012 Jirapa 17 14 15 14 Lambussie 17 1 6 9 4 Lawra 31 34 45 35 35 Nadowli 16 22 20 17 23 Sissala East 5 6 4 4 4 Sissala West 1 1 5 6 7 Wa East 3 5 4 14 7 Wa Municipal 43 48 46 51 69 Wa West 12 10 8 16 6 Region 128 144 152 167 169

The region planned to (1) strengthen implementation of Standard Operating procedures – facility based case detection (2) Conduct routine sensitization of Health Tutors in the region on new developments (3) Continue with routine facilitative supervision to facilities including the private facilities (4) Carryout EQA monitoring to improve the Quality of TB microscopy services. (5) Onsite orientation of coordinators, prescribers, DHMT etc. (6) Conduct TB treatment outcome assessment as well as continue with TB case detection assessment (8) Continue involvement of local partners such as barbers, chemical sellers, etc. in case detection and (9) Strengthen community-based TB Care to improve treatment outcomes

37 5.1.4 HIV/AIDS The objectives of the Programme are to decrease the spread of infection, to properly manage Sexually Transmitted Infections (STI) and to decrease the impact of positive HIV status on the individuals, families and communities. The key issues emanating at the beginning of the year which the region focused on included lack/Inadequate counselors/prescribers in facilities, poor access to ARVs by pregnant women, the need for PMTCT scale up and the low TB screening among clients accessing HTC services and KYS etc.

Activities carried out in the period under review include orientation of 9 tutors and 96 students at Jirapa NTC and MTS on updated PMTCT guidelines, training on HTC/PMTCT for 27 staff in the Sissala districts, dissemination of 2011 HSS results, updates on new PMTCT guidelines, algorithm for screening of TB in PLHIV both adults and children to districts and facilities and distribution of National monthly registers to districts and facilities. The programme held four Data managers quarterly data validation meetings as well as three TB/ HIV review meetings with DDHS, biomedical scientist, districts and facility coordinators. The media was also sensitised on HIV and AIDS issues. The Heart to Heart team was present to give testimonies. There was also Training of selected sites on EQA/DTS.

HTC/PMTCT service data There have been a decline in client load over same period last year. This may be due to testing services not reaching clients as well as inadequate counsellors in the facilities. Positive clients were linked to ART sites for further management. The client load for the period under review is as shown in Table 34. Regional hospital and Wa East district recorded the highest positivity rates.

38 Table 34: HTC by district – 2011 - 2012 Facility 2011 2012 No. given No. No. No. Post % No. given No. No. No. % Pre test Tested Positi test Positi Pre test Teste Positi Post Positiv info ve counsell ve info d d ve test e ed counsel led Jirapa 1476 1475 49 1475 3.3 718 716 48 716 6.7 Lambussie 772 772 22 771 3.3 649 614 11 641 1.8 Lawra 2108 2099 230 2086 2.8 1803 1805 135 1752 7.5 Nadowli 1296 1297 71 1229 11.0 1323 1209 53 1192 4.4 Sissala East 536 536 34 504 5.5 390 378 28 367 7.4 Sissala W 159 158 6 158 6.3 196 195 32 195 16.4 Wa East 886 875 6 878 3.8 582 579 0 578 0.0 Wa Mun 822 822 35 813 0.7 839 834 26 757 3.1 Wa West 320 319 19 314 4.3 203 193 16 182 8.3 Reg Hosp. 567 568 126 568 6.0 751 751 114 751 15.2 Total 8942 8921 598 8796 22.2 7454 7274 463 7131 6.4

Know Your Status Campaign (KYS) Know your status or outreach/ mobile HIV testing was conducted by facilities. It was observed that all districts declined on the coverage except Wa Municipal (Refer Table 35). This could be due to inadequate counsellors in the various facilities as well as intermittent shortage of test kits. Table 35: Know your status campaign by district /Facility- 2011-2012 District 2011 2012 No. Pre test No. No. No. Pre test No. No. Counselled Tested Positive Counselled Tested Positive Jirapa 11,531 11,531 29 8,120 8,120 30 Lambussie 2,025 2,000 4 1,926 1,915 11 Lawra 6,069 6,001 89 1,458 4,158 32 Nadowli 6,507 6,385 16 4,825 4,730 5 Sissala East 3,173 3,111 4 2,078 2,078 6 SissalaWest 1,401 1,401 8 1,140 1,136 9 Wa East 2,955 2,946 4 1,122 1,116 1 Wa Municipal 4,598 4,598 15 6,191 6,158 4 Wa West 3,816 3,816 10 366 366 2 Total 42,07 4 41,789 179 27,226 29,777 100

39 Prevention of Mother to Child Transmission of HIV (PMTCT). There is a general decline in pregnant women tested for HIV. There is however an improvement in pregnant women tested for syphilis (Refer Table 36).

Table 36: PMTCT Service Data, 2010-2012 Category 2010 2011 2012 ANC Registrants 24,367 24,407 21,940 No of clients Tested for HIV 23,743 21,441 20,527 No positive for HIV 295 187 171 No Post test counselled for HIV 23,047 20,465 19,688 No screened for Syphilis 9,760 11,804 16,767 No Positive for Syphilis 110 186 123 No Treated for Syphilis 108 172 101

Antiretroviral Therapy All the hospitals in the region provide ART services. The region took delivery of CD4 machines for Funsi, Gwollu, Wechiau and Hain for PMTCT. The client load is shown in Table 37. There was a high number of the clients who were lost to follow up. The region has put in place a strategy to track/trace the lost to follow-up through the PLHIV groups in the respective districts. Table 37: Clients on HAART, year 2011 – 2012, UWR Indicators 2011 2012 Adults Paediatric Total Adults Paediatric Total M F M F M F M F No. on clinical care 88 323 19 14 444 12 239 19 11 390 No. on Anti -Retroviral Therapy 65 195 6 10 276 76 206 12 5 299 No. with change of regimen due to drug toxicity 1 6 0 0 7 0 0 0 0 0 No. of deaths 13 16 1 0 30 24 33 1 0 58 No. lost to follow-up 28 44 1 1 74 39 94 0 0 133 No. on second line 0 0 0 0 0 4 4 0 0 8 No. of new clients on co-trim. Prophylaxis 77 287 16 13 393 105 218 19 7 349 With Opportunistic Infections (OI) A total number of 1,041 clients with Opportunistic Infections were treated in 2012 compared with 679 in 2011 As a national policy, all blood and blood products meant for transfusion are tested for HIV

40 antibody among other tests. In line with this all Laboratories in the region were provided with the necessary test kits for HIV screening. There has been slight decline in percentage positive among blood donors – Refer Table 38. Table 38: Prevalence of HIV infection among blood donors by sex – 2010-2012 Category 2010 2011 2012 Sex No. No. % No. No. % No. No. % screened reactive screened Reactive screened reactive Male 8453 2310 27 10040 2865 29 5595 1140 20% Female 17 1 6 59 12 20 1 0 0% Total 8470 2311 27 10099 2877 28 5596 1140 20%

5.1.5 Leprosy Control Programme The Region began the year 2012 with 78 patients on register; out of which 67 were Multibacillary and 11 Paucibacillary, giving a prevalence rate of 1.6/10,000 population. This means that the region has not yet attain the World Health Organisation’s (WHO) elimination target of less than 1.0 case of leprosy per 10,000 populations. During the period Sixty (60) new cases were detected in addition to the 78 that were on register. Four (4) defaulter patients resumed treatment and 1 transferred in, giving a total of 143 patients on register. Out of the total of 143 cases, 78 completed the stipulated doses and were released from treatment with 1 death, leaving 56 Multibacillary and 2 Paucibacillary patients on register, giving a prevalence rate of 0.83/10,000 population which is less than the World Health Organization (WHO) target.

5.1.6 Malaria Control Malaria continuous to be a major burden in the region and in the country as a whole, and in view of this several interventions and strategies were put in place in the year under review in an attempt at reducing malaria cases in the region and the country at large. Among these strategies are: • The use of insecticide treated nets (ITNs) (including hang-up campaigns) • Chemoprophylaxis for pregnant women(IPT) • Early detection and appropriate prompt treatment. (HBC) • Rapid Diagnostic Testing of all clinical malaria cases(RDT) • In door residual spraying of rooms • Advocacy and social mobilisation • Prescription of ACT to all malaria patients Malaria cases put on Artemisinin Based Combination Therapy (ACT) increased in the period under review from 83% in 2011 to 93.6% in 2012. Out of the total of 127,270 clinical malaria

41 cases only 119,079 were put on ACTs in 2011. This further increased to 516,375 in 2012 out of which 446,719 were put on ACTs due to the continuous availability of ACTs in the system – Refer Table 39. Table 39: Malaria cases put on ACT District 2010 2011 2012 Clinical No.Put %Cases Clinical No.Put %Cases Clinical No.Put %Cases Malaria on ACT Put on Malaria on ACT Put on Malaria on ACT Put on Cases ACT Cases ACT Cases ACT

Jirapa 27,440 21,843 80.0 14,275 10,571 74.1 57,187 54,292 94.9 Lambussie 15,273 13,293 87.0 9,187 8,821 96.0 29,990 27,633 92.1 Lawra 41,067 34,330 84.0 15,532 14,181 91.3 35,356 34,334 97.1 Nadowli 42,931 37,247 87.0 20,468 18,343 89.6 103,719 77,246 74.5 S.East 23,956 15,770 66.0 31,747 27,915 87.9 18,784 17,993 95.8 S.West 15,032 11,902 80.0 11,186 9,499 84.9 33,551 30,000 89.4 Wa East 15,632 13,018 84.0 7,875 7,601 96.5 17,625 17,050 96.7 Wa.Mun. 48,468 38,781 80.0 25,795 30,589 118.6 201,610 168,645 83.6 Wa.West 17,905 16,402 92.0 9,543 7,867 82.3 18,533 19,526 105.2 Total 247,704 204,463 83.0 127,270 119,079 93.6 516,375 446,719 86.5

Long lasting insecticide nets (LLINs) campaign The region successfully carried out LLINs campaign in the entire region and distributed a total of three hundred and seventy four thousand, nine hundred and forty eight (374,948) LLINs to the general population using the universal coverage formula of two persons per net. In all 99.9% of the total population was covered (Refer Table 40) Table 40: Coverage of Long lasting insecticide nets (LLINs) # of H/H # of sleeping # allocated/ LLINs District registered place supplied Hanged % Coverage Jirapa 10,879 43,261 36,144 36,144 100 Lambussie 6,133 27,763 21,877 21,877 100 Lawra 18,158 60,585 50,518 50,518 100 Nadowli 18,303 52,373 50,292 50,265 99.9 Sissala E 13,883 34,936 31,857 31,857 100 Sissala W 9,110 29,427 25,440 25,440 100 Wa East 16,592 42,212 40,372 40,372 100 Wa Mun 34,909 86,340 72,595 72,475 99.8 Wa West 20,322 52,902 46,015 46,000 99.9 UWR 148,286 429,799 375,110 374,948 99.9

42 5.2 Expanded Programme on Immunization (EPI) The major objective of the EPI programme is to increase the coverage of all antigens to at least ninety-five percent (95%) and to reduce the morbidity and mortality, control, eliminate or eradicate vaccine preventable diseases through immunization as an essential component of primary Health Care.

