ACCELERATING CHILD SURVIVAL AND DEVELOPMENT (ACSD) Final Report The Retrospective Evaluation of ACSD: Ghana Submitted to UNICEF on 7 October 2008 Institute for International Programs Johns Hopkins Bloomberg School of Public Health Baltimore, MD Disclaimer: This report was prepared by IIP-JHU under contract with UNICEF. All photos were taken by members of the IIP-JHU evaluation team after requesting permission from those who were photographed. All text, data, photos and graphs should be cited with permission from the authors and UNICEF. ii IIP-JHU | Retrospective evaluation of ACSD in Ghana Summary Introduction UNICEF implemented the Accelerated Child Survival and Development (ACSD) project between 2001 and 2005 in 11 countries in Africa with support from Canadian CIDA. The aim of ACSD was to reduce mortality among children less than five years of age by working with governments and other partners to increase coverage with a set of proven interventions. In the “high-impact” countries of Benin, Ghana, Mali and Senegal, a total of 16 districts worked to deliver the full set of interventions grouped into three packages: “EPI+” including vaccinations, vitamin A supplementation and the use of insecticide-treated nets (ITNs) for the prevention of malaria; “IMCI+” including promotion of exclusive breastfeeding for six months, timely complementary feeding, use of iodized salt and improved and integrated management at the health facility and community levels of children suffering from pneumonia, malaria and diarrhea, including home-based ORS use, treatment of malaria, and treatment of pneumonia with antibiotics; and “ANC+” including intermittent preventive treatment of malaria with SP (Fansidar) for pregnant women (IPTp), tetanus immunization during pregnancy to prevent maternal and neonatal tetanus and supplementation with iron/folic acid during pregnancy and with vitamin A post-partum. An internal evaluation by UNICEF estimated through modeling that the levels of coverage achieved through ACSD were associated with about a 20 percent reduction in all-cause under-five mortality relative to comparison districts in participating districts in four “high-impact” countries. This retrospective evaluation was commissioned by UNICEF to confirm these findings and provide additional information that could be used in planning effective programs to reduce child mortality and achieve the 4th Millennium Development Goal (MDG-4) in poor countries in Africa. The IIP evaluation team worked with ACSD managers at international and national levels to develop a generic ACSD framework that defined the pathways through which ACSD activities were expected to lead to reductions in child mortality and improvements in child nutritional status. The generic framework served as the “backbone” of the evaluation design. The country-specific evaluations also addressed equity across socioeconomic and ethnic groups, for urban-rural residence and for girl and boy children. At the request of UNICEF, the evaluation does not include an economic evaluation or a full assessment of the effects of ACSD on national policy. Aim of the independent retrospective evaluation in Ghana The aim of the evaluation was to provide valid and timely evidence to child health planners and policy makers about the effectiveness of ACSD in reducing child mortality and improving child nutritional status in Ghana, as a part of the larger retrospective evaluation designed to inform future programs intended to reduce child mortality and accelerate progress toward MDG-4. Equity was also assessed. Two questions served as a guide to the analysis and reporting of the evaluation findings: a) Was ACSD implementation associated with improvements in coverage, nutrition and mortality over time? b) If so, was progress in the ACSD districts faster than that observed for the national comparison area? ACSD implementation in Ghana UNICEF-Ghana received approximately $3.8 million from Canadian CIDA to support ACSD activities in sixi “high-impact” districts (HIDs) with a combined population of about one million located in the Upper East region, and two expansion regions (Upper West and Northern regions) between 2001 and 2004. ACSD was implemented at the regional, district and sub-district levels in partnership with the Ghana i These six districts subdivided into eight districts in 2005 during redistricting. IIP-JHU | Retrospective evaluation of ACSD in Ghana iii Health Service (GHS) and other development partners. The GHS supported EPI+ and ANC+ activities after 2004 by incorporating them into routine health services. After a hiatus of about one year, other ACSD activities received continued support from UNICEF funds, DANIDA and the Government of the Netherlands. ACSD inputs and activities in the Ghana