Activities Carried Out • Conducted one round of Polio (1)NIDs in March 2012 and vaccination of the general population age 1-29 years with meningitis type A vaccines in all the nine districts • Successfully introduced a second dose of the measles vaccine in February into the EPI schedule for children at 18months • Successfully introduced two new vaccines (Rotarix and PCV13) in May into the EPI schedule for children • Conducted routine quarterly monitoring and supervisory visit to all levels • Carried orientation of districts on the two new vaccines introduced into the routine schedule , data capturing/management using the new DVD template • Conducted 2 round of cold chain inventory • Successfully carried out routine immunization throughout the year

In 2012 the regional total of eligible children immunized with BCG was 23,753 as compared 23,596 in 2011. Three district ( Sissala East, Wa Municipal and Wa West) immunized more children in 2012 than in 2011 (Refer Table 41). With the change in the proportion of the target group ( e.g. proportion of < 1 years from 4% to a regional specific of 2.7%) from the 2012 population and housing census the region in line with the national directive has chosen to use the absolute figures for the year to year comparative analysis instead of the percentage coverage Table 41: BCG Coverage by Districts 2006-2012, UWR District 2008 2009 2010 2011 2012 Jirapa 2,520 2,694 2,520 2,683 2,582 Lambussie 1,632 1,855 1,632 1,250 1,165 Lawra 3,383 3,665 3,383 3,018 2,938 Nadowli 2,915 3,147 2,915 2,727 2,714 S. East 1,804 2,012 1,804 2,013 2,164 S. West 1,779 1,813 1,779 1,821 1,635 Wa East 2,517 3,866 2,517 2,281 2,302 Wa Mun. 6,560 6,090 6,560 5,110 5,409 Wa West 2,864 2,953 2,864 2,693 2,844 Total 25,974 28,095 25,974 23,596 23,753 Penta 3 vaccination coverage by districts is indicated in Table 42. Only four districts ( Sissala East, Wa East, Wa Municipal and Wa West) recorded more coverage than they had in 2011.

43 Table 42: Penta 3 Coverage by District 2009-2012 District 2009 2010 2011 2012 Jirapa 2,144 2,338 2,481 2,275 Lambussie 1,675 1,477 1,445 1,379 Lawra 3,040 2,833 2,695 2,570 Nadowli 3,149 2,895 2,707 2,673 Sissala East 1,943 1,612 1,899 1,917 Sissala West 1,658 1,648 1,890 1,663 Wa East 3,474 2,536 2,561 2,645 Wa Mun. 4,205 4,423 4,120 4,314 Wa West 2,888 2,780 2,605 2,810 Total 24,176 22,542 22,403 22,129

OPV3 performance also shows a slight drop in the total number of eligible children receiving OPV 3 from 22,229 in 2011 to 22,089 in 2012. Four districts Lambussie, Sissala East, Wa Municipal and Wa West recorded more coverage in 2012 than in 2011. (Refer table 43) Table 43: OPV 3 Coverage by District 2006-2012 District 2009 2010 2011 2012 Jirapa 2,184 2,338 2,486 2,278 Lambussie 1,671 1,468 1,294 1,379 Lawra 3,040 2,822 2,699 2,580 Nadowli 3,119 1,612 2,699 2,669 Sissala East 1,927 2,529 1,899 1,902 Sissala West 1,548 1,653 1,881 1,663 Wa East 3,439 2,529 2,567 2,528 Wa Mun. 4,205 4,423 4,124 4,312 Wa West 2,913 2,752 2,580 2,778 Total 24,046 22,460 22,229 22,089 The regional performance of Measles during the period under review stands at 21,741 which is higher than 21,223 immunized in 2011 (Refer Table 44). Four districts (Wa Municipal, Wa East, Wa West and Lambussie immunized more people in 2012 than in 2011. Table 44: Measles Coverage by District 2006-2012 District 2009 2010 2011 2012 Jirapa 2,075 2,093 2,433 2,207 Lambussie 1,792 1,490 1,223 1,387 Lawra 3,066 2,666 2,706 2,532 Nadowli 2,878 2,666 2,706 2,660 S. East 1,820 1,643 1,957 1,896 S. West 1,559 1,734 1,785 1,709 Wa East 3,373 2,925 2,141 2,488 Wa Mun. 4,722 5,527 3,873 4,136 Wa West 2,991 2,630 2,393 2,726 Total 24,276 22,978 21,223 21,741 The regional performance in the case of Yellow Fever immunization improved from 21,237 in

44 2011 to 21,726 in 2012. Lambussie, Wa East, Wa Municipal and Wa West had higher coverage in 2012 than in 2011. (Refer Table 45) Table 45: YF Coverage by District 2006-2012 District 2009 2010 2011 2012 Jirapa 2,077 2,099 2,433 2,202 Lambussie 1,750 1,488 1,227 1,385 Lawra 3,067 2,687 2,702 2,644 Nadowli 2,878 2,683 2,702 2,668 S. East 1,869 1,641 1,957 1,896 S. West 1,558 1,734 1,785 1,708 Wa East 3,391 2,531 2,141 2,488 Wa Mun 4,709 5,527 3,878 4,012 Wa West 2,793 2,624 2,412 2,723 Total 24,092 23,014 21,237 21,726

TT2+ performance for the region decreased with only Sissala West and Sissala East attaining more coverage in 2012 than in 2011 .(Refer Table 46) Table 46: TT2+ Coverage by Districts absolute figures Jan –Dec 2009 -2012 District 2009 2010 2011 2012 Jirapa 1,553 1,857 1,827 1,725 Lambussie 1,275 1,273 1,171 1,178 Lawra 2,448 2,420 2,186 1,943 Nadowli 2,515 2,888 2,433 2,246 Sissala East 1,820 1,678 1,688 1,732 Sissala West 1,041 1,080 974 1,089 Wa East 2,325 2,129 2,084 1,470 Wa Mun 2,902 3,660 3,918 3,622 Wa West 3,482 2,100 1,657 1,388 Total 19,361 19,079 17,938 16,393

National Immunization Days Table 47 illustrates the coverage of the March, 2012 OPV immunization round one. All districts performed well above the target of 95% which reflected in the regional coverage of 99.8%. The picture is not very different from what happened in the four rounds of NIDs conducted in 2011.

45 Table 47: Number of children immunized during the March 2012 NID No of children 0 -59 No. of % Coverage of months vaccinated No. of children children 12 - Total children children during October 2011 0 - 11 Months 59 months vaccinated vaccinated with District (4th Round) NIDs vaccinated vaccinated (D+E) OPV (F/C *100 ) Jirapa 147,768 25,305 122,171 147,476 99.8 Lambussie 10,197 1,460 8,758 10,218 100.2 Lawra 18,021 2,807 15,303 18,110 100.5 Nadwoli 17,606 2,867 14,061 16,928 96.1 S East 12,493 2,770 10,260 13,030 104.3 S West 10,738 1,841 8,931 10,772 100.3 Wa East 15,944 2,531 12,861 15,392 96.5 Wa Mun 28,602 5,482 23,415 28,897 101 Wa West 21,164 3,351 17,898 21,249 100.4 Region 147,768 25,305 122,171 147,476 99.8

The campaign was nearly marred by communal violence at Goripie in the Wa East district but this was sorted out quickly and the NID was successfully implemented. In the Lawra district volunteers complained about low level of remuneration of GHC 7.00. The age long conflict in areas to cover between the Tuggo sub-district of Jirapa and the Babile sub- district in Lawra district persisted and there are efforts underway to resolving it.

Meningococcal Meningitis Type A Immunization The Upper West region is one of the three regions in Ghana that fall within the meningitis belt which has since 1996 suffered from meningitis/CSM outbreaks. The disease normally takes a heavy socio-economic and human toll. As a result, the three northern regions benefitted from the mass immunization with the new Meningitis A Conjugate vaccine (MenAfriVac™). This campaign was conducted in October 2012 from the 12th -22 nd in all three northern regions to cover all persons aged 1- 29 years who are the most vulnerable group. It is also evidenced that the vaccine induces a higher and more sustained immune response in the 1-29 years age group.

The main reason for the campaign was to reduce the incidence of the meningitis epidemic that regularly hits the northern sector of the country, maintain stock of vaccines for epidemic response, enhance surveillance and build national capacity, and finally improve case management. Table 48 shows the regional and district specific coverage. With the exception of Lawra(75.6%), Nadowli (82.6%) and Wa East (80.0%) districts, all districts performed above 85.0% with Wa Municipal recording the highest (103.6%).

46 Table 48: Meningococcal Meningitis Type A Coverage by Districts, UWR October 2012 Target # Vaccinated % Vaccines District Total Pop Pop 1- Wastage AEFI 1-29yrs Coverage Used 29yrs Jirapa 91,793 64,255 55,859 86.9 58,020 3.4 31 Lambussie 53,635 37,545 34,946 93.1 35,730 1.9 16 Lawra 104,801 73,361 55,451 75.6 58,490 3.9 7 Nadowli 98,009 68,606 55,644 82.6 61,060 5.5 8 S. East 58,696 41,088 37,911 92.3 39,020 2.3 1 S. West 51,475 36,032 31,038 86.1 32,210 2.7 8 Wa East 74,839 52,387 41,888 80.0 44,030 3.3 13 Wa Mun. 111,327 77,929 80,706 103.6 81,910 2.2 17 Wa West 84,469 59,128 57,336 97.0 59,270 2.3 9 Total 729,044 510,321 451,779 88.5 469,740 3.1 110

Figure 3 shows Men A cluster coverage results for the three low performing districts (Lawra, Nadowli and Wa East) during the Men A campaign.

Figure 3: Men A Cluster Coverage Results for the three Low performing districts 200 180 160 180 183 140 166 120 144 Number 100 80 102 106 89 93 60 40 63 20 0 1-4 5-14 15-29 Lawra 102 180 106 Nadowli 89 166 144 Wa East 63 183 93

5.3. Nutrition Programme The nutrition programme embarked on several interventions aimed at improving maternal and child health and nutrition. These interventions include: Routine Growth Monitoring and Promotion Bi-annual Nutrition surveillance Micronutrient supplementation (Vitamin A) • Rehabilitation of Severely Malnourished Children • Capacity building of staff

47 • Monitoring and support visits Activities Carried Out The activities carried out in the period under review include (1) Trained health staff from three districts to scale up Community-based Management of Severe Acute Malnutrition (CMAM) (2) Supported the training of Community Volunteers to support in CMAM implementation (3) Trained health staff from five hospitals to start Nutrition Assessment, Counseling and Support (NACS) for PLHIV and/or TB clients (4) Organized CMAM technical support team meetings (5) Organized CMAM/Nutrition review meetings with stakeholders (6) Conducted two Nutrition Surveillance (in June and November) (7) Conducted onsite Coaching/Mentorship of newly trained staff in OPC (8) Sensitized selected communities on CMAM in three districts (9) Undertook monitoring and support visits to districts and sub-districts and (9) Coordinated and Supported Districts nutrition activities

The nutrition programme also carried out activities at community and facility levels that comprised of (1) rehabilitation of malnourished children (2) organized growth monitoring and promotion for children under 0-5 years. And (3) administration of routine Vitamin A supplementation for children (6 – 59) and post partum mothers

Table 49: Summary of Achievement on key indicators Achievement Indicator Target (%) (%) Source Defaulter rate in CMAM < 15 5.9 CMAM Report Cure rate in CMAM > 75 91.2 CMAM Report Underweight (0 -59 months) < 10 13.5 Nutrition Surveillance Stunting < 20 22.3 Nutrition Surveillance Wasting < 5 7.2 Nutrition Surveillance

5.3.1 Growth Monitoring and Promotion (GMP) Growth monitoring and promotion sessions are organised by sub-district level health staff every month in order to keep track of growth especially, among children 0-23 months. This is usually done at both outreach and static points during Child Welfare Clinics (CWCs).

Coverage of GMP GMP coverage has reduced in all districts. All the districts recorded a coverage of less than 50% with the exception of Sissala West and Wa Municipal, that recorded 52.7% and 52.3% respectively. Nadowli (37.8%) and Wa West (38.7%) districts recorded the lowest coverage. Regionally, the GMP coverage reduced from 73.3% in 2007 to 43.8%, though the absolute

48 figure increased from 24,948 in 2011 to 25,527 in 2012. This could be due to the proportion of the population that was used to estimate the under two population (i.e. 8%) in the past. 5.3.2 Prevalence of Underweight among children 0-23 Months in GMP The prevalence of malnutrition among children 0-23 months in the region has improved from 2007 to 2012 (20.4% to 12.2%). Though there has been an improvement in the trend of underweight (that is, W/A less than -2 standard deviation) among under twos. The current rate is poor based on WHO classification of malnutrition, which only accepts underweight prevalence of less than 10%. There was a reduction in underweight in all districts since 2007 except Sissala West which increased from 19.8% to 30.8%, a situation classified as critical by WHO. Lambussie district had a reduction in their underweight prevalence (30.7% in 2008 to 29.5% in 2012) but the current rate is classified as serious by WHO. The districts that were within acceptable range (less than 10%) for underweight were Jirapa, Lawra, Sissala East, Wa Municipal and Wa West. The factors that might have contributed to this improved nutritional status is unclear, but could be related to the effectiveness of services and interventions that have been implemented in these districts. For example, the CMAM programme that seeks to rehabilitate severely malnourished children has been doing very well in all these districts except Sissala East that just started implementation.

On the other hand, a number of factors could have contributed to the poor malnutrition situation in the region, especially Sissala West and Lambussie districts. These may include household food insecurity, inadequate maternal and child care and unsanitary/inadequate health services, which are important causes of malnutrition. Of particular concern is the way the available food is utilized in feeding children. The determinants of food utilization include the quantity and quality of food intake, child care including feeding practices. Care refers to the behaviour and practices of caregivers (mothers, siblings, fathers, and health care providers) who provide the food, health care, psychosocial stimulation and emotional support necessary for the healthy growth and development of children. These practices and the ways in which they are performed (with affection and with responsiveness to children) are critical to survival, growth, and development of children. However, it is almost impossible for caregivers to provide these care without sufficient resources, such as time, energy and money.

49 Inadequate child care include inadequate breastfeeding, delayed complementary feeding, and inadequate quality or quantity of complementary feeding. Impaired absorption of nutrients due to intestinal infections or parasites can also greatly affect effective food utilization.

In order to fully understand the causes of malnutrition in the region, there is the need to carry out a study in which cause-effect analysis will feature prominently. Often this kind of analysis is absent in routine data collection.

5.3.3. Community-based Management of Severe Acute Malnutrition (CMAM)

The CMAM programme which started with five districts in June 2010 has now been scaled up to all 9 districts of the region. The programme is mainly meant for treatment of severely malnourished children whose Mid Upper Arm Circumference (MUAC) measurement less than 11.5cm. The region currently implements 3 components of the programme; Outpatient (OPC), Inpatient (IPC) and Community outreach components. The outpatient component currently runs in 127 facilities across the region while 5 out of the 6 hospitals trained implements the inpatient component. The regional hospital is the only hospital that was trained but faces implementation challenges. The reason has been that no medical doctor was trained from that hospital. A total of 484 new cases were admitted in 2012 against 840 admissions in 2011. This downward trend could imply that as more children are admitted into the programme and treated, the total number of malnourished children in the region reduces. However it could also be that there are not enough active case searches at the community levels. Probably a research is needed to ascertain this fact.

Achievement The performance of the programme has been improving since its inception in 2010. There has been a downward trend in defaulter rate from 32% to 5.9% since 2010 to 2012 respectively. The worst performing districts in 2010 in terms of defaulter rate has improved from 56.7% and 41.0% in Wa West and Wa East to 4.6% and 10.5% in 2012 respectively.

Series of efforts went into achieving these results. In 2010 annual performance review meeting, high defaulting in the CMAM programme was revealed. The DDPH, the district directors concern and the regional nutrition officer held a meeting to find a way forward.

50 Early 2011 a series of monitoring visits were made to the sub-districts. It was found that most staff did not understand the concept of defaulter under the CMAM programme. In addition, health staff have failed to follow up to the communities to find the patients thus defeating the community based concept of the programme.

Regular onsite coaching/mentoring visits to identified sub-districts with specific challenges in these districts started in 2011. Review meetings with districts were also instituted to address district specific challenges and best practices from well performing districts. One notable action that contributed immensely to achieving and sustaining these gains was the inclusion of CMAM indicators into the regional priority monitoring indicators. The CMAM programme has received remarkable improvement in the year under review. The number of SAM cases treated and were cured increased from 82% to 91.2% in 2011 and 2012 respectively. One district that needs commendation is Wa West district that moved from the worst performing to the best performing district. Defaulter rate was reduced from 56.7% in 2010 to 4.6%. All districts met the various targets for cured (>75%), defaulter (< 15%) and death (<10%). Non-recovery rates also improved from 2010 to 2012 Table 50 indicates the various admissions categories for 2012 and table 8 summaries the expected case load as against the actual SAM cases admitted. Table 50: Trend of Admission of Severe Acute Malnourished (SAM) Cases 2010-2012 Admission criteria 6-59 Months 6-59 Months Other (children > 59 District (Oedema cases) (MUAC <11.5cm) months, infants <6 m) Total Admissions Jirapa 0 47 3 50 Lawra 0 80 1 81 Wa East 6 43 2 51 Wa Mun 2 72 7 81 Wa West 1 175 5 181 Nadowli 4 29 4 37 Region 16 446 22 484

51 Figure 4: CMAM Cure Rate 2010 -2012

120 100 80 60 40

PERCENTAGE 20 0 Wa Jirapa Lawra Wa East Wa West Nadowli Region Municipal 2010 72.4 82.3 50.8 66.4 40.7 63.5 2011 80.7 87.9 75 86.2 73.9 93.6 82 2012 90.8 95.8 84.2 86.3 91.9 100 91.2

Figure 5: CMAM Defaulter Rate, 2010 - 2012

60 50 40 30 20 10 PERCENTAGE 0 Wa Jirapa Lawra Wa East Wa West Nadowli Region Municipal 2010 23.6 15.7 40.3 23.7 56.8 31.5 2011 15.8 9.9 23.2 8 23 5.1 14.8 2012 3.5 4.2 10.5 11.3 4.6 0 5.9

Figure 6: CMAM Death Rate- 2012

7 6 5 4 3 2

PERCENTAGE 1 0 Wa Jirapa Lawra Wa East Wa West Nadowli Region Municipal 2010 2 2 5.8 1.5 2.8 2.4 2011 1.8 2.2 1.8 3.2 1.3 1.3 2 2012 4.6 0 5.3 1.6 3.5 0 2.5

52 Figure 7: CMAM Non-Recovery Rate 2010 - 2012

14 12 10 8 6 4 2 0

Percentage Wa Jirapa Lawra Wa East Wa West Nadowli Region Municipal 2010 0 0 0 12 0 0 3 2011 1.8 0 0 3 2 0 1.2 2012 1.2 0 0 1 0 0 0.4

5.3.4 Nutrition Surveillance System (NSS) Two rounds of Nutrition Surveillance were conducted during the year; that is in June and November 2012.

Summary of Nutrition Surveillance Results Summary of some selected indicators from the two rounds of nutrition surveillance and the 2011 MICS survey report are indicated on Table 48.