HIDs, comprised of the entirety of the Upper East region, focused on: 1) Providing essential drugs, supplies, equipment and other support for outreach and campaign activities. ACSD-Ghana: a) provided an estimated 814 bicycles, 18 motorcycles and one vehicle to the HIDs over the course of the project for outreach and supervision activities; b) equipped health facilities with 553 refrigerator units for cold chain; c) supported local and national campaigns for vaccination and vitamin A supplementation, as well as routine health-facility outreach activities; and d) supplied commodities including vitamin A supplements, antihelminths, ORS, antimalarials and ITNs and retreatment chemicals for the prevention of malaria. 2) Supporting distribution and retreatment of ITNs at various levels. Over 200,000 ITNs were distributed in the HIDs between 2002 and 2005 through health centers, community outreach and distribution systems and campaigns. ACSD supported retreatment efforts at the community and facility levels, as well as through campaigns starting in 2004. All health workers and volunteers involved in ITN distribution and retreatment received training. 3) Training and supervising of facility-based workers. Forty-eight clinicians and three regional staff received standard 11-day IMCI training in 2005. 4) Training, equipping and supervising community health workers. ACSD-Ghana provided support for the training and supervision of over 1900 community-based agents (CBAs) in 600 communities to deliver messages to promote infant feeding, careseeking and treatment of childhood illness and ITNs, and immunization. The CBAs received health kits containing chloroquine, ORS, and handwashing and educational materials. ASCD also provided training and educational materials to community-based mothers’ groups for the promotion of infant feeding practices. 5) Supporting facility and outreach activities for pregnant women. The ANC+ package of ACSD included support for tetanus toxoid supplemental immunization activities, as well as facility and community distribution of postnatal vitamin A. IPTp was introduced in 2004 and ACSD supported its regional scale-up. Important barriers to full implementation of the ACSD implementation plan, as reported by program staff and reflected in project documentation, included: a) commodity insecurity, particularly stockouts of ITNs from late 2005 to late 2006; b) changes in the first-line antimalarial policy and the delayed authorization to distribute these drugs at the community level; and c) inadequate incentives and support and supervision systems for community-based workers. Evaluation design and methods The IIP evaluation team worked with UNICEF-Ghana, the Government of Ghana and other partners to adapt the generic ACSD evaluation design to ACSD as implemented in Ghana. The intervention area was defined as the six HIDs located in the Upper East region. The comparison area was the remainder of Ghana excluding the urban areas of Greater Accra and Ashanti regions (Accra and Kumasi). The primary data sources for estimates of intervention coverage were DHS surveys conducted in 1998-99 and 2003 at baseline, and a national MICS survey carried out in 2006 supplemented by a special extension of the MICS in the HIDs carried out in 2007. Information was collected and summarized in order to document ACSD intervention activities and contextual factors through key informant interviews, document reviews and field visits carried out as part of a mapping exercise by investigators at Kwame Nkrumah University of Science and Technology (KNUST). All results and interpretations were reviewed with representatives of the Government of Ghana and UNICEF-Ghana. iv IIP-JHU | Retrospective evaluation of ACSD in Ghana Results In Ghana, coverage for most of the ACSD interventions improved over time in the HIDs and reached the target coverage levels set by ACSD. Indicators showing positive trends over time in the HIDs included vaccinations, vitamin A, ITNs, antibiotics for suspected pneumonia, timely initiation of breastfeeding, exclusive breastfeeding, antenatal care, IPTp and the presence of a skilled attendant at delivery. Indicators that were observed to stagnate or decline included case management of common childhood illnesses, tetanus toxoid vaccination and postnatal vitamin A. Utilization of ITNs, antibiotics for pneumonia, breastfeeding initiation, skilled delivery and IPTp for pregnant women increased significantly more in the HIDs than in the comparison area. Appropriate management of childhood fever and diarrhea decreased in the HIDs, while stagnating in the comparison area; the difference in trends was statistically significant. For coverage, the answers to the two primary evaluation questions are as follows: (a) Coverage