Table 51: Summary of Some Key Indicators Compared Indicator NSS June 2012 NSS November 2012 MICS 2011 Wasting 5.4 7.2 6.2 Stunting 20.0 22.3 22.8 Underweight 15.2 13.5 13.4 Initiation Breast Feeding(within 1hr) 32.6 50.7 46.0

Figure 8: Initiation of Breastfeeding

60 54.6 40 50.7 32.6 44.4 20 4.6 8.3 4.9 0 0 Less than 1 hour Between 1 -23 hours More than 24 hours Don’t know

NSS Jun 2012 NSS Nov 2012

53 Figure 9: Consumption of Food groups by children 6-23 months, NSS November 2012 40 30 20 10 0 Animal Vegetable Nuts and

Pecentage Cereals Milk Eggs Fruits products s Legumes 6 – 8 36.4 4.5 18.2 2.3 9 13.6 15.9 9 – 23 27.9 1.6 26.3 1.2 18.6 10.5 13.8

The anthropometric results of the two rounds of Nutrition Surveillance conducted this year showed similar results for all three anthropometric indices. It is also consistent with the 2011 Multi Indicator Cluster Survey results (MICS). Comparing these results to the WHO classification of malnutrition it is very clear that the nutritional status of the children is poor. The possible causes of this that immediately come to mind include: inappropriate feeding, poor health status and poor maternal and child care practices. The surveillance also revealed that majority of the children (63.9%) were affected by either malaria or fever two weeks before the June surveillance was conducted. There were a good number also reporting diarrheoa (22.7%). The irony however was that the use of insecticide treated net among the children was very high (93.3%), hence the level of malarial infections among the children was expected to be low. Initiation of breast feeding and exclusive breastfeeding rate were also found to be low for surveys an even in the 2011 MICS survey. For instance the initiation of breast feeding in the June NSS was as low as 32.6% which is not significantly different from the November NSS (50.7%) and 2011 MICS survey (46.0%). The quality of food usually given to these children is also below recommendations. It is observed that very view children from both age groups actually ate eggs, milk, fruits and vegetables. The most highly consumed food group is the cereals hence compromising on quality. All these issues identified ranging from the high malaria and diarrheoa infections; poor feeding among others are most likely to be the cause of the poor nutritional status observed. Control of Micronutrient Deficiencies Control of micronutrient deficiencies remain significant in efforts towards the reduction of child mortality and improved survival of children. The control of iron, vitamin A and iodine deficiencies are being tackled through supplementation and targeted food fortification.

54 Routine Children (6-59 Months) Vitamin A Supplementation Vitamin A supplementation for children 6-59 months are done during Child Health Promotion Week (CHPW) celebrations and routine child welfare service delivery at static and outreach points. The vitamin A supplementation coverage during CHPW reduced from 2007 to 2010 (56.3% to 6.4%). This was because NID campaigns were organised prior to the CHPW celebration in 2009 and 2010, where vitamin A was administered to children 6-59. This resulted to only children eligible for vitamin A supplementation to be dosed during the CHPW in those years. It was however realised in 2011 that when NID was combined with CHPW, children vitamin A supplementation was very encouraging with a regional coverage of 94.3%. Routine data for 2012 indicated that 50.8% of the children were given at least one those of vitamin A. Jirapa, Lambussie, Sissala West, Wa East and Wa West were the districts that recorded more than 50% with Lambussie recording the highest coverage (69.5%). Nadowli district recorded the least coverage (22.3%). It could be concluded that vitamin A supplementation is more encouraging when it is combined with NID campaigns.

5.3.5 Routine Maternal Vitamin A Supplementation Apart from the national campaigns on Vitamin A supplementation for children 6-59 months, routine Vitamin A supplementation also goes on at all service delivery points for post partum mothers. There has been a reduction in maternal Vitamin A supplementation comparing coverage for 2012 to previous years (2008 to 2011). This gives a regional coverage of 55.7% when the region recorded 15.5%, 61.4%, 58.7%, 54.2% and 56.2% in the years 2007 to 2011. This indicates a downward trend in coverage of post partum vitamin A. Wa Municipal recorded the highest coverage (91.4%) and the lowest coverage was recorded by Lawra district (19.4%). With the exception of Lawra, Nadowli (38.3%) and Sissala East (44.7%), all the other districts recorded coverage more than 50%. Lawra district has recorded very low coverage for post partum vitamin A supplementation for the past two years (25.1% for 2011 and 19.4% for 2012), and this is very worrying. Strategies need to be put in place to improve on the maternal vitamin A supplementation in the district. The highest coverage from Wa Municipal could have been as a result of the influx of pregnant women from across the region to deliver at the regional hospital.

55 The region had to grapple with some challenges confronting routine Vitamin A Supplementation that included delay in the release of funds for planned activities , p oor documentation at facility level , delay in the submission of reports by districts and high attrition of staff (Especially in CMAM)

5.4 Health Promotion As part of promotion of healthy lifestyle in the region, the following activities were carried out: communication support for emergency preparedness, radio programmes on the following topics – CSM, LLIN, Indoor residual spraying, measles 2 nd dose, breast feeding, leprosy and Neglected tropical disease, introduction of new vaccines (Pneumococcal and Rotavirus) and MenAfric mass vaccination campaign- Communication for Development (C4D) Programme, Commemorations/Celebrations/Launchings and post LLIN Campaign. Other activities carried out consisted of, Message Design and Material Development on Maternal and Child Health, Communication support for National SIA’s & Campaigns, Monitoring health education activities in the Region, Regenerative Health /Healthy Lifestyle activities Report and Distribution of Communication materials

5.4.1 Communication for Development (C4D) Programme. The status of implementation during the period under review is that all the three districts (Jirapa, Sissala East and Wa Municipal) had completed the orientation of CBA’s, Mother to Mother support groups and Chiefs in the 90 communities, Health staff, Better Ghana Management Services limited staff, SHEP coordinators and Heads of Departments. Sixty eight (68) chiefs, ninety one (91) health staff, one hundred and ninety four (194) CBA’s, Two hundred and twenty two (222) mother to mother support groups and sixty nine (69) school health coordinators have been sensitized on the C4D programme in readiness to provide support for the programme. (Refer Table 52 Table 52: Number and category of people orientated on Communication for Development No. Category orientated Number 1 Chiefs 68 2 Health staff 600 3 CBA’s 194 4 Mother -To -Mother Support Group 222 5 SHEP Coordinators 69 6 Heads of Departments 50

56 Also, the Centre for national culture at the regional and district level together with Ghana Health Service have completed the selection of community drama groups who have started rehearsing for the drama in all the selected communities in the three districts. As at now all the three 3 districts (Jirapa, Sissala East and Wa Municipal) have had live drama performances on malaria prevention using LLINs especially, among children and pregnant women in the selected communities with the exception of six communities under Jirapa District, Two under Sissala East and four communities under Wa Municipal The recorded drama has being shown in 20 communities each in the three districts for communities that did not have the live drama and that will be preceded within the communities by the CBA’s interpersonal communication. The CBA’s in the communities that have had live drama are embarking on household dialogue to encourage and remind the communities’ members on the need to use the LLIN The RHD supported the C4D implementation districts in preparation of plans and budgets for the second phase and facilitated in sending them to UNICEF office on time.

5.4.2 Material Development on Maternal and Child Health The second phase of the JICA supported Community Based Health Planning and Services (CHPS) programme is focusing on Maternal and Child Health educational materials. In view of this, the unit in collaboration with the Japanese International Corporation Agency (JICA) initiated the development of flipchart that would be used by the CHO’s. Questionnaire for focus group discussions (FGD) were developed and FGDs carried out in four communities namely; Pulima, Tendomo, Piree and Koho in Sissala West, Wa West, Nadowli and Lambussie districts respectively. Issues raised in the FGDs were discussed at a health workers forum where messages to address the issues raised were developed. An artist designed the illustrations which were sent to JICA experts in Japan for final editing.

57 Figure 10: Training session for CHO’s on the use of flip chart before the field pre- testing

On the 30 th and 31 st of October, 2012 the unit carried out a pre- testing and training session on the use of the flip chart with selected Community Health Officers of the printed flipchart at Mangu and Siriyiri communities. The pre-testing was done with three 3 groups’ (opinion leaders, Traditional Leaders and Mothers support group). Corrections have been done based on the findings and the recommendations from the various groups and the health workers whiles awaiting the final comments and corrections from the artist.

Figure 11: Pre-Testing of Flip Chart with Opinion Leaders

58 CHAPTER 6 - OBJECTIVE 5 Improving Clinical care including Mental Health Services

General activities carried out by clinical care unit 6.1 Activities carried out in 2012 The clinical care strengthened supervision and visited all the hospitals and pretested tools for the roll out of peer review in the hospitals. The Unit also participated in the 1 st quarter FSV as well as supervision on malaria case management under the support of ProMPT , Ghana .

In connection with MAF programme, the unit in conjunction with ICD, headquarters carried out monitoring activities to maternity units of all hospitals in the region and also inspected a private clinic in Tumu for accreditation for NHIS

A regional workshop on quality assurance and their formation was carried out in collaboration with Project Fives Alive and a meeting was held with pharmacists in the region to sensitize them to be interested in public health activities.

In order to facilitate the operationalisation of the new polyclinics they were inspected to assess their human resource needs and also held meetings with the DHMTS of districts with the new polyclinics and the various in-charges

6.2 Specialised Clinical Care Services 6.2.1 General Eye Care Service The Ghana Health Service in partnership with the Swiss Red Cross and the Ghana Red Cross Society has supported over 3 million beneficiaries with various forms of curative, corrective, preventive and promotional services; ensuring that both rural and urban poor populations in its supported operational areas and beyond now enjoy quality and affordable eye care services. The number includes individuals seen at OPD (23,570), Community Outreach (23,570), School health outreaches (13,098) and Surgical Operation (861). (Refer Table 53) It’s worth noting that the region contribute to over a 10th of the cataract surgical rate in Ghana. The 23,570 OPD visits were registered at eight (8) static clinics spread over the districts. Conjunctivitis (infective / allergic) largely accounts for eye disorders under others (37.17%) of

59 the top ten causes of attendance. Conjunctivitis does not directly cause blindness. Non - Blinding and Blinding Cataract featured second and third respectively indicating cataract backlog in the region. Cataract is the leading cause of avoidable blindness in the UWR, which is not different from the global perspective. With the community Outreach Services Non blind and blind cataract cases amounted to 1,017 (4.55%) and 488 (2.01%) respectively. The outreach points provide enough bases to strengthen these outreach activities beside the static clinics in our quest to reduce the prevalence of avoidable blindness in the region. During the clinical outreach services to schools 13,098 children were examined. Children with refractive errors accounted for 0.31% which heralds the need to continue visual assessment service for possible optical corrections since the children have more learning years than adults. Non blind cataract accounting for also 0.31% indicated that the children are developing cataract at younger age which is a deviation from the basic cause of cataract as advancing age in this sub region.

In the absence of a resident ophthalmologist, the region depended on the services of external ophthalmologists who are invited in every quarter to carryout surgical sessions in all the 8 eye units. Through the concerted efforts of the Regional Health Administration and the Swiss Red Cross. Within the year under review a total of 861 surgeries were performed. (Refer Table 53)

Table 53: Statistics on Eye Care Services 2006 – 2012 Indicator 2006 2007 2008 2009 2010 2011 2012 No. of patient attendance at static clinic 12,700 22,658 18,233 19,675 24,302 26,532 23,570 No. of patient attendance at outreach clinics 25,000 17,847 18,902 28,260 30,723 48,090 22,333 No. of pupils reached during sch. outreach visit 10,500 13,508 11,571 22,294 18,973 10,513 13,098 No. of cataract surgeries 322 256 732 283 725 422 681 No, of other eye surgeries 613 214 313 231 152 153 180

Prominent among the cases operated was cataract which accounted for 79.09% (681) of the cases operated. This has been an impressive performance over the last year which saw 575 surgical operations within the year. This is an indication that the myth surrounding eye surgeries is eventually ebbing away also emphasises the need for all facilities to continue to honour their commitment towards the Eye Care fund, so as to sustain the service delivery in the region with the exit of the Swiss Red Cross by December 2013.

60 Challenges The lack of a resident regional Ophthalmologist is a major constraint for the region as most complicated cases have to referred out of the region and in most instances clients conditions get worse over time. The region is losing its already low numerical strength of 13 ophthalmic nurses to academic advancement, re-appointment to administrative post and retirement within the next 5 years. This situation is compounded by the lack of interest in eligible nurses specializing in Ophthalmic Nursing in the region . The lack of a visual field analyzer in the region truncates the effective diagnoses and monitoring of the glaucoma, which is currently one of the reported conditions of non – avoidable cause of blindness at various points of service delivery. 6.2.2 Mental health care The Regional Hospital is the only facility with an established psychiatry unit in the region although services are also provided in the district hospitals by psychiatric Nurses and community psychiatric Nurses supporting from the districts. Activities carried out in 2012 included, two psychiatrist specialist visits carried out in some selected districts in the region, monthly outreach clinics by community psychiatric nurses, mental health education to 12 senior high schools and two tertiary institutions, weekly home visits and crisis interventions and weekly radio programmes on mental health and development. Table 54: Statistics on mental health care 2009 - 2012

INDICATORS 2009 2010 2011 2012 M F Total M F Total M F Total M F Total

Psychoses 174 182 256 185 145 330 222 158 380 261 211 472

Seizure Disorders 228 174 402 229 191 420 296 260 556 507 300 807 Substance Abuse 51 2 53 75 0 75 55 8 63 76 10 86

Depression 20 24 44 12 24 36 17 30 47 14 24 38 Neuroses 36 39 75 37 63 100 88 90 178 31 47 78

Total 509 321 830 463 423 886 678 546 1,224 889 592 1,481

It is observed that there has been a steady increase in mental cases over the past four years. (Refer Table 54). Psychoses and seizure disorders recorded the highest registrant as regards to mental disorders in the region. This could be due to the increase in awareness creation about the causes and treatment of mental illness.

61 6.2.3 Physiotherapy Service The Upper West Regional Hospital and St. Joseph’s hospital in Jirapa are the only facilities providing physiotherapy services in the region. Services rendered during the year included, education and counselling, exercises (various), dry and wet therapy massaging and manipulation. A specialist visited the St. Joseph’s hospital twice in 2012 and rendered services to a165 clients, of which 18 clients were referred for surgery and 9 for prosthesis (Refer Table 55). Both centres saw a total of 348 new cases in the year under review with 1,664 revisiting. Table 55: Summary of physiotherapy clients seen by specialist Indicator 2009 2010 2011 2012 No. Specialist visit 2 2 2 2 No. Patient’s seen 25 50 69 165 No. Referred for surgery 3 7 6 18 No. Referred for prosthesis 2 2 2 9

The two centres though not fully functional because of inadequate staff provide rehabilitation services, on the job training and supporting the physically challenged to enable them become functionally independent.

6.2.4 Oral Health The Regional Hospital, St. Joseph’s hospital and Tumu hospital are the only facilities with dental clinic in the region, although services like health education are provided by nurses from the various districts. Activities carried out at the various clinics are, tooth extraction, filling, scaling/ polishing, minor oral surgeries fractures and dentures. Number of cases seen in 2010 was 2,644, and in 2011 increased to 3,673. There was however a decline in 2012 with 3,071 total cases as compared to the previous year. The resident dentist at the Regional Hospital left for school in 2011.

6.3 Service Statistics - OPD Attendance 6.3.1 OPD attendance - 2012 The region in the period under review recorded a total OPD attendance of 814,406 compared to 758,084 in 2011. The OPD attendance shows an increase of 56,322 (7.4.%) over the previous year. The region recorded an increase in OPD attendance over the past six years. The

62 performance of the various districts for the year 2012 is illustrated in Table 56. Table 56: OPD attendance by district 2012

District Total OPD Attendance % of Total Jirapa 85,150 10.5% Lambussie 49,035 6.0% Lawra 151,204 18.6% Nadowli 120,499 14.8% Sissala East 65,219 8.0% Sissala West 49,597 6.1% Wa East 33,069 4.1% Wa Municipal 206,537 25.4% Wa West 54,096 6.6% Regional Total 814,406 100.0%

Wa Municipal recorded the highest OPD attendance of 206,537 representing 25.4% of the regional total, followed by Lawra District with 151,204 (18.6% of regional total). Wa East, Lambussie Wa West, and Sissala West recorded the least OPD attendance contributing 4.1%,.6.0% 6.6%, and and 6.1% respectively to the regional total. The continues increase in the OPD attendance is due to the improvement in the coverage of the NHIS and increase in health facilities especially CHPS in the region.

6.3.2 Per capita OPD attendance by districts - 2012

The region recorded per capita OPD attendance of 1.1 for the period under review which is the same as what was attained in 2011. The performance of the respective districts however ranges from 1.9 in the Wa Municipality to to 0.4 in Wa East and 0.6 in Wa West districts. The reasons for the high OPD per capita in the Wa Municipal, Lawra and Sissala East may be explained by the availability of hospitals in these districts and the influx of clients from other districts and regions. The least performing districts have no district hospitals .Refer Table 57 and Figure 12. Table 57: Per capita OPD attendance by districts – 2012 District Pop Total OPD Attendance OPD Per Capita Attendance Jirapa 91,793 85,150 0.9 Lambussie K 53,635 49,035 0.9 Lawra 104,801 151,204 1.4 Nadowli 98,009 120,499 1.2 Sissala East 58,696 65,219 1.1 Sissala West 51,475 49,597 1.0 Wa East 74,839 33,069 0.4 Wa Mun 111,327 206,537 1.9 Wa West 84,469 54,096 0.6 Total 729,044 814,406 1.1

63 Figure 12 : Per capita OPD attendance by districts – 2012 2.0 Regional Average 1.9 1.8 1.6 1.4 1.4 1.2 1.2 1.1 1.1 0.9 1.0 1.0 0.9 0.8 0.6 0.6 0.4 OPD OPD PerCapita 0.4 0.2 0.0

District

6.3.3 Trend of per capita OPD attendance

The trend in the regional Per Capita OPD Attendance for the past six years has revealed that the region has improved on the Per Capita OPD attendance of 0.5 in 2006 through 0.7 from 2007 to 2009 to 0.9 in 2010 . Performance of 1.1 attained in 2011 and 201 2 are the highest in the past 6 years. (Refer Table 58 & Annex 1 & Annex 2)

Table 58 : Trend of per capita OPD attendance 2005 – 2012

YEAR Total OPD Attendance Regional Pop Per capita OPD Attendance 2005 364,996 627,288 0.6 2006 349,539 637,851 0.5 2007 456,598 648,797 0.7 2008 479,360 659,826 0.7 2009 484,513 671,043 0.7 2010 598,533 682,451 0.9 2011 758,084 687,104 1.1 2012 814,406 729,044 1.1

6.3.4 Financial accessibility of OPD services by use of Health Insurance

Out of the total of 814,406 that utilised OPD services 778,304 representing 95.6% were insured clients an improvement of 1.3% over that of 2011 The 2011 regional coverage was 94.3%. The proportion of insured clients vary from district to district. Municipal r ecorded the highest insured clients (98.3%) and Wa Ea st recorded th e least (83.2%). (Refer Table 59 and Figure 13 ))

64 Table 59: % of OPD clients accessing health care with NHIS by districts – 2012 Total Non Total OPD District Total Insured Insured Attendance % Insured % Non Insured Jirapa 82,496 2,654 85,150 96.9% 3.1% Lambussie 46,498 2,537 49,035 94.8% 5.2% Lawra 146,164 5,040 151,204 96.7% 3.3% Nadowli 115,278 5,221 120,499 95.7% 4.3% Sissala East 61,942 3,277 65,219 95.0% 5.0% Sissala West 48,515 1,082 49,597 97.8% 2.2% Wa East 27,516 5,553 33,069 83.2% 16.8% Wa Municipal 202,972 3,565 206,537 98.3% 1.7% Wa West 46,923 7,173 54,096 86.7% 13.3% Regional Totals 778,304 36,102 814,406 95.6% 4.4%

Figure 13: Insured & non-Insured by districts 2012 % Insured % Non Insured Regional Average 120.0% 96.9% 96.7% 97.8% 98.3% 100.0% 94.8% 95.7% 95.0% 95.6% 83.2% 86.7% 80.0%

60.0%

40.0% Regional Average 16.8% 20.0% 13.3% 3.1% 5.2% 3.3% 4.3% 5.0% 2.2% 1.7% 4.4% 0.0%

6.3.5 Trend of insured clients at OPD 2006 – 2011. The regional trend in the proportion of OPD clients using health insurance indicates that there is a gradual increase from 27.5% in 2006 to 94.3% in 2011. The coverage of 95.6% attained in 2012 is the highest since the start of the Insurance scheme. This is an indication that the use of health insurance scheme is gradually taking hold and provision of service by cash and carry is gradually being phased out. This also shows the confidence people have in the intervention. There is however the need to improve coverage in the Wa East and Wa West districts. (Refer Table 60)

65 Table 60: Trend of proportion of OPD clients accessing health care with NHIS 2006 – 2011 Total OPD Year Insured Non-Insured Attendance % Insured % Non-Insured 2006 96,197 253,342 349,539 27.5% 72.5% 2007 240,162 216,436 456,598 52.6% 47.4% 2008 345,102 134,258 479,360 72.0% 28.0% 2009 419,842 64,671 484,513 86.7% 13.3% 2010 543,118 55,415 598,533 90.7% 9.3% 2011 714,937 43,147 758,084 94.3% 5.7% 2012 778,304 36,102 814,406 95.6% 4.4%

Challenges The intervention is confronted with problems such as (1) Delay issuance of cards to prospective clients (2) delays in reimbursement to facilities (3) reduction in claims submitted by facilities and (4) Coverage for accident victims and other emergency cases.

6.4. Inpatient statistics

In the year under review the region received 72 inpatient returns. These returns were received from a total of 6 health facilities providing inpatient care. The facilities included 4 GHS facilities and 2 CHAG/Agency institutions.

6.4.1 Inpatient performance by facilities - 2012

The total number of admissions recorded in the period under review was 63,655 as compared to 61,546 in 2011. The total number of deaths recorded in the period was 1,264 compared to 1,262 in 2011. The institutional death rate declined from 2.1%. in 2011 to 2,0% in 2012. Nandom hospitals recorded the highest death rate of 2.7%. Tumu hospital (1.5%) recorded the least death rate for the period. Table 61 gives the statistics with regards to the individual facilities. Except for Nadom hospital that recorded an increase in the death rate from 2.2% in 2011 to 2.7% in 2012 all the other hospitals recorded a decline in the death rate. This development needs to be investigated.

66 Table 61: Admissions and Institutional death rate by facilities – 2012

Facility Admissions Deaths % Death Rate Jirapa Hosp 12,515 229 1.8 Lawra Hosp 5,561 106 1.9 Nadowli Hosp 6,545 113 1.7 Nandom Hosp 9,736 259 2.7 Tumu Hosp 6,752 100 1.5 UWR Hosp 22,546 457 2.0 Total 63,655 1,264 2.0

6.4.2 Trend of admission and institutional death rate 2005-2012 There has been a gradual decline in the institutional death rate from 3.7% in 2005 through 2.4% in 2008. It increased slightly to 2.5 in 2009 and has since been on the decline. For the past three years. (Refer Table 62)

Table 62: Trend of admission and institutional death rate 2005 – 2012 Year Admission Deaths % Death Rate 2005 29,723 1,095 3.7% 2006 29,819 921 3.1% 2007 36,956 931 2.5% 2008 44,632 1,057 2.4% 2009 43,785 1,095 2.5% 2010 51,686 1,175 2.3% 2011 61,546 1,262 2.1% 2012 63,655 1,264 2.0%

6.4.3 Admission rate – 2012 and regional trend 2005 - 2012

The Admission rate for the region (i.e. admission per 1000 population) for the period was 87.3 in 2012 compared with 89.6 for 2011. (Refer Table 63) Table 63: Regional trend of admission rate - 2005 – 2012 YEAR Total Regional Admission Admissions Pop Rate 2005 29,723 627,288 47.4 2006 29,819 637,851 46.7 2007 36,956 648,797 57.0 2008 44,632 659,826 67.6 2009 43,785 671,043 65.2 2010 51,686 682,451 75.7 2011 61,546 687,104 89.6 2012 63,655 729,044 87.3

67 6.4.4 Bed utilisation 2012

In the year under review the region recorded 72.6% bed occupancy. The average length of stay recorded for the period also stood at 3.1. There are wide variations in the performance of respective facilities. Nandom hospital recorded the highest occupancy rate of 84.7% followed by Jirapa hospital with 73.3%. Tumu hospitals and Nadowli hospitals recorded the least percentage bed occupancy of 51.8% and 64.6% respectively. All the hospitals achieved significant increases in the occupancy rate. The average length of stay reduced from 3.2 in 2011 to 3.1 in 2012. (Refer Table 64. and Figure 14 & 15). Generally Nandom Hospital needs more beds especially the maternity wing. Table 64: Bed statistics by facilities – 2012 Average Turn Turn Facility Available Length of Over Av. Daily % Bed Over Per Bed Days Stay Interval Occupancy. Occupancy Bed Jirapa Hosp 53,070 3.1 1.1 106.2 73.3 86.1 Lawra Hosp 32,940 3.4 3.1 46.6 51.8 56.4 Nadowli Hosp 28,182 2.9 1.6 49.7 64.6 82.5 Nandom Hosp 62,586 *4.9 0.9 144.8 84.7 62.8 Tumu Hosp 32,940 2.8 2.3 49.4 54.9 71.1 UWR Hosp 73,200 2.3 0.9 142.1 71.1 111.8 Total 282,918 3.1 1.4 538.8 69.7 82.0

Figure 14: Percentage bed occupancy by facilities – 2012 90.0 84.7 Regional Average 80.0 73.3 71.1 69.7 70.0 64.6 54.9 60.0 51.8 50.0 40.0 30.0 % Bed%Occupancy 20.0 10.0 0.0 Jirapa hosp Lawra hosp Nadowli Nandom Tumu hosp UWR hosp Regional hosp hosp Average Hospital

68 Two hospitals recorded Average Length of Stay higher than the regional average. These hospitals include Lawra (3.4) and Nandom (4.9). The high average length of stay for the Nandom hospital was due to a resident neuro-surgeon and visiting orthopaedic surgeon. Figure 15: Average length of stay by facilities – 2012 6.0

5.0 Regional Average 4.9 4.0

3.0 3.4 3.1 3.1 2.9 2.8 2.0 2.3

AverageLength of Stay 1.0

0.0 Jirapa hosp Lawra hosp Nadowli hosp Nandom hosp Tumu hosp UWR hosp Regional Average Hospital

6.4.5 Trend in bed statistics 2008- 2012

The regional trend in the bed statistics revealed an improvement in percentage bed occupancy from a little over 62.% in 2008 and 2009 to over 67% in 2010. This has improved further to 72.6% in 2011 with decline to 69.7% in 2012. Refer Table 65. Table 65: Trend of bed statistics 2006 – 2012

Patient Av. Daily % Av. Length Turn Over Turn Over YEAR Days Occupancy Occupancy of Stay Per Bed Interval 2006 107,445 294 43.2% 3.6 43.8 4.7 2007 48.0% 48.0 2008 157,794 432.3 62.5% 3.3 69.0 2.0 2009 156,862 429.8 62.1% 3.5 64.0 2.2 2010 177,124 485.3 67.2% 3.5 70.6 1.7 2011 192,489 527.4 72.6% 3.2 83.1 1.2 2012 282,918 538.8 69.7% 3.1 82.0 1.4

6.5. Inpatient and outpatient Morbidity 6.5.1 Out Patient Morbidity – 2012 The top ten cause of OPD morbidity cases in 2012 ( all ages - male and female) include malaria

69 (47.8%) , Acute respiratory infections (12.16%), diarrhoea diseases (4.29%) skin infections and ulcers (4.13%), and acute eye infections (2.61%). Others are acute ear infections, rheumatism and joint pains, acute urinary tract infections, Anaemia and intestinal worms (Refer Table 5). Hypertension and pneumonia which were in the top ten in 2011 have been replaced by Anaemia and intestinal worms. The outpatient morbidity frequencies with regards to female only shows a similar pattern as that of all ages with malaria emerging as the highest cause of outpatient morbidity for female (47.84%). The ranking of the other diseases is almost the same as that of all ages though with variation in proportions of the totals. Hypertension however has featured amongst the top ten causes of OPD attendance for female attendance. (Refer Annex 4) The major cause of under five morbidity in 2012 include malaria (54.64%), Acute respiratory infections (15.15%) and diarrhoea diseases (8.24%). Other diseases featuring in the top ten under five morbidity include skin diseases, anaemia, acute eye infection, pneumonia, intestinal worms, acute ear infection and home accidents and injuries (Annex 3) The trend of the ranking of the top OPD morbidity cases ( all ages male and female) for the past five years has not changed much. However, the proportion of OPD cases due to malaria declined from 57.1% in 2009 through 49.0% in 2010 to 47.8% in 2011 and 2012. The places of Hypertension and pneumonia which were in the top ten in 2011 have been taken over by Anaemia and intestinal worms (Refer Annex 5). 6.5.2 Inpatient morbidity

The top ten inpatient disease conditions for the period under review include, Malaria (54.73%) Road Traffic Accident (RTA) (2.54%) Pneumonia (2.46%) Pneumonia (2.46%), other Gastroenteritis and colitis of infections (2.44%) Snake bites (2.12%) hernia (2.08%). Other conditions include Anaemia, hypertension , Typhoid fever and Acute upper respiratory infection. The major concern with regards to the inpatient morbidity is the high cases of RTAs and Snake bite in the region. Most of these accident were as result of the reckless use of motorbikes which is the major means of transport in the region. (Refer Annex 7) The analysis of the trend in inpatient morbidity frequency reveals that the proportion of admissions due to malaria has gone up from 45.5% in 2009 to 49.0% in 2010 it reduced to 44’7% in 2011 but went up 54.73% in 2012.

70 6.5.3 Burden of some selected non-communicable diseases

The burden of four selected non-communicable diseases -- hypertension, cardiac disease, diabetes mellitus and sickle cell disease- have been analysed in terms of gender for the year 2012. The analysis revealed a higher burden of all these diseases for females. Refer Table 66 for the details.

Table 66: Some selected non - communicable diseases: Proportion of Proportion of Data element Male Female Total Total Male Total Female Hypertension 2,528 5,987 8,515 29.7% 70.3% Cardiac Diseases 331 494 825 40.1% 59.9% Diabetes Mellitus 227 288 515 44.1% 55.9% Sickle Cell Disease 273 287 560 48.8% 51.3%

The trend of these selected non-communicable diseases from 2009 to 2012 reveals an increasing trend these diseases. The figures of these diseases for 2012 are far higher in absolute terms than that of 2011 (Refer Table 67) Table 67: Trend of some selected non-communicable diseases 2009 – 2012 Diseases 2009 2010 2011 2012 Hypertension 4,966 5,835 7,974 8,515 Diabetes 410 277 397 515 Sickle Cell disease 225 388 517 560

Challenges The challenges identified include (1) inadequate staff (2) Inadequate equipment (3) Inadequate facilities (4) Delays in referrals (6) Staff attitude

The region has planned to tackle these challenges by doing the following: (1) promote specialist outreaches and extend it to more facilities (2) make deliberate attempts to attract doctors to the region (3) Conclude discussions and put in place incentive packages for the purpose of attracting doctors to the region (4) Provide staff and make the five (5) newly constructed polyclinics functional to contribute to clinical care. (5) Make conscious efforts to support poor performing districts due to lack of facilities and (6) Ensure GOG funding to districts for clinical care reflects to workload.

71

The region is poised for the year 2013 with strengthening customer care in all facilities as its fulcrum and carry out training on Infection prevention and control with emphasis on maternal and neonatal care and that of TB care, peer review mechanism as a way of monitoring facilities with the finalization of the monitoring tools, trainings on TB care in collaboration with the TB programme, support and coaching visits using experienced coaches will be carried out to hospitals and health centres especially the new polyclinics and customer care in all facilities Other planned activities for 2013 include, Outreach programmes for eye and dental services, Special surgical outreach programmes with experts from other regions, Visits to training institutions to educate would be staff on customer care, quality assurance and leadership skills and a critical look will be paid to the logistics situation in our hospitals especially that of medicines and the non drug consumables

72 CHAPTER 7 – REGIONAL INITIATIVES AND OTHER EVENTS 7.1 Key Innovations and Best Practices The year under review recorded a number of best practices and innovations in some districts and health facilities. In the Sissala East and Nadowli District Hospitals for instance, all staff were screened for Hepatitis B and those found negative were given vaccines to prevent them from contracting it. On the other hand, those tested positive were assisted with counseling and other prescriptions to manage the condition. St Joseph’s Hospital in Jirapa also carried out regular screening of patients and staff for Non-Communicable Diseases (NCD) including Hypertension, Diabetes etc.

Triaging is another concept which is seriously being implemented in a number of hospitals in the region. The main objective of this practice is to reduce to the barest minimum the waiting time for certain categories of patients such as children U5, pregnant women etc. In Nandom Hospital for instance, separate drug collection points have been created for pregnant women, children <5 and the general OPD clients. This has led to the drastic reduction in waiting time for all clients but more so for children <5 and pregnant women. Another related innovation being implemented in the same facility is the pre-packing of drugs at the dispensary for the pregnant women which also brought about a significant reduction in the waiting.

And in order to encourage pregnant women to deliver in health facilities a number of innovative ideas have been adopted by the District Health Management Teams (DHMTs). These included amongst others organizing antenatal classes for pregnant women to educate them on a number of relevant issues such as reporting for antenatal in the 1 st trimester, putting in place birth preparedness plans, and the importance of going to a health facility to be delivered by trained personnel. In line with this, districts rewarded pregnant women who reported during the 1 st trimester with mackintosh materials as well as roasting of groundnuts for them. In addition, TBAs/Volunteers who brought pregnant women to facilities to be delivered were also rewarded with cakes of soap.

Moreover, a number of things were done for women who delivered in the facilities to motivate them to embrace facility-based childbirth as the norm. Some of these things included amongst

73 others bathing of babies before discharge from the facility, boiling of water for mothers after delivery and provision of second-hand clothes for the babies. Other best practices that were implemented in the region included the Community-Based Ambulance System to ensure transport availability for emergencies. Another important initiative that is assisting in a significant way to improve the accuracy and reliability of health data is the institutionalization of monthly and quarterly data validation meetings at all levels. Indeed, the practice has contributed to the reduction of data inconsistencies at various levels. Regular holding of clinical conferences and data analysis is now the norm in Tumu District Hospital. These conferences have brought about better understanding of the weaknesses in the hospital system and the identification of better solutions to address problems

7.2 Annual General Meetings (AGMs) of DDHS and AHSAG During the year under review, two professional groupings in the Ghana Health Service namely; the District Directors of Health Services (DDHSs) or the District Directors Group (DDG) and the Association of Health Service Administrators (AHSAG) held their respective Annul General Meetings (AGMs) in the region. The DDG’s AGM of was the 20 th and was held from 11 th – 16 th June 2012 under the theme “Strengthening sub-district health systems to achieve MDG 4, 5 and 6: the role of the District Director”. The HASAG AGM was the 36 th and came on from 10 th - 12 th under the theme Towards The Achievement of MDGs 4 & 5; The Role of The Health Service Administrator. Both AGMs were well attended with high participation by top hierarchy of the MOH and GHS.

74 ANNEXES

Annex 1: Trend of total OPD attendance by districts 2007 – 2012 District 2007 2008 2009 2010 2011 2012 Jirapa - 81,977 91,433 58,214 60,659 74,035 85,150 Lammbussie 28,604 30,806 44,897 49,035 Lawra 83,354 106,938 97,509 127,130 147,738 151,204 Nadowli 52,129 73,781 76,234 90,876 108,847 120,499 Sissala East 43,556 61,197 52,569 57,391 59,356 65,219 Sissala West 13,392 19,053 18,161 34,516 47,765 49,597 Wa East 18,547 20,051 21,916 24,031 31,557 33,069 Wa Mun 133,911 84,589 108,776 142,331 199,716 206,537 Wa West 29,673 22,318 22,530 30,793 44,173 54,096 Region 456,539 479,360 484,513 598,533 758,084 814,406

Annex 2: Trend of OPD attendance per capita -2007 2012 District 2007 2008 2009 2010 2011 2012 Jirapa 0.7 0.8 0.9 0.9 1.1 0.9 Lambussie 0.6 0.6 0.9 0.9 Lawra 0.8 1.1 1.0 1.2 1.4 1.4 Nadowli 0.6 0.8 0.8 0.9 1.1 1.2 Sissala East 0.8 1.2 1.0 1.1 1.1 1.1 Sissala West 0.3 0.4 0.4 0.7 1.0 1.0 Wa East 0.2 0.3 0.3 0.4 0.5 0.4 Wa Municipal 1.2 0.7 0.9 1.2 1.7 1.9 Wa West 0.5 0.4 0.3 0.4 0.5 0.6 Region 0.7 0.7 0.7 0.9 1.1 1.1

Annex 3: OPD Morbidity Under Five years - 2012 Data element Total % of Total Malaria 160,519 54.64 Acute Respiratory Tract Infections 44,510 15.15 Diarrhoea Diseases 24,198 8.24 Skin Diseases & Ulcers 14,567 4.96 Anaemia 5,673 1.93 Acute Eye Infection 4,225 1.44 Pneumonia 2,937 1.00 Intestinal Worms 2,895 0.99 Acute Ear infection 2,006 0.68 Home Accidents and Injuries 1,167 0.40 All others 31,093 10.58

75 Annex 4: OPD morbidity by gender (female only) all ages -2012 Data element Female % of Total Malaria 258,234 47.84 Acute Respiratory Tract Infections 65,726 12.18 Diarrhoea Diseases 20,496 3.80 Skin Diseases & Ulcers 20,271 3.76 Acute Eye Infection 13,749 2.55 Acute Ear infection 9,842 1.82 Rheumatism & Other Joint Pains 8,296 1.54 Acute Urinary Tract Infection 7,381 1.37 Anaemia 6,244 1.16 Hypertension 5,987 1.11 All other Cases 123,573 22.89

Annex 5: OPD morbidity all ages male & female -2012 Data element Total % of Total Malaria 445,522 47.80 Acute Respiratory Tract Infections 113,369 12.16 Diarrhoea Diseases 39,940 4.29 Skin Diseases & Ulcers 38,479 4.13 Acute Eye Infection 24,294 2.61 Acute Ear infection 14,918 1.60 Rheumatism & Other Joint Pains 12,655 1.36 Acute Urinary Tract Infection 11,248 1.21 Anaemia 10,912 1.17 Intestinal Worms 9,235 0.99 All Others 211,501 22.69

76 Annex 6: Top ten causes of OPD morbidity 2010 -2012 2010 2011 2012 Disease No. % of Total Disease No. % of Total Disease No. % of Total Malaria 287,799 49 Malaria 374,759 47.8Malaria 445,522 47.8 Other ARI(Acute 52,946 9 Other ARI(Acute88,984 11.4 Other ARI(Acute 113,369 12.16 Skin Diseases Diarrhoea & Ulcers 23,829 4.1 Skin Diseases &33,694 Ulcers 4.3 Diseases 39,940 4.29 Diarrhoea Skin Diseases & Diseases 17,954 3.1 Diarrhoea Diseases28,725 3.7 Ulcers 38,479 4.13 Acute Eye Acute Eye infection 15,425 2.6 Acute Eye infection24,615 3.1 Infection 24,294 2.61 Rheumatism and Joint 8,471 1.4 Rheumatism and12,444 Joint 1.6 Acute Ear infection 14,918 1.6 Rheumatism & Acute Ear infection 7,562 1.3 Acute Ear infection11,889 1.5 Other Joint Pains 12,655 1.36 Acute Urinary Hypertension 5,835 1 Acute Urinary Tract8,614 1.1 Tract Infection 11,248 1.21 Pneumonia 5,821 1 Hypertension 7,974 1Anaemia 10,912 1.17 Home Accidents and 5,258 0.9 Pneumonia 7,622 1Intestinal Worms 9,235 0.99 All others 156,659 26.7All Others 184512 23.5All Others 211,501 22.69 Total 587,559 100Total 783,832 100Total 932,073 100

Annex 7: Top ten causes of inpatient admissions 2010 - 2012 2010 2011 2012 Principal % of Principal Diagnosis Count Total Diagnosis Count % of Total Diagnosis Count % of Total Malaria 11,375 48.4Malaria 13,954 44.7Malaria 2758 54.73 Anaemia 942 4 Anaemia 1,230 3.9 RTA 128 2.54 Pneumonia 593 2.5RTA 956 3.1Pneumonia 124 2.46 Other gastroenteritis RTA 576 2.5Pneumonia 923 3 and colitis 123 2.44 Enteric Fever/ Typhoid fever 531 2.3 Gastroenteritis 743 2.4 Snake venom 107 2.12 Snake Bite 504 2.1Hypertension 597 1.9hernia 105 2.08 Gastroenteritis 353 1.5 Snake Bite 595 1.9 Anaemia 81 1.61 Enteric Fever/ Hernia 462 2 Typhoid fever 475 1.5 Hypertension 75 1.49

Hypertension 305 1.3Cellulitis 420 1.3Typhoid fever 65 1.29 Infection of Infection of Acute upper Urinary Tract Respiratory respiratory (UTI) 295 1.3 Tract (RTI) 343 1.1 infection 63 1.25 All Others 7,548 32.1All Others 10,979 35.2 All Others 1410 27.98 Total 23,484 100Total 31,215 100Total 5039 100

77 Annex 8 : Sector- Wide Indicators 2006 2013 Indicator 2006 2007 2008 2009 2010 2011 2012

Total Population 637,578 648,798 659,827 671,043 702,110 715,450 729,044 Expected pregnancies / children under 1 25,503 25,952 26,393 26,842 18,957 19,317 19,684 WIFA 127,516 129,760 158,358 161,050 116,400 169,562 172,783 HO1 Bridge equity gaps in access to health care and nutrition services and ensure sustainable financing arrangements that pro tect the poor Number of demarcated zones 197 197 197 197 197 197 197 No. of functional CHPS zones 24 42 63 85 94 114 166 No. of CHPS compounds 24 38 49 77 93 105 113 Total population living within functional CHPS zones 77,846 143,036 140,660 198,647 210,560 226,563 Number of doctors (Ghanaians) 15 17 13 13 15 14 12 Number of medical assistants 35 16 15 20 23 26 Number of nurses (all categories) 544 691 787 934 966 1,333 1,250 Number of midwives 121 153 158 147 135 Number of Community resident Nurses (CHOs) 69 95 108 113 135 Number of Under five years who are weighed at facility & Outreach 38,028 25,433 31,046 25,801 24,948 25,527 Number of Under five years who are under weight presenting at facility & Outreach 7,758 6,708 7,871 4,969 5,472 3,102 Total number of outpatient visits 349,539 456,598 479,360 484,513 598,533 758,084 814,406 Number of OPD visits by insured clients 96,197 240,162 345,102 419,842 543,118 714,937 778,304 Number of cases seen and treated by the CHOs.(OPD Cases ONLY) 22,212 44,212 64,784 114,589 123,297 HO2: improve governance and strengthen efficiency in health service delivery, including medical emergencies Revenue Mobilization IGF Insured clients 1,917,503.35 6,141,631.01 5,792,942.49 9,144,150.45 11,746,183.56 11,552,647.44 Non - Insured Clients 705,231.68 189,947.36 2,043,503.42 931,629.97 827,338.95 947,640.53 Drugs 1,049,094.01 2,532,631.34 5,759,482.42 4,205,255.12 5,098,752.30 4,799,494.33 Non -Drugs 1,573,641.02 3,798,947.03 8,639,223.64 6,652,666.09 8,940,114.46 9,599,211.73 Approved Budget Item 1: Personnel Emolument -Approved Budget Item 2: Administration -Approved Budget Item 3: Service -Approved Budget Item 4: Investment Expenses -Approved Budget

78 Indicator 2006 2007 2008 2009 2010 2011 2012 Sector Budget Support (SBS) Approved Budget Global Fund(Malaria/TB/HIV) Approved Budget Receipts Item 1: Personnel Emolument Item 2: Administration 455,158.50 271,011.77 166,224.98 172,103.21 241,331.89 107,799.55 Item 3: Service 682,737.76 103,512.83 211,481.15 128,279.87 137,712.72 0 Item 4: Investment Expenses Sector Budget Support (SBS) 140,225.03 31,927.61 114,451.00 207,316.06 270,224.13 60,871.50 Global Fund(Malaria/TB/HIV) 1,084,765.76 4,353,699.34 5,654,231.16 5,629,256.98 5,364,261.95 2,575,396.63 Extra -Budgetary (MMDAs, NGOs etc) Expenditure Drugs 1,363,526.58 1,611,031.88 2,770,653.11 2,581,165.90 3,751,152.82 4,110,813.84 Non -Drugs 2,045,289.87 2,416,547.84 4,155,979.68 3,319,727.45 7,477,440.12 9,594,639.32 Item 1: Personal Emoluments Item 2: Administration Expenses 258,611.02 246,367.20 164,742.46 131,506.16 296,683.57 121,382.84 Item 3: Service Expenses 878,781.97 196,777.29 165,470.12 126,405.87 123,147.19 Item 4: Investment Expenses 98,321.20 Sector Budget Support (SBS) 149,240.07 38,343.05 70,721.36 139,002.99 169,073.24 197,480.78 Global Fund(Malaria/TB/HIV) 1,038,750.82 4,353,699.34 3,306,925.24 4,378,789.82 4,965,814.31 1,830,710.44 Number of road worthy vehicles 80 90 27 46 55 81 123 Number of vehicles from 0 -5 years 38 42 14 31 48 61 47 Number of vehicles 10 years & Above 16 26 8 15 15 17 21 Number of motorbikes road worthy 288 396 143 329 332 385 654 Number of motorbikes 0 -3 years old 95 146 113 254 348 265 339 Number of motorbikes 6 years & Above 88 211 60 75 75 75 87 HO3: Improve access to quality maternal, neonatal, child and adolescent health services. Number of ANC registrants 22,232 25,004 23,471 24,124 22,007 23,943 24,720 Number of clients making 4+ visits (4 or More) 8,576 14,724 12,812 19,036 17,225 16,320 15,870 Total ANC attendance 75,229 86,023 61,466 73,730 71,664 83,869 85,188 ANC Registrants receiving IPT1 16,384 13,496 18,668 17,832 16,541 17,538 17,793 ANC Registrants receiving IPT2 12,678 10,399 15,820 15,826 14,242 13,465 15,567 ANC Registrants receiving IPT3 9,047 7,661 12,512 13,202 11,302 9,431 11,708 Number of pregnant women receiving Tetanus toxoid (TT2+) 13,316 19,505 19,288 19,361 19,079 17,938 16,393 Total Deliveries 18,966 19,811 20,850 16,802 18,541 15,389

79 Indicator 2006 2007 2008 2009 2010 2011 2012 16,249 Number of deliveries by skilled attendants (by doctors and nurses only) 7,335 8,588 11,126 13,976 11,676 14,687 15,389 Number of deliveries by TBAs 8,914 10,378 8,685 6,874 5,126 3,854 3,328 Number of institutional maternal deaths 21 29 22 43 26 29 28 Number of institutional maternal deaths audited 19 29 19 43 26 29 28 Total number of still births 176 439 266 356 310 365 334 Total number of fresh still births 53 64 83 161 105 127 106 Number of PNC registrants 16,458 18,195 16,684 18,322 17,540 19,113 19,199 WIFA accepting modern family planning methods 62,771 132,211 91,154 87,360 78,870 81,234 79,021 Total Couple Years of Protection (CYP) 6,860 21,150 20,917 21,254 78,885 70,230 78,666 Number of Institutional infants deaths 158 120 139 178 163 103 83 Number of institutional under five deaths 260 301 280 296 215 Number of children immunized BCG 32,970 25,974 28,095 25,974 23,596 23,753 Number of children immunized Penta 1 20,534 21,442 22,527 22,058 20,932 Number of children immunized Penta 3 28,411 21,638 24,176 22,542 22,404 22,129 Number of children immunized OPV1 16,899 20,906 36,263 22,324 22,146 20,908 Number of children immunized OPV 3 28,503 23,760 24,046 22,460 22,229 22,089 Number of children immunized Measles 29,935 25,447 24,276 22,978 21,223 21,741 Number of children immunized Yellow Fever 29,564 25,250 24,092 23,014 21,237 21,726 Number of children under 5 years receiving at least 1 dose of Vitamin A 47,140 65,737 95,691 122,204 120,054 51,853 66,693 Number of clients (15 -24years) who accepted FP services HO4: Intensify prevention and control of communicable and non -communicable diseases and promote healthy lifestyles Number of cases of Hypertension seen at OPD in District/Region 3,302 3,501 4,011 7,564 8,515 Number of cases of Diabetes seen at OPD 500 401 260 372 515 Number of cases of Sickle Cell Disease seen at OPD in 362 190 366 471 560 No. of new HIV positive cases diagnosed 1,170 1,309 1,384 962 734 Number of HIV+ cases receiving ARV therapy (cumulative) 358 2,643 569 276 299 No. of guinea worm cases seen 2 - - - - Number of guinea worm cases contained 2 - - - - No. of non polio AFP cases detected 7 10 14 12 16 14 Total OPD cases that is due to malaria 15,687 172,906 208,830 227,703 287,799 374,759 445,522

80 Indicator 2006 2007 2008 2009 2010 2011 2012 Total of OPD cases that is lab confirmed malaria(microscopy +RDTs) 102,588 132,559 142,284 126,446 98,671 Total number of admissions due to lab confirmed malaria (all ages) 15,172 18,796 13,677 20,714 25,572 Total number of deaths due to lab confirmed malaria (all ages) 245 258 247 327 364 Total number of admissions due to lab confirmed malaria (under 5) 3,345 4,803 5,439 5,942 8,808 11,312 14,547 Total number of deaths due to lab confirmed malaria (under 5) 116 142 117 119 93 132 88 Number of children under 5 using ITN No. of TB patients Notified 188 202 221 283 316 Total number of TB cases cured(sputum microscopy) 50 74 75 93 78 Total number of TB cases completing treatment. 52 62 21 84 11 HO5. : Improve Institutional Care Including Mental Health Service Delivery. Total admissions 29,819 36,956 44,632 43,785 51,686 61,546 63,655 Number of patient days 107,445 157,794 156,862 177,124 192,489 197,212 Total number of beds 682 688 692 692 722 728 773 Total number of discharges 28,981 41,537 43,184 49,785 59,093 62,145 Total number of deaths 921 931 1,094 1,095 1,175 1,262 1,264 Major operations performed 2,284 3,386 3,466 2,540 2,532 3,831 2,786 Minor operations performed 2,227 2,518 2,987 3,911 4,063 3,694 5,666 Number of Beds in District/Region allocated to Mental Health clients ------Number of mental health staff 3 3 3 3 4 9 9